The Power of Implementation Science: Community-Based Provision of injectable Contraceptives in Sub-Saharan Africa

The Power of Implementation Science: Community-Based Provision of injectable Contraceptives in Sub-Saharan Africa John Stanback, PhD Health Services Research, FHI 360 January 25, 2016

Overview 1. Background: Community-based access to injectables 2. Arc of implementation science 3. Examples 4. New directions

What is community-based access to injectables (CBA2I)? Appropriately trained community health workers providing injectable contraceptives as part of full range of available family planning methods.

Why focus on injectable contraceptives? High use: More than 42 million women worldwide use injectables Demand: Women express a preference for injectables In sub-saharan Africa, almost half of FP users rely on injectables. In 21 USAID priority countries, 14 million current users, but 24 million more reporting intent to use FP and preference for injectables. Safe: DMPA has been studied extensively and found to be a safe and highly effective contraceptive. Widely Available: In 2006, DMPA was registered for use in 179 countries.

Why focus on community-based services? Expands access beyond health facilities to reach underserved Evidence-based, replicable model for increasing uptake of modern contraceptive methods Can alleviate health worker shortages through task sharing/shifting

40+ Years of Expanding Community-based Access to Injectables (CBA2I) 1970s: Bangladesh 1980s: Haiti 1990s: Bolivia, Hond., Guat., Peru, Mexico 2000s: Nepal, Afghanistan 2004: Uganda 2006: Madagascar, Pakistan 2008: Ethiopia, Malawi 2009: Nigeria, Zambia, Kenya, Rwanda 2011: Togo 2012: Guinea, Liberia, Senegal 2014: Sierra Leone, Mozambique 2015: Benin Lady Health Worker, Pakistan

Research sites 2004-2012 TUNISIA MOROCCO SAHARA ALGERIA MAURITANIA MALI NIGER LIBYA CHAD EGYPT SUDAN DJIBOUTI ERITREA SOMALIA KENYA TANZANIA DEMOCRATIC CENTRAL RWANDA GABON EQUATORIAL ANGOLA CONGO NIGERIA BENIN DTVOIRE SIERRA SENEGAL GHANA THE GUINEA LIBERIA CAMEROON I ZAMBIA MOZAMBIQUE ZIMBABWE BOTSWANA SWAZILAND LESOTHO NAMIBIA ANGOLA WESTERN UGANDA OF THE CONGO REPUBLIC BURUNDI GUINEA REP. OF TOGO COTE BURKINA FASO GUINEA LEONE GAMBIA BISSAU SOUTH REPUBLIC AFRICAN THE AFRICA MADAGASCAR

Implementation Obstacles? Weak infrastructure and logistics Resistance by medical professional communities Reluctance of conservative MOHs Concerns over safety Doubts about CHWs ability to screen and counsel correctly Questions about acceptability of CHWs offering this new service

IMPLEMENTATION SCIENCE

IMPLEMENTATION SCIENCE (EMBEDDED IN PILOT STUDIES AND PROGRAMMATIC RESEARCH)

FHI 360 criteria for implementation research Deals with studying, as opposed to conducting, implementation Evaluates the implementation of an evidence-based intervention Produces generalizable results Examines intervention fidelity Includes pilot studies when testing the feasibility and planning of a complex intervention little or no evidence exists on a given topic, and if the risk from a larger study is too great

Implementation Science Outcome Variables Source: Peters DH, Tran N, Adam T, Ghaffar A. Implementation research in health: a practical guide. Alliance for Health Policy and Systems Research, World Health Organization, 2013., (Adapted from Proctor E, Silmere H, Raghavan R, Hovmand P, Aarons G, Bunger A, et al. Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda. Adm Policy Ment Health 2010;38:65-76.)

Arc of Implementation Research Acceptability Adoption Appropriateness Feasibility

Arc of Research, cont d Coverage Sustainability Cost Fidelity

Feasibility Acceptability Adoption Appropriateness Feasibility

Madagascar 2006 Pilot Introduced in 13 communes across 4 districts Added to a preexisting CBD programs 61 CBD agents participated, along with 26 supervisors

Madagascar pilot: What we measured 1. Did services conform to quality standards? 2. Did use of contraception increase? 3. How did the support mechanisms function? 4. Is CBD of DMPA acceptable?

Madagascar pilot: What we measured 1. Did services conform to quality standards? 2. Did use of contraception increase? 3. How did the support mechanisms function? 4. Is CBD of DMPA acceptable?

Key lesson: Strengthen support mechanisms Train supervisors Ensure consistent DMPA supplies at health centers Streamline reporting Reduce training class size

Acceptability Acceptability Adoption Appropriateness Feasibility

Zambia 2009-2011 Collaboration between FHI 360, ChildFund, and MOH To measure the impact of adding DMPA provision by CBD agents on uptake of FP, couple-years of protection, method mix, continuation, and cost

Zambia 2009-2011, Acceptability 98% satisfied with service by CBD 93% planned to get another injection 99% wanted next injection from CBD 98% would recommend CBD provision of injectable to a friend

Adoption Acceptability Adoption Appropriateness Feasibility

Nigeria Gombe State, 2009-10 FHI 360, MOH, ARFH Client characteristics, uptake & safety Contributed to policy change at State and Federal level

Injectable Uptake in Gombe State, Nigeria 1200 1000 800 600 400 200 0 DMPA NET-En CHEW Clinic

Injectable Uptake in Gombe State, Nigeria 1200 1000 800 600 400 200 0 DMPA NET-En CHEW Clinic

Appropriateness Acceptability Adoption Appropriateness Feasibility

Senegal 2011-2013 collaboration with MOH and ChildFund 3 districts in Thies, Kaolack, & Fatick regions Assessed injectable provision by matrones posted in community health huts. Provider competence, uptake, reinjection, logistics and community perceptions

Senegal Appropriateness Surveyed variety of community stakeholders to assess appropriateness of intervention Nurse-midwives District health team members Women Men Community leaders Positive results used to support policy change and scale-up

Fidelity Coverage Sustainability Cost Fidelity

Uganda Nakasongola, Uganda, 2004-5 MOH & Save the Children 758 Depo acceptors followed to time of 2nd injection Compared CBD vs. clinic clients CBD equal or better in acceptability, continuation & safety

Scale-up versus Pilot Clients who received a 2nd Injection (6 mo. continuation) 100% 88% 85% 80% 60% 40% 20% 0% Pilot CBD n=415 Pilot Clinic n=242

Scale-up versus Pilot Clients who received a 2nd Injection (6 mo. continuation) 100% 88% 85% 80% 96% 60% 40% 20% 0% Pilot CBD n=415 Pilot Clinic n=242 Scale-up CBD n=169

Scale-up versus Pilot Satisfaction with Care ( satisfied or very satisfied ) 100% 80% 60% 40% 95% 93% 20% 0% Pilot CBD n=449 Pilot Clinic n=328

Scale-up versus Pilot Satisfaction with Care ( satisfied or very satisfied ) 100% 80% 60% 40% 95% 93% 98% 20% 0% Pilot CBD n=449 Pilot Clinic n=328 Scale-up CBD n=188

Scale-up versus Pilot Client Knowledge of Common Side Effects Irregular bleeding Heavy bleeding Spotting Amenorrhea Pilot CBD Clients Pilot Clinic Clients Bar 1 Headache Weight gain 0% 20% 40% 60% 80% 100%

Scale-up versus Pilot Client Knowledge of Common Side Effects Irregular bleeding Heavy bleeding Spotting Amenorrhea Pilot CBD Clients Pilot Clinic Clients Scale-up CBD Clients Headache Weight gain 0% 20% 40% 60% 80% 100%

Cost Coverage Sustainability Cost Fidelity

Zambia Costs To determine the incremental cost per couple-years of protection (CYP) of adding injectable contraceptives to CFZ s existing CBD program

Incremental costs per CYP of CFZ s FP program

Range of Potential Cost per CYP

Coverage Coverage Sustainability Cost Fidelity

Kenya Tharaka District, 2009-10 Collaboration with MOH, JHPIEGO, AFP Uptake, coverage, continuation Led to policy change (but only limited scale-up)

Coverage, Tharaka catchment area 100% 80% 60% 40% 20% 0% 32% 9% 14% Pre Post Clinic CBD

Provision of injectable contraceptives by CHWs increases contraceptive coverage 46% 34% 27% Baseline Follow-up 9% 9% 2% Bangladesh, 1977-79* Afghanistan, 2005-06** Kenya, 2009-10*** *Bhatia S, Mosley WH, Faruque AS, Chakraborty J. The Matlab family planning-health services project. Stud FamPlann 1980;11:202 12. **Huber D, Saeedi N, Samadi A. Achieving success with family planning in rural Afghanistan. Bull WHO 2010;88:227-231. ***Olawo A, Bashir I, Solomon M, Stanback J, Ndugga BM, Malonza I. These days we take a cup of tea with our CBD agent: Community Provision of Injectable Contraceptives in Tharaka, Kenya. Global Health: Science and Practice, 2013;1(3):287-288.

Sustainability Coverage Sustainability Cost Fidelity

Uganda Scale-up

Uganda Scale-up

Status of CBA2I in Africa - 2005 MOROCCO TUNISIA WESTERN SAHARA ALGERIA LIBYA EGYPT Pilot initiated MAURITANIA THE GAMBIA GUINEA BISSAU SENEGAL SIERRA LEONE GUINEA LIBERIA COTE DTVOIRE MALI BURKINA FASO GHANA BENIN TOGO NIGER NIGERIA CAMEROON CHAD CENTRAL AFRICAN REPUBLIC SUDAN ERITREA ETHIOPIA DJIBOUTI EQUATORIAL GUINEA GABON REP. OF THE CONGO DEMOCRATIC REPUBLIC OF THE CONGO UGANDA KENYA SOMALIA ANGOLA RWANDA BURUNDI TANZANIA ANGOLA ZAMBIA MALAWI NAMIBIA ZIMBABWE MOZAMBIQUE MADAGASCAR BOTSWANA LESOTHO SWAZILAND SOUTH AFRICA

Status of CBA2I in Africa - 2009 MOROCCO TUNISIA WESTERN SAHARA ALGERIA LIBYA EGYPT Exploring possible introduction MAURITANIA THE GAMBIA GUINEA BISSAU SENEGAL SIERRA LEONE GUINEA LIBERIA COTE DTVOIRE MALI BURKINA FASO GHANA BENIN TOGO NIGER NIGERIA CAMEROON CHAD CENTRAL AFRICAN REPUBLIC SUDAN ERITREA ETHIOPIA DJIBOUTI Pilot initiated Policy dialogue underway and scale up in progress EQUATORIAL GUINEA GABON REP. OF THE CONGO DEMOCRATIC REPUBLIC OF THE CONGO RWANDA BURUNDI UGANDA KENYA SOMALIA Policies changed ANGOLA TANZANIA ANGOLA ZAMBIA MALAWI NAMIBIA ZIMBABWE MOZAMBIQUE MADAGASCAR BOTSWANA LESOTHO SWAZILAND SOUTH AFRICA

Status of CBA2I in Africa - 2012 MOROCCO TUNISIA WESTERN SAHARA ALGERIA LIBYA EGYPT Exploring possible introduction MAURITANIA THE GAMBIA GUINEA BISSAU SENEGAL SIERRA LEONE GUINEA LIBERIA COTE DTVOIRE MALI BURKINA FASO GHANA BENIN TOGO NIGER NIGERIA CAMEROON CHAD CENTRAL AFRICAN REPUBLIC SUDAN SOUTH SUDAN ERITREA ETHIOPIA DJIBOUTI Pilot initiated Policy dialogue underway and scale up in progress EQUATORIAL GUINEA GABON REP. OF THE CONGO DEMOCRATIC REPUBLIC OF THE CONGO RWANDA UGANDA KENYA SOMALIA Policies changed BURUNDI ANGOLA TANZANIA ANGOLA ZAMBIA MALAWI NAMIBIA ZIMBABWE MOZAMBIQUE MADAGASCAR BOTSWANA LESOTHO SOUTH AFRICA SWAZILAND Afghanistan and Pakistan: CHW are providing injectable contraceptives.

Status of CBA2I in Africa - 2015 MOROCCO TUNISIA WESTERN SAHARA ALGERIA LIBYA EGYPT Exploring possible introduction MAURITANIA THE GAMBIA GUINEA BISSAU SENEGAL SIERRA LEONE GUINEA LIBERIA COTE DTVOIRE MALI BURKINA FASO GHANA BENIN TOGO NIGER NIGERIA CAMEROON CHAD CENTRAL AFRICAN REPUBLIC SUDAN SOUTH SUDAN ERITREA ETHIOPIA DJIBOUTI Pilot initiated Policy dialogue underway and scale up in progress EQUATORIAL GUINEA GABON REP. OF THE CONGO DEMOCRATIC REPUBLIC OF THE CONGO RWANDA UGANDA KENYA SOMALIA Policies changed BURUNDI ANGOLA TANZANIA ANGOLA ZAMBIA MALAWI NAMIBIA ZIMBABWE MOZAMBIQUE MADAGASCAR BOTSWANA LESOTHO SOUTH AFRICA SWAZILAND Afghanistan and Pakistan: CHW are providing injectable contraceptives.

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2016 The Evidence Project. All rights reserved. Use of these materials is permitted only for noncommercial purposes. The following full source citation must be included: Stanback, John. 2016. The Power of Implementation Science: Community-Based Provision of Injectable Contraceptives in Sub-Saharan Africa, PowerPoint slides. Washington DC: Evidence Project This presentation may contain materials owned by others. User is responsible for obtaining permissions for use from third parties as needed.