Assessment of the Pregnancy Test Market in Malawi

Publication date: 2017

Assessment of the Pregnancy Test Market in Malawi Malawian reproductive health policies support the use of pregnancy tests in family planning services. The tests are widely available at private facilities. However, there is currently no public procurement by the Central Medical Stores Trust. The SHOPS Plus project conducted a market shaping assessment of pregnancy tests in Lilongwe, Malawi. The assessment shows that pregnancy tests are widely available in the private sector, which offers a range of different brands at varying price points. However, the tests are rarely available at public clinics, leading providers to send clients to the private sector or to ask them to return during their menses. In both scenarios, women may exit the health care system without ever obtaining a family planning method. The primary opportunity to increase the availability of pregnancy tests in family planning services is advocacy and support for public procurement, through funding and possibly a country-specific impact model. There may also be room to improve supply chain systems. Partnering with existing social marketing or community programs could make private sector pregnancy tests more affordable for public sector clients who are referred to a retail outlet when a public clinic is stocked out. 2 | Assessment of the Pregnancy Test Market in Malawi Demand satisfied (married women) 75% Contraceptive prevalence rate, modern methods (married women) 59% Background Screening for pregnancy is often an important step in supporting the immediate start of a contraceptive method when a woman seeks family planning services. Pregnancy status can be determined by conducting a pregnancy test or patient history using the pregnancy checklist. The checklist was developed by the World Health Organization (WHO) and comprises six questions about medical history. Answering “yes” to at least one of the questions allows the provider to be reasonably sure that the patient is not pregnant. If pregnancy cannot be ruled out, the patient may be asked to come back during her next menses. Ensuring same-day provision of family planning methods is an important way to ensure reliable access to contraception for women and protect them from unplanned pregnancy. Studies suggest that making pregnancy tests more widely available can increase the same-day start of contraception for women seeking family planning services and reduce delay and denial by providers. Family Planning 2020’s goal includes an emphasis on country-level efforts related to increasing access to quality family planning information, services, and products. Pregnancy tests can play an important role in these efforts. In Malawi, 45 percent of women use modern contraception (table). Six percent of women in Malawi get their family planning method or information from a private medical source (Figure 1). The purpose of this market assessment was to collect and analyze country-level market data for pregnancy tests and their use in family planning services to evaluate whether interventions are needed to increase availability and access to low-cost, quality pregnancy tests. Contraceptive prevalence rate, modern methods (all women) Key family planning indicators in Malawi Family Planning 2020 Indicator Percent 45% Source: 2016 Family Planning 2020 Progress Report Figure 1. Source of family planning methods and information in Malawi Source: Malawi Demographic and Health Survey 2015—2016 79% 15% Public source Private source Other 6% SHOPS Plus | 3 Methods Several methods were used to collect the information for this assessment in Lilongwe, Malawi, including secondary research, email inquiries, stakeholder interviews, and field visits. Between June and August 2016, a consultant based in Malawi conducted 60 in-depth interviews and site visits with public and private sector providers, government staff, retailers and other stakeholders. The assessment team also conducted desk research regarding national guidelines for the use of pregnancy tests in the delivery of family planning and related health services, the inclusion of pregnancy tests on essential commodity lists, and procurement practices. Interviews focused on provider clinical practices, availability and costs of pregnancy tests, and procurement practices. The assessment team collected data regarding the manufacturers, types, and costs of pregnancy tests that were available in various outlets. Outlet types included public and private clinics, private sector pharmacies, and clinics run by social marketing organizations. In-country data collection was limited to Lilongwe and the surrounding areas. Following data collection, the SHOPS Plus team analyzed the findings, utilizing the USAID Center for Accelerating Innovation and Impact market shaping primer Healthy Markets for Global Health (Figure 2). This process involved identifying possible market weaknesses using the criteria of affordability, availability, assured quality, appropriate design, and awareness. The team assessed provider perceptions of pregnancy test quality, but objective quality standards will be completed through a separate process led by FHI 360. To increase the access and Extent to which the price point maximizes market efficiency between payers and suppliers to support health outcomes Capacity and stability of global supply to meet demand; and consistency of local access at service delivery points Level of evidence that a product is consistently efficacious and safe Degree to which possibilities of technology maximize cultural acceptability, choice, and ease of use Extent to which end users, health care providers, and key influencers can make informed choices about product use DEFINITION Affordability Availability Assured Quality Appropriate Design Awareness Figure 2. The five A’s of market health availability of quality, lower-cost pregnancy tests, the team identified potential interventions to address market shortcomings. Source: USAID Center for Accelerating Innovation and Impact (2014) 4 | Assessment of the Pregnancy Test Market in Malawi Findings The following sections outline findings for the Lilongwe region in Malawi from the interviews conducted with stakeholders. Family planning policy The government supports the use of pregnancy tests in the context of family planning services. Policies related to the use of pregnancy tests are outlined in the Malawi National Reproductive Health Service Delivery Guidelines 2014–2019. The guidelines include both a hormonal contraceptive checklist and an adapted version of the WHO pregnancy checklist. They emphasize that in most cases, the safe provision of contraceptive methods do not require a pelvic examination or use of a pregnancy test. If available and affordable, pregnancy tests are to be used to confirm pregnancy after using the checklist and when results of the pelvic examination are equivocal. When pregnancy testing is not available, the guidelines advise the provision of a temporary method or to have the client abstain from intercourse and wait for menses to appear to confirm that she is not pregnant. Provider use of the checklist and pregnancy tests Public sector providers have copies of the adapted WHO checklist specified in the Malawi National Reproductive Health Service Delivery Guidelines 2014–2019, but are infrequently using this tool. Most public sector providers who were interviewed claimed to have memorized which questions need to be asked of new family planning clients. The Malawi Women’s Health Passport family planning checklist is often used to guide providers during a family planning examination. Pregnancy status is one of the observations a provider must make; however, the passport does not give guidance on how to determine it. Pregnancy determination is mostly done by patient history. If clients are not menstruating, they are either told to return when they are, or are referred to the private sector to purchase a pregnancy test. Although providers who were interviewed do not track how many women returned to the clinic for a family planning method, some estimated it was less than 50 percent. In the private sector, both awareness of the WHO checklist and practice related to the use of pregnancy tests in family planning varied. Providers at Population Services International and Banja La Mtsogolo affiliated franchises, Tunza and Blue Star, use their franchise’s guidelines in the provision of family planning methods. Providers were aware of these guidelines and reported conducting pregnancy tests on all new family planning clients. Independent private providers indicated that they typically do not use the WHO checklist, but did report using pregnancy tests to confirm status when the patient’s history suggested pregnancy was possible. Practice is not standard across independent providers. SHOPS Plus | 5 Availability Pregnancy tests are not typically available in public clinics in Lilongwe. Interviewees indicated that their facilities had been stocked out of pregnancy tests for three years or longer. Anecdotally, the limited stock that is available may be prioritized for antenatal care clients. Public providers expressed concerns about referring clients to private clinics or pharmacies to purchase pregnancy tests, as some of their clients are unable to pay for them. In contrast, pregnancy tests appear to be widely available in Lilongwe’s private sector. All private independent clinics and franchised clinics had pregnancy tests available at the time of the consultant’s visit. All pharmacies and drug stores visited (18) had pregnancy tests available at the time of the consultant’s visit. While 13 different pregnancy test brands were identified, all but one product were dipstick tests. Notably, the secretariat of the Christian Health Association of Malawi, a large faith-based association of facilities that primarily serve rural and hard-to-reach areas, recently began stocking pregnancy tests in response to facility demand, but reported being stocked out for nearly a year. Public procurement The assessment showed that pregnancy tests are not currently being procured for public clinics where family planning services are provided. The Central Medical Stores Trust (CMST) is Malawi’s central procurement agency through which public facilities order their supplies. The government of Malawi has not procured pregnancy tests through CMST in more than six years. At the time of the assessment, CMST had pregnancy tests in stock that were donated by the United Kingdom Department for International Development in 2015. While pregnancy test stock was available at CMST, public clinics in the Lilongwe area did not have them. Pregnancy tests are not on the country’s essential medicines list. They are classified as medical supplies, which do not require a special product registration and are not subject to any quality standards. 11101213 Brands identified Dipstick Cassette Midstream Manufacturers identified Number of pregnancy test brands, types, and manufacturers 6 | Assessment of the Pregnancy Test Market in Malawi Pricing and costs The assessment revealed a range of pregnancy test brands at varying price points available at private sector clinics and pharmacies. Prices start as low as $0.28 in retail pharmacies. Prices in private clinics are higher, ranging from $0.69 to $2.08 for the test. While retail margins are relatively high (60 to 93 percent), pregnancy tests are a low rotation product, and retail prices remain low. In both independent and franchised clinics, the cost of the pregnancy test is an additional cost to the family planning consultation fee, which ranged from $0.14 to $1.39. Pregnancy test prices are comparable to emergency contraception, and there is no evidence to suggest that pregnancy tests are unaffordable for clients that typically seek services in the private sector. For clients with limited ability to pay who typically seek free services in the public sector, it is possible that the price of pregnancy tests (when clients are referred to the private sector) is unaffordable. When available, pregnancy tests in the public sector are reportedly provided free of charge. Data on pregnancy test prices in rural, hard-to-reach areas was not collected in this assessment, nor was it designed to assess affordability. Product design and quality While the predominant product design available in Malawi was the dipstick, there was no evidence of provider or client concerns with design or usability. Similarly, while an objective evaluation of pregnancy test quality was not included in the assessment, interviews did not indicate procurer, provider, or client concerns with test quality. $0.69–2.08$0.14–1.39$0.69 –2.08$0.28–1.80Pregnancy tests not available Pregnancy test at public clinic Pregnancy test at retail pharmacy Pregnancy test at private provider Family planning consultation at private provider Other product for comparison (emergency contraceptive pill) Costs of pregnancy tests and family planning consultations SHOPS Plus | 7 Recommendations Enable regular procurement of pregnancy tests for family planning services in public clinics. Pregnancy tests are not typically available in Malawi’s public sector clinics because the central procurement agency, CMST, does not procure them on a regular basis. To address this gap, steps should be taken to enable the regular procurement of pregnancy tests for family planning services in public clinics. Doing so will require that funding for procurement of pregnancy tests be made available, and be prioritized amidst competing resource needs. As a first step, donors and implementing partners could validate and apply a country-specific impact model that forecasts the contribution pregnancy tests could make to family planning outcomes. Doing so would enable the Ministry of Health to make an informed decision about how to allocate resources. Partner with existing social marketing or community programs. Given that many public sector clients are forced to buy pregnancy tests in the private sector because public clinics are stocked out, a complementary intervention could seek to lower the cost of pregnancy tests for public sector clients that cannot afford pregnancy tests. One option is to partner with an existing social marketing or community-based distribution program operating in underserved areas to introduce lower-cost pregnancy tests through the private sector. This intervention may not be sustainable in the long term without subsidization of some programmatic costs. 8 | Assessment of the Pregnancy Test Market in Malawi Bibliography Family Planning 2020. “Malawi.” Accessed March 21 2017, http://www.familyplanning2020.org/entities/69. The DHS Program. “STATcompiler.” Accessed March 21 2017, http://www.statcompiler.com. Kachule, T. 2016. Pregnancy Test Marketing Shaping Activity Report – Malawi. Unpublished paper. Ministry of Health. Malawi National Reproductive Health Service Delivery Guidelines 2014–2019. USAID Center for Accelerating Innovation and Impact. 2014. Healthy Markets for Global Health: A Market Shaping Primer. Washington, DC: USAID. Sustaining Health Outcomes through the Private Sector (SHOPS) Plus is a five-year cooperative agreement (AID-OAA-A-15-00067) funded by the United States Agency for International Development. The project strategically engages the private sector to improve health outcomes in family planning, HIV, 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, Marie Stopes International, Population Services International, Praekelt.org, and William Davidson Institute at the University of Michigan. July 2017 Abt Associates Inc. 4550 Montgomery Avenue, Suite 800 North Bethesda, MD 20814 USA Telephone: 301.347.5000 Find Us SHOPSPlusProject.org Contact Us info@shopsplusproject.org

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