““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 !