By Sandy Garcon, Population Services International (PSI), Nov. 11, 2018
Although there is progress, use of modern contraceptives in Haiti remains stubbornly low. At 31 percent, the country’s unmet need for family planning is among the highest in the world.
Haiti also has a high rate of teen pregnancy, which intensifies risks for both girls and their babies. A startling one in three of those who give birth are under 20 years old. Fifty percent of girls and women ages 15 to 24 want contraception but don’t have access to it.
“We cannot continue to bury our heads in the sand when we have pregnancies that are happening to 14 and 15-year-olds,” says Dr. Reynold Grand’ Pierre, director of the Family Health Unit of Haiti’s Ministry of Health.
In support of efforts to reverse adolescent and youth sexual and reproductive health and rights (AYSRHR) trends in the country, PSI and the Dutch Ministry of Foreign Affairs have joined forces with the government of Haiti. Countering the risks associated with early pregnancy and unsafe abortions necessitates radically broadening how girls can source sexual and reproductive health services. Doing so effectively, however, requires better addressing the supply and demand realities on the ground.
Through the Ignite project, PSI is working to give young consumers easier access to family planning solutions by transforming the health market and ensuring sustainability beyond the life of the project.
We take a look at the different players along the supply chain working to increase and sustain the informed use of contraception among Haitian girls and women aged 15 to 24.
THE CONVENOR OF MARKETS
PSI has a long been a key player in the family planning space in Haiti. In the early 1990s, PSI, in collaboration with USAID, successfully introduced the socially marketed Pantè condom brand, which became a household name.
Despite widespread familiarity with condoms, injectables and oral contraceptives (OC), close analysis of the market revealed that most modern methods were largely unknown or simply absent in the private sector, where most Haitians seek care. OHMaSS, PSI’s local affiliate, discovered that the challenge was not getting commodities to Haiti, but instead was the means for wholesale distribution once the products arrived in the country.
With a focus on increasing the availability and variety of contraceptive products, OHMaSS found a likely partner and presented Disprophar, a commercial distributor, an opportunity to become a leader in the contraception space.
As a result, the distribution partner added to its business model a portfolio of family planning products, including OC, emergency contraception, intrauterine devices (IUDs), implants, the injectable Sayana® Press and medical vacuum aspiration kits for post-abortion care.
“In addition to our own brands, we leveraged our partnerships with manufacturers Merck and Pfizer to offer a menu of high-quality contraceptives at competitive prices,” explains Stéphane Docteur, OHMaSS medical services coordinator.
“We took a big bet that we could change the way we do business in Haiti,” says Frédérick Persoons, OHMaSS executive director. “Now it’s a matter of promoting and making women aware that these methods are available on the market.”
As a market convener, OHMaSS not only unblocked obstacles to supply, but also started to drive demand. Frédérick and his team looked no further than PSI’s Adolescents 360 (A360) project, which aims to increase contraceptive access for adolescent girls in Ethiopia, Nigeria and Tanzania.
Applying an A360-inspired Human-Centered Design approach, OHMaSS worked alongside adolescent girls and young women (aged 15-24) to understand their experiences, needs and barriers surrounding contraceptive access and use. Utilizing insights gathered, OHMaSS launched a multilayered marketing campaign built around the idea of creating a youth movement.
The campaign is Djanm, which symbolizes strength, determination, vigor, dynamism and tenacity in Haitian Creole. It encompasses participation in major cultural events such as Carnival, organization of youth-focused events called Djanm Buzz in local communities and a presence on social media channels like Facebook and Instagram. Djanm’s dedicated Facebook page features videos, live Q&A with providers and other interactive content that has become a viable touch point to reach youth with AYSRHR information and services.
At the community level, Djanm’s trained youth ambassadors are another element of the campaign critical to spreading the message to their peers.
Already, Frédérick and his team have a greater vision for Djanm, “We want to create a movement that can serve as a sponsor to any form of positive attitude or activities that are related to sexual and reproductive health.”
Daniel Malherbe greets guests at Disprophar, the pharmaceutical distribution company he founded with two colleagues 30 years ago, like he’s welcoming guests in his home. Disprophar’s founders, who started their careers as pharmaceutical sales representatives, are bringing their vast experience to help OMHaSS create a market for family planning products and services in the Port-au-Prince metropolitan area.
Until recently, the family planning market in Haiti was completely supported by international nongovernmental organizations (NGOs). But a gap in NGO-provided reproductive health products has opened up the opportunity for a sustainable private sector market.
“We have a social responsibility to diminish the number of unwanted children in Haiti,” remarks Daniel. “But first, we must sell family planning—not just the products, but family planning as a concept—to the Haitian people.”
They’ve done it before and intend to do it again.
Haitians are predisposed to eye diseases like glaucoma. But until recently, there was little demand for ophthalmology services due to lack of awareness. The Disprophar team identified the opportunity and launched a large-scale campaign to raise awareness about glaucoma and the importance of regular eye exams.
With the help of a robust radio and television advertising campaign, Disprophar reached millions of Haitians and changed behaviors related to eye care. “We sold the disease, not the products,” Daniel says. “We must do the same thing for family planning.”
Marie Lucie Poteau is part of the dedicated team of medical detailers employed by Disprophar to do just that. She focuses on getting doctors to both carry the family planning products that OHMaSS procures and counsel their patients— especially young women—on the benefits of contraception. She also connects the providers to trainings offered by OHMaSS.
A team of commercial detailers focuses on working through pharmacies to get the products into the hands of consumers. They cater to more than 200 outlets in the Port-au-Prince metropolitan area, ranging from pharmaceutical depots, to high-end drugstores, to small shops.
To help them more effectively sell their products, OHMaSS used an application called BaseCase. The tool helps manage potential objections from providers. Individual providers are categorized as one of the following: ‘aware of the products,’ ‘ready for trial,’ ‘already adopted,’ ‘advocate.’ Depending on where the provider falls, BaseCase provides videos and information sheets that medical and commercial detailers can use to influence behaviors at each level.
But Marie Lucie emphasizes that she doesn’t encounter much pushback from doctors. “My experience is that most doctors are willing and just need us to help them cut through the myths Haitians have about family planning.”
Daniel and his team are optimistic about the market. “There is a huge unmet need for family planning services here. I only see demand going up.”
Many people are under the impression that women in Haiti do not take the proper precautions to avoid unwanted pregnancy. The truth is that most often these women don’t know they have options or where to turn.
This is the reality that Dr. Pascal Thierry often faces.
He is among the 150 providers— nurses and doctors—in the Port-au-Prince metropolitan area who were trained by Disprophar and OHMaSS to provide youth-friendly modern contraception services.
He takes a break from his busy patient schedule to chat with Marie Lucie, the Disprophar medical detailer who sells him family planning products, including implants and IUDs.
Few of his patients request family planning methods. “Those with more education ask for it,” says Dr. Thierry, “but other women, they don’t mention it at all.”
Nevertheless, Dr. Thierry counsels women on family planning when he thinks the time is right.
“After I deliver a baby, I talk about a method. Twenty to 30 percent of women come back for one. If I think someone is sexually active, I’ll counsel her, too. But it can be awkward, especially if she comes in with her parents.”
Dr. Thierry thinks PSI’s Djanm initiative is crucial to turn things around. “It’s a good project. We must reach young women in their early 20s who don’t want to get pregnant. I want them to say to me, ‘I saw this on Facebook and I want a method.’”
Across town, more than 100 women crowd into the local community center in Simon-Pelé, a neighborhood bordering the infamous Cité Soleil slums. They are gathering for the OHMaSS mobile clinic that calls the community center home once every three months.
Nurse Maritane Henry, whose mobile clinic team regularly visits underserved areas like Simon-Pelé, credits improved awareness in the community for the turnout.
Many of the women learned of this mobile team through community criers who circulated through the neighborhood announcing the upcoming services.
“The mobile clinic is a way to provide services for those who cannot pay,” explains Maritane. Distribution is capped at 10 percent of the market so as not to interrupt the long-term health of efforts to go beyond aid.
All of the women who visited the clinic were aware of at least one modern contraceptive method, the most common being condoms and injectables. Some were afraid of contraception after having heard stories of medical procedures gone wrong or being told by parents or peers that birth control is not good.
At their local pharmacies, consumers can now purchase emergency contraceptives and, with a prescription, birth control pills and injectables. “There is always a shortage of emergency pills, because it is less expensive. We often have to suggest alternative methods because we stockout,” remarks pharmacist Leo Guerson.
Providers like Leo must also get acquainted with new products and new brands that have replaced those that were discontinued. But there is much excitement for the new arrivals and providers are eager to test how the new products and brands fare with consumers.
The next big challenge for OHMaSS is to design a network of clinics to help ensure service providers are youth-friendly, and to build partnerships that effectively spread the word.
“Yell loud so the priest can hear!” As usual, Lindsay Toulouse starts her peer counseling session by encouraging the young participants to belt out the Djanm motto: My life is my choice.
Not only are most of the participants members of Lindsay’s own Eucharistic Youth Movement chapter, this particular session is being held in the courtyard of a local Catholic church, with full blessings from the priest.
At 22 years old, Lindsay is one of 19 peer mentors with the Djanm campaign, which aims to educate young Haitian women and men about family planning and empower them to play an active role in choosing the method that is right for them.
“Many girls in my neighborhood are getting pregnant. I see it a lot, especially when I go to the mobile clinic. Last week, there was a 14-year-old holding twins.”
Lindsay is a second-generation helper. Her father died when she was three years old. From that moment on, her mother Marie Carol Laurent dedicated herself to raising her children. She never remarried, and her professional career centered on helping people as a nurse, which inspired Lindsay to join the OHMaSS team as a community health worker.
Marie Carol has seen all too well the damage unwanted pregnancy can inflict on young Haitian women. She mentions a girl who got pregnant and tried traditional methods to end her pregnancy. She was unsuccessful and after she had the baby, she visited Marie Carol, who told her about modern contraception.
“It’s so important. Young kids don’t want to get pregnant and now that they can see Lindsay beforehand, it’s better.”
Lindsay just finished her law studies and is writing her thesis. She also works full-time with Djanm. Every other day, she conducts one or two sessions educating her peers on contraceptive options and connecting them to providers through referrals. She also identifies community leaders in churches, schools and community centers who she can approach to advocate for the Djanm campaign.
Getting people to attend her trainings is the hardest part of her job. But she remains confident in her message. She wants people in her community to be aware of how they can protect themselves from unwanted pregnancies.
It takes Junie Joseph nearly two hours to travel to the clinic. To get there, she takes a tap tap, one of the iconic colorful buses that are most Haitians’ favored mode of public transportation. Then she hails a private taxi. She makes this trek every three months. She trusts the OHMaSS-trained nurses and doesn’t want to go anywhere else.
“I came for the first time in December 2017,” Junie says. “I got an implant, but I had to take it out.”
Junie lives with her older brother and sister. When they saw the implant under the skin in her arm, they told her to move out of the house. “They said I’m living a messed-up life. But I just don’t want a baby.”
After an open talk with her siblings, they agreed to turn a blind eye as long as they couldn’t see the method. That’s why she asked Nurse Maritane Henry, the woman who runs the OHMaSS mobile clinic, to remove the implant and start giving her injections. And that’s why she returns to this clinic every three months.
After each visit Maritane gives Junie a note reminding her when to return.
Junie is open about why she’s here. She is sexually active with her boyfriend Augustin, who is 22. They met when she was visiting a relative’s neighborhood. He saw her on the street and said, “You look like a model. Can you spare two minutes?” She agreed, and they made a date. They’ve been an item since, going to movies and spending time at each other’s homes.
Augustin is supportive of Junie’s decision. “He appreciates that we don’t have the economic means,” she says. “He knows I have dreams.”
Junie wants to be a nurse just like Maritane. “I’d like to be in her place. I would like to help women protect themselves. I would like to serve people like that.”
Posted Nov. 25, 2018