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Scaling up contraceptive implants: case closed or untapped potential?


The introduction and scale-up of contraceptive implants have unequivocally increased access to family planning (FP) method choice around the world. Late last year, Jhpiego and Impact for Health (IHI) collaborated to document the experience of contraceptive implant introduction over the last decade (primarily through a desk review and key informant interviews) and identified recommendations to scale up implants in the private sector. This piece summarizes some of the key findings available in the suite of resources available here.

Case closed or untapped potential? A debate

It is just over a decade since world leaders gathered at the 2012 London Summit on Family Planning (FP) and committed to one goal: meeting women’s unmet need for contraception. This goal was operationalized through the creation of Family Planning 2020 (FP2020), a global partnership to empower women and girls by investing in rights-based FP, and extended through FP2030 to reaffirm this global commitment. The emergence of FP2020 also paved the way for the introduction of the Implants Access Program (IAP) in 2013: a public-private partnership to increase access to contraceptive implants for women in low-income countries. The results are awe-inspiring: the IAP led to a 50% price reduction for those procuring implants for FP2020 countries and, over the past decade, annual global procurement of implants for FP2020 countries increased from 3.9 million to 10.6 million and is projected to increase further in the coming years. Implants have also been incorporated into national universal health coverage (UHC) plans, such as those in Ghana and Zambia. Further, an analysis considering recent and longer-term changes found that increases in implant use during this period were the main driver of mCPR gains in 11 countries in Africa. The introduction and scale-up of contraceptive implants have unequivocally increased access to family planning (FP) method choice around the world.

Does this mean we can close the book on implants, considering them fully mainstreamed? Or are there untapped frontiers for expanding method choice – choice that includes implants?

What made implants such a success story?

From our analysis (including a desk review and key informant interviews), meeting demand through implants is underpinned by a few key lessons.

  • Coordinated action at all levels helped to fast-track implant introduction and scale-up; including national government stewardship and global coordination for investment, volume guarantees, clinical guidance, and sharing lessons learned.
  • Ensuring availability of implants through multiple public service delivery channels (e.g. CHWs and mobile clinics in addition to primary healthcare centers) and task sharing were key strategies to increase access and uptake.
  • Demand generation activities designed with providers and users helped ensure women could make an informed choice about contraceptive use and method choice, while also increasing acceptability of implants.
  • Comprehensive quality assurance systems and training programs helped ensure quality of implant services – both insertions and removals – by a range of providers.
  • Addressing price barriers through volume guarantees was critical for equitable access, but scale-up through the private sector will require new, innovative solutions and financing.

For the FP2030 goal to be realized, contraceptive implant availability, acceptability, accessibility and quality need to be maximized; however, a number of challenges remain.

An unfinished agenda?

Expanding method choice is an integral component of family planning programs. Some estimates indicate that for each new contraceptive method added to the mix/basket of choice, overall contraceptive prevalence in a country will rise 4-8%. But sustaining such expanded choice over the long term requires attention to method-contextual delivery features – features that, if ignored, could stifle a method’s ability to meet the needs of individuals and couples who wish to use it. For contraceptive implants, such features requiring continued attention include:

Removal access: Improving access to quality implant removal helps to meet clients’ rights, helping ensure that they have full, free, and informed choice to both use and stop using their method. However, data continue to demonstrate a disconnect in access and utilization of quality implant removal services when compared to implant insertion. A recent study using Performance Monitoring for Action (PMA) service delivery point data in 6 countries in sub-Saharan Africa indicates that a substantial proportion (31-58%) of implant-providing facilities report at least one barrier to offering implant removal services.

A vector graphic image that has an avatar in the middle with the text "implant user." There are 8 circles around the avatar. Circle 1: Supplies & Equipment in Place. Circle 2: Implant Removal Data Collected & Monitored. Circle 3: Service is Affordable or Free. Circle 4: Service Available When She Wants, Within Reasonable Distance. Circle 5: User knows when & where to go for removal. Circle 6: Reassurance, counseling & reinsertion/switching are offered. Circle 7: System in place for managing difficult removals. Circle 8: Competent & confident provider.
Figure 1: Client-centred conditions for ensuring access to quality implant removal.

Developed by the Implant Removal Task Force, these eight standards need to be upheld to satisfy clients’ implant removal needs (further questions program managers can explore to ensure removal-inclusiveness are included here):

  • Providers are competent and confident. Are continuing education, refreshers, and recertification opportunities offered for healthcare workers providing implant services to ensure that their skills are up to date?
  • Adequate supplies and equipment are in place: Are adequate equipment and consumable supplies in place for both standard and difficult implant removals at service delivery points?
  • There’s a system in place for managing difficult removals: Is there adequate coverage of healthcare workers who can localize and remove non-palpable implants?
  • Implant removal data is collected and monitored: Are systems in place to collect and use HMIS data to understand coverage, source, utilization, and outcome of implant removal services?
  • Implant removal services are affordable (or free): Is the cost of removal equal to or less than the cost of insertion, and are financial mechanisms in place for clients who cannot pay?
  • Implant removal services are available when the user wants, and within reasonable distance: Are all facilities that offer implant insertions able to offer implant removal services? And when not, are referral mechanisms in place?
  • The implant user knows when and where they can go for removal: Do healthcare workers provide accurate communication about when, where, and why removal services can be accessed?
  • At the time of removal, reassurance, counseling and reinsertion or method switching are offered: Do service delivery sites offering implant removal services have a full range of FP method choices for clients who desire implant reinsertion or a different method of choice?

A suite of materials to support program managers, technical advisors, and other FP program stakeholders in designing, implementing, and measuring FP programs with an implant removal-inclusive lens is available here.

Private Sector Expansion: The last decade is testimony to how coordinated efforts have transformed women’s access to implants in the public sector. A recent analysis of 36 countries showed that 86% of implant users obtained their implant from a public-sector source. To maximize the private sector’s ability to deliver implants, a similarly coordinated effort, led by national governments and global partners, can release the untapped potential of the private sector to deliver contraceptive implants at greater magnitude and contribute to FP2030 goals. Such efforts should focus on transforming four key areas:

  1. Supply: Currently, the implant supply chain and market are reliant on donor funding, which negatively impacts long-term sustainability. This severely curtails private sector healthcare outlets’ interest and ability to access affordable contraceptive implant commodities – and suppresses any business case to do so.
  2. Training: Historically, opportunities for implant training have not met private providers’ needs, resulting in a lack of insertion and removal skills and quality assurance measures. This, in turn, hinders quality-assured service delivery. Training that meets the needs of private providers can transform their ability to provide quality implant services.
  3. Demand: With a free ‘supply’ of implants widely available in public sector facilities, a key challenge to creating demand for implants in the private sector, is elucidating why a woman should pay for this service. What additional benefits are gained by accessing this service in the private sector? And which of these benefits resonate most with the target consumer?
  4. Stewardship and Coordination: As the last decade demonstrated in the public sector, for change to occur, efforts need to be appropriately stewarded and carefully coordinated. National governments are best placed to steward these efforts in partnership with private sector actors who are represented by an appropriate private body to unify and represent the interests and voice of private sector providers.

What’s next? A call to action

In some ways this debate around contraceptive implants reinforces what we know about new method introduction and sustainable service delivery: the importance of considering mixed health systems actors (their opportunities, abilities and motivations) in new product introduction; using a rights-based lens to inform product introduction and service delivery in all contexts (e.g. not promoting one method over another) and so much more (this article doesn’t touch on the need to expand method choice in humanitarian contexts, for example!). But just because these principles are widely known doesn’t mean they’re easy to deliver.

This begs the question: is this a pivotal moment to reframe how we support implants to ensure sustainable choice and scale?

What could this look like in practice? We’d like to offer two concrete recommendations:

  1. Plan for service delivery through mixed health systems during (not after!) method introduction, paying particular attention to sustainable financing mechanisms (for supply and the service) and engage the private sector throughout the product introduction journey so they are motivated to deliver methods that are simultaneously subsidized in the public sector.
  2. Consider the full scope of a method’s use (including uptake as well as discontinuation or method switching) as a part of contraceptive method service and access. This is particularly important for implants, which require access to a service provider to discontinue the method (i.e. remove the implant). Planning for and supporting an individual’s choice to discontinue any contraceptive method is necessary to ensure autonomy, choice, and access to begin and end methods.

ABOUT: Jhpiego and Impact for Health, as a component of the Expanding Family Planning Choices (EFPC) project, undertook rapid literature reviews and key informant interviews with experts in the contraceptive implant and family planning field, to better understand programmatic learnings, tips, best practices and challenges, including the potential for private sector engagement for implant introduction and scale-up. The results of this review led to the development of a series of products for continued learning and sharing, available here.

Contraceptive Implant Introduction and Scale-up
Andrea Cutherell

Partner, Impact for Health

Andrea Cutherell is an experienced strategist, facilitator, and global health technical leader with a focus on market systems approaches to improve health outcomes. She brings over 15 years of experience leading complex initiatives; managing teams; and providing technical assistance in sexual and reproductive health (SRH), maternal and child health, nutrition, malaria, HIV, private sector engagement, and health systems strengthening. She has extensive in-country experience in 13 countries across South Asia and Sub-Saharan Africa. A skilled coalition builder, Andrea established and grew the Evidence and Learning Working Group (ELWG) of the Self Care Trailblazer Group. A rigorous and creative thinker and communicator, she led Population Services International’s thought leadership initiative to improve its use of evidence and experience to influence global health policy and practice. Andrea holds a Master of Health Science from the Johns Hopkins University Bloomberg School of Public Health and served on faculty with them in Afghanistan where she co-designed the country’s first national HIV/AIDS surveillance system.

Megan Christofield

Technical Advisor, Jhpiego, Jhpiego

Megan Christofield is a Project Director & Senior Technical Advisor at Jhpiego, where she supports teams to introduce and scale access to contraceptives by applying evidence-based best practices, strategic advocacy, and design thinking. She is a creative thinker and recognized thought leader, published in the journal of Global Health Science & Practice, BMJ Global Health, and STAT. Megan is trained in reproductive health, design thinking, and leadership & management from the Johns Hopkins Bloomberg School of Public Health and the Johns Hopkins Carey Business School, and has an undergraduate degree in Peace Studies.

Jaitra Sathyandran

Associate, Impact for Health International

Jaitra Sathyandran is an Associate at Impact for Health International. Jaitra has worked as a Consultant and Technical Officer for the WHO Regional Office for the Western Pacific, in Manila, Philippines supporting country offices on applying a gender and health equity lens to their work. Prior to this, she worked as a Public Health Intern with the Ministry of Health in the Northern Province of Sri Lanka. Jaitra has also worked in service design research to improve hospital wayfinding, as well as with migrants and refugees in Toronto, Canada, with accessing social and health services. Jaitra holds a Master of Public Health with a Specialization in Health Promotion and Social Behavioural Sciences from the Dalla Lana School of Public Health, from the University of Toronto.

Sarah Gibson

Senior Global Health Consultant

Sarah Gibson is a results-oriented, global health practitioner with over 18 years of experience in striving to improve health. A skilled communicator, highly effective at: Strategy development and planning; Project design, implementation and evaluation; Consumer and social behavior change; Private sector engagement; Facilitation and workshop development; Organizational change management and capacity building; and Leadership alignment, mentorship and coaching talent.  Sarah has extensive experience across sub-Saharan Africa and has served as a USAID Chief of Party, and Country Director and Senior Country Director with Population Services International in Malawi and Tanzania, respectively. Sarah holds a Master of Public Health from Johns Hopkins Bloomberg School of Public Health and was awarded the Top Thesis Award for Health Communication by the International Communication Association on graduating.

Sarah Webb

Technical Advisor, Jhpiego

Sarah is a Technical Advisor at Jhpiego, where she works across the organization’s RMNCAH and Innovations Portfolios. Sarah provides technical assistance on both family planning and maternal newborn health projects, as well as on approaches for engaging the private sector and utilizing market solutions in reproductive health. She has close to 10 years of experience in global health and international development, with a focus on advocacy and business-oriented solutions to global health challenges. Sarah has experience throughout Africa, South Asia, and Central and South America. She holds a Bachelor’s Degree in Politics & Government from the University of Puget Sound and a Master’s in Public Health and Master’s in Business Administration from Johns Hopkins University.

Marley Monson

Senior Program Officer, Jhpiego

Marley Monson is a Senior Program Officer at Jhpiego, where she supports implementation of the organization’s India portfolio and manages Jhpiego’s projects on contraceptive implant scale-up. Prior to Jhpiego, Marley served as Humanitarian Assistance Officer for USAID’s Bureau for Humanitarian Assistance and worked for Alight (formerly the American Refugee Committee). Marley received her MA from Freie Universität Berlin.

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