Meeting Rising Demand Efficiently
Faced with limited resources, family planning programs need to serve more users of injectables without greatly increasing costs. Programs can increase efficiency by:
Also, programs can recover some costs by asking users to pay for injectables if they can.
Organizing Work Better Can Save Time
Improving the flow of clients through clinics allows programs to care for more clients without lowering quality, hiring more providers, or increasing staff hours. For example, in Guatemala a clinic providing maternal and child health services improved client flow after a self-assessment by staff and a survey of clients. Clients used to wait, have a pre-visit discussion, return to the waiting room, see the provider, return to the waiting room, and then have a post-visit discussion. In the improved flow clients wait once and receive all services in one visit with one provider. This change enabled staff to see 33% more clients and reduced the wait for clients (28). For injectables users returning for routine repeat injections, clinics can set up an “express” line to save time for both clients and staff (172), while giving returning clients the option of more time with a provider if they have questions, problems, or something to discuss.
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A distributor for a social marketing program in Kenya delivers injectables to a pharmacy. Clients buy the injectable and take it to a health care provider for the injection. The availability of injectables in the public and private sector is increasing in Kenya. A projected shortfall in supplies persuaded the government to allocate funds for injectables and seek help from donors. Many women are willing to pay for injectables, and sales in the private sector have increased. Population Services International
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Recording clients’ waiting time and providers’ time spent with clients can help programs identify problems with organization of work. The COPE® (Client Oriented, Provider Efficient) process developed by EngenderHealth can help to organize work more efficiently. COPE tools include software to track the cost of staff time and supplies (52). The NGO (Non-Governmental Organization) Service Delivery Program (NSDP) in Bangladesh uses the CORE (Cost and Revenue Analysis) computer program developed by Management Sciences for Health to model the effects on efficiency and cost recovery of changes in client flow, prices, and staff time (133) (see Table 3).
Programs Can Hold Down Costs of Supplies and Facilities
DMPA and monthly injectables currently cost US$0.78 to $0.84 per dose from UNFPA. NET-EN costs 30%–50% more (91, 197). The cost of supplies for DMPA, for example, for one woman for one year (four injections) would be US$3.36 to $3.60, including four auto-disable syringes costing $0.06 each. By comparison, 12 cycles of oral contraceptives at US$0.16 to $0.63 per cycle from UNFPA would cost $1.92 to $7.56 (197). The total cost of providing injectables, of course, includes the time of the provider to counsel and give the injection and the overhead cost of the facility and equipment (see Table 3, for resources to estimate total costs).
To keep costs down programs can buy supplies in bulk, set up services in existing buildings, and share facilities with other health services.
Procure good-quality injectables, injectable equipment, and other contraceptives at the lowest available price. Programs that buy their own commodities can get low prices by asking for competitive bids from some of the more than two dozen manufacturers of injectables (83). To ensure the quality of supplies, programs should ask for bids only from manufacturers that have been assessed for quality. WHO will prequalify injectables and manufacturers by mid-2007 and will provide this information on its Web site (http://mednet3.who.int/prequal/default.htm) (104).
Programs can also work with the UNFPA, which helps countries procure injectables and other contraceptives at low prices. Also, a number of procurement agents consolidate orders from several clients to qualify for volume discounts from manufacturers, and they ensure the quality of the products that they order (38, 127).
Adjust procurement to match demand. As users switch to injectables from other methods, demand for other methods may rise more slowly or even decrease. If so, programs can place larger orders for injectables and smaller orders for other methods. Monitoring use with a logistics management system will indicate changes in demand and in the method mix and will help programs avoid overstocking some contraceptives if demand for them decreases.
Set up more outlets for injectables without building more clinics. Injections have been given in existing community clinics, mobile clinics, and the homes of clients or community providers (8, 61, 139, 183). Facilities for giving injections need not be elaborate: a private examination area, a waiting area for clients, space to store supplies and client records, and, if possible, a place for providers to wash hands (204, 227).
Share cost of outreach services with other services. Outreach services can follow the example of clinic-based integrated family planning and maternal and child health services. In Thailand mobile clinics offered STI services, Pap smears, and other services as well as contraceptives (8). In rural Ethiopia teams offering DMPA, immunizations, and antenatal care set up monthly outreach sites in a project managed by Save the Children/USA (61). Offering multiple services can save on fixed costs and is likely to be more convenient for clients who need several types of health care.
Some Providers Can Increase Productivity
Family planning providers in many programs are overworked. If they are providing other services, especially curative services, clients typically form long lines at the clinic, and providers are fully occupied.
In some programs, however, there may be opportunities to increase providers' productivity and serve more clients without increasing costs. Studies in several countries report that providers in some public or NGO clinics do not work a full day, and they spend less than half their time with clients. Many spend considerable time performing administrative duties or waiting for clients (76, 88, 89, 133). For example, from observations of nurses and doctors in 82 Mexican Ministry of Health (MOH) facilities in 1996, a study concluded that, with small changes in providers' schedules, the MOH could meet demand for family planning through the year 2010 without increasing costs or hiring more providers. If providers increased their work time from six to seven hours a day and increased the time spent with clients from about 3 to 4½ hours a day, the cost per client using combined injectables for a year would decrease from about US$49 to $37 (76).
Providers can be more productive if more clients come during times of the day when the clinic is normally not busy. Appointments can be scheduled during these times, generally after 1:00 p.m., and clients could be charged less. More research is needed, however, to assess providers' motivation and the best ways to reward them for seeing more clients (88). Programs may need to raise salaries or reward providers for seeing more clients, but the result can still be a net decrease in cost per client served (89).
Some Injectables Users Are Willing to Pay
Program managers can recover some costs from users of injectables. Starting to charge clients who have received free services and supplies, or increasing existing charges, does not always decrease demand substantially. In general, managers of public and private nonprofit family planning programs overestimate the effect of price increases on demand (2, 56). In fact, even doubling the price of contraceptives has reduced demand by no more than 15%, according to five studies in Bangladesh, Indonesia, and Nigeria (107). In Indonesia during the economic crisis in the late 1990s, prices rose faster than incomes. The price of injectables more than doubled on average, but demand was unchanged (58, 118).
In some countries, however, family planning clients are sensitive to price changes. In Malawi, for example, increases and then decreases in prices by an NGO in response to changes in donor funding led to dramatic decreases and then increases in numbers of family planning clients (180).
To gauge what people would pay for injectables and other contraceptives, program managers can conduct a willingness-to-pay survey. Applied to injectables, the survey starts with two questions: What do you pay for injectables? Would you be willing to pay X amount (a moderately higher price) for injectables? The third question suggests a higher price if a woman is willing to pay X, or less of an increase if she is not willing to pay X amount. Before increasing prices throughout the program, managers can raise prices in a few clinics first to check the accuracy of any predicted changes in demand (2, 56).
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In rural Ethiopia teams offering DMPA, immunization, and antenatal care set up monthly outreach sites.
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By definition, social marketing programs charge for their products. Pricing is not based on costs but rather on ability to pay. Some social marketing programs set the annual price of injectables and other contraceptives at 1% or less of median annual family income—a price that most people can afford. These programs use attractive packaging for injectables and other contraceptives to promote them and distinguish them from public-sector products (69). Sales of injectables in social marketing programs have risen dramatically. Among country programs with total annual contraceptive sales of at least 10,000 couple-years of protection, sales of injectables more than doubled from 8.4 million doses in 2000 to 20.2 million doses in 2005. By comparison, sales of oral contraceptives increased by about 50% and total couple-years of protection provided by these programs increased by 57% (46).
Cross-subsidization is another way to shift costs. Programs charge more than cost for some products or services and use the profits to subsidize services that do not cover costs or to offer free services for the poor. For example, social marketing programs in Brazil, China, El Salvador, the Philippines, and other countries have charged more than cost for some brands of injectables, oral contraceptives, and condoms (9).
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