Corea Family Planning Services Integrated Family Planning Scale-up Plan 2013 - 2020 i < : i : i ; : 8Abbreviations ADs anc ART ‘ASRH or AYSRH sco BMGF BTL cep CHA CHAZ cH co PR cso cyP DFP BHO DHS MUP ewret FP one orz HOW HOP a Huis HPCZ HRH are lec ID or luco. LARC Law ww McoMcH MCPR wos MMR. MOESVTEE ‘Acquited immune Deficiency Syndrome: see HIV Aotenatal Care ‘Anteerovral Therapy ‘Adolescent and Youth Sexual and Reproductive Health Behaviour Change Communication Bil & Melinda Gates Foundation Bistoral Tubal Ligation (Community Based Distribution ‘Community Health Assistant Churches Health Association of Zambia ‘Community Heath Worker Ginical Oficer Contraceptive Prevalence Rate; includes modem, tredtional and folk ‘meitiods| see MCPR CContral Statistical Oe Couple Years of Protection Department for Intemational Development Dedicate family planning providers District Heath Ortce Demographic and Heath Survey; also called ZDHS for Zambia DHS Essential Mecicines Logistics Improvement Programme Elimination of Mothet-to-Chid Transmission (o HIVIAIDS); see PMTCT Family Planning GGoneral Nursing Counc Goverment of the Republic of Zambia Healthcare Worker Heathcare Provider Human immunodeficiency Vis; soe AIDS Health Management Information System Health Professionals Council of Zambia Human Resources for Heath HIV Testing and Counsoing lnformation, Education, Communication Intrauterine Contraceptive Device Long-acting Reversible Contraceptive; includes implants and IUDs Lactational Amenorrhea Method Logistios Management Unit Ministry of Community Development, Mother and Chis Heath Modein Contraceptive Prevalence Rate (women maried and in-union; ‘300 CPR \itlnsium Development Goal Matemal Mortality Ratio Moisiry of Education, Science, Vocational Tralning and Early Education Page |ist. PAC PHO Ministry of Heat ‘Medial Stores Limited Post Abortion Care Provincial Health Offco Prevention of Mother-to-Child Transmission of HIVIAIDS}; see eMTCT Postpartum intrauterine Contraceptive Device Reproductive Health Reproductive Health Commodity Securty SDP ‘Service Delivery Point ScBV ‘Sexual and Gender-Based Violence ‘SMAG. Safe Mothemnood Acton Group SRH ‘Sewal and Reproductive Health st ‘Sexually Transmitted infection SWAP Sector Wide Approach yor “Training of Trainers 1st Technical Support Team ws Technical Working Group usuR Under 5 Morality Rate uncer United Nations Chiron's Fund UNFPA United Nations Population Fund UsAID Unites States Agency for Intemational Development vue Voluntary Modical Male Circumcision wHo ‘Wer Heath Organization WRA Women of Reproductive Age: women 15-49 years of age zuw Zambian Kwacha (rebased from ZMK) Activity categories o Demand SDA Service delivery and access psc. Procurement and supply chain PE Policy and environment F Financing smc ‘Superson, monitoring and coordination Page|Preface Foreword from the Honourable Minister of Community Development, Mother and Child Health Zambia has one of the highest total fertity rates (6.2 chien er woman) in the world, and unfortunately also one of the highost maternal mertalty ratios (591 per 100,000 lve biths). ur efforts in scaling up of modem family planning mathods fare motivated by proof that this is one of the most effective ‘ways to prevent maternal, fant, and child mertaty. Moceaver, Inereasing access to family plansing has supplementary social and economic benefits, such as. increasing educational aitainment, reducing poverty and promoting gender equalty ‘This Eight-Year Scale-up plan is intended to increase the ( contraceptive prevalence rate for modern methods from 33% 1 58% by 2020, in ine with the commitments that were ‘made at the London Summit in July 2012 by the Goverment of the Republic of Zambia. The plan was propared by the Ministy of Community Development, Mother and Child Health (MCDMCH) In collaboration with its partners. ‘The Eigh-Year Scaloup pian focuses on a numberof key strategic proties that wil halp us Teach our objective, including: strengthening demand for family planning services by providing easly-accessitie and targeted information; bullding the capabitias of provigers and increasing the health system capacty to delve high qualty contraceptive services to provide greater choice of methods; providing in and out of school adolescents with accurate land up-to-date sexual and reproductive health information; and, increasing coverage and ‘access to qualty Integrated family planning services to people Iving in rural and underserved areas. ‘The MCDMCH would Ike to encourage all stakeholders to commit to this important scale-up Plan to reach our family planning goal for 2020, co that we can continue to save ives, and ‘women and familes can continue to uly enjoy the benefits of family planning “Hom. Dr. Joseph Katema | a (Wlebe—— = Hon Dr. Joseph Katema (MP); ‘MINISTER - COMMUNITY DEVELOPMENT, MOTHER AND CHILD HEALTH Page iMESSAGE BY HER EXCELLENCY DR. CHRISTINE KASEBA-SATA, ‘THE FIRST LADY OF THE REPUBLIC OF ZAMBIA ‘Working 2s an advocate In prometing mathe and child neath [ Y 1 ‘and more inpotenty fay heath fora better Zambia, | have Awinessed firsthand the Way In whieh sexual reproductive health information and services, including family planning, can Inorease epportuntes for families, uot them out of poverty, land enable young people to realise thelr full potential “The fat tat famiy planning is rot bout stopping people from having chile nor is enly a woman's issue cannot be over sa ‘emphasized. It is about enabling men and women, to make informed decisions about the ‘wefare of the women, existing chidren and the family as a whole. Famiy planning helps individuals and communtias maintain ther averall health by supporting men and wemen to have unsoneywoagdn 2qae94 af Pse3) Ae HoUoN DJou eu 140 sHaNDN SWN0.)— EDK 5 80.2 HELSection 4: Projected Method Mix, Contraceptive Needs, and Impacts The interventions of this FP Scale-Up Plan wil lad to reaching 912255 new users of contraception, with 516.201 implans, 88,165 [UDs, 14,681,269 ijectabies, 31,737 967 pil celes, and 55,978 with permanent family planning methods between 2013 and 2020, leading io an increase in CPR for medem methods from the curent 32.7% t 66% bythe year 2020 This sa ttl 1,827,581 women users of eonacepion 2020, MS's impact 2 Mode!" vas used to calculate the impacts that the Republic of Zambia will benefit from by increasing MCPR to 68% by 2020. These demographic, health and ‘economic impacts include: ‘= Unintended pregnancies averted; ‘= Abortions averted: Unsafe abortions averted: = Maternal deaths aver ‘= Child deaths averted (due to improved bith spacing) ‘= Healthcare costs saved (2M) and = Total CvPs. ‘These calculations estimate that the FP interventions in Zambia wil avert 3,519,126 Unintended pregnancies, 478,559 unsafe abortions, and 9,924 matemal deaths between 2019 and 2020. The services provided over the eight yoars wil lead to 10,754,065 couple years of protection (CYP). Adltionaly. the intorvention wil lead to saving 1.483 bilion ZMWV ‘uring the eight year project poriod * ‘These impacts were calculated by estimating the current MCPR for all women for modern methods, and inputing method mx assumption for the baseline year of 2012, based on 2007 DHS data as wel as the true 2010-2012 commodity issues in Zambia, The method mx used is roughly an average of the two dataset, which is suitable uni a more recent DHS is released. A target method mix for 2020 was projected by the TST, based on the following assumptions and guided by recommendations made by members ofthe FP Working Group 1) The FP Scale-Up Pian wil be fully implemented by MCOMCH and partners, including ‘pectic emphasis on reaching underserved women, such as rural populations, urban or, and youth, and creating demand and improving access for LARC. 0 2013 Calculations by TST using Mace Stopes nteratonal. Impact 2.2013 31 Mare Stopes iteraional 2013. Impact 2. Wielnberger WM, Pozo-Matin F, Boor T, Fy K, and Hopkins K. Impact 2: An innovative tool for lesimatng the impact of reproductive heath programmes mthedaiogy paper. Landon’ Mie ‘topos Itematonal, 2072. {32 Mai Stopes ntmatonsl, 2013, Impact 2 Page| 292) LARCS will ise at a similar rate to othar counties in the region based on similar data for demand and access” once LARC are avaiable at ore service delivery points and ‘demand-creation activi fr LARCs have begun. The greatest rise in LARCs vil be for Implants, accompanied by an increased demand for IUDs, though ata lower rate Injectable use wil increase inne with slilar rises in other countries in the region doe to increased access resulting from planned policy change to allow task-shiting for injectable provision by CBDs, and in ine with historical increase in injectable uptake. ** 4) Piluse wil decrease sighty asa percent ofall methods used, due to improved access to injectadles and LARC." “The use of condoms as a primary form of contraception wll decrease. “The calculated numberof women using LAM wil decrease, asthe high figures inthe “Zambia 2007 DHS are inconsistent with clinical studies reporing thatthe numberof women who use LAM correctly in Zambia fs 20%™. Thus, the forecast inthe number of ‘women aaning contraceptive coverage due to LAM decreases. 3 5) 8 ‘The 2012 baseline method mix assumptions and the 2020 objecie method mi assumptions, forall women, are cutined below. “Table 4 Beseline method mix (2012) ve. iss data and DHS method mix, forall women Contraceptive method Implied method mix ‘Suggested method mix {sues data (2010-2012) DHS 2007 Baseline (2012) Pie 155% 30.1% 21.5% Injoctables 380% 252% 30.0% Condoms (male) 29.1% 203% 218% Condoms (female) 07% (0.0% 0.4% Impiants 79% 12% 6.0% lups 23% 04% “2.0% Female str. 14% 87% 40% Male str. 00% 00% 0% Other (nctudos LAM) 41% 17.1% 55% eee 135 CF Intemational, 2012. MEASURE DHS STAToamplr. Avalabl at hipdimwsalcomaller cm, ‘Recostod oly 222013 {4 1CF national, 2012. MEASURE DHS STAToomplr. Avalable a floJluw statcomsiles cm. ‘Receneed on ly 222013. 35 GF ntrnabona, 2012, MEASURE OHS STATeompler. Avalable at: ina statcompin con, ‘Aoseeso on Jy 22 2013, 36 Short Fabca, M, Chola, Y. 2012. Measuring Use of he Lactatlonal Amenohea Method though the Demographic and. iHealh Suevys: Dats ually and Ingleadons, Preseniation a te 2013 PAA "amval meetin. Popustion Assodiaton of America, Available at tpipaa2013 princeton lpapers191 148 Page |30‘Table 5: Objective method mix (2020, fora women Contraceptive method ‘Suggested method mix ‘Objective (2020) Pills 210% Injectabies 33.0% ‘Condoms (male) 15.0% ‘Condoms (female) 02% Implants 18.0% tubs 4.0% Female str. 5.0% Mate ster. 03% (Other (inciudes LAM) 3.5% Details of the annual mothod mix, sericesicommodiies, contraceptive prevalence by ‘methods, and demographic and heath impacts are shown in Tablas 6, 7, 8 and 9 below, "Note tha for condoms, pis and injectabes, the numbers in Table 6 represent the umber of ‘commodities (condoms, pl cycles, and injections) and not the number of users. ‘Teblo 6: Method mix of FP users served each yoar METHOD 2013 2014 2015 2016 2017 2018 2019 2020 ‘Long-Acting and Permanent Methods (LAPM) Female Steisation 05% 05% 05% 05% 06% 06% 06% 06% ale Sterisation eed eget ee etiam’ Implent- year 26% 32% 38% 44% 50% 5.7% 64% 7.1% |UD. 10 year 05% 06% 07% 08% 08% 09% 10% 1.1% ‘Short-term methods Male Condoms 201% 27.7%) 264% 249% 235% 220% 204% 18.6% Female Condoms 04% 04% 04% 04% 03% 09% 0.9% 0.3% Pills 2AO% 243% 246% 249% 253% 25.6% 260% 26.9% Injoctabies 340% 35.0% 360% 370% 380% 39.1% 402% 414% ec 88% 82% 77% 70% 64% 58% 5.1% 44% Page |31‘Table 7; Sercs and Commodities Provided by Year” ars 24 ms Gata Lew Fete a ee ee) Straten we, me impores—~«2SSDH~CSGaT2 EBB SATE or 2s1 GHD Bees 119404 UO foyer 5426 Be— 806 Some) abe S867 7 a6D ‘Short-term matnods Wale 2957557 27025587 27,886,528 28486436 28,78725 28,760,947 28 98.708 27:77 902 Conon ange, T3401 soe rams aazser soa tesey ste S2 Pate 2643766 AWATET 486971 S77—eI9 4.11105 444605 4787478 5.18857 Injcubles 1230700 1.991.882 155005 1.723540 1908123 2ows4tS 22ee4e 2404346 ws ‘anss7e2ozs age 20% © 090TH 2248.98 “Table @: Contracopive Provalance by Method ll women) ‘merHo0s (acting) 2019 20M 2015 «2016 aor 201820492020 Female Te 1ze Aaa TAKER THT 1K aie 00% 00% 0% 00h 00k OHO OTK OK inpare ee ee ec uo 08% 08K 7K OTK BK OM «TOK «19K ie a a ee ce Female 0% 01K OAK OH OTK OTK OH IH OTH ‘Restate Pale 60% GOR TOK TARTAR BRK ABR BH OK Inetabies 88% 89K TOOK 108% Tek 129K TOT TOEH 140% uw 2am 24% 24% 2S «2PK 21K TMK 18H Anymodem «285% OI WI TAK S5OH BAR VM HOOK LTH ‘meted 437 Tis isthe estimated nunber of services by metnod that would nocd to be provided inorder to reach the EP goa,” Theas hava boon elclated basod on the tal users needed to reach tho {ool cotnuad use of LAPME fem Desaine use (fem Fitri services or CPR), and method- Specie disconnuaton. The resis oe dependent onthe metid mix of services st for each ese Page 132(e1oiy80u) swopuco eewes | Se;AeIO!L| I Swed) —vogmENUeRS OIE ‘SwOUOD OM oud MT nl muons 18 FN, owe fa ‘owoM We 0} oUsTeAaId axdeseNUeD WoPOM * YeHD“Tobie: Annual impacts ofthe FP Scalesip zis 204-2015 2016 « «20172018018 2020 Couple Years 904.425 1,016,248 1,135,906 1,261,908 1,304,108 1,532,061 1,678,104 1,602.495, (of Protection (cP) Demographic impacts Unintended 288,81, 380498 S7O,041 409,772 482.000 490,720, 540,600 609.949, pregnancies ered ofwhich 65550 72878 80064 0548 08971 100202 120,100 191,647 are among, twonagers (519) ‘boron ‘svecod Health impacts tora ei 911.044.8627 140 1.851 1.702 deaths ‘eres CChid deans 8.809873 10954 T2131 TSAO 14.759 16278 17.61 vertod* Unsafe 4og76 45447 50426 S5as1 GI.TI8 08.08 74.935 92,719 sboriens ‘vero Economie impacts Wainer, (212A whe aa fez at mz Ss (elns, . zum) 686 47480 2659 S813 G44sO 71,113 78252 05,059 Page |34Annex A: M&E Tools List of HMIS indicators to track [Monitoring and evaluation tools for this FP plan should not be developed independenty of exiting tools forthe health system in Zambia to ensure sustainably, relevance and ease of use by healthcare workers who must enter the data. The current Health Management Information System (HMIS) tracks several service delvery indicators in healthcare atthe facity, cistict and province levels. These already Include safe matherhaod and family Planning indicators. SmartCare tracks patient records in select facilities, including FP use ‘and method. Incatos related to famiy planning are already included In the HMIS system and tracked ‘monthly athe facility level. Current incicators are listed bolow: 1 Attendance safe motherhood (Number of women receiving counseling on safe motherhood). ‘= Aitendance family planning (Number of women receiving counseling oF services in family planning) = New = Revisit ‘= Family planning methods dstibuted or administered (Number of women receiving the ‘service in each type of method or quantity of product sitibuted) ~ Male condoms distibuted — Female condoms distributed Oral pill cycle (COC) = Progesterone only pill (COP) Mecrexyprogestorone injection (8-month injectable) Norethistrone enanthal injection (2-nonth injectable) — Implant ~ ICD inserted ~ Steiisation female Sterlsation male Existing HMIS indicators are sufficient to track progres ofthe plan in terms of users, but the issue es in that they are not aways reported or entered into the system by healt facites. “his is furher complicated as some faites nandwritereporis and send them tothe district, ‘who do not entor the data into the system, Furthermore, the current data is not effectively used, as i s not necessariy reviewed regulary at existing maetings, to track progress or highight concems. These Issues are addressed in activites In Supervision, Monitoring and Coordination inthe pian Find below a tentative ist of HMIS indicators to includalupdate as part of the next HMIS. review. These are defined keeping in mind what can easily be racked and reported on atthe Page| 95‘acity level, for analysis at a higher level. These would be very valuable in tracking the progress ofthe family planning program, and bettor understanding the needs of users (0.0. these could be used In forecasting commodities) The list is tentative but not necessarily ‘complete, as other indicators or ideas may be added over time based on what is suggested by MCDNCH and partners during regular review meetings. if DHIS2 is rolled ou, these indicators should be considered for integration ino the new system. These mestings wil iso focus onthe numberof fcities reporting data. The suggested indicators ar: 1 Percentage of facies reporting data (Number of facilites reporting / Total number of feces) 1s Ailendance safe motherhood (Number of women receiving counseling on safe ‘motherhood ‘= Attendance family planning (Number of women receiving counseling or services in family planning) ~ New ~ Revisit ‘+Family planning methods distributed or administered (Number of women reesiving the ‘Service n each ype of method or quantity of product distributed) = Male condoms distributed — Female condoms distributed — Emergency contraceptive pills distibuted ~ Oral pill eyele (COC) = Progesterone ony pil (COP) = Medroxyprogestorone injection (3-month injectable) = Norethisterone enanthate injection (2-month injectable) lmplanon implant inserted — Sinoplant implant inserted ~ Jadelle implant inserted = WWOD inserted = Steisation fomale = Sterlsation mate 1+ Family planning methods distibuted by CBDs (Quantly of product istibuted by CBDS ‘associated wit the health conte) = Male condoms distributed = Female condoms dstrbuted (Oral pil eye (COC) Progesterone only pil (COP) ‘Mecroxyprogesterone injection (8-month injectable) — Norethisterone enanthate injoction (2-month injectable) Page| 96Family planning methods removed (Number of women recaving the service in each ‘ype of method) Implanon implant removed ~ Sinoplant implant removed ~ Jade implant removed = WWCD removed (Of family planning methods disbuted, those cistibuted to adolescents (15-19 years) ‘and youth (20-24 years), for each method [recommended but not necessary] Referrals to higher levels of care for FP services (Number of women counseled on FP, choosing a methad not avaiable at this faclty, ln ‘each type of method) ~ Injectable (refered by C8Ds) = Implant = eo Stesisation female ~ Steriisaton male [recommended but not necessary] Referals to family planning from other health Services (Number of women who came infor services or counseling an anather topic but were also counseled in FP) HIVAIDS = Postpartum services ~ Postaborton care = Under5 immnization ~ Other (e.g. pre-and postnatal care, male circumcision, cervical cancer screening, {gender based viclence, and STI management) . [recommended but nt necessary] Number of users coming from rteralst family planning from other heath services (Number of referred women accepting and receiving FP commodities after counseling) — HIVIAIDS: ~ Postpartum services Postaborton care Under: 5 immunization — Other (e.g, pre-and post-natal care, male circumcision, cervical cancer screening, ‘Gonder based violence, and STI management) {recommended but not necessary] Stock-outs of family planning commodities (Number ‘of days with no facity stock in each typ of method) “Note that his Is separate trom ‘lock data and orders which ae tracked by MSL ~ Male condoms ~ Female condoms Emergency contraceptive pls Page| 97= Oral pill eyele (COC) = Progesterone only pill (COP) = Mecroxyprogesterone injection (3-month injectable) — Norethisterone enanthate injection (2-mont injectable) = Implanon implant, applicable to that facity = Singplantimplent, i applicable to that facity = Jadelle implant, applicable to that faciity — CD, it applicable to that feity From these suggested indicators, districts, provinces or the central evel wl be able to fiy ‘accurately estimate the current MCPR (based on attendance, methods distributed, methods istributed by CBDs and methods removed). Additional data on removals wll highlight issues with LARCs; with referals from other neath issues the integration of FP with other health senfoes; and wih stock-outs and referrals to higher levels of care, any issues in the supply chain and method avaiabilty. Dashboard “The executive dashboard is tool for monitoring the progress on the plan. The outcome indicators included come from a varety of sources, end so new jnformation will not be ‘available for every indicator quartery (@.., data from the DHS is only released every 5 years), Partners are expected to help in competing the dashboard by providing servioe and other data rogualy. Data sources and dates are sted recy in the dashboard for easy reference. The dashboard is avalable from MCDMCH upon request for review, and is ao Updated and cistbuted quarter for review at regular FP TWG meetings. ‘The dashboard includes three kinds of outcome indicators: specie outcome indicators related to plan activites, as listed in the full implementation matrix, overall outcome Indicators tracking the plan's objectives, end impact indicators. Together, these allow forthe rmontoring of he plan's progress, fr individual activites, overall progress and impact onthe health system 1 Specie outome indicators: = Demand ‘> Contac of non-users with FP providers (% educated about FP) 1 Accepiabilty of media messages on FP = FP2020 myth-ispeing commitment: dialogue wih reigious and traditional leaders ~ Service deivery and access > Services provided by GRZ faites, including CBDSs, by method 1 Services provided by NGOs, by method 5 Ofal services provided, those provided to adolescents and youth (15-24 years of eae) 1 Source of supply for modem contraceptive methods Page 138© Informed choice (as defined inthe DHS, % of users who were informed about side ofc, what todo i they experience side effects, and other methods they could use} '> Competence of provers (as pat of regular supervision, judged to have Salsfactorly completed counseling, service delivery, and supervision) ‘Size of poo of trainers in FP "Number of providers trained in LARC ~ Procurement and supply chain © Months of stock at central level, by method 4. Stock-ous at central level, by method 2. Slock-outs at fact level, by method (average days out of stock) = Policy and envionment 12 FPZ020 policy bariers commitment task-shiting to CHAS ard CBD ~ Financing 2 Budget ine Budget line for FP services (both MCOMCH and MOH) ~ Budget ine for FP commodities (or RH commodtes, unt the FP commodity bucget lin is created) + FPZ020 budgetary commitment: doubling of FP commodity budget ine ~ Supervision, monitoring and coordination 2. Percentage of faites reporting = HMI ~ Stock reports and orders to MSL. ~ Supervisory reports ‘Overall indicators (Cor comparison against objective): = MCPR (both martied women only and all women of reproductive age) 12 From DHS 1 From any other government or parier stu © Implied from facity-ievel data, from attendance, and methods ditibuted and removed ~ Unmet need ~ Teenage pregnancy Impact inclestors = Unintended pregnancies and abortions averted (MSI estimate based on service delivery) — Matomal mortalty rato Unsafe abortion, matemal deaths and child deaths avered (MSI estimate based on service delivery) Page| 29