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

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.

Modeling health impact of global health programs implemented by Population Services International.

BACKGROUND: Global health implementing organizations benefit most from health impact estimation models that isolate the individual effects of distributed products and services - a feature not typically found in intervention impact models, but which allow comparisons across interventions and intervention settings. Population Services International (PSI), a social marketing organization, has developed a set of impact models covering seven health program areas, which translate product/service distribution data into impact estimates. Each model's primary output is the number of disability-adjusted life-years (DALYs) averted by an intervention within a specific country and population context. This paper aims to describe the structure and inputs for two types of DALYs averted models, considering the benefits and limitations of this methodology. METHODS: PSI employs two modeling approaches for estimating health impact: a macro approach for most interventions and a micro approach for HIV, tuberculosis (TB), and behavior change communication (BCC) interventions. Within each intervention country context, the macro approach determines the coverage that one product/service unit provides a population in person-years, whereas the micro approach estimates an individual's risk of infection with and without the product/service unit. The models use these estimations to generate per unit DALYs averted coefficients for each intervention. When multiplied by program output data, these coefficients predict the total number of DALYs averted by an intervention in a country. RESULTS: Model outputs are presented by country for two examples: Water Chlorination DALYs Averted Model, a macro model, and the HIV Condom DALYs Averted Model for heterosexual transmission, a micro model. Health impact estimates measured in DALYs averted for PSI interventions on a global level are also presented. CONCLUSIONS: The DALYs averted models offer implementing organizations practical measurement solutions for understanding an intervention's contribution to improving health. These models calculate health impact estimates that reflect the scale and diversity of program operations and intervention settings, and that enable comparisons across health areas and countries. Challenges remain in accounting for intervention synergies, attributing impact to a single organization, and sourcing and updating model inputs. Nevertheless, these models demonstrate how DALYs averted can be viably used by the global health community as a metric for predicting intervention impact using standard program output data.

Applying the disability-adjusted life year to track health impact of social franchise programs in low- and middle-income countries.

BACKGROUND: Developing effective methods for measuring the health impact of social franchising programs is vital for demonstrating the value of this innovative service delivery model, particularly given its rapid expansion worldwide. Currently, these programs define success through patient volume and number of outlets, widely acknowledged as poor reflections of true program impact. An existing metric, the disability-adjusted life years averted (DALYs averted), offers promise as a measure of projected impact. Country-specific and service-specific, DALYs averted enables impact comparisons between programs operating in different contexts. This study explores the use of DALYs averted as a social franchise performance metric. METHODS: Using data collected by the Social Franchising Compendia in 2010 and 2011, we compared franchise performance, analyzing by region and program area. Coefficients produced by Population Services International converted each franchise's service delivery data into DALYs averted. For the 32 networks with two years of data corresponding to these metrics, a paired t-test compared all metrics. Finally, to test data reporting quality, we compared services provided to patient volume. RESULTS: Social franchising programs grew considerably from 2010 to 2011, measured by services provided (215%), patient volume (31%), and impact (couple-years of protection (CYPs): 86% and DALYs averted: 519%), but not by the total number of outlets. Non-family planning services increased by 857%, with diversification centered in Asia and Africa. However, paired t-test comparisons showed no significant increase within the networks, whether categorized as family planning or non-family planning. The ratio of services provided to patient visits yielded considerable range, with one network reporting a ratio of 16,000:1. CONCLUSION: In theory, the DALYs averted metric is a more robust and comprehensive metric for social franchising than current program measures. As social franchising spreads beyond family planning, having a metric that captures the impact of a range of diverse services and allows comparisons will be increasingly important. However, standardizing reporting will be essential to make such comparisons useful. While not widespread, errors in self-reported data appear to have included social marketing distribution data in social franchising reporting, requiring clearer data collection and reporting guidelines. Differences noted above must be interpreted cautiously as a result.