Dynamic discounts for contraception: how innovations in financing might improve coverage and equity

 

Note: In early 2018, we spent a few months investigating how to build a technology solution to enable dynamic, targeted discounting for health products and services. Though Impact for Health is not working independently to test the impacts and cost-effectiveness of the concept, we are excited to work as thought-partners as others iterate on the technology and develop a more nuanced understanding of the costs, benefits and risks of this approach. The following is illustrative thinking on how this type of innovation might be applied in a context like DRC for contraception.

In spite of many challenges, the modern contraceptive prevalence rate (mCPR) in DRC has been increasing. Not only is mCPR growing but the share of women using more expensive, more effective and longer acting methods (specifically implants) appears to be increasing as well, among users in union and those who are unmarried and sexually active. (1) Finding ways to amplify these successes is critical.

In a context of high poverty rates and low public financing for basic health care, it is no surprise that Congolese women cite cost as a major barrier to use of contraceptives, among other reasons. For example, 66% of DHS respondents who identified as ‘intenders’ cited high cost as a barrier to use (Figure 1). Development partners in DRC anecdotally describe care-seeking behaviour that corresponds to extreme price sensitivity: when contraceptives are offered for free via campaigns clinical providers see huge spikes in demand, which wanes drastically at other times. In shops and pharmacies providers report that customers price shop extensively to find the lowest cost options, signalling that cost is likely influencing method choice and use at this level as well. (2) In spite of price sensitivity, care-seeking in the private sector is very common: in Kinshasa in 2016, ~67% of new users obtained their methods from a private source. (3)

Figure 1. Percentage of non-users of FP by type reporting reason for non-use (4,5)

Helping ensure continued increases in mCPR and continued expansion in access to a wide range of modern methods is likely to require additional work to address the barriers of cost, especially for adolescents and poor women whose purchasing power could be very low.

To date, partners have taken several approaches to reducing the barrier of price in the private sector for consumers in DRC. One approach has been to offer full subsidy on a range of contraceptives at the point-of-care via campaigns, which appears to have been very popular and may have helped increase use of longer-acting, more effective methods like implants. However, a few inter-related challenges with this approach exist:

  • Social marketers worry that free product and services are eroding the market. Many believe that subsidies could be more effectively targeted towards empowering priority populations such as the poor and young women.
  • Total subsidy doesn’t respond to the heterogeneity of consumers in DRC. It is possible that not all women who utilize services via campaigns require a full subsidy of their desired products or services, and public funding could be stretched further through more precise targeting.
  • Subsidizing services via campaigns does not empower consumers to access contraception at the times and places they prefer: access is strongly influenced by the campaign schedules and provider choice is limited.

In order to continue to expand access to contraception, financing mechanisms that more efficiently empower consumers without eroding the private market should be identified. ​

​Over the past sixty years, many attempts to scale financing mechanisms that reduce cost barriers for uninsured consumers and increase demand have been made. Notably, multiple systematic reviews have found strong evidence that voucher programs are an effective mechanism for providing discounts for services in a way that increases utilization of reproductive and maternal care for targeted groups. (6, 7, 8) However, several operational challenges with traditional voucher programs render them difficult to scale. First, the process for enrolment has been time-consuming and labor intensive. Participants have traditionally been enrolled in-person by a community health agent, who (depending on the program structure) may also be required to complete a need identification survey to justify enrolment and dispensation of a discount. Secondly, discounts offered through voucher schemes have been blunt: all who qualify are offered the same level of discount on services even though their needs for discounts, products and services may vary by person and over time. The combination of expensive processes to enrol participants combined with blunt discounting has contributed to high operational costs. High costs render vouchers unattractive for both donors and governments, though the impact of vouchers on increasing utilization is strong. (9)

Recent advances in technology and practice from the social and commercial sectors may offer opportunities to decrease the cost of offering targeted discounts without sacrificing effectiveness. First, couponing for fast-moving consumer goods is emerging on the African continent and players have developed inexpensive methods for recruiting participants and segmenting them into customer groups. These processes might be leveraged to decrease the traditional costs of enrolment in a voucher scheme. Second, advances in data science has allowed for the scale of subsidy in the form of dynamic price discounts in the commercial sector in OECD countries. To our knowledge, offering discounts that vary by 1) customer segment or 2) over time has not been used by organizations in the SRH field to reduce out-of-pocket expenditures – neither in the voucher programs nor in social marketing programs. Though notably, providers in LMICs utilize dynamic discounting, in the form of a sliding scale of pricing, with their customers every day. Third, companies in the commercial and social sectors are developing longitudinal relationships with our target customers to deliver information, microloans, cash transfers, care recommendations and more. These platforms could layer on additional capabilities to enable the use of their technology for health discounts. Drawing on systems created in the commercial and social sectors, it’s relatively easy to imagine a dynamic couponing program being built to empower a young Congolese girl. Companies such as AskNivi, mClinica, Snap n Save, WFP, Triggerise and more have many of the capacities required to test such a system.

What might this mean for a young girl seeking contraceptives in Kinshasa? Below we illustrate a simplistic care seeking journey for an 18-year old, Jane, who has completed primary education, is not married but has a boyfriend, does not regularly use contraception, does not own but can access a feature phone.

Though Impact for Health is not working independently to test the impacts and cost-effectiveness of the concept, we are excited to work as thought-partners as others iterate on the technology and develop a more nuanced understanding of the costs, benefits and risks of this approach. Stay tuned!

 

​[1] “PMA2016 / Kinshasa Round 5”. PMA2020.
[2] M Hansen Staples, Exploring the role of drug shops in sexual & reproductive health care in Kinshasa. February 2017. PATH.
[3] Brunner, Bettina, Combet, Virginie, Callahan, Sean, Holtz, Jeanna, Mangone, Emily, Barnes, Jeff, Clarence, Cathy, Assi, Auguste, Gober, Stephanie. 2017. The Role of the Private Sector in Improving the Performance of the Health System in the Democratic Republic of Congo. Bethesda, MD Abt Associates Inc.
[4] Ministère du Plan et Suivi de la Mise en œuvre de la Révolution de la Modernité (MPSMRM), Ministère de la Santé Publique (MSP) et ICF International, 2014. Enquête Démographique et de Santé en République Démocratique du Congo 2013-2014. Rockville, Maryland, USA : MPSMRM, MSP.
[5] Brunner et al 2017.
[6] Bellows, B et al. “Family Planning Vouchers in Low and Middle Income Countries: A Systematic Review.” Ed. Moazzam Ali and Craig L. Lissner. Studies in Family Planning 47.4 (2016): 357–370. PMC. Web. 14 Apr. 2018.
[7] Bellows, Nicole et al. “The use of vouchers for reproductive health services in developing countries: Systematic review.” Tropical Medicine and International Health 16(1): 84-96. 2 Nov. 2010.
[8] Meyer C, Bellows N, Campbell M, Potts M. “The impact of vouchers on the use and quality of health goods and services in developing countries: a systematic review.” London: University of London, Institute of Education, Social Science Research Unit, EPPI-Centre . EPPI Report. 2011.
[9] WHO and HRP December 2015 Report on the Systematic Reviews of Financing Mechanisms for Family Planning: Evidence and Gaps.