Service Delivery Shift of Emphasis From Long term And Permanent Towards Temporary Methods of Contraception

During the first two years of the project, the emphasis for service delivery was on the promotion of long term and permanent methods of contraception. During the transition period, UMT reviewed the service delivery strategies and explored data of current DHS surveys as a step in conducting strategic planning for expanded reproductive health access. At the end of this exercise UMT decided to shift the supply and promotion emphasis towards temporary methods, i.e. condoms, pills, injectables. SFPS will continue to support the provision of the full range of contraceptive methods but comparatively more emphasis will go towards temporary methods as opposed to long term and permanent methods of contraception. The following are some of the reasons that led to this decision.

DHS data indicate that there is little use of contraception overall, below 10% in contraceptive prevalence rate in the sub-region. Preferred methods among intenders are condoms, pills and injectables as couples decide how to control their fertility and when to have children. Most couples struggle with traditional methods such as prolonged and periodic abstinence. The biggest obstacle to reproductive health is lack of access to family planning services.

Given the unmet need for FP is estimated at 20% of women of reproductive age, and the evident access problem, SFPS would like to assure a minimum acceptable number of methods per site and increase the number of sites that offer at least this minimum. The strategy then for SFPS, is to move this increased number of SDPs along a continuum of number of modern FP methods. The continuum begins with the minimum temporary supply methods and adds methods as providers become competent in provision of these methods and other long term or permanent methods. As the providers and clinics increase their method range, clients are better educated/counseled on the benefits of modern family planning and temporary methods. The temporary methods offer greater flexibility to couples which have not yet decided on their longer term fertility goals. As the temporary methods grow in popularity, the number of users increases, and family planning becomes a community norm. This community movement in support of FP makes the transition for users to longer term methods more evident.

SFPS seeks to expand access to temporary methods as it continues Norplant and minilap services as part of the full range of family planning methods. It is worth noting that programmatic and logistic requirements for the temporary methods are more affordable and manageable than long term and permanent methods provision. In addition, improving access through the provision of long term and permanent methods of contraception requires more work at the policy and cultural level and more time before an impact can be observed. As a result, SFPS expects to rapidly increase access in the target areas for temporary methods while it addresses the political and programmatic issues associated with LT/P methods. One benefit of SFPS decision to shift its emphasis to temporary methods is the opportunity it offers to promote social marketing and community-based strategies for the expansion of these methods, therefore contributing to a rapid improvement of access to family planning services in the region.

Norplant presents a specific set of programmatic requirements. Over the last five years, program managers have learned a lot about the substantial and other comparatively sophisticated program requirements associated with Norplant implants provision often unavailable in resource-poor settings like West and Central Africa (WCA):

Norplant programs require excellent counseling skills; good tracking systems to insure clients return after five years; a system with a clear commitment and capacity to provide removal upon demand and a strategy to sustain provider availability for both removals and insertions; a lack of sufficient number of competent providers in removal in WCA is a concern especially for women users who want to become pregnant, including women who may have had Norplant beyond 5 years and whose risk of ectopic pregnancy is elevated. Moreover, medical monitoring and quality of services are key difficult aspects related to the provision of long term and permanent methods of contraception.

A sustainable financial strategy for dealing with both commodity and programmatic cost issues is needed in a Norplant program but is not always available in WCA. There is also an opportunity cost. SFPS funds may be better spent on other methods that do not require extensive infrastructure. If not handled well, all these issues can lead to extensive negative publicity and repercussions for the entire family planning program. Moreover, the supply environment for Norplant is not conducive to large expansions. USAID is currently questioning its continue support for Norplant implants commodities and the programs that support Norplant implants users. Two options essentially are being considered: letting the current contract with no renewal or negotiating another 3-5 year contract to support phase-out activities.

In the near future, SFPS will play a leadership role in bringing together decision-makers of each WCA "Norplant country" (Burkina Faso, Cameroon, Mali, Rwanda, Senegal, Togo) to review their Norplant programs, receive an update in new developments (U removal technique, cost-analyses, donor environment, new technologies). It is expected that the workshop participants will begin the process of deciding on the future of the method in their countries and developing commitment to a regional strategy for Norplant quality service standards and training.

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