In
1995, seven international reputed organizations met in Bellagio(Italy) for expanding
access to Emergency Contraception as a potential choice to decrease the number
of unintended pregnancies and formed a Consortium for emergency contraception.
The main aim of this Consortium was to demonstrate the role of this ‘second chance
contraceptive’ as a part of mainstream reproductive healthcare. Essentially the
Global Consortium for Emergency Contraception is a partnership between
public and private sectors to introduce EC products in countries around the world.
The seven Consortium members included : The Concept Foundation; International
Planned Parenthood Foundation (IPPF); Pacific Institute for Women’s Health; Pathfinder
International; Program for Appropriate Technology in Health (PATH); Population
Council; and World Health Organization Special Program for Research, Development
and Research Training in Human Reproduction (WHO/HRP). The lessons learnt from
their experience can provide valuable insight to expand the access to this important
contraceptive option. The Consortium has been
essential for introducing Emergency Contraception, for showing its importance,
and for demonstrating that its acceptance is possible.
A stepwise approach to Introduction
The Consortium’s basic introduction framework included
the following 9 steps: • assess user needs and
service capabilities • build support for EC
introduction at appropriate levels • register
a product • develop a distribution plan
• identify and meet client needs •
train providers • introduce the products
• monitor and evaluate EC services •
disseminate evaluation results Besides introduction
in selected countries, the Consortium actively pursued adding Emergency Contraceptive
pills to the WHO model list of essential drugs. Accordingly, the Combined Pill
was added to the list in late 1995, and ‘Progesterone Only’ Pill (levonorgestrel)
in 1997. Initially, 4 countries were selected to adopt the model introduction
framework. Country
experiences with EC The
first four countries chosen for EC Consortium activity were - Sri Lanka,
Kenya, Mexico and Indonesia. The countries were selected on the basis
of a combination of factors like interest expressed by the collaborators in these
countries, presence of Consortium field staff and a perceived need for EC to reduce
unsafe abortions. These countries have diversity of cultural and religious perspectives
and service delivery systems.
Sri Lanka Sri
Lanka has a high contraceptive prevalence rate of 67%, yet the number of illegal
abortions performed is unacceptable. Approximately, 750 abortions are performed
countrywide every day, and the number of unwanted pregnancies is specially high
in the ‘Free Trade Zone’. In September 1997,
the Family Planning Association of Sri Lanka (FPASL) organized the Sri Lanka Consortium.
A baseline survey showed a high level of awareness in the service-providers. The
aim of the Consortium was, therefore, to make a dedicated EC product available
throughout the country and to increase the awareness of the general public.
Postinor-2 was approved for sale in both private and public sector in April 1998.
FPASL then negotiated to take over the sole rights for distribution of Postinor-2.
A tiered pricing system was developed, which ensured price regulation of the product
and also generated some revenue for the FPASL to organize its promotional activities.
The price was fixed at Sri Lankan Rs. 100 (approx. US $ 1.40). The key activity
launched was a telephone hotline, which was popularized by advertisements in newspapers,
magazines and radio talks shows. To provide education on EC, the volunteers conducted
educational campaigns. Brochures were prepared in local languages and also for
non-literate clients. Training of the providers was initiated by training the
doctors of FPASL and then expanded to include midwives, public health educators,
general practitioners and pharmacists. EC was made available through clinics,
pharmacies, general practitioners, youth groups, community health workers and
midwives. The program has been successful with
the hotline receiving approximately 75 calls per day and the sale of about 4600
packets of EC per month, which is expected to increase. The challenges faced by
the providers were women requesting EC after the 72 hours window of treatment,
and the political unrest in Sri Lanka, which partly affected educational and training
programs. Future activities to ensure programme sustainability include introduction
into plantation areas. Kenya
In Kenya EC was relatively unknown and a potentially
controversial public health issue. Unlike Sri Lanka where a majority of the providers
had prior knowledge of EC, less than 50% of service-providers and only 10% of
clients knew about EC. Postinor, an older version of EC, was already available
as a 10-tablet pack for EC, and regular OC pills were also being prescribed for
use as EC. However, the results of a survey showed that the knowledge about the
proper prescription of combined pills as EC was poor and there was no uniformity
in the dosage used. Pathfinders International
Regional Office for Africa, Population Council and Path Kenya staff coordinated
the Kenya Consortium and in collaboration with the Ministry of Health made a dedicated
product, Postinor-2 approved in April 1997 at a cost of 64 Kenyan shillings (US
$ <1.00). Training of service-providers was based on a standard training curriculum,
which addressed various regimens, effectiveness, mode of action, indications and
contra-indications, side-effects and client screening and counselling. They, in
turn, trained other providers at their site. Brochures were developed for both
trainers and clients. Postinor-2 was made available both through public sector
as well as private sector outlets. Though collaboration
with Government officials from the outset facilitated product registration and
inclusion of EC in Government Family Planning guidelines, the involvement of Government
agencies proved to be a setback as the pace of the program was slower than expected.
Another problem realized during the implementation of the program was that providers
needed repeated training and more technical support than was anticipated. Currently,
3500 packets are sold every month. Mexico
Although Mexico has a high rate of unwanted pregnancies and maternal complications
due to illegal abortions, it is a highly political and religion sensitive country.
Health workers were, therefore, hesitant to launch a wholehearted promotion of
EC. The Mexico Consortium, therefore, adopted a demand-oriented strategy with
a focus initially on increasing awareness. It was realized that registration of
a dedicated EC product may take years, so efforts were concentrated on the available
oral contraceptive pill. Simultaneously improving provider training, service delivery
system and introducing marketing and educational campaigns directed at the potential
method users, prepared an environment conducive to introduction of a dedicated
product. A baseline survey conducted by Mexico
Consortium showed that 74% of service-providers had heard of EC but less than
40% knew the correct dose. Among the clients, only 18% were familiar with EC but
70% indicated that they would use it, if made available. The results of this survey
were disseminated by organizing press releases and seminars, which were attended
by policy-makers, practitioners, scientists and pharmaceutical executives.
Consortium began its provider training by educating 600 trainers in the government
system. Training kits were prepared containing key scientific activities, Spanish
language abstracts and a slide show for use in training lectures. These trainers,
in turn, trained 12000 providers. The Consortium also met with medical school
teachers to include information about EC in courses for interns and medical, nursing
and pharmacology undergraduate programs. To
reach the general population, the Mexico Consortium developed brochures, book-markers,
pamphlets, and also organized a website and a hotline which proved to be extremely
successful (10,000 calls/day). Innovative marketing strategies were introduced
like condom packs with stickers containing the hotline numbers for EC if condom
broke. Leaflets were distributed at rock concerts and at other women-oriented
events, EC mouse pads were distributed at Internet cafes, and calendars for 2001
with information on EC were distributed to pharmacists.
Concurrently, efforts were on to get Postinor-2 registered, which finally succeeded
in September 1999. Another product has been approved since June 2000, but these
products have yet to become available. Despite the successes, there has been some
opposition by conservative religious groups, and as a consequence, the official
Mexican Family Planning guidelines have still not incorporated EC.
Indonesia
Approximately one million abortions are performed
each year in Indonesia. A total of 19,000 Indonesian women died due to pregnancy,
delivery or abortion complications in 1999. A baseline survey of knowledge of
EC showed that less than 5% of clients and about 25% of healthcare providers were
aware of EC. The activities of Indonesian Consortium
were coordinated by Pathfinder and then later by PATH. To increase awareness and
build support for the method, the Consortium organized a series of meetings and
workshops with government and non-government organizations, and developed a range
of publications for providers and clients. The
registration process for Postinor-2 was initiated in mid 1997. However, the political
turmoil, devaluation of Indonesian currency and misconceptions about EC have all
hampered the progress and it has yet to gain approval.
The Consortium was, however, able to gain confidence of an important Islamic group
which was a significant achievement, and also established ties with the Indonesian
Society of Obstetricians and Gynaecologists. With their support, seminars on EC
for health professionals were conducted. Consortium also gradually involved women’s
groups. However, after initial distribution of Postinor-2 as part of demonstration
project, failure to provide a sustained delivery of the product was a major setback
to the program. Also, a need for refresher courses and technical supervision of
providers was recognized. Besides the experience
of these 4 countries, EC introduction approaches used in some other countries
included: • Latin America – EC has been
identified as an integral step in empowering women to reduce unintended pregnancies.
• Brazil – Lead has been taken by private sector to
provide EC in collaboration with USAID’s Commercial Market Strategies (CMS) Project.
• Nigeria – Social marketing of a dedicated product
has helped in ensuring access and correct use of EC.
Currently, there is a dedicated LNG only product (Postinor-2) approved in Bangladesh,
Brazil, Czech Republic, Egypt, Jamaica, Kenya, Mexico, Sri Lanka, Venezuela, Vietnam
and Yamen. Both estrogen-progesterone product (Preven™) and progesterone only
(Plan-B™) are freely available in USA and Canada. Levonorgestrel only product
(NorLevo) is available over the counter in France and is registered in Brazil,
Mexico, South Africa, Sri Lanka and most European countries. Postinor-2 is also
registered in United Kingdom. Overall, the Consortium
approach brought together different groups which worked towards a common goal.
Coming together as a united front in support of Emergency Contraception helped
the Consortium in its negotiations with funding agencies, drug manufacturers,
and other collaborating government and non-government agencies.
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