Paying More Than Lip Service to LAPMs

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Paying More Than Lip Service to Long-Acting
and Permanent Methods
Nicholas Kanlisi John M. Pile Alyson Smith
USAID Mini-U October 27, 2006
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In the developing world, LAPMs account for what
percentage of all methods use among currently
married women?
Pop-Up Quiz
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(No Transcript)
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So Einstein, if 2 out of 3 couples are already
using LAPMs, why do we have to give them more
than lip service?
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(No Transcript)
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Though globally LAPM use is high, there is wide
regional and country variations
LAPM use as percent of all method use, CMWRA
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More than 100 million women17 of currently
married womenwould prefer to avoid a pregnancy,
but are not using contraception
Need for Family Planning Percent MWRA withunmet
need
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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

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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

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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.

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Case 1 Norplant Introduction in Ghana

• However, a decade later, Norplant use remains
  low throughout
• the region.
• Prevalence is lt1 in all but two countriesGhana
  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.

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Case 1 Norplant Introduction in Ghana

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

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Provider Education
Training
Client IEC
Strategy for introduction of Norplant
Regulatory Approval
Quality Assurance
Commodities
Financing
MIS
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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

Norplant insertions
Norplant sites
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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
  vasectomyand they have been proven wrong.
  Vasectomy use in Latin America has increased
  nearly four-fold in the past 10 years.

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Vasectomy in GhanaKnowledge

• 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

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Vasectomy in GhanaProviders

• 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

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Case 2 Vasectomy in Sub-Saharan Africa

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

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A Strategy for a Successful Vasectomy Program

• Interventions
• Demand
• Media Campaign
• Community outreach

• Gaps
• Demand
• Low knowledge
• Misinformation

• Supply
• Less available
• Provider bias

• Supply
• Clinical/counseling training in NSV
• Create male-friendly services

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Ghana Campaign Marketing Approach

• Several channels used to deliver messages
• Messages relevant to mens 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.
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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.

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Persistence will yield results

• 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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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

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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)