Provision of Emergency Contraceptive Pills in Kinshasa's Informal Drug Shops: Results from a Mystery Client Study.

CONTEXT: Despite the prominence of informal drug shops as sources of contraceptives in Kinshasa, Democratic Republic of the Congo, evidence on the quality of services they provide is scant. Given efforts to leverage the private sector to increase contraceptive access, evaluating the contraceptive knowledge, attitudes and practices of these providers is warranted. METHODS: In April-May 2018, a mystery client study on the provision of emergency contraception (EC) was conducted in 854 informal drug shops in Kinshasa. Twelve mystery clients, presenting as younger or older than 18 and married or unmarried, visited the outlets to request something to "avoid getting pregnant" after unprotected sex, and to purchase the recommended medicine. Frequencies of key outcomes were calculated, and chi-square testing assessed associations between client age and marital status and the methods and counseling received. RESULTS: Overall, providers recommended EC in 77% of visits, and in 54% of visits, clients left with the method. In 62% of the visits in which providers recommended EC, they specified a time frame for taking the pill; the correct window of efficacy was indicated in 75% of these visits. In 18% of visits, other (noncontraceptive) drugs were provided, and in 7% of visits, providers did not help the client. Regardless of the visit outcome, providers were nearly always deemed respectful (96%). CONCLUSIONS: Leveraging informal outlets to increase contraceptive provision will require identifying quality outlets, strengthening supply chains and advocating for policy changes that recognize them as effective contraceptive providers without decreasing their perceived advantages for women.

RESUMEN Contexto: A pesar de la importancia de las farmacias informales como fuente para obtener anticonceptivos en Kinshasa, República Democrática del Congo, la evidencia sobre la calidad de los servicios que prestan es escasa. Ante los esfuerzos para aprovechar al sector privado con el fin de aumentar el acceso a los anticonceptivos, se justifica evaluar los conocimientos, las actitudes y las prácticas anticonceptivas de esos proveedores. Métodos: Entre abril y mayo de 2018, se realizó un estudio de cliente simulado acerca de la provisión de anticoncepción de emergencia (AE) en 854 farmacias informales en Kinshasa. Doce clientas simuladas que se presentaron como menores o mayores de 18 años y como casadas o solteras, visitaron los puntos de venta para solicitar algo para "evitar quedar embarazadas" después de haber tenido relaciones sexuales sin protección y para comprar el medicamento recomendado. Se calcularon las frecuencias de los resultados clave, y las pruebas de chi-cuadrado evaluaron las asociaciones entre la edad de la clienta, el estado conyugal, los métodos y el asesoramiento recibido. Resultados: En general, los proveedores recomendaron AE en el 77% de las visitas; y, en el 54% de las visitas, las clientas llevaron el método. En el 62% de las visitas en las cuales los proveedores recomendaron AE, especificaron el tiempo adecuado para tomar la píldora; el 75% indicó la ventana correcta de eficacia en esas visitas. En el 18% de las visitas, se proporcionaron otros medicamentos (no anticonceptivos) y en el 7% de las visitas, los proveedores no ayudaron a la clienta. Independientemente del resultado de la visita, se consideró que los proveedores casi siempre fueron respetuosos (96%). Conclusiones: Aprovechar los puntos de venta informales para aumentar la provisión de anticonceptivos requerirá identificar puntos de venta de calidad, fortalecer las cadenas de suministro y abogar por cambios en las políticas que los reconozcan como proveedores efectivos de anticonceptivos sin disminuir sus ventajas percibidas para las mujeres.

RÉSUMÉ Contexte: Malgré l'importance des dépôts de vente de médicaments informels en tant que sources de contraceptifs à Kinshasa (République démocratique du Congo), il n'existe guère de données sur la qualité de leurs services. Étant donné les efforts déployés pour mettre le secteur privé à contribution dans l'élargissement de l'accès à la contraception, l'évaluation de la connaissance, des attitudes et des pratiques de ces prestataires à son égard est justifiée. Méthodes: En avril-mai 2018, une étude par clientes fictives sur la fourniture de la contraception d'urgence (CU) a été menée dans 854 dépôts de vente de médicaments informels kinois. Douze clientes fictives, se présentant comme ayant moins ou plus de 18 ans et comme mariées ou célibataires, se sont rendues dans les dépôts pour y demander quelque chose qui leur permette de « ne pas tomber enceintes « après un rapport sexuel non protégé et pour acheter le médicament recommandé. Les fréquences des principaux résultats ont été calculées et les associations entre l'âge et la situation matrimoniale de la cliente et les méthodes et le conseil reçus ont été évaluées par tests chi carré. Résultats: Globalement, les prestataires ont recommandé la CU dans 77% des cas et, dans 54%, les clientes ont obtenu la méthode. Dans 62% des cas où les prestataires avaient recommandé la CU, ils ont spécifié un délai de prise de la pilule. La période correcte d'efficacité a été indiquée dans 75% de ces cas. Dans 18% des cas, d'autres médicaments (non contraceptifs) ont été fournis et dans 7%, les prestataires n'ont pas aidé la cliente. Indépendamment du résultat de la visite, les prestataires ont presque toujours été qualifiés de respectueux (96%). Conclusions: La mise à contribution des dépôts informels pour l'accroissement de l'offre contraceptive nécessitera l'identification des dépôts de qualité, le renforcement des chaînes d'approvisionnement et le plaidoyer en faveur de changements de politique qui reconnaissent ces dépôts comme prestataires efficaces de la contraception sans réduire leurs avantages perçus pour les femmes.

Attitudes toward sexual and reproductive health among adolescents and young people in urban and rural DR Congo.

BACKGROUND: In the Democratic Republic of Congo (DRC), onset of sexual intercourse is initiated during adolescence, however only two in ten sexually active unmarried women are using modern contraception. Improving adolescents' and young peoples' knowledge and practices related to sexual and reproductive health (SRH) is necessary to improve health outcomes. However, little is known about the SRH attitudes and needs among young people in the DRC. The study aims to contribute to the available evidence by examining adolescents' and young people's insights on their cultural norms, practices and attitudes towards SRH services. METHODS: Fourteen focus group discussions were conducted with a total of 224 adolescents and young people aged 15-24 years in urban and rural areas of the DRC. The topics discussed and age groups of participants differed somewhat in the urban and rural areas. Data were analyzed to identify themes in the participants' discussion of their attitudes towards SRH. RESULTS: Regardless of age differences, common themes emerged. Both in rural and urban areas premarital sex was largely sanctioned by peers but not adults; adolescents feared pregnancy and had limited knowledge of contraceptive methods. Many were misinformed that certain common pharmaceutical products (e.g., decaris) prevent pregnancy. Key barriers to accessing contraception from health facilities and pharmacies included shame and stigma; urban participants also cited cost and judgmental attitudes of health providers. CONCLUSION: Addressing the SRH needs of adolescents and young people can have life-long protective benefits. Increasingly decision-makers and gatekeepers in the DRC are accepting the concept of providing SRH services and information to young people. This study shows the pressing need for information and services for young people in both urban and rural areas. The continued expansion SRH programming to all health zones and the developed of the National Strategic Plan for Health and Wellbeing of Adolescents and Youth 2016-2020 are steps toward that goal.

Family Planning in the Democratic Republic of the Congo: Encouraging Momentum, Formidable Challenges.

Momentum for family planning in the Democratic Republic of the Congo (DRC) is evident in multiple ways: strong political will, increasing donor support, a growing number of implementing organizations, innovative family planning programming, and a cohesive family planning stakeholder group. Between 2013 and 2017, the modern contraceptive prevalence rate (mCPR) in the capital city of Kinshasa increased from 18.5% to 26.7% among married women, but as of 2013-14, it was only 7.8% at the national level. The National Multisectoral Strategic Plan for Family Planning: 2014-2020 calls for achieving an mCPR of 19.0% by 2020, an ambitious goal in light of formidable challenges to family planning in the DRC. Of the 16,465 health facilities reporting to the national health information system in 2017, only 40% offer family planning services. Key challenges include uncertainty over the political situation, difficulties of ensuring access to family planning services in a vast country with a weak transportation infrastructure, funding shortfalls for procuring adequate quantities of contraceptives, weak contraceptive logistics and supply chain management, strong cultural norms that favor large families, and low capacity of the population to pay for contraceptive services. This article describes promising initiatives designed to address these barriers, consistent with the World Health Organization's framework for health systems strengthening. For example, the national family planning coordinating mechanism is being replicated at the provincial level to oversee the expansion of family planning service delivery. Promising initiatives are being implemented to improve the supply and quality of services and generate demand for family planning, including social marketing of subsidized contraceptives at both traditional and non-traditional channels and strengthening of services in military health facilities. To expand contraceptive access, family planning is being institutionalized in nursing schools, allowing students to operate as community-based distributors. While major challenges remain, significant progress in family planning has been made in the DRC, which should be judged not in comparison with sub-Saharan African countries with high mCPR and mature programs, but rather with those starting from much further behind.

The provision of emergency contraception in Kinshasa's private sector pharmacies: experiences of mystery clients.

OBJECTIVES: Recent programmatic and research efforts on addressing gaps in health systems of low-income countries increasingly see task shifting, i.e. the provision of healthcare by non-medically trained personnel, as a possible solution to increase the availability of specific services and commodities. In Kinshasa, private-sector pharmacies are the primary and preferred provider of family planning (FP) methods, and thus constitute a potential resource for expanding access to specific contraceptives. The objective of this study is to explore selected pharmacies' readiness to serve women seeking emergency contraception (EC). STUDY DESIGN: This study used a mystery client (MC) methodology to visit 73 pharmacies in Kinshasa, Democratic Republic of Congo (DRC). Trained interviewers posed as novice EC users and asked specific questions to evaluate the pharmacy staff's technical knowledge of EC and their attitudes towards EC clients. The results of the MC visit were recorded immediately after the MC left the pharmacy. RESULTS: Findings indicate that more than two-thirds of EC providers were knowledgeable about EC dosage, timeframe, and side effects, and 90% were deemed helpful towards novice EC users. Rare but glaring misconceptions about EC timeframe (20% of providers) and long-term side effects (4% of providers), as well as frequent stock-out (22%) and cost issues highlight priorities for programmatic improvements. CONCLUSIONS: As new service delivery strategies are explored to complement the uneven network of health structures in DRC, this study suggests that, given proper training and integration in FP programming, private-sector pharmacies have the potential to meet specific contraceptive needs for women living in Kinshasa. IMPLICATION STATEMENT: Private pharmacies included in study sample in Kinshasa (DRC) have adequate family planning (FP) service skills to provide clients with emergency contraceptive pills. These higher-end outlets constitute an opportunity for expanding access to FP, although, under total market approaches, a more diverse range of drugs shops should be investigated.