Assessment of the Pregnancy Test Market in Kenya

Publication date: 2017

Assessment of the Pregnancy Test Market in Kenya Kenya Ministry of Health policy supports the use of pregnancy tests in family planning services. Pregnancy tests are widely available across the public and private sectors. Public procurement of these commodities for family planning service provision is done at the county level. The SHOPS Plus project conducted a market shaping assessment of pregnancy tests in the greater Nairobi area of Kenya. The assessment shows that pregnancy tests are widely available across the public and private sectors. However, prices in both sectors vary and may be high for some patients. Kenya’s devolution of primary health care services to the county level has led to variability in procurement practices. Because county-level procurement varies, smaller orders may lead to higher prices. However, the majority of the cost to end users is added through the pharmacy and clinic retail margins. Some public and private clinics purchase directly from pharmacies at retail prices, which may also explain prices charged to end users. There may be opportunities to reduce prices of pregnancy tests for public clinics and end users by improving procurement practices. Another opportunity is to partner with social marketing organizations or community programs to make private sector pregnancy tests more affordable. There may also be opportunities to partner with professional associations and private facilities to increase provider adherence to family planning protocols. 2 | Assessment of the Pregnancy Test Market in Kenya Demand satisfied (married women) 74% Contraceptive prevalence rate, modern methods (married women) 57% Background Screening for pregnancy is often an important step in supporting the immediate start of a contraceptive method when a woman seeks family planning services. Pregnancy status can be determined by conducting a pregnancy test or patient history using the pregnancy checklist. The checklist was developed by the World Health Organization (WHO) and comprises six questions about medical history. Answering “yes” to at least one of the questions allows the provider to be reasonably sure that the patient is not pregnant. If pregnancy cannot be ruled out, the patient may be asked to come back during her next menses. Ensuring same-day provision of family planning methods is an important way to ensure reliable access to contraception for women and protect them from unplanned pregnancy. Studies suggest that making pregnancy tests more widely available can increase the same-day start of contraception for women seeking family planning services and reduce delay and denial by providers. Family Planning 2020’s goal includes an emphasis on country-level efforts related to increasing access to quality family planning information, services, and products. Pregnancy tests can play an important role in these efforts. In Kenya, 43 percent of women use modern contraception (table). Thirty-four percent of women get their family planning method or information from a private medical source (Figure 1). The purpose of this market assessment was to collect and analyze country-level market data for pregnancy tests and their use in family planning services to evaluate whether interventions are needed to increase availability and access to low-cost, quality pregnancy tests. Contraceptive prevalence rate, modern methods (all women) Key family planning indicators in Kenya Family Planning 2020 Indicator Percent 43% Source: 2016 Family Planning 2020 Progress Report Figure 1. Source of family planning methods and information in Kenya Source: Kenya Demographic and Health Survey 2014 60% 6% Public source Private source Other 34% SHOPS Plus | 3 Methods Several methods were used to collect the information for this assessment in Kenya, including secondary research, email inquiries, stakeholder interviews, and field visits. Between July and September 2016, a consultant based in Kenya conducted 27 in-depth interviews and site visits with Kenyan public and private sector providers, government staff, retailers, and other stakeholders. The assessment team also researched national guidelines for the use of pregnancy tests in the delivery of family planning and related health services, the inclusion of pregnancy tests on essential commodity lists, and procurement practices. Interviews focused on provider clinical practices, availability and costs of pregnancy tests, and procurement practices. The assessment team collected data on the manufacturers, types, and costs of pregnancy tests that were available in various outlets. Outlet types included public and private clinics, private sector pharmacies, and clinics run by social marketing organizations. In-country data collection was limited to Nairobi and the surrounding areas. Following data collection, the SHOPS Plus team analyzed the findings using the market shaping framework presented in the USAID Center for Accelerating Innovation and Impact primer Healthy Markets for Global Health (Figure 2). This process involved identifying possible market weaknesses using the criteria of affordability, availability, assured quality, appropriate design, and awareness. The team assessed provider perceptions of pregnancy test quality, but objective quality standards will be completed through a separate process led by Extent to which the price point maximizes market efficiency between payers and suppliers to support health outcomes Capacity and stability of global supply to meet demand; and consistency of local access at service delivery points Level of evidence that a product is consistently efficacious and safe Degree to which possibilities of technology maximize cultural acceptability, choice, and ease of use Extent to which end users, health care providers, and key influencers can make informed choices about product use DEFINITION Affordability Availability Assured Quality Appropriate Design Awareness Figure 2. The five A’s of market health FHI 360. To increase the access to and availability of quality, lower-cost pregnancy tests, the team identified potential interventions to address market shortcomings. Source: USAID Center for Accelerating Innovation and Impact (2014) 4 | Assessment of the Pregnancy Test Market in Kenya Findings The following sections outline findings for the greater Nairobi area in Kenya from the interviews conducted with stakeholders. Family planning policy The Kenyan government supports the use of pregnancy tests in the context of family planning services. Policies related to the use of pregnancy tests in family planning are outlined in the Division for Reproductive Health’s National Family Planning Guidelines for Service Providers. The guidelines include a section entitled, “How to be reasonably sure a client is not pregnant,” which lists a series of scenarios that directly align with the questions in the WHO checklist. The guidelines state that pregnancy testing is not essential except when (1) the woman answers “no” to all questions on the pregnancy checklist, (2) it is difficult to confirm pregnancy, or (3) the results from the pelvic examination are equivocal. In these cases, providers are advised to use a pregnancy test if it is readily available or affordable. The WHO checklist is listed as a recommended job aid for providers. Provider use of the checklist and pregnancy tests Interviews indicated that public sector providers follow the Ministry of Health’s guidelines for the provision of family planning services. Providers interviewed were aware of the WHO checklist, felt the checklist was reliable, and had the checklist present in their facility at the time of the interview. Method- specific job aids, including checklists for combined oral contraceptives, IUDs, and implants, were also available. In line with national guidelines, providers reported conducting pregnancy tests if they could not confirm pregnancy through taking a patient’s history or conducting physical examination. When a pregnancy test is required, providers reported different practices for obtaining the pregnancy tests and test results. One facility described that pregnancy tests are administered at a cost by sending the patient to their own lab. Providers at facilities without labs sometimes send their clients to purchase pregnancy tests outside of their facility, and then have them return with their test results. In the private sector, protocols and practice related to the use of pregnancy tests in family planning service provision varied. Providers at franchised clinics, including Tunza (led by PSI) and Amua (led by Marie Stopes International) use their franchise’s guidelines in the provision of family planning methods. These providers had varied awareness of the WHO checklist, with one franchised clinic having the checklist on-site at the time of visit. Most independent private providers reported being aware of the WHO checklist and consider it reliable. However, none of the facilities had the checklist available on site. Independent private providers reported using different tools and protocols to determine eligibility for family planning methods. All private facilities that were visited conduct pregnancy tests on site. SHOPS Plus | 5 Public procurement Kenya’s decentralized health care system includes two levels of management and responsibility: the national level and the county level. Primary health care delivery management and procurement of related supplies are county-level responsibilities. For this reason, the Kenya Medical Supplies Authority does not routinely procure or distribute pregnancy tests. Rather, counties are responsible for the procurement of pregnancy tests for their facilities. County officials reported that data on use is collected from health care facilities by the sub-county lab coordinator, who in turn quantifies and submits requests to the county headquarters. The county then issues a tender or request for quotation for pregnancy tests and completes the procurement process. Most pregnancy tests are procured from the local market. Once pregnancy tests arrive, public facilities collect pregnancy test supplies from the county headquarters. One stakeholder shared that in some cases, there is no regular county procurement of pregnancy tests, so local clinics procure the tests directly from retail pharmacies. Availability Pregnancy tests are typically available in public clinics in the greater Nairobi area. In some cases, patients are sent out to purchase pregnancy tests when they are not available on site. Pregnancy tests are widely available in private sector clinics, which reported stable availability of pregnancy tests and no problems with stockouts. The seven retail pharmacies and chemists visited by the assessment team had pregnancy tests available at the time of visit. The team identified 14 different pregnancy test brands from nine different manufacturers, all of which were dipstick tests. Research conducted by FHI 360 suggests at least 25 different brands are available in the Kenyan market. Retailers reported sourcing pregnancy tests from a variety of suppliers, as the tests are widely available at competitive prices. 9001414 Brands identified Dipstick Cassette Midstream Manufacturers identified Number of pregnancy test brands, types, and manufacturers 6 | Assessment of the Pregnancy Test Market in Kenya Pricing and costs There is a range of pregnancy test brands at varying price points available through private sector clinics and pharmacies. Prices start as low as $0.29 in retail pharmacies, but were found to be as high as $4.17. Prices in private clinics range from $0.97 to $1.94 for a pregnancy test, which is comparable to the prices found for emergency contraception. The cost of a family planning consultation at private sector providers ranged from $0.99 to $3.00, and typically includes the family planning method and service, but not the pregnancy test, if required. Retail- and clinic-level margins are relatively high; for one brand, margins were calculated to be 85 percent and 96 percent respectively. In comparison, wholesaler margins are low at 12 percent. These margins, while higher than normal for pharmaceutical products, are consistent with the need for pharmacists to generate minimum profitability from low-volume, low-cost products such as pregnancy tests. There is no evidence to suggest that pregnancy tests are unaffordable for those that typically seek services in the private sector. While the Kenyan government abolished user fees for primary care services, public sector clinics were found to charge for pregnancy tests. In public clinics that were visited, pregnancy tests were priced between $0.99 and $1.40. Anecdotally, public facilities sometimes purchase pregnancy tests directly from retail pharmacies, which would result in significantly higher costs to public facilities. For those with limited ability to pay that typically seek free services in the public sector, it is possible that the price of pregnancy tests from public clinics or private pharmacies is unaffordable. Data on pregnancy test prices in rural, hard-to-reach areas was not collected in this assessment, nor was the analysis designed to precisely assess affordability, which would require a population-based survey. Product design and quality The only product type found to be available through this assessment was the dipstick. There was no evidence of provider or client concerns with design or usability. While an objective evaluation of pregnancy test quality was not included in the research, interviews did not indicate procurer, provider, or client concerns with test quality. Most providers in the public and private sectors indicated that the pregnancy tests were reliable. $0.99–1.48$0.99–3.00$0.97–1.94$0.29–4.17$0.99–1.40 Pregnancy test at public clinic Pregnancy test at retail pharmacy Pregnancy test at private provider Family planning consultation at private provider Other product for comparison (emergency contraceptive pill) Costs of pregnancy tests and family planning consultations SHOPS Plus | 7 Recommendations Develop a better understanding of why public facilities are charging for pregnancy tests. This assessment found that pregnancy tests are not free in the public sector, but did not thoroughly investigate what is leading public facilities to charge for pregnancy tests. Investigation into procurement practices and the occurrence of stockouts at public facilities could explain why some public providers are purchasing pregnancy tests from pharmacies and charging clients for pregnancy tests. Further analysis of county procurement practices could indicate whether optimal prices are achieved by most counties, especially given their relatively small order sizes. Partner with existing social marketing or community programs. Because some public sector clients are expected to buy pregnancy tests in the private sector, a complementary intervention could seek to lower the cost of pregnancy tests for public sector clients who cannot afford them. One option is to partner with an existing social marketing or community-based distribution program operating in underserved areas to introduce lower-cost pregnancy tests through the private sector. This intervention may not be sustainable in the long term without subsidization of some programmatic costs. Partner with professional associations and private facilities to change or standardize clinical practice. Because clinical practice related to determining pregnancy in the context of family planning services varied, there is an opportunity to improve private provider adherence to family planning protocols. Doing so would require strong support from medical associations and private facilities, and may require changes to the medical curriculum for family planning. An existing program mechanism or funding source would also be required. This recommendation may be difficult to implement due to the large number of independent private facilities. 8 | Assessment of the Pregnancy Test Market in Kenya Bibliography Bunyi, M. 2016. “Pregnancy Test Market Shaping Activity Report, Kenya.” 2016. Unpublished paper. DHS Program. “STATcompiler.” Accessed March 21, 2017, http://www.statcompiler.com. Family Planning 2020. “Kenya.” http://www.familyplanning2020.org/entities/77. Kenya Ministry of Public Health and Sanitation. 2010. National Family Planning Guidelines for Service Providers. Nairobi: Kenya Ministry of Public Health and Sanitation, Division of Reproductive Health. Solomon, M., Project Director of Applied Research – Kenya, FHI 360, phone call, December 15, 2016. Rademacher, K., J. Stanback, T. Brett, FHI 360. “Crossing over the Thin Blue Line: Assessing the Availability of Pregnancy Tests.” Reproductive Health Supplies Coalition webinar, January 2016. USAID Center for Accelerating Innovation and Impact. 2014. Healthy Markets for Global Health: A Market Shaping Primer. Washington, DC: USAID. Sustaining Health Outcomes through the Private Sector (SHOPS) Plus is a five-year cooperative agreement (AID-OAA-A-15-00067) funded by the United States Agency for International Development. The project strategically engages the private sector to improve health outcomes in family planning, HIV, child health, and other health areas. Abt Associates implements SHOPS Plus in collaboration with the American College of Nurse-Midwives, Avenir Health, Broad Branch Associates, Banyan Global, Insight Health Advisors, Iris Group, Marie Stopes International, Population Services International, Praekelt.org, and William Davidson Institute at the University of Michigan. July 2017 Abt Associates Inc. 4550 Montgomery Avenue, Suite 800 North Bethesda, MD 20814 USA Telephone: 301.347.5000 Find Us SHOPSPlusProject.org Contact Us info@shopsplusproject.org

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