Assessment of the Pregnancy Test Market in Madagascar
Publication date: 2017
Assessment of the Pregnancy Test Market in Madagascar Madagascar Ministry of Public Health policy supports the use of pregnancy tests in family planning services. Pregnancy tests are widely available in the private sector, but are only available in the public sector through donor-supported community health agents. Public procurement of these commodities for family planning service provision is limited. The SHOPS Plus project conducted a market shaping assessment of pregnancy tests in the Antanavario region in Madagascar. The assessment shows that pregnancy tests are widely available in the private sector, but only available in the public sector through donor- supported community health agents. The majority of providers interviewed said that they never experienced stockouts. When pregnancy cannot be ruled out using the World Health Organization (WHO) pregnancy checklist, potential family planning clients are asked to return later or are sent to a private pharmacy to purchase pregnancy tests. Redirecting family planning clients to the private sector to purchase a pregnancy test can result in a delay in starting contraception, unforeseen cost to the public clinic client, and ultimately the possibility of client drop-off. There are opportunities to increase the availability of pregnancy tests in Madagascar. The Ministry of Public Health (MOPH) can emphasize the reliability of the WHO checklist in conjunction with pregnancy tests and revise guidelines accordingly. Training could reinforce this practice in the public sector. In the private sector, franchises can reinforce this through either guideline revisions, refresher trainings, or both. 2 | Assessment of the Pregnancy Test Market in Madagascar Demand satisfied (married women) 62% Contraceptive prevalence rate, modern methods (married women) 38% 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 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 Madagascar, 31 percent of women use modern contraception (table). Twenty 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 Madagascar Family Planning 2020 Indicator Percent 31% Source: 2016 Family Planning 2020 Progress Report Figure 1. Source of family planning methods and information in Madagascar Source: Madagascar Demographic and Health Survey 2008–2009 73% 7% Public source Private source Other 20% SHOPS Plus | 3 Methods Several methods were used to collect the information for this assessment in the Antanavario region in Madagascar, including secondary research, email inquiries, stakeholder interviews, and field visits. Between June and August 2016, a consultant based in Madagascar conducted 26 in-depth interviews and site visits with Malagasy 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 Antanavario 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 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 Madagascar Findings The following sections outline findings for the Antanavario region in Madagascar from interviews conducted with stakeholders. Family planning policy The policy environment around pregnancy test use is evolving in Madagascar. The 2015 Integrated Family Planning Reference Manual does not include use of pregnancy tests for the detection of pregnancy. According to the head of the Family Planning Department of the MOPH, public providers currently use the WHO checklist to rule out pregnancy. Use of pregnancy tests is not routine in family planning service provision, and pregnancy tests are not available free of charge in public facilities. It was reported that pregnancy tests are used in cases of doubt, and in these cases the patient is sent to purchase a pregnancy test at a pharmacy. However, pregnancy tests have recently been included in the essential medicines list based on an intervention and research conducted by USAID-funded Strengthening Health Outcomes through the Private Sector (SHOPS) project. SHOPS provided community health workers with pregnancy tests for free distribution. Only about half of the community health workers considered the WHO checklist to be reliable, so pregnancy tests were used as a substitute. The intervention helped increase the number of new hormonal contraceptive clients by 24 percent per month over the four month mentoring period. In addition to including pregnancy tests in the essential medicines list, the MOPH is scaling up the intervention through the USAID-funded Mikolo project. The initial scale-up is focused on community- based distribution. However, there is interest in increasing availability in public sector facilities. Provider use of the checklist and pregnancy tests The protocol for determining pregnancy in public sector facilities is to use the WHO checklist. Providers rarely delay providing a family planning method until the client’s next menses. If pregnancy cannot be ruled out, women are typically offered condoms or oral contraceptives and asked to come back for a long-acting reversible contraceptive. Pregnancy tests are sometimes used as an alternative when there is doubt, but they are not available at public clinics. In these cases, women are sent to purchase a pregnancy test from the nearest pharmacy. Given this practice, women that seek long-acting and reversible contraceptive methods may delay family planning visits outside their menses. Public providers interviewed were asked to rate the reliability of the checklist and pregnancy tests on a scale of 1 to 5, with 5 being the most reliable. Providers gave the checklist a “3” rating because the client could fail to be completely honest in answering the questions. Providers identified pregnancy tests as more reliable, and gave them a “4” rating. The use of checklists and pregnancy tests varies depending on the type of private sector facility. Providers affiliated with social marketing organizations follow their own guidelines and tools. Top Réseau, led by PSI, and BlueStar clinics, led by Marie Stopes Madagascar, use the WHO checklist. If required, a pregnancy test is used to determine eligibility. Providers from these networks also reported using their own family planning eligibility sheets and the WHO medical eligibility criteria wheel to select a family planning method. In some cases, clients are asked to return if pregnancy SHOPS Plus | 5 cannot be determined. Providers in Fianakaviana Sambatra facilities use the MOPH family planning eligibility sheet and the WHO checklist. Providers in Organisation Sanitaire Tananarivienne Inter- Entreprises facilities use the WHO checklist but do not administer pregnancy tests for family planning services. Providers at these facilities expressed some reliability concerns with the checklist, and if the client is not menstruating, providers prefer to give them a barrier method and ask them to return when they are menstruating. Public procurement Public procurement of pregnancy tests is currently limited in Madagascar. SALAMA, the central medical store, does not procure pregnancy tests for the government, but manages the distribution of pregnancy tests donated by UNFPA for gender-based programs. Districts have state-allocated budgets and can make their own requests to SALAMA. District procurement requests are consolidated and supplied through tenders. Quantities of pregnancy tests that SALAMA had acquired and distributed in recent years were very small in relation to the number of public facilities. While pregnancy tests are currently procured in small numbers, there are efforts underway by the MOPH to scale up the availability of pregnancy tests. Availability This assessment found that pregnancy tests are not typically available in public sector facilities. At the time of the consultant’s visit, pregnancy tests were unavailable in the two public facilities that were visited. Pregnancy tests available in social marketing organizations are supplied by donors, and four out of five providers who were interviewed said that they never experienced stockouts. Pregnancy tests in Fianakaviana Sambatra and Organisation Sanitaire Tananarivienne Inter-Entreprises facilities are supplied by wholesalers. These facilities also reported stable supply of pregnancy tests. Commercial brands are widely available in pharmacies at various prices. The assessment identified 14 different brands and 8 manufacturers. The most common type was the dipstick (7), though cassette and midstream tests were also available. 834714 Brands identified Dipstick Cassette Midstream Manufacturers identified Number of pregnancy test brands, types, and manufacturers 6 | Assessment of the Pregnancy Test Market in Madagascar Pricing and costs Pregnancy tests are not typically available at public sector clinics, so the assessment could not determine the cost. However, the MOPH supports increasing the free distribution of pregnancy tests at the community level through the Mikolo project. At retail pharmacies, pregnancy tests can cost as low as $0.33 and as high as $3.45, comparable to emergency contraceptive pill prices. Retailer gross margin is 25 to 45 percent. At private providers, pregnancy tests cost between $0.49 and $0.99 in addition to the consultation fee, which is between $0.99 and $1.66. There is no evidence to suggest that pregnancy tests are unaffordable for those that typically seek services in the private sector. While prices for pregnancy tests in absolute terms are low, they may be unaffordable for women who typically seek care in the public sector (and who must purchase a pregnancy test from a pharmacy because their public facility is stocked out). Data on pregnancy test prices in rural, hard-to-reach areas was not collected in this assessment, nor was it designed to assess affordability. Product design and quality The predominant product design available in Madagascar was the dipstick. However, the cassette and midstream tests were available in the market, which gives providers and clients some choice to use the pregnancy test design they prefer. This assessment did not find any evidence of provider or client concerns with design or usability. While an objective evaluation of pregnancy test quality was not included in this assessment, interviews did not indicate procurer, provider, or client concerns with the quality of pregnancy tests. $0.33–3.25$0.99–1.66$0.49–0.99$0.33–3.45Pregnancy tests not available at the clinics visited 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 Encourage the Ministry of Public Health to incorporate the use of pregnancy tests into public facility guidelines and mobilize resources for public procurement. Building on the success of the Mikolo project, family planning advocates can encourage the MOPH to revise current guidelines to support the use of pregnancy tests in family planning service provision at public facilities. With this shift, pregnancy tests for family planning should be made available at public facilities, ideally free of charge. Doing so would also require the government to mobilize resources for the public procurement of pregnancy tests. Emphasize the reliability of the WHO checklist in conjunction with pregnancy tests in private provider trainings and guidelines. Despite its use, providers reported lacking confidence in the WHO checklist. They reported varying their provision practices among women seeking family planning methods who were not menstruating. In the public sector, this inconsistency should first be addressed by changing policy, as described earlier, and could be reinforced through training. In the private sector, the various franchises could reinforce the reliability of the checklist and clarify its use in conjunction with pregnancy tests and other tools through either guideline revisions, refresher trainings, or both. Doing so would require support from franchise organizations, a better understanding of provider behaviors, and resources for these programs. 8 | Assessment of the Pregnancy Test Market in Madagascar Bibliography Comfort, A., S. Chankova, R. Juras, N. Hsi, L. Peterson, and P. Hathi. “Impact of Free Pregnancy Test Kits on Contraceptive Distribution: Evidence from an Experiment in Madagascar.” Webinar, Reproductive Health Supplies Coalition, January 14, 2016. The DHS Program. “STATcompiler.” Accessed March 21, 2017, http://www.statcompiler.com. Family Planning 2020. “Madagascar.” http://www.familyplanning2020.org/entities/124. Rakotomalala, B. 2016. “Madagascar/Pregnancy Tests Data Collection: Summary of Findings.” Unpublished paper. 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 firstname.lastname@example.org
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