Last week, the Population Council and colleagues who play critical roles in providing contraceptives and other reproductive health supplies convened in Kathmandu, Nepal at the 19th Reproductive Health Supplies Coalition Membership Meeting. Members discussed and shared the latest updated on efforts to ensure that all people in low- and middle-income countries can access and use affordable, high-quality supplies to ensure their better reproductive health.
Read on for a summary of recommendations around the introduction of a vaginal contraceptive ring for breast-feeding women in Nigeria that the Population Council and partners shared during sessions throughout the meeting.
Population Council researchers are generating evidence to determine the feasibility and likely impact of introducing the Population Council’s three-month progesterone vaginal ring (‘PVR’) into countries in sub-Saharan Africa. The PVR provides breastfeeding mothers with a unique, effective, woman-controlled method for preventing pregnancy. It is approved and being used by women in 10 Latin American countries. However, availability of the PVR outside Latin America has been limited, leaving breastfeeding women who wish to delay another pregnancy few contraceptive options that meet their needs.
The PVR is a postpartum contraceptive that releases a continuous low dose of the natural hormone progesterone, reinforcing the inhibitory effect of breastfeeding on ovulation to delay the return of menstruation and therefore prevent pregnancy. Each ring can be used continuously for three months, and rings can be used successively for up to one year as long as the woman is breastfeeding. Since it does not require refrigeration, the PVR can be more easily distributed in low-resource settings.
The PVR in Nigeria
Recognizing the need to expand contraceptive options beyond Latin America, in 2018 the Population Council and Dalberg Advisors assessed what it would take to introduce the PVR to the Nigerian market. They found that many of the key challenges and opportunities to launch and scale the PVR are relevant for ring technologies generally, but also for next-in-class contraceptives in comparable market settings.
The lessons below from the Nigerian assessment are intended to guide product developers and market facilitators as they launch and scale-up availability of ring technologies and contraceptives, and ensure that women in markets like Nigeria can access affordable, high-quality reproductive health products.
- Lesson 1: Optimize for price throughout the supply chain
The Nigerian market benefits from an array of available contraceptives, including a portfolio of injectables and implants whose accessibility has improved over time. To contribute to this method mix, the PVR’s near-term uptake would likely depend on both its differentiated benefit to women and their infants, and its end-market price.
The price of ring technologies today is largely driven by costs early in the value chain, notably the cost of raw materials and long-distance shipping from specialized facilities. Bringing costs down over time could improve affordability for larger numbers of women accustomed to paying out of pocket within private markets. This could also make it more attractive to public procurers who have historically considered cost in designing large-scale subsidies or guarantees. Coupled with close forecasting of future volumes, securing import waivers, and collaborating with local social marketing firms familiar with high-margin wholesalers, this could help drive market access.
- Lesson 2: Find early adopters, with the larger market in mind
Establishing a ‘foothold’ with specific segments as the product enters, expands and scales in the market is a strategy to help introduce the product into the method mix and grow the product’s recognition as the product is made more affordable. In the Nigerian case, this may include focusing initially on urban settings and higher-ability-to-pay pockets with easier access to private commercial and social marketing family planning retail points. These users also exhibit relatively strong health-seeking behaviors that lead to positive reproductive and maternal health outcomes (e.g., high antenatal care attendance and private facility use for delivery and postpartum care).
- Lesson 3: Broaden channel access through product registration
A third and critical consideration faced by both PVR and comparable technologies is that of regulatory registration. Entering a new market as a prescription-only product sidesteps a substantial market opportunity. This is particularly critical in Nigeria, where independent private chemists command a huge share of the family planning market and depend largely on distributing over-the-counter (OTC) products. While securing an OTC designation may take longer, several activities, such as high-quality safety and efficacy data collection during a prescription-only product’s initial roll-out, may help boost the product’s regulatory chances for OTC registration over time.
As we begin PVR launch plans in more markets, these considerations will be key to its success. And as we see more rings and more contraceptives adding to the method mix, these learnings will be even more important. Larger product volumes and large end-market demand can also naturally contribute to optimizing production costs and hence help meet users at a lower price point. This adds to the importance of collaborating closely with procurers and providers in increasing users’ reproductive health rights to choice and quality.
Expanding the method mix in Nigeria could be a particularly useful way of improving contraceptive prevalence, although more research is warranted to measure robust public health impact. And as actors like Population Council begin to move dialogue beyond R&D-focused coordination, such as through licensing agreements, and into category-wide strategy-setting, there is an even more urgent need to align efforts and bring implementation partners together at gatherings like the RHSC Membership Meeting.