Mobile clinics. In Thailand and Jamaica mobile clinics provide DMPA along with other family planning methods (12, 48). The McCormick Family Planning Program, directed by Edwin B. McDaniel, the head of Obstetrics and Gynecology at McCormick Christian Hospital, set up the first and best-known mobile clinic in 1969 in Chiang Mai and Lumpoon provinces in northern Thailand. The Planned Parenthood Association of Thailand has run the program since 1986. A team consisting of a doctor, nurses, midwives, and paramedical workers provides DMPA, OCs, condoms, STD treatment, Pap smears, and other health services to 45 rural towns in the two provinces. Hundreds of women may come to a town for family planning services, some walking for a day or more, and towns often set up markets on the day that the clinic is scheduled (97).

CBD programs. In Bangladesh CBD workers in government or private family planning programs offer injectables in about 20 of the 490 thanas in the country (263). The International Center for Diarrhoeal Disease Research, Bangladesh (ICDDR,B), was the first to offer injectables in a CBD program, the Family Planning-Health Services Project in Matlab thana. In 1993 the government began offering injectables through CBD programs in eight additional thanas.

Contraceptive social marketing programs. Of the approximately 50 social marketing programs throughout the developing world, 10 carry injectables: programs in Egypt, El Salvador, Indonesia, Jamaica, Jordan, Kazakhstan, Nepal, Peru, the Philippines, and Sri Lanka (18, 68, 90, 210). The Blue Circle project in Indonesia sells by far the most injectables, almost 2 million doses of DMPA in 1993, for example. The program in Peru, the second largest, sold almost 65,000 doses in 1993 (68). In Latin America particularly, injections are given in pharmacies (179). In contrast, in Indonesia doctors and midwives usually give the injections.

Issues posed by nonclinical distribution of injectables, particularly in CBD and social marketing programs, include:

Giving injections safely and appropriately. Training and supervision can help CBD workers and pharmacy staff to give injections safely. The experience of the Matlab project is reassuring about CBD workers' skills: Infections after injections have been rare, only about 3 per 10,000 injections (5). By comparison, in a study in West Africa 23 per 10,000 people had infections from the various injections that they received each year (344). Social marketing programs in Nepal and the Philippines distribute kits to help pharmacy staff give injections safely. Each kit contains a vial of DMPA, a disposable needle and syringe, and an appointment card (90, 252). In the Contraceptive Retail Sales (CRS) project in Nepal, a nurse or doctor visits pharmacies and medical shops regularly to observe injections and ensure that enough alcohol and soap are available to give injections safely (18). Some pharmacists may give injectables inappropriately to women who seek an abortifacient (172). Injectable contraceptives cannot induce abortion. Training programs must emphasize that injectables should be given only for contraception and for no other reason.

Maintaining the injection schedule. Staff in mobile clinics and CBD programs are responsible for returning to the user on time. In Thailand the Chiang Mai-Lumpoon mobile clinic keeps a strict schedule. In 1987 the program reported having made almost 3,000 visits over 18 years without missing a scheduled stop (12). In Nepal injectionists must post and keep to a schedule (18).

Maintaining the injection schedule in a CBD project in Bangladesh required more frequent visits and more CBD workers than expected. Managers had thought that one visit every three months would be enough to administer DMPA. As more women chose DMPA, however, workers needed to return to each village once a month to provide injections on time. The government of Bangladesh hired an additional 10,000 CBD workers, increasing the work force by one-third, partly to increase visits for women using DMPA (251).

Counseling. Encouraging pharmacy staff and CBD workers to counsel clients well is especially challenging. Even when trained by social marketing programs, pharmacists may not know all the answers to customers' questions about contraceptives, and in general they do not volunteer information unless asked. Also, pharmacists are not always in the pharmacy, and staff turnover is high. Pharmacy assistants, often young people with no pharmacy training, wait on most customers (179). To help address these problems, the appointment cards in the DMPA kits distributed in some social marketing programs include counseling information (90, 252). The CRS project in Nepal interviews selected women who have bought injectables to ensure that they are receiving enough information (18).

Follow-up. Women may not want to discuss side effects with the pharmacist but may have nowhere else to go. Women served by CBD programs or mobile clinics have to wait until providers return or else go to a clinic, if possible. In the Matlab CBD program women with side effects can visit community clinics, each staffed by a paramedical worker, or a referral clinic staffed by a female medical officer. When CBD workers meet at the community clinics to discuss problems and obtain supplies, they also set up a schedule for the paramedical worker to visit women with side effects (128, 251). In Nepal clinics of the Nepal Fertility Care Center, a private family planning organization, provide information and back-up care for women who obtain injectables through the CRS project (90).