How cost influences access to medical abortion in the public and private sector

Sharad D. IyengarAction Research & Training for Health (ARTH), Udaipur, Rajasthan, India

Expanding Access to Medical Abortion: Building on two decades of ExperienceLisbon, Portugal, 2-4 March 2010

Expanding Access to Medical Abortion; Lisbon, Portugal, 2-4 March 2010 2

Access to medical abortion in the new millenium…

Mifepristone is registered in 44 countries, misoprostol in most, though not for abortion

In several countries, access to abortion services is legally restricted, while in some others with a relatively liberal law, weak implementation of the law leaves women with poor access

Expanding Access to Medical Abortion; Lisbon, Portugal, 2-4 March 2010 3

The cost of older, obsolete techniques

Dilatation and curettage (“D&C”) Hypertonic (concentrated) saline Ethacridine lactate dye Intra/ extra- amniotic prostaglandins

Require more dilatation >> more pain control (general anesthesia) >> hospital admission >> longer travel, need for accompanying persons (lower confidentiality)

Less safe – more complications, including hemorrhage, perforation and infection

Health systems have responded to lower safety by over-medicalizing services

Expanding Access to Medical Abortion; Lisbon, Portugal, 2-4 March 2010 4

Modern abortion techniques Manual or electric vacuum aspiration Medical abortion Dilatation and evacuation

Less pain and greater safety >> no anesthesia, less pain control, no admission, no need for an accompanying person

However, modern techniques require the state to invest as much or even more, for providing abortion services

Expanding Access to Medical Abortion; Lisbon, Portugal, 2-4 March 2010 5

Who pays…..?

Greater state investment in abortion services Drug regulation and management of services Developing human resources for delivering services Equipment, supplies and logistics Information and communication

would be expected to reduce costs for the user Instead, most governments have under-resourced

SRH services, including those for safe abortion Women compensate for poor access by paying

more – directly and indirectly

Expanding Access to Medical Abortion; Lisbon, Portugal, 2-4 March 2010 6

What women pay

Direct costs for getting an abortion and/or managing complications Formal or informal fees to providers and support staff Hire and use of facilities Drugs, supplies and antiseptics

Indirect costs for getting an abortion and following up Travel to and from a provider or facility Wage loss and arranging for domestic support Travel and wage loss for companion

Expanding Access to Medical Abortion; Lisbon, Portugal, 2-4 March 2010 7

What the system must pay for

A drug and services regulatory framework, which includes ground level monitoring of service - delivery

Training institutions – better pedagogy, skills and opportunities for learning

Delivery of information, support and drugs to the user

Channels of information and communication – communicators, counselors and media (including internet)

A referral system for dealing with failures and complications

Expanding Access to Medical Abortion; Lisbon, Portugal, 2-4 March 2010 8

Social / commercial marketing: of drugs or services?

Of course, women self-medicate – for abortion, infertility, infections (STIs, TB, etc) just like men do

High transaction costs of setting up commercial or social marketing operations

In poorly regulated regions, large scale competitive delivery of drugs into the hands of (untrained or poorly trained/ informed) providers

Women get the pills, with little information or back-up (India: 10.5 mi mife pills sold in 2009, but only about 800,000 reported abortion procedures)

Expanding Access to Medical Abortion; Lisbon, Portugal, 2-4 March 2010 9

Informal providers segment their market…

Bihar and Jharkhand, India: Lower paying customers – offered cheaper “ayurvedic”

(herbal) pills Higher paying customers – offered mife =/- misoprostol“First we give Gynomic Forte; if it does not work, we give

Aromic Forte. If that does not work, we give misoprotol, then mifepristone, and finally we suggest, go to madam [nearby gynecologist]”

(Ganatra B et al. RHM, 2005)

The actual use of abortion pills follows the logic of minimizing cost to the greatest extent possible

Expanding Access to Medical Abortion; Lisbon, Portugal, 2-4 March 2010 10

Women too, “segment the market” of providers

Predominantly surgical abortion providers: Highly qualified and safe Intermediate Unqualified and unsafe(Ramchandar L, Pelto PJ. RHM, 2004)

Based on collective experience, women assessed the cost of the service, the likelihood of complications and the cost of dealing with them, before opting for a service

Some delayed seeking a service till enough money was collected, to pay for a better provider

We may expect medical abortion services too, will be held to similar standards

Expanding Access to Medical Abortion; Lisbon, Portugal, 2-4 March 2010 11

The surgically inclined public sector Abortion services continue to be rooted in the

“facility based surgical (D&C) procedure” paradigm

Few countries provide medical abortion drugs through the public sector

Even in the presence of rent-seeking, the cost to women is likely to become substantially lower, if abortion pills were provided or subsidized by the state

The state is likely to thereby save on costs of surgical services, but the argument has to be well made

Expanding Access to Medical Abortion; Lisbon, Portugal, 2-4 March 2010 12

How best can provision of medical abortion reduce costs?

By promoting and delivering medical abortion as a (high-quality) service rather than as a pharmaceutical product

By freeing up controls and levies on the pills (as has been attempted for anti-retrovirals)

By providing or financing the pills through the public sector, at least for the most vulnerable sections of the population

13

Changing technology: jumping two steps

Telephone services Right up to the nineties,

telephone services were poorly accessible in several developing countries, in part because of the high cost of fixed telephone lines

The advent of mobile phones technology allowed countries to rapidly expand access without having to first provide fixed phone services

Abortion services Health systems and

providers continue to resist moving from D&C to VA or D&E

Medical abortion allows countries to rapidly expand access without having to first provide surgical services

Existing surgical services (with some required expansion) could be used as a referral back-up for incomplete procedures and failures

Expanding Access to Medical Abortion; Lisbon, Portugal, 2-4 March 2010

Expanding Access to Medical Abortion; Lisbon, Portugal, 2-4 March 2010 14

The pill will….