Ten Best Public and Private Sector Practices In Reproductive Health and Family Planning in the Europe and Eurasia Region

This 12-page United States Agency for International Development (USAID) brief, developed through a collaborative effort by John Snow Inc. (JSI) and PSP-One, intends to synthesise best practices in achieving reproductive health and family planning (RH/FP) goals for the Europe and Eurasia (E&E) region and to highlight the role of the private sector in meeting these goals. It is designed for policymakers, service providers, FP organisations, and other stakeholders with an interest in developing better public/private collaboration in achieving RH/FP goals. The criteria used to identify these best practices included effectiveness in improving RH/FP services and outcomes, potential for sustainability and replication, innovation, and ability to address local needs.

As stated here, "RH/FP services have experienced considerable progress in the last 15 years since the fall of Communism. Donor-supported health reform has given doctors and, in some countries, midwives and nurses, the opportunity to provide FP services. This liberalization of service delivery has significantly increased access to services, particularly in rural areas. In most countries, FP services are a basic health benefit provided free of charge. Significant barriers exist that limit access to information, services, and commodities for certain groups. In some cases, the barrier is financial, when free or subsidised commodities are unavailable to low-income users. Other obstacles include legal restrictions in the provision of FP services, unnecessary tests, and medical examinations, and a lack of reliable information about modern methods." Most modern contraceptives are supplied by private pharmacies in urban centres for a fee. Those without access or unable to pay for commercially available products rely on a "declining supply of USAID or the United Nations Population Fund (UNFPA)" available in the public sector. In addition, "most countries in the region have developed and endorsed evidence-based guidelines and protocols for RH/FP service delivery, with the support of various donors. However, to date, there are few or no mechanisms for monitoring adherence to the new RH/FP service protocols or uniform evidence that service providers are fully aware of the new provisions.... [H]ealth authorities in most countries have committed to improving in-service provider education in FP by incorporating the World Health Organization (WHO) recommendations and other... evidence into in-service curricula."

As reported here, "the private sector plays a critical role in the region mainly as a major supplier of contraceptive products at a wide range of price levels." Private sector interest in FP varies substantially from one country to another and tends to focus on specific and saleable products, which results in limited method availability, impacting on the method mix in the region. Private sector interests vary depending on demand and ability to pay. There is growing demand throughout the region for oral contraception, including newer, more costly methods such as the vaginal ring and contraceptive patch. There is limited availability of injectables and implants, given the low demand for these products.

"The private sector can help decrease the burden on the public health sector, allowing it to focus its limited resources on vulnerable population groups. The public sector, however, retains a fundamental role in setting the parameters of service provision and ensuring universal access to a broad method mix. Governments in the regions can play a strategic role in maximizing private sector contribution to RH/FP goals while maximizing equitable access to a range of FP services and methods."

The article highlights 10 best practices in RH/FP common to the E&E region, including:

• "Use of the Whole Market Approach, which strives to create balance and complementarity between the public and private sector efforts to deliver RH/FP services and products. JSI’s Romanian Family Health Initiative is an ...example of how the [Ministry of Health] MOH increased access to affordable FP services and products by mobilizing both public and private sector actors."
• "Liberalisation" of FP services, which implies "enabling a wide range of health professionals to provide FP counseling and services, and fostering efficient public and private sector contraceptive distribution networks...coverage." As in public facilities, often private health providers are restricted in their ability to offer FP services. "The provision of FP counseling and services (including IUD insertion) by private doctors, midwives, and nurses at family medicine centers, independent family group practices, and rural health posts has proven particularly effective in increasing contraceptive prevalence and reducing abortion rates in sparsely populated villages."
• Include FP products, services, and counselling in basic health benefit packages, and "complement insurance programs with efforts to increase the demand for products and services through consumer and provider education. Insurance schemes are among the most effective ways to encourage private sector participation in RH/FP programs because they allow low- and middle-income users to access products and services outside the public sector that may not otherwise be affordable. If free or subsidized services are carefully targeted, they need not dampen the private sector market for FH services and products."
• Establish evidence-based quality assurance policies, regulation, and standards, supportive supervision approaches that "conform to international standards and that will apply to both public and private sector providers and to all facilities providing FP services and products. The greatest challenge to ensure quality in both sectors focuses on strengthening the often weak regulatory bodies and institutions with the mandate to guarantee compliance and enforcement. Enforcing appropriate use of evidence-base approaches in the private sector only through regulation is not realistic and should be educational and collaborative. The report lists a variety of non-regulatory strategies to improve quality in the private sector."
• Address the needs of special and vulnerable subgroups. "The public sector will not be able to provide free contraceptives to all potential FP users; therefore it is important for government to develop strategies to target free and subsidized contraceptives to most vulnerable groups. This will require political will and financial commitment. Since private providers and pharmacies tend to focus on high-income clients and products in urban areas, vulnerable population groups are not typically of interest for the private sector. The ministry of health, however, can play a strategic role in creating the conditions to motivate private providers to serve this population group by fostering demand among rural and vulnerable population groups. A social marketing unit at the ministry of health could bring these two components together and manage collaboration between private providers and the government on demand generation and supply provision."
• "Include RH/FP training in pre- and in-service training and continuous medical education for both public and private providers. Pre-service training for a wide range of health professionals is one of the most important interventions in RH/FP because it ensures a continuous supply of trained and motivated providers. [Continuing Medical Education] CME is also an effective strategy to update skills and knowledge and should be part of the certification of health professionals. The public sector can play an important role in ensuring that private providers receive accurate information and training on FP standards and practices that can help balance the undue influence the pharmaceutical industry may have in the Region. There is a tendency in the E&E region to rely on pharmaceutical companies to fund continuing education and update doctors on innovations and research in RH/FP. Although the information provided by pharmaceutical companies is not necessarily inaccurate, it invariably reflects a bias toward newly introduced and generally expensive brands."
• "Promote a 'culture' of FP counselling and client education involving providers, government, and the private sector by providing adequate educational materials, job aides and training in client-oriented counseling and education. In addition, there is strong evidence that well-informed clients are more likely to use their FP methods effectively and consistently. Private providers are motivated to treat their patients well because they have to compete with free public sector services. Nonetheless, public sector initiatives to improve counseling skills should systematically include private providers because the industry-sponsored conferences tend to focus on scientific innovations and do not include this component. Actively promote health benefits of FP to the general population."
• "Social mobilization/marketing is a ...practice that complements counselling and individual client education and can help move societal norms toward acceptance of modern FP. Direct promotion of FP products to consumers is a widespread practice in the region by pharmaceutical companies despite regulatory restrictions. In the E&E region, there are some social marketing programs promoting the benefits of FP. But the marketing efforts by pharma industry are often the only source of information on FP for consumer. Generic, unbiased information is needed by the MOH but can also be offered through a variety of non-profit organizations such as women’s groups, non-governmental organizations, and social marketing programs."
• "Collect reliable FP data and analysis, for benchmarking the progress of RH/FP programmes and strategic decision making. Most E&E countries have the tools to collect and analyze the FP data. But health information systems and contraceptive logistic systems still require strengthening throughout the Region. The private sector plays a limited role in FP data collection and generally considers data they gather proprietary. But some pharmaceutical companies and distributors will share data if they are involved in public/private partnerships, and in some cases, it may be purchased by the public sector."

The article concludes that progress has been made in FP services in the E&E region. The 10 best practices outlined in the article, such as liberalising the provision of FP services, or including FP services and commodities as part of the basic health benefit package, were found to help contribute to the advances achieved in FP. Integrating these best practices, according to the document, can help governments design approaches reflecting trends specific to the region. In addition, a "whole market approach" focuses on leveraging of private sector resources to achieve FP goals, thereby increasing the impact and sustainability of FP programmes in the region.