Effect of an expansion in private sector provision of contraceptive supplies on horizontal inequity in modern contraceptive use: evidence from Africa and Asia

Abstract

BackgroundOne strategic approach available to policy makers to improve the availability of reproductive and child health care supplies and services as well as the sustainability of programs is to expand the role of the private sector in providing these services. However, critics of this approach argue that increased reliance on the private sector will not serve the needs of the poor, and could lead to increases in socio-economic disparities in the use of health care services. The purpose of this study is to investigate whether the expansion of the role of private providers in the provision of modern contraceptive supplies is associated with increased horizontal inequity in modern contraceptive use.MethodsThe study is based on multiple rounds of Demographic and Health Survey data from four selected countries (Nigeria, Uganda, Bangladesh, and Indonesia) in which there was an increase in the private sector supply of contraceptives. The methodology involves estimating concentration indices to assess the degree of inequality and inequity in contraceptive use by wealth groups across time. In order to measure inequity in the use of modern contraceptives, the study uses multivariate methods to control for differences in the need for family planning services in relation to household wealth.ResultsThe results suggest that the expansion of the private commercial sector supply of contraceptives in the four study countries did not lead to increased inequity in the use of modern contraceptives. In Nigeria and Uganda, inequity actually decreased over time; while in Bangladesh and Indonesia, inequity fluctuated.ConclusionsThe study results do not offer support to the hypothesis that the increased role of the private commercial sector in the supply of contraceptive supplies led to increased inequity in modern contraceptive use.

Who, What, Where: an analysis of private sector family planning provision in 57 low‐ and middle‐income countries

“…The gradients in contraceptive use among women in need generally followed expected patterns of higher use and greater private sector use among the wealthier, urban and most educated women. These patterns have been reported by others .…”

“…Among studies on family planning use across multiple countries [5][6][7][8][9][10][11][12][13][14][15][16][17][18], few have examined the sector in which women seek services. We identified eight peer-reviewed papers [19][20][21][22][23][24][25][26] and twelve grey literature reports [27][28][29][30][31][32][33][34][35][36][37][38] that examined provision by sector across multiple countries. The characteristics and findings of these studies are described in Table S1.…”

Inequality in fertility rate and modern contraceptive use among Ghanaian women from 1988–2008

“…They suggest that reducing inequality in access to modern contraception will also reduce the inequality in fertility [7]. Hotchkiss and colleagues observed that the increased role of the private commercial sector in supplying modern contraceptives in Nigeria, Uganda, Bangladesh and Indonesia resulted in reduced inequality in modern contraceptive prevalence rates over time [23]. …”

Equity monitoring for social marketing: use of wealth quintiles and the concentration index for decision making in HIV prevention, family planning, and malaria programs

“…The combined approach we have used corresponds to standard methods used by the World Bank to measure equity and financial protection in the health sector, and the presentation of wealth quintiles and concentration indices is in line with other health equity studies [29-31]. Our approach expands on these methods in several key areas, however.…”

“…With our aim of assessing health in social marketing programs, we worked with sub-national datasets from defined geographic areas that reflect programmatic implementation plans. We are therefore limited in being able to make national policy recommendations that other health equity studies have had [7,8,31]. Second, in light of our concern with programmatic decision making, our calculation of the asset index for determining wealth quintiles and concentration indices differed from the nationally representative populations used by the World Bank and others [32,33].…”