Can an IUCD get lost in the cervix? Do contraceptives make women infertile? Are implants painful?
 
This infographic considers five common misconceptions about family planning in Ethiopia.
 

As displayed prominently on the Federal Ministry of Health’s website, Ethiopia has 625 days to reach its Health Sector Transformation Plan (HSTP) targets. This includes a goal of 55% of married women using modern contraceptives by 2020.
 
According to the June 2018 Track 20 Report, a monitoring service in support of the FP 2020 agenda, the modern contraceptive prevalence rate (mCPR) needs to increase by eight percentage points per year to reach this target, a rate considerably above historic averages.
 

“The Track 20 Report shows that we are at an mCPR of 37%,” says Dagnachew Alemayehu, National Key Accounts Manager for DKT.

 
 
“This means that 60% of the contraceptive need in Ethiopia has been met, but 40% of women that would like to use contraceptives are unable to do so for a variety of reasons.”
 
Results from the sixth round of PMA 2020 data collection are expected in early September. Track 20 monitoring reports use data from PMA 2020 surveys as well as the Ethiopian Demographic and Health Surveys (EDHS).
 
One interesting development to watch will be the emergence of implant contraceptives, particularly among unmarried sexually active women.
 
Between Rounds 4 and 5 of PMA 2020 data collection, implant use increased from 15.3% to 33.2% of method mix among sexually active unmarried women. Over the same period, the use of injectable contraceptives decreased from 51.2% to 33.2% of method mix.
 
“The emerging importance of implant contraceptives is interesting,” says Rory Harrington, DKT Ethiopia Country Director.
 
“Is this being fueled by word of mouth? What is attracting young women to the method?”
 
DKT’s own distribution, which targets the private sector, seemingly supports the trend around implants.
 
“In the first six months of 2018, implant contraceptive sales were up 30% year-over-year,” says Dagnachew.
 
“This was considerably ahead of most of our other products.”
 
DKT distributed 20,193 implant contraceptives from January - June 2018.
 
The latest PMA 2020 report shows that the private sector may hold the greatest opportunity for increasing mCPR.
 
While approximately 90% of public facilities had stock of most methods in the PMA 2020 R5 report, just 11.4% and 15.9% of private facilities offered IUCDs and implants, respectively.
 
“Catalyzing the private sector could be the key to the next phase of mCPR growth and reaching our national targets,” says Dagnachew.
 
 

MCPR in Africa

Gains in West Africa, Uganda with mixed results elsewhere

Ethiopia and Kenya’s successes in family planning programming are well-known, but what about other African countries? The chart below shows recent trends in modern contraceptive prevalence (mCPR) among married women ages 15 - 49 years old. (Data from PMA 2020 reports, Rounds 3 - 6).
 

Fifth-year medical students at St Paul’s Hospital, Millennium Medical College (SPHMMC) recently helped test the Pregna PPIUD(TM) against traditional, Kelly forceps-based intrauterine device (IUD) insertion.
 
The students, who had no prior experience with IUD insertion, successfully used the Pregna PPIUD 28/33 (84.8%) times compared to 22/33 (66.7%) times for Kelly forceps, though the results were not statistically significant. Students also rated the Pregna inserter as easier to use than Kelly forceps.
 
The study was a single-day pilot and testing was conducted on anatomical models.
 
Following the pilot, the FMoH held a public tender for 55,863 PPIUD devices.
 
According to Ajit Raje, Vice President of Pregna International, the PPIUD is already in use in a number of locations globally.
 
“We’ve already completed two clinical trials - a proof of concept trial followed by a full clinical trial.”
 
“Including India, the PPIUD has now been used in 18 countries and registration is under way in many more.”
 
“Pregna has supplied in excess of 110,000 units in international markets in addition to supplies made in India.”
 
“Encouragingly, there have been repeat orders which indicates customers are satisfied with the product.”
 
The post-partum period or period immediately following birth is an ideal time to place an IUD given that the woman and provider are both available in the same location at the same time and the woman is known to not be pregnant.
 
Additional benefits of the PPIUD are that the woman’s cervix is dilated, increasing the ease and accuracy of IUD placement. There is also no need to sterilize instruments, which can be a difficult task in rural areas without electricity and running water.
 
DKT Ethiopia currently markets the LongAct copper IUD. Registration has been completed for the Pregna PPIUD and is underway for a hormonal IUD.
 
DKT plans to supply the Pregna PPIUD on a pre-order basis.

A study from 52 health posts in four regions indicates that Level 4 Health Extension Workers (L4HEWs) are viable conduits for implant and IUD provision.

Could experienced Health Extension Workers (L4HEWs) be the key to catalysing uptake of long-acting reversible contraceptives (LARC) in Ethiopia?
 
An 8-month pilot conducted at 52 health posts in four regions in 2016-17 suggests that L4HEWs have the ability to effectively provide LARC insertion and removal following intensive training.
 
The pilot, which included data from 702 clients who received LARCs from L4HEWs, showed that efforts should be taken to ensure site readiness and increase the capacity of L4HEWs, particularly regarding IUD insertion and removal.
 
The full report can be found here.

One of the great distinctions of social marketing is the volume of sales data generated. Years and even decades of transaction history are available to help program managers refine existing product offerings and plan for the next generation of products to meet consumer needs.
 
DKT recently strengthened its sales recordkeeping system by transitioning to an electronic sales recordkeeping system, referred to internally as e-sales.
 
“E-sales is bi-directional,” says Yishak Ibrahim, an independent IT Consultant in Addis Ababa who designed the system.
 
“Transactions are streamed to a server using Ethiopia’s 2G and 3G networks.”
 
“DKT’s Head Office can also push updated pricing and sales history out to field reps.”
 
One of the advantages of the system is that it reduces duplicate data entry.
 
“We used to keep records at the individual, regional and national levels, but with e-sales, it’s a single record shared across the organization,” says Negussie GebreTsadik, DKT’s National Operations Director.

DKT’s Partner Clinic network reached the 100-member mark in July 2018, a milestone outlined in the organization’s grant with the Bill and Melinda Gates Foundation (BMGF).
 
“Having 100 high-quality partners across Ethiopia means we have viable service points for comprehensive family planning and reproductive health services,” says Dagnachew Alemayehu, DKT’s National Key Account Manager.
 
“We’re very proud of this accomplishment.”
 
As of June 2018, Partner Clinics have served 149,000 clients, the majority for family planning, including 64,000 first-time clients. Clinics have also distributed 81,000 couple years protection (CYP).
 
The majority of clinics are Medium Clinics, though the network also includes 9 OB/GYN speciality clinics and 13 MCH Centers.
 
In addition to BMGF, the network is supported by the Embassy of the Kingdom of the Netherlands and the Swedish International Development Cooperation Agency (SIDA).

Myths about family planning persist in Ethiopia despite years of effort. This issue of Access takes a look at common myths and the facts that correct them. Plus, progress on the HIV front.

Recent data shows that Ethiopia has achieved a 37% modern contraceptive prevalence rate (mCPR) among married women. Implant use jumped among all users and particularly unmarried women. This issue of Access looks at the status of Ethiopia's FP landscape, including in relation to the rest of Africa. Also, PPIUD testing at Paulos, digital sales recordkeeping, and update from DKT's Partner Clinic network.

Sensation Xtra, DKT’s new brand extension, is now available in outlets throughout Ethiopia.
 
“We introduced Sensation Xtra nationally in early September and it’s now available in all regions,” says Negussie GebreTsadik, DKT Ethiopia’s National Operations Director.
 
“We’re excited to continue the success of Sensation while giving the brand a fresh look and feel.”
 
Sensation Xtra replaces the previous Sensation line. Sensation Xtra includes Cinammon, Coffee and Delay variants. In a first for DKT Ethiopia, Sensation Xtra Delay includes a mild benzocaine anaesthetic that dulls feeling and can slow ejaculation.
 
DKT also updated packaging and artwork for Sensation Ribbed to refresh the brand.
 
DKT has marketed the Sensation line of condoms since 2004. In September 2007, DKT introduced Sensation Coffee, a global first at the time that has gone on to become the organization’s second leading Sensation variant after Sensation Ribbed.
 
Some estimates put the total condom market in Africa to be around six billion condoms annually against a current distribution of approximately three million condoms.
 
Approximately 700 million condoms were distributed by social marketing projects in 29 sub-Saharan countries in 2017. Nearly 70% of these condoms were sold through private sector channels and the remainder was given away for free.
 
The ratio of SM condom distribution to total population was highest in Swaziland, Lesotho, and South Africa and lowest in Burkina Faso, Mauritania and Niger in 2017. In Swaziland, nine condoms were distributed per population through social marketing programs compared to .01 per population in Niger.
 
In addition to private sector and social marketing distribution, significant quantities of condoms are distributed through Government channels.

Social marketing is the application of commercial principles and practices to sell socially beneficial goods that are not sustainable by commercial distribution alone. Social marketing generates revenue on a sliding scale based on overall economic development and donor subsidy makes up any gap. DKT Ethiopia is a social marketing enterprise - an NGO by definition - but a business at heart.

PILLAR 1: Commodity procurement
DKT Ethiopia’s current range of 13 products and 25 variants is sourced from leading manufacturers in India, Thailand, China, and other countries. Many DKT vendors are World Health Organization (WHO) pre-qualified while others conform to Global Fund regulatory (SRA) requirements. All are certified by Ethiopia’s Food, Medicine and Health Care Administration and Control Authority (FMHACA). DKT International, DKT Ethiopia’s parent organization, is an emerging supplier in its own right, recently joining with WomanCare Global to supply the Ipas manual vacuum aspiration (MVA) kit as well as the Levoplant 2-rod implant.

PILLAR 2: Sales & Distribution
An axiom of contraceptive social marketing is that condoms, pills and other products should be as accessible as, “tea, cigarettes, or Coca-Cola”.
 
DKT Ethiopia’s 28 sales teams routinely service 9,000 clinical and 7,000 pharmaceutical outlets across Ethiopia’s 11 regions. This is effectively all outlets in the country. DKT’s partnership with 90 youth and anti-AIDS clubs, Young Marketers, enables the organization to distribute condoms to tens of thousands more outlets like souks, hotels, pensions, and supermarkets. Unlike most NGOs, DKT generates revenue, which is wholly reinvested into the project. As Ethiopia continues to develop economically, the country’s ability to sustain a commercial FP/RH program, like DKT’s, grows.

1 CYP equals 100 Condoms; 200 Free Condoms; 14 Pill cycles; 4 Injections (3 mos) or 6 Injections (2 mos) or 12 Injections (1 mo); 20 Female Condoms; 14
EC;.33 Implants (3), .25 Implants (4), .20 Implants (5); .23 IUDs; .59 MA Doses; .0208 MVA Kits; 16 Miso.

PILLAR 3: Marketing
Great brands are trusted, affordable, desirable and essential to social marketing. Every year, DKT Ethiopia disseminates thousands of radio and television commercials that inform the public and encourage use of DKT products.
 
DKT Ethiopia adheres to DKT International’s affordability guidance, which requires at least one brand in any category to cost a couple no more than 0.25% of annual per-capita gross national income (GNI) adjusted for purchasing power parity (PPP). To meet this standard while also generating revenue, DKT markets multiple brands of similar products at different price points.

30 years, 43m couple years protection later, social marketing leader continues to thrive

 
Reliable.
 
The first core value in DKT Ethiopia’s 2015-19 Strategic Plan is an appropriate encapsulation of the organization’s 30 year history in Ethiopia.
 
Starting with a single product, Hiwot Trust condoms, in 1989, DKT Ethiopia now boasts a robust family planning and reproductive health portfolio that routinely reaches 16,000 clinics and pharmacies across the country.
 
Through multiple funding cycles, HIV’s emergence and control, the Millennium Development Goals (MDG) period, and other macro-developments, DKT has managed to expand its project and product offerings.
 
“DKT Ethiopia now accounts for approximately one third of all couple years protection (CYP) in the country,” says Rory Harrington, DKT Ethiopia’s Country Director since 2014.
 
“We are the key conduit for family planning and reproductive health products to the private sector.”
 
The journey has not been without its challenges.
 
“Like any importer, we face hard currency shortages,” says Mr. Harrington.
 
“But our commitment to Ethiopia’s women and children coupled with strong support from the Government and donors has allowed us to carve out a viable niche in the private sector.”

A serendipitous outgrowth of social marketing

When Phil Harvey started DKT International in 1989, he did not foresee surplus revenues from countries like Brasil and the Philippines one day being used to seed family planning programs in Ghana and Mozambique.
 
But that’s exactly what has happened.
 
In 2013, DKT do Brasil, one of DKT’s oldest projects, transferred $650,000 to DKT’s headquarters in Washington, DC, which was then forwarded to new project sites. As of 2016, DKT do Brasil had remitted $3.9 million in total against an initial investment of $6 million.
 
Just as important, DKT do Brasil achieved this surplus while keeping at least one brand of each product category affordable to most Brazilians and also while driving down prices in the market. For example, when DKT entered Brasil in 1990, a condom cost $.60/piece or more. Today, Prudence, DKT’s long-standing brand, sells for $.27/piece.
 
In Ethiopia, DKT is likely to require donor support for many years to come.
 
But that doesn’t mean the organization isn’t contributing already.
 
“Every time we reduce cost and increase our own viability, that potentially frees funds for other projects,” says Negussie GebreTsadik, DKT’s National Operations Director.

Read More:
This article is based on a 2016 article by Phil Harvey in Global Health: Science and Practice http://dx.doi.org/10.9745/GHSP-D-15-00182

Playing the odds never felt so good.
 
A grant from the Dutch Postcode Lottery to DKT International and its partner, the Netherlands-based non-profit Rutgers, means that DKT Ethiopia has a new funding source.
 
The grant runs from 2018-2021 and supports DKT Ethiopia in the procurement and promotion of several RH commodities as well as provider training and marketing campaigns.
 
Since 1990, the Dutch Postcode Lottery has distributed 5.5 billion Euros to charities throughout the world and 50% of the lottery’s gross proceeds are distributed annually.
 
The PostcodeKanjer, the largest prize given out annually, was awarded on January 1.

The Dutch Postcode Lottery is DKT Ethiopia's newest donor as part of a collaboration with the Dutch non-profit Rutgers. Since 1990, the Dutch Postcode Lottery has distributed 5.5 billion Euros to charities. Fifty percent of the lottery’s gross proceeds are distributed annually and the lottery currently supports 112 charities globally.

Myths about family planning persist in Ethiopia despite years of effort. This issue of Access takes a look at common myths and the facts that correct them. Plus, progress on the HIV front.

Recent data shows that Ethiopia has achieved a 37% modern contraceptive prevalence rate (mCPR) among married women. Implant use jumped among all users and particularly unmarried women. This issue of Access looks at the status of Ethiopia's FP landscape, including in relation to the rest of Africa. Also, PPIUD testing at Paulos, digital sales recordkeeping, and update from DKT's Partner Clinic network.

Sensation Xtra, DKT’s new brand extension, is now available in outlets throughout Ethiopia.
 
“We introduced Sensation Xtra nationally in early September and it’s now available in all regions,” says Negussie GebreTsadik, DKT Ethiopia’s National Operations Director.
 
“We’re excited to continue the success of Sensation while giving the brand a fresh look and feel.”
 
Sensation Xtra replaces the previous Sensation line. Sensation Xtra includes Cinammon, Coffee and Delay variants. In a first for DKT Ethiopia, Sensation Xtra Delay includes a mild benzocaine anaesthetic that dulls feeling and can slow ejaculation.
 
DKT also updated packaging and artwork for Sensation Ribbed to refresh the brand.
 
DKT has marketed the Sensation line of condoms since 2004. In September 2007, DKT introduced Sensation Coffee, a global first at the time that has gone on to become the organization’s second leading Sensation variant after Sensation Ribbed.
 
Some estimates put the total condom market in Africa to be around six billion condoms annually against a current distribution of approximately three million condoms.
 
Approximately 700 million condoms were distributed by social marketing projects in 29 sub-Saharan countries in 2017. Nearly 70% of these condoms were sold through private sector channels and the remainder was given away for free.
 
The ratio of SM condom distribution to total population was highest in Swaziland, Lesotho, and South Africa and lowest in Burkina Faso, Mauritania and Niger in 2017. In Swaziland, nine condoms were distributed per population through social marketing programs compared to .01 per population in Niger.
 
In addition to private sector and social marketing distribution, significant quantities of condoms are distributed through Government channels.

Social marketing is the application of commercial principles and practices to sell socially beneficial goods that are not sustainable by commercial distribution alone. Social marketing generates revenue on a sliding scale based on overall economic development and donor subsidy makes up any gap. DKT Ethiopia is a social marketing enterprise - an NGO by definition - but a business at heart.

PILLAR 1: Commodity procurement
DKT Ethiopia’s current range of 13 products and 25 variants is sourced from leading manufacturers in India, Thailand, China, and other countries. Many DKT vendors are World Health Organization (WHO) pre-qualified while others conform to Global Fund regulatory (SRA) requirements. All are certified by Ethiopia’s Food, Medicine and Health Care Administration and Control Authority (FMHACA). DKT International, DKT Ethiopia’s parent organization, is an emerging supplier in its own right, recently joining with WomanCare Global to supply the Ipas manual vacuum aspiration (MVA) kit as well as the Levoplant 2-rod implant.

PILLAR 2: Sales & Distribution
An axiom of contraceptive social marketing is that condoms, pills and other products should be as accessible as, “tea, cigarettes, or Coca-Cola”.
 
DKT Ethiopia’s 28 sales teams routinely service 9,000 clinical and 7,000 pharmaceutical outlets across Ethiopia’s 11 regions. This is effectively all outlets in the country. DKT’s partnership with 90 youth and anti-AIDS clubs, Young Marketers, enables the organization to distribute condoms to tens of thousands more outlets like souks, hotels, pensions, and supermarkets. Unlike most NGOs, DKT generates revenue, which is wholly reinvested into the project. As Ethiopia continues to develop economically, the country’s ability to sustain a commercial FP/RH program, like DKT’s, grows.

1 CYP equals 100 Condoms; 200 Free Condoms; 14 Pill cycles; 4 Injections (3 mos) or 6 Injections (2 mos) or 12 Injections (1 mo); 20 Female Condoms; 14
EC;.33 Implants (3), .25 Implants (4), .20 Implants (5); .23 IUDs; .59 MA Doses; .0208 MVA Kits; 16 Miso.

PILLAR 3: Marketing
Great brands are trusted, affordable, desirable and essential to social marketing. Every year, DKT Ethiopia disseminates thousands of radio and television commercials that inform the public and encourage use of DKT products.
 
DKT Ethiopia adheres to DKT International’s affordability guidance, which requires at least one brand in any category to cost a couple no more than 0.25% of annual per-capita gross national income (GNI) adjusted for purchasing power parity (PPP). To meet this standard while also generating revenue, DKT markets multiple brands of similar products at different price points.