Transcript from manufacture to social change - International Consortium for

Exploring the Transformative Potential of
Medical Abortion for Women in India
A value chain analysis
From Manufacture to Social Change
Study team : Priya Nanda, Alka Barua, Suchitra
Dalvie**, Shuchita Mundle, Ashutosh Paturkar
** Presenting author
“Pharmaceuticals are not only products of
human culture but producers of it. As vehicles
of ideology, facilitators of self care , and
perceived sources of efficacy, they direct
people’s thoughts and actions and influence
their social life. The availability of medicines
affects how practitioners and patients deal
with sickness.”
( Geest et al , 1996, page 157)
Medical Abortion Pills in India
• In 2002 the Drug Controller approved the use of Mifepristone
(200 mg) followed by Misoprostol (400 µgm) oral for upto 49
days gestation. MTP Act amended in 2003 to facilitate provision
of MA
• Currently around 20 brands available in the market, price range
from USD 2 to 6 for single Mife pill.
•
Combipack approved for use upto 63 days
• Approx 10 million Mife pills sold in 2009
Despite this Access to & use of MA pills is limited
We asked……..
• Does MA meet the abortion service needs of women?
• Can access for those needing safe abortion services
be widened with the availability of de-medicalized
MA?
• How much can access to MA be increased without
compromising quality and safety?
Supply Chain
Policy
makers
Focus
Relevant,
distinctive,
consistent laws
Manufacturers
Focus
Market
Profit
Competition
Distribution
Stockist/
Retailers
Focus
Brands in
demand
Adequate stocks
Distribution
channels
Providers
Focus
Services in
demand
Meet client needs
Profit (??)
Competition (??)
Women
Focus
Easily available
Easy to use
Safe
Effective
Affordable
Confidential
Supply Chain: Expected Value Addition
Policy makers
Manufacturers
Stockist/Retailers
Liberal policies &
laws that support
information,
access & good
quality services
Ensure widespread
easy availability of
effective, safe,
affordable
commodity.
Provide information
on commodity
Knowledgeable,
Support access,
Ensure supplies,
Provide information
about commodity
Providers
Knowledgeable,
Trained,
Give information,
choice,
Provide safe
services,
Follow protocol
Ensure
confidentiality
Women
Find it
Safe
Easy-to-use
Private
Cost effective
Non-surgical
Non-invasive
Study Design & Methodology
• Qualitative with Mapping and In-depth interviews
• Site: Western state in India, Urban + Rural area
• Sample:
– Stakeholders: 13
– Stockists: 8, Retailers: 28
– Service Providers: 39 (Formal & Informal)
– Women Users: 120 (h/o Induced abortion <= 2 years)
Women
• Acknowledge the positive and potentially transformative
attributes of MA pills
• Though the decision for the abortion was a joint one, most felt
that the woman should choose the method
• All 120 MA users expressed a sense of relief
• Reported easy availability, affordability & privacy. Do NOT
want to do it alone !
Source: IDIs with Providers & Women users of MA pills
Access a diversified provider base, both within & outside the
purview of the law
ObGyn
Non MBBS
GPs
Retailers
Nurses
Reasons: Convenience, familiarity, affordability, confidentiality
Providers
Followed different protocols for everything!
• Consent
• Confirmation of pregnancy
• Information on need for surgical intervention, FU
• Tablets: Regimen variable, 2 to >=4, Oral / vaginal
ObGyn not supportive of MA demedicalization
“On day 1 we give Mife 200mg 1 or 2 tablets orally. After 48
hours we give 4 tablets of Miso 2 orally and 2 PV or only 1 PV
depending upon dilatation. On day 5 we confirm completion of
the procedure.
If not complete after 48 hours, sometimes we repeat 2 tablets of
Mife 12 hourly. Also we titrate the dose of Miso.
If she doesn’t abort with one tablet of Miso, we give 2 tablets
and if she is overweight, we give 3 tablets of Miso stat.”
ISM practitioner, 15 years rural practice
Limited knowledge about the MA pills & relevant laws,
policies & guidelines
Women aware of PCPNDT
Women aware of MTP
Series 1
Series 2
Providers aware of MA
guidelines
Column1
Providers aware of MTP rules
0
50
100
Retailers
• See it as just another product
• Most often men come to buy the pills
• Claim to ask for prescription every time but women confirm
OTC sales
• Great need for values clarification
• Lack of information about drug s/e
Access
•
Not yet in the public sector
• Pharmaceutical companies and social marketing organizations
appear to be directing the expansion of this method. Sales are
increasing by 40% every year. Is this necessarily good ? (
rights based approach and accountability of health systems ??)
•
It is currently easier to access it outside the legal system than
within.
• Although much cheaper than surgical , cost is still an issue for
some.
Concept of ‘Misuse’
• Use by unmarried women
• At higher gestational age ( 2nd TM and Sex selection)
• Incorrect or incomplete regimen
• Lack of medical supervision and
• Lack of follow up and lack of post abortion contraception
Transformative potential along a value chain: Scenario
Policy makers
Manufacturers
Stockist/Retailers
Liberalize law &
access
Provide
information &
access points
Reduce cost
Information
Distribute widely
Stocks
Access
Knowledge
Information
Providers
Information
Knowledge
Choice
Safe services
Follow-up
Counselling
Women
Safe
Easy-to-use
Private
Non-surgical
Non-invasive
Choice
Cost
Information
While none of the women interviewed spoke of empowerment
or rights as an issue, it was clear that the existence of MA as a
method moves them from a position of no choice to some
choice and from some choice to more choice and therein is the
beginning of the social transformation.
There is a sense that this is a technology whose time has come
and women are increasingly likely to demand as well as obtain
access by their own means.
Thank You