This resource provides a high-level summary of the current state of self-injection policy development, implementation, and monitoring in each of the Injectables Access Collaborative’s 11 focus countries: Benin, DRC, Ghana, Kenya, Madagascar, Malawi, Mozambique, Nigeria, Togo, Uganda, and Zambia. The policy cycle landscape (i.e., policy development, implementation, and monitoring) features an overview of the enabling environment for self-injection in each country, including general self-injection and self-care policies, as well as local authorizations for task-sharing/task-shifting. The information is current as of Quarter 2, 2025.

Progress and Potential of Self-Care: Taking Stock and Looking Ahead

The momentum around self-care is building through an array of self-care practices, policies, and interventions worldwide. This report aims to take stock of the SRH self-care field and document its progress. It is intended to provide a resource for global and national advocacy, to inform implementation of self-care guidelines, and to link the reader to evidence and learning exchanges. It includes case examples describing the process of introducing and scaling up DMPA-SC self-injection in Malawi and Nigeria.

Lessons learned from training and support for health workers in the public and private sectors

Malawi has made significant progress in scaling up DMPA-SC and self-injection in the public sector with 100% of service delivery points activated. The country has also learned valuable lessons through private sector pilots and is in the process of finalizing new guidelines to authorize pharmacies and drugstores to provide self-injection training to clients. The country’s approach is widely appreciated as an example of effective government-led and partner-supported scale-up involving both the public and private sector.

This webinar hosted by the PATH-JSI DMPA-SC Access Collaborative Learning and Action Network on August 3, 2022 featured public and private partners’ insights on national scale-up of DMPA-SC and self-injection, with a focus on provider training and supportive supervision as well as strong cross-sectoral partnerships. Speakers included representatives from the Malawi Ministry of Health Reproductive Health Directorate, Clinton Health Access Initiative, FHI 360, and Population Services International.

Drawing from program data and research, panelists discussed practical lessons learned from Malawi’s national scale-up of public-sector provider training, public provider reflections on integrating self-injection, and experiences from a private sector provider training pilot. These lessons may benefit governments and public and private partners in other contexts who are in the process of introducing or scaling up DMPA-SC for self-injection.

The Injectables Access Collaborative Learning and Action Network hosted this webinar on September 26, 2024 featuring new evidence on innovative peer support models for family planning, followed by discussion with researchers, peer leaders, and ministry of health champions for expanding choice to include self-injection.

The Innovations for Choice and Autonomy (ICAN)* project is rooted in the idea that women’s autonomy and agency should be prioritized in all sexual and reproductive health efforts. The project used human-centered design to develop models that foster women’s agency to make and act on contraceptive decisions in line with their preferences. Given clients often express doubts about their ability to administer the method themselves, ICAN models include support to improve women’s self-efficacy to self-inject DMPA-SC if they choose to do so. ICAN researchers and peer leaders shared the implementation process and evaluation findings from peer support pilot programs in Malawi and Uganda.

*The ICAN research consortium includes: AkenaPlus Health, Kenya Medical Research Institute, Makerere University School of Public Health, Malawi University of Science and Technology, and the University of California San Francisco.

The Innovations for Choice and Autonomy (ICAN)* project is rooted in the idea that women’s autonomy and agency
should be prioritized in all sexual and reproductive health efforts. Leveraging a community-engaged human-centered design approach, ICAN developed and piloted interventions to enhance self-injectable contraceptive service delivery in Malawi, Nigeria, and Uganda. Each intervention leverages social support from peers to foster women’s agency to make and act on contraceptive decisions. These briefs summarize ICAN’s intervention components and pilot evaluation results.

*The ICAN research consortium includes: AkenaPlus Health, Kenya Medical Research Institute, Makerere University School of Public Health, Malawi University of Science and Technology, and the University of California San Francisco.

PSI’s Delivering Innovation in Self-Care (DISC) project began a formal evaluation of DISC’s DMPA-SC self-injection service delivery impact in 36 participating health facilities in Niger, Lagos, and Oyo states of Nigeria in July 2022, with ongoing data gathering intervals through May 2023. The evaluation sought to measure and understand trends in service delivery of specific contraceptive methods as well as assess the impact of DISC interventions on DMPA-SC self-injection service provision and uptake.

DISC’s empathy training model—which extends beyond self-injection training and also encompasses community mobilization, follow-up supervision and mentoring, and capacity building for data reporting—has been shown to be highly effective at delivering provider and consumer behavior change to overcome fears around self-injection. In close collaboration with the national and local governing bodies and partners, DISC has rolled out this model in three countries (Nigeria, Uganda, and Malawi) where it has been associated with DMPA-SC self-injection market growth at the national level.

This policy landscape can be leveraged by applicants interested in applying to the DMPA-SC Regulatory Advocacy Catalytic Opportunity Fund (COF). The landscape was originally developed in 2020 to understand policies and regulations, including over-the-counter regulations, that impact women’s access to DMPA-SC and identify short- and long-term advocacy opportunities. In 2022, it was refreshed to understand policy shifts and additional advocacy opportunities in a subset of 12 of the original 18 countries currently eligible for the Regulatory Advocacy COF. Insights from the policy landscape have informed the design and eligibility criteria of the Regulatory Advocacy COF, proactively identified opportunities, and provided frameworks and guidance for interested applicants.

A mixed-methods, clustered randomized controlled study

Objective: While self-injection of subcutaneous depot medroxyprogesterone acetate (DMPA-SC) has well-documented benefits, uptake may be improved by addressing client concerns such as fear of self-injury and low self-efficacy. However, current training materials for family planning providers do not address these concerns. We used an iterative process with family planning providers and clients, male community leaders and partners, and stakeholders in Malawi to develop a counseling message addressing user-centered concerns about self-injection. We report on our testing of the effectiveness of this evidence-based message for increasing self-injection uptake in the context of full method choice.

Methods: We randomized 60 public facilities across two districts in southern Malawi to orient their providers to the message (treatment) or not (control). After strengthening data quality, we extracted routine service delivery data from the facilities six months before and after introducing the message. We compared pre- and post-orientation trends for the treatment and control groups using generalized linear mixed models. We conducted eight focus group discussions with a sample of providers oriented to the message.

Results: The message was feasible to implement and highly acceptable to providers. During June 2020–June 2021, 16,593 new clients used injectables in Mangochi district (52% DMPA-SC; 15% self-injected). In Thyolo district, 7,761 new clients used injectables during July 2020–July 2021 (29% DMPA-SC; 14% self-injected). We observed high variability in number of clients and self-injection uptake across facilities and over time, indicating inconsistent offering of self-injection. In both districts, we found significant increases in self-injection in treatment facilities after message introduction. However, this increase was not sustained, especially when DMPA-SC was unavailable or about to expire.

Conclusion: Based on the study findings, we recommend the evidence-based message be used in programs offering DMPA-SC self-injection services. However, effective use of the message is contingent upon a consistent supply of DMPA-SC.

Implications for waste disposal of subcutaneous depot medroxyprogesterone acetate

Self-administered subcutaneous depot medroxyprogesterone acetate (DMPA-SC) is poised to increase access to contraception; however, governments are concerned about the waste management of used units. Self-injectors in Malawi and Uganda are currently instructed to store used units in containers and return them to health workers for disposal. However, this may not be feasible in low-resource settings, especially for younger or covert self-injectors. We describe adolescent (15–19 years) and adult (20–49 years) self-injectors’ disposal experiences in Uganda and Malawi. When possible, we compare covert and overt users’ experiences.

The country dashboard is a visual presentation of key data for a select list of priority countries; it provides a snapshot of the state and stage of DMPA-SC introduction/scale-up, allowing stakeholders to assess progress, identify roadblocks, guide course corrections, and inform decisions.