Among the many indirect impacts that Covid-19 has had on healthcare services, it’s been reported that many women across the globe have lost access to contraceptives this year, due to issues including lockdowns and supply chain disruptions. We looked at Maisha Meds point of sale data to explore the impact of Covid-19 on Kenyan women’s contraceptive options and concluded that there was a sudden and significant disruption in sales of contraceptives in April 2020. Sales returned to normal levels by June and Covid-19 does not appear to have had long term effects on demand, prices, or brands sold in the market.

Across Eastern Africa, 42% of women who want to avoid pregnancy have an unmet need for contraception, and 46% of pregnancies are unintended. Previous public health programs have been successful at ensuring widespread access to products like vaccines, oral rehydration salts, and bed nets. However, for reproductive health products, widespread public sector stock-outs combined with limited availability of long-acting reversible contraceptives in the private sector make access a significant challenge for women.

What happened at pharmacies in Kenya?

Many reproductive health services are provided by public health centres and through organizations like Marie Stopes International, but contraceptives are also purchased at private pharmacies. Maisha Meds provides a digital point of sale solution to over 300 pharmacies in Kenya that allows us to view trends in the market. We looked at our data to see if internationally reported issues around contraceptive access could be seen in pharmacy dispensing patterns within our network. 

In general, emergency contraception pills (Levonorgestrel), also called Plan B or the morning after pill, are sold more often than longer term forms of contraception like oral contraceptive pills and injectables (Depo shots, Sayana Press) in small to medium pharmacies in Kenya. Condoms are frequently sold as well, at a rate slightly lower than the emergency pill. As they can be purchased at many other places, pharmacy sales may be less reflective of overall condom sale trends.

Reproductive health sales breakdown 2020

Contraceptive sales dropped in April by one quarter

Emergency contraception patient visits dropped by 26% from March to April 2020 at pharmacies in Maisha Meds’ network. While March 2020 saw around 4300 people purchasing the emergency pill at our pharmacies, this dropped to around 3200 in the following month. This was partially due to reduced sales at each pharmacy on average, and partially due to pharmacy closures. 

Total emergency pill patient visits; overall sales are increasing over time as our pharmacy network grows.

The drop in sales is likely due to Covid-19 related restrictions implemented by the Kenyan government in March and April. Sales gradually increased through May and June, and returned to early 2020 levels by July. There don’t appear to be long term changes to sales patterns, however it is possible that supply chain disruptions could have longer term impacts.

A similar pattern occurred with condom sales in pharmacies, which dropped 26%, or 1000 patient visits, from March to April across pharmacies. 

Long term contraceptives, primarily the oral contraceptive pill also dropped 23% from March to April.

Overall pharmacy operations slowed in April

Although Maisha Meds’ pharmacy network has been growing steadily over time, there was a big slowdown in pharmacy activity in April. The change in pharmacies selling contraceptives was similar to the overall decline in active pharmacies that month. The average number of daily pharmacies operating was lowest in the third week of April.

Maisha Meds pharmacy network

March 2020 April 2020 Percent change
  Active Pharmacies 269 251 -6.7%
  Pharmacies selling contraceptives 209 192 -8.1%

 

The change in contraceptive sales was in line with the change in sales of all types of medication at pharmacies through the spring months. Antibiotics and Cough / Cold medication sales dropped most dramatically, whereas sales of medications for malaria and chronic conditions like high blood pressure changed less. Overall pharmacy sales were slow until July, unlike contraceptives which rebounded more quickly.

Change in total sales by drug category, April 2020

April / March Change
  Antacid / Gastrointestinal / Genitourinary

-20%

  Antibiotic

-32%

  Antifungal

-22%

  Antimalarial

-18%

  Cough / Cold / Expectorants

-45%

  Heart / Blood thinners / Cholesterol

-17%

  Medical Supplies

-12%

  Painkillers / NSAIDs

-21%

  Reproductive Health

-23%

  Steroids / Corticosteroids

-21%

  Other

-13%

  Total

-24%

What drove the changes?

The decline in sales as Kenya entered lockdown occurred in part because fewer pharmacies were open or actively selling products, and in part because the average number of products sold at each pharmacy went down. The graphs below show the estimated change in total patient visits resulting from each effect for emergency pill and condom sales respectively.

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The drop in per-pharmacy contraceptive sales appear to be driven by customer demand. There was no significant reduction in the value of orders received by pharmacies in April, and estimated stock-outs didn’t increase – they actually decreased along with sales. It’s possible that factors like lower income or limited mobility resulting from the lockdown could have influenced customers’ decisions to buy medication during this period.

Covid-19 does not appear to have had longer term effects on the market for contraceptives in pharmacies in Kenya. Sales returned to levels within a normal range by June. Average prices have remained steady over time. The brands of contraceptives sold have stayed the same; there appear to be no shortages of specific brands in the market.

Possible Consequences

It’s likely that much fewer people purchasing emergency pills, condoms, and long term contraceptives would have resulted in more unintended pregnancies. Changes here are harder to ascertain based on pharmacy information, as only a small number of pregnancy tests are sold at pharmacies in our network and it’s unclear if they’re an indicator of larger pregnancy trends. Pregnancy test visits per pharmacy have not varied significantly this year. There was a small increase in the quantity of tests sold per pharmacy in July, as a result of multiple tests being sold per patient visit, but it was within a historically normal range and it was not sustained into August or September.

Our dataset provides an insight into private sector demand for contraceptives, as well as other types of drugs, and how the Covid-19 pandemic and associated restrictions caused sudden changes in purchasing patterns. The consequences to customers are unclear right now, but over time public health data will reveal the extent of the indirect impact the pandemic has had on women’s reproductive health.

References

[1] Darroch JE et al., (2018) Adding It Up: Investing in Contraception and Maternal and Newborn Health, 2017—Supplementary Tables / Estimation Methodology. New York: Guttmacher Institute. https://www.guttmacher.org/.
[2] Unpublished forthcoming manuscript by IPA and K. Tumlinson at UNC; results reported by Dr. Tumlinson via email.
[3] Kenya National Bureau of Statistics, Ministry of Health/Kenya, National AIDS Control Council/Kenya, Kenya Medical Research Institute, and National Council for Population and Development/Kenya. 2015. Kenya Demographic and Health Survey 2014. Rockville, MD, USA. Available at http://dhsprogram.com/pubs/pdf/FR308/FR308.pdf.

Notes

Pharmacies participating in program providing subsidized contraceptives to patients were excluded from the analysis of relevant products.