Thinking of a Career in Emergency Management?
- BY Nicole Pelette
Terms of reference:
Mid-term Assessment of Sida’s Contribution to Improving SRHR in Southern Africa through the Establishment of a Regional Pharmaceutical Social Enterprise
Intervention Background / The Programme
Low contraceptive prevalence rates for modern methods and high unmet need for contraceptives are driving unintended pregnancies in Sub-Saharan Africa. In 2012 alone, there were an estimated 19 million unintended pregnancies, of which six million resulted in abortions, nearly all of which were unsafe. In 2014, only 44.8% of married women of reproductive age (WRA) who wanted to avoid pregnancy were using a modern family planning (FP) method, and 29% of WRA were facing an unmet need for modern methods, with unmet need highest among women younger than 20.,
The unmet need for FP in Sub-Saharan Africa is expected to grow from 34.7 million WRA in 2015 to 40.6 million WRA in 2030. The drivers of unmet need and unsafe abortion include limited contraceptive method mix, socio-economic barriers such as desired high fertility and disproportionate use of modern methods by higher-income quintiles, poor quality of care, provider biases, particularly towards youth, high costs for contraceptives, gender and human rights disparities in access to healthcare, and policy barriers around task shifting and restricted abortion services.,
The Southern Africa region is not immune to these challenges. For example, in South Africa, a relatively robust modern contraceptive prevalence rate of 54% masks uncomfortable truths about access to reproductive health services, including safe termination of pregnancy. Recent demographic and health results suggest family planning services are stagnant at best, including estimates that 16% of those aged 15-19 had started childbearing, a percentage unchanged since 1998. At least 30% of teenagers in South Africa report ‘ever having been pregnant’, the majority unplanned and of those who fall pregnant, less than a third return to school and all face abandonment by boyfriends and families.
Inequities between countries, rural and urban areas, and among age groups are particularly pronounced. For example, In South Africa’s more rural and lower income provinces--Eastern Cape, Kwa-Zulu Natal and Limpopo—display total fertility rates (TFR) rates above the country’s average. In Zambia, demand for modern contraceptive methods is highest amongst: women aged between 25-29 (68%); urban women (73%); those in Lusaka (74%); women with more than secondary education (79%) and those in the highest wealth quintile (78%). In Namibia, Kavango, Kunene, Ohangwena and Omaheke which are amongst the poorest regions in Namibia display the highest TFR in comparison to other regions.
While Southern Africa’s public sectors have tried to address these barriers by reaching some segments of the population with free or subsidized HIV and Sexual and Reproductive Health and Rights (SRHR) products/services, these efforts are often under-resourced to address the full burden of health care needs in the region, particularly for young women. In addition, the public sector has made limited investments in FP, due at least in part to the focus on HIV in the region. Total development assistance for health grew by 9% annually from 2007 to 2011 but has held steady since then with projections to reduce in the coming years.
Despite growth of the private sector, the pharmaceutical sector is not addressing the SRHR needs of young women, particularly low-income women, due to limited investment in market development and building provider capacity. The for-profit commercial sector has catered to the health needs of wealthier segments of the populations given their mandate for sales revenues and profitability, as well as institutional sales to the public sector. High prices, limited availability of a range of contraceptives, lack of infrastructure to deliver products/services—particularly to vulnerable populations, and low quality of care—including provider biases that undermine the rights of women, especially youth, remain shortfalls across a range of countries in Southern Africa. As a result, access, choice and quality for other segments of the population have become a significant challenge and are often limited to the public sector.
PSI sees an opportunity to expand access to low-cost SRHR products through a regional social enterprise with the aim of addressing health needs at scale and leveraging regional operational efficiencies to deliver long-term, financially sustainable health impact. The private sector is showing potential to fill an important health need for populations underserved by the public sector. Today approximately 60% of health care financing in Africa comes from private sources, and approximately 50% of the population receives care from the private sector; these numbers are continuing to grow.,
In addition, the development community has realized that as the public sector and local governments become increasingly stretched and donors are pushing to reduce subsidies over time, harnessing rapidly growing private-sector markets with a high unmet need for SRHR holds great promise. This is due to a number of converging trends: growing economies, widespread access to technology and information sharing, active participation of multi-national corporations—including manufacturers and pharmaceuticals, and increased mobility and urbanization of populations. As such, some marketplaces in the Southern Africa region are ripe for a fresh approach—one that marries the opportunities traditional donor funding provides to address health needs in a financially sustainable way through social enterprise operations.
Finally, PSI believes there is significant potential in the lower tier of the market, particularly as purchasing power is increasing and subsidy for free products is declining; this allows for a social enterprise approach that leverages investments in the market to improve sustainability for consumers. To establish a social enterprise and harness this untapped potential, there is a need for initial donor investments for market activation and development to create the appropriate conditions to make sustained health impact a reality. This will allow for the private sector to continue to serve low-income populations, focusing on large volumes with thin margins, as compared to purely commercial companies that are focused on profit.
With investment from the Swedish International Development Agency (Sida) PSI added a pharmaceutical division to its existing social enterprise in Southern Africa to sustainably improve SRHR among young women in Southern Africa by reinvigorating and refocusing SRHR efforts to include the delivery of health impact using cutting edge marketing and business strategies to target subsidies appropriately and reduce reliance on donors. The social enterprise seeks to grow and sustain voluntary use of SRHR products for girls and women in Southern Africa with a focus on equity, choice and value. This approach is an evolution from more traditional social marketing, and represents a transition from a model that applies subsidy regardless of target audience segment towards one where subsidy is applied strategically to:
PSI’s social enterprise approach is grounded in commercial models and places an emphasis on appropriate marketing and pricing strategies to grow the market as well as significant procurement and operational efficiencies to provide affordable pricing while moving towards sustainable funding in the medium to long term. PSI aims to grow and diversify the product base over time, setting up a model that contributes to contraceptive security and a more viable business model for the future.
PSI expects that the pharma division will not be fully sustainable for a long time. However, PSI is innovating its business model in response to the challenges of entering the market in Southern Africa, limited donor funding and the need to lay the foundation for sustainability in the medium to long term. The Sida investment is intended to set the right systems in place to ensure long-term sustainability.
The goal of this program will be to harness and strengthen Southern Africa’s regional health markets (Zambia, Zimbabwe, Angola, South Africa, Namibia) to improve SRHR of young women through a regional social enterprise approach. The outcome of the enterprise will be to grow and sustain voluntary use of SRHR products among young women in Southern Africa.
Key program outputs include:
As mentioned above, PSI established a pharma division of a regional social enterprise to deliver health impact in the Southern Africa region by offering a comprehensive suite of SRHR solutions to respond to women’s needs, including short-term and long-acting reversible contraceptives, and other reproductive health and HIV products and services. Through this offering, the pharma division will work through the private sector to enhance informed choice, meet the holistic needs of WRA, and contribute to the prevention of unsafe abortion, unintended pregnancies, maternal death, and HIV incidence. The enterprise will focus on FP products at launch, specifically OCs and ECPs, and over the life of the project will use sales revenue to introduce additional FP products such as implants, and injectables. This strategy is aligned with PSI’s global FP and reproductive health strategy to shape reproductive health markets by sustaining use, addressing need, expanding choice, and targeting subsidies appropriately. Later in the life of the enterprise, we will explore to the potential to introduce other SRHR products including oral pre-exposure prophylaxis (PrEP), ARV, misoprostol for post-abortion care and medical abortion, and Dapivirine anti-HIV rings depending on the legal framework in each country and market/health need.
Evaluation Object and Scope
The purpose of the review is to assess progress to date (compared to the program outputs as outlined above) and inform decisions on how implementation may be adjusted and improved with specific attention to understanding the potential of the social enterprise approach to contribute to improved access to SRHR products as well as opportunities and risks of the model from a human-rights based , its potential market-distorting and/or market development effects, and the sustainability of the PSI social enterprise over the medium to long term.
PSI is therefore recruiting a consultant with the following scope of work:
Review of the market dynamics for reproductive health products and services in Southern Africa with special attention to barriers to entry for reproductive health technologies, challenges and opportunities for taking products to scale, equity of access, pricing regulations, and whether and how the market is serving poorer segments of the population. The review should take into consideration the perspectives of commercial players where feasible. (2 days)
Review and assess business strategy, business plans and action taken to date towards improved access to a broad range of quality assured SRHR products from a human rights perspective. The analysis should include identification of challenges and opportunities and consider the potential of the social enterprise business approach within the context of the following drivers which underpin the business model (5 days).
Access: Putting into place strategic partnerships across the value chain necessary for a robust offering through private sector channels across key geographies; potential of the model to contribute to improved commodity security and streamlining of supply chain systems for key FP products by addressing market failures that constrain access.
Choice: Growing the user base by developing and launching a portfolio of affordable, high quality products tailored to improve method mix and respond to consumers’ needs.
Equity: Assessing the degree to which equity is addressed through improved segmentation; the appropriateness of the customer segmentation strategy and pricing model, particularly to help scale the organization and reach the target group.
Quality: Improving quality of use across the production to use spectrum, from the point of manufacture through the distribution supply chain to the end user. This includes action taken globally and locally to ensure product quality assurance, medical and ethical responsibility, enhancing the client/provider experience and reinforcing informed choice across all modern contraceptive methods.
Prepare two country case studies of the PSI business, in order to assess country-level marketing and sales as well as assess availability, access and affordability. The current proposed countries include Angola and South Africa but will depend on consultants’ assessment (5 days on the ground in each country)
Overview of the total contraceptive market in the country, should such analysis not be available
Analysis of the potential market developing and competition distorting effects of the PSI programs in the country including assessing the potential for the approach to crowd-in or crowd-out private sector. What are the potential risks that PSI (and Sida) should be aware of?
Review of data from PSI routine monitoring framework against the defined results framework and key performance indicators, and reach of target group to the extent possible by socioeconomic background, gender, rural/urban and other relevant demographic indicators
Assess the operational and financial sustainability of the social enterprise once Sida support is phased out.
Assessment of PSI’s overall model for social enterprise and the operational model for the social enterprise business in Southern Africa.
Assessment of the business plan and business cost and revenue model and how (if) it is being used to revise PSI market strategies and drive operational efficiencies to improve cost recovery for the total business.
Assessment of challenges related to reaching the poor and the so called Base of the Pyramid consumers and achieving financial sustainability.
Identify lessons-earned and make recommendations that can help PSI adjust the program, its results framework, and indicators (if necessary)
Assess progress in relation to the objectives of the program and also assess whether the program is relevant to the Swedish Sub-Saharan Strategy on SRHR and the five perspectives in Swedish Development Cooperation.
Assess the regulatory landscape in the region and opportunities for global (WTO), continental (African Union) and regional (e.g. SADC) regulatory harmonization that could be utilized by PSI for registering products and medicines in countries within the region.
Assess effectiveness and value for money (from an investment perspective) of the PSI approach
Methodology & Methods for Data Collection and Analysis (to be finalized during inception phase)
Inception phase, including an initial meeting between the consultant, PSI and Sida and production of a draft report refining the components of the methodology including the documents to be reviewed in the desk review, the list of key informants to be interviewed, and the process and timeline to be followed, key milestones and contact people within PSI and Sida
Evaluation Team Qualifications:
It is anticipated that the consultancy will require at least one technical expert with demonstrated public health expertise with an understanding of the sexual and reproductive health and rights sector, development cooperation, Sida’s development priorities, and key actors, as well as a business, commercial and / or economic development expert with experience in sub-Saharan Africa. The following are recommended qualifications for members of the evaluation team: