Paying More Than Lip Paying More Than Lip Service to Service to

Long-Acting and Permanent Long-Acting and Permanent MethodsMethods

Nicholas KanlisiJohn M. Pile

Alyson Smith

USAID Mini-UOctober 27, 2006

In the developing world, LAPMs account for what percentage of all methods use among

currently married women?

Pop-Up Quiz

So Einstein, if 2 out of 3 couples are already using LAPMs, why do we have to give them

more than lip service?

LAPM use as percent of all method use, CMWRA

Though globally LAPM use is high, there is wide regional and country variations

Need for Family Planning Percent MWRA with

unmet need

More than 100 million women—17% of currently married women—would prefer to avoid a pregnancy, but are not using contraception

Successful initiatives to introduce/ strengthen LAPM service delivery require behavior change

LAPMs are more difficult to deliver than short-acting methods– Many more myths and rumors

– Provider dependent

– Require community referrals

– Benefits are not recognized due to lack of in-depth knowledge

Behavior change is necessary prior to delivery by providers and adoption by clients

It is a challenge to communicate behavior change and services for LAPMs

Not so subliminal messages…

Taking a holistic approach that pays attention to supply, demand and advocacy program elements

The fundamentals of care – Informed decision-making, clinical safety, and quality

assurance and management

Data for decision-making

Participatory programming – Fostering ownership and sustainability

Identification, adaptation and use of proven, or “best,” practices

Case # 1: Supply-Side Barriers to Norplant Introduction in Ghana

Norplant® was introduced in Sub-Saharan Africa in the early 1990s with high hopes that it would provide an option for couples who did not want or did not have access to sterilization or who were not satisfied with other long-acting methods, such as the IUD.

Case # 1: Norplant Introduction in Ghana

However, a decade later, Norplant® use remains low throughoutthe region. Prevalence is <1% in all but two countries—Ghana and

Kenya. In most countries, awareness of the method is significantly

less than that of other hormonal methods (e.g., pills, injectables).

In many countries, access has been unnecessarily limited by restricting insertions/removals to physicians.

Many programs/sites have been plagued by limited supplies and stockouts.

In many countries, clients have had difficultly accessing removal services.

Case # 1: Norplant Introduction in Ghana

Given what you’ve heard this morning, if you had been tasked to introduce implants in Ghana, how would you go about it?

Strategy for introduction of

Norplant®

Commodities

Regulatory Approval

Provider Education

Quality Assurance

Financing

Training Client IEC

MIS

Case # 1: Norplant Introduction in Ghana

Policy Environment: who can provide implant services?– Only doctors could provide Norplant– A policy change was needed so nurses could provide– Managers saw benefit of shifting services from doctors to

nurses• Reduced doctor workload• Motivated nurses to provide new services• Shorter client waiting times• Services more accessible to clients

Early stakeholder involvement – Regional health administrators– Teaching hospitals – Lead to increased ownership and greater commitment

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Case # 1: Norplant Introduction in Ghana

Shifting services from

doctors to nurses, had

a positive impact An estimated 44,000

women are currently using Norplant®.

Prevalence of the method increased 10-fold, from 0.1% in 1998 to 1% in 2003, and an estimated 1.2% in 2006

Case # 2: Demand-Side Barriersto Vasectomy in Sub-Saharan Africa

Researchers have suggested that vasectomy is unacceptable to most African men and probably will long remain so. However, similar predictions in the late 1980s that female sterilization would never be an acceptable method proved unfounded.

Thirty years ago, “experts” and providers said that men in Latin America would never accept vasectomy—and they have been proven wrong. Vasectomy use in Latin America has increased nearly four-fold in the past 10 years.

Vasectomy in Ghana—Knowledge

Vasectomy suffering from lack of awareness/knowledge

Much of the awareness is negative and consists of false myths and rumors– How do you increase vasectomy uptake when

vasectomy is perceived as castration?

Vasectomy acceptors are very satisfied

Vasectomy in Ghana—Providers

Limited number of providers trained

Providers have biases. They frequently:– Lack knowledge, are misinformed, or have a personal

dislike of the method

– Are used to working with women and may not be comfortable with or know how to talk to men or how to provide them services

– Have untested presumptions about what men think and want

Case # 2: Vasectomy in Sub-Saharan Africa

Given what you’ve heard this morning, if you had been tasked to introduce/scale up vasectomy in Ghana, how would you go about it?

GapsGapsDemand Low knowledge Misinformation

Supply Less available Provider ‘bias’

InterventionsInterventionsDemand Media Campaign Community outreach

Supply Clinical/counseling training

in NSV Create ‘male-friendly’

services

A Strategy for a Successful Vasectomy Program

Ghana Campaign: Marketing Approach

Several channels used to deliver messages

Messages relevant to men’s actual concerns

Satisfied vasectomy clients used to recruit new clients

Messages also targeted to women and the general public

Click the button for one of two spots run on National TV.

Hotlines allowed men (and women) to ask questions anonymously.

~30 calls were made per week.

Calls showed a need for basic information on the procedure and to counter myths.– Nine out of 10 callers

wanted basic information.

– Over half raised myths/misconceptions.

Seven out of 10 callers asked where they could go for the procedure.

One out of six asked about the cost.

In the first six weeks of the campaign the number of vasectomies performed surpassed the total for the last fiscal year. In 2005 the number of procedures dropped to the pre-campaign levels. Plans are in place to repeat the media spots in 2007 as periodic promotion is needed in settings where awareness is low and myths abound

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Persistence will yield results

Lessons Learned

Every context is different – Supply-side factors can present the major obstacles in

some settings, while in others demand-side factors such as myths and rumors are the biggest barrier

Programming for LAPM requires selling more than a product– It requires changing behavior at every level (provider,

client, community)

– Individual realities and perceptions matter• People act on perceived benefits

LAPM programs can have successful results and contribute to a more balanced method mix

Pearls

“Marketing” LAPM requires supporting behavior change and promoting services, not just selling a product

No access, no equipment, no trained provider, no product, no services, no program

Persistence– The wasp says that making several regular trips to

the mud pit enables it to build a house.” (Ewe proverb)