Series K, Number 7
Injectables and Implants

CONTENTS

Home (Key Points)

New Implants Can Expand Access
Table 1. Comparing Implants
Table 2. Continuation Rates for New Implants
Table 3. Estimated Worldwide Use of Implants

Box: Which New Implant to Introduce?

Spotlight: From Norplant to Jadelle: Smooth Transition in a Dominican Republic Clinic

Preparing to Offer New Implants

Spotlight: Training Nurses Increases Implant Use in Ghana

Box: Information and Communication Technology Supports Implant Programs

Meeting Demand for New Implants Requires Supply and Access
Table 4. Key Resources for Program Managers and Providers of Implants

Bibliography

Credits

• Box: What Clients Should Know About Insertion and Removal
• INFO Reports: “Implants: Tools for Providers”

• Table 1: Comparing Implants
• Table 4: Key Resources for Program Managers and Providers of Implants

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Which New Implant to Introduce?

The entry of new contraceptive implants and the exit of Norplant leaves family planning programs to decide whether to add one of the new implants to their method mix and if so, which one to introduce— Jadelle, Implanon, or Sino-Implant (II). Increasing or maintaining the range of methods offered is important because, when more methods are available, people are more likely to find a method that suits them (89). Where Norplant has been an important method, clients will expect an alternative implant to replace it. Such decisions are often made at the national level, by the ministry of health or national family planning program, or at the program level by program managers. If more than one implant is already in the country, local programs will probably want to decide on one implant to offer. Experience with injectable contraceptives finds that carrying multiple types of injectables complicates forecasting, distribution of supplies, training, and service delivery (44, 56, 85, 92).

Programs evaluate a variety of factors in deciding which implant to introduce. First comes regulatory approval. An implant already approved will be fastest to incorporate into programs. If another implant provides comparative advantages, however, starting the process to obtain regulatory approval can be appropriate. If none of the new implants has regulatory approval, programs consider the comparative ease of the approval process. Often Jadelle is easiest to approve because it is based on Norplant, which has already received approval in many countries. Currently, both Jadelle and Sino-Implant (II) meet the criteria for a two-rod levenorgestrel-releasing implant in the World Health Organization Model List of Essential Medicines (123). This, too, should help speed approval of these implants. At the same time, approval of Implanon may be just as straightforward. Many countries rely on U.S. or European regulatory approval as a guideline (119), and both Jadelle and Implanon have received regulatory approval in the United States and many European countries.

The second factor programs must consider is cost. Currently, Sino-Implant (II) is the cheapest implant available. At US $4.50- $7 per unit, several African countries are choosing to introduce this implant into their programs (see Sino-Implant (II) is cheaper). Currently, Implanon is just slightly cheaper than Jadelle on a per-unit basis, but with large bulk orders, the total cost difference could be substantial. Programs must consider cost-effectiveness within the service delivery system as well. Does the longer, five-year active life of Jadelle make it more cost-effective than Implanon, which lasts three years? Any such comparison would need to incorporate the proportion of users who would actually keep the implants for longer than three years if it were an option.

Third, programs must consider service delivery issues, including training and support for providers. For programs that have substantial experience providing Norplant, it may be easiest to shift to Jadelle. Experience in the Dominican Republic (12) and Ghana (78) demonstrates that such a transition is smooth and easy, requiring only brief additional training of providers. Transition to Implanon can be easy, too. Organon, which produces Implanon, provides substantial support in countries introducing Implanon, including training of trainers programs (90). In Tanzania the Ministry of Health and Social Welfare, the ACQUIRE Project, and Organon are collaborating to train providers in Implanon insertion and removal. In 2006 and 2007 some 150 providers received training, and some 12,000 women had Implanon inserted (78).

Family planning programs will need to consider these factors and others in deciding which new implant to offer. A strategic approach to introducing a new method will improve the overall quality of family planning programs in addition to increasing users’ contraceptive choices (93, 104). For more information on introducing a new contraceptive method, see the World Health Organization’s Making Decisions About Contraceptive Introduction.