Implementing Best Practices: Improving 
Service Delivery in Nakuru, Nyeri and 
Homabay 
ENDLINE REPORT 
NOVEMBER, 2006 
MINISTRY OF HEALTH/ JHPIEGO/ ACCESS
Page 2 of 37 
Table of Contents 
1.0 BACKGROUND .................................................................................................................3 
1.1 PROJECT OBJECTIVES ....................................................................................................4 
2.0 DATA COLLECTION PROCESS......................................................................................5 
2.2 KEY DEMOGRAPHINC RESULTS..................................................................................7 
2.3 MAIN DEMONGRAPHIC FINDINGS ON SERVICE PROVIDERS ..............................9 
3.0 KEY INTERVENTIONS AND RESULTS.......................................................................11 
3.1 TRAINING ON FAMILY PLANNING COUNSELLING ..............................................11 
3.1.1 Service Provider practice after training ..............................................................14 
3.1.2 Contraceptive Dispensed in three Districts after training...................................16 
3.1.3 Contraceptive use among clients after service provider training........................19 
3.1.4 Contraceptive Methods used by clients ..............................................................20 
3.1.5 Client perceptions on provider practice on contraceptives.................................22 
3.1.6 Contraceptive stock-outs.....................................................................................24 
3.1.7 Knowledge and skills needed in family planning...............................................24 
3.2 INFECTION PREVENTION ............................................................................................26 
3.2.1 Medical Waste Disposal .....................................................................................27 
3.3 TRAINING ON SUPERVISION ......................................................................................30 
4.0 CONCLUSION, CHALLENGES AND WAY FORWARD ............................................33 
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1.0 BACKGROUND 
Implementing Best Practices, (IBP) is an initiative, which began in 1999 to enhance the 
ability of countries to identify and apply evidence-based and other demonstrated practices 
that improve the quality and delivery of reproductive health services. The World Health 
Organization (WHO) started the initiative in collaboration with other partner 
organizations and agencies including the US Agency for International Development 
(USAID), United Nations Population Fund (UNFPA), International Planned Parenthood 
Federation (IPPF) and 14 other global organizations. 
The key to implementing the best practices initiative is to identify and facilitate synergies 
that can improve value for money spent in the effort to improve reproductive health 
services. Focus is placed on helping governments enhance programmes and maximize 
available resources through participation in a network operating at the country, regional 
and global levels; promoting harmonized approaches and sharing experiences, tools and 
lessons learned. The IBP initiative aims at meeting an important need through applying 
evidence-based standards, norms, guidelines and proven practices in collaboration with 
policy makers, programme managers and providers. In 2004, multiple countries came 
together in Uganda to discuss evidence based reproductive health best practices that 
could work well in their respective countries to reduce maternal mortality within 18 
months. Kenya participated in this important meeting and pledged to reduce maternal 
mortality through improvements in family planning (FP) service delivery and availability. 
The 2003 Kenya Demographic and Health Survey (KDHS) shows that maternal mortality 
remains high, estimated at 414 per 100,000 live births. Similarly, the data shows that 
fertility levels remain high in rural areas (5.4 children per woman) and unplanned 
pregnancies are common with 20% of the births being characterized as unplanned. 
Contraceptive use is estimated at 41% among married women and about a quarter of 
currently married women have an unmet family planning need. In addition, 38% of the 
women discontinue use within a twelve month period after adopting a contraceptive 
method. Against this backdrop, during the IBP meeting in June 2004, Kenya identified 
Page 4 of 37 
various activities among them being the training of service providers to improve services 
in general and family planning in particular. 
As part of the IBP partnership in Kenya, JHPIEGO/ ACCESS trained service providers in 
three districts namely: Nakuru, Nyeri and HomaBay. JHPIEGO, in collaboration with 
the Ministry of Health (MOH)/ Division of Reproductive Health (DRH), undertook a 
needs assessment in the three priority districts to establish the current levels of 
knowledge and practices among providers, supervisors and clients in relation to family 
planning and availability of contraceptives in selected facilities. Generally, the findings 
indicated that most facilities offer oral contraceptive pills (OCPs), condoms and 
injectables. Referrals for both Vasectomy and Tubal Ligation were common; 89% and 
17% respectively. Over 70% of the clients interviewed indicated a preference to 
injectables. As much as they were aware of other methods including the IUCD (88%), 
77% said they would not consider using it. 
Following this assessment, the DRH and JHPIEGO/ ACCESS implemented interventions 
that sought to improve providers’ and supervisors’ knowledge and skills in order to 
increase uptake of contraceptive methods (method mix) and strengthen service provision. 
This report outlines the findings since the baseline assessment and the technical 
intervention, in relation to the following programme objectives. 
1.1 PROJECT OBJECTIVES 
ƒ Increase FP uptake by 5% in selected facilities through the training of service 
providers; 
ƒ Improve service providers' skills through training in infection prevention, 
contraceptive technology updates, and family planning counseling courses; 
ƒ Strengthen service provision through training of supervisors and administrators on 
supervision. 
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2.0 DATA COLLECTION PROCESS AND KEY 
DEMOGRAPHIC FINDINGS 
2.1 Data collection process 
In collaboration with the Division of Reproductive Health (DRH), JHPIEGO/ACCESS 
updated the assessment tools to capture key information that was not captured during the 
baseline. The client contraceptive tool captured information from Jan-April 2005 and 
Jan-April 2006. The data was collected mid May 2006. Four tools were developed: 
1. Facility Assessment tool 
2. Service provider interview 
3. Client Exit interview 
4. Client contraceptive use 
The target facilities were the same as those used in the baseline. The selection process, 
which was carried out during the initial advocacy meetings, was done together with the 
district health management teams (DHMTs) and key stakeholders within the district. Ten 
(10) facilities from each district were agreed upon. They included hospitals, health 
centers and dispensaries from both the public and private sector. In each of the districts, 
the number of facilities and individuals interviewed is shown in table 1 below. 
Table 1: Interviews a numbers interviewed in study 
Tool HomaBay Nakuru Nyeri Total No.
Facility Assessment tool 12 11 10 33
Service provider interview 13 20 20 53
Client Exit interview 49 51 81 181
Client contraceptive use- 9 10 10 29
Total 
A total of 33 health facilities were reached and 53 service providers interviewed. 181 
client exit interviews were conducted. Below is a discussion on the key demographic 
findings as they relate to facilities and service providers. Figure 1 shows the three 
districts in which this activity was implemented, and those included in the Co Rapid 
Results Initiative. 
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Figure 1: Districts implementing IBP and those in the Rapid Results Initiative 
Page 7 of 37 
2.2 Key demographic results 
2.2.1 Facility information 
Thirty-three health facilities were included in the sample. Of these, 13 were health 
centers, 11 hospitals and nine dispensaries. Figure 2 shows the type of health facility 
visited in each district. Most (27%) of the facilities visited were operated by the 
Government, one health center was operated through a non-government organization and 
three facilities (one hospital, one health center and one dispensary) were operated through 
the private sector. 
2.2.1.1 Services offered in facility 
Figure 2 Type of Health Facilities per District 
44
3
6
2
5
1
44
0
2
4
6
8
Nakuru Nyeri HomaBay
Target Districts
Frequency
Hospital
Health Center/Clinic
Dispensary
Figure 3 shows the types of services offered in the facilities visited. All the facilities are 
offering family planning, antenatal and postnatal care services. Obstetrics and 
Gynaecology services and post-abortion care services are offered, although to a much 
lesser extent. The larger health facilities tended to offer all the contraceptive services due 
to the developed infrastructure and trained medical doctors. 
Page 8 of 37 
Figure 3 Services offered at sampled facilities 
444
10 10
12
11
9
12
11
10
12
8
6
5
0
2
4
6
8
10
12
14
Nakuru(n=11) Nyeri(n=10) HomaBay(n=12)
Target Districts
Obstetrics/Gynaecology
Sexually Transmitted Infections
Family Planning
Antenatal/Postnatal Care
Post-abortion care
In Nyeri and Homabay districts, family planning services are said to be offered everyday 
in most health facilities. Nine facilities in Nakuru District offer family planning services 
on demand, while two facilities offer FP services on limited days/hours per week. Pills, 
condoms and injectables are the most common form of FP methods provided by all the 
facilities in Nakuru, Nyeri and Homabay. Vasectomy and natural family planning 
counselling are provided the least. Almost all the facilities in Nakuru (90%) were 
providing IUCD during this study. All facilities in Nyeri provided IUCD, while only 66% 
of the facilities in Homabay were providing IUCD. Additionally, the majority of health 
centres and hospitals have a trained clinician on staff trained to handle medical 
emergencies. However, none of the dispensaries had emergency transport mechanisms in 
place. An aspect, that needs to be addressed. 
All facilities offered pills and condoms and nearly all offered injectables. The IUCD is 
more widely available in hospitals and health centers (see table 2 below). Very few 
facilities are offering Tubal Ligation, vasectomy, Jadelle and Norplant, although these are 
more prevalent in hospitals and health centers. This could be indicative of lack of 
provider skills at all levels to offer methods such as Tubal Ligation, vasectomy, Jadelle 
and Norplant. A Chi-Square test for relationship between availability of different types of 
Page 9 of 37 
contraceptives and facility level showed that there is no significant relationship between 
contraceptive type and facility level (Chi-square=8.64, p-value=0.8536). 
Table 2 Availability of FP Methods by Type of Facility 
Type Of Facility 
Hospital(n=11) Health 
Center/Clinic(n=13)
Dispensary(n=9) Total(n=33) 
Pills 11(100.0%) 13 (100.0% 9 (100.0%) 33 (100.0%)
Condoms 11 (100.0%) 13 (100.0%) 9 (100.0%) 33 (100.0%)
Tubal Ligation 7 (63.6%) 5 (38.5%) 2 (22.2%) 14 (42.4%)
Vasectomy 2 (18.2%) 3 (23.1%) 5 (15.2%)
IUCD 10 (90.9%) 12 (92.3%) 6 (66.7%) 28 (84.8%)
Norplant/Implants 4 (36.4%) 4 (30.8%) 8 (24.2%)
Injectables 11 (100.0%) 12 (92.3%) 9 (100.0%) 32 (97.0%)
Jadelle 9 (81.8%) 9 (69.2%) 2 (22.2%) 20 (60.6%)
Natural FP 1 (9.1%) 1 (11.1%) 2 (6.1%)
2.3 Main demographic findings on service providers 
Fifty-three service providers were interviewed from Nyeri, Nakuru, and HomaBay. 
58.5% of the providers interviewed were female. Age of respondents varied, although a 
substantial number of providers were over 50 years of age. The majority of providers are 
registered nurses and midwives. A large proportion of providers have had a basic family 
planning certificate course. The number of years in service varied, although clearly 
providers from HomaBay have been working the longest (over 30 years). Table 3 below 
shows demographic information on service providers interviewed. 
In Nyeri, 35% of service providers had been in service for between 10-19 years compared 
to 30% in Nakuru and 41% in Homabay. The Majority of the providers were registered 
nurses or midwives (53% in Nyeri; 47% in Nakuru and 63% Homabay). Many are over 
50 years old. 
Page 10 of 37 
Table 3 Demographic information on service providers 
Nyeri (n= 20) 
% 
Nakuru (n=20) 
% 
Homa bay (n= 13) 
% 
Gender 
Male 6
Female 3
65.0 
35.0 
20.0 
80.0 
38.5 
61.5 
Age 
24yrs to 29yrs 
 30yrs to 34yrs 
 35yrs to 39yrs 
 40yrs to 44yrs 
 45yrs to 49yrs 
 50yrs and above 3
15 
10 
15 
15 
15 
30 
5.3 
21.1 
10.5 
26.3 
36.8 
8.3 
25 
33.3 
33.3 
Qualification 
KRCHN 2
 CO 
 ECN 2
 RN/M 
21.1 
5.3 
21.1 
52.6 
5.9 
35.3 
11.8 
47.1 
25 
12.5 
62.5 
Have basic FP 80 85 76.9 
Number of years in service 
Less than 9 years 
10-19 years 
20-29 years 
30-39 years 
25 
35 
25 
15 
15 
30 
55 
41.7 
50 
8.3 
Page 11 of 37 
3.0 KEY INTERVENTIONS AND RESULTS 
3.1 Training on Family Planning Counselling, Contraceptive 
Technology Update (CTU) 
 
Implementing Best Practices began in May 2005 in Kenya. The Ministry of Health – 
Division of Reproductive Health (MOH-DRH) spear-headed a team effort that included 
the IBP task force and training team. The training team developed a manual that consists 
of 4 major update topics- contraceptive technology updates (CTU), Infection Prevention 
(IP) Counselling and Facilitative supervision. JHPIEGO in collaboration with the MOH 
implemented this activity in Nyeri, Nakuru and Homabay. 
In each of the districts JHPIEGO and the MOH conducted district planning meetings. 
Approximately 60 participants, drawn from the DHMT, DRHT&S teams, private 
institutions and NGOs, attended the advocacy and planning meetings in the 3 districts. A 
number of issues were deliberated on:- 
ƒ Inclusion of IBP in the district work-plan. 
ƒ Number of facilities to be selected for trainings and baseline. 
ƒ Selection criteria of service providers to attend trainings. 
The three districts had not been supported with training over the last few years. Most 
service providers had last been trained in Family Planning ( FP) more than 20 years ago 
with the last update on FP having been conducted 10 years ago. 
In each of the three districts service providers were trained on contraceptive technology 
updates (CTU). The materials used were: 
• The Essentials of Contraceptive Technology 
• Implementing Best Practices Manual 
Page 12 of 37 
• New Family Planning Guidelines 
• Family Planning Wall Chart 
• WHO Eligibility criteria 
The updates included dissemination of the new FP guidelines, discussions on the WHO 
eligibility criteria. The focus of the updates was the application of the new FP guidelines 
and extensive discussions on the WHO eligibility criteria as applied to contraceptive use. 
Emphasis was laid on the latest technologies on all the contraceptive methods including 
integration of FP into HIV/AIDS. Additionally, providers’ FP skills were reviewed and 
updated through classroom demonstrations and coaching. These were:- 
• FP counseling skills. 
• IUCD insertion and removal skills. 
• Implant insertion and removal skills. 
• Management of FP methods side effects. 
• Dispelling rumors and misconceptions of FP methods (problem solving 
approach). 
Discussions in plenary led to agreement about best practices and to dispel rumours and 
misconceptions on each method. These sessions were concluded with problem solving 
activities for each site. On the whole, knowledge gained by providers was good. 
However, this varied according to the time frame each provider had had an update 
previously ( that is if the last update had been 3 yrs ago or 20 yrs ago). Contrary to the 
statistics from the baseline that service providers felt they were deployed to areas that 
they could best practice their skills, assessments during the training indicated otherwise. 
Skills on methods like IUCD were weak and it became clear that most providers tended 
to use methods that were quicker and easier to dispense such pills and Depo Provera. 
Hence, service providers were trained on these methods through skills demonstration. 
Figure 4 shows service providers practicing IUCD insertion on a humanistic model 
during the training. 
The training program covered two courses in Nakuru (52 participants), 2 courses in Nyeri 
(50 participants) and 2 courses in Homabay (51 participants). In total, 153 service 
providers were trained in the three districts. Providers were expected to update a 
Page 13 of 37 
minimum of 5 others on the job. Each provider was given materials to assist them to 
sensitize other providers’. They were also given a reporting format to document on their 
progress. Work-plans were developed indicating the areas they identified as needing extra 
attention within their facilities in order to implement IBP. By the end of the activity, it 
was projected that a minimum of 755 providers will have been updated through the 
cascade approach. 
Figure 4 Demonstration during the training on IUCD insertion 
Evidence based on the training suggests that service providers were appreciative of the 
skills learned. The providers were trained on the use of methods such as Jadelle and the 
female condom. They were also given correct information on the IUCD. The WHO 
eligibility criteria were introduced with a view to reducing medical barriers in providing 
some methods such as Depo Provera, IUCD and the pill. The baseline study in the three 
districts had shown that service providers had beliefs related to provision of 
contraceptives to women with diabetes, hypertension, breastfeeding women and women 
with HIV/AIDS thus limiting access to contraceptives among this group of women. The 
usefulness of the training was expressed by one provider after information on the WHO 
eligibility criteria. The service provider commented: 
 “This training has been very useful. I feel that even the 
youth will benefit from the training we have received – in 
Page 14 of 37 
 terms of being able to access contraceptives.” He added: “This 
has been most useful to those of us who are clinical officers”. 
Yet another service provider noted during support supervision: 
 “I now have an appreciation of the importance of counselling. This has 
been very useful in my work. Since I have up to date information on FP, I 
am now confident in discussing with my clients and I am able to 
adequately address their concerns” 
3.1.1 Service provider practice after training 
Training is essential in improving service provider skills and practice in family planning. 
In this follow up survey, all the service providers who had been trained and were 
interviewed indicated that they were using the skills learnt. Table 4 shows that the 
majority of providers have been able to apply new knowledge and skills acquired in 
trainings from the previous year. Most of the skills used were in infection prevention, 
basic family planning skills, and IUCD insertion/removal especially in Nyeri and Nakuru. 
Table 4 Service provider use of knowledge and skills gained in training 
Nyeri 
 (n=7) 
Nakuru 
(n=8) 
HomaBay 
(n=10) 
Total 
(n=25) 
Infection prevention 5 (71.4%) 8 (100.0%) 9 (90.0%) 22 (88.0%)
Basic family 
planning skills 7 (100.0%) 8 (100.0%) 6 (60.0%) 21(84.0%)
IUCD 
insertion/removal 7 (100.0%) 8 (100.0%) 3 (30.0%) 18 (72.0%)
STI/HIV prevention 
counselling 5 (71.4%) 5 (62.5%) 6 (60.0%) 16 (64.0%)
STI/HIV diagnosis 
and treatment 3 (42.9%) 5 (62.5%) 6 (60.0%) 14 (56.0%)
Jadelle 
insertion/removal 3 (42.9%) 6 (75.0%) 3 (30.0%) 12 (48.0%)
How to involve men 
in RH 4 (57.1%) 2 (25.0%) 4 (40.0%) 10 (40.0%)
Norplant 
insertion/removal 1 (14.3%) 3 (37.5%) 2 (20.0%) 6 (24.0%)
Quality improvement 
(COPE) 3 (42.9%) 2 (25.0%) 1 (10.0%) 6 (24.0%)
Mini lap under local 
anesthesia 0 (0.0%) 3 (37.5%) 0 (0.0%) 3 (12.0%)
Vasectomy 0 (0.0%) 2 (25.0%) 0 (0.0%) 2 (8.0%)
Page 15 of 37 
Asked how the training received had been useful in their work, the providers explained 
that they were now able to: 
• Offer their clients contraceptive options without relying on methods that are easy 
to dispense (hence contraceptive mix) 
• Give methods confidently and adequately respond to client concerns 
• Use of FP Guidelines as a reference thus improving on their work 
• Practice appropriate infection prevention measures. Service providers noted that 
there was a greater appreciation for the need to reduce infections especially for 
both clients and providers. 
As figure 5 below shows, the practice of service providers’ improved in Nyeri after 
the training with service providers offering more contraceptive choice to their clients. 
This was also the case in Nakuru and Homa Bay. Earlier findings had indicated that 
service providers tend to offer contraceptive methods which are easier to dispense 
such as pills or injectables. 
Figure 5 – Contraceptive practice before and after training in Nyeri
Percentage of Facilities offering FP Methods in Nyeri District
27%
9%
36%
82%
91%
100% 100% 100%
70%
50%
60%
100% 100%
10%
100% 100%
0
0.2
0.4
0.6
0.8
1
1.2
Jadelle
Norplant/Implant
Tubal ligation
IUCD
Injectables
Pills
Condoms
Vasectomy
FP Methods Provided
Percentage(%)
Baseline(n=11)
Endline(n=10)
Page 16 of 37 
In Nyeri after the training and with the availability ofJadelle, its use increased by about 
43%, while the use of Norplant increased by 41% and Tubal Ligation 24%. In regards to 
Tubal Ligation, it was explained that after the training, some service providers used a 
public forum to create awareness on the importance of this and other long term methods. 
This was followed by provision of Tubal Ligation services through a mobile clinic by 
Marie Stopes. Because of this awareness, women turned up for the service suggesting 
that there may be an unmet need among women for this, and other long term 
contraceptive methods. 
In general, after the training there was an increase in the use of long term methods in all 
the districts (Table 5). For example, the use of IUCD increased by 17% whiles the use of 
Norplant increased by 45% and Jadelle by 23%. Knowledge and skills are important in 
service provider practice. As noted by KSPA 2004 there are methods that can be 
provided with minimal training (pills, injections, and condoms, as well as counseling on 
periodic abstinence) and those that require higher level of skill and a more developed 
infrastructure such as IUCD and implants. 
Table 5 – Contraceptives offered before and after training (all districts) 
 Baseline(n=31) Endline(n=33) %Change 
Pills 100.0% 100.0% 0.0%
Condoms 100.0% 100.0% 0.0%
Tubal ligation 38.7% 42.4% 3.7%
IUCD 67.7% 84.8% 17.1%
Norplant/Implant 12.9% 57.6% 44.7%
Injectables 96.8% 75.8% -21.0%
Jadelle 25.8% 48.5% 22.7%
3.1.2 Contraceptives Dispensed in the three districts before and after training 
Prior to the IBP intervention and the targeted trainings, the number of contraceptives 
dispensed was estimated at 138,367. This increased substantially one year later to a 29% 
increase. The FP uptake reveals that the most popular contraceptive methods in the three 
Page 17 of 37 
districts are male condoms, Depo Provera and OCPs. The methods less practiced were 
vasectomy and Tubal Ligation. Use of Depo Provera showed an increase while use of 
female condoms and vasectomy were declining. Review of the change in contraceptive 
uptake by district and under four categories barrier, short term, long term and permanent 
revealed inter and intra district differences (table 6). 
Table 6 Total Percentage change in contraceptive use 
 Contraceptives Year 
2005 
Year 
2006 
Total Change %Change 
IUCD 520 525 1,045 5 0.96
Jadelle 303 621 924 318 104.95
Long term 
Norplant 0 19 19 19 100.00
Permanent Vasectomy 86 0 86 -86 -100.00
Tubal Ligation 75 117 192 42 56.00
Barrier Male condoms 109,365 147,237 256,602 37,872 34.63
Female 
condoms 
2,943 1,839 4,782 -1,104 -37.51
Short term Depo Provera 16,020 19,419 35,439 3,399 21.22
Oral pills 9,055 8,819 17,874 -236 -2.61
Data shows that in Homa Bay - uptake increased greatly for male condoms and 
moderately for other methods while in Nakuru, there is a mixed picture across all 
categories showing the increase in Depo Provera uptake is highest compared to other 
districts. Nyeri has the highest uptake for long term contraceptives replacing short term 
or barrier methods. There exists a significant association between the contraceptive type 
and dispensation by district (Chi-square=160.96, p-value=0.000<0.05 at 5% significance 
level) implying that some districts dispense certain types of contraceptives more than the 
others. It is important to establish the inter and intra district variations so that they can 
inform future trainings and the implementation of IBP. 
One of the objectives in the implementation of IBP by JHPIEGO and MOH was to 
improve FP uptake by 5% in the three districts. After the training, JHPIEGO 
collaborated and supported the Ministry of Health in three of the six districts in a 
Ministry initiative dubbed the Rapid Results Initiative (RRI) to track the increase in 
Family planning (Figure 6). As the figure shows, the use of family planning increased by 
Page 18 of 37 
22% in Homa Bay, 21% in Nakuru and 3% in Nyeri respectively. There is need to 
further review the low increase in Nyeri. 
Figure 6 Increase use of contraceptive in Nyeri, Nakuru and Homabay 
0
5
10
15
20
25
30
35
40
45
KWALE NYERI KILIFI MERU
SOUTH 
NAKURU HOMA BAY 
District
Percentage Increase
Base line 
Mid-term
End-term
Support supervision revealed that service providers had not only gained knowledge on 
family planning, but the training had motivated them to be innovative in their work. 
During support supervision, one service provider narrated how the training and access to 
information had positively impacted on his facility. He explained: 
 “ There used to be many cases of STIs in this facility. After 
 the training, I took the initiative to share the materials in 
 schools, other institutions and forums around this 
area and create awareness. Since then, the number of STIs has 
decreased in the facility and there is an increased demand 
for condoms. In the past, we always run out of drugs for 
treating STIs – this is not the case anymore!” 
In yet another facility, the team undertaking support supervision found that the service 
provider who had been trained was not on duty. This provider had however oriented the 
other staff after the training. Indeed, the staff were very knowledgeable on FP and the 
facility had innovatively designated a specific room for FP which had not been the case 
before the training. 
Page 19 of 37 
3.1.3 Contraceptive use among clients after service provider training 
Client use of contraceptives is in part influenced by service provider practice. Clients 
who are satisfied with the services offered are more likely to make return visits and also 
to discuss the services offered with friends and other members of their social networks. 
Data in this follow up survey shows that the numbers of new clients increased by about 
25% between 2005 and 2006 (Figure 7). Nakuru district had the highest number of new 
clients followed by Nyeri and Homabay districts. Although the numbers are still 
generally small, data analysis shows that there exists a significant association in the 
number of new clients by district in both the year 2005 and 2006 (Chi-square=48.48, p￾value=0.000). Nakuru District had more new clients than any other district. Although the 
increase may not be solely attributed to the training of providers there is no doubt that 
this contributed to the increase. 
Figure 7 Percentage change in clients in target districts 
New FP clients for 2005 and 2006
3688
1959
4613
1291 1352
1045
1525
1129
0
500
1000
1500
2000
2500
3000
3500
4000
4500
5000
Homabay(8.0%) Nakuru (51.7%) Nyeri (12.8%) Grand Total (25.1%)
Target Districts
No. of new clients
New 2005
New 2006
The number of revisits among clients also increased between 2005 and 2006. Homabay 
had the highest number of revisits (23%) followed by Nyeri (10%) and then Nakuru 
(2.3%). 
Page 20 of 37 
3.1.4 Contraceptive methods used by clients 
There has been an effort toward encouraging women to use long term family planning 
methods. During this study, it was found that the use of IUCD had increased by only 
about 1.0% between 2005 and 2006 overall. In Nyeri District, it rose by about 11% while 
in Nakuru District it decreased by 7.6% and in Homa bay use of IUCD decreased by 13% 
(Figure 8). The slow increase in the up take of IUCD may be attributed in part to 
community beliefs and misconceptions. For example, it is believed in many communities 
that the IUDC may ‘disappear in the uterus” and that the string can be felt during intimate 
relations with a spouse. The fear of infection especially in facilities where clients may not 
be comfortable with IP procedures could also be a contributing factor. In addition, lack of 
skills among service providers and poor infrastructure in lower level facilities may 
influence the failure to use the IUCD. There is need for awareness creation to dispel 
myths, improve on infection prevention practices, additional training of service providers 
and provision of essential equipment that is supportive of the use of the IUCD. 
Figure 8 Comparison on Use of IUCD in Nyeri, Nakuru and Homabay 
Comparison on Use of IUCD
30
237 253
520
26
219
280
525
0
100
200
300
400
500
600
Target District
No of IUCD used
Year 2005
Year 2006
Year 2005 30 237 253 520
Year 2006 26 219 280 525
Homabay(-13.3%) Nakuru(-7.6%) Nyeri (10.7%) Grand Total (1.0%)
The use of Jadelle rose significantly by 105.0% over all. In Nakuru District alone it rose 
by 144.1% from the baseline. Fewer Jadelle were dispensed in Homabay District where 
the figure dropped by 17%. A chi-square test for association between the number of 
Page 21 of 37 
Jadelle dispensed by district revealed a significance relationship (Chi-square=29.36, p￾value=0.000). The increase in the use of Jadelle may be attributed to the training of 
service providers on its insertion and removal and also to its availability. Tubal ligation 
practice among clients was highest in 2006 with a 56.0% increase. In Nyeri District 
alone, the figure rose by 146.7%. In Nakuru District, the figure rose by 44% and declined 
by 37% in Homa bay (Figure 9). As noted earlier, the increase in Nyeri was a direct 
result of service providers using public fora to create awareness and the availability of the 
service. 
Figure 9 Use of Jadelle in the three districts 2005 and 2006 
Comparison on Use of Jadelle
64
145
94
303
53
354
214
621
0
100
200
300
400
500
600
700
Homabay(-17.2%) Nakuru(144.1%) Nyeri (127.7%) Grand Total (105.0%)
Target Districts
No of Jadelle Used
Year 2005
Year 2006
Use of Depo Provera increased significantly between 2005 and 2006 (25.2%). The 
highest increase was in Nakuru (38%), Nyeri (19%) and Homa bay (9%). Use of oral 
contraceptives decreased in Nakuru (22%) but increased in Nyeri (18%) and Homa Bay 
(5%). The decrease may in part be due to the increased reliance on other contraceptives 
especially long term methods as indicated above. 
The total number of male condoms dispensed between 2005 and 2006 increased 34.6%. 
The majority of condoms were distributed in Nakuru with Homabay having the highest 
increase (79.8%) of condoms dispensed. Nakuru District had the highest uptake of male 
Page 22 of 37 
condoms. Dispensing of the female condoms decreased 37.5% between 2005 and 2006. 
This may partly be explained by the unavailability of the female condoms and issues 
related to its use by women. 
3.1.5 Client perceptions on provider practice on contraceptives 
The way a service provider interacts and communicates with a client is one of the 
determining factors on whether or not a client will return to the facility for continued 
services. To ascertain the service providers’ practice, the clients were asked a set of 
questions including whether or not the service provider explained how to use the method. 
Table 7 shows clients’ views on interactions with service providers. According to the 
clients many of the providers discussed the key issues to their satisfaction. Of note is the 
fact that few service providers are discussing negotiation for safe sex or whether the 
contraceptive methods provide protection against HIV/AIDS. This may be attributed to 
understaffing a factor that may not allow service providers adequate time with their 
clients, or cultural barriers in discussing these issues. 
Table 7 Information shared with clients by Service providers 
Nakuru
(n=51) 
% 
Nyeri 
(n=81) 
% 
Homabay 
(n=49) % 
Total 
(n=181) 
% 
Provider explained how to use the method 92.0 78.2 70.8 80.1
Provider said what to do if there is any 
problems using the method 88.0 74.4 84.8 81.0
Provider said when to return for a follow-up 
visit 92.0 94.9 89.6 92.6
Provider discussed how to negotiate with a 
partner about the method 60.0 41.0 39.6 46.0
Provider talked about whether the method 
gives any protection against STIs/HIV/AIDS 42.0 39.2 55.3 44.3
The majority of clients from each district said that they were satisfied with overall 
services offered by the providers. Clients reported overall satisfaction with, consultation 
time, method received, privacy and information received (Table 8). Additionally, the 
majority of clients reported that the waiting time was reasonable, although most clients 
wait at least one hour before they are seen by a provider. However, some clients did 
Page 23 of 37 
report that some issues were not clear to them. In Nakuru (28%), Nyeri (20%) and Homa 
Bay (32%) clients said that some issues were still unclear to them. Suggesting the need 
for further training and an emphasis on client counseling. 
Table 8 Clients overall evaluation of services received 
District Total 
Nakuru(n=51) Nyeri(n=81)
Homabay(n=4
9) (n=181) 
Felt that the consultation 
with the provider was 
long enough to ask all 
questions. 
Yes 
42 (82.4%) 68 (84.0%) 39 (79.6%) 149 
(82.3%)
Satisfied with the 
method received. 
Yes 45 (88.2%) 75 (92.6%) 45 (91.8%) 165 
(91.2%)
Had enough privacy 
during consultation so 
that others could not 
HEAR. 
Yes 
44 (86.3%) 77 (95.1%) 37 (75.5%) 158 
(87.3%)
Had enough privacy 
during your consultation 
so that others could not 
SEE. 
Yes 
46 (90.2%) 78 (96.3%) 35 (71.4%) 159 
(87.8%)
Feel that the information 
shared with the provider 
will be kept private and 
confidential. 
Yes 
48 (94.1%) 79 (97.5%) 41 (83.7%) 168 
(92.8%)
Very 
Well 38 (74.5%) 52 (64.2%) 26 (53.1%) 116 
(64.1%)
How were you treated by 
the provider during your 
visit to the clinic today 
 Well 13 (25.5%) 26 (32.1%) 21(42.9%) 60 
(33.1%)
Was there anything 
unclear 
to you during your 
conversation with the 
provider 
Yes 14 (27.5%) 16 (19.8%) 16 (32.7%) 46 
(25%) 
Page 24 of 37 
3.1.6 Contraceptive Stock-outs 
Adequate and regular supplies of contraceptives are important in order to meet clients’ 
needs. Stock outs of injectables were the most commonly reported. This could be due to 
the fact that it was also the most popular method. While most facilities (54%) did not 
experience stock outs in the last six months, 30% of the facilities reported that they did. 
Table 9 shows the number of facilities reporting stock –outs. 
Table 9 Facilities reporting having had contraceptive Stock-outs 
No of Facilities Reporting Stockouts 
Nakuru (n=11) 27% 
Nyeri (n=10) 40% 
Homabay (n=12) 25% 
It is essential to ensure continued availability of contraceptives in all facilities. It is 
important to note that the Ministry of Health has over the recent past worked towards 
ensuring that this issue is addressed. 
3.1.7 Knowledge and Skills still needed in family Planning 
As noted earlier, only a small proportion of service providers were trained in each of the 
three districts. Hence, a large proportion of providers are yet to be trained. When service 
providers were asked what knowledge and skills they needed, those identified included 
Jadelle and Norplant insertion/ removal (table 10). Nearly half of providers in Nakuru 
indicated the need for basic family planning. This may be attributed to the fact that only 
25 service providers were trained in the district. There is need to ensure that training on 
FP is scaled up in these districts especially to cover service providers who may not have 
been reached through the process of cascade. Similarly, such training is necessary in 
order to ensure that thorough training on long term methods takes place. 
Page 25 of 37 
Table 10 Knowledge and skills still needed in family planning 
Nyeri(n=20) Nakuru(n=20) HomaBay(n=13) 
% % % 
Jadelle insertion/removal 55.0 47.1 75.0
Norplant insertion/removal 45.0 17.6 66.7
Quality improvement (COPE) 50.0 88.2 33.3
IUCD insertion/removal 15.0 17.6 33.3
Basic family planning skills 35.0 47.1 16.7
Mini lap under local anesthesia 65.0 35.3 16.7
How to involve men in RH 45.0 76.5 8.3
Vasectomy 55.0 29.4 8.3
Infection prevention 5.0 17.6 8.3
STI/HIV prevention counselling 30.0 29.4
STI/HIV diagnosis and treatment 30.0 29.4
Page 26 of 37 
3. 2 Infection Prevention 
The second objective of this project was to improve service provider practice through 
training on infection prevention (IP). 126 service providers were trained in infection 
prevention. The training emphasized the purpose of Infection Prevention (IP) which is to 
prevent disease transmission in the clinical and hospital setting, to minimize the risk of 
infection to clients and healthcare workers, including support staff and the community. 
Nosocomial infections are a significant problem throughout the world and are increasing, 
with rates ranging from 1% in some countries in Europe to more than 40% in parts of 
Asia, Latin America and sub-Saharan Africa.
During the training, the purpose of IP in healthcare facilities was emphasized. IP in 
clinical settings is meant to: 
• Minimize infection due to microorganisms causing serious infections; and 
to prevent the transmission of serious life threatening diseases such as 
hepatitis B and HIV/AIDS 
• Prevent the spread of infection by disrupting the disease transmission 
cycle 
The training discussed standard precautions being a set of clinical practice 
recommendations designed to help minimize the risk of exposure to infectious materials, 
such as blood and other body fluids, by both clients and staff. Standard precautions help 
break the disease-transmission cycle at the mode of transmission step. This can be 
achieved through decontamination, cleaning, sterilization and disinfection. It has been 
observed that in many health facilities, the disposal of waste is not always in line with 
recommended international standards. It is not uncommon in many facilities to see poor 
waste disposal as depicted in figure 10 below. 
Page 27 of 37 
Figure 10 Poor waste disposal in some health facilities 
3.2.1 Medical Waste Disposal, Sterilization and Disinfection of Instruments as 
practiced in facilities
During this follow up study, it was found that all the health facilities had in place various 
infection prevention measures. Out of the 33 facilities visited, 16 facilities said they 
dispose of medical wastes, such as syringes and bandages, by burning them in an open 
pit. The majority of facilities use chemicals to disinfect their instruments. (See table 11 
below). 
Page 28 of 37 
Table 11 Medical waste disposal, sterilization and disinfection of instruments 
Nakuru (n=11) Nyeri (n=10) HomaBay(n=12) Total (n=33) 
Medical Waste Disposal 
Burn in an open 
pit 6(54.5%) 2(20.0%) 8(66.7%) 48.5%
Burn in the 
incinerator 5(45.5%) 6(60.0%) 2(16.7%) 39.4%
Burried 3(27.3%) 1(10.0%) 2(16.7%) 18.2%
Put in pit latrine 1(9.1%) 1(10.0%) 3(25.0%) 15.2%
Others 2(18.2%) 2(16.7%) 12.1%
Sterilization of Instruments 
Steam 
sterilization 
/autoclave 7(63.6%) 7(70.0%) 5(50.0%) 20(60.6%)
Chemical 2(18.2%) 6(60.0%) 8(66.7%) 16(48.5%)
Boiling 4(36.4%) 5(50.0%) 3(25.0%) 12(36.4%)
Disinfection of Instruments 
Chemical 5(45.5%) 7(70.0%) 6(50.0%) 18(54.5%)
Boiling 7(63.6%) 7(70.0%) 3(25.0%) 17(51.5%)
Not done here 1(9.1%) 2(16.7%) 3(9.1%)
39.4% of the facilities noted that waste such as bandages, syringes and other 
contaminated materials are burned in incinerators, 48.5% burned in an open pit and 18% 
buried. 15% put the waste materials in a pit latrine. It is important to note that multiple 
ways of disposing waste are utilized. In terms of sterilization of equipment, 60.6% of 
facilities use steam sterilization/autoclave, 36 % boiled the equipment and 48% used 
chemicals. Many of the service providers trained indicated their satisfaction with the 
training on IP. 
The importance of IP in the context of family planning cannot be over emphasised. 
Proper practice of IP is essential in encouraging client use of contraceptives especially 
those that are invasive. Increased knowledge and awareness on transmission of infections 
especially HIV through contaminated instruments requires that service providers are up 
to date and practice infection prevention. During the training, it was clear that there are a 
lot of assumptions on IP and hand washing for example is taken for granted though not 
always practiced. Service providers also do not always have access to adequate 
disinfectants such as jik and many lack protective clothing. During the training, on 
Page 29 of 37 
realising how much disinfectant was required for effective IP, one supervisor 
commented: 
 “I now understand why the jik gets finished so 
 quickly in the facility. I always assumed it was 
 due to wastage” 
No doubt this realization will ensure that service providers are supported through having 
the necessary resources to ensure IP is practiced. In some of the facilities in Homabay, it 
was noted that the Constituency Development Fund (CDF) had been used to remove 
wooden floors replacing them with cement floors – which are much easier to maintain 
and to ensure IP. 
Page 30 of 37 
 
3.3 Training on Supervision 
The last objective of this IBP intervention was to train service providers on supervision. 
This activity was planned to strengthen the supervision skills of the provincial 
management teams who are and would be actively involved in the follow up of trained 
providers in the IBP districts which fall under their docket. The Purpose of the Course 
was to prepare service supervisors to improve the performance of service delivery 
systems and to ensure the provision of high quality services. 
The emphasis of the supervisor training was to ensure that supervisors understand how 
to: 
• Define desired performance for delivery site/s 
• Assess performance 
• Find root causes of performance gaps 
• Select and implement appropriate interventions to improve performance 
• Monitor and evaluate performance 
A five day supervision training for district, provincial and national level managers from 
Nakuru, Migori, Homabay, Nyeri, and the Division of Reproductive Health, were 
updated on supervision knowledge and skills. A total of 41 supervisors were trained. The 
training on supervision was necessary as earlier indications were that supervision at best 
was erratic. During the base line, many service providers indicated that they do not get 
regular supervision. 
The results based on this follow up survey after the training show that a lot still remains 
to be done (table 12). For example, only 26% of the service providers interviewed 
indicated that they had written job description. However, after the training and as a result 
of the Ministry of Health Rapid Results Initiative (RRI), 75% of service providers in 
Nyeri indicated that they had received performance appraisals at least once, although not 
necessarily in the last 3 months. The actual numbers remain low though. These providers 
Page 31 of 37 
had received verbal/written recognition for a job well done in the past three months either 
from a supervisor, colleague, client or community member. 
Table 12 Service provider experience with supervision 
District 
Have a written job 
description 
Receive 
performance 
appraisals 
Received 
verbal/written 
recognition for job 
well done 
Nyeri(n=20) 10 (50.0%) 15 (75.0%) 16 (80.0%)
Nakuru(n=20) 2 (10.0%) 12 (60.0%) 8 (40.0%)
Homabay(n=13) 2 (15.4%) 5 (38.5%) 8 (61.5%)
Total (n=53) 14 (26.4%) 32 (60.4%) 32 (60.4%)
During the training, there were various issues raised in relation to supervision. Among 
these was the fact that most of the supervisors do not have any training on supervision as 
they are normally promoted on their job with no sensitization to the roles and 
responsibilities of a supervisor is created. Many of the supervisors noted that the training 
on supervision was a ‘new’ concept to them! One of the provisional health officers 
explained: 
 “I have been supervising for the last several years but I did not 
 know that there was need to supervise against a standard! This 
 training is an eye opener”. 
The lack of written job descriptions for many of the service providers makes the work of 
supervisors difficult as they do not have a basis for evaluating and checking the 
performance of service providers. Job descriptions are urgently required. There is also 
need for Kenya to adopt standards for family planning that supervisors can use. Those 
trained on supervision appreciated this initiative. Many liked the opportunity to learn and 
to have demonstrations on effective supervision. This activity was further strengthened 
by the Ministry of Health Rapid Results Initiative (RRI) in which districts are expected to 
show results. 
Page 32 of 37 
In the follow up support supervision by the MOH and JHPIEGO, there was indication 
that supervision was starting to take place in some health facilities. However, some 
challenges identified in relation to supervision included: 
• Staff roles and responsibilities not well defined hence each team member is 
unaware of the others’ duties.
• Translating the supervision checklists into report is difficult and documentation of 
supervision reports is time consuming hence mostly remains undone.
• Selection criteria for site visits is rarely set, thus some facilities get more attention 
than others. 
• Team leaders have inadequate management skills. 
• Vertical cadres report to different supervisors hence role conflicts prevent 
harmonization of teams. 
Despite these continuing challenges, it is important to note that supervision has been 
incorporated in the district work plans because of the skills and knowledge acquired 
during the training. This is essential for sustainability. 
Page 33 of 37 
4.0 CONCLUSIONS, CHALLENGES AND WAY 
FORWARD 
4.1 Conclusions 
JHPIEGO in collaboration with the Ministry of Health was able to train 126 service 
providers on FP, infection prevention and 41 supervisors in three districts: Nyeri, Nakuru 
and Homa Bay. The IBP initiative emphasizes the importance of quality reproductive 
health care that meets the expectations of the clients who seek such services. This in part 
requires that service providers have the necessary skills to be able to deliver the required 
services. In addition, it is important to have a contraceptive mix that provides protection, 
has fewer side effects and are easier to use. Such contraceptives are likely to encourage 
use among clients (Ushma, 2005)1
. 
This endline survey shows that after the training, the use of contraceptives increased in 
all three districts with the exception of vesectomy and the female condom. In Homa Bay, 
uptake increased greatly for male condoms; moderately for other methods. In Nakuru, 
there was a mixed use of various FP methods with Depo Provera uptake being highest 
compared to other districts. In Nyeri there was an increase in the use of long term 
methods and especially Tubal Ligation. Overall, the use of family planning increased by 
22% in Homabay, 21% in Nakuru and 3% in Nyeri respectively. The increase in Nakuru 
and Homa bay was well beyond that of the target set for this activity. In Nyeri, though, 
the increase was below 5%. These findings clearly indicate that training of service 
providers is important. However, there are various factors that need to be addressed in 
order to increase contraceptive uptake. For example, the fact that Jadelle was available 
during the training offered an opportunity to train service providers on its insertion and 
removal. This coupled with the availability created an opportunity for providers to offer 
Jadelle to their clients. Similarly, after the training, some service providers indicated that 
 
1
 Ushma D. et al. Population reports series M No. 19 April 2005 
Page 34 of 37 
they were now more confident in discussing and addressing clients concerns and offering 
a contraceptive mix. This was well articulated by a service provider who after the training 
commented: 
“Inadequate knowledge and practice on “what is new” in this area, has 
lead us as service providers to offer “less cumbersome methods” such as 
Depo Provera. In addition to the work load in our facilities, I would say 
that lack of competency makes us avoid implant insertion all together”
Training on infection prevention is important in IBP and especially in reducing infections 
that may emanate from use of invasive contraceptives. Although many of the service 
providers interviewed indicated that they had adequate knowledge on IP, it is essential 
that IP is reinforced to avoid lapses in practice - that may endanger the clients and service 
providers. 
Family planning (FP) services in Kenya are guided by clear national guidelines and 
policies. However, there are no national FP standards. Performance standards serve as a 
guide to providers, supervisors and trainers during the course of their work, to enable 
them to improve the quality of service. MOH/JHPIEGO, held a supervision workshop 
where this issue came out as key. An initial draft of standards was developed within the 
concept of two frameworks. Performance and Quality Improvement (PQI) framework, 
which formed the supervisory basis for the workshop and provided the facilitative 
supervision principles for health care supervisors, and the Kenya Quality Model (KQM). 
KQM has been used before in developing Standards for Maternal Care in Kenya
published in 2002, and VCT accreditation Standards in Kenya. KQM is a national 
model developed by the Ministry of Health in 2000 to provide guidance and direction for 
quality management and improvement of health care delivery in Kenya. Based on three 
pillars: evidence-based practice, total quality management, and patient partnership2
, this 
would serve as an excellent framework to complete the process of developing FP 
standards. 
 
2
Information provided by the CNO’s office 
Page 35 of 37 
Traditionally, health care providers and researchers in the field of reproductive health 
have focused almost exclusively on women when planning programmes and services, 
especially with regard to family planning, prevention of unwanted pregnancy and 
promotion of safe motherhood. Efforts are now being made to broaden men’s 
responsibility for their own reproductive health as well as that of their partners.3
 It is 
evident that when men are involved, more women adopt and continue using FP methods. 
Indeed there is no “special formula” for involving men. Different approaches which are 
culturally acceptable, appropriate and have the potential to work, are required. This 
means that there is need for appropriately trained counsellors to interact with men and a 
broader range of topics needs to be dealt with (gender violence, female genital cut and 
promotion of positive behaviour towards women ) that will look at the sexual and 
reproductive needs of men holistically—not simply from a family planning perspective—
if efforts to reach men are to be successful. This was one of the key areas of training 
service providers in the three districts. However, as table 7 shows, service providers are 
still not adequately discussing male involvement and especially how to negotiate the use 
of a method with partner. 
4.2 Challenges 
Some of the key challenges that emerged during the implementation of this project 
include: 
• The realization that a 5-days FP training is not adequate especially for service 
providers lacking technical update for many years 
• Irregular contraceptive supplies. The findings show that the availability of 
contraceptives can lead to increased use. For example, the availability Jadelle, 
coupled with the training on insertion and removal led to a tremendous 
increase in all the districts 
• Shortage of service providers for FP. Many providers indicated that FP tended 
to be relegated low priority given the lack of staff and in many cases FP 
practice was being overtaken by the emphasis placed on HIV/AIDS in the 
health care sector 
• Lack of training and resources for support supervision 
 
3
 Programming for male involvement in RH. A report of the meeting of WHO regional advisors in RH. 
September 2001. 
Page 36 of 37 
• Limited geographical access to FP services (for example, Homa Bay has only 
25 facilities compared to 160 in Nyeri and 190 in Nakuru) in some of the 
districts 
• Poor record keeping for tracking FP monitoring 
It is recommended that: 
• In addition to training, other factors that are supportive to women accessing 
contraceptives be addressed 
• There is need to adequately address: 
- Cultural beliefs, misconceptions and practices 
- Lack of knowledge among service providers 
- Health systems issues (supplies, staffing, records) 
• It is necessary to improve work environment for service providers 
• It is essential to promote male involvement and community participation 
• On the Job Training (OJT) should be reinforced 
On supervision it is recommended that: 
• If funding is available JHPIEGO in collaboration with the MOH conduct 
training for higher level of management teams, such as national, PMO’s, 
PHO, PNO, PRCO, in order to ease the implementation of IBP and other 
programs at all levels 
• JHPIEGO assist in facilitation of the development of written job descriptions 
with MOH/DRH/CNO’s office 
• With availability of funds, JHPIEGO facilitate support supervision of trained 
supervisors to enable them to practice knowledge and skills and follow up on 
the implementation of their action plans 
4.3 Way forward 
The IBP Kenya initiative has been implemented by the Ministry of Health in 
collaboration with JHPIEGO in three districts. The development of training materials on 
implementing best practices was achieved through the support of different partners. It is 
thus essential that the lessons learnt in the implementation in these initial districts is 
shared and used as a basis for scaling up training of service providers on FP, Infection 
Page 37 of 37 
prevention and supervision. It is clear from this report that in addition to the above 
recommendations, as a way forward: 
• There is need to train more service providers in the three districts on FP. 
Many providers have not been trained for a long time and as such, are not 
aware of the national guidelines and international standards. More 
importantly, as the results show, training is essential in improving provider 
practice; 
• Given the positive results based on this intervention, the IBP needs to be 
scaled up beyond the three initial districts; 
• The new MOH initiative on Rapid Results Initiative aims at one level to 
measure results in FP uptake with bi-monthly reports. This initiative offers an 
opportunity for partners working in the area of FP to “piggy bag” on the 
regular results and reporting to inform their interventions.