Few policy barriers unduly restrict access to commercial products and services. Distributors and policymakers alike see the new registration procedures as a distinct improvement over past practices. Although no products have been approved in the past 7 months since the new system was first instituted, no one interviewed felt that it would constitute an obstacle to registering new products. In addition, the absence of price controls allows for increased profits and investments (though it may contribute to a trend towards increasingly expensive hormonal contraceptives). Finally, the provision of services through the private sector appears to be viewed favorably by the government and there are no laws that currently prohibit this expansion. Lack of capital is a more likely barrier to further development of private practice.
Contraceptive products are reasonably available in Azerbaijan. Although the PSP-One team was not able to survey the market exhaustively, it found no evidence of widespread shortages of contraceptive products in the private sector. Azerbaijan has a very high abortion rate and few users trust modern methods of contraception. As a result, demand for these methods is likely to remain low, which is reflected in product choice. However, most users are likely to be able to afford the lowest-price commercial OCs, IUDs and condoms because their prices are consistent with other frequently used pharmaceutical products. In areas where product choice is limited, this decreased availability primarily affects high-price products, which many rural people cannot afford.
There are, however, differences between contraceptive methods.Condoms may be the most widely available method, but the presence of counterfeit brands and products of unknown origin may be a threat to the quality of product supply. In addition, self-imposed restrictions by pharmacists affect consumer access to these products in rural areas. OCs are well represented in pharmacies but the majority of brands marketed by private companies may only be accessible to middle and upper income women, and the possible discontinuation of low-cost OCs is a key threat to contraceptive security. Spermicides remain a marginal method and their high prices may keep demand for these products low, affecting both product choice and availability. Though less readily available than other methods, IUDs were ultimately found to be adequately supplied through distributors and wholesale pharmacies.
Few private sector suppliers have an interest in the contraceptive market. This is an important finding as private sector interest influences both product supply and the financing of demand-creation programs. In countries with high-perceived growth potential, manufacturers are willing to invest (and even lose money for a while) in order to build demand for their products. Distributors actively seek new products to import in the country and work to ensure adequate stock levels at all times. This is not yet the case in Azerbaijan. As a result, it may be difficult to convince suppliers to keep low-cost products on the market, or partner with them to grow the market. In small, undeveloped markets, there is also less common ground between public health needs and commercial interests, as evidenced by Schering’s focus on a high-income user segment. It should be noted, however, that this company’s efforts to change provider attitudes toward hormonal contraception can go a long way toward increasing overall demand for this method in Azerbaijan.
Needy populations are not being adequately served by the private sector. Low-income users and those unable to access commercial retail outlets require services that the private sector cannot currently provide. For example, rural users may not be able to obtain re-supply methods on a regular basis, often lack information about hormonal methods, and wile they may prefer to use an IUD, the unofficial cost of prescreening as well insertion may make them unaffordable. In addition, private sector facilities serve primarily urban, middle and upper class users or those fee patients with access to insurance. Because the private sector is unlikely to meet the needs of low income and rural populations, it will be necessary to supply contraceptive products to these users through alternative programs and channels.
Quality of care in the private sector may be lacking or inconsistent. In spite of laws regulating private practice in Azerbaijan, quality controls do not appear to be enforced evenly or systematically. When it comes to family planning services, there may be a tendency in the private sector to limit access to certain methods, in part by requiring more tests than needed. Private providers are typically paid a percentage of the cost of services provided. In some clinics, particularly those overstaffed with ob/gyns, clients may be charged for unnecessary tests and services. This practice increases costs to users and limits access to contraception.
Family planning services are not an area of focus in private health facilities. Private clinics draw the bulk of their revenue from specialized care and family planning services are not sufficiently lucrative to merit being promoted. Abortion is a better source of revenue for private sector ob/gyns over the long term, followed by IUD insertion. Although a number of private facilities are equipped to offer family planning services, the same biases found among public sector providers, notably against hormonal contraceptives, are prevalent among private providers.
6.1CONTRACEPTIVE SECURITY overview and conclusions
Azerbaijan faces considerable challenges to improving its contraceptive security. There is both evidence of public and private sector failure to provide Azeri women with the contraceptives they need. These failures are compounded by externalities in service provision and provider attitudes as well as lack of information amongst policy makers and the wider population. While richer urban women are getting access to modern FP methods through the private sector, income disparities and public sector service failures are reducing access for the rural poor and possibly even the urban poor. Product availability by client can be summarized as follows, the shaded access indicated no or very limited access:
TABLE XX : Existing Market Segmentation in Azerbaijan – Neglected rural poor
With approximately half the population living in Baku, these people potentially have access to private sector services and would benefit from planned IEC and BCC campaigns to generate demand. The ability of the urban poor to access the private sector requires further study.
The situation outside Baku is far less positive. While detailed income distribution figures have not been analyzed, anecdotally providers in both rural and CRH facilities consistently talked about 20 to 30% of the population who can afford to pay and access contraceptives from pharmacies or from publicly provided services typically incurring unofficial fees. As many as 40 to 50% were judged to be unable to pay for contraceptives while the balance able to afford some financial contribution. Reaching these rural poor and near poor represents the major challenge for improving product availability in Azerbaijan.
Despite these challenges, FP stakeholders identified a number of strengths that can be built on as well as weaknesses that need to be overcome.
Dr. Faiza (National NRHO Coordinator) and NRHO team
Tap into existing evidence supporting FP (PHC and ACQUIRE)
Share/get endorsement of statistics that justify FP investment
Involve political people in FP/RH activities
Workshop for influential people plan carefully and invite key decision makers
National and international conferences should be organized on a regular basis
Tarana would like briefs with talking points and data that will help lobby MOH, Parliament, GOAZ, etc
Organize regular round table discussions with stakeholders
Need a transition strategy to carry us to 2008 so FP efforts thus far will not be jeopardized (MOH/Tirana says to raise this issue to MOH)
Strategies for improving product availability should build on identified strengths and seek to address identified weaknesses. Strategies are required to address availability for the rural poor as well as strengthen the private sector response in Baku and other urban settings. A four pronged strategy should be considered to encourage the private sector to serve more the needs of the urban populations while the public sector seeks to be more effective in reaching the rural poor. Several elements of this approach are already in place with the ACQUIRE and PHC projects.
Advocacy with senior policy makers to demonstrate the importance of FP for the health and welfare of the Azeri population
Demand creation activities geared to improving information about modern contraceptive use with work with the private sector in Baku as well as rural towns to increase private product availability. These activities should be undertaken in partnership with the private sector and include ensuring a private supply of affordable OCs.
Provision of free commodities to the poor in rural communities, rural towns and in a limited way to targeted poorer clients in Baku.
The objective will be to increase product availability from both the private and public sector. Public expansion should be focused on rural Rayons and include a full method mix. With increased product availability, ACQUIRE pilot sites can seek to expand out reach services. Work with private sector should include continued support through the communications campaign and work with pharmacies in Baku as well as the pilot rural Rayons.
TABLE XX: Proposed Market Segmentation in Azerbaijan – reaching the rural poor