The case for investing in provider-administered subcutaneous DMPA: a costing study.

INTRODUCTION: Depot medroxyprogesterone acetate (DMPA) is available as provider-administered intramuscular (DMPA-IM) and subcutaneous injections (PA DMPA-SC), as well as DMPA-SC self-injection (SI), which enhances accessibility and continuation by reducing facility visits. However, DMPA-SC has a higher unit price than DMPA-IM, and low SI uptake can undermine its cost-effectiveness. This study assessed whether PA DMPA-SC's potential benefits justify its higher cost compared with DMPA-IM in Malawi, an early SI adopter with a higher proportion of SI. METHODS: In this costing study, we used recursive Markov models to examine 12-month service use patterns and costs for each injectable option. We collected data on supplies and infrastructure supporting injectable services (by product and location: facility or community) through site assessments and group discussions with facility-based providers and community health workers across nine facilities. We derived transition and discontinuation probabilities from longitudinal surveys about service use and experiences in a concurrent cohort study of injectable users aged 15-49. RESULTS: We conducted 23 provider group discussions and enrolled 992 cohort participants. PA DMPA-SC users were twice as likely to discontinue their method than DMPA-IM users (HR 2.01 (1.66-2.43)). However, a significantly higher proportion of PA DMPA-SC users transitioned to SI (47.1%), and did so faster, compared with DMPA-IM users (20.4%).The annual DMPA service cost per person-year of use was not substantially different between DMPA-IM (US$11.01) and PA DMPA-SC (US$11.47). Community-based services were 31% lower in cost at US$8.07 than facility-based services at US$11.61.In facilities, DMPA-SC is less expensive than DMPA-IM when 40% or more of all DMPA-SC visits are for SI; for community-based services, the threshold is 23%. Service volume data indicate these thresholds are achievable in Malawi. CONCLUSIONS: Not all DMPA-SC users need to self-inject for DMPA-SC to be cost-competitive with DMPA-IM. Use of PA DMPA-SC may increase the uptake of SI over time.