The Role of Public–Private Partnerships to Increase Access to Contraception in an Emergency Response Setting: The Zika Contraception Access Network Program

Abstract

The Zika Contraception Access Network (Z-CAN) program was a short-term emergency response intervention that used contraception to prevent unintended pregnancies to reduce Zika-related adverse birth outcomes during the 2016–2017 Zika virus outbreak in Puerto Rico. The Centers for Disease Control and Prevention (CDC) reported that a collaborative and coordinated response was needed from governments and private-sector partners to improve access to contraception during the Zika outbreak in Puerto Rico. In response, the National Foundation for the CDC, with technical assistance from CDC, established the Z-CAN program, a network of 153-trained physicians, that provided client-centered contraceptive counseling and same-day access to the full range of the Food and Drug Administration-approved reversible contraceptive methods at no cost for women who chose to prevent pregnancy. From May 2016 to September 2017, 29,221 women received Z-CAN services. Through Z-CAN, public–private partnerships provided a broad range of opportunities for partners to come together to leverage technical expertise, experience, and resources to remove barriers to access contraception that neither the public nor the private sector could address alone. Public–private partnerships focused on three areas: (1) the coordination of efforts among federal and territorial agencies to align strategies, leverage resources, and address sustainability; (2) the mobilization of private partnerships to secure resources from private corporations, domestic philanthropic organizations, and nonprofit organizations for contraceptive methods, physician reimbursement, training and proctoring resources, infrastructure costs, and a health communications campaign; and (3) the engagement of key stakeholders to understand context and need, and to identify strategies to reach the target population. Public–private partnerships provided expertise, support, and awareness, and could be used to help guide programs to other settings for which access to contraception could improve health outcomes.

Introduction

Zika virus is a cause of serious birth defects, including brain and eye abnormalities, in ~5% of pregnancies with possible Zika infection.^1,2 Zika virus can be transmitted through the bite of an infected Aedes species mosquito, during pregnancy from mother to child, and through sexual transmission.³ During the 2016–2017 Zika virus outbreak, Puerto Rico reported the highest number of Zika cases in the United States and its territories.⁴

The widespread transmission of the Zika virus in Puerto Rico created an urgent public health need to prevent Zika virus transmission,^5,6 especially among women of reproductive age who were at risk of unintended pregnancy, which was defined as nonsterilized, sexually active with a male partner, and not currently pregnant or seeking pregnancy. Before the Zika virus outbreak, an estimated 65% of pregnancies in Puerto Rico were unintended, and ~138,000 of the 715,000 women aged 15–44 years in Puerto Rico did not desire pregnancy and were not using an effective contraceptive method.⁷

To prevent pregnancies affected by the Zika virus, the Centers for Disease Control and Prevention (CDC) identified the prevention of unintended pregnancy among women who chose to delay or avoid pregnancy during the Zika outbreak as a primary prevention strategy.³ However, women in Puerto Rico faced barriers to accessing effective contraception, including limited availability of the full range of reversible contraceptive methods, high out-of-pocket costs, a lack of patient education, and a shortage of providers who were trained to insert, remove, and manage long-acting reversible contraception (LARC) (i.e., intrauterine device [IUD] and implant).⁷

CDC reported that a collaborative and coordinated response was required from governments and private-sector partners to improve access to contraception during the Zika outbreak in Puerto Rico.⁸ In response, the National Foundation for the CDC (CDC Foundation), with technical assistance from CDC, established the Zika Contraception Access Network (Z-CAN) in Puerto Rico.⁹ The Z-CAN program used contraception as a medical countermeasure to prevent unintended pregnancies among women who chose to delay or avoid pregnancy during the Zika virus outbreak.^9,10 From May 2016 to September 2017, a total of 29,221 women received Z-CAN services.¹¹

This report describes the role of public–private partnerships in the Z-CAN program during the 2016–2017 Zika virus outbreak in Puerto Rico. Through Z-CAN, public–private partnerships provided a broad range of opportunities for partners to come together to address the immediate emergency response needs of women of reproductive age in Puerto Rico; neither the public nor the private sector alone could address this challenge. The collaboration among the public and private partners brought together the expertise and resources needed to increase contraception access and provide high-quality contraception services, and these partnerships were efficient and flexible, characteristics that were required in the fast-paced environment of the Zika virus emergency response.

Public–private partnerships were important in three focus areas: (1) the coordination of efforts among federal and territorial agencies to align strategies, leverage resources, and address sustainability; (2) the mobilization of private partnerships to secure resources from private corporations, domestic philanthropic organizations, and nonprofit organizations for contraceptive methods; physician reimbursement; training and proctoring resources; infrastructure costs; and a health communications campaign; and (3) the engagement of key stakeholders to understand context and need, and to identify strategies to reach the target population (Fig. 1).

FIG. 1.

Zika contraception access network public–private partnership framework. ^aFederal agencies included CDC, CMCS, HRSA, OPA. ^bTerritorial agencies included the following: Puerto Rico Department of Health, Puerto Rico Health Insurance Administration, HRSA Office of Regional Operations, Puerto Rico Primary Care Association. ^cStakeholders included the following: Puerto Rico Obstetrics and Gynecology, University of Puerto Rico, professional medical associations, community-based organizations serving women of reproductive age, physicians providing reproductive health services. CDC, Centers for Disease Control and Prevention; CDC Foundation, National Foundation for the CDC; CMCS, Centers for Medicare and Medicaid Services; HRSA, Health Resources and Services Administration; OPA, Office of Population Affairs.

Key Public–Private Partnership Focused Activities

Coordinate efforts among federal and territorial agencies

In January 2016, CDC led the domestic emergency response effort in response to the Zika virus. CDC investigated the association between Zika virus infection in pregnancy and adverse birth outcomes, developed guidance for the clinical management of pregnant women with Zika virus infection, and developed prevention strategies to mitigate adverse outcomes of prenatal Zika virus infection. CDC assessed barriers and estimated contraceptive needs among women of reproductive age in Puerto Rico and conducted a cost-effectiveness analysis on the health and economic consequences of a hypothetical Z-CAN-like intervention^7,12 (Table 1).

Table 1.

Zika Contraception Access Network Public–Private Partnership Focus Areas, Activities, and Outcomes

Partner	Focus area	Activity	Outcome
CDC	Coordinate federal and territorial agency efforts Mobilize private partnerships Engage key stakeholders	Provide leadership and technical expertise to respond to Zika virus infection in pregnancy and its association with adverse birth outcomes Provide leadership and technical expertise to the development, implementation, and monitoring and evaluation of Z-CAN Assess barriers and estimate contraceptive needs among women of reproductive age in Puerto Rico Conduct a cost-effectiveness analysis on the health and economic consequences of a hypothetical Z-CAN-like intervention Leverage federal, territorial, and key stakeholder partnerships and resources to coordinate efforts to increase access to contraception and address sustainability	Establish a formal federal workgroup to disseminate scientific and programmatic information and coordinate activities among federal and territorial agencies Align strategies and leverage federal resources, existing health systems and infrastructure, and existing resources (e.g., CDC’s contraceptive guidelines, CDC’s evidence-based strategies) to increase contraception access in coordination with CDC’s Zika emergency response efforts Conduct formative research to inform health communication campaign and channels for effective messaging Disseminate information, resources, and lessons learned to document the Z-CAN program’s development, implementation, and evaluation for sustainability
National Foundation for the CDC (CDC Foundation)	Mobilize private partnerships Engage key stakeholders	Mobilize philanthropic and private-sector resources to support CDC’s emergency response Establish Z-CAN as short-term emergency effort Provide programmatic administrative and logistics management of Z-CAN	Secure contraceptive products or negotiated nominal pricing to obtain the full range of reversible contraceptive methodsa Identify local pharmaceutical distributor to receive, store, and distribute contraceptive products to Z-CAN providers Establish a plan for contraception procurement and distribution adherent to FDA and territorial guidelinesb Secure resources to support training, program implementation, health communication campaign, and program infrastructure Provide a physician reimbursement fee for Z-CAN services commensurate with Medicaid fee schedules in the continental United States Developed health education campaign to promote awareness of Z-CAN services among those who chose to prevent pregnancy during the Zika outbreak Develop a safety net to ensure no-cost LARC removal after the program’s end
Federal agenciesc	Coordinate federal and territorial agency efforts Engage key stakeholders	Engage federal and regional staff to provide context to identified barriers and needs, strategies to reach target population, and strategies to increase access to contraception and build partnerships Align strategies and leverage resources across federal agencies for capacity building	Coordinate federal funding to prevent, prepare for, and respond to the Zika virus and its related health conditions Identify federally funded programs and activities and barriers related to provision of contraceptive services in Puerto Rico Provide technical assistance to territorial agencies directed to reduce barriers and increase access to contraception Obtain guidance on federal and territory distribution regulations for reversible contraceptive methods in Puerto Rico Leverage federal funding, federal programs, local infrastructure, policies, and technical assistance to support sustainability efforts
Territorial agencies and stakeholdersd	Coordinate federal and territorial agency efforts Engage key stakeholders	Provide context to identified barriers and needs, strategies to reach target population, and strategies to increase access to contraception Engage key stakeholders to provide feedback and leverage support of Z-CAN program Coordinate efforts to sustain high-quality contraceptive services	Implement short-term policy or practice change to increase access to contraception Issue Administrative Order to public and private health care payors to broaden access to effective contraceptive methods during the Zika virus outbreak Issue a letter to support AO 350 to request compliance by private health care insurers to broaden contraceptive method coverage Identify key stakeholders and local implementation partners to provide feedback and support for Z-CAN Identify local OB/GYNs to participate in Z-CAN Provide waiver to Z-CAN physicians to allow on-site stocking of contraceptive methods for same-day provision
Private corporations	Mobilize private partnerships	Support CDC’s efforts to prevent Zika-related birth defects	Donate, or provide at nominal pricing, the full range of FDA-approved reversible contraceptive methods Support the development of a health communication campaign to educate women about prevention of unintended pregnancy in the context of Zika and raise awareness of the full range of contraceptive methods available through Z-CAN
Domestic philanthropic organizations	Mobilize private partnerships	Support CDC’s efforts to prevent Zika-related birth defects	Donate resources for physician and staff training Donate resources for proctoring and mentorship for Z-CAN physicians Donate resources for a Z-CAN physician reimbursement commensurate with Medicaid reimbursement rates in continental United States Support program infrastructure costs in Puerto Rico Fund the development, implementation, and evaluation of a health communication campaign
Nonprofit organizations	Mobilize private partnerships	Support CDC’s efforts to prevent Zika-related birth defects	Donate, or provide at nominal pricing, on-site training for Z-CAN physicians and staff Donate clinic tools and educational materials for on-site trainings and Z-CAN clinics Provide training resources and family planning experts for on-site physician mentorship and clinic readiness assessment

^aThe full range of reversible contraceptive methods includes IUDs, implants, injections, pills, patches, vaginal rings, and condoms.

^bFederal agencies consulted included the following: FDA, VA, OIG.

^cFederal agencies included the following: CDC, CMCS, HRSA, OPA.

^dTerritorial health agencies included Puerto Rico Department of Health, Puerto Rico Health Insurance Administration, HRSA Office of Regional Operations, Puerto Rico Primary Care Association; Territorial stakeholders included PROGyn, University of Puerto Rico, professional medical associations, community-based organizations serving women of reproductive age, physicians providing reproductive health services.

Z-CAN, Zika Contraception Access Network; IUD, intrauterine device; FDA, Food and Drug Administration; VA, Veterans Affairs; OIG, Office of the Inspector General; CDC, Centers for Disease Control and Prevention; CMCS, Centers for Medicare and Medicaid Services; HRSA, Health Resources and Services Administration; OPA, Office of Population Affairs; LARC, long-acting reversible contraception; AO, Administrative Order; OB/GYN, Obstetrician/Gynecologist; PROGyn, Puerto Rico Obstetrics and Gynecology.

CDC used their Guiding Principles for Public–Private Partnership as a framework for them and the CDC Foundation’s ability to leverage existing partnerships and build new ones to address the needs of the women of reproductive age in Puerto Rico during the Zika virus outbreak.¹³ CDC led and coordinated efforts across the federal government to reduce Zika-related adverse birth outcomes during the Zika outbreak through the prevention of unintended pregnancies. In addition, CDC worked with other federal agencies, including the Centers for Medicare and Medicaid Services (CMS), Health Resources and Services Administration (HRSA), and the Office of Population Affairs to align strategies, leverage resources, provide timely updates, and solicit input for shared and coordinated efforts (Table 1). CDC also coordinated emergency response efforts with territorial partners, including the Puerto Rico Department of Health (PRDOH), Puerto Rico Health Insurance Administration, HRSA Office of Regional Operations, and Puerto Rico Primary Care Association. Territorial partners worked closely with the CDC to provide context about public and private health systems; to provide input on the development, implementation, and sustainability of the Z-CAN program; to engage key stake-holders; and to provide leadership on strategies to address identified barriers to contraception access (Table 1).

Mobilize private partnerships

The CDC Foundation, an independent nonprofit created by Congress to mobilize philanthropic and private-sector resources to support CDC’s critical health protection work, activated its emergency response efforts to support CDC’s work during the Zika virus outbreak. In March 2016, the CDC Foundation established the Z-CAN program and began to rapidly mobilize the private sector, including pharmaceutical manufacturers of all Food and Drug Administration (FDA)-approved reversible contraceptive methods, to support CDC’s efforts to prevent unintended pregnancy among women who chose to delay or avoid pregnancy during the Zika virus outbreak in Puerto Rico (Table 1). In April 2016, the CDC Foundation held an emergency briefing for philanthropic and business leaders, which included private corporations and domestic philanthropic, and nonprofit organizations, to support CDC’s emergency response specific to the identified needs of Z-CAN, including support for programmatic activities and the provision of contraceptive services in Puerto Rico. The CDC Foundation provided programmatic, administrative, and logistics management for Z-CAN in Puerto Rico.

Engage key stakeholders

CDC engaged federal and territorial government partners during program development to identify key stakeholders in Puerto Rico, including Puerto Rico Obstetrics and Gynecology, Puerto Rico Primary Care Association, Puerto Rico Section of American Congress of Obstetricians and Gynecologists, Puerto Rico Title X federal family planning clinics, Puerto Rico Health Insurance Administration (Administración de Seguros de Salud de Puerto Rico [ASES]), the Puerto Rico Office of the Insurance Commissioner, community-based organizations serving women of reproductive age, universities (public health and medical schools), and physicians providing reproductive health services. From February to April 2016, discussions were held with key stakeholders to understand and identify previous or current family planning, reproductive health, or maternal and infant health interventions or programs. These discussions probed the context and needs of these programs to learn from successes and challenges, as well as to align strategies to prevent pregnancies among women who chose to delay or avoid pregnancy during the Zika outbreak (Table 1).

Outcomes that Resulted from the Public–Private Partnership Efforts

As has been reported previously, the Z-CAN program rapidly established a network of 153-trained physicians who provided Z-CAN services at 139 clinics across all 5 public health regions in Puerto Rico.⁹ The Z-CAN program provided client-centered contraceptive counseling and same-day access to the full range of the FDA-approved reversible contraceptive methods at no cost for women who chose to prevent pregnancy.⁹ All nonsterilized women of reproductive age were eligible to receive Z-CAN services, irrespective of income and insurance status. Outcomes are reported in table that are specific to the coordination of federal and territorial agencies, mobilization of public–private partnerships, and engagement with key stakeholders in the Z-CAN program.

Federal and territorial agencies

A federal workgroup was formed as a result of the federal and territorial agencies’ coordinating efforts. Scientific and programmatic information was disseminated among federal and territorial agencies, and included the following: strategies to prevent unintended pregnancies to reduce Zika virus-related adverse birth outcomes;⁸ quantifying the contraceptive needs among women of reproductive age in Puerto Rico;⁷ identifying barriers and developing strategies to improve access to contraception in Puerto Rico; and determining that an intervention to increase access to contraception for women during the Zika virus outbreak was cost-effective and could substantially reduce the number of cases of Zika-associated birth defects and associated health care costs.¹² Consequently, CDC partnered with the HRSA Bureau of Primary Health Care to align strategies and leverage federal Zika virus funding to train community health center physicians and staff to provide client-centered contraceptive counseling and same-day access to the full range of reversible contraceptive methods. CDC also used existing health systems and infrastructure in Puerto Rico (e.g., community health centers, residency programs, private clinics) to recruit and establish the network of physicians who participated in Z-CAN and to increase contraceptive access across the territory.¹⁰ Furthermore, CDC used existing federal guidelines and resources (e.g., CDC’s contraceptive guidelines and evidence-based strategies) to train physicians to provide high-quality contraceptive services and reduce barriers to contraception access^14–17 (Table 1).

The territorial government agencies implemented short-term policy or practice change strategies to increase access to contraceptive services because of the coordinated federal and territorial activities. In March 2016, the Puerto Rico Secretary of Health issued Administrative Order (AO) 350,¹⁸ which called upon public and private health care payors to broaden access to contraceptive methods during the Zika virus outbreak by acknowledging that Zika virus is a cause of serious birth defects in infants resulting from Zika infection during pregnancy; educating providers about the prevention of adverse outcomes associated with Zika and training providers on the insertion, removal, and management of LARC; establishing a plan to expand access and coverage to effective contraceptive methods, including implants, IUDs, oral contraceptive pills, injectable, vaginal ring, patch, and condoms; and requiring all public and private insurers under the jurisdiction of the Insurance Commissioner and the Puerto Rico Health Insurance Administration (ASES) to disclose and issue plans for execution of the order. The Commissioner of Insurance issued a letter of support for AO 350 and requested compliance by health insurers to broaden contraceptive method coverage.¹⁹ The PRDOH also helped identify key stakeholders to provide feedback on strategies to increase contraception access and to identify Obstetrician/Gynecologists to recruit to participate in Z-CAN. In addition, the PRDOH provided a waiver to Z-CAN physicians to allow on-site stocking of contraceptive methods for same-day provision (Table 1).

In July 2016, federal and territorial partners identified components of Z-CAN that would be needed to sustain high-quality contraceptive services after the Z-CAN program ended. Federal funding, through the Zika Response and Preparedness Act (P.L. 114–223),²⁰ supported territorial agencies to prevent, prepare, and respond to the Zika virus and its related health conditions. In addition, the funding included a required component to increase access to contraceptive services for women and men, and to provide training and technical assistance to states and territories with active or local transmission of the Zika virus. A toolkit with information, resources, tools, and lessons learned from the development, implementation, and evaluation of the Z-CAN program²¹ was developed to further support sustainability efforts (Table 1).

Private partnerships

The CDC Foundation secured contraceptive product donations, or negotiated nominal pricing, from pharmaceutical manufacturers to make the full range of reversible contraceptive methods available to Z-CAN patients at no cost. As a result, federal agencies were consulted to provide guidance with federal and territory distribution regulations for contraceptive methods in Puerto Rico, including the Food and Drug Administration (FDA), Veterans Affairs, and the Department of Health and Human Services Office of the Inspector General. Accordingly, partnership with a local pharmaceutical distribution company that received, stored, and distributed the contraceptive methods to participating Z-CAN physicians ensured compliance with federal, state, and territorial laws and regulations. Furthermore, the CDC Foundation secured resources to support physician and staff training and proctoring of Z-CAN physicians to ensure the delivery of high-quality contraceptive care, a physician reimbursement fee schedule commensurate with Medicaid fee schedules in the continental United States, infrastructure costs, and a health communications campaign to increase awareness of the availability of contraception through the Z-CAN program.^7,9,22 Finally, the CDC Foundation developed a 10-year safety net to ensure that no-cost LARC removal is available to Z-CAN patients and to establish communication channels to help women find a Z-CAN physician for removal^11,23 (Table 1).

Key stakeholders

Key stakeholder discussions identified barriers to providing contraceptive services (e.g., low reimbursement, lack of full range of reversible methods, limited training in LARC insertion, removal, and management, and limited same-day provision). Among local family planning providers and women of reproductive age, discussions identified obstacles to obtaining contraceptive services (e.g., high out-of-pocket costs, limited access to the full range of methods, and referral or multiple visits to obtain contraceptive methods) (Table 1). Furthermore, formative research yielded information from women and men of reproductive age in Puerto Rico about contraception decision making and preferred formats for dissemination of health communication messaging to guide the development of the health education campaign, Ante La Duda, Pregunta (When in Doubt, Ask)²⁴ (Table 1). Finally, resources and trainings were provided to key stakeholders for education and outreach on Zika virus prevention through seminars, grand rounds, community outreach events, and for a website for Z-CAN physicians with evidence-based resources (Table 1).

Discussion

Public–private partnerships played a key role in supporting Z-CAN’s program development and implementation efforts to address the immediate emergency response needs of women of reproductive age in Puerto Rico through the coordination, mobilization, and engagement of federal and territorial agencies, key stakeholders, and private-sector partners. Previous research on public–private partnerships has reported that partnerships can provide a mechanism for the development and implementation of evidence-based strategies and innovative practices,^25,26 and for health system and health service delivery to improve health outcomes.^27–32 Public–private partnerships can provide opportunities to address barriers that neither the public nor the private sector could address alone, and can increase health care access, quality, and efficacy.^29,31

Aligned with CDC’s Guiding Principles for Public–Private Partnership,¹³ the public–private partnerships established to support Z-CAN increased the speed of response and innovation, provided insight and perspectives from key stakeholders, addressed identified barriers and needs, built capacity of local agencies and physicians, and raised awareness among women of reproductive age of Z-CAN services. The following efforts were most notable: public–private partnerships facilitated the timeliness of the response and efficiency of the Z-CAN program’s rapid development and scale-up, which included the procurement of the full range of contraceptive methods; the development of a system for contraceptive product distribution; training for Z-CAN physicians on LARC insertion and removal; development of a health communication campaign to increase demand for services; and implementation of Z-CAN, which would have been challenging for any of the partners to accomplish alone.^9–11

The CDC and CDC Foundation also made important partnership considerations following guidance that recommended determining impact and value,³³ feasibility,³⁴ and conflict of interest.^13,33,35,36 During the development of Z-CAN, a cost-effectiveness analysis was conducted on the health and economic consequences of a hypothetical Z-CAN-like intervention.¹² Results suggested that increasing contraceptive access in Puerto Rico during the Zika virus outbreak could substantially reduce the number of cases of Zika-associated birth defects and associated health care costs.¹² Results were shared to help guide decision makers, including public–private partners and key stakeholders, on the estimated impact and value of the Z-CAN intervention. Determining feasibility was also important during the development of Z-CAN. On the basis of an assessment of existing data and in-depth interviews with key informants and stakeholders early in the Zika virus outbreak, CDC reported administrative, logistical, and financial barriers that limited access to contraception, including LARC.⁷ CDC provided technical expertise on the design of Z-CAN, including clear goals, objectives, and strategies that were feasible and included specific milestones and a timeline. CDC communicated to the CDC Foundation the critical needs to support rapid program scale-up and implementation. The CDC Foundation developed collaborations with the multisector private and philanthropic entities with a mutual shared objective to rapidly address the Zika virus outbreak. However, although private-sector partnership was needed, it was critical that CDC’s independence of scientific judgment and credibility be retained, and that no conflict of interest existed (e.g., implied or direct endorsement). Recommendations from the CDC Ethical Considerations for Public-Private Partnerships³⁷ guided the CDC Foundation in mobilizing partnerships with the private sector. Public–private partnerships required that all partnerships be transparent (e.g., identity of partner, funding amount, and their role); not primarily benefit the funder; not potentially decrease public trust; and not conflict with CDC’s work or mission, or harm the public’s health. In addition, the CDC or CDC Foundation had control of public–private partnership project, not the private funder.³⁷

Furthermore, given Z-CAN was a short-term emergency response intervention, CDC and the CDC Foundation worked with federal and territorial partners to address sustainability. During the development and implementation of Z-CAN, key stakeholders identified components of Z-CAN that they would prefer to be maintained after the Z-CAN program ended: availability of the full range of reversible contraceptive methods at low or no cost and with same-day access; trained physicians to provide high-quality contraceptive services; expanded contraceptive service access sites; continued discussions with health plans in Puerto Rico (public and private) on elimination of prior authorization requirements and cost sharing and the addition of contraceptive methods to formularies; and increased awareness among women of reproductive age about the full range of contra ceptive methods to allow them to choose a method that best meets their needs. Federal and territorial partners worked together to align strategies and leverage resources for sustainability. For example, in January 2017, CMS Zika Health Care Services grant funded $US 60.6 million to the PRDOH to support efforts in providing and expanding health care services to all pregnant women and of child-bearing age, as well as infants and men adversely or potentially affected by the Zika virus infection.²⁰ The four primary components funded by the grant included the following: (1) increasing access to contraceptive services for women and men; (2) reducing barriers to diagnostic testing, screening, and counseling for pregnant women and newborns; (3) increasing access to appropriate specialized health care services for pregnant women, children born to mothers with maternal Zika virus infection, and their families; and (4) improving provider capacity and capability.²⁰ As requested by CMS and PRDOH and in relation to the CMS grant, CDC and the CDC Foundation shared lessons learned from Z-CAN and provided technical assistance to sustain efforts for increased contraceptive access within the territory after the Z-CAN program ended. Although there is continued commitment from the territory health agency and key stakeholders to sustain the improved access and availability of quality contraceptive services, long-term sustainability continues to need to be addressed.

Conclusion

The 2016–2017 Zika virus outbreak in Puerto Rico posed a serious risk to pregnant women. Efforts to prevent pregnancy among women who chose to delay or avoid pregnancy during the Zika outbreak required coordination, mobilization, and engagement among federal and territorial agencies, key stakeholders, and private-sector partners. The use of public–private partnerships was important to provide expertise, context, speed, support, and awareness for the Z-CAN program’s rapid development, implementation, and sustainability efforts. Strategies and lessons learned from the Z-CAN program’s public–private partnerships can serve as a model to other settings for which access to contraception could improve health outcomes.