Expanding Voluntary Contraceptive Methods to include LARCs in Youth-Friendly Service Units: Assessment of Scale-Up - Ethiopia

"To increase the up-take of FP methods, the USAID-funded Evidence to Action (E2A) Project tested a YFS model in Amhara and Tigray regions focused on offering young people, ages 15-24, voluntary access to the full range of contraceptive methods, including LARCs."

From USAID's Evidence to Action for Strengthened Family Planning and Reproductive Health Services for Women and Girls Project (E2A), this document describes the process of scaling up the expanded choice model of family planning (FP) for youth in Ethiopia to include long-acting reversible contraceptives (LARCs) (i.e., implants and intrauterine devices), highlighting facilitating factors as well as the barriers and challenges encountered.

The Ethiopian Federal Ministry of Health (FMOH) deploys health care providers who are certified as youth friendly (YF) to youth-friendly services (YFS) units whose services include FP and reproductive health (RH). The YF trained providers counsel on all contraceptive methods after a five-day training on privacy, confidentiality, respect, and non-judgmental attitudes, as well as covering specifics of adolescent RH, based on national YFS standards, protocols, and policies.

"The process for testing the [expanded choice] model, scaling it up, and documenting the scale-up process followed E2A’s "evidence to action cycle." The evidence-based approach, which includes generation of evidence, dissemination, and implementation, is embodied in the different phases of the cycle: testing the model (Phase 1), scaling up the model (Phase 2), and conducting a retrospective analysis of the factors influencing scale-up o f the model (Phase 3)."

In phase 1 a study was conducted to test the YFS expanded choice model, designed to address supply, demand (through peer counsellor refresher training), supportive supervision in 10 intervention and 10 non-intervention units. Results of the pilot study showed that train- ing YFS providers resulted in higher LARCs uptake. In phase 2, the model was scaled up to 105 YFS units. ([A]ddressing systemic health systems challenges, including staff turnover and absences, poor quality of care, commodity security issues, and data quality problems were not components of the tested model or its scale-up.) In phase 3, three systematic scale-up frameworks ("ExpandNet’s Nine Steps for Developing a Scaling-up Strategy,...the Com-plex Adaptive Systems (CAS)/Paina and Peters Framework,...and the AIDED/Perez-Escamilla Framework...") were used in an exploratory study to understand the scale up experience. The study included 56 interviews of partner implementers and analysed data from registers of 8 health centres. Specific recommendations from the findings, in brief, include the following:

• Stakeholder Engagement: Stakeholder engagement, through technical working groups, should a platform for technical deliberations that are "continuous and occur before, during, and after testing and scale-up... to ensure a common understanding of challenges, lessons learned, and promote adequate resource allocations."
• Roles and Responsibilities: "Ensure mutual understanding of roles and responsibilities and conflict-resolution processes ...."
• Supportive Policy Environment: Service-delivery protocols should be disseminated to all service providers and senior technical staff at health centres and higher administrative levels..."so that managers ensure the use of guidelines and protocols... and ensure application of emerging evidence-based practices. The FMOH should update the strategy periodically "to ensure application of newly emerging evidence-based practices and/or new technology."
• Mobilising Financial Resources: “The FMOH and RHB should ensure that funding allocations are appropriately adjusted to address young persons’ FP/RH needs... and strengthen health centers’ administrative boards" to implement the updated health financing reform law that allows health centres to generate and use their own funds. The FMOH and RHB should ensure "that investments in youth include resource allocation for youth- friendly FP/RH provision of contraceptive methods. YFS units and YFS-trained providers need to offer an expanded method choice, including LARCs, to young people in a private, confidential, and respectful environment...." In addition, "socioeconomic investments in education, employment, and health must also be made that support youth development."
• Quality of  Voluntary FP Services (Counseling and Service Provision): "Concerted efforts must be made to ensure that the four inter-linked factors (i.e., competent and available providers, separate space, commodity security and supportive supervision with timely feedback) that directly impact quality of FP counseling and service provision are addressed. The RHBs, zones, woredas, and health centers must be tasked with resolving lingering quality of care issues through strengthened supportive supervision, training, and commodity security."
• Data Availability and Use: "Continued and sustained advocacy and dialogue with FMOH, development partners, and stakeholders will be important to revising the HMIS reporting format to include age-disaggregated data on FP uptake and accelerating the implementation of the revised system."