 It
is important to learn from the experience of different countries, so that India
does not repeat the mistakes that others made.
The Consortium Core Team in Indonesia included: •
Pathfinder International • Program for Appropriate
Technology (PATH) • World Health Organization
(WHO) and • International Council on Management
of Population Programmes (ICOMP) on behalf of WHO
WHO was specifically invited for conducting baseline survey and evaluation. The
first step in evaluation was baseline survey of providers’ and clients’ attitudes,
knowledge and practice, so that it could guide the local adoption of strategies
for IEC developed by the Consortium and help designing the model services. The
survey was conducted from February to June 1997 in four provinces. The findings
indicated (i) knowledge of FP was almost universal, still there was frequent inappropriate
use of contraception; (ii) knowledge about EC was very limited, only 25% providers
and 4% clients knew about it; (iii) most respondents considered EC as an abortifacient
(because it is taken after sex); since abortion is illegal, this was a major barrier;
(iv) most respondents were aware of both modern and traditional methods to induce
menstruation, if late, and various practices were widely used. Evaluation revealed
that when designing intervention, the base- line survey findings were forgotten.
The first stage project was launched in 12 IPPA clinics in six provinces. The
clinics selected were primarily used by women seeking menstrual regulation and
long-term contraceptive methods such as sterilization and IUD. Many women presented
themselves to the clinic either too late or were not suitable for EC. In the first
nine months of project implementation, only 186 units of Postinor-2 were provided
to the clients. Subsequently, expansion of
service delivery sites was done in 1998. Ten NGO clinics in Jakarta and Bali and
the University of Indonesia and Obstetrics & Gynaecology teaching clinics
participated in the project. In 1999, Indonesian Midwives Association in Jakarta,
Bali, and Central Java were incorporated, as many Indonesian women access reproductive
health services through midwives. This distribution route was thought to have
a potential to make EC more widely available. Following this, the number of clients
increased significantly. Over 180 midwives,
doctors and counsellors were trained as service-providers of Postinor-2. They,
in turn, informally trained other personnel. Orientation sessions were conducted
for over 1300 midwives, physicians, obstetricians and gynaecologists, senior policy-makers,
officials and reporters. Formal training was initially for 2 days, but was later
reduced to one and half days. Informal training period was variable without any
curriculum. 5500 units of Postinor-2 were sent
to Indonesia. Of these, 4575 were distributed to providers and 1819 issued to
the clients. The price ranged from free to 50,000 Rupia (approximately US $ 7).
Evaluation of introductory activities
Evaluation was conducted from June 1999 to March
2000 to assess the impact of the activities on the availability and use of Postinor-2,
the operational problems, and the lessons learnt in implementation. Data collection
utilized in-depth interviews, focus-group discussions and use of mystery clients.
Interviews with clinic managers, service-providers and stock-holders were conducted.
They were all enthusiastic and supported future introduction of Postinor-2. The
interviews revealed that clinic managers and service-providers both had insufficient
knowledge, a number of misconceptions, and many queries related to Postinor-2.
The providers reported difficulties in identifying clients who met the indications
for use of Postinor-2. Many providers suggested that there should be future efforts
to inform the general public through mass media and hotline services. Training
sessions needed to include real life scenarios. Single training was not sufficient.
Refresher training with service delivery guidelines in regional language was required.
Evaluation of profile of users and user behaviour revealed that most women sought
EC after a missed period. The clients were predominantly married, between 25-36
years, with one to three living children. The reasons for taking Postinor-2 were
as follows: • late for contraceptive injection
(20%) • late for menstrual period (20%)
• had sex without contraception (11%) •
forgot to take oral contraceptive pill (9%) •
husband returned unexpectedly (8%) It was felt
that EC was mostly used when it was not required e.g. taken as a menstrual inducer
or given to women presenting late for DMPA re-injection even when within one week
of the safe window. It was concluded from these
interviews that a need for Emergency Contraception clearly exists in Indonesia.
Registration would be required before the scope of Postinor-2 could be further
expanded. If registration was not obtained, Indonesia might consider promotion
of combined oral contraceptives or the copper IUD. Clear strategies were needed
to be developed if the method was to be introduced widely and with appropriate
quality of care. Approval process was expected
to take less than one year. Although the Consortium met with a National Family
Planning Coordinating Board throughout the introductory trial, the Board continued
to have concerns. It was felt that the key religious groups must give their approval
before the Ministry of Health could take any action.
The Consortium was able to promote discussion on Emergency Contraception among
a broad range of stakeholders and mobilize the participation of many of these
groups. These efforts led to a high profile for Emergency Contraception in the
national media. Of particular importance was the involvement of the Indonesian
Midwives’ Association and the Muhammadiyah Health Council.
Lessons Learnt / recommendations
• A need exists for a more systematic and strategic
approach to introduction. • The involvement
of key stakeholders is essential to ensure broad delivery coverage, as well as
product registration. • Advocacy and promotion
of Postinor-2, including adequate technical information, to be targeted at programme
managers. • Selection of appropriate channels
for provision is essential in the introduction process. •
A single brief training session was insufficient. Technical back-up, supervision
and refresher training is required. • The training
sessions need to include not only theoretical content, but also cover practical,
real life scenarios. • Service delivery protocols
and medical guidelines should be translated and supplied to service-providers
to be referred to in future. • A strong IEC
component is an essential part of introductory activities. •
Ensuring sustainability of supply will help to alleviate concerns of providers.
• Package inserts for Postinor-2 should be written in local
language and include answers to common questions.
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