1. FP: What’s New, What’s Hot, What’s Not: Considerations for Maximizing FP Access and Quality in LAC Roy Jacobstein, M.D., M.P.H. LAC HPN SOTA Antigua, Guatemala December 7, 2007

2. Context: Modern Method FP Access, Quality and Use in LAC LAC most advanced region –Most countries: high modern CPR, but low use in: Haiti (23%), Guatemala (31%), Bolivia (35%), Peru (46%) –High unmet need: Haiti: 40%; Guatemala & Bolivia: > 20% Suboptimal quality / use patterns Equity differentials in access & use USAID phasing support down / out

3. Context: Phaseout of USAID FP Support in LAC What are the key FP issues in your program?

4. Quality client-provider interaction Leadership and champions fostered Supportive service policies promoted Human and financial resources allocated Leadership and champions fostered Supportive service policies promoted Human and financial resources allocated 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 Communities engaged Accurate information shared Image of services enhanced Communities engaged Fundamentals of Care Stakeholder Participation Holistic Programming: Key to Quality, Access, Use of FP Services Data for Decision Making Increased knowledge + acceptability Increased availability Improved policy + program environment DemandSupply Advocacy Increased Access, Quality and Use Gender Equity

5. “Degree to which services can be obtained at effort & cost acceptable to a (potential) client, & within her means” Access barriers prevent even motivated clients from using services “Hard enough, not enough”: Programs must go beyond difficult challenge of increasing availability of commodities, equipment & supplies, & of skilled providers, to address the many access barriers Especially a challenge with clinical services – but these are the most effective FP, the most needed, & the most underutilized in LAC Considerations: FP Access

6.  Cognitive barriers  Socio-cultural barriers  Geographic barriers  Financial barriers (Cost / Affordability)  Health care system barriers  Contraceptives, equipment, supplies  Provider-level factors  Structure / organization of work  Medical (policy & practice) barriers Many Types of FP Access (and Quality) Barriers in LAC

7. Contraceptive Prevalence in LAC SubregionAll methods %Modern % Total7162 Mexico & Central America6658 Caribbean5955 South America7566 Fuente: PRB, 2007

8. Rationales for FP - Still Valid in LAC Reduces maternal mortality & morbidity –LAC MMR 190/100,000: ~ 1 death per 500 births Reduces abortion (LAC [2 nd ] highest in world) Young & growing population (30% < 15): greater need for FP in future is certain in LAC Poverty / equity / gender / natl. development

9. Población (millones de personas) Year 1950 166 Million 2000 513 Million 2050 808 Million Population Growth in LAC

10. Peru Discontinuation within 1 year Source:MEASURE/DHS, Peru DHS Survey, 2004-2008. Guatemala Source:MEASURE/DHS, Guatemala DHS Survey, 1999. Suboptimal Quality & Use of FP in LAC Countries: Discontinuation data not available

11. Nicaragua FP method use by limiters (65% of total MWRA) Source:MEASURE/DHS, Nicaragua DHS Survey, 2001. Bolivia Source:MEASURE/DHS, Bolivia DHS Survey, 2003. FP method use by limiters (71% of total MWRA) Suboptimal Quality, Access & Use of FP in LAC: Fit With Intentions Resupply methods / traditional methods / non-use 77% Resupply methods / traditional methods / non-use 49%

12. Poor Fit Between FP Method Use & Reproductive Goals — Why? In your experience, what are the main reasons for this discontinuation and poor fit in your country? –Reasons at client level? –Reasons at provider level? –Reasons at program level? Is this problem recognized in your country? If so, what is being done by the program / health system?

13. Pregnancy Rates by Method Typical use “Perfect” use (but humans are imperfect) Modern FP Methods (Absolute & Relative) Effectiveness

14. % Women and men continuing FP methods at one year: Tubal ligation~100% Vasectomy~100% Implants94% IUD84% OCs52% Injectables51% Periodic abstinence51% Condoms44% Source: The ACQUIRE Project 2007. Reality √ Modern FP Methods: Satisfaction, Quality, Use

15. Modern FP Methods: Cost Effectiveness (& Access) Source: UNFPA 2005. Achieving the ICPD Goals: Reproductive Health Commodity Requirements 2000-2015. Assumes IUD and Jadelle used for 3.5 years; Implanon for 3 years; and female sterilization and vasectomy for 10 years. Commodity Cost (US$) to Health Care System Per Year of Protection, by Method

16. Long-Acting & Permanent Methods (LAPMs)

17. LAPMs: Good Choices for People Very wide eligibility: almost all can use Meet needs of many categories / most women: –Spacers & delayers (HSTP), as well as limiters –Younger / older –Postpartum / post-abortion –HIV-infected women and PLWA Very convenient (one act confers long protection) Highly effective (why they want FP!)

18. LAPMs: Good Methods for Health Systems, but … Meet clients’ needs / provide choice Reduce burden on other health services: –FP (re-supply clients); obstetric/maternity / pediatric The most cost-effective FP — over time, but –Higher upfront costs –Higher continuous program effort needed (costs) –Programs often lack will or resource to provide LAPMs –Even harder in HSR, phaseout –What have you and your country program counterparts tried?

19. New Developments in FP: Implants Popular if cost not an issue & skilled providers available New USAID price for implants (Jadelle: $20.80) Da Hua Pharmaceutical / Shanghai: Sinoplant: –Same characteristics as Jadelle –Cost: wholesale ~$4.80, sells / will sell for ~$7 –5.3 million in China & Indonesia –FHI partnering for registration in 14 countries / Gates Potential impact: modeling: avert 26,000 unwanted pregnancies in 100,000 OC users

20. LNG-IUS

21. ICA Foundation: Free Subsidized LNG-IUS Partnership: Bayer Schering & Population Council Gives combination of donations (free) & sales at public sector price of US$40 per IUS Projects in LAC in Brazil, Ecuador, El Salvador Who can apply for a donation?: public health organizations (public & private sector), NGOs For more information: –ICA Foundation, PO Box 581, FI-20101 Turku, Finland –Website: http://www.ica-foundation.org

22. Hot Off the Press (soon in Spanish)

23. What Can USAID Do to Help? What May Have Biggest Payoff? In light of information discussed today, & USAID phasedown / phaseout in your country: What do you think can / should be done by the FP program in your country to meet current & future needs? What can USAID do to help?