Ensuring that all women and men are able to access the contraceptive products and services they demand, when and where they can conveniently obtain them, is essential to our work.
Bringing Contraception Closer to the Client
Despite a clear demand for family planning services, many men and women in developing countries cannot access them. Worldwide, more than 225 million women and girls lack access to contraception that they desire.
In rural areas especially, understaffed and underserviced facilities are able to offer only short-acting methods, such as pills and condoms, that do not require specially trained staff or equipment. The closest health center may be hours away from home, making it impractical to return on a regular basis for refills or regular injections. With stockouts common, even if a woman does return to the clinic, she may not be able to find her method of choice there.
In urban areas, busy health centers may limit family planning services to just a few hours per week, and they often lack the staff and equipment to provide more time-consuming services such as the provision of intrauterine devices and implants.
Addressing these shortfalls requires novel approaches to make contraception available where and when women want it. In the face of health worker shortages, we also continue to advocate for greater task sharing in line with WHO guidelines to improve contraceptive access. Here are some examples of the approaches we have found to be effective in bringing family planning services closer to clients:
- The Dedicated Provider Model. This model taps into women’s current health-seeking behavior to expand both the hours of family planning availability and range of methods offered. Through this model, PSI-employed nurses and midwives visit busy public health centers and give health talks to women waiting for other services, such as vaccines, antiretroviral (ARV) therapy or post-natal care. Interested women can undergo further counseling and receive the method of their choice that same day. We have used this approach in Mali, Mozambique, and Zambia among others.
- Mobile services. In other settings, we use mobile services to bring family planning and other health services to women in their communities. In more remote locations with no health facility, either a secure and private structure is turned into a temporary clinic, or the mobile outreach team erects a tent as a mobile health unit, ensuring that services can be delivered safely and privately no matter the location.
- Community-based distributors (CBDs). We work closely with local leaders and existing networks to make select family planning products and services available through CBDs. After intensive training in integrated health communications, community members educate their peers on a range of health topics, offering products and referrals as needed. For family planning, CBDs commonly carry oral contraceptives, condoms, CycleBeads, and, where permitted by local regulations, can also provide injectable contraceptives. The availability of contraceptives outside of the health center means that more women can get information and product refills when they need them, making it easier for them to continue method use.
- Pharmacies and drug shops. We work with pharmacies and drug shops to increase access to accurate family planning information and quality contraceptive methods. In rural areas with few public and private clinics, pharmacies and drug shops are often used as a convenient location to purchase nonprescription drugs and prepackaged medications. We train and support pharmacy and drug shop staff to provide quality services and information on family planning.
In all health area programs, PSI works to address market failures, as part of a market development approach (MDA). For each country and health sector, we analyze and evaluate the market, defining where we can best add value through direct implementation or technical assistance.
The goal is to ensure that those in need are reached with the appropriate products and services at prices they can afford, while carving out a space for commercial providers where they can be successful. For example, those in the poorest communities receive free products, while those with slightly greater resources benefit from partially subsidized products, and those with a greater ability to pay purchase their products from the commercial sector. Our vision is for greater efficiency in the market and increased sustainability through better targeting of public and social sector subsidies.
Two key approaches to MDA are social marketing and social franchising. We use social marketing and social franchising to increase use of modern contraceptives, promote safe motherhood interventions, and reduce unsafe abortions.
We recognize and address the need for an enabling environment to introduce and roll-out needed reproductive health products and services. Many health-related objectives require policy changes, support from influential decision-makers and funding commitments that can be difficult to obtain. We use advocacy efforts to create an enabling environment and ensure that men, women and youth are able to access essential health services and products.
We also build the capacity of advocates in-country to identify barriers to implementation, influence key decision-makers and achieve strategic advocacy objectives. We work to support the development of national advocacy strategies and improve the policy environments for community-based services, for post-partum IUD provision and for registration of medications like misoprostol for post-abortion care.
One example of PSI’s work to create healthy enabling environments is by focusing on the various influences on the lives of young people. Influences at multiple levels — from male partners, parents, peers and family members to the broader community — affect a young person’s ability to forge healthy relationships, make choices about sex and reproduction, and pursue goals. Evidence shows that youth-friendly services work only if adolescents know their options and have the social and community support needed to feel comfortable seeking services. For these reasons, PSI works to strengthen social norms that favor health and rights, starting with a focus on the key transition period of adolescence.
To address gender inequality and male opposition to family planning in the Democratic Republic of the Congo (DRC), PSI is working in partnership with the Institute for Reproductive Health and the faith-based organization, Tearfund, to pilot a scalable intervention to encourage family planning use by married youth in Kinshasa. With the support of local Protestant Christian religious leaders, Tearfund is working to create an enabling environment by training young champions to lead young, newly married couples from their congregations through a series of dialogues about gender, power and health. PSI provides the young couples with sexual and reproductive health and rights education, and referrals to youth-friendly services, including services for survivors of gender-based violence. The model will be evaluated to assess scalability.
Provider Behavior Change Communication
We work to improve access to reproductive health products and services primarily through the private sector. Often, private sector healthcare providers are viewed as simply a channel for delivery, and it’s taken for granted that if providers are trained and stocked with products, they will offer services.
Healthcare providers are as important a target audience as clients. For many reproductive health services, such as long acting reversible contraception and permanent methods, those we serve rely on the healthcare provider to be capable, willing and motivated to provide these services. Providers, especially private sector providers, must believe in the value of providing the service or product for clients as well as for their own clinical practice.
We use our marketing acumen to tap into provider insights to understand provider biases, needs, obstacles and motivations to providing services. Our network member staff visit providers and use specialized communication skills to address provider needs and build intrinsic motivation to offer a full range of products and services to those we serve and their families by demonstrating the direct benefits that doing so will have for the provider.
We have also developed a comprehensive toolkit for structuring teams to support providers in the field, develop provider specific messaging, capacity building plans for our representatives to make the most of their interactions with providers and coaching modules for supervisors to continually improve the skills of representatives.
Health Service Integration
The World Health Organization defines the integration of services as “the organization and management of health services so that people get the care they need, when they need it, in ways that are user-friendly, achieve the desired results and provide value for money. Integration means that separate technical services, and their management support systems, are provided, managed, financed and evaluated either together, or in a closely coordinated way. For clients, healthcare is seamless, holistic and easy to navigate.
Our reproductive health programs are quickly moving to integrate with critical health services including those for maternal and child health, HIV prevention, non-communicable diseases and gender-based violence.
- Integration with maternal and child health services. We strive to make it as easy as possible for women to receive health services before, during and after pregnancy, to ensure their own health and that of their children. One of the best ways to do this is to offer a broad range of contraceptive and maternal and child health services together, in one place and at one time. We integrate contraceptive services that are tailored to women’s needs into prenatal care visits, delivery, postnatal visits and immunization services, as well as post-abortion care visits wherever possible. Each of these visits offers a unique opportunity to introduce contraceptive options to women who wish to space or limit childbirth, and are especially important for those with limited access to medical care. During prenatal care visits, interested women can choose their preferred contraceptive method before the stress of childbirth and newborn care begins. If a woman chooses an intrauterine device (IUD) during a prenatal visit, it can even be arranged ahead of time with her provider so that the IUD is inserted immediately following delivery. Inserting the IUD post-partum means one less clinic visit for the new mother, and the health benefits to mother and child of spacing and limiting future pregnancies. We have post-partum IUD (PPIUD) programs in eleven countries. In one successful example from Zambia, since an initial PPIUD training in February 2009, our network has provided over 4,000 PPIUDs. Routine and campaign infant immunization services often reach large numbers of women in the postpartum period as well. An integrated contraception and immunization program ensures that trained staff, adequate space and a full range of contraceptives and counseling services are available at infant immunization sites, especially on the busiest days.
- Family planning/HIV integration. Integrating family planning with HIV services maximizes resources, which ultimately increases coverage and improves uptake of both contraceptive use and HIV prevention behavior among key populations that often intersect – such as female sex workers or women from low-income households. Integration can also reduce mother-to-child HIV transmission and improve health outcomes among HIV-positive women through the prevention of unintended pregnancies and regular contact with the healthcare system. Integration also contributes to the destigmatizing of HIV services, which could lead to improved rates of attendance at HIV counseling and testing and treatment and care services over time. We are championing integration through our existing HIV and contraception programs. In high HIV-burden countries across Africa, our programs are moving to integrate contraceptive services into HIV testing and counseling sites. In other countries -, such as Cambodia, Madagascar, Swaziland, Zimbabwe, Zambia, Benin, Togo, Cameroon, Malawi and Mali – contraceptive service providers are trained to provide HIV testing, counseling, treatment and care. Clients seeking HIV services and those seeking reproductive health services share many common needs and concerns. Integrating these services leads to greater efficiency through cost savings and reduced duplication of efforts; increased health outcomes due to greater access to and uptake of services; client satisfaction; and greater equity for people who may have been less likely to access these services in the past.
- Reproductive health/Gender-based violence integration. We are currently working with national health systems and training reproductive health providers to integrate reproductive health and gender-based violence services in Guatemala, the Caribbean, India, Papua New Guinea and Zimbabwe. This increases women’s access to gender-based violence prevention and treatment services via reproductive health networks. We are also finalizing clinical care guidelines for country reproductive health teams that include technical guidance on identifying and treating survivors of gender-based violence, as well as developing strong linkages to long-term support mechanisms such as psychosocial counseling, economic empowerment and legal support services. In addition to integrated service provision, we have integrated gender-based violence messaging into reproductive health behavior change communication campaigns in Zimbabwe, the Caribbean, India, Swaziland, Madagascar, Benin and Papua New Guinea.
- Integration of sexual and reproductive health services with non-communicable diseases (NCDs). We recognize strategic opportunities to link cervical cancer prevention to broader national health agendas, including HIV/AIDS, sexual and reproductive health and adolescent health services. In terms of sexual and reproductive health, we integrate our family planning and HIV-related services alongside our cervical cancer programs in order to provide women with the range of reproductive health services that meet their individual needs.
Making a Difference
Providing family planning during infant immunization days in Mali
In Mali, only 11.3% of married women use family planning, and 79% of women who have recently given birth do not want to become pregnant again soon but are not using effective contraception. To address this urgent situation, midwives trained to provide family planning visit a number of public and private clinics in Bamako on the clinic’s busiest days: when women bring their infants to be immunized. The program ensures that on immunization days, the clinics have trained staff, adequate space for family planning counseling and services, and a full range of contraceptives. Improved access to long-acting methods, otherwise available only by seeing another health provider, led a significant number of women to choose such methods between 2008 and 2010.
- “Stigma And Discrimination-Free Zones”: An Innovative Approach to Engaging the Private and Public Sectors in Creating More Inclusive Environments for Key Populations in Central America (TUPED509)
Central America's HIV epidemic is concentrated in key populations (KPs). Despite existing HIV laws and policies that respond to KP's specific needs, there is evidence of widespread discriminatory attitudes and practices towards these populations, and stigma and discrimination continue to be important barriers to accessing HIV services and care. In 2016, under the USAID Combination Prevention Program for HIV in Central America, PASMO designed an intervention entitled “stigma and discrimination-free zones” as part of a broader initiative known as Generation Zero, contributing to the goal of “getting to zero discrimination.”
- Community HIV Care and Treatment for Female Sex Workers in Ethiopia: Successful Service Provision Through Drop-In Centers (THPEE774)
Female sex workers (FSWs) in Ethiopia are disproportionately affected by HIV, with a prevalence of 23%. To improve uptake of ART among FSWs living with HIV, the USAID-funded MULU/MARPs project began offering ART in 25 FSW-friendly drop-in-centers (DICs) in October, 2016. DICs are safe hubs for FSW located in hot-spots, and providing integrated behavioural and clinical services including peer support in a “one-stop-shop” format.
- HIV Care is Fine, But What if I Get the Flu? (THPED546)
In Guatemala, a concentrated epidemic within a highly stigmatizing social context creates an environment fraught with challenges for reaching, testing, and linking vulnerable men who have sex with men (MSM) and transgender women (TW) with HIV testing and care. PASMO commissioned an ethnographic study in 2016-2017 to understand the sexuality, identity construction, health care seeking behaviors, and MSM/TW-health provider relationships to design consumer-focused strategies to facilitate access to HIV services.