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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
Advances in Task Sharing
• 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
Marie Stopes International
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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
Marie Stopes International
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
Advances in Task Sharing
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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
Marie Stopes International Advances in Task Sharing
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Sierra Leone: Challenges
Advances in Task Sharing
• Ebola Virus Disease outbreak• Intensive monitoring & supervision requirements
Marie Stopes International
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Sierra Leone: Conclusion
Advances in Task Sharing
• 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
Marie Stopes International
Uganda: Task Sharing Tubal Ligation by Clinical Officers
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Uganda: Rationale
Advances in Task Sharing
• 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
Marie Stopes International
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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
Marie Stopes International Advances in Task Sharing
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Uganda: Training for Clinical Officers (CO)
Advances in Task Sharing
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
Marie Stopes International
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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
Marie Stopes International Advances in Task Sharing
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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
Marie Stopes International
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Uganda: Findings - Acceptability
Advances in Task Sharing
• 99% of clients were ‘very satisfied’ with the service
• 97% would recommend the facility where they had the procedure to a friend
Marie Stopes International
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Uganda: Evidence to Action – Policy Success
Advances in Task Sharing
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
Marie Stopes International
Any Questions
Advances in Task Sharing
Marie Stopes International