In family planning service delivery, when countries attain improvements in key indicators such as contraceptive prevalence rate (CPR) we feel proud about those achievements. Yet, within countries that have seen such gains, there are still hard-to-reach populations with exceptionally poor contraceptive use, as well as other health challenges; this is the case for many of the communities in which the Advancing Partners & Communities (APC) project works. This is particularly true in three countries— Ethiopia, Kenya, and Tanzania—where APC is implementing community-based FP projects through grantee partners (Global Teams for Local Initiatives, HealthRight International and World Vision Kenya, and Pathfinder International, respectively).
In Ethiopia, national CPR for modern methods has increased by over 20 percent in the last decade, from 14 percent in 2005[i] to 40 percent in 2014.[ii] In South Omo, the home of pastoralist communities who have almost no access to modern health care, education, or infrastructure, the CPR was close to 0 at the beginning of APC’s FP intervention, much lower than the national level. Similarly in Kenya, the national CPR is over 50 percent,[iii] increasing by almost 15 percent between 2008 and 2014. In the two communities where APC partners work, Marakwet in the north west, and Garba Tulla in the north east—two of the poorest, most rural communities in Kenya—have CPRs for any method of 36 percent and 10 percent, respectively. And lastly, Tanzania’s national CPR increased from 20 percent to 27 percent between 2004 and 2010.[iv] In Greater Mahale in the Kigoma Region where the APC funded project is being implemented, the CPR is nearly half the national rate at 14 percent.
What makes these communities particularly hard-to-reach? In general, information and cultural barriers such as lack of knowledge of family planning and low social status of women, far distances from health facilities and essential medicines, and a shortage of skilled health workers contribute to low CPRs in these regions. In South Omo, Ethiopia, GTLI works with pastoral tribes that have had little to no access to family planning information or services in the past. Traditionally, women in these tribes do not have decision-making power within their communities. GTLI’s work focuses on changing these adverse gender and cultural norms to elevate the status of women, increase knowledge of and demand for family planning, and allow women to advocate for their own reproductive health needs. “The more we are able to implement activities that allow the voice of a woman to be heard, the more success we have with family planning,” explains Lori Pappas, Executive Director of GTLI.
The people of Garba Tulla, Kenya face similar barriers to those in South Omo. Garba Tulla is a traditionally pastoralist, predominantly Muslim community where women have little social capital and large family sizes dominate. In order to reach women, World Vision Kenya has engaged men as well as older faith leaders to begin to reverse cultural norms of wanting big families and household decisions dominated by men. In both of these communities, it has been essential to meet the community where they are in order to even begin working towards uptake of family planning; first comes cultural transformation, then behavior change, and lastly engagement in FP services.
Geographic isolation is another defining characteristic in hard-to-reach communities. In Tanzania, the villages within Greater Mahale that Pathfinder works with are scattered on the shores of Lake Tanganyika and are most easily reached by boat. Health commodities must make the 24 hour journey by boat from the district medical store to the health facilities where they will be distributed. In places where commodity stockouts are already a reality, stockouts are commonplace in Greater Mahale. Outreach by community-based health workers, as well as project staff, is crucial to reaching community members.
In South Omo, Ethiopia some of the tribes GTLI works with are 60 kilometers from the nearest health post, requiring a two-day walk. “The more rural, the more difficult it is,” says Pappas. “And what I’ve learned is that in the margins of the country, they’re the most difficult to access, they’re the furthest away and populations are more disbursed.” Addressing geographic isolation means increased planning as well as increased resources in order to give communities access to the basic health commodities they need. It also means ensuring a well-trained workforce is available to help communities obtain health information and essential services like family planning.
Training community-health workers (CHWs) is essential to any community-based project. However, when working with the last quarter of the last mile, it is critical that CHWs are well trained and happy. In both Marakwet and Garba Tulla, attrition of CHW supervisors is poor, giving added importance to the organization’s role in providing oversight and supervision to CHWs. HealthRight has incorporated CHW supervision training as an essential competency when training and expanding the CHW workforce in Marakwet. This builds the confidence and investment of CHW supervisors as well as ensuring higher quality FP services. Nonetheless, a shortage of CHW supervisors continues to be a problem in this area, making it difficult to reach all community members with FP services. Similarly, Pathfinder trains health facility supervisors in appropriate supervision techniques and proper ordering of contraceptive supplies so that CHWs can provide the best possible services to their communities. Supervision and training are important motivators for CHWs, as well as essential to quality service delivery. In hard-to-reach communities, where CHWs are often the main FP service provider, it is essential to acknowledge their important contribution to community-based service delivery.
Despite the efforts of APC’s partners, communities continue to face extraordinary challenges in receiving basic healthcare. GTLI, HealthRight International, World Vision Kenya, and Pathfinder International have all helped to increase CPR in the communities in which they are working—but these changes take time. When working at the last quarter of the last mile, progress is slower and comes in varying forms that may be difficult to capture through standard indicators. As practitioners, it is important to consider that despite progress in achieving the Millennium Development Goals/Sustainable Development Goals or national-level population-based surveys, there are communities living at the last quarter of the last mile who continue to need tailored, culturally appropriate, and creative solutions to achieve results.
[i] Ethiopia DHS 2005
[iii] Kenya DHS 2008 and 2014
[iv] Tanzania DHS 20014 and 2010