Post on 02-Jan-2016
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
?
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)