“Bringing it Home” Taking Family Planning Services to the Community Good afternoon, I am Victoria Gaham, I work in the Office of population and reproductive health at USAID here in Washington, DC. This is John Stanback, a Senior Researcher at Family Health International in North Carolina with expertise in reaching the issues of community-based distribution of Depo Provera. We are so glad that you have joined us to learn more about what is going on in the world of community-based distribution of Depo Provera. Over the years, there have had many groups and various organizations who have worked to expand the availability of Depo-Provera. USAID has been a significant supporter of many programs, but we are not the only donor working in this area. John Stanback here is a representative of FHI he will be sharing his experiences with us. But, FHI is one of our many partners with whom we are working to expand Depo-Provera - we work with community-based organizations, non-profits, and for-profits who are working on this as well. Do any of you represent those organizations? We hope in the future there will be many more of you joining us, because that is the way to move this forward - increase our partners. September 9, 2009 Victoria Graham, USAID/GH John Stanback, PROGRESS Project, FHI 2009 Global Health Mini University Washington, DC

SESSION OUTLINE The What and Why of Depo-Provera? What is the Priority? What are we doing? What is the future? Where are we headed? Discussion

The What and Why of Depo-Provera? Victoria Graham

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 From UN population Division 2007: 35.6 million injectable users worldwide. The majority reside in the less developed countries. By far the most popular is DMPA. Significantly less use the once-a-month injectable and even less use NET-EN. Contrast this to implants – there are about 3 million implant users – Of course, this number may change with the introduction of SinoPlant

What is Depo Provera? Safe for nearly all women 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 Safe for nearly all women The most widely used Progestin-only injectable contraceptive It is highly effective - 99% effective in women obtaining injections in a timely manner. Administered as an intramuscular Injection (IM) Fertility resumes after 4 months on average after injections are stopped.

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

Injectable contraceptive use as % of modern method use among women aged 15-49, married or in union, 2007 Percentages > 60 >50 - 60 >40 - 50 >30 - 40 >20 - 30 >10 - 20 0 - 10 No data Injectables represent a significant % of contraceptive use in Western and central Africa Madagascar, Mozambique, Ethiopia, Erythrea Papua New Guinea, Myanmar Afghanistan Source: UN, World Contraceptive Use 2007

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

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/globalatlas/default.asp WHO Global Atlas of the Health Workforce has information by country and by profession – the database is still being populated – for some countries data is incomplete Distribution of Health workers by type of worker (dentist, physician, nurse, midwives) - urban/rural Gender of health workers – M/f Age 0-29; 30-49; 50+

Density of HCWs/1000 population So, where are we in reaching the 2.5 health worker minimum per 1000 in some of our key African countries? Let’s take a look None of these – Nigeria who has the highest proportion of nurses per 1000 comes up shy of the 2.5. Look at Rwanda – even when the community health workers are counted it doesn’t meet the Sorry, to the physicians in the room, but if we were to take you out of the calcualtion – it doesn’t make any difference!!

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

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.

What is the Priority? What are we doing? John Stanback

Strategies for Increasing Access to Depo-Provera Increased access at clinics or outposts Outreach or mobile services Pharmacy sales of injectable contraceptives Subsidized sales Fully commercial models Administration of injectables by a trained Pharmacist Administration by Community Health Workers* There are several approaches to increasing access to Depo-provera at the community level. Today we will focus primarily on the last strategy – Community Health Worker administration of Depo-Provera. At this time, this is one of the most promising strategy to significantly increase access to this method. While we focus on injectables we also need to be mindful that injectables should be given in the context of other methods. Remember that our programs provide a variety of methods and informed choice.

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 Lack of agreements on standards Availability and functioning distribution channels MOH concerned about introducing practices in the commnities whichthey are uncertain. They do not want a backlash were smething bad to happen. Health providers feel they are encroacing on their professional status. Agreements on standards educational level of providers, training requirements, policy guidelines, introduction strategies

Goal: Reach the Tipping Point For a New Standard of Practice So, how are we doing? Task Shifting or Task Sharing are terms that we use for this practice. Significantly increase women’s access to Depo-proera Appropriate strategy for researching underserved rural and urban populations – distance from facility Very logical for us to say – what options do you have? It will require changes in national policy to permi ttrained provider to administer IM – often there is resistance to this. MOH recognize community-based workers as providers of Depo Provera

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 SAHARA EGYPT MAURITANIA MALI ERITREA SENEGAL THE SUDAN GAMBIA DJIBOUTI BURKINA FASO GUINEA GUINEA BISSAU BENIN NIGERIA COTE TOGO ETHIOPIA SIERRA DTVOIRE GHANA LEONE AFRICAN LIBERIA REPUBLIC CAMEROON DEMOCRATIC UGANDA SOMALIA EQUATORIAL REP. OF KENYA GUINEA THE REPUBLIC GABON CONGO OF THE CONGO RWANDA BURUNDI Let’s take a look at Africa in 2004 – There was one country … There were no countries where policy had been implemented. ANGOLA TANZANIA MALAWI ANGOLA ZAMBIA MOZAMBIQUE MADAGASCAR ZIMBABWE Updated: 9/30/2004 NAMIBIA BOTSWANA LESOTHO SWAZILAND SOUTH AFRICA

Status and Opportunities for Expansion and Scale-up of CBD of Depo-Provera 2009 TUNISIA MOROCCO SAHARA ALGERIA MAURITANIA MALI NIGER LIBYA CHAD EGYPT SUDAN ETHIOPIA DJIBOUTI ERITREA SOMALIA KENYA TANZANIA DEMOCRATIC CENTRAL RWANDA GABON EQUATORIAL CONGO NIGERIA BENIN 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 REP. OF TOGO D’VOIRE COTE BURKINA FASO GAMBIA BISSAU SOUTH AFRICAN 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 Updated 9/15/2009

Meeting held at WHO, Geneva Technical Consultation, Expanding Access to Injectable Contraception, June 2009 Meeting held at WHO, Geneva Convened by WHO, USAID, and FHI 30 experts from 8 countries and 18 organizations Experts reviewed scientific evidence and programmatic experience of community-based provision, with focus on DMPA

Technical Consultation, Expanding Access to Injectable Contraception, June 2009 Overall Conclusions “Evidence supports the introduction, continuation, and scale-up of community-based provision of progestin-only injectable contraceptives.” “Provision by appropriately trained community health workers is safe, effective, and acceptable.”

III. Where do we go from here?

Changing Environment Uniject – a potential game-changer Implants (sino-plant) – an unknown factor Government transitions and changing priorities

Where is CBD of Depo going? Scale-up of CBD of Depo Subcutaneous Depo and Uniject Social Marketing of Depo Home injection of Depo

Depo SubQ and Uniject

Comparable Commodity Cost Technologies 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? Autodisable – IM syringes. Unlike conventional disposable syringes, the AD syringe cannot be reused because it inactivates after a single use. WHO recommends AD syringes for all contraceptive injections. Purchased in bulk, AD syringes cost approximately US$0.06 each, about $0.02 apiece more than conventional disposable syringes. USAID began including the AD syringes with all shipments of DMPA in 2002. Uniject: its single-use, prefilled, nonreusable syringe. Uniject would allow community health workers to provide the injections or women to give themselves the injections. In Brazil a study found that about two-thirds of participants agreed to receive training, and to use Uniject to self-administer a monthly injectable contraceptive. Of these 56 women, 93% correctly self administered the injectable, and 57% preferred self-injection at home over going to a clinic each month. PATH which developed and patented Uniject, licensed the Uniject technology to Becton Dickenson (BD) in 1996 cost-saving when the wastage rate for multidose vials is greater than 33% subQ: FDA 2004. Injected into the tissues just under the skin with a finer, shorter needle than for conventional DMPA. As a result, providers giving DMPA-SC injections require less training than is needed for conventional DMPA. Effectiveness and reported side effects are similar. Available only in a pre-filled Uniject syringe. Pfizer is currently negotiating an agreement with PATH and BD to distribute DMPA-SC in the Uniject syringe to developing countries, with USAID support. In sum, I hope that I’ve provided you with a reasonable overview of the history, research, and rationale for promoting this option widely – particularly in Africa. There is demonstrated success. It works. It’s acceptable. It’s getting easier. Let’s scale it up. Comparable Commodity Cost DMPA - $3.88 per CYP NET-EN - $6.30 per CYP OCs - $3.00 per CYP http://www.infoforhealth.org/injectables/program_mgrs/index.shtml#EstimatingCost http://www.infoforhealth.org/pr/k6/index.shtml

Uniject Components Blister Valve Hub Needle Cap Size varies with drug or vaccine Valve Prevents re-use by resisting refilling through needle Hub Needle Size varies with drug or vaccine Cap

Home Injection of Depo

Would you prefer getting Depo… From a clinic 34% From a CBD 22% Not sure 19% By self-injecting at home 24%

Moving Forward Be champions for Task Shifting – CBA of DMPA Influencing policy change at the country level Working with other donors on CBA of DMPA Links with other sectors to introduce CBA of DMPA

Thank You !