1. Plugging the Leaking Bucket
Ramakrishnan Ganesan
March 4, 2016
Good morning! My name is Ram Ganesan and I work with Abt Associates.
Thank you for coming to this session, titled PLUGGING THE LEAKING BUCKET. This session focuses on use of mHealth to address contraceptive discontinuation.
Before I start, could we do a quick show of hands, please? How many of you are currently managing family planning projects? Thank you!

2. The Leaking Bucket phenomenon
Anrudh Jain of the Population Council used the analogy of the ‘Leaking Bucket’ to draw attention to the contraceptive discontinuation. FP programs aim to reach women who want to regulate their fertility, but are not using contraception. Most programs address this “unmet need” by helping these women to initiate contraceptive use—opening the tap to fill the bucket with water.
Yet many users of reversible contraception stop using their method and leave the pool of current users, just like the water leaking through the hole in the bucket.
Clearly, programs must not only ‘open the tap’, but must also minimize leakage from the bucket. A simple and effective analogy to draw our attention to discontinuation.

3. Why do users discontinue?
Pause here. Elicit responses from the

4. Reasons for contraceptive discontinuation
Not in need
In need, stopped
In need, switched
Wants to become pregnant
Infrequent sex / partner away
Infecund
Failure (became pregnant during use)
Health concerns / side effects
Method related factors
Cost, access issues
Opposition (partner, family, religion)
Switched to a more effective or less effective method?
Of these three groups, whom should we be more concerned about?
Purpose of family planning programs is to help people achieve their reproductive goals. So, #1 is not a concern. Neither is group #3 – they are using another method. #2 is at risk of unwanted/unplanned pregnancy
Sometime or the other, all of us have bought a product that did not meet our expectations. What do we do then?

5. Case study
A telephone-based mechanism to improve contraceptive continuation
For users of DMPA – a 3-month, progestin only, injectable contraceptive

6. About DMPA A three-month injectable contraceptive
Effective and easy to use
Very safe, can be used by lactating women
Causes changes in monthly bleeding, delayed return to fertility

7. DMPA in India A “new” method Not available in the public sector
Available through private sector doctors for just over a decade
Low use rates (~ 1%): Low community knowledge of the product
Nearly 80% of women discontinue using the method within the first year, mostly after the 1st injection

8. Why is the discontinuation rate so high?

9. Mystery client surveys show high quality of counseling

10. Formative research findings
Women need confirmation / reassurance when experiencing the effects
Many of those concerned about the side effects they are experiencing do not return to their doctor
Real and opportunity costs, distance, waiting time at clinic
Some forget when the next injection is due, and go late

11. Potential ways to reassure and remind
Communication route
In-person follow-up
Mass media
Moblie phone
Advantages
Personal touch,
Interactive
Dis-advantages
Could be intrusive
Low scale
High reach,
ease of management
Not targeted, could increase health concerns
Interactive
High reach
Technology, connectivity limitations

12. The mHealth mechanism
Call-back to new adopters of DMPA who own mobile phones
Voice calls preferred over text messages (SMS)
Outsourced to a call center
Monthly training and on- site mentoring by the project team

13. Call-back elements
DMPA users call to enroll
Reassurance call: 22 days from 1st injection
Users can request additional call-back at any time by giving a “missed call”
Reminder calls before subsequent injections are due
Follow-up through the first year of use

14. Promoting enrollment Promoted as a “careline”
DMPA users call a toll-free number to enroll
Careline promoted in clinics offering DMPA; recommended by doctors and paramedics to their clients

15. First year continuation rates
38%
of DMPA users who received support from the Careline
continued using the method for a year
compared to 23% observed in an earlier survey

16. Factors to consider in adopting this approach
Reason for discontinuation and underlying cause
Importance of interactive communication
Acceptability of receiving calls on contraception
Ownership rates? Is it a family phone or the client’s individual’s phone? Do people switch service providers / phone numbers often?
Infrastructure available: Can we use an existing call center, or do we need to set up one?

17. Questions?
Ramakrishnan Ganesan