Title: When Opportunity Comes a Knockin CBD of Depo Provera in Africa
1When Opportunity Comes a Knockin CBD of Depo
Provera in Africa
September 12, 2008
Mini University Washington, DC
Victoria Graham (USAID/GH) and
John Stanback (PROGRESS Project, FHI/North
Carolina)
2SESSION OUTLINE
- What about Depo Provera?
- Victoria Graham, USAID/GH
- A brief history of the global expansion of CBD of
Depo?
- John Stanback
- The situation in Malawi - the latest success
- Victoria Graham
- Where are we headed? (Scale-up Sub-Q/Uniject
Self Injection and, social marketing, drug
shops, and OTC
- John Stanback
- Discussion
- John and Victoria
3What about Depo Provera?
4What is Depo Provera?
- Progestin-only injectable contraceptive
- Highly effective-when timely injections given 99
effective over the first year.
- Administered as
- an intramuscular
- Injection (IM)
- Fertility resumes
- after 4 months
- on average
5Rising Proportion of Injectables in the
Composition of CPR
6Why do women prefer Depo Provera?
- ? Safe
- ? Private
- ? Effective
- ? Convenient
- ? Easy to use
7Challenge Expand Service Delivery of Depo Provera
- Take services to population without access to
facility services.
- Take service provision of Depo Provera to a lower
level cadre of provider
8A Brief History of the Global Experience
9Ancient History
- 1970s - Bangladesh
- 1990s - Latin America
- Guatemala
- Bolivia
- Mexico
- Peru
- 2000s - Nepal
Modern History
- Ex Africa semper aliquid novi
10Paraprofessional Provision of DMPA Status in
Africa
2005
TUNISIA
Implementing (MOH approved)
Policies changed Interested
MOROCCO
ALGERIA
WESTERN
LIBYA
EGYPT
SAHARA
MAURITANIA
MALI
NIGER
ERITREA
SENEGAL
CHAD
SUDAN
THE
DJIBOUTI
GAMBIA
BURKINA FASO
GUINEA
GUINEA
BENIN
BISSAU
NIGERIA
ETHIOPIA
TOGO
COTE
CENTRAL
SIERRA
DTVOIRE
GHANA
AFRICAN
LEONE
REPUBLIC
LIBERIA
CAMEROON
UGANDA
SOMALIA
DEMOCRATIC
KENYA
EQUATORIAL
REP. OF
REPUBLIC
GUINEA
THE
OF THE CONGO
GABON
CONGO
RWANDA
BURUNDI
TANZANIA
ANGOLA
MALAWI
ANGOLA
ZAMBIA
MOZAMBIQUE
MADAGASCAR
ZIMBABWE
NAMIBIA
BOTSWANA
SWAZILAND
LESOTHO
SOUTH
AFRICA
11Paraprofessional Provision of DMPA Status in
Africa
2008
TUNISIA
MOROCCO
Implementing (MOH approved)
Policies changed Interested
ALGERIA
WESTERN
LIBYA
EGYPT
SAHARA
MAURITANIA
MALI
NIGER
ERITREA
SENEGAL
CHAD
SUDAN
THE
DJIBOUTI
GAMBIA
BURKINA FASO
GUINEA
GUINEA
BENIN
BISSAU
NIGERIA
ETHIOPIA
TOGO
COTE
CENTRAL
SIERRA
DTVOIRE
GHANA
AFRICAN
LEONE
REPUBLIC
LIBERIA
CAMEROON
UGANDA
SOMALIA
DEMOCRATIC
KENYA
EQUATORIAL
REP. OF
REPUBLIC
GUINEA
THE
OF THE CONGO
GABON
CONGO
RWANDA
BURUNDI
TANZANIA
ANGOLA
MALAWI
ANGOLA
ZAMBIA
MOZAMBIQUE
MADAGASCAR
ZIMBABWE
NAMIBIA
BOTSWANA
SWAZILAND
LESOTHO
SOUTH
AFRICA
12The USAID/Malawi Experience
Victoria Graham
13Profile of Malawi
- Population 13.9 million
- CPT 28
- TFR 6.0
- Residence 80 rural
- 20 urban
- Adult HIV 12
- MMR 984 per 100,000
- Data obtained from 2004 Demographic Health Survey
(DHS)
14What is the status of CBD in Malawi?
- July 2008 MOH announced the revision of national
policy to allow CBD of Depo Provera through HSAs
the public sector paramedical health
professionals - MOH obtained consensus a challenging process
- Key to the success Madagascar Study Tour
- Lesson Learned Many pathways to policy change
15Where is CBD of Depo going?
- Scale-up of CBD of Depo
- Subcutaneous Depo and Uniject
- Self-injection of Depo
- Social Marketing of Depo
16Scale-up
SubQ
Social-Marketing
Self-Injection
17Scaling Up CBD of Depo
- 1. District/Community Level a. Demand
creation activities b. Orientation of
clinics/supervisors and trainers c. Adaptation
of ME tools and supervision systems d.
Training of CBD agents e. Ongoing ME during
service provision2. National level a.
Facilitation of national level leadership and
support b. Stakeholder sensitization and
engagement of professional associations
and other groups c. Policy and guidelines
review and adaptation d. Local adaptation and
dissemination of tools/advocacy materials
18Challenges to Scaling Up CBD of Depo
- Sustainability of supplies
- Ongoing monitoring and evaluation
- Supportive supervision
- Health establishment
- National regulations
- Improving counseling
19Sustainability - depends on
- Achieving policy change enabling trained and
supervised CHWs to provide DMPA
- Creating partnerships that facilitate scale up of
CBD of DMPA to other districts
- Addressing challenges related to CBD programming
- Motivations for CBD agents
- Training / supervision of CBD agents
- Effective LMIS and HMIS that incorporate CBD
needs and data
20Depo SubQ and Uniject
21Technologies
- Autodisable syringes
- Intramuscular
- Increases safety and disposal
- Prevents reuse
- US.06 each
- Uniject
- All-in one prefillable
- Prevents reuse
- Ensures dose accuracy
- Simple to use
- Cost savings with wastage rate
- Minimizes transmission of pathogens
- Opens up the possibility for self-administration
- Depo-subQ provera 104
- Subcutaneous
- Revised formulation
- Lower dose than DMPA
- Easier for health providers to administer
- Will be available in pre-filled Uniject syringe
- Cost?
Comparable Commodity Cost DMPA - 3.88 per CYP
NET-EN - 6.30 per CYP OCs - 3.00 per CY
P http//www.infoforhealth.org/injectables/progra
m_mgrs/index.shtmlEstimatingCost
http//www.infoforhealth.org/pr/k6/index.shtml
22Home Injection of Depo
23Would you prefer getting Depo
- From a clinic 34
- From a CBD agent 22
- Not sure 19
- By self-injecting at home 24
24Social Marketing of Depo
- How Social Marketing works
- Social marketing of Depo
- Drug shops
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28Survey of Rural Drug Shops in Uganda 8/2007
Do you sell and inject Depo-Provera?
29Selected Results
- Keep a register 33
- Take medical history 91
- Use sharps container 45
- Ever re-use syringes 10
- Needle-stick (12 mo.) 24
- Abscess this year 16
- Know risks of unsafe injection 76
- Know irregular bleeding 60
- is side effect
30 Resources and Tools
- Advocacy strategy and briefs
- The Implementation Handbook
- DMPA Screening Checklists
- Key Factors for Replication Checklist
- Rapid assessment of CBD program
- Counseling and training tools
- Available at http//www.fhi.org/en/Topics/CBDof
DMPA.htm
31Thank You