02 Sep Three Questions with Sara Stratton: Analyzing progress on task sharing and self-care on family planning in Burkina Faso
Sara Stratton has worked in international family planning and reproductive health for more than 25 years, translating innovations and best practices into policies and programs. At Palladium, a program partner in the HRH2030 consortium, she is a director in the Health Practice, where she contributes to both the HRH2030 and HP+ projects.
Sara and her colleague, Erin McGinn, are the authors of a new HRH2030 case study report, Burkina Faso: In-depth analysis of family planning task sharing and self-care policies, and alignment with WHO guidelines.
Question 1: This report is a follow-on case study to a phase 1 report published by HRH2030 last year, that looked at 10 countries progress in adopting family planning policies, guidelines, or other directives in line with the World Health Organization guidelines on task sharing and self-care. In this new report, you note in the beginning that the prior study showed that Burkina Faso had made some interesting advancements from the policy perspective on task sharing and self-care, and that was one reason for developing this new-depth case study. Can you explain what some of those prior advancements were?
Burkina Faso is a member of the Ouagadougou Partnership, where task sharing is a cornerstone of country commitments. Burkina Faso is also a member of the Economic Community of West African States (ECOWAS) which issued a resolution in 2017 in favor of task sharing. This momentum in the region has encouraged the Burkina Faso Ministry of Health to embrace task sharing, and now self-care, as a way to improve access to family planning information and services, particularly in rural areas.
The national policies, norms, and protocols (PNP) were updated in 2019 and were very much in line with WHO guidelines. They also issued a specific policy on task sharing in 2019 that addresses family planning along with other health services. The policy acknowledges the importance of task sharing and authorizes for additional cadres to offer family planning. For example, the policy authorizes auxiliary nurses and auxiliary nurse midwives to offer long-acting reversible contraceptives (LARCs), specifically implants and IUDs’ insertion and removal. WHO guidelines promote auxiliary nurse midwives to provide implants, but the latest guidance (2017) recommends IUD services only be delivered by this cadre in the context of research so that this intervention can be evaluated. In 2017-2018, Burkina Faso demonstrated that auxiliary nurses and auxiliary nurse midwives cadres can safely insert and remove IUDs and implants, provided there is strong supervision. Thus, Burkina Faso authorized task sharing with these cadres for both IUDs and implants and has continued to conduct regular supervision since 2018. Not many other countries allow this level of cadre to offer LARCs. In addition, Burkina has authorized community health workers (CHWs) to initiate and resupply pills, and offer DMPA-SC. While other countries do allow CHWs to offer pills, Burkina Faso is still one of the early adopters of CHW provision of DMPA-SC.
This case study was an opportunity to better understand any further advancements on these task sharing and self-care policy changes, particularly for community level cadres and pharmacists, and if there were any further recommendations that could be made to strengthen the policy environment.
Question 2: Tell us about what the new report shows in terms of how Burkina Faso is exceling in task sharing and self-care in family planning services, where it’s lagging, and the key opportunities to further advance progress.
Having identified Burkina Faso a potentially interesting case study, we were particularly interested in what other policies, such as health worker scopes of practice, pharmaceutical (or other) regulations, support or hamper the implementation of the PNPs and national task sharing policy as they relate to task sharing, over-the-counter access to contraceptives, and self-care. We also wanted to better understand which policies, regulations, etc. take precedent over others and if there were any further policy development or advocacy that is needed to create an even more favorable policy environment for increased family planning access.
We determined that overall, the family planning policy and regulatory environment in Burkina Faso is in line with WHO guidelines, as we described in the phase 1 report. What this additional analysis revealed is that Burkina Faso has progressed even further since 2019 with task sharing and self-care, yet there are still several opportunities to further improve alignment with WHO guidelines and harmonization across Burkina’s policy environment of laws, policies, strategies, plans, and curricula.
As mentioned above, Burkina Faso is excelling in advancing tasking sharing for LARCs and should be recognized regionally and globally for this. Also, with the self-care directives and guidelines published in late 2020, they are working to accelerate implementation of self-care (see below). The COVID-19 pandemic and the growing insecurity situation served as facilitating factors to allow self-care and task sharing since access has been such a challenge over the last two years.
Where Burkina Faso should further revise their policies is to remove unnecessary medical barriers for female sterilization and to allow CHWs to offer DMPA-IM. Better alignment in county is also needed to permit pharmacists to offer DMPA-SC injections and thus play their key role as front-line health workers for many women. The public health code has been revised to support authorization of pharmacists to provide DMPA-SC, but it awaits final acceptance and approval by the national assembly (expected December 2021). Finally, Burkina needs to update its 2005 reproductive health law to remove policy contradictions with MOH directives regarding emergency oral contraceptive pills, thus allowing health workers to deliver this method without fear of reprisals. The way the law is currently phrased is ambiguous and could lead health workers to interpret ECPs as being illegal. In a religiously conservative country, our key informant interviews pointed out that revision to the law would foster a more favorable environment for health workers and allow ECPs to be included in the national free contraceptives policy.
Question 3: What effect has COVID-19 had on task sharing and self-care in Burkina Faso?
While COVID-19 has stressed all health systems, including Burkina Faso’s, the country has taken the crisis as an opportunity to dramatically push forward implementation of its family planning task sharing and self-care vision. In December 2020, Burkina Faso issued new self-care operational guidelines and self-care directives, that point more service provision towards self-care, rather than task sharing. For example, the operational guidelines indicate that oral contraceptive pills can be dispensed in “sufficient quantity” according to the woman’s interest and need. Thus, if a client has experience with oral contraceptive pills and would like a 12-month supply (WHO’s recommendation on advance provision), the provider can provide them, if the facility has that quantity in stock.
The directives call for an accelerated scale up process for DMPA-SC self-injection and instruct providers to counsel women on use and disposal of DMPA-SC, as they have previously been authorized to do; these guidelines further emphasize the importance of this scale-up. Adolescents and youth also benefit, as these new directives eliminate the requirement for parental consent. COVID-19, along with ongoing insecurity in Burkina Faso, is listed as the rationale for these changes. There is also a reference to the benefit of telemedicine to assist with task sharing and self-care, a delivery channel not referenced in other policy environment documents previously.
According to the Ministry of Health’s Pharmaceutical Supply Coordination Directorate, the COVID-19 pandemic has had an impact on the supply of contraceptive products in Burkina Faso. Suppliers were unable to meet delivery deadlines and some manufacturers were unable to meet demand, with delays were due to freight disruption and new international priorities. At the facility level, the pandemic affected the use of family planning services in the first few months of the pandemic, March and April 2020, when health workers and clients had little information about the pandemic and hesitated to offer or use services. After May 2020, according to MOH routine family planning service data, clients availed themselves of family planning health services at similar pre-pandemic levels, so there seems to be limited longer-term effects on service delivery levels/statistics.
Photo: Sara Stratton is a director in Palladium’s Health Practice, where she contributes to the HRH2030 program and HP+ projects.