Encouraging commercial family planning services for people who are able to pay is one way to improve services for those who cannot pay, experts say. By attracting some clients to the commercial sector, public resources can be used more effectively to serve lower-income clients.
"Governments need to identify their most appropriate role. They need to provide free services for those who cannot afford them, but in a lot of countries, middle-class people use these free government clinics as well," says Robert Bonardi, who was deputy director of the recently concluded Promoting Financial Investments and Transfers (PROFIT) project, an effort that coordinated private sector initiatives throughout the world.
Few developing countries, however, have a viable commercial market for contraceptives. Well-trained commercial providers, a dependable supply system for commodities and a pool of potential customers are needed for a commercial system to succeed. "You have to convince consumers that the private sector can be advantageous to them, that these services are affordable, high-quality and convenient," says Bonardi. "Governments can play a supportive role by ensuring that regulations do not hinder the private sector and that public programs do not compete with the private sector in counterproductive ways."
The commercial sector may include physicians, clinics, pharmacies or hospitals that are generally financially independent of ongoing government or donor agency subsidies. Public funds might be used, however, to stimulate consumer interest in the commercial sector.
Across varying cultures and political systems, researchers have identified a few common factors that seem to be crucial to commercial success. These include the level of urbanization, the number of physicians per capita, and the extent of free contraceptive services available. "Because family planning is a relatively specialized market, a large enough client base in an urban area needs to exist in order for a commercial medical practice or clinic to survive," says William Winfrey of The Futures Group International, a U.S.-based organization. Also, places where there are more doctors per capita tend to have more physicians working in the private sector, making a commercial effort more viable. Where people have access to free contraceptives, says Winfrey, "they have little or no incentive to pay for the same products at a commercial facility" unless other aspects are appealing, such as convenience. Winfrey has found no association between a country's contraceptive prevalence and commercial sector involvement.1
The commercial sector has generally been slow to expand into the family planning field because of free public services, lack of information and training, legal restrictions and other reasons. Free contraceptives reduce the competitiveness of the private sector, notes Dr. Jaikishan Desai, formerly a Futures Group International research analyst. Moreover, promoting contraceptive services through advertising is rarely done where services are free or at low cost. Since advertising is a powerful motivating force among consumers deciding how to spend disposable income, lack of advertising makes commercial interest less likely.2
Convenience and access
Despite these obstacles, a strong commercial market in family planning has evolved in a few developing countries, mostly in Latin America, North Africa and the Middle East. The commercial sector provides about 60 percent of contraceptives in Bolivia and Paraguay and more than 40 percent in most other Latin American countries, as well as in Turkey, Egypt and Jordan.3 While the commercial sector is generally small in other regions of the developing world, some governments have recently made commercial involvement a priority.
For the commercial family planning sector to survive and expand, consumers must have incentives to use these services. "These consumers prefer private sector services because of convenience, greater access, better confidentiality and quality," says Don Levy, director of the Future Group's Social Marketing for Change (SOMARC) project. For example, he says, consumers prefer using the same doctor regularly and receiving private, personalized service, as long as the price remains affordable. "Our expansion in the direction of clinical services through the private sector demonstrates that affordable services for intrauterine devices (IUDs) or sterilization, for example, are much preferred to less expensive public services."
Analysts debate the viability of expanding the commercial market in countries where contraceptive prevalence is very low, especially in sub-Saharan Africa. Some say the level of consumer interest is insufficient for a viable commercial sector. Another perspective, says Winfrey, "is that the commercial sector can be leveraged, from the earliest stages of program development, to foster program growth in terms of increasing both contraceptive prevalence and sustainability."
A recent review of family planning costs and financing in sub-Saharan Africa found that many countries do not encourage the private sector. "Many of the constraints to commercial sector expansion in sub-Saharan Africa stem from a lack of appreciation of the potential for public-private collaboration in service delivery or financing," explains Dr. Barbara Janowitz, who directs FHI's research on economic issues. "The government must sign on to any effort to improve the environment for commercial sector expansion if it is to be effective."
Some African countries are seeking to eliminate laws, regulations and other structural barriers to private sector involvement. In Sudan, for example, the government placed oral contraceptives on its list of essential drugs, reducing import barriers and improving supply. In Senegal, after a meeting between the Ministry of Health and the National Association of Pharmacists, the tariff on imported condoms was abolished.4
Training private providers
Some donor agencies and government health ministries help train private-sector providers in family planning. Some also help to develop employer-based services. Projects in Zimbabwe, Romania, Indonesia, Jamaica and Turkey illustrate various approaches under way.
The Zimbabwe National Family Planning Council (ZNFPC), which coordinates public family planning clinics, is training private doctors, nurses, midwives and pharmacists in family planning information and skills. The project has also worked closely with two medical insurance companies to publicize the fact that coverage is available for family planning services, and it is encouraging pharmaceutical companies to sell commodities at a low cost to the private sector.
"The public sector was unable to meet all the demands because people who can afford to pay for contraceptives are using the free clinics," says Roxana Rogers, family planning advisor for the U.S. Agency for International Development (USAID) in Zimbabwe and a member of a coordinating committee of physicians, pharmacists, retailers and others planning ways to encourage commercial services. "People were already shifting to the private sector, but in an uncoordinated way. We were able to make this happen in a quicker way."
An assessment of the commercial sector found that 6 percent of Zimbabwe's population is covered by medical aid societies, a form of private insurance. While most of the groups offer coverage for family planning, few members use this option. Moreover, most private clinic managers did not know they could submit claims for family planning services to the medical aid societies. The project also encouraged companies that have nurses for their employees to send the nurses to a four-week course on family planning services. And, nearly 200 peer educators have been trained at eight companies to talk especially with men about family planning issues.5
A consumer information campaign is emphasizing quality and convenience. "We need to let women know that they can get good quality services from private providers," says Rogers. "We also need to help the providers have access to low-cost contraceptives in the commercial sector." In 1997, the coordinating committee worked closely with the Ministry of Finance to reduce the tariffs on contraceptives.
Pharmacists and midwives
Two groups of commercial providers that are often underutilized are pharmacists and midwives. The Zimbabwe project trained 90 private pharmacists in providing family planning services. It also developed a quick reference guide for pharmacists on contraceptives, communication and counseling skills, and business practices, and distributed it to more than 300 pharmacists. The reference guide was endorsed by the Ministry of Health, ZNFPC, University of Zimbabwe Medical School and the Retail Pharmacist Association (RPA). "This project provided the coordination we needed," says Andrew Vaughn, RPA vice-president. "We did not have the time and resources to take these steps on our own."
The project also assisted six model pharmacies to have a nurse on hand for family planning counseling and minimum screening tests in a quiet, private space. In Zimbabwe, pharmacists can dispense contraceptives.
 A project in Romania involved the National Pharmacists Association, the University of Bucharest Department of Pharmacy and a local ad agency. Coordinated by PROFIT, it sought primarily to involve young people in family planning. The project trained 195 private pharmacists, almost all of them women, and developed an easy-to-read resource book summarizing contraceptive technology, distributed to 3,500 pharmacists.
An information and ad campaign used television, radio, print media, brochures and special events to encourage young women to buy contraceptives at pharmacies, using a silhouette of a young man and woman and the slogan, "Love Carefully -- You Can Choose When to Have a Child." From 1996 to 1997, the sale of oral contraceptives at private pharmacies increased 25 percent. Also, a survey comparing 67 trained pharmacists with 102 pharmacists without training found that those with training demonstrated more knowledge about mechanism of action, correct use, side effects and effectiveness.6
In some countries, midwives could provide more contraceptive services. The Indonesian health ministry has trained midwives, but there are not enough public-sector jobs for all of them. To bolster the involvement of these midwives in the commercial sector, a U.S. $1 million revolving loan fund project in Indonesia was implemented through a midwives association, the national family planning program and a major bank. PROFIT supplied half the money for the loans, with the bank providing the other half, allowing relatively low interest rates for loans to renovate clinics, buy equipment or purchase supplies. Some midwives used loans to establish a new practice.
Among the 372 midwives who participated, most borrowed the maximum amount of U.S. $2,300 for 36 months. Only 6 percent of the borrowers were from villages, despite efforts to encourage village participation. In addition to attracting public sector clients, the project may be expanding overall contraceptive use. About 12 percent of the borrowers' new clients had previously used public sector sources, while more than 75 percent had never used family planning. The remaining new clients had previously seen other private providers.7
Midwives and pharmacists can help expand commercial sector involvement, concluded PROFIT. "Pharmacists can be effective family planning educators, particularly in countries where they can sell contraceptive pills without a doctor's prescription," PROFIT said in a "lessons learned" report, written when the USAID-funded project ended in 1997. Similarly, PROFIT found that midwives in Indonesia, Philippines and Zimbabwe had a "strong desire to expand into the private sector and a strong need for assistance to do so."
Private physicians
Innovative means to get private doctors involved is also needed, such as targeted training programs. In the Caribbean country of Jamaica, some 200 private physicians have attended a series of continuing medical education seminars on family planning methods over three years. USAID funding for family planning has been gradually declining in Jamaica, putting more pressure on the National Family Planning Board to find ways to engage the commercial sector.
Jamaica has high contraceptive prevalence (67 percent) and a substantial middle class that can afford to pay for family planning services. Yet few private physicians have been providing these services, since free commodities have been available at public clinics. An assessment found that private doctors opposed using some methods because of a lack of knowledge. For example, 24 percent of those surveyed thought incorrectly that the injectable depot-medroxyprogesterone acetate (DMPA) was unsafe and 16 percent believed incorrectly that it resulted in permanent fertility problems.8
The Medical Association of Jamaica, which has chapters throughout the island, working with the National Family Planning Board and FHI, developed a series of training seminars for private physicians. FHI has conducted eight seminars covering reproductive physiology, an overview of all modern contraceptive methods and special issues, such as family planning for adolescents. More than 70 physicians who attended at least six of the eight seminars received certification in family planning through the Medical Association of Jamaica.
"We know the interest among private physicians for offering family planning is high," says Lynn Adrian of FHI, who worked with the project. "We hope this interest will result in substantially more commercial-sector provision of services."
Social marketing
Social marketing has successfully involved the private sector in contraceptive distribution, especially the distribution of condoms to prevent the spread of sexually transmitted diseases, including HIV.
Social marketing uses commercial marketing strategies for a social purpose, usually selling the product at a subsidized rate. A typical project develops a network of outlets for selling contraceptives, building consumer awareness of the product through advertising, often using a logo or symbol that can be displayed at participating pharmacies and shops. In Uganda, while millions of condoms are given away free through the public sector, a social marketing program still sells millions more per year by targeting messages to specific audience segments. An appealing logo and packaging build a loyal clientele.
In several projects, this social marketing model has been expanded to promote providers as well as specific products. In Turkey, for example, SOMARC developed a network of commercial health-care facilities to offer high quality family planning services at affordable prices. Called Kadin Sagligi Ve Aile Planlamasi Hizmet Sistemi (KAPS), which means Women's Health and Family Planning Service System, the network includes more than 150 outlets in Istanbul. The Turkish Family Health and Planning Foundation (TFHPF), Marketing Systems and AVSC International are partners in the effort.
The project recruited providers for the network, developed a site assessment form to monitor quality, and in order to promote quality practices, required those providers who wished to belong to KAPS to send their staff to a three-day training program.
It negotiated with the members of the network to reduce their fees because consumer surveys showed high prices discouraged use. Several hospitals reduced sterilization fees by 30 percent, for example, and KAPS members agreed to post a price board in the reception area, making consumers aware of available services and prices. KAPS operates a telephone hotline to answer family planning questions. Also, local community promoters contact women to tell them about services.
Client surveys found that the portion of postpartum clients who received family planning information went from virtually no counseling to 31 percent after the network's first year.9 "The services network is evolving, being improved and revised," says Levy of SOMARC. "The model is being tried in Nepal and the Philippines."
-- William R. Finger
References
- Winfrey W, Heaton L, Dayaratna V. What drives the commercial sector for family planning? a comparative analysis. Presentation at Population Association of America meeting, Washington, March 27-29, 1997.
- Desai J. The private sector in family planning services: demand and supply issues. Unpublished paper. The Futures Group International, 1997.
- Winfrey W, Heaton L, Fox T. The commercial sector in family planning: preliminary results. Unpublished paper. The Futures Group International, 1997.
- Janowitz B, Measham D, West C. Family planning costs and financing in sub-Saharan Africa -- Draft. Unpublished paper. Family Health International, 1997.
- Weinman JM. Private Sector Subproject, Zimbabwe. Final Evaluation Report, September 1995-August 1997. Arlington, VA: PROFIT, 1997.
- Weinman JM. Private Sector Subproject, Romania. Final Evaluation Report, October 1995-September 1997. Arlington, VA: PROFIT, 1997.
- Sherpick AR, Hopstock PJ. Baseline and Follow-up Data on Participants in the PROFIT Revolving Loan Fund for Midwives (Indonesia). Arlington, VA: PROFIT, 1997.
- Bailey W, McDonald OP, Hardee K, et al. Family Planning Service Delivery Practices of Private Physicians in Jamaica. Final Report. Kingston: National Family Planning Board, 1994.
- Cisek CR, Cankatan H. Stimulating private health-care facilities to increase and improve reproductive health services: the KAPS network in Turkey. Unpublished paper. The Futures Group International, 1997.
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