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      Rapid Contraceptive Uptake and Changing Method Mix With High Use of Long-Acting Reversible Contraceptives in Crisis-Affected Populations in Chad and the Democratic Republic of the Congo

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          Abstract

          Offering a broad choice of contraceptives can rapidly expand use in crisis-affected settings, particularly when the choice includes long-acting reversible contraceptives (LARCs). Over 5 years, the governments of Chad and the Democratic Republic of the Congo, with support from an NGO, provided nearly 85,000 new clients with contraceptives. LARC users, which included an increasing number of IUD users, accounted for 73%.

          Abstract

          Offering a broad choice of contraceptives can rapidly expand use in crisis-affected settings, particularly when the choice includes long-acting reversible contraceptives (LARCs). Over 5 years, the governments of Chad and the Democratic Republic of the Congo, with support from an NGO, provided nearly 85,000 new clients with contraceptives. LARC users, which included an increasing number of IUD users, accounted for 73% of the new clients.

          ABSTRACT

          The global health community has recognized that expanding the contraceptive method mix is a programmatic imperative since (1) one-third of unintended pregnancies are due to method failure or discontinuation, and (2) the addition of a new method to the existing mix tends to increase total contraceptive use. Since July 2011, CARE has been implementing the Supporting Access to Family Planning and Post-Abortion Care (SAFPAC) initiative to increase the availability, quality, and use of contraception, with a particular focus on highly effective and long-acting reversible methods—intrauterine devices (IUDs) and implants—in crisis-affected settings in Chad and the Democratic Republic of the Congo (DRC). This initiative supports government health systems at primary and referral levels to provide a wide range of contraceptive services to people affected by conflict and/or displacement. Before the initiative, long-acting reversible methods were either unknown or unavailable in the intervention areas. However, as soon as trained providers were in place, we noted a dramatic and sustained increase in new users of all contraceptive methods, especially implants, with total new clients reaching 82,855, or 32% of the estimated number of women of reproductive age in the respective catchment areas in both countries, at the end of the fourth year. Demand for implants was very strong in the first 6 months after provider training. During this time, implants consistently accounted for more than 50% of the method mix, reaching as high as 89% in Chad and 74% in DRC. To ensure that all clients were getting the contraceptive method of their choice, we conducted a series of discussions and sought feedback from different stakeholders in order to modify program strategies. Key program modifications included more focused communication in mass media, community, and interpersonal channels about the benefits of IUDs while reinforcing the wide range of methods available and refresher training for providers on how to insert IUDs to strengthen their competence and confidence. Over time, we noted a gradual redistribution of the method mix in parallel with vigorous continued family planning uptake. This experience suggests that analyzing method mix can be helpful for designing program strategies and that expanding method choice can accelerate satisfying demand, especially in environments with high unmet need for contraception.

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          Trends in contraceptive need and use in developing countries in 2003, 2008, and 2012: an analysis of national surveys.

          Data for trends in contraceptive use and need are necessary to guide programme and policy decisions and to monitor progress towards Millennium Development Goal 5, which calls for universal access to contraceptive services. We therefore aimed to estimate trends in contraceptive use and unmet need in developing countries in 2003, 2008, and 2012 . We obtained data from national surveys for married and unmarried women aged 15-49 years in regions and subregions of developing countries. We estimated trends in the numbers and proportions of women wanting to avoid pregnancy, according to whether they were using modern contraceptives, or had unmet need for modern methods (ie, using no methods or a traditional method). We used comparable data sources and methods for three reference years (2003, 2008, and 2012). National survey data were available for 81-98% of married women using and with unmet need for modern methods. The number of women wanting to avoid pregnancy and therefore needing effective contraception increased substantially, from 716 million (54%) of 1321 million in 2003, to 827 million (57%) of 1448 million in 2008, to 867 million (57%) of 1520 million in 2012. Most of this increase (108 million) was attributable to population growth. Use of modern contraceptive methods also increased, and the overall proportion of women with unmet need for modern methods among those wanting to avoid pregnancy decreased from 29% (210 million) in 2003, to 26% (222 million) in 2012. However, unmet need for modern contraceptives was still very high in 2012, especially in sub-Saharan Africa (53 million [60%] of 89 million), south Asia (83 million [34%] of 246 million), and western Asia (14 million [50%] of 27 million). Moreover, a shift in the past decade away from sterilisation, the most effective method, towards injectable drugs and barrier methods, might have led to increases in unintended pregnancies in women using modern methods. Achievement of the desired number and healthy timing of births has important benefits for women, families, and societies. To meet the unmet need for modern contraception, countries need to increase resources, improve access to contraceptive services and supplies, and provide high-quality services and large-scale public education interventions to reduce social barriers. Our findings confirm a substantial and unfinished agenda towards meeting of couples' reproductive needs. UK Department for International Development, the Bill & Melinda Gates Foundation, and the UN Population Fund (UNFPA). Copyright © 2013 Elsevier Ltd. All rights reserved.
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            Use of modern contraception increases when more methods become available: analysis of evidence from 1982–2009

            BACKGROUND Use of modern contraception is prevalent across much of the developing world, but countries vary widely in total use and in the number and range of method choices available to potential users. For example, in sub-Saharan Africa the IUD is hardly available anywhere, but pills and injectables are generally available in the east and south. On the other hand, the IUD is commonly available in the Middle East. Female sterilization is not easily accessible in either region, but it is present in much of Latin America and in parts of Asia. 1 No single method serves the needs of every subgroup in a population. The one-method programs established by some ministries of health exclude many people interested in using family planning and tend to result in low proportions of the population using contraception. In such cases, the addition of another modern method to a program's method mix can raise total use. Adding more methods helps up to a point, until diminishing returns set in. All this depends partly upon which methods are offered, but the very presence of more choices can assist users whose needs could not be met by any single method. Analyses from 1971 onward have helped to demonstrate this relationship. For example, a Taiwan analysis showed a considerable rise in the duration of contraceptive use when family planning programs began offering multiple methods, estimating that the addition of one method would increase total contraceptive use by about 12 percentage points (from 30% to 42%). 2 A simulation study demonstrated the limitations of any one method, noting that the usual discontinuation rate for a method would leave users with no alternative protection for their remaining reproductive years, except to have multiple abortions. 3 A cross-national analysis found a systematic correlation between access to methods and their use. 4 A recent study using detailed cluster-level data and service availability assessments from the Demographic and Health Surveys (DHS) demonstrated that improvements in family planning supply have a positive effect on contraceptive prevalence. 5 Expanding the contraceptive method mix has been shown to improve continuation rates. A striking example of the adoption of newly available contraceptive methods comes from the early experience of the first large-scale family planning programs in 4 Asian countries, during the advent of the IUD and pill (Figure 1). In these 4 countries, contraceptive use rose sharply after each new method emerged from the research stage and was made accessible to the population at large. 6 Counter-examples, at least in part, include India and Pakistan, where the method mixes changed more erratically during the turbulent years of the late 1960s and 1970s. Figure 1. Impact of Adding New Contraceptive Methods on the Number of Users, 1965–1973 Reproduced with permission from Freedman R, Berelson B. The record of family planning programs. Stud Fam Plann. 1976, 7(1):1–40. The objective of this article is to extend previous research by examining how much contraceptive use increases as additional methods become available to whole populations, using national survey data and estimates of the degree of method availability. DATA SOURCES Nationally representative data from the DHS series 7 and from other national surveys compiled by the United Nations (UN) Population Division 8 provide time trends for the modern contraceptive prevalence rate (MCPR), which includes use of male and female sterilization, IUDs, pills, injectables, implants, and condoms. We also refer to the contraceptive prevalence rate (CPR), which includes the previously mentioned modern methods, plus traditional methods, such as rhythm and withdrawal. We obtained estimates of the MCPR for each country for each of the 6 years examined in our research from the surveys included in the UN compilation. Where surveys did not fall exactly on 1 of the 6 dates included in our analysis, we estimated the MCPR by interpolation between surveys bracketing the desired date. Where pairs of surveys were unavailable for interpolation, we set the MCPR value for the earliest years in question to the first available survey, and for years after the last available survey, we set the MCPR value to the latest available survey. This approach simplified the analysis and avoided questionable extrapolations before or after a survey estimate, although some error may be involved. The national surveys with MCPR data cover nearly every developing country, many with multiple surveys for various dates. The number of contraceptive methods available in national family planning programs comes from the “Family Planning Effort (FPE) Index,” a score measuring the strength of national family planning programs on 4 dimensions (policies, services, evaluation, and method access) compiled through detailed questionnaires administered periodically over the past 4 decades. 1 For the method access dimension, 10–15 expert observers from various professions and agencies in each country rate the extent to which the population has access to IUDs, pills, female sterilization, male sterilization, condoms, and, since 2004, injectables. (The addition of injectables to the questionnaire in 2004 could increase the number of available methods in our analysis for some countries, depending on the percentage judged to have access to the method.) Their responses are averaged after inspection for extreme outliers; as a further check, standard deviations are examined for each item in each country. We used FPE Index data on method access from 1982, 1989, 1994, 1999, 2004, and 2009 to determine the number of methods available. Over all survey rounds, the FPE Index included 113 countries one or more times, drawn from all developing-country regions. In the survey rounds up to and including 1999, respondents rated “the percentage of couples of reproductive age who have ready and easy access to each method.” From 1999 to 2009, the FPE Index used a simpler questionnaire by asking respondents to rate the percentage of couples with access to each method on a scale from 1 to 10, which was then converted to the percentage estimate. (The 1999 index used both sets of ratings to compare the 2 methodologies.) METHODS We considered a method to be “available” in the national family planning program if FPE Index survey respondents judged that a certain percentage (ranging from 20% to 80%) of the population had access to it. We used alternative accessibility rules of at least 20%, 40%, 50%, 60%, 70%, and 80% of the population having access to a method, in order to test the consistency of the relationships. These values were chosen somewhat arbitrarily but give a broad range and permit a check on the robustness of results when “availability” is defined differently. If we define method availability as low as a mere 20% of the population having access to the method, many more countries will be included in the analysis than if 60% of the population must have access to the method. The consistency of the conclusions under multiple assumptions is important since standard significance tests are not applicable, due to the complexities of sampling error in the original surveys compounded with survey errors in the access information for the 6 methods. Table 1 shows how a more lenient accessibility rule increases the number of countries included in the analysis. It gives the number of countries with at least 1 available method qualifying under each accessibility rule, in each survey. The more severe the rule, the fewer the countries that qualify, as shown by the diminishing numbers in each column. In the 1982 survey, for example, 65 countries made 1 or more methods available, as defined by the lenient accessibility rule of only 20% of the population having access to the method, while only 26 countries met the stricter rule of 80% accessibility. An individual country therefore might have 4 methods, each accessible to 20% of the population, but only 1 method accessible to 80% of the population. Table 1. Number of Countries With At Least 1 Available Contraceptive Method Included in the Analysis, by Method Accessibility Rule and Survey Year Accessibility Rulea Survey Year 1982 1989 1994 1999 2004 2009 20% 65 81 91 86 83 81 40% 46 68 84 85 83 80 50% 45 64 78 82 81 80 60% 38 57 71 79 77 80 70% 35 51 65 74 65 67 80% 26 40 59 53 41 39 a Per judgment of respondents to the Family Planning Effort Index survey that a certain percentage of the population in their country had access to a particular contraceptive method. The other variable, the percentage of married/in-union women using modern methods (MCPR), is entirely separate, both empirically and conceptually. Accessibility/availability and use are quite different; a method may be widely available but little used. An example is the condom, which is generally available but used by only a small proportion of couples. (Another example is the traditional method of withdrawal, which is universally available but used only selectively.) We conducted 4 different analyses using these data: Time trends: to compare the trends in the mean MCPR and the mean number of available methods from 1982 through 2009 Variability: to compare variation in the MCPR with the average number of available methods, repeated for each year Correlational: to examine the correlation across countries for the MCPR and the average number of available methods, repeated for each year Fixed effects regression: to measure the relationship between method availability and MCPR, controlling for within-country variation Although these 4 approaches explore the relationship of method availability and contraceptive use, they do not control for such confounding influences as the social setting, the health structure, or the particular method mix at each level of contraceptive use. RESULTS Using these 4 approaches, we compare results for the relationship between contraceptive availability and use, selected from the 6 years and the 6 alternative contraceptive accessibility rules. Time Trends Analysis First, the number of methods available and the MCPR have both been increasing over time (Figure 2). The average MCPR rose from 23% to 37% between 1982 and 2009, represented by the dashed line in Figure 2. The solid lines show the average number of methods available among all surveyed countries in each year (right-hand axis), by the different accessibility rules. The more restrictive accessibility definitions (from 40% to 80%) produce lower estimates of the number of methods available. Nevertheless, each trend line for the accessibility rules from 20% through 60% rises in the analysis. The rise is more gradual (lower slope) as the accessibility percentage increases, and it is even negative at 80%. That is, the slopes rise less with more stringent levels of accessibility, probably because some saturation effect occurs once methods are fairly widely accessible. Use of modern contraception, and the number of available methods from which people can choose, have both been increasing over time. Figure 2. MCPR and Number of Available Methods, by Various Accessibility Rules, 1982–2009 Abbreviation: MCPR, modern contraceptive prevalence rate. Variability Analysis Second, cross-sectional correlations between the MCPR and the number of available methods for the 113 surveyed countries also show the MCPR-Availability correspondence. Figure 3 uses 2009 data to show the distribution of MCPR values for countries according to the average number of available methods according to the 50% accessibility rule. The least squares line gives an R 2 value of 0.37 and a slope of 9.8, suggesting that 1 additional method raises the MCPR by nearly 10 percentage points in the latest survey round of FPE method accessibility scores. Figure 3. Relationship Between MCPR for 113 Surveyed Countries and Number of Available Methods, According to the 50% Accessibility Rule, 2009 Abbreviation: MCPR, modern contraceptive prevalence rate. Solid line represents the least squares line across all countries. The earlier survey years have somewhat smaller slopes of about 7 to 8 points (Table 2). Still, the patterns are again striking. Using the 50% accessibility rule for every year, once more the R 2 values start high and descend (until 2009), while the slopes start low and rise. Modern contraceptive use has increased over time with each additional method made available to the population. Table 2. Relationship Between Mean MCPR and Mean Number of Available Methods According to the 50% Method Accessibility Rule, by Survey Year Survey Year R 2 Slope 1982 0.66 7.2 1989 0.58 7.5 1994 0.43 7.4 1999 0.34 8.7 2004 0.22 8.0 2009 0.37 9.8 Abbreviation: MCPR, modern contraceptive prevalence rate. There appears to be a large variation in the MCPR, especially at 3, 4, and 5 available methods (Figure 3), but this is partly because more countries fall into those categories, creating more data points. Nevertheless, the MCPR can vary due to a number of determinants that are not included in the analysis. For example, traditional contraceptive methods compete with and can reduce use of modern methods, as can extended breastfeeding. Also, where fertility rates are high, the proportion of women who are currently pregnant or postpartum is larger than in countries where fertility rates are lower, and total contraceptive use is lower. In addition, the uptake of available methods can be depressed where conservative attitudes prevail, as in some sub-Saharan African countries. Finally, the social setting matters; favorable socio-economic factors (such as education, income, urbanization) tend to raise contraceptive use levels, apart from the number of available methods. Much research over the years finds that the social setting and national family programs share credit in increasing contraceptive use levels: each has an independent effect, and both can act in concert. 9 Correlational Analysis Third, correlations show the rise in the MCPR with the increasing average number of available methods for each year. Figure 4 shows the relationships for the 40%, 50%, and 60% accessibility rules. The 6 points on each line represent the 6 survey years, from 1982 at the lower left to 2009 at the upper right, and each point shows the relationship between the average number of available methods and the average MCPR. For example, the 50% line in the middle starts low, with an average of slightly more than 2 methods available in 1982, rising regularly until in 2009, it exceeded 3.5 methods. Over the same time period, the average MCPR rose from just above 23% to about 37%. Regardless of the accessibility rule used, the association is always positive, and both values rise regularly over the years, in a linear pattern. (Note that the 40% line is positioned at the far right of the graph since it yielded the largest number of available methods.) Regardless of the method accessibility rule used, modern contraceptive use always rises with each additional method made available. Figure 4. Relationship Between MCPR and the Number of Available Methods, by Accessibility Rule, 1982–2009 Abbreviation: MCPR, modern contraceptive prevalence rate. The 6 points on each line represent the 6 survey years, starting with 1982 at the lower left of each line and moving up to the right for 1989, 1994, 1999, 2004, and 2009. We repeated this analysis for all accessibility rules, from 20% through 80% (Table 3). The R 2 values start high (at the least stringent accessibility rule) and decrease, while the slopes start low and increase (until the strict 80% rule, for which fewer countries qualified). The essential point is that different accessibility rules, through 60%, show very consistent MCPR results, which fade only at the extremes of 70% and 80%. The increase in the MCPR ranges from 5–11 percentage points (indicated by the slope of the line) for each additional method made available. By the 50% accessibility rule, an increase of 1 new method is accompanied by nearly an 8 percentage point rise in the MCPR. Table 3. Relationship Between Mean MCPR and Mean Number of Available Methods, by Method Accessibility Rule, 1982–2009 Accessibility Rule R 2 Slope 20% 0.97 4.9 40% 0.98 5.9 50% 0.96 7.9 60% 0.88 10.9 70% 0.25 11.2 80% 0.16 (5.3) Abbreviation: MCPR, modern contraceptive prevalence rate. Fixed Effects Regression Analysis Fourth, a “fixed effects” analysis measures the MCPR-Availability relationship with a control for within-country variation; this also corrects for the unequal numbers of data points among countries (some countries reported method access in all 6 survey years while others reported method access in fewer surveys; the average was 4.7 years of reporting). The fixed effects analysis finds the MCPR-Availability relationship within each country and then accounts for variations across the countries. As an example of the within-country relationship, Figure 5 uses the 6 surveys in Ethiopia. Over the 27 years from 1982 to 2009, availability improved steadily (indicated by the “sum of access scores” line), and the MCPR among married/in-union women rose from under 5% to 23%. Figure 5. Relationship Between MCPR and Sum of Access Scores for All Modern Methods, Ethiopia, 1982–2009 Abbreviation: MCPR, modern contraceptive prevalence rate. In this analysis, we summed the accessibility ratings for male and female sterilization, pills, IUDs, condoms, and injectables to create a total access score as a continuous variable. The resulting data set had 447 observations for 96 countries. The analysis, conducted with Stata 9.0, found that the access score is highly significant (P<.01, t350 = 11.9) and indicated an increase in MCPR of 4.5 percentage points (95% confidence interval = 3.8–5.3) with each additional method made available. DISCUSSION Using multiple approaches to analyze the data, we found a consistently close correspondence between the number of available methods and the MCPR. The first 3 analyses showed that the addition of a new method raises the MCPR by approximately 7–8 percentage points, for example, from 40% to 47% or 48%, and somewhat more so in the latest survey data from 2009. The fixed effects regression in the fourth analysis confirms a significant relationship between method availability and MCPR, although the impact is at the low end of the range produced by the other approaches. As noted above, our analyses cannot separate the effects of method availability on the MCPR from the ways by which increasing demand for contraception may encourage a program to make new methods available. But it does support the finding that greater availability of a number of contraceptive methods produces increases in MCPR over time. The correspondence between method availability and the MCPR appears both over time (1982–2009) and cross-sectionally each year among the set of countries included in these analyses. This correspondence also exists under a variety of accessibility rules governing how much of the population must have access to a method for it to be regarded as an additional available method in the mix. (In the past, the 50% accessibility rule alone has been used to determine which methods, and which combination of methods, were available in most countries. 10 ) And finally, the correspondence exists when the sum of contraceptive prevalence for all modern methods is the access measure. As a country adds more methods to its offerings, it broadens the method mix, reducing “method skew,” 11 which is a measure of the narrowness of the mix. A country that depends on only 1 or 2 prominent methods has more skew than a country with 3 or more methods. A broader offering gives options to more women and couples in the population with their differing needs. This tends to raise the MCPR. A broader method mix helps meet the individual and varied family planning needs of women and couples. The present results appear sufficiently strong to suggest that entirely new methods of family planning can increase modern contraceptive use in countries that make them widely available, giving more options to meet the needs of individuals. The impact may be less for new methods that are minor variations of existing methods, such as a new 6-month injectable compared with the existing 1- and 3-month injectables, although such new methods may improve contraceptive continuation rates. In addition, a method that dramatically expands availability through lower cost or other advantages may be expected to have significant impact on contraceptive use, even if the method itself is not new. One example includes contraceptive implants, which are already growing in popularity and benefiting from markedly reduced pricing. 12 Further, community-based distribution of some methods may be extended, for example by Sayana® Press (formerly known as depo-subQ provera 104™ in Uniject™)—a new subcutaneous formulation of Depo-Provera® packaged in the Uniject prefilled injection system. 13 Introduction of new methods or improvements to features of existing methods may increase use of modern contraception. The results of this analysis are not limited to inventions of new methods; they also suggest that increases in the MCPR may occur by simply widening geographic access to more of the existing methods. Patterns across 64 countries show that those with higher contraceptive prevalence tend to have a broader mix of methods. 1 Currently, our analysis indicates that only about 3.5 methods are available, on average, to 50% of the population, and less than 2 methods are available by the 70% accessibility rule. On average, only 3.5 methods are available to half of the population in surveyed countries. This analysis also implies a significant effect of stockouts on contraceptive use. To the extent that stockouts of a method are equivalent to lack of availability as measured here, the effect on MCPR may be similar. One study showed an association between the CPR and the average availability of methods at service delivery points on the day of survey across 7 countries. 14 The results show an effect roughly equivalent to a 5–6 point increase in CPR associated with availability of 1 additional method, not far from the 7–8 point increase emerging from 3 of our analyses. There is the possibility of a dual influence between access to a method and popular interest in it. When it becomes clear that a method such as the injectable in eastern and southern Africa is taking off, programmatic efforts may be made to extend its availability to more clinics and to remote areas of the country. Conversely, if a new method is offered in selected areas but few women find it attractive or continue using it, efforts may slacken to supply it throughout the country or to seek budgetary funds to purchase large quantities of it. Limitations Limitations to our analyses provide leads for further research. The results here do not control for possible confounding influences, such as education and income levels, the degree of urbanization, or differences in health systems. Similarly, programs that are intrinsically stronger may improve overall access in a variety of ways other than by adding to the number of available methods. These and other determinants of the MCPR and the CPR can be explored in future research, apart from the number of methods that are reasonably accessible to the population. In addition, a more detailed focus on individual contraceptives would be of interest, to show the uptake of the pill alone, the IUD, or the injectable after each method becomes generally accessible in most of the country. Some of this research might be pursued by grouping methods into resupply and long-acting categories. Which particular methods comprise the method mix as the mix changes over time is a topic of interest. A mix made up primarily of resupply methods may produce a lower MCPR than a mix that contains more long-acting methods, because of the inferior continuation rates of resupply methods compared with long-acting methods. Within-country studies to compare differential responses to varying levels of accessibility by province would control some confounding variables that are present in cross-country research. Further, there are interesting questions about the factors that affect program managers' perceptions of which new methods promise widespread programmatic use, in light of their apparent advantages and disadvantages. CONCLUSION Our research indicates that there is significant potential to increase contraceptive use by expanding access to existing methods and by making new or modified methods widely available. Although the method mix has been improving over time, as of 2009 only about 3.5 methods, on average, were available to half of the population in the 113 surveyed countries included here. Improving method availability would simultaneously expand benefits to individual women and to couples through wider contraceptive choice.
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              Scaling up delivery of contraceptive implants in sub-Saharan Africa: operational experiences of Marie Stopes International

              INTRODUCTION Availability of contraceptive implants in sub-Saharan Africa expands the family planning options from which women of reproductive age can choose to limit or space their children. Currently, nearly 1 in 3 sub-Saharan African women have an unmet need for family planning, the highest proportion (31%) of any region in the world. 1 Moreover, only 16% of women in sub-Saharan Africa use modern methods of contraception compared with 67% in Latin America and 60% in Asia. 2 Yet many women want to use contraception. The demand to limit births has risen among married women in a number of countries in East and Southern Africa and is rising more slowly in West and Central Africa. 3 – 6 Implants, a long-acting and reversible contraceptive method (LARC), offer women a viable and highly effective hormonal method for family planning, providing 3 to 5 years of protection against pregnancy (depending on the type of implant used). With a rate of just 1 unintended pregnancy per 2,000 women, implants are more effective than any other reversible method, including the intrauterine device (IUD). 7 Easily inserted into the arm by a trained health worker, implants are convenient, discreet, and suitable for nearly all women and family planning intentions (delaying, spacing, and limiting childbearing). 7 Implants are more effective than any other reversible method. In sub-Saharan Africa, a growing number of women and sexually active adolescents are using family planning, and many are choosing contraceptive implants. While implants account for just 7% of all contraceptive methods used in the region, interest in implants has risen sharply in less than a decade. 8 For example, between 2004–05 and 2010–11, use of implants rose 17-fold in Ethiopia, 16-fold in Rwanda, 5-fold in Tanzania, and 2.5-fold in Malawi. 7 A number of factors help explain this dramatic increase: Women's desire to limit family size and growing acceptability of modern methods 6 Wider availability of implants through the introduction of the cost-competitive implant, Sino-implant (II), and the subsequent launch of public-private partnerships, 7 , 9 , 10 resulting in price-volume guarantees for Implanon and Jadelle Growing awareness of the benefits of implants among sub-Saharan African women and growing interest in long-acting methods 5 , 7 Prioritization of family planning and increasing availability of implants by the donor community and development organizations, including government policy makers 7 , 11 , 12 Within this favorable environment, Marie Stopes International (MSI), an international nongovernmental organization (NGO) committed to broadening women's contraceptive choices around the world, has successfully scaled up its delivery of implants in recent years to meet growing demand in sub-Saharan Africa and help clients gain access to information to make informed family planning choices. (We define scale up as an increase in the number of clients using implants, measured by the number of implants delivered.) MSI offers implants as one of many family planning options, including other LARCs, voluntary permanent methods, and short-acting methods. MSI counsels clients on the full range of available methods, so they can choose the method that best fits their lifestyle and family planning goals in accordance with the principles of informed choice and reproductive rights outlined at the Cairo International Conference on Population and Development and underpinning U.S. Government support for voluntary family planning programs. 13 , 14 In Nigeria, a family planning client has her contraceptive implant inserted by Marie Stopes International (MSI) providers. Provision of implants by MSI increased more than 10-fold in Nigeria between 2009 and 2012. MSI HELPS TO EXPAND ACCESS TO IMPLANTS In 2008, MSI provided 80,041 implants in the 15 sub-Saharan African countries where we work. In just 5 years, we increased this number considerably to 754,329 implants provided in 2012 (Table 1). Cumulatively, during the 5-year period, MSI delivered more than 1.7 million contraceptive implants in these countries. Between 2008 and 2012, MSI provided more than 1.7 million contraceptive implants in 15 sub-Saharan African countries. TABLE 1. Number of Implants Provided by MSI in Selected sub-Saharan African Countries,a 2008–2012 MSI Country Program 2008 2009 2010 2011 2012 % Growth (2011–12) Burkina Faso N/A 2,440 7,835 7,086 14,386 103% Ethiopia 14,286 31,953 45,737 68,347 88,206 29% Ghana 2,602 5,549 3,117 14,433 23,162 60% Kenya 6,652 43,330 69,651 72,477 117,106 62% Madagascar 6,206 17,535 26,899 34,175 65,229 91% Malawi 1,719 1,369 2,595 21,691 84,389 289% Mali 30 3,295 10,588 17,649 33,019 87% Nigeria N/A 1,184 5,944 6,388 12,749 100% Senegal N/A N/A N/A 535 6,600 1,134% Sierra Leone N/A 8,387 21,792 29,257 37,672 29% South Sudan N/A N/A N/A 153 1,138 644% Tanzania 25,457 28,157 24,465 36,705 64,752 76% Uganda 13,730 29,875 42,498 81,544 143,762 76% Zambia 639 3,037 4,724 4,457 9,900 122% Zimbabwe 8,720 16,166 24,862 40,107 52,259 30% TOTAL 80,041 192,277 290,707 435,004 754,329 73% Abbreviations: MSI, Marie Stopes International; N/A, not available (because the MSI country program had not yet begun providing implants). a Data from MSI's service delivery statistics for MSI country programs in sub-Saharan Africa that were active in implant service delivery in 2012. Data from Sudan and Swaziland recorded in 2010 and 2011 are not included because these country programs were closed in 2012. (The 2 countries contribute an additional 864 implants in 2010 and 486 in 2011.) Rapid expansion occurred in several key East and Southern African countries as well as in West Africa, a region where MSI began intensifying its presence as recently as 2007. Kenya, Madagascar, Malawi, and Uganda scaled up provision of implants considerably from 2008 to 2012, resulting in growth rates near or well over 1,000%, with a 49-fold increase in Malawi and an 18-fold increase in Kenya (Table 1). In Uganda, the number of implant users grew from under 20,000 in 2006 to more than 140,000 in 2011 (Box 1). The high growth rates from 2011 to 2012 in all countries indicate that implant service delivery still has room for further expansion. The high growth rates in implant provision between 2011 and 2012 in sub-Saharan Africa indicate that implant service delivery has room to expand further. BOX 1. Marie Stopes Uganda Scales Up Provision of Implants Between 2006 and 2011, Marie Stopes Uganda scaled up provision of implants and, in so doing, increased the size of the overall market for implants in the country. In 2001 and 2006, the total number of implant users in Uganda—comprised of new users and those who had their implants inserted in years prior—remained under 20,000 (Figure 1). Between 2006 and 2011, the number of users expanded more than 7-fold to more than 140,000 users. FIGURE 1. Number of Women Using an Implant Provided by Marie Stopes Uganda Versus Other Providers,a 2001, 2006, and 2011 a “Other providers” includes all private-sector organizations offering implants, other than Marie Stopes Uganda, and all public-sector providers, including Ministry of Health facilities. Data for Marie Stopes Uganda users are from Marie Stopes International (MSI) service statistics and are modeled using MSI's Impact 2 model. These estimated user numbers include women who received an implant supplied by MSI that year as well as women who received implant services from MSI in past years who are modeled to still be protected by the implant. Data for implants provided by other providers are from 2001, 2006, and 2011 Uganda Demographic and Health Surveys and 2010 UN Population Prospects. By 2011, Marie Stopes Uganda had become the dominant implant provider in the country. We estimate that approximately 3 of every 4 women using an implant in Uganda in 2011 received their method from MSI. When we consider that the number of women choosing family planning in the general population increased by 60% between 2006 and 2011 and that the proportion choosing implants also expanded greatly (from 1 in 50 to 1 in 10), the role of Marie Stopes Uganda in reaching 76% of these users is significant. 8 These data suggest that our scale-up efforts in implant services likely changed Uganda's national pattern of contraceptive use by 2011. A number of factors contributed to the growth in implant provision by Marie Stopes Uganda: Strong mobilization of donor resources, including bilateral funding from the U.S. Agency for International Development (USAID) A large expansion in the number of service delivery sites An increase in the number of community campaigns to generate demand for the contraceptive options available from Marie Stopes Uganda, including implants The steep increase in implant provision between 2008 and 2012 (more than 9-fold) demonstrates a marked difference from our provision of other long-acting and permanent methods (LAPMs) during the same period (Figure 2). Like implants, use of IUDs has steadily increased in sub-Saharan Africa since 2008 due to MSI's overall family planning program scale up in the region. However, stronger demand for implants resulted in a much faster pace of growth in comparison with IUDs. For tubal ligations, the number of services provided per year remained fairly steady over the 5 years. The number of female sterilization users, however, still accounts for the highest proportion of MSI family planning users in the region (Figure 3), because MSI has delivered more tubal ligations than other LAPMs historically; therefore, the estimated number of sterilization users in 2012 reflects these past trends. FIGURE 2. Number of LAPMs Provided by MSI in sub-Saharan Africa, by Method, 2000–2012 Abbreviations: LAPMs, long-acting and permanent methods; MSI, Marie Stopes International. Data from MSI service statistics. FIGURE 3. Method Mix Among Modern Method Users, Marie Stopes International (MSI) Users Versus the General Population, in African Countries Where MSI Operates, 2012 Data for MSI users are from MSI service statistics, with user numbers modeled using MSI's Impact 2 model. As explained in the footnote to Figure 1, LAPM users include those who received their method in prior years who continue to be protected. Because sterilization protects women for a longer duration than IUDs and implants, previous sterilization clients remain in the total “user” number for more years (until aging out at 49, based on median age of sterilization). Data for the general population are from Demographic and Health Surveys for those sub-Saharan African countries where MSI operates. 8 For MSI user numbers, short-acting methods exclude condoms to avoid the risk of overestimating condom use because of user wastage and dual protection. MSI's capacity to deliver implant services—and to scale up efforts in response to client demand—complements the existing method mix provided by the public sector and other private-sector providers, helping to meet the needs of clients who prefer implants. Public-sector facilities in sub-Saharan Africa often face constraints in providing LARCs, including implants, on a reliable basis. A lack of adequate infrastructure, frequent commodity stockouts, and a lack of skilled providers hinder public-sector provision. 15 , 16 Moreover, many public- and private-sector family planning programs deliver predominately short-acting methods, and, commercial pharmacies, social marketing programs, and public facilities often offer better access to short-acting methods than to long-acting methods, including implants. As a result, the method mix of women in the region using an MSI-provided method differs considerably from the method mix of the wider sub-Saharan African population as a whole. In 2012, whereas 83.8% of women of reproductive age in sub-Saharan Africa overall were using a short-acting method, only 10.4% of MSI users were. 8 In contrast, a far greater proportion of MSI users (36.6%) than the general population (6.5%) were using implants and other LAPMs for their family planning needs (Figure 3). MSI SERVICE DELIVERY CHANNELS MSI has successfully delivered family planning services through a number of channels, including the 3 main channels of: Mobile outreach Social franchising Static clinics Using more than one service delivery channel broadens the access points for a client, thereby increasing the likelihood that information about family planning choices will reach her and that she will have access to choose a method she wishes. 1 , 6 In 2012, the largest proportion of MSI's implant provision in sub-Saharan Africa was through mobile outreach services (Figure 4). Accounting for nearly 70% of all implants delivered, our outreach services provided almost 4 times as many implants as our social franchisees (18.0%) and nearly 8 times as many as our static clinics (8.9%). Still, the social franchising proportion is notable, since half of our social franchising programs in sub-Saharan Africa were recently established in the latter half of 2012. These results underscore the importance of mobile outreach and social franchising for expanding access to implants as part of a comprehensive method mix. 70% of MSI's implant clients in sub-Saharan Africa were reached through mobile outreach. Social franchising also showed promise, accounting for 18% of implant clients. FIGURE 4. Proportion of Implants Delivered by MSI in sub-Saharan Africa, by Service Delivery Channel, 2012 Abbreviations: MSI, Marie Stopes International. a “Other” includes community-based distribution, community health workers, and miscellaneous providers. Data from MSI service statistics. Data do not include 1,898 implants delivered through social marketing in Mali. Typically, variations or service delivery innovations build on 1 of these 3 channels. The scale of each of these channels also varies by country, depending on client needs and infrastructure availability. Table 2 contains a summary of our country program operations in those sub-Saharan African countries active in implant service delivery in 2012. TABLE 2. Summary of MSI Country Programs Active in Implant Service Delivery in sub-Saharan Africa, 2012 MSI Country Program Month/Year Program Opened No. of FP Clients (all channels) No. of Implants Provided No. of Mobile Outreach Teams No. of Clinics No. of Social Franchisees Month/Year Social Franchising Started Burkina Faso 07/2009 24,517 14,386 4 1 N/A N/A Ethiopia 09/1990 206,723 88,206 10 31 443 10/2008 Ghana 10/2006 39,798 23,162 6 5 106 03/2008 Kenya 03/1986 229,836 117,106 15 25 279 04/2004 Madagascar 06/1992 147,661 65,229 46 14 127 11/2009 Malawi 09/1987 229,310 84,389 39 31 54 06/2008 Mali 11/2008 45,787 33,019 7 3 34 06/2012 Nigeria 04/2009 16,446 12,749 5 1 51 09/2012 Senegal 11/2011 9,989 6,600 3 1 10 10/2012 Sierra Leone 03/1988 127,148 37,672 13 12 100 12/2008 South Sudan 08/2011 1,778 1,138 2 2 N/A N/A Tanzania 09/1990 149,252 64,752 26 12 N/A N/A Uganda 07/1993 260,466 143,762 24 15 419 06/2012 Zambia 06/2008 18,261 9,900 7 3 7 07/2012 Zimbabwe 04/1988 146,680 52,259 9 9 61 08/2012 Abbreviations: FP, family planning; MSI, Marie Stopes International; N/A, not applicable. Data from MSI service statistics. Number of FP clients were estimated from MSI service statistics, in which each service for a long-acting and permanent method is equal to 1 client and each year's supply of short-acting methods is equal to 1 client. When determining which channels to use, MSI considers the efficiency and reach of each one within the specific country context. Monitoring both efficiency and reach are essential considerations for enabling service delivery scale up and ensuring scale up is equitable. 1 Efficiency refers to allocating time, effort, and resources strategically in service delivery to maximize the greatest program impact. 17 Matching the size of a clinic or provider team to client demand and service patterns of a facility or catchment area is one example of efficiency. To measure efficiency, MSI teams use cost per couple-year of protection (CYP), a metric that shows the average cost of delivering a contraceptive method relative to the number of years the method protects against pregnancy. Currently, MSI uses cost per CYP for internal program monitoring and decision making; costing data will be made available in future studies focused on service delivery and scale-up costs. It is important to note that this metric is not simply about minimizing the cost per CYP, but rather about ensuring we use our resources to achieve the most impact—accounting for our role in expanding access and choice, improving quality, and ensuring equity. Reach refers to expanding access to family planning services, meaning that every potential client can obtain services regardless of financial, geographical, and/or cultural barriers. 17 We select service delivery channels that will reach clients affected by gaps in service outlets or contraceptive methods. At the same time, we consider channels that will enable existing clients to continue and/or switch their methods, if they choose. MSI monitors a program's reach through indicators such as the number of CYPs generated or the number of service delivery sites established. Recently, MSI also began monitoring the number of high-impact CYPs generated by different service delivery channels. Developed by MSI, this indicator measures a program's ability to deliver services to those facing the highest barriers to access, such as the poor, young women, those who have not previously been using family planning (called “adopters”), and users of short-acting methods who seek services at MSI to meet their desire for a LAPM (called “switchers”). Mobile Outreach MSI's mobile outreach services deliver implants and other contraceptive methods through a team of MSI dedicated providers that brings equipment and commodities directly to clients. The use of these dedicated providers—those who fill a specific service delivery gap by focusing primarily on the provision of certain contraceptive methods, such as LAPMs—is a key component of MSI′s mobile outreach strategy. 18 Unlike some dedicated provider models, we employ MSI staff, not external providers. These teams visit outreach sites on a regular basis, ranging from every 4 to 6 weeks to once per quarter in the most remote regions, expanding access to contraceptive choice through provision of LAPMs during these visits. (In support of informed choice, our dedicated providers refer clients who want short-acting methods to their public-sector counterparts located at the same site when available, or they furnish these methods directly in cases of stockouts at the public facility.) To help achieve equity, MSI provides underserved clients who do not otherwise have access to implants or other LAPMs with free or highly subsidized family planning services. As a result, the mobile outreach channel often generates high demand and commonly attracts new family planning adopters, a key metric for monitoring scale-up efforts. 19 – 21 In 2012, 41% of mobile outreach family planning clients were adopters, reached through our 216 mobile outreach teams in the sub-Saharan African countries offering implants (Table 2). Moreover, and importantly for implant scale up, 39% of our outreach clients switched from short-acting methods to LAPMs, indicating client preference for longer-acting contraception. 8 41% of MSI's mobile outreach family planning clients in 2012 were adopters and 39% switched from short-acting methods to long-acting and permanent methods. Mobile outreach services can also be an effective channel for program scale up in terms of efficiency. By strategically using existing community infrastructure, small teams, and outreach schedules that coincide with client demand, mobile teams can maximize impact from its program inputs. For areas that are not too rural but still hard to reach, this channel has proved to be cost-effective. 22 Teams of dedicated providers also have been shown to increase the number of IUD and implant insertions, and therefore, program scale up. 18 Depending on the geography of a particular catchment area, MSI uses either a mobile clinical service team or a mobile community outreach worker team, its 2 primary outreach models. 23 The mobile clinical service team model deploys small teams, typically 3 MSI dedicated providers and a driver, to rural areas for delivery of family planning services in existing health centers (usually public facilities) where possible. Through a collaborative process with local governments, MSI chooses these clinics because of their infrastructure, their ties to the community, and their visibility among clients. Some women also prefer to access family planning at a health center in order to disguise the reason for their visit. If needed, a team uses other community facilities (for example, schools and community centers), or sets up a low-cost, temporary structure such as a tent. In an effort to serve densely populated urban and peri-urban areas, our second model, the mobile community outreach worker team, is a flexible, low-cost adaptation of the clinical service team model. In the community outreach worker team model, a smaller team—often consisting of just 1 or 2 MSI dedicated providers of lower-level cadres—provides implants and other contraceptive methods, often in client homes or other non-health facility locations. A typical example is when 1 paramedic or nurse and 1 family planning counselor will use local transport, rather than MSI-owned vehicles, to reach clients (Box 2). Although the teams for both models are based out of an MSI clinic, they mobilize interest in their services in advance of their arrival in the community through a variety of demand-generation activities (Table 3). BOX 2. Marie Stopes Tanzania Develops Innovative Urban Outreach Model Throughout its 30-plus year history, Marie Stopes Tanzania reached middle-income urban clients through MSI clinics and low-income rural clients through mobile outreach. However, by 2010, we had identified a growing gap in contraceptive-seeking behavior: our static clinics were not adequately reaching many low-income urban and peri-urban women wishing to use injectables and LARCs, including implants. MSI's existing rural outreach model consisted of MSI-owned 4x4 vehicles and large clinical teams. Such a model would be too cumbersome in a peri-urban context, and so Marie Stopes Tanzania set out to innovate urban outreach. In 2010, we launched a pilot bajaji (motorized auto-rickshaws) outreach model in Zanzibar, with support from USAID. This new urban outreach model, using a team consisting of 1 MSI nurse and 1 bajaji driver, is a streamlined and more flexible version of MSI's rural outreach model. The bajaji outreach model significantly reduces startup and operational costs due to lower staffing, fuel, and vehicle expenses. Bajaji nurses deliver contraceptive methods directly in clients' homes, in addition to providing family planning services at standard mobile outreach model sites (public health facilities or other community-based static sites). Clients report that these home-based services allow them to circumvent key access challenges, including lack of time to attend clinics, need for discretion in seeking family planning, and, in some contexts, cultural norms requiring women to be accompanied when traveling outside the home. Within several months of starting bajaji services in Zanzibar, the Ministry of Health in Mwanza City invited Marie Stopes Tanzania to expand the model for its underserved urban neighborhoods. In the 12-month pilot period in Zanzibar, bajaji teams delivered family planning services to 3,650 clients, of which 2,122 chose implants. In the 7-month pilot in Mwanza City, bajaji teams delivered family planning services to 2,531 clients, of which 1,432 chose implants. Client interest in voluntary permanent methods resulted in 86 referrals to MSI clinics for tubal ligations (73 in Zanzibar and 13 in Mwanza City). Several MSI country programs in Africa and Asia are currently replicating this model to reach underserved urban and peri-urban clients. TABLE 3. Demand-Generation Activities to Educate Clients About Family Planning and MSI Services, by Channel Mobile Outreach Services Social Franchising Clinics Delivery of high-quality services to enable word-of-mouth referrals Delivery of high-quality services to enable word-of-mouth referrals Delivery of high-quality services to enable word-of-mouth referrals Educational outreach by community health workers (CHWs) or other community agents about importance of family planning and different methods through: Door-to-door mobilization Group information sessions Educational/promotional communication and media Educational outreach about family planning and long-acting and reversible contraceptives (LARCs), including implants, as well as about BlueStar family planning services through: CHWs and other community agents Print or radio advertisements Educational outreach about family planning and MSI services through: Kiosks at regular markets and popular events Radio show appearances by MSI clinic staff Flyers and promotional materials available at locations frequented by young women, such as markets, universities, and beauty salons Designated day for team visit, making it a noteworthy and anticipated community event Special discount days on LARC services Local media advertisements about voluntary family planning and LARCs, including implants Promotion of BlueStar brand, as an overall sign of quality service delivery Training for all clinic staff including receptionists and support staff to ensure client-friendly, non-judgmental environment Where appropriate, referrals from other MSI service delivery channels Referrals from: Other non-MSI services at franchisee Other MSI service delivery channels, where appropriate Where appropriate, referrals from other MSI service delivery channels Announcement of upcoming mobile team visit via: Town crier Radio CHWs or other community agents Both of these outreach program models are examples of how MSI collaborates with the public sector, building the clinical competencies of public-sector providers and creating synergies between public and private systems. For example, we prepare public providers for assessing and handling any complications that may arise from implant insertions. Such training is critical to meet follow-up needs of clients between visits from the MSI team. To ensure clients receive high-quality follow-up care, MSI coordinates referral networks with higher-level facilities to manage side effects that infrequently arise and that are beyond the capacity of lower-level public-sector providers. In the event that a client experiences a severe side effect, defined as a frequent level of discomfort requiring medical attention, we provide technical expertise and pay for transport and hospital fees if higher-level facility referral is needed. Where possible, we also build the clinical skills of public-sector providers in other ways, focusing on specific areas that need reinforcement (such as client counseling techniques and implant removal protocols). Social Franchising MSI's BlueStar social franchise networks* engage existing private providers to deliver high-quality sexual and reproductive health services, including implants, in underserved areas. Contracted to MSI but operated and owned by private providers, these networks are organized under commercial franchising principles, which have been shown to facilitate standardization and increase client volume, including for family planning services. 24 – 26 MSI has adopted a “partial franchising” model for our social franchise networks. In this model, we regulate and support only some of the franchisees' services and commodities, namely the reproductive health and family planning services; the franchisee may offer additional services that we do not oversee. In sub-Saharan Africa, franchisees are typically located in urban and peri-urban areas as well as towns and trading centers in rural areas. By engaging these existing providers, we leverage and strengthen the health infrastructure and aim to achieve greater health system integration between the public and private sectors. MSI gains access to an established clinic and existing client base in a community when we invite new members to the BlueStar network, obviating the need for the startup costs and effort associated with opening a new MSI clinic. At the same time, we expand client access to key services that these private clinics would otherwise not be able to provide adequately, allowing health systems to make better use of the capacity in the private sector to achieve public health-sector goals, such as increases in contraceptive prevalence. At the individual level, BlueStar franchisees increase options for existing contraceptive users as well as increase the market for family planning users and attract new users. In 2012, 78% of our BlueStar LAPM clients in sub-Saharan Africa chose implants—135,144 implant clients in 12 countries. Due to this demonstrated potential, social franchise networks will be key channels for scaling up implant services in many MSI country programs in the coming years. In 2012, 78% of MSI's social franchising LAPM clients chose implants. To help family planning program scale up and to offer services at affordable prices to our clients at our 1,691 BlueStar clinics in sub-Saharan Africa, MSI facilitates access to high-quality implants (and other commodities for other franchised services delivered) in 2 ways. We either supply these implants at a reduced price or negotiate access to pooled commodities at the national level on behalf of franchisees. Discounts vary from country to country. For example, while an MSI subsidy enables our Ghana franchisees to receive implant commodities at the same price as their public-sector counterparts, we are able to supply our Madagascar franchisees with implants (and other contraceptive methods) free of charge. Prior to joining the BlueStar network, individual clinics are not usually in a position to offer implants or other LAPMs to their clients; in most countries, there is no private-sector supply chain for implants outside of social franchise networks. By joining BlueStar, the benefits of supply-chain support—namely, more reliable and affordable access to consumables and implants themselves—enable BlueStar clinics to provide a wider range of contraceptive methods. These economies of scale result in cost savings for our clients, thereby increasing access for lower-income clients and scaling up equitable service provision. MSI Clinics Clinics have been our longest-standing service delivery channel. Owned and operated by MSI, our clinics are located in cities, towns, and peri-urban areas throughout 42 countries worldwide, with 165 delivering reproductive health and family planning services in the 15 sub-Saharan African countries that provided implants in 2012 (Table 2). In many of these countries, our clinic services augment the contraceptive method mix available from the public and private sector in urban and peri-urban areas, attracting new clients because of the different services that MSI offers, including implants. In fact, in 2012, 38% of our clinic clients in sub-Saharan Africa were family planning adopters. 8 Therefore, these clinics are important for expanding implant access to women in their respective catchment areas. In 2012, 38% of MSI's clinic clients in sub-Saharan Africa were family planning adopters. MSI clinics offer some advantages to scaling up access to implants over other service delivery channels in terms of efficiency and reach. Because the clinics are well-established in their catchment areas, with appropriate equipment and trained providers, our clinics can offer implant services in a manner that uses program inputs strategically to maximize impact. For example, we can scale up implant service delivery without significantly increasing overhead costs, such as transport with mobile outreach services. In terms of reach, these clinics tend to serve a population that is relatively wealthier than those served by our mobile outreach channel; in 2012, approximately 17% of our clinic clients in sub-Saharan Africa lived on less than US$1.25 per day compared with 42% of our mobile outreach clients. 8 At the same time, income generated from the sliding scale fees charged by our clinics helps subsidize our outreach service delivery, in which fees are typically not charged. QUALITY ASSURANCE MEASURES All MSI delivery channels prioritize service quality when providing clients with contraceptive methods. High-quality programs yield high levels of client satisfaction, a principal determinant of a client's initial and continued use of family planning services. 27 – 30 The quality level of family planning service delivery, including implant provision, also directly influences the demand generation facilitated by client experiences and word-of-mouth communication, and, in turn, program scale-up efforts. MSI implements various quality-control activities, such as competency-based training and refresher courses, to train providers on MSI standards. We also train facility staff and outreach teams on how to use MSI's management information system to record client visits, services provided, expenditures, and stock of commodities and equipment. We then use various tools, such as mystery clients, supportive supervision, and audits, to monitor and ensure these service standards are met. See the Appendix for a complete list of MSI's quality-assurance activities. Through these measures, our staff and partners pay attention to quality throughout each stage of service delivery. As a result of this rigorous attention to quality, MSI clients have reported high rates of satisfaction with the services received, regardless of the channel from which they obtained family planning services. In 2012, MSI family planning clients across 11 sub-Saharan African countries gave our services an average rating of 4.4 on a 5-point Likert scale, in which 5.0 signified “very good.” The highest-rated aspect of service delivery was “friendliness and respect from the health care provider,” followed by “friendliness and respect from staff.” These data are potentially subject to “courtesy bias,” in which the clients are reluctant to express negative opinions to the interviewer. Other sources of data, however, support these positive findings. For example, when asked which source of information was most important in influencing their decision to choose MSI services, 31.5% of our sub-Saharan African clients cited a “person who used the service” (Figure 5). Furthermore, 29.9% of our clients in sub-Saharan Africa from across all delivery channels noted that MSI's “good reputation” was the driving force behind their decision to visit an MSI service site (Figure 6). The proportion citing our “good reputation” was also substantial by service delivery channel: 44% of clinic clients, 32% of social franchise clients, and 23% of mobile outreach clients. Such evidence underscores the importance of informal demand generation, based on client acknowledgment of high-quality services and word-of-mouth communication, in influencing MSI client health-seeking behavior for family planning. It also underscores how high-quality service delivery is necessary for expanding access to family planning and scaling up programmatic efforts. Satisfied clients can help generate demand for family planning services through informal word-of-mouth communication. FIGURE 5. Most Influential Source of Information Affecting Decision to Choose MSI Services Among sub-Saharan African Clientsa Across All Service Delivery Channels,b 2012 (N = 6,225) Abbreviations: CBD, community-based distribution; MSI, Marie Stopes International. a Data from exit interviews in 11 sub-Saharan African countries, from August 2012 through December 2012. b Results were weighted by region and delivery channel where appropriate. When weighting by delivery channel, data were only used from countries where the relevant delivery channel had been surveyed. FIGURE 6. Most Important Reason for Choosing Services From Marie Stopes International Among sub-Saharan African Clientsa Across All Service Delivery Channels,b 2012 (N =  6,225) a Data from exit interviews in 11 sub-Saharan African countries, from August 2012 through December 2012. b Results were weighted by region and delivery channel where appropriate. When weighting by delivery channel, data were only used from countries where the relevant delivery channel had been surveyed. INFRASTRUCTURE AND IMPLEMENTATION STRATEGIES REQUIRED FOR SCALE UP Underlying MSI's multichannel approach to scaling up delivery of implant services in sub-Saharan Africa were 3 strategies that leveraged and supported key country infrastructure: Provider supply Commodity supply chains Program financing mechanisms In addition, our experience points to a number of key implementation strategies that should be considered when planning and rolling out programs (Box 3). Finally, operational issues such as access to implant removal services must be planned for in the initial design phase. Each of these factors can pose a barrier to family planning program implementation and expansion if they are not sufficiently addressed. BOX 3. Key Implementation Strategies for Scaling Up Delivery of Implants Focus on clients with unmet family planning need. In order to successfully expand reach, programs must identify and focus on serving prospective users who lack access to a broad range of contraceptive methods, including implants. MSI identifies areas of unmet need through site visits, Ministry of Health input, and analysis of the latest health service and Demographic and Health Survey data. Devote resources to raising awareness and diffuse communications through multiple channels. Sustained awareness-raising activities are critical for attracting new family planning users, including those who choose implants from a wide array of options. Clients may be spread out across a large geographical area and may have limited access to mainstream media channels. Thus, health promotion messages about family planning and implants must be disseminated through different communication channels. Data from MSI client exit interviews in sub-Saharan Africa indicate clients have access to various communication channels, including: community health workers, radio, newspapers, community events, and friends or satisfied clients (Figure 5). Deliver high-quality services. Ensuring high-quality service delivery, at clinical and operational levels, serves as a catalyst for future demand and expansion of service delivery. A positive reputation among clients creates a feedback loop in which existing clients refer new clients. See the Appendix for specific activities MSI uses for establishing service quality. Deliver implants through multiple, interconnected service delivery channels. Using a multipronged strategy to deliver implants helps: (1) ensure the program reaches women of reproductive age in different geographic areas and social strata, as well as with different preferences for health care delivery; (2) generate demand; and (3) ensure comprehensive family planning care for follow up, eventual implant removal, and continued contraceptive use, including family planning counseling and services for clients who do not choose implants. In Madagascar, MSI successfully increased implant uptake and reached the poorest and least accessible women of reproductive age, through its USAID-funded SHOPS (Strengthening Health Outcomes through the Private Sector) program, by using and linking outreach and social franchising channels. 39 Build and leverage public-private partnerships. Given the central role of the Ministry of Health in the health system and its high community visibility, successful private programs work with and strengthen the public health system by: (1) filling gaps in contraceptive method availability, which is sometimes limited to short-acting methods; (2) training public providers in contraceptive counseling and implant removals; and (3) establishing a robust referral system for follow-up care and implant removals. In MSI's SHOPS program in Madagascar, public facilities or providers proved to be the most common referral source for outreach clients and contributed substantially to scaling up implant provision. 39 Sufficient Provider Supply Sufficient health workforce availability and distribution within countries is a key requirement for scaling up implant service delivery. 4 Unlike condoms or other short-acting methods, implants require a skilled health worker in order for clients to use them. To address health worker deficits, many sub-Saharan African governments have implemented task-shifting and task-sharing initiatives, which increase a country's service delivery capacity by delegating some health care delivery tasks from higher-level to less-specialized health workers. 31 Various studies have demonstrated the feasibility of these practices for family planning service delivery, and they have proved effective in the scale up of family planning programs, including delivery of implants. 19 , 32 – 36 As a result, the World Health Organization (WHO) currently recommends the use of task shifting/sharing for implant delivery, recently endorsing 2 new cadres, auxiliary nurses and lay health workers, for this practice. 37 WHO recommends task shifting or sharing for implant service delivery to address health worker shortages. Where allowed by national guidelines, MSI employs task sharing and task shifting to deliver reproductive health and family planning services. 19 , 36 In Ethiopia, Malawi, Mozambique, and Uganda, mid-level providers routinely deliver implants. For example, MSI Ethiopia has dramatically increased its implant delivery capacity through participation in the Integrated Family Health Program, supported by USAID, which has trained more than 10,000 health extension workers to provide implants. Strong Supply Chains Successful health interventions that deliver products to clients in the developing world require robust and predictable commodity supply chains. 38 Stockouts can reduce service uptake; conversely, a reliable supply of commodities is an important component of high-quality service delivery and can increase uptake and loyalty. MSI's 2012 client exit interview data show that 11.6% of sub-Saharan African clients reported that “services or medicines available” was the most important reason for choosing MSI services (Figure 6). To ensure a steady supply of implants to its programs in sub-Saharan Africa, MSI uses a multipronged procurement strategy. First, MSI country programs work to integrate their supply chains into national supply chains to the greatest extent possible. Large quantities of implants are sourced through Ministry of Health central supplies, many of which are funded by USAID. As funding permits, MSI global headquarters in London also procures implants at bulk prices through international tenders. Implant price-volume guarantees from donors and Implanon and Jadelle manufacturers Merck and Bayer, respectively, allow MSI to secure many more implant units with a finite budget. Additionally, MSI receives a global allocation of implants from the United Nations Population Fund (UNFPA). Together, these international supplies provide the flexibility to smooth out individual countries' implant supplies when shortages occur. MSI's product registration initiatives are another way we strive to ensure availability of implants. MSI works to increase the number of implant brands registered and available in countries. Working in partnership with FHI 360, MSI has registered Sino-implant (II) implants under its branded name Femplant in Burkina Faso, Ghana, and Mali. We have also supported Pharm Access Africa Ltd. in introducing Sino-implant (II) in Kenya, Madagascar, Malawi, Nigeria, Senegal, Sierra Leone, and Tanzania. MSI providers are not limited to using Sino-implant (II) implants, however. They use Implanon and Jadelle brands as well, aiming to meet client preferences regarding the duration of contraceptive protection. However, as MSI typically sources implants through Ministries of Health, the registered brands vary by country, and procurement decisions between brands are often outside of MSI's direct influence. To date, MSI's experience in sub-Saharan Africa shows that demand for implants, and thus program scale up, has occurred regardless of brand. Diverse Program Financing Mechanisms For program scale up in sub-Saharan Africa to be successful, it is essential to reach those underserved clients with the highest unmet need. Unmet need for family planning is higher among low-income sub-Saharan African women than among middle- and higher-income groups. 1 With 81% of the sub-Saharan African population (in the countries in which MSI works) living on less than US$2.50 per day, the cost of delivering implants must be subsidized to ensure price does not become a barrier to client uptake. 8 Client exit interview data from 2012 indicate that 9.6% of clients across all service delivery channels in sub-Saharan Africa cited “low-cost” services as the reason why they chose MSI for their family planning services (Figure 6). MSI uses various financing mechanisms to reduce costs to clients and ensure equity in scale up: Part of the surplus generated from clinic operations in developed countries (for example, Australia and the United Kingdom) helps fund the cost of programs in developing countries. Any surpluses generated from services for wealthier clients at developing-country clinics help to subsidize services for lower-income clients, primarily mobile outreach services. Donor subsidies reduce the true cost of implant service delivery, which encompasses both commodity and operations costs. Program efficiencies such as bulk pricing and good logistical management further reduce the cost of service delivery. Vouchers distributed in catchment areas with high unmet family planning need and low access to services direct subsidies specifically toward lower-income clients. (MSI uses a needs test to determine eligibility. 40 ) Vouchers enable clients to choose from any participating, accredited provider to receive free family planning services. Over the last 5 years, MSI has piloted and scaled up the use of vouchers in its social franchising networks in certain countries, including Ethiopia, Madagascar, Sierra Leone, and Uganda. In the USAID-funded SHOPS program in Madagascar, the vast majority of social-franchising clients receiving vouchers chose implants. Between January and September 2011, 3,467 LARCs were provided, 3,001 of which were implants (87%). The number of services delivered to non-voucher clients during the same time period remained fairly stable. Thus, the voucher clients did not significantly displace non-voucher clients, indicating market expansion. 39 In Madagascar, almost 90% of family planning clients receiving vouchers chose implants. Implant Removal Services Contraceptive implants have either a 3-, 4-, or 5-year life span, and clients may decide to discontinue use at any time. Thus, it is essential to have infrastructure in place for implant removals to maintain client trust in the program's family planning services. 7 Robust and reliable removal services can also help maintain a client as a contraceptive user; removal poses an opportune time to counsel the client on method switching or continuation. Ensuring reliable implant removal services is essential to maintain client trust in family planning services. Clients who receive their implants through an MSI clinic or BlueStar franchisee typically return to the same location for their removal service or other follow-up care. Outreach clients, however, must be linked to a static site to access removal services or follow-up care when needed. Mobile outreach teams do offer removal services; however, a client may require a removal in the weeks between outreach visits to her catchment area. As part of comprehensive counseling, MSI providers counsel clients on where to go when a removal or follow-up care is required. For clients living far from an MSI clinic or BlueStar franchisee, MSI maintains active referral networks of public-sector and, in some cases, other NGO facilities that are trained in implant removal. Clients incur no additional charge for removals as this procedure is considered part of service delivery for implants. To ensure provider willingness to deliver these removal services, MSI requires that all staff and all social franchise service providers complete competency-based training on implant and IUD removals as well as on management of side effects. Refresher courses occur at regular intervals and are mandatory. Combined with ongoing provider mentoring by MSI's clinical services managers from the country office, these courses aim to bolster provider confidence and knowledge of the procedures for removal and other follow-up care. To date, MSI has not experienced widespread provider reluctance to remove implants, although continued monitoring of this issue is needed. Maintaining contact with clients after insertion is a key challenge, however. Until recently, MSI, like other family planning service delivery organizations, relied on paper reminder cards to remind clients when to seek implant removals. Since 2012, MSI has been developing a client registration system called the Client Information Center, or CLIC. The system is a combination of software and paper tools that track client profile information including the services and products received during client-provider interactions and any adverse events experienced during the visits. CLIC has been designed to function in the MSI clinic and at outreach delivery channels, ultimately allowing MSI to track clients between facilities when they present in one location and later in another. Built-in reports allow staff to access information on which clients are due for return visits as well as view user-friendly statistical information on who our clients are and what services they receive over time. If clients wish to share their phone number, it is entered into CLIC so that providers can follow up with appointment reminders, information on minor side effects such as changes in menstruation patterns, information on the timing and location of removal services, and post-removal contraceptive choices. To safeguard confidentiality, clients are contacted by phone only with their permission. Thus, this new system provides MSI with a powerful yet easy-to-use tool to track clients post-procedure, ensuring timely removals of implants at the end of their life span and enabling a better understanding of client follow-up behavior. The use of CLIC may also help mitigate any provider reluctance to perform removals as the electronic record may standardize and normalize removal protocols. Discontinuation and Side Effects MSI has tracked discontinuation rates and side effects experienced by outreach clients in some sub-Saharan African countries. Only a small proportion of clients surveyed in Ethiopia (0.4%), Sierra Leone (0.7%), and Uganda (2.7%) had discontinued use of implants after 3 months, with rates increasing at later intervals but still remaining low (Table 4). TABLE 4. Implant Discontinuation Rates Among Clients Receiving Implants From MSI in Ethiopia, Sierra Leone, and Uganda, 2010 Duration of Use Discontinuation Rate Ethiopiaa Sierra Leonea Ugandab (N = 562) (N = 433) (N = 470) 3 months 0.4% 0.7% 2.7% 6 months 0.7% 3.0% N/A 8 months 5.7% 6.2% N/A Abbreviations: MSI, Marie Stopes International; N/A, not applicable. a Data from Ethiopia and Sierra Leone were collected in April 2010 during retrospective follow-up studies on women who received implants in 2009 at mobile outreach sites. 19 b Data from Uganda were collected in a prospective cohort study among women receiving implants, IUDs, or tubal ligations between February and April 2010 at mobile outreach sites. 41 In terms of side effects, only 1.1% of Ugandan clients experienced severe side effects 15 days following insertion; however, none had complications and all received follow-up care. 41 Severe side effects were defined as a frequent level of discomfort that required medical attention to determine whether a complication had arisen. A much larger proportion, 61.9%, also reported pain around the insertion area at this interval, although these clients did not find it severe. At 6 months post-insertion among clients in Ethiopia and Sierra Leone, the proportion of clients reporting they had ever experienced side effects was 40% and 45%, respectively. 19 These side effects included cramping and changes in menstrual bleeding that many implant users experience. In Zambia, Marie Stopes International clients examine contraceptive implants during a group counseling session about the variety of family planning methods from which women can choose. IMPLICATIONS OF MSI'S SERVICE DELIVERY APPROACH With a cumulative 5-year yield of more than 1.7 million contraceptive implants distributed in sub-Saharan Africa, MSI's family planning service delivery approach can be useful for governments and other organizations aiming for similar program expansion. MSI's experience demonstrates that service delivery expansion can be done successfully in sub-Saharan Africa by leveraging existing service delivery channels that many implementing organizations already use: clinics owned and operated by NGOs, social franchising networks, and mobile outreach teams of dedicated providers that work in partnership with the public sector. Underlying our channel operations is a strong infrastructure that enables channels to complement each other in user reach and operational structure. Key elements of this infrastructure include a sufficient number of trained providers, strong commodity supply chains, and diverse financing mechanisms. MSI's implementation experience underscores that quality assurance also matters, in the interest of clinical standards but also to help ensure that clients are satisfied with their experience and that they communicate their satisfaction to generate further demand for services. These systems and strategies have enabled our sub-Saharan African country programs to be nimble in responding to the rising demand for implants over the last 5 years. Governments and organizations wishing to scale up their own programs will likely recognize that the infrastructure investments required to deliver implants as part of a comprehensive method mix can also be leveraged to deliver and expand the uptake of other contraceptive methods. The adaptive quality of MSI's service delivery models is also an important component of its scale-up efforts in sub-Saharan Africa. In response to changing demand, MSI modified its models to best meet the specific context where family planning service delivery was needed. For example, the mobile community outreach worker team emerged as a low-cost alternative to our original clinical services outreach model, enabling MSI to reach underserved communities in urban and peri-urban areas. A new MSI initiative with the government of Ghana offers another example of a model variation. In this expansion of the public-private partnership component of our outreach model, Ghana Health Services will assume MSI's demand-generation costs for MSI Ghana's mobile outreach channel. Other variations include contracting out opportunities, in which governments contract private-sector implementing organizations to deliver specific services, as MSI has recently established with the government of Tanzania for our outreach services. This adaptation responds to the evolving shift occurring in public-private partnerships, in which governments are assuming greater responsibility for the strategic direction of NGO-provided services (Table 5). TABLE 5. Key Components of Mobile Outreach and Implications for Scale Up, Replication, and Sustainability Mobile Outreach Component Implications for: Scale Up Replication Sustainability Free or highly subsidized services Helps facilitate rapid expansion, since poor and rural clients have highest unmet need Requires adequate financing mechanisms to subsidize costs Requires continued investment and greater role of country governments, through contract arrangements and other innovations Teams of dedicated providers Can encourage expansion in areas of high demand by filling service gaps at existing public and private clinics, particularly with high-quality services that can be monitored more easily with such providers Requires trained staff whocan be deployed to remote areas Greater emphasis on integrated service delivery models may generate hybrid models. As public-sector capacity develops, dedicated providers may shift their role to a support function. Public-private partnerships Must be in place for channel to operate properly, and therefore, for service delivery expansion to occur Requires collaborative relationships with public sector and robust referral systems Possible to sustain over the long term, although dynamics may change with the private sector mentoring public-sector providers who assume a larger role in service delivery (presuming the supply of competent public providers increases) Looking forward, the increasing availability of implants will generate demand, and growing numbers of women in sub-Saharan Africa are likely to choose this method. Our recent results in the region, in which every country where we work produced steep rates of growth, demonstrate this demand; our data also show that implant service delivery, among other contraceptive methods, still has room to expand. Concurrent with this rising demand for implant insertion services will be an increase in the need to remove implants. As early users reach the end of their implant's life span, clients will seek removals in greater numbers than before. Such demand for removals will need to be met with additional family planning services in the context of informed choice; post-removal contraceptive counseling services and method choice availability are key for women who wish to continue using a contraceptive method following the removal. Meeting sustained demand for implant insertion, removal, and post-removal services in the long term will require MSI and other service delivery organizations to develop innovative responses to changing needs and to forge strategic partnerships between stakeholders, including clients. The public-private partnerships that have brought us to the current stage in implant scale up—including the price-volume guarantees and the partnerships between NGOs and local governments that underpin outreach and dedicated provider models—set the tone for further collaboration. Rather than viewing mobile outreach, dedicated provider, and social franchising models as stop-gap measures to support shortfalls in public- or private- (commercial) sector capacity, organizations may be able to integrate these models into the existing health system. MSI's new contract models with the governments of Ghana and Tanzania are examples of this integration. Other sustainability strategies include the incorporation of social franchise clinics in national and social health insurance schemes, and publicly funded voucher programs delivering free or very low-cost services for the poorest clients. As donors, governments, and implementing partners work to reach 120 million additional contraceptive users by 2015 as part of the Family Planning 2020 (FP2020) goals, responsiveness within the global health community will be essential. With the recent price-volume guarantees on implants from manufacturers and donors, important progress has already been made in reducing the financial burden of implant procurement. However, continued investment in the implementation costs required for reaching the client is essential—as a “service-volume guarantee” to meet demand among all current and future clients. Taken together, such investments in commodity supplies and effective, high-quality service delivery will enable all of us to deliver on our FP2020 commitments, and ultimately, ensure that all individuals have access to their contraceptive method of choice.
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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
                11 August 2016
                11 August 2016
                : 4
                : Suppl 2 , Long-Acting Reversible Contraception Crucial to Meeting Unmet Need Goals by 2020: Key Papers From the 2016 International Conference on Family Planning
                : S5-S20
                Affiliations
                [a ]CARE , Atlanta, GA, USA
                [b ]Independent consultant
                Author notes
                Correspondence to Jesse Rattan ( jrattan@ 123456care.org ).
                Article
                GHSP-D-15-00315
                10.9745/GHSP-D-15-00315
                4990162
                27540125
                © Rattan 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 the license, visit http://creativecommons.org/licenses/by/3.0/. When linking to this article, please use the following permanent link: http://dx.doi.org/10.9745/GHSP-D-15-00315.

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