title: Policy and programmatic considerations for introducing a longer-acting injectable contraceptive: perspectives of stakeholders from Kenya and Rwanda.
abstract: BACKGROUND
  More than 40 million women use injectable contraceptives to prevent pregnancy, and most current or previous injectable users report being satisfied with the method. However, while women may find injectables acceptable, they may not always find them accessible due to stock-outs and difficulties with returning to the clinic for reinjections. FHI 360 is spearheading efforts to develop a longer-acting injectable (LAI) contraceptive that could provide at least 6 months of protection against pregnancy. This article addresses systems-level considerations for the introduction of a new LAI.
  
  
  METHODS
  We conducted qualitative case studies in Kenya and Rwanda-two countries that have high levels of injectable use but with different service delivery contexts. Between June and September 2012, we conducted in-depth interviews with 27 service providers and 19 policy makers and program implementers focusing on 4 themes: systems-level barriers and facilitators to delivering LAI services; process for introducing an LAI; LAI distribution approaches; and potential LAI characteristics. We also obtained electronic feedback from 28 international family planning opinion leaders.
  
  
  RESULTS
  Respondents indicated strong interest in an LAI and thought it would appeal to existing injectable users as well as new family planning clients, both for spacing and for limiting births. Providers appreciated the potential for a lighter workload due to fewer follow-up visits, but they were concerned that fewer visits would also decrease their ability to help women manage side effects. The providers also appreciated the 1-month grace period for follow-up LAI injections; some seemed unaware of the latest international guidance that had increased the grace period from 2 weeks to 4 weeks for the currently available 3-month injectable. The majority of policy makers and program implementers were supportive of letting community health workers provide the method, but many nurses and midwives in Kenya had reservations about the approach. At the policy level, respondents indicated that obtaining regulatory approvals before introducing the new method could be costly and time-consuming. Manufacturing and procurement decisions could also affect cost and availability.
  
  
  CONCLUSIONS
  Successful introduction of a potential longer-acting injectable may be enhanced by considering broader systemic issues, including managing cost to the health system and users, expanding access through community-based distribution, and training providers on the latest service delivery guidelines.
authors.affiliation: FHI 360, Durham, NC, USA kmckenna@fhi360.org.
authors.forename: Kevin
authors.initials: K
authors.lastname: McKenna
authors.affiliation: University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
authors.forename: Jennet
authors.initials: J
authors.lastname: Arcara
authors.affiliation: FHI 360, Durham, NC, USA.
authors.forename: Kate H
authors.initials: KH
authors.lastname: Rademacher
authors.affiliation: FHI 360, Nairobi, Kenya. Now with Ipsos, Nairobi, Kenya.
authors.forename: Caroline
authors.initials: C
authors.lastname: Mackenzie
authors.affiliation: Ministry of Health, Kigali, Rwanda.
authors.forename: Fidele
authors.initials: F
authors.lastname: Ngabo
authors.affiliation: FHI 360, Kigali, Rwanda. Now with Company for Research in Social, Behavior and Health (RSH) Ltd, Kigali, Rwanda.
authors.forename: Emmanuel
authors.initials: E
authors.lastname: Munyambanza
authors.affiliation: FHI 360, Kigali, Rwanda. Now with IntraHealth International, Chapel Hill, NC, USA.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Wesson
authors.affiliation: FHI 360, Durham, NC, USA.
authors.forename: Elizabeth E
authors.initials: EE
authors.lastname: Tolley
mesh_terms: D000328:Adult; D001291:Attitude of Health Personnel; D003267:Contraception / Q000379:methods*; D003271:Contraceptive Agents, Female / Q000008:administration & dosage* / Q000191:economics; D005193:Family Planning Services / Q000379:methods* / Q000458:organization & administration; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006297:Health Services Accessibility; D006801:Humans; D007630:Kenya; D008875:Middle Aged; D036301:Qualitative Research; D012432:Rwanda; D011795:Surveys and Questionnaires; D055815:Young Adult
chemical_list: D003271:Contraceptive Agents, Female