खोज्न टाइप गर्नुहोस्

गहिराइमा पढ्ने समय: 7 मिनेट

दाता कोष घट्दै गएको युगमा गर्भनिरोधकमा पहुँच विस्तार गर्न निजी क्षेत्रको सदुपयोग गर्दै

The Case of Contraceptive Implants

Family planning (FP) commodities and services in lower- and middle-income countries (LMIC) have historically been heavily subsidized by the donor community. However, donor funding for FP has plateaued and is expected to decline while many countries have yet to meet their FP goals. Countries are looking toward new financing methods and delivery models to create more resilient reproductive health systems, in part through leveraging the private sector’s contributions towards expanding the reach of FP services.

The private sector has been a significant source from which people obtain contraception, with roughly a third of women in LMICs going to private sector outlets particularly for short-term methods, like condoms and pills. Fewer users rely on the private sector for long-term methods such as injectables, implants and IUDs, which are predominantly obtained in the public sector.[1] The private sector consists of both the not-for-profit private sector and the commercial sector, with only the former historically having access to – and the benefit of – subsidized commodities and services. All sectors – the public sector, not-for-profit private sector, and the commercial sector – are key to ensuring that women everywhere have access to the services and care they need. But more effort is needed to support market stewardship so that the private sector is more effectively harnessed to expand access to FP method choice. Ideally, market stewardship is delivered through government mechanisms, but in some instances an intermediary needs to play an interim role.

Contraceptive implants provide an intriguing case study where opportunities exist to better steward and leverage the private sector amidst this broader funding shift. While they have gained significant popularity as an FP method in the public sector, the share of implants obtained in the private sector has remained minimal at 13% in LMICs compared to 86% in the public sector.[2] Over a decade ago, implants were made available at a reduced price to public purchasers through the Implants Access Program (IAP) which aided a nearly three-fold increase in global procurement of implants from 3.9 million in 2012 to 10.6 million in 2021.[3] The public health impact of implants is unquestioned. However, for implants to be sustainably available in the long term, actors throughout the private sector value chain need to be engaged – and appropriately incentivized – to offer implant services. Doing this at scale is particularly challenging given the high upfront unit cost of implants (roughly USD $8.50/unit) and mixed practices and expectations around financing FP supplies and services across LMICs.

The Rationale

As a part of the Expanding Family Planning Choices (EFPC) project, Jhpiego and Impact for Health collaborated in 2022 to understand the barriers to quality provision of contraceptive implant services by the private sector (check out our project landing page and associated blog for more information). In 2023, we collaborated again to build on these findings to develop roadmaps to cultivate the private sector market for implants in two countries: केन्याPunjab, Pakistan.

केन्या is well-poised to expand its private implant market with an active private sector for FP (33% of all FP users access care through the private medical sector: private pharmacies, hospitals and clinics),[1] a comprehensive FP Total Market Approach (TMA) strategy ready to implement, and widespread population awareness and use of implants (37% of women who use a modern form of FP use implants).[2] However, the private sector has a disproportionately lower share of the implants market (14%) compared to other similar methods (injectables – 37%; and IUCDs – 34%) that also require services from a trained provider. If barriers to private sector expansion are addressed, the implant market could double in size to over 500,000 users within the next few years. Currently, the vast majority of implants are provided by the government to public facilities and select private facilities at no cost and explicitly labeled “not for sale”. But access to free commodities is expected to end as donor funding declines and the Ministry of Health plans to fully fund their FP commodity purchasing by 2025, thus creating pressure to optimize and restrict use of publicly funded goods and, in turn, an opportunity for a true private market for implants.

मा Pakistan, despite significant donor investment, the CPR has stagnated around 30% for nearly two decades[3] while unmet need for family planning ranged from 25% to 17% during this time.[4] Traditional methods, condoms and female sterilization account for over 75% of the method mix. More work is needed to diversify method choice and leverage all possible channels to reach women. Only 1% of FP users in Pakistan use implants, 86% of whom obtain it from the public sector (funded by the government) with the remaining 14% obtaining them from the private not-for-profit sector (funded by donors). The commercial private sector, while an active source of healthcare, has not played a significant role in FP provision including implants. Jadelle is the only implant currently in the market, but it is currently registered at a Maximum Retail Price (MRP) that, due to the devaluating PKR, is lower than the purchase price set in USD. However, DKT with support from DKT WomenCare Global is planning to import significant volumes of Levoplant in 2024 and sell to the public sector, private sector (NGO and large hospitals), and small private sector providers, which could be a starting point to build the market.

The Process

Literature review and key informant interviews were conducted to compile country Market Analysis Reports for केन्यापाकिस्तान. Then, building on these reports, key stakeholders across the value chain in each country were convened to develop Roadmaps charting a pathway for private sector provision of implants in Kenya and Punjab, Pakistan.

Kenya Roadmap explores several key opportunities:

  • Supporting the establishment of a viable supply chain for the private sector through the development of affordable yet differentiated implant products that can provide sufficient margins for all actors in the chain; and the products are valued by consumers. Free provision of commodities to the private sector must stop to allow for natural profit-seeking behaviors to develop amongst private providers.
  • Exploring appropriate financing options to offset the anticipated cost increase in the private sector once free public commodities are withdrawn, such as expanding inclusion of FP/implants in health insurance schemes and financing upfront capital for distributors/wholesalers through loan guarantees or guaranteed buyer models.
  • सुनिश्चित गर्दै private providers are sufficiently trained to deliver quality services through improved pre-service training curriculum, and that they report into KHIS regardless of from where they receive commodities.
  • अन्तमा, launching the roadmap मार्फत Kenya’s TMA Task Force offers a starting point to operationalize the strategy which has struggled to gain traction.

Punjab, Pakistan Roadmap explores:

  • Supporting registration of multiple brands of implant products with the Drug Regulatory Authority Pakistan (DRAP) at a maximum retail price (MRP) that leaves room for profit margin across the value chain in the context of a devaluing rupee while commodities are purchased in USD. DKT has recently registered Levoplant with an MRP much higher than the expected selling point to account for the devaluating rupee, and the same could be done for Jadelle and Implanon NXT.
  • Supporting inclusion of multiple brands of implants in Punjab’s Essential Medicine List (EML) to make public purchasing easier, and therefore increase availability and awareness of this otherwise nascent product.
  • Temporarily increasing private provider profit margin from offering implants through potential supply side subsidy mechanisms during ramp-up while decreasing the cost to the consumer through vouchers. The temporary subsidies aim to boost profits during the initial low-volume period. If volume increases to a sufficient level, subsidies may be removed, expecting a decrease in profit margin but still providing enough profits to the provider.
  • Coordinating demand generation efforts for implants as the product becomes available, leveraging existing community platforms and digital platforms/social media.
  • Increasing private provider capacity to provide implants, including mid-level providers such as male family physicians and Lady Health Visitors.

To read the Roadmaps in full, as well as associated products, please click यहाँ.

What’s Next?

These Roadmaps offer starting points. In Kenya, the Division of Reproductive Health under the Ministry of Health was engaged in the development and is supportive of the recommendations outlined in the Roadmap. The TMA Task Force is expected to convene and commence the operationalization of these recommendations. Likewise, in Pakistan, both the Department of Health and the Population Welfare Department were part of the roadmap development and support the recommendations, which should be taken forward in provincial FP2030 forums to inform future plans for public and private sectors.

The market assessments and roadmaps have also been shared with funders and partners active globally in the FP product scale-up space, to inform thinking on opportunities to leverage the private sector to expand access to contraception, surfacing several key questions relevant to all FP commodities including:

  • How can product subsidy in the public sector serve to de-risk entry and sale of the product for the private sector, without stymying the private market?
  • What is the path to reducing subsidies across market functions (i.e., commodity, information, training providers, demand generation) over time to enable all actors to play their role most effectively?
  • What are the “right” mechanisms to make products with comparatively high upfront cost (such as implants) more accessible, including but not limited to commodity subsidy?
  • Can market segmentation and product differentiation enable varying levels of subsidy within the same market, without distorting it?
  • How can multiple sources of financing be leveraged and coordinated to ensure adequate funding for reproductive health supplies while keeping them affordable to the end users? And, how can limited donor investment better target such transformations?
  • What market conditions and interventions सक्छ stimulate or enable LARC provision in the private sector?

While there are no definitive answers to these questions, progress lies in our collective efforts to invest in and actively share insights and learnings across products and markets – efforts that are increasingly needed to drive meaningful, sustained change in FP access and equity.

[1]  Bradley SEK, Shiras T. Where Women Access Contraception in 36 Low- and Middle-Income Countries and Why It Matters. Glob Health Sci Pract. 2022 Jun 29;10(3):e2100525. doi: 10.9745/GHSP-D-21-00525. PMID: 36332074; PMCID: PMC9242616.

[2] Ibid.

[3]  Jhpiego and Impact for Health International. 2022. Journey to Scaling Contraceptive Implants.https://www.impactforhealth.com/lessonsforcontraceptiveimplants-journeytoscalingcontraceptiveimplants

[4] Kenya National Bureau of Statistics and ICF international. (2023). Kenya Demographic and Health Survey (2022).https://dhsprogram.com/pubs/pdf/FR380/FR380bis.pdf

[5] Performance Monitoring for Action Kenya. (2021). PMA Kenya (National) Results from Phase 3 panel survey  https://www.pmadata.org/sites/default/files/data_product_results/KEP3_National_XS_Results%20Brief_FINAL_0.pdf

[6] Khan AA. Family planning trends and programming in Pakistan. J Pak Med Assoc. 2021 Nov;71(Suppl 7)(11):S3-S11. PMID: 34793423.

[7] National Institute of Population Studies (NIPS) [Pakistan] and ICF. 2019. Pakistan Demographic and Health Survey 2017-18. Islamabad, Pakistan, and Rockville, Maryland, USA: NIPS and ICF. https://dhsprogram.com/pubs/pdf/FR354/FR354.pdf

यो लेख मनपर्छ र यसलाई पछि सजिलो पहुँचको लागि बुकमार्क गर्न चाहनुहुन्छ?

यसलाई बचत गर्नुहोस् लेख तपाईंको FP अन्तर्दृष्टि खातामा। साइन अप छैन? सामेल हुनुहोस् तपाईका 1,000 भन्दा बढी FP/RH सहकर्मीहरू जसले FP अन्तर्दृष्टि प्रयोग गर्दै आफ्ना मनपर्ने स्रोतहरू सजिलै फेला पार्न, बचत गर्न र साझेदारी गर्न।

Andrea Cutherell

साझेदार, स्वास्थ्यको लागि प्रभाव

Andrea Cutherell एक अनुभवी रणनीतिकार, सहजकर्ता, र स्वास्थ्य परिणाम सुधार गर्न बजार प्रणाली दृष्टिकोण मा ध्यान केन्द्रित संग विश्वव्यापी स्वास्थ्य प्राविधिक नेता हो। उनले जटिल पहलहरूको नेतृत्व गर्ने 15 वर्ष भन्दा बढी अनुभव ल्याउँछिन्; प्रबन्धन टोलीहरू; र यौन र प्रजनन स्वास्थ्य (SRH), मातृ र बाल स्वास्थ्य, पोषण, मलेरिया, एचआईभी, निजी क्षेत्र संलग्नता, र स्वास्थ्य प्रणाली सुदृढीकरणमा प्राविधिक सहयोग प्रदान गर्दै। उनीसँग दक्षिण एसिया र उप-सहारा अफ्रिकाका १३ देशहरूमा बृहत अन्तरदेशीय अनुभव छ। एन्ड्रियाले जोन्स हप्किन्स युनिभर्सिटी ब्लूमबर्ग स्कूल अफ पब्लिक हेल्थबाट स्वास्थ्य विज्ञानमा स्नातकोत्तर गरे र अफगानिस्तानमा उनीहरूसँग संकायमा सेवा गरे जहाँ उनले देशको पहिलो राष्ट्रिय एचआईभी/एड्स निगरानी प्रणालीको सह-डिजाइन गरे।

नाओको डोई

Naoko Doi is Team Lead of Market Access at Jhpiego, where she works across Jhpiego’s portfolio, including maternal and newborn health, infectious diseases, and women’s cancer, to improve affordability and availability of health products in LMICs. In this role, she provides thought leadership and technical guidance to Jhpiego’s technical and country teams on developing and executing interventions to expand sustainable access to transformative products and building partnerships to systematically address barriers to access. Prior to Jhpiego, Naoko spent more than 25 years in global health as well as private sector, focused on new product introduction for infectious diseases in LMICs, strategic planning and market intelligence.

मेगन क्रिस्टोफिल्ड

प्रिन्सिपल र परियोजना निर्देशक, परिवार योजना र आत्म-हेरचाह, Jhpiego, झपिगो

मेगन प्रमुख प्राविधिक सल्लाहकार र परियोजना निर्देशक हुन् जसले विश्वव्यापी गर्भनिरोधक पहुँच र छनोट प्राप्त गर्ने अन्तरालहरू बन्द गर्नमा केन्द्रित छिन्। Jhpiego मा, उनले RMNCAH डिभिजनका कार्यक्रमहरूमा नेतृत्व र प्राविधिक सल्लाहकार सेवाहरू प्रदान गर्छिन्, र आत्म-हेरचाहको लागि विश्वव्यापी प्राविधिक नेतृत्वको रूपमा सेवा गर्दछ। Megan प्रजनन स्वास्थ्य उत्पादनहरू परिचय र मापन गर्न, व्यवस्थित वकालत दृष्टिकोणहरू लागू गर्न, र प्रभावलाई विस्तार गर्न प्रणाली सोच, दूरदर्शिता, र डिजाइन प्रयोग गर्न सहयोग गर्ने टोलीहरूलाई माहिर छ। मेगनलाई जोन्स हप्किन्सबाट महिला स्वास्थ्य, जनस्वास्थ्य वकालत, नेतृत्व र व्यवस्थापन र पार्सनबाट फ्युचर्स स्टडी र सट्टा डिजाइनमा तालिम दिइएको छ। उनले सेन्ट बेनेडिक्ट कलेजमा स्नातकको रूपमा शान्ति र सामाजिक न्यायको अध्ययन गरे।

जैत्रा सत्यन्द्रन

एसोसिएट, स्वास्थ्य अन्तर्राष्ट्रियको लागि प्रभाव

जैत्रा स्वास्थ्यका लागि प्रभावमा सहयोगी हुन्, जहाँ उनी यौन र प्रजनन स्वास्थ्य (SRH), सेल्फ हेरचाह, र बजार प्रणाली विकासमा प्राविधिक परियोजनाहरू प्रबन्ध गर्छिन्, निजी क्षेत्रलाई संलग्न गराउनमा केन्द्रित छन्। पहिले, उनले फिलिपिन्सको मनिलामा रहेको पश्चिमी प्रशान्त क्षेत्रका लागि WHO क्षेत्रीय कार्यालयमा परामर्शदाता र प्राविधिक अधिकारीको रूपमा काम गरिन्, देशका कार्यालयहरूलाई उनीहरूको कार्यक्रमहरूमा लैङ्गिक र स्वास्थ्य इक्विटी लेन्स लागू गर्न सहयोग गर्दै। त्यो भन्दा पहिले, उनले श्रीलंकाको उत्तरी प्रान्तमा स्वास्थ्य मन्त्रालयमा पब्लिक हेल्थ इन्टर्नको रूपमा सेवा गरिन्, जहाँ उनले प्रान्तका अस्पतालहरूको निर्माण गरिएको वातावरणको मूल्याङ्कन गर्न पहुँचयोग्यता जाँचसूची विकास गर्न सहयोग गरे र अटिजम नीतिको विकासमा योगदान पुर्‍याइन्। । जैत्राले पश्चिमी विश्वविद्यालयबाट स्वास्थ्य अध्ययनमा बीएचएससी र टोरन्टो विश्वविद्यालयको डल्ला लाना स्कूल अफ पब्लिक हेल्थबाट स्वास्थ्य प्रवर्द्धन र सामाजिक व्यवहार विज्ञानमा विशेषज्ञताको साथ सार्वजनिक स्वास्थ्यमा स्नातकोत्तर गरेका छन्।

आयशा फातिमा

Aisha Fatima Senior Program Manager, Jhpiego Pakistan Aisha is leading Reproductive Maternal, Newborn and Child Health and Nutrition portfolio in Pakistan as a Senior Program Manager. At Jhpiego, she provides strategic and technical leadership to programs in the RMNCH. Aisha brings over 10 years’ experience in RMNCH&N strategy formulation, program designing, implementation and policy advocacy in both development and humanitarian settings. She has been leading maternal, new born, child health and adolescent/sexual and reproductive health, family planning and nutrition programs. She is an active advocate for RH/FP issues through her association with civil societies for more than 15 years. She is internationally trained in Minimum Initial Service Package, Clinical Management of Rape and family planning and post abortion care and have contributed in development of national and sub-national health and nutrition strategies and guidelines. She is basically a medical doctor with post-graduation in public health.

हुमा हैदर

Huma is a Public Health Specialist with 10 plus years’ experience in planning, implementing and managing community based programs, system strengthening, public speaking, community engagement, curriculum development and strategy development. Skilled in engaging with stakeholders and donor communication, interpreting public health guidance, and proposing public health policies. A knowledge management champion advocating for maternal and sexual and reproductive health improved outcomes, Huma has developed a deep understanding of the unique needs of health systems and policy frameworks in developing countries and the challenges that need to be overcome. Huma provides critical support for system strengthening and bringing systemic and strategic reforms in the Health Department and in operationalizing various reform initiatives including the expertise and approach to engage with the private sector through market systems approach. Huma holds a master’s degree in public health and is a medical doctor working with governments and donors at a senior advisory level.

Levis Onsase

Levis is a dedicated professional with a robust background in public health, specializing in Health Systems Strengthening. Currently, serving as a City Manager with Jhpiego under The Challenge Initiative Platform in East Africa, bringing over a decade of experience in global health programming, program implementation, and public health research. He has been instrumental in advancing family planning and reproductive health initiatives in Kenya, making significant contributions to the field. Levis holds an undergraduate degree in Public Health, which laid the foundation for his career. Currently, pursuing a Master of Science in Public Health, to further enhance his expertise in the field. Notably, he has undertaken specialized coursework in Market Systems Development from Springfield Center, Implementation Science from the University of Washington, and Evaluation and Applied Research from Claremont Graduate University. This additional training has equipped him with invaluable skills in market systems development, knowledge management, and learning. Levis has demonstrated a strong commitment to improving health systems and promoting the well-being of communities.

सारा बरी

Sarah is an experienced medical professional with a background in clinical medicine and global health. As a Senior Associate at IHI, she excels as a strategic facilitator and possesses subject matter expertise in primary healthcare and health systems strengthening. Prior to joining IHI, Sarah served as the Medical Director for a Kenyan NGO, overseeing service delivery, health programs, and strategic planning for the organization. Her background as a medical doctor is complemented by academic achievements, including a Diploma in Tropical Medicine from the London School of Tropical Medicine, post-graduate specialization exams for the Royal College of Anaesthetists in the UK, and her ongoing pursuit of a master's in Public Health at King’s College London. Sarah also has valuable experience in health research in Sub-Saharan Africa and during her time in the National Health Service in the UK, she served as a Health Innovation Fellow.