1. Save Lives, Alleviate Poverty, Spur Development: Invest in LAPM Services Roy Jacobstein, M.D., M.P.H. John M Pile, M.P.H. Fredrick Ndede, M.B.,Ch.B. (NBI), MMed. (Ob/Gy) Joan Taylor The ACQUIRE Project/EngenderHealth 7 th Annual Global Health Mini-University October 5, 2007

2. Three Compelling Rationales for Family Planning:  Health  Program (health system)  Development

3. Health Rationale  1 maternal death for every ~ 110 births in Africa  1 in 16 lifetime risk of maternal death in Africa  ~ 250,000 women’s lives could be saved, each yr  200,000 infants saved, annually, with >2-yr spacing  Reduces vertical HIV transmission ( more than ARVs)

4. Program Rationale  Unmet need for FP is very high:  Only 14% of women in Africa uses modern FP  1 of every 3 women in Africa has unmet need  1 of every 4 in Asia and LAC has unmet need  Effective FP services reduce system costs  350 million people have limited access to FP

5.  1.5 billion more people by 2025  500 million in South Asia  450 million in Africa (will ↑ 60% in < 20 years)  75% of sub-Saharan Africa now living on <$2/day  Just to maintain current rates of contraceptive use, services need to expand 40%  Critical to national development Development Rationale

6. Outline of Presentation 1.The case for long-acting and permanent contraception (LAPM) 2.A holistic program model for LAPM services 3.The program model in action

7. The Case for LAPMs

8.  The most effective FP methods 995-999/1000 do not get pregnant  Very safe (minor complications <10%; major, rare)  Long duration of effectiveness (up to 3-12 yrs) Positive Method Characteristics

9. Language Conditions Thought What is the difference between “Long-acting” and “Long-term”?

10. Good for People  Meet needs of many categories of users  Very wide eligibility: almost all can use  Spacers / limiters / delayers  Younger / older  Postpartum / post-abortion  HIV-infected women and PLWA  Convenient (one act confers long protection)  Highly effective (why they want FP!)

11. Pregnancy Rates by Method Highly Effective

12. Good for Health Systems  Meet clients’ needs / provides choice  Reduce burden on other health services:  FP (re-supply clients)  Obstetric/maternity (unwanted births, abortions)  HIV (PMTCT)  Pediatric  The most cost-effective FP

13. % Women and men using FP methods at one year: Condoms44% Periodic abstinence51% Injectables51% OC pills52% IUD84% Implants94% Tubal ligation100% Vasectomy100% Source: The ACQUIRE Project 2007. Reality √ Low Discontinuation Rates

14. Source: UNFPA 2005. Achieving the ICPD Goals: Reproductive Health Commodity Requirements 2000-2015. Comparison of Annual Contraceptive Commodity Costs, Short-acting, Long-acting, & Permanent Methods, Per Year of Use Cost-Effective

15. 1.The case for long-acting and permanent contraception (LAPM) 2.A holistic program model for LAPM services 3.The program model in action Outline of Presentation

16. Quality client-provider interaction Supportive service policies promoted Human and financial resource allocation fostered Gender equity advanced Supportive service policies promoted Human and financial resource allocation fostered Gender equity advanced Service sites readied Staff performance improved Training, supervision, referral, and logistics systems strengthened Service sites readied Staff performance improved Training, supervision, referral, and logistics systems strengthened Accurate information shared Image of services enhanced Communitie s engaged Accurate information shared Image of services enhanced Communitie s engaged Fundamentals of Care Stakeholder Participation Data for Decision Making DemandSupply Advocacy Increased knowledge + acceptability Increased availability Improved policy + program environment to in to in “More More More Services People Places” Services People Places” Increased Access, Quality and Use

17. Outline of Presentation 1.The case for long-acting and permanent contraception (LAPM) 2.A holistic program model for LAPM services 3.The program model in action

18. The Model in Action: Kisii IUD Initiative  National effort to revitalize IUD  IUD prevalence ↓ from 4.2 [‘93] to 2.4 [‘03]  IUD share of modern method use ↓ from 21% [‘89] to 8% [‘03]  Kisii District, Nyanza Province, Western Kenya

19. LAPMs Underutilized Despite Need in Kenya: Contraceptive methods and limiting Source:MEASURE/DHS, Kenya DHS Survey, 2004. Using to limit: LAPMs (28%) Long-Acting and Permanent Methods %

20. LAPMs Underutilized Despite Need in Kenya: Contraceptive methods and spacing Source:MEASURE/DHS, Kenya DHS Survey, 2004. % Long-Acting and Permanent Methods Using to limit: LAPMs (8%)

21. GapsDemand v Low knowledge v Misinformation Supply v Less available v Providers’ not comfortable providing InterventionsDemand v Media Campaign v Community outreach/participation Supply v Ensuring readiness of sites to provide services v Clinical/counseling training Advocacy v Eligibility v Where provided Advocacy v Guidelines revised v Services expanded to health centres and dispensaries Supply, Demand and Advocacy

22. The Model in Action: Kisii IUD Initiative Providers trained  CTU/Basic FP counseling: 51  IUD Insertion and Removal: 28  Comprehensive Family Planning Counseling: 18  Sites Upgraded (equipment): 13

23. Primary: Women 25-45 Reaching the Community IEC materials 900 posters 6000 brochures 10,000 leaflets Community Outreach 72 Peer Educators 375 CBD Agents Mass Media Radio spots & interviews National and local radio station spots over 5 months Secondary: Their partners Experiential 4 Roadshows –11,000 people Ladies Clubs, Men’s barazas

24. Fahamu ukweli wa mambo “Now you know the truth” Promotional Campaign Message: “Stand Up”

25. Post-campaign Household Survey: 45% reported exposure to IUD messaging

26. Stakeholder Meeting Feb. 05 CTU Trainings Aug. & Sept. 05 IUD Clinical Skills Training Oct. 05 December is historically a slow month for FP clients – IUD trained providers were on holiday – Increased Uptake in Jan. 06 CBD Agent and Peer Ed. Training April & May 06 IUCD Campaign Launch July 06 FP Counseling Training & TOT for CBD Supervisors Feb. 06 PNA May 05 2 nd IUD Skills Training Oct. 06 Project Ends Dec. 2006 Depo Stockout Jan.-Feb. 2007 IUD Uptake 579% Higher than Jan. 2005 Baseline April 2007 Kisii IUD Initiative: 122% Increase in IUD use District Restructuring, Staff Transfers May-Jul. 2007 SupplyDemandAdvocacy

27.  Sites with peer educators/CBD agents  Provider’s perspective is that peer educators/CBD agents ↓ client fear of providers Give messages in villages and bring clients to facilities Remove myths Create a link between providers & community What Makes A Difference: Reaching the Community

28. Action was a Strong Output of Community Sessions

29.  Counseling Training - “Made us change our attitudes; we give clients all the information”  Providers identified counseling as important component of CTU and IUCD skills trainings  Intensive one-week FP counseling training  Providers seemingly made even more CPI changes What Makes a Difference: Quality Counseling -- Critical for LAPMs

30. What Makes a Difference: Facilitative Supervision: From ‘Policing’ to ‘Friendly’  “Improved Approach” in supervision: impact beyond FP  “Friendly” “Supportive” “Appreciating Work”

31. What Makes a Difference: Engage Men in Family Planning  Over 21,000 men reached in the community by peer educators  Male champions emerged  Men called into radio program  Men began talking about FP in public and with providers

32.  Demand for FP (both met and unmet) is significant and growing  FP programs need to expand by ____ in the next 10 years just to maintain current CPRs Summing up 40%

33. Summing up LAPM service programs need to be holistic, integrating  S  D  A program elements  Supply  Demand  Advocacy

34. Summing up  LAPMs are  fesa  vefeectif  eptableacc  dlabaffore  underutilized  endede  LA(P)Ms are excellent for spacing (& limiting)  safe,  effective  acceptable,  affordable,  underutilized, and  needed

35. Thank You!