Côte d’Ivoire Family Planning Private Health Sector Assessment

Publication date: 2018

Côte d’Ivoire Family Planning Private Health Sector Assessment Keywords: assessments, condoms, Côte d’Ivoire, emergency contraception, family planning, health insurance, health financing, implants, IUDs, oral contraception, injectables, midwives, pharmacies, provider associations, social marketing Photo: Elizabeth Corley Recommended Citation: SHOPS Plus. 2018. Côte d’Ivoire Family Planning Private Health Sector Assessment. Brief. Rockville, MD: Sustaining Health Outcomes through the Private Sector Plus Project, Abt Associates. December 2018 Summary Despite economic and political progress in Côte d’Ivoire, a number of health challenges persist and high quality family planning products and services remain inaccessible for many. Expanding the role of the private health sector can help address these issues, but data and information about this sector are limited. The SHOPS Plus project, in collaboration with USAID/Côte d’Ivoire, conducted an assessment of the family planning market and provided targeted recommendations to empower stakeholders to sustainably engage the private sector and help Côte d’Ivoire achieve its Family Planning 2020 targets. This brief highlights key findings and recommendations from the full assessment report. SHOPS Plus • 1 Côte d’Ivoire Family Planning Private Health Sector Assessment Located in West Africa, Côte d’Ivoire is home to approximately 23 million people. Following a period of civil war in the early 2000s, political and security conditions have stabilized and the country has experienced an impressive period of economic growth of more than 8 percent per year in both 2015 and 2016 (World Bank 2017). As a result, Côte d’Ivoire has achieved lower middle-income status. Despite these political and economic improvements, a significant number of health challenges persist in Côte d’Ivoire. Fertility rates (5 children per women), neonatal mortality rates (38 deaths per 1,000 live births), and maternal mortality rates (645 deaths per 100,000 live births) remain high (WHO 2016). Only 977,000 women—or 17 percent all women and 15 percent of married women—used a modern contraceptive method as of 2016 (Track20 Project 2017). Only an estimated 34 percent of demand for modern methods is successfully satisfied (Track20 Project 2017). As a result of these gaps in family planning use, nearly one-third of all adolescent girls have given birth or are currently pregnant (Direction Générale de l´Office National de la Population 2016). Scope of the assessment The government, in partnership with international donors, seeks to improve the country’s ability to meet the demand for family planning information, products, and services. Achieving this goal requires the participation of both the public and private sectors, yet there is limited information on the private market for family planning products and services in Côte d’Ivoire. In Côte d’Ivoire, only one-third of the demand for modern family planning methods is met. Photo: ©EC/ECHO/Anouk Delafortrie 2 • Côte d’Ivoire Family Planning Private Health Sector Assessment To inform future family planning programming and better understand the dynamics of the family planning market in Côte d’Ivoire, USAID/Côte d’Ivoire requested that the Sustaining Health Outcomes through the Private Sector (SHOPS) Plus project conduct a family planning-focused private sector assessment.* The purpose of the assessment was to identify opportunities and provide recommendations for USAID/Côte d’Ivoire to support increased access to and use of modern family planning methods through the private sector. To this end, SHOPS Plus focused the assessment on the following areas and objectives: • Policy and health sector overview – Provided an overview of the private health care sector, including relevant stakeholders, focusing on their size, scope, and role in the provision of family planning. Reviewed existing and draft legislation, policies, financing, and human resources capacity to identify opportunities and potential barriers to greater public-private engagement in health. • Demand for family planning in the private sector – Assessed current and potential future demand for family planning products and services in the private health sector, including identifying user demographic characteristics, motivations, and any barriers in accessing private sector products and services. • Supply of family planning products and services in the private sector – Identified opportunities and barriers that affect the delivery of family planning methods by the private sector, such as government policies, regulations, health financing, access to finance, human resources, training, and access to products. For this assessment, the “private sector” encompasses both for-profit and nonprofit providers and organizations. * Armand, Françoise, Emily Mangone, Sean Callahan, and Virginie Combet. 2017. Côte d’Ivoire Private Health Sector Assessment: Family Planning. Rockville, MD: Sustaining Health Outcomes through the Private Sector Plus Project, Abt Associates Inc. SHOPS Plus • 3 SHOPS Plus and its predecessor project, Strengthening Health Outcomes through the Private Sector (SHOPS), have conducted more than 30 private sector assessments, including many in sub-Saharan Africa. This assessment followed the SHOPS Plus methodology and consisted of five phases: plan, learn, analyze, share, and act (Figure 1). Methods Figure 1. Private sector assessment process PLAN ACTANALYZELEARN SHARE 1. Plan: The process began with a comprehensive review of the peer-reviewed and gray literature to obtain a rich overview of the landscape and context, as well as key challenges and gaps in information. The results of this review informed the planning for key stakeholder interviews during the in-country assessment in the second phase. 2. Learn: SHOPS Plus engaged a multidisciplinary team to conduct interviews with more than 30 key stakeholders in the public and private health sectors in Abidjan and Yamoussoukro in May and June 2017. 3. Analyze: The analysis began in country, where the assessment team shared findings with government and private sector stakeholders, determined whether additional key informants should be added, and began to form practicable recommendations. This process continued past the field work, as the team integrated findings and developed recommendations. 4. Share: The team debriefed USAID/Côte d’Ivoire during the trip to Abidjan and disseminated the final report both locally and globally. 5. Act: The final step of a private sector assessment is to support action and programming based on findings and recommendations. 4 • Côte d’Ivoire Family Planning Private Health Sector Assessment The private health sector in Côte d’Ivoire In Côte d’Ivoire, health care is dominated by the public sector, but the private sector, which was formally recognized in the late 1990s, is an important source of care and a growing contributor to public health initiatives. This sector includes a well-developed pharmaceutical distribution network, for-profit facilities, and nonprofit health organizations. Though the private sector plays an important role in service delivery, data on this sector are outdated (the most recent publicly available data on the size and distribution of medical facilities across sectors and across the country date back to 2011). The majority of health facilities in the private sector were categorized as Level 1 (Table 1), followed by Levels 2 and 3 based on a 2010 survey by the Ministère de la Santé et de l’Hygiène Publique or MSHP (Ministry of Health and Public Hygiene). The private sector accounted for 80 to 90 percent of the supply of pharmaceutical products in 2014 (MSHP 2014). Findings Table 1. Types and numbers of private health facilities in Côte d’Ivoire Type of private health facility Level 1 Source: Direction de l’information, de la planification et de l’évaluation or Directorate of Information, Planning and Evaluation (2011) Number Nursing centers 964 General medicine and ob/gyn offices 114 Dental offices 101 Laboratories 20 Radiology centers 4 Chinese clinics 67 Ambulatory care centers 4 Hemodialysis centers 1 Osteopathy centers 2 Miscellaneous care units (counseling centers, homeopathic offices, etc.) 147 Workplace health centers 463 Clinics 136 Polyclinics 13 2,036Total Level 3 Level 2 SHOPS Plus • 5 Private facilities tend to be concentrated in urban areas, especially in and around Abidjan, although both for-profit and nonprofit facilities are found throughout the country. Many of these facilities operate outside of the formal health system. As of 2015, nearly three-quarters of private facilities did not have formal authorization from the MSHP, according to a 2015 analysis in West Africa by the SHOPS project. There are multiple organizations in Côte d’Ivoire that represent and advocate for private providers, including professional councils (ordres), professional associations (e.g., Association des Infirmiers de Côte d’Ivoire or the Nurses Association of Côte d’Ivoire), and industry/business associations (e.g., Association des Cliniques Privées de Côte d’Ivoire or the Association of Private Clinics of Côte d’Ivoire). Private facilities face difficulties attracting highly skilled providers and must hire public sector specialists under the widespread convention of “dual practice.” Up to 70 percent of physicians and 50 percent of other health workers engage in dual practice, according to estimates from a previous assessment (Barnes et al. 2013). Private providers in Côte d’Ivoire tend to struggle with limited opportunities for training, low access to financing for equipment and infrastructure, and a lack of representation in discussions about health policy and law. In addition, they experience difficulties dealing with insurance providers and protecting their ability to charge prices that enable them to make a profit. A 2014 assessment of the legal and regulatory framework for the private health sector in Côte d’Ivoire (Sanogo and Kouakou 2014) determined that regulatory texts would need to be adapted to enable the private sector to contribute more actively to health outcomes. It also found that regulatory bodies lack the resources required to fulfill their roles and enforce regulations. The MSHP is keenly aware of the need to better understand and engage the private sector, especially private providers and clinic owners. The Direction des Etablissements et des Professions Sanitaires (Directorate of Establishments and Health Professions) is responsible for the governance of the private sector and recently completed a census of private providers in the southern and western regions of the country (MSHP 2017). More research is needed to understand this sector and develop effective public-private collaboration. Up to 70 percent of physicians and 50 percent of other health workers engage in dual practice. Support for family planning At the International Conference on Population and Development (2011) and the London Summit on Family Planning (2012), the government of Côte d’Ivoire committed to increasing the availability of family planning products and services in health facilities from 60 percent in 2010 to 100 percent in 2015. To support these ambitious goals, the MSHP developed the 2013–16 Family Planning Strategic Plan and key policy documents to operationalize it. Among the most successful initiatives of the MSHP has been the reintroduction of contraceptive distribution through community health agents, which is credited with a general increase in the demand for and use of family planning services. Côte d’Ivoire receives family planning assistance from a number of donors and multilateral agencies (Figure 2). Historically, government funding for family planning has focused on staff salaries, program management, and supervision, while 6 • Côte d’Ivoire Family Planning Private Health Sector Assessment development partners contributed to the purchase of contraceptive products and to specific family planning programs. Donor financing and donations of specific methods can vary significantly from year to year. There is a heavy reliance on UNFPA commodity donations for family planning programs in both the public and private sectors. Most of the donated products are channeled through the public sector, but some are also distributed through NGOs such as Association Ivoirienne pour le Bien- Etre Familial or AIBEF (Ivoiran Association for the Well-Being of Families), an International Planned Parenthood Federation affiliate. Figure 2. Donor financing of contraceptive products Despite the country’s and its partners’ efforts, Côte d’Ivoire did not reach the 25 percent target for modern contraceptive prevalence rate (mCPR) in 2016 and may have difficulties achieving the 2020 target of 36 percent included in the national action plan for family planning (Figure 3). Figure 3. Côte d’Ivoire’s modern contraceptive prevalence rate targets and actual performance Côte d’Ivoire also received disappointing scores in the 2014 Track20 Survey (Avenir Health 2015). All four components of the family planning effort score (policy, services, monitoring and evaluation, and accessibility) registered lower scores in 2014 than in 2009, and the overall country score was 45 percent compared with 54 percent in 2009. Demand for family planning methods In the period between the most recent Demographic and Health Surveys (DHS) of 1998–99 and 2011–12, the overall contraceptive prevalence rate remained relatively steady at 19 to 20 percent of women of reproductive age. Although the overall rate has remained the same, the use of modern methods increased from 10 to 14 percent (Figure 4). UNFPA 61% KfW 22% USAID 13% 4% Other Targeted mCPR (%) Actual mCPR (%) 2013 2016 2020 0 5 10 15 20 25 30 35 40 36 25 15 17 17 SHOPS Plus • 7 Nongovernmental or faith-based organization Clinic Shop or market Pharmacy or drug shop Non-private 0% 10% 20% 30% 40% 50% 60% Unknown/Missing Other* Public Private 4% 14% 26% 56% Figure 4. Contraceptive use has changed little Figure 5. Sources of family planning methods The majority of modern users obtain their methods from private sources, mainly through pharmacies or shops (Figure 5). Users of methods involving a service provider are more likely to obtain them from the public sector. A significant number of women still have unmet need for modern contraception, which private providers could potentially address. Approximately 940,000 women have a need for birth spacing and 266,000 for limiting births. In addition, many of the women who do not currently have an unmet need intend to use contraception in the future. Many of these women could be potentially served through the private sector. Source: Côte d’Ivoire DHS 2011–12 *Other sources include friends and relatives. 1998–99 2011–12 None Short-acting Traditional Method 79% 10% 11% 80% 14% 6% Source: Côte d’Ivoire DHS 1998–99 and 2011–12 Note: The use of long-acting reversible and permanent methods was 0.2% in 1998–99 and 0.3% in 2011–12. 8 • Côte d’Ivoire Family Planning Private Health Sector Assessment Family planning product supply in the private sector The private sector plays a large role in providing contraceptive products through pharmacies, drug depots, private clinics, and social marketing distribution channels. The supply chain infrastructure for these products is fairly robust, with four major wholesalers, more than 800 private pharmacies, two active social marketing organizations—L’Agence Ivoirienne pour le Marketing Social or AIMAS (the Ivorian Agency for Social Marketing) and DKT—and commercial manufacturers of hormonal contraceptives. As with most other pharmaceutical products, contraceptives are imported and subject to a fairly strict pricing and marketing environment. With the exception of condoms, inexpensive socially marketed products dominate the contraceptive market, with shares as high as 90 to 100 percent. Table 2. Overview of the contraceptive market in Côte d’Ivoire Product type Commercially marketed/ socially marketed Units sold (May 2016– April 2017) No. of brands Price range in pharmacy (USD)3 Oral contraceptive pills Emergency contraception Injectables Commercial $1.08–$12.2419+ 94,3201 Social $0.82–$0.871 851,5471 Commercial $3.67–$9.179+ 169,7081 Social $1.841 139,1651 Commercial $6.771 2,3971 Social $1.75–$1.981 97,2802 Commercial $0.72–$2.6217+ UnavailableCondoms (pack of 3) Sources: 1 IMS Health data 2 Estimates from data shared by wholesalers (IMS Health data unavailable) 3 Observations from six pharmacies in Abidjan and Yamoussoukro Social $0.51–$0.903 Unavailable SHOPS Plus • 9 Figure 6. Distribution of oral contraceptive pill market share This near-monopoly stems from the extremely low cost and a high availability of the product. Adding to its appeal, Confiance also comes in packs of three cycles, whereas many other oral contraceptive pill brands come in packs of one cycle. Although it is difficult for commercial products to compete with the highly subsidized Confiance, both Pfizer and Bayer have been able to capture 7 percent and 1 percent of the oral contraceptive pill market, respectively. While most commercial oral contraceptive pills are two to five times as expensive, the prices for Bayer’s commercial Microgynon brand (approximately $1.03) are fairly competitive with Confiance (approximately $0.86) thanks to a public-private partnership between USAID and Bayer Healthcare. Despite a relative price-point similarity, Microgynon has not seen the same kind of uptake as Confiance or other commercial brands, and this discrepancy warrants further exploration. A few brands of emergency contraception available in Côte d’Ivoire—Levo-BD, Nornet, Norvel-72, and Secufem. Data show there may be ability and willingness to pay for emergency contraception products, particularly for recognized brands. Photo: Emily Mangone Clients have many emergency contraception brands from which to choose, at a wide variety of prices. While sales of commercial emergency contraception brands increased by an average of 62 percent between 2016 and 2017, sales of the socially marketed product, Pregnon (AIMAS), decreased by 78 percent. Pregnon still has 45 percent of the market, followed by Norlevo (HRA Pharma). Twenty-two percent of the market pays for one of the most expensive brands, which indicates there may be ability and willingness to pay for emergency contraception products, particularly for recognized brands. The data on emergency contraception has limitations. IMS Health only captures data on products sold through wholesalers. Moreover, the DHS does not collect data the use of emergency contraception, making it difficult to assess the Emergency contraception AIMAS (Confiance) Pfizer (multiple brands) Bayer (multiple brands including Microgynon) Other 90% 7% 1% 2% Oral contraceptive pills Oral contraceptive pills are the most popular birth control method and dominate the market, particularly among methods available through pharmacies. The oral contraceptive pill market offers fairly robust choice for users with a wide range of brands and pricing across four formulations (monophasic, triphasic, multiphasic, and progestin- only). Confiance, a brand that is socially marketed (donor-subsidized) through AIMAS, dominates the market (Figure 6). 10 • Côte d’Ivoire Family Planning Private Health Sector Assessment population segment of consumers. Because of the high levels of emergency contraception use, it is important to better understand the demographics and reproductive intentions of populations who use this method. A woman in West Africa holds Sayana Press, which is a lower-dose, all-in-one injectable contraceptive that is administered every three months under the skin into the fat rather than into the muscle. Photo: © 2016 PATH/Gabe Bienczycki, Courtesy of Photoshare Injectable contraceptives Two potential barriers to injectable use are logistical inconvenience and cost. Injectables are much less expensive per couple years of protection compared with Pregnon (emergency contraception), but are still more than twice the cost of a three-cycle pack of Confiance oral contraceptive pills. Getting the injections often requires multiple trips, since the method may not be on hand at a clinic; women must get their prescription at a clinic, pick up their injectable at a pharmacy, then return to the clinic to get it injected. As with the oral contraceptive pill and emergency contraception markets, the socially marketed injectable Harmonia (AIMAS) is heavily preferred over Pfizer’s commercially available Depo-Provera, likely because of the wide price differential. While still slower to sell in pharmacies than other short- acting methods, injectables are reportedly becoming more popular in clinics. Their growing popularity could in turn raise their profile in pharmacies. Pfizer’s Sayana Press is available in some private clinics, such as AIBEF clinics. A key advantage is its ability to be self-administered. There is currently a pilot exploring the feasibility and acceptability of self-injection in three districts in Côte d’Ivoire, though AIBEF reportedly offers this method of administration already. Sayana Press was registered in Côte d’Ivoire for use in 2013, but is not yet permitted to be sold commercially. In May 2017, Pfizer agreed to reduce the price of Sayana Press from $1 per dose to $0.85 for qualified purchasers (Assonken 2017). While this reduced price was not immediately accessible to private sector entities, the reduction could lead to increased supply. The increased supply will likely increase availability among nonprofit providers, and perhaps for-profit providers. Condoms The condom market is filled with a variety of colors, flavors, brands, and competitors. Condoms are mostly sold through pharmacies and drug depots in Côte d’Ivoire. There are three socially marketed brands of condoms and a large number of commercial brands. Despite the higher cost, commercial brands are preferred to less-expensive social brands, a fact confirmed by wholesalers and pharmacists whose popular Manix products were outselling the social brands by a factor of seven. This is a change from 2011, when 86 percent of women who used condoms opted for a social marketing brand (Côte d’Ivoire DHS 2011–12). Prices for a package of one to three condoms are comparable to those of oral contraceptive pills. This indicates that there is some capacity and willingness to pay among purchasers of short-acting contraceptive products—an important nuance of the contraceptive market worth further exploration. SHOPS Plus • 11 IUDs As in many other settings, IUDs are not typically sold through pharmacies because they are used primarily by health providers who acquire them through other supply sources. However, Bayer’s Mirena IUD is available commercially, though the sales are minimal. The year 2017 saw much momentum around IUDs in the private sector. Four new IUD brands came onto the commercial market in 2017 through DKT, which will increase access to, and affordability of, this product. AIMAS has also reportedly brought an IUD to the commercial market, though it has not yet been reflected in their online communications. Because of its long duration, the IUD is the least expensive product over time. With five new diverse products on the market, the IUD may see an increase in uptake as long as adequate provider training and client communication are offered in tandem. One potential opportunity for increasing use of IUDs is to ensure that they are offered for postpartum insertion, and this could start with the private sector. A postpartum IUD insertion would fit well in basic maternal health and delivery packages already covered by insurance companies. Implants The current offering of contraceptive implants in the private sector is limited. Subdermal contraceptive implants are not sold through wholesalers or pharmacies and there are not currently any socially marketed implants available. Jadelle (Bayer) and Implanon NXT (MSD) are both available through UNFPA donations in donor-associated clinic networks. In the small number of private clinics where implants are available and health workers received the appropriate clinical training (typically at AIBEF or other donor-related networks), implants are reportedly the most popular method. This commodity, however, is usually provided to private clinics at a price of $8.50 below its replacement cost (only $5.00 in one of the Private Health Sector Project network clinics). As a result, the provision of implants through the private sector further increases the level of subsidization of this method. The Blata Medical Center in Abidjan carries two brands of implants: Implanon and Jadelle. Implants are the most popular family planning method in private clinics, although they are not often available in the private sector. Photo: Emily Mangone 12 • Côte d’Ivoire Family Planning Private Health Sector Assessment Key suppliers In Côte d’Ivoire, there are three social marketing organizations: AIMAS, DKT, and PSI, though currently only AIMAS and DKT are actively marketing products. All AIMAS products are funded by KfW except for Pregnon, which is financed exclusively with AIMAS funds. AIMAS is currently advocating with the Direction de la pharmacie du médicament et des laboratoires (Directorate of Pharmacies, Medication and Laboratories) to increase the price so that they can have a more sustainable business model. DKT is a relative newcomer to the market, having opened a social marketing office in Côte d’Ivoire in 2017. DKT recently launched its Kiss brand of condoms and is rolling out four brands of IUDs, while also exploring offering brands of emergency contraception, oral contraceptive pills, and an injectable. Prominent commercial manufacturers that have offices in the country include Bayer and Pfizer. Bayer has a public-private partnership with USAID to market Microgynon FE, which attempts to address the growing gap between the demand for contraceptive products and the ability of donors to pay for these contraceptives. It is an important opportunity for Bayer to increase its visibility and potentially introduce additional brands and products in the future. Pfizer offers five brands of oral contraceptive pills as well as two injectables. Pfizer sells products to wholesalers (commercial) and to UNFPA (public sector). Family planning service delivery in the private sector The main providers of family planning services in the private sector are the AIBEF clinics and facilities affiliated with AIBEF or donor-supported networks. AIBEF has been instrumental in expanding the number of private facilities that offer family planning services by providing training and technical support and helping facilities maintain a stock of contraceptive products on their premises. AIBEF is also piloting a provider franchise project, called Belfam, consistent with the national strategy to increase the number of franchised facilities. The Belfam franchise network of 30 facilities received an initial donation of contraceptive commodities and receives additional supplies when it participates in promotional “fairs” where community members receive free consultations and services. Otherwise, private facilities can purchase commodities from the health district or from AIMAS. The Private Sector Health Project Private Sector Network also offers family planning services. Currently, 33 of the 44 clinics in the network have received family planning assistance in the form of training and technical support, and are able to obtain commodities from the MSHP or AIBEF. SHOPS Plus • 13 The Blata Medical Center A private community clinic affiliated with Belfam, the Blata Medical Center, is the main source of primary, obstetric, pediatric, and family planning services in Gonzagueville, a densely populated suburb of Abidjan. Between 50 and 100 people come to the clinic seeking family planning services every month. The clinic also participates in “free day fairs” that attract large numbers of new and existing clients. Family planning services are provided by one midwife who is trained to administer implants (50 percent of clients choose this method) and IUDs. Because it serves very low-income clientele, the clinic suffers from a lack of resources to purchase equipment and supplies, and struggles to break even while keeping its fees very low. The cost of an IUD insertion at this clinic is 4,000 CFA, or $6.91. The Blata Medical Center, a private community clinic in Abidjan, offers a variety of health care services, including obstetrics and gynecology, pediatrics, vaccinations, and echocardiograms. Unaffiliated facilities also play a role in family planning service delivery. They tend to follow a business model that favors specialists as family planning providers, rather than using task sharing or a solo practitioner model. Clinicians in for-profit clinics often prescribe oral contraceptive pills and are less likely to provide long- acting reversible contraceptive methods because of the additional training required. In general, it is more of a challenge for unaffiliated facilities to offer the full range of family planning services due to the lack of access to training and subsidized products. Midwives and gynecologists do not work as collaboratively in the private sector as they do in the public sector. Some clinics visited for this assessment appeared to have no problem with midwives providing family planning clinical services, while at others, midwives merely provided counseling, referring the client back to the gynecologist for an implant or IUD insertion. 14 • Côte d’Ivoire Family Planning Private Health Sector Assessment Challenges in the private sector The private contraceptive market in Côte d’Ivoire faces several challenges in achieving a sustained supply of affordable products: • High degree of market subsidization: Socially marketed products dominate the oral contraceptive pill, emergency contraception, injectable, and IUD markets, and donated products are the only available options for implants. There is a small commercial market for most products; however, the level of commercial investment may be deterred by the current market balance. As UNFPA looks to transition the sustainable financing of contraceptives to public and private sources, there may be some issues around contraceptive security for the implant. Markets for injectables and IUDs are minimal but growing as additional brands and products are developed and brought to the market. • Regulatory constraints: The strict regulatory environment limits where pharmacies can be established, who can sell products, and how much products can be sold for. Commercial advertising of all pharmaceutical products is restricted, including for contraceptives. Both commercial companies and social marketers must petition the government if they want to change the price of a product. These regulations prevent family planning suppliers from responding quickly to market forces and generating demand for their specific products through commercial marketing. • Lack of market visibility for emergency contraception: There is limited understanding of the demand for emergency contraception and the demographics of users. Understanding who uses emergency contraception may provide an opportunity to move users along a contraceptive continuum to more proactive or longer-acting methods. It would be useful to assess capacity and willingness to pay for long-acting reversible methods among short-term contraceptive users and potential users. The low availability of family planning counseling and methods in the private sector is primarily due to the following factors: • Dependency on donors: The main sources of family planning services in the private sector are AIBEF-affiliated clinics and donor-supported facilities. The supply of these services is very much dependent on donors, which is likely to constrain further expansion of service delivery capacity. AIBEF, a key supplier of commodities and technical assistance to public and private clinics, is actively considering strategies to improve its financial sustainability, such as implementing price increases and launching new products. SHOPS Plus • 15 • Pharmaceutical sales regulations: Private facilities are not legally authorized to dispense pharmaceutical products to patients. Although some clinics are thought to sell medicines illegally, they are unlikely to take this risk for contraceptive products if the method can easily be purchased from a pharmacy. • Inability to provide implants: It is nearly impossible for private facilities unaffiliated with a franchise or network to offer implants because they are not available through commercial pharmaceutical distributors, wholesalers, or pharmacies. When independent providers (most likely gynecologists) are asked about implants, they must refer the client to the public sector or an AIBEF clinic. • Organization of services in the for-profit sector: Private clinics lack access to financing for expansion and equipment, and they are unable to hire many full-time providers, especially for specialty services. The independence of individual contractors makes it difficult to standardize service delivery. When it comes to family planning services, private facilities can earn more money from having highly paid specialists perform certain tasks, such as IUD insertions, that are perceived to have higher value by patients who choose private facilities to see a specialist. • Provider competency: Specialists who are hired by private clinics as contractors are not necessarily well trained in family planning, as training is mainly provided in the context of MSHP employment or through affiliation with a donor-funded project. Moreover, they are more likely to assist with deliveries than provide family planning services while working in private clinics. • Insurance coverage for family planning services: According to the Association of Private Clinics of Côte d’Ivoire (Association des cliniques privées de Côte d’Ivoire), about 90 percent of private clinic patients carry some form of private insurance. Most employer-sponsored insurance programs offer employees plans that include comprehensive maternal and delivery care, yet almost none offer family planning services such as the placement of a postpartum IUD. As a result, insured patients who do not want to pay out of pocket are routinely referred to public or nonprofit facilities, which is an added burden for these facilities. It also is a lost opportunity for for-profit providers to grow their revenue and expand their practices, exacerbating the clinical competency issue in private facilities. 16 • Côte d’Ivoire Family Planning Private Health Sector Assessment SHOPS Plus • 17 Recommendations Based on the findings from the assessment, SHOPS Plus identified several opportunities for supporting access to and use of modern family planning methods through the private sector. Foster improved contraceptive security through a more balanced approach to the contraceptive market. Contraceptive supply in Côte d’Ivoire is currently not threatened, but the dominance of donated and subsidized brands in the private sector is concerning. Should UNFPA donations be considerably reduced in the future, the burden of supporting subsidized programs would likely fall on the government. More flexible product pricing and less-restrictive regulations around direct-to-consumer advertising of contraceptive products can help create a more sustainable and competitive market. SHOPS Plus recommends advocating with the Directorate of Pharmacies, Medication and Laboratories to allow social marketing brands to increase prices or segment their portfolio and to allow commercial manufacturers to advertise their brands to stimulate commercial competition. Private clinics need better access to implants but should purchase them at a price above the replacement cost for this commodity, to avoid further increasing the burden on the public sector. Expand the availability of Sayana Press in the private sector. The introduction of Sayana Press presents a unique opportunity to increase mCPR by engaging the private sector. The practice of providing clients with a supply of Sayana Press for future use at AIBEF helps to increase the acceptability of self-injection. SHOPS Plus recommends expanding the distribution of Sayana Press commercially through private providers in the short term, and through commercial pharmacies with a doctor’s prescription in the long term. Secure and sustain access to implants. Implants are becoming the preferred contraceptive method in private clinics that offer them. Currently, the only way to make this commodity available to private clients is to allow clinics to buy it from public and nonprofit channels. Allowing private providers to obtain implants from a sustainable source in the public or private sector is necessary for this method to be more accessible to clients, but it should be done at or above replacement cost to avoid further increasing the burden on the public sector. Photo: ©EC/ECHO/Anouk Delafortrie 18 • Côte d’Ivoire Family Planning Private Health Sector Assessment Enable more for-profit facilities to provide family planning services. In the long term, it is critical to ensure that unaffiliated, for-profit facilities have an incentive to provide family planning services. Failure to do so implies that people who are privately insured or have the ability to pay out of pocket will continue to use publicly funded services and products. A flexible approach is needed to address the specific needs of providers because the private sector is not homogenous. The “one-stop shop” model used in public and nonprofit facilities is not easily replicable in for-profit facilities, but some clinics simply need a source of implants and better access to training and technical support. Support public-private collaboration. Some private facilities play a critical role in meeting the needs of underserved and low-income populations. Their ability to generate a profit, however, is weak because most of their clients are not insured, and many cannot afford to pay anything. These facilities have a service delivery model based on high volume, low fees, task sharing, and a reduced reliance on specialists that makes them natural partners of the public sector. Creating better linkages and contracting mechanisms between MSHP facilities and providers that serve vulnerable populations should be a key priority. Support insurance coverage for family planning. Because for-profit facilities are more likely to serve insured clients, it makes more sense to advocate for expanded coverage for family planning than to subsidize products and services, or to refer private clients to the public sector. A sustainable approach to include in the Programme national de santé de la mère et de l’enfant (National Program for Health of the Mother and Child) strategy to leverage financing from employers is to encourage them to purchase insurance coverage for family planning services, particularly postpartum IUD insertions. At the other end of the spectrum, facilities located in vulnerable areas where clients need commodity and financial support should eventually be contracted under the National Health Insurance indigent fund. Conduct market research. SHOPS Plus recommends conducting market research to better understand the demographics and reproductive intentions of users of emergency contra- ception, who are not reflected in the DHS. A second market area that warrants exploration is the capacity and willingness to pay among users of short-acting methods, so that public resources are effectively targeted to low-income users. Another opportunity for research will arise in the phaseout of the family plan- ning component of the Private Sector Health Project provider network. A short survey of these providers after the program ends can shed light on their motiva- tions and help develop tailored approaches to working with for-profit providers. SHOPS Plus • 19 Conclusion The private health sector can play an increasingly important role in addressing Côte d’Ivoire’s health challenges, particularly in the area of family planning, and help achieve the country’s mCPR target. The findings and recommendations from this private sector assessment are intended to empower donors and stakeholders to understand the dynamics of the family planning market in Côte d’Ivoire and support increased access to and use of modern family planning methods in collaboration with both the public and private sectors. A family sits in the waiting area of the Abobo Central Polyclinic in Abidjan. Photo: Elizabeth Corley 20 • Côte d’Ivoire Family Planning Private Health Sector Assessment References Assonken, F. (Medical manager/medical quality oversight liaison, Pfizer Essential Health, West Africa), discussion with the authors, May 2017. Avenir Health. 2015. Family Planning Program Effort Scores in 2014: Côte d’Ivoire. Abidjan: Track20 Project. Barnes, J., D. Boko, M. Koné, A. Kouakou, T. Uwamahoro, and J. White. 2013. Ivory Coast Private Health Sector Assessment. Bethesda, MD: Strengthening Health Outcomes through the Private Sector Project, Abt Associates Inc. Direction Générale de l´Office National de la Population. 2016. La problématique de l’investissement dans les adolescentes en Côte d’Ivoire. Abidjan: Direction Générale de l´Office National de la Population. Direction de l’Information, de la Planification et de l’Évaluation. 2011. Répertoire des Structures Publiques et Privées de Côte d’Ivoire. Abidjan: Direction de l’information, de la planification et de l’évaluation. Institut National de la Statistique (INS) Côte d’Ivoire and ICF International. 2012. Enquête Démographique et de Santé et à Indicateurs Multiples de Côte d’Ivoire 2011-2012. Calverton, Maryland, USA: INS/Côte d’Ivoire and ICF International. Institut National de la Statistique (INS) Côte d’Ivoire and ORC Macro. 2001. Enquête Démographique et de Santé, Côte d’Ivoire 1998–1999. Calverton, Maryland, USA: INS/Côte d’Ivoire and ORC Macro. Ministère de la Santé et de l’Hygiène Publique (MSHP). 2014. Plan d’Action National Budgétisé de Planification Familiale 2015–2020. Abidjan: MSHP. . 2017. Projet de Loi sur la Sante Sexuelle et Reproductive SSR. Working paper. Abidjan: MSHP. Sanogo, P. and A. Kouakou. 2014. Cadre législatif et règlementaire régissant le secteur privé de santé en Côte d’Ivoire. Bethesda, MD: Strengthening Health Outcomes through the Private Sector Project, Abt Associates. Strengthening Health Outcomes through the Private Sector (SHOPS) Project. 2015. West Africa Private Health Sector: Six Macro-Level Assessments. Bethesda, MD: SHOPS Project, Abt Associates. Track20 Project. 2017. “Côte d’Ivoire Country Page – Indicator Graphs.” Washington, DC: Track20 Project for the Bill & Melinda Gates Foundation. http://www.track20.org. WHO. 2016. “Global Health Observatory: Côte d’Ivoire Statistics Summary (2002–present).” http://apps.who.int/gho/ data/node.country.country-CIV. World Bank. 2017. “Country Overview: Côte d’Ivoire.” http://www.worldbank.org. 22 • Côte d’Ivoire Family Planning Private Health Sector Assessment Abt Associates Inc. 6130 Executive Boulevard Rockville, MD 20852 USA Tel: +1.301.347.5000 www.abtassociates.com Sustaining Health Outcomes through the Private Sector (SHOPS) Plus is a five-year cooperative agreement (AIDOAA- A-15-00067) funded by the United States Agency for International Development (USAID). The project strategically engages the private sector to improve health outcomes in family planning, HIV, maternal and child health, and other health areas. Abt Associates implements SHOPS Plus in collaboration with the American College of Nurse-Midwives, Avenir Health, Broad Branch Associates, Banyan Global, Insight Health Advisors, Iris Group, Population Services International, and the William Davidson Institute at the University of Michigan. Find Us SHOPSPlusProject.org

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