Developing a Total Market Plan for Family Planning in Vietnam - PATH

Publication date: 2011

R E P R O D U C T I V E H E A L T H Developing a Total Market Plan for Family Planning in Vietnam An innovative public and private collaboration to enhance equity and sustainability Acknowledgments The project that serves as the basis for this document was implemented by PATH in collaboration with the General Office for Population and Family Planning (GOPFP) of the Ministry of Health in Vietnam. This work was funded in whole by a grant from the Fred H. Bixby Foundation. The following individuals were key contributors both to project implementation and document development: PATH: Janet G. Vail, Jennifer Kidwell Drake, Luu Thi Thanh Huong, Pham Duc Minh, Nguyen Quynh Nga, Jane Hutchings, Chutima Suraratdecha, Scott Wittet, Jasmine Baleva, Mona Byrkit, and Michelle Gardner. GOPFP: Dr. Duong Quoc Trong, Mr. Nguyen Van Tan, and Dr. Dang Van Nghi. The project team would like to thank our Technical Advisory Group (TAG) in Vietnam, which served as a valuable resource and sounding board throughout the project period: the Maternal and Child Health Department, Vietnam Ministry of Health; United Nations Population Fund (UNFPA) Vietnam; Marie Stopes International (MSI) Vietnam; Population Services International (PSI) Vietnam; DKT Vietnam; Vietnam Family Planning Association (VINAFPA); and the Vietnam Women’s Union. Key project consultants were Dr. Ha Phan Thi Thi, Do Thi Thai Thanh, Dr. William Winfrey, Dr. Ann Levin, and Dr. Hoang Van Minh. Administrative support was provided throughout the project by Matt Havlik, Claire Suni, Nancy Engel, Dinh Ngoc Han, Hoang Thi Thu Huong, Hoang Thi Thi, and Shannon Mills. This document was designed by Cornelius Brudi and proofread by Teri Gilleland Scott. Finally, the project team would like to express our gratitude to family planning stakeholders in Vietnam and Washington State, as well as additional PATH staff in Seattle and Hanoi, who participated in project activities and contributed to the ultimate development of a total market plan for family planning in Vietnam. Suggested citation: Drake JK. Developing a Total Market Plan for Family Planning in Vietnam. Seattle: PATH; 2011. Cover photo: PATH/Nga Le Thi. Copyright © 2011, Program for Appropriate Technology in Health (PATH). All rights reserved. The material in this document may be freely used for educational or noncommercial purposes, provided that the material is accompanied by an acknowledgment line. Contents Acronyms ii Introduction 1 Background 1 The current family planning challenge 1 The context for a PATH-GOPFP collaboration 3 Partners 4 Key steps and activities for total market planning 6 Step 1: Engaging stakeholders 6 Step 2: Assembling evidence to develop the total market plan 8 Step 3: Building the total market plan 14 Lessons learned 15 What worked? 15 What have been some key challenges? 16 Conclusion: Moving forward 17 Advancing equity and sustainability of family planning: new advocacy targets 17 Ensuring achievements are sustained: implementing, monitoring, and updating the plan 18 Related resources 19 ii DEVELOPING A TOTAL MARKET PLAN FOR FAMILY PLANNING IN VIETNAM Acronyms CYP couple years of protection DHS Demographic and Health Survey EC emergency contraceptive GOPFP General Office for Population and Family Planning HCFP Health Care Fund for the Poor IUD intrauterine device MCH Maternal and Child Health MOH Ministry of Health MOLISA Ministry of Labor, Invalids and Social Affairs MSI Marie Stopes International OC oral contraceptive PATH Program for Appropriate Technology in Health PSI Population Services International TAG technical advisory group UNFPA United Nations Population Fund USD US dollar VINAFPA Vietnam Family Planning Association VMICS Vietnam Multiple Indicator Cluster Survey VSPS Vietnam Self Paying Survey AN INNOVATIVE PUBLIC AND PRIVATE COLLABORATION TO ENHANCE EQUITY AND SUSTAINABILITY 1 Introduction On June 27, 2011, the Vietnamese Ministry of Health officially approved the Operational Plan for the Contraceptive Total Market—a significant step for the country and for the family planning field. Many other governments faced with family planning funding shortfalls also have explored “total market” solutions (see Box 1 for more on the total market concept). Yet Vietnam is the first country to develop and approve a total market plan for family planning collaboratively with private-sector stakeholders. The total market plan identifies specific roles for the public and private sectors in meeting the family planning needs of the Vietnamese population. It outlines activities necessary to ensure that free or subsidized contraceptives remain available in Vietnam for vulnerable groups, while enhancing social marketing and commercial sales of contraceptives for those who are able to pay. Since 2009, PATH had been working with government family planning officials to engage stakeholders and apply evidence to develop this plan. As part of this work, PATH also helped the government plan a 2012 pilot program to compare different mechanisms to protect vulnerable populations within the context of new fees, and to advocate for the eventual inclusion of family planning in the national health insurance program. What follows is the story of how this new policy evolved. This case study is intended to highlight lessons learned and recommendations for those considering similar initiatives in other settings. Background the current fAmily plAnning chAllenge The Vietnamese contraceptive market is growing. In 2008, the government estimated that 68 percent of women of reproductive age were already using a modern contraceptive method—an impressive achievement. While intrauterine devices (IUDs) have always been popular in Vietnam, more and more women are using oral contraceptive pills and condoms, and to a lesser extent, injectables, as their regular contraceptive method. The Vietnamese budget for the family planning program has long been dependent on foreign aid; government estimates are that about 80 percent of funding for purchasing contraceptives came from donors between 1996 and 2006. Vietnam is also attaining middle-income country status, and the major donors, including KfW banking group (the German government development bank) and the United Nations Population Fund (UNFPA), have ended their support. Vietnam’s Ministry of Health (MOH) is now responsible for providing contraceptives to the population in the absence of such support. At the outset of the total market approach collaboration Box 1. Total market background How did PATH and our partners in Vietnam define a total market approach? Government coordination and support of public and private stakeholders to leverage their comparative advantages to enhance equitable, sustainable family planning. Why did PATH implement this project in Vietnam? A total market approach made sense for Vietnam due first to government interest in the approach, as well as: • Decreasing donor support for family planning. • Strong government commitment to family planning. • Perceived ability and willingness to pay among some women. • A nascent/emerging private sector. How is the term “private sector” defined in this document? The private sector includes not-for-profit nongovernmental organizations (e.g., social marketing groups) and for-profit manufacturers, distributors, and providers. The term “commercial sector” refers exclusively to for-profit groups. 2 DEVELOPING A TOTAL MARKET PLAN FOR FAMILY PLANNING IN VIETNAM between the government and PATH, a shortfall of 45 million USD was projected for 2011-2015. The program also faced operational challenges, including absent or weak coordination between clinical and non-clinical channels of service provision, and public and private service providers. The government’s capacity to forecast needs and maintain a consistent supply of contraceptives for all women who need them was limited. Available data on the economic status of contraceptive users and their source for contraception (e.g., public, social marketing, or private clinics and pharmacies) were between five and ten years old. Counseling, supportive supervision, and health education for adolescents were additional areas needing strengthening in public-sector services. Another challenge in recent years has been structural. Shortly before donor support ended, the General Office for Population and Family Planning (GOPFP) transitioned from an autonomous program on par with the MOH to a division within the ministry. The authority of the family planning program was therefore somewhat diminished, especially in relation to other government ministries (e.g., Finance or Planning and Investment, both significant in terms of budget decisions). GOPFP is formally responsible for policy development, coordination, and supply of family planning commodities. The MOH Department of Maternal and Child Health (MCH) in Vietnam is responsible for providing guidance on family planning service provision. The private family planning sector in Vietnam also faced important challenges. A decade ago, according to the last Demographic and Health Survey (DHS), conducted in 2002 in Vietnam, about 14 percent of contraceptive users obtained their method in the private sector. Family planning stakeholders have noted that there are numerous barriers to private- sector growth in Vietnam, including taxes on imported products, a slow and difficult process for obtaining government approval to update pricing strategies, and restrictions on marketing and communication related to family planning. Source: Vietnam Ministry of Health Proportion of national contraceptive budget from foreign donors, 1996-2006 Projected contraceptive budget shortfall in USD, 2011-2015 84% foreign donors 16% national budget 0 10 20 30 40 50 60 70 45 million shortfall 64 million contraceptive budget 19 million Source: Vietnam Ministry of Health Contraceptive prevalence rate (CPR) by method (%), Vietnam, 2010 Total population of Vietnam: 86.7 million Total fertility rate in Vietnam: 2.0 Source: Vietnam General Statistics Office Condom 10.2 Female sterilization 3.0 Injection 1.4 Intrauterine device 40.6 Male sterilization 0.2 Oral contraceptive 12.1 Periodic abstinence/withdrawal/others 10.5 Total modern method CPR 67.5 Total CPR 78.0 AN INNOVATIVE PUBLIC AND PRIVATE COLLABORATION TO ENHANCE EQUITY AND SUSTAINABILITY 3 the context for A pAth-gopfp collAborAtion When PATH first approached GOPFP regarding a potential project to address equity and sustainability within the context of decreased donor funds for family planning, officials were enthusiastic. The government had already worked with UNFPA on a preliminary plan to ensure contraceptives were available for all who needed them, but it did not move beyond the drafting stage. Additionally, private- sector (especially commercial) stakeholders were not consulted when this plan was being developed. At the same time, GOPFP officials were pondering how to address their funding shortfall. For example, a population policy document reviewed in 2008 pledged to “shift from the provision of free contraceptives, family planning services, and information/ education/communication to social marketing, making sure market-driven initiatives will take hold by 2020 and beyond” in areas with already low fertility rates. PATH staff also learned before the project started in 2009 that GOPFP was in the process of developing their National Reproductive Health and Population Strategy for 2011-2020. This presented a key opportunity to situate total market planning within the larger context of government strategic planning for the next ten years, and ultimately, to link with the budgeting process. The National Strategy document submitted to the prime minister for approval included the relevant key commitment: “Prioritize free or subsidized supplies of contraceptives for poor, socially and economically disadvantaged and especially disadvantaged areas and, at the same time, enhance social marketing and sales of contraceptives in the free market.” The government also planned to introduce fees for family planning services in government clinics, and wanted to ensure that access for poor and vulnerable women was not negatively impacted. In 2009, PATH and GOPFP signed an agreement to develop operational plans for the delivery of contraceptives to targeted market segments; strengthen public- sector leadership in public-private planning for the total market approach; and strategically disseminate approaches and lessons learned to promote country-led and evidence-based decision-making around the total market. At the same time, government officials were still looking to international fundraising as a potential solution. At an early PATH meeting with GOPFP in 2009, General Director Dr. Duong Quoc Trong acknowledged that the government needed to encourage the private sector to provide contraceptives, and that individuals who can afford to pay should shift from subsidized products to paying for products themselves. He also noted that they were hoping to secure additional support from international donors. Dr. Dang Van Nghi, Vice Director of Planning and Finance for GOPFP, made similar remarks at a major GOPFP planning meeting later in 2009. Dr. Nghi discussed the need to mobilize and establish a management system for the private sector, and strengthen social marketing in rural areas, but he also noted, “There is still a major need to mobilize international aid for at least 50 percent of the total budget needs for contraceptives.” This way of thinking remained a consistent theme throughout the project—not surprising, given that the Vietnamese family planning program had worked with international donors for so long—and yet the potential for significant foreign investment was low. PA TH /J en ni fe r D ra ke Dr. Dang Van Nghi, Vice Director of the Planning and Finance Division at GOPFP, at the November 2010 dissemination meeting for stakeholders. 4 DEVELOPING A TOTAL MARKET PLAN FOR FAMILY PLANNING IN VIETNAM pArtners PATH began working in Vietnam in the early 1980s and established an office in Hanoi in 1997. The Hanoi office has a strong relationship with the MOH. The close relationships and expertise of the staff in reproductive health helped facilitate development of key partnerships for the project. GOPFP was PATH’s key partner for implementation of this work in Vietnam. GOPFP and PATH co-convened a technical advisory group (TAG) to advise on critical project components, to provide access to other critical decision-makers, and to advocate for the principles of the project. The TAG comprised the following members: MCH Department of the MOH. PATH has a long- standing relationship with the MCH Department, and they helped to facilitate collaboration with GOPFP. UNFPA. UNFPA is an international development agency that works with countries to protect and promote the sexual and reproductive health of women, men, and young people. UNFPA was a commodity donor to the family planning program for many years and now provides technical assistance to GOPFP on reproductive health, including contraceptive access and condom programming. Working closely with UNFPA and keeping them apprised of activities was important throughout the project, as they are prominent and active in reproductive health in Vietnam. For example, in November 2010, they convened a Workshop on Planning for the Security of Reproductive Health Commodities for 2011-2015, which was chaired by the vice minister of health. PATH’s project representative was able to facilitate a panel on the role of the private sector at that meeting. Marie Stopes International (MSI). MSI is an important private-sector (not-for-profit) family planning service provider in Vietnam. The MSI-supported Blue Star and Tinh Chi Em (Sisterhood) social franchise networks have approximately 500 clinics throughout the country. MSI is implementing a voucher program in ten provinces, through which they have identified low-income urban and rural women with high unmet need through segmentation and offered a voucher for bundled services (a pelvic exam, cervical cancer screening, and provision of family planning methods, including IUD insertion). From the early days of the project, they offered to help reach private-sector providers and shared their experience working with the private health sector in Vietnam. MSI was also a powerful example of a nongovernmental entity committed to reaching disadvantaged populations. Box 2. Creative and flexible approaches to engaging the commercial sector While there was initial interest in the idea of involving the commercial sector in the government-led technical advisory group at the beginning of the project, it was not clear how to facilitate their representation in a meaningful way. There was no active family planning provider association, for example, nor had there been much private-sector strengthening work in Vietnam in family planning previously. The General Office for Population and Family Planning (GOPFP) had little history of engagement with the private commercial sector. Two initial research activities helped PATH and GOPFP to identify key commercial manufacturers and distributors active in Vietnam: the family planning stakeholder analysis (see page 6) and a review of data on family planning sales, purchased from IMS Health, a provider of health care information in more than 100 countries worldwide (see page 9). Then, by conducting one-on-one meetings, PATH was gradually able to involve commercial groups most interested and engage them in larger group planning meetings led by GOPFP. Outreach to commercial groups focused on incentivizing their active participation in project activities: for example, talking points cited the government’s key commitment to private-sector engagement in the national strategy, availability of new research results on ability to pay and commercial contraceptive markets, and the chance to share opinions about opportunities and obstacles in family planning. Broad stakeholder meetings were designed to enable discussion through interactive, small-group sessions. During development of the total market plan document, additional individual conversations focused on addressing barriers to commercial participation. AN INNOVATIVE PUBLIC AND PRIVATE COLLABORATION TO ENHANCE EQUITY AND SUSTAINABILITY 5 Population Services International (PSI). PSI’s work in Vietnam is focused on HIV/AIDS; thus, their link to family planning is limited to condoms. At the time of the project, they were considering a total market approach for condoms, with a focus on groups at high risk for HIV/AIDS. At our first TAG meeting in November 2009, we learned that GOPFP did not know that PSI was working in Vietnam, illustrating the limited exchanges between the HIV/AIDS and family planning teams of the MOH. DKT International. DKT provided partially subsidized family planning products to private-sector providers. The organization also provided helpful information, including their products price list. Vietnam Family Planning Association (VINAFPA). VINAFPA is the local affiliate of the International Planned Parenthood Federation. The president of VINAFPA was the vice minister of health for many years, and in that role, was responsible for family planning, so they have a close relationship with the MOH and GOPFP. The government recently contracted with VINAFPA to implement its social marketing program for condoms and oral contraceptive pills. For that reason, VINAFPA was very interested in this project, as they felt that strong advocacy and policy work are necessary to support a total market approach. Women’s Union. The Women’s Union is a quasi- governmental “mass organization” (common in Vietnam) that represents women’s interests. Although not TAG members, other groups also were consulted informally and provided key inputs at critical junctures in the project. Both Pathfinder International and the Population Council provided helpful advice and data. For example, Pathfinder shared a baseline study they had conducted of consumer preferences in family planning, as well as a cost study of oral contraceptive pills that KfW banking group had commissioned. PATH also consulted with the World Bank regarding their experience with reaching the poor with free or subsidized health services in Vietnam (not family planning). Project TAG members at the second official meeting, convened in Hanoi in July 2010. Vi et na m M in is tr y of H ea lt h 6 DEVELOPING A TOTAL MARKET PLAN FOR FAMILY PLANNING IN VIETNAM Key steps and activities for total market planning GOPFP-PATH project activities were organized within three key steps: engaging stakeholders, assembling evidence, and building a total market plan (see Figure 1). Work in each of these three key steps overlapped: for example, activities to assemble evidence began before all activities to engage stakeholders were completed. For more information on the chronology of different activities, see the timeline on pages 8 and 9. step 1: engAging stAkeholders This step, which emphasized government leadership and participation of diverse stakeholders, began with a stakeholder analysis to determine who to engage and how to engage them in the plan development process. Activity 1.1: Conducting a stakeholder analysis The PATH team conducted a network analysis and stakeholder perceptions survey to involve key stakeholders in the planning process, address their interests, and document relevant opportunities and obstacles. Based on interviews with 38 stakeholders, in which they were asked to identify key influencers, PATH developed a map (see Figure 2) of the family planning network in Vietnam. The network of stakeholders is closely connected, with GOPFP and UNFPA serving as dominant forces for family planning policy and programming. Other prominent stakeholders include the Women’s Union, provincial officials, national government agencies responsible for planning and finance, and the MCH Department of the MOH. The analysis confirmed that stakeholders were well represented in the project TAG, but that engagement of provincial leaders would need to be a future priority for GOPFP. The analysis also identified the opportunity for improved coordination among the government, nongovernmental, and commercial sectors. The interviews also gathered information about perceptions of a total market approach. The team learned that there was strong support for public leadership of public-private coordination—in other words, government stewardship—among family planning stakeholders. In fact, many respondents welcomed a stronger government role in coordinating and mobilizing all sectors as a means of improving family planning in the country. Eighteen of the 38 respondents said that engaging the private sector in policy and planning should be a priority, and 27 said clear guidelines regarding private-sector participation in family planning were needed. Stakeholders emphasized that information on ability and willingness to pay, market segmentation, products and prices in the commercial sector, and costs of providing services in the public sector were required to move Total market plan Ca pa cit y-b uild ing Coordination Advisory group Information priorities • Commercial markets and products • Market segments • Projections of contraceptive users • Willingness to pay Network analysis Stakeholder perceptions study Targeting and supply Government stewardship Monitoring and evaluation Engaging stakeholders figure 1. Steps to a national total market plan Assembling evidence Building the total market plan AN INNOVATIVE PUBLIC AND PRIVATE COLLABORATION TO ENHANCE EQUITY AND SUSTAINABILITY 7 forward with total market planning. These findings helped shape the information-gathering activities for total market planning. Following the completion of the stakeholder analysis, the PATH team focused on assembling evidence on the commercial market and ability and willingness to pay (see pages 10-12 for more information). Activity 1.2: Convening stakeholders to discuss assembled evidence for total market planning By the fall of 2010, sufficient evidence had been assembled (see Step 2) to at least begin collaborative total market planning. This was aligned with GOPFP’s need to provide an update of the family planning situation and the new ten-year strategy to key stakeholders. Both the stakeholder analysis and the commercial market analysis helped generate the participant list for the November 2010 dissemination meeting (see Box 2). In addition to presenting research findings, the objectives of the meeting were to clarify the roles of different providers in family planning in Vietnam, and to garner participation from stakeholders in development of a total market plan. More than 70 stakeholders from 35 organizations attended the meeting, and were actively engaged throughout the day asking questions and participating in small group discussions. These sessions were designed to elicit thoughts about different elements of a total market plan: which providers should serve which types of clients (segmented by age, marital status, residence, gender; see Figure 3 for an illustrative diagram developed by meeting participants); user fee development (fee collection mechanisms, communicating to the public, timely information on costs); key steps for the total market plan (assessment of what had been done and what needed to be done, short- and long-term objectives, priorities, role of each sector, periodic monitoring); introduction of new products; and regulations (imports, pharmacies, PCSA MPI MOF GOPFP MCH PFD VAAC PPFP HSPH IHPS NGOH PRHC MSI PATHF LI CCRD PC NAPHACO DKT PSI DONGK MEDIVICE MERUFA WU FF YU FU VGCL VINAFPA OGA UNFPA USAID KFW PCSA MPI MOF GOPFP MCH PFD VAAC PPFP HSPH IHPS NGOH PRHC MSI PATHF LI CCRD PC NAPHACO DKT PSI DONGK MEDIVICE MERUFA WU FF YU FU VGCL VINAFPA OGA UNFPA USAID KFW figure 2. Family planning stakeholders in Vietnam This graphic highlights the centrality of GOPFP and UNFPA to the family planning network. Collaboration with private-sector groups on the periphery, including MSI, PSI, and commercial groups like Dongkuk, NAPHACO, MERUFA, and Medivice, could be improved. (A large red dot indicates that an organization is part of the most closely connected subgroup in the analysis; the other dots designate smaller and less closely connected subgroups.) 8 DEVELOPING A TOTAL MARKET PLAN FOR FAMILY PLANNING IN VIETNAM insurance, private-sector training, pilot). The groups engaged in lively discussions and reported their conclusions back to the larger group. The PATH and GOPFP teams kept a record of these sessions and incorporated them directly into the draft total market plan a few months later. Outcomes of the meeting included a clear and public commitment by GOPFP General Director Dr. Trong to private-sector involvement in family planning policy and programming, corresponding expressions of interest by private-sector stakeholders, a potential list of key steps for developing a total market plan generated by participants, and detailed ideas of how the Vietnamese family planning market might be segmented. All commercial manufacturers who attended reported that the meeting provided a useful opportunity to engage with government stakeholders, and expressed interest in attending future meetings. However, some still needed a clearer picture of their roles in government planning and policy. This feedback helped GOPFP and PATH to develop specific areas of contribution and collaboration for the commercial sector moving forward (see Box 2). step 2: Assembling evidence to develop the totAl mArket plAn A traditional approach to total market work is to begin with a market segmentation analysis based on DHS data; however, as noted, no DHS had been conducted in Vietnam since 2002 and such studies are large and expensive. It became clear that it would be important to have a thorough inventory of available data sources that would shape what types of information-gathering were necessary and feasible to identify market segments. Talking with stakeholders familiar with total market work in other countries (including PATH staff) and colleagues working in Vietnam proved helpful. Keeping an ongoing inventory of data sources enabled PATH and GOPFP to both determine research needs and ultimately demonstrate that it was feasible to move forward with a total market plan when the time came. Box 3 outlines the evidence gaps identified, the approaches used to fill those gaps, and the results applied to the total market planning process. The activities to address the first four gaps are described in greater detail on pages 9-14 (the commodity needs and projections referenced in the last gap were developed by GOPFP independently of this project and are addressed in the “Lessons learned” section). Activities timeline Q 3-4 2009 • Initial meetings with key stakeholders • GOPFP and PATH sign project agreement • First TAG meeting Q 1-2 2010 • Stakeholder research (Activity 1.1) Q 3-4 2010 • Second TAG meeting • IMS commercial market analysis (Activity 2.1) • Ability/Willingness to pay analysis (Activity 2.2) • Dissemination meeting for stakeholders (Activity 1.2) PA TH /J en ni fe r D ra ke Ms. Nguyen Thu Giang, Deputy Director of the Light Institute of Community Health Development, presents the results of a small group discussion at the November 2010 dissemination meeting (see page 9 for more information on the diagram shown). AN INNOVATIVE PUBLIC AND PRIVATE COLLABORATION TO ENHANCE EQUITY AND SUSTAINABILITY 9 Q 1-2 2011 • Costing study (Activity 2.3) • GOPFP targeting study tour to Seattle, Washington (Activity 2.4) • Working group meeting for total market planning (Activity 3.1) • Draft total market plan developed (Activity 3.2) • Operational Plan for the Contraceptive Total Market approved Q 3-4 2011 • Rollout of operational plan to provincial level • Planning pilot of waiver mechanism Activity 2.1: Characterizing the commercial contraceptive market The project team consulted with PATH colleagues working in commercial markets in other countries to solicit ideas for approaches to gathering more information about the market in Vietnam. An early suggestion was to purchase data from IMS Health. An analysis of the data showed that oral contraceptive pills (both monthly pills and emergency contraceptives) from the commercial sector made an important contribution to contraceptive coverage in Vietnam. There is a good diversity in sources of oral contraceptive pills in Ho Chi Minh City, the Mekong River Delta, Hanoi, and the Southeast and Central This diagram was developed by participants at the November 2010 dissemination meeting to illustrate potential segmentation for rural populations. For example, the group perceived that the government is the most important provider for married women aged 15–49 in rural areas, while it is less important for those older than 49 years and is not available to single women for policy reasons (degree of perceived importance is signified with + and – symbols). • Government (++) • Nongovernmental/Private/Social marketing (+) • Population collaborator (non-clinical) (++) • Government (-) • Nongovernmental/Private/Social marketing (±) • Population collaborator (non-clinical) (-) Ages 15–49 Married Older than 49, mainly men Ages 15–49 Single Teenagers • Government (-) • Nongovernmental/Private/Social marketing (+) • Population collaborator (non-clinical) (-) • Government (-) • Nongovernmental/Private/Social marketing (±) • Population collaborator (non-clinical) (-) Rural figure 3. Potential segmentation for rural populations 10 DEVELOPING A TOTAL MARKET PLAN FOR FAMILY PLANNING IN VIETNAM Box 3. Evidence gaps, solutions, and results Gap: What contraceptive products are available in the commercial sector? What do they cost and who can afford them? Solution: Purchase and analyze existing data from IMS Health. Results: Women of all income levels can afford to buy emergency contraceptives (ECs), monthly oral contraceptive pills (OCs), and injectables through commercial channels. Commercial sales of emergency contraceptives and monthly oral contraceptive pills provide substantial couple years of protection (CYP) (ECs: ~175,000 CYP; OCs: ~245,000 CYP). Most sales are in Ho Chi Minh City, Mekong River Delta, Southeast, Central, and Hanoi. Sales are increasing in the first three markets. Lower-priced oral contraceptive pills (~3 USD per year) have 30 percent of the commercial market (units). Unrealized potential for injectables (based on availability of an affordable product). Implants and intrauterine devices are not significant in commercial channels. Gap: What is the ability and willingness to pay of different groups of family planning users in Vietnam? Solution: Identify and complete a secondary analysis of existing national and global data collected by other groups. Results: Poor women, women who are not working, and women in informal-sector jobs are less willing to pay and should receive some type of subsidy. First-time users of a clinical method need a price break to incentivize use. Explore segmentation on a regional basis, such as in Hanoi or Ho Chi Minh City. User fees may not result in declining use. High willingness to pay among the urban not-poor, government workers, and workers in the formal sector. High knowledge of oral contraceptive pills. Diverse products and prices. Ability to pay exists. parts of the country. An interesting finding was that emergency contraceptives were sold at more than twice the rate of monthly pills in Central Vietnam. On the other hand, there were limited commercial offerings of some methods: one brand each of IUDs, patches, implants, and spermicides; and two injectable products. None of these latter commercial products contributed significantly to contraceptive coverage in Vietnam. The project team also used 2008 government data on household living standards to make general estimates of ability to pay for these commercially available methods. Using established wealth quintiles (defined by average personal income) and average expenditures for health per month by quintile, the team considered whether the commercial methods identified were within the range of health expenditures for the different quintiles. This very general analysis showed that women of all income levels could potentially buy both monthly oral contraceptive pills and emergency AN INNOVATIVE PUBLIC AND PRIVATE COLLABORATION TO ENHANCE EQUITY AND SUSTAINABILITY 11 Box 3. Evidence gaps, solutions, and results (cont.) Gap: How much should government clinics charge family planning users? Solution: Use project funds to conduct primary data collection and an analysis of costs. Results: Costs of providing family planning services across different facilities in Vietnam vary considerably. Costs were highest at centrally based facilities, due mainly to staffing and commodities costs. Data can be used to plan and develop appropriate fee schedules. Gap: How can the government identify and provide free services to (i.e., target) vulnerable groups most effectively? Solution: Conduct a literature review of global targeting experience, meetings with stakeholders in Vietnam with health-targeting experience, a study tour, and a situation analysis regarding family planning use among vulnerable groups. Results: Poor women to be identified through existing government mechanisms. Different targeting mechanisms (user cards, vouchers) will be compared in a GOPFP pilot. Clinical contraceptive use by poor and rural women is high. Obstacles for youth are operational rather than cost driven (e.g., lack of services for unmarried people), and so fee exemptions alone would not address their primary obstacles. Gap: What are projections for contraceptive commodity needs within the context of the new total market plan? Solution: GOPFP and UNFPA commitment to develop projections. Results: Detailed numbers used as the basis for total market operational plan. Gaps regarding unmarried women, youth, and the private sector persist. contraceptives from a diversity of sources. Another result was that commercially available injectables could actually be affordable for women across wealth quintiles, indicating that there may be an undeveloped market in Vietnam for this method. Activity 2.2: Assessing willingness and ability to pay for different methods Identifying both ability and willingness to pay of different population groups (often population quintiles divided by wealth status) is a crucial step in total market planning—specifically, by matching different types of providers to their appropriate target groups. In Vietnam, the annual population survey did not collect information about the sources for contraceptives or the wealth of contraceptive users. To estimate willingness to pay, the project team worked with a consultant PA TH /K at rin a Pe ac h A woman harvests rice in the Hai Duong province of Vietnam. 12 DEVELOPING A TOTAL MARKET PLAN FOR FAMILY PLANNING IN VIETNAM from the Futures Institute who pooled and compared data from the 2006 Vietnam Multiple Indicator Cluster Survey (VMICS) conducted by the Vietnam General Statistics Office and the 2009 Vietnam Self Paying Survey (VSPS) conducted by the Military Medical Institute. The 2006 VMICS provided stronger economic data and was nationally representative, while the VSPS gathered detailed information about family planning and willingness to pay from a large sample in five provinces. The analysis demonstrated that many women were used to paying for family planning, especially for oral contraceptive pills. It also helped demonstrate that many government workers and urban women were willing to pay something for family planning at government clinics (in response to a yes/no question), especially clinical methods like IUDs; while rural women, poor women, and women working in the informal sector were less willing to pay anything. (See Figure 4.) Activity 2.3: Determining the costs of family planning service provision in the public sector Discussions with GOPFP in 2010 confirmed that basic information was needed on how much it cost to deliver family planning services. This cost information would be helpful to GOPFP and provincial governments in understanding the amounts and types of resources (personnel, equipment, supplies, etc.) required for family planning services in the public sector. These cost estimates could also facilitate realistic projections of the financing needed for sustainable public services, as well as decisions about which methods to provide and how to provide them. GOPFP would propose a fee structure to the MOH, and the MOH would work with the Ministry of Finance to determine how much to charge. In early 2011, PATH and GOPFP worked with a Vietnamese health economist to conduct a study of the average costs of providing selected family planning services (oral contraceptives, IUDs, male and female sterilization, injectables, and implants) at public-sector health facilities in Vietnam. Data on direct and indirect costs were gathered from 104 public health facilities selected to represent different points of service in Vietnam (e.g., levels of health care, geographic location, and type of facility). The considerable variations in the costs of providing family planning services across different facilities in Vietnam have important implications for developing a nationally based fee schedule to be implemented in different service areas with different costs. Activity 2.4: Collecting experience with targeting family planning services GOPFP officials expressed a desire early in the project to learn about health-targeting approaches that could inform their new approach to serving vulnerable groups. A global literature search of targeting in low- and middle-income countries identified Vietnam’s own health-targeting program, the Health Care Fund for the Poor (HCFP), as most relevant. In contrast to family planning, most health care services and goods provided at public health facilities have been charged to users for decades. In 2002, the government initiated HCFP to ensure that the poor can access care from public health facilities. Through this fund, health insurance cards are provided by Vietnam Social Security to provinces. Provinces in turn distribute these cards to identified beneficiaries. The Ministry of Labor, Invalids and Social Affairs (MOLISA) has established specific guidelines for how to identify the poor. All population groups regardless of wealth status Poor Uneducated informal sector Educated informal sector Formal- sector worker Government worker 0 20 40 60 80 100 figure 4. Women’s willingness to self-pay for family planning, by work status Women’s work status % o f w om en w ill in g to s el f- pa y AN INNOVATIVE PUBLIC AND PRIVATE COLLABORATION TO ENHANCE EQUITY AND SUSTAINABILITY 13 have the same health insurance card in Vietnam, but the cost of the card is either fully or partially subsidized for the poor or near poor, respectively. In late 2010, the PATH project team contracted an economist with targeting expertise to help the government identify the population for targeting and plan implementation of a targeting program. The consultant visited Vietnam, and GOPFP helped to set up meetings with MOLISA, the Health Economics Association, and the Health Insurance Department of the MOH. At these meetings, MOLISA shared its documentation on their methodology for identifying the poor and indicated that they would be happy to coordinate with GOPFP on applying the same mechanisms for family planning. The Health Insurance Department agreed to consider a pilot project to include family planning in the health insurance program that is intended to establish universal coverage by 2014, although noted it would not be possible to formally implement until 2015 due to the budget planning process. In general, all stakeholders contacted, including GOPFP, felt that MOLISA’s approach was an acceptable mechanism for family planning targeting and that GOPFP should conduct a pilot study to assess the impact of introducing user fees and exemptions for the poor in Vietnam. Given that the United States has long had subsidized programs for providing family planning to vulnerable groups, GOPFP officials wanted to visit to learn more about the US experience. Specifically, they were interested in gathering details on targeting methods and mechanisms to determine which clients can and cannot pay, and how to communicate systems changes and the need to pay to clients. The objectives of the study tour on family planning targeting are featured in Box 4. In late February 2011, four officials from GOPFP, including General Director Dr. Trong, arrived in Seattle, Washington, for visits to Planned Parenthood, the Public Health Department of Seattle and King County, and the Washington State Department of Box 4. Family planning targeting study tour objectives • Identify government financing streams for family planning, the objectives of these programs, and how financing is allocated among service providers (public and private). • Identify methods and challenges to determine clients who are eligible for government financing and their ability to pay for services. Identify variations between public and private providers. • Identify how fee schedules are determined, administered, and communicated to clients. • Learn about how clients enroll in subsidized programs and what happens at point-of-service in determining their eligibility and ability to pay. • Identify how service providers request and obtain reimbursement from the government for the services they provide to targeted clients. Identify challenges with the reimbursement system. • Determine how the public and private sectors serve different market niches, and what role the private sector plays in reaching low-income and vulnerable populations. • Learn about coordinating bodies within the public sector and between the public and private sectors. • Discuss strategies for maintaining equity, quality, and accessibility of services within the context of funding shortfalls. • Determine next steps for implementing changes in Vietnam to finance family planning. What is targeting? Targeting involves directing scarce resources in a planned manner to the people who need them most, a key priority for the General Office for Population and Family Planning within the context of increasingly scarce funding for contraceptives. 14 DEVELOPING A TOTAL MARKET PLAN FOR FAMILY PLANNING IN VIETNAM Social and Health Services and the Department of Health. Overall, the GOPFP delegation members were surprised by the scale of subsidized family planning services in a relatively wealthy country such as the United States. Other notable takeaways from the meetings included the fact that clients who are unable to pay are not turned away at public family planning clinics that receive federal funding—even if it is not possible to confirm their eligibility for subsidized services; and that all adolescents in Washington are served for free, regardless of their income. The strong collaboration between the government and Planned Parenthood in Washington, particularly in the Seattle area, was seen as a potential model for collaboration with not-for-profit private providers in Vietnam (though at the time, the study tour participants did not support using public funds to contract with non-state providers). A public- private collaborative group called the Washington State Family Planning Leadership team provided their workplan as a potential model for the GOPFP operational total market plan. Detailed information from the study tour hosts on contraceptive procurement mechanisms, sliding scales, and fee schedules was also catalogued as a future resource for operational plan implementation. step 3: building the totAl mArket plAn Close collaboration with GOPFP from start to finish helped to ensure that the total market plan was incorporated into family planning policies and programs in Vietnam. In June 2010, the MOH requested that GOPFP develop a five-year action plan to determine who would be subsidized, how many subsidized contraceptives would be required, and a budget. The operational plan for the total family planning market to be developed through the project enabled GOPFP to fulfill the MOH request. Activity 3.1: Convening a small working group to build the total market plan In March 2011, GOPFP and PATH co-convened a focused meeting with the MOH, government planning and finance ministries, the commercial sector, provincial governments, and mass organization representation, and also including representatives of MSI, UNFPA, and VINAFPA. Participants provided more detailed input on the content of a total market plan and ideas for priorities on segmentation. At the meeting, Dr. Trong clearly stated the need for a total market plan, and noted that addressing the needs of unmarried women and youth, diversifying the method mix to include more short-term methods (including condoms), and figuring out the roles of pharmacies and commercial distributors were PA TH /M at t H av lik PA TH /D o Th i T ha i T ha nh GOPFP study tour participants and PATH team members meet with officials from the Washington State Department of Social and Health Services and the Department of Health. Dr. Duong Quoc Trong, General Director of GOPFP, addresses participants at the March 2011 working group meeting for total market planning. AN INNOVATIVE PUBLIC AND PRIVATE COLLABORATION TO ENHANCE EQUITY AND SUSTAINABILITY 15 particular priorities. As expressed by Mr. Nguyen Thien Truong, a veteran official and the deputy head of VINAFPA, GOPFP previously prepared family planning plans unilaterally, and providers and distributors were simply expected to follow them. “A total market plan with active involvement of various stakeholders (including public-sector, social marketing, nongovernmental, and commercial organizations) will definitely help better meet the demands of different target groups,” he said. The Ministry of Finance and the Ministry of Planning and Investment, influential government ministries in terms of budget allocations, both expressed clear support for the plan to GOPFP officials. Activity 3.2: Drafting the plan and coordinating key inputs PATH gathered input for and drafted an extensive background document to shape the operational plan, and GOPFP was ultimately responsible for refining the content, finalizing the plan, and gaining MOH approval. PATH had hoped to work with an existing coordinating body to draft the plan, but that did not exist. In addition, drafting detailed documents in meetings or large groups can be challenging. Instead, GOPFP and PATH convened the key stakeholders at the beginning of the process as noted, and then followed up with stakeholders on an individual basis to obtain their feedback on the plan once drafted. Private nongovernmental organizations and private commercial groups responded to answers to specific questions, such as potential strategies for reaching women outside urban areas or improving youth knowledge about and access to contraception. For example, Bayer representatives suggested developing a concrete budget for communicating with vulnerable groups, since they are very hard to reach. Lessons learned whAt worked? Aligning project work with the health policy process in Vietnam. The need for a paradigm shift in family planning funding mechanisms, the revision of the ten-year population and family planning strategy, and GOPFP’s pre-existing desire to introduce fees in the public sector all laid an important foundation for the project. Having a full-time staff person in Vietnam with strong existing relationships with government officials and working knowledge of government systems was also critical to building trust with a division of the MOH that was a new partner for PATH. By the end of the project, GOPFP took full ownership of the total market plan, to the extent that they set their own deadline for completion and approval and saw the process through to the end. Formation of a TAG. Having an advisory group to provide input into activities helped to secure local buy-in for the work, especially in the absence of a relevant coordinating body in Vietnam (e.g., a contraceptive security committee). For example, GOPFP officials presented preliminary data on willingness to pay for family planning at a TAG meeting in July 2010. The questions and responses of TAG members helped to identify some key information gaps and focus future data collection and analysis efforts before the wider stakeholder meeting that November. The concept of government stewardship. By the end of the project, it was clear that GOPFP officials saw their role not only as a provider of services PA TH /J en ni fe r D ra ke PATH project director Janet Vail and Dr. Nghi of GOPFP at the November 2010 dissemination meeting for stakeholders. 16 DEVELOPING A TOTAL MARKET PLAN FOR FAMILY PLANNING IN VIETNAM but also as a steward of the total family planning market. In February 2011, for example, Dr. Trong stated, “I think that the private sector will play a greater role in distribution of contraceptives. This is also our government’s policy orientation, to support the private sector.” Engagement with private-sector representatives at meetings and through total market plan development helped to position these stakeholders as collaborators rather than competitors. In addition, GOPFP intends to include private services in its pilot evaluation of exemptions for the poor. The initial stakeholder analysis. This activity provided an opportunity for outreach and education on the concept of the total market. This was especially important given early lack of understanding regarding total market concepts. In addition, the analysis helped gather information on which total market concepts might resonate most with stakeholders in Vietnam. For example, the concept of government stewardship was nicely aligned with the fact that the government is a dominant force for family planning policy and programming in Vietnam, and with the desire for coordination and leadership from the government expressed by numerous stakeholders. Focusing on those total market concepts that garnered the most support from key allies bought time for information- gathering to support the elements that were more confusing or unfamiliar—for example, market segmentation, targeting, and supporting private- sector participation. Finally, the stakeholder analysis identified some key stakeholders to involve after central government planning. For example, provincial family planning officials were highly connected to other key stakeholders and were especially influential in the process of policy implementation. In late 2011, GOPFP convened meetings to promote understanding of total market concepts and the total market plan among these stakeholders. Individual engagement of commercial stakeholders. While inviting commercial-sector representatives to group meetings helped initiate communication with government officials and include a new perspective on total market planning, more focused engagement with commercial-sector representatives also was beneficial. Many private-sector groups were unwilling to share information about their target markets and priorities in groups with other commercial manufacturers and distributors. Through individual meetings, the project team identified new market opportunities such as reaching unmarried women and youth and introducing new methods like injectables and implants. As one company put it, they are interested in many market segments, not just the top market segments, yet competing with the government’s free products is a challenge for these segments, and it is also difficult to communicate directly with them. In fact, all manufacturers and distributors noted that reaching rural (often lower-income) markets is their biggest challenge. Strategic data collection and analysis. Information needs identified through the stakeholder analysis and careful inventory of existing data sources helped to identify where it was necessary to conduct primary data collection activities (e.g., the costing study) and where secondary analyses using existing data sources—even if they were imperfect—would be sufficient for development of the total market plan (such as the ability to pay analysis). As Mr. Nguyen Van Tan, GOPFP Vice General Director, said, “If you wait for perfect data, you will sit and do nothing.” Clearly cataloguing available information about the family planning market (see Box 3, pages 10-11) helped make stakeholders more comfortable with moving forward on a total market plan in the March 2011 planning meeting. Drawing careful conclusions that fully accounted for the limitations of the data was also helpful. whAt hAve been some key chAllenges? Developing comprehensive projections of contraceptive supply needs. GOPFP first presented their projections of free supply needs at a project TAG meeting, and TAG members requested more information on the methodology for the projections and whether they took ability to pay into account. In addition, unmarried women traditionally have not been included in contraceptive projections or programs in Vietnam. There was no readily available data source on the contraceptive behavior of unmarried women on which to base projections. While GOPFP and UNFPA (which helped with AN INNOVATIVE PUBLIC AND PRIVATE COLLABORATION TO ENHANCE EQUITY AND SUSTAINABILITY 17 projections) agreed that it would be important to include unmarried women in the projections, this was ultimately not possible. No resources were available for that level of data collection, especially within the time frame of drafting the total market plan. Additionally, the projections were not verified in consultation with private-sector representatives. Minimizing reliance on limited international funding. There is a persistent perception and expectation among GOPFP officials that it will be possible to raise funds from bilateral or multilateral donors to address funding shortfalls for supplies. While that may be true, any degree of reliance on external support for contraceptives may delay investment in sustainable internal solutions. It is not completely clear whether the government has truly shifted from a fundraising focus to a total market planning focus. Sustaining direct communication and collaboration between GOPFP and the commercial sector. As an example, one pharmaceutical company contacted the PATH team late in the project to discuss concerns about the government’s views and policies on over- the-counter access to emergency oral contraceptive pills. It is unclear what degree of interaction and communication will continue in the absence of the project and without PATH as a go-between. An existing forum for these issues would help to address that, but the status of such a group is unclear at this point. Conclusion: Moving forward AdvAncing equity And sustAinAbility of fAmily plAnning: new AdvocAcy tArgets In addition to the total market plan, the project identified related priorities for family planning in Vietnam, with a focus on strengthening government stewardship, coordination among total market players, and ensuring access to quality services for vulnerable groups. These include the following: • Incorporating information on unmarried women’s family planning needs and desires into projections of contraceptive supply needs in Vietnam, as well as private-sector contributions and perspectives. • Considering how use of injectable contraception might be increased in Vietnam. Specific priorities might include gathering more information on user attitudes and acceptability, or regulatory issues around community-based distribution of injectables. This is a good example of a stewardship opportunity for the government; for example, establishing regulations and corresponding oversight that could facilitate administration of injections by non-physicians. (Current MOH technical regulations state that injectables cannot be provided by non-health care staff.) There are signs that the government is open to considering a new emphasis on this method: GOPFP Vice General PA TH /J en ni fe r D ra ke Mr. Nguyen Van Tan, Vice General Director of GOPFP, talks with participants at the November 2010 stakeholder meeting. N gu ye n Ba Q ua ng A pharmacist explains a product to a customer in Hai Phong, Vietnam. 18 DEVELOPING A TOTAL MARKET PLAN FOR FAMILY PLANNING IN VIETNAM Director Mr. Tan has said that there would be more emphasis on injectables and implants in family planning activities going forward. • In 2015, conducting a pilot project to integrate coverage of family planning into the current national health insurance program for vulnerable groups. Ongoing attention to equity, even within the context of universal health insurance, will be important. • Addressing regulations to ensure quality. While the concept of government stewardship was accepted, GOPFP is focusing its efforts on ensuring availability and affordability of products. However, they have not yet worked with the MCH Department to address the issue of service quality, for either the public or private sectors. This was identified by stakeholders as an important issue, since it is closely linked to willingness to pay and the expansion of commercial service provision. • It is the official policy of the government that communication and marketing by commercial entities around clinical family planning is not permitted. Given the communication challenges highlighted by the commercial manufacturers, potential for changing this restriction should be explored. ensuring Achievements Are sustAined: implementing, monitoring, And updAting the plAn As GOPFP General Director Dr. Trong noted, there will be a need to closely monitor and update this total market plan moving forward: “It’s difficult to develop a total market plan and it will be more difficult to coordinate this plan. Even though it is possible to determine the number of users of contraceptive services, the market structure is always changing. GOPFP only hopes that the total market plan will provide a relative vision, and it will need to be adjusted every year.” In order to ensure that this happens, a multisectoral group, including the commercial sector, can help GOPFP to monitor implementation of the plan. PA TH /J en ni fe r D ra ke Family planning stakeholders at the November 2010 dissemination meeting participate in small group discussion. AN INNOVATIVE PUBLIC AND PRIVATE COLLABORATION TO ENHANCE EQUITY AND SUSTAINABILITY 19 Related resources • To read the Vietnam Operational Plan for the Contraceptive Total Market (2011), visit: http://www.e.gopfp.gov.vn/web/guest/policy • For more information about population dynamics and family planning in Vietnam, see: Government of Vietnam, General Statistics Office (GSO). Population Change and Family Planning Survey 1/4/2010. Hanoi, Vietnam: GSO; 2011. Available at: http://www.gso.gov.vn/default.aspx?tabid=512&idmid=5&ItemID=11010 United Nations Population Fund (UNFPA). Viet Nam Population 2008. Hanoi, Vietnam: UNFPA; 2008. Available at: http://vietnam.unfpa.org/webdav/site/vietnam/shared/UNFPA_ThucTrangDanSo%20VN%202008_VIE_ FINAL.pdf • For more information on the stakeholder analysis (Activity 1.1, page 6), see: Drake JK, Thanh LHT, Suraratdecha C, Thu HPT, Vail JG. Stakeholder perceptions of a total market approach for family planning in Vietnam. Reproductive Health Matters. 2010;18(36):46–55. Abstract available at: http://www.rhm-elsevier.com/article/S0968-8080(10)36529-3/abstract • For more information on the ability and willingness to pay analysis (Activity 2.2, page 11), see: Winfrey W. Ability and Willingness to Pay for Family Planning in Vietnam. Seattle, Washington: PATH; 2011. Available at: http://www.path.org/publications/detail.php?i=1986 • For more information on the PATH project, “Enhancing Equity and Sustainability of Public-Sector Family Planning,” see: http://www.path.org/publications/detail.php?i=1695 Enhancing Equity and Sustainability of Public-Sector Family Planning: A PATH Project PATH is currently working with governments in Nicaragua and Vietnam to develop operational plans for public-sector contraceptive distribution to targeted market segments. The project aims to strengthen public-private dialogue around family planning service delivery—including for the poorest populations. Lessons learned are being disseminated to promote widespread readiness for country-led decision-making that draws on the total family planning market. The project will end in 2012. PATH is an international nonprofit organization that creates sustainable, culturally relevant solutions, enabling communities worldwide to break longstanding cycles of poor health. By collaborating with diverse public- and private-sector partners, PATH helps provide appropriate health technologies and vital strategies that change the way people think and act. PATH’s work improves global health and well-being. street address 2201 Westlake Avenue Suite 200 Seattle, WA 98121 USA mailing address PO Box 900922 Seattle, WA 98109 USA info@path.org www.path.org November 2011

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