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Thinking (Re)Productively

It’s all about women: creating healthy, functional markets to address the unmet global need for contraception

Denise L. Harrison, Thu Do

In 2012, dozens of organizations and hundreds of individuals met in London for a groundbreaking Summit on Family Planning to increase global access to family planning services. This visionary group of governments, civil-society members, multilateral organizations, donors and private sector groups agreed to support the research and development community to enable 120 million more women and girls in 69 developing countries to use contraceptives by the year 2020 [1]. The work of this Summit has been organized under the banner of Family Planning 2020 (FP2020) and is facilitated through the FP2020 Secretariat, headquartered at the United Nations Foundation offices in Washington, DC. This initiative represents an unprecedented step forward in improving the quality of life of women and girls worldwide [2].

As the global family planning community ratchets up efforts to empower these 120 million women and girls, FP2020 collaborators have put into motion a set of diverse approaches to create societal change. For developing and developed countries, we strongly advocate for infusing a robust, business-oriented approach into FP2020 strategies that explicitly incorporates women’s voices. We are proposing a fresh “total market” perspective that incorporates lessons learned from past efforts that focused on using market forces but did not include more business-oriented approaches. A large number of women in developing countries obtain their family planning from the private sector, and we propose that more intentional integration of private sector strategies will increase overall sustainability of these services in the developing world [[3][4]]. It is essential to listen carefully and to thoroughly integrate their varied contraceptive needs and support requirements into our plans. Otherwise, FP2020’s goal will be difficult to meet.

One fundamental marketing framework — the “4Ps and 4Cs” — has great potential for success if incorporated into the international family planning community’s strategies over the next decade [see the chart]. The 4Ps (product, price, placement and promotion) and the 4Cs (customer, cost, convenience and communication) encompass the commonly accepted lenses through which most market dynamics are analyzed [[5][6][7]]. While a successful business approach addresses profit and loss, it is important to take the first step, which is developing a strong marketing mix framework that pays attention to the 4Ps and 4Cs as drivers of a healthy market. Developing and developed countries can benefit by defining the global contraceptive market to include the public and nongovernmental, social marketing and commercial organizations — also called a “Total Market Approach” — to optimize the use of public and private resources [8].

Recent analysis on contraceptive market strategy and market shaping typically takes the perspective of donor and funder objectives [9]. Unfortunately, this focus presents a potential sustainability challenge: donors will not be able to subsidize contraceptive commodities for evolving markets over time. Donor subsidies will remain necessary where there is no viable commercial channel, but in evolving markets, there is the opportunity to optimize these systems for efficiency. There is evidence that public sector supply chains are crowding out commercial supply chains, making increasing family planning support through the public sector unnecessarily more costly for donors and governments, without maximizing choice for women [10]. Ensuring that women have choices does not mean that government has to pay for or subsidize all the choices. Women and various forms of risk pooling or insurance schemes can pay for choices as well, as long as they are available in the market.

The long-term success of FP2020 depends on strategically enabling healthy contraceptive markets in which all stakeholders — donors, governments, the commercial sector, nongovernment organizations and the public — carefully focus on the long-term needs and wants of women.

The current literature leads to the conclusion that a functioning market can result in increased contraceptive choice and affordability [9]. Choice, in this context, is defined as the ability of women to choose from among several contraceptive methods according to personal preference, culture, age and medical condition; sexual and relationship status and other factors. Affordability — which is a part of sustainable health outcomes — is defined as prices that meet users’ and funders’ ability and willingness to pay, but also incentivizes manufacturers to remain in the business. We challenge this prevailing definition of a functioning market and instead propose what a healthy, functioning market that can help reach FP2020 goals looks like. This approach should involve both the public and commercial sectors, and it needs to utilize the right mix of 4Ps/4Cs to focus on end-user objectives.

The 4Ps and 4Cs are parallel elements in a marketing strategy [[5][6][7]].

Product/Customer — The type of contraceptive (and packaging) that addresses the needs and wants of the end user, meeting a wide range of needs and wants for a wide-range of customers.

Price/Cost — The price of the contraceptive is affordable to the end user, and there are varying prices for varying perceived benefits.

Placement/Convenience — The placement of contraceptives is convenient to end users, available in accessible outlets such as pharmacies, drug stores, private clinics as well as public health centers.

Promotion/Communication — The promotion of contraceptives is communicated in a way that is easy to come by and addresses cultural and societal barriers to contraception.

By optimizing the 4P/4C mix, access to and use of family planning can be increased.

1. Signs of a healthy market: products and customers

1.1. Requirement: a wide range of contraceptive methods and of quality products and brands are available, and an innovative pipeline is in place that meets women’s needs

A healthy market should offer a wide variety of contraceptives that are approved by appropriate regulatory agencies, which meet end users’ needs and wants, and that are perceived to be valuable. The current literature states that a functioning contraceptive market offers different methods. However, a healthy market in the eyes of the end user offers not only a wide range of methods but also a wide range of products and brands [8].

We propose that, in an attractive marketplace, newer formulations of products are available in addition to basic products. Options for long-acting, reversible contraception, sterilization, continuous regimen pills and fertility awareness methods, for example, are currently available and valued and should be added to the mix. Also, while brands may not matter much to a funder, they matter to end users — especially in emerging contraceptive markets [11]. Regulatory bodies are aware that there are reports noting that some people may experience an undesired effect when switching from brand name drugs to a generic formulation or from one generic drug to another generic drug [[12][13]]. Brands tell women what to expect and assure that they are making good choices. Funders may be tempted to reduce costs by focusing on making just one product per method available in each region. However, to meet women’s needs more choices may be necessary, and increasingly, pharmaceutical companies are reaching low-income clients in developing countries with a diverse portfolio of affordable, quality, sustainable products — why not for contraceptives? [14]. A wide range of methods, products and brands that truly meet women’s preferences needs to be available if we wish to sustain a healthy market over the long term.

Regulatory bodies are essential partners in developing a healthy market by helping to ensure quality manufacturing and importation. Functional contraceptive markets feature regulatory agencies that enforce consistently high-quality products across all outlets and establish contraceptive safety and efficacy while allowing women to select products based on their desire to avoid side effects and other quality-of-life measures.

1.2. Requirement: incentives are in place for a wide choice of contraceptives and for their consistent availability

The future market for contraceptives is potentially made more successful through regulatory and pricing environments, which encourage and reward innovation while safeguarding safety and effectiveness. Such policies are likely to attract investors, resulting in a healthy pipeline of innovative products. The most functional market necessitates a balance between the predominance of very low-priced products and a healthy, innovative pipeline. There is evidence that drug companies are focusing more on developing drugs that governments and insurance companies will purchase and reimburse over innovation, which may be considered too costly by institutional payers regardless of need [15]. However, a sign that a market is healthy is that customers believe that their options will continue to grow and improve, resulting in increasingly attractive contraceptive technology for both end users and business. If new technology is commercially successful and adopted, prices are likely to come down with increased use and competition. We advocate for increased investment in contraceptive technology to help ensure a functional marketplace [16].

2. Signs of a healthy market: price and cost

2.1. Requirement: financing options are widely available that allow women to obtain the method, product and brand that is best for them

In a healthy market, contraceptives are perceived to offer good value for their price, and there are options for payment. In these conditions, women believe that they are getting good value for their money, including health, economic and personal benefits. Moreover, end users who want to pay for better services, brands, manufacturers, locations or increased privacy have the freedom and opportunity to do so. Insurance plans cover all safe and effective methods and most brands in this scenario, and women understand that they have a wide range of options of paying for their optimal contraceptive. Another condition is that free and subsidized products are available but in limited quantities that are well targeted such that large institutional purchases do not ‘crowd out’ retail markets or discourage new innovations or entrants [10]. In the U.S., the Affordable Care Act provides for some contraceptive brands and methods to be free while others require payment, reflecting a business-oriented and total market approach [17].

3. Signs of a healthy market: placement and convenience

3.1. Requirement: convenient private retail and public sector outlets with trained personnel are readily available

Contraceptive funders and users have similar interests in ensuring product availability. However, women may value convenience and privacy more than funders. We propose that a healthy contraceptive market makes birth control widely available in public and private facilities, including retail outlets and other regulated channels. Providers and pharmacists in these environments should be incentivized to recommend and provide products based on a woman’s health, medical needs, lifestyle and interest in spacing or limiting births. Through culturally appropriate outreach, women should know that her provider/pharmacist can suggest a method that best meets her personal needs and wants and can then help her select different methods as her lifestyle changes or when a product does not work for her.

4. Signs of a healthy market: promotion and communication

4.1. Requirement: culturally appropriate, market-tested outreach for branded and generic products is implemented regionally and globally

Healthy contraceptive markets can also support women who are starting — or continuing — to use birth control. Information on these conditions should be easy to come by and to understand. Direct-to-consumer advertising and other communications addressing cultural and societal barriers to contraception should be acceptable and common. Contraceptive education and promotion can have great potential for impact when linked to the emotional, cultural and religious issues surrounding sex. Pharmacies, clinics, doctors’ offices, libraries, schools, spas, beauty salons and other places frequented by women should have educational information available. For women to believe that they can use contraceptives easily and successfully, branded and unbranded advertisements must be seen in mass media, social media and other information outlets, using celebrities and other well-known spokespersons. Social marketing organizations should not be the only organizations to use such successful communications approaches — government strategies should adopt them as well, and more financial support by governments and donors for social, behavior and communications change (SBCC) is needed.

How Changing “Convenience” and “Communication” in the Marketing Mix Is Increasing Postpartum Acceptability of IUDs in India

In 2007, IUD use in India represented only around 2% of all modern methods. To increase women’s knowledge and acceptability of this well-known, low-cost contraceptive, Jhpiego and PSI decided to work with the Ministry of Health to focus on postpartum services within maternal and child health care services in addition to stand-alone family planning service delivery points. Contraceptives are free of charge for all women in India, and IUDs have been available for decades. Therefore, Cost and Client did not seem to be as much of a barrier as Convenience and Communication to improve provider/patient product perceptions of the IUD did. Offering one-stop services for delivery and postpartum FP services including IUD insertion made accessing IUD insertion more convenient. Although the method is still not very popular, dispelling myths about the IUD among clients and advocating WHO guidelines on IUD postpartum insertion is resulting in more women having access, the ability and ease of making a method choice including IUDs in India [18].

The ultimate sign of a healthy contraceptive market is when most sexually active women who want to avoid pregnancy use contraceptives and believe that contraceptives are good for their health and help them achieve their personal and intimate goals. How can the international family planning community play a stronger role in addressing women’s nonuse of contraceptives in the FP2020 69 priority countries?

(1) Increase the family planning community’s understanding of the 4Ps and 4Cs of market dynamics and revive U.S. Agency for International Development’s Strategic Pathway to Reproductive Health Commodity Security framework, which was developed in 2004 to strengthen family planning programs across sectors and puts the end user at the center of interventions [19].
(2) Develop significantly more market-based incentives to attract a competitive number of quality manufacturers and suppliers to invest in products meeting women’s needs and wants.
(3) Advocate for effective policies regarding pharmacy/pharmacy chain ownership, pharmacy and “drug store” regulation and licensing, pharmacist certification and financing to increase the availability of quality products at different price points [20].
(4) Encourage policy development at the country level that advances more accurate and attractive information for end users, including direct-to-consumer and brand advertising across diverse channels in addition to the creation and effective diffusion of SBCC and communication materials.
(5) Improve and secure supply chains in all sectors while advocating for liberalized trade and distribution processes.
(6) Advocate for product and trade regulation that ensures quality without compromising market growth, especially the nonsubsidized private market.
(7) Prioritize routine collection of market data by third-party experts to determine current product availability, pricing and distribution in all sectors as well as its impact on end users. Such data should be used as a part of evidence-based decision making.
(8) Conduct research to determine how this approach impacts family planning advancement in developing countries.

Developing a healthy contraceptive market in the developing and developed worlds is essential if we are to reduce the unmet need for contraception and meet FP2020 goals, and it is all based on the needs and wants of women.

Disclaimer

The views expressed in this editorial are solely those of the authors and do not necessarily reflect the opinions or views of the U.S. Agency for International Development, the Results for Development Institute or the Association of Reproductive Health Professionals.

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