For a recent pilot project implemented by Management Sciences for Health, Afghan nongovernmental organizations, and the Afghanistan Ministry of Public Health (MOHP), the MOPH granted community health workers (CHWs) permission to administer a client's first injection of Depo-Provera. CHW's had previously been restricted to providing only second and subsequent injections. During the pilot, the contraceptive prevalence rate increased by roughly 25 percent in the project areas. The pilot revealed that traditional rural communities largely accepted CHW provision of injectables, due in part to the quality counseling that accompanied initiation. The rapid uptake of injectables demonstrated by the pilot project spurred the MOPH to endorse community-based access to injectables (CBA2I) for national scale-up. In 2009, national policy was revised to permit CHWs to provide the first dose of DMPA using a screening checklist.

In 1975, the government of Bangladesh initiated community-based distribution (CBD) of injectable contraceptives in six villages to assess its effect on contraceptive use. In 1977, injectables were made available to all 150 villages in the Matlab subdistrict that were receiving CBD services. B 1979, DMPA was the most popular contraceptive method, relied on by roughly half of all women using modern methods in the region. CBD of injectables was expanded to two more subdistricts in 1984 and then eight more in 1993, the year the Ministry of Health (MOH) piloted an program in which family welfare assistants (FWAs) provided DMPA in 15 subdistricts. In 2005-2006, this program was scaled up nationally.

In 2008-2009, a pilot project was conducted by the Bixby Center for Population, Health & Sustainability, the Tigrai Regional Health Bureau, and Venture Strategies for Health and Development to increase contraceptive prevalence and reduce the current high unmet need for family planning in rural areas of Ethiopia. In addition, the project was intended to provide evidence to policy makers to expand community based distribution (CBD) of the injectible contraceptive, depot medroxyprogesterone acetate (DMPA), in both Tigray and other regions of Ethiopia where community based reproductive health agents (CBRHAs) or other community health workers (CHWs) are present. The implementers of this successful pilot are currently exploring the expansion of CBD of injectables with the ultimate goal of regional and national policy change to support community-based access to injectables (CBA2I).

In 1995, the Guatemalan family planning association Asociación Pro-Bienestar de la Familia de Guatemala (APROFAM), in partnership with the Population Council, conducted operations research comparing acceptance and continuation rates between clinic provision and community-based provision of the injectable contraceptive depot-medroxyprogesterone acetate (DMPA). At 15 months, the continuation rate for clients of community-based distributors (CBDs) was 90 percent, which was identical to the clinic continuation rate. CBDs also achieved high acceptance and continuation rates among rural Mayan women, an important goal of the program. Due to the success of this program, APROFAM expanded community-based distribution of DMPA throughout the country to all of its 22 districts of operation. All community-based promoters in APROFAM's rural development program are trained to provide DMPA services. Furthermore, CBDs now distribute not only progestinonly DMPA, but also the monthly combined (progestin and estrogen) injectable Cyclofem.

A recently-completed pilot has generated local evidence that confirms safety, acceptability, and feasibility of community-based provision of Depo Provera. Based on the positive results of the pilot, the Division of Reproductive Health and collaborating partners are recommending that the Kenya Ministry of Health take steps to create a policy environment conductive to CBA2I and consider scaling up this service delivery model.

As of 2006, Madagascar’s guidelines allow community health workers to provide injectables. Since CBA2I was piloted in 2007, the program has been scaled up to 24 additional districts.

As of 2008, Malawi’s guidelines permit Health Surveillance Assistants (HSAs) to provide injectables. In 2009, HSAs began providing the injectable, Depo Provera, in nine pilot districts, following a feasibility study by the Health Policy Initiative. An evaluation demonstrated that the provision of Depo Provera by HSAs was safe, acceptable, and expanded access by attracting clients to family planning.

In the 1990's pilot programs demonstrated that community health workers (CHWs) could be trained to provide Depo-Provera at the community level using a simple checklist. Based on the findings of these pilots, the Nepal Ministry of Health (MOH) revised its national policy to support CHW provision of injectables. Today roughly 8,000 CHWs provide community-based access to injectables (CBA2I) in Nepal.

Nigeria’s guidelines allow provision of injectables by Senior Community Health Extension Workers (CHEWs) in clinics. A pilot project completed in 2010 demonstrated a significantly higher uptake of injectables by clients from community-based compared to facility-based provision and showed that CHEWs can safely administer injections and dispose of wastes. This evidence fostered a verbal policy change which permitted Senior CHEWs to provide injectable contraceptives at the community level. There is large potential to scale-up CBA2I using the Senior CHEW cadre given the existing public health infrastructure.

The Rwanda Ministry of Health is rolling-out a phased approach to scale up community-based family planning, including injectables. Under the National Guidelines on Community Based Distribution of Family Planning, community health workers are allowed to administer injectable contraception to women who receive their first injection at a health center. More than 3,000 community health workers have been trained and more than 3,600 clients have received a contraceptive method. 41% of those clients received injectable contraception.

CBA2I in Uganda began in 2004 with a pilot. Within three years, the community-based distribution of injectables program was replicated in six additional districts by both public- and private-sector partners. In February 2011, the Ministry of Health signed into policy an addendum to Uganda’s National Policy Guidelines and Service Standards for Sexual and Reproductive Health in support of CBA2I. Nine districts are currently implementing CBA2I. With the impending policy amendment and the development of new national public health sector Village Health Teams, the potential for national scale-up of CBA2I in Uganda is great.

A CBA2I pilot was completed in February 2011, with positive results. Though current guidelines do not allow community health worker provision of injectables, the Ministry of Health has expressed desire for a public sector community-based family planning program and is permitting the provision of DMPA by CBD agents in the pilot districts to continue without interruption. Planning for scale up began after the dissemination of preliminary findings in May 2011 and there is potential for policy change in the future.