Bangladesh - Counting What Counts: Tracking Access to Emergency Contraception

Publication date: 2013

April 2013 ABOUT BANGLADESH Bangladesh is one of the most densely populated nations in the world, with a total population of approximately 163,654,860, of which 82,795,401 are women. The country is largely rural, with only 28% of the population living in cities.1 Only 12% of women have completed secondary education or higher, compared to 18% of men.2 CONTRACEPTIVE KNOWLEDGE AND USE Emergency Contraception (EC) Knowledge and Use: Information about EC knowledge and use in Bangladesh is not available. Questions on EC were not included in the 2011 Demographic and Health Survey. POLICIES Essential Drug List: Levonorgestrel in the dose needed for emergency contraceptive use is not included in the 2008 edition of Bangladesh’s essential medicines list.3 National norms and guidelines: In 2001 the Government of Bangladesh introduced EC into the National Family Planning Program and between 2003 and 2004, trained 44,774 providers and trainers in the provision of EC.4 Prescription status: Field workers, NGO providers, pharmacists, nurses, and physicians are all permitted to provide EC. Regulations allow it to be sold directly to women without a prescription.5 Post-rape care: With rare exceptions, EC was not found to be available as part of post-rape care in either hospitals or police stations in Bangladesh.6 Providers in hospitals and police stations report having received little or no training regarding post- rape care, and while some believed that there are existing guidelines for care, no one had ever seen such a document.6 PRODUCT AVAILABILITY Registered Products: Levonorgestrel alone EC products are registered and distributed: Emcon (Renata Ltd.) and Postinor-2 (Gedeon Richter).5 Locally manufactured products: Emcon is manufactured by Renata Limited, a pharmaceutical company based in Bangladesh. Poor quality or counterfeit EC products: While not specific to contraception, Bangladesh has been cited as a country struggling with a large counterfeit drug market. Cases of morbidity and mortality in Bangladesh resulting from counterfeit drugs have been reported.7,8 WHERE WOMEN CAN ACCESS EC EC in the commercial sector: EC is available for purchase in the private sector without a prescription.Ba ng lad es h COUNTING WHAT COUNTS: TRACKING ACCESS TO EMERGENCY CONTRACEPTION • Total fertility rate: 2.3 births per woman (2% urban, 2.5% rural). Fertility has fallen rapidly over the past few decades. • Unmet need for contraception (among currently married women): 14% • Current modern contraceptive use (among currently married women): 52% Source: Demographic and Health Surveys, Bangladesh 2011 BANGLADESH Policies in Bangladesh support the use of EC in Bangladesh: EC has been incorporated into the national norms and guidelines for family planning, is distributed in government and NGO clinics free of charge, and is available for purchase in private sector pharmacies and social marketing clinics. Bangladesh is one of the few countries where EC is available truly over the counter without intervention from medical providers, and also one of the few to integrate EC into community-based distribution systems. Ba ng lad es h 2 EC in the Public Sector: Emergency contraceptive pills (ECPs) are available free of charge at public hospitals and clinics.9 Stock outs have been reported in the public sector, however. EC in the NGO, Social Marketing, and Social Franchising Sectors: ECPs are available in multiple NGO clinic systems and social franchising programs, including IPPF member the Family Planning Association of Bangladesh10 and the Smiling Sun franchise system.11 Community-Based Distribution of EC: The Government of Bangladesh has approved free, community-based distribution of EC wherein all providers, including outreach workers, are able to dispense the method.12 PROVIDERS A 2009 survey13 of 3,285 government and non- government service providers in randomly selected regions assessed knowledge, attitudes, and behavior in regards to EC provision. 95% of the service providers had heard of EC, with the government service providers (98%) having slightly higher rates of knowledge than non-government service providers (92%). More than half of those surveyed had heard about EC from training. Nearly all of the service providers cited poor publicity of EC as the major obstacle to promoting it in Bangladesh. A similar 2009 survey14 of 1,367 drug-sellers throughout Bangladesh assessed their knowledge of and practices around EC. The results found that while around 50% of the respondents had no formal training on selling drugs, 87% had heard of EC, and the majority (77.9%) mentioned the Postinor-2 pill. Reasons cited for poor sales of EC were inadequate supply (38%), low demand (37.2%), and lack of knowledge and high cost (24.8%). MEDIA COVERAGE OF EC Only about half of women in Bangladesh (51.2%) have access to at least one type of mass media on a weekly basis.2 Media coverage of emergency contraceptive pills has been present, but not abundant. The coverage is generally positive, and promotes EC.15 DONOR SUPPORT Donors have supported both EC programs and the purchase of EC commodities. According to RHInterchange, between 2009 and 2012, two shipments of EC were made to Bangladesh, totaling 183,160 packets; the funding sources were UNFPA and IPPF.16 Bangladesh 3 REFERENCES 1 CIA World Factbook, Retrieved April 1, 2013 from https://www.cia.gov/library/publications/the-world- factbook/geos/bg.html 2 Demographic and Health Survey 2011, Bangladesh. ICF International and the National Institute of Population Research and Training, Bangladesh, January 2013. 3 List of Essential Drugs. Ministry of Health & Family Welfare. Public Health-1 Branch, Bangladesh, 2008. (http://www.who.int/selection_medicines/country_lists/ bgd_eml_2008.pdf) 4 FRONTIERS, Population Council. Building National Capacity to Deliver Emergency Contraception Services in Bangladesh. Research Updates 3, 2005. 5 ICEC EC Status and Availability Database, Retrieved April 3, 2013 from http://www.cecinfo.org/country- by-country-information/status-availability-database/ countries/bangladesh/ 6 Khan, M.E., et al. A Situation Analysis of Care and Support for Rape Survivors at First Point of Contact in India and Bangladesh. Frontiers in Reproductive Health, September 2008. 7 McKenna, Maryn. Are Counterfeit Drugs Driving Resistance? Wired Magazine, August 2011. http:// www.wired.com/wiredscience/2011/08/counterfeit- driving-resistance/ 8 Sengupta, Avik. Beware of Counterfeit Drugs. The Financial Express, 2009. http://www. thefinancialexpress-bd.com/more.php?news_ id=112434 This fact sheet has been prepared by the International Consortium for Emergency Contraception and represents the best information we have been able to gather. We welcome your input for future revisions. Please contact us at info@cecinfo.org. Visit our website at www.emergencycontraception.org for more information on EC. 9 Khan, M.E. and Sharif M.I. Hossain. Forthcoming. Introducing and scaling up delivery of emergency contraceptive pills in the national family planning program of Bangladesh: Enhancing utilization of operations research results and lessons learned from program implementation. FRONTIERS Final Report, Population Council, Washington, DC. 10 Family Planning Association of Bangladesh: Services, Retrieved April 1, 2013 from http://www.fpab.org/inner_ page.php?mid=19 11 Clinical Social Franchising Compendium. “Annual Survey of Programs, 2011.” The Global Health Group, 2011. Web. 12 Khan, M.E., Sharif Mohammed Ismail Hossain, and Moshiur Rahman. Introduction of Emergency Contraception in Bangladesh: Using Operations Research for Policy Decisions. Population Council, Washington, DC, December 2004. 13 Luftun, N, Khan, T.I, Akhtar, S. Practice of emergency contraception among government and non-government service providers in Bangladesh. Proc. of Annual Scientific Conference, 2009. 14 Akhtar, Shameem. Knowledge and Practice of Emergency Contraception among Drug-sellers in Bangladesh. Proc. of Annual Scientific Conference, ICDDR,B, 2009. 15 Akhtar, Shameem. Emergency Contraception: A New Way to Reduce Abortion. The Daily Star, December 19, 2009.  16 RHInterchange, Retrieved April 3, 2013 from http://rhi. rhsupplies.org/rhi/shipmentsummary.do

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