Increasing Access to LARCs: The Women’s Health Project in Cambodia
Global data shows that increasing access to modern methods of family planning (FP) reduces the maternal mortality rate by preventing unintended pregnancies, and reducing closely spaced pregnancies and the need for unsafe abortion.1 Over the past two decades, Cambodia has made significant strides in expanding access to FP services — and since 2000, the modern method contraceptive prevalence rate (mCPR) has more than doubled.
The Women’s Health Project (WHP), implemented by Population Services International/Cambodia (PSI/Cambodia) between 2008–2020, was essential to expanding access to high-quality long-acting reversible contraceptive (LARC) products and services for all who need them, and ensuring that individuals havethe information and resources they need to plan the lives and families they desire.
WHP PROGRAM FOCUS
Increase the number of trained quality healthcare providers and distribute LARC products to outlets, ensuring high-quality commodities and services are available to women at multiple points of sale across the country.
Improve Provider Quality of Care
Provide technical trainings and supportive supervision visits to network providers.
Improve Perceptions & Increase Demand
Increase access to information, combat common myths, and connect women with services through interpersonal communication (IPC), mass media, and digital technology.
Strengthen Enabling Environment
Collaborate with stakeholders to improve the regulatory environment for LARC service provision.
Between 2008–2020, PSI/Cambodia distributed over 251,580 IUDs and 61,320 implants to both Sun Quality Health Network (SQHN) providers and non-network outlets across the country (Graph 1).
LARC commodities were subsidized under WHP until 2020 when, as a result of PSI/C’s market development approach and incremental price increases over time, both the OK IUD® and Jadelle® implants achieved cost recovery for cost of goods sold. As of 2020, both products have been integrated into PSI/C’s Enterprise Fund product portfolio and will continue to be available to women across Cambodia through multiple points of sale after project close out.
Research has consistently identified the fear of real or perceived side effects as a major barrier to women’s use of modern FP methods, with the IUD cited as the least trusted method.
Social and behavior change communication (SBCC) activities are an essential strategy to counter common misconceptions, improve perceptions, and ultimately increase demand for modern FP methods.
Under WHP, PSI/Cambodia used a range of SBCC activities, including digital technology, mass media, and IPC.
Reproductive Health Hotline: Since 2013, the hotline received over 107,440 calls, approximately 40,410 of which were related to FP.
3-2-1 Service: In 2016, PSI/Cambodia produced a series of pre-recorded audio messages for Viamo’s Interactive Voice Response Service, 3-2-1, to include awareness of modern FP methods and address common myths and rumors.
Youth Friendly Facebook Page: Samphors Pannha has earned over 20,000 likes and more than 21,000 followers.
Audio Drama: PSI/Cambodia produced a 16-episode audio drama titled “Two Sisters, One Dream, and a Deeply-Buried Secret” and shared it across mass media, the 3-2-1 Service, and social media. Since the audio drama launched on the 3-2-1 Service in 2019, there has been a significant increase in the number of callers to the hotline, growing from 559 callers annually in 2018, to over 8,000 in 2019.
Mass Media Campaigns
PSI/Cambodia aired more than 159,900 radio spots and over 6,000 TV spots promoting voluntary modern FP methods. PSI/Cambodia research found that those who were exposed to PSI/Cambodia’s TV FP campaigns, regardless of the number of times they saw the campaign, were more likely to have a positive belief about modern FP methods than women who were not exposed.
IPC is essential to increase access to correct information, combat common misconceptions, and generate demand for modern FP methods.
Under WHP, PSI/Cambodia used two IPC models — direct implementation through community mobilizers (CM) managed by PSI/Cambodia, and indirect implementation through subgrants to local non-governmental organizations.
PSI/Cambodia research found that women exposed to IPC interventions were more likely to believe that modern methods of FP are effective and easy to use, and have a positive perception of IUDs.
In addition to combating misinformation and improving perceptions of LARCs, IPC interventions through WHP directly contributed to an increase in the number of women using LARCs through effective referrals to network and non-network providers.
Since 2013, more than 74,000 women were successfully referred to private clinics or public health centers for IUDs, 10,610 for implants, and 18,390 for short-term methods. The majority of referrals (85%) between 2013–2019 were to private clinics; the remaining 15% were to public health centers.
Evolving IPC Models
Between 2010–2015, the IPC program was conducted primarily through lecture-style community events. After several iterations of this model, PSI/Cambodia discovered that the effectiveness of this model was decreasing, and many women reached through these sessions were either uninterested or happy with their current method.
In 2015, PSI/Cambodia launched a more targeted approach, with five clearly defined target groups:
- New Mama
- Big Mama
- Post-Abortion Women
- Traditional Method Users
- Interested Non-Users
Using the new IPC algorithm and job aids, CM/IPC Agents were able to easily customize their messaging based on the household make-up.
As a result of the new model, the number of successful referrals per CM or IPC agent increased from 100 successful referrals per year in 2014 to 142 per year in 2015.
IMPROVED QUALITY OF CARE
In 2008, WHP began supporting the SQHN, PSI/Cambodia’s social franchise of private sector providers. Through WHP, PSI/Cambodia supported over 250 private providers with facility renovations, trainings, routine supportive supervision visits designed to improve counseling skills and service provision, and support for the management of adverse events and complications.
By 2020, with PSI/Cambodia’s support, over 90% of providers had met or exceeded minimum quality assurance standards.
The high quality of services provided by SQHN providers is also reflected in client satisfaction surveys. PSI/Cambodia conducted three rounds of surveys – in 2014, 2016, and 2018 – across 14 provinces. Across all three surveys, over 85% of FP clients would recommend the facility to others, and between 2016–2018 positive trends for client satisfaction were found in the following areas: appointment convenience, privacy and confidentiality, attitude of staff, and attitude of the provider.
PSI/Cambodia collaborated with the Royal Government of Cambodia and other stakeholders to change national protocol to allow nulliparous women – those who have never given birth – to receive an IUD, change the medical eligibility criteria for IUD insertion from six weeks post-partum to four weeks post-partum, and also allow immediate post-partum IUD insertions at the referral hospital level in the public sector.
WHP was made possible through generous donor support and in partnership with key stakeholders.
PSI/Cambodia wishes to thank the Royal Government of Cambodia and local partners for over a decade of support and close collaboration. PSI/Cambodia would also like to thank each SQHN provider for their commitment to high-quality services and dedication to improving the health of Cambodian women. Finally, thank you to the entire PSI team for their invaluable technical support.
DR. HENG KHENG
Sexual and Reproductive Health Director
Senior Technical Advisor, Service Delivery