1. Paying More Than Lip Service to Long-Acting and Permanent Methods Paying More Than Lip Service to Long-Acting and Permanent Methods Nicholas Kanlisi John M. Pile Alyson Smith USAID Mini-U October 27, 2006

2. In the developing world, LAPMs account for what percentage of all methods use among currently married women? Pop-Up Quiz

4. So Einstein, if 2 out of 3 couples are already using LAPMs, why do we have to give them more than lip service?

6. LAPM use as percent of all method use, CMWRA Though globally LAPM use is high, there is wide regional and country variations

7. Need for Family Planning Percent MWRA with unmet need More than 100 million women—17% of currently married women— would prefer to avoid a pregnancy, but are not using contraception

8. Successful initiatives to introduce/ strengthen LAPM service delivery require behavior change LAPMs are more difficult to deliver than short-acting methods –Many more myths and rumors –Provider dependent –Require community referrals –Benefits are not recognized due to lack of in-depth knowledge Behavior change is necessary prior to delivery by providers and adoption by clients It is a challenge to communicate behavior change and services for LAPMs

9. Not so subliminal messages… Taking a holistic approach that pays attention to supply, demand and advocacy program elements The fundamentals of care –Informed decision-making, clinical safety, and quality assurance and management Data for decision-making Participatory programming –Fostering ownership and sustainability Identification, adaptation and use of proven, or “best,” practices

10. Case # 1: Supply-Side Barriers to Norplant Introduction in Ghana Norplant ® was introduced in Sub-Saharan Africa in the early 1990s with high hopes that it would provide an option for couples who did not want or did not have access to sterilization or who were not satisfied with other long-acting methods, such as the IUD.

11. Case # 1: Norplant Introduction in Ghana However, a decade later, Norplant ® use remains low throughout the region. Prevalence is <1% in all but two countries—Ghana and Kenya. In most countries, awareness of the method is significantly less than that of other hormonal methods (e.g., pills, injectables). In many countries, access has been unnecessarily limited by restricting insertions/removals to physicians. Many programs/sites have been plagued by limited supplies and stockouts. In many countries, clients have had difficultly accessing removal services.

12. Case # 1: Norplant Introduction in Ghana Given what you’ve heard this morning, if you had been tasked to introduce implants in Ghana, how would you go about it?

13. Strategy for introduction of Norplant ® Commodities Regulatory Approval Provider Education Quality Assurance Financing TrainingClient IEC MIS

14. Case # 1: Norplant Introduction in Ghana Policy Environment: who can provide implant services? –Only doctors could provide Norplant –A policy change was needed so nurses could provide –Managers saw benefit of shifting services from doctors to nurses Reduced doctor workload Motivated nurses to provide new services Shorter client waiting times Services more accessible to clients Early stakeholder involvement –Regional health administrators –Teaching hospitals –Lead to increased ownership and greater commitment

15. # Norplant® sites # Norplant® insertions Case # 1: Norplant Introduction in Ghana Shifting services from doctors to nurses, had a positive impact An estimated 44,000 women are currently using Norplant ®. Prevalence of the method increased 10- fold, from 0.1% in 1998 to 1% in 2003, and an estimated 1.2% in 2006

16. Case # 2: Demand-Side Barriers to Vasectomy in Sub-Saharan Africa Researchers have suggested that vasectomy is unacceptable to most African men and probably will long remain so. However, similar predictions in the late 1980s that female sterilization would never be an acceptable method proved unfounded. Thirty years ago, “experts” and providers said that men in Latin America would never accept vasectomy—and they have been proven wrong. Vasectomy use in Latin America has increased nearly four-fold in the past 10 years.

17. Vasectomy in Ghana—Knowledge Vasectomy suffering from lack of awareness/knowledge Much of the awareness is negative and consists of false myths and rumors –How do you increase vasectomy uptake when vasectomy is perceived as castration? Vasectomy acceptors are very satisfied

18. Vasectomy in Ghana—Providers Limited number of providers trained Providers have biases. They frequently: –Lack knowledge, are misinformed, or have a personal dislike of the method –Are used to working with women and may not be comfortable with or know how to talk to men or how to provide them services –Have untested presumptions about what men think and want

19. Case # 2: Vasectomy in Sub-Saharan Africa Given what you’ve heard this morning, if you had been tasked to introduce/scale up vasectomy in Ghana, how would you go about it?

20. Gaps Demand v Low knowledge v Misinformation Supply v Less available v Provider ‘bias’ Interventions Demand v Media Campaign v Community outreach Supply v Clinical/counseling training in NSV v Create ‘male-friendly’ services A Strategy for a Successful Vasectomy Program

21. Ghana Campaign: Marketing Approach Several channels used to deliver messages Messages relevant to men’s actual concerns Satisfied vasectomy clients used to recruit new clients Messages also targeted to women and the general public Click the button for one of two spots run on National TV.

22. Hotlines allowed men (and women) to ask questions anonymously. ~30 calls were made per week. Calls showed a need for basic information on the procedure and to counter myths. –Nine out of 10 callers wanted basic information. –Over half raised myths/misconceptions. Seven out of 10 callers asked where they could go for the procedure. One out of six asked about the cost.

23. In the first six weeks of the campaign the number of vasectomies performed surpassed the total for the last fiscal year. In 2005 the number of procedures dropped to the pre-campaign levels. Plans are in place to repeat the media spots in 2007 as periodic promotion is needed in settings where awareness is low and myths abound ? Persistence will yield results

24. Lessons Learned Every context is different –Supply-side factors can present the major obstacles in some settings, while in others demand-side factors such as myths and rumors are the biggest barrier Programming for LAPM requires selling more than a product –It requires changing behavior at every level (provider, client, community) –Individual realities and perceptions matter People act on perceived benefits LAPM programs can have successful results and contribute to a more balanced method mix

25. Pearls “Marketing” LAPM requires supporting behavior change and promoting services, not just selling a product No access, no equipment, no trained provider, no product, no services, no program Persistence –The wasp says that making several regular trips to the mud pit enables it to build a house.” (Ewe proverb)