Putting Consumers at the Center in a Context of Limited Choice and Availability of Modern Contraception in Luanda, Angola. Authors' Response to “Assessing Angola's Contraceptive Market Landscape”

Author(s): Nieto-Andrade, Benjamin; Fidel, Eva; Simmons, Rebecca; Sievers, Dana; Fedorova, Anya; Bell, Suzanne; Weidert, Karen; Prata, Ndola


ANGOLA'S ECONOMIC CRISIS
We agree with Harrison that the economic crisis, inflation, and shortage of foreign exchange are contributing factors affecting supply and availability, a point that our original article discusses as well. As supply constricts, increase in price is a common outcome.

MEASURING MARKET COMPETITIVENESS
Harrison questions our statement that there is limited choice and availability of contraceptives in Angola.
Instead, she seems to suggest that contraceptive prevalence drives the current availability of modern contraceptive methods and that this relationship is unidirectional. We contend that the relationship between the modern contraceptive prevalence rate (mCPR) and availability of contraceptive methods is circular. We believe one of the main reasons mCPR is low in Angola is because contraceptive products and services are not easily available. A recent analysis of international data from 1982 to 2009 found that for each additional method available to at least half of the population, the percentage of married women using a modern method increases by 4 to 8 percentage points. 1 We agree with Harrison that along with the number of brands, the number of manufacturers or distributors in a market is also worth considering. Brands do "speak" to consumer segments and offer different price points, thereby increasing the likelihood that a consumer finds a choice that's right for her. For that reason, the number of brands remains a useful, but not the sole, measure of choice in a market.
In our original article, we state that public health policies must ensure the availability and affordability of contraceptives on the market and expand the range of options for women. Harrison argues ". . . that public health policies should instead support fair market competition and optimize the use of both public and private resources." On that point, we agree with Harrison on the need to optimize use of public and private health resources, but we also believe that when public health goals are paramount, policy must consider public health outcomes in addition to the goal of creating a competitive market place.
We agree that subsidies need to be discrete and targeted to market failures in which market players are likely to underinvest. It is one of the reasons why Population Services International (PSI) spends a disproportionate amount of funding on health behavior change. If such investments were made by the commercial sector, they would need to be recouped from consumers, making health products and services unaffordable for most. Using subsidies and/or government policies to correct market failures could help to stimulate both demand and interest in market entry by commercial actors.
The questions on timing of phasing out subsidy and its effect in the market, although not a topic of our original article, are very interesting and should be explored further. Nevertheless, it is worth noting that PSI no longer uses donor subsidy to market its condom brands in Angola, as these products have become fully sustainable.

CLARITY ON PSI'S OWN INVOLVEMENT IN THE MARKET
PSI seeks to put the consumer at the center and bring health care closer to her. In contraceptive markets, this means ensuring women can easily access a broad range of contraceptive choices that are directly available on the market. In the oral contraceptive market in Angola, where PSI has not been playing a role until recently, there is a paucity of third-generation pills that are more suited to new and young users. With seed money from the Swedish government (the Swedish International Development Cooperation Agency, or Sida), in May 2017 PSI launched a thirdgeneration oral contraceptive pill (note: our original article was accepted in November 2016) and will soon launch an emergency contraceptive, with the aim of providing additional choices to young women in Angola. With these oral contraceptive products, PSI is advancing a cost-recovery Social Enterprise model that will not require continuous subsidy from external sources.
On leakage, PSI believes in the role of publicsector subsidies to provide free contraceptives to consumers who cannot afford them. That subsidy is wasted when products meant for free distribution are misappropriated, essentially providing a subsidized product to consumers with ability to pay, and enriching those who manipulate the supply chain. Having found evidence of this in the marketplace in Luanda, the authors felt it important to share the finding.
Again, we offer our thanks to Harrison and to GHSP for this opportunity to discuss the contraceptive market in Angola.