advances in task sharing: findings from uganda & sierra leone julia byington programme advisor,...

Advances in Task Sharing:

Findings from Uganda & Sierra Leone

Julia Byington

Programme Advisor, Marie Stopes International

Sierra Leone: Task Sharing Depo-Provera to Community Health Workers

Marie Stopes International2

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Sierra Leone: Rationale

Advances in Task Sharing

• Low CPR nationally – 16% (DHS, 2013)

• Unmet need for FP – Married Women – 25% (DHS,2013)

• Married Women intending to use FP – 49% (DHS, 2013)

• Restrictions on access to health services related to:

–Distance to health facilities

– Poor and pricey travel infrastructure

• Paucity of health care workers – 1.7 nursing/midwifery personnel per

10,000 people (WHO, 2014)

Marie Stopes International

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Sierra Leone: Study ObjectivesObjectives:1. Determine the feasibility and safety of training CHWs

to provide Depo-Provera2. Determine whether CHWs can provide Depo-Provera

safely and providing quality counseling3. Determine the acceptability of CHWs providing Depo-

Provera to clients

Location:Six chiefdoms in the Koinadugu District selected because of its high unmet need and being the only District then Ebola free.

Marie Stopes International Advances in Task Sharing

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Sierra Leone: Design


• 150 CHWs were selected and participated in a competency-based training; 100% pass rate

• Implementation used a phased approach – each group of CHWs provided Depo for 3 months between July to December 2014

• CHWs were placed under the supervision of PHU-in-Charges in their respective communities using monitoring checklist

• CHWs recorded client data, reported all adverse events, responsible for waste management at the community level

• Client interviews were conducted by Marie Stopes supervisory staff


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Sierra Leone: Findings

• 42.4% of services were provided to first time users of modern FP

• 53.6% of services were provided to single women


Under 25:; 59.0%

19- 24:; 26.4%

18 and un-der:; 32.6%

Age of clients

CHWs collectively provided 10,810 Depo-Provera injections throughout the pilot intervention period


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Sierra Leone: FindingsNo clinical incidents occurred

Supervisors reported satisfaction with FP counseling and Depo-Provera provision

99.1.% of clients reported to have been given clear information instructions for potential problems

99.5% of clients reported that they were given clear understanding of all the various available FP methods

99.5% of clients said they would return to a CHW for Depo-Provera or another service

25% of respondents said that without the CHW they would not continue to use FP and 51.4% said that they would have to travel further to access FP


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Sierra Leone: Challenges


• Ebola Virus Disease outbreak• Intensive monitoring & supervision requirements


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Sierra Leone: Conclusion


• With specific training and supervision, CHWs can safely and successfully provide Depo-Provera to women in their communities.

• This intervention was successful in reaching first-time users, as well as young women

• Scaling up CHW provision of injectable contraceptives nationally could increase FP choice and access to remote and most-in-need communities

• Awaiting MOHS pilot validation meeting and further policy discussions


Uganda: Task Sharing Tubal Ligation by Clinical Officers

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Uganda: Rationale


• Shortage of qualified health providers skilled in LAPM provision

• National development goal to reduce unmet need for FP (spacers and limiters), especially in rural areas

• National policy guidelines & service standards for SRH allow clinical officers to provide TL

• Request to generate evidence on safety and feasibility for Clinical Officers to provide TL in rural settings


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Uganda: Study Objectives

Primary: To assess intra- and post-operative complications associated with Clinical Officer provision of TL in mobile outreach settings

Secondary: To evaluate client satisfaction levels associated with Clinical Officer provision of TL


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Uganda: Training for Clinical Officers (CO)


Theoretical training (one week) • COs had to pass the theoretical training before moving to

practical training

Practical training • Close supervision from trainer: observed & assessed the

trainee’s performance of 50+ procedures

Competency assessment: 1.Effective administration of local anaesthesia 2.Effective in surgical steps of the TL procedure 3.Preparedness to manage possible complications


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Uganda: Design

Prospective cohort study (N=518) conducted March – June 2013 in 4 rural regions of Uganda

4 clinical officers, theory training, 50+ TLs under close supervision

Audit team included trained COs, supervising physician, 2 data collectors - linked with MSU mobile outreach teams

Safety & acceptability outcomes collected at baseline & 3 follow-up visits (days 3,7,45)

Safety outcomes – Adverse events data collected intra-operatively & post-operatively; categorized (minor/mod/major) according to MSI guidelines; major adverse events were considered complications


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Uganda: FindingsCohort - 41% of women aged 35-39 years; 49% had 5-7 living children;

60% were using short-term methods (injectables, pills, condoms)

Safety - Overall complication rate (major adverse events) - 1.5% (lower than other country studies)

Baseline: 2 major adverse events – perforation and failure to mobilize tubes

Day 3: 1.9% complications (pain; fever; poor wound healing; infection)

Day 7: 0.2% complications (pain)

Day 45: no complications


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Uganda: Findings - Acceptability


• 99% of clients were ‘very satisfied’ with the service

• 97% would recommend the facility where they had the procedure to a friend


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Uganda: Evidence to Action – Policy Success


The following policies were decided by the Ugandan MoH (Sept 2013):

1. Implement the policy on task sharing for TLs by trained and supervised Clinical Officers

2. Service provider agencies can continue training & employment of Clinical Officers for TL through outreach


Any Questions



advances in task sharing: findings from uganda & sierra leone julia byington programme advisor,...

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