Community Based Distribution of Depo Provera

Bixby intern Alice Cartwright interviews a health worker in Ethiopia where there is a high unmet need for family planning. Ms. Cartwright evaluated a Bixby program expanding the community-based distribution of Depo Provera (Depo Provera) in rural Tigray, the northern-most region of Ethiopia.

Injectable contraceptives are the leading method of family planning in sub-Saharan Africa and have played a major role in the recent increase in contraceptive prevalence in the region. Ethiopia is the second most populous country in Africa, with the highest levels of fertility found in rural regions and among the poorest and least-educated women. Rural Ethiopian women consider injectable contraceptives their preferred method of contraception. For those using injectable contraceptives in Ethiopia, the main source of supply is the public sector (85%), through hospitals, health centers, and health posts. However, many women, particularly in rural areas where over 80% of the population resides, live far from health facilities and are unable to easily access family planning services. The obstacles to access for rural women demonstrate the need for inclusion of injectable contraceptives into community-based distribution (CBD) systems. Through a pilot study conducted from 2007-2009, the Bixby Center and its partners, Tigray Regional Health Bureau and Venture Strategies for Health and Development, demonstrated that community-based reproductive health agents (CBRHAs) are acceptable and capable distributors of injectable contraceptives in Ethiopia. This study confirmed pilot findings from other countries in sub-Saharan Africa, including Malawi, Madagascar, and Uganda, that CBD is a safe and effective means of increasing access to injectable contraceptives. The preliminary findings from this study also aided the WHO in their decision to support task-shifting and CBD of injectable contraceptives. The findings of this pilot study were published in the WHO Bulletin in April 2011. http://www.who.int/bulletin/volumes/89/8/11-086710/en/index.html

Analyses of CBD, however, suggest that CBD alone is not cost effective and a degree of cost recover is necessary to support the regular presence of CBRHAs in the community without burdening the public health system. At the same time, there needs to be some remuneration to retain CBRHAs. There is vast body of research that highlights the effectiveness, as well as feasibility and acceptability, of social marketing of contraceptives. In addition, over 95% of women in the pilot project were willing to pay for injectable contraceptives. For women who are unable to reach a health post, social marketing of injectable contraceptives by CBRHAs could lead to a more sustainable model of distribution that will create access beyond public sector distribution, while at the same time targeting rural women (an unusual social marketing consumer) and providing income generation for CBRHAs.

Currently, the Bixby Center is collaborating with Mekelle University, Women’s Association of Tigray, and DKT-Ethiopia to assess the feasibility of incorporating social marketing into existing CBD. With funding from the Joffe Charitable Trust and approval by the Tigray Regional Health Bureau, this three year study explores the marginal cost and benefits of adding injectable contraceptives to existing community health worker family planning programs, while investigating the scalability and sustainability of combining social marketing with existing CBD strategies. Ultimately, findings from this three-year study will provide much needed evidence and proof of concept of how to scale up a model for increasing access to injectable contraceptives.

Working with Venture Strategies the Bixby Center is researching the safety of community based distributions and administration of Depo Provera.

To view the full results of our baseline survey on Community-Based Distribution of DMPA in Tigray, please click here.