Getting to FP2020: Harnessing the private sector to increase modern contraceptive access and choice in Ethiopia, Nigeria, and DRC

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Abstract

Background

An estimated 214 million women have unmet need for family planning in developing regions. Improved utilization of the private sector is key to achieving universal access to a range of safe and effective modern contraceptive methods stipulated by FP2020 and SDG commitments. Until now, a lack of market data has limited understanding of the private sector’s role in increasing contraceptive coverage and choice.

Methods

In 2015, the FPwatch Project conducted representative outlet surveys in Ethiopia, Nigeria, and DRC using a full census approach in selected administrative areas. Every public and private sector outlet with the potential to sell or distribute modern contraceptives was approached. In outlets with modern contraceptives, product audits and provider interviews assessed contraceptive market composition, availability, and price.

Findings

Excluding general retailers, 96% of potential outlets in Ethiopia, 55% in Nigeria, and 41% in DRC had modern contraceptive methods available. In Ethiopia, 41% of modern contraceptive stocking outlets were in the private sector compared with approximately 80% in Nigeria and DRC where drug shops were dominant. Ninety-five percent of private sector outlets in Ethiopia had modern contraceptive methods available; 37% had three or more methods. In Nigeria and DRC, only 54% and 42% of private sector outlets stocked modern contraceptives with 5% and 4% stocking three or more methods, respectively. High prices in Nigeria and DRC create barriers to consumer access and choice.

Discussion

There is a missed opportunity to provide modern contraception through the private sector, particularly drug shops. Subsidies and interventions, like social marketing and social franchising, could leverage the private sector’s role in increasing access to a range of contraceptives. Achieving global FP2020 commitments depends on the expansion of national contraceptive policies that promote greater partnership and cooperation with the private sector and improvement of decisions around funding streams of countries with large populations and high unmet need like Ethiopia, Nigeria, and DRC.

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Quality of Private and Public Ambulatory Health Care in Low and Middle Income Countries: Systematic Review of Comparative Studies

Sima Berendes, Peter Heywood, Sandy Oliver … (2011)

Introduction The private sector is the main provider of primary health care for the poor in many low and middle income countries (LMICs). For example, in South Asia about three quarters of children from the poorest income quintile with acute respiratory conditions seeking health care go to a private provider [1], and about 45% of sick children from the poorest income quintile across 26 African countries go to a formal or informal private provider rather than a public provider for health care [2]. Private providers are also increasingly important for providing ambulatory care as non-communicable diseases (NCDs) increase [3]. Private providers may be “formal”, i.e. recognised by law or by legally recognised regulatory authorities, or “informal”, i.e. not recognised [4]. Formal private providers include “for-profit” hospitals and self-employed practitioners, and “not-for-profit” non-governmental organizations (NGOs). NGOs include churches, and are particularly common in Africa, although the for-profit/not-for-profit dichotomy is not so clear cut in practice, with some NGOs simply representing private practitioners securing tax breaks [5],[6]. Informal allopathic providers include “quacks”, lay health workers, drug sellers, and ordinary shop keepers [7]. Advocating that formal for-profit private services are preferable to government provision raises considerable ideological debates [8]–[10]; equally, not-for-profit private providers such as those run by churches are seen by some as good and as providing value for money [11]. Whatever the debates, there is agreement that influencing the quality of both public and private providers could have a major impact on health outcomes. Adequate state stewardship and oversight of these mixed systems is widely advocated [9],[12], but the mechanisms to assure quality are not simple and are of unclear effectiveness [13],[14]. Improving stewardship and oversight is complex, involving resources, management, legislation, and approaches to influence the market [15],[16]. Thus, an understanding of how quality and performance in the formal private sector compares with that of the public sector would help governments to focus strategies to improve delivery. Putting this simply, if the private sector is generally providing poorer quality care than the public sector, then there is an imperative to improve the quality and outcomes; on the other hand, if the quality of private-sector care is good, the priority for policy is to influence the market somehow to further improve access for low income groups. “Quality” has many dimensions [17], including structural quality, aspects of delivery, and the technical or professional content of care, all of which are likely to influence service use. Each dimension will have complex effects on patient satisfaction, patient use of the service, and outcomes for their health. In addition, each is interrelated: population health outcomes will depend on service use, technical quality, and drug availability, for example. A recent substantive analysis that examined the use of medicines in primary care reported poor quality prescribing for both sectors, with little change over time [18]. The authors also reported the relatively poor quality of data and the need for research assessing the difference between the public and private sector. Thus, our objective was to systematically identify and summarise the results of studies that directly compare the quality of private providers and public services in relation to ambulatory health care in LMICs. Methods Criteria for Inclusion We included field-based studies that directly compared service quality in ambulatory care from private versus public medical health services. The purpose was to include studies using the same methods to measure the differences, and in the same countries, to avoid confounding factors related to overall differences in service quality between countries. We included studies conducted in LMICs that assessed ambulatory care, defined as the “delivery of personal health care services on an outpatient basis” [19]. We only included studies that compared private and public services in the same country, at the same time, using the same methods, and which met particular quality criteria (Table S1). “Private” refers to “all organizations and individuals working outside the direct control of the state” [20], and we included only those working within the allopathic medical systems. “Private for-profit providers” included individuals or groups of practitioners in privately owned clinics, hospitals, and pharmacies that operate on a for-profit basis, while “private not-for-profit providers” included practitioners in facilities that operate on a non-profit basis, such as various (missionary or non-missionary) NGOs and private voluntary organizations. Informal providers included those without formal health professional qualifications, such as street vendors and shop keepers. We included studies reported in English, French, or German and published from January 1970 to April 2009. We screened all titles/abstracts found by the search methods described below for potential inclusion, and then carefully applied the detailed inclusion criteria (Table S1) to the full text of those identified in the screening search. Studies using qualitative methods were identified and were included if they (a) used internationally accepted data collection methods (e.g., in-depth interviews, focus group discussion, or observation), (b) indicated the methods used in analysis (e.g., thematic analysis, content analysis, or grounded theory), and (c) presented data by theme or in the form of verbatim quotes. Search Methods The search strategy for Medline can be found in Table S2, and a list of the databases searched in Table S3. In addition, we searched all records of the World Health Organization's (WHO's) library database, WHOLIS (on 27 April 2009), all Service Availability Mapping reports published on the WHO Web site (http://www.who.int/healthinfo/systems/samdocs/en/index.html) (on 5 December 2010) [21], all Service Provision Assessment Survey reports published on the Measure DHS Web site (http://www.measuredhs.com/aboutsurveys/search/search_survey_main.cfm?SrvyTp=type&listtypes=3) (on 3 December 2010) [22], and all research studies published on the Core group Web site (http://www.coregroup.org/) (on 6 December 2010), and we examined reference lists of relevant reviews [23]–[25] and of the included studies. The search strategies included indexed and free-text terms: health sector, health care, delivery of health care, primary health care, medical care, health clinic, outpatient service, ambulatory care, practitioner, health provider, health provision, hospital, pharmacy, drug vendor, drug seller, drug store, public sector, public, private sector, private, quality of health care, Africa, Asia, South America, developing countries, less developed countries, third world countries, underdeveloped country, low income country, low income nation, middle income country, middle income nation, low and middle income countries. Data Collection and Analysis We applied the inclusion criteria to all titles and abstracts. We retrieved full-text copies of potentially relevant records, and discussed each to resolve uncertainties. We then appraised potential studies against a set of basic minimum methodological criteria to exclude studies where data were unlikely to be reliable (Table S1). We adapted Donabedian's [17] classification of quality of care using structural, delivery, and technical categories (Table 1). We incorporated “responsiveness” [26] to reflect aspects such as waiting time, communication quality, and dignity, as well as an assessment of the “effort” providers make, such as whether they examine the patient, and the length of the consultation time [27],[28], and we divided technical quality into measures of competence and clinical practice (Table 1). 10.1371/journal.pmed.1000433.t001 Table 1 Quality categories, sub-categories, and indicators used. Quality Category Sub-Category Description and Indicators Structural Building, equipment, materials Availability and condition of health facilities, and of defined equipment, materials, and supplies Drug availability Availability of essential drugs in health facilities and pharmacies Delivery Responsiveness Waiting time, privacy, confidentiality, staff friendliness, communication, dignity Effort Length of consultation time, whether a physical examination is performed, number of explanations given Patient satisfaction Patients' satisfaction with last consultation Technical Competence Professional knowledge and skills Clinical practice Presence or absence of critical elements of care, whether practice is according to standards or guidelines, proxies for correct prescribing behaviour S. B. extracted data using a standard form, entered into an Access database, with about 80% verified by a second author to ensure standardisation of coding. We contacted 33 authors for further information, and all but nine authors responded. Standard data describing the study were extracted. If a study reported several comparisons, we selected groups that were most similar within the health system (e.g., public hospitals versus private hospitals, or public health centres versus private clinics). If results were presented separately for different cadres or levels of staff qualification, we chose the comparison group with the staff qualification levels that were most comparable and most frequented by the population. If the latter could not be established, we chose the highest qualified comparison group. We then separately computed summary measures of (a) the overall level of quality of care in the private and in the public sector and (b) the difference of quality of care between both sectors stratified by quality categories and components. If there were several data measures for one component in a study, we computed the median for all reported measures to calculate a single measure for component quality for the provider. For example, in the case of a public-sector score (on a linear scale, with 100% being the maximum obtainable) of 45% for physical infrastructure, 50% for availability of basic diagnostic equipment, and 60% for availability of basic material, the median for the structural component “building, equipment, and material” would be 50%. The median was also computed for the quality score difference between private and public provider. For example, in case of a difference of +5% in physical infrastructure, +11% in availability of basic diagnostic equipment, and +14% in basic material, the median difference would be +11% for the given comparison in a study. After computing the medians for the overall quality of care and for the difference of care for each single comparison in each study, we computed medians and inter-quartile ranges (IQRs) across all comparisons. The size of the difference and the IQRs of the difference were used to judge whether a difference was evident. Results Of 8,812 titles and abstracts identified, 80 studies included direct quantitative comparisons of public and private formal providers (Figure 1, adapted from PRISMA 2009 flow diagram [29]; Tables S4 and S5 describe excluded studies). These yielded 133 comparisons, of which we were able to convert 101 to a 100% scale (Table S6). Most studies were carried out after 1990; they were mainly conducted in sub-Saharan Africa (n = 39) and in Asia and the Pacific (n = 23); and most were intended to compare quality, examining all types of primary service and disease category (Table 2; details in Table S9). Most studies did not report socio-economic status of public and private service users, and only five presented data by different wealth groups [30]–[34]. No study compared the same individual providers working in public and private care settings. For two studies [35],[36] that reported results separately for different cadres, we chose public versus private doctors rather than public versus private nurses or midwives as comparison groups, but it should be noted that for both groups results pointed in the same direction. 10.1371/journal.pmed.1000433.g001 Figure 1 Selection of studies. * See Table S4 for reasons of exclusion; † see Table S5 for reasons of exclusion. 10.1371/journal.pmed.1000433.t002 Table 2 Characteristics of quantitative studies comparing public and formal private providers by region (n = 80). Characteristic South Asia, East Asia, and Pacific Sub-Saharan Africa Othera Total Number of Studies Language English 23 33 16 72 French 0 6 2 8 Study year range 1980–1989 1 2 1 4 1990–1999 8 16 7 31 2000–2009 14 21 10 45 Primary study purpose Describe or compare quality of private and public services 17 28 13 58 Assess drug availability and affordability 4 3 2 9 Assess demand for, access to, or utilisation of services, or efficiency of service delivery 2 8 3 13 Service type Promotive or preventive 1 4 2 7 Curative, rehabilitative, or palliative 7 14 7 28 All types 12 18 8 38 Not specified 3 3 1 7 Disease category Both CD and NCD 14 24 9 47 CD 7 13 5 25 NCD 1 0 3 4 Not specified 1 2 1 4 Population age Adult 6 11 2 19 Both adult and child 15 21 7 43 Child 1 3 4 8 Not specified 1 5 5 11 Population gender Both (male and female) 21 34 15 70 Female 2 5 3 10 Total number of studies 23 39 18 80 a Includes Europe and Central Asia (n = 1), Latin America and the Caribbean (n = 6), the Middle East and North Africa (n = 7), and studies reporting on countries in more than one world region (n = 4). We found only two studies comparing public providers and private informal providers. The first [37] compared malaria-related knowledge and chloroquine availability in public dispensaries and informal drug vendors, and suggested that the public sector was slightly better. The second [38] mixed both formal and informal private providers together. These two studies were excluded from further analysis. Of the 101 formal private versus public sector comparisons that were converted to a 100% scale, 57 compared government with private for-profit providers, 10 with a mix of for-profit and not-for-profit providers, and 34 with private not-for-profit providers. Of the last 34 comparisons, most (n = 29) were conducted in sub-Saharan Africa. Study-level summary values for each quality component are presented in Table 3, along with the summary of the within-study differences. We also carried out an analysis that separated private for-profit and private not-for-profit providers (Table S7). As the results in the for-profit and not-for-profit providers were remarkably consistent, they are presented as combined. 10.1371/journal.pmed.1000433.t003 Table 3 Overall level of quality and comparative quality difference of public and formal private providers. Category Component Number of Comparisons Converted to 100% Scale Public Quality Score (%) Private Quality Score (%) Difference Private-Publica (%) Median IQR Median IQR Median IQR Structural Building, equipment, and materials 26 41.9 25.0, 76.5 44.5 22.0, 86.6 2.8 −2.9, 20.6 Drug availability 14 45.3 38.8, 58.5 63.0 45.4, 94.8 17.9 12.5, 29.1 Delivery Responsiveness 7 85.0 56.9, 86.3 89.1 75.7, 94.5 7.5 7.0,12.4 Effort 3 84.9 46.5, 87.0 92.9 54.5, 93.5 8.0 5.5, 8.0 Patient satisfaction 10 75.0 56.9, 78.8 75.0 68.0, 79.1 0.5 −2.0, 4.4 Technical Competence 19 52.8 36.3, 54.2 45.2 35.0, 53.3 −3.0 −7.6, 0.8 Clinical practice 22 44.5 27.5, 60.9 47.0 39.1, 66.5 5.2 1.3, 14.0 a Within each comparison, the difference between the public score and the private score was calculated. The data in this column are the median of these values across all studies. For this reason, they will not correspond to an arithmetic difference of the absolute median scores in the previous columns. In addition, ten studies included qualitative data that met our eligibility criteria, with a similar geographic spread to the quantitative data. Structure For buildings, equipment, materials, and supplies, no difference was detected. For the 26 comparisons, the IQR of the difference included 0. Respondents in two qualitative studies reporting on this category described private facilities as better [39],[40]. For drug availability, private-sector care was substantially better than public-sector care, from 14 comparisons. Nine studies used a standard method and referred to the WHO essential drug list [41],[42]. None of the quantitative studies compared the quality of drugs available in the public versus private sector. Qualitative studies reported that the private sector was more trusted for drug quality [43] and that the drugs were more readily available [39],[40],[44],[45]. Service Delivery For responsiveness, private-sector care was better (see Table 1 for definition), from seven comparisons. Studies used patient interviews, observations, or simulated visits. In six of the seven comparisons measuring waiting time, the time was shorter in the private sector. Qualitative data in five studies indicated that the private sector provided more personalised, respectful [39],[40],[46],[47], listening [43], and client-centred service, as well as service that was more convenient [48] and quicker and easier to access [47],[49]. For effort, private-sector care was better, from three comparisons. A further four studies reported on average consultation times, which were longer in the private sector in all studies, although statistical significance was only computed and confirmed in two of them [6],[50]–[52]. Qualitative data were consistent with this finding. Studies consistently reported criticisms of the public sector (with providers showing favouritism for some patients and less respect for poorer clients [39],[40],[43],[44],[46],[48],[49]) and praise for the private sector [39],[40],[43],[48],[49]. For patient satisfaction, no difference between private and public sector was detected, from ten comparisons. None of the studies measuring “satisfaction” reported the use of a validated questionnaire. Only one took into account possible differences in expectations of public and private services [53]. Technical Quality For competence, scores for private- versus public-sector care were similar, and generally poor, from 19 comparisons; competence was measured by case scenarios or vignettes, provider interviews, or a formal test. In qualitative studies the private sector was reported as quicker and easier to access, although the competence of some providers was questioned [40],[48]. The public sector was often perceived as technically competent but inconvenient and provider centred, with complex systems that took time and effort to negotiate [44],[47],[49],[54]. For clinical practice, private-sector care was marginally better, from 22 comparisons. Of those not convertible to a linear 100% scale, 14 studies used the same standard methods to assess prescribing behaviour, summarised in Table S8, with no obvious differences. In qualitative studies, respondents perceived public providers as qualified and well trained [43], although some were thought to overprescribe to raise their income [40],[48]. The private sector was also criticised for overprescribing and collusion between doctors and pharmacists [46], for suspected “fake” or unlabelled drugs, for “fake” doctors, and for nurses practicing illegally in private pharmacies in need of regulation [40],[46],[48]. We carried out a sensitivity analysis including only studies and comparisons (n = 67) classified as high quality because of their size (Table S1 provides the criteria); the results obtained were very similar to Table 3. For-Profit and Not-for-Profit Providers As mentioned above, most of the not-for-profit studies were carried out in sub-Saharan Africa (29 of 34 comparisons). Table S7 contains an analysis stratified by private for-profit and private not-for-profit. The direction of the difference is the same as for the aggregated value for all components. Notably, clinical practice was much better in the for-profit sector, and the difference was less marked for the not-for-profit sector, but the number of comparisons in the for-profit sector is limited. Factors Contributing to a Quality Difference Some of the qualitative studies (n = 8) sought to explain the quality difference between the two sectors. Factors perceived to be related to low public-sector quality included resource constraints, low salaries, high workload, and poor incentives and conditions of service [39],[40],[44], the lack of a public family/general practice system that enables patients to return to the doctor(s) of their choice and develop relationships of trust over longer periods of time [43], public-sector drugs being sold privately [39],[40], staff favouring particular patients [39],[47], and clients lacking sufficient information about the appropriate use of drugs, resistance to antibiotics, costs, and their rights to challenge poor service [39],[46],[49],[54]. Discussion Summary The results of our analyses indicate that, in both private and public sectors, median values for structure, competence, and clinical practice fall around or below scores of 50/100. Whilst these values depend on the instruments used and the stringency of the primary research studies in applying these standards, the trends provide some insight into absolute performance, with obvious problems with technical aspects of care in both sectors. In comparative performance, the formal private sector was better for drug availability, responsiveness, and effort. Overall, the median differences were modest, so stereotyped opinions that one sector is clearly better than another are not supported by this review. Qualitative data portrayed formal private services that, in contrast to the public sector, were more client centred. This is consistent with the differences in care delivery shown by the quantitative data. Interpretation In a formal private setting, drugs may be more available because funds are not restricted in the same way as in the public sector, and private providers are motivated to encourage patients to return, so responsiveness and effort are greater. These results, combined with the fact that the private sector provides a substantial amount of health services, raise two further issues—the importance of paying attention to both sectors if overall quality is to be raised, and the need for governments to play a more active role in assuring quality of care. Many efforts to improve the quality of ambulatory care are restricted to the public sector on the grounds that public funds should be reserved for the public sector because that is where the poor turn for their health care. But concentrating on the public sector misses a large proportion, the majority in some cases, of the providers used by the poor. Raising the quality of care delivered by private, as well as public, providers would, in fact, be a pro-poor intervention as it would improve the effectiveness of the money the poor spend on health care. A second argument advanced against spending public money on private providers is that because they provide a lower quality of care it is more effective to reserve funds for the public sector. The results of this review indicate that the overall quality of care from the two sets of providers is similar; if anything, the private sector is more responsive and drug availability is greater. The overall low quality of care is likely to become even more so as the double burden of communicable disease (CD) and NCD becomes more prominent. Most health care providers, public or private, practicing today have been trained by institutions and work in health systems primarily oriented to CDs. Consequently, providers have only limited knowledge of NCDs, which demand a different set of clinical skills and a different approach to treatment. On most dimensions, effective treatment for NCDs requires approaches quite different to those that are available through the current health systems, and, contrary to views held by many, NCDs and associated risk factors are not the preserve of the rich; they are equally, if not more, prevalent among the poor [55]. Thus, it has to be considered that certain types of diseases, such as some NCDs, but also more complex CDs, such as AIDS, might require particularly high levels of structural quality, drug availability, and provider competence, while for other diseases, such as childhood diarrhoea, that are easy to diagnose and treat, it is most important to motivate providers to exert effort and practice what they already know [56]. Raising the quality of care in a health system is a long-term effort and requires attention to various aspects, including the incentive structure and training, both areas in which government has an important role, but to which it frequently pays little attention. Systematic and comprehensive traditional narrative reviews suggest a variety of strategies that can help increase quality. For example, supervision and audit with feedback, especially if combined with training, have been found to be effective [57]. However, an overall government bias against the private sector frequently means that too little attention is paid, and too few resources devoted, to overall supervision of the private sector. But setting standards, partly through ensuring standards of training, partly through licensing and accreditation of professionals (including emphasis on continuing education), and partly through consumer protection laws, is an important role of government [16],[58]. Researchers such as Leonard and colleagues [15] have provided useful theoretical frameworks for influencing the private sector based on the “principal-agent theory”. Others have proposed different ways of classifying the variety of strategies that have so far been used to improve the quality of private care, for example, classifying strategies according to the influence they have either on supply or demand or on the overall market environment [16],[59]. However, empirical evidence on the effectiveness of various approaches is somewhat limited, as the review by Peters et al. shows for reproductive health care [14]. Strengths and Weaknesses of This Review The search was comprehensive, the inclusion criteria were applied carefully, and quality criteria were applied to ensure comparisons were valid and were direct comparisons using the same methods. Given that studies used a very varied set of tools to measure quality of care, results on the absolute level of quality of care have to be interpreted with caution. However, results on the difference in quality of care can be interpreted with more confidence, because, as mentioned above, we took care to include only those studies that directly compared quality of care in the same country at the same time, using the same methods. A further strength is that we were able to categorise the various quality components to allow comparisons between studies. A disadvantage is that small studies could contribute as much to the estimates as large studies, but the sensitivity analysis—excluding the smaller studies—did not alter the direction of the differences between the sectors. Although this review fully assessed eligible comparative studies on quality, additional work is needed to compare costs and aspects of equity. Similar to the dispute on quality, there are controversial views on whether private or public care is more costly or more accessible to the poor. The review also highlights the lack of comparative evidence between the public sector and the private informal sector, although the latter is widely used [2],[60]. Implications for Policy and Research With the current evidence base, there is a clear need to consider quality of primary health services in both the public and private sector in order to improve health outcomes. There is a tendency for the private sector to provide better quality services, but further research on the overall quality and testing feasibility and effectiveness of mechanisms to improve quality will be critical for future health gains in LMICs. Research needs to standardise outcomes and measures of socio-economic position across studies to improve comparability and to assist in between-country dialogue on effective quality assurance policies. Research on the effectiveness of market-led strategies to influence the private sector is important. Studies of dual practice, examining the same providers' behaviour in the two settings, could be useful specific studies in identifying factors in terms of the setting. Lastly, establishing minimum standards of care, and research to help identify effective approaches to achieve them, is central to achieving the health gains that are possible with current preventive and treatment medical technologies. Supporting Information Alternative Language Abstract S1 Translation of the Abstract into French by Sima Berendes. (0.02 MB DOCX) Click here for additional data file. Alternative Language Abstract S2 Translation of the Abstract into German by Sima Berendes. (0.03 MB DOCX) Click here for additional data file. Table S1 Inclusion criteria for study reliability. (0.07 MB DOC) Click here for additional data file. Table S2 Search strategy for Medline. (0.07 MB DOC) Click here for additional data file. Table S3 Databases searched. (0.05 MB DOC) Click here for additional data file. Table S4 Reasons for exclusion during screening of titles/abstracts or full papers. (0.05 MB DOC) Click here for additional data file. Table S5 Excluded studies after reliability criteria application. (0.09 MB DOC) Click here for additional data file. Table S6 Number of studies and comparisons per category. (0.06 MB DOC) Click here for additional data file. Table S7 Results of comparisons between public and private providers for sub-Saharan Africa only and stratified by private provider type. (0.06 MB DOC) Click here for additional data file. Table S8 Comparison of selected prescribing behaviours for patient visits to public-sector and formal for-profit private-sector care providers in LMICs. (0.08 MB DOC) Click here for additional data file. Table S9 Characteristics of included quantitative studies summarised by world region. (0.22 MB DOC) Click here for additional data file.

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Scaling up delivery of contraceptive implants in sub-Saharan Africa: operational experiences of Marie Stopes International

Susan Duvall, Sarah Thurston, Michelle Weinberger … (2014)

INTRODUCTION Availability of contraceptive implants in sub-Saharan Africa expands the family planning options from which women of reproductive age can choose to limit or space their children. Currently, nearly 1 in 3 sub-Saharan African women have an unmet need for family planning, the highest proportion (31%) of any region in the world. 1 Moreover, only 16% of women in sub-Saharan Africa use modern methods of contraception compared with 67% in Latin America and 60% in Asia. 2 Yet many women want to use contraception. The demand to limit births has risen among married women in a number of countries in East and Southern Africa and is rising more slowly in West and Central Africa. 3 – 6 Implants, a long-acting and reversible contraceptive method (LARC), offer women a viable and highly effective hormonal method for family planning, providing 3 to 5 years of protection against pregnancy (depending on the type of implant used). With a rate of just 1 unintended pregnancy per 2,000 women, implants are more effective than any other reversible method, including the intrauterine device (IUD). 7 Easily inserted into the arm by a trained health worker, implants are convenient, discreet, and suitable for nearly all women and family planning intentions (delaying, spacing, and limiting childbearing). 7 Implants are more effective than any other reversible method. In sub-Saharan Africa, a growing number of women and sexually active adolescents are using family planning, and many are choosing contraceptive implants. While implants account for just 7% of all contraceptive methods used in the region, interest in implants has risen sharply in less than a decade. 8 For example, between 2004–05 and 2010–11, use of implants rose 17-fold in Ethiopia, 16-fold in Rwanda, 5-fold in Tanzania, and 2.5-fold in Malawi. 7 A number of factors help explain this dramatic increase: Women's desire to limit family size and growing acceptability of modern methods 6 Wider availability of implants through the introduction of the cost-competitive implant, Sino-implant (II), and the subsequent launch of public-private partnerships, 7 , 9 , 10 resulting in price-volume guarantees for Implanon and Jadelle Growing awareness of the benefits of implants among sub-Saharan African women and growing interest in long-acting methods 5 , 7 Prioritization of family planning and increasing availability of implants by the donor community and development organizations, including government policy makers 7 , 11 , 12 Within this favorable environment, Marie Stopes International (MSI), an international nongovernmental organization (NGO) committed to broadening women's contraceptive choices around the world, has successfully scaled up its delivery of implants in recent years to meet growing demand in sub-Saharan Africa and help clients gain access to information to make informed family planning choices. (We define scale up as an increase in the number of clients using implants, measured by the number of implants delivered.) MSI offers implants as one of many family planning options, including other LARCs, voluntary permanent methods, and short-acting methods. MSI counsels clients on the full range of available methods, so they can choose the method that best fits their lifestyle and family planning goals in accordance with the principles of informed choice and reproductive rights outlined at the Cairo International Conference on Population and Development and underpinning U.S. Government support for voluntary family planning programs. 13 , 14 In Nigeria, a family planning client has her contraceptive implant inserted by Marie Stopes International (MSI) providers. Provision of implants by MSI increased more than 10-fold in Nigeria between 2009 and 2012. MSI HELPS TO EXPAND ACCESS TO IMPLANTS In 2008, MSI provided 80,041 implants in the 15 sub-Saharan African countries where we work. In just 5 years, we increased this number considerably to 754,329 implants provided in 2012 (Table 1). Cumulatively, during the 5-year period, MSI delivered more than 1.7 million contraceptive implants in these countries. Between 2008 and 2012, MSI provided more than 1.7 million contraceptive implants in 15 sub-Saharan African countries. TABLE 1. Number of Implants Provided by MSI in Selected sub-Saharan African Countries,a 2008–2012 MSI Country Program 2008 2009 2010 2011 2012 % Growth (2011–12) Burkina Faso N/A 2,440 7,835 7,086 14,386 103% Ethiopia 14,286 31,953 45,737 68,347 88,206 29% Ghana 2,602 5,549 3,117 14,433 23,162 60% Kenya 6,652 43,330 69,651 72,477 117,106 62% Madagascar 6,206 17,535 26,899 34,175 65,229 91% Malawi 1,719 1,369 2,595 21,691 84,389 289% Mali 30 3,295 10,588 17,649 33,019 87% Nigeria N/A 1,184 5,944 6,388 12,749 100% Senegal N/A N/A N/A 535 6,600 1,134% Sierra Leone N/A 8,387 21,792 29,257 37,672 29% South Sudan N/A N/A N/A 153 1,138 644% Tanzania 25,457 28,157 24,465 36,705 64,752 76% Uganda 13,730 29,875 42,498 81,544 143,762 76% Zambia 639 3,037 4,724 4,457 9,900 122% Zimbabwe 8,720 16,166 24,862 40,107 52,259 30% TOTAL 80,041 192,277 290,707 435,004 754,329 73% Abbreviations: MSI, Marie Stopes International; N/A, not available (because the MSI country program had not yet begun providing implants). a Data from MSI's service delivery statistics for MSI country programs in sub-Saharan Africa that were active in implant service delivery in 2012. Data from Sudan and Swaziland recorded in 2010 and 2011 are not included because these country programs were closed in 2012. (The 2 countries contribute an additional 864 implants in 2010 and 486 in 2011.) Rapid expansion occurred in several key East and Southern African countries as well as in West Africa, a region where MSI began intensifying its presence as recently as 2007. Kenya, Madagascar, Malawi, and Uganda scaled up provision of implants considerably from 2008 to 2012, resulting in growth rates near or well over 1,000%, with a 49-fold increase in Malawi and an 18-fold increase in Kenya (Table 1). In Uganda, the number of implant users grew from under 20,000 in 2006 to more than 140,000 in 2011 (Box 1). The high growth rates from 2011 to 2012 in all countries indicate that implant service delivery still has room for further expansion. The high growth rates in implant provision between 2011 and 2012 in sub-Saharan Africa indicate that implant service delivery has room to expand further. BOX 1. Marie Stopes Uganda Scales Up Provision of Implants Between 2006 and 2011, Marie Stopes Uganda scaled up provision of implants and, in so doing, increased the size of the overall market for implants in the country. In 2001 and 2006, the total number of implant users in Uganda—comprised of new users and those who had their implants inserted in years prior—remained under 20,000 (Figure 1). Between 2006 and 2011, the number of users expanded more than 7-fold to more than 140,000 users. FIGURE 1. Number of Women Using an Implant Provided by Marie Stopes Uganda Versus Other Providers,a 2001, 2006, and 2011 a “Other providers” includes all private-sector organizations offering implants, other than Marie Stopes Uganda, and all public-sector providers, including Ministry of Health facilities. Data for Marie Stopes Uganda users are from Marie Stopes International (MSI) service statistics and are modeled using MSI's Impact 2 model. These estimated user numbers include women who received an implant supplied by MSI that year as well as women who received implant services from MSI in past years who are modeled to still be protected by the implant. Data for implants provided by other providers are from 2001, 2006, and 2011 Uganda Demographic and Health Surveys and 2010 UN Population Prospects. By 2011, Marie Stopes Uganda had become the dominant implant provider in the country. We estimate that approximately 3 of every 4 women using an implant in Uganda in 2011 received their method from MSI. When we consider that the number of women choosing family planning in the general population increased by 60% between 2006 and 2011 and that the proportion choosing implants also expanded greatly (from 1 in 50 to 1 in 10), the role of Marie Stopes Uganda in reaching 76% of these users is significant. 8 These data suggest that our scale-up efforts in implant services likely changed Uganda's national pattern of contraceptive use by 2011. A number of factors contributed to the growth in implant provision by Marie Stopes Uganda: Strong mobilization of donor resources, including bilateral funding from the U.S. Agency for International Development (USAID) A large expansion in the number of service delivery sites An increase in the number of community campaigns to generate demand for the contraceptive options available from Marie Stopes Uganda, including implants The steep increase in implant provision between 2008 and 2012 (more than 9-fold) demonstrates a marked difference from our provision of other long-acting and permanent methods (LAPMs) during the same period (Figure 2). Like implants, use of IUDs has steadily increased in sub-Saharan Africa since 2008 due to MSI's overall family planning program scale up in the region. However, stronger demand for implants resulted in a much faster pace of growth in comparison with IUDs. For tubal ligations, the number of services provided per year remained fairly steady over the 5 years. The number of female sterilization users, however, still accounts for the highest proportion of MSI family planning users in the region (Figure 3), because MSI has delivered more tubal ligations than other LAPMs historically; therefore, the estimated number of sterilization users in 2012 reflects these past trends. FIGURE 2. Number of LAPMs Provided by MSI in sub-Saharan Africa, by Method, 2000–2012 Abbreviations: LAPMs, long-acting and permanent methods; MSI, Marie Stopes International. Data from MSI service statistics. FIGURE 3. Method Mix Among Modern Method Users, Marie Stopes International (MSI) Users Versus the General Population, in African Countries Where MSI Operates, 2012 Data for MSI users are from MSI service statistics, with user numbers modeled using MSI's Impact 2 model. As explained in the footnote to Figure 1, LAPM users include those who received their method in prior years who continue to be protected. Because sterilization protects women for a longer duration than IUDs and implants, previous sterilization clients remain in the total “user” number for more years (until aging out at 49, based on median age of sterilization). Data for the general population are from Demographic and Health Surveys for those sub-Saharan African countries where MSI operates. 8 For MSI user numbers, short-acting methods exclude condoms to avoid the risk of overestimating condom use because of user wastage and dual protection. MSI's capacity to deliver implant services—and to scale up efforts in response to client demand—complements the existing method mix provided by the public sector and other private-sector providers, helping to meet the needs of clients who prefer implants. Public-sector facilities in sub-Saharan Africa often face constraints in providing LARCs, including implants, on a reliable basis. A lack of adequate infrastructure, frequent commodity stockouts, and a lack of skilled providers hinder public-sector provision. 15 , 16 Moreover, many public- and private-sector family planning programs deliver predominately short-acting methods, and, commercial pharmacies, social marketing programs, and public facilities often offer better access to short-acting methods than to long-acting methods, including implants. As a result, the method mix of women in the region using an MSI-provided method differs considerably from the method mix of the wider sub-Saharan African population as a whole. In 2012, whereas 83.8% of women of reproductive age in sub-Saharan Africa overall were using a short-acting method, only 10.4% of MSI users were. 8 In contrast, a far greater proportion of MSI users (36.6%) than the general population (6.5%) were using implants and other LAPMs for their family planning needs (Figure 3). MSI SERVICE DELIVERY CHANNELS MSI has successfully delivered family planning services through a number of channels, including the 3 main channels of: Mobile outreach Social franchising Static clinics Using more than one service delivery channel broadens the access points for a client, thereby increasing the likelihood that information about family planning choices will reach her and that she will have access to choose a method she wishes. 1 , 6 In 2012, the largest proportion of MSI's implant provision in sub-Saharan Africa was through mobile outreach services (Figure 4). Accounting for nearly 70% of all implants delivered, our outreach services provided almost 4 times as many implants as our social franchisees (18.0%) and nearly 8 times as many as our static clinics (8.9%). Still, the social franchising proportion is notable, since half of our social franchising programs in sub-Saharan Africa were recently established in the latter half of 2012. These results underscore the importance of mobile outreach and social franchising for expanding access to implants as part of a comprehensive method mix. 70% of MSI's implant clients in sub-Saharan Africa were reached through mobile outreach. Social franchising also showed promise, accounting for 18% of implant clients. FIGURE 4. Proportion of Implants Delivered by MSI in sub-Saharan Africa, by Service Delivery Channel, 2012 Abbreviations: MSI, Marie Stopes International. a “Other” includes community-based distribution, community health workers, and miscellaneous providers. Data from MSI service statistics. Data do not include 1,898 implants delivered through social marketing in Mali. Typically, variations or service delivery innovations build on 1 of these 3 channels. The scale of each of these channels also varies by country, depending on client needs and infrastructure availability. Table 2 contains a summary of our country program operations in those sub-Saharan African countries active in implant service delivery in 2012. TABLE 2. Summary of MSI Country Programs Active in Implant Service Delivery in sub-Saharan Africa, 2012 MSI Country Program Month/Year Program Opened No. of FP Clients (all channels) No. of Implants Provided No. of Mobile Outreach Teams No. of Clinics No. of Social Franchisees Month/Year Social Franchising Started Burkina Faso 07/2009 24,517 14,386 4 1 N/A N/A Ethiopia 09/1990 206,723 88,206 10 31 443 10/2008 Ghana 10/2006 39,798 23,162 6 5 106 03/2008 Kenya 03/1986 229,836 117,106 15 25 279 04/2004 Madagascar 06/1992 147,661 65,229 46 14 127 11/2009 Malawi 09/1987 229,310 84,389 39 31 54 06/2008 Mali 11/2008 45,787 33,019 7 3 34 06/2012 Nigeria 04/2009 16,446 12,749 5 1 51 09/2012 Senegal 11/2011 9,989 6,600 3 1 10 10/2012 Sierra Leone 03/1988 127,148 37,672 13 12 100 12/2008 South Sudan 08/2011 1,778 1,138 2 2 N/A N/A Tanzania 09/1990 149,252 64,752 26 12 N/A N/A Uganda 07/1993 260,466 143,762 24 15 419 06/2012 Zambia 06/2008 18,261 9,900 7 3 7 07/2012 Zimbabwe 04/1988 146,680 52,259 9 9 61 08/2012 Abbreviations: FP, family planning; MSI, Marie Stopes International; N/A, not applicable. Data from MSI service statistics. Number of FP clients were estimated from MSI service statistics, in which each service for a long-acting and permanent method is equal to 1 client and each year's supply of short-acting methods is equal to 1 client. When determining which channels to use, MSI considers the efficiency and reach of each one within the specific country context. Monitoring both efficiency and reach are essential considerations for enabling service delivery scale up and ensuring scale up is equitable. 1 Efficiency refers to allocating time, effort, and resources strategically in service delivery to maximize the greatest program impact. 17 Matching the size of a clinic or provider team to client demand and service patterns of a facility or catchment area is one example of efficiency. To measure efficiency, MSI teams use cost per couple-year of protection (CYP), a metric that shows the average cost of delivering a contraceptive method relative to the number of years the method protects against pregnancy. Currently, MSI uses cost per CYP for internal program monitoring and decision making; costing data will be made available in future studies focused on service delivery and scale-up costs. It is important to note that this metric is not simply about minimizing the cost per CYP, but rather about ensuring we use our resources to achieve the most impact—accounting for our role in expanding access and choice, improving quality, and ensuring equity. Reach refers to expanding access to family planning services, meaning that every potential client can obtain services regardless of financial, geographical, and/or cultural barriers. 17 We select service delivery channels that will reach clients affected by gaps in service outlets or contraceptive methods. At the same time, we consider channels that will enable existing clients to continue and/or switch their methods, if they choose. MSI monitors a program's reach through indicators such as the number of CYPs generated or the number of service delivery sites established. Recently, MSI also began monitoring the number of high-impact CYPs generated by different service delivery channels. Developed by MSI, this indicator measures a program's ability to deliver services to those facing the highest barriers to access, such as the poor, young women, those who have not previously been using family planning (called “adopters”), and users of short-acting methods who seek services at MSI to meet their desire for a LAPM (called “switchers”). Mobile Outreach MSI's mobile outreach services deliver implants and other contraceptive methods through a team of MSI dedicated providers that brings equipment and commodities directly to clients. The use of these dedicated providers—those who fill a specific service delivery gap by focusing primarily on the provision of certain contraceptive methods, such as LAPMs—is a key component of MSI′s mobile outreach strategy. 18 Unlike some dedicated provider models, we employ MSI staff, not external providers. These teams visit outreach sites on a regular basis, ranging from every 4 to 6 weeks to once per quarter in the most remote regions, expanding access to contraceptive choice through provision of LAPMs during these visits. (In support of informed choice, our dedicated providers refer clients who want short-acting methods to their public-sector counterparts located at the same site when available, or they furnish these methods directly in cases of stockouts at the public facility.) To help achieve equity, MSI provides underserved clients who do not otherwise have access to implants or other LAPMs with free or highly subsidized family planning services. As a result, the mobile outreach channel often generates high demand and commonly attracts new family planning adopters, a key metric for monitoring scale-up efforts. 19 – 21 In 2012, 41% of mobile outreach family planning clients were adopters, reached through our 216 mobile outreach teams in the sub-Saharan African countries offering implants (Table 2). Moreover, and importantly for implant scale up, 39% of our outreach clients switched from short-acting methods to LAPMs, indicating client preference for longer-acting contraception. 8 41% of MSI's mobile outreach family planning clients in 2012 were adopters and 39% switched from short-acting methods to long-acting and permanent methods. Mobile outreach services can also be an effective channel for program scale up in terms of efficiency. By strategically using existing community infrastructure, small teams, and outreach schedules that coincide with client demand, mobile teams can maximize impact from its program inputs. For areas that are not too rural but still hard to reach, this channel has proved to be cost-effective. 22 Teams of dedicated providers also have been shown to increase the number of IUD and implant insertions, and therefore, program scale up. 18 Depending on the geography of a particular catchment area, MSI uses either a mobile clinical service team or a mobile community outreach worker team, its 2 primary outreach models. 23 The mobile clinical service team model deploys small teams, typically 3 MSI dedicated providers and a driver, to rural areas for delivery of family planning services in existing health centers (usually public facilities) where possible. Through a collaborative process with local governments, MSI chooses these clinics because of their infrastructure, their ties to the community, and their visibility among clients. Some women also prefer to access family planning at a health center in order to disguise the reason for their visit. If needed, a team uses other community facilities (for example, schools and community centers), or sets up a low-cost, temporary structure such as a tent. In an effort to serve densely populated urban and peri-urban areas, our second model, the mobile community outreach worker team, is a flexible, low-cost adaptation of the clinical service team model. In the community outreach worker team model, a smaller team—often consisting of just 1 or 2 MSI dedicated providers of lower-level cadres—provides implants and other contraceptive methods, often in client homes or other non-health facility locations. A typical example is when 1 paramedic or nurse and 1 family planning counselor will use local transport, rather than MSI-owned vehicles, to reach clients (Box 2). Although the teams for both models are based out of an MSI clinic, they mobilize interest in their services in advance of their arrival in the community through a variety of demand-generation activities (Table 3). BOX 2. Marie Stopes Tanzania Develops Innovative Urban Outreach Model Throughout its 30-plus year history, Marie Stopes Tanzania reached middle-income urban clients through MSI clinics and low-income rural clients through mobile outreach. However, by 2010, we had identified a growing gap in contraceptive-seeking behavior: our static clinics were not adequately reaching many low-income urban and peri-urban women wishing to use injectables and LARCs, including implants. MSI's existing rural outreach model consisted of MSI-owned 4x4 vehicles and large clinical teams. Such a model would be too cumbersome in a peri-urban context, and so Marie Stopes Tanzania set out to innovate urban outreach. In 2010, we launched a pilot bajaji (motorized auto-rickshaws) outreach model in Zanzibar, with support from USAID. This new urban outreach model, using a team consisting of 1 MSI nurse and 1 bajaji driver, is a streamlined and more flexible version of MSI's rural outreach model. The bajaji outreach model significantly reduces startup and operational costs due to lower staffing, fuel, and vehicle expenses. Bajaji nurses deliver contraceptive methods directly in clients' homes, in addition to providing family planning services at standard mobile outreach model sites (public health facilities or other community-based static sites). Clients report that these home-based services allow them to circumvent key access challenges, including lack of time to attend clinics, need for discretion in seeking family planning, and, in some contexts, cultural norms requiring women to be accompanied when traveling outside the home. Within several months of starting bajaji services in Zanzibar, the Ministry of Health in Mwanza City invited Marie Stopes Tanzania to expand the model for its underserved urban neighborhoods. In the 12-month pilot period in Zanzibar, bajaji teams delivered family planning services to 3,650 clients, of which 2,122 chose implants. In the 7-month pilot in Mwanza City, bajaji teams delivered family planning services to 2,531 clients, of which 1,432 chose implants. Client interest in voluntary permanent methods resulted in 86 referrals to MSI clinics for tubal ligations (73 in Zanzibar and 13 in Mwanza City). Several MSI country programs in Africa and Asia are currently replicating this model to reach underserved urban and peri-urban clients. TABLE 3. Demand-Generation Activities to Educate Clients About Family Planning and MSI Services, by Channel Mobile Outreach Services Social Franchising Clinics Delivery of high-quality services to enable word-of-mouth referrals Delivery of high-quality services to enable word-of-mouth referrals Delivery of high-quality services to enable word-of-mouth referrals Educational outreach by community health workers (CHWs) or other community agents about importance of family planning and different methods through: Door-to-door mobilization Group information sessions Educational/promotional communication and media Educational outreach about family planning and long-acting and reversible contraceptives (LARCs), including implants, as well as about BlueStar family planning services through: CHWs and other community agents Print or radio advertisements Educational outreach about family planning and MSI services through: Kiosks at regular markets and popular events Radio show appearances by MSI clinic staff Flyers and promotional materials available at locations frequented by young women, such as markets, universities, and beauty salons Designated day for team visit, making it a noteworthy and anticipated community event Special discount days on LARC services Local media advertisements about voluntary family planning and LARCs, including implants Promotion of BlueStar brand, as an overall sign of quality service delivery Training for all clinic staff including receptionists and support staff to ensure client-friendly, non-judgmental environment Where appropriate, referrals from other MSI service delivery channels Referrals from: Other non-MSI services at franchisee Other MSI service delivery channels, where appropriate Where appropriate, referrals from other MSI service delivery channels Announcement of upcoming mobile team visit via: Town crier Radio CHWs or other community agents Both of these outreach program models are examples of how MSI collaborates with the public sector, building the clinical competencies of public-sector providers and creating synergies between public and private systems. For example, we prepare public providers for assessing and handling any complications that may arise from implant insertions. Such training is critical to meet follow-up needs of clients between visits from the MSI team. To ensure clients receive high-quality follow-up care, MSI coordinates referral networks with higher-level facilities to manage side effects that infrequently arise and that are beyond the capacity of lower-level public-sector providers. In the event that a client experiences a severe side effect, defined as a frequent level of discomfort requiring medical attention, we provide technical expertise and pay for transport and hospital fees if higher-level facility referral is needed. Where possible, we also build the clinical skills of public-sector providers in other ways, focusing on specific areas that need reinforcement (such as client counseling techniques and implant removal protocols). Social Franchising MSI's BlueStar social franchise networks* engage existing private providers to deliver high-quality sexual and reproductive health services, including implants, in underserved areas. Contracted to MSI but operated and owned by private providers, these networks are organized under commercial franchising principles, which have been shown to facilitate standardization and increase client volume, including for family planning services. 24 – 26 MSI has adopted a “partial franchising” model for our social franchise networks. In this model, we regulate and support only some of the franchisees' services and commodities, namely the reproductive health and family planning services; the franchisee may offer additional services that we do not oversee. In sub-Saharan Africa, franchisees are typically located in urban and peri-urban areas as well as towns and trading centers in rural areas. By engaging these existing providers, we leverage and strengthen the health infrastructure and aim to achieve greater health system integration between the public and private sectors. MSI gains access to an established clinic and existing client base in a community when we invite new members to the BlueStar network, obviating the need for the startup costs and effort associated with opening a new MSI clinic. At the same time, we expand client access to key services that these private clinics would otherwise not be able to provide adequately, allowing health systems to make better use of the capacity in the private sector to achieve public health-sector goals, such as increases in contraceptive prevalence. At the individual level, BlueStar franchisees increase options for existing contraceptive users as well as increase the market for family planning users and attract new users. In 2012, 78% of our BlueStar LAPM clients in sub-Saharan Africa chose implants—135,144 implant clients in 12 countries. Due to this demonstrated potential, social franchise networks will be key channels for scaling up implant services in many MSI country programs in the coming years. In 2012, 78% of MSI's social franchising LAPM clients chose implants. To help family planning program scale up and to offer services at affordable prices to our clients at our 1,691 BlueStar clinics in sub-Saharan Africa, MSI facilitates access to high-quality implants (and other commodities for other franchised services delivered) in 2 ways. We either supply these implants at a reduced price or negotiate access to pooled commodities at the national level on behalf of franchisees. Discounts vary from country to country. For example, while an MSI subsidy enables our Ghana franchisees to receive implant commodities at the same price as their public-sector counterparts, we are able to supply our Madagascar franchisees with implants (and other contraceptive methods) free of charge. Prior to joining the BlueStar network, individual clinics are not usually in a position to offer implants or other LAPMs to their clients; in most countries, there is no private-sector supply chain for implants outside of social franchise networks. By joining BlueStar, the benefits of supply-chain support—namely, more reliable and affordable access to consumables and implants themselves—enable BlueStar clinics to provide a wider range of contraceptive methods. These economies of scale result in cost savings for our clients, thereby increasing access for lower-income clients and scaling up equitable service provision. MSI Clinics Clinics have been our longest-standing service delivery channel. Owned and operated by MSI, our clinics are located in cities, towns, and peri-urban areas throughout 42 countries worldwide, with 165 delivering reproductive health and family planning services in the 15 sub-Saharan African countries that provided implants in 2012 (Table 2). In many of these countries, our clinic services augment the contraceptive method mix available from the public and private sector in urban and peri-urban areas, attracting new clients because of the different services that MSI offers, including implants. In fact, in 2012, 38% of our clinic clients in sub-Saharan Africa were family planning adopters. 8 Therefore, these clinics are important for expanding implant access to women in their respective catchment areas. In 2012, 38% of MSI's clinic clients in sub-Saharan Africa were family planning adopters. MSI clinics offer some advantages to scaling up access to implants over other service delivery channels in terms of efficiency and reach. Because the clinics are well-established in their catchment areas, with appropriate equipment and trained providers, our clinics can offer implant services in a manner that uses program inputs strategically to maximize impact. For example, we can scale up implant service delivery without significantly increasing overhead costs, such as transport with mobile outreach services. In terms of reach, these clinics tend to serve a population that is relatively wealthier than those served by our mobile outreach channel; in 2012, approximately 17% of our clinic clients in sub-Saharan Africa lived on less than US$1.25 per day compared with 42% of our mobile outreach clients. 8 At the same time, income generated from the sliding scale fees charged by our clinics helps subsidize our outreach service delivery, in which fees are typically not charged. QUALITY ASSURANCE MEASURES All MSI delivery channels prioritize service quality when providing clients with contraceptive methods. High-quality programs yield high levels of client satisfaction, a principal determinant of a client's initial and continued use of family planning services. 27 – 30 The quality level of family planning service delivery, including implant provision, also directly influences the demand generation facilitated by client experiences and word-of-mouth communication, and, in turn, program scale-up efforts. MSI implements various quality-control activities, such as competency-based training and refresher courses, to train providers on MSI standards. We also train facility staff and outreach teams on how to use MSI's management information system to record client visits, services provided, expenditures, and stock of commodities and equipment. We then use various tools, such as mystery clients, supportive supervision, and audits, to monitor and ensure these service standards are met. See the Appendix for a complete list of MSI's quality-assurance activities. Through these measures, our staff and partners pay attention to quality throughout each stage of service delivery. As a result of this rigorous attention to quality, MSI clients have reported high rates of satisfaction with the services received, regardless of the channel from which they obtained family planning services. In 2012, MSI family planning clients across 11 sub-Saharan African countries gave our services an average rating of 4.4 on a 5-point Likert scale, in which 5.0 signified “very good.” The highest-rated aspect of service delivery was “friendliness and respect from the health care provider,” followed by “friendliness and respect from staff.” These data are potentially subject to “courtesy bias,” in which the clients are reluctant to express negative opinions to the interviewer. Other sources of data, however, support these positive findings. For example, when asked which source of information was most important in influencing their decision to choose MSI services, 31.5% of our sub-Saharan African clients cited a “person who used the service” (Figure 5). Furthermore, 29.9% of our clients in sub-Saharan Africa from across all delivery channels noted that MSI's “good reputation” was the driving force behind their decision to visit an MSI service site (Figure 6). The proportion citing our “good reputation” was also substantial by service delivery channel: 44% of clinic clients, 32% of social franchise clients, and 23% of mobile outreach clients. Such evidence underscores the importance of informal demand generation, based on client acknowledgment of high-quality services and word-of-mouth communication, in influencing MSI client health-seeking behavior for family planning. It also underscores how high-quality service delivery is necessary for expanding access to family planning and scaling up programmatic efforts. Satisfied clients can help generate demand for family planning services through informal word-of-mouth communication. FIGURE 5. Most Influential Source of Information Affecting Decision to Choose MSI Services Among sub-Saharan African Clientsa Across All Service Delivery Channels,b 2012 (N = 6,225) Abbreviations: CBD, community-based distribution; MSI, Marie Stopes International. a Data from exit interviews in 11 sub-Saharan African countries, from August 2012 through December 2012. b Results were weighted by region and delivery channel where appropriate. When weighting by delivery channel, data were only used from countries where the relevant delivery channel had been surveyed. FIGURE 6. Most Important Reason for Choosing Services From Marie Stopes International Among sub-Saharan African Clientsa Across All Service Delivery Channels,b 2012 (N = 6,225) a Data from exit interviews in 11 sub-Saharan African countries, from August 2012 through December 2012. b Results were weighted by region and delivery channel where appropriate. When weighting by delivery channel, data were only used from countries where the relevant delivery channel had been surveyed. INFRASTRUCTURE AND IMPLEMENTATION STRATEGIES REQUIRED FOR SCALE UP Underlying MSI's multichannel approach to scaling up delivery of implant services in sub-Saharan Africa were 3 strategies that leveraged and supported key country infrastructure: Provider supply Commodity supply chains Program financing mechanisms In addition, our experience points to a number of key implementation strategies that should be considered when planning and rolling out programs (Box 3). Finally, operational issues such as access to implant removal services must be planned for in the initial design phase. Each of these factors can pose a barrier to family planning program implementation and expansion if they are not sufficiently addressed. BOX 3. Key Implementation Strategies for Scaling Up Delivery of Implants Focus on clients with unmet family planning need. In order to successfully expand reach, programs must identify and focus on serving prospective users who lack access to a broad range of contraceptive methods, including implants. MSI identifies areas of unmet need through site visits, Ministry of Health input, and analysis of the latest health service and Demographic and Health Survey data. Devote resources to raising awareness and diffuse communications through multiple channels. Sustained awareness-raising activities are critical for attracting new family planning users, including those who choose implants from a wide array of options. Clients may be spread out across a large geographical area and may have limited access to mainstream media channels. Thus, health promotion messages about family planning and implants must be disseminated through different communication channels. Data from MSI client exit interviews in sub-Saharan Africa indicate clients have access to various communication channels, including: community health workers, radio, newspapers, community events, and friends or satisfied clients (Figure 5). Deliver high-quality services. Ensuring high-quality service delivery, at clinical and operational levels, serves as a catalyst for future demand and expansion of service delivery. A positive reputation among clients creates a feedback loop in which existing clients refer new clients. See the Appendix for specific activities MSI uses for establishing service quality. Deliver implants through multiple, interconnected service delivery channels. Using a multipronged strategy to deliver implants helps: (1) ensure the program reaches women of reproductive age in different geographic areas and social strata, as well as with different preferences for health care delivery; (2) generate demand; and (3) ensure comprehensive family planning care for follow up, eventual implant removal, and continued contraceptive use, including family planning counseling and services for clients who do not choose implants. In Madagascar, MSI successfully increased implant uptake and reached the poorest and least accessible women of reproductive age, through its USAID-funded SHOPS (Strengthening Health Outcomes through the Private Sector) program, by using and linking outreach and social franchising channels. 39 Build and leverage public-private partnerships. Given the central role of the Ministry of Health in the health system and its high community visibility, successful private programs work with and strengthen the public health system by: (1) filling gaps in contraceptive method availability, which is sometimes limited to short-acting methods; (2) training public providers in contraceptive counseling and implant removals; and (3) establishing a robust referral system for follow-up care and implant removals. In MSI's SHOPS program in Madagascar, public facilities or providers proved to be the most common referral source for outreach clients and contributed substantially to scaling up implant provision. 39 Sufficient Provider Supply Sufficient health workforce availability and distribution within countries is a key requirement for scaling up implant service delivery. 4 Unlike condoms or other short-acting methods, implants require a skilled health worker in order for clients to use them. To address health worker deficits, many sub-Saharan African governments have implemented task-shifting and task-sharing initiatives, which increase a country's service delivery capacity by delegating some health care delivery tasks from higher-level to less-specialized health workers. 31 Various studies have demonstrated the feasibility of these practices for family planning service delivery, and they have proved effective in the scale up of family planning programs, including delivery of implants. 19 , 32 – 36 As a result, the World Health Organization (WHO) currently recommends the use of task shifting/sharing for implant delivery, recently endorsing 2 new cadres, auxiliary nurses and lay health workers, for this practice. 37 WHO recommends task shifting or sharing for implant service delivery to address health worker shortages. Where allowed by national guidelines, MSI employs task sharing and task shifting to deliver reproductive health and family planning services. 19 , 36 In Ethiopia, Malawi, Mozambique, and Uganda, mid-level providers routinely deliver implants. For example, MSI Ethiopia has dramatically increased its implant delivery capacity through participation in the Integrated Family Health Program, supported by USAID, which has trained more than 10,000 health extension workers to provide implants. Strong Supply Chains Successful health interventions that deliver products to clients in the developing world require robust and predictable commodity supply chains. 38 Stockouts can reduce service uptake; conversely, a reliable supply of commodities is an important component of high-quality service delivery and can increase uptake and loyalty. MSI's 2012 client exit interview data show that 11.6% of sub-Saharan African clients reported that “services or medicines available” was the most important reason for choosing MSI services (Figure 6). To ensure a steady supply of implants to its programs in sub-Saharan Africa, MSI uses a multipronged procurement strategy. First, MSI country programs work to integrate their supply chains into national supply chains to the greatest extent possible. Large quantities of implants are sourced through Ministry of Health central supplies, many of which are funded by USAID. As funding permits, MSI global headquarters in London also procures implants at bulk prices through international tenders. Implant price-volume guarantees from donors and Implanon and Jadelle manufacturers Merck and Bayer, respectively, allow MSI to secure many more implant units with a finite budget. Additionally, MSI receives a global allocation of implants from the United Nations Population Fund (UNFPA). Together, these international supplies provide the flexibility to smooth out individual countries' implant supplies when shortages occur. MSI's product registration initiatives are another way we strive to ensure availability of implants. MSI works to increase the number of implant brands registered and available in countries. Working in partnership with FHI 360, MSI has registered Sino-implant (II) implants under its branded name Femplant in Burkina Faso, Ghana, and Mali. We have also supported Pharm Access Africa Ltd. in introducing Sino-implant (II) in Kenya, Madagascar, Malawi, Nigeria, Senegal, Sierra Leone, and Tanzania. MSI providers are not limited to using Sino-implant (II) implants, however. They use Implanon and Jadelle brands as well, aiming to meet client preferences regarding the duration of contraceptive protection. However, as MSI typically sources implants through Ministries of Health, the registered brands vary by country, and procurement decisions between brands are often outside of MSI's direct influence. To date, MSI's experience in sub-Saharan Africa shows that demand for implants, and thus program scale up, has occurred regardless of brand. Diverse Program Financing Mechanisms For program scale up in sub-Saharan Africa to be successful, it is essential to reach those underserved clients with the highest unmet need. Unmet need for family planning is higher among low-income sub-Saharan African women than among middle- and higher-income groups. 1 With 81% of the sub-Saharan African population (in the countries in which MSI works) living on less than US$2.50 per day, the cost of delivering implants must be subsidized to ensure price does not become a barrier to client uptake. 8 Client exit interview data from 2012 indicate that 9.6% of clients across all service delivery channels in sub-Saharan Africa cited “low-cost” services as the reason why they chose MSI for their family planning services (Figure 6). MSI uses various financing mechanisms to reduce costs to clients and ensure equity in scale up: Part of the surplus generated from clinic operations in developed countries (for example, Australia and the United Kingdom) helps fund the cost of programs in developing countries. Any surpluses generated from services for wealthier clients at developing-country clinics help to subsidize services for lower-income clients, primarily mobile outreach services. Donor subsidies reduce the true cost of implant service delivery, which encompasses both commodity and operations costs. Program efficiencies such as bulk pricing and good logistical management further reduce the cost of service delivery. Vouchers distributed in catchment areas with high unmet family planning need and low access to services direct subsidies specifically toward lower-income clients. (MSI uses a needs test to determine eligibility. 40 ) Vouchers enable clients to choose from any participating, accredited provider to receive free family planning services. Over the last 5 years, MSI has piloted and scaled up the use of vouchers in its social franchising networks in certain countries, including Ethiopia, Madagascar, Sierra Leone, and Uganda. In the USAID-funded SHOPS program in Madagascar, the vast majority of social-franchising clients receiving vouchers chose implants. Between January and September 2011, 3,467 LARCs were provided, 3,001 of which were implants (87%). The number of services delivered to non-voucher clients during the same time period remained fairly stable. Thus, the voucher clients did not significantly displace non-voucher clients, indicating market expansion. 39 In Madagascar, almost 90% of family planning clients receiving vouchers chose implants. Implant Removal Services Contraceptive implants have either a 3-, 4-, or 5-year life span, and clients may decide to discontinue use at any time. Thus, it is essential to have infrastructure in place for implant removals to maintain client trust in the program's family planning services. 7 Robust and reliable removal services can also help maintain a client as a contraceptive user; removal poses an opportune time to counsel the client on method switching or continuation. Ensuring reliable implant removal services is essential to maintain client trust in family planning services. Clients who receive their implants through an MSI clinic or BlueStar franchisee typically return to the same location for their removal service or other follow-up care. Outreach clients, however, must be linked to a static site to access removal services or follow-up care when needed. Mobile outreach teams do offer removal services; however, a client may require a removal in the weeks between outreach visits to her catchment area. As part of comprehensive counseling, MSI providers counsel clients on where to go when a removal or follow-up care is required. For clients living far from an MSI clinic or BlueStar franchisee, MSI maintains active referral networks of public-sector and, in some cases, other NGO facilities that are trained in implant removal. Clients incur no additional charge for removals as this procedure is considered part of service delivery for implants. To ensure provider willingness to deliver these removal services, MSI requires that all staff and all social franchise service providers complete competency-based training on implant and IUD removals as well as on management of side effects. Refresher courses occur at regular intervals and are mandatory. Combined with ongoing provider mentoring by MSI's clinical services managers from the country office, these courses aim to bolster provider confidence and knowledge of the procedures for removal and other follow-up care. To date, MSI has not experienced widespread provider reluctance to remove implants, although continued monitoring of this issue is needed. Maintaining contact with clients after insertion is a key challenge, however. Until recently, MSI, like other family planning service delivery organizations, relied on paper reminder cards to remind clients when to seek implant removals. Since 2012, MSI has been developing a client registration system called the Client Information Center, or CLIC. The system is a combination of software and paper tools that track client profile information including the services and products received during client-provider interactions and any adverse events experienced during the visits. CLIC has been designed to function in the MSI clinic and at outreach delivery channels, ultimately allowing MSI to track clients between facilities when they present in one location and later in another. Built-in reports allow staff to access information on which clients are due for return visits as well as view user-friendly statistical information on who our clients are and what services they receive over time. If clients wish to share their phone number, it is entered into CLIC so that providers can follow up with appointment reminders, information on minor side effects such as changes in menstruation patterns, information on the timing and location of removal services, and post-removal contraceptive choices. To safeguard confidentiality, clients are contacted by phone only with their permission. Thus, this new system provides MSI with a powerful yet easy-to-use tool to track clients post-procedure, ensuring timely removals of implants at the end of their life span and enabling a better understanding of client follow-up behavior. The use of CLIC may also help mitigate any provider reluctance to perform removals as the electronic record may standardize and normalize removal protocols. Discontinuation and Side Effects MSI has tracked discontinuation rates and side effects experienced by outreach clients in some sub-Saharan African countries. Only a small proportion of clients surveyed in Ethiopia (0.4%), Sierra Leone (0.7%), and Uganda (2.7%) had discontinued use of implants after 3 months, with rates increasing at later intervals but still remaining low (Table 4). TABLE 4. Implant Discontinuation Rates Among Clients Receiving Implants From MSI in Ethiopia, Sierra Leone, and Uganda, 2010 Duration of Use Discontinuation Rate Ethiopiaa Sierra Leonea Ugandab (N = 562) (N = 433) (N = 470) 3 months 0.4% 0.7% 2.7% 6 months 0.7% 3.0% N/A 8 months 5.7% 6.2% N/A Abbreviations: MSI, Marie Stopes International; N/A, not applicable. a Data from Ethiopia and Sierra Leone were collected in April 2010 during retrospective follow-up studies on women who received implants in 2009 at mobile outreach sites. 19 b Data from Uganda were collected in a prospective cohort study among women receiving implants, IUDs, or tubal ligations between February and April 2010 at mobile outreach sites. 41 In terms of side effects, only 1.1% of Ugandan clients experienced severe side effects 15 days following insertion; however, none had complications and all received follow-up care. 41 Severe side effects were defined as a frequent level of discomfort that required medical attention to determine whether a complication had arisen. A much larger proportion, 61.9%, also reported pain around the insertion area at this interval, although these clients did not find it severe. At 6 months post-insertion among clients in Ethiopia and Sierra Leone, the proportion of clients reporting they had ever experienced side effects was 40% and 45%, respectively. 19 These side effects included cramping and changes in menstrual bleeding that many implant users experience. In Zambia, Marie Stopes International clients examine contraceptive implants during a group counseling session about the variety of family planning methods from which women can choose. IMPLICATIONS OF MSI'S SERVICE DELIVERY APPROACH With a cumulative 5-year yield of more than 1.7 million contraceptive implants distributed in sub-Saharan Africa, MSI's family planning service delivery approach can be useful for governments and other organizations aiming for similar program expansion. MSI's experience demonstrates that service delivery expansion can be done successfully in sub-Saharan Africa by leveraging existing service delivery channels that many implementing organizations already use: clinics owned and operated by NGOs, social franchising networks, and mobile outreach teams of dedicated providers that work in partnership with the public sector. Underlying our channel operations is a strong infrastructure that enables channels to complement each other in user reach and operational structure. Key elements of this infrastructure include a sufficient number of trained providers, strong commodity supply chains, and diverse financing mechanisms. MSI's implementation experience underscores that quality assurance also matters, in the interest of clinical standards but also to help ensure that clients are satisfied with their experience and that they communicate their satisfaction to generate further demand for services. These systems and strategies have enabled our sub-Saharan African country programs to be nimble in responding to the rising demand for implants over the last 5 years. Governments and organizations wishing to scale up their own programs will likely recognize that the infrastructure investments required to deliver implants as part of a comprehensive method mix can also be leveraged to deliver and expand the uptake of other contraceptive methods. The adaptive quality of MSI's service delivery models is also an important component of its scale-up efforts in sub-Saharan Africa. In response to changing demand, MSI modified its models to best meet the specific context where family planning service delivery was needed. For example, the mobile community outreach worker team emerged as a low-cost alternative to our original clinical services outreach model, enabling MSI to reach underserved communities in urban and peri-urban areas. A new MSI initiative with the government of Ghana offers another example of a model variation. In this expansion of the public-private partnership component of our outreach model, Ghana Health Services will assume MSI's demand-generation costs for MSI Ghana's mobile outreach channel. Other variations include contracting out opportunities, in which governments contract private-sector implementing organizations to deliver specific services, as MSI has recently established with the government of Tanzania for our outreach services. This adaptation responds to the evolving shift occurring in public-private partnerships, in which governments are assuming greater responsibility for the strategic direction of NGO-provided services (Table 5). TABLE 5. Key Components of Mobile Outreach and Implications for Scale Up, Replication, and Sustainability Mobile Outreach Component Implications for: Scale Up Replication Sustainability Free or highly subsidized services Helps facilitate rapid expansion, since poor and rural clients have highest unmet need Requires adequate financing mechanisms to subsidize costs Requires continued investment and greater role of country governments, through contract arrangements and other innovations Teams of dedicated providers Can encourage expansion in areas of high demand by filling service gaps at existing public and private clinics, particularly with high-quality services that can be monitored more easily with such providers Requires trained staff whocan be deployed to remote areas Greater emphasis on integrated service delivery models may generate hybrid models. As public-sector capacity develops, dedicated providers may shift their role to a support function. Public-private partnerships Must be in place for channel to operate properly, and therefore, for service delivery expansion to occur Requires collaborative relationships with public sector and robust referral systems Possible to sustain over the long term, although dynamics may change with the private sector mentoring public-sector providers who assume a larger role in service delivery (presuming the supply of competent public providers increases) Looking forward, the increasing availability of implants will generate demand, and growing numbers of women in sub-Saharan Africa are likely to choose this method. Our recent results in the region, in which every country where we work produced steep rates of growth, demonstrate this demand; our data also show that implant service delivery, among other contraceptive methods, still has room to expand. Concurrent with this rising demand for implant insertion services will be an increase in the need to remove implants. As early users reach the end of their implant's life span, clients will seek removals in greater numbers than before. Such demand for removals will need to be met with additional family planning services in the context of informed choice; post-removal contraceptive counseling services and method choice availability are key for women who wish to continue using a contraceptive method following the removal. Meeting sustained demand for implant insertion, removal, and post-removal services in the long term will require MSI and other service delivery organizations to develop innovative responses to changing needs and to forge strategic partnerships between stakeholders, including clients. The public-private partnerships that have brought us to the current stage in implant scale up—including the price-volume guarantees and the partnerships between NGOs and local governments that underpin outreach and dedicated provider models—set the tone for further collaboration. Rather than viewing mobile outreach, dedicated provider, and social franchising models as stop-gap measures to support shortfalls in public- or private- (commercial) sector capacity, organizations may be able to integrate these models into the existing health system. MSI's new contract models with the governments of Ghana and Tanzania are examples of this integration. Other sustainability strategies include the incorporation of social franchise clinics in national and social health insurance schemes, and publicly funded voucher programs delivering free or very low-cost services for the poorest clients. As donors, governments, and implementing partners work to reach 120 million additional contraceptive users by 2015 as part of the Family Planning 2020 (FP2020) goals, responsiveness within the global health community will be essential. With the recent price-volume guarantees on implants from manufacturers and donors, important progress has already been made in reducing the financial burden of implant procurement. However, continued investment in the implementation costs required for reaching the client is essential—as a “service-volume guarantee” to meet demand among all current and future clients. Taken together, such investments in commodity supplies and effective, high-quality service delivery will enable all of us to deliver on our FP2020 commitments, and ultimately, ensure that all individuals have access to their contraceptive method of choice.

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Accrediting retail drug shops to strengthen Tanzania’s public health system: an ADDO case study

Edmund Rutta, Jafary Liana, Martha Embrey … (2015)

Introduction Retail drug sellers are a major source of health care and medicines in many countries. In Tanzania, drug shops are widely used, particularly in rural and underserved areas. Previously, the shops were allowed to sell only over-the-counter medicines, but sellers who were untrained and unqualified often illegally sold prescription drugs of questionable quality. Case description In 2003, we worked with Tanzania’s Ministry of Health and Social Welfare to develop a public-private partnership based on a holistic approach that builds the capacity of owners, dispensers, and institutions that regulate, own, or work in retail drug shops. For shop owners and dispensers, this was achieved by combining training, business incentives, supervision, and regulatory enforcement with efforts to increase client demand for and expectations of quality products and services. The accredited drug dispensing outlet (ADDO) program’s goal is to improve access to affordable, quality medicines and pharmaceutical services in retail drug outlets in rural or peri-urban areas with few or no registered pharmacies. The case study characterizes how the ADDO program achieved that goal based on the World Health Organization’s health system strengthening building blocks: 1) service delivery, 2) health workforce, 3) health information systems, 4) access to essential medicines, 5) financing, and 6) leadership and governance. Discussion and evaluation The ADDO program has proven to be scalable, sustainable, and transferable: Tanzania has rolled out the program nationwide; the ADDO program has been institutionalized as part of the country’s health system; shops are profitable and meeting consumer demands; and the ADDO model has been adapted and implemented in Uganda and Liberia. The critical element that was essential to the ADDO program’s success is stakeholder engagement—the successful buy-in and sustained commitment came directly from the effort, time, and resources spent to fully connect with vital stakeholders at all levels. Conclusions Beyond improving the quality of medicines and dispensing services, availability of essential medicines, and the regulatory system, the impact of a nationwide accredited drug seller approach on the pharmaceutical sector promises to provide a model framework for private-sector pharmaceutical delivery in the developing world that is sustainable without ongoing donor support.

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Christina Riley:

ORCID: http://orcid.org/0000-0002-6167-1284

Role: ConceptualizationRole: Data curationRole: Formal analysisRole: MethodologyRole: ValidationRole: VisualizationRole: Writing – original draftRole: Writing – review & editing

Danielle Garfinkel: Role: ConceptualizationRole: Data curationRole: InvestigationRole: MethodologyRole: Project administrationRole: VisualizationRole: Writing – original draft

Katherine Thanel: Role: ConceptualizationRole: Data curationRole: Formal analysisRole: InvestigationRole: MethodologyRole: Project administrationRole: ValidationRole: Writing – original draftRole: Writing – review & editing

Keith Esch: Role: Data curationRole: MethodologyRole: ValidationRole: Writing – original draft

Endale Workalemahu: Role: InvestigationRole: Project administration

Jennifer Anyanti: Role: InvestigationRole: Project administration

Godéfroid Mpanya: Role: InvestigationRole: Project administration

Arsène Binanga: Role: InvestigationRole: Project administration

Jen Pope: Role: ConceptualizationRole: Funding acquisitionRole: SupervisionRole: Validation

Kim Longfield: Role: ConceptualizationRole: ResourcesRole: SupervisionRole: ValidationRole: Writing – review & editing

Jane Bertrand: Role: ConceptualizationRole: SupervisionRole: ValidationRole: Writing – review & editing

Bryan Shaw: Role: ConceptualizationRole: Funding acquisitionRole: InvestigationRole: MethodologyRole: Project administrationRole: ResourcesRole: SupervisionRole: ValidationRole: Writing – original draftRole: Writing – review & editing

Ganesh Dangal: Role: Editor

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Journal ID (nlm-ta): PLoS One

Journal ID (iso-abbrev): PLoS ONE

Journal ID (publisher-id): plos

Journal ID (pmc): plosone

Title: PLoS ONE

Publisher: Public Library of Science (San Francisco, CA USA )

ISSN (Electronic): 1932-6203

Publication date (Electronic): 14 February 2018

Publication date Collection: 2018

Volume: 13

Issue: 2

Electronic Location Identifier: e0192522

Affiliations

[1 ] Population Services International, Washington, D.C., United States of America

[2 ] Population Services International–Ethiopia, Addis Ababa, Ethiopia

[3 ] Society for Family Health, Abuja, Nigeria

[4 ] Association de Santé Familiale, Kinshasa, Democratic Republic of Congo

[5 ] Tulane International, Kinshasa, Democratic Republic of Congo

[6 ] Independent consultant, Washington, D.C., United States of America

[7 ] Department of Global Health Systems and Development, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, United States of America

[8 ] Institute for Reproductive Health, Georgetown University, Washington, D.C., United States of America

National Academy of Medical Sciences, NEPAL

Author notes

Competing Interests: The authors have declared that no competing interests exist.

¶ Membership of the FPwatch Group Working Group is listed in the Acknowledgments.

* E-mail: riley.christinam@ 123456gmail.com

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Christina Riley http://orcid.org/0000-0002-6167-1284

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Publisher ID: PONE-D-17-33269

DOI: 10.1371/journal.pone.0192522

PMC ID: 5812628

PubMed ID: 29444140

SO-VID: 5258d90e-3490-427a-b94a-ac03294d12eb

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This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

History

Date received : 12 September 2017

Date accepted : 16 January 2018

Page count

Figures: 4, Tables: 2, Pages: 16

Funding

Funded by: funder-id http://dx.doi.org/10.13039/100000865, Bill and Melinda Gates Foundation;

Award ID: OPP1112709

Award Recipient : FPwatch Group

The authors are grateful to the Bill & Melinda Gates Foundation (grant no. OPP1112709) for funding support. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. https://www.gatesfoundation.org/How-We-Work/General-Information/Grant-Opportunities.

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Data Availability All study data are available from the Harvard Dataverse as follows: DRC (URL: http://dx.doi.org/10.7910/DVN/OJD10N, DOI: 10.7910/DVN/OJD10N), Ethiopia (URL: http://dx.doi.org/10.7910/DVN/JRTCW5, DOI: 10.7910/DVN/JRTCW5), Nigeria (URL: http://dx.doi.org/10.7910/DVN/2HRQON, DOI: 10.7910/DVN/2HRQON).

Getting to FP2020: Harnessing the private sector to increase modern contraceptive access and choice in Ethiopia, Nigeria, and DRC

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Quality of Private and Public Ambulatory Health Care in Low and Middle Income Countries: Systematic Review of Comparative Studies

Scaling up delivery of contraceptive implants in sub-Saharan Africa: operational experiences of Marie Stopes International

Accrediting retail drug shops to strengthen Tanzania’s public health system: an ADDO case study

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