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 SOTAAntigua, GuatemalaDecember 7, 2007

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

Context: Phaseout of USAIDFP Support in LAC

What are the key FP issues in your program?

Quality client-provider

interaction

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 informationshared

• Image of services enhanced

• Communities engaged

• Accurate informationshared

• Image of services enhanced

• Communities engaged

Fundamentalsof Care

StakeholderParticipation

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 UseIncreased Access, Quality and Use

Gender Equity

“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

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

Contraceptive Prevalence in LAC

Subregion All methods % Modern %

Total 71 62

Mexico & Central America 66 58

Caribbean 59 55

South America 75 66

Fuente: PRB, 2007

Rationales for FP - Still Valid in LAC

Reduces maternal mortality & morbidity

– LAC MMR 190/100,000: ~ 1 death per 500 births

Reduces abortion (LAC [2nd] highest in world)

Young & growing population (30% < 15): greater

need for FP in future is certain in LAC

Poverty / equity / gender / natl. development

Po

bla

ció

n

(mil

lon

es d

e p

erso

nas

)

Year

1950 166 Million

2000 513 Million

2050 808 Million

Population Growth in LAC

Peru65

58

44

20

0

10

20

30

40

50

60

70

Pill Condom Injection IUD

Discontinuation within 1 year

Source: MEASURE/DHS, Peru DHS Survey, 2004-2008.

Guatemala

51

69

56

0

10

20

30

40

50

60

70

80

Pill Condom Injection IUD

Source: MEASURE/DHS, Guatemala DHS Survey, 1999.

Suboptimal Quality & Use of FP in LAC Countries: Discontinuation

data not available

Implants

0%

Female steriliza

tion40%

IUD10%

Vasectomy1%

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)

Vasectomy0%

IUD14%

Female sterilizat

ion9%

Implants0%

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%

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?

Pregnancy Rates by Method

Typical use

“Perfect” use(but humans are imperfect)

Modern FP Methods(Absolute & Relative) Effectiveness

% Women and men continuing FP methods at one year:

Tubal ligation ~100%

Vasectomy ~100%

Implants 94%

IUD 84%

OCs 52%

Injectables 51%

Periodic abstinence 51%

Condoms 44%

Source: The ACQUIRE Project 2007. Reality √

Modern FP Methods: Satisfaction, Quality, Use

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.

$4.20

$3.86

$3.60

$6.80

$6.00

$1.01

$0.55

$0.16

0 1 2 3 4 5 6 7 8

Condoms

Depo Provera

Pills

Implanon

Jadelle

Female Sterilization

Vasectomy

IUD

US$

Commodity Cost (US$) to Health Care System Per Year of Protection, by Method

Long-Acting & Permanent Methods (LAPMs)

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!)

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?

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

LNG-IUS

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

Hot Off the Press(soon in Spanish)

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?