1. “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

2. 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

3. The What and Why of Depo-Provera?
Victoria Graham

4. 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

5. 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.

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

7. Injectable contraceptive use as % of modern method use
among women aged 15-49, married or in union, 2007
Percentages
> 60
>
>
>
>
>
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

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

9. 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
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+

10. 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!!

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

12. 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.

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

14. 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.

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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.”

21. III. Where do we go from here?

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

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

27. Depo SubQ and Uniject

28. 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 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

29. 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

30. Home Injection of Depo

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

32. 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

33. Thank You !