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Osebo C, Grushka J, Deckelbaum D, Razek T. Assessing Ethiopia's surgical capacity in light of global surgery 2030 initiatives: Is there progress in the past decade? Surg Open Sci 2024; 19:70-79. [PMID: 38595832 PMCID: PMC11002296 DOI: 10.1016/j.sopen.2024.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 03/25/2024] [Indexed: 04/11/2024] Open
Abstract
Background Surgical, anesthetic, and obstetric (SAO) care plays a crucial role in global health, recognized by the World Health Organization (WHO) and The Lancet Commission on Global Surgery (LCoGS). LCoGS outlines six indicators for integrating SAO services into a country's healthcare system through National Surgical Obstetrics and Anesthesia Plans (NSOAPs). In Ethiopia, surgical services progress lacks evaluation. This study assesses current Ethiopian surgical capacity using the LCoGS NSOAPs framework. Methods We conducted a narrative review of published literature on critical LCoGS NSAOPs metrics to extract information on key domains; service delivery, workforce, infrastructure, finance, and information management. Results Ethiopia's surgical services face challenges, including a low surgical volume (43) and a scarcity of specialist SOA physicians (0.5) per 100,000 population. Over half of Ethiopians reside outside the 2-hour radius of surgery-ready hospitals, and 98 % face surgery-related impoverished expenditures. Lacking the LCoGS-recommended SOA reporting systems, approximately 44 % of facilities exist for handling bellwether procedures. Despite the prevalence of essential surgeries, primary district hospitals have limited operative infrastructures, resulting in disparities in the surgical landscape. Most surgery-ready facilities are concentrated in cities, leaving Ethiopia's 80 % rural population with inadequate access to surgical care. Conclusion Ethiopia's surgical capacity falls below LCoGS NSOAPs recommendations, with challenges in infrastructure, personnel, and data retrieval. Critical measures include scaling up access, workforce, public insurance, and information management to enhance SAO services. Ethiopia pioneered in Sub-Saharan Africa by establishing Saving Lives Through Safe Surgery (SaLTS) in response to NSOAPs, but progress lags behind LCoGS recommendations.
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Affiliation(s)
- Cherinet Osebo
- McGill University Health Centre, Centre for Global Surgery, Department of Surgery, Montreal General Hospital, Montreal, Quebec, Canada
- Hargelle Hospital, Emergency Surgery and Obstetrics Unit, Hargelle, Ethiopia
| | - Jeremy Grushka
- McGill University Health Centre, Centre for Global Surgery, Department of Surgery, Montreal General Hospital, Montreal, Quebec, Canada
| | - Dan Deckelbaum
- McGill University Health Centre, Centre for Global Surgery, Department of Surgery, Montreal General Hospital, Montreal, Quebec, Canada
| | - Tarek Razek
- McGill University Health Centre, Centre for Global Surgery, Department of Surgery, Montreal General Hospital, Montreal, Quebec, Canada
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Roberts SLE, Healey A, Sevdalis N. Use of health economic evaluation in the implementation and improvement science fields-a systematic literature review. Implement Sci 2019; 14:72. [PMID: 31307489 PMCID: PMC6631608 DOI: 10.1186/s13012-019-0901-7] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 04/29/2019] [Indexed: 01/09/2023] Open
Abstract
Background Economic evaluation can inform whether strategies designed to improve the quality of health care delivery and the uptake of evidence-based practices represent a cost-effective use of limited resources. We report a systematic review and critical appraisal of the application of health economic methods in improvement/implementation research. Method A systematic literature search identified 1668 papers across the Agris, Embase, Global Health, HMIC, PsycINFO, Social Policy and Practice, MEDLINE and EconLit databases between 2004 and 2016. Abstracts were screened in Rayyan database, and key data extracted into Microsoft Excel. Evidence was critically appraised using the Quality of Health Economic Studies (QHES) framework. Results Thirty studies were included—all health economic studies that included implementation or improvement as a part of the evaluation. Studies were conducted mostly in Europe (62%) or North America (23%) and were largely hospital-based (70%). The field was split between improvement (N = 16) and implementation (N = 14) studies. The most common intervention evaluated (43%) was staffing reconfiguration, specifically changing from physician-led to nurse-led care delivery. Most studies (N = 19) were ex-post economic evaluations carried out empirically—of those, 17 were cost effectiveness analyses. We found four cost utility analyses that used economic modelling rather than empirical methods. Two cost-consequence analyses were also found. Specific implementation costs considered included costs associated with staff training in new care delivery pathways, the impacts of new processes on patient and carer costs and the costs of developing new care processes/pathways. Over half (55%) of the included studies were rated ‘good’ on QHES. Study quality was boosted through inclusion of appropriate comparators and reporting of incremental analysis (where relevant); and diminished through use of post-hoc subgroup analysis, limited reporting of the handling of uncertainty and justification for choice of discount rates. Conclusions The quantity of published economic evaluations applied to the field of improvement and implementation research remains modest; however, quality is overall good. Implementation and improvement scientists should work closely with health economists to consider costs associated with improvement interventions and their associated implementation strategies. We offer a set of concrete recommendations to facilitate this endeavour.
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Affiliation(s)
- Sarah Louise Elin Roberts
- King's Health Economics, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, David Goldberg Centre, De Crespigny Park, London, SE5 8AF, UK.
| | - Andy Healey
- King's Health Economics, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, David Goldberg Centre, De Crespigny Park, London, SE5 8AF, UK.,Centre for Implementation Science, King's College London, London, UK
| | - Nick Sevdalis
- Centre for Implementation Science, King's College London, London, UK
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Geta ET, Belete YS, Yesuf EA. Cost of treatment among self-referred outpatients in referral hospitals compared to primary health care facilities in East Wollega, western Ethiopia: A comparative cross-sectional study. J Public Health Afr 2019; 10:1024. [PMID: 31244983 PMCID: PMC6562257 DOI: 10.4081/jphia.2019.1024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 05/29/2019] [Indexed: 11/22/2022] Open
Abstract
Patient self-referral is a condition when patients refer themselves to higher level health facilities without having to see anyone else first. Despite the expansion in the number of health facilities, it has been seen when patients routinely accessed referral hospitals without a formal referral. The study aims to evaluate cost of treatment among self-referred outpatients at referral hospitals compared to primary health care facilities. Comparative cross-sectional study design was used and the required sample size for the study was determined by using formula of double populations mean comparison cost of treatment for diseases leading to outpatient visits. A total of 794 participants (397 from referral hospital and 397 from primary health facilities) were included in the study. Data was collected using face-to-face interview from December 1 to 30, 2017. Data entry and analysis were made using SPSS version 20. Descriptive statistics and independent samples t-test were performed. A total of 783 outpatients responded to the interview of the study and 391 of them were from referral hospital and 392 from primary health facilities. The mean of outpatient visit cost per visit for the treatment of diseases leading to outpatient visits was significantly higher at referral hospitals compared to primary health facilities [95% CI=6.13 (5.07-7.18)] USD. The mean cost of outpatient visits for the treatment of all type of diseases leading to outpatient visits was significantly higher at referral hospitals and at least two times of primary level health facilities. Health care providers should create awareness in the community about referral linkages to inform patients and their families the additional costs they incur when they bypass the proximal primary health facilities.
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Affiliation(s)
- Edosa Tesfaye Geta
- Department of Health Economics, Management and Policy, Faculty of Public Health, Institute of Health, Jimma University, Ethiopia
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Iverson KR, Garringer K, Ahearn O, Alidina S, Citron I, Esseye S, Teshome A, Mukhopadhyay S, Burssa D, Mengistu A, Ashengo T, Meara JG, Barash D, Drown L, Kuchuckhidze S, Reynolds C, Joshua B, Barringer E, Skeels A, Shrime MG, Gultie T, Sharma S, Geiger J. Mixed-methods assessment of surgical capacity in two regions in Ethiopia. Br J Surg 2019; 106:e81-e90. [DOI: 10.1002/bjs.11032] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 08/05/2018] [Accepted: 10/01/2018] [Indexed: 12/13/2022]
Abstract
Abstract
Background
Surgery is among the most neglected parts of healthcare systems in low- and middle-income countries. Ethiopia has launched a national strategic plan to address challenges in the surgical system. This study aimed to assess surgical capacity in two Ethiopian regions to inform priority areas for improvement.
Methods
A mixed-methods study was conducted using two tools adapted from the Lancet Commission's Surgical Assessment Tools: a quantitative Hospital Assessment Tool and a qualitative semistructured interview tool. Fifteen hospitals selected by the Federal Ministry of Health were surveyed in the Tigray and Amhara regions to assess the surgical system across five domains: service delivery, infrastructure, workforce, information management and financing.
Results
Service delivery was low across hospitals with a mean(s.d.) of 5(6) surgical cases per week and a narrow range of procedures performed. Hospitals reported varying availability of basic infrastructure, including constant availability of electricity (9 of 15) and running water (5 of 15). Unavailable or broken diagnostic equipment was also common. The majority of surgical and anaesthesia services were provided by non-physician clinicians, with little continuing education available. All hospitals tracked patient-level data regularly and eight of 15 hospitals reported surgical volume data during the assessment, but research activities were limited. Hospital financing specified for surgery was rare and the majority of patients must pay out of pocket for care.
Conclusion
Results from this study will inform programmes to simultaneously improve each of the health system domains in Ethiopia; this is required if better access to and quality of surgery, anaesthesia and obstetric services are to be achieved.
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Affiliation(s)
- K R Iverson
- Department of Global Health and Social Medicine, Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
- Department of Surgery, University of California Davis Medical Center, Sacramento, California, USA
| | - K Garringer
- Department of Global Health and Social Medicine, Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | - O Ahearn
- Department of Global Health and Social Medicine, Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | - S Alidina
- Department of Global Health and Social Medicine, Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | - I Citron
- Department of Global Health and Social Medicine, Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | - S Esseye
- Federal Ministry of Health, Addis Ababa, Ethiopia
- Jhpiego, Addis Ababa, Ethiopia
| | - A Teshome
- Federal Ministry of Health, Addis Ababa, Ethiopia
| | - S Mukhopadhyay
- Department of Global Health and Social Medicine, Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
- Department of Surgery, University of Connecticut, East Hartford, Connecticut, USA
| | - D Burssa
- Federal Ministry of Health, Addis Ababa, Ethiopia
| | | | | | - J G Meara
- Harvard Medical School and Children's Hospital of Boston, Boston, Massachusetts, USA
| | - D Barash
- GE Foundation, Boston, Massachusetts, USA
| | - L Drown
- Harvard Medical School, Boston, Massachusetts, USA
| | | | - C Reynolds
- Assist International, Ripon, California, USA
| | - B Joshua
- Assist International, Ripon, California, USA
| | | | - A Skeels
- Jhpiego, Baltimore, Maryland, USA
| | - M G Shrime
- Harvard Medical School, Boston, Massachusetts, USA
| | | | - S Sharma
- Harvard Medical School, Boston, Massachusetts, USA
| | - J Geiger
- Harvard Medical School, Boston, Massachusetts, USA
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Zegeye EA, Reshad A, Bekele EA, Aurgessa B, Gella Z. The State of Health Technology Assessment in the Ethiopian Health Sector: Learning from Recent Policy Initiatives. Value Health Reg Issues 2018; 16:61-65. [PMID: 30195092 DOI: 10.1016/j.vhri.2018.07.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 07/02/2018] [Accepted: 07/11/2018] [Indexed: 11/25/2022]
Abstract
Health technology assessment (HTA) has previously been implemented only in a fragmented manner in the Ethiopian health sector decision-making cycle, and the sector has been hampered by limited institutional capacity and skilled human resources to inform evidence-based decision making. The country is in the midst of widescale implementation of a community-based health insurance scheme and is preparing for the launch of a social health insurance scheme. The country continues to face a limited financial resource envelope, undergoing an epidemiological transition, and is facing a much greater burden of noncommunicable diseases, for which the essential health benefit package, defined 12 years ago, may no longer be suitable. This has called for an in-depth review of the application of HTA in the context of the current health needs and institutional settings. To meet the increasing need for HTA, the Health Economics and Financing Analysis (HEFA) team was established within the Finance Resource Mobilization Department under the Ministry of Health. The HEFA team is tasked with spearheading the application of evidence-based health care decision making in Ethiopia by organizing available evidence, costing interventions, and defining effectiveness measures of the different health programs and then supporting policymakers at the national and regional levels. Improving and harmonizing the institutional approach to HTA, including staffing the HEFA team with the appropriate mix of expertise, and networking with relevant sector organizations will improve Ethiopia's ability to tackle the current health sector challenges as well as protect fledgling insurance schemes' progress toward universal health coverage.
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Affiliation(s)
- Elias Asfaw Zegeye
- Health Economics and Financing Analysis Team, Finance Resource Mobilization Directorate, Federal Ministry of Health, Addis Ababa, Ethiopia.
| | | | - Eyersualem Animut Bekele
- Partnership and Coordination Team, Finance Resource Mobilization Directorate, Federal Ministry of Health, Addis Ababa, Ethiopia
| | - Belay Aurgessa
- Partnership and Coordination Team, Finance Resource Mobilization Directorate, Federal Ministry of Health, Addis Ababa, Ethiopia
| | - Zenebech Gella
- Health Economics and Financing Analysis Team, Finance Resource Mobilization Directorate, Federal Ministry of Health, Addis Ababa, Ethiopia
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Tansley G, Stewart BT, Gyedu A, Boakye G, Lewis D, Hoogerboord M, Mock C. The Correlation Between Poverty and Access to Essential Surgical Care in Ghana: A Geospatial Analysis. World J Surg 2017; 41:639-643. [PMID: 27766400 PMCID: PMC5558014 DOI: 10.1007/s00268-016-3765-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Surgical disease burden falls disproportionately on individuals in low- and middle-income countries. These populations are also the least likely to have access to surgical care. Understanding the barriers to access in these populations is therefore necessary to meet the global surgical need. METHODS Using geospatial methods, this study explores the district-level variation of two access barriers in Ghana: poverty and spatial access to care. National survey data were used to estimate the average total household expenditure (THE) in each district. Estimates of the spatial access to essential surgical care were generated from a cost-distance model based on a recent surgical capacity assessment. Correlations were analyzed using regression and displayed cartographically. RESULTS Both THE and spatial access to surgical care were found to have statistically significant regional variation in Ghana (p < 0.001). An inverse relationship was identified between THE and spatial access to essential surgical care (β -5.15 USD, p < 0.001). Poverty and poor spatial access to surgical care were found to co-localize in the northwest of the country. CONCLUSIONS Multiple barriers to accessing surgical care can coexist within populations. A careful understanding of all access barriers is necessary to identify and target strategies to address unmet surgical need within a given population.
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Affiliation(s)
- Gavin Tansley
- Department of Surgery, Dalhousie University, Room 8-821, 1276 South Park St, Halifax, NS, B3H2Y9, Canada.
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK.
| | - Barclay T Stewart
- Department of Surgery, University of Washington, Seattle, WA, USA
- School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
- Department of Interdisciplinary Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Adam Gyedu
- Department of Surgery, School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Godfred Boakye
- School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Daniel Lewis
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Marius Hoogerboord
- Department of Surgery, Dalhousie University, Room 8-821, 1276 South Park St, Halifax, NS, B3H2Y9, Canada
| | - Charles Mock
- Department of Surgery, University of Washington, Seattle, WA, USA
- Harborview Injury Prevention & Research Centre, Seattle, WA, USA
- Department of Global Health, University of Washington, Seattle, WA, USA
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7
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Verguet S, Memirie ST, Norheim OF. Assessing the burden of medical impoverishment by cause: a systematic breakdown by disease in Ethiopia. BMC Med 2016; 14:164. [PMID: 27769296 PMCID: PMC5075208 DOI: 10.1186/s12916-016-0697-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 09/16/2016] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Out-of-pocket (OOP) medical expenses often lead to catastrophic expenditure and impoverishment in low- and middle-income countries. Yet, there has been no systematic examination of which specific diseases and conditions (e.g., tuberculosis, cardiovascular disease) drive medical impoverishment, defined as OOP direct medical costs pushing households into poverty. METHODS We used a cost and epidemiological model to propose an assessment of the burden of medical impoverishment in Ethiopia, i.e., the number of households crossing a poverty line due to excessive OOP direct medical expenses. We utilized disease-specific mortality estimates from the Global Burden of Disease study, epidemiological and cost inputs from surveys, and secondary data from the literature to produce a count of poverty cases due to OOP direct medical costs per specific condition. RESULTS In Ethiopia, in 2013, and among 20 leading causes of mortality, we estimated the burden of impoverishment due to OOP direct medical costs to be of about 350,000 poverty cases. The top three causes of medical impoverishment were diarrhea, lower respiratory infections, and road injury, accounting for 75 % of all poverty cases. CONCLUSIONS We present a preliminary attempt for the estimation of the burden of medical impoverishment by cause for high mortality conditions. In Ethiopia, medical impoverishment was notably associated with illness occurrence and health services utilization. Although currently used estimates are sensitive to health services utilization, a systematic breakdown of impoverishment due to OOP direct medical costs by cause can provide important information for the promotion of financial risk protection and equity, and subsequent design of health policies toward universal health coverage, reduction of direct OOP payments, and poverty alleviation.
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Affiliation(s)
- Stéphane Verguet
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Boston, MA, 02115, USA.
| | | | - Ole Frithjof Norheim
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Boston, MA, 02115, USA
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
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Shrime MG, Verguet S, Johansson KA, Desalegn D, Jamison DT, Kruk ME. Task-sharing or public finance for the expansion of surgical access in rural Ethiopia: an extended cost-effectiveness analysis. Health Policy Plan 2015; 31:706-16. [PMID: 26719347 DOI: 10.1093/heapol/czv121] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/27/2015] [Indexed: 11/14/2022] Open
Abstract
Despite a high burden of surgical disease, access to surgical services in low- and middle-income countries is often limited. In line with the World Health Organization's current focus on universal health coverage and equitable access to care, we examined how policies to expand access to surgery in rural Ethiopia would impact health, impoverishment and equity. An extended cost-effectiveness analysis was performed. Deterministic and stochastic models of surgery in rural Ethiopia were constructed, utilizing pooled estimates of costs and probabilities from national surveys and published literature. Model calibration and validation were performed against published estimates, with sensitivity analyses on model assumptions to check for robustness. Outcomes of interest were the number of deaths averted, the number of cases of poverty averted and the number of cases of catastrophic expenditure averted for each policy, divided across wealth quintiles. Health benefits, financial risk protection and equity appear to be in tension in the expansion of access to surgical care in rural Ethiopia. Health benefits from each of the examined policies accrued primarily to the poor. However, without travel vouchers, many policies also induced impoverishment in the poor while providing financial risk protection to the rich, calling into question the equitable distribution of benefits by these policies. Adding travel vouchers removed the impoverishing effects of a policy but decreased the health benefit that could be bought per dollar spent. These results were robust to sensitivity analyses.
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Affiliation(s)
- Mark G Shrime
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA, Office of Global Surgery, Massachusetts Eye and Ear Infirmary, Boston, MA, USA,
| | - Stéphane Verguet
- Department of Global Health and Population, Harvard School of Public Health, Boston, MA, USA
| | - Kjell Arne Johansson
- Department of Global Public Health and Primary Care, Bergen University, Bergen, Norway
| | - Dawit Desalegn
- Department of Obstetrics and Gynaecology, Addis Ababa University School of Medicine, Addis Ababa, Ethiopia and
| | - Dean T Jamison
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Margaret E Kruk
- Department of Global Health and Population, Harvard School of Public Health, Boston, MA, USA
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Verguet S, Olson ZD, Babigumira JB, Desalegn D, Johansson KA, Kruk ME, Levin CE, Nugent RA, Pecenka C, Shrime MG, Memirie ST, Watkins DA, Jamison DT. Health gains and financial risk protection afforded by public financing of selected interventions in Ethiopia: an extended cost-effectiveness analysis. LANCET GLOBAL HEALTH 2015; 3:e288-96. [DOI: 10.1016/s2214-109x(14)70346-8] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Duvall S, Thurston S, Weinberger M, Nuccio O, Fuchs-Montgomery N. Scaling up delivery of contraceptive implants in sub-Saharan Africa: operational experiences of Marie Stopes International. GLOBAL HEALTH, SCIENCE AND PRACTICE 2014; 2:72-92. [PMID: 25276564 PMCID: PMC4168608 DOI: 10.9745/ghsp-d-13-00116] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/09/2013] [Accepted: 10/24/2013] [Indexed: 11/24/2022]
Abstract
Contraceptive implants offer promising opportunities for addressing the high and growing unmet need for modern contraceptives in sub-Saharan Africa. Marie Stopes International (MSI) offers implants as one of many family planning options. Between 2008 and 2012, MSI scaled up voluntary access to implants in 15 sub-Saharan African countries, from 80,041 implants in 2008 to 754,329 implants in 2012. This 9-fold increase amounted to more than 1.7 million implants delivered cumulatively over the 5-year period. High levels of client satisfaction were attained alongside service provision scale up by using existing MSI service delivery channels-mobile outreach, social franchising, and clinics-to implement strategies that broadened access for underserved clients and maintained service quality. Use of adaptive and context-specific service delivery models and attention to key operational components, including sufficient numbers of trained providers, strong supply chains, diverse financing mechanisms, and implant removal services, underpinned our service delivery efforts. Accounting for 70% of the implants delivered by MSI in 2012, mobile outreach services through dedicated MSI provider teams played a central role in scale-up efforts, fueled in part by the provision of free or heavily subsidized services. Social franchising also demonstrated promise for future program growth, along with MSI clinics. Continued high growth in implant provision between 2011 and 2012 in all sub-Saharan African countries indicates the region's capacity for further service delivery expansion. Meeting the expected rising demand for implants and ensuring long-term sustainable access to the method, as part of a comprehensive method mix, will require continued use of appropriate service delivery models, effective operations, and ongoing collaboration between the private, public, and nongovernmental sectors. MSI's experience can be instructive for future efforts to ensure contraceptive access and choice in sub-Saharan Africa, especially as the global health community works to achieve its Family Planning 2020 (FP2020) commitments to expand family planning access to 120 million new users.
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