Challenges

In 2021, Madagascar renewed its family planning (FP) commitments, setting targets to increase the modern contraceptive prevalence rate (mCPR) to 60% from 43%, and reduce the unmet need to 8% from 20.8% by 2030. To achieve these goals, the Ministry of Health prioritized the scale-up of self-administered DMPA subcutaneous (s/c) injections as a key strategy. Although self-administered DMPA s/c injections were introduced in Madagascar in 2019, several challenges prevented its scale-up. In response, the Ministry of Health requested WHO’s support in 2022 to initiate a South-South Learning Exchange (SSLE) with a country that has successfully implemented and scaled-up self-administered DMPA s/c injections. Improvements in access to FP services through this initiative contribute to the attainment of SDG goals 3 and 5 of reducing maternal mortality, which remains high, at 426 deaths per 100,000 live births.

Toward a Solution

In 2022, Madagascar and Burkina Faso embarked on a South-South Learning Exchange (SSLE), following WHO’s structured five-step methodology outlined in the SSLE guide.

 Step 1: Define the need for and the purpose of the learning exchange

In response to the request from the Madagascar Ministry of Health, Burkina Faso was identified as a suitable knowledge provider, having launched a pilot program on self-administered DMPA s/c injection in 2018 in four health districts that had expanded by 2020 to 26 additional districts.

Step 2: Plan the South-South Learning Exchange

The learning exchange started in May 2022 with representatives from the Ministry of Health and WHO from both countries discussing and identifying their learning agenda.  In Burkina Faso, only healthcare providers were allowed to initiate and train new users on self-administered DMPA s/c injections, while in Madagascar, trained community health workers educated and supported women in using these injections. Thus, Burkina Faso expressed interest in learning how to expand this task to community-based health workers.  A reciprocal learning exchange was established. Madagascar’s learning need was ‘how to strengthen scaling-up of self-administered DMPA s/c injection’ and Burkina Faso’s need was ‘how to improve the community-based implementation of the self-administered DMPA s/c injection’.

WHO facilitated the learning exchange, which employed a combination of virtual exchanges and in-person study tours.

Step 3: Facilitate the learning exchange

Following the planning meeting, a virtual learning exchange between the two countries continued using the Zoom platform.  Country teams shared experiences, challenges and best practices related to self-administered DMPA s/c injections. This was followed by an in-person study tour by the Madagascar team to Burkina Faso from 18 to 20 April 2023, to gather insights on how to improve the scale-up of self-administered DMPA s/c injections and overcome implementation challenges. The Malagasy delegation visited two health districts and two health centers to directly engage with district managers, health care providers and clients.

Subsequently, from 22 to 25 May 2023, a delegation from Burkina Faso visited Madagascar to explore and learn about community-based strategies for increasing the uptake of self-administered DMPA s/c injections. The team visited a health centre and a district referral hospital, engaging with community health workers and clients to understand how task sharing and community outreach were being implemented to support self-injection practices.

Step 4: Support implementation of the action plan

Following the learning exchange, both countries started implementing the lessons learned starting in June 2023.  Key outcomes include:

Madagascar:

• The National action plan for scale-up of self-administered DMPA s/c injections was updated. As a result, the Ministry of Health launched a 100-day strategy aiming to increase the number of women using family planning services to over 3 million.

Burkina Faso:

• The task delegation strategy and scale-up plan were revised to include the initiation of self-administered DMPA s/c injections by community health workers. This approach was piloted in two health districts- Yako and Boromo, and within just two months, 967 women in Yako and 134 women in Boromo had initiated self-administered DMPA s/c use.

 Step 5: Follow-up after the learning exchange

Both Madagascar and Burkina Faso continue to provide regular updates on the implementation of their respective action plans.