save lives, alleviate poverty, spur development: invest in lapm services roy jacobstein, m.d.,...

Save Lives, Alleviate Poverty, Spur Development:

Invest in LAPM Services

Roy Jacobstein, M.D., M.P.H.

John M Pile, M.P.H.

Fredrick Ndede, M.B.,Ch.B. (NBI), MMed. (Ob/Gy)

Joan Taylor

The ACQUIRE Project/EngenderHealth

7th Annual Global Health Mini-UniversityOctober 5, 2007

Three Compelling Rationales for Family Planning:

Health

Program (health system)

Development

Health Rationale

1 maternal death for every ~ 110 births in Africa

1 in 16 lifetime risk of maternal death in Africa

~ 250,000 women’s lives could be saved, each yr

200,000 infants saved, annually, with >2-yr spacing

Reduces vertical HIV transmission (more than ARVs)

Program Rationale

Unmet need for FP is very high:

Only 14% of women in Africa uses modern FP

1 of every 3 women in Africa has unmet need

1 of every 4 in Asia and LAC has unmet need

Effective FP services reduce system costs

350 million people have limited access to FP

1.5 billion more people by 2025

500 million in South Asia

450 million in Africa (will ↑ 60% in < 20 years)

75% of sub-Saharan Africa now living on <$2/day

Just to maintain current rates of contraceptive use, services need to expand 40%

Critical to national development

Development Rationale

Outline of Presentation

1. The case for long-acting and permanent contraception (LAPM)

2. A holistic program model for LAPM services

3. The program model in action

The Case for LAPMs

The most effective FP methods

995-999/1000 do not get pregnant

Very safe (minor complications <10%; major, rare)

Long duration of effectiveness (up to 3-12 yrs)

Positive Method Characteristics

Language Conditions Thought

What is the difference between

“Long-acting” and “Long-term”?

Good for People

Meet needs of many categories of users

Very wide eligibility: almost all can use Spacers / limiters / delayers Younger / older Postpartum / post-abortion HIV-infected women and PLWA

Convenient (one act confers long protection)

Highly effective (why they want FP!)

Pregnancy Rates by Method

Highly Effective

Good for Health Systems

Meet clients’ needs / provides choice

Reduce burden on other health services: FP (re-supply clients)

Obstetric/maternity (unwanted births, abortions)

HIV (PMTCT)

Pediatric

The most cost-effective FP

% Women and men using FP methods at one year:

Condoms 44%

Periodic abstinence 51%

Injectables 51%

OC pills 52%

IUD 84%

Implants 94%

Tubal ligation 100%

Vasectomy 100%

Source: The ACQUIRE Project 2007. Reality √

Low Discontinuation Rates

Source: UNFPA 2005. Achieving the ICPD Goals: Reproductive Health Commodity Requirements 2000-2015.

0

5

10

15

20

25

At FirstVisit

After 1Year

After 2Years

After 3years

After 4years

After 5years

US

$

Condoms

Pills

Depo

Noristerat

IUCD

Jadelle

Norplant

Fem. Ster.

Vasectomy

Comparison of Annual Contraceptive Commodity Costs, Short-acting, Long-acting, & Permanent Methods, Per Year of Use

Cost-Effective

1. The case for long-acting and permanent contraception (LAPM)

2. A holistic program model for LAPM services

3. The program model in action

Outline of Presentation

Quality client-provider

interaction

Quality client-provider

interaction

• Supportive service policies promoted• Human and financial resource allocation fostered• Gender equity advanced

• Supportive service policies promoted• Human and financial resource allocation fostered• Gender equity advanced

• 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 informationshared

• Image of services enhanced

• Communities engaged

• Accurate informationshared

• Image of services enhanced

• Communities engaged

Fundamentalsof Care

StakeholderParticipation

Data for Decision Making

DemandSupply

Advocacy

Increased knowledge Increased knowledge + acceptability+ acceptability

Increased availabilityIncreased availability

Improved policy + program environmentImproved policy + program environment

to into in ““More More MoreMore More More Services People Places”Services People Places”

Increased Access, Quality and UseIncreased Access, Quality and Use

Outline of Presentation

1. The case for long-acting and permanent contraception (LAPM)

2. A holistic program model for LAPM services

3. The program model in action

The Model in Action: Kisii IUD Initiative

National effort to revitalize IUD IUD prevalence ↓ from

4.2 [‘93] to 2.4 [‘03]

IUD share of modern method use ↓ from 21% [‘89] to 8% [‘03]

Kisii District, Nyanza Province, Western Kenya

LAPMs Underutilized Despite Need in Kenya:

Contraceptive methods and limiting

Injectables35%

Pills17%

Condoms3%Traditional

17%

Sterilization

17%

IUD6%

Implants5%

Source: MEASURE/DHS, Kenya DHS Survey, 2004.

Using to limit: LAPMs (28%)

Long-Acting and Permanent Methods

%

LAPMs Underutilized Despite Need in Kenya:

Contraceptive methods and spacing

Pills18%

Condoms10%

Traditional25%

Injectables39%

IUD4%

Implants4%

Source: MEASURE/DHS, Kenya DHS Survey, 2004.

%

Long-Acting and Permanent Methods

Using to limit: LAPMs (8%)

GapsDemandDemand Low knowledge Misinformation

SupplySupply Less available Providers’ not comfortable

providing

InterventionsInterventionsDemandDemand Media Campaign Community outreach/participation

SupplySupply Ensuring readiness of sites to

provide services Clinical/counseling training

AdvocacyAdvocacy Eligibility Where provided

AdvocacyAdvocacy Guidelines revised Services expanded to health

centres and dispensaries

Supply, Demand and Advocacy

The Model in Action: Kisii IUD Initiative

Providers trained CTU/Basic FP

counseling: 51 IUD Insertion and

Removal: 28 Comprehensive Family

Planning Counseling: 18

Sites Upgraded (equipment): 13

Primary:Women 25-45

Reaching the Community

IEC materials900 posters6000 brochures10,000 leaflets

Community Outreach72 Peer Educators

375 CBD Agents

Mass MediaRadio spots &

interviewsNational and local radio

station spots over 5 months

Secondary: Their

partners

Experiential4 Roadshows –11,000 peopleLadies Clubs, Men’s barazas

Fahamu ukweli wa mambo

“Now you know the truth”

Promotional Campaign Message: Promotional Campaign Message: “Stand Up”“Stand Up”

0% 20% 40% 60% 80%

Radio

Doctor/Nurse

Posters

Friend

Men Women

Post-campaign Household Survey: 45% reported exposure to

IUD messaging

Stakeholder Meeting Feb. 05

CTU Trainings Aug. & Sept. 05

IUD Clinical Skills

Training Oct. 05

December is historically a slow

month for FP clients – IUD

trained providers were on holiday – Increased Uptake

in Jan. 06

CBD Agent and Peer Ed. Training April

& May 06

IUCD Campaign

Launch July 06

FP Counseling Training &

TOT for CBD Supervisors

Feb. 06

PNA May 05

2nd IUD Skills TrainingOct. 06

Project Ends

Dec. 2006 Depo

StockoutJan.-Feb.

2007

IUD Uptake 579% Higher than Jan. 2005 Baseline

April 2007

Kisii IUD Initiative:122% Increase in IUD use

District Restructuring, Staff TransfersMay-Jul. 2007

Supply Demand Advocacy

Sites with peer educators/CBD agents Provider’s perspective is that

peer educators/CBD agents

• ↓ client fear of providers

• Give messages in villages and bring clients to facilities

• Remove myths

• Create a link between providers & community

What Makes A Difference: Reaching the Community

Action was a Strong Output of Community Sessions

0%

10%

20%

30%

40%

50%

60%

70%

got printmaterials

went/madeplans foranothersession

went healthfacility

talked partner talked friend/family

Counseling Training - “Made us change our attitudes; we give clients all the information”

Providers identified counseling as important component of CTU and IUCD skills trainings

Intensive one-week FP counseling training

Providers seemingly made even more CPI changes

What Makes a Difference: Quality Counseling -- Critical for

LAPMs

What Makes a Difference:Facilitative Supervision: From ‘Policing’ to

‘Friendly’

“Improved Approach” in supervision: impact beyond FP

“Friendly” “Supportive” “Appreciating Work”

What Makes a Difference: Engage Men in Family Planning

Over 21,000 men reached in the community by peer educators

Male champions emerged Men called into radio program

Men began talking about FP

in public and with providers

Demand for FP (both met and unmet) is

significant and growing FP programs need to expand by ____ in the

next 10 years just to maintain current CPRs

Summing up

40%

Summing up

LAPM service programs need to be holistic,integrating

S

D

A

program elements

Supply

Demand

Advocacy

Summing up

LAPMs are fesa

vefeectif

eptableacc

dlabaffore

underutilized

endede

LA(P)Ms are excellent for spacing (& limiting)

safe,

effective

acceptable,

affordable,

underutilized, and

needed

Thank You!