Setting the Stage: Increasing Community Access to Injectable Contraception Victoria Graham, USAID/GH/PRH/SDI September 30, 2009

Strategies for Increasing Access to Depo-Provera Increased access at clinics or outposts Increased access at clinics or outposts Outreach or mobile services Outreach or mobile services Pharmacy and drug shops sales of injectable contraceptives Pharmacy and drug shops sales of injectable contraceptives Subsidized sales Subsidized sales Fully commercial models Fully commercial models Administration of injectables by a trained provider at a retail outlet Administration of injectables by a trained provider at a retail outlet Administration by Community Health Workers* Administration by Community Health Workers*

Presentation Outline I. Depo-Provera: The Injectable Contraceptive II.Expanding Access through CHWs III. Issues and Moving Forward

I. Depo-Provera: The Injectable Contraceptive

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

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

Why do women prefer injectables ? Privacy and confidentiality Privacy and confidentiality Short-term method Short-term method Good option for spacing, delaying, and limiting Good option for spacing, delaying, and limiting Easily administered Easily administered Safe and effective Safe and effective

Injectable contraceptive use as % of modern method use among women aged 15-49, married or in union, 2007 Percentages > 60 > > > > > No data Source: UN, World Contraceptive Use 2007

In several African countries, CPR has increased because of increased access to injectable contraceptives

Increased injectable use is not associated with a decrease in use of other methods

The Health Workforce for Injectables 2.3 workers/1000 pop – minimum needed to achieve the MDGs 2.3 workers/1000 pop – minimum needed to achieve the MDGs Based on number needed to provide high coverage of selected essential services Based on number needed to provide high coverage of selected essential services Number includes doctors, nurses and midwives only Number includes doctors, nurses and midwives only CHWs not included in calculation – reliable information lacking for most countries 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 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 WHO Global Atlas of the Health Workforce – workforce provider information for single or multiple countries, visit

Density of HCWs/1000 population

Urban and Rural Differences in Problems Accessing Health Care: Distance to Facility

Percent of Women with No Contact with FP Providers Among Women who Do Not Use Contraception

What we have learned... In many African countries, injectable contraception is the preferred modern method (private and confidential) 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 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 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 Rural and urban women are underserved There is an insufficient health workforce to provide services in rural and urban areas. There is an insufficient health workforce to provide services in rural and urban areas.

II. Expanding Access through Community Health Workers

MOH recognize community-based workers as providers of DMPA Goal: Reach the Tipping Point For a New Standard of Practice

Status and Opportunities for Expansion and Scale-up of CBD of Depo-Provera 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 MOROCCO SAHARA ALGERIA MAURITANIA MALI EGYPT SUDAN ETHIOPIA DJIBOUTI ERITREA SOMALIA KENYA TANZANIA DEMOCRATIC RWANDA GABON EQUATORIAL ANGOLA CONGO NIGERIA BENIN DTVOIRE SIERRA 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 TOGO COTE BURKINA FASO GUINEA LEONE GAMBIA BISSAU SOUTH REPUBLIC AFRICAN THE AFRICA Updated: 9/30/2004

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

Introducing CHW Provision of Injectables: Challenges to Overcome Conservative MOH and medical communities resistant to having lower level health workers perform injections Conservative MOH and medical communities resistant to having lower level health workers perform injections Concerns regarding acceptability and safety Concerns regarding acceptability and safety Agreements on standards Agreements on standards Availability and functioning distribution channels Availability and functioning distribution channels

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

III. Issues and Challenges

Commodities - Funding and Donor Support

B. Changing Environment Uniject – a potential game-changer Uniject – a potential game-changer Implants (Sino-implant) – the unknown factor Implants (Sino-implant) – the unknown factor Other Global Initiatives Other Global Initiatives Please move forward with Depo-Provera IM. Do not delay program introduction until Depo-Provera in Uniject is available.

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