Program managers face a number of issues specific to
injectables. These include:
Setting Up Services
Introducing a new contraceptive and expanding services are
formidable tasks. Programs need to train providers, deliver
supplies to clinics and other outlets, and start communication
campaigns. Training and communication each can take 18 months or
more to set up. Getting injectables and other contraceptives to
clinics can take six months to a year or more from the time that
they are ordered. Realistic estimates of the time required to
prepare each component are essential for a well-coordinated
introduction (311).
Many programs conduct pilot studies or operations research
to gauge potential users' response to injectables. In Ecuador
operations research is assessing users' attitudes toward DMPA
compared with other methods, the characteristics of users, and
the effectiveness and cost-effectiveness of clinic and
community-based distribution (254). In Peru operations research
is studying community-based distribution of DMPA and users'
responses to menstrual disruption. In one part of the study,
mystery clients—program staff posing as DMPA users—visited 26
community health workers and evaluated their knowledge of DMPA
and their counseling skills. They found that about three-quarters
offered a choice of methods including DMPA, but only about
one-quarter gave users enough information about side effects
(181, 255). WHO conducted introductory trials of Cyclofem in
national family planning programs in Indonesia, Jamaica, Mexico,
Thailand, and Tunisia. Such trials, a transition between clinical
trials and full-scale introduction, allow program managers to
assess the effectiveness and popularity of a new method and its
impact on overall service delivery (110, 288). Other initiatives
need not wait for the results of such pilot studies. Work on
postpartum programs or social marketing programs can start at the
same time.
Pilot programs are especially important where injectables
are little known or have been controversial. In Turkey, for
example, where few women have used injectables, the Ministry of
Health introduced DMPA in a one-year pilot study in 15 urban
clinics to assess clients' reactions (352). Communication
programs await the completion of the pilot study. In the
Philippines injectables were available in the private sector but
were controversial because of religious opposition and lack of
approval of DMPA in the US. After the US FDA approved DMPA, the
Philippines Department of Health began to offer DMPA in 1994
through government clinics in six provinces and four cities,
where about 15% of the population lives (51). Introductory
programs generally offer only one type of injectable.
The private sector is helping to introduce injectables in
some government family planning programs. In Ecuador, for
example, the Centro Médico de Orientación y Planificación Familiar
(CEMOPLAF), a private nonprofit family planning organization, is
conducting the introductory study (255). The social marketing
project in the Philippines added DMPA to its line of
contraceptives, sold under the brand name Couples' Choice, and is
sharing the lessons of its experience with the Department of
Health (210).
