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USAID GLOBAL HEALTH SUPPLY CHAIN PROGRAM
Procurement and Supply Management
Modern contraceptive use in South Africa – a focus on the private sector
Peter Stephens and Elna Steyn, IQVIA
USAID GLOBAL HEALTH SUPPLY CHAIN PROGRAM-Procurement and Supply Management
Agenda
• Introduction
• Comparisons between Public and Private Sectors
oMethod mix
oPrices
• Contraceptive security
oChanges to supply associated with the end of the public sector tender for
injectables and oral contraceptives in September 2017
• Summary/Conclusions
2
USAID GLOBAL HEALTH SUPPLY CHAIN PROGRAM-Procurement and Supply Management
Abbreviations used
• CYP – Couple Years of Protection
• Methods
oEC – Emergency Contraception
o IUD – Intra-Uterine Device
o IUS – Intra-Uterine System
oOC – Combined Oral Contraceptive
oPOP – Progestogen only Oral Contraceptive
oPatch – Transdermal Patch
oRing –Vaginal Ring
USAID GLOBAL HEALTH SUPPLY CHAIN PROGRAM-Procurement and Supply Management
Many ways that modern contraceptives can reach user
Final Point of Dispensing
Courier Pharm Wholesalers/DepotDistributors
• Family planning supply chain is complex within both the tender/government system or the private sector with many pathways users can access the product/method of choice
• Final point of dispensing can include:
o Chain pharmacies,
o Community pharmacies,
o Supermarket pharmacies,
o Hospitals or clinics and
o Dispensing doctors
4
USAID GLOBAL HEALTH SUPPLY CHAIN PROGRAM-Procurement and Supply Management
Wide range of granular data assets used
• Estimated~95% coverage of private market with data captured at wholesaler to final level before it reaches the patient
(e.g. pharmacy, hospital or dispensing doctor)
• Single Exit Price (SEP) used
Wholesaler Data – used to provide insight into market trends
• Data represents products dispensed (Rx or OTC) by pharmacies, some dispensing doctors and private clinics
• Captured from dispensing software systems, representing ~ 85% of the private market in South Africa
Dispensed data – used to describe users by age
• Public sector data is only available for both depot and direct wholesale supply in 4 provinces in South Africa
• Pricing is a mixture of tender prices plus wholesaler purchases
o May omit direct sales from manufacturers
Public Sector Data – used to compare with private sector sales
5
USAID GLOBAL HEALTH SUPPLY CHAIN PROGRAM-Procurement and Supply Management
• Statistical analysis was carried out using the “R” package
for Changepoint Analysis implemented for a change in
mean values, using a significance level of p<0.05. Analysis
was directed to identify multiple changepoints, should they
exist
• The Changepoint algorithm used to detect a significant
change in mean value was the Pruned Exact Linear Time
(PELT) algorithm.
Statistical analysis
Actual CYP values
Mean values for each changepoint period
Example Changepoint output, showing actual values (grey dotted line), mean values for segmented periods (red line),
1
2
2 Changepoint identified
USAID GLOBAL HEALTH SUPPLY CHAIN PROGRAM-Procurement and Supply Management
Public versus Private sector
USAID GLOBAL HEALTH SUPPLY CHAIN PROGRAM-Procurement and Supply Management
Public sector dominates modern contraceptive supply, except for EC
Note: Comparison carried out in the 4 provinces only that IQVIA collects public sector data
Note: Condom sales not known for public sector, and only partial coverage of private sector
In comparison to many countries, South Africa has a relatively low usage of implants
Due to impact of the DoH Circular 2014 warning of interactions with drugs like ARVs and rifampicin
USAID GLOBAL HEALTH SUPPLY CHAIN PROGRAM-Procurement and Supply Management
Private sector delivers wider method mix, with OC taking majority share of CYP, and EC more prominent
9
EC 12%
Implant
1%
Injection - 2
monthly
5%
Injection -
3 monthly
22%IUD
5%
IUS
12%
OC
36%
Patch
6%POP
1% Ring
0%
Share of CYP, Private Sector, 2018
EC0%
Implant7%
Injection - 2
monthly10%
Injection - 3
monthly60%
IUD11%
IUS0%
OC12%
Share of CYP, Public Sector, 2018
OC more popular in private sector facilities located in more urban areas
Private sector growth in CYP +27% 2013-2018
Note: Public sector shares calculated from 4 provinces, private sector national data
Note: Condom sales not known for public sector, and only partial coverage of private sector
USAID GLOBAL HEALTH SUPPLY CHAIN PROGRAM-Procurement and Supply Management
Younger age group dominates EC demand in the private sector
10
USAID GLOBAL HEALTH SUPPLY CHAIN PROGRAM-Procurement and Supply Management
Prices paid by public sector lower than Single Exit PriceInjectables and OCs prices in public sector increase following end of public sector contract
Note: Public sector prices calculated from 4 provinces, private sector national data
USAID GLOBAL HEALTH SUPPLY CHAIN PROGRAM-Procurement and Supply Management
Impact of end of public sector contract in September
2017 on contraceptive security
• Contract for Injectables and Oral contraceptives ends September 2017
• 3 monthly injectable contract
o No company bids for 3 monthly injectable contract
o Fresenius persuaded to continue supply to April 2018
o Post this period ad hoc arrangements with Pfizer for direct orders
• 2 monthly injectable contract
o No agreement reached with Bayer until May 2018 for supply of 2-monthly
injectable
• OC contract
o Shortages reported for OCs in short-term as Mylan reported to struggle to
meet demand
Source: Media reports, Stop Stockouts Project, Department of Health tender
USAID GLOBAL HEALTH SUPPLY CHAIN PROGRAM-Procurement and Supply Management
End of public sector contract coincides with significant drop in both public and private sector of 2 monthly injectable
Public sector, 2 monthly injectable Private Sector, 2 monthly injectable
Note: Public sector volumes derived from 4 provinces, private sector volumes national data
USAID GLOBAL HEALTH SUPPLY CHAIN PROGRAM-Procurement and Supply Management
No significant negative impact of contract end on 3 monthly injectables in public sector, but private sector sees significant increase
14
Public sector, 3 monthly injectable Private Sector, 3 monthly injectable
Note: Public sector volumes derived from 4 provinces, private sector volumes national data
USAID GLOBAL HEALTH SUPPLY CHAIN PROGRAM-Procurement and Supply Management
End of contract (and disruptions to supply of injectables) led to increase in OC volumes in public and private sectors
15
Public sector, OC Private Sector, OC
• Most reports of public sector stock outs come from provinces where IQVIA does not collect public sector data
Note: Public sector volumes derived from 4 provinces, private sector volumes national data
USAID GLOBAL HEALTH SUPPLY CHAIN PROGRAM-Procurement and Supply Management
EC volumes show significant increases over time, but private sector increase coincides with end of public sector contract
16
Public sector, EC Private Sector, EC
Note: Public sector volumes derived from 4 provinces, private sector volumes national data
USAID GLOBAL HEALTH SUPPLY CHAIN PROGRAM-Procurement and Supply Management
Concentration of market may explain significant impacts of public sector supply challenges
17
1
18
4
1
1
2
1
1
8
1
1
1
0 2 4 6 8 10 12 14 16 18 20
Condom (female)
Condom (male)
EC
Implant
Injection - 2 monthly
Injection - 3 monthly
IUD
IUS
OC
Patch
POP
Ring
No. of manufacturers, 2018Very similar
manufacturers in
public and private
sector
Even private sector
OC market is
relatively
concentrated with two
manufacturers (Aspen
& Bayer) taking 86% of
volume
USAID GLOBAL HEALTH SUPPLY CHAIN PROGRAM-Procurement and Supply Management
Conclusions
• Contraceptive security is largely dependent on injectables
o ~70% of CYP linked to injectables
• End of public sector tender linked to interruptions in supplies of injectables and oral contraceptives
o Limited number of manufacturers prepared to bid
• Analysis suggests that:
o Some users switched methods in public sector;
o Some users procured more modern methods from private sector, including EC;
o 3 monthly injectable volumes increased in 4 provinces where IQVIA collects private sector data, despite
market withdrawal of one manufacturer
• Possible solutions (for discussion)
o Wider method mix – resources also needed for training and to ensure availability at facility level
o Multiple factories to be registered where manufacturing supply is concentrated
o Alternative injectable suppliers could be investigated e.g. Manufacturers of those other injectables on
WHO EML, or manufacturers of the same molecule/formulations used in other parts of the world