Situational Analyses of Key Reproductive Health Services in Angola
Muiji wa Disanze II / Healthy Families II USAID Associate Award: CA#AID-654-A-13-00001
Prepared by Pathfinder International Submitted to USAID Luanda, Angola
October 31, 2014 Table of Contents
Acronyms ...... 2 Introduction ...... 4 Situational Analysis: Preliminary Concept Framework for a National Family Planning Strategy in Angola . 5 Situational Analysis: Contraceptive Commodity Security in Angola ...... 13 Situational Analysis: Adolescent and Youth Sexual and Reproductive Health in Angola ...... 19 Situational Analysis: Long-Acting and Permanent Methods of Family Planning in Angola ...... 25 Situational Analysis: Improving the Quality of Family Planning Services in Angola ...... 36
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Acronyms
ANC Antenatal care AYSRH Adolescent and youth sexual and reproductive health BCC Behavior change communication CBD Community-based distribution CECOMA Central de Compras de Medicamentos de Angola COCs Combined oral contraceptive pills CPR Contraceptive prevalence rate CYP Couple-year protection EC Emergency contraception ENSSR Estratégia Nacional de Saúde Sexual e Reprodutiva/National Sexual and Reproductive Health Strategy FP Family planning HIP High Impact Practice HIV Human immunodeficiency virus HPV Human papilloma virus HTSP Healthy Timing and Spacing of Pregnancy ISS Integrated Systems Strengthening approach IUD Intrauterine device LAPM Long-acting and permanent methods LARC Long-acting, reversible contraceptive methods LMIS Logistics management information system MCH Maternal and child health MDGs Millennium Development Goals MIS Management information system MOH Ministry of Health MSH Management Sciences for Health M&E Monitoring and evaluation NGO Non-governmental organization PMTCT Prevention of mother-to-child transmission PNDS Plano Nacional de Desenvolvimento Sanitário/National Health Development Plan
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POP Progestin-only pills RH Reproductive health RH/FP Reproductive health/family planning SASH Strengthening Angola Systems for Health SDP Service delivery point SOP Standard operating procedure SRH Sexual and Reproductive Health STI Sexually-transmitted infection TA Technical assistance TWG Technical working group UNFPA United Nations Population Fund USAID United States Agency for International Development WHO World Health Organization
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Introduction
Pathfinder is pleased to share this compilation of situational analyses that address a selection of key issues affecting the delivery of quality family planning (FP) services in Angola. These assessments were prepared by Pathfinder International during the period of 2012-2014 as part of an USAID funded advocacy and technical assistance project to reposition FP as a strategic priority in Angola.
Many of the ideas discussed in these assessments have been shared with, and supported by, key stakeholders in Angola, who are working along with Pathfinder International to address barriers and to advance the quality of reproductive health services in Angola.
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Situational Analysis: Preliminary Concept Framework for a National Family Planning Strategy in Angola
Prepared by: Marcos Arevalo, MD, MPA, MA - Chief of Party Graciela Davila-Salvador, MD, MS, MPH - Sr. Technical Advisor for Maternal Health & Family Planning Susan White, MPIA, MPH - Program Director
Submitted to USAID: 31 July 20121
Introduction As the Government of Angola moves forward on its commitment to provide quality family planning (FP) services to all Angolans, it is critically important that investments made for this purpose be utilized strategically and in ways that maximize effectiveness, equity, cost-effectiveness, and sustainability. This situational analysis proposes a broad framework for a national strategy that would guide the planning of work in FP in Angola. It addresses issues related to supply of FP services, such as coverage and quality of the services, and issues related to demand for said services.
Multiple studies have shown that maternal mortality is highest in very young women who are poor, malnourished, anemic, and not fully mature. For youth between the ages of 15 and 19 in these circumstances who become pregnant, the risk of death is double that of older women; and for girls under age 15, the risk is five times as high. For a woman who becomes pregnant less than six months after giving birth, the risk of death is doubled and the risk of (spontaneous) abortion triples. The risk also increases for women over 40 years of age, and for those who have had four or more pregnancies. Reducing the number of these high-risk pregnancies can potentially reduce the maternal mortality ratio by as much as 450 points during the transition to high levels of contraceptive use2 (thus, the ratio in Angola could move from the current rate of 610 per 100,000 live-births3 to less than 400). Reducing the number of unsafe abortions, which account for 13% of maternal mortality in developing countries,4 also would bring further improvements in maternal health.
Healthy Timing and Spacing of Pregnancy (HTSP) reduces the likelihood of pre-term, low-birth weight, and small-for-gestational-age babies, thus lowering neonatal mortality in general and allowing for extended breastfeeding. It also improves child survival indirectly by reducing the probability of maternal death from complications of pregnancy and birth such as pre-eclampsia. HTSP is an approach that:
• Supports women and families to delay or space their pregnancies; • Helps achieve the healthiest outcomes for women, newborns, infants, and children; • Works within the context of free and informed contraceptive choice; and • Takes into account fertility intentions and desired family size.
1 Additional Contributions from Susan White, MPIA, MPH, Program Director 2 Stover J, Ross J. 2010. How Increased Contraceptive Use has Reduced Maternal Mortality. Maternal and Child Health Journal, Vol 14 No.15, 687-695. 3 UNICEF. Angola Statistics, 2010. 4 Okonofua F. 2006. Abortion and Maternal Mortality in the Developing World. Journal of Obstetrics and Gynaecology, 28(11);974-979. Over the past few years, the United States Agency for International Development (USAID) has sponsored a series of studies on pregnancy spacing and health outcomes, which produced landmark publications on the effects of pregnancy spacing on maternal,5 newborn,6 and child health outcomes. This best evidence was summarized by the World Health Organization (WHO) in 2005 in a technical review of studies on HTSP,7 in which it generated the following recommendations:
1. Individuals and couples should consider health risks and benefits along with other circumstances such as their age, fecundity, fertility aspirations, access to health services, child-rearing support, social and economic circumstances, and personal preferences in making choices for the timing of the next pregnancy.
2. After a live birth, the recommended interval before attempting the next pregnancy is at least two years to reduce the risk of adverse maternal, perinatal, and infant outcomes.
3. After a miscarriage or induced abortion, the recommended minimum interval to the next pregnancy is at least six months in order to reduce risks of adverse maternal and perinatal outcomes.
This information is most effective when incorporated into health education, counseling, and service delivery for women and couples who would like to delay or space their pregnancies and who are adequately informed about the available choices in contraceptive methods, taking into account their fertility intentions and desired family size, as well as the social and cultural environment.
Angolan Context The reproductive health/family planning (RH/FP) situation in Angola could greatly improve with implementation of an FP strategy framed within the HTSP approach and that follows a health systems strengthening model such as Pathfinder International’s Integrated Systems Strengthening (ISS)8 approach. The limitations of the Angolan health care system, low levels of contraceptive prevalence, and low education levels of the wider populace are factors that need to be taken into consideration when designing and implementing an FP strategy.
Angolan Healthcare: Healthcare in Angola in 2012 is limited, as the country only recently emerged in 2002 from 27 years of civil war. With both infrastructure and the social order disrupted, millions were left with very limited access to healthcare. The government continues to focus on re-building damaged facilities and expanding availability to services.
Contraceptive Use: The maternal mortality rate of 6109 per 100,000 live-births and under-five mortality rate of 6110 per 1,000 live-births are direct results of limited access to healthcare, exacerbated by a
5 Conde-Agudelo et al. (2000) Maternal Morbidity and Mortality Associated with Interpregnancy Interval: Cross Sectional Study. BMJ 321:1255 6 Conde-Agudelo et al. (2006) Birth Spacing and Risk of Adverse Perinatal Outcomes. JAMA 295(15): 1809-1823 7 World Health Organization,2006. Report of a WHO Technical Consultation on Birth Spacing. 8 Pathfinder International. Integrated Systems Strengthening 9 UNICEF. Angola Statistics, 2010. 10 World Health Organization: Trends in Maternal Mortality 1990 to 2008: Estimates developed by WHO, UNICEF, UNFPA, and The World Bank, 2010. (www.unicef.org/infoby.country/angola.statistics.html).
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contraceptive prevalence rate among married women of 6%11 and total fertility rate of 5.54.12 According to a 2011 study,13 only 9.4% of urban women and 3.0% of rural women used contraceptives. Low levels of contraceptive use were strongly associated with youth, poverty, and cultural beliefs, as well as rural isolation. Many rural communities have no healthcare facilities; fewer than 15% of service delivery points (SDPs) offer FP services,14 and they offer a limited choice of methods. Adolescent fertility rates reached 165/1,000 in 2011.15 One-third of Angolan teens have had a child by the age of 18.16 Some girls try to get pregnant to “get a man,”17 and some sell sex to meet basic needs. There are no youth-friendly services; however, there is increasing interest at the Ministry of Health (MOH) level in this area as critical to a comprehensive family planning approach.
Customary beliefs in large families deter the use of FP, and many men continue to believe that children represent wealth. However, most women interviewed for the 2011 Decker study18 expressed objections to having many children in hard times; unmet need is a growing challenge. Most had heard of contraception, though few had ever used it. The unavailability of contraceptives and their cost are major limiting factors, particularly for rural women.
Today, 44% of females are under the age of 15, which means some 4.5 million additional women will potentially need FP services within the next decade and a half.19
HTSP Approach to Promote Contraceptive Use To maximize adoption of contraceptive use and HTSP among vulnerable women, we propose the following:
1. Implement comprehensive community-wide education In line with the government’s commitment to bring health information to communities, effective, compelling, and informative messages must be crafted to communicate the health, safety, and personal benefits of HTSP to all community members, from youth, women, and men to community and healthcare decision-makers, senior citizens, and especially healthcare providers. Common sense arguments for preserving the mother’s health for the sake of each child can attract the support of all members of a community. All messages should be in accordance with an Angolan national RH communications strategy, to be developed by the government.
Popular, harmful misconceptions about contraception abound, highlighting the need for informed counseling and community information. In many traditionally conservative countries like Angola, large families are signs of wealth and success, and standard rationales for contraceptive use are not persuasive to many decision makers, including men and senior family members. However, research data has demonstrated that new and compelling messages can be developed around child health and survival. Providers need to be trained to provide correct information during community group talks
11 Population Reference Bureau. Datafinder: Contraceptive use among married women, all methods (age 15-49), 2011. 12 World Fact Book, CIA, Angola (April 26, 2012). 13 Decker, Martha, Constantine, Norman A., “Factors Associated with Contraceptive Use in Angola,” African Journal of Reproductive Health, December 2011; 15(4). 14 Ministry of Health data. 15 WHO: Reproductive Health at a Glance, Angola April 2011. 16 Op sit, Decker, et al. 17 Ibid. p. 74. 18 Op sit, Decker et al. 19 Population Reference Bureau 2011. The World’s Women and Girls Data Sheet.
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(“palestras”) and address the concerns of youth, women, men, influencers, mothers-in-law, healthcare providers, and others. Training can help resolve frequent provider concerns on contraceptives such as weight gain or libido loss. Health workers can provide compelling health evidence that appeals to all community members. In addition, HTSP messages can be incorporated into non-health programs such as agriculture extension worker programs, literacy and religious groups, and progressive women’s groups. By doing so, we will support an increase in contraception uptake and contribute to narrowing the knowledge gap on HTSP information.
Suggested Action Step: Community knowledge-building and message acceptance could be significantly accelerated if the Angolan MOH, with the support of international and local development agencies, were to standardize FP information based on updated sources such as the new Manual de Formacao de Formadores em Planeamiento Familiar.20
2. Continue to strengthen the knowledge and skills of healthcare providers in HTSP counseling as well as method provision at all levels. Good counseling is key to adoption of HTSP that leads to contraception uptake and correct use of the method, which in turn is closely linked to method efficacy. If clients choose a method appropriate to their needs, satisfaction will contribute to higher continuation rates and increase positive word-of- mouth communication. Providers must see all client contacts as opportunities to offer and provide FP services.
For effective and speedy program integration, Angola would benefit from model integration service sites within each level of health service provision. Physicians, nurses, technical personnel, and community health workers should be trained at these sites, both in counseling and method provision, and they would then provide training and model service provision for providers from additional sites.
Suggested Action Step: A successful model for this effort was developed by Pathfinder International in four Luanda Municipalities,21 where service providers are gaining both understanding of the benefits of HTSP and the communication skills to share them with clients. This can be scaled up and expanded to other parts of the country.
3. Provide HTSP messages at every point of contact with women and adolescents, including: Focus on Youth: The burgeoning number of youth in Angola includes a vast number of adolescent girls with low status and education. Limited information is available to them on contraception and the benefits of delaying or spacing pregnancies. Evidence shows that girls in Angola commonly initiate sexual activity in their early teens. However, this not socially approved. As a result of this cultural resistance and the limited health system infrastructure, there are no youth-friendly reproductive healthcare services. This limitation is further compounded by providers who have not been trained to work in the area of adolescent youth sexual and reproductive health (AYSRH) services, so provider attitudes are often judgmental toward adolescent clients. In some instances, adolescents give birth without trained assistance. Religious and community leaders also need to be engaged to provide comprehensive, accessible, and supportive quality care to young people. Youth-friendly RH services, including counseling and HTSP information, must be recognized as a national healthcare priority and
20 MOH Angola, Direccao Nacional de Saude Publica. Manual de Formacao de Formadores em Planeamiento Familiar 21 Funded by USAID 2009 to 2011
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established as a fundamental component of a national family planning strategy. Rural women should also be a target for HTSP messages.
Suggested Action Step: The national government has declared that services for youth, including RH/FP services, must be a priority. Initial effort must be invested in researching channels for reaching youth (male and female, in- and out-of-school, married and unmarried) with HTSP information.
4. Apply an integrated service delivery model relevant to the Angolan health system context. Antenatal, Postpartum, and Post-Abortion Care Visits: Maternal health services are utilized by sexually active and fertile women. In countries with low resources, antenatal care, delivery, and postnatal care are the most common – and often the only – points of healthcare contact for women. While women in the immediate postpartum or post-abortion period are not fertile, their fertility will return soon, and they will be at high risk if they become pregnant again. Women who are offered FP information and services during antenatal or postpartum care have the added benefit of time to select a method and discuss it with their partners.
An estimated 40% of women who have an unsafe abortion in Angola die due to complications.22 Any adolescent or adult woman seeking an abortion or post-abortion care should be given supportive counseling on HTSP benefits and the use of contraception. Every effort should be made to provide her with a method before she leaves the clinic. There is evidence that when FP is routinely offered to women who seek post-abortion care, the majority accept a method (primarily one that is a long-acting or permanent).23
Child Immunization and Well-Baby Clinics: Children should be brought to a clinic for immunization at two, four, six, and nine months of age. In the majority of cases, it is the mother who brings them. These visits are ideal opportunities to offer and provide FP services to the mother, who is already past the postpartum period. The child is already a few months old, so she can begin using almost any method at this time without interfering with breastfeeding. Given that fertility returns within a few months after childbirth (even strictly exclusive breastfeeding does not offer enough protection beyond six months), it’s important that she starts using FP as soon as possible after childbirth. General child health services and well-baby clinics are also good opportunities to offer and provide FP and to emphasize HTSP.
Community-Based Family Planning Services: A majority of Angolans still live in rural areas, and many more live in peri-urban environments with physical and cultural characteristics similar to rural areas. Many health services are already being provided or facilitated by community health agents in these areas. Community-based distribution (CBD) of FP can be more effective and cost-effective in these settings. Demand generation activities can also be carried out more effectively by community agents.
Suggested Action Step: The National Directorate of Public Health has stated its intention to increase availability of all FP methods. To achieve coverage most efficiently, FP services should be integrated into maternal and child health programs and strengthen community-based FP services. Small scale activities can be started at the outset to demonstrate the feasibility and desirability of integration and of community-based FP services.
22 Wikipedia, Maternal Health in Angola: http://en.wikipedia.org/wiki/Maternal_health_in_Angola#Unsafe_Abortion. 23 www. mariestopes.org
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The Angolan MOH, together with USAID and UN supporting agencies such as UNFPA, WHO, and UNICEF, is in a strong position to develop a series of FP integration models that could be replicated and scaled up in the future. Challenges and opportunities surrounding each model must be documented to prepare for replication in other settings as well as program scale-up.
According to the latest USAID High Impact Practice (HIP) brief,24 a wide range of models integrating FP with immunization services have been developed at both facility and community levels. Pathfinder could take advantage of its successful projects elsewhere to adapt appropriate aspects of these models into programming in Angola. As the MOH moves towards designing an FP strategy, it must take into consideration key integration opportunities such as the ones presented in the chart below.
The table below provides examples of opportunities for integration of FP and other services. It includes information of successful experiences using the specific approach.
Table 1: FP and Immunization Integration Models25 VAC=vaccinator, FPP = FP provider, MFP = multifunction provider, MFCW= multifunction community worker Model Provider Illustrative Models Service Organization
FIXED FACILITY SERVICES Combined Service MFP or • Immunization and FP services provided PSI Zambia, PSI Mali, Provision VAC and during the same visit IntraHealth Senegal FPP • Clients able to receive immediate services; no referral needed • Both services may be provided by one MFP, or by a team of VAC and FPP • In some settings, clients can receive long- acting and permanent methods (LAPMs) on the same day Linked Referral VAC and • Vaccinator provides referral for same-day FP RTI Philippines, FPP services MCHIP Liberia, FHI • Typically both services co-located in same 360 Ghana, FHI 360 facility Zambia, FHI 360 • If client selects LAPMs, lower level facilities Rwanda may still require future/offsite appointment Future/Offsite VAC, FPP • Vaccinator provides client a referral for FP Referral services at a future date and/or at an offsite facility • May be less effective due to potential loss to follow-up Group-Based FP MFP or • Health worker leads group discussions on FP PSI Benin, PSI DRC Education at Facility FPP while women wait for immunization services, or during regular group talks at facility (PSI Zambia and PSI • Referrals for services may also be provided Mali included this
24 USAID 2007. Scaling Up High-Impact FP/MNCH Best Practices in the ANE Region. Bangkok, Thailand. 25 USAID, ibid.
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along with a combined service delivery approach) COMMUNITY-BASED Routine Joint MFP or • Routine outreach services for FP and Jharkhand, India Outreach FPP and immunization carried out during the same VAC community visits at an outreach post or mobile health clinic Integrated Home- MFCW • MFCW conducts home visits including Pakistan, India, Based immunization and FP education and/or Ethiopia, Bangladesh services, often within a comprehensive package of MNCH services • MFCW may distribute contraceptives, or may provide referrals, including for LAPMs Community-Level MFCW • MFCW conducts group education and leads . Group Education on discussion on immunization and FP during Immunization and FP community outreach and mobilization activities. CROSS-CUTTING FEATURES Postpartum Screener, • Provider at health facility or in community MCHIP Nigeria, MCHIP Systematic Screening VAC, FPP uses standardized instrument to identify each India client’s needs including need for FP services. • Services may be offered during same visit (for facility screening), or referral for services may be provided Dedicated Provider FPP • A dedicated provider is tasked ONLY with FP PSI Zambia, PSI Mali service provision during days when immunization services are offered (can include provision of only certain FP methods such as LAPMs) • May be incorporated within the linked referral or facility-level group education models (i.e. a dedicated provider may lead group discussion efforts and/or receive clients referred from the vaccinator) NOT RECOMMENDED Integrated Campaign VAC or • FP messages and/or services provided in Not recommended MFP the community during episodic because campaigns immunization campaigns occur episodically, are donor-dependent and disease specific.
5. Improve availability of long-acting and permanent methods (LAPM) through a combined service delivery model.
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LAPMs (IUDs, hormonal implants, tubal ligation, vasectomy) are significantly more effective at preventing pregnancy than shorter-term methods26 (condoms, pills, injectables) which currently dominate the national Angolan program. LAPMs are significantly more cost-effective for both users and programs, and because they do not require frequent follow-up or re-supply, they place less stress on the service delivery system. This is especially important where a system lacks resources to meet even the small current demand. When LAPMs are introduced, it is important to ensure that clients are effectively counseled on the advantages and disadvantages of method choices, as well as taught how to use the adopted method correctly.
Suggested Action Steps: Continue efforts to scale up availability of hormonal implants, which have been well received and have gained significant momentum in Angola. This must be coupled with advocacy for the national government to begin procuring the commodity. Implants have a higher initial cost, but if services include good screening and counseling, the long duration and high efficacy of implants make them a good FP investment. Increase effective availability of IUDs. This requires training personnel in clinical aspects of service delivery, as well as addressing prevalent misperceptions and biases against the method.
6. Continuous investment in human resource capacity building. Capacity building is at the top of the list of systems that need strengthening. USAID has been investing in training activities such as those being carried out by the Jhpiego SASH Project and the World Learning Eye Kutoloka Project grants. It is also important to strengthen the capacity building system itself, taking advantage of existing reference materials while developing or adapting training materials, provider level tools, and supervision tools. Capacity building activities should be done through the provincial level “Nucleos de Formacao,” to form provincial level trainers and support them to train and supervise others.
7. Investing in an efficient supply chain management system for contraceptive commodities. Commodities are an indispensable component of FP services. The MOH is investing resources to improve distribution of FP commodities. An efficient supply chain management system must be established to ensure that contraceptive commodities are reliably available at all SDPs. Work needs to be done on several fronts to develop a functional supply chain management system that will deliver IUDs, implants, injectables, pills, condoms, and other supplies when and where they are needed. The logistics/distribution system needs to be strengthened beyond provincial capitals all the way to the SDPs (“the last kilometers”). The management information system (MIS) must be further strengthened as well, particularly beyond provincial capitals. A critical element of this system strengthening is the revision or development of standard operating procedures (SOPs) for all the functions involved in supply chain management.
Suggested Action Step: At the highest level, advocacy efforts need to continue to be advanced so the Government of Angola and the key Ministries of Finance and Health will prioritize and allocate funds to improve contraceptive commodity security, including procuring and efficiently distributing the contraceptives necessary to meet the needs of the Angolan population. A comprehensive contraceptive security strategy that guides all other work done in this area should be developed.27
26 WHO 2007. Family Planning. A Global Handbook for Providers. 27 Pathfinder International 2012. Situational Analysis: Contraceptive Commodity Security in Angola.
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Situational Analysis: Contraceptive Commodity Security in Angola
Prepared by: Marcos Arevalo, MD, MPH, MA Chief of Party John Granda, BSc (Econ) Senior Technical Logistics Advisor Graciela Davila-Salvador, MD, MS, MPH Sr. Technical Advisor for Maternal Health & Family Planning Susan White, MPIA, MPH Program Director
Submitted to USAID: 31 July 2012
Introduction As the Government of Angola moves forward on its commitment to reduce maternal mortality, providing quality family planning (FP) services to all Angolans is one of the strategies being pursued. Contraceptive commodity security is one of the key areas for investment. This situational analysis proposes a framework for activities to reach contraceptive commodity security in Angola. It addresses issues related to procurement and distribution/logistics. It follows a systems strengthening approach. This document considers only the commodity aspects of overall contraceptive security; it does not touch on other equally important aspects such as actual delivery of FP services.
This situational analysis is presented to the USAID Mission in Angola as part of Pathfinder’s work under its Associate Award to strengthen the environment for FP in Angola. In its present form, it is intended for a USAID audience, as a platform for discussions on the topic and preparation of a more detailed document to be shared with the Government of Angola, and which would be utilized by broader groups of stakeholders as input for the development of an integrated supply chain management system which includes FP and RH commodities. This system will be developed and implemented by the government’s central health procurement agency, CECOMA.
Contraceptive commodity security exists when people are able to choose and obtain contraceptives whenever they need or want them.1 The International Conference on Population and Development included universal access and availability of reproductive health care as one of the key goals for programs.2 By meeting the contraceptive commodity needs of families, FP programs can contribute to the achievement of this goal.3 This will be achieved by making the right commodities available in the right quantities, in the right conditions, in the right place, and at the right time and right cost. Commodity security is a key pillar of FP services: clients can only utilize and benefit from FP services if contraceptives are reliably available at the service delivery or sales point (“no product, no program”). When clients can find the range of contraceptives they want to use, they are less likely to have unwanted pregnancies,4 but a constant supply of contraceptives is necessary for investments in service delivery, training, and demand generation to produce any results.5
A supply chain management system needs to function efficiently to: accurately determine and meet the future contraceptive needs supported by evidence/data-based forecasting; order and buy
1 USAID/DELIVER (2011). Sistema de Alerta Antecipado Sobre Desabastecimento de Contraceptivos, Expandido para África Occidental. 2 UNFPA. Programme of Action of the ICPD. www.UNFPA.org 3 Directorate General of Family Planning, MOHFW Bangladesh 2010. National Strategy on Reproductive Health Commodity Security. Dhaka. 4 Gribble J. 2010 Contraceptive Security, A Toolkit for Policy Audiences. Population Reference Bureau, Washington DC. 5 USAID/DELIVER op cit. contraceptives from abroad or locally via best practice procurement processes; distribute and warehouse contraceptives to and at various physical locations; track commodity movements; and provide this information to those managing the system (Logistics Management Information System- LMIS). A well-functioning LMIS is one of the pillars for contraceptive security systems as much as a lack of reliable data is a major obstacle to improving contraceptive security systems.6 Each of these activities has functional responsibilities that require specific skills and knowledge gained through training. A contraceptive security strategy informed by a comprehensive FP strategy with key stakeholder input enhances the likelihood of improved efficacy that will result in increased contraceptive options for user beneficiaries in the communities.
Angolan Context In Angola, contraceptive commodity security faces challenges on many fronts. Three dominant challenges include: limited contraceptive forecasting capacity; a weak centralized distribution and information management system; and an over- reliance on foreign donations. Through its current award to Pathfinder, USAID is addressing some of these challenges; however, more work needs to be done.
The public sector is the primary provider of available FP methods (mostly short-term methods such as pills, condoms, and injectables, all of which require frequent resupply). Thanks to improved forecasting at the central level, contraceptives are increasingly available in-country (e.g. the central warehouse now has a 10-month supply of injectables, 30 months of combined oral contraceptive pills (COCs), 26 months of progestin-only pills (POP), 18 months of intrauterine devices (IUD), and 9 months of implants). However, contraceptive stock outs still occur at service delivery points (SDPs), particularly in urban tertiary facilities due to lack of accurate and reliable forecasting and unreliable data record keeping. Both of these factors negatively impact and cause delays in contraceptive re-supply requests to the central level. In other cases, there are significant overstocks of commodities as a result of inaccurate forecasting that result in contraceptive quantities shipped that are not based on actual consumption or stock levels. The outcome of the supply chain management system shortcomings results in unmet need for even the small current demand for contraceptives. Demand and distribution totals by the public system in 2011 were:
• 180,700 cycles of COCs, • 76,300 cycles of POPs, • 161,000 injectables vials, and • 2,121 IUDs.7
Some functions of the supply chain management system in the areas of forecasting, planning, and monitoring and evaluation (M&E) are now conducted sporadically. Improvements in this area are occurring with support from Pathfinder to define six month national forecasts. This information is being utilized by UNFPA and USAID to plan their procurements. However, forecasting needs to be conducted continuously and adopted by Ministry of Health (MOH) staff as a core responsibility. Other components are improving: all contraceptive logistics are now being managed through a single consolidated central system; the central warehouse now keeps its commodities in better physical order and maintains more accurate records of its stocks; coordination is ongoing for UNFPA to supply a commodity management software package which will provide managers with user-friendly information for evidence-based
6 USAID/DELIVER op cit. 7 National Directorate of Public Health/Angola MOH data.
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decision-making; shipments are going out regularly to the provincial capitals before stocks run out; and quantities shipped are now based on demand and existing stocks.
Capacity for warehouse management, distribution, supervision, and personnel skills in general are still limited. The LMIS is still in a nascent stage. Information on consumption and stock levels of contraceptives has started to flow from most provinces into the central level. However, data improvements are needed to provide consistent evidence-based management decisions.
In spite of the aforementioned limitations, progress has been made over the last two years. Enough contraceptives are now available in warehouses in all provincial capitals. When contraceptives became available in selected municipalities (Cacuaco, Viana, Cazenga, and Kilamba Kiaxi) of Luanda province, there was a rapid increase in uptake of oral contraceptives (45% increase), injectables (72%), condoms (144% increase), and IUDs (252% increase).8 Implants are not yet available in these sites. Notably, these increases in uptake happened without any additional promotion or other interventions in these selected sites. At the entry point of the contraceptive commodity supply chain, the national FP program relies almost entirely on foreign donations for its supply of contraceptives.9 This situation places Angola in a vulnerable situation, and is not sustainable in the long term. Additionally, alternative sources of financing must be identified if the quantities of contraceptives increase beyond the small quantities currently distributed.
Analysis Two of Angola’s most pressing issues are the high maternal mortality rate of 610/100,000 live-births10 and the high infant mortality rate of 102/1,000 live-births11 and under-five mortality rate of 61/1,000 live-births.12 These are directly linked to limited access to healthcare, but are exacerbated by a contraceptive prevalence rate (CPR) among married women of only 6%13 and a total fertility rate of 5.54.14 Secure and reliable contraceptive systems are a fundamental way to improve these statistics and to improve the opportunity for women to have more control over their health.
As part of its efforts to reduce maternal and infant mortality, the Government of Angola is committed to achieving significantly higher levels of contraceptive prevalence. This commitment means providing an expanded method mix and commodities to more people in more places. However, even if financial resources were available to buy all the necessary commodities, the existing system would be inadequate to get the commodities in time where they are needed. Building on current initiatives, a more effective and cost-effective approach is underway that will result in greater impact than isolated interventions, such as continued commodity donations, which can choke the supply chain and create imbalances in commodity supply and in what and how methods are offered to clients. Investing in systems strengthening, such as in the current USAID supported Jhpiego’s SASH project and Pathfinder International’s FP advocacy project, will produce outcomes that improve the likelihood of institutional sustainability over time.
8 Ministry of Health. 2012. MIS data. Luanda. 9 In 2011, UNFPA and USAID donated 60% and 40%, respectively, of all contraceptives procured for the public sector. 10 UNICEF. Angola Statistics, 2010. 11 Population Reference Bureau. 2011 World Population Data Sheet. 12 World Health Organization: Trends in Maternal Mortality 1990 to 2008: Estimates developed by WHO, UNICEF, UNFPA, and The World Bank, 2010. www.unicef.org/infoby.country/angola.statistics.html). 13 Population Reference Bureau. Datafinder: Contraceptive use among married women, all methods (age 15-49), 2011. 14 World Fact Book, CIA, Angola (April 26, 2012).
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Proposed Strategic Approaches Several ongoing USAID-funded projects are addressing key issues affecting contraceptive security in Angola. These are investments in systems strengthening: Pathfinder is supporting development and implementation of systems for supply chain management; Management Sciences for Health (MSH) is providing technical assistance (TA) to improve commodity logistics at the hospitals and health center level; PSI is building up the social marketing system. Among the UN agencies, UNFPA has recently started channeling more of their support towards systems strengthening in addition to their continued commodity donations. Even more importantly, there is now improved communication and coordination among a group of key stakeholders, including central and provincial governments, UNFPA, and key non- governmental organizations (NGOs). This stakeholder group is interested in developing a more formal Contraceptive Security Committee or Technical Working Group (TWG). These initiatives will build a fundamental platform that the Angolan government will need to meet the commodity needs of Angolan population. Key focus areas include:
1. Continue developing and strengthening all areas of the distribution system. Significant improvements are being made particularly in the linkage among warehousing, distribution, and MIS. Specific system improvement work in MIS includes setting up systems and mechanisms, reviewing and revising Standard Operating Procedures (SOP), and capacity building. An M&E system and mechanisms for government procurement of contraceptives need to be put in place. Strengthening of all these areas can continue even before an FP strategy is in place, as efficient systems will be necessary regardless of program goals or specific commodity targets.
2. Ensure that the supply chain management is designed and built in a way that accommodates for growth and strengthening of the community-based distribution (CBD) component.
3. Continue strengthening the LMIS for supply chain management. The goal is to have a system that generates accurate and timely information, allowing the FP program to manage and monitor the flow of contraceptives, and donors to plan their procurements. A well-functioning LMIS should collect information on consumption (which reflects client preferences), stock levels, and amounts on order and in transit. With this information, the program can account for products in the supply chain, reducing stock outs, overstocks, loss, and wastage, thus improving the program’s effectiveness and helping meet the unmet need. Input from the LMIS is critical to forecasting demand, procurement, and distribution to SDPs and to clients.15 The LMIS should be designed in a way that makes it easy for information to flow from and to community-based distributors.
Key steps to improve the current LMIS include: • Do an assessment of the LMIS to determine what data is needed for decision-making at each level in the system and what gaps still exist, developing and enforcing systems and mechanisms for collection of accurate data in a standardized digital format, and for timely electronic submission • Define responsibilities and develop capacity at the central, provincial, district, and SDP levels to process and analyze data from the LMIS and to make decisions.
15 Setty V, Jacoby R, Hart C. 2002. Family Planning Logistics: Strengthening the Supply Chain.” Population Reports, series J no. 51. Baltimore. Johns Hopkins School of Public Health.
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4. Build human capacity at all levels (National Directorate of Public Health, central warehouse, provincial level, and SDPs) for forecasting, procurement, warehouse management, ordering, distribution, shipping, and LMIS as appropriate. This includes setting up a capacity building system with a budget and personnel, conducting a needs assessment, and developing training curriculum and tools.
5. Support the improvement of the government’s contraceptive procurement process. As the government increasingly funds its own contraceptive supplies for the public sector, it will have to take a more active role in the procurement process. This can be done through CECOMA, the MOH directorate in charge of procuring medications and equipment. If the government decides to use other sources of funding, such as World Bank loans, coordination with World Bank must be started with enough anticipation to set up the necessary systems and build capacity.
6. Expand the sources for contraceptive procurement with a whole market approach to reduce dependence on the free commodities distributed by the public sector. This includes strengthening social marketing, NGO, and private-for-profit aspects of contraceptive supply. There is a growing working class in Angola who have some disposable income and who could purchase contraceptives at subsidized prices. Some contraceptives could be sold through the increasing cadre of small-scale retailers (“lojas”) who are effectively bringing consumer products wherever there is demand. Social marketing is a vehicle to distribute longer-acting methods such as injectables, IUDs, and implants through private physicians or clinics, and through health programs run by NGOs. Even if most Angolans who use contraceptives continue relying on free commodities from the public sector, options to access private sector sources would potentially broaden access and availability, thereby increasing FP use, and simultaneously relieve pressure on the public sector as the sole contraceptive commodity provider.
Suggested Action Steps: First, create a National Contraceptive Security Committee or TWG. This Committee could evolve from the existing Reproductive Health Committee, from the Logistics group of the Intersectorial Coordination Committee, or from a stakeholder group who currently coordinates their supply chain management needs. The Contraceptive Security Committee would need active participation of government (Ministries of Health, Finance, and Planning), major commodity donors, FP service delivery groups, social marketing and other relevant private sector entities, technical partners, supply chain managers, and other key stakeholders.16 This committee will be more effective if it is chaired by the Government and receives support from a non-government secretariat. Committee functions include gathering information relevant to contraceptive security, identifying issues and problems, consolidating comments, and drafting a strategy.
Second, conduct a detailed review and diagnosis of the entire supply chain management system up to the SDPs throughout the country. This review would be followed by the prioritization of the system’s needs. While some equipment and maybe even infrastructure may be necessary, the priorities will likely include setting up systems and processes, SOPs, and capacity building.
Third, develop a comprehensive, medium-term (e.g. five year) Contraceptive Security Strategy. This strategy must be based on an overall FP strategy, as contraceptive commodity needs should be
16 Rao R, Olson N, Bornbusch, A, Pilz K. 2008. The SPARCHS Process Guide: A Planning Resource to Improve Reproductive Health Commodity Security. Baltimore. INFO Project/CCP, Johns Hopkins School of Public Health.
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determined by the general goals dictated by the FP strategy. This strategy would propose concrete, feasible, and realistic solutions; mechanisms for their implementation; and plans for monitoring progress. Preparation of this strategy can be led by the Contraceptive Security Committee.
Fourth, advance dialogue between donors and the Government of Angola on the procurement of contraceptives by the government in the near future. This includes setting realistic budgets, identifying potential funding sources, and establishing concrete timelines.
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Situational Analysis: Adolescent and Youth Sexual and Reproductive Health in Angola
Prepared by: Marcos Arevalo, MD, MPH, MA Chief of Party Gwyn Hainsworth, M.Ed, Sr. Technical Advisor for Adolescent Sexual and Reproductive Health Callie Simon, MPH, Technical Advisor, Adolescent Sexual and Reproductive Health Graciela Davila-Salvador, MD, MS, MPH Sr. Technical Advisor for Maternal Health & Family Planning Susan White, MPIA, MPH Program Director
Submitted to USAID: 30 April 2013
Introduction This situational analysis of sexual and reproductive health of adolescents and youth (AYSRH) in Angola identifies root and proximate factors leading to the current status, and identifies and prioritizes interventions that can help improve the current situation, including lowering Angolan adolescents’ risk of maternal morbidity and mortality.
AYSRH is a comprehensive area which includes prevention of unwanted pregnancy; prevention, screening, and treatment of HIV and other sexually transmitted diseases (STIs); antenatal, delivery, and postpartum care; gender-based violence; safe abortion and post-abortion care; prevention of mother- to-child transmission of HIV (PMTCT); HPV vaccines; and other services. In the context of government priorities and what is programmatically feasible in Angola, this situational analysis focuses more on family planning (FP) than in other areas. This does not mean other areas of AYSRH are less important or less urgent in Angola. They must also be addressed, but given where public and other programs are concentrating their resources, it may be more synergistic for AYSRH work to begin by addressing prevention of unwanted pregnancies.
While the causes of poor AYSRH involve males and females, it is young women who bear most of the burden; this burden frequently accompanies them for the rest of their lives. “Simply put, no society can truly flourish if it stifles the dreams and productivity of half of its population” (Bill Clinton).1
Young people have the potential to lift their families and nations out of poverty and contribute to sustained economic growth and security, and to the realization of the Millennium Development Goals (MDGs). If a large population cohort2 is followed by a smaller one, the country benefits from the productivity of a large working labor force. At the same time, the country saves resources because of the reduced need for expenditures to meet the needs of the smaller, younger generation; these resources can then be invested for economic development and family welfare.3 Improving the future and well-being of a nation requires a focus on the well-being of the adolescent and youth population, particularly females: when girls and women earn income, they re-invest 90% of it into their families (vs. 30-40% for men), thus having a greater impact in their communities.4, 5 But early and/or unwanted
1 Clinton, B. 2012. The Case for Optimism. Five Ways the World is Getting Better all the Time. TIME Oct 1 2012. 2 In Angola, 69% of the population is under 25 years of age. PRB 2012. World Population Data Sheet. 3 Ross, J. 2004. Understanding the Demographic Dividend. Policy Project, Futures Group. Washington DC. 4 GMMB, Lake Research Partners, Pathfinder International, 2010. Advancing Adolescent and Youth Sexual and Reproductive Health: Advocacy Findings and Recommendations. 5 Taylor, Manisha 2011. The Girl Effect: A Whole New Way to Investing. Forbes. pregnancy and reproductive health (RH) problems can have a profound and long-lasting negative impact on young women’s lives.
To realize their potential, young people, particularly girls, must be provided with opportunities for education and employment, and have access to the information and resources they need to adopt healthy sexual and reproductive behaviors and decision-making.6
Adolescence can be a very healthy period of life; however, adolescents, specifically young women, may be particularly vulnerable to threats to their sexual and reproductive health (SRH). Girls and young women bear most of the physical and socio-economic burden of poor SRH in Angola. Adolescent girls are exposed to risks such as early, unprotected sexual activity.7 They are more likely than older women to experience unintended pregnancy because of provider, and sometimes parental, opposition to their use of contraception. Other contributing factors include gender and power imbalances, lack of SRH information, lack of access to and availability of contraceptive services, and socioeconomic factors.8
Complications from pregnancy and childbirth are the leading cause of death for young women aged 15 to 19 in poor countries. For young women in this age group who become pregnant, the risk of death is double that of older women; and for girls under age 15, the risk is five times as high.9, 10 For younger adolescents, the higher mortality is due more to biological factors related to their young age, whereas for older adolescents, it is influenced more by poverty, low social status, and lack of access to health services and/or delays in seeking care. Delaying the first birth by ensuring adolescent access to contraception can have an important positive effect on maternal morbidity and mortality and MDG 5, as well as reduce lifelong fertility.11 Up to 41% of unsafe abortions in developing countries occur in young women aged 15 to 24. Mortality from complications of unsafe abortion is high,12 and there are no safe abortion services in Angola.
Angolan Context The total fertility rate in Angola (6.3 births per woman13) remains among the top five highest rates in the world. Adolescent fertility rates reached 165/1,000 in 2011,14 and 239/1,000 for rural girls aged 15 to 19. Two-thirds of Angolan teens have had a child by the age of 19.15 Today 48% of the population is under the age of 15,16 which means that close to 10 million additional young women and men will potentially need FP and SRH services within the next decade and a half.
6 GMMB, Lake Research Partners, Pathfinder International, 2010. Advancing Adolescent and Youth Sexual and Reproductive Health: Advocacy Findings and Recommendations. 7 The National Research Council and Institute of Medicine. 2005. Growing up global: the changing transitions to adulthood in developing countries. Washington DC. 8 World Health Organization 2012. Expanding access to contraceptive services for adolescents. Geneva. 9 McIntyre, P. 2006. Pregnant Adolescents: Delivering on Global Promises of Hope. WHO, Geneva. 10 UNFPA 2005. State of the World Population, the Promise of Equality. New York. 11 GMMB, Lake Research Partners, Pathfinder International, 2010. Advancing Adolescent and Youth Sexual and Reproductive Health: Advocacy Findings and Recommendations. 12 Up to 40% mortality according to http://en.wikipedia.org/wiki/Maternal_health in_Angola#Unsafe_Abortion. 13 Population Reference Bureau. 2011. The World’s Women and Girls Data Sheet. 14 WHO: Reproductive Health at a Glance, Angola April 2011. 15 Pathfinder Intl. 2008. Conhecimentos, Atitudes e Práticas em Matéria de Planeamento Familiar en Angola. Inquérito de Linha de Base. Luanda. 16 Population Reference Bureau 2011. The World’s Women and Girls Data Sheet.
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Official contraceptive prevalence rate (CPR) for modern methods among young women aged 15 to 19 living in union is 12.4%17 and only 1.0% for girls aged 12 to 14 living in union. Only about 1 of every 16 FP users uses a long-acting method (which are more effective).18, 19 Emergency contraception (EC) is officially available throughout the country, but utilization is extremely low. Low levels of contraceptive use were strongly associated with young age, poverty, and cultural beliefs, as well as rural isolation.20 Although prevalence of HIV is still low for the region now that the war has ended (2% national prevalence, somewhat higher in border provinces), commercial movement and immigration are increasing, internally and from neighboring countries, some of which have significantly higher HIV prevalence.21,22 Adolescents’ pattern of sexual activity (only 3.6% of sexually active adolescents use condoms, sequential boyfriends with frequent turnover, liaisons with older men for transactional sex) poses a potential high risk of HIV transmission once the virus becomes present in specific communities.23
Cultural and Behavioral Issues Affecting AYSRH in Angola It is not unusual for Angolan girls to initiate sexual activity in their early teens. It is also not unusual for boys and girls, particularly in urban settings (59% of the population of Angola lives in urban settings), to have more than one partner concurrently and several partners sequentially.24 Transactional sex between adolescent girls and older men is not infrequent. These behaviors are well known to the population in general, and while they are not approved, they are accepted and considered a fact of life. Many men consider it acceptable to prey on adolescent girls and young women.25 While society in general does not approve of this practice, it is not widely condemned either.
Angolan adolescents lack basic knowledge of their bodies, how their reproductive system works, and of contraceptive methods.26 Only 37% of adolescents aged 15 to 19 know about at least one contraceptive method, and only 7% know about long-acting methods.27 This lack of knowledge coupled with cultural beliefs and norms detailed below hinder adolescents’ use of contraception.
The perceived (but not real) scarcity of males and widespread notion that a woman is not eligible to marry until she demonstrates her fertility are linked to high rates of adolescent pregnancy.28 Becoming pregnant is a socially approved and even encouraged mechanism to procure oneself a husband, and many families would not approve that their sons marry a woman who is not already pregnant.29 Thus, purposely unprotected sex is widespread and considered a “smart” tactic.30
17 Government of Angola, INE 2012. Inquerito Integrado sobre o Ben-estar da Populacao (IBEP). 18 Government of Angola, INE 2012. Inquerito Integrado sobre o Ben-estar da Populacao (IBEP). 19 Trussel J 2007. Choosing a Contraceptive: Efficacy, safety and personal Considerations. Contraceptive Technology 19th Revised edition. Ardent Media Inc. New York. 20 Decker, Martha, Constantine, Norman A., “Factors Associated with Contraceptive Use in Angola,” African Journal of Reproductive Health, December 2011; 15(4). 21 PRB 2012. World population Data Sheet. 22 Namibia HIV prevalence 13%; Zambia 14%. PRB 2012. World Population Data Sheet. 23 Government of Angola, INE 2011. Inquerito Integrado sobre o Bem-estar da Populacao, IBEP. 24 PRB 2011. World Population Data Sheet. 25 PSI Angola 2012. Focus groups conducted in working class neighborhoods and townships of Luanda. 26 PSI Angola 2012. Focus groups conducted in working class neighborhoods and townships of Luanda. 27 Government of Angola, INE 2011. Inquerito Integrado sobre o Bem-estar da Populacao (IBEP) 28 PRB 2011. World Population Data Sheet. 29 PSI Angola 2012. Focus groups conducted in working class neighborhoods and townships of Luanda. 30 PSI Angola 2012. Focus groups conducted in working class neighborhoods and townships of Luanda.
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In addition, Angola is a strongly pro-natalist society. Having a large family is still viewed as a symbol of power and/or wealth. Even though most women interviewed for a 2011 study expressed objections to having many children in hard times, motherhood is encouraged at every level, and it is considered socially unacceptable to use contraception before having a child.31 Furthermore, there is a perception that the country needs to make up for the lives lost during the 27-year long war, and that large numbers of people are necessary to populate the empty lands. All this deters increased contraceptive use.
Angolan Healthcare System Barriers Users and potential users of contraception of all ages are affected by many shortcomings of the health service delivery system, but this is especially acute among young people. Many rural communities have no healthcare facilities. Reproductive health services in general, and FP services in particular, are not widely available in Angola, and those that exist tend to be of poor quality and not youth-friendly. Out of an estimated 2,500 service delivery points (SDP) to serve some 20 million Angolans throughout the country, less than 200 are known to offer FP services.32 In those SDPs that do offer FP, method choice is limited: availability of long-acting methods is scarce. Implants are only available in some 30 (of 2,500) health facilities, IUD services are limited, and permanent methods are not available anywhere in the country.
Due partly to the impact of the civil war, there is a severe shortage of health personnel, and those that are active lack updated knowledge and skills in FP and comprehensive SRH care delivery. Facilities lack clear or updated guidelines for FP service delivery, communications materials, and other tools to support services. FP clients do not receive counseling. Health workers have misconceptions and limited training about the medical contraindications of FP methods and certain drug interactions. Myths and misconceptions go unchallenged as there are not currently regular training opportunities for upgrading healthcare worker skills in these areas.
Issues with FP and other SRH Services that Impact Adolescents In Angola, there are no FP or other SRH services directed toward meeting the needs of adolescents and youth. Although it is tacitly accepted for adolescents to be sexually active, it is culturally unacceptable for them to request FP services. SRH services are frequently denied to them because, for example, providers believe adolescents are too young and should abstain from sexual activity.
Health personnel lack information on how to provide youth-friendly SRH services, and they frequently spread incorrect information.33 Many health workers believe that contraceptives are physically harmful for adolescents and for women who have not yet had a child, so they may actively discourage use of contraception by adolescents.34 Other community members also discourage it.
Impact on AYSRH Low economic status, ignorance, lack of empowerment, an unsupportive environment, unavailability, and poor quality of services all contribute to girls’ and young women’s low use of contraception in Angola. One of the first consequences is that these girls and young women become pregnant. Aside from the risk of maternal mortality and morbidity, a vicious cycle may start: with pregnancy and then having to look after a child, they are less likely to attend school and get further education, and less likely
31 Decker, Martha, Constantine, Norman A., “Factors Associated with Contraceptive Use in Angola,” African Journal of Reproductive Health, December 2011; 15(4). 32 Ministry of Health data. 33 PSI Angola 2012. Focus groups conducted in working class neighborhoods and townships of Luanda. 34 PSI Angola 2012. Focus groups conducted in working class neighborhoods and townships of Luanda.
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to find employment or engage in productive work, thus hampering opportunities for professional development and improvement of economic status. This increases the pregnant adolescent’s dependence on others, including the child’s father or other men. This dependence puts them at higher risk for subsequent pregnancies, potentially poorly spaced, and perpetuates overall high fertility.
There are no youth-friendly SRH services such as prevention, screening, and treatment for STIs including HIV. Information on these issues is scarce and it is not directed at adolescents or youth, although they are among the most at-risk groups.
Angolan adolescents and youth also have several factors conducive to cervical cancer: early sexual debut,35 multiple partners, low condom use, early childbirth, and eventually high parity. Limited access to and availability of screening services for cervical cancer and STIs means that early detection is poor. As a result, cervical cancer cases are in advanced stages when detected, thereby increasing mortality rates.
Suggested Action Steps: The current circumstances in Angola are adverse for adolescents and youth, particularly for young girls. However, there is awareness among key stakeholders about the gap in AYRSH services and information, and increasing acknowledgement by MOH decision makers that this is a critical need that must be addressed. While young women bear most of the direct burden of the lack of AYSRH services and information, interventions need to also involve young men and other members of the community, including older men, parents, health workers, teachers, and community leaders.
The objectives of the set of proposed interventions below are to increase the availability of information about AYSRH and increase the utilization of AYSRH services as ways to prevent behaviors that are harmful to adolescents and youth, and to address some of the consequences of these behaviors. Behavior change communication (BCC) plays a major role in achieving this.
It’s important to address the needs of different cohorts of youth – adolescent girls, young men, very young adolescents (aged 10 to 14), engaged and married couples, and first-time parents – with tailored services that include counseling.36
Proposed Strategic Approaches 1. Establish youth-friendly FP and SRH services • Sensitize all health workers about the needs of adolescents and youth, and train them on appropriate ways of interacting with youth. Providers must also receive training on youth- friendly counseling skills. • Train providers who come in contact with adolescents and youth on the benefits of Healthy Timing and Spacing of Pregnancy (HTSP), and on the real contraindications and side effects of contraceptives. They must know that all modern contraceptive methods, aside from permanent methods, are appropriate options to meet the contraceptive need of adolescents. For adolescents under 18 years of age, all modern contraceptive methods are classified in one of two ways: “Category 1: may use the method under any circumstance” (e.g. combined and
35 Sexual debut at 11 or 12 years old is not uncommon 36 WHO definitions: Adolescents: 10-19 years of age; Youth: 15-24; Young people: 10-24.
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progestin-only orals, condoms, and implants); “Category 2: in general, may use the method” (e.g. progestin-only injectables, IUDs).37 • Train providers in youth-friendly postpartum and post-abortion FP, to meet the needs of the large number of adolescents and youth who are already becoming pregnant. • Integrate youth-friendly postpartum and post-abortion FP services into existing maternal and child health (MCH) services.
2. Foster positive community norms through BCC • Train teachers, community leaders, and others on comprehensive sexuality education, peer education, and group reflection and dialogue to help them raise adolescents’ awareness about the direct links between HTSP, particularly delaying the first pregnancy, and their opportunities for personal and professional development and health. Adolescents, particularly young girls, need to learn about their right to agency regarding their sexual behavior. While schools are a good venue to carry out many of these activities, mechanisms must be included to bring his information to those youth, especially girls, who are outside the education system. These activities must be linked with other programs that address education and economic empowerment. • Carry out BCC activities at the community level to increase awareness of youth-friendly FP and SRH services, and to promote their utilization. • Train peer educators to raise awareness among parents, young men, and older men about girls’ and young women’s rights, the importance of HTSP, and other related topics.
37 World Health Organization 2008. Medical Eligibility Criteria for Contraceptive Use. Geneva.
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Situational Analysis: Long-Acting and Permanent Methods of Family Planning in Angola
Prepared by: Marcos Arevalo, MD, MPH, MA - Chief of Party Carlos Laudari, MD, MPH - Sr. Technical Advisor for HIV Candace Lew, MD, MPH - Sr. Technical Advisor for Contraception
Submitted to USAID: 31 July 2014
Introduction As people move through different stages of their lives, their family planning (FP) needs change. This situational analysis examines the availability and use of different types of contraceptive methods in Angola and recommends actions to provide a broader contraceptive mix, including long-acting and permanent methods (LAPM), to more effectively meet the FP needs of women, men, and couples throughout their life cycle.
Long-acting, reversible contraceptive methods (LARC) provide protection from pregnancy for long periods of time with one single application. Methods such as hormonal contraceptive implants and intrauterine devices (IUD) can provide continuous protection from pregnancy for many years. If the woman wants to become pregnant, she can stop using the method and her fertility will resume.
Other methods such as tubal ligation and vasectomy provide permanent protection from pregnancy. A person only needs to undergo a one-time procedure to receive the method and is then protected from pregnancy for the rest of his/her life. Permanent methods are not intended or designed for individuals who desire to become pregnant again, and should be considered irreversible.
The above methods are in contrast with other methods such as male and female condoms, diaphragms, and spermicides, which only provide protection for a single act of intercourse; or pills, injectables, hormonal patches, and vaginal rings, which protect the user for a short period of time and are defined as short-acting methods.
See Annex 1 at the end of this chapter for additional information on specific LAPMs.
Advantages of LAPMs Long-acting and permanent methods have several important advantages over shorter-acting methods: • LAPMs provide protection from pregnancy - and therefore from the risk of maternal morbidity and mortality - for much longer periods of time (between three years and a lifetime). • Neither the user nor his/her partner need to do anything (which includes no interference with sex), which makes these methods easier to use and may make them more acceptable for some clients. • Frequent resupply visits are not necessary, as with short-acting methods. IUDs should be replaced every 10-12 years, and implants every 3-5 years (depending on the type of implant). • LAPMs are not visible, and there are no visible commodities; once the client is using a method, only he/she needs to know about it. This discretion can be particularly important in contexts where family members or other persons in the community may not approve of the use of FP methods. • LAPMs can be used by women and men of any age, including adolescents, and of any parity, including those who have not yet had a child. • LAPMs are the most cost-effective methods by couple-year of protection (CYP) provided. (See Table 1 below.) The total cost of FP services has many components, including labor, equipment, and infrastructure, which can vary from place to place. Another important element for consideration is the cost of the commodities. There are important differences in the cost from method to method. Commodities for LARCs are more cost-effective than those for short-acting methods. (See Table 1 below.)
Table 1. Relative Cost of Commodity-Based Methods Available in Angola
Method CYP per unit Commodity cost Cost per CYP per unit (commodity only) in US Dollars US Dollars IUD 4.6 years 0.63 0.14 Implant1 3.8 years 8.50 2.23 Male condom 1/120 year 0.031 3.72 Pills (combined) 1/15 year 0.27 4.05 Injectable (DMPA) 1/4 year 0.80 3.20 Female condom 1/120 year 0.55 66.00 Sources: USAID 2011 updated CYP conversion factors. USAID 2014 FP commodity price list. CYP (couple years of protection): refers to the duration of protection provided by one unit of the contraceptive.
• LAPMs are significantly more effective. The top four most effective methods are all LAPMs: implants, IUDs, tubal ligation, and vasectomy. Each method has an efficacy rate over 99%.2 (See Table 2 below.) The higher protection from pregnancy that LAPMs provide includes the following factors:
1. Some of their mechanisms of action are inherently more effective: e.g. surgically blocking the passage of sperm or ova is more effective than containing semen within a condom; likewise continuously suppressing ovulation and thickening cervical mucus is a highly effective approach. 2. Once a client receives an LAPM, he/she does not need to do anything to prevent pregnancy, so there is no chance of forgetting to use the method, losing it, being pressured to not use it, or using it incorrectly. 3. Continuation rates are higher,3 so LAPM users are protected from pregnancy for longer periods of time.
When individuals or couples decide to use contraception, their main goal is to postpone, space, or limit their pregnancies. Studies from other parts of the world show that the most frequent questions FP clients ask are about methods’ efficacy.4 However, in Angola, very few individuals or couples use the most effective methods due to a lack of access, knowledge, and availability of trained providers.
1 FP services in Angola offer Jadelle,™ effective for up to 5 years. 2 Hatcher et al. Contraceptive Technology 20th Ardent Media 2011. 3 Hatcher, ibid. 4 Grady WR et al. Contraceptive characteristics: the perceptions and priorities of men and women. Fam.Plan. Perspectives 1999;31:168-75.
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Table 2. Family Planning Use in Angola - Methods Ranked by Efficacy
Relative Efficacy of FP Methods FP use in Angola Method Efficacy rate Method CPR % of couples protected from % of women in union 12-49 years pregnancy in first year of typical use old using each method Implant 99.95% > 0.5% Vasectomy 99.85% 0 Tubal ligation 99.5% 0 IUD (copper T) 99.2% > 0.5% Depo-provera 94% 3.7% Pills 91% 3.2% Standard Days Method 88% n/a Male condom 82% 4.5% Female condom 79% n/a Traditional practices 76-78% 8.3% No method 15% 82% Source: based on Trussell, 2011 Sources: IBEP 2010, Angola Direção Nacional de Saúde Pública (DNSP) 2013
From Table 2, it is evident that LAPMs, which are the most effective methods, are the ones used least in Angola (e.g. male condoms are the most frequently used method in Angola, but a typical condom user is approximately 360 times more likely than an implant user to become pregnant). Even high-parity women predominantly reported their choice as “some traditional method,” and only 0.3% report use of “other modern methods.”5 Furthermore, of the 12.1% of adolescents 15 to 19 years old who use FP, the vast majority use short-acting methods and only 0.9% use a LARC.6
5 IBEP 2010. Inquerito Integrado sobre o Bem-Estar da Populacao. INE, Luanda. 6 IBEP 2010.
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Graph 1: Determinants of Method Effectiveness (Adapted from Steiner et al)7
When an individual or couple uses an FP method, they are protected from pregnancy. The degree of protection can be higher or lower depending on the intrinsic efficacy of the specific method. But the level of protection is also greatly influenced by clients’ compliance (or lack of) with correct method use (e.g. a client who loses her pills, fails to go for a refill, forgets to take them, etc. is more likely to experience an unwanted pregnancy than someone who takes her pill every single day and at the same time).
Because LAPMs are non-client-dependent (they function with no client intervention), the possibility of client error is almost non-existent, and the methods confer all the contraceptive protection intrinsic to their contraceptive technology. (See Graph 2 below.)
7 Steiner M, Dominik R, Trussel J, Hertz-Piccioto I. Measuring Contraceptive Effectiveness: A Conceptual Framework. Obstetrics and Gynecology 1996; Vol. 88, No. 3: 24S-30S.
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Graph 2: Difference in Efficacy between Client-Dependent and Non-Dependent Methods.
Disadvantages of LAPM • All LAPMs involve some type of procedure, performed by a health worker, to start and stop method use; clients can’t stop using the methods on their own. • All LAPMs require providers with specialized skills and some surgical instruments, as well as infection prevention practices. Tubal ligation requires a surgical setting. • Compared to shorter-acting methods, LAPMs require a higher initial investment of resources (the total cost of the commodity has to be paid up front) and time (the insertion or surgical procedure requires more time than the initial visit for a short-acting method). • Tubal ligation and vasectomy should be considered permanent and not reversible. • LAPMs do not protect the user from sexually transmitted infections (STIs), including HIV.8
Programmatic Status of LAPMs in Angola There is an imbalance in method use in Angola: of the 12.8% of women in union who use a modern method, most use the least effective methods (“traditional practices,” male condoms) and less than 1% use a highly effective, LAPM method. (See Table 2 above for method-specific numbers.)
Most health workers in Angola do not have the updated knowledge or the skills necessary to provide quality information and individual client counseling on LAPMs. Although LARC commodities (IUDs, implants) are available at service delivery points (SDPs) where FP is provided, not all of these SDPs have all of the necessary equipment to provide the services.
Tubal ligation and vasectomy are not available anywhere in the country as an FP service. There are some physicians – mostly from large hospitals in the capital city – who reportedly have the surgical skills to perform tubal ligation. But these methods are not included in the information given to FP clients, even
8 Any client who considers him/herself at risk of an STI, including HIV, should use dual protection: an effective method for protection from pregnancy and condoms for protection from STI/HIV infection.
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in these higher-level facilities, and mechanisms are not in place to provide the services. Other SDPs lack the skilled staff and equipment.
A number of providers have received training on insertion of IUDs at some point in the past, but few of them have been updated. The method is not necessarily offered to clients interested in FP. Some providers and program managers state that clients and/or their partners are not interested in the method. All this is reflected in the very low use of the method (less than 0.5% of women in union, with an average of fewer than 100 IUDs inserted per month during 2012 and 2013).9
Starting in 2012, providers from 42 sites in two provinces (22 in Luanda and 20 in Huambo) were trained in how to provide implant services. The training included how to counsel clients and insertion and removal techniques. Demand for the implants has been strong: more than 3,400 clients received implants in the last four months of 2012 and over 9,500 in 2013. Implant services became available in other provinces following a subsequent round of training activities. In 2014, implant services are available in additional health facilities throughout the 18 provinces of the country.
Analysis The current method mix offered in Angola is heavily weighted towards shorter-acting methods, and does not meet the needs of all existing and potential users throughout the different stages in their life cycle, particularly individuals and couples who want a highly effective method, want to space their pregnancies by several years, or who already have the number of children they desire.
Broadening the method mix by scaling up LARC and introducing permanent methods would be a significant improvement in the quality of FP services, consistent with the National Sexual and Reproductive Health Strategy (ENSSR, 2008) which states than Angolans should not be at risk of unwanted pregnancy, and the draft National Family Planning Strategy (2014). Current users of shorter- acting methods who switch to LAPMs would have a lower risk of pregnancy. (By definition, a pregnancy occurring to an FP user is an unintended one.)
Recent experiences, including the introduction of implants, which were adopted by almost 13,000 women in less than 18 months, suggest that there is a significant but latent demand for FP, including LARC, in Angola. In 2011, after several years of frequent and widespread stock outs, contraceptives became fully available in 27 clinics in the periphery of Luanda. Uptake of FP increased almost immediately, particularly for IUDs, which increased by 250% within a few months. This happened despite there being no specific demand-generation activities.
Overall use of FP is growing, at least in Luanda. A comparison between figures from 2008 (IBEP) and 2012 (TRaC study) shows significant increases in overall modern method contraceptive prevalence rate (CPR) in Luanda province (from 24% to 59%). This includes significant numbers of implant and IUD users, despite the known weaknesses on the supply side.
Approaches to Increase Availability and Use of LAPMs Recommended strategies to increase availability and improve quality of LAPM services include the following approaches:
9 Service statistics from DNSP MIS.
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• Revise protocols for FP services to include all modern FP methods, including LAPMs, and make information on all methods and one-on-one client counseling a standard component of services provided to all FP clients. • Develop quality assurance standards and incorporate them into supervision checklists and other tools. • Carry out large-scale capacity building re: IUDs (e.g. so that all 403 facilities in the country that currently offer FP10 have at least one trained health worker who can provide quality IUD services). Training should include client counseling and should be complemented by follow-up support to facilitate actual implementation of services by trained providers. This scaling-up should be accompanied by demand-generation activities. • Ensure that all facilities that offer FP have the necessary equipment to provide IUDs; this includes the instruments (speculums, histerometers, forceps, tenaculums) and equipment to disinfect and sterilize these instruments. • Strengthen the supervision system to ensure that IUD services are of high-quality and that information provided to clients is accurate and complete, and includes the IUD’s safety, effectiveness, and convenience. • Provide refresher courses, additional follow-up support, and mentoring to sites where the second round of training in implants took place to help providers actually offer the method and to reinforce initial training. Ensure that these sites have the necessary equipment to insert and remove implants. • Strengthen the management information system (MIS) to ensure that SDPs report the number of FP clients served, by specific method, accurately and in a timely manner, and to strengthen the logistics system nationwide. These two improvements combined will facilitate the timely provision of commodities to the SDPs and ensure their availability even if demand increases sharply. • Ensure a sustainable source of funding to purchase FP contraceptive commodities. • Start tubal ligation and vasectomy services in a small number (even as few as one or two) demonstration sites, offering these permanent methods as part of regular FP services. These sites can be located in main hospitals where the surgical setting and equipment already exist and where there already are skilled personnel to support the services. This location will allow for careful supervision and documentation. High-quality information and individual counseling must be an integral part of these services.
Opportunities • The draft National FP Strategy asks for making a broad menu of methods available to clients; this is also consistent with the ENSSR, which calls for increasing availability and use of quality FP services to avoid unwanted pregnancies and reduce maternal morbidity and mortality. It is also consistent with the National Health Development Plan (PNDS, 2013) which calls for reductions in maternal morbidity and mortality. • Recent data suggests that overall use of FP is increasing (see above). This trend can provide momentum to scale up LARC and introduce permanent methods. • Recent experiences suggest that there is a latent demand for LAPMs (see the above descriptions of experiences with IUDs and implants). • Recent evidence that there is some demand for permanent methods: the 2013 TRaC Study11 found that 0.6% of women aged 15 to 49 in Luanda have been sterilized. The survey did not ask why they had been sterilized or if they had received the tubal ligation service in Angola or abroad. Additionally, 0.8% of those with unmet need declare that tubal ligation is their preferred FP option.
10 Source: Reports from the 18 provincial directorates of health, 2014. 11 TRAC study PSI 2013.
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Challenges • The belief held by many providers and even program managers that Angolan men and women are not interested in permanent contraception or even in long-acting methods. • Even if there is latent demand for permanent contraception, initial numbers of clients could be small. Program managers would need to be convinced that demand could eventually grow. • Large numbers of staff at multiple levels, including clinicians and FP counselors, need to be trained or updated in LAPM information and skills. They then have to be supported and supervised to ensure they provide quality LAPM services. • As part of the above training, health workers, supervisors, and program managers need to be trained in how to provide quality information and individual client counseling, which currently are not necessarily standard components of FP services. This need can be framed as an opportunity to improve FP services in general; nevertheless, the need for training has to be addressed and resources have to be allocated to it. • SDPs must be furnished with the equipment necessary to provide LAPMs.
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Annex 1.
Key Facts about Specific Long-Acting and Permanent Methods
The World Health Organization (WHO) has developed an easy-to- use Medical Eligibility Criteria for Contraceptive Use (MEC guide) which can be used when determining if women with certain medical conditions can use certain methods. LAPMs do not protect against sexually transmitted infections (STIs), including HIV.
Intrauterine Device (IUD) The IUD is a small object, made of flexible plastic, in the general shape of a letter “T.” It is inserted by a health worker into the uterus and provides protection from pregnancy while it is in place. Once the IUD is in place, the user does not have to do anything to be protected from pregnancy. There are two types of IUDs: those with copper (“copper T”) and newer ones with a progestin hormone (levonorgestrel). The combined effect of the plastic and the medication (copper or the hormone) causes temporary changes in the interior lining of the uterus (endometrium), which make the intrauterine environment hostile to sperm and ova, and prevent fertilization.12 There is ample evidence that IUDs act in the early stage of the reproductive process,13 before fertilization.14
The copper IUD can provide protection for 12 or more years;15 the manufacturer certifies it for 10 years, and there are reports of safe use for up to 20 years.16 The hormonal IUD provides protection for at least 5 years.17
The IUD is one of the most effective methods that exist: under typical-use circumstances, 99.2% of copper IUD users and 99.8% of hormone IUDs will not become pregnant during the first year of use.18
The IUD is one of the safest methods available19 and can be used by almost any woman, including adolescents20 and women who have never been pregnant.21 In addition, it can be used postpartum if inserted during the first 48 hours postpartum or after the first month postpartum. There are very few contraindications for its use (e.g. current genital cancer, active genital infection, untreated AIDS, very high individual risk for some sexually-transmitted infections [STIs]).22
IUDs are by far the most commonly used reversible method in the world.23
12 Ortiz ME, Croxatto H, Bardin CW. Mechanisms of action of intrauterine devices. Obstet Gynecol Surv. 1996; 51 (12 Suppl) S42- 51. 13 WHO 1987. Mechanism of Action, safety and efficacy of intrauterine devices: technical report series. Geneva. 14 Rivera R, Yacobson I, Grimes D. The mechanism of action of hormonal contraceptives and intrauterine devices. Am J Obstet Gynecol 1999; 181:1263-1269. 15 WHO. Family Planning. A Global Handbook for Providers. WHO 2007. 16 WHO Special Programme for Research Development and Research Training in Human Reproduction. Long-term reversible contraception. Twelve years of experience with the TCu380A and TCu220. Contraception.1997; 56:341-352. 17 WHO. Family Planning. A Global Handbook for Providers. WHO 2007. 18 Hatcher et al. Contraceptive Technology 20th Ardent Media 2011. 19 WHO. Family Planning. A Global Handbook for Providers. WHO 2007. 20 American College of Obstetrics and Gynecology committee opinion No. 450. Obstet Gynecol. 2009; 114:1434-8 21 World Health Organization. Medical Eligibility Criteria for Contraceptive Use 4th Ed. WHO 2009. 22 WHO. Family Planning. A Global Handbook for Providers. WHO 2007. 23 Population Reference Bureau 2002. Family Planning Worldwide Data Sheet.
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Hormonal Implant Implants are small plastic rods (about the size of a matchstick) impregnated with a progestin hormone. They are designed to be inserted just under the skin (usually on the internal side of the upper arm), and provide protection from pregnancy for three to five years, depending on the type of implant.24 Once the implant is in place, the user does not need to do anything to be protected from pregnancy. Fertility returns within weeks of implant removal.25 It is considered very safe; the hormones it contains are not associated with clinically important changes in metabolism.26 It can be used by almost all women regardless of age; it is safe for use by adolescents,27 women who have not had children, and women who are breastfeeding (use can start at 6 weeks post-partum28).
The hormone works by suppressing ovulation,29 thickening the cervical mucus, and impeding the passage of sperm into the uterus.30
Hormonal implants are among the most effective contraceptive methods available: under typical-use circumstances, 99.95% of implant users will not become pregnant during the first year of use.31
Tubal Ligation Tubal ligation (also called tubal occlusion or female sterilization) is a surgical procedure to permanently impede fertilization of the egg. A specially trained health worker accesses the Fallopian tubes through a small incision in the abdominal wall and performs a small surgical procedure to block them. This is usually done by cutting and/or tying each tube, or placing a special elastic ring over a small loop of the tube. The result is permanent interruption and/or scarring of the tube; sperm cannot go through it and thus cannot fertilize the egg.
The client usually receives mild sedation and local anesthesia on the organs involved. The entire procedure lasts a few minutes. Tubal ligation is considered very safe and serious complications are rare. Clients can usually walk on their own within two or three hours and can return to normal activity within two or three days. Tubal ligation can be performed in the first 24 hours postpartum or at any moment after the sixth week postpartum.
Vasectomy Vasectomy is a minor surgical procedure to permanently impede sperm from being present in semen. A specially trained health worker accesses the vas deferens (the thin tubes that normally carry sperm from the testicles) through a small incision in the scrotum. The vas are usually cut and tied. The result is permanent interruption and scarring of the vas; sperm cannot go through the blocked tubes. The man’s semen will then have no sperm, so it cannot fertilize the egg.
24 WHO. Family Planning. A Global Handbook for Providers. WHO 2007. 25 Davies GC et al. Release characteristics, ovarian activity and menstrual bleeding pattern with a single contraceptive implant releasing 3-ketodesogestrel. Contraception.1993;47:251-6. 26 Blumenthal PD et al. Tolerability and clinical safety of Implanon. Eur J Contracept Reprod Health Care. 2008;13 Suppl 1:29-36. 27 WHO. Family Planning. A Global Handbook for Providers. WHO 2007. 28 WHO. Family Planning. A Global Handbook for Providers. WHO 2007. 29 Makareinen L et al. Ovarian function during the use of a single contraceptive implant. Fertil Steril 1998;69:714-21. 30 Van den Bosch T et al. Ultrasonographic features of the endometrium and the ovaries in women on the etonorgestrel implant. Ultrasound Obstet Gynecol. 2002;20:377-80. 31 Hatcher et al. Contraceptive Technology 20th Ardent Media 2011.
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The procedure is done with local anesthesia and lasts a few minutes. Clients can move around after about one hour and are instructed to rest at home for one or two days. Vasectomy is very safe, and serious complications are very rare. Vasectomy does not affect libido or sexual performance.
After a vasectomy, the man needs to use another contraceptive method for three months to allow for all sperm still remaining in his distal vas and urethra to be flushed out.
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Situational Analysis: Improving the Quality of Family Planning Services in Angola
Prepared by: Marcos Arevalo, MD, MPH, MA - Chief of Party Carlos Laudari, MD, MPH - Sr. Technical Advisor for HIV Candace Lew, MD, MPH - Technical Advisor for Contraception
Submitted to USAID: 31 July 2014
Introduction There is a global effort underway to provide voluntary family planning (FP) information, services, and commodities that allow individuals and couples to choose whether, when, and how many children to have.1, 2 All clients – women, men, adolescents, and youth – have the right to quality SRH care, including the right to make an informed choice from a broad mix of modern family planning methods.3
It is critical that FP service delivery programs provide services of a certain level of quality in order to meet their goals of helping individuals achieve their reproductive intentions. If FP services are accessible and have an acceptable level of quality, clients will be more likely to use them. This document outlines key elements of quality of care in FP programming and provides practical, context-appropriate recommendations to improve the overall quality of FP services in Angola.
The Angolan government is committed to undertake efforts to reduce the current rates of maternal and neonatal morbidity and mortality in the country. Ensuring that quality, comprehensive FP services are available to all individuals and couples who want to use them - particularly those at higher risk (adolescents, older women, high parity women, and women who have recently given birth) - is an effective and cost-effective approach to achieve this goal of reduction in maternal, neonatal, and infant mortality rates.4 Access to quality FP services can also reduce mortality due to complications from abortion, which account for up to 13% of maternal mortality in developing countries.5
The quality of FP services is a key element to both sides of the supply-demand equation: • Quality FP services are those that provide clients with easy access to a wide method mix of methods appropriate to their needs at different stages in their lifecycle including comprehensive, correct, and easy-to-understand information on how to use these methods. • When clients are satisfied with the quality of the care they receive, they are more likely to return to FP service delivery points (SDPs) and continue using their chosen method. Furthermore, as satisfied FP users, they often act as positive role models for others in the community.
Angola’s Commitments to Reduction of Maternal, Newborn, and Child Morbidity and Mortality Angola’s 2008 National Sexual and Reproductive Health Strategy (ENSSR – Estratégia Nacional de Saúde Sexual e Reprodutiva) recognizes that the Healthy Timing and Spacing of Pregnancy (HTSP) approach can
1 Standards of Quality in Service Delivery and Programing. Pathfinder International, 2012. 2 Choices not Chance. UNFPA Family Planning Strategy. UNFPA, 2012. 3 UNFPA, ibid. 4 Stover J, Ross J. How Increased Contraceptive use has Reduced Maternal Mortality. Maternal and Child Health Journal Vol. 14 No. 15 687-695, 2010. 5 Okonufua F. Abortion and Maternal Mortality in the Developing World. MCH Journal, Vol. 14 No.15, 687-695, 2006. be an effective strategy to reducing maternal morbidity and mortality by providing couples and individuals with access to quality FP services to delay and space pregnancies. This is particularly relevant in Angola as very few female non-users of FP want to become pregnant (6.5 – 12.7% of adult non-users, 2.4% of adolescent non-users).6
The ENSSR includes among its specific objectives and areas of intervention:
• Integrate sexual and reproductive health (SRH) services within the primary health care services. • Increase access to these integrated SRH services, including FP and prevention of HIV and AIDS. • Increase the availability, access, and utilization of SRH services by adolescents and youth. • Prevent unwanted pregnancies, mainly through the provision of FP services.
The 2012-2015 National Health Development Plan (PNDS – Plano Nacional de Desenvolvimento Sanitário) reiterates the commitments made in the ENSSR, including among its targets:
• To increase the availability of FP services and counseling. • To increase the utilization of modern contraceptives.
Angola is making impressive improvements in the access to FP services: the number of SDPs where FP services are available has increased by almost 50%: from 270 in 2012, to 403 in 2014.7 This must now be complemented by improvements in the quality of the FP services offered, consistent with the 2014 draft National Family Planning Strategy which includes actions to improve the quality of FP services in the country.
Elements of Quality of Care Many institutions and individuals working in FP follow a common standard FP quality framework (sometimes called “Bruce framework”) which has been used by numerous service delivery programs to develop their own quality standards.8 This framework has six elements which are considered the basic characteristics of quality FP services. These elements are:
1. Choice of FP methods; 2. Technical competence of providers; 3. Information and individual counseling for clients; 4. Interpersonal relations; 5. Mechanisms to ensure continued use; and 6. Appropriateness and acceptability of services.
These six elements are interrelated, and there is some overlap between them. They are all necessary for the total quality of an FP program. Thus, even excellence in one element is not sufficient for overall quality if other elements are missing. Internationally-accepted sources of information on quality FP services that take these elements into account include the original Bruce framework,9 WHO’s “FP, a
6 National Population and Health Survey/Inquérito Integrado sobre o Bem-Estar da População). IBEP, 2010. 7 DSNSP data, April 2014. 8 Organizations which developed and/or use tools which incorporate the elements in the framework include the International Planned Parenthood Federation/IPPF, The Population Council, USAID, UNFPA, and many governments and NGOs throughout the world. 9 Bruce, J. Fundamental Elements of the Quality of care: A Simple Framework. Studies in Family Planning, Vol. 21, No. 2:61-91, 1990.
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Global Handbook for Providers,”10 Pathfinder International’s “Standards of Quality in Service Delivery and Programming,”11 and the USAID-WHO-UNFPA “Training Resource Package for FP.”12
Choice of FP Methods Clients have different FP needs, depending on their personal characteristics, lifestyle, and where they are in their lifecycle. No single method can meet the needs of the majority of the population. All people have the right to choose their FP method. Clients who receive their preferred method that better meets their needs and suits their lifestyle are more likely to use it correctly, consistently, and for a longer time, thus increasing their protection from pregnancy.13 This makes it critical for services to offer the widest possible diversity of methods to meet the needs and personal preferences of as many clients as possible. This includes offering short- and long-acting methods for clients who want to space their pregnancies, as well as permanent methods for those clients who already have the number of children they want. An important consideration is that long-acting methods are significantly more effective for pregnancy prevention than short-acting ones.14 When a particular method is not available in a specific location (e.g. permanent methods not available in lower-level SDPs), clients should be referred to another SDP to receive their desired method.
As people reach their desired number of children, they should be able to select and use a permanent method, which may meet their needs better than a temporary one. Given some of the intrinsic characteristics of permanent methods (e.g. they require surgery), it may be better to offer them in a limited number of higher-level facilities where setting up services is simpler because infrastructure, equipment, and surgically trained staff are already available, and quality can be monitored closely.
Adolescents and youth have the right to receive modern contraceptives as well as the information they need and desire to make healthy, informed decisions regarding contraception. According to the WHO Medical Eligibility Criteria,15 all reversible methods are appropriate for use by adolescents as young as 15, as these methods are classified in one of two ways: “Category 1: may use the methods under any circumstance” (e.g. condoms, combined pills); “Category 2: in general, may use the method” (e.g. IUD, progestin-only pills, injectables, and implants). Importantly, policy makers and those who will prepare technical norms must take into account the enormous cost of not using any contraception, in terms of health risks associated with adolescent pregnancies, and in terms of lost opportunities to pursue an education or other avenues of professional development.
Activities to offer a broad menu of FP methods include: • Update service delivery norms to explicitly include all modern methods, including long-acting and permanent methods (LAPM).16 The norms need to address task sharing to allow a larger number of health workers with appropriate training and skills to provide a broader array of methods.17 • Continue expanding the availability of FP services in general, including provision of long-acting, reversible contraceptive methods (LARC).
10FP, a Global Handbook for Providers. WHO, USAID, Johns Hopkins Bloomberg School of Public Health, 2011. 11 Standards of Quality in Service Delivery and Programming. Pathfinder International, 2012. 12 Training Resource Package for FP. USAID-WHO-UNFPA, Pathfinder international, 2012. 13 Hatcher R. et al. Contraceptive Technology 20th Edition. Ardent Media, 2011. ibid. 14 Hatcher, ibid. 15 Medical Eligibility Criteria for Contraceptive Use. World Health Organization, 2009. 16 It’s important that the norms mention dual protection: use of condoms for prevention from STIs including HIV, in addition to a more effective method for protection from pregnancy (Pathfinder 2012). 17 Task shifting. Global Recommendations and Guidelines. World health Organization, 2008.
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• Add permanent methods (tubal ligation, vasectomy) to the methods available in the country. • Ensure that all SDPs offer short-acting and long-acting methods, either on-site or by referral. • Build the capacity of health workers on technical aspects of all FP methods available in the country.18 • Sensitize providers about clients’ right to receive their method of choice if they meet eligibility requirements. • Sensitize providers to change their attitudes about certain methods (e.g., IUDs) that currently are not offered effectively, and certain populations (e.g., adolescents) who are currently underserved. • Make necessary equipment available at additional locations to facilitate the provision of certain methods (e.g. equipment to provide IUDs, such as speculums, hysterometers, equipment to sterilize instruments, gynecological tables). • Strengthen the supply chain management system (“logistics”) to avoid stock outs of contraceptive commodities at the SDPs. Managers need to take into account the planned increase in number of SDPs that will provide FP, and in the possibility that the demand for contraceptives will increase. • Establish a referral and counter-referral network with two-way communications and client-friendly mechanisms to refer clients if their preferred method is not available at a particular SDP.
Technical Competence of Providers Qualified personnel at all levels (including provincial hospitals, national and municipal maternities, health centers, and health posts) and for all functions ensure quality services. Of particular importance are workers who directly provide services to clients. The workers must have the knowledge and skills to:
• Provide correct and complete counseling and information to clients about the methods and the services, and answer clients’ questions. This can be initiated in group sessions and completed in individual counseling sessions. • Help clients choose a method that meets their needs and is medically appropriate for them. • Correctly prescribe any commodity the client will need. • Perform, with technical competence, procedures for the provision of methods such as IUDS, implants, tubal ligation, and vasectomy when these become available.
Activities to build the capacity of health workers include: • Merge ongoing capacity building activities into a managerially discrete unit, led and staffed by a team of skilled staff dedicated full time to capacity building activities. This team will be responsible for other activities listed below. • Conduct an assessment to determine the capacity building needs of health workers throughout the country. When planning training activities, managers must take into account that the existing deficit of skilled workers may be more evident as more SDPs start offering FP services, some methods (IUDs, implants, injectables) become more widely available, and additional methods (tubal ligation, vasectomy) are added to the method mix.19 • Develop or adapt training curricula; use existing, evidence-based local resources such as the FP Training of Trainers Manual (2011, Manual de Formação de Formadores em Planeamento Familiar) and the FP Pocket Guide for Health Workers (2013, Guia de Bolso de Planeamento Familiar para Trabalhadores de Saúde).
18 Modern methods effectively available in Angola include male and female condoms, combined and progestin-only pills, progestin-only injectables, IUDs, and implants. 19 Task shifting. Global Recommendations and Guidelines. World health Organization, 2008.
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• Establish standard procedures and mechanisms to ensure that training activities are comprehensive and competency-based with some type of certification. • Develop training plans and schedules for training activities. • Train selected professionals in different geographical locations with the goal of developing them into local training resources (training of trainers). • Follow up with these trained professionals, providing them continued mentoring to ensure they master the skills and knowledge necessary to perform as trainers. • Once these new trainers are accredited, support them to ensure they have the resources and start training activities, and monitor their performance (a supported and supervised training cascade). • Establish a quality assessment program, with comprehensive protocols and tools; technical competence of providers needs to be as a standard item in checklists and other supervision tools.
Some contraceptive methods (e.g. condoms, pills, injectables) are easy to provide, and lower-level personnel such as auxiliary nurses, health technicians, or community-based personnel can be trained in a relatively short time so they have the knowledge and skills to provide good information and the actual services to clients. LARC methods (IUDs, implants) and injectables can be provided by auxiliary nurses or similar personnel who have received appropriate training. This task shifting/sharing would allow for greatly expanding the number of health workers who can provide FP, while at the same time freeing scarce nurses and physicians for other, more complex tasks.
Mobile technology can be a valuable tool to support capacity building,20 including: • Sharing general technical updates with health workers in general and more specialized information with those who work in specific technical areas. • Sending additional information as part of follow-up support to health workers who have participated in training workshops or other capacity building activities.
Information and Individual Counseling for Clients Counseling should include providing and discussing with the client information on HTSP and on all the methods appropriate for that individual client, including dual method use.
The goal of individual counseling is that each client receives and understands the key information to: • Choose a method that meets her/his needs and suits her/his preferences. • Use the method correctly. • Know when and how to obtain any necessary resupplies. • Cope with the most frequent side effects or know when to return to the SDP if necessary.
Information provided in a context and manner that facilitates two-way communication between the client and the health worker is most effective. Individual counseling, with opportunities for the client to ask questions and express doubts, and for the provider to verify the client’s understanding, is a good way to achieve this type of two-way communication. Providing this type of counseling is not difficult, but it requires specific skills that providers can learn through training and practice.
Providing clients with correct and appropriate information can have many benefits for clients, for providers, and for the program as a whole:21
20Introducing mHealth to Reduce Maternal Mortality among Adolescents. Pathfinder International, 2013. 21 Hatcher, ibid.
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• Clients who are well-informed about the characteristics of the methods available are better able to choose a method that meets their needs and suits their preferences and lifestyles, and these clients are more likely to become satisfied users. • Clients who choose a method appropriate for them are less likely to experience side effects (e.g. a client with a history of excessive or painful menstrual bleeding would not select a copper IUD, thus avoiding exacerbation of her problem). • Clients who have accurate and complete information on how to use their method are more likely to use it correctly, thus increasing the efficacy of the method and experiencing fewer side effects. • Even in the cases when side effects do appear, clients with good information may be better able to manage these side effects, know if they need to return to the clinic, or cope with a side effect in the understanding that it is a normal side effect of the method and not a sign of a major complication.
Throughout the world, including Angola, side effects are the most frequent reason mentioned by clients for discontinuing use of a method.22 Thus, helping clients avoid, manage, or cope with side effects is a critically important component of quality services.
Steps to improve information and counseling: • Integrate information on HTSP and FP methods into antenatal care (ANC), postnatal care, child health, vaccination, post-abortion care, HIV, and other information and services. • Update national service delivery norms to specify that all FP clients must receive information on all appropriate modern methods, that no method should be promoted or restricted unnecessarily, and that all clients receive individual counseling. Disseminate the revised norms to providers in all 18 provinces. • Develop or adapt evidence-based information and counseling protocols and tools, and include them in training curricula and activities. • As part of all FP capacity building activities, train health workers in counseling techniques. • Sensitize health workers to the importance of individual counseling. • Include individual counseling as an item on supervision checklists and other tools.
Interpersonal Relations In order for FP clients to return to the SDP and become continuing FP users, their initial experience with the services must be satisfactory. If clients perceive that they have been treated discourteously, they will not return, regardless of how much other areas of service quality improve. Dissatisfied clients may even discourage others from going to a particular SDP. This can be particularly problematic for adolescents, who must not be treated dismissively and denied FP services on the grounds that they are too young to be sexually active.
Key components of interpersonal relations include: • Being respectful of clients and their cultural values, without any biases regarding the clients’ age, socioeconomic status, or educational level. • Being respectful of clients’ modesty and need for privacy. • Giving clients the opportunity to ask questions.
Achieving and maintaining appropriate interpersonal relations is an issue best addressed through sensitization of health workers, as part of training activities and ongoing supportive supervision.
22 IBEP. Inquérito Integrado sobre o Bem-Estar da População. INE, Luanda.
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Mechanisms to Foster Continued Use When an FP client becomes a continuous user, they remain protected from an unintended pregnancy and from the risk of maternal morbidity and mortality.
Suggested Action Steps: • Update service delivery protocols to include follow-up schedules that are not unnecessarily burdensome for clients or health workers. • Give clients enough supplies for several months of use instead of requiring them to return frequently for supplies; issues of client compliance with correct use of the method and dealing with possible side effects are better addressed by providing good counseling. • Give clients clear information about their resupply and/or their follow-up schedule and location. • Set up mechanisms so that in rural areas at least some of the resupply and follow-up can be done by community-based agents close to the clients’ home.
Appropriateness and Acceptability of Services This is a broad area that includes location and physical conditions of SDPs, schedules, arrangements for privacy, levels of staffing, and other considerations. Facilities should be located in accessible locations and meet a minimum standard of appropriateness and cleanliness. Physical arrangements should be done to ensure clients’ privacy, both for counseling (clients should be confident that they cannot be overheard) and for any physical examination or procedure that may take place.
Clients’ time should be respected. This can be accomplished by offering services within a client-friendly schedule (e.g., not limiting services to the morning), reducing waiting time as much as possible, and trying to provide services in clients’ initial visit. The number of staff available at a facility may be a limiting factor when trying to provide services faster, but program managers and providers themselves can also contribute by reducing staff absenteeism.
Services should be designed taking into account the context, preferences, and specific characteristics of specific populations (such as adolescents and youth) that are being targeted. Examples of this youth- friendliness may include special schedules more appropriate for those attending school, having staff trained specifically to provide information and services in ways that resonate with adolescents, decorating and furnishing facilities or spaces to make them attractive for adolescents, and using youth- friendly materials.
Suggested Action Steps: Improving overall quality of FP services will require significant and sustained efforts. Below are concrete initial steps that will have major impact on quality of the services and also provide a strong platform for further improvements: • Update service delivery norms to include all six core elements of quality for FP programming. • Sensitize health workers and managers on the importance of quality of services. • Expand the menu of methods available to include LARC, and make them available at all appropriate SDPs throughout the country. • Train health workers to equip them with the comprehensive skills and knowledge to provide evidence-based information, counseling, and services. • When developing a monitoring and evaluation system for FP, include indicators related to the core elements of quality.
Pathfinder International: October 31, 2014 – page 42