Increasing Contraceptive Use Through Free Family Planning Special Days in Poor Urban Areas in Francophone West Africa

Through the support of local governments and The Challenge Initiative, Family Planning Special Days successfully facilitated the delivery of free family planning services to urban West African populations with high levels of poverty and unmet need.


INTRODUCTION
A lthough health care access has concerned authori- ties in francophone West Africa (FWA) for many years, they have been focused primarily on the issue of geographical proximity.However, persistent low health care service utilization has highlighted the multiple issues limiting access, including financial barriers.This is particularly true in urban areas, where many people do not access care, particularly family planning (FP) services, despite proximity to health care facilities. 1 FWA cities have a high prevalence of poverty, with widening gaps between classes, low contraceptive prevalence rates, and high unmet need (28%). 2 Building on the demonstrated success of the Urban Reproductive Health Initiative, The Challenge Initiative (TCI) was established to accelerate contraceptive method use in poor urban areas.Since 2016, TCI FWA, led by IntraHealth International, has improved access to FP services for women of reproductive age (15-49 years) using high-impact interventions, including free Family Planning Special Days (FPSDs) adopted from the Urban Reproductive Health Initiative.Documentation of that project's interventions showed that for the free FPSDs, the targets were largely exceeded in terms of recruitment of new FP clients (104%) and couple-years protection (118%). 3The free FPSD approach was also tested in Mauritania as part of the U.S. Agency for International Development-funded Agir Pour La Planification Familiale project in 2017.Documentation of the approach there showed exceptional performance of the special days compared to routine days, with 5.5 more clients recruited and 7 more new clients recruited. 4PSDs were also included on TCI Universityan online platform housing the framework and tools associated with evidence-based FP and adolescent and youth sexual and reproductive health interventions. 5e describe how municipalities and the health system collaborated to implement FPSDs in FWA, the effectiveness in reaching women with FP services, associated costs, lessons learned, and recommendations to sustain and scale FPSDs.

FPSD
FPSDs were an intervention organized by municipalities to provide free FP services on specific days in the community.Each FPSD event was held over 2 to 5 consecutive days in the health facility (fixed strategies) or in other sites close to people's homes (advanced or mobile strategies).This intervention was implemented in a regional context where the public health facilities, except for those in Burkina Faso, routinely charged fees for contraceptive products and services.

Roles of Different Stakeholders
The cities supported by TCI FWA included FPSDs in their action plans to strengthen FP and adolescent and youth sexual and reproductive health.As part of the implementation of these plans, TCI, municipalities, and health systems created program management and coordination units (PMCUs) composed of government focal points from each municipality (including financial officers), health districts, and the regional health directorate.Each municipality signed bylaws establishing the PMCU and integrated it into the city's institutional set-up to ensure the PMCUs' sustainability.

Preparation and Resource Mobilization
The PMCU met monthly to plan activities and evaluate progress.Decisions were made on the following: locations; target population (typically poor, disadvantaged populations); number of FPSDs; required personnel, logistics, and contraceptive products and consumables; and budget.The terms of reference for the FPSDs and the bud-  Preparatory meetings were organized between the health system, the municipality, and the community (represented by a community relay or the neighborhood delegate) to estimate the need for contraceptive products and consumables, prepare management tools (e.g., forms, registers, cards, etc.), mobilize logistics (e.g., vehicles, tarpaulins, chairs, and sound system), and identify qualified health system personnel (doctors, midwives, and nurses) and support staff (e.g., community health agents, drivers, maintenance agents, etc.).Finally, an advance site visit was conducted to verify that the premises (health huts, town halls, and sociocultural centers) were adequate.

Marketing and Communication
A communication plan for FPSDs was developed and implemented for 4 to 5 days (2 to 3 days before the activity and the first 2 days of the activity).Messages were disseminated through mass media (e.g., posters, banners, radio, television, social networks, and newspapers) and town criers.Community volunteers held informational meetings with religious, traditional, and community leaders and conducted home visits, during which they gave referral cards with information about FPSDs.

Conduct of the FPSDs
FPSDs were an outreach service conducted in health facilities (fixed strategies) or in other sites close to where people live (advanced or mobile strategies).During FPSDs, after health providers provided educational talks, women were directed to consultation rooms where they were counseled, offered their FP method choice, and given follow-up visit advice.For follow-up and management of complications, clients had to return to the health facility.If the site staff could not manage the complication, the client was referred to the district hospital using a standard referral form.The FPSDs were conducted under the supervision of the health system district management team to ensure that the services offered were of high quality and the activity ran smoothly.In 2021, FPSDs were implemented in 10 cities across 5 FWA countries (Table 1).

Data Management
FPSD management tools were the same as those used in the health system, including appointment cards, FP cards, FP registers, referral and counterreferral forms, and an FPSD data summary form.
Women attend a Family Planning Special Day in Niamey, Niger.© 2021 Fatimata Sow/The Challenge Initiative Francophone West Africa-IntraHealth International During FPSDs, health providers provide educational talks after which women are directed to consultation rooms where they are counseled, offered their FP method choice, and given followup visit advice.
Family Planning Special Days in Francophone West Africa www.ghspjournal.org Daily reports and a summary report were prepared and sent to the district, which were then sent to TCI.The summary report included the location, populations sensitized to the FPSDs, health personnel mobilized, FPSD service users, and quantities of products distributed.Each month, health facilities integrated these data into their own monthly report.The district data manager entered these data into TCI FWA's database and archives the collection sheets and reports.

METHODS
This descriptive analysis, which covers the period from July 2020 to June 2021, was based on document review of activity reports, analysis of health management information system data, and retrospective data collection of implementation costs.All health facilities that organized FPSDs with data entered in the project database from July 2020 to June 2021 were selected in the 36 districts supported by TCI.We developed a data collection form in Epi Info 7 to enter and analyze data on finances from all FPSD expenditure reports of all cities during the study period.Table 2 includes the indicators used for this analysis.

Ethical Approval
This analysis is consistent with international standards for the ethical conduct of research.No personal information was collected; key informant questions related only to the normal course of the informants' work.

Characteristics of Health Facilities Implementing FPSDs
During the period analyzed, 1,046 FPSDs were conducted in 452 health facilities.More than half (51.2%) of TCI partner health facilities organized FPSDs, with the percentage varying greatly by city, from 23.8% in the Union of Zou Municipalities (UCOZ), Benin, to 91% in Bouake, Côte d'Ivoire (Figure 1).Of the health facilities that organized FPSDs, 94% were public and 6% were private.The average number of days of FPSDs organized per health facility across all cities was 2.3, with Bouake holding the highest number of days (5.1) (Table 3).

Characteristics of Health Personnel Mobilized for FPSDs
FPSDs were primarily conducted by midwives, with an average of 221 (42%) midwives per month, followed by community health workers, nurses, and doctors (Figure 2).This was expected because midwives generally offered FP services with support from community health workers and nurses.Physicians generally supervised the conduct of the FPSDs.Ouagadougou mobilized the largest number of staff, while Bouake mobilized only midwives (Figure 3).

Sensitization of Populations About the FPSDs
During the FPSDs, 583 community volunteers (or health workers) conducted 22,960 awareness activities.A total of 1,638 media broadcasts reached 181,792 people, 17% of whom were men.Among people made aware of the FPSDs, the majority were aged 20-24 years (53%) compared to those aged 25-49 years (44%).Niamey, UCOZ, and

Service Delivery Results
From July 2020 to June 2021, FPSDs enabled the provision of services to 71,669 users of modern contraceptive methods.Almost half (46%) of FPSD service users were aged 15-24 years.The most used contraceptive methods were implants, followed by injectables and pills, with 34.3%, 33.9%, and 15.2%, respectively (Table 4).A similar percentage of long-acting methods was found with the implementation of the FPSDs in Mauritania. 4 This distribution may be explained in part by the lack of fees during FPSD days compared with the high price of these methods on non-FPSD days.Long-acting methods are generally more expensive than other methods on non-FPSD days in health facilities.For example, in Côte d'Ivoire, the cost of routine service delivery for implant insertion, including consumables, is 3000 Central African CFA francs (FCFA) (US$5), FCFA1000 (US$1.70) for injectables, and FCFA200 ($0.34) for pills, while in Senegal the costs for the same services are lower, at FCFA1500 (US$2.60)for implants, FCFA200 (US$0.34)for injectables, and FCFA100 (US$0.17)for pills.
Across all age groups, 58% of beneficiaries were new contraceptive users.This percentage was much higher among adolescents and youth, who represented 51% of new contraceptive users.This finding suggests that the FPSD intervention mobilized new users through a combination of free services, proximity, convenience, and awareness raising.
These results were adjusted for seasonality and the couple-years protection for short-acting method users to calculate the annual client volume of 34,061 users (Table 5).Method mix analysis showed that 78% of these users adopted longacting methods and 22% chose short-acting methods from July 2020 to June 2021.Among users choosing long-acting methods, 43% were adolescents and youth.
The average number of total users recruited per day during FPSDs (daily output) was 68.This is much higher than the daily output found in Mauritania, which was only 28 users recruited on average per day. 4 Abidjan, with an average of 222 total users recruited per day, had the highest daily output, followed by UCOZ (99 users) and Niamey (97 users) (Table 6).[8][9][10] The number of health facilities that organized FPSDs and the number of days of FPSDs organized did not have a substantial influence on the performance of FPSDs.Abidjan, which organized 56 days of FPSDs in 42 health facilities, had a higher yield than Koudougou, Cotonou, Nioro, or Ziguinchor, which organized more days of FPSDs with slightly more health facilities.
In addition, the overall average number of clients served per day per provider (doctors, midwives, and nurses) was 0.2, with significant variations by city.The city of Abidjan had the highest number of clients served per day per provider (13.1), and the cities of Koudougou and Ouagadougou had the lowest number of clients served per provider (0.7) (Table 6).The low number of users served by providers in certain cities (Cotonou, Nioro, or Ziguionchor) may reflect low attendance on special days, often due to a lack of preparation (e.g., low communication).For the cities of Burkina Faso, it could be linked to the country's context, which included free family planning services.

Implementation Costs
Overall, FPSDs in FWA cost FCFA145382501 (US$252839).Contributions came mainly from municipalities (FCFA51223176 [34.9%]) and TCI FWA (FCFA94159325 [64.8%]), with the remaining balance from health facility management committees made up of community members.Niamey, which bore 53% of the expenses (FCFA11735400), was the only city that spent more than TCI.Apart from Niamey, Cotonou, Abomey Calavi, Abidjan, and Bouaké had contributions that exceeded the average, with FCFA5046800 (44%), FCFA2279720 (41%), FCFA9671200 (39%), and FCFA6090000 (39%), respectively (Table 7).Ouagadougou and Koudougou had the lowest contributions because contraceptive products were free in Burkina Faso, so expenditures were only made in cases of shortages of contraceptive products or consumables.TCI's expenses supported marketing and communication, logistics, and staff per diems.The bulk of the municipalities' contribution was for the purchase of contraceptive products (90.8%).Per diems for personnel represented 33.8% of expenses, followed by contraceptive products (31.7%) (Figure 4).
The average cost per day of organizing an FPSD event in FWA was FCFA138989 (US$242).The highest average costs for 1 FPSD day were in Abidjan, Bouake, and Niamey.Cotonou and Koudougou had the lowest average cost per day of FPSDs (Table 8).Differences in per diem rates and the categories of personnel mobilized for FPSDs, especially in Abidjan and Bouake, where nearly 85% of the personnel were midwives, could explain this variation.
The average cost of recruiting 1 FP user was FCFA2029 (US$4) from July 2020 to June 2021.This average cost varied from FCFA860 (US$1) for UCOZ to FCFA3419 (US$6) for Ziguinchor (Table 8).Differences in the performance of cities in recruiting FP users at the FPSDs were not related to the amount of money spent.Indeed, Koudougou and Ziguinchor cities had the highest average cost of recruiting an FP user compared to Abidjan and UCOZ, which were more successful in terms of users recruited and had lower average costs per FP user.In terms of couple-years protection, the average cost of a user for FPSDs was FCFA4268 (US$7).

LESSONS LEARNED
FPSDs improved geographical and financial access to contraception for women of reproductive age.With the provision of free FP services, FPSDs enabled 71,669 women of reproductive age to access modern contraceptive methods in urban areas of FWA, with an annual client volume of 34,061.In Mauritania, the number of clients served per day during FPSDs was 5.5 higher than on the routine fee-for-service basis, with 6 new clients and 21 existing clients. 4FPSDs helped remove economic barriers that prevent some women from accessing contraceptive methods, particularly in poor urban areas.
FPSDs provided an opportunity for clients to benefit from free long-acting methods.Of the total client volume during the FPSDs, a majority (78%) of users adopted long-term methods and only 22% adopted short-acting methods.A similar trend exists almost everywhere in sub-Saharan Africa, where implant use has increased substantially and evenly across almost all sociodemographic categories. 11SDs strengthened collaboration between stakeholders.We noted substantial ownership by the municipalities and the health system, FPSDs help remove economic barriers that prevent some women from accessing contraceptive methods, particularly in poor urban areas.
Family Planning Special Days in Francophone West Africa www.ghspjournal.orgwhich set up the PMCUs.This body strengthened collaborations, bringing municipalities closer to the health system.This collaboration involved several actors: doctors (2%), midwives (42%), and nurses (20%); community health workers (35%); municipal representatives; and the general population.
FPSDs were a highly cost-effective intervention.Providing comprehensive, high-quality contraceptive services to the growing number of women who need modern had important cost implications. 12The average cost of organizing 1 FPSD day was FCFA138989 (US$242), and the average cost of recruiting an FP user was FCFA2029 (US$4).In 2012, the average annual cost per user for all modern methods in the developing world was estimated at US$6.15 and for the Africa region at US$11.26. 12

RECOMMENDATIONS
The promising results of FPSDs in FWA support the following recommendations.
Ministries of health must make contraceptive supplies and consumables available to significantly reduce the costs associated with implementing this intervention and allow municipalities to cover the remaining costs, such as per diems and logistics.
Ministries of health should include FPSDs in their FP strategic plans to enable health districts to include them in their annual work plans.
Members of the coordination and management units, along with advocacy groups, must advocate with municipalities to include a substantial budget line for FP in their annual budgets to ensure the sustainability of this intervention.
The Ministry of Health should build the FP communication capacity of community relays and providers to strengthen activities to help remove barriers to FP, create or increase demand for FP, and reinforce positive values and norms. 13

CONCLUSION
FPSDs could improve geographic and financial access to FP services.The results of the FPSDs in francophone West Africa were encouraging, despite the COVID-19 pandemic, because of the financial support of the participating municipalities and TCI.Successful implementation requires coordination and engagement of all stakeholders.These results should spur municipalities and health systems to institutionalize the FPSD intervention by integrating it into country policies and norms, increasing availability of contraceptive products and consumables, and continuing to provide financing.
members attend a family planning sensitization session as part of a Family Planning Special Day intervention during the COVID-19 pandemic in Abobo, Abidjan, Côte d'Ivoire.© 2020 Kouakou Yao Degah Bienvenu Attoumbre/The Challenge Initiative Francophone West Africa-IntraHealth International

FIGURE 1 .
FIGURE 1. Percentage of The Challenge Initiative-Supported Health Facilities That Organized Family Planning Special Days in Francophone West Africa by City, July 2020-June 2021

FIGURE 3 .
FIGURE 3. Number of Health Personnel Mobilized for Family Planning Special Days in Francophone West Africa by Category and City, July 2020-June 2021

FIGURE 4 .
FIGURE 4. Expense Categories for Family Planning Special Days in Francophone West Africa, July 2020-June 2021

TABLE 1 .
TCI-Supported Cities Implementing Family Planning Special Days in Francophone West Africa, July 2020-June 2021 Abbreviations: TCI, The Challenge Initiative; UCOZ, Union of Zou Municipalities.Global Health: Science and Practice 2023 | Volume 11 | Supplement 1 S4

TABLE 2 .
Indicators Used in Analysis of Family Planning Special Days in Francophone West Africa The total amount spent on FPSDs divided by the total number of FP users recruited through FPSDs Project dataAbbreviations: CYP, couple-years protection; FP, family planning; FPSD, Family Planning Special Day; HMIS, health management information system.

TABLE 3 .
Average Number of Family Planning Special Days in Francophone West Africa per Health Facility in Cities, July 2020-June 2021 Abbreviations: FPSD, Family Planning Special Day; UCOZ, Union of Zou Municipalities.FIGURE 2. Percentage of Health Personnel Mobilized for Family Planning Special Days in Francophone West Africa by Category, July 2020-June 2021 (N=525)

TABLE 4 .
Beneficiaries of Family Planning Special Days in Francophone West Africa by Age Group and Method Type, July 2020-June 2021

TABLE 5 .
Annual Family Planning Client Volume During Family Planning Special Days in Francophone West Africa by Age Group and Method Category, July 2020-June 2021 Contraceptive Method Users Aged 15-19 Years, No. Users Aged 20-24 Years, No. Users Aged 25-49 Years, No.Total Users, No. (%)

TABLE 6 .
Daily Performance of Family Planning Special Days by City in Francophone West Africa, July 2020-June 2021 Abbreviations: FPSD, Family Planning Special Day; UCOZ, Union of Zou Municipalities.

TABLE 7 .
Distribution of Financial Contribution a to Family Planning Special Days in Francophone West Africa by City and Source, July 2020-June 2021

TABLE 8 .
Average Cost per Day of Family Planning Special Days by City, July 2020-June 2021