India - Counting What Counts: Tracking Access to Emergency Contraception
Publication date: 2013
April 2013 Policies support the use of Emergency Contraception (EC) in India: EC is included in national policies for family planning, social marketing programs have procured EC, and local drugstores and pharmacies distribute EC. In addition, community health workers can distribute EC. Many EC products are available, but knowledge of EC is still very low and use seems to be more common in urban areas. ABOUT INDIA India is the second most populous country in the world; it has an estimated population of 1,220,800,359.1 The country is predominantly rural with 70% of the population living in non-urban areas.1 CONTRACEPTIVE KNOWLEDGE AND USE POLICIES Essential Drug List: The 2011 EDL does not include levonorgestrel (LNG) at the dose needed for EC.2 National Norms and Guidelines: The Drug Controller General of India approved LNG for EC in 2001 and it has been distributed as part of the Family Welfare Programme since 2003. In 2008, the Ministry issued the Guidelines for Administration of Emergency • Total fertility rate: 2.68 births per woman (2.98 Rural, 2.06 Urban) • Unmet need for contraception among married women: 12.8% • Current contraceptive modern method use among currently married women: 48.5% • Female sterilization accounts for the majority of current contraceptive use. • Ever use of EC is reported at 0.6% nationally in 2007-2008. • Knowledge of EC: Overall, the average level of EC knowledge across states was 13.83%. However, EC knowledge differs greatly by state, with several states having levels lower than 5% and others having levels above 25%. Sources: National Family Health Survey, India 2005-2006 (for knowledge and ever use of any modern method and knowledge of EC); District Level Household and Facility Survey 2007-2008 (for ever use of EC). Contraceptive Pills by Health Care Providers3 which states that EC “is a safe and effective method of preventing these unwanted pregnancies following failure of contraception or unprotected sexual exposure, which in turn helps in reducing the maternal morbidity and mortality due to unsafe abortions.” ECPs can be distributed over-the- counter by all clinical, nursing, and paramedical providers. EC is also included in the kits of the cadre of community health workers known as Accredited Social Health Activists (ASHAs). Sales data indicate that sales of EC are growing each year, with 15 million packs of EC being sold in 2010, about two- thirds in urban areas and a third in rural areas.4 Prescription Status: LNG pills are classified as over-the-counter drugs and do not require a prescription. Policy on Advertising: Previously, advertising of EC was allowed and for some months it was aggressively advertised by manufacturers, including on television. These advertisements generated complaints from groups that considered them risqué. In response, in 2010 the government issued a temporary ban on EC advertising. After about a year the government began developing a policy to allow manufacturers to advertise their ECP products, after review of their advertisements by a committee set up by the Ministry of Health and Family Welfare. Post-rape care: A 2008 study of post-rape care in India found that 67% of practitioners offered victims of sexual violence ECPs, however only 25% of clinics were stocked with ECPs at the time (clients were often referred to purchase them in the INDIA In di a COUNTING WHAT COUNTS: TRACKING ACCESS TO EMERGENCY CONTRACEPTION In di a 2 market).5 More information is needed on the official policy for post-rape provision of ECPs. PRODUCT AVAILABLITY Registered products: The ICEC database (accessed at www.emergencycontraception.org) lists 7 LNG EC pill products registered and distributed in India; anecdotal evidence suggests that there are many more brands of ECPs available in India. Locally manufactured products: India has a strong hormonal manufacturing sector which supplies ECPs within India and increasingly around the world, including to social marketing organizations. Poor quality or counterfeit EC products: There is concern about poor quality ECPs in India. A 2010 article reported that 1 in 5 ECPs is fake or of sub-standard quality.6 In October 2011, the BBC reported that up to 25% of pharmaceuticals available in developing countries may be counterfeit, most of which are produced in India or China.7 WHERE WOMEN CAN ACCESS EC EC in the commercial sector: India’s commercial sector is vibrant and we are informed that the vast majority of ECPs distributed in India are through the commercial sector. EC in the public sector: The health system is administered by the Ministry of Health and Family Welfare and provides contraceptive counseling and distribution through its Family Welfare Programme. ECPs were introduced into the Family Welfare Program in 2003. EC in the NGO, social marketing, and social franchising sectors: The Contraceptives Social Marketing Statistics report (from DKT International) indicates that 979,050 packets of EC were sold in 2011 by four organizations – PSI, DKT, MSI/PHS, and World Health Partners.8 Community-based distribution of EC: In 2011, India approved community level distribution of EC by community health workers (ASHAs). ASHAs are authorized to sell EC and other short- term contraceptive methods (condoms and oral contraceptives) at a nominal price. However, in districts where ASHAs are selling EC, the free supply of EC will be withdrawn from the primary health center level. As this is, to our knowledge, the first large-scale community-based distribution of EC, evaluation of this effort could provide valuable lessons for other countries invested in community- based health workers. PROVIDERS AND KEY OPINION LEADERS A recent study9 on providers’ knowledge of ECPs found that 19% of doctors and 29% of paramedics had incorrect beliefs about EC’s mechanism of action. Key opinion leaders (KOLs), including OB/GYN experts, senior officials of medical associations and donor agencies, and senior program managers of the Ministry of Health and Family Welfare support ECP remaining available over the counter; however, some medical bodies are opposed to such access, preferring that women should obtain EC through medical providers. Two- thirds of KOLs (13 out of 19) expressed serious concern that EC is not being used as an emergency pill but as a repeated method, and that it is advertised or promoted as such. Some suggested that there is a need to advertise ECP correctly (i.e. should only be used in emergencies), that EC promotion should be linked with regular methods, and the pack should be more informative. MEDIA COVERAGE OF EC According to the 2005-2006 National Family Health Survey, approximately 65% of women are exposed to some form of mass media at least once per week.2 There has been wide coverage of EC in India over the last few years. In July 2011, the Times of India published a potentially polarizing article entitled “Morning-after pill: A medical nightmare?” asserting repeat use to be rampant, especially among young people who, the story incorrectly claimed, could suffer serious health consequences.10 Throughout 2010, however, the Times also reported on less controversial aspects of ECPs, including an Indian Council of Medical Research study demonstrating that nearly 70% of women had no side effects from taking ECPs11 and a study by the Surat Government Medical College that found that very few women knew how to properly use ECPs.12 In the international media, Time Magazine published an article in May 2010 reporting on high sales of EC in India. India 3 DONOR SUPPORT The Indian government procures 100% of contraceptives distributed in the public system. However, donors (including USAID, the Bill & Melinda Gates Foundation, and others) are also involved in the family planning sector in India. CONCLUSION EC access in India is generally good with many products on the market, and favorable policies. However, EC knowledge among women is low, particularly in rural areas, and many concerns about EC have been expressed by key opinion leaders. REFERENCES 1 CIA World Factbook. Retrieved November 21, 2011, from https://www.cia.gov/library/publications/the- world-factbook/geos/in.html. 2 National List of Essential Medicines of India 2011. WHO National Medicines Lists. (http://www.who.int/selection_ medicines/country_lists/India_NLME_2011.pdf) 3 Guidelines for Administration of Emergency Contraceptive Pills by Health Care Providers. November 2008. Family Planning Division, Ministry of Health and Family Welfare. 4 Khan, ME. Emergency Contraception in India: Current Status and Future Challenges. Presented at International Conference on Family Planning in Dakar, November 2011. 5 Khan, ME et al. A Situation Analysis of Care and Support for Rape Survivors at First Point of Contact in India and Bangladesh. USAID, September 2008. (http://pdf.usaid.gov/pdf_docs/PNADP414.pdf) 6 Shwetha, S. Fake contraceptive tablets flood the market. DNA India, January 9, 2010. (http://www. dnaindia.com/bangalore/report_fake-contraceptive- tablets-flood-the-market_1332636) 7 Kannan, Shilpa. Counterfeit Drugs Targeted by Technology in India. BBC News, October 11, 2011. (http://www.bbc.co.uk/news/business-15208595) 8 Contraceptive Social Marketing Statistics. DKT International, Washington, DC, June 2012. 9 Khan, M.E., et al. Providers’ and Key Opinion Leaders’ Attitudes, Beliefs, and Practices Regarding Emergency Contraception in India: Final Survey Report. Population Council: New York, 2012. 10 Durgesh Nandan Jha, TNN. Morning-After Pill: Medical Nightmare? The Times of India, July 23, 2011. (http://articles.timesofindia.indiatimes.com/2011-07- 23/delhi/29806984_1_morning-after-pill-emergency- pills-population-council) 11 No Side Effect of Emergency Contraception. The Times of India, August 21, 2010. (http://articles.timesofindia. indiatimes.com/2010-08-21/health/28273329_1_ emergency-contraceptive-pills-levonorgestrel-pill-users) 12 Emergency contraceptives! What is that? Times of India, October 13, 2010. (http://articles.timesofindia. indiatimes.com/2010-10-13/surat/28251160_1_ contraceptives-pills-spread-awareness) This fact sheet has been prepared by the International Consortium for Emergency Contraception and represents the best information we have been able to gather. We welcome your input for future revisions. Please contact us at firstname.lastname@example.org. Visit our website at www.emergencycontraception.org for more information on EC.