By: Fiona Walugembe (Project Director), Allen Namagembe (Deputy Project Director) Uganda Self-Injection Scale-Up project, PATH
Uganda’s commitment to expanding contraceptive access and options
Uganda has made notable progress in increasing access to family planning services. Yet many women and adolescent girls who want to prevent or delay pregnancies are not using contraceptives—especially those who live in remote places, far from health clinics. This makes the work of community health workers as family planning providers particularly important.
Thanks to strong national leadership on family planning, the government of Uganda has pioneered the introduction and scale-up of the novel injectable contraceptive, subcutaneous DMPA* (DMPA-SC, brand name Sayana® Press), to help expand family planning access and options for women and girls. DMPA-SC is an “all-in-one” contraceptive that combines the drug and needle in the prefilled BD Uniject™ injection system. A single injection prevents pregnancy for three months. The product’s simple design makes it easy for transportation and administration by community health workers, or even by family planning clients themselves after a short 20- to 30-minute training. DMPA-SC is now available in at least 50 countries and is approved by regulatory agencies in more than 70 countries worldwide, including in the European Union.
An opportunity to serve, learn, and teach
The Uganda Ministry of Health established the Village Health Team (VHT) program to empower communities to take part in the decisions that affect their health, mobilize communities for health programs, and strengthen the delivery of health services at the household level. VHT volunteers have been offering family planning services for more than 15 years and play a critical role in increasing access to contraception. The mix of methods they provide to villages and rural areas includes injectable contraceptives, like DMPA-SC.
Phiona Nakabuye is a farmer in Uganda’s Mubende District who has served as a VHT for 17 years. When asked why she became a VHT, Phiona says, “I was fortunate to be selected by my local council committee members to serve as a VHT for my village. This provided a perfect opportunity for me to serve and interact a lot and learn from health workers at the facility.”
Upon starting, Phiona was eager to learn about family planning as well as the other health services VHTs offer, such as mobilizing the community to seek services such as antenatal care and facility-based deliveries, integrated community case management, and supporting immunization outreach activities. For family planning, she counsels clients on all contraceptive methods, but she only provides short-acting methods such as oral contraceptive pills, condoms, and the injectables intramuscular DMPA (DMPA-IM) and DMPA-SC. If a client chooses a longer-term method (e.g., an intrauterine device or implant) or a permanent method (e.g., tubal ligation) she refers them to the nearest health facility that can provide that method.
Phiona first learned about family planning during her VHT orientation. She says, “This taught me as an individual to space my children, to serve other people in the community, and to be a good example to others, especially during health education talks and sensitization meetings.”
Being a VHT is not without its challenges. Phiona reports that it can be difficult to find resources to travel to the health facility, outreach activities, or to people’s homes. She also notes that product stockouts are a frequent challenge, as she sometimes travels to the facility to pick up products only to find that they are not available, so she must return to the community without all the supplies she needs.
Yet she maintains a positive outlook, explaining that “being a VHT has made me popular in my community, and I feel very proud whenever I am referred to as a health care provider …. I get to fulfill my dream of serving my community in an important role.”
Globally, momentum is growing around advocacy to ensure that all lay health workers, including VHTs like Phiona, are paid for the work they perform. In addition, recent research examining Uganda’s community health worker programs has highlighted the need to better support these workers, including through improved coordination, streamlined data collection, local ownership, and sustainable funding.
Self-injection: The ultimate task-shifting approach
Research by PATH and its partners including ministries of health in several countries has shown that women can self-administer DMPA-SC safely and effectively, that they like doing so, and that self-injection enables them to continue using the method longer than injections from providers.
Self-care approaches, like self-injection, are the ultimate form of “task-shifting,” or redistributing certain tasks from highly trained health workers to others with shorter training, such as community health workers. This makes more efficient use of human resources and increases access to primary health care. In the case of self-injection, the client is trained to administer the intervention herself, which can free up health workers to address other critical tasks.
VHTs are instrumental in facilitating that task-shifting process by counseling and training women to successfully self-inject contraception if they wish to do so.
Supporting women to self-inject
VHTs first began providing subcutaneous DMPA-SC as a new contraceptive option through a pilot program coordinated by the Ministry of Health and PATH in 2014. Initially, Phiona gave DMPA-SC injections to clients who chose the method.
In 2017, Uganda became the first country in sub-Saharan Africa to begin offering contraceptive self-injection outside of a research setting. After receiving training from PATH, Phiona began counseling and training women to self-inject every three months.
She begins her counseling sessions by orienting clients on all their family planning method options. For women who express interest in learning to self-inject DMPA-SC, Phiona relies on an instruction sheet or job aid that helps clients go through each step of the injection process, with an emphasis on the four critical steps that are key to self-injection. She also confirms each woman’s eligibility for the method and makes sure they understand both benefits and potential side effects. After each client learns how to self-inject, Phiona provides them with as many as three DMPA-SC devices to take home. This enables women to inject on their own every three months at a time and place that is convenient for them.
Regarding how best to support clients to self-inject successfully, Phiona says, “Always make use of the job aid, [so as] not to miss out on any step but emphasize the four critical steps. Support women who are interested, but lack confidence, to build their confidence to self-inject.” She remarks that self-injection “is easy to do for almost all women, even those with little confidence in themselves.”
When asked about any advice she would give VHTs or other CHWs counseling women on family planning, Phiona says, “Always counsel women on all family planning methods, including self-injection, and let the woman make their choice.”
*DMPA-SC: Subcutaneous depot medroxyprogesterone acetate.
Sayana Press is a registered trademark of Pfizer Inc. Uniject is a trademark of BD.