In Six Months, A Big Change

Expanded access to modern contraception through targeted advocacy in DRC

What can an organization like Pathfinder achieve in six short months? A lot!

Our recent advocacy efforts in Democratic Republic of the Congo (DRC) have paved the way for improving access to women’s and girls’ access to contraception—demonstrating what a targeted advocacy project can achieve. Our “DMPA-SC Regulatory Advocacy Project” was a short-term, strategic, and targeted intervention that aimed to eliminate policy barriers to the provision of family planning services in pharmacies and drugstores across the country. Additionally, we worked to include the self-injectable method, DMPA-SC, more commonly known as Sayana Press, as an option.

While pharmacies and drugstores are a common outlet for contraceptives, pharmacists weren’t authorized to administer family planning onsite or provide counseling services, representing a missed opportunity for the health system. More than this, pharmacies and drugstores weren’t listed among service delivery points for family planning.

In the end, Pathfinder’s work culminated in a Circular Note (an official document that informs of a new regulation and formally authorizes its application) that made access to family planning services more accessible in pharmacies and drugstores, as well as authorized the inclusion of DMPA-SC (Sayana Press) and self-injection. Specifically, pharmacies and drugstores are now authorized to provide family planning services, including comprehensive counseling and provision/administration of FP methods such as Sayana Press, as well as support for self-injection to clients who choose this option. Pathfinder also provided support for the development of a manual, guidelines, and tools to operationalize these shifts.

WHAT DOES A SIX-MONTH ADVOCACY CAMPAIGN LOOK LIKE?

Month 1 – Project Launch

In the first month of the project, Pathfinder conducted targeted ‘influencer’ meetings, bringing key decision makers to the table and discussing the proposed policy shifts. These meetings included technical experts from Ministry of Health Departments including the DGOGSS, DSFGS, PNSR, DPM, PNSA, and with the National Council of the Order of Pharmacists. Pathfinder also met with the National Malaria Program to learn more about their experience with the integration of the rapid malaria testing in pharmacies and drugstores. Out of these meetings, Pathfinder:

• Gathered ideas and advice from experts on the inclusion of family planning services in pharmacies and drugstores.
• Identified strategies and technical considerations that would help achieve the integration of these services.
• Proposed the necessary supervisory measures to maintain and supervise the provision of family planning services in pharmacies and drugstores.
• Proposed the supporting documents to be developed for the operationalization of these shifts, including the administration of Sayana Press.

Pathfinder then conducted targeted advocacy ‘audience’ events, which worked to generate political support. These ‘audience events’ included representatives from the General Directorate of the Health Services Organization, the Pharmacy and Medicines Department, UNFPA, WHO, USAID, and other national and international organizations involved in family planning like DKT, EngenderHealth and IPAS. Pathfinder worked to strengthen relationships and coordination between the various stakeholders, and incorporated technical feedback on how to operationalize proposed shifts. These sessions allowed Pathfinder to share an advocacy kit that outlined the DRC context and key arguments to support the intended policy change. Decision makers provided inputs on incorporating family planning services in pharmacies and drugstores.

Key takeaways included:

• Agreement on the proposed path to achieve policy change.
• Summary of decision-makers’ points of view regarding the issue of the provision of family planning  services in pharmacies and drugstores.
• Identification of  potential stakeholders for the integration of family planning  services in pharmacies and drugstores.

Month 2 – Building Consensus

In our second month, Pathfinder conducted a three-day ‘consensus workshop’ with Ministry of Health experts to define how to operationalize the provision of contraceptives in pharmacies and drugstores. Through this workshop, a series of outcomes were achieved:

• Consensus on the package of family planning services to be integrated into pharmacies and drugstores. This included the standard community-based services package (comprehensive family planning  counseling, provision of pills, condoms and cycle beads, referrals for long acting reversible and permanent methods), and administration, initiation, and self-injection of DMPA-SC.
• A document describing how to provide FP services in pharmacies and drugstores.
• Criteria for selecting eligible pharmacies, development of a logo to ensure the visibility of pharmacies providing family planning services, including DMPA-SC and self-injectables.

Out of this workshop, a draft Circular Note was developed, which would authorize the provision of modern contraception and family planning services in pharmacies and drugstores.

Month 3 – Implementation Details

In our third month, a technical working group convened. Five experts (from the Ministry of Health) with knowledge of the DRC health system, provision of family planning services, and the pharmaceutical sector participated. The working group drafted guidelines and supporting documents for the provision of family planning services in pharmacies and drugstores, as well as the inclusion of Sayana Press.

Month 4 – Finalizing the guidelines

In our fourth month, Pathfinder conducted a five-day working session to finalize and adopt the proposed guidelines and supporting tools that would help pharmacies and drugstores operationalize a more inclusive approach to the provision of family planning services. Documentation included:

• Manual for the operationalization of family planning services in pharmacies and drugstores;
• Guidelines for the provision of quality family planning services including DMPA-SC and self-injection in pharmacies and drugstores;
• Supporting tools for supervision, data collection, contraceptive management and reporting.

Month 5 – Formalization of the shift

In our fifth month, Pathfinder led a full-day meeting with 75 experts from government institutions, representatives of the private sector and civil society, health development partners, and implementing partners. During this meeting, the Ministry of Health General Secretary formally endorsed and signed the Circular Note, authorizing a pilot introduction of family planning services offer in pharmacies and drugstores, including administration and self-injection of DMPA-SC.

Month 6 – Dissemination

The culmination was the dissemination of family planning service guidelines and supporting tools for pharmacies and drugstores. This dissemination included:

• Three face-to-face meetings to disseminate the documents in Kinshasa, which brought together experts from DGOGSS, DSFGS, DPM, PNSR, PNSA, of HIV/AIDS Control (PNLS), and members of the Society of Midwives and of the National Council of the Order of Pharmacists.
• A Zoom session organized with the 26 Provincial Divisions of Health under the leadership of the PNSR, involving experts from the central level of DPM, DSFGS and PNSR, which brought together three experts by province, for a total participation of more than 75 people in a videoconference.
• Printing and distribution of the final version of the documents.This included sharing of the manual, guidelines, and related tools as well as the Circular Note in PDF format in the various WhatsApp groups that support family planning, and hard copies, at both national and provincial levels, in order to promote the use and ownership of the approach. The tools include the supervision guide, monthly reporting form, record of services and contraceptive stocks.

The Results

Throughout the project, Pathfinder worked in close collaboration with the Directorate of Pharmacies and Medicines, the National Program of Reproductive Health and the key Ministry of Health departments concerned by this change, in all stages of the project implementation. Other relevant Ministry of Health departments involved include the General Directorate of Organization and Management of Health Services (DGOGSS), Directorate of Family Health and Specific Groups (DSFGS), and National Program of Adolescent Health (PNSA).

We know that conducting advocacy often takes significant amounts of time. Conducting advocacy to address a policy change within a six-month timeframe requires having solid knowledge of the health system and of its relevant departments, how they operate and correlate to each other, a good sense of the decision-making process for policy change in the area concerned, and knowledge of the best approaches to influence the decision. This allows for establishing a decision-making map, identifying all the relevant individuals and departments or organizations that influence decisions on the issue, and working closely with them to design an appropriate advocacy approach and implementation strategy. Pathfinder had these items in place, as well as preparation of an advocacy kit with strong, supportive evidence for the policy shift.

AND WHAT DID WE ACHIEVE? A MAJOR WIN FOR ACCESS TO FAMILY PLANNING SERVICES IN THE COUNTRY!

Ultimately, Pathfinder:

• Achieved the issuance of formal authorization for the pilot introduction of FP services in pharmacies and drugstores including initiation and self-injection of DMPA-SC, in the DRC;
• Developed a key stakeholder-informed and validated manual, guidelines, and tools for the operationalization of this change;
• Achieved ‘buy in’ through influencer and advocacy sessions that took place at the beginning of the project.

To put it simply – as a result of Pathfinder’s targeted advocacy, the DRC will expand access to contraceptive methods, including DMPA-SC self-injection, and contribute to more equitable access for vulnerable demographic groups, adolescents, and unmarried women, who will find pharmacies and drug stores more accessible.

What’s next?

In the upcoming months, Pathfinder will pilot the introduction of community-based family planning services including the provision of DMPA-SC and self-injection in at least 120 selected pharmacies and drugstores. The Ministry of Health has developed an implementation plan, with support from Pathfinder International and the World Health Organization (WHO), and in collaboration with key FP stakeholders. This action plan aligns with the FP National strategic plan 2021-2025.