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