Setting the Stage: Increasing Community Access to Injectable Contraception

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Setting the Stage Increasing Community Access
to Injectable Contraception

• Victoria Graham, USAID/GH/PRH/SDI
• September 30, 2009

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Strategies for Increasing Access to Depo-Provera

• Increased access at clinics or outposts
• Outreach or mobile services
• Pharmacy and drug shops sales of injectable
  contraceptives
• Subsidized sales
• Fully commercial models
• Administration of injectables by a trained
  provider at a retail outlet
• Administration by Community Health Workers

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Presentation Outline
I. Depo-Provera The Injectable Contraceptive

• Issues and
• Moving Forward

• Expanding Access through CHWs

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I. Depo-Provera The Injectable Contraceptive
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Estimates of injectable users worldwide

• Over 35 million women use injectables for
  contraception (UN Population Division, 2007)
• Tentative estimates
• 28 million use DMPA (13 million, 10 years ago)
• 6 million use once-a-month injectables
• Less than 1 million use NET-EN

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DMPA

• Hormonal based progestin-only injectable
  contraceptive
• Highly effective
• 99 if used per schedule
• Fertility resumes after 4 months on average
• Administered intramuscularly (IM) using
  disposable syringes.
• Safe for nearly all women

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Why do women prefer injectables ?

• Privacy and confidentiality
• Short-term method
• Good option for spacing, delaying, and limiting
• Easily administered
• Safe and effective

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Injectable contraceptive use as of modern
method use among women aged 15-49, married or in
union, 2007
Percentages gt 60 gt50 - 60
gt40 - 50 gt30 - 40 gt20 - 30
gt10 - 20 0 - 10 No
data
Source UN, World Contraceptive Use 2007
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In several African countries, CPR has increased
because of increased access to injectable
contraceptives
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Increased injectable use is not associated with a
decrease in use of other methods
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The Health Workforce for Injectables

• 2.3 workers/1000 pop minimum needed to achieve
  the MDGs
• Based on number needed to provide high coverage
  of selected essential services
• Number includes doctors, nurses and midwives only
  
• CHWs not included in calculation reliable
  information lacking for most countries
• 57 countries in the world have less than 2.3
  workers/1000 population 36 of these countries
  are in Sub-Saharan Africa
• WHO Global Atlas of the Health Workforce
  workforce provider information for single or
  multiple countries, visit http//apps.who.int/glob
  alatlas/default.asp

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Density of HCWs/1000 population
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Urban and Rural Differences inProblems Accessing
Health Care Distance to Facility
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Percent of Women with No Contact with FP
Providers Among Women who Do Not Use Contraception
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What we have learned . . .

• In many African countries, injectable
  contraception is the preferred modern method
  (private and confidential)
• When made available, injectables do not reduce
  other modern method use
• Where a preferred method, there is a direct
  relationship between increased access to
  injectable contraception and increases in CPR
• Rural and urban women are underserved
• There is an insufficient health workforce to
  provide services in rural and urban areas.

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II. Expanding Access through Community Health
Workers
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Goal Reach the Tipping PointFor a New Standard
of Practice

• MOH recognize community-based
• workers as providers of DMPA

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Status and Opportunities for Expansion and
Scale-up of CBD of Depo-Provera -2004
MOROCCO
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
ALGERIA
WESTERN
EGYPT
SAHARA
MAURITANIA
MALI
ERITREA
SENEGAL
SUDAN
THE
DJIBOUTI
GAMBIA
BURKINA FASO
GUINEA
GUINEA
BENIN
BISSAU
NIGERIA
ETHIOPIA
TOGO
COTE
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
Updated 9/30/2004
ZIMBABWE
NAMIBIA
BOTSWANA
SWAZILAND
LESOTHO
SOUTH
AFRICA
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Status and Opportunities for Expansion and
Scale-up of CBD of Depo-Provera 2009
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
Updated 9/15/2009
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Introducing CHW Provision of Injectables
Challenges to Overcome

• Conservative MOH and medical communities
  resistant to having lower level health workers
  perform injections
• Concerns regarding acceptability and safety
• Agreements on standards
• Availability and functioning distribution channels

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Strategies for Overcoming Challenges

• Support a champion in the MOH
• Utilize modeling tools to highlight the impact of
  population growth and the emerging health
  workforce crisis
• Conduct south-to-south study tours
• Implement demonstration projects

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III. Issues and Challenges
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Commodities - Funding and Donor Support
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B. Changing Environment

• Uniject a potential game-changer
• Implants (Sino-implant) the unknown factor
• Other Global Initiatives

Please move forward with Depo-Provera IM. Do not
delay program introduction until Depo-Provera in
Uniject is available.
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C. Moving Forward

• Be champions for CBA of DMPA
• Influencing policy change at the country level
• Promote CBA within Bilateral Projects
• Working with other donors on CBA of DMPA
• Links with other sectors to introduce CBA of DMPA.

Goal Engage more organizations and groups to
advocate, educate, and champion this initiative
and tip the scales