The Sustainable Development Goals target 3.7 aimed to achieve 75% of the global demand for contraception by 2030 [1,2]. However, many women of reproductive age might never get access to quality contraceptive services and commodities for reasons such as insufficient information about available methods, stigma [3], shortage of family planning commodities, and few adequately trained health providers. A modeling study estimated that the global prevalence of modern contraceptive use among 1.9 billion women of reproductive age increased from approximately 55.0% in 2000 to 57.1% in 2019 [4]. However, the study also noted that approximately 164 million women of reproductive age still face unmet need for family planning and that Sub-Saharan Africa experiences a disproportionately higher proportion of women with an unmet need for family planning (23.1% [5]) compared with other regions such as Asia and Latin America, where the unmet need is approximately 10% [4].

In many low- and middle-income countries, the number of trained health providers is not sufficient to address the need for contraception [6,7]. In addition, less than half of the available trained health workers serve rural areas, where a significant proportion of the population resides [7,8]. To address this challenge, the World Health Organization acknowledges task shifting as an innovative approach to promote and accelerate equitable access to care, especially in low- and middle-income countries. It is defined as “the rational redistribution of tasks among health workforce teams,” where tasks are moved, transferred, or delegated, as appropriate, from trained and qualified health workers to other health workers with shorter training and fewer qualifications [8], to make more efficient use of the available human resources for health and improve service access.

In 2010, Uganda developed ambitious goals and targets for the transformation of its people and the achievement of a modern and prosperous society as per Vision 2040. Between 2010 and 2040, the country aimed to reduce the maternal mortality rate from 336 to 15 deaths per 100,000 live births, increase modern contraceptive prevalence rates from 35% in 2016 to 50% in 2030, and reduce unmet need for family planning from 28% in 2016 to 10% by 2030 [9]. To achieve these targets, various strategies have been instituted, including scaling up self-care and task shifting through engaging community health extension workers (CHEWs) to support service access and increase family planning uptake at the community level.

The Uganda Ministry of Health developed a CHEWs strategy to support the achievement of the ambitious Vision 2040 and the 2030 Sustainable Development Goals targets. The objective of the strategy is to competently train and launch a cadre of health care providers, known as CHEWs, to deliver quality, preventive, promotive, and selected basic curative health services at the community level, including providing contraceptives.

The Uganda Ministry of Health implemented a pilot community-based implant project, which involved training CHEWs to provide long-acting reversible contraceptives. Specifically, CHEWs were trained to insert family planning implants and refer clients who needed services of removing the implants to health facilities. This approach has previously been tested in Ethiopia [10] and Nigeria [11]. However, there is a need to generate context-relevant evidence in Uganda to support the community-level provision of implants, even as global health stakeholders advance task shifting and sharing [12,13], community-based service delivery, and self-care for sexual and reproductive health.

The community-based implant provision project was piloted in Lira City, Kyotera, and Namutumba districts in Uganda. All CHEWs in the aforementioned districts underwent additional training specific to family planning focused on implant insertion. The additional training focused on implant provision and was designed to equip the CHEWs with knowledge, skills, and clinical competencies to provide Implanon NXT (Organon Pharma Limited) insertion as well as appropriate referral for implant removal. The training on implant insertion was provided for 8 days, with 4 days of classroom-based learning and 4 days of facility-based practicum. The training was delivered by national-level trainers using a training manual developed by the Uganda Ministry of Health. After successful training, the CHEWs were accredited and deployed at their immediately supervising health facility to conduct implant insertion services. By the end of the training, the CHEWs were expected to have acquired knowledge and demonstrate the following clinical competencies: (1) provide effective client counseling sessions addressing concerns and misconceptions, for informed choice and obtain consent from at least 3 to 5 women, (2) perform comprehensive client screening and medical eligibility for Implanon NXT, (3) prepare the insertion site, (4) perform Implanon NXT insertion in 5 clients using correct techniques, (5) provide clear postinsertion care instructions to 5 clients, (6) manage clients with family planning–related side effects and provide appropriate referral pathways (optional), (7) accurately and appropriately record the family planning services provided in family planning registers and client cards (5 records), and (8) maintain a safe and sterile environment during 5 procedures.

The project was facility-based, whereby CHEWs were stationed at their supervising facilities within their communities. During the duration of the intervention, the CHEWs worked alongside and were supervised by health workers to offer Implant NXT contraception to any woman who required it, was eligible, and consented. The CHEWs were then accredited to offer the services independently.

The overall objective is to evaluate the implementation of a community-based implant intervention to inform efforts aimed at task shifting the provision of long-term reversible family planning methods in Uganda.

The specific objectives of the study are to (1) explore the perceptions of the stakeholders toward implant provision task shifting to the CHEWs (stakeholders including the CHEWs, clients, health workers or professionals, and policymakers), (2) assess the acceptability of the community-based implant insertion by CHEWs among the stakeholders (health workers at the facility and family planning clients in the community), and (3) determine the competence of the CHEWs regarding insertion of implants following training.

The evaluation will be conducted in 3 pilot districts in the regions of East (Namutumba), North (Lira Municipality), and South (Kyotera) (Figure 1). These districts were selected because training and certification of the CHEWs have been completed and the electronic Community Health Information System has been rolled out.

The evaluation will use a convergent parallel mixed-method cross-sectional design using both quantitative and qualitative methods. The quantitative component will use a noninferiority design [14]. This involves a comparison of the competence of the currently authorized cadre to offer the service to the proposed cadre (CHEWs). The noninferior design is methodologically more rigorous than pre-post designs that have been used for assessments in previous studies [10,11].

The qualitative component will use the descriptive qualitative study approach. The descriptive qualitative study approach is an emerging approach that has been used in health care research to understand or identify participants’ experiences and perceptions [15] of the intervention or why the intervention worked or did not work and how the intervention might be improved [16].

The study population will include trained CHEWs, clients, health workers, program managers, and policymakers.

The evaluation will include CHEWs who were trained and engaged in implant insertion as well as health workers who were engaged in the intervention as either trainers or supervisors of the CHEWs. Health workers engaged in the provision of long-term reversible family planning or those at the policy level at the national and district levels will also be included. The evaluation will also include clients defined as women of reproductive age who have obtained family planning services provided by CHEWs. To obtain perspectives from spouses of family planning users, men who are aged ≥18 years and in a relationship or union with a woman will also be included in the evaluation.

Critically ill clients or those deemed unable to answer questions due to living with cognitive disabilities will be excluded. All potential respondents who refuse to respond or do not consent, or those who will not be available during the duration of the study, will be excluded.

We will discuss the findings and their implications for improving access to family planning services at the community level. We anticipate that in general, the competence of CHEWs in insertion of implants will not differ significantly from that of the authorized cadre. We will compare how task sharing has been used for other service delivery, such as community case finding during integrated management of childhood illnesses, to identify lessons to inform family planning provision. For example, policymakers in Kenya noted concerns about the policy framework within which community health workers can distribute drugs at the community level and how this might affect the delivery of vertically oriented programs [18]. Conversely, task shifting in maternal and child health service delivery has the potential to reduce the workload on authorized cadre to spend more time on tasks that require more advanced training [19].

We will also compare our findings with similar approaches in Burkina Faso [20], Kenya [21], Ethiopia [10], Ghana [22], and Nigeria [11]. In Burkina Faso, health providers, community representatives, government officials, and clients were generally agreeable with the idea of implants being provided by trained community health workers [20]. However, community health workers in Burkina Faso were trained to provide several family planning options in addition to the implants. In Kenya, 95% of 434 respondents agreed that task sharing can increase and expand access to family planning services. It was found to benefit both clients and health service providers, particularly where the community health workers were provided with training, support supervision, and conducted within the requisite policy environment [21]. Similarly, qualitative findings from Ghana revealed that community health nurses could provide safe intrauterine devices to clients if they were well trained and provided with the requisite resources and technical support supervision [22].

Findings will also be compared with other studies that used similar noninferiority designs that assessed for safety, quality, and acceptability of community health workers providing the implants in rural settings [23]. We will also discuss other factors to be considered before scale-up, such as the influence of the fact that the services are provided by CHEWs on cost, method choice, and uptake [24], and the broader impact on health system performance [25].

Methodological strengths and limitations will also be discussed to inform future research.

This study has several strengths and limitations. The study applies a noninferior design, which is methodologically more rigorous compared with pre-post designs that have been used for assessment in previous studies [10,11]. In addition, the study uses a convergent parallel mixed methods design, which allows for the collection of both quantitative and qualitative data to reinforce each other. The limitations are the risk of clustering of observations around factors such as the district, the health facility where observations are made, and the observers making the observations. However, we will adjust for clustering in the quantitative analysis.

Findings will be disseminated to the districts where the study took place, the Ministry of Health, and other stakeholders to inform scale-up. Findings will also be disseminated to the scientific community through abstracts and scientific manuscripts.