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      Scaling up delivery of contraceptive implants in sub-Saharan Africa: operational experiences of Marie Stopes International

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          Abstract

          Between 2008 and 2012, Marie Stopes International (MSI) provided 1.7 million contraceptive implants in sub-Saharan Africa as part of a comprehensive method mix, primarily through mobile outreach using dedicated MSI providers and also through social franchising and MSI-run clinics. Large-scale access, quality, and informed choice were key elements of MSI's strategy.

          Abstract

          Between 2008 and 2012, Marie Stopes International (MSI) provided 1.7 million contraceptive implants in sub-Saharan Africa as part of a comprehensive method mix, primarily through mobile outreach using dedicated MSI providers and also through social franchising and MSI-run clinics. Large-scale access, quality, and informed choice were key elements of MSI's strategy.

          Abstract

          Contraceptive implants offer promising opportunities for addressing the high and growing unmet need for modern contraceptives in sub-Saharan Africa. Marie Stopes International (MSI) offers implants as one of many family planning options. Between 2008 and 2012, MSI scaled up voluntary access to implants in 15 sub-Saharan African countries, from 80,041 implants in 2008 to 754,329 implants in 2012. This 9-fold increase amounted to more than 1.7 million implants delivered cumulatively over the 5-year period. High levels of client satisfaction were attained alongside service provision scale up by using existing MSI service delivery channels—mobile outreach, social franchising, and clinics—to implement strategies that broadened access for underserved clients and maintained service quality. Use of adaptive and context-specific service delivery models and attention to key operational components, including sufficient numbers of trained providers, strong supply chains, diverse financing mechanisms, and implant removal services, underpinned our service delivery efforts. Accounting for 70% of the implants delivered by MSI in 2012, mobile outreach services through dedicated MSI provider teams played a central role in scale-up efforts, fueled in part by the provision of free or heavily subsidized services. Social franchising also demonstrated promise for future program growth, along with MSI clinics. Continued high growth in implant provision between 2011 and 2012 in all sub-Saharan African countries indicates the region's capacity for further service delivery expansion. Meeting the expected rising demand for implants and ensuring long-term sustainable access to the method, as part of a comprehensive method mix, will require continued use of appropriate service delivery models, effective operations, and ongoing collaboration between the private, public, and nongovernmental sectors. MSI's experience can be instructive for future efforts to ensure contraceptive access and choice in sub-Saharan Africa, especially as the global health community works to achieve its Family Planning 2020 (FP2020) commitments to expand family planning access to 120 million new users.

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          Most cited references 26

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          Family planning: the unfinished agenda.

          Promotion of family planning in countries with high birth rates has the potential to reduce poverty and hunger and avert 32% of all maternal deaths and nearly 10% of childhood deaths. It would also contribute substantially to women's empowerment, achievement of universal primary schooling, and long-term environmental sustainability. In the past 40 years, family-planning programmes have played a major part in raising the prevalence of contraceptive practice from less than 10% to 60% and reducing fertility in developing countries from six to about three births per woman. However, in half the 75 larger low-income and lower-middle income countries (mainly in Africa), contraceptive practice remains low and fertility, population growth, and unmet need for family planning are high. The cross-cutting contribution to the achievement of the Millennium Development Goals makes greater investment in family planning in these countries compelling. Despite the size of this unfinished agenda, international funding and promotion of family planning has waned in the past decade. A revitalisation of the agenda is urgently needed. Historically, the USA has taken the lead but other governments or agencies are now needed as champions. Based on the sizeable experience of past decades, the key features of effective programmes are clearly established. Most governments of poor countries already have appropriate population and family-planning policies but are receiving too little international encouragement and funding to implement them with vigour. What is currently missing is political willingness to incorporate family planning into the development arena.
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            Fundamental elements of the quality of care: a simple framework.

             J Bruce (2015)
            This article argues for attention to a neglected dimension of family planning services--their quality. A framework for assessing quality from the client's perspective is offered, consisting of six parts (choice of methods, information given to clients, technical competence, interpersonal relations, follow-up and continuity mechanisms, and the appropriate constellation of services). The literature is reviewed regarding evidence that improvements in these various dimensions of care result in gains at the individual level; an even scarcer body of literature is reviewed for evidence of gains at the level of program efficiency and impact. A concluding section discusses how to make practical use of the framework and distinguishes three vantage points from which to view quality: the structure of the program, the service-giving process itself, and the outcome of care, particularly with respect to individual knowledge, behavior, and satisfaction with services.
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              Family planning in sub-Saharan Africa: progress or stagnation?

              OBJECTIVE: To review progress towards adoption of contraception among married or cohabiting women in western and eastern Africa between 1991 and 2004 by examining subjective need, approval, access and use. METHODS: Indicators of attitudes towards and use of contraception were derived from Demographic and Health Surveys, which are nationally representative and yield internationally comparable data. Trends were examined for 24 countries that had conducted at least two surveys between 1986 and 2007. FINDINGS: In western Africa, the subjective need for contraception remained unchanged; about 46% of married or cohabiting women reported a desire to stop and/or postpone childbearing for at least two years. The percentage of women who approved of contraception rose from 32 to 39 and the percentage with access to contraceptive methods rose from 8 to 29. The proportion of women who were using a modern method when interviewed increased from 7 to 15% (equivalent to an average annual increase of 0.6 percentage points). In eastern African countries, trends were much more favourable, with contraceptive use showing an average annual increase of 1.4 percentage points (from 16% in 1986 to 33% in 2007). CONCLUSION: In western Africa, progress towards adoption of contraception has been dismally slow. Attitudinal resistance remains a barrier and access to contraceptives, though improving, is still shockingly limited. If this situation does not change radically in the short run, the United Nations population projections for this subregion are likely to be exceeded. In eastern Africa, the prospects for a future decline in fertility are much more positive.
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                Author and article information

                Journal
                Glob Health Sci Pract
                Glob Health Sci Pract
                ghsp
                ghsp
                Global Health, Science and Practice
                Global Health: Science and Practice
                2169-575X
                February 2014
                04 February 2014
                : 2
                : 1
                : 72-92
                Affiliations
                [a ]Global Health Consultant , Seattle, WA, USA
                [b ]Global Health Consultant , New York, NY, USA
                [c ]Marie Stopes International , Washington, DC, USA
                [d ]Marie Stopes International , London, UK
                Author notes
                Correspondence to Nomi Fuchs-Montgomery ( nomi.fuchs-montgomery@ 123456mariestopes.org ).
                Article
                GHSP-D-13-00116
                10.9745/GHSP-D-13-00116
                4168608
                © Duvall et al.

                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. To view a copy of this license, visit http://creativecommons.org/licenses/by/3.0/

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