IMPACT MAGAZINE

SECTION 3

Moving Care
Closer to Consumers

By Dr. Lillian Sekabembe, Deputy Country Representative, and Precious Mutoru, Advocacy and Partnerships Coordinator, PSI Uganda 

With the WHO’s published, Consolidated Guideline on Self-Care Interventions for Health, self-care had been formally recognized as a core strategy for strengthening health systems and advancing universal health coverage, while reducing strain on overburdened health systems.  

But what does it look like to put these guidelines to practice? In Uganda, we, alongside the government, sought to find out.  

STEP BY STEP: PILOTING THE WHO GUIDELINES  

The Uganda Ministry of Health kick-started the process of structuring self-care for sexual and reproductive health and rights (SRHR); first, by establishing the Self-Care Expert Group (SCEG) to coordinate the development of national SRHR self-care guidelines. To adapt the WHO’s guidelines to Uganda’s needs, the SCEG adopted an iterative evidence-based approach, implemented in three phases — inception, development and guideline test implementation. 

The guidelines were tested in 10 public and 8 private sector facilities. Research is ongoing to understand the acceptability, feasibility, and applicability of the National Guidelines in supporting SRHR self-care practices.  

Preliminary findings suggest that the guidelines helped to facilitate the acceptance and use of SRHR self-care practices. For example, in the Mukono District just west of Kampala, SRHR self-care practices such as HIV self-testing, male condom use, and the use of iron supplements during pregnancy were prevalent in part, because these products were readily available and health providers supported self-care practices. Other popular self-care interventions included self-injectable contraception and rapid diagnostic test kit for Malaria, though their use is undermined by commodity stockouts. Other self-care interventions including self-sampling for human papilloma virus (HPV) and sexual and gender-based violence (SGBV) kits gained significantly less traction as only a few health facilities were equipped to support these practices.  

The takeaway? Self-care isn’t reliant on the individual alone. Consumers have questions and, at times, may need support from health facilities for varying self-care interventions.  

ACROSS ALL LEVELS, THE ADOPTION OF SELF-CARE POLICY AND PRACTICES LED TO POSITIVE CHANGES IN HEALTH SEEKING BEHAVIORS. SPECIFICALLY: 
  • Consumers favor SRHR self-care interventions, saying that it saves them time and money. Consumers further emphasized the importance of trusted health workers, as they feel most comfortable with practicing self-care following instruction from a health provider.   
  • Health providers, particularly those in the public sector facilities, say self-care helps to minimize the overcrowding of clinics and hospitals and prioritize more hands-on healthcare needs. For instance, a health provider in one of the public sector health facilities shared that after the self-care training, they adopted group testing for malaria using rapid diagnostic test kits with expecting mothers during their antenatal care appointments, increasing the efficiency of their malaria and antenatal care.  

With self-care, health providers recommend building robust follow-up mechanisms to ensure continuity of care. Further, both public and private health facilities need improved platforms to help record self-care data, which is not currently being captured effectively. From this data we can glean learnings about how to improve, localize and scale self-care interventions.  

The Ugandan National Guidelines on Self-Care Interventions for SRHR will be finalized and presented for approval by 2023, which includes a suite of operational tools for training, monitoring, evaluation and learning, quality assurance, and a costed implementation plan, customized SCTG SBC framework. SRHR self-care presents a unique opportunity for health systems to deliver optimized, equitable, high-quality healthcare to diverse communities. The Ugandan experience has important implications for how countries can develop feasible, effective and contextually relevant national guidelines that align with global standards for SRHR self-care. 

By Andrea Cutherell, Team Lead Innovation Sites, PSI; Alexandrina Nakanwagi, Project Lead, DISC Uganda, PSI Uganda; Roselyn Odeh, Deputy Team Lead, DISC Nigeria, SFH Nigeria; Oluwatosin Adeoye, Senior Learning Advisor, DISC Nigeria, SFH Nigeria

Self-care presents an opportunity to strengthen overstretched health systems by offering delivery efficiencies while placing people at the center of its design. Countries around the world are recognizing this potential, many of whom are adopting and adapting the World Health Organization’s Consolidated Guideline on Self Care Interventions for Health, which provides clear recommended self-care approaches worthy of integration in national/subnational health systems. This shift to integrate self-care more formally within health systems requires a new set of behaviors. Not just for the consumer (or ‘self-carer’) but for the entire health ecosystem around them, including, perhaps most importantly, the healthcare provider. But critical questions remain: 

  • What might behavior change for an ecosystem of healthcare actors look like in practice? 
  • What is the role of the healthcare provider in self-care? 
  • How might consumer insights light a path toward defining those behavior change efforts? 

The Population Services International-led Delivering Innovation in Self-Care (DISC) program—being implemented in Nigeria and Uganda—aims to answer these questions as they relate to self-injectable contraception, DMPA-SC. And, in doing so, demonstrate that self-care offers health systems a new and critical partner: consumers themselves.  

In 2020-2021, DISC conducted extensive programmatic research, including interviews with ‘early adopters’ of DMPA-SC, prospective users, and the public and private sector providers on whom women rely (distilled in this Insight Synthesis Report). In collaboration with the PATH-led Access Collaborative initiative and the Ministries of Health in Nigeria and Uganda, we honed in on the insight that fear of the needle and/or pain was a major barrier at the decision stage to self-inject. Yet, most providers aren’t trained to address this fear. This presented a behavior change opportunity worth testing: what if providers were equipped to directly address client fear to self-inject? Would more women voluntarily choose to self-inject? 

In response, DISC launched the ‘Moment of Truth’ Innovation in 20 public and private outlets–designated as “Innovation Sites,” –throughout Nigeria and Uganda to test this question and to incubate and test new training approaches. Our work in the innovation sites is focused on optimizing the training curriculum for self-inject providers by improving providers’ confidence in counseling women to take up self-injectable contraceptives and helping them to address client fears related to taking up self-inject. Innovation Sites were launched in September 2021 and qualitative and quantitative data were captured over a six-week period. The emerging results are promising. While qualitative findings need to be explored to fully understand the drivers of performance, voluntary uptake conversion rates dramatically increased following exposure to the ‘Moment of Truth’ Innovation approach. In fact, Innovation Sites in both countries quickly outperformed global benchmarks for self-injection conversion rates in both public and private sectors (see figure).  

DISC is currently in the process of analyzing the results to optimize provider training and associated activities. We’re also working with partners to identify pathways to scale up in Nigeria and Uganda—either through other partners or by incorporating the training into national curricula.  

This small-scale innovation illustrates the potential for consumer insights to better inform behavior change of a health ecosystem and, in doing so, support the evolution of health systems to be more responsive and resilient. 

During its ongoing update of the National Family Planning Curriculum, the Uganda Ministry of Health is incorporating a module on addressing client fear. In Nigeria, the Ministry of Health is excited about this approach and sees it as something that may inform policy change. If the results are as promising as they appear to be during our initial stages of analysis, this relatively simple adjustment to provider curriculum could help encourage providers to offer self-injection. It could also increase the potential for women to experience her own power and agency over her sexual and reproductive health care needs, a unique advantage of this self-care method. Equally important, this small-scale innovation illustrates the potential for consumer insights to better inform behavior change of a health ecosystem and, in doing so, support the evolution of health systems to be more responsive and resilient, with consumers at their core. 

By Amanda Burgess, Advance Family Planning, United States; Angeline Mutunga, MOMENTUM Country and Global Leadership, Kenya; Carina Ubisse Capitine, The African Women’s Development and Communication Network, Mozambique; Claire Mathonsi, Advocacy Accelerator, Kenya; Goodness Ogeyi Odey, International Youth Alliance on Family Planning, Nigeria; Mwenya Chiti, Phakama Africa, Zambia

Colonialism and its legacy are part of our shared human history. The social structures, funding models, and knowledge generation practices that define global health are rooted in a history of inequality, exploitation, and racism. For the family planning community, this is a history of coercion, population control, and eugenics. This history may not be un-done and prior calls to challenge this legacy have fallen short. Now is the time to boldly move forward to address the underlying systems of oppression, to shift power, and to create a more equitable world. 

At the core of our focus: what can the family planning community do to shift power and accelerate efforts to advance equity in global health now?  

There are four key questions we will explore at the Shifting Power and Advancing Equity in Global Health pre-conference on Nov. 14, 2022: 

  1. What historical legacies in family planning and development do we need to unpack as a community before we can move forward? 
  1. What can donors and partners do right now to deliver on the promise to meaningfully move leadership and development funding to local experts? 
  1. How can we minimize operational barriers–like institutional architecture, funding models, and leadership–to help individuals, organizations, and donors act more equitably? 
  1. What is the current state of power dynamics at play at the global, regional, national, subnational, and community levels? 

Shifting power requires each of us to approach this work courageously, honestly, and humbly. It requires self-reflection and a commitment to engage in open and honest dialogues. It also calls us to more equitably partner with the communities we serve. We believe that everyday choices and actions will create the world we want to see.  

This International Conference on Family Planning (ICFP) community dialogue takes place in person from 7:30am–12:30pm at the Royal Cliff Grand Hotel in Pattaya City–thanks to the support of our generous sponsors the Transforming INGO Models for Equity (TIME) initiative, the Advocacy Accelerator, and the Guttmacher Institute. We hope this event is only the beginning of a growing movement to address power shifting and increase equity within the family planning community. 

We invite you to share your voice and join us to address racism, shift power, and challenge structural inequality in family planning and global health. If you are interested in remaining engaged in this work sign up to stay in touch here. For more information on the pre-conference check out the website. 

When it comes to improving family planning in low and middle-income countries (LMICs), we must focus amplifying the voices of young people, who face disproportionate barriers to accessing quality sexual education and comprehensive health services. Adolescents and youth are a diverse social group that have unique sexual and reproductive health, rights and justice (SRHR-J) needs. Addressing these needs is critical to their physical, mental, and emotional wellbeing.

It is for this reason, IYAFP and 120 Under 40, with the support of the Bill & Melinda Gates Institute for Population and Reproductive Health and Bayer AG, have assembled a group of youth-led initiatives and thought-leaders for the creation of a Youth-Led SRHR Global Roadmap for Action (AYSRHR GRA). The AYSRHR-J GRA is youth voices together outlining a new vision for adolescent and youth SRHR and establish goals and priorities for 2030. AYSRHR-J GRA will promote unity in the expression of young people’s SRHR-J needs and values across the world. 

Finally, it is time for governments, donors, the private sector, iNGOs, and youth-led organizations to come together and commit to a common AYSRHR-J vision and priorities. It is time we Let Them Know what we want, what we need, and what we expect.

LET THEM KNOW WHAT WE WANT

As youth, we want the opportunity and access for all youth to achieve their fundamental right to SRHR-J. To achieve this, youth and adolescents require accurate information on and access to modern contraception, emergency contraception, menstruation hygiene, HIV/AIDS and STI prevention, testing and treatment, obstetrics and gynecology services, pregnancy testing and services, safe (and legal) abortion services, gender-based violence prevention, and treatment services, harmful practices counseling and referrals, among other topics.

These services to be adolescent and youth-friendly, they must respect privacy, prioritize confidentiality, and obtain informed consent. They also must be tailored to the specific needs of young women and girls, especially LGBTQIA+ youth and adolescents, young people living with disabilities, as well as young people living in humanitarian emergencies. 

LET THEM KNOW WHAT WE NEED

AYSRHR-J GRA presents a comprehensive plan for governments, donors, iNGOs, and youth-led organizations to prioritize the sexual and reproductive health and rights of young people. To achieve our overall vision, we are prioritizing the following needs:

  • Acknowledgement of the diverse youth identities and needs: A just, equitable, and sustainable AYSRHR-J field in which every youth, including LGBTQIA+ youth and youth with disabilities, enjoy the right to a life of dignity worldwide.
  • Meaningful youth partnerships and engagement: A world in which equitable, mutually respectful, and beneficial youth partnerships are the norm. Where young people participate fully in decision-making for AYSRHR-J and are integrated in all stages of SRHR-J policy-making to ensure their health needs are met and are able to hold decision-makers accountable for the commitments made toward sustainable development.
  • Progressive AYSRHR-J policies: A world in which AYSRHR-J policies address and are responsive to the diverse set of youth needs and identities to catalyze the social and political changes necessary to ensure their reproductive health needs are met.
  • Transparent AYSRHR-J data and reporting: A world in which comprehensive and transparent data on adolescents and youth, including disaggregation by age and gender and inclusion of diverse youth identities, is available for decision making.
  • Equitable AYSRHR-J financing: A world where all unmet needs for AYSRHR-J services and commodities are equally funded and resourced through increased financial resources and technical support supplied both by the donor community, the private sector, and governments.
LET THEM KNOW WHAT WE EXPECT

Finally, it is time for governments, donors, the private sector, iNGOs, and youth-led organizations to come together and commit to implementing the GRA at the local, national, and global levels. The health, rights, and lives of adolescents and young people depend on it.

This GRA provides a vision of what we want and need. The how is determined by the young people and their local contexts.

Bring youth to the table in decision-making & funding. Invest in youth voices and youth-led organizations. The GRA recommendations providing a range of input and resources on how to effectively accomplish this. 

Implement recommendations outlined in the GRA to ensure youth-led and youth-said priorities and actions are implemented. Donors and policymakers can submit their GRA commitments here.

As the GRA evolves and grows, we expect that donors and decision-makers invest in the structure of the GRA, including the creation and support of accountability and evaluation mechanisms and resources, the maintenance of advisory groups and coalitions of youth led-organizations, and funding mechanisms for GRA activities globally and locally. Donors and policymakers can indicate their interest in investing in the GRA here.

Youth & Youth-Led Organizations – Join us

We invite youth and youth-led organizations to join us in the creation of a coalition of youth-led organizations charged with the maintenance, implementation, and evaluation of the GRA. Youth-led initiatives joining this initiative have the unique opportunity to utilize the GRA as an advocacy tool in their campaigns and hold your governments accountable for their commitments to AYSRHR-J. Together, we can create a world where all young people have access to comprehensive sexual and reproductive healthcare and knowledge and are able to exercise their rights fully.

Youth and Youth-Led organizations can join us here.

By Dionne Oguna, A360 Associate Communications Manager, PSI and Fifi Ogbondeminu, Acting 360 Project Director, PSI  

When girls have the tools – like contraception – to take charge of their lives, they have the power to achieve their goals. A360’s girl-centered approach to contraceptive programming supports girls’ voluntary uptake of contraception and helps them to choose the lives they want to live.

A360 partners with governments across Ethiopia, Nigeria and Kenya to help incorporate this girl-centered model into their health systems.

PSI’s flagship adolescent sexual and reproductive health (ASRH) program, A360, aims to increase voluntary, modern contraceptive use among adolescent girls (15-19 years old) in Ethiopia, Nigeria, and Kenya. A360 country projects utilize an aspirational program approach, tapping into what adolescent girls say they want and need and positioning contraceptive use as relevant to achieving their goals.

Since its inception in 2016, the project has reached over 600,000 girls with contraceptive services and supported over 400,000 girls to voluntarily adopt a modern method of contraception.

But we know we can do more. And that starts by integrating the model into health systems – supporting governments to advance their ASRH goals, and girls to access girl-centered ASRH services. We spoke to Mrs. Jemimah Menwyah, an adolescent desk health officer for Nigeria’s Kaduna State Primary Health Care Agency, and Hannatu John, a program assistant for A360 in Kaduna state, to discuss where we go from here.

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A360 has supported KADUNA STATE TO STRENGTHEN ASRH SYSTEMS AND SUPPORT GIRLS to take CHARGE OF THEIR LIVES 
Viewpoint from MRS. JEMIMAH MENWYAH,  ADOLESCENT DESK HEALTH OFFICER, KADUNA STATE PRIMARY HEALTH CARE AGENCY

Kaduna state has a rampant and fast-growing population, of which 40 percent are adolescents and young people. Our government has recognized adolescent pregnancy as a significant health problem and the introduction of the A360 project in 2018 helped them take action.

The A360 project helped the State effectively reach adolescent married girls and provided them with the much-needed ASRH services. Based on the project’s success, the state was able to decisively sustain the model and take steps to institutionalize the Matasa Matan Arewa (MMA) program, an off-shoot A360 program in Northern Nigeria that works to support adolescent married girls in their SRH journey.

As part of this program, ASRH counseling and training has been integrated throughout government health systems to offer safe, youth friendly services in primary care. The MMA model has also been implemented to support families and communities in creating safe environments for girls to access ASRH services. To measure the success of these programs, A360 partners supported the disaggregation of the national health data systems by age to help isolate adolescent health metrics.

With A360, Kaduna state has worked to strengthen ASRH systems and support adolescent girls in taking charge of their lives. By institutionalizing the A360 model, we are able to multiply our impact on the adolescent girls in Kaduna.

The A360 model has been incorporated into state family planning and annual operational plans since 2018. As part of the institutionalization effort, government stakeholders worked closely with the A360 team to strengthen the Adolescent Technical Working Group (ATWG), which includes other partners, ministries, departments and agencies with similar goals in improving adolescent girls’ health outcomes.

The state has also signed a letter of commitment and Memorandum of Understanding (MOU) to enshrine MMA intervention into state systems. In this letter, the state committed to the domestication of the Adolescent Health and Young Person Policy which reflects critical components of the A360 model.

 

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YOUNG PEOPLE ARE AT THE CORE OF THE PROGRAM DESIGN, OWNERSHIP AND IMPLEMENTATION
Viewpoint from HANNATU JOHN, PROGRAM ASSISTANT A360, KADUNA STATE, SFH NIGERIA

A360’s primary focus is creating an enabling environment and safe space for young people to access ASRH services. The program has a meaningful youth engagement framework that deliberately ensures that young people are at the core of the program design, ownership and implementation.

Before the A360 program, state efforts to drive young people to access SRHR services in health centers were limited. The commencement of A360 strengthened youth access to ASRH counseling sessions focused on life, family, and health. The sessions allow peers to discuss personal hygiene, nutrition and SRHR and address myths and misconceptions through quality ASRH services and information.

Within the system, those interested in taking up a contraceptive method are referred to a trained youth-friendly provider in the health facility for access to further quality ASRH information and services. In some cases, married adolescent girls are linked directly to the facility through the male interpersonal agent who engage their husbands within the community, creating support and an enabling environment for their wives to access SRH care. The husbands, in turn, refer their wives to access SRH services at the health care centers.

Overall, the A360 program is helping meet youth where they are and supporting adolescents in their ASRH journeys.

 

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To learn more about how you can work with A360, drop us a note: [email protected]. And visit our website a360learninghub.org. 

By Matthew Wilson, Former A360 Project Director, Former PSI

A360 is on a learning journey, and we have committed to being radically transparent even if this is uncomfortable sometimes.

As we learn, our thinking evolves.

In recent months we have been giving a lot of thought to metrics. A360 is more than a service delivery program – we exist to support health systems to be more responsive to the unique needs of adolescent girls and to generate evidence and learning others can utilise.

But how do you measure the service delivery component of an adolescent sexual and reproductive health (ASRH) intervention?

Broadly speaking, sexual and reproductive health (SRH) interventions serve first-time users (never used), lapsed users (ever used) and continuing users (currently using, including method continuers and method switchers)[1]. However, the sector’s pursuit of additional user commitments[2] has all too often been reduced to the pursuit of first-time users when it comes to programming. Although during the first phase of the program A360 focused on reporting both first-time users and lapsed users[3], we have also felt the impetus to focus on first-time users.

Here’s what we are learning though: the value of an ASRH intervention goes well beyond first-time users.

 
1. Adolescent girls have unique patterns of need and use

Focusing on first-time users implies behaviour change pathways and user journeys are linear and unidirectional; that the best investment we can make is supporting women who have never used a modern contraceptive method to adopt one. We are learning it is not this simple, especially for adolescents.

Adolescents’ sexual activity – especially that of unmarried adolescents – is often unplanned, infrequent and fleeting. This is exacerbated by the prevalence of non-consensual sex[4]. Consequently, their need for and use of contraception may be far more intermittent than other age groups of women of reproductive age. They may choose to start and stop using contraception on a regular basis, discontinuing whenever relationships end[5]. Likewise, they may choose on-demand methods such as emergency contraception (EC) and condoms.

So what?

  • We need to be responsive to adolescent girls’ unique patterns of need and use and support them to achieve the contraceptive user journeys they want. This may mean supporting adolescent girls to start, stop and resume contraceptive use on a regular basis.
  • We need to be careful not to assume discontinuation is inherently problematic; the reality is more complex for adolescents.
  • We need to work harder to expand access to and acceptability of on-demand methods such as emergency contraception (EC). Currently, EC represents a fraction of our method mix but it may be uniquely suited to adolescents who have infrequent and sometimes non-consensual sex.
 
2. We risk attributing too much value to prior use; prior use is heterogenous

Focusing on first-time users attributes a value to prior use which is unjustified given current adolescent contraceptive norms.

A first-time user is someone who adopts a modern contraceptive method for the first time in their life[6]. Any prior use of a modern method would disqualify someone from being categorised as a first-time user. A modern method that they self-administer (e.g. condom, EC, OCP), or one that requires an invasive medical procedure (e.g. LARC)[7]. A modern method used once (e.g. condom, EC), or one that provides protection for a several months / years without any further action (e.g. injectable, LARC). A modern method purchased from a pharmacy without counselling, or a modern method received after one-to-one counselling with a trained provider.

The expansive definition sets a low bar for prior use. This is problematic if we have a singular focus on first-time users because it assigns too much value to prior use. This is not a value judgement about which method or outlet a girl adopted a method, but a question of quality.

The evidence suggests lapsed and continuing users are likely to be / have been users of short-term self-administered methods, purchased from pharmacies and drug

shops without quality counselling or a full method choice (directly or through the offer of referral)[8]. Furthermore, they are more likely than other age groups to have experienced contraceptive use failure and/or discontinued.[9] Given this, we must question how many lapsed and continuing users exercised informed choice[10] when they adopted their first or previous modern contraceptive method?

So what?

  • We need to recognise the limitations of the first-time user metric and give more consideration to quality and informed consent. We need to distinguish between a decision to adopt a method and an informed choice to do so. Providing informed choice to an adolescent girl – whether she is a first-time user, lapsed user or continuing user – means providing more than a modern contraceptive method. It means equipping her with knowledge, confronting myths and misconceptions, providing a choice of methods, and improving the prospects of method fit and continuation when in need.
  • We need to gather method information index data from first-time users to better understand the quality of prior use.
 
3. We need to accord the same value to all users

When we focus on first-time users it inevitably means we under value the time and expertise required to support lapsed and continuing users and the impact this makes. Current adolescent contraceptive norms mean many lapsed and continuing users will have similar knowledge of and attitudes towards contraception as a first-time user. Their prior use may have been a negative experience and left them more fearful of and resistant to contraception than a first-time user[11]. Consequently, it would require a comparable amount of time and expertise to reposition contraception, expand method choice[12], and provide evidence-based, user-centred counselling[13] to a lapsed or continuing user as a first-time user. Likewise, the impact this generates will be significant. Note too, continuing users include method switchers.

So what?

  • The magnitude of the ASRH challenge and the scarcity of resources to meet it inevitably means we search for a panacea. We need to concede that there is none. The challenge is unavoidably multifaceted and complex.
  • ASRH programmes cannot afford to focus on first-time users. We need to place equal emphasis on first-time, lapsed and continuing users. Ultimately, generating additional users[14] is dependent on it.

 
4. First-time user data on adolescents is fallible

A further challenge associated with focusing on first-time users is that identifying them is dependent on adolescent girls accurately recalling and reporting prior use. We are learning that this is constrained by several factors:

  • Adolescent girls are often deterred from reporting prior use due to the stigma attached to premarital sex, which is often perpetuated by providers. This can be compounded by the age of consent, which stands at 18 years old in each of countries A360 works in.
  • Prior use may be interpreted differently by the girl and/or the provider. For instance, the client and/or provider may reach different conclusions about whether prior use includes the condom a girl’s partner used, or the emergency contraception a girl used after unprotected sex.
  • A short interaction with a stranger is not very conducive to accurate disclosure of prior use, particularly if there is stigma or confusion to overcome.
  • Finally, whether a girl reports prior use accurately has no bearing on whether she receives the service. Faced with the stigma attached to premarital sex and an age of consent of 18 years old, it is conceivable an adolescent girl would choose not to disclose prior use.

So what?

  • It is challenging to distinguish between first-time users and lapsed users accurately and meaningfully. Reporting first-time users alongside lapsed users means a program captures girls who recall and report prior use accurately and those who do not.
  • To interpret this data we need to invest in mixed methods research to better understand girls’ contraceptive journeys.
  • We need to mitigate the risks associated with recall and self-reporting of prior use. Strategies include employing client exit interviews to explore prior use with greater sensitivity and rigour than in a counselling moment.

By Andrea Novella, Social Business Global Digital Advisor, PSI and Emma Beck, Sr. Corporate Communications Manager, PSI  

INTRODUCING VIYA, PSI’S FIRST GLOBAL SEXUAL WELLNESS LIFESTYLE BRAND THAT’S USING #THEVWORD (AHEM, VAGINA) TO PUT THE POWER OF HEALTH CHOICE INTO WOMEN AND GIRLS’ HANDS.  

From periods to pleasure, the only way to normalize women’s sexual and reproductive health and rights (SRHR) is to freely talk about it.  

Population Services International (PSI) is going all the way – starting with one word: vagina. 

The global health NGO just launched VIYA, its first global sexual wellness lifestyle brand, igniting a movement under #TheVWord aimed at disrupting the narrative around women’s healthcare and supporting women to make and own their health choices throughout their lifecycle.  

Harnessing technology including artificial intelligence, e-commerce and telemedicine, VIYA plans to deliver SRHR information, products and services across the stages of their lives – from menstruation to menopause – to women across low- and middle-income countries (LMICs). 

It’s Femtech meets NGO; VIYA leverages private sector tactics while building on a foundation of sustainable impact through a social business model. 

Unreliable markets, siloed approaches and entrenched taboos too often stand between women and their reproductive health choices. The impact reverberates; 218 million women and girls in LMICs want to avoid a pregnancy but are not using modern contraception.  

VIYA responds. 

“Up for discussion is everything women’s health. Masturbation, contraception, pleasure, STIs and more – you name it, VIYA’s open to talking about it,” says Marcie Cook, PSI’s Vice President of the Social Business Unit. “VIYA will close the loop in women’s health by reimagining the way we deliver healthcare and putting the consumer at the center. Firstly, by expanding on PSI’s existing health products and services to include a comprehensive, digitally enabled platform. Secondly, by igniting a movement that normalizes women’s sexual health and wellness.” 

VIYA is delivered through PSI’s Social Business and funded through a blended-finance model, including grants from PSI’s Maverick Collective, the Swedish International Development Agency, the Foreign, Commonwealth and Development Office, the Bill and Melinda Gates Foundation, the Australian Ethical Foundation and income earned from PSI’s nine business units that operate in 21 global markets. VIYA exemplifies how donor investments into pilot research and innovation can lay a foundation for financially viable social impact at scale. 

PLEASURE-FORWARD, EVIDENCE-BACKED 

For women from South Africa to El Salvador, the journey to sexual wellness is confusing, unreliable and stigmatized. They need an alternative that is trustworthy, discreet, AND fun, which is exactly what VIYA aims to deliver.  

Evidence emerging from PSI pilot projects indicates that when women and girls feel confident in embracing sexual health and pleasure, they are more likely to communicate contraceptive needs with a sexual partner, and seek out clinic-based SRHR care.  

In Kenya, for example, PSI and the Foreign, Commonwealth & Development Office (FCDO) tested a “pleasure-bot” to understand if and how integrating pleasure-forward content into a chatbot could motivate SRH-seeking behaviors among Kenyan youth. 

The team learned that young women didn’t feel they had confidential sources and spaces for SRHR questions and care. They only went to clinics when health risks presented, opting for Google to self-diagnose. They said they wanted sex-positive content but didn’t have access to curated content from credible sources. Instead, they turned to porn sites to learn about sex and encrypted social media platforms like Telegram to share X-rated content. 

“Up for discussion is everything women’s health. Masturbation, contraception, pleasure, STIs and more – you name it, VIYA’s open to talking about it.”

– Marcie Cook, Vice President – Social Business, PSI

FEMTECH MEETS NGO 

Marrying digital privacy with relatable, sex-positive educational content, VIYA equips women with the tools to choose and own their health journeys. The platform spans women’s lifecycles, going beyond standard siloed approaches that focus on one health area at one point in women’s lives.  

For now, the brand leverages popular platforms like Facebook, Instagram, and Tik Tok, to provide a safe space for women to connect and engage with information and support around all things sexual wellness —  from periods to pleasure. It delivers trusted, high-quality, accurate information—backed by research —on sexual health and contraceptive methods so women can make informed decisions about their bodies. 

VIYA creates opportunities for women to get informed, take control and advocate for themselves. 

 

Over the next four years, VIYA aims to cover all aspects of the sexual wellness journey for increasing access to sexual wellness products and services, through a “Glocal” model – blending efficiencies around global technology and content development, with the flexibility for in-market adaptation and local-led ownership and execution. This includes: 

  • An AI-enabled chatbot that will provide personalized health information and signpost to product and service delivery outlets  
  • Personalized follow-up and support 
  • E-commerce and alternative delivery options  
  • Telemedicine to offer a full range consultation, prescription and online sales  
  • Referrals to nearby clinics and/or pharmacies 

VIYA launched in South Africa in Dec. 2021, building from donor funding for pilot projects in Kenya and South Africa. By 2023, the platform aims to be available around the globe, in markets including Africa, Southeast Asia, India and Latin America.  

“It’s clear: standard ‘family planning’ programs are simply not enough,” says Cook. “It’s time to go beyond the functional – like preventing unplanned pregnancies and STIs– and link to the emotional ride of consumers’ lifelong SRHR journeys.” 

QUESTIONS? WANT TO WORK TOGETHER? GET IN TOUCH. EMAIL ANDREA NOVELLA ([email protected]) AND CLAIRE STOKES ([email protected]).
 

By Dr. Claire Watt Rothschild, Senior Research Advisor, Sexual and Reproductive Health (SRH), PSI DC, and Dr. Hambulle Mohammed, Division of Reproductive and Maternal Health, Kenya Ministry of Health

In designated “underserved or hard-to-reach” areas, making contraceptive methods available only through facilities poses a major barrier to contraceptive accessibility and uptake.  

“Even if the doctor will come over, still the CHV is the pillar”

–Community health volunteer from a focus group discussion in Sokoke Sub-Country, Kilifi County 

In coastal Kilifi County of Eastern Kenya, for example, use of modern contraceptive methods is substantially lower than the national average – just 44 percent of women of reproductive age (15-49-years-old) report currently using a method, compared to over 60 percent nationally.  

Specifically: 

  • In Kilifi, and in Kenya as a whole, contraceptive injectables and implants are the most popular methods of contraception.  
  • Contraceptive injectables, implants and intrauterine devices are also among the methods that are typically only administered by medical personnel at health facilities. 
  • In contrast, consumers can often access short-acting methods such as oral contraceptive pills condoms  from a variety of sources: health facilities, pharmacies, and through lay health workers such as community health volunteers. 

To increase consumer choice, improvements to community-based distribution models are needed. In 2018, Population Services Kenya and PSI, in partnership with the Kilifi County Department of Health and the Division of Reproductive and Maternal Health of the Kenyan Ministry of Health, sought to determine whether community-based distribution models could increase community access to a wider range of contraceptive options and strengthen social and policy environments supportive of informed contraceptive choice. 

What did we learn? We outline, below. 

OUR RESEARCH  

Our formative qualitative and quantitative research aimed to: 

  • Understand current roles and responsibilities of existing cadres of community health workers in Kilifi County – including community health extension works (CHEWs) and community health volunteers (CHVs) 
  • Assess community perspectives toward community-based distributions 
  • Evaluate current trends in contraceptive practices and their key behavioral drivers among women of reproductive age and their partners 
OUR FINDINGS? 
  • Geographic inaccessibility and overburdened facilities presented as the primary barriers to contraceptive access 
  • Entrenched social norms for large family sizes were deeply entwined with ideals of masculinity and social status. As one Ministry of Health key informant succinctly put it, “When you have many children, you are taken as a hero.” Correspondingly, male community members described women’s contraceptive use as a “sin” or as a perceived threat to the social fabric – a “mode of doing promiscuity.”  
  • Many men and women alike expressed deep concerns about the health effects and impacts on long-term fertility of modern contraception 

And still, female community members brought diverse perspectives, describing women’s desire to use contraception to avoid the stress of multiple closely-spaced pregnancies and the need to engage men in community dialogue about the benefits of contraception.  

The opportunity is there. 

ENGAGING COMMUNITY HEALTH WORKERS INCREASES CONSUMERS’ CONTRACEPTIVE ACCESS  

The Riziki (meaning “sustenance” or “livelihood” in Swahili) Demonstration Project was designed to address both upwards and downwards barriers to informed contraceptive choice.   

On the supply-side, non-medical CHEWs – professional community members already employed by Kilifi County – underwent an intensive training to prepare them for community-based contraceptive counseling and method provision. For the first time, CHEWs would be authorized to administer contraceptive injectables and implants to community members in their homes or in community settings outside of health facilities. CHVs, who received an enhanced training to deliver comprehensive community-based counseling and to engage community leaders in dialogue, were tasked with addressing social norms and positioning contraception as a tool that can benefit family health.  

The pilot received critical support from the national Division of Maternal and Reproductive Health, which supported training of the CHEWs using an adapted version of the national FP curriculum, and from the Kilifi Department of Health, which granted temporary authorization for the expanded duties of CHEWs under the Riziki Project. Three years later, the County is still working with  this authorization, and CHEWs and CHVs continue to work together to engage communities and to deliver a wider range of contraceptive products directly in people’s homes.  

To evaluate the program, PSI and Population Services Kenya reviewed contraceptive service delivery data from every public health facility in the County and conducted qualitative research with community members, leaders, and other key stakeholders. Health facilities with affiliated CHEWs who participated in the Riziki project (and whose client delivery numbers were included in those of the facility) had a 14 percent higher increase in implant clients (equivalent to an average of 6 additional implant clients per month per facility) after, compared to before program implementation than those facilities that did not have CHEWs in the program. Similarly, the program increased provision of injectables by 11 percent (an average of 13 additional clients per facility per month). Method provider increased overall, with no decreases observed for any of the short-term methods with existing community-distribution delivery models. Importantly, no safety concerns were reported during and after implementation.  

OUR LEARNINGS: 
  1.  Multilevel programming is critical: Formative research highlighted access issues to the full range of methods (including the most popular method types), but also highlighted engrained social norms that limited male support for FP. Riziki intervened to improve contraceptive access and informed choice at three levels of the health system: at the individual level, home-based distribution removed transportation, cost, and time barriers associated with accessing facility-based contraceptive services; at the community level, social education and dialogue about norms that engaged community and religious leaders position FP as aligned with community values; and at the policy level, deep engagement by regional and national government allowed for a critical policy change that authorized high-quality training and support to expand the role of CHEWs.   
  1. With appropriate support, administration of contraceptive implants by lay health workers is feasible and safe. While ongoing research is critical to understand which FP interventions can be safely shifted to lay health workers and in what contexts, evidence from Riziki suggests that community-based distribution of contraceptive methods – including contraceptive implants – by lay health workers is an effective strategy in hard-to-reach areas. While task-shifting of contraceptive injectable provision has been demonstrated to be safe and effective in a number of countries, Riziki is the first project, our our knowledge, to extend task-shifting to implant insertion. While Riziki’s CHEWs have only be trained in implant insertion, developing programs for community-based removal of long-acting reversible methods is also critical. 
  1. Additional research is needed to ensure that community-based distribution programs safeguard contraceptive autonomy. While many women interviewed at the formative research stage expressed the need for greater male engagement in FP, male engagement may come with unintended consequences – in settings where men are often viewed as the “head of the household,” greater male engagement can come at the expense of female contraceptive autonomy. Programs that engage men need to carefully plan for ways to safeguard women’s contraceptive decision-making and bodily autonomy. 

To further explore the research, drop a note – Claire Rothschild ([email protected]).

By Dr. Celia Karp, Assistant Scientist, Dr. Linnea Zimmerman, Assistant Professor, Department of Population, Family and Reproductive Health at the Johns Hopkins Bloomberg School of Public Health, Dr. Elizabeth Gummerson, Executive Director of the Performance Monitoring for Action project, Bill & Melinda Gates Institute

Restricted access to quality healthcare during COVID-19 threatened reproductive autonomy. Health facility closures and restrictions on movement threatened to limit the ability of women and girls to avoid unwanted pregnancies, switch their contraceptive methods, stop using contraception to become pregnant, and receive critical and timely reproductive healthcare. Projections from early in the pandemic estimated an additional 15 million unintended pregnancies worldwide due to reduced access to and use of reproductive health services.

Understanding barriers to reproductive healthcare amidst the evolving pandemic primed us to support people today—and prepare for the challenges of tomorrow.

Our capacity to measure the pandemic’s impact on sexual and reproductive health and rights (SRHR), however, was limited because of scarce empirical evidence on SRHR needs, particularly in low- and middle-income countries. Fortunately, the Performance Monitoring for Action (PMA) project was well situated to fill this data gap.

The PMA project of the Bill & Melinda Gates Institute for Population and Reproductive Health collects nationally and regionally representative data on a range of reproductive health indicators from women in eight countries in sub-Saharan Africa and South Asia to guide family planning policies and programs. When COVID-19 hit, PMA quickly adapted to collect data on the pandemic’s impact on SRHR.

Leveraging its existing cohorts of survey participants, PMA project partners adapted the in-person survey design to capture COVID-19-related outcomes via phone-based follow-up interviews six months into the pandemic. To understand how COVID-19 was likely to impact reproductive health, interviews focused on understanding changes in women’s fertility desires, availability of reproductive services, and contraceptive use.

Data from the phone-based surveys were some of the first population-based evidence generated from sub-Saharan Africa during this period, offering critical insights into women’s SRHR needs. As the pandemic conditions improved, PMA resumed its in-person surveys, following safety protocols, collecting data two years into the pandemic.

So, what did the PMA project learn?

A recent study using PMA’s longitudinal data from Kenya found that women were overwhelmingly consistent in their fertility intentions before and during the first year of the pandemic, despite widespread economic loss during this time. Data also revealed that the most vulnerable women—those who reported food insecurity before and during the pandemic—were more likely to accelerate their childbearing desires, wanting children earlier than when they were asked just before the pandemic. While many people feared that COVID-19 would lead to drastic increases in unintended pregnancy and associated increases with maternal and newborn morbidity and mortality, due in part to increased desires to avoid pregnancy, PMA found little evidence of this at the population level.

Concerns of rising unintended pregnancies were also informed by the anticipated negative impacts of the pandemic on health services. Data collected from public and private health facilities revealed wide variations in COVID-19’s impact across different PMA geographies. Disruption to available family planning services was highest in Rajasthan, India—where COVID-19 cases rose quickly—and was lowest in Cote d’Ivoire.

Despite differences in case numbers and service availability, PMA observed large reductions in the number family planning clients across geographies. This may have reflected people’s apprehension about seeking care, suggesting declines in demand for facility-based services. Overall, data showed health services were largely resilient during the pandemic, overcoming significant barriers to ensure continuity of reproductive healthcare.

PMA also explored how demand for and use of contraception changed during the pandemic. Study results from Burkina Faso and Kenya indicated that most women did not change their contraceptive status—that is, discontinuing contraception altogether or newly adopting contraception—during the first six months of the pandemic. Those who did change, however, were more like to adopt a method than discontinue.

Similarly, research from Burkina Faso, Kenya, and Nigeria found evidence that a greater number of women were using contraception within the first six months into the pandemic, relative to before COVID-19 began. While these findings suggested continued coverage of reproductive health services, the impact of COVID-19 on reproductive health was not uniform. Researchers also found an increase in need for contraception among women who had never given birth, underscoring the importance of ensuring sustained availability and accessibility of family planning services for all women and girls amid health emergencies.

The story of PMA’s pivot is just one example of how health programs, surveys, and services transformed to meet global health needs. Rapid data collection and analysis demonstrated some of the ways that the expectations of researchers and advocates did not necessarily match women’s lived experiences. At least in the early stage of COVID-19, women’s fertility desires, contraceptive use, and access to reproductive health services were less impacted than initially expected. We will continue to learn about the pandemic’s long-term impact on SRHR with further data collection and triangulation of key data sources, like DHIS2 and DHS, over time.

As the public health community prepares for future health emergencies, the ability of data systems to adapt quickly will enable the global health community to better anticipate and address women’s health needs in dynamic environments.

Sara had sex. But not the feel-good kind. Rather, the unprotected kind.
Sara is worried.

What if she is infected with HIV?  What if she is pregnant?

Sara has questions. She wants answers. 

Explore her story here.

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