Breaking Through Barriers in Ghana to Reach the Last Mile .

This post was originally published by the Global Health Supply Chain Program-Procurement and Supply Management (GHSC-PSM) project, and is cross posted with permission. 

When Family Planning 2020 (FP2020) was launched in 2012, it aimed to make high-quality, voluntary family planning (FP) services, information and supplies more available, acceptable and affordable for an additional 120 million women and girls in the world’s poorest countries by 2020. Ghana made significant progress, increasing the number of additional users of modern methods of contraception from 166,000 to 719,000, or by 330 percent, between 2014 and 2020, according to FP2020.

However, the COVID-19 pandemic threatened to erode these gains.

“We always thought that having the commodities available at the facility was all we needed to be able to provide uninterrupted services to our clients,” said health worker Philip Domi of Sasekpe Health Center in Ghana’s eastern Volta Region. “However, with the outbreak of the COVID-19 pandemic in Ghana, we observed that attendance to the facility was gradually declining. We had clients who were due to come for their FP services, yet when we contacted them, they were unwilling to come to the facility for fear of contracting COVID either at the facility or while using public transport to commute to the facility.”

The FP acceptor rate in Ghana declined from 14 million in 2019 to 10.9 million in 2020, according to the Ghana District and Health Information Management System (DHIMS). Demand for almost all FP commodities fell, but more so for short-acting contraceptives such as Microgynon (pills) and Depo-Provera (injection) because they require more frequent visits to a health facility than longer lasting contraceptive implants, for example.

To reduce unmet need and strengthen the supply chain for contraceptives, the USAID Global Health Supply Chain Program-Procurement and Supply Management (GHSC-PSM) project collaborated with the Family Health Division of the Ghana Health Service and Health Keepers Network (HKN), a local nongovernmental organization, to help ensure FP access through last mile distribution. Stakeholders signed a memorandum of understanding for last-mile delivery of FP commodities to improve access to short-term contraceptive methods, such as Microgynon and male condoms, at the community level.

While GHSC-PSM assured the commodities were available and transported as close as possible to the client, HKN leveraged “health keepers” like Fuseina Alhassan in the community of Sakpei in Ghana’s Northern Region to provide comprehensive education on all the available FP services while providing clients with access to short-term methods and referring those who required other options to health facilities. GHSC-PSM and HKN also conducted monitoring visits to community-based distributors to ensure they were well trained to record accurate data, properly store and maintain optimum stock levels, and follow project goals.

The intervention was also aimed to build capacity and generate demand for FP commodities in epidemic and pandemic situations, improve knowledge about FP methods, and correct cultural myths and misconceptions about contraception. Because of these misconceptions and other factors husbands often prevent their wives from accessing FP services, leading to unplanned pregnancies, potential health complications from pregnancies spaced too close together, and associated socioeconomic challenges. That’s where health keepers like Alhassan come in. She works in Sakpei and other communities, providing short-term contraceptive methods, such as Microgynon and male condoms. Now women like Mariam Mumin can access FP counseling and services in private and at their convenience. Alhassan provides FP services Mumin and more than 30 other women every month. She said the joy in helping ease the burdens of the women in local communities and making them happy is worth every mile she has to travel to deliver FP services.

Stakeholders implemented the first phase of the memorandum of understanding from December 2020 to May 2021, with the possibility of extension. Through this collaboration, over 1,935 clients in three selected regions (Greater Accra, and Northern and Volta regions) have had access to FP services (male condoms and Microgynon) in privacy without extra risk of contracting or spreading COVID-19.

Ghana Health Keeper Stories

Going the Extra Mile at the Last Mile

Philip Domi is a health worker at Sasekpe Health Center in the eastern Volta Region of Ghana.

“We always thought that having the commodities available at the facility was all we needed to be able to provide uninterrupted services to our clients. However, with the outbreak of the COVID-19 pandemic in Ghana, we observed that attendance to the facility was gradually declining [from about 40 a day to 10 or less], and this also affected the uptake of family planning (FP) services. We had clients who were due to come for their FP services, yet when we contacted them, they were unwilling to come to the facility for fear of contracting COVID, either at the facility or while using public transport to commute to the facility. We knew we had to adopt a strategy, even if it meant going the extra mile, so we decided to go to the community to render our services.

“Even with that, we were faced with yet another challenge. People were not comfortable with us coming to their community because [they believed] we carried COVID-19. However, since the health keepers started their advocacy in December 2020, uptake of FP is gradually improving. Because they are from the community, people trust them and feel safe interacting with them. Training and equipping them with the right information about FP is helping to demystify some of the misconceptions they had about FP usage. Now clients are able to access FP services it the comfort of their homes without ‘risking’ to travel to the facility. This has helped us a lot because at the end of the month we receive consumption data from them, and we consolidate it with our data. Also, sometimes they are able to refer clients who require long-term methods to the facility. Now we know what last mile really means; it is being able to provide services to the clients whenever and wherever they need them.”

Health Keeper Fulfills Dream for His Community

James Gabienu is a teacher, health volunteer and an elected community assemblyman in Ghana’s eastern Volta Region.

“As an assemblyman I saw an opportunity to make a change in my community. I see a lot of people having kids which they do not plan to have, especially the young people. I know the burden it brings on the family and the community—this is one of the most deprived areas in the district. As a community leader my dream is to see these young people climb higher on the education ladder. However, I have observed that the rate of teenage pregnancy is quite high in this community. I see promising students drop out of school quite often as a result of unplanned pregnancies. I desire to see this change; that is why I chose to be a health keeper. I use every opportunity I get to educate young people on the need to do family planning (FP) to prevent unplanned pregnancies, and now, through the Health Keepers Network (HKN) and partners, we have some of the commodities available, so when my clients need them, they have easy access.”

On average, Gabienu attends to 20 clients a month, most of them teenagers, giving them a greater chance at avoiding pregnancy and continuing their education. Officially, teens can seek FP services at health facilities where many have an “adolescent corner” where teens can feel comfortable seeking counseling. However, cultural barriers and misconceptions about FP in general, especially in rural areas, often prevent them from seeking assistance.

Mother Overcomes Barriers to Provide Family Planning for Herself and Other Women

Mabel Avi is a mother of three children aged 6, 4 and 2 in Ghana’s eastern Volta Region. She plans to wait until her third child turns four before she will consider having another. Waiting, she said, will enable her to concentrate on her gari (cassava flour) processing business to be able to support her family. Avi knows the importance of using family planning (FP) and staying consistent to her chosen method to help her achieve her goal. However, the outbreak of the COVID-19 pandemic presented a challenge for Avi to maintain her method of contraception.

“I was on a three-month FP method until COVID came. When it was time for me to go for my next appointment, my husband prevented me from going to the facility because he thought that I might get COVID-19 from there and bring it home. I was really devastated because in as much as I was not ready to get pregnant, I also did not want to risk contracting a disease and infecting the rest of my family. When a friend from the facility informed me about this program [health keepers], I embraced it because I saw that this could be a good opportunity for me and other women like me who are in this same dilemma.”

“Apart from the fear of getting COVID, distance from this village to the nearest health facility is about seven kilometers, and not many people in this community can afford the cost of transportation—this in itself was a barrier for us. After receiving comprehensive training and having access to the FP commodities, I am able to meet the unmet FP need of members of my community. In addition to providing FP services, I also take the opportunity to educate my community members, especially mothers, on how to practice basic hygiene. Now a lot of women come to me to access FP services.”

On average, Avi is able to provide FP services to about 15 clients a month. This is gradually contributing to improving access to and uptake of FP in the community.

Health Keeper Happy to Go the Last Mile for Clients

Sakpei is a close-knit and socially conservative community of about 1,000 mainly peasant farmers and traders in the Northern Region of Ghana where some cultural misconceptions about family planning (FP) remain. These include the perception that women who seek FP services are promiscuous, that FP is a conscious challenge to God’s plan for childbirth, and that using FP to space childbirth could lead to infertility.

Because of these and other factors, husbands often prevent their wives from accessing FP services, leading to unplanned pregnancies and associated socioeconomic and health challenges. The few women who are able to access FP services from nearby facilities only opt for short-term methods for fear of being caught by their spouses if they chose long-term methods. Therefore, these women have to visit the facilities more frequently to renew their methods, which can be problematic because of the long distance, the cost of transportation and time away from income-generating activities.

The emergence of the COVID-19 pandemic in Ghana placed an extra burden on these women because of lockdowns and fears of contracting the virus if they visited health facilities. In the meantime, people like Fusiena Alhassan became a health keeper so she could provide short-term contraceptive methods, such as Microgynon and male condoms, in communities like Sakpei.

Now women like Mariam Mumin in Sakpei can access FP counseling and services in private and at their convenience. Alhassan provides FP services to over 30 women every month in her community and those nearby. She said the joy in helping ease the burdens of the women in local communities and making them happy is worth every mile she has to travel to deliver FP services.

Banner image caption: Fusiena Alhassan (right) provides family planning services to Mariam Mumin in Sakpei, Ghana. The photo was taken by Gloria Agyekum for GHSC-PSM.