 Thank you all for coming. I'm hoping that there will probably be a few more people who will show up. But one of the things we do with the seminar series is to record for the open crosswear program so that we can reach a broader audience. And the last time we did this, some people who viewed the video talked about the noise in the hallway. So I close that for now, but hopefully we will try to minimize noise. It's also a very hot day, so we'll keep the windows closed. But if you're feeling starved for air, let me know. So welcome. My name is Dele Wicheltan. I'm delighted to welcome to our campus today Dr. Andola Prata. She's a public health physician and medical demographer originally from Angola. She's an associate professor in residence of McDonald and Child Health in the School of Public Health at UC Berkeley. And she's the scientific director for the Bixby Center for Population Health and Sustainability and also medical director for the Venture Strategies Innovations Group. She's worked throughout Africa and Asia in many areas including family planning, financing for the productive health programs, the private sectors role in health care in developing countries, priorities for maternal health, maternal mortality, and the use of misoprostol for postpartum obstetrics. She's a frequent fire, so she just returned from a trip, and I just don't understand that she will be leaving again in less than a week. So this is a privilege to have her while she's in the country to come to Irvine and talk with us about her work. Please join me in welcoming Dr. Prata. Good afternoon everybody, it's a real pleasure to be here at UCI. I'm especially invited by the School of Public Health to discuss some of the work that I'm doing. And Deli mentioned that I'm traveling and I'm actually going on Saturday to go back to the project that I will discuss with you today. So today my plan is to talk with you about some of the financing and distribution strategies that we have put in place, the case of Ethiopia World, Ethiopia Tool Increase, community-based access to injectables. Usually my style of presentation is very interactive, so please feel free to interrupt and ask questions, raise your hand if I'm going too fast or if I'm using too many acronyms and you don't understand what I'm talking about. Is that okay? So just very quickly a little bit of background on Ethiopia. It's a country in East Africa that is moving quite fast when it comes to changes in reproductive health. So the contraceptive prevalence, especially modern methods, and I'm shown here so that you can see some of the more recent trends using the last two demographic and health surveys have increased. It's very interesting that most of the increase actually comes from rural areas. But there's still a large number of women who would like to use family planning methods, do not want to get pregnant and are not using family planning, which is the definition of unmet need for family planning. Now among all the methods for family planning, most women in rural areas, and please note that Ethiopia is 85% rural, so most women in rural areas like injectable contraceptive, and you will see as I continue this presentation some of the reasons why. And it's not just in Ethiopia, but in most of rural Africa it's the fastest growing method of contraception. But in the case of Ethiopia, Ethiopia has probably one of the highest unmet need for injectables if you compare with other countries for which we have demographic and health survey. So in order to respond to some of those needs, especially related to the use of injectables, between 2008 and 2009, the Bixby Center led by myself, we sort of tried to demonstrate if it would be possible that community-based reproductive health agents, which are community health workers that are usually only distributed pills and condoms, could give injections. That was the method that women wanted to use. And to understand why we embarked on this, you have to understand a little bit my past. And my past in public health has been always working with the lay healthcare workers, community workers, working with the women, working with communities and empower them to use the easy-to-use technologies to improve their health. So please remember that giving an injection you do not need to go to medical school or nursing school is a skill that you learn similar to meeting, cooking, and some other skills, probably more complicated skills. So what we did was looking at the safety, acceptability, continuation rates of injections by the community health workers and we compared them with the health extension workers, which are the health system, when governments have a last provider that is in health posts, that is by mandate authorized to give injections. Community health workers cannot give injections, only them. But they are in the health posts and women will have to come to the health posts. A lot of issues happen when women go to the health posts. There are two health extension workers per village in a health post and they deal with all of the health issues of the communities that they serve. Child health, adult health, all of the diarrhea, all of the tuberculosis. If there is a meningitis outbreak, all of these issues, they deal with everything. So if you are young women that come to get an injection, you will probably be, as you can imagine, the last one to be served if the day doesn't end with women waiting all day there and having to go back home. So what we were trying to do is to see if the level of services related to getting an injection would be similar after training of course between this community health workers and the health extension workers. So over the course of 12 months, unfollowing women through three injections, an injection is to be given every three months, we realized, as you can see from this graph, that CDRI chains here are the community health workers and the hues are the health extension workers. So we realized that the community health workers actually could over time recruit a lot more women because as you can imagine, they were walking and going to their homes while the health extension worker was waiting for them most of the times in the health post. And this individual case is for repeat. So every three months, the women have to come. Yes. These numbers include the same women coming three times or unique cases? Yes. Yes, this is over time, so we followed more or less the same women. And you will see in the next one, because the importance of going back to the same women, it's very, very important to ensure continuation rates. And then also having consideration why we have in this continuation rates, just to give you our discontinuation rates, as you can see, were quite low. So we had some laws to follow up during the course of the study, but as some women have moved, some women, their husbands have moved to another village and they moved, but we were able to, in these villages during this time, actually track down every single household to know what was going on. And basically, we were able to realize that the community-based reproductive health agents were doing, in terms of the safety in giving injections, they were doing just as good job. And it could do even better job at continuation rates and recruiting, especially in the recruitment of new users, first time family-friendly users. The issue with hormonal contraceptive methods that is also leads women to discontinue is the counseling process and explaining the expected side effects. So these methods have side effects. And depending on the culture, in many countries where I work in Africa, women understand these side effects differently. You know, if you feel something once you take a medicine, you might understand as, for example, something, you know, that this medicine are giving you a different disease, rather than understand as a reaction to that medication. So we realized that the community health workers, because they had a lot more time to discuss these issues, did a significant better job at explaining to women what to expect. That when they had, when the side effect occurred, they could quickly go back to them, ask more questions, and be reassured that it wasn't a new disease that they were having. It was something that could be manageable. And if not, we paid very careful attention to all side effects. And if not, they will be able to then change the method without interruption so that pregnancy wouldn't happen in between. So after we were able to complete this study, and I have to say this study was published in the WHO bulletin, and as part of, it was also part of a large technical consultation meeting organized by the World Health Organization, after which the World Health Organization put out statements about the countries with the low contraceptive use, where the preferred method of choice in rural areas was injectables, that they should go and increase community-based use of injectables. Now, the problem after you do this type of pilot project is how do you scale it up? In the case of Ethiopia, for example, there are more than 7,000 community health workers. Now, who's going to train them? Who's going to pay their salaries because they work as voluntary community health workers? So who's going to pay their salaries? Who's going to do the supervision? You know, it becomes really overwhelming for healthcare systems that are already, you know, dealing with limited resources. So, but we felt like we had to work on models to scale it up to address the two main problems, the distribution so that, as you know, if you live in rural areas, they don't have pharmacists there. So pharmacists end where asphalt ends. So there's no asphalt. You won't find, for the most part, the pharmacists. And if you don't have pharmacists, then you don't have these drugs available. Now, we have to bring the drugs to the community health workers so that they can then do the distribution. But for us, it was really, really important, and this is more or less the landscape that we see in the integrity where we work. It's very, very important to decrease the animate need. This is an area where unwanted pregnancies are very, very high, which leads to unsafe proportions. And those unsafe proportions have consequences in terms of mobility and maternal mortality. It is also part of government strategy to increase contraceptive prevalence. But also, most importantly for us, by scaling up this project, we will be responding to women's needs and women's desire to use this method, given that pills and condoms were already there, but not being used in the same way. So what we then needed to do, and this is a poster of confidence, the social marketing brand of injectable contraceptive that was being used in Ethiopia. So what we needed to do is to test the feasibility to scale up a model because the social marketing is already well-established in urban areas, a very successful program. And then you have the community-based distribution of condoms and pills that are doing quite a good job in terms of distribution and accessing women, but women actually want and request injectable. So what we wanted to do is to see if we can marry both the community-based distribution and the social marketing. In a way, pushing the boundaries of social marketing into rural areas in a little bit out of the comfort zone, because as you know, social marketers, they rely on existing infrastructure, so the shops, the small pharmacies or drug shops, rural drug vendors, et cetera. So we wanted to bring together both in a really sort of a public-private partnership. A grid is a good public-private partnership to increase access to injectables. Now, the other problem that we found is like, in the financing of injectables, we know already because during our pilot, we also did surveys that sort of asked about willingness to pay for the injection. And we know that in rural areas, there's going to be at any point in time a certain percentage of women that will not be able to pay for the injection, especially something that, you know, in rural economies where today you might have some disposable income next month you don't have, and this is a location that you actually need to have consistent funds available every three months. So what we were able to do is then team up with the Women Stickers Association, which is a grassroots organization, and basically request that with some initial seed funding if they could handle a drug-revolving fund that started for injectable contraceptives, but then it could sort of evolve to many, many other things. So this partnership includes the Women's Degree Association, and I said, that basically handles all of the management procurement of the drug through DKT, Teopia, which is the social market organization. McKelley University and the Bixby Center, which are the two universities, so we train McKelley University to do the training of the community health workers and help us with the monitoring of supervision, and then the Tigray Health Bureau, which is sort of a public sector, higher sort of an organizational structure responsible for the health of the population. And this is a picture of all of us there, as you can imagine. There's a good balance right there in the leadership of this project. But basically what we needed to do to scale up this project is to train the community-based reproductive health agents in the case of Tigray Day, almost 1500, and refocus the social marketing to include rural areas instead of focusing just on urban areas. We're starting by providing each individual community-based reproductive health agent with a stock of injectables, and that stock works as micro-credit, like a micro-credit loan, but clean kind instead of money. And they took those injections home, so they sell, when the administration sends each injection, they sell it for five dollars, the local currency, and they keep two with them, and they pay back to the Drug Revolving Fund a three-book, because that is the price that we actually purchase from the Haiti Ethiopia. So that takes also care of some of the issues related to just being voluntary, because these women now are making their own money. And the Drug Revolving Fund would then address issues for adolescents that have no money to pay, and also for those months where certain women will not be able to pay. And I have to say that after a few months, we started the project, the expansion in October with this model, and after a few months, when we met with all community health workers, some of them have given free injections, so they don't get reimbursed for free injections, but they were happy to do that for now. And what we also did was we conducted a baseline survey, so we know the preferences, the fertility levels, where women would like to receive their injection. We also did a survey for the provider's characteristics, so the community health workers. And as you can imagine, it was a lot of controversy given that 39% of the injection providers are farmers. So in the medical establishment, it was a crisis, because how can you allow farmers to give injections to other farmers? But usually doctors have those kinds of questions. But they did very well. They're doing an excellent job. We have established a micro-credit system and a re-bumping fund, so most of the women have already come back for the second. So they take in the loads of 25 injections each time. So after training, they went home with the 25, and then they come back to their local, so at the district level, the local women's association, and they pay back the money for the injections that they took, and they receive, again, another loan of 25 injections. So the first cohort that we trained was about 100. The 31 were those who we sort of did a refresher course, because they participated in doing the pilot. So in doing the pilot, everything was free. But then they had to sort of learn new processes. And in the first three months, they were giving about six injections per month on average, which was quite what we were expecting at that time. And of course, as you can imagine, the majority of their clients were new users out of family planning. There is still a lot to accomplish in this project. This is a three-year project. We are planning on actually training all of the community-based reproductive health agents in this area of T-grade. One thing that we still need to figure out is what is sort of the fixed amount required for the drug-revolving fund to sustain itself. Right now we have about 15% of users that are not paying for the drugs. So we estimated that the funds that we have for the drug-revolving fund could run up to 20% to 25% free injections. But if for some reason we have more than that, then the fund will be in trouble and we are really worried about raising the price of injections and losing. We expect probably 10 to 15% of users to raise the price of injections. So this is something that we still are trying to figure out, but it puts a lot of things in perspective that some of these concepts of sustainability are really, really difficult when you are addressing a major issue that can improve maternal and child health, but in rural areas, but at the same time, there is a financing contribution that needs to take place and the populations that are being served are very, very poor. So sustainability, even when you have public-private partnerships, are going to become very, very difficult. But one of the good things that came out of this project is that in discussions with the Tigray Health Bureau, there are some projects to be put in place where the population is expected to have some funding contribution to their health care in general as part of the community health funds using community health insurance. And the examples from this project could be a really good example to build upon as they move on to community health insurance for just general maternal and child health. So we still need to also demonstrate that the project itself and this methodology that addresses distribution and financing has the necessary acceptability from the population, that sort of the combination of social marketing and community-based distribution, at least for injectables, can work, and what more can be learned from there. It is also important to note that even though we are trying by giving the part of the profits from the injections to the distributors themselves, that in their mind they will be using this after a certain amount of money, they will be using it towards their community. So the money goes back, what they themselves raised goes back to their community to do things that they would like to do in their communities like buy another animal or more food or vegetable garden or things like that. So it's a very small quantity but at the same time for them it's also a sign of the respect that we sort of as part of the healthcare system have for them giving that a lot of what we do in the community is based on community volunteers. So basically they get absolutely nothing except when they come for training and there's refreshments and lunch and things like that. So I am going to stop here and thank you and open up for a discussion. So I have the public-private partnership I think it looks like it works in this case. But my question is about the message and the perception of this more of I guess property life. What is the word? Prevention of pregnancy. How does the cost compare between the indexables and condoms and the idea that another program is giving out the message about pregnancy prevention should be linked to disease prevention especially maybe HIV transmission might be effectively controlled by condoms whereas injectables this may not necessarily be the case. So is the partnership to combine it to as opposed to just combining the strategy of delivery and financing that the messages are not conflicting when we talk to the women? Thank you for the question. You are absolutely right. The messages are not conflicting. We know during the counseling that the community health workers tell them that injectables does not prevent against disease and some of them had the dual protection. The problem with the condoms is an old one that you all know. It works even in rural areas much better for pregnancy prevention or disease prevention and occasional encounters but it doesn't work very well with regular partners including husbands. There's a lot of resistance from partners especially to use condoms for various reasons and women as they explained to us they have difficulties making their partners use the condoms. So in that case they basically have no protection whatsoever not for disease and not for pregnancy prevention and they really prioritize pregnancy prevention especially when they are in stable relationships. Now there's a lot of women I didn't show the data here but there's a lot of women that actually take on both. So they use both. But it is also important to note that this is a quite low contraceptive HIV prevalence community. So even when we talk about they understand the risks but you have to understand that for them unwanted pregnancy which is associated with a huge amount of stigma is a more oppressing issue for them and that's why they desire some method that is not quite independent to use a certain length of protection rather than for example taking pills every day and not having to have the cooperation so to speak of their husbands to do. That's why injections become a very important method for this problem. But it is important. So even if condoms are cheaper they are not sustainable for a completely different reason which is their acceptance. They don't just cheaper condoms are being distributed. For free that's quite fine. And so are the pills. But the worst part is they have injectables also at the health post but due to the convenience and trusting basically the neighbor that gives the injection they would rather pay than walk to the health post. So in some instances actually some of the community health workers say why do you think they pay? They say they pay for the practices of the method. There's still a lot of issues related to fertility and how many children do they expect or how many children this young woman need to have. You also have to remember that these women they're quite early. They start childbearing at 15, 16. So by the time they are 30 they might already have fibrocytes and the injections are sort of as they say it, their preferred method. Even though in some areas where we are now trying to pilot the implants the single rod implant that the health extension workers in health posts can do some of them are switching especially those who don't want to have any more children. Not the ones they want to space they might have a bit of switching going on which is okay. They sort of are switching from the depot to a more sort of a long acting method. I have a quick question. Just to be clear the community health workers are those people from the rural areas so they're okay. Yes, yes they are. And they do in this particular case I mean throughout Africa I do various things but in this particular case they do a lot of health promotion. They actually started by the government to improve sort of a basic hygiene and knowledge about for example not sleeping with animals in the same hut to sort of have some distance breastfeeding, teaching others about breastfeeding how best to use the local nutritional sort of elements to incorporate in their diet and things like that and over time we basically started to add more and more as the needs was growing more tasks to them but usually each village might have four or six community health workers and they have also in Ethiopia they have what they call the coffee ceremonies so where a lot of women come together and there's the roasting of the coffee and serving of the coffee three or four small little expressos and during that time there's a lot of discussions about health and reproductive health specifically in this case. So did you find a need in all the educational programs to educating in the males of the family? Absolutely. It's a working progress and we continue to educate and we actually found evidence we have in the project three priests, Portuguese Christian priests that are also community-based distributors of contraceptives and they do also a really nice job at involving men in the discussions the importance of sort of spacing for the benefits of the mother and the children so for what we were able to do during this education campaigns apart from what you will say is to give the local communities those that have a louder voice and are trusted by the communities the ability to explain all this the ability to just not oh we need to reduce fertility you know you're having too many children but to have a more sort of health rationale maternal child health rationale to family planning and that doesn't mean that everybody agrees with it it doesn't mean there's a lot of women that are part of the category that we call covert use so basically we know that their husbands don't know that they're losing their mother and that is something that community health workers know and do that continue to provide services in privacy not to put there one more question so when you looked at the baseline I guess you probably saw some crossover between you know after the program people were taking other contraceptives and so the demand for injection increased but what was the overall demand increased from the baseline after the program oh we haven't we just have the baseline we haven't measured yet so we are planning on measuring after three years after three years yes we haven't measured so what we saw is a desire to change the of those who wanted to use which is a you know 67% of women of reproductive age want to use when they plan methods and of those wanting to use the vast majority wanted the injectable but that is at this point in time as other methods and they move in their reproductive life they're going to need and want other much longer methods so the injectables are you know it's a quick response for now but it's probably not going to hold forever because very quickly you know in the late 30s they already don't want to have any more children and at that point in time they don't want also every three months to get an injection they want something more permanent I want to have one more question so has there been any sort of just general economic analysis the cost of implementing this program you know versus the cost of not implementing this program and dealing with all the health repercussions not that I have complete numbers to give you but that is something that is part of our project so we're tracking costs we're tracking costs including when you know they're taking their time voluntarily but we're tracking how many hours a week they actually spent on this project and we will do the economic analysis but I can tell you that it's going to be a substantial difference in price I mean there's many studies that you can find looking at the return on investment for family planning programs in general even those that cost quite a bit even in California we have Family Pack as one of the best surf in America family planning services and even though we spend you know hundreds of thousands of dollars more than any family planning program in sub-Saharan Africa it's still a very important return on investment you shouldn't quote me on this but it's something like one so you receive back $100 for every dollar that you spent which would be spent on infant mortality education programs special education programs water and sanitation I mean not just health but also other social programs for which if these children are born and survive, we'll need services you talked about scaling up and I I don't know one of the things you would build into your training program let's say for example this is a very highly diverse society in terms of language maybe some sub-cultural issues that you may have to train differently how is this region in that respect my sense of Ethiopian I've met with being is homogenous but in other parts of Africa you might go from one village to another and it's all different in Ethiopia too this region called Tigray is mostly Christian there's a little bit of a very small percentage of other religions but in other places in other regions in Ethiopia you have a much diverse with different needs and different perspectives on family planning that would have to be would have to be addressed one of the things that is cross-cutting among all ethnic groups in Ethiopia is their desire to care for your children that has you can see demographic health survey demographic health survey how it's going their desire for families is increasing so the number of children they have more than more children that they actually want on average so it's just sometimes how to deliver the family planning message that is non-friendly to the different survey ethnic groups but you train in English the training program is in English and they put it in the local language yes all of the materials all of the things are in local language and even for example the education portion we don't really script what to say they actually teach us what to say we give them the knowledge of what it is that we want to achieve so here is how I would say well if there are no further questions we have a little thing for you that you take on your travels it's more for water it's too big for Ethiopian espresso I can put 3 or 4 so please thank Dr. O'Connor