Closing Uganda’s Contraception Gap with Market Development for IUCDs

By Noha Zeitoun

Despite much progress in increasing access to modern contraceptive methods, in Uganda, the unmet need for voluntary family planning is still a high 34%. Barriers including limited choice, availability and knowledge have led to gaps in access and affordability for the girls and women who want contraceptive options. This week at the International Conference of Family Planning, PSI’s Uganda network member PACE presented multiple presentations and posters offering insight into how it is working to build the market for long-acting reversible contraceptive (LARC) methods using innovative private-sector and total market approaches to meet the need.

Knowing the Market for IUCDs

According to the 2011 Uganda Demographic Health Survey (UDHS), Uganda’s contraceptive prevalence rate (CPR) is 30%. Currently, the market is dominated by short term methods. Injectables account for about half of the method mix, while long-term methods like intrauterine contraceptive devices (IUCDs) account for less than two percent.

To increase Uganda’s CPR, PACE/PSI aimed to increase method mix at private and public facilities, with a focus on IUCDs. To successfully add IUCDs to the menu for voluntary contraception in Uganda, PACE needed a clear understanding of current perceptions towards IUCDs among women of reproductive age. To better understand the market for IUCDs, PACE/PSI conducted a survey of women on their way out of both public and private health facilities, including PACE’s social-franchise Pro-Fam clinics.

Jenerose Waiswa is an enrolled midwife and owner of St. Maama Tereza Clinic Domiciliary a Profam partner in Nsenkwa, Wakiso District, Uganda. Jenerose counsels Namuduma Mbabazi Every, 27 years old, who already has three children on different options for contraception. Mbabazi came to get an injection of depoprovera which lasts for three months but is considering changing to an IUD. Profam helps subsidize the products St. Maama Tereza ClinicDomiciliary provides so that lower to middle income Ugandans can afford care. An IUD costs 3,000 Uganda Shillings or the equivalent of $1.25 US dollars for the IUD and insertion. June 26, 2012. Copyright © Vanessa Vick 2012

Jenerose Waiswa, an enrolled midwife and owner of St. Maama Tereza Clinic Domiciliary a ProFam partner in Nsenkwa, Wakiso District, Uganda, counsels a client on different options for contraception. Credit: Vanessa Vick 2012

Among the 1,505 women surveyed at 282 randomly selected facilities, less than 40% of women perceive IUCD use as a common behavior or social norm. The survey also found that only 35.6% had the correct knowledge about the device, however nearly two-thirds agreed they’re safe and a good method of family planning. Access and affordability also proved to be an issue. Only 51.4% of women surveyed believed that IUCDs were available close by and 45.5% believed that IUCDs are affordable. Low spousal support was also cited as a barrier to entry.

As a result of the survey data, PACE/PSI can develop holistic approaches to ensure that the right supply side interventions, such as developing the ProFam social franchise with an improved method mix, are accentuated with effective demand side interventions.

Expanding Services by Building Capacity

To increase the uptake of IUCDs among Uganda’s women of reproductive age, PACE/PSI offered increased capacity-building support to both public sector facilities in 20 districts and its own private sector ProFam social franchise clinics. Key activities implemented focused on health systems strengthening in the public sector, namely, skills building (through training, mentoring, supervision, health events), availing relevant equipment and commodities, demand generation, improving coordination of implementing partners, and data management.

Through measurement and evaluation tools including HMIS and DHIS2, a 2013 baseline assessment in the focus districts showed that 3.4% of the eligible government facilities, had capacity to offer IUCDs. A facility was considered to have capacity if it had at least one provider trained on LARCs service provision, had equipment to provide IUCD insertions, had facilities to deal with infection prevention and had records to show active provision of IUD services. PACE/PSI increased the geographical coverage by starting with 20 public health centers in 10 districts in 2013, then increasing to 60 facilities in 20 districts (3 facilities per district) in 2014, and 170 public sector facilities in 20 districts in the year 2015.

The intervention led to 64,697 IUD insertions and 35,226 implants in the public sector; in ProFam franchises 56,542 IUD insertions and 41,469 implants. In all districts that were targeted, the strengthening of health systems contributed to the improvement of IUD access within two years. Additionally, geographic equity improved with both public sector services and ProFam franchises allowing for an increased distribution area.

Creating Youth-Friendly Services

Forty-nine percent of Uganda’s population is under the age of 14 and 21% is between 15 and 24. Coupled with a high fertility rate of 6.2% and a high maternal mortality rate of 438 per 100,000, increasing access and knowledge of voluntary family planning methods for youth will be critical to the country’s population health in the coming years. Reproductive health programs must create youth-friendly health services to increase Uganda’s contraceptive prevalency rate.

Assumpta Mayanja registered midwife, nurse and owner of St. Joseph Domiciliary a Profam partner in Kitetika a suburb of Kampala, Uganda. Mayanja counsels clients at her clinic about different birth control options. Profam helps to subsidize the products that St. Josehp Domiciliary provides so that lower to middle income Ugandans can afford care. An IUD costs 3,000 Uganda Shillings or the equivalent of $1.25 US dollars for the IUD and insertion. June 26, 2012. Copyright © Vanessa Vick 2012

Assumpta Mayanja counsels clients at her clinic about different birth control options. ProFam helps to subsidize the products that St. Josehp Domiciliary provides so that lower to middle income Ugandans can afford care. Credit: Vanessa Vick 2012

Building on its efforts to increase method mix and develop the market for IUCDs in the public and private sector, PACE/PSI created a program to increase LARC use with women from 15-24, the majority of them in a marriage union. The program trained youth advocates and providers; set up youth corners within clinics; identified a youth contact person to identify youths as special interest groups; and formed youth groups to meet every month and talk about HIV, malaria, STI and other issues. Within the group setting, each member was encouraged to save at least 1,000 shillings every month and to pool their resources. In case one of the youths in the group falls sick, her treatment fee is deducted from the pool.

Between 2013 and 2014, PACE/PSI reached over 121,239 women with IUD services, 20% — or 24,398 — of them were under 24.

Quality Assurance Leads to Increased Access for Services

In Uganda, 58% of those seeking health care prefer the private sector, it is therefore crucial that health care services provided in this sector are of high quality and affordable. PACE/PSI supports over 200 private health facilities that offer high-quality service, including but not limited to family planning with a high-concentration on LARCs, across Uganda. To ensure clients seeking health care services have access to high-quality services, quality assurance protocols are implemented through external auditors. Document reviews, observations, and interventions with stakeholders are conducted to assess the quality of care given by private for-profit providers.

In February-March 2014, PACE/Uganda’s FP program and services were audited by a team comprised of external programmatic and clinical experts using PSI’s five global standards and Standards Based Management and Recognition (SBM-R). Overall, ProFam facilities show high adherence to PSI’s global standards with 81.5% of standards met. Providers scored highest on the privacy and confidentiality standard at 89.6%. This was closely followed by informed choice at 87.5%, meaning that over 87% of the providers were assessed to have given clear, unbiased information about services to the client. Also measuring continuity of care, client safety, infection prevention adherence and technical competency, including licensure and registration by appropriate professional bodies, ensures a high quality private sector experience.

This protocol includes the need for continuous training of providers, support supervision, client exit interviews and annual internal and bi-annual external audits of FP services.

Overall Findings
To increase the contraceptive prevalence rate in Uganda, PACE/PSI found it was imperative to build a market for LARCs, and IUCDs in particular, for all women with an unmet need for modern contraception, including youth. Understanding the consumer, building capacity, targeting consumers with messages they relate to, creating an environment the consumer can trust all contribute to addressing the social barriers to LARC uptake. PACE/PSI uses this information and service delivery mechanism to implement interventions that will educate and enhance the knowledge of women of reproductive age on voluntary family planning methods.