Contraceptive Security Assessment: Azerbaijan

Publication date: 2006

Date This publication was produced for review by the United States Agency for International Development. It was prepared by (First author’s First Name, Last Name), (Second author’s First Name, Last Name), (Third author’s First Name, Last Name) for Private Sector Partnerships-One project. [image: image8.png] Technical Report No. Technical Report Series: PSP-One Technical Report Series addresses important issues relating to the private sector's role in reproductive health and family planning. Papers in the series may discuss lessons learned and best practices, highlighting PSP-One technical areas. Recommended Citation: [First Author’s Last Name], [First Author’s First Name], [Second Author (First Last], and [Third Author (First Last]. [Report Date]. [Report Title]. Bethesda, MD: Private Sector Partnerships-One project, Abt Associates Inc. Download: Download copies of PSP-One publications at: www.psp-one.com Contract/Project No.: GPO-I-00-04-00007-00 Submitted to: Susan Wright, CTO Bureau of Global Health Global Health/Population and Reproductive Health/Service Delivery Improvement Center for Population, Health and Nutrition Bureau for Global Programs, Field Support and Research United States Agency for International Development DELIVER DELIVER, a six-year worldwide technical assistance support contract, is funded by the U.S. Agency for International Development (USAID). Implemented by John Snow, Inc. (JSI), (contract no. HRN-C-00-00-00010-00) and subcontractors (Manoff Group, Program for Appropriate Technology in Health [PATH], and Social Sectors Development Strategies, Inc.), DELIVER strengthens the supply chains of health and family planning programs in developing countries to ensure the availability of critical health products for customers. DELIVER also provides technical management of USAID’s central contraceptive management information system. [image: image9.jpg] Abt Associates Inc.( 4800 Montgomery Lane, Suite 600 ( Bethesda, Maryland 20814 ( Tel: 301/913-0500.( Fax: 301/652-3916 ( www.PSP-One.com ( www.abtassoc.com In collaboration with: Banyan Global ( Data Management Systems ( Dillon Allman and Partners Family Health International ( Forum One Communications ( IntraHealth International ( O’Hanlon Consulting ( Population Services International ( The London School of Hygiene and Tropical Medicine ( Tulane University’s School of Public Health and Tropical Medicine DISCLAIMER The author’s views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development (USAID) or the United States Government Contents iiiContents Acronyms vii Acknowledgments ix 1. Executive Summary xi 1.1 Demographic Situation xi 1.2 Public Commitment and Policy xii 1.3 Public Service Provision and Access xii 1.4 Product Availability and Supply Chain Management xiii 1.5 The Private Distribution Network xiv 1.6 Private Contraceptive Product Supply xv 1.7 Private Sector Services xv 1.8 Conclusions and Recommendations xvi 2. Introduction 1 2.1 Chronicle of a Death Foretold 1 2.2 Purpose 2 2.3 Methodology 3 2.3.1 Site Visit Approach 4 2.3.2 Stakeholder Meeting 5 3. Demographic Situation and Family Planning Demand 7 3.1 Desired family size and fertility in Azerbaijan 7 3.2 How Azeri familIES achieve their desired fertility levels 7 3.3 Low modern use, high abortion rates, and potential demand 9 4. Public Sector Findings 11 4.1 commitment 11 4.2 opportunities/Recommendations 13 4.3 service provision 14 4.3.1 Policies 14 4.3.2 provider bias 14 4.3.3 Access 15 4.3.4 Recommendations/Opportunities 16 4.4 Product Availability 17 4.4.1 Opportunities/recommendations 18 4.5 Supply Chain Management 19 4.5.1 Forecast 19 4.5.2 Finance 20 4.5.3 Procurement 20 4.5.4 Distribution/Storage/waste management 21 4.5.5 LMIS 22 4.5.6 opportunities/recommendations 24 5. Azerbaijan’s Pharmaceutical Distribution Network 26 5.1 Manufacturers 27 5.2 Distributors 28 5.3 Pharmacies 29 5.4 Sales in Private Clinics 30 5.5 Contraceptive Products 30 5.5.1 Oral Contraceptives 30 5.5.2 Injectable Contraceptives (IC) 32 5.5.3 Intra-Uterine Devices (IUDs) 32 5.5.4 Spermicides 33 5.5.5 Condoms 33 5.6 Private Sector Services 35 5.6.1 Legal Environment 35 5.6.2 Types of Facilities 35 5.6.3 Opening and Managing a Private Clinic 36 5.6.4 Private Clinic Patients 36 5.6.5 Services and Costs 37 5.6.6 Health Providers 38 5.7 Conclusions 39 6. recommendations 41 6.1 CS overview and conclusions 41 6.2 Short term Recommendations 42 6.2.1 Commitment and Policies 43 6.3 Longer Term 44 6.4 Using Demographic Data to Estimate Contraceptive Consumption 48 6.5 Methodology 48 6.6 Limitations 50 6.7 Findings 50 6.8 Costs 51 6.9 Recommendations 52 6.9.1 Product Management in the Rayons 53 6.9.1.1 Sheki 53 6.9.1.2 Ismaili 55 List of Tables Error! Bookmark not defined.Table 1: Table Title List of Figures Error! Bookmark not defined.Figure 1: Figure Title Acronyms AMC Average Monthly Consumption ALS Automated Logistics System CCM Contraceptive Commodity Manager CHS COC Combined Oral Contraceptive CPT Country Procurement Tables CRH Central Rayon Hospital CYP Couple Years of Protection DAC EC Emergency Contraception EDL Essential Drug List ENT Ears, nose and throat (specialist) EU European Union FAP GOA Government of Azerbaijan IDP Internally Displaced Person ISC Innovation and Supplies Centre IUD Intrauterine Device IVF Invetro Fertilization FP Family Planning LMIS Logistics Management Information System MoH Ministry of Health MOF Ministry of Finance NRHO OC Oral contraceptives OTC Over the counter PHC USAID-funded Primary Health Care Strengthening Project in Azerbaijan POP Progestin only Pill PSP-One Private Sector Partnerships-One Project (USAID-funded; 2005- 2009) RH Reproductive Health RHC RHS Reproductive Health Survey STI Sexually Transmitted Infection SPARHCS Strategic Pathway to Reproductive Health Commodity Security TFR Total Fertility Rate UNFPA United Nations Family Planning Agency USAID United States Agency for International Development VFT Acknowledgments Executive Summary LP’s summary In Azerbaijan, the SPARHCS framework was used to ensure essential components on contraceptive security were included in the assessment. For example, the team assessed the demographic situation and demand issues (to the best of its ability given the out of date information). Other components included government commitment for family planning, policy factors, public sector service provision and supply chain issues as well as issues affecting pharmaceutical distribution and private sector services. The team interviewed both public and private sector individuals and organizations and visited hospitals, clinics and pharmacies, and conducted a review of key documents, data and systems. The CS assessment in Azerbaijan reminds us of the difficulty in using an assessment tool to evaluate something that is not functioning. The intention was to modify SPARHCS to develop a formal commodity assessment tool for the assessment. However, the paucity of product availability and the general dysfunction of the logistics management information system (LMIS) made this redundant. Modified SPARHCS framework with greater focus on private sector and supply chain. Preasssessement desk review conducted ( (available data limited; focused on demographic FP trends) Key informant interviews, key informant workshop and field visits to collect data (the latter was necessary because not a lot of data was available). Low commitment, despite awareness raising and assessement because of pro-fertiltiy policy. Qs: Were preliminary findings from the assessement presented to stakeholders prior to depature? YES Has there been any positive action to address FP or CS – process wise or concrete – that resulted from the assessement? NO, LONG TERM STOCK OUT ISSUES AND GENERAL LACK OF COMMITMENT TO FAMILY PLANNING MADE IT DIFFICULT TO APPLY SPARHCS QUESTIONNAIRE - EVEN TO DETERMINE INTENTION IN ABSENCE OF SYSTEMS AND SUPPLY • At the request of USAID/Azerbaijan, the DELIVER and PSP-One projects undertook a joint assessment focusing on respectively the public and private sector’s current and potential contribution to contraceptive security. Key issues addressed in this assessment were the availability and affordability of contraceptive products and services in the public and private sector, legal and regulatory factors affecting product availability, a forecast of potential public sector commodity needs and options for government and private sector collaboration on increasing access to contraceptive methods. Contraceptive security is said to exist when every woman and man can chose obtain and use the family planning methods they need. As this report will demonstrate, Azeri women and men suffer from “contraceptive insecurity” as products are not available to the majority of the population who would like to use them. The assessment adapted USAID’s SPARHCS framework and conducted individual meetings with key stakeholders as well as a small workshop with public sector UNFPA and USAID project participants. Site visits to 19 public service delivery points and xx private clincs were also conducted in Baku and seven other rayons. Meetings with the private sector included pharmacy visits, distributors and manufacturers agents. Demographic Situation Couples in Azerbaijan have been successful in actually achieving their desired family size with the total fertility rate (TFR) falling to 2.1 in 2001 from 2.8 in 1994-96. Because of the large proportion of the population in its reproductive years, the total population will continue to grow until it stabilizes at 9.5 million in 2025. Azerbaijan’s fertility reflects trends throughout Europe and Central Asia but is higher than elsewhere in the Caucuses and Eastern Europe. Azeri couples achieve their desired fertility through use of traditional contraceptive methods (43.5%), which dwarfs modern contraceptive use (11.9%). The high use of withdrawal (41%) is amongst the highest in the world, and demonstrates a commitment of both men and women to regulating the size of their families. Unfortunately, high failure rates from withdrawal contribute significantly to Azerbaijan’s abortion rate, which at 116 per thousand (WRA) of reproductive age, is the second highest in the World. According to the RHS , failure of traditional methods accounts for 58% of abortions, resulting in over 150,000 abortions per year. With 20.6% leading to complications, this contributes to maternal mortality as well as creating unnecessary financial and psychological burdens on Azeri families. Some 53% of WRA are reported as having an unmet need for contraception, those who do not want to get pregnant and those using ineffective traditional methods. This is amongst the highest levels reported not only in Europe but the world. Public Commitment and Policy There is a lack of interest in investing in reproductive health and family planning among the senior leadership in the Government of Azerbaijan (GOA). This is fueled partly by outdated notions on the fertility aspirations of Azeri couples and ignorance of the true consequences of “contraceptive insecurity”. There is presently no commitment from the GOA or donors to fund future contraceptive commodities and no sense of urgency amongst the higher echelons of the MOH of the consequences of the imminent expiry of the last remaining donated products in the system. There is a real risk that recent progress in Family Planning (FP) will be lost without some attention and funding. This lack of commitment contrasts with the innovation and dedication the MOH and new Minster of Health, Dr. Shiraliev, have shown to implementing the World Bank support integrated primary health care based health reforms. These reforms alongside increased GOA funding for health care including maternal health initiatives present opportunities for increasing the attention on RH/FP as part of an integrated package of care. Champions at the National Reproductive Health Office (NRHO) have been working to promote FP for many years in Azerbaijan. Allied with emerging champions within the MOH itself, and with interested parliamentarians, there is an active nexus to help promote FP in Azerbaijan. Public Service Provision and Access Public provision of FP services is concentrated in the hands of Obstetrician/Gynecologists ( Ob/Gyns) . These are typically located in either FP/RH centers at CRH or specialist wards of these facilities, with little or no service provision in rural health facilities. Historic biases in service provision reflect the tradition of over medicalization of RH/FP, mistrust of modern hormonal methods and a conflict of interest because many Ob/Gyn derive their main source of income from abortions. Provider attitudes are typically negative to modern contraception, although attitudes have actually improved in several sites compared to a USAID assessment conducted in 2004. Even where Ob/gyn provide FP, there is a tendency for unnecessary screening and tests of uncertain medical benefit as these help generate revenue. Clients in rural areas have little or no access to FP services in either the public or private sector. Rural clients are typically referred to the CRH for their FP services, and the transport and opportunity costs represent an important barrier in addition to the commodity cost and cost of unofficial fees for any consultation or service. Using World Bank data from the World Development Institute, the median household income for Azerbaijan is $4,000 with the poorest 20% of households having an average income of $2,500 and for the 20% near poor, an average household income of a little over $3,100. These income levels suggest that oral pills and IUDs in the private sector and from public facilities where doctors are charging unofficial fees for services are probably not affordable. Product Availability and Supply Chain Management IN THE PUBLIC SECTOR UNFPA stopped commodity donations in 2004 with the last shipment arriving in Baku in January 2005. Products were either stocked out or expired in all but two of the 19 public facilities visited and the two facilities with products only had a single method available. Relatively large numbers of products were expired in several regional distribution sites with staff apparently unconcerned. ACQUIRE is trying to get almost expired IUDs used, identifying interested clients and setting up mobile services. Forecasting commodity needs for the public sector is a challenge in Azerbaijan for a number of reasons. Demographic data based projections depends on 2001 RHS information and much may have changed since then. The public sector last attained something like full supply in 2004 but examination of logistics management information system raises questions on whether the data recorded accurately reflects actual consumption. Whether a consumption-based or demographic based forecasting approach is used, forecasts must be constantly monitored and updated for changes in actual program performance. The low level of modern method CPR of only 12% and the fact that private sector pharmacies are the main source for pills and condoms means that for some commodities the amounts being forecast are relatively low. The estimated cost of filling the public sector pipeline is $345,735 in 2007 and $106,667 for maintaining it in 2008. The higher initial costs reflect the need to ensure full supply at the central and regional levels as well as with service delivery points. USAID is the only potential source of funding for the public sector in the short term. Advocacy is required at several levels to get the GOA to take on this funding ideally through inclusion of FP services in the proposed basic package. There is no GOA procurement capacity in place to purchase contraceptives. UNFPA could be used as a procurement agent to reduce procurement costs and ensure governance in the medium term. Longer term, either an integrated GOA procurement and distribution capacity would need to be developed or patient access to drugs and FP commodities be assured through an outpatient drug benefit package. The NRHO has a distribution and LMIS in place but this has not worked effectively for a number of reasons. Deficiencies in the data reported, lack of resources for field based supervision and monitoring and lack of urgency in addressing these problems have all contributed to stock outs and product expiry. The GOA needs to fund the NRHO adequately to allow it to perform its role as manager and supervisor of FP commodities and service improvement. The automated LMIS needs to be revised to include reporting on stock on hand, consumption and losses and adjustments and to track consumption in relation to maximum and minimum stock levels. Staff throughout the system need to be retrained and more effective supervision visits are required to ensure commodities are being managed and used properly. The Private Distribution Network While product availability in the public sector is limited or non existent, there is better product availability in the private sector. The key issue affecting the private market is demand creation, particularly where a high proportion of rural and some urban populations have limited ability to pay for contraceptives. The private distribution network in Azerbaijan is similar to that of other post-Soviet countries. Most pharmaceutical products are manufactured in other countries and imported by local distributors although overseas-based manufacturers sometimes maintain a local marketing office in Azerbaijan. Oral contraceptives (OCs), intrauterine devices (IUDs) and condoms share similar distribution patterns. All are currently sold through registered pharmacies and the same distributors tend to import all three products. Most demand-side activities are channeled through providers because mass media advertising for prescription drugs is prohibited. Only three contraceptive manufacturers have a local representative office in Baku: Schering and Gideon Richter (GR), which produce mainly oral contraceptives, and Innotech, a French manufacturer of condoms and spermicides. Schering appears to be the only company expressing interest in developing the Azerbaijan market, though it is primarily interested in a high-price segment. Gideon Richter supplies the most affordable and widely available product on the market but does not actively promote contraceptives. Both Schering and GR have an interest in promoting the use of high-price, newer formulations because such products are more profitable. The rumored discontinuation of Rigevidon, a combined oral contraceptive, however, would force users to switch to a much more expensive brand. There are reportedly over a hundred pharmaceutical distributors in Azerbaijan, though a few large distributors import the bulk of contraceptive products sold in the country. The distributor business is heavily concentrated in Baku (60 to 95 percent of sales volume), in part because many district pharmacies obtain their products from Baku wholesalers. The largest distributors offer marketing services, including detailing and promotional activities. The presence of distributors with marketing capacity increases the range of products that can be sold in Azerbaijan, particularly those made in countries with low production costs. Distributors focus on products with a fast turnover or high margin. Contraceptives have a low turnover but major distributors carry OCs because they are supported by a marketing office or are part of a manufacturer’s larger portfolio. Condom and IUD importation and distribution tend to be opportunistic, driven by demand and not based on a long-term market development strategy. The low demand and low profit associated with contraceptives make them highly unlikely to be counterfeited if illegally imported. There are reportedly about 1,500 retail pharmacies (apteks) in Azerbaijan. Product choice is largely determined by local demand, which is a combination of consumer awareness and purchasing power. There are virtually no pharmacies outside towns, requiring rural users to travel to the nearest district apteks. This situation is not specific to contraceptives but contributes to making resupply methods less practical than IUDs in rural areas. The differences in pharmacies’ ability to buy in bulk contribute to the wide variations in prices found in Baku. Prices in district apteks in contrast were found to be more consistent and in the mid-range. Pharmacists tend to be misinformed about contraceptive products and frequently recommend abortive and gynecological treatments in lieu of contraceptives. Private Contraceptive Product Supply Several types of OCs are currently available in the private sector in Azerbaijan, though their availability varies widely, and product choice decreases drastically outside Baku. OC formulations include monophasic combined pills(including third-generation formulations containing newer progestins(triphasic pills, and emergency contraceptive pills (EC). Progestin-only pills (POP) are not available in Azerbaijan. The large-scale introduction of this formulation through the commercial sector appears highly unlikely. Injectable contraceptive formulations are virtually absent from commercial retail pharmacies, although there are reports that some pharmacies bring in Depo-Provera (DMPA) upon request. As for POPs, the chances that a private sector manufacturer will choose to market injectables in Azerbaijan are slim. The availability of IUDs is heavily influenced by health providers. The IUD is the only product not spontaneously requested by users in pharmacies. The IUD market is not well established, assumedly because donated products were available for several years in the public sector. The most widely requested and available IUDs in pharmacies are the Russian made cu380, and Schering’s NovaT , which retail respectively for US$1.13 andUS$5.60. Another Schering product, Mirena, which releases a progestin (Levonorgestrel) is beyond the means of many users, at an average retail price of $200. Pharmacies do not carry IUDs at all times. According to distributors and pharmacists, IUDs are not stocked on a consistent basis because demand is unpredictable. Though less readily available than other methods, the social marketing adviser ultimately concluded they were adequately supplied through distributors and wholesale pharmacies. The IUD market may take some time to stabilize. It is likely to grow and become less erratic if donated products disappear from clinics and pharmacies. New supplies of donated IUDs on the other hand may limit demand in pharmacies to the more expensive options. There are a wide variety of condom brands available in Azerbaijan, though product choice and prices differ substantially between Baku and rural districts. Only one major condom importer (FBI) appears to be actively investing in growing the market through promotion and advertising. The estimated size of the condom market is 3 million yearly unit sales though re-exports to Georgia may account for half of this figure. Reports of counterfeit Durex were verified but a more thorough analysis of brands sold in Azerbaijan would be required to assess the quality of the country’s condom supply. Private Sector Services Private medical practice is a relatively new concept in Azerbaijan. Although the government is still the predominant provider of health services in Azerbaijan, laws exist that provide for the establishment of private health care services. In general, the government appears in favor of growing the private health sector. Laws also exist that create opportunities for various types of insurance, but private insurance is accessed by less than 1% of the population. Most private clinics are in Baku although a few are found along the oil pipeline and in some rural areas. These clinics must adhere to government licensing standards, renew their licenses every five years, and pay income and property taxes. Some government-owned facilities are privately managed. This structure allows for some autonomy and flexibility in salaries and quality control, while alleviating the need for start-up capital. A third variation of private services includes providers who see patients in their homes. Private providers and clinic owners reported that opening a private facility is easy as long as one has enough start-up capital. Although private health care facilities were often established to provide services to employees of oil companies and foreign embassies, unaffiliated middle and upper income clients routinely utilize private facilities. People choosing private clinics apparently feel they are getting more value for their money than in the public sector where they have to pay unofficial fees. Most private facilities in Baku are outpatient clinics and many are specialized. The clinics visited for this assessment offer a wide range of services but tend to focus on high-revenue specialized services. Ob/gyn services account for 5-10% of services rendered and consist mostly in lab tests, ultrasound screening or abortions. Family planning is seen as not profitable even though a battery of tests is typically required before prescribing a contraceptive method. Private sector providers do not routinely provide or promote family planning services to patients, in part because they do not generate high revenue. As in the public sector, providers can earn more money over time by performing frequent abortions. Even when FP services are provided, women are not likely to be fully informed about hormonal methods. About half of the providers interviewed said they did not like to prescribe hormonal contraceptives and would suggest IUDs or condoms to a woman asking for advice. Conclusions and Recommendations The contraceptive security market in Azerbaijan can be broadly classified by source of supply, the geographic location/wealth of clients and the methods they use. The following table classifies the market based on the sites visited during the assessment and anecdotal evidence collected. A more thorough market segmentation based on the latest DHS is required to more accurately define market segments. While products are available in private pharmacies and accessible for wealthier clients in Baku and regional towns, there is less accessibility for the urban and rural poor. The shaded areas in the table indicate a lack of supply. TABLE XX: Existing Market Segmentation in Azerbaijan – Neglected Rural poor Population Publicly provided services and products Private clinical services Private Pharmacies Baku Wealthy IUDs IUDs Orals Condoms Orals Poor Condoms Outside Baku Wealthier in towns IUDs Condoms Orals Rural poor Recommendations for action need to consider this market segmentation to ensure an effective public private approach is adopted for improving the total market for contraceptives. To improve access for all segments of the population, a four pronged strategy should be considered that seeks to encourage the private sector to serve more the needs of the urban populations while the public sector seeks to be more effective in reaching the rural poor. Several elements of this approach are already in place with the ACQUIRE and PHC projects. Advocacy with senior policy makers to demonstrate the importance of FP for the health and welfare of the Azeri population Demand creation activities geared to improving information about modern contraceptive use with work with the private sector in Baku as well as rural towns to increase private product availability. Retraining and continuous education for service providers including both Ob/gyn and general practitioners in pilot sites Provision of free commodities to the poor in rural communities, rural towns and in a limited way to targeted poorer clients in Baku. TABLE XX: Proposed Market Segmentation in Azerbaijan – reaching the rural poor Population Publicly provided services and products Private clinical services Private Pharmacies Baku Wealthy IUDs Orals Condoms Orals Poor IUDs Pills Condoms Outside Baku Wealthier in towns IUDs Condoms Orals Rural poor IUDs ,Orals Condoms, Spermicides Shouldn’t this cell be shaded? Condoms Advocacy Recommendations Advocacy activities should include: Providing advocacy materials to support lobbying of the MOH and MOF. Supporting the NRHO to update FP guidelines. Supporting a forum for defining policy priorities and common approaches for reproductive health and family planning advocacy. Preparing the groundwork to facilitate including FP services in the basic package and commodities in the drug benefit package when the time comes to make those decisions. Supporting the planned maternal health initiative presuming it comes to fruition. The planned market segmentation study PHC will undertake should be combined with an analysis of ability to pay to help identify target populations for the public and private sector. The results of this study will help define the extent that the population can access private supplies and help identify those that will need supply through the public sector. Demand and Private Sector Recommendations Few policy barriers unduly restrict the ability of the private sector to supply products and services. Consequently, efforts to increase the use of modern methods should focus on generating demand for use of contraception. While adequate product supply is needed for consumers to access contraceptive methods, it cannot solve the problem of misinformation, provider bias or high service delivery costs that all contribute to low demand. All evidence points toward the need to educate health providers. Efforts such as those of the ACQUIRE project in 5 pilot districts should be scaled up as they can only motivate manufacturers and distributors to increase product supply and choice. Contraceptive products are reasonably available in the private sector, especially in urban areas of Azerbaijan but availability varies by method. Public-private partnerships should focus on ensuring affordable product access for most users. Ensuring sustained availability of products such as Rigevidon, a low-dose, high quality OC, should be a priority for USAID and the ACQUIRE project. Other products with limited commercial potential can be made available by partnering with a local distributor and a network of providers interested the method. Few private sector suppliers have an interest in the contraceptive market. Moreover, needy populations are unlikely to be adequately served by the private sector. Subsidized or donated products may be needed for targeted interventions. In specific circumstances, a limited supply of free OCs, IUDs and condoms will ensure that demand generated through educational and counseling efforts may be satisfied without cost serving as a barrier. In addition, because low return-on-investment will continue to limit the number of registered pharmacies in rural districts, legal provision may be considered that permits the sale of basic drugs, including contraceptives, through feldsher-obstetrican points. Quality of care in the private sector may be lacking or inconsistent. Health providers (especially pharmacists) are in acute need of information. ACQUIRE’s training and communication activities, if scaled up to include heavily populated, urban areas could have a tremendous impact on overall contraceptive use. In addition, private sector facilities would benefit from inclusion in family planning training programs. To the extent possible, quality control in private facilities should be improved, with a focus on better patient information, and reduced service protocols for contraceptive methods. RECOMMENDATIONS FOR IMPROVING Provider training and service ACQUIRE should continue to develop its community based FP service delivery and counseling. Ideally ACQUIRE activities should be expanded into other pilot sites to increase the reach of their support. Work with the NRHO should revise FP guidelines and draft waivers to allow staff in pilot sites initially to prescribe pills and then to insert IUDs given sufficient training and sanitary insertion conditions. WHO support should be sought to help get modern FP methods included in preservice training for medical staff. RECOMMENDATIONS FOR Public sector Supply for target populations The forecasts presented in detail in the Annex indicate that the estimated cost of filling the public sector pipeline is $345,735 in 2007 and $106,667 for maintaining it in 2008. USAID should consider funding this commodity commitment. UNFPA should support the provision of technical assistance support to redesigning the LMIS and training in its application and supporting NRHO supervision and monitoring. The GOA should fund the salaries of NRHO staff to ensure they can carryout necessary supervision and monitoring. Supplies should be targeted to rural towns and rural communities. Any supply in Baku should be carefully managed and monitored to ensure public supplies are only being provided to the poor and socially disadvantaged. While supplies should reach ACQUIRE sites they should not be limited to them. Rather public sector supplies should seek to reach all Rayons outside of Baku. With an improved LMIS, more effective product management should ensure supplies are being properly used and if not commodities redistributed. The results from public provision of services should be tracked carefully to help provide the evidence base for future policy decisions on including of FP services and supplies for target populations in the basic service package. A transition plan to GOA procurement of FP commodities would depend on the direction of health reforms as well as the inclusion of FP in the basic package. If a drug benefit approach is being adopted with supplemental FP commodity benefits then there would not be a need for public procurement of contraceptives other than for IUDs. If public procurement for targeted populaions is required, GOA should initially use UNFPA as a procurement agent to ensure best value for money and good governance in procurement. Introduction Chronicle of a Death Foretold Shahadat died from complications following her self administered abortion. She and her husband did not want more children as they were struggling to feed their existing family. She became pregnant because the withdrawal method they used is less effective than modern family planning. She could not afford the $20 or more needed for her to get an abortion at the Central Rayon hospital (CRH). The return bus fare and unofficial fee to the gynecologist was beyond her ability to pay given her family income. Shahadat had received counseling from staff at her local FAP and was interested in having an IUD inserted. These six failures resulted in Shahadat ultimately not having an IUD inserted which in the end contributed to her death. Policy failure – Only OB/Gyns are permitted by the MOH to insert IUDs. In other countries WHO guidelines are followed that recommend that other trained providers including nurses can undertake IUD insertion. As a consequence of this concentration of service provision in the hands of Ob/gyns, who seldom can be found outside the central rayon hospital, Shahadat did not have access to the services she needed. Service delivery failure - The concentrated service provision is impeding women’s access to family planning. Anecdotal evidence from her rayon suggests the cost of IUD insertion at the CRH in terms of unofficial fees may be as expensive as the cost of an abortion. The chief midwife at Shahadat’s local FAP with training could have inserted the IUD, removing the need for her to pay the bus fare to town. It is not clear whether there would have been a service charge for this option if it had been available. In some facilities visited, staff seemed unaware or uninterested in FP service provision. ACQUIRE is planning an intensive IUD insertion campaign but this is pending negotiation with the National Reproductive Health office who have requested additional payments for doctors to undertake procedures for clients they should already be serving. Private sector failure – None of the pharmacies visited stock IUDs. Several claimed doctors obtain these directly from distributors for their private procedures. The cost of alternative contraceptive methods is relatively high in relation to the purchasing power of rural women. The low volume of sales has not attracted interest from rural pharmacies, where they exist. Logistics failure – While Shahadat was dying, excess stocks of IUDs sat idly in the storage room of a Central Rayon Hospital in an adjacent Rayon. These 1000 IUDs, have just reached their “sell by” date. The National Reproductive Health Office (NRHO) was not aware of the excess stock because of insufficient monitoring and supervision capacity and an LMIS system that did not highlight excess supply. The doctor managing the supply did not recognize that others could use these supplies and had no standing orders for their redistribution. Funding failure – Only five out of 17 facilities visited had remaining stocks of UNFPA donated products and in only one case was more than one method available. Since humanitarian assistance ended in January 2005, the burden of funding for FP has fallen entirely on private households sometimes, as with Shahadat, with tragic results. There is no clear evidence on the ability and willingness of Azeri women to pay for their contraceptives. What is certain is that women in Baku are more likely to be able to afford to pay themselves than those in rural areas. As in all societies, some women can pay the full cost, some a partial cost and some very little or no cost. Leadership, commitment and coordination failure – That all of the above failures persist in Azerbaijan while they are being addressed in other countries in the Caucuses, Central Asia and Eastern Europe reflects a lack of leadership and commitment. In terms of reproductive health statistics, Azerbaijan is out performed by most other countries in Euarasia. Addressing these six failures requires a concerted effort by all stakeholders – government, especially the MOH, NRHO, medical specialists, other service providers, community leaders, the private sector, NGOs and international donors. It requires coordination and commitment to make difficult decisions, to overcome vested interests, redefine roles and responsibilities and to hold stakeholders accountable to their communities for their actions. Progressive actions are being taken in several areas on a pilot basis to involve communities, work with the private sector and to retrain medical staff. The effectiveness and sustainability of these measures though will be undermined unless all of the identified failures are addressed simultaneously. Until this happens, preventable deaths like Shahadat’s will continue to occur. Shahadat did not have the ability to choose, obtain and use the contraceptives she wanted; she did not have contraceptive security. Addressing contraceptive security in Azerbaijan, her story describes the sad consequences of the absence of contraceptive security. Achieving contraceptive security – that is, when people are able to choose, obtain and use high quality, affordable contraceptives and condoms for family planning and HIV/AIDS/STI prevention – in Azerbaijan requires looking at each of the failures Shahadat encountered and taking a strategic approach to addressing each one of them. Experience elsewhere has shown that interventions that only tackle part of the problem are less successful. Rather a concerted effort is needed to address all the issues, engaging many partners and stakeholders to do so. Purpose The purpose of this activity was twofold, namely to assess public sector contraceptives commodity security at all levels of service delivery in Azerbaijan and to assess the private sector’s capability and capacity to contribute to contraceptive security in the country. The public sector assessment, led by staff from the DELIVER Project, focused on the following issues: Current legal and regulatory situation affecting provision of contraceptives through the public sector; Availability and accessibility of contraceptives through public sector channels in both urban and rural areas; Condition of existing logistics and supply chain management system in the public sector from initial procurement to the end user; Estimated future availability, affordability and accessibility of contraceptives through the public sector; Existing options for public sector provision of contraceptive supply (donor and Government of Azerbaijan); and Recommendations for engagement of the government in procurement of contraception in the public sector. The private sector assessment, led by ……., focused on the following issues: Legal and regulatory issues affecting private sector provision of contractive products and services; Availability, affordability and accessibility of privately and, especially, commercially provided contraceptive products and services; Reach of private sector contraceptive products and services in rural and peri-urban areas; Options for public/private approaches for securing contraceptive supply, including public/private partnerships for contraceptive procurement; Estimated future availability, affordability and accessibility of contraceptive products and services provided through the private sector; and Recommendations for further engagement of the private sector in promoting modern contraception. The principal outcomes of the entire assessment include: a comprehensive assessment of contraceptive availability issues in both the public and private sector which encompasses an assessment of policies supporting or restricting the provision of the contraceptive commodities in the public and private sector, supply chain management, and existing public and private sector supplies and services; and long- and short-term recommendations for building contraceptive security through both public and private sector channels. Methodology The DELIVER/PSP-One/UNFPA Team modified the SPARHCS Framework to carry out the contraceptive security assessment. PSP-One conducted spot visits of multiple pharmacies to identify prices, affordability and how far the private sector reached into rural areas. Moreover, they used elements of their Legal and Regulatory Guide to interview public sector authorities to determine supportive and obstructive policies. DELIVER’s Logistics Indicator Assessment Tool (LIAT) provided the basis for the clinic surveys. (Please see Appendices x and x, respectively for sample interview guides). The team partnered with and relied heavily on key in-country stakeholders including USAID, ACQUIRE, PHC Strengthening, UNFPA/Azerbaijan. The team interviewed both public and private sector individuals and organizations and visited hospitals, clinics and pharmacies, and conducted a review of key documents, data and systems. Site Visit Approach After an initial joint visit to the Baku reproductive health center (RHC), the public sector assessment team split into two further teams to visit service delivery points in different districts. One team combined with UNFPA to visit Imishili, Salyan and Jalilabad Rayons in the south while the second team was joined by ACQUIRE field office staff and USAID to visit Shamaxi, Goychay, Ismaili and Sheki Rayons in the west. The purpose of these site visits was to review service provision and product availability at the Central Rayon Hospital (CRH) and RHC attached to the CRH where these existed. In addition, various rural service delivery points (SDP) were visited including rural hospitals with inpatient beds as well as Feldsher (FAP) and D A C? (DAC). The districts surveyed included a mix of those that had UNFPA supported reproductive health centers and those that did not, those targeted to receive ACQUIRE support and those with no support. One rural facility not receiving ACQUIRE support was also visited in each ACQUIRE target district. In total 18 facilities were visited between August 8th and 12th. TABLE: XX Rayon (number of SDPs visited) CRH UNFPA RHC ACQUIRE Target Rayon ACQUIRE FAP/DAC Non ACQUIRE FAP/DAC TOTAL by Rayon Baku (1) ( 2 Imishili (2) ( ( ( 3 Masalli (1) ( ( 2 Jalilabad (1) ( 1 Shamaxi (4) ( ( ( ( ( 5 Goychay (5) ( ( ( ( 4 Ismaili (3) ( ( ( ( ( 5 Sheki (1) ( ( Planned 2 TOTAL by Site 8 6 3 3 4 24 The visit to each facility and district sought to collect information on: The provision of family planning services; Client preferences; and Contraceptive commodity information. A formal commodity assessment tool had been developed to guide the assessment but the paucity of product availability and the general dysfunction of the logistics management information system (LMIS) made this redundant. DELIVER staff also intended to conduct client interviews but actually saw so few clients that this was not possible. Separate confidential discussions with community workers and midwives were possible and these provided some consistent anecdotal evidence on Azeri women’s struggle to receive family planning services. Pharmacies in each district were also visited and information on contraceptive sales price and volumes collected. Stakeholder Meeting or WORKSHOP In addition to individual meetings with stakeholders, a workshop was organized to present information on commodity forecasting methodologies and to glean opinion on CS strengths and weaknesses. Participants in the meeting included representatives from the MOH, NRHO, UNFPA, USAID, ACQUIRE, and PHC. The full list of attendees is provided in Appendix x . Demographic Situation and Family Planning Demand The most recent survey information in Azerbaijan is the Reproductive Health Survey, Azerbaijan, 2001 (RHS) . In the absence of more recent data, most of the information in this section is from this survey. However, there are no obvious reasons to believe there have been major changes in the situation in the last five years. A Demographic and Health Survey (DHS) is currently in the field. Results of this survey will add more current information, as well as document and changes and trends that have emerged. Desired family size and fertility in Azerbaijan Desired family size in Azerbaijan is currently estimated at about 2 children per family. This is in line with a world-wide trend to smaller families, with virtually all countries in the world experiencing decline in desired family size, while none are experiencing increases. In Azerbaijan, 77% of women that have two children want no more children; 88% of women with three children want no more, and even 21% of women with one child want no more. Couples in Azerbaijan have been successful in achieving their desired family size, with the Total Fertility Rate (TFR) declining to 2.1 in 2001 from, 2.8 in 1994-96 . The TFR in Azerbaijan is slightly higher than other nations in the Caucasus (Armenia, 1.7, Georgia, 1.7), higher than countries in Eastern Europe (1.3 to 1.9), and somewhat less than countries in Central Asia (2.1 to 3.4) Population momentum, the result of a relatively large population in its reproductive years, will cause the population of Azerbaijan to continue to grow after it achieves replacement fertility, or a TFR of 2.1. The population of Azerbaijan is expected to stabilize in 2025 at about 9.5 million. Some officials have speculated that the low fertility rate is a result of bad economic conditions, and that higher fertility will occur when the economy improves. However, world-wide, regional, and European experience indicates that such a rebound in fertility is unlikely. How Azeri familIES achieve their desired fertility levels There are a series of factors that determine fertility which are collectively known as “Proximate Determinants” of fertility. They are: Age of marriage/marital status Breastfeeding/post-partum insusceptibility Sterility Use of Contraception Abortion This section will discuss the effect of the last two of these determinants, as used by couples in Azerbaijan to reduce their fertility. The use of modern contraception for married women in Azerbaijan is only 12% -- the lowest in the region. The most widely-used method is the IUD, which is used by 6% of married women, followed by condoms (3.2%), tubal ligation, which appears to almost always be used by women experiencing other reproductive problems (1.2%), pills (1%), and “other modern” methods, presumably spermicides (0.4%). The dominance of the IUD is typical of the region, as there is some remaining historical distrust of hormonal methods. However, in a country which still has significant anemia, particularly in rural regions, the favoring of IUDs in the method mix over hormonal contraception is concerning. Figure 1 compares modern method use in Azerbaijan to other regional and European countries. As can be seen, Azerbaijan has the lowest modern method use in the countries presented. FIGURE XX: [image: image1.emf] Traditional method use (43.5%) dwarfs modern method use (11.9%) in Azerbaijan. The very high use of withdrawal, at 41%, is especially striking. (Azerbaijan may have the highest reported use of withdrawal in the world.) The RHS noted that withdrawal was higher in rural areas, among women with three or more children, and among women with low SES. Use of withdrawal at such a high level is important because it requires the participation of both partners to avoid pregnancy. In fact, when OB/GYNs in the Central and Southern regions were queried about why so many couples used withdrawal, the response was “Some choose to use it, and other use it because they cannot afford modern contraception.” High failure rates for withdrawal and other traditional methods contribute significantly to Azerbaijan’s high abortion rate. The abortion rate in Azerbaijan, 116 per 1000 Women of Reproductive Age (WRA), is second only to that of Georgia at 125 per 1000 WRA. According to the RHS, failure of traditional methods accounts for 58% of abortions, resulting in over 150,000 abortions per year . The high volume of abortions and ensuing complications (20.6% of abortions result in complications ) strain the health care system while contributing to maternal morbidity. Traditional method users are likely to play a key role in a transition from dependence on traditional methods backed up by abortion to improved contraceptive use with less need for back up abortion as a strategy for fertility regulation. Turkey’s experience may be instructive in understanding the dynamics between traditional method use, abortion and adoption of modern contraception in neighboring – and culturally linked -- Azerbaijan. In Turkey the process of persuading women to give up ineffective traditional family planning methods such as withdrawal – and the back-up method of abortion when those methods invariably failed – in favor of more effective modern contraceptive methods took place over a long period of time. Abortion rates dropped sharply over the decade 1988-1998 while the total contraceptive rate remained stable. Women slowly shifted away from the use of traditional methods and abortion to acceptable modern methods (See Senlet, 2001). Senlet and colleagues conclude, "Marked reductions in the number of abortions have been achieved in Turkey through improved contraceptive use rather than increased use" (italics added). In Azerbaijan, where withdrawal is the most commonly method practiced and here half of all abortions in the country are preceded by the failure of a traditional method, a shift in the method mix toward more effective methods and more effective use of methods has considerable potential to reduce abortion levels, even in the absence of increased use. Low modern use, high abortion rates, and potential demand The term “Unmet Need for Modern Methods” is defined to include married women who both do not want to get pregnant and who are using relatively ineffective traditional methods (in Azerbaijan mainly withdrawal and to a lesser extent, the “rhythm method”) or no method at all. Figure 3 shows the Unmet Need for Modern Methods in Azerbaijan as compared to other countries. FIGURE XX: [image: image2.emf] In Azerbaijan, 53% of women fall into this category. Of this group 85% of this need is for “limiting”, meaning that the women stated they want no more children. In Azerbaijan the unmet need for limiting is almost six times the need for spacing births, consistent with Azeris’ low desired family size and strong desire to terminate childbearing after achieving their ideal number of children. The high levels of unmet need for modern methods suggest use of modern contraceptives could rise rapidly if provider knowledge and attitudes regarding modern family planning were to be changed and voluntary family planning services and commodities were to be made readily available to women, including women in the villages, in Azerbaijan. Public Sector Findings This section presents the findings according to the key components of contraceptive security. The private sector findings are included in summary within this section and are presented in more detail in Section 4. commitment There is a lack of interest and investment in reproductive health, specifically family planning among senior leadership in the Government in Azerbaijan. Overall the government is committed to goals that will help put them on a par with European countries. For example, as indicated in the introduction, the TFR is 2.1 and comparable to many countries in the EC. However, due to a lack of investment in family planning, couples are largely relying on traditional methods, and when these fail, abortion, to achieve their desired fertility. The GOA should be aware that the high abortion rate was cited as a barrier to Romanian entry to the EU and was a major motivator in the Romanian Government taking an active interest in contraceptive security. The imminent stock out of donated family planning commodities exemplifies the lack of commitment to FP at the highest level. During their phase out of commodity support, UNFPA sponsored several interventions to increase awareness and commitment to family planning targeting high-level stakeholders. Despite these efforts, no action has been taken to address the imminent stock outs of donated methods in the public sector and there does not appear to be interest in the Ministry in pursuing GOA funding for contraceptives in the near future. The head of the international department at the Ministry of Health did express concern that there are no donor commitments for future contraceptive donations to the public sector but this unfortunately has not translated into any real commitment. Many stakeholders felt that opposition to family planning stems from a lack of knowledge of both the situation and preferences of women and the benefits of FP for the country. For example, the Deputy Minister of Health seems to be ill-informed regarding the fertility preferences and practices of women in Azerbaijan, including the country’s low fertility, high levels of traditional method use and role of traditional method use failure as a driving factor behind abortion. In an interview, he spoke of the strong desire of Azeri women to have large families. The most recent survey data indicate desired fertility size is low, 2.1 children. Ministry of Finance policymakers are suspected to suffer from similar misconceptions and to hold generally conservative views about family planning and women’s issues. With no senior leadership in the Ministry of Health backing family planning, it is lower still on the agendas of the Ministry of Finance and the Cabinet of Ministers who approve national budgets. As decision-making inches forward regarding the implementation of the joint World Bank-GOA health project, it remains unclear who, if anyone, participating in high levels meetings will ensure that reproductive health and family planning are included in discussions about the integrated basic package of services being considered. Furthermore, at present no forum exists for raising visibility of family planning generally or contraceptive supply issues in particular. Despite the lack of awareness in the upper echelons of the MOH about reproductive health and contraceptive security there are a number of potential champions. The recently named Minister of Health, Dr. Oktai Shiraliev, is widely regarded as reform-minded and serious about improving access to health care in Azerbaijan. There are some key reproductive health champions occupying mid-level advisory positions in his Ministry and related agencies. Moreover, there are at least two Parliamentarians, both of whom participated in USAID-funded reproductive health study tour to Turkey, who are strong advocates for women’s health and gender issues, including family planning and are committed to increasing public funding for women’s issues. However, it is important to note that despite this commitment; at least one of the key parliamentarians is not optimistic that public funding would happen in the near term. The establishment and placement of the National Reproductive Health Office (NRHO) within the MOH shows at least some government support for reproductive health. While the MOH must focus on numerous products and programs, an organization such as the NRHO has the mandate to focus exclusively on family planning. The NRHO was established in 1994 and is considered part of the MOH structure, coming under the auspices of the Department of International Relations. A Memorandum of understanding (MOU) was signed between the MOH and UNFPA in April 2006 defining the terms of future collaboration. The NRHO is responsible for managing the distribution of (UNFPA) donated contraceptives to districts and service delivery points, coordinating implementation and supervision, and providing training for RH/FP service delivery. For the most part, the NRHO provided a mechanism for UNFPA implementation of its family planning assistance to the government. . Commitment is also evident in the appointment of such a strong family planning champion as director of the NRHO. Dr. Faisa is widely regarded as an FP pioneer and leader in Azerbaijan. She is credited with helping to foster more positive attitudes toward family planning among clients, communities, municipalities and health care providers. She is the principal author of a draft RH strategy recently submitted to the MOH. Although the team has not seen the RH strategy, there was concern that it may not be approved because of potential overlap with the basic package reforms and the associated reorganization of the MOH being discussed as part of the recently embarked upon program of health reforms. Depite this recognition of NRHO within the MOH and the appointment of such a champion as its director, there is little commitment to funding family planning. For example, while the NRHO Director draws a state salary, NRHO staff salaries appear to be paid for by donor program funds, e.g. in the form of fees from UNFPA for NRHO training activities, and the future role and existence of the NRHO are uncertain. The principal advocate for wider maternal health within the MOH appears to be Dr. Tarana Taghizadeh, the coordinator for Maternal and Child Health in the Ministry of Health. The team understood that she is involved in preparing a maternal health initiative, which while still in at a formative stage, is said to have the possibility of receiving funding through the President’s Fund. Although our information is incomplete, if confirmed, there could be a window of opportunity for family planning to be included in the initiative as a key component of maternal health. 4.1.2 opportunities/Recommendations Prepare the groundwork for including FP in the basic or supplemental benefit package: With important support from the PHC project, the GOA has agreed to the World Bank funded health sector reform project. This will involve piloting establishment of an integrated primary care package along side rationalized hospital services. Decisions about the content of the basic benefit and supplemental benefit packages are several years off. However, to make the case for including family planning when the time comes, family planning champions need to work together to cultivate supporters at the highest levels of the MOH as well as in the Parliament and in the powerful financial ministries. Create a forum. A key first step in this process is to establish a forum for the family planning champions to share information, define common priorities and approaches to building a broader base of support for family planning. Get out the facts. Education and awareness-raising awareness among parliamentarians, high level MOH official and financial decision makers about fertility preferences, high rates of traditional method use and continued if not increased dependence on abortion services must be a top priority. While some of this information is already available from other sources (forthcoming DHS, ACQUIRE baseline survey), it needs to be made relevant to policy makers concerns, distilled into easy-to-digest morsels, and made available in Azeri. Inreach to post-partum and post-abortion women may be an option to build on maternal health concerns. Because policymakers, providers and Azeris generally seem to be relatively untroubled about the strong reliance on abortion, it may make sense to explore emphasizing post-partum and post-abortion family planning services. The potential for complications for a woman of having an abortion soon after delivery or after a previous abortion should fit into a strategy for improving maternal health. Moreover, while a fairly high proportion of abortions in Azerbaijan are reported to result in complications, the risk for complications following closely post-partum or post-abortion are that much greater, better understanding and appreciation of the contribution of family planning to public health in Azerbaijan is required before the inclusion of family planning in the national essential drug list (EDL) or in the supplemental drug benefit package can be addressed. Reinforce NRHO supervision and monitoring: The NRHO has the leadership and expertise to support national FP/RH programs. Their involvement will be crucial in addressing policy barriers to FP service delivery outlined in Section 3.3. Until a decision is made about integrating FP into the basic package, the NRHO should continue to play their role in managing and supervising FP commodities and training service providers. Weaknesses in the FP commodity management system need to be addressed, most noticeably in the supervision and monitoring function, and these are addressed in Section 3.5. As a condition for future donor support for family planning, salary support should be provided for NRHO staff and the Office should be given clear responsibilities for supervising and managing supporting FP commodity programs for the MOH Explore opportunities for family planning support within emerging Maternal health initiative: While the NRHO has a short to medium term role in promoting improved CS, longer term more sustainable improvements will require the better integration of FP with maternal and child health services. Although poorly understood by the team and apparently emergent, the President’s maternal health initiative may provide one important opportunity to galvanize political support and resources around maternal health concerns. As mentioned previously, early experience in the Turkish program suggested that post-partum and post-abortion contraceptive inreach may be a successful strategy for building acceptance for family planning in the medical community and among policy makers (check exact wording in paraphrase on Armand, 2003). Documentation of best practice from other successful examples of integrated maternal and RH/FP services in Eastern Europe need to be shared with Dr Tarana. service provision Policies At present only obstetricians/gynecologists (Ob/gyn) can insert IUDs, perform medical sterilizations, inject contraceptives or prescribe oral pills. These service providers are concentrated in either the FP/RH centers in the Central Rayon Hospital (CRH) or specialist Ob/gyn wards of these facilities. Because of the centralization of services resulting from these policies, women in rural areas are typically forced to travel to the local CRH to be prescribed a pill or have an IUD inserted. Sterilization services can not be performed except in circumstances when another surgical procedure is taking place and were not performed in any of the facilities visited outside of Baku. While the medical law does not prohibit sterilizations per se, it describes that they “May only be undertaken following prescribed regulations,” yet does not define the conditions. Doctors are warned, however, that they face criminal prosecution if they violate the conditions. provider bias Compared to the CS Assessment conducted in Azerbaijan on behalf of USAID in 2004, there was a marked improvement in the attitudes and perceptions of service providers in some of the clinics visited. While anecdotal this points to the impact of work that UNFPA, ACQUIRE and other implementing agencies have had in raising awareness. That said, several obstacles to providing quality family planning services exist. For example, Ob/Gyns gain income from performing abortions and therefore in providing family planning risk losing an important source of revenue from their abortion practice. Provider attitudes are further affected from an historic distrust of hormonal methods and the over medicalization of services that creates a culture of over use of diagnostic checks as a prelude to inserting an IUD or prescribing a pill. Again, the need for tests is driven more by income generation than any evidence based best practice. Access Clients in rural areas have very restricted access to public or private sector services. No Ob/Gyns were seen in any of the rural facilities visited although one rural hospital did say they had had one stationed there previously. With service provision limited to Ob/Gyns, rural clients for FP are either referred to the CRH or wait for outreach services from the CRH. These do exist where supplies and funding are available but are the exception rather than the norm. Pharmacies are found in most rural towns but typically not in villages with a population less than 4,000. Rural clients therefore incur transport costs as well as opportunity costs of traveling to the CRH. Another important dimension to access is affordability and the total cost of services. While those within Baku can likely afford and access family planning supplies and services, the situation outside of Baku is another issue. Anecdotal evidence suggests that commodity costs themselves are a barrier let alone the cost of unofficial payments for repeat visits to Ob/Gyns. The Figure below uses information from the World Bank on the distribution of household income to highlight disparities between different income quintiles in Azerbaijan. (include urban/rural graph and GINI score) TABLE: Average ANNUAL Household Income by Quintile 2004 [image: image3.emf] Source: World Bank WDI 2003, http://www.worldbank.org/data/databytopic/GNIPC.pdf While not a precise comparison because of exchange rate differences, prices quoted anecdotally for the multiple visits for an IUD insertion would appear to be greater than 1% of the average income for the bottom 40% of the population. This is broadly consistent with claims made by providers in rural sites that 40% of their clients could not afford modern contraception, 30% to 40% could afford to pay something while 20% to 30% could afford. While these anecdotal statements do not provide a firm basis for drawing policy conclusions, it does suggest a rural affordability gap for modern methods. Recommendations/Opportunities Family planning services in Azerbaijan are organized inefficiently. Consideration should be given to determine what part of an integrated package of basic services can be assigned to general practitioners and to involve members of the community (GF/family doctor, midwives, volunteer) in family planning promotion and eventually, service provision (for medical professionals). Decentralized service delivery brings providers closer to community and increases accountability. This will alsohave new program implications and require: training protocols materials regulations/guidelines The team understands ACQUIRE is providing the training, equipment upgrades and other assistance necessary for primary health care level facilities in their project area to provide family planning counseling and, as permitted, services. However, without access to commodities or the ability to prescribe pills, rural clients in these pilot communities are still forced to incur the additional costs of time and money to travel to the CRH for services. Away from their communities they are more prone to the demands for unofficial fees for diagnostic tests, screenings and post service check ups in addition to the cost of an IUD insertion or pill prescription. To date the Ob/Gyn community has resisted devolving authority for prescribing FP and performing IUD insertions to non-specialist medical providers. Given this resistance to change, a transition plan is in place and involves training and a gradual approach – pill prescribing first and IUD insertion later. The MOH is willing to review job descriptions for general family medicine which could include FP and explicit attention should be given to this immediately. Specifically the HR and retraining elements of including FP in the basic package should be defined. Support should be considered for providing training and information for Ob/gyns in modern contraceptive methods and technology. NRHO’s role as afocal point should be supported to produce Azeri language information on modern contraception and a series of training workshops held to inform Ob/gyns. This should be coordinated with the ACQUIRE and PHC pilot sites. The NRHO should produce contraceptive dispensing guidelines based on evidence and best practice from Western and other advanced Eastern European settings. These should address whether pre and post screening tests and checks are really necessary. With an understanding that sound demonstration should pave the way for policy reform, waivers should be sought to allow general practitioners to prescribe pills in ACQUIRE and PHC pilot sites. Training should be given to general practitioners on modern contraception in the pilot areas. For generalists to be permitted to undertake IUD insertions requires practical experience, with at least 15 insertions in supervised settings a norm before unsupervised insertion. IUD insertions also require sanitary conditions and equipment. The NRHO and ACQUIRE should examine the scope for a pilot trial to train and permit generalist practitioners to conduct IUD insertions based on training and in selected reequipped and sanitary facilities. Preservice training in family planning must also be addressed in setting the stage for liberalizing provider eligibility requirements. To date, there does not appear to be any organized effort underway to introduce pre-service family planning training for obstetricians/gynecologist, reproductologists or family medical doctors, for example in the form of post-graduate certification course. Institutionalized training and formal certification of family planning skills as part of pre-service training has been effective elsewhere in helping to liberalize service delivery policy , for example in Romania. Finally, analysis is required based on the new DHS of the distribution of contraceptive use and unmet need. A more detailed ability to pay analysis is required to determine the ability of different population segments to pay for commercially available contraceptives and the unofficial fees for public services. An initial desk based analysis of the costs of contraception should be conducted with available data on income distribution and household expenditure. A tailored contraceptive expenditure survey could then be commissioned if more detailed information is required. Product Availability The following table summarizes the product availability at the 19 public sector sites visited during the assessment, the shaded areas represents a total lack of supplies . TABLE XX: VSC IUD Depo COC POP Condom RH/FP Center in Baku 660 Imishly FP Center 450 (all expired 8/06) FAP/IDP Clinic Masalli FP Center 144 (all expired 3/06) Jalilabad FP/RH Center Shamaxi FP/RH Center 1,000 (all expiring 8/06) Goychay CRH Ismaili center?? 1,100 tubes (all expired Jan 05) 1,056 (half expiring 8/06 half in 2008) 7,604 (all expired 2004) 33,000 (all expired 03/06) Sheki FP/RH Center Expired- how many? 698 (all expiring in 2008) Expired stock- how many? Expired stock- how many? In addition to these central sites a further 10 rural facilities were visited, none of which had any supplies. Although the survey represents a small subset of facilities, the lack of product availability is consistent with those presented in the ACQUIRE baseline. If anything, it appears that since the baseline, the situation has deteriorated with almost no stock available. One of the key components of contraceptive security is that women have a choice of methods when considering family planning, In the sites visited, the method mix and therefore choice was either very limited (one method) or non existent (no products). Service providers did indicate that when a method was stocked out or not provided at the site, clients were referred to pharmacies. However, it was unclear whether the referrals were converted or if they did not access private sites. Opportunities/recommendations Recognizing product availability problems ACQUIRE is undertaking important steps to prepare and empower family medical doctors and midwives to provide family planning counseling in the pilot districts where the project is working. Previous USAID projects, notably Pathfinder International’s, have had modest success in receiving temporary waivers to allow non-obstetrician/gynecologists to provide selected contraceptive methods. We understand ACQUIRE is providing the training, equipment upgrades and other assistance necessary for primary health care level facilities in their project area to provide family planning counseling and, as permitted, services. However, without access to commodities or the ability to prescribe pills, rural clients in these pilot communities are still forced to incur the additional costs of time and money to travel to the CRH for services. Away from their communities they are more prone to the demands for unofficial fees for diagnostic tests, screenings and post service check ups in addition to the cost of an IUD insertion or pill prescription. Supply Chain Management Discussion of supply chain management in Azerbaijan should be organized around the four elements of the contraceptive procurement cycle – forecast, finance, procure, delivery. Forecast The most recent contraceptive forecast for the GOA was conducted for the years 2005-2009. The forecasts are done yearly by UNFPA and NRHO using UNFPA’s CCM methodology . This is largely based on converting estimated contraceptive prevalence rates from the 2001 RHS into contraceptive commodity needs using standard adjustment figures for the amount of each contraceptive needed to generate a couple year of protection (CYP). It appears there is sufficient capacity at both UNFPA and NRHO to conduct the forecasts using CCM. In particular, it appeared that NRHO staff understood many of the concepts related to forecasting and the importance of this function. For advocacy purposes, the CCM methodology is extremely useful for providing sufficient information for long term budgeting and lobbying purposes. However, for short to medium term forecasting and quantification, it is recommended that the country adopt DELIVER’s PipeLine methodology. (Seems we should highlight this recommendation. What do you think?) CCM does not appear to provide the data source for certain information (i.e., Current stock, average monthly consumption) nor does it require or generate minimum and maximum stock levels – considered key criteria for effective contraceptive commodity management information systems. Furthermore, if USAID procures commodities for the GOA, it must use the standard Contraceptive Procurement Table (CPT) format. The PipeLine methodology complies with the CPT criteria while the CCM process does not. The NRHO with UNFPA support has developed a computerized, Access database management information system for contraceptive management and reproductive health service statistics monitoring. The system was introduced in 2001 in 27 of the UNFPA supported FP/RH centers although only six are currently providing computerized data feedback. The system has not been used and is not designed to provide information for stock management or forecasting purposes as several data elements are not collected including losses and adjustments. Finance In many countries, funding for contraceptives is derived from five possible sources: humanitarian donations, government budget, donor-funded budget or health sector reform support, private companies and households. In Azerbaijan the burden of funding is falling almost entirely on private households as there is virtually no funding commitment from other sources. From 1994 until 2003-2004, UNFPA was the sole source of FP supplies for the GOA. While CCM exercises were completed, it appears that the financing and provision of supplies was not solely based on need. They were rather based on a combination of need and the availability of funds and product. For example, UNFPA donated a multitude of brands of pills based on what was available globally. This has implications for service provision (prescribing) as well as demand considerations as women prefer to use one brand. Some of the donations included product like Marvelon that were close to expiring when they arrived in country. Since 2003-2004, no new funding has been provided by UNFPA to finance FP procurements. The last supplies of commodities were delivered to Baku in June 2005. Since then there has been no new provision of commodities for GOA FP services. UNFPA and USAID have attempted to get government support for commodity funding although as yet without success. Unlike in many countries, the lack of government financing of family planning commodities is less to do with available funding and more to do with political will. (see commitment section). The World Bank supported health sector reform project heralds an increased attention and commitment by the GOA to increase funding for health services. Within this there is a growing commitment to increase funding for primary health care services. A basic benefit package is going to be developed and the government should commit to pay for this package which will be guaranteed for every person. In addition a supplemental benefit package will be defined to provided extended services to the poor and vulnerable populations. These positive developments could provide a source of funds for FP services and commodities if these are included in either the basic or supplemental benefits package of services. That itself would require FP being seen as a priority intervention of care. While funding is increasing there are other “priorities” that will absorb these increased funds. The basic package will be piloted in 5 regions between 2008 and 2011. A key challenge will be to set the groundwork in place for including FP services and/or supplies in the package. Further analysis is required of the ability and willingness to pay of private households for contraceptives. Anecdotal evidence suggests urban populations in Baku represent an important market but that low disposable incomes are an access barrier for many rural women. Procurement When UNFPA funded FP commodities, procurement was done by UNFPA under the umbrella of its global contraceptive procurement system. According to the UNFPA CS Assessment report, “The request (for commodities) is determined by funds available and based on the forecast developed by the Project Officer and the national Office.” While the UNFPA procurement mechanism is an efficient one, its effectiveness in meeting country needs is determined by the accuracy of the forecasts used. As indicated above, forecasts are based on applying CPR estimates and CYP conversion factors to estimate commodity needs and not on consumption data? Or not on more reliable accurate data such as consumption data?. No one donor or agency currently procures FP commodities for the GOA and in the (still unlikely) event that the GOA chooses to purchase commodities, their procurement capacity is weak. The Innovation and Supplies Centre (ISC) is the current procurement body for MOH supplies. The ISC is under new leadership and is in the midst of strengthening its role and improving its functions with a focus on quality assurance. They are currently “in discussions” with either the Global Fund or World Bank for capacity building technical assistance including the renovation of the dilapidated central warehouse. This capacity building will be a critical requirement. Stakeholders identified several issues concerning the feasibility/likelihood of the ISC procuring FP commodities. For example, it is unclear whether the ISC will be able to procure and store FP supplies as they are not on the EDL. There are also concerns about governance around public procurement. Another option would be for the GOA to appoint UNFPA to act as their procurement agent. Typically, the UNFPA charges a 6% commission as procurement agent, purchasing commodities on account and delivering them to the main port of entry. The advantage in this arrangement is that the MOH can tap into an existing procurement capacity and get access to high quality commodities at a fraction of the cost of purchasing locally. This approach is most effective where the local private sector is either non existent or disinterested in specific brands. Distribution/Storage/waste management According to the NRHO, their contraceptive distribution system is designed to be a pull system - with quantities pulled through the system based on SDP reported need. Evidence from the site visits suggests otherwise. Numerous sites reported that they often received more or less than needed, indicating that the NRHO was pushing the commodities. Examples were cited of both rationing where NRHO did not have enough commodities to meet demand or dumping when they did not have storage capacity at the central level. Both the central and SDP stakeholders indicated that the distribution was a combination of the NRHO bringing commodities to the regional centers or the nurses/doctors from the sites picking them up. The NRHO operates a completely vertical distribution system. While this provides the FP program with more control of where and when commodities are distributed, it does not take advantage of economies of scale provided through integrated distribution. Until recently, FP commodities were stored at the UNHCR/UNFPA Warehouse and then distributed to the NRHO for distribution to the RH centers. There was almost no actual storage done at NRHO, rather the Office served essentially as a transfer point for distribution. The purpose of such a system appears to be due to lack of space at the NRHO providing no added value. With UNFPA’s phase out of donations, it is unclear whether they can continue to be the storage point or if an alternative option such as the ISC, will have to be identified. At the FP/RH centers within the Central Rayon hospitals, FP commodities were kept separately from other commodities and treated as a vertical program. According to the UNFPA report, this separate storage may be a result of FP not included on the EDL and therefore not “included in the MOH distribution and storage system and processes.” This has implications both at the regional level as well as at the central level if FP commodities are integrated into an essential drug logistics system. Contrary to the findings in the UNFPA CS Assessment, the site visits in 2006 uncovered several SDPs with expired (or soon to be expired) products. Some SDPs reported that it was their reponsibility for disposing of such products through incineration; however, several indicated they did not know what to do with expired product. This was consistent with what was reported from the ISC which indicated that they had no role in reverse logistics, i.e. responsibility for collecting and disposing of expired or damaged stock. However, it appears that those sites with expired product are not performing this function. Stock management functions are also flawed. During site visits, we saw four sites with expiring Copper T IUDS. According to UNFPA’s records of commodity donations, they donated 100,000 Copper T in 1999 and 10,000 Multiload CU 375 in 2001. We do not have a complete picture of inventory throughout the country and therefore do not know the stock status of the CU 375. However, one would assume if they were following proper first expired, first out (FEFO) stock management, they would have expended the Copper T first, followed by the CU 375, which still has a shelf life of several years. There were also several other instances of expired product indicating both a lack of supervision and resources or management ability to move products between sites. LMIS An automated logistics management information system (ALS?) was established by UNHCR and UNFPA in 2000. Written in Microsoft Access, it allows the computerized data entry and consolidation of service and commodity statistics that are sent back to the NRHO. Initially computers and training were provided to 27 districts RHC but a lack of budget for maintenance and upgrading the computers has resulted in computers being operational in 2006 in only 5 districts. The other districts are reportedly sending written reports back to the NRHO. A manual in Azeri, Russian, and English provides instructions for data entry. It does not provide any guidelines on the analytical use or purpose of the data and this is a weakness as RHC simply reports the data without analysis. There are three essential data items needed for a logistics system to work: Stock on hand for each method Consumption for each method Losses and adjustments for each method Information on receipts is also necessary for program monitoring but not stock management. The LMIS system used by the NRHO allows entry of the opening balance, and receipts and distribution. It then calculates the balance for the next reporting period. There is a lack of reporting of losses and adjustments in the LMIS. This means that there is no reporting or explanation of when products are damaged, expired or lost. There is also no instruction on calculating the average monthly consumption (AMC) nor monitoring this against stock on hand. AMC is a key logistics item that is necessary to forecast resupply needs. There is also no definition of maximum or minimum stock levels. These are important if stock levels are to be managed to avoid over stock or stock outs. Typically to avoid stock outs a maximum stock level should be set to the monthly consumption rate times twice the delivery interval. The minimum stock level should be the monthly consumption times the delivery interval. So if a SDP uses 100 condoms a month and it gets resupplied once a quarter then the maximum stock level should be 600 condoms = 100 x 3 months x 2 and the minimum should be 300 = 100 x 3. The procedure of conducting monthly physical inventory does not seem to be included in the manual. Comparing the stock on hand to the maximum and minimum levels can help determine if there is too much or too little stock. If stock levels fall below the minimum, emergency orders should be made. If stock levels exceed the maximum then consideration should be given to redistributing available stock to avoid product expiry. This process can help ensure full supply when products are available and reduce waste. It also puts the onus on logistics managers at each level to monitor their stock levels and to take appropriate action. As indicated above , the sites visited have standardized forms and data collection procedures. They collect mostly service statistics but also report some logistics data in their quarterly requisition form (get copy). For family planning, the regions collect data on IUDs, pills, injectables, and condoms. They do not collect dispensed data on VFTs nor do they differentiate between COCs and POPs. In addition to mapping the intended process of the LMIS, we also evaluated how it actually functions. Because no commodities were flowing in the system due to national stockouts, the operational assessment is largely based on anecdotal observations. It appears that the system is not being operationalized as designed. Due in part to the lack of guidelines, the capacity appears to be insufficient at the sub-Central level to properly manage FP commodities with questionable data accuracy and stock management (see following example of Sheiki region). This is despite the regular NRHO supervisory visits reported by many of the sites visited. According to the NRHO, the ALS (the automated logistic system?) is a “bottom up approach” where districts write requests for (and “pull”) commodities on a quarterly basis. However, districts reported receiving more than needed with NRHO “pushing” amounts to them and also less than needed with NRHO having to “ration” stock (example: asked for 300 IUDs but received only 200). Lastly, while some essential data is being collected, it is not being fully used for decision making. Routine monitoring is a critical and ongoing component of the logistics cycle and data for decision making (DDM) at all levels. The NRHO and sites should use this information to better plan and assess their stock status. The development of and agreement to logistics indicators would support this function. opportunities/recommendations Ideally the GOA should take responsibility for providing contraceptives to the poor and vulnerable population. If this commitment can be made there are three possible procurement models that can be considered GOA procures either centrally or locally as part of the purchase and distribution of an integrated package of drugs. This would require establishing a procurement capacity, addressing governance concerns and establishing a distribution system. GOA would procure through agent UNFPA has access to lowest prices. UNFPA charges administrative cost of 6%. This would overcome the lack of procurement capacity and mitigate governance concerns but would not address distribution. This would either need to be through the NRHO or through an integrated MOH distribution system. The NRHO would be a short term solution but in the longer term it would be more efficient to integrate FP commodities with other essential health commodities. No GOA procurement with access to commodities financed through a drug benefit and supplemental drug benefit package that would entitle eligible clients to access supplies through private pharmacies. While elegant in design experience, in Russia and elsewhere with drug benefit reimbursement mechanisms has pointed to the importance of prompt payment if pharmacies are to participate and clients are to get access to their drug benefits. In the short term, until GOA funding commitment is obtained and a decision about the best procurement option made. USAID should consider funding commodities for rural populations and facilities leaving product availability in Baku to the private sector. This segmentation approach was very successful in Romania. GOA commitment should be sought in the short term to funding NRHO supervision to allow proper management of these commodities. In the medium to long term the NRHO logistics function should be integrated with whatever essential medicines supply system emerges from proposed basic package health reforms. The existing NRHO LMIS should be adapted to include information on stock on hand, consumption and losses and adjustments. Maximum and minimum levels should also be set and monitored. A retraining program for the staff managing supplies at various levels is required in good logistics management practices. Supervision and management by the NRHO needs to improve with a budget provided for supervision visits by NRHO staff. Azerbaijan’s Private Pharmaceutical Distribution Network The private distribution network in Azerbaijan is similar to that of other post-Soviet countries. Most pharmaceutical products are manufactured in other countries and imported into Azerbaijan by Baku-based distributors. These local companies supply pharmaceutical products to wholesalers and retail outlets, such as pharmacies and clinics (the latter accounting for a very small percentage of products sold in the private sector). As a result, distributors play a key role in controlling product availability and prices. The companies that manufacture pharmaceutical products (mostly based in Europe and the US) sometimes maintain a local marketing office in Azerbaijan. These offices are not allowed to import and sell products but support local distributors contracted to do this work with marketing and public relations activities. Their staff focuses on lobbying government officials, organizing lectures and conferences, and visiting prescribing doctors on a regular basis (this is called “detailing” in industry terminology). Unlike distributors that focus on product supply, representative offices invest in creating demand for their products. The presence of a scientific office is a good indicator of a manufacturer’s willingness to invest in Azerbaijan. All pharmaceutical products must be registered through the Ministry of Health’s (MOH) Innovation and Supply Center. New WHO-based procedures for registering pharmaceutical products have been put in place. Although no products have been approved in the past 7 months since the new system was instituted, no one we interviewed felt the new practice would serve as an obstacle to registering new products. Manufacturers (through their appointed distributors) must provide all necessary paperwork and make their products available for testing by the Center’s laboratory. According to major distributors, this was welcome change from the previous system, which did not ensure adequate control of the quality and safety of Azerbaijan’s drug supply. Oral contraceptives (OCs), intrauterine devices (IUDs) and condoms share similar distribution patterns. All are currently sold almost exclusively through registered pharmacies as required by law (OCs and IUDs) or dictated by custom (condoms). Distributors tend to sell IUDs directly to doctors rather than to pharmacies. The same distributors also tend to import all three products. Most demand-side activities are channeled through providers because mass media advertising for prescription drugs is prohibited. However, promotion of contraceptive use or of particular methods is permissible, and brochures and posters may be displayed in pharmacies. Although condoms can be freely advertised to consumers, there is limited private sector investment in these products because they are mostly brought in by distributors without the benefit of a manufacturer’s marketing support. Figure XX: Private Sector Distribution of Contraceptives [image: image4.wmf] Manufacturers Only three contraceptive manufacturers have a local representative office in Baku: Schering and Gideon Richter, which produce mainly oral contraceptives, and Innotech, a French manufacturer of condoms and spermicides. Schering. This German contraceptive manufacturer appears to be the only company expressing interest in developing the Azerbaijan market. Although the manager of Schering’s local marketing office considers this market to be relatively unprofitable in comparison with other post-soviet countries, the company already has a substantial investment in Azerbaijan. Schering employs a staff of medical representatives who call on 600 of the estimated 3,000 gynecologists in Baku, the only providers legally permitted to prescribe contraceptives. The company also works with dermatologists and endocrinologists who are allowed to prescribe these products for other indications. Schering currently markets six OC brands and two IUDs in Azerbaijan. Its best-selling product is Diane 35, an OC with dermatological properties. Other important brands for this manufacturer are Yarina, a late-generation OC, and Mirena, a hormone-releasing IUD. These products have recommended retail prices of about US$6.80, US$15.00 and US$200, respectively. Their popularity indicates that there is substantial willingness to pay among a portion of the current urban user population. This is the market segment that Schering is most interested in developing. Sales outside of Baku are more limited, although Diane 35 was observed in most pharmacies visited, typical sales number two or three cycles a week. Gideon Richter (GR). The Hungarian manufacturer has a major presence in the post-Soviet region and is known as a producer of high-quality generic drugs. GR markets leukemia, diabetes and renal deficiency treatments, as well as women’s health products. Although GR sells many unbranded generics worldwide, it markets contraceptives (mostly copies of off-patent Schering products) as branded products. GR plays an important role in Azerbaijan as a supplier of affordable contraceptives. Its low-dose combined OC, Rigevidon, is the most widely available product on the market, both in and outside Baku. Contraceptives however represent only 10% of GR’s overall business in Azerbaijan and are not actively promoted by its medical representatives. This is reflected in the limited range of GR brands sold on this market. According to GR’s local distributor (Vita Richter), the manufacturer plans to introduce new products in a higher price range in the coming months, though they will remain cheaper than equivalent Schering formulations. Both Schering and GR have an interest in promoting the use of high-price, newer formulations as opposed to so-called “second generation” OCs (such as Rigevidon). This is understandable in a small, undeveloped market: Increasing units sales of low-cost OCs (by recruiting new users) requires more effort and generates less profit than convincing current users to switch to newer, more expensive formulations. There is also a perception that the market does not need any more low-cost OCs: Schering, which produces Microgynon, the originator brand for Rigevidon, reports that there is virtually no demand for this product. More disturbing is a rumor that GR may discontinue Rigevidon, which would force users to switch to a much more expensive brand (see Table 2). While a high-price product strategy does not serve the needs of low-income potential users. It is instrumental in creating general awareness and acceptance of hormonal contraception, especially among providers who are allowed to prescribe these products. Schering’s efforts to detail providers in Baku for example, contribute to decreasing misconceptions about oral contraceptives and help prescribers address patients’ concerns. Laboratoires Innotech (LI). This French pharmaceutical manufacturer has a well-developed presence in Eastern Europe and central Asia. This company produces various treatment lines in the areas of gynecology, metabolism, central nervous system, gastroenterology and contraception. Their contraceptive line includes Pharmatek spermicides (creams, tablets, and ovules) and Innotech condoms. LI typically employs medical representatives, supports continuing provider education, and invests in consumer advertising (which is permitted for topical contraceptives) throughout the region. In Azerbaijan, however, LI does not appear to spend time or resources on the promotion of contraceptives and its medical representatives focus their efforts on other classes of products. One local sales representative sells and promotes condoms in and outside Baku, though she admits that Innotech condoms are too expensive for many people. In addition to condoms, the only widely available Innotech product in Azerbaijan is its Pharmatek vaginal tablets. Distributors There are reportedly over a hundred pharmaceutical distributors in Azerbaijan, mostly based in Baku. A few large distributors (Riadfarm, Liderfarm, Avromed, and Vita Richter) import the bulk of contraceptive products sold in the country. Many more distributors reportedly import contraceptives on a limited basis from large Russian consolidators (such as Moscow-based Protek). Exclusive distribution contracts are rare. Most manufacturers sell their products to several major distributors who then compete with each other for the wholesale and retail business. Bartering(whereby two distributors exchange goods in order to widen their own product range(is widespread in Azerbaijan, making it difficult to track down the origin of products sold in pharmacies. Distributors interviewed by the PSP-One team estimated their business to be heavily concentrated in Baku (60 to 95 percent of sales volume). This does not mean that rural regions are inadequately supplied because many district pharmacies obtain their products from Baku wholesalers. Few manufacturers can afford to maintain a marketing office in Azerbaijan. As a result, the largest distributors offer marketing services, including detailing and promotional activities. Riadfarm, for example employs 100 medical representatives in the Baku area who promote the more than 60 house brands carried by this distributor. HB, another large distributor, specializes in importing, repackaging and marketing pharmaceutical products made in Asia (mostly India, Pakistan and Malaysia). The presence of distributors with marketing capacity increases the range of products that can be sold in Azerbaijan, particularly those made in countries with low production costs. Although HB does not carry contraceptives at the moment, it is well-positioned to import and market low-cost Asian products if potential demand existed for such products. Distributors handle hundreds of products on which they earn a 10 to 20% margin. Their strategy is to focus on products with a fast turnover or high margin (preferably both). Contraceptives have a low turnover but major distributors carry these products because they are supported by a marketing office (Schering) or are part of a manufacturer’s larger portfolio (Gideon Richter). Condom and IUD importation and distribution tend to be opportunistic, that is, essentially driven by demand and not based on a long-term market development strategy. The only condom distributor displaying an interest in growing this market and investing in demand-side activities appears to be FBI (see Condom section below). The low demand (less than 25,000 OC cycles were sold in Azerbaijan last year) and low profit associated with contraceptives make them highly unlikely to be counterfeited of illegally imported. A few pharmacies in Baku appear to be importing products from Turkey, where the market for contraceptives is more developed. For example, two Schering products not registered in Azerbaijan (Miranova, Yasmin) were found in some Baku pharmacies. This parallel importation, however, do not seem widespread. Although counterfeit products are reportedly a problem in other therapeutic areas, the PSP-One team found no evidence of counterfeit contraceptive products in pharmacies. Pharmacies All pharmacies must be licensed by the Center for Innovation and Supply, which is also responsible for the registration of pharmaceutical products. Licenses are renewed every five years. At present, approximately 90 percent of pharmacies are described as private. There are reportedly about 1,500 retail pharmacies (apteks) in Azerbaijan . These are mostly individually owned businesses, though there is a trend towards multiple ownership, mostly by distributors. The common classification of pharmacies into “kiosks”, “points”, and “3rd level” apteks does not appear to influence the range of contraceptive products offered in these outlets. Product choice is largely determined by local demand, which is a combination of consumer knowledge and purchasing power. For example, some expensive OCs are only found in Baku where more consumers are likely to have heard about them and can afford them. Pharmacies in Baku can be found in every neighborhood, District pharmacies on the other hand tend to congregate around a central “bazaar”, though some can also be found on major roads. There are virtually no pharmacies outside towns, requiring rural users to travel to the nearest district apteks. This situation is no different for contraceptives than it is for other pharmaceutical products but contributes to making resupply methods (such as OCs or condoms) less practical than IUDs in rural areas. Azerbaijan’s retail pharmacies are typically well stocked and rely on distributors for their product needs, reporting an average of 1-3 weekly visits from Baku-based distributors. In addition, pharmacists frequently travel to Baku to purchase products from wholesalers (large pharmacies with warehousing capacity), which place direct orders with distributors and can offer lower prices. The differences in pharmacies’ ability to buy in bulk contribute to the wide variations in prices found in Baku (see table 2). Prices in district apteks in contrast were found to be more consistent and in the mid-range. Pharmacists tend to be misinformed about contraceptive products. The PSP-One and DELIVER team observed a striking contrast between pharmacies trained and monitored by the ACQUIRE project in Gourchay, Shamakha and Imsaili, and those in Baku, Quba and Qusar, which are not part of the Acquire intervention area. Untrained pharmacists frequently recommended abortive and gynecological treatments as contraceptives. Unlike ACQUIRE participating pharmacies, which display contraceptives in a specially designed cabinet, non-participating pharmacies typically mix them with gynecological, abortive, and hormonal replacement products. Sales in Private Clinics Clinics and hospitals account for a small percentage of products sold through private sector channels (10 to 15%). Tenders seem to be rare and not particularly sought after by distributors. Some private clinics with gynecological services carry contraceptives and may be a suitable channel for new methods with limited demand (such as POPs, implants or injectables) though these products would still have to be imported by a registered distributor. Contraceptive Products Oral Contraceptives The following major types of OCs are currently available in Azerbaijan, though their availability varies widely, and product choice decreases drastically outside Baku. Monophasic combined pills, which provide a fixed combination of ethinylestradiol (an estrogen) in doses of 20-50 mcg and a progestin. Azerbaijan is one of those rare markets where high-dose combined pills (containing 50 mcg or more of estrogen) are still available under the Ovidon (GR) and Non Ovlon (GR) brand names. The most-commonly found OC formulation worldwide is ethinylestradiol 30mg/llevonorgestrel 0.15mg, which is recognized as safe and effective by the international medical community (IPPF 2002). This is also the formulation of GR’s Rigevidon brand, which is the lowest-cost OC available in Azerbaijan. Monophasic pills containing newer progestins, such as gestodene, desogestrel(known as “third generation” OCs(as well as even more recent formulations with the progestins drospirenone and dienogest, sold as Yarina and Jeanine (are actively marketed by Schering in Azerbaijan. Despite their high prices and a reported slightly increased health risk for users, these newer formulations are very popular because they are thought to produce fewer side effects. Multiphasic (Biphasic and triphasic) pills, which provide different doses of progestin and estrogen throughout the cycle, are found under the brand names Tri-Regol (GR) and Trisiston (Jenapharm). These OC formulations are popular in certain markets (USA, Canada, Western Europe) but are not in great demand in the post-soviet region. Progestin-only pills (POP), recommended for women who are breastfeeding or cannot take combined pills, are not available in Azerbaijan. GR does not market a POP, and there appears to be no demand for Organon’s Excluton at the present time. Organon does not have a marketing office in Azerbaijan, and the Schering representative expressed no interest in selling its POP (Microlut) on this market. As a result, the large scale introduction of this formulation through the commercial sector appears highly unlikely. Emergency Contraceptive Pills (ECP) are available under the brand name Postinor. This original GR brand is widely sold in Baku pharmacies at an average price of US$4.50. Its availability appears to decrease outside Baku, where ECPs are not well know and are often confused with abortive products. Table XX: Brands of Oral Contraceptives Available in Pharmacies Type of OC Formulation Manufacturer Price per cycle (AZNM) High-dose Ovidon Levonorgestrel 0.25 mg + Ethinylestradiol 50 mcg Gideon Richter 1.30-1.70 Non Ovlon Norethisterone acetate 1mg + Ethinyloestradiol 50 mcg Schering 2.40-3.50 Low-dose Monophasic Rigevidon Levonorgestrel 0.15 mg + Ethinylestradiol 30 mcg Gideon Richter 0.80-1.60 Regulon Desogestrel 0.15 mg + Ethinylestradiol 30 mcg Gideon Richter 7.80-8.60 Novinette Desogestrel 0.15 mg + Ethinylestradiol 20 mcg Gideon Richter 3.20_3.50 Femoden Gestodene 0.075 mg + Ethinylestradiol 30 mcg Schering 6.00-7.80 Logest Gestodene 0.075 mg + Ethinylestradiol 20 mcg Schering 5.00 Jeanine Dienogest 2 mg + Ethinylestradiol 30 mcg Schering 6.60-13.00 Yarina Drospirenone 3 mg + Ethinylestradiol 30 mcg Schering 6.40-15.20 Diane 35 Cyproterone acetate 2 mg + Ethinylestradiol 35 mcg Schering 5.20-7.00 Marvelon Desogestrel 0.15 mg + Ethinylestradiol 30 mcg Organon 4.00-5.20 Low-dose Multiphasic Tri-Regol Levonorgestrel 0.05/0.075/0.125 mg + EE 30/40/30 mcg Gideon Richter 1.80-4.30 Trisiston Levonorgestrel 0.05/0.075/0.125 mg + EE 30/40/30 mcg Jenapharm ECP Postinor 2 Levonorgestrel 0.75 mg Gideon Richter 2.90-4.70 Injectable Contraceptives (IC) Injectable contraceptive formulations are virtually absent from commercial retail pharmacies in Azerbaijan, although there are reports that some pharmacies bring in Depo-Provera (DMPA) upon request. Schering manufactures two injectable formulations: Noristerat (monthly), and Mesigyna (2-month formulation). The Baku-based Schering representative, however, feels that these products are not appropriate for the Caucasus region and is reluctant to introduce them in this market. Gideon Richter does not produce injectable contraceptives. As for POPs, the chances that a private sector manufacturer will choose to market injectables in Azerbaijan are slim. Distributors (who can choose to bring in these products if they see market potential) stated that there is no demand for these products at the present time. Intra-Uterine Devices (IUDs) The availability of IUDs is heavily influenced by health providers. While all contraceptive methods are subject to provider intervention (through medical prescription and patient counseling), the IUD is the only product not spontaneously requested by users in pharmacies. Women who purchase their own IUDs typically do so after being counseled by a gynecologist, even though IUDs can be easily obtained without a prescription. The IUD market is not well established, assumedly because donated products were available for several years in the public sector (where most users obtain this method) and sometimes leaked into commercial pharmacies. Reports of Indian IUDs being available in pharmacies most likely refer to generic Copper T products donated by UNFPA. These IUDs were not available in the pharmacies surveyed by PSP-One, suggesting that they are not currently imported and distributed through commercial channels. One Russian made IUD was observed in a pharmacy in Sheki. The most widely requested and available IUD in pharmacies is the Russian made cu380, which has a consistent retail price of US$1.13. Another popular product is Schering’s NovaT, which sells for an average price of US$5.60 in Baku pharmacies but is not widely available in district apteks. Another Schering product, Mirena, which releases a progestin (Levonorgestrel) and is considered one of the most effective contraceptive methods by the health community, is unfortunately beyond the means of many users, at an average retail price of $200. Pharmacies do not carry IUDs at all times. According to distributors and pharmacists, IUDs are not stocked on a consistent basis because demand is unpredictable. For example, a health provider may purchase 50 IUDs in one day and not re-supply for months. However, IUDs are said to be easily available from distributors, and most pharmacists claim that they can obtain them upon request within a few days. It should be noted that many doctors purchase IUDs directly from distributors ands wholesalers at discount prices, which further explains why this product is not widely available in retail pharmacies. At least one public sector hospital (in Quba) purchases and keeps IUDs in stock for patients who elect this method. It was not possible to assess how many distributors import IUDs into Azerbaijan. Two of the largest companies interviewed by PSP-One carry Schering’s NovaT and one (Riadfarm) brings in the cu380. Avromed imported a Russian-made IUD at one time but discontinued it because of low sales. The IUD market may take some time to stabilize. It is likely to grow and become less erratic if donated products disappear from clinics and pharmacies. On the other hand, new supplies of donated IUDs may limit demand in pharmacies to more expensive options, such as or Schering’s NovaT or Mirena. Spermicides Spermicide use is not widespread in Azerbaijan, but two products appear to be widely available: Innotech’s Pharmatex vaginal tablets, and Russian-made Kontraseptin suppositories. This is a more limited range than typically found in post-soviet countries, where mistrust of hormonal contraception has fueled demand for these products. This method may be too expensive for average users, judging by its decreased availability in rural apteks. Pharmatek ovules, at an approximate retail price of US$7.40 for 10, were only available in a few pharmacies in Baku. Table XX: Topical Contraceptive Brands Available in Azerbaijan Brand Manufacturer Country Price AZNM Pharmatex vaginal tablets (12) Innotech France 3.20-4.00 Pharmatex ovules (10) Innotech France 6.50 Kontraseptin T vaginal suppositories (10) Nigfarm Russia 1.30-1.70 Condoms There are a wide variety of condom brands available in Azerbaijan, though product choice and prices differ substantially between Baku and rural districts. Table3 provides a list of condom brands and price ranges in pharmacies. The sale of condoms is not legally restricted to pharmacies, but most condoms are distributed through these outlets, though many are small apteks selling over the counter (OTC) products. There is limited condom presence in Baku supermarkets. Table 3: Condom Brands Available in Azerbaijan Brand Manufacturer Country 3-pack price (AZNM) Carex Bolear Medica Russia 1.60 Benetton Benetton Italy 2.00-3.00 CSport N/A N/A 1.20 Durex LIG UK 1.90-3.00 Duty Free FBI UK 3.00-4.00 Extra Pleasure Ansell Belgium 1.00 Gussarski N/A Russia 0.80-0.94 Innotech Lab. Innotech France 1.00 Kama-Sutra J.K. Ansell Belgium 0.90-1.40 King N/A N/A 1.00 Lifestyles Ansell Belgium 1.70 Love Nest FBI N/A 0.20-1.00 Oops Hind Biotech India 0.80 Pleasure FBI N/A 0.80 Revenge FBI Japan Rosetex Erco Ltd Czech Rep. 5.00-6.50 Rough Rider Ansell UK 0.80 Sexy Lady FBI Brazil 0.60 Sico CPR Germany 0.80 Simplex Latexindo Indonesia 0.60-1.20 Viva Unilatex Spain 0.30 Vizit BS Russia 0.60-1.30 Only one major condom importer (FBI) appears to be actively investing in growing the market through promotion and advertising. This Canadian-based company imports condoms made by Ansell (Kamasutra, Extra Pleasure, Rough Rider) and Russia-based BS (Vizit). FBI also imports condoms from India, Japan, Brazil and the UK that it markets under its own brand. Proprietary FBI brands include Revenge, Heartbeat, Love Nest, Sexy Lady, Pleasure and Duty Free. These products range in prices from US$0.68 to $4.50 for 3 condoms. FBI supplies condoms through other distributors (such as Avromed and Riadfarm) and large Baku-based wholesalers, as well as through direct sales to retail outlets. The FBI Managing Director estimates the size of the condom market to be 3 million yearly unit sales but admits that re-exports to Georgia may account for half of this figure. FBI claims to have invested about US$ 2 million in 1999-2000 in generic mass media advertising to raise HIV/AIDS awareness and increase condom use. The campaign, however, ran into (unspecified) opposition and had to be discontinued. FBI expressed interest in pursuing market-building activities, including collaborating with FP/RH projects aiming to increase condom use. It is unclear how many companies distribute condoms in Azerbaijan, or where these condoms come from. Determining the country of production is difficult, as this information is apparently not required by law (the countries appearing in table 2 are those of the companies that market them). Allegedly counterfeit Durex products made in China were found in several pharmacies for as low as US$0.35. LIG, the manufacturer of Durex condoms, does not have an official distributor in Azerbaijan at this time. It is also difficult to determine the quality of a particular product by simple examination. Many condoms marketed by reputable companies (such LIG and Ansell) are made in Asia. As a result, the country of manufacture is not a reliable indication of quality. Low-cost Indian and Chinese-made condoms, however, are more likely to be produced under less stringent quality control than those made in Japan, Malaysia or Thailand. A more thorough analysis of brands sold in Azerbaijan would be required to assess the quality of the country’s condom supply. Some pharmacists (mostly located in rural areas) refuse to stock condoms, hide them from public view, and even prohibit female attendants from selling them. This attitude makes it more difficult for customers to access condoms and has a negative impact on the country’s contraceptive security and ability to prevent sexually transmitted infections. Private Sector Services Private sector services are a key element of the private sector’s contribution to contraceptive security. This section of the report assesses the availability, affordability and quality of FP services in private clinics and hospitals, and the attitudes of health providers towards various contraceptive methods. Information for this assessment was generated through interviews with managers and providers working in private health facilities, policymakers, and a member of parliament (see Contacts for a complete list). This section focuses on privately operated facilities. Azerbaijan is not undergoing the type of privatization whereby state health services (supported with state funds and delivered by state employees) are converted into private health services. None of the private clinics visited by PSP-One were purchased from the state by private individuals, but either created with private capital, or converted into “quasi-private” entities where government-owned property and equipment are leased to independent providers. Legal Environment Private medical practice is a relatively new concept in Azerbaijan. While the Ministry of Health reports that there are approximately 30 private medical establishments, there appear to be more variations of private ownership in this area than in the case of pharmacies. Regulatory practices, including the licensing of providers and enforcement of licensing requirements, also appear to be less well defined/understood and not uniformly enforced. Although the government is still the predominant provider of health services in Azerbaijan, laws exist that provide for the establishment of private health care services (notably, the 1999 Law of the Azerbaijan Republic covering Private Medical Sector Activities; and the 1995 law titled “Rights of Persons in the Medical Field”). In general, government officials and private providers and clinic managers interviewed by PSP-One reported that the government is in favor of growing the private health sector. One government official stated that private facilities are less of a burden on the government than public facilities. Laws also exist that create opportunities for various types of insurance, although there is no mandatory health insurance in Azerbaijan at the moment. Voluntary health insurance, which is very costly, is accessed by less than 1% of the population. Most insurance companies do not cover reproductive health services such as STI screening and family planning methods. Types of Facilities According to both interviews with government employees and private insurers, only 2% of all health care facilities are fully private. One government official estimated the number of licensed private clinics in the country (not including pharmacies and dentists) at 30. Most of these private clinics are in Baku although a few are found along the oil pipeline and in some rural areas. These clinics are created and financed by private investors, as opposed to privatized former public clinics. These clinics must adhere to government licensing standards. Licenses are issued for specific services, not by facility, and must be renewed every five years. Private facilities must also pay income and property taxes. Some government-owned facilities are privately managed. In this case, the government owns the property, facility structure, and equipment for which the “owner” pays rent. The government also sets the prices for services. However, these facilities’ staff, maintenance and supplies are independent from the state and are paid, renovated and purchased respectively with profits generated by the facility. There are reportedly, 90 such “quasi-private” facilities in Azerbaijan, which, as other private facilities, are mostly located in Baku. This structure allows for some autonomy and flexibility in salaries and quality control, while alleviating the need for start-up capital. A third variation of private services includes providers who see patients in their homes. According to the Network Survey conducted by the International Medical Corps (2000), 32 percent of private providers fell in this category. Opening and Managing a Private Clinic Private providers and clinic owners interviewed reported that opening a private facility is easy as long as one has enough start-up capital. Current owners reported that legal paperwork and other administrative proceedings are not barriers, and that procedures are clear. According to one clinic manager, “you simply fill in the forms and pay a minor processing fee.” The most difficult requirements to meet in the private sector registration protocol are reportedly space specifications, such as surgical room dimensions. Carving up existing space to meet room specifications often means major infrastructure renovations. Keeping a fully private facility open may be difficult in Azerbaijan. The laws governing the licensing of clinics in the public sector also apply to the private sector and the MOH is expected to monitor private clinics every three months. Media reports of private clinics being closed as a result of poor quality conditions were discussed in interviews. According to one MOH official, these clinics were closed because they failed to meet licensing standards. Private clinic managers, however, reported that their clinics were rarely visited by government officials or monitored for adherence to licensing standards. Private Clinic Patients Fully private health care facilities were often established to provide services to employees of oil companies and foreign embassies. Facility managers and staff report, however, that unaffiliated middle and upper income clients routinely utilize private facilities. Quality is perceived as higher, equipment newer and essential supplies (gloves, drugs) more readily available in those facilities than in the public sector. One private provider stated that 20-25% of the urban population chooses the private sector, reasoning that they are getting more value for their money than in the public sector where they have to pay unofficial fees. Among fully private facilities, the first private clinic in Baku, MediClub, seems a special case. About 12,000 of it s 40,000 clients have private insurance. Its primary clients are pipeline workers and foreign embassy staff, though it reports about 40% “off the street” clients. It is also the only clinic with malpractice insurance and foreign quality audits from the UKAS (United Kingdom Association of Standards). This clinic boasts a custom-built health management information system and provides continuing medical education for its staff. Services and Costs Most private facilities in Baku are outpatient clinics and many are specialized. The clinics visited for this assessment offer very specialized services, as they generate the most revenue, but also offer a wide range of other services, including family planning. The outpatient clinics are less than four years old and services include dentistry, ob/gyn, pediatrics, ENT, laboratory, blood diagnostics, ultrasound, neurology diagnostics, dermatology, endocrinology laboratory and diagnostics, urology and minor surgery. Reproductive health services include family planning, abortion, IVF counseling (and treatment in the hospital), ultrasound, cancer screening (and treatment in the hospital), referral for delivery (or delivery at the hospital) and STI screening and treatment. Family planning commodities were only found at one facility, but had to be purchased at the pharmacy on a different floor. Other clinics told clients where to get contraceptives and then in the case of IUD insertion or injectables return for the additional service. Of the clinics surveyed, approximately 5-10% of the services rendered are ob/gyn services. Of that 5-10%, the most common services are lab tests, ultrasound or abortion. Family planning is not profitable and according to private providers interviewed, “free” in the public sector. In addition, prices for family planning, while lower as a stand alone cost versus abortion, are actually costlier to the patient and less time efficient for the provider. All the providers interviewed reported that a battery of tests are first needed before prescribing a contraceptive method including STI screening, blood tests and pregnancy test. The table below is a summary chart of prices for FP and other RH services in both private and “quasi” private facilities. Keep in mind that the government sets the price for “quasi” facilities so those prices should reflect prices in the public sector. Table XX: Price of RH/FP Services in Private and Quasi Private Clinics in Baku Service Quasi Private Cost (USD) Average private sector cost* (USD) Induced mini abortion $10 $30 Gyn Screening Pelvic exam** $1 $7 STI screening (Syphilis, Hepatitis B, Gonorrhea, Chlamidia, Herpes etc)** No price given $8.50 per test Gyn Ultrasound** No price given $11 Hormone tests (estrogen, progesterone)** No price given $9 IUD insertion $10 $20 *Average prices from two private outpatient services and one private hospital. ** Necessary test prior to IUD insertion or prescription for hormonal methods The clinics surveyed generate revenue from fees for services and from insurance reimbursement (less than 5% of patients had such insurance). Most insured patients work for foreign embassies and businesses, such as oil companies. Most revenues are generated from out of pocket service fees. A miniabortion in a fully private clinic costs US$30, not including gyn screening, which costs an additional US$7. In a quasi-private clinic, the same miniabortion would cost $11. IUD insertion services would cost as much as a mini abortion in a quasi-private institution. In a fully private institution, an IUD insertion costs $20, but a series of tests are required before the insertion, including a general pelvic exam, STI screening, hormone testing and ultrasound, all of which drive up the cost of IUD insertion to $55.50. Health Providers According to several private and public sector providers, approximately 70% of health providers in Azerbaijan are working in both the public and private sector. The private sector is thought to provide better working conditions (equipment, supplies, autonomy, reduced competition for clients, and often better pay). Most providers, however, keep their government jobs in order to retain their pensions and job security. In Azerbaijan, working in both sectors simultaneously is not restricted. In the private sector, providers are typically paid a percentage of the amount of services they render. For example, if a client’s bill is $100, the provider earns 20% of that bill. Very few clinics offer salaries to providers. Private doctors working in a large clinic stated that they would like to start their own practices, but do not have access to start up capital, which is necessary to rent space and purchase equipment. When asked how they were brought into private practice, some mentioned hearing about opportunities from colleagues and applying for work on the spot. Others were brought in by clinic owners they worked with in the government. Three of the clinics seemed to be staffed appropriately (the ob/gyn saw about 5 to 10 patients per day). The other three seemed to be overstaffed with ob/gyns and saw an average of two patients per day. Private sector providers do not routinely provide or promote family planning services to patients, in part because they do not generate high revenue. As reflected in table 4, the package of contraceptive services in the private sector is more expensive than an abortion. However, testing for family planning takes place only once and IUD insertions provide protection for five years. As a result, providers can earn more money over time by performing frequent abortions. Even when these services are provided, women are most likely not fully informed about hormonal methods. Private sector providers reflect the same bias and misconceptions regarding hormonal contraception that are often found in the public sector. About half of the providers interviewed said they did not like to prescribe hormonal contraceptives (OCs and injectables) because they cause tumors and are a cancer factor. Providers are reportedly much more likely to suggest IUDs or condoms to a woman interested in family planning. Those women determined to use oral contraceptives typically go to a clinic for a consultation and first pill pack then re-supply on their own in pharmacies. Conclusions Few policy barriers unduly restrict access to commercial products and services. Distributors and policymakers alike see the new registration procedures as a distinct improvement over past practices. Although no products have been approved in the past 7 months since the new system was first instituted, no one interviewed felt that it would constitute an obstacle to registering new products. In addition, the absence of price controls allows for increased profits and investments (though it may contribute to a trend towards increasingly expensive hormonal contraceptives). Finally, the provision of services through the private sector appears to be viewed favorably by the government and there are no laws that currently prohibit this expansion. Lack of capital is a more likely barrier to further development of private practice. Contraceptive products are reasonably available in Azerbaijan. Although the PSP-One team was not able to survey the market exhaustively, it found no evidence of widespread shortages of contraceptive products in the private sector. Azerbaijan has a very high abortion rate and few users trust modern methods of contraception . As a result, demand for these methods is likely to remain low, which is reflected in product choice. However, most users are likely to be able to afford the lowest-price commercial OCs, IUDs and condoms because their prices are consistent with other frequently used pharmaceutical products. In areas where product choice is limited, this decreased availability primarily affects high-price products, which many rural people cannot afford. There are, however, differences between contraceptive methods . Condoms may be the most widely available method, but the presence of counterfeit brands and products of unknown origin may be a threat to the quality of product supply. In addition, self-imposed restrictions by pharmacists affect consumer access to these products in rural areas. OCs are well represented in pharmacies but the majority of brands marketed by private companies may only be accessible to middle and upper income women, and the possible discontinuation of low-cost OCs is a key threat to contraceptive security. Spermicides remain a marginal method and their high prices may keep demand for these products low, affecting both product choice and availability. Though less readily available than other methods, IUDs were ultimately found to be adequately supplied through distributors and wholesale pharmacies. Few private sector suppliers have an interest in the contraceptive market. This is an important finding as private sector interest influences both product supply and the financing of demand-creation programs. In countries with high-perceived growth potential, manufacturers are willing to invest (and even lose money for a while) in order to build demand for their products. Distributors actively seek new products to import in the country and work to ensure adequate stock levels at all times. This is not yet the case in Azerbaijan. As a result, it may be difficult to convince suppliers to keep low-cost products on the market, or partner with them to grow the market. In small, undeveloped markets, there is also less common ground between public health needs and commercial interests, as evidenced by Schering’s focus on a high-income user segment. It should be noted, however, that this company’s efforts to change provider attitudes toward hormonal contraception can go a long way toward increasing overall demand for this method in Azerbaijan. Needy populations are not being adequately served by the private sector. Low-income users and those unable to access commercial retail outlets require services that the private sector cannot currently provide. For example, rural users may not be able to obtain re-supply methods on a regular basis, often lack information about hormonal methods, and wile they may prefer to use an IUD, the unofficial cost of prescreening as well insertion may make them unaffordable. In addition, private sector facilities serve primarily urban, middle and upper class users or those fee patients with access to insurance. Because the private sector is unlikely to meet the needs of low income and rural populations, it will be necessary to supply contraceptive products to these users through alternative programs and channels. Quality of care in the private sector may be lacking or inconsistent. In spite of laws regulating private practice in Azerbaijan, quality controls do not appear to be enforced evenly or systematically. When it comes to family planning services, there may be a tendency in the private sector to limit access to certain methods, in part by requiring more tests than needed. Private providers are typically paid a percentage of the cost of services provided. In some clinics, particularly those overstaffed with ob/gyns, clients may be charged for unnecessary tests and services. This practice increases costs to users and limits access to contraception. Family planning services are not an area of focus in private health facilities. Private clinics draw the bulk of their revenue from specialized care and family planning services are not sufficiently lucrative to merit being promoted. Abortion is a better source of revenue for private sector ob/gyns over the long term, followed by IUD insertion. Although a number of private facilities are equipped to offer family planning services, the same biases found among public sector providers, notably against hormonal contraceptives, are prevalent among private providers. recommendations CONTRACEPTIVE SECURITY overview and conclusions Azerbaijan faces considerable challenges to improving its contraceptive security. There is both evidence of public and private sector failure to provide Azeri women with the contraceptives they need. These failures are compounded by externalities in service provision and provider attitudes as well as lack of information amongst policy makers and the wider population. While richer urban women are getting access to modern FP methods through the private sector, income disparities and public sector service failures are reducing access for the rural poor and possibly even the urban poor. Product availability by client can be summarized as follows, the shaded access indicated no or very limited access: TABLE XX : Existing Market Segmentation in Azerbaijan – Neglected rural poor Population Publicly provided services and products Private clinical services Private Pharmacies Baku Wealthy IUDs IUDs Orals Condoms Orals Poor Condoms Outside Baku Wealthier in towns IUDs Condoms Orals Rural poor With approximately half the population living in Baku, these people potentially have access to private sector services and would benefit from planned IEC and BCC campaigns to generate demand. The ability of the urban poor to access the private sector requires further study. The situation outside Baku is far less positive. While detailed income distribution figures have not been analyzed, anecdotally providers in both rural and CRH facilities consistently talked about 20 to 30% of the population who can afford to pay and access contraceptives from pharmacies or from publicly provided services typically incurring unofficial fees. As many as 40 to 50% were judged to be unable to pay for contraceptives while the balance able to afford some financial contribution. Reaching these rural poor and near poor represents the major challenge for improving product availability in Azerbaijan. Despite these challenges, FP stakeholders identified a number of strengths that can be built on as well as weaknesses that need to be overcome. TABLE XX: Strengths Dr. Faiza (National NRHO Coordinator) and NRHO team Parliament members interested in FP issues Dr. Tarana/MOH Coordinator, MCH NRHO HSR – primary health care priority USAID and UNFPA donor leadership PHC, ACQUIRE Weaknesses Top officials have a lack of awareness of FP issues particularly in the MOH and MOF and are not listening to the evidence of role of FP for women’s health There is a wider lack of awareness in the parliament Unclear structure for FP FP service provision issues Lack of regular coordination No identified funding sources for public sector Private sector disinterested in rural areas No product availability at public clinics LMIS management issues with NRHO Short term options/strategies Short term supply should be considered by USAID Tap into existing evidence supporting FP (PHC and ACQUIRE) Share/get endorsement of statistics that justify FP investment Involve political people in FP/RH activities Workshop for influential people plan carefully and invite key decision makers National and international conferences should be organized on a regular basis Tarana would like briefs with talking points and data that will help lobby MOH, Parliament, GOAZ, etc Organize regular round table discussions with stakeholders Need a transition strategy to carry us to 2008 so FP efforts thus far will not be jeopardized (MOH/Tirana says to raise this issue to MOH) Strategies for improving product availability should build on identified strengths and seek to address identified weaknesses. Strategies are required to address availability for the rural poor as well as strengthen the private sector response in Baku and other urban settings. A four pronged strategy should be considered to encourage the private sector to serve more the needs of the urban populations while the public sector seeks to be more effective in reaching the rural poor. Several elements of this approach are already in place with the ACQUIRE and PHC projects. Advocacy with senior policy makers to demonstrate the importance of FP for the health and welfare of the Azeri population Demand creation activities geared to improving information about modern contraceptive use with work with the private sector in Baku as well as rural towns to increase private product availability. These activities should be undertaken in partnership with the private sector and include ensuring a private supply of affordable OCs. Retraining and continuous education for service providers including both Ob/gyn and general practitioners in pilot sites Provision of free commodities to the poor in rural communities, rural towns and in a limited way to targeted poorer clients in Baku. The objective will be to increase product availability from both the private and public sector. Public expansion should be focused on rural Rayons and include a full method mix. With increased product availability, ACQUIRE pilot sites can seek to expand out reach services. Work with private sector should include continued support through the communications campaign and work with pharmacies in Baku as well as the pilot rural Rayons. TABLE XX: Proposed Market Segmentation in Azerbaijan – reaching the rural poor Population Publicly provided services and products Private clinical services Private Pharmacies Baku Wealthy IUDs Orals Condoms Orals Poor IUDs Orals Condoms Orals Outside Baku Wealthier in towns IUDs Condoms Orals Rural poor IUDs, Orals Condoms, Spermicides Does this need to be shaded? Condoms Short term Recommendations Advocacy Policy Research Advocacy activities should focus on i dentifying and addressing likely information needs among champions for elevating the role of family planning. Specifically, the importance of family planning commodities in discussions about family planning generally and, as health reform progresses, in the context of the national EDL, supplemental benefit package and in any additional drug benefit schemes. Work is needed to a ddress low awareness and misperceptions by disseminating fact sheets and conducting briefings on the following topics, for example: desired and actual family size, rates of contraceptive use including use of traditional methods, rates of abortion and trends in abortion (Azerbaijan only one of two countries – the other is Turkmenistan -- in the FSU to experience an increase in abortion rates, See Westoff, ND); duration until return to fertility post-abortion; the apparent reversal in maternal mortality over the past decade for Azerbaijan. Materials should be prepared on the contributions of family planning to reducing maternal death and morbidity. A number of different source materials could be used. The recently published second edition of Disease Control Priorities in Developing Countries, edited by Jamison et al, 2006 summarizes the latest evidence. See http://www.ncbi.nlm.nih.gov/books/bv.fcgi?call=bv.View.ShowTOC&rid=dcp2.TOC&depth=2) The Guttmacher analysis on the Benefits of investing in Sexual and Reproductive Health Care for Azerbaijan . This indicates that globally WHO estimates that poor reproductive health accounts for up to 18 percent of the global burden of disease and 32 percent of the total burden of disease for WRA. While globally these figures are dominated by the consequences of unwanted pregnancies in developing countries – Some issues related to the impact of the lack of modern contraceptives on abortion and self induced abortion are relevant in Azerbaijan. The planned market segmentation and ability to pay analysis should provide information that will help inform policy discussions. Related to that, and as data permits, present information on the out-of-pocket expenditures on abortion services, especially among rural and/or poor populations. Education about the potential for “inreach,” e.g. post-abortion and post-partum family planning counseling, as a means of reducing abortions. Turkish experience with “inreach” is highly relevant and it would be appropriate to consider sponsoring leading Turkish MOH/MCH or Ob/GYNs to technical meetings to share experience. Russian language copies of JHPIEGO contraceptive methods, Hatcher’s contraceptive technology should be obtained and distributed to pilot sites and through The NRHO Advocacy Activities With information collected, several activities can help mobilize stakeholders and build awareness. Convening a women’s health/maternal health/reproductive health and family planning group to organize and sponsor expert forums to identify misperceptions among policymakers regarding family planning in Azerbaijan and to identify opportunities and specific activities to correct them. Continued close monitoring of a possible maternal health initiative by ACQUIRE may identify opportunities for highlighting the importance of post-partum and/or post-abortion family planning counseling as part of maternal health initiative. Ensure RH FP group members participate in broader primary health care coordination efforts so that they stay fully apprised of initiatives to be tested during the pilot period of the health reform program, including for example, community financing of basic package of drugs, so they are able to mobilize efforts to include family planning . Consult widely to identify possible effective approaches for educating MoF and Cabinet of Ministers about family planning’s maternal health and general health benefits. Demand Creation and the Private sector Expand potential availability of distribution points for commercial medical products in rural areas. Even if the private sector were to continue to make available low cost but high quality hormonal contraceptives (e.g. Rigevidon), the absence of pharmacies in rural areas would limit the extent to which access to the method could be increased. In other FSU countries, notably the Ukraine, legal provision has been made permitting the sale through feldsher-obstetrican points (FOPs) and rural ambulatories of a list of basic medications, including contraceptives. In Urban areas efforts to increase the use of modern methods should focus on demand. In a free market economy, the most effective way to increase the supply of a product or service in the private sector is to facilitate increased demand from consumers. In the area of contraception, increased demand can be achieved through unbiased information and access to counseling. While adequate product supply is needed for consumer to access contraceptive methods, it cannot solve the problem of misinformation, provider bias or service delivery costs that contribute to low demand. Large increases in product supply would probably not yield much improvement in method use and may even negatively affect private sector provision of these methods. All evidence points toward the need to educate health providers. The ACQUIRE project is undertaking important steps to prepare and empower family medical doctors and midwives to provide family planning counseling in 5 pilot districts. More efforts in this area can only motivate manufacturers and distributors to increase product supply and choice. Public-private partnerships should focus on ensuring product access for most users. The main contribution of the private sector to contraceptive security should be to keep high-quality, affordable products on the market. Ensuring sustainable access to products such as Rigevidon, a low-dose, high quality OC should be a priority for public/private partnerships. If rumors of discontinuation of Rigevidon are confirmed, every effort should be made to find a compromise with GR that would ensure its continued availability or replacement with an equally affordable product. Alternatively, Schering could be approached to re-introduce Microgynon (a product with the same formulation) at a low price. Products with limited commercial potential (such as injectables, implants, and progestin-only pills) can be made available by partnering with a local distributor willing to import a limited supply for a network of providers interested the method. Market development efforts by manufacturers such as Schering can be leveraged when general awareness and education objectives are being pursued by donors and/or the MOH. Health providers (especially pharmacists) are in acute need of information. Pharmacy attendants generally displayed a lack of knowledge of hormonal contraceptive products, though many seemed eager to receive information about these products. The ACQUIRE project is currently implementing a badly-needed training and merchandising program in pilot areas that could be scaled up to a national level. ACQUIRE’s carefully designed and monitored activities will go a long way towards demonstrating that well-targeted programs can increase contraceptive use in pilot areas. The potential impact of scaling up such program to include heavily populated, urban areas cannot be overstated. The expansion of distribution outlets for contraceptives in rural area merits exploration. Even though low-cost contraceptives are available through the private sector, the reduced presence of registered pharmacies in rural areas limits opportunities for increasing product use. In other FSU countries, notably the Ukraine, legal provision has been made permitting the sale of basic drugs, including contraceptives, through feldsher-obstetrican points (FOPs). Because low return-on-investment will continue to limit the number of registered pharmacies in rural districts for some time, this particular policy intervention may substantially increase method choice in underserved areas. Private sector facilities would benefit from inclusion in family planning training programs. Although private sector clinics may send their providers to conferences and continuing education workshops, they are unlikely to focus on family planning because it is not a very lucrative service area. Training programs developed by the MOH or donor-funded projects should systematically include private sector providers. These providers serve a sizable proportion of the population in Baku and have the reputation of providing high quality services, even though they display the same bias and knowledge gaps as public sector providers. To the extent possible, quality control in private facilities should be improved, with a focus on better doctor and patient information, and reduced service protocols for contraceptive methods. Provider training and service improvements ACQUIRE should continue to develop its community based FP service delivery and counseling. Ideally ACQUIRE activities should be expanded into other pilot sites to increase the reach of their support. Work with the NRHO should revise FP guidelines and draft waivers to allow staff in pilot sites initially to prescribe pills and then to insert IUDs given sufficient training and sanitary insertion conditions. WHO support should be sought to help get modern FP methods included in preservice training for medical staff. Public sector Supply for target populations The forecasts presented in detail in the Annex indicate that the estimated cost of filling the public sector pipeline is $345,735 in 2007 and $106,667 for maintaining it in 2008. USAID should consider funding this commodity commitment. UNFPA should support the provision of TA support to redesigning the LMIS and training in its application and supporting NRHO supervision and monitoring. The GOA should fund the salaries of NRHO staff to ensure they can carryout necessary supervision and monitoring. Supplies should be targeted to rural towns and rural communities. Any supply in Baku should be carefully managed and monitored to ensure public supplies are only being provided to the poor and socially disadvantaged. While supplies should reach ACQUIRE sites they should not be limited to them. Rather public sector supplies should seek to reach all Rayons outside of Baku. With an improved LMIS, more effective product management should ensure supplies are being properly used and if not commodities redistributed. The results from public provision of services should be tracked carefully to help provide the evidence base for future policy decisions on including of FP services and supplies for target populations in the basic service package. A transition plan to GOA procurement of FP commodities would depend on the direction of health reforms as well as the inclusion of FP in the basic package. If a drug benefit approach is being adopted with supplemental FP commodity benefits then there would not be a need for public procurement of contraceptives other than for IUDs. If public procurement for targeted populations is required, GOA should initially use UNFPA as a procurement agent to ensure best value for money and good governance in procurement. Activities USAID UNFPA GOA Strengthen NRHO capacity to manage public sector FP commodities ACQUIRE appoint field logistics team to support product management in pilot sites Strengthen LMIS to include stock on hand consumption and losses and adjustments Support supervision and management training for staff at national and rayon levels Update commodity forecasts Fund NRHO salaries and supervision costs Purchase commodities 2007 2008 USAID fund two years supply chain Purchase commodities post 2008 UNFPA act as procurement agent for GOA purchase of IUDs after 2008 GOA Purchase IUDs after 2008 Other commodities depend on whether FP included in supplemental drug benefit Need a piece on Logistics Recs in the final conclusion section . Appendix: Contacts International and NGO Sector Abt Associates Dr. Peter Hauslohner, Chief of Party, Primary Health Care Project Engender Health Ehtiram Rustamzadeh, Field Coordinator, ACQUIRE Project Meridian Group International Sevinj Hasanova, Health Communications Officer, ACQUIRE Project Meridian Group International Maia Smit, Communication & Media Advisor, Acquire Project UNFPA Teymur Seidov, Caucasian Reproductive Health Youth Initiative Private Sector Suppliers AvroMed Javanshir Feyziyev, General Manager HB Co LTD Hikmet Butayev, Chairman, General Director RiadFarm Samir Ashurbekov, Head Manager Schering Gunnar Schrofel, Managing Director, Region Caucasia Leyla Akhmerova, Country Manager FBI Corporation Bazzi Fadal, Managing Director Vita Richter Rada Ismailova, Sales Manager Laboratoires Innotech International Nigar Mirzabekova, Country Manager Private Sector Providers MediClub, clinic Gynecology staff MediLuxe Dr. Sevijn Sevdimaliyeva, Gynecologist HB Co., Ltd, clinic Gynecology staff Oki Clinic, Dr. Malik Kerimov, General Manager Republican Center for Family Planning Anyone? Public Sector MOH Innovation and Supply Center Vahid M. Naghiyev, Director MOH Innovation and Supply Center Abulfas Abdullazadeh, Deputy Director National Reproductive Health Office Dr. Faiza Aliyeva, National RH/FP coordinator National Reproductive Health Office Dr. Zemphira Huseynova, Training Specialist Parliament of Azerbaijan Mrs. Malahat Hasanova Ministry of Health MCH Coordinator - Dr. Tarana Taghi-zadeh (MOH) Quba Central Hospital Gynecology staff Ismaili Family Planning Center Gynecology staff Annex A: Forecasting Contraceptive Use and Estimating Costs To determine future consumption of contraceptives, it is recommended to use a logistics based forecast which has proven to be the most accurate and reliable of the forecasting methodologies. The key data points required for a logistics based forecast are consumption data, stock on hand, and losses and adjustments and are usually generated in an LMIS system. However, there are several issues in Azerbaijan that cause us to question the feasibility of conducting a logistics based forecast: Lack of true consumption data: Ideally, a logistics based forecast should be based on consumption data agreggated from the lowest level. In Azerbaijan, we largely have issues data from the central level. Non full supply: According to the records and based on our site visits, it appears that the public sector has had irregular and/or no stock over the past 2-3 years. Because of this, it would be very difficult to determine the true consumption from this data. Another option would be to use the data from 2003. In doing so, we would not be able to substantiate this data or determine its completeness or accuracy. Questionable quality of data in current ALS: According to the NRHO, the data in their ALS is often compromised due to lack of capacity of SDP staff to correctly report as well as lack of completeness of the data (not representative). Using Demographic Data to Estimate Contraceptive Consumption For these reasons, we have conducted the following forecast using a population (or demographic) based methodology and reconciling this with anectodal information from our site assessments and interviews. The 2007-2008 population based forecast was conducted using data from the 2001 Reproductive Health Survey for Azerbaijan, including CPR, method mix, rate of abortion, source mix, TFR and other variables. This forecast also considered assumptions and factors provided through our key informant interviews. Methodology We conducted this exercise both using a software program called Spectrum developed by the Futures Group International. We also conducted this same forecast using a basic manual approach with key family planning stakeholders. This stakeholder meeting provided us with the opportunity to: 1) confirm our reservations about using logistics data as the primary source for this forecast, 2) advocate for the importance of using this evidence based approach in developing forecasts and funding allocations, 3) build capacity in the forecasting methodologies, and 4) learn about many of the assumptions and factors that may influence such a forecast. We developed the following two scenarios and forecasted each of them: Scenario #1: constant indicators from 2001 RHS 2001 Pills IUDs condoms VFT MMX 1.80% 11% 5.80% 1.00% Source Mix (public sector) 12.40% 93.80% 3.10% 4% Source: 2001 RHS Given the current situation in the country with stock outs and service delivery limitations, we do not estimate that the CPR would have changed dramatically in the past 5 years. Therefore, our first scenario has kept all information constant. It is important to note that while the population growth rate stays the same, the population increases thereby being the only major dynamic indicator in this scenario. Scenario # 2: increased modern MMX (pills, condoms, spermicides) and increased public sector source mix (pills, spermicides) While we do not envision any changes in the past data, there may be opportunity for the current interventions (i.e., ACQUIRE) to affect demand and access in the immediate future. The likely result would be a very slight increase in modern method mix with a corresponding decrease in traditional. In addition, IF public sector contraceptives are made available, it is likely that there will be a slight uptake in methods from the public sector. For this scenario, we have assumed the following method and source mix changes: Scenario # 2: increase in modern MMX and public sector source mix 2001 Pills IUDs condoms VFT MMX 5.40% 11% 7.20% 3.60% Source Mix (public sector) 15.00% 93.80% 3.10% 5% Source: 2001 RHS Limitations As indicated, for Scenario #1, the data was based on the 2001 RHS for Azerbaijan. This information is very old and much has likely occurred since then that will have affected the family planning program. Scenario #2 was based on 2001 RHS data in combination with key stakeholder conjecture. While changes were conservative, these were essentially guestimates. Similarly, the numbers of users forecasted for some of the methods is extremely low. For example, for scenario #1, approximately 300 public sector spermicide acceptors were forecasted for each year. For condoms and pills, the number of public sector acceptors is between 1000-2000. These numbers are extremely low and therefore are highly sensitive to any kind of change (sensitivity). Because of these limitations, we have only developed a two year forecast for each scenario and strongly recommend that a new forecast be conducted in six months using the 2006 DHS. Findings Scenario #1: constant indicators from 2001 RHS Commodity requirements Pills IUDs Condoms VFT 2007 30,304 27,428 193,940 20,528 2008 30,507 27,414 195,242 20,666 Scenario # 2: increased modern MMX (pills, condoms, spermicides) and increased public sector source mix (pills, spermicides) Commodity requirements Pills IUDs Condoms VFT 2007 109,973 27,428 242,429 175,957 2008 110,710 27,414 244,053 177,135 As part of the reconciliation process, we examined some of the NRHO data. It appears that they have been issuing approximately 25,000 pill cycles per year to the Rayons (to be distributed further). This number is consistent with the forecast in Scenario #1. The NRHO data for IUDs is not consistent with this forecast. This forecast estimates approximately 25,000 IUDs required each year. UNFPA’s CCM forecast estimates a requirement of 14,000 IUDs for 2007. However, the NRHO data indicates that they have issued approximately 2,200 IUDs per year. This could represent a rationing by NRHO as UNFPA only donated a total of 120,000 IUDs since 1998. However, anectodally, we saw an overstock of IUDs in at least 2 sites with the stock expected to expire this month. For condoms, this forecast estimates approximately 180,000 units (scenario #1) and 220,000 units (scenario #2). According to NRHO data, they have issued approximately 250,000 condoms per year. The CCM forecast is 2.16 million condoms for 2007 and 2.88million for 2008. Given the significant reliance on the private sector for condoms, this number seems extremely high. Spermicides: NRHO does not capture this info. --- should be a recommendation. CCM: 120,000 for 2007 and 120,000 for 2008. Based on this analysis and the input from key stakeholders, we recommend that Scenario #2 be adopted and we will base estimated costs on this scenario. Costs Unit costs associated with this forecast are based on USAID Contraceptive Price List for 2007. The following unit costs, which represent Free on Board (FOB), were applied: Pill: .23 Condom .04 IUD 1.55 Spermicide n/a by USAID In addition, the following costs need to be applied: Freight: 76.18% (air freight %) Surcharge: 5.5% Filling the pipeline Estimated costs for the 2007-2008 contraceptive forecast are: product 2007 2008 No logo 52mm non-colored $50,326 $19,840 Copper T $187,323 $53,602 Lo-Femenal $91,735 $27,687 Ovrette $16,351 $5,538 TOTAL $345,735 $106,667 Costs not included are internal country distribution, supply chain management costs. If USAID opts for procuring contraceptives based on the estimated forecast, Pipeline software must be used to complete the calculations and a CPT must be prepared and submitted and approved by USAID’s Contraceptive Security and Logistics Management Division (CSL) before orders can be placed. In addition, the Mission must ensure that the proposed products are properly registered by the appropriate regulatory authorities for use in-country. Included in Appendix X is a draft Pipeline report, CPT and memo for USAID CSL. However, if USAID elects to procure these commodities, these documents will have to be modified to reflect specific needs (air vs. sea shipment, timing and consolidation of shipments, etc) Recommendations It is recommended that USAID procure commodities for the public sector for 2007 and 2008. It is also recommended that USAID support the NRHO or other GOA stakeholder in updating this forecast based on the upcoming 2006 DHS data. While supply chain management costs are not factored into this forecast, they are essential to improving the availability of this investment to public sector clients in the rural areas. UNFPA is considering supporting the management of the logistics system through the following activities: sponsor GOA and UNFPA representative to DELIVER logistics training provide ongoing TA to NRHO in the management of the 2007 and 2008 commodities It is therefore encouraged for USAID to follow up with UNFPA to confirm this commitment. It is also suggested that ACQUIRE use this distribution and logistics management system for its sites. Annex B: product management in the rayons Product Management in the Rayons While visits were made to six different Rayons we highlight the product management situation in the two rayons visited that had the most stock. Information on other facilities visited is provided in Appendix. Sheki The Rayon store in Sheki was formerly a transshipment point for UNFPA commodities. At one point the store distributed contraceptives to ten adjacent districts as well as facilities in Sheki. They have however not received new shipments since 2005 and have not dispensed commodities to other regions since 2004 when they supplied Agsu, Ismyili, Gakh, Oguz, Gabala, Balakan, Agdash and Goychay. Contraceptives are received by the Chief Midwife who stores them in her room on the third floor of the building adjacent to the RHC. The temperature in the room was 31.5 C on the day of the visit, slightly cooler than the outside temperature. The room is unfortunately in a poor state of repair and the office is cramped and not air conditioned. There is little spare storage space as she still stores products that were expired since 2004. While records are kept at the store, the information recorded is incomplete and errors were identified. There are no store cards per se but a record of individual stock issued and received is maintained allowing a running commodity balance to be calculated over time by product. There is however, no accounting for adjustment and losses, no attempt to estimate the average monthly consumption, nor months of stock on hand. With products pushed to Sheki from the National RHO this has resulted in an over supply of many commodities that then expired because of the short remaining shelf life. It is not clear whether the National RHO has been informed either about passed over supply or expired product. There was also no attempt to estimate and monitor what SDPs were actually dispensing to clients. The Chief Midwife said she could not estimate what commodities were being used by various SDPs and had never undertaken a forecasting exercise. She simply accepted whatever products were pushed down the system to her and sent product out when requested when she had available supplies. A quick review of the requisition requests made by various SDPs indicated that a analysis of use was possible and could have helped forecast need. Data was provided by the Store for three years on the products received and dispensed and is presented in the Table below. When provided to the assessment team the data was said to relate to the three FP centers in Sheki, but it may have also included commodities issued to other Rayons in 2004. This point was not entirely clear and requires further investigation because the amounts dispensed only suggest a barely functioning flow of commodities from Sheki RH/FP to other facilities. The columns marked Opening balance, received, dispensed and closing balance were the data provided. The assessment team added the calculation of the estimated months of supply and added the comments. Dividing the amount dispensed by 12 gives the average monthly consumption each year. Dividing the closing balance by the average monthly consumption gives the estimated months of supply. While no maximum or minimum stock levels were set by the NRHO, a quick check of the estimated months of supply suggests that at the end of 2003 four out of the six methods were over stocked while one was probably under stocked. In 2004 the situation was even worse with one method expired, one new method stocked out, four over stocked and one under stocked. In 2005 three products were stocked out, two expired, one completely, there is an anomaly in the amount shown for IUDs with 1200 IUDs unaccounted for, Marvelon was overstocked and condoms the only product with a reasonable stock balance. By 2006 only IUDs remained unexpired or stocked out. SHEKI RHC STORE LOGISTICS DATA 2003 – 2006 2003   Opening Balance Received Dispensed Closing Balance Estimated months of supply Comment Marvelon Cycle 1700   1008 692 8.2 OK Adepal Cycle 720   148 572 46.4 Overstocked Regividon Cycle 2777   51 2726 641.4 Overstocked Condoms Unit 72000   59629 12371 2.5 Understocked IUD Unit 1500   139 1361 117.5 Overstocked Depo Provera Ampule 100   19 81 51.2 Overstocked 2004   Marvelon Cycle 692 4800 1522 3970 31.3 Overstocked Adepal Cycle 572   133 439 39.6 Overstocked Regividon Cycle 2726   2 2724 16,344.0 Overstocked Condoms Unit 12371 13639 23075 2935 1.5 Understocked IUD Unit 1361   74 1287 208.7 Overstocked Depo Provera Ampule 81         Expired Pharmatex     1116 1116 0 - Stocked out 2005     Marvelon Cycle 3970   928 3042 39.3 Overstocked Adepal Cycle 439   439 0 - Stocked out Regividon Cycle           Product expired in 2004 Condoms Unit 2305 10066 8310 4061 5.9 Some product expired in 2004 IUD Unit 1287 926 228 1985 104.5 Discrepancy in books, which show 698 2006     Marvelon Cycle 3042         Expired Condoms Unit 4061         Expired IUD Unit 698     698     This sorry history of poor product management reflects the lack of a working LMIS, no supervision from the NRHO, lack of analytical capacity of the Chief Midwife and lack of concern that so much product was near or at expiry. Expired product is still stored in the Chief Midwife’s office and includes: 3,600 pharmatex, expired April 2004 5,000 cycles Marvelon that expired in February 2006 720 condoms that expired in March 2005 Several hundred cycles of Adepal that expired in October 2004 – this does not tally with the records in the table above. 450 IUDs that expired in 2004 The only product available in the store is 700 IUDs that will expire in 2008. Ismaili The CRH in Ismaili has a RHC that was funded and equipped by UNFPA and DFID. They serve a population of 76,000 and insert 10 to 15 IUDs per month and perform 10 to 12 abortions per month with a total patient load of 30 to 50. They have received Humanitarian aid support but products were close to expiration. They currently have 1,056 IUDs with half expiring in August 2006 and half in 2008. They have 33,000 condoms that expired in March 2006, 7,604 cycles of Marvelon that expired in 2004 and 1,100 tubes of spermicide that expired in January 2005. Products were simply pushed from the NRHO without attention to their expiration or their needs. Clients have prejudices about modern methods. The staff of the RHC seemed very defensive and were not forthcoming in answering questions. Gushaya is a rural community close to the CRH serving a population of 3020. They have recently refurbished their DAC. They do not have supplies but send women to the CRH after counseling. Clients complain that they only give advice and no commodities and staff estimate that 40 % of their clients can not pay. Kurdmashye is 30 KM from the CRH and serves a population of 3250. They provide counseling but with no commodities to distribute women need to travel to town to get FP methods. IUDs can cost between $12 to $20 but many can’t afford to pay and so revert to abortions because people do not have a fixed source of income. Perhaps as many as 70% can’t afford FP commodities. They did receive UNIFCEF supplies in 2000 and at that time Depo Provera was the most popular method followed by condoms and then pills and then IUDs. There was a tragic case because a women took Iodine to self abort and ended up poisoning herself. The pharmacy visited in the town sells Pharmatex for 4 Manat and sell one or two a month. Diane sells one or two a week. They sell 15 to 20 condoms for 0.6 to 1 Manat for three. Rigivedon sells for 2.4 for 3 cycles and they sell one a week. They never sell IUDs as these are supplied directly by the Ob/gyn. Annex c: Summary of site visit findings Baku National RHC The Baku National RHC is the leading RHC in the country. It has three related functions: To demonstrate technical leadership and set national RH/FP policy; To provide technical and training support to district RHCs; and To serve the RH/FP needs of Baku. With UNFPA support it has organized FP service delivery, MCH services, adolescent health services and laboratory services. It has also organized training of staff and training of trainers in the provision of FP services for training RHC in other regions. The Center has also formed a joint venture with a Turkish provider to offer IVF treatment for $240, a fraction of the cost of treatment abroad. The National RHC Facilities were modern, clean and well appointed and equipped. There were plenty of clients awaiting services on the day of the site visit. Each FP client is given counseling by a trained nurse/midwife on different contraceptive methods in a private sound proof room. Clients are then recommended a method. Spermicides and condoms are provided free of charge when supplies are available by the midwife providing counseling services. The National RHC last received supplies of humanitarian commodities from UNFPA in January 2005. They only have stocks of 6,600 condoms left, enough for two more months. It is not clear if they issue standard numbers of condoms to women, one patient record reviewed showed the woman had been given 60 condoms, equivalent to half the number needed for a couple year of protection. They have used all of their stock of Pharmatex spermicide, while the Marvelon they received was near expiry and has now finished. They have noticed a decrease in demand for contraceptives with the ending of humanitarian assistance. They do not believe women have switched to private supplies because of the high cost of contraceptives. They are developing a relationship with Schering who has provided information on hormonal pills for doctors to give patients. With limited supplies to dispense, the National RHC has been advising women on using LAM and other natural methods of contraception. Access to IUDs seems limited because of cost. With no remaining stocks, women need to go to a pharmacy to buy the IUD for the centre staff to insert. While WHO standards say that an IUD can be inserted by a trained nurse, national policy is more restrictive and limits IUD insertion to Obstetricians/gynecologists (Ob/Gyn). National policies also state that a smear test must be conducted before an IUD is inserted and that a check up is also required before hormonal pills can be prescribed for the first time. After the initial cycle has been issued, a further consultation is typical with the Ob/Gyn to see if there are any side effects. After that visit pills can be subsequently prescribed by other trained medical staff. The National RHC Director gave the following justification for doctors continuing to be the gatekeepers for most FP services: “There are a lot of Doctors in Azerbaijan and women have a lot of endocrine diseases and infections and therefore need trained medical attention.” The National RHC as a specialist centre does not require MOH orders to implement policy. For example it does not follow the prior smear test pr otocol for IUD insertion. It can rather develop FP policy and then have the MOH endorse it. There are currently no standard treatment guidelines for FP services or for that matter other clinical services. A separate review of State regulations indicates that while sterilizations are permitted, they “Can only be conducted in accordance with approved procedures. Failure to follow these approved procedures can result in the medical staff facing criminal prosecution.” The State regulations do not describe what these approved procedures are. Discussions with the National RHC confirmed that female sterilization may only be provided if a woman is undergoing another operation. It seemed that most of the attention of the clinic’s staff was to providing services to clients in Baku rather than supporting districts or setting national policy. This reflects the lack of funding for the latter with attention given to areas generating revenues. For example, the attention given to the IVF partnership seems to be given priority over FP services. One adjacent pharmacy visited revealed that they sell 10 to 15 cycles of Marvelon a month for 2 Manat a cycle. Imishili The Imishili RHC is attached to the CRH and was established with UNFPA support. The only commodities available on the day of the visit at the RHC were 450 IUDs, all due to expire in August 2006. There were no stock cards suggesting weak product management. All other methods were stocked out. They confirmed that they can only provide female sterilization when undertaken with another operation. Clients prefer combined oral contraceptives and condoms and they had many more clients when they had supplies to dispense free of charge. The service provider interviewed stated that she doesn’t like to use Depo Provera because clients are afraid of amenorrhea. The district has a large internally displaced population (IDP) and the RHC staff used to do daily outreach when they had supplies to dispense and this had been an effective means of increasing access as it took product to the client. Now they are limited to once a month visits as part of a mobile team but they can only refer women to pharmacies for FP supplies and the CRH for abortion. According to their monthly coordinators meeting, the most common problem facing their clients is the affordability of modern contraceptive methods. A visit to a FAP in the district confirmed a total absence of any supplies. The closest pharmacy for women in this rural community was a two to three kilometer bus ride away where condoms and pills are sold. A visit to a pharmacy in the town centre indicated that they sold Rigivedon for 1.4 Manat a cycle and Triregol for 3.8 Manat a cycle. Masalli Masalli district is very densely populated and has a major problem with unwanted children and abortion complications according to the head nurse at the UNFPA funded RHC. Almost half of the clients visit the FP centre for FP services. They used to have more clients when they had products to dispense. They have been stocked out of combined oral contraceptives for nearly two years. The only stock available at the RHC on the day of the visit was 144 condoms that had expired in March 2006. The biggest challenge that they are facing is the supply of commodities and the falling demand. When they had stocks of Depo staff thought it was an effective method but women did not like it because it made them put on weight. The most popular method was IUDs but they had no supplies left to insert. The cost of an abortion is estimated at around 13 Manat. Two pharmacies were visited close to the CRH. One sold Rigivedon for 1.4 Manat a cycle and a triphasic oral for 3.6 a cycle. Condoms were sold at 0.1 Manat each. In a the second pharmacy, Rigivedon was also sold for 1.4 Manat and Postinor for 3.8 Manat. Condoms were sold at three for 0.2 Manat and they sold 20 a day. Oxcitocin was also sold for 0.6 Manat. Jalilabad Jalilabad is a very large rayon and given the great distances the staff at the CRH do mostly outreach. The CRH does not have a UNFPA supported RHC but they did used to get supplies from humanitarian aid from the National RH office. They are currently stocked out of all methods. When they had supplies, IUDs used to be the preferred method but now staff think that combined oral pills are more popular. The believe clients would like Depo Provera but it is very expensive at 7 Manat and in any case it is not available in the country. The CRH had far more FP clients when they had supplies. Now women have to rely on natural methods and abortion, the latter costing 5 Manat. The staff thinks referrals translate to actual use and that cost isn't an issue. A pharmacy next to the clinic sold Rigivedon for 1.8 Manat and Marvelon for 5.2 Manat. Spermicides were stocked out but sold for 3.6 Manat for 12 tablets. Condoms were rarely sold and cost 0.4 for three while they were also stocked out of IUDs. Postinor is expensive and so the pharmacist doesn’t buy as this is not recommended by Doctors. Shamaxi Shamaxi CRH has a UNFPA funded RHC. Services at the RHC include post abortion and post partum FP counseling, distribution of information on FP and distribution of FP supplies. IUDs are the most popular method but they only inserted 6 last month. While the centre has had 500 clients this year, they have only served 30 to 40 clients for FP services. Clients know there are no commodities and so don’t come for FP advice. They have performed 107 abortions. Women typically are in denial about FP but once they have an abortion and get post abortion counseling they change their minds. The RHC centre has 1000 IUDs in stock but no other commodities. ACQUIRE conducted a stock assessment and identified the excess in supply and is organizing to identify women in different communities who are interested in having IUDs inserted. They have obtained an order from the NRHO to allow products to be redistributed between districts and are now trying to confirm the arrangement with the NRHO for doctors to be identified to perform the insertions. The NRHO has asked that the doctors be reimbursed. The RHC have been working with ACQUIRE to train community teams. Pills are too expensive for many clients. Staff estimate that 50-60% of the population can pay something but the balance can not. Counseling is given for natural methods like LAM Three rural facilities were also visited in Shamaxi Rayon. Sabir is a community of 3,700 several miles outside of the town and has a 35 bed hospital including 5 maternity beds. Staff has received FP training and will get counseling training so that they can provide community based services to their population. Client preferences are for IUDs pills and condoms but they have no commodities. Women are referred to the CRH for IUD insertion but with the cost of a return trip equivalent to around $2 they are not sure if women have had the IUDs inserted. They do not have good information on what commodities or services are available at the RHC. They used to get commodities a few years ago from the RHC based on some population based distribution – these were pushed down to them rather than reflecting their needs. Not all of their community are able to buy and they would like to have commodities to distribute. They estimate perhaps 30% of their community could afford to buy from the pharmacy in Shamaxi. The adjacent smaller rural community of Merzendiyye has a population of 1000 and a FAP staffed by a nurse. Women want contraception but they do not have access. It costs $2.75 to get to the closest pharmacy and they can not afford to buy pills or condoms. They rely on natural methods and abortion. The small community of Melem has a population of 1383. They provide counseling services with community out reach volunteers. There are 300 women of reproductive health age and at least 70 persons with three or four children who need FP support but at least 25 can not afford the cost. They sent 6 women recently for IUD insertions and know that at least four received them. Most though can not afford the costs of the bus ride plus the cost of the insertion. They know charges are made at the CRH but don’t know what they are. They had once received condoms but no more. With no commodities they are recommending natural methods and their clients are frustrated. A pharmacy in Shamaxi was visited. It is part of the ACQUIRE network, has received training and provides more counseling to clients who are referred from ACQUIRE supported SDPs. They were stocked out of methods as they were expecting a resupply. Diane sells for 6.7 Manat a cycle while condoms sell for 0.3 Manat for three. Rigivedon sells for 1.2 Manat and they sell 3 cycles a week. They sell 1 cycle of Diane and 20 to 30 condoms weekly. Their retail margins are 20%. Goychay Goychay CRH does not have a UNFPA RHC but is building one with support from ACQUIRE’s small projects program. The population is 110,000 and the level of awareness about contraceptives is very low. They have started to provide support to target locations with support from ACQUIRE to establish more interest in the local communities with local officials and staff. They have participated in training local midwives and community workers in an effort to get the population to change their mentality. But all the work with providers and communities will be to no avail unless commodities are made available. They are sending out their staff to work ikn the communities to help them change the thinking of providers. Each year they perform 120 mini abortions but the real figure is higher as doctors are doing more. They insert 320 IUD and won’t to do more. Sheki sent them supplies in the past but currently have no supplies. The NRHO has given ACQUIRE permission to bring IUDS from Shamaxi to perform procedures in Goychay. Charaka is a rural community with a population of 4,560 with no pharmacy. An Ob/Gyn comes from the CRH every day for three hours. For those that can afford they recommend contraceptives but at most 10 to 15% can afford to pay, 60% can pay something and 30% have no ability to pay. They have never received donated products. IUDs are the preferred method followed by pills. Poor women use natural methods and abortions including self induced, sometimes with tragic consequences. While clients are responding to their counseling services they fear that without commodities their efforts will be undermined. Another rural community Shahadat has a population of 1815 with 430 women of reproductive age. There is no pharmacy and the return bus fare is around $2. Weekly they see 20 women who come for consultations and all would use contraceptives if they could afford them but only 10% can afford them. Most can pay something but 15% can not pay anything. Women can’t even afford the $10 for an abortion so they try to self abort with some tragic results. The final rural location was the village of Garrabage and has a DAC to serve a population of 2,700 and 2,300 in an adjacent village. Pills and withdrawal are the most popular methods but women revert to abortion when they can’t pay. The building is in a very bad condition and they have not received any support. Neither the resident doctor nor the nurses seemed aware of modern FP methods. Garameryen has a population of 1,872 but the health facility also serves four agency villages so it has a total population of 5,280. There are two pharmacies in the village but as many as 75% of the population can not pay for services. The pharmacies did not sell contraceptives until the community asked them to stock. The health facility gives advice and counseling to their clients and have recommended modern methods but products are not available. One woman died when she tried to self abort because of a lack of commodities. They have identified 15 women interested in having an IUD inserted. The problem is that this is expensive. A return taxi costs $8 to the CRH and the procedure can cost $20 or more. The city pharmacy visited had no IUDs and sold Rigivedon for 1.4 Manat a cycle, Marvelon for 5 Manat a cycle, Diane for 6 Manat, postinor for 3.8 Manat and condoms for 0.2 to 0.4 for three. Since joining the ACQUIRE accreditation scheme they have noticed that the number of their clients has increased. Sheki Sheki Rayon has a population of 170,000, of which 65,000 live in the city itself. A high proportion of males are migrant workers in Russia and are absent from the Rayon for part of the year. This affects the family planning choices of woman who may only chose to use a method for part of the year, and seem less likely to use long term methods. There is also a high incidence of STI including HIV/AIDS and this also affects FP use, with increased use of condoms. The CRH in Sheki has been selected as a pilot site for the World Bank health reform loan and will receive $15 million to rebuild the hospital and implement the proposed basic service package. Both ACQUIRE and the IMC (?) will be providing local support in the future to implementation of the primary care based basic package. The RHC was established with UNFPA funding and is well maintained with active and enthusiastic staff. During our visit, several clients were getting family planning services. There are actually three centers providing FP/RH services on the same site as the CRH. One of these is the Gynecological department at the CRH. FP services provided include IUD insertions and counseling about other methods. The RHC get their supplies from the CRH FP store in the adjacent building. The RCH are stocked out of only have remaining stock of 73 IUDs with 43 due to expire in August 2006 and 30 expiring in 2008. The other centers also have stocks of IUDs but not other FP methods. The three centers performed 213 IUD insertions in 2002, 139 in 2003, 146 in 2004 and 148 in 2005. These figures taken from service statistics do not however tally with commodity statistics being kept. The CRH has conducted 16 IUD insertions in the last month. There also appear to be 700 IUDs in the Sheki store room While they counsel on FP methods they have no other methods to give to their clients. Women prefer to use pills and condoms but most women can not afford modern methods from pharmacies and so rely on traditional methods. They estimate that 10% of their clients can pay pharmacy prices, 40% can pay some contribution while 60% are unable to pay. A visit to a pharmacy next to the CRH identified Rigevdeon being sold for 1.6 Manat a cycle with six sold weekly. Izaprost 4 Manat an ampule with one usually sold each week. Condoms were being sold for 0.2 for a single condom or 0.4 Manat for three. The pharmacy had a single Russian made IUD for one Manat but they never sell any. The also had Diane oral pill but hardly sell any. The pharmacist also should us a menopausal supplement, assuming that we would be interested in that as a FP method. Annex D: Bibliography The Alan Guttmacher Institutue (AGI) United Nations Population Fund (UNFPA). Adding It Up: The Benefits of Investing in Sexual and Reproductive Health Care. New York: AGU UNFPA ; 2004. http://www.guttmacher.org/pubs/covers/addingitup.html Beitz, J, H Srimuangboon, A Lion-Coleman, R Transgrud, J Hutchings, M Weldin. 2003. Youth-Friendly Pharmacy Program Implementation Kit: Guidelines and Tools for Implementing a Youth-Friendly Reproductive Health Pharmacy Program. Seattle, WA: PATH. Holley J, Akhundov O, Nolte E. Health care systems in transition: Azerbaijan. Copenhagen, WHO Regional Office for Europe on behalf of the European Oservatory on Health Systems and Policies, 2004. The AQUIRE Azerbaijan Reproductive Health and Family Planning Project. Baseline Study Report. December 2004. Westoff, Charles F. 2005. Recent Trends in Abortion and Contraception in 12 Countries. DHS Analytical Studies No. 8. Calverton, Maryland: ORC Macro. Beer, Kim O./UNFPA. Reproductive Health Commodity Security (RHCS) Contraceptive Availability Assessment. April 2005. Rogosch, John, Fielding F, Pavin M, Shamilova N. USAID/Caucasus/Azerbaijan Primary Health Care Assessment. January 2005. Azerbaijan Ministry of Health, State Committee of Statistics, Mercy Corps, Adventist Development and Relief Agency, Centers for Disease Control and Prevention. Reproductive Health Survey, Azerbaijan 2001. Final Report. March 2003. http://www.imf.org/external/pubs/ft/scr/2004/cr04322.pdf is an IMF document about poverty. Health Financing Study, World Bank. Serbanescu, F; et al; Reproductive Health Survey, Azerbaijan, 2001; ADRA, Azerbaijan Ministry of Health, State Committee of Statistics, Mercy Corps, (Baku) Centers for Disease Control and Prevention (Atlanta), USAID, UNFPA, UNHCR; March, 2003 UNFPA. Reproductive Health Commodities Price List 2006. UNFPA, New York. USAID. Contraceptive Procurement Guide and Product Catalog 2006. USAID, Washington, D.C. Westoff, Charles F. 2003. Recent Trends in Abortion and Contraception in 12 Countries. DHS Analytical Studies No. 8. Calverton, Maryland: ORC Macro. � � Contraceptive security assessment Azerbaijan John Snow, Inc. 44 Farnsworth Street Boston, MA 02210-1211 Phone: 1.617.482.9485 Fax: 1.617.482.0617 Internet: � HYPERLINK "www.jsi.com" ��www.jsi.com� � EMBED Photohse.Document ��� contraceptive security assessment azerbaijan Wild Reproductive Health In the absence of free public contraceptives and with many modern methods financially out of their reach, rural women are reverting to “Wild” traditional methods for averting pregnancy and self aborting. The following Wild methods were shared with ACQUIRE field staff by community participants in FP training. Applying raw egg whites in the cervix. Drinking tea made from bay leaves. Putting lemon in the cervix. Drinking tea made from saffron. Picking up 100 match sticks from the ground. Jump from a high place down to the ground. Take a hot bath and drink wine. Drink a tea of boiled onion skin. Take a synestrol injection. Put tampons with iodine in the cervix. Drink tea made from poppy seeds. Sit on a hot brick. Drink herbal tea made with “gatir dirnagi” Wash genitalia with urine. Insert cloth soap into the cervix. Lift a heavy object. Insert the branch of alcha (sort of plum) into the cervix. Insert chicken feathers into the cervix. Drink coffee or cocoa. In addition the assessment team heard anecdotal evidence of women drinking poisonous substances like iodine, leading in several instances to their deaths. Source: ACQUIRE Project, Assessment team interviews � Shahadat’s story is true but her name has been changed. It is based on anecdotal evidence given by rural community health staff and reflects several stories told to the assessment team during field visits. � Serbanescu, F; et al; Reproductive Health Survey, Azerbaijan, 2001; ADRA, Azerbaijan Ministry of Health, State Committee of Statistics, Mercy Corps, (Baku) Centers for Disease Control and Prevention (Atlanta), USAID, UNFPA, UNHCR; March, 2003 � TFR is defined as the average number of live births a woman would have during her reproductive lifetime (15-44) if she experienced the currently observed age-specific fertility rates. � Westoff, p. 27 � RHS, p. 65 � Romania’s 2004 survey did not categorize unmet need a/c to spacing and limiting. The overall unmet need is almost exactly the same in 2004 as it was in 1999. Therefore, we have used the 1999 data which includes the subanalysis by spacing and limiting. � Data are in current U.S. dollars. GNI, calculated in national currency, is usually converted to U.S. dollars at official exchange rates for comparisons across economies, although an alternative rate is used when the official exchange rate is judged to diverge by an exceptionally large margin from the rate actually applied in international transactions. To smooth fluctuations in prices and exchange rates, a special Atlas method of conversion is used by the World Bank. This applies a conversion factor that averages the exchange rate for a given year and the two preceding years, adjusted for differences in rates of inflation between the country, and through 2000 � CCM Contraceptive Commodity Manager is UNFPA’s central commodity management tool. � PipeLine is a computerised tool for forecasting contraceptive needs available as a free download from � HYPERLINK "http://www.deliver.jsi.com" ��www.deliver.jsi.com� � UNFPA report, p. ???? � UNFPA CS assessment, p. 14 � UNFPA CS assessment, p. 21 � UNFPA CS assessment, p. 15 � Source: MOH Center for Innovation and Supply � Source: International Planned Parenthood Federation 2002. International Medical Advisory Panel (IMAP) Statement on Hormonal Methods of Contraception. http://www.ippf.com/ContentController.aspx?ID=6525 � The Alan Guttmacher Institutue (AGI) United Nations Population Fund (UNFPA). Adding It Up: The Benefits of Investing in Sexual and Reproductive Health Care. New York: AGU UNFPA ; 2004. � HYPERLINK "http://www.guttmacher.org/pubs/covers/addingitup.html" ��http://www.guttmacher.org/pubs/covers/addingitup.html� � Post-abortion care encompasses emergency care, counseling and referral components. In public sector health service delivery settings where abortion is legal the provisions of the Helms Amendment create special challenges for supporting emergency care services. However, experience in similar settings, notably Russia (see Savelieva, Pile, Sacci and Loganathan, 2003; http://www.popcouncil.org/pdfs/frontiers/FR_FinalReports/Russia_PAC.pdf) indicate that post-abortion counseling for family planning with or without dispensing of family planning methods at the time of counseling can be an effective strategy for reducing repeat abortions. Nothing within the Helms Amendment prohibits the provision of family planning services to women who have received abortion care provided no other terms of the amendment are violated. The Helms Amendment provides � Contact the Futures Group International in Washington, DC, to request a copy of Spectrum. The software can also be downloaded from their website: � HYPERLINK "http://www.tfgi.com" ��www.tfgi.com� �Quite a few more in the paper- I added a few but it would be good to go back and check that they all get captured at the end �Add date…when? �Spell out if first use of acronym �Had two uses of commitment in the same sentence �Going to use Gyn or Gyns- need to standardize throughout �Would be good to have a bit of a short phrase/sentence on who ACQUIRE is, what they do etc. �Do you want to mention the lack of IUDs here or somewhere else? �Would it be good to also note this directly below each table in case some people are skimming and don’t catch this here. �Should we include a short sentence before this to preface the table- highlight the differences? �What does “Supporting” mean in this section? I think this whole section needs to be a bit meatier- here and in the main text. We need some more concrete r

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