Contraceptive self-injection (SI) is a new self-care practice with potential to transform women’s family planning access by putting a popular method, injectable contraception, directly into the hands of users. Research shows that SI is feasible and acceptable; evidence regarding how to design and implement SI programs under real-world conditions is still needed. This evaluation examined women’s experiences when self-injection of subcutaneous depot medroxyprogesterone acetate (DMPA-SC) was introduced in Uganda alongside other contraceptive options in the context of informed choice. We conducted structured survey interviews with 958 randomly selected SI clients trained in three districts in 2019. SI clients demonstrated their injection technique on a model to permit an assessment of injection proficiency. A randomly selected subset of 200 were re-interviewed 10–17 months post-training to understand resupply experiences, waste disposal practices and continuation. Finally, we conducted survey interviews with a random sample of 200 clients who participated in training but declined to self-inject. Data were analyzed using Stata IC/14.2. Differences between groups were measured using chi square and t-tests. Multivariate analyses predicting injection proficiency and SI adoption employed mixed effects logistic regression. Nearly three quarters of SI clients (73%) were able to demonstrate injection proficiency without additional instruction from a provider. Years of education, having received a complete training, practicing, and taking home a job aid were associated with higher odds of proficiency. Self-reported satisfaction and continuation were high, with 93% reinjecting independently 3 months post-training. However, a substantial share of those trained opted not to self-inject. Being single, having a partner supportive of family planning use, training with a job aid, practicing, witnessing a demonstration and exposure to a full training were associated with higher odds of becoming an SI client; conversely, those trained in a group had reduced odds of becoming an SI client. The self-care program was successful for the majority of women who became self-injectors, enabling most women to demonstrate SI proficiency. Nearly all those who opted to self-inject reinjected independently, and the majority continued self-injecting for at least 1 year. Additional research should identify strategies to facilitate adoption by women who wish to self-inject but face challenges.

The DMPA-SC Access Collaborative provides data-driven technical assistance (TA), resources, and tools that countries need for designing, implementing, and monitoring the introduction and scale up of DMPA-SC self-injection as part of an expanded range of contraceptive methods, delivered through informed choice programming.

In addition to general information and evidence on DMPA-SC, partners can access the support outlined in the menu below by submitting a request through the technical assistance request form, also linked below. Your request can be submitted by emailing the completed form to FPoptions@path.org.

The DMPA-SC Access Collaborative has published a collection of briefs on countries where we have provided focused technical assistance between 2017 and 2021. This includes the Democratic Republic of the Congo, Kenya, Madagascar, Nigeria, Uganda, and Zambia. Each brief describes the country’s introduction and scale-up experiences for DMPA-SC and self-injection, including accomplishments, challenges, innovations, key lessons, factors for success, and plans for the way forward.

Costed implementation plans play an important role in transforming family planning commitments into concrete programs and policies by informing budget creation and management as well as funding allocations and tracking. As part of introduction and scale-up planning across countries, the DMPA-SC Access Collaborative has worked with ministries of health and partners to create costed implementation plans for DMPA-SC specifically and map commitments or available budgets against costed plans to understand funding gaps. This brief describes the Access Collaborative’s costed implementation plan approach as well as costing tools available to enable countries to estimate their own plan’s requirements and potential funding gaps. For more information or assistance, please visit the Access Collaborative technical assistance page or contact FPoptions@path.org.

The DMPA-SC Access Collaborative hosted this April 21, 2021 webinar highlighting lessons learned to date through four years of data-driven technical assistance and coordination to ensure that women have increased access to self-injection as a contraceptive option, delivered through informed choice programming. The discussion focused on key topics for the introduction and scale-up of self-injection—and self-care interventions more broadly—at the country level including:

• Policy and advocacy for new product introduction.
• How to coordinate scale-up of a new product.
• Using data to inform program introduction and scale-up.
• Effective innovations and adaptations in provider training.

This discussion was moderated by Monica Mutesa, Zambia Country Coordinator, DMPA-SC Access Collaborative, PATH. Speakers included:

• Caitlin Corneliess, Project Director, DMPA-SC Access Collaborative, PATH
• Adewole Adefalu, Nigeria Country Coordinator, DMPA-SC Access Collaborative, JSI
• Allen Namagembe, Uganda Deputy Director, DMPA-SC Access Collaborative, PATH
• Avotiana Rakotomanga, Madagascar Country Coordinator, DMPA-SC Access Collaborative, JSI
• Alain Kabore, Regional Technical Advisor, DMPA-SC Access Collaborative, PATH

For more information, please contact FPoptions@path.org.

In this Making Self-Injection Count workshop session, participants were engaged in a lively discussion and interactive collaboration around the important considerations for private sector data collection and reporting on self-care products such as DMPA-SC. This session began with a short presentation to set the stage on the important role of private sector and data within the context of mixed health systems. Participants joined a moderated discussion with three in-country implementers from Nigeria (DKT), Uganda (PSI) and Zambia (JSI) who shared their experiences and lessons from introducing DMPA SC self-injection and other self-care products through private delivery channels. The session concluded with a facilitated, interactive activity to identify and prioritize private sector data needs.

Objectives

By the end of the session, participants were able to:

• Characterize the private sector within the context of the total market for DMPA-SC and other self-care products.
• Describe the current landscape for provision of DMPA-SC self-injection through the private sector.
• Identify the unique considerations and feasibility for collecting private sector data within mixed health systems.

Key takeaways

• The private sector is highly diverse and fragmented, comprised of profit and non-for-profit, formal and informal, domestic and global non-state actors. A total market approach (TMA) considers all channels of service delivery–public and private–to increase equitable and sustainable access to health products and services by maximizing the comparative advantage of all sectors. TMA builds upon market segmentation, using various channels to expand the overall market and meet demand for family planning, particularly where the public sector is not meeting women’s preferences/needs.
• Aligning and harmonizing data in mixed health systems is complicated. Different types of data are needed at various levels to understand the total market. By taking a holistic perspective–one that considers both the public and private sectors–we can identify the opportunities and gaps that exist at client, provider and systems level to guide policy, program, and investment decisions. Some data is more readily available, such as public sector procurement and distribution trends. However, other data, such as consumer retail price, willingness to pay or volumes of product sold, are often less available due to a variety of reasons, and sometimes require additional research.
• It is important to engage and understand the perspectives of the private sector when it comes to data collection/reporting desires and needs of governments and other stakeholders.

Presenters

• Ariella Bock, Senior Technical Advisor, JSI
• Mika Bwembya, Health Supply Chain and Total Market Director, USAID DISCOVER Health Project
• Kimberly Cole, Private Sector Service Delivery Programs, USAID’s Global Health Bureau’s Office of Population and Reproductive Health
• Tanvi Pandit-Rajani, Private Sector & Health Markets Lead, JSI
• Christine Prefontaine, Senior Human-Centered Design Advisor, JSI
• Victoria Webbe, Regional Knowledge Manager, DKT Francophone West and Central Africa

Participants in this Making Self-Injection Count workshop session learned about interim data sources for self-injection data, including Performance Monitoring for Action (PMA) surveys, demographic and health surveys (DHS) surveys, and low-resource, short-term auxiliary data collection systems. This session also highlighted efforts made to collect and use family planning data in humanitarian settings. Presenters addressed general timelines for data access in different countries and evaluated differences in indicators across data sets.

Objectives

By the end of the session, participants were able to:

• Describe how questions on self-injection are being incorporated into broader surveys and get a sense of the timeline for when self-injection survey data will become available in select countries.
• Describe alternative approaches for gathering data on self-care methods, including self-injection, when routine systems are not available.
• Strategize practical solutions for accessing data in their local setting.

Key takeaways

• It can take time (one to five years) for new products to be integrated into routine information systems (HMIS/LMIS). While work is underway to integrate self-injection into routine systems, interim and complementary data solutions can fill that missing dataset.
• Four considerations for interim data collection:
  • Clarity of rationale: Collect data critical for tracking progress and informative for decision- making.
  • Feasibility: use existing systems to the extent possible.
  • Acceptability: aim to make data collection simple for FP focal persons.
  • Institutionalization: collaborate and coordinate with the MOH and other partners, critically reviewing self-injection’s contribution to the method mix with the goal of adapting the HMIS to include SI data.

Presenters

• Phil Anglewicz, Principal Investigator, Performance Monitoring for Action (PMA) project
• Joy Fishel, Senior Survey Coordinator, Demographic and Health Surveys Program
• Stephen Mawa, Program Management Specialist, UNFPA South Sudan
• Allen Namagembe, Uganda Country Coordinator, PATH
• Avotiana Rakotomanga, Madagascar Country Coordinator, JSI
• Shannon Wood, PMA, Assistant Scientist, Department of Population, Family and Reproductive Health at the Johns Hopkins Bloomberg School of Public Health

This session wrapped up the Making Self-Injection Count workshop and highlighted key takeaways. Participants had an opportunity to reflect on what they learned and the action steps they have identified to move forward with their work.

Key takeaways

The workshop closed with four calls to action:

1. Add your country’s data to the global DMPA-SC monitoring system. For more information, email FPoptions@path.org.
2. Request technical assistance from the Access Collaborative.
3. Organize for action planning with the Access Collaborative’s action planning resources. Action planning can be facilitated on your own or with one of our technical advisors.
4. Participate in discussions and knowledge exchange through the Learning and Action Networks. Sign up for the LAN newsletter here.

Presenter

• Caitlin Corneliess, MPH, Project Director, Access Collaborative

In this practical, hands-on simulated data use session in the Making Self-Injection Count workshop, participants first learned about experiences running data review meetings in Kenya and Tanzania, highlighting lessons learned and best practices. Then they practiced skills using a mock decision-support tool to solve a common self-injection data challenge.

Objectives

By the end of the session, participants were able to:

• Describe key components of successful data use meetings and how data use meetings can be used to strengthen service delivery for family planning and self-care.
• Identify the skills, knowledge, and competencies (i.e., role profiles) needed for an effective data use team.
• Apply practical, hands-on strategies to run a data use meeting (including virtual meeting).

Key takeaways

• Data availability in HMIS/LMISes is necessary but not sufficient for efficient data use, strong service delivery, and commodity availability.
• Data-use teams comprise people from various levels of the health system with a common goal, a structured approach, and tools for reviewing data and taking action. Teams are trained to use data to clearly define and prioritize problems, conduct a root-cause analysis, and recognize small wins and good performance.
• There are seven key roles of an effective data-use team. Team members may assume different roles depending on the context and the problem being addressed.
  • Organizer (logistics, agenda, notes).
  • Problem solver (questions why, addresses challenges, steering to root cause of problems).
  • Data wizard (indicators and interpretation, analysis of raw data, graph trends, visualize data).
  • Supply chain (deep understanding of technical areas, supply chain processes, critical analysis of systems).
  • Influencer (access to decision-makers, suggestions are taken seriously, advocacy).
  • Resource (handles/advocates for funding).
  • Leader (needs to endorse or support decisions, big picture/vision of the team).
• Critical components for effective data use:
  • Deliberate design: multidisciplinary team with a common performance goal.
  • Decision-support tool: user-friendly visualized data.
  • Follow a structured process.
  • Consistency: regular data review meetings with consistent attendance because data change with time.
  • Champions and leaders who guide implementation and work to sustain the gains achieved.
  • Institutionalization of and resources for the data-use approach into existing structures.

Presenters

• Johnson Anyona, Analyst, InSupply Health
• Judy Anyona, Senior Advisor, InSupply Health
• Janet Makena, Analyst, InSupply Health
• Nomena Raberaoka, AC MLE and HCD Consultant, Madagascar
• Avotiana Rakotomanga, Madagascar Country Coordinator, JSI

This session of the Making Self-Injection Count workshop took an advocacy lens to highlight the importance of self-injection data. Representatives from the Government of Malawi—which has included self-injection in their HMIS since 2019—shared an overview of their self-injection program, highlighting the process for updating their HMIS including success and challenges. They also highlighted how self-injection data has been used at the national and district program levels. Participants had an opportunity to ask questions during the question and answer session.

Objectives

By the end of this session, participants were able to:

• Describe the value of integrating self-care methods, including self-injection, into an HMIS.
• Understand the challenges and success factors for HMIS integration.
• Describe how data has been used in countries where this integration has already happened.

Key takeaways

• Inclusion of SI indicators in the Malawi national health management information system (HMIS) involved a collaborative effort among the reproductive health directorate, the central M&E division, MoH district teams, and DMPA-SC task force partners.
• In Malawi, key lessons learned were:
  • all relevant stakeholders should be involved from the beginning to minimize back-and-forth process flow.
  • high-quality data and services are dependent on routine mentorship, supervision, SI counseling, and process-review meetings.
• Visibility on self-injection uptake in Malawi has improved efficiency of targeted support, implementation adjustments, and supply chain management. Being able to track DMPA-SC visits stratified by self-injection versus provider administration has helped with supply management and reduction of waste, and findings on reasons for discontinuation at the facility level have informed support needs and service delivery.

Presenters

• Gracious Ali, Program Associate, Clinton Health Access Initiative (CHAI)
• Jessie Chirwa, Family Planning Program Officer, Malawi Ministry of Health Reproductive Health Directorate
• Philemon Moses, CHAD Monitoring and Evaluation Officer
• Regina Mponya, Family Planning Coordinator, Malawi Ministry of Health Reproductive Health Directorate