““Bringing it Bringing it Home”Home”

Taking Family Taking Family Planning Services Planning Services to the Communityto the Community

September 9, 2009

Victoria Graham, USAID/GH

John Stanback, PROGRESS Project, FHI

2009 Global Health Mini UniversityWashington, DC

SESSION OUTLINESESSION OUTLINE

The What and Why of Depo-The What and Why of Depo-Provera? Provera?

What is the Priority? What are we What is the Priority? What are we doing?doing?

What is the future? Where are we What is the future? Where are we headed? headed?

Discussion Discussion

The What and The What and Why of Depo-Why of Depo-

Provera?Provera?Victoria GrahamVictoria Graham

Estimates of injectable Estimates of injectable users worldwideusers worldwide

Over 35 million women use Over 35 million women use injectables for contraceptioninjectables for contraception (UN (UN Population Division, 2007)Population Division, 2007)

Tentative estimates:Tentative estimates: 28 million use DMPA 28 million use DMPA (13 million, 10 years (13 million, 10 years

ago)ago) 6 million use once-a-month injectables6 million use once-a-month injectables Less than 1 million use NET-ENLess than 1 million use NET-EN

What is Depo Provera?What is Depo Provera? Progestin-only injectable contraceptiveProgestin-only injectable contraceptive Highly effective-when timely injections Highly effective-when timely injections

given 99% effective over the first year.given 99% effective over the first year. Administered as Administered as an intramuscular an intramuscular Injection (IM) Injection (IM) Fertility resumes Fertility resumes after 4 months after 4 months on averageon average Safe for nearly all Safe for nearly all womenwomen

Why do women prefer Why do women prefer injectables ?injectables ?

Privacy and confidentialityPrivacy and confidentiality

Short-term methodShort-term method

Good option for spacing, Good option for spacing, delaying, and limitingdelaying, and limiting

Easily administeredEasily administered

Safe and effective Safe and effective

Injectable contraceptive use as % of modern Injectable contraceptive use as % of modern method usemethod use

among women aged 15-49, married or in union, among women aged 15-49, married or in union, 20072007

Percentages

> 60

>50 - 60

>40 - 50

>30 - 40

>20 - 30

>10 - 20

0 - 10

No data

Source: UN, World Contraceptive Use 2007Source: UN, World Contraceptive Use 2007

In several African countries, CPR In several African countries, CPR has increased because of has increased because of

increased access to injectable increased access to injectable contraceptives contraceptives

0

5

10

15

20

25

30

Orals Injectables IUD Sterilization Implants

The Health Workforce for The Health Workforce for InjectablesInjectables

2.3 workers/1000 pop 2.3 workers/1000 pop – minimum needed to – minimum needed to achieve the MDGs achieve the MDGs Based on number needed to provide high coverage Based on number needed to provide high coverage

of selected essential servicesof selected essential services Number includes doctors, nurses and midwives Number includes doctors, nurses and midwives

onlyonly CHWs not included in calculation – reliable CHWs not included in calculation – reliable

information lacking for most countriesinformation lacking for most countries 57 countries in the world have less than 57 countries in the world have less than

2.3 workers/1000 population2.3 workers/1000 population – 36 of these – 36 of these countries are in Sub-Saharan Africacountries are in Sub-Saharan Africa

WHO Global Atlas of the Health WHO Global Atlas of the Health Workforce Workforce – workforce provider information – workforce provider information for single or multiple countries, visit for single or multiple countries, visit http://http://apps.who.int/globalatlas/default.aspapps.who.int/globalatlas/default.asp

Density of HCWs/1000 populationDensity of HCWs/1000 population

0

0.5

1

1.5

2

2.5

DRC* Kenya* Madagascar Malawi Nigeria Rwanda Tanzania* Uganda Zambia*

CHWs

Nurses/Midwives

Doctors

Urban and Rural Differences Urban and Rural Differences inin

Problems Accessing Health Problems Accessing Health Care: Care:

Distance to FacilityDistance to Facility

0

10

20

30

40

50

60

70

80

Ethio

pia 2

005

Mad

agas

car 2

003/

04

Mal

awi 2

004

Nigeria

 2003

Rwan

da 200

5

Tanzania

 200

4

Uganda 

2006

Zambia

 200

1/02

Haiti 

2005

Pe

rce

nt

of

Wo

me

n

Urban Rural

What we have learned . . .What we have learned . . . In many African countries, injectable In many African countries, injectable

contraception is the preferred modern contraception is the preferred modern method (private and confidential)method (private and confidential)

When made available, injectables do not When made available, injectables do not reduce other modern method usereduce other modern method use

Where a preferred method, there is a direct Where a preferred method, there is a direct relationship between increased access to relationship between increased access to injectable contraception and increases in CPRinjectable contraception and increases in CPR

Rural Rural andand urban women are underserved urban women are underserved There is an insufficient health workforce to There is an insufficient health workforce to

provide services in rural and urban areas.provide services in rural and urban areas.

What is the What is the Priority? What Priority? What are we doing?are we doing?

John Stanback John Stanback

What is the Priority?What are we doing? John Stanback

Strategies for Increasing Strategies for Increasing Access to Depo-ProveraAccess to Depo-Provera

Increased access at clinics or outpostsIncreased access at clinics or outposts Outreach or mobile servicesOutreach or mobile services Pharmacy sales of injectable Pharmacy sales of injectable

contraceptivescontraceptives Subsidized sales Subsidized sales Fully commercial modelsFully commercial models

Administration of injectables by a Administration of injectables by a trained Pharmacist trained Pharmacist

Administration by Community Administration by Community Health Workers*Health Workers*

Introducing CHW Provision Introducing CHW Provision of Injectables: Challenges of Injectables: Challenges

to Overcometo Overcome Conservative MOH and medical Conservative MOH and medical

communities resistant to having lower communities resistant to having lower level health workers perform injectionslevel health workers perform injections

Concerns regarding acceptability and Concerns regarding acceptability and safetysafety

Lack of agreements on standards Lack of agreements on standards Availability and functioning distribution Availability and functioning distribution

channelschannels

MOH recognize community-based MOH recognize community-based

workers as providers of Depo workers as providers of Depo ProveraProvera

Goal: Reach the Tipping Goal: Reach the Tipping PointPoint

For a New Standard of For a New Standard of PracticePractice

Status and Opportunities for Status and Opportunities for Expansion and Scale-up of CBD of Expansion and Scale-up of CBD of

Depo-Provera -2004Depo-Provera -2004National policies now permit and programs are scaling-up. Pilot or limited implementation w/ MOH support and policy restrictions

Potential country for policy change and introduction efforts

MOROCCO

SAHARA

ALGERIA

MAURITANIA MAL

I

EGYPT

SUDAN

ETHIOPIA

DJIBOUTI

ERITREA

SOMALIAKENY

A

TANZANIA

DEMOCRATIC

RWANDA

GABON

EQUATORIAL

ANGOLA

CONGO

NIGERIA

BENIN

DTVOIRE

SIERRA

SENEGAL

GHANA

THE

GUINEA

LIBERIA

CAMEROON

MALAWI

ZAMBIA

MOZAMBIQUE MADAGASCARZIMBABWE

BOTSWANA

SWAZILANDLESOTHO

NAMIBIA

ANGOLA

WESTERN

UGANDA

OF THE CONGO

REPUBLIC

BURUNDI

GUINEAREP. OF

TOGOCOTE

BURKINA FASOGUINEA

LEONE

GAMBIA

BISSAU

SOUTH

REPUBLIC

AFRICAN

THE

AFRICA

Updated:9/30/2004

Status and Opportunities for Status and Opportunities for Expansion and Scale-up of CBD of Expansion and Scale-up of CBD of

Depo-Provera 2009Depo-Provera 2009TUNISIAMOROCCO

SAHARA

ALGERIA

MAURITANIA

MALI

NIGER

LIBYA

CHAD

EGYPT

SUDAN

ETHIOPIA

DJIBOUTI

ERITREA

SOMALIA

KENYA

TANZANIA

DEMOCRATIC

CENTRAL

RWANDA

GABON

EQUATORIAL

CONGO

NIGERIABENIN

SIERRA LEONE

SENEGAL

GHANA

THE

GUINEA

LIBERIA

CAMEROON

MALAWI

ZAMBIA

MOZAMBIQUE MADAGASCAR

ZIMBABWE

BOTSWANA

SWAZILAND

LESOTHO

NAMIBIA

ANGOLA

WESTERN

UGANDA

OF THE CONGO

REPUBLIC

BURUNDI

GUINEA

REP. OF

TOGOCOTE

D’VOIRE

BURKINA FASO

GUINEA

GAMBIA

BISSAU

SOUTH

REPUBLIC

AFRICAN

THE

AFRICA

National policies now permit and programs are scaling-up. Pilot or limited implementation w/ MOH support and policy restrictions

Potential country for policy change and introduction efforts

Updated9/15/2009

Technical Consultation, Expanding Access to Technical Consultation, Expanding Access to Injectable Contraception, June 2009Injectable Contraception, June 2009

Meeting held at WHO, GenevaMeeting held at WHO, Geneva Convened by WHO, USAID, and FHIConvened by WHO, USAID, and FHI 30 experts from 8 countries and 18 organizations30 experts from 8 countries and 18 organizations Experts reviewed scientific evidence and Experts reviewed scientific evidence and

programmatic experience of community-based programmatic experience of community-based provision, with focus on DMPAprovision, with focus on DMPA

Technical Consultation, Expanding Access to Technical Consultation, Expanding Access to Injectable Contraception, June 2009Injectable Contraception, June 2009

Overall ConclusionsOverall Conclusions

““Evidence supports the introduction, continuation, Evidence supports the introduction, continuation, and scale-up of community-based provision of and scale-up of community-based provision of progestin-only injectable contraceptives.”progestin-only injectable contraceptives.”

““Provision by appropriately trained community Provision by appropriately trained community health workers is safe, effective, and acceptable.”health workers is safe, effective, and acceptable.”

III. Where do we III. Where do we go from here?go from here?

Changing EnvironmentChanging Environment

Uniject – a potential game-changerUniject – a potential game-changer Implants (sino-plant) – an unknown Implants (sino-plant) – an unknown

factorfactor Government transitions and Government transitions and

changing prioritieschanging priorities

Where is CBD of Depo Where is CBD of Depo going?going?

Scale-up of CBD of DepoScale-up of CBD of Depo Subcutaneous Depo and Subcutaneous Depo and

UnijectUniject Social Marketing of DepoSocial Marketing of Depo Home injection of DepoHome injection of Depo

Depo SubQ and UnijectDepo SubQ and Uniject

Technologies Technologies UnijectUniject

All-in one prefillable All-in one prefillable Prevents reusePrevents reuse Ensures Ensures dose accuracydose accuracy Simple Simple to useto use Cost savings with Cost savings with

wastage ratewastage rate Minimizes transmission Minimizes transmission

of pathogensof pathogens Opens up the possibility Opens up the possibility

forfor self-administration self-administration

Depo-subQ provera 104Depo-subQ provera 104 SubcutaneousSubcutaneous Revised formulationRevised formulation Lower dose than DMPA Lower dose than DMPA Easier Easier for health for health

providers to administerproviders to administer Will beWill be available in pre- available in pre-

filled Uniject filled Uniject syringesyringe Cost?Cost?

Comparable Commodity Cost

DMPA - $3.88 per CYP

NET-EN - $6.30 per CYP

OCs - $3.00 per CYPhttp://www.infoforhealth.org/injectables/program_mgrs/index.shtml#EstimatingCost

http://www.infoforhealth.org/pr/k6/index.shtml

Uniject ComponentsUniject ComponentsBlister

Needle

Valve

Cap

Hub

Size varies with drug or vaccine

Prevents re-use by resisting refilling through needle

Size varies with drug or vaccine

Home Injection of DepoHome Injection of Depo

Would you prefer getting Would you prefer getting Depo…Depo…

From a clinicFrom a clinic 34%34% From a CBDFrom a CBD 22%22% Not sureNot sure 19%19% By self-injecting at homeBy self-injecting at home 24%24%

Moving ForwardMoving Forward

Be champions for Task Shifting – Be champions for Task Shifting – CBA of DMPACBA of DMPA

Influencing policy change at the Influencing policy change at the country levelcountry level

Working with other donors on CBA Working with other donors on CBA of DMPAof DMPA

Links with other sectors to introduce Links with other sectors to introduce CBA of DMPACBA of DMPA

Thank You !Thank You !