Assessing Contraceptive Security in Paraguay- SPARHCS

Publication date: 2006

[image: image1.emf] Documentation of the Use of SPARHCS: Paraguay Introduction Contraceptive security (CS) is achieved when individuals have the ability to choose, obtain, and use contraceptives and condoms whenever they need them. The Strategic Pathway to Reproductive Health Commodity Security (SPARHCS) framework provides countries with a tool to assess contraceptive security and to design plans for advancing it in both the short and long term. In March 2004, with input from Paraguay’s CS committee, a team from Futures Group/POLICY and John Snow Inc. (JSI)/DELIVER conducted a SPARHCS assessment as part of the Latin America and the Caribbean (LAC) Regional CS Feasibility Study. It was the fourth of five SPARHCS assessments conducted in the region. The overall goal of the study was to analyze and identify barriers and opportunities to achieving contraceptive security at both the country and regional levels. As a follow on to the study, the POLICY and DELIVER projects are working with USAID on assistance strategies for countries at regional, subregional, and national levels, under the LAC Regional CS Initiative. The technical assistance will build capacity within Paraguay and in the LAC region to address CS issues in the short, medium, and long term. This brief describes the Paraguay CS context and SPARHCS assessment and the findings and recommendations, lessons learned, and activities and progress made since the SPARHCS application. CS Context in Paraguay The SPARHCS team reviewed the demographic indicators, the history of donor financing of contraceptives, the family planning (FP) market, and the economic and political environment in Paraguay to understand the context related to achieving contraceptive security (Quesada et al., 2004). Demographic indicators. Donor investment in family planning during the 1990s resulted in increases in the contraceptive prevalence rate (CPR) among married women ages 15–44, from 44 percent in 1990 to 57 percent in 1998. From 1995–1998, the CPR for modern methods increased from 41 to 48 percent. Despite these overall gains in the past decade, regional and economic disparities still exist in the use of contraceptives. In 1998, the CPR was lower in rural areas (49 percent) than urban areas (65 percent). Unmet need for family planning was 17 percent among all married women in 1998 and as high as 33 percent among poor women (ENDS, 1990; ENDSR, 1995/1996; ENSMI, 1998). History of donor financing of contraceptives. Until 2001, the United Nations Population Fund (UNFPA) and USAID served as the sole sources of contraceptives for the Ministry of Public Health and Social Welfare (MSP y BS). From 2002–2003, both donors together provided nearly 95 percent of MSP y BS’s contraceptives, with the MSP y BS purchasing the remainder with its own funds. At present, the UNFPA is the principal provider of contraceptives for MSP y BS’s FP program, with USAID providing contraceptive donations to MSP y BS on an emergency basis when there are shortfalls in supplies. In addition, USAID continues its regular contraceptive donations to select nongovernmental organizations (NGOs) and provides condoms to MSP y BS for HIV/AIDS programs. Importantly, annual donations of contraceptives from UNFPA, USAID, and the International Planned Parenthood Federation (IPPF) together have never exceeded US$500,000, suggesting that the government of Paraguay could likely cover the amount in the near future (Quesada et al., 2004). FP providers and methods. Unlike many countries in the LAC region, pharmacies are the main providers in Paraguay’s FP market, providing contraceptive methods to 43 percent of FP users in 1998 (see Figure 1). Pharmacies offer commercially marketed products and some offer socially marketed products. The MSP y BS served 27 percent of FP users in 1998, followed by private providers (16 percent), other private sector sources (7 percent), and NGOs (4 percent). Other public providers, which include the Armed Forces/Police, the Red Cross, and the Social Security Institute (IPS) together serve 3 percent of FP users. Because the vast majority of IPS facilities do not have contraceptive methods, IPS beneficiaries turn to MSP y BS establishments and/or pharmacies for their contraceptive needs (ENSMI, 1998). Paraguay has a diverse method mix, comprised mainly of modern methods (see Figure 2). Among those using family planning in 1998, 24 percent used oral contraceptives (OCs), 19 percent used intrauterine devices (IUDs), 17 percent used traditional methods, 14 percent used female sterilization, 13 percent used injectables, and 13 percent used condoms (ENSMI, 1998). [image: image2.emf][image: image3.emf] Economic and political environment. The changing political climate in support of family planning has been a challenge since the government began providing FP services in the 1970s. Throughout the 1980s, the government opposed provision of contraceptive products, and its FP program consisted only of education and promotion of the Billings method. In the late 1980s, the Paraguayan government restored its provision of modern contraceptive methods, only to have a conservative administration in 1998 suspend public sector FP efforts again, albeit for a brief 7-month period. Since 1999, however, government commitment to family planning has been strong, and policies have been established to guarantee Paraguayans’ sustained access to contraceptives. Serious economic challenges impede Paraguay’s progress toward contraceptive security. The country suffered an economic crisis in 1995 and it is still recovering. Estimates from 2001 reveal that 36 percent of the population lives below the poverty line (CIA, 2004). Moreover, there is a high rate of unemployment and a budget deficit. However, despite its economic problems, the government increased health spending in the late 1990s, which contributed to advances in FP indicators like the CPR. Unfortunately, since 2000, government health spending has decreased, affecting funding for reproductive health and FP programming. The SPARHCS Assessment in Paraguay Paraguay’s CS assessment, conducted from March 8–29, 2004, articulated national objectives, including identifying barriers to achieving contraceptive security in the public and NGO sectors; increasing awareness among key decisionmakers about the need for coordinated action to overcome existing barriers to contraceptive security; and discussing strategies for decreasing dependence on donated contraceptives while, at the same time, protecting the important progress made in reproductive health within the last decade. Key players. The SPARHCS team included five individuals from DELIVER and POLICY, and it relied on collaboration and input of individuals from various divisions of MSP y BS, IPS, four local NGOs (including a social marketing program), the pharmaceutical association, USAID/Paraguay, and other international agencies. The CS committee in Paraguay , formed after the 2003 LAC Regional CS Conference in Managua, Nicaragua, played a valuable role in planning for the SPARHCS assessment by identifying interviewees and arranging meetings for the team. After completing the assessment, the CS committee assisted the team in reviewing the assessment’s findings and formulating the national CS recommendations. Information gathering. The SPARHCS team gathered information through a document review, interpersonal interviews, field visits, and debriefings with USAID and CS committee members. In addition, the team prepared contraceptive commodity and cost projections through 2015 using Spectrum software, with inputs drawn from available national data. Findings and dissemination of results. After completing the assessment, the SPARHCS team presented the preliminary findings and recommendations to the CS committee and the Minister and Vice Minster of Health, who provided comments, additional information, and revisions to the recommendations. The SPARHCS team wrote an in-depth assessment report in Spanish and a summary report, titled “Contraceptive Security in Paraguay: Evaluation of Strengths and Weaknesses,” in both Spanish and English. The summary report was distributed at the LAC Regional CS Forum in Lima, Peru, in October 2004, and is available on the websites of POLICY and DELIVER. The Paraguay CS committee distributed the country and regional reports to high-level political decisionmakers in Paraguay. Overview of SPARHCS Findings The SPARHCS assessment revealed both barriers and opportunities to achieving contraceptive security in the areas of financing, market segmentation, procurement, logistics, policy, and political commitment in Paraguay (Quesada et al., 2004). Financing. The establishment and partial funding of a budget line item in 2002, which included contraceptives, allowed the MSP y BS to purchase contraceptives for the first time in 2002 and 2003. MSP y BS made small purchases (US$10,000) each year, covering 5–10 percent of the total contraceptives needed by the MSP y BS. One reason for the small purchases was that the contraceptives were procured locally and thus at high prices, thereby yielding a small quantity of contraceptives for the cost. In addition, due to a budget deficit, the line item was not fully funded, so a smaller sum was made available for contraceptives. To address unmet need and respond to imminent donor phaseout of contraceptive commodities, MSP y BS would need to rapidly increase purchases of contraceptives. Contraceptive commodity projections reveal that in 2015, the public sector will need between US$380,000 (at low prices ) and US$620,000 (at intermediate prices ) to satisfy clients’ contraceptive needs. It is reasonable to expect the Paraguayan government to achieve these financing goals if it can procure contraceptives at low prices and especially if it works closely with donors and other FP providers to estimate and negotiate respective functions and financial responsibilities. IPS should begin financing contraceptives for its beneficiaries so they are not dependent on MSP y BS for contraceptives. Imminent decentralization may pose challenges for national contraceptive security unless significant awareness-raising and advocacy efforts are made at the regional level to keep family planning a program and budget priority and to ensure that local government officials are sufficiently trained to take on new responsibilities. Market segmentation. Paraguay’s FP market is well-segmented because the private sector plays a leading role in the provision of contraceptive methods, especially for those in the middle and upper economic groups. The important role of pharmacies across economic groups suggests that prices are manageable for most segments of the population; however, pharmacies are concentrated in urban areas. To address unmet need and reach periurban and rural areas with socially or commercially marketed products, efforts should be made to locate pharmacies in these underserved areas. With an active private sector covering the FP needs of many Paraguayans, the MSP y BS can focus its services on those with limited or no ability to pay. Though the MSP y BS serves mainly women from low economic groups, 19 to 26 percent of women from middle and upper-middle economic groups consult MSP y BS for their contraceptives. Since many of these women could afford commercial sector prices, redirecting these clients to the private sector could free up resources for meeting the FP needs of the poor. Targeting resources or waiving prohibitive user fees could further enhance the efforts of MSP y BS in reaching the poor. Also, the IPS could expand its capacity to provide contraceptive methods so beneficiaries do not have to rely on MSP y BS. Procurement. The MSP y BS faces few barriers to procuring contraceptives. Procurement laws are relatively flexible in Paraguay, so purchasing contraceptives either locally or internationally are feasible options. Such flexibility potentially allows MSP y BS to procure contraceptives at competitive prices. One key challenge, however, is that MSP y BS has limited experience in contraceptive procurement. Fortunately, it does have experience in procurement of medicines and supplies, which can be applied to contraceptive procurement, but overall, capacity building will be important to ensure the procurement of competitively priced, high-quality contraceptives in a timely manner. Logistics and information systems. Personnel involved in managing logistics systems within the MSP y BS are adequately trained. However, stockouts affect access to FP services, and thus, it is necessary to improve the use of current data to forecast necessary quantities. Furthermore, a lack of coordination at the central level has resulted in mistakes with orders and overall inefficiency in the contraceptive supply system. Because of these inefficiencies in the logistics system, MSP y BS often underestimates its needs quoted to UNFPA, requiring USAID to step in with emergency donations. Policy, political commitment, and leadership. The government of Paraguay has a policy framework that supports family planning and reproductive health, and it has shown commitment to improving contraceptive security. The National Constitution guarantees the rights of individuals to time their births. The National Sexual and Reproductive Health Program for 2003–2008 identifies family planning as a priority and uses the amount of national budget funds spent on contraceptives as an indicator for measuring improvement in political and economic commitment. Since 2002, the MSP y BS has had a budget line item for reproductive health, under which contraceptives are earmarked. However, while these four aspects are promising for future contraceptive security in the country, the budget line item has yet to be fully funded, in part due to a budget deficit. Main Recommendations for Achieving Contraceptive Security The Paraguay SPARHCS assessment revealed many potential interventions for achieving contraceptive security. These were grouped into five priority strategies: In the face of reforms, ensure that future health sector budgets and policies maintain commitment to family planning and that these policies improve Paraguayans’ ability to choose, obtain, and use contraceptives. Develop strategies to reach the underserved (poor women, those in rural areas, adolescents) while redirecting those who can afford to purchase contraceptives to the private sector. Encourage the IPS to be more actively involved in the contraceptive market, thereby ensuring that scarce MSP y BS resources are not spent on those who are actually covered by social security. Assure that public sector funds cover the needs of MSP y BS clients and identify the best ways to spend those funds. Address contraceptive stockouts in the MSP y BS establishments, improving central logistics coordination and ensuring that the right amount of supplies are ordered. Lessons Learned Using SPARHCS in Paraguay Overall, the LAC SPARHCS assessments provided important lessons that can be used to inform SPARHCS assessments in other countries. Paraguay’s SPARHCS assessment benefited from lessons learned from the three prior assessments conducted in the region. Use SPARHCS to create a common understanding of contraceptive security. POLICY and DELIVER presented the SPARHCS framework to country teams from Bolivia, Honduras, Nicaragua, Paraguay, and Peru at the 2003 LAC Regional CS Conference in Managua, Nicaragua. The presentation included a comprehensive review of the main CS concepts and the range of stakeholders that could participate in CS initiatives. As a result, the country teams gained a common understanding of contraceptive security and saw the value of SPARHCS as a consensus-building tool. Adapt SPARHCS locally to achieve a more effective application in the field. SPARHCS was adapted for application in the LAC region and in the field, allowing it to become a more operational and efficient tool. Adaptations for the LAC region included expanding the key CS areas to 10 (environment, policy, leadership and commitment, financing, market segmentation, client demand and use, access and quality of services, procurement, coordination, and logistics). For field use, the Peru SPARHCS team created several formats for data collection in Spanish, which were adapted and used in Paraguay. Draw on the SPARHCS framework as a guide. In Paraguay, the SPARHCS team used the framework as a general guide for conducting the assessment rather than a stringent set of instructions. For example, the SPARHCS team found it necessary to fine tune interview questions for country relevance and to organize interview questions by institution (e.g., MSP y BS, commercial sector), depending on which would have the necessary information. The Paraguay SPARHCS team also chose to conduct free-form interviews, using the questions as guidance and later as an organizational tool for the information collected. Use SPARHCS as a complementary tool. SPARHCS is not a stand-alone tool; it requires an array of sources and types of information for its proper use. The SPARHCS team relied on notes from interviews, health facility data, various cost calculations, Spectrum analysis, and market segmentation analysis. As such, the assessment generated a large volume of information, and ultimately the greatest challenge to the SPARHCS team was culling the information into specific next steps and recommendations at the country level. A noted limitation was that the SPARHCS tool does not provide a framework for analyzing the information that is collected for use in strategy development. Involve national CS committees in all stages of the assessment process. In the five LAC countries, CS committees have provided valuable assistance to SPARHCS teams in preparing for assessments, revising and fine tuning findings and recommendations, and planning how to use them to move CS activities forward in-country. Activities and Progress in Paraguay since the SPARHCS Application SPARHCS served to identify key weaknesses and focus attention on developing and implementing solutions in Paraguay. Selected activities and progress include the following: With eight other countries, Paraguay participated in the CS LAC Regional Forum held in October 2004 in Lima, Peru. The CS committee created a CS action plan, which centered on policy and financing issues. Activities in the plan included advocacy with civil society groups on family planning, follow up with IPS to include family planning in its roster of services, revision of the legal framework for procurement mechanisms, work with the Congress on an FP commodity law, exploration of alternatives for international procurement, inclusion of contraceptives in the essential drugs list, support for revision of the 2005 budget for purchase of contraceptives, creation of a phaseout plan, design of plans for market segmentation, and the strengthening of logistics and information systems. Since the SPARHCS assessment, the IPS has become more involved in contraceptive security. The institute became part of Paraguay’s CS committee, which represents an important step in taking a multisectoral approach to contraceptive security. IPS also assumed a greater role in FP provision for its beneficiaries. By mobilizing all potential sources of financing for family planning and involving all stakeholders in FP provision, the country can secure access to contraceptives for all who want them. POLICY and DELIVER conducted an in-depth procurement options analysis for Paraguay, which will form part of a LAC regional procurement options analysis. This analysis will help countries identify the best procurement option and consider advocacy strategies directed at eliminating obstructive laws/regulations. DELIVER is completing a market segmentation analysis using Paraguay’s 2004 Survey of Demography and Sexual and Reproductive Health. Paraguay’s new survey data reveals FP users’ continued reliance on pharmacies (50 percent) and on MSP y BS (27 percent). The CPR for married women between 15 and 44 years of age has increased to 73 percent, with modern method use measuring 61 percent, thus showing an increased demand for contraceptive methods. While the active participation of pharmacies in FP provision is an important component of Paraguay’s national contraceptive security, it is important to secure access to contraceptives for those who cannot pay even subsidized prices for contraceptives (ENDSSR, 2004). If pharmacies increasingly serve the contraceptive needs of those with the ability to pay, the MSP y BS can free up their resources for those who cannot pay. As part of the LAC CS Initiative, Paraguay will continue to take part in activities through 2006 to advance progress toward achieving contraceptive security. POLICY and DELIVER will provide technical assistance to increase momentum. The main activities include capacity building on the use of data for projections and CS advocacy and CS strategic planning. These activities will ensure that Paraguay can continue advancing toward contraceptive security after 2006. References Central Intelligence Agency (CIA). 2004. The World Fact Book 2005. Washington, DC: CIA. Centro Paraguayo de Estudios de Población and Institute for Resource Develepment/Macro Systems, Inc. 1991. Paraguay: Encuesta Nacional de Demografía y Salud 1990 (ENDS, 1990). Columbia, MD: Institute for Resource Develepment/Macro Systems, Inc. Centro Paraguayo de Estudios de Población, United States Agency for International Development (USAID), and Centers for Disease Control and Prevention (CDC). 1997. Paraguay: Encuesta Nacional de Demografía y Salud Reproductiva 1995–1996 (ENDSR, 1995/1996). Asunción, Paraguay: Centro Paraguayo de Estudios de Población. Centro Paraguayo de Estudios de Población, USAID, and CDC. 1999. Paraguay: Encuesta Nacional de Salud Materno Infantil 1998 (ENSMI, 1998). Asunción, Paraguay: Centro Paraguayo de Estudios de Población. Centro Paraguayo de Estudios de Población, USAID, and CDC. 2004. Encuesta Nacional de Demografía y Salud Sexual y Reproductiva 2004 (ENDSSR, 2004). Asunción, Paraguay: Centro Paraguayo de Estudios de Población. Quesada, N., C. Salamanca, J. Agudelo, P. Mostajo, V. Dayaratna, L. Patykewich, and A. Karim. 2004. Paraguay: Contraceptive Security Assessment, March 8–19, 2004. Arlington, VA: John Snow, Inc., DELIVER, and Washington, DC: Futures Group, POLICY Project. The Strategic Pathway to Reproductive Health Commodity Security (SPARHCS), developed by the DELIVER, POLICY, and Commerical Market Strategies (CMS) projects (in collaboration with the United States Agency for International Development (USAID), the United Nations Population Fund (UNFPA), and other donors and technical agencies), serves as an assessment, planning, and implementation tool to help countries address contraceptive security (CS) issues and to determine areas for strengthening and intervention. SPARHCS examines six key areas that factor into a country’s CS situation: client use and demand, context, commitment, capital, capacity, and coordination. Moreover, it is a universal assessment tool that can be tailored to specific timelines, country contexts, or program objectives. �The briefs in this series outline the experience of using SPARHCS in assessing contraceptive security in Peru, Bolivia, Honduras, Nicaragua, and Paraguay. The assessments’ findings have been used to stimulate dialogue on strategies to advance toward achieving contraceptive security in Latin America and the Caribbean. � EMBED Excel.Chart.8 \s ��� �USAID’s Bureau for Latin America and the Caribbean (LAC/RSD-PHN) conducted a Regional CS Feasibility Study to guide future policy and programmatic decisions at the regional and country levels. USAID’s DELIVER and POLICY projects implemented the study by creating CS assessments in Bolivia, Honduras, Nicaragua, Paraguay, and Peru, using SPARHCS. � USAID’s Bureau for Latin America and the Caribbean (LAC) launched a regional initiative, following the Regional CS Feasibility Study, to determine how contraceptive security in the LAC region could be more effectively addressed in light of the phase out of contraceptive donations. The initiative, being implemented by the POLICY and DELIVER Projects, is now in its third year of activities. � This section reviews the CS context at the time of the SPARHCS assessment. � Paraguay is home to 6 million inhabitants. Nearly 3.5 million (57 percent) reside in urban areas. Almost 1.5 million (25 percent) of Paraguay’s population are women of reproductive age, which is expected to grow to 2 million by 2015. � The “married” classification includes both women who are married legally and by common law. � At the time of the SPARHCS assessment, 1998 data was the most current survey data available. � The Billings method is a natural FP method consisting of observing cervical mucus characteristics to determine the timing of ovulation, which is the most fertile period. � The CS committee in Paraguay includes representatives from the RH division of MSP y BS; local NGOs, including CEPEP (IPPF affiliate) and PROMESA (social marketing); the commercial sector’s Chamber of Pharmacies of Paraguay; and UNFPA and USAID. � Spectrum is suite of policy models, designed by the POLICY Project, used to project the need for reproductive healthcare and the consequences of not addressing reproductive health needs. � � HYPERLINK "http://www.policyproject.com" ��www.policyproject.com�; � HYPERLINK "http://www.deliver.jsi.com" ��www.deliver.jsi.com� � Low prices are those that governments and organizations pay for contraceptives using UNFPA’s reimbursable procurement mechanism. These prices include shipping and a 5 percent charge for UNFPA’s management costs. � Intermediate prices are comparable to the lowest prices quoted by commercial distributors or to the prices paid by NGOs with social marketing programs or by governments in other LAC countries when purchasing large quantities of contraceptives directly from pharmaceutical companies. PAGE 8 _1200316424.xls Chart6 24 19 17 14 13 13 Figure 2: Method Mix among Users of Family Planning in Paraguay (1998) Peru 2000 MINSA 68.7 EsSALUD 10.8 Priv. provider 8.5 Pharmacy 8.3 NGO 2.3 Other 1.5 2000 Injectables 21 Sterilization 17 IUDs 13 OCs 10 Condoms 9 Traditional 27 Other 3 Peru 68.6888231277 10.7671295242 8.5249260187 8.297291145 2.2535852493 1.4682449351 2000 Figure 1. Source Mix Among Users of Modern Methods in Peru (2000) Bolivia 0 0 0 0 0 0 0 Figure 2. Method Mix Among Users of Family Planning in Peru (2000) Sterilization 17% Paraguay 1998 MSD 33.0 Priv. provider 32.0 Pharmacy 25.0 CNS 9.0 Other 1.0 100.0 1998 IUD 23 Sterilization 13 OCs 8 Injectables 2 Other 5 Traditional 49 100 Paraguay 33 32 25 9 1 Figure 1: Source Mix among Users of Modern Methods in Bolivia (1998) Nicaragua 0 0 0 0 0 0 Figure 2: Method Mix among Users of Family Planning in Bolivia (1998) Honduras Figure 1: Source Mix Among Current Users of Modern Methods in Paraguay (1998) Pharmacy 43.5 MSP y BS 26.9 Private providers 16.4 Other private sources 6.7 NGOs 3.6 Other public 2.9 100 Figure 2: Method Mix Among Current Users of Family Planning in Paraguay (1998) OCs 24 IUDs 19 Traditional 17 Sterilization 14 Injectables 13 Condoms 13 100 Honduras 0 0 0 0 0 0 Figure 1: Source Mix Among Users of Modern Methods in Paraguay (1998) Other Public 2% Other private 7% Other public 3% Madagascar 0 0 0 0 0 0 Figure 2: Method Mix among Users of Family Planning in Paraguay (1998) Ukraine Figure 1: Source Mix Among Current Users of Modern Methods in Nicaragua (2001) MINSA 64 NGO 14 Pharmacy 12 Priv. Provider 7 Other 3 100 Figure 2: Method Mix Among Current Users of Family Planning in Nicaragua (2001) Sterilization 36 Injectables 21 OCs 21 IUD 9 Condoms 5 Trad. 4 Other 4 100 Ukraine 0 0 0 0 0 Figure 1: Source Mix Among Current Users of Modern Methods in Nicaragua (2001) Jordan 0 0 0 0 0 0 0 Figure 2: Method Mix Among Current Users of Family Planning in Nicaragua (2001) Egypt Figure 1: Source Mix Among Current Users of Modern Methods in Honduras (2001) SS 40 Ashonplafa 29 Pharmacy 12 Priv. Provider 10 IHSS 5 Other 4 Figure 2: Method Mix Among Current Users of Family Planning in Honduras (2001) Sterilization 29.1 OCs 16.8 Injectables 16 IUD 16 Condoms 5 Traditional 17.5 100.4 Egypt 0 0 0 0 0 0 Figure 1: Source Mix Among Current Users of Modern Methods in Honduras (2001) 0 0 0 0 0 0 Figure 2: Method Mix Among Current Users of Family Planning in Honduras (2001) 2003 Public 58 Commerical 33 NGO 9 100 Injectables 35 OCs 13 Condoms 5 LAM 5 Sterilization 3 IUD 2 Traditional 35 Other 2 100 58 33 9 Figure 1: Source Mix among Current Users of Modern Methods in Madagascar (2003) 35 13 5 5 3 2 35 2 Figure 2: Method Mix among Users of Family Planning in Madagascar (2003) IUD Condom Women Consult. Centers 66 Women Consult. Centers 10 Pharmacy 3.7 Pharmacy 56.6 Hospital 20.4 Hospital 2.1 Maternity House 5.3 Drug kiosk 7.3 Other 4.7 Other 24 100.1 100 1999 Method IUD 18.6 Condoms 13.5 OCs 3 Steriliz. 1.4 Other 1.1 Traditional 30 0 0 0 0 0 Figure 1: Source Mix among IUD Users in Ukraine (1999) 0 0 0 0 0 Figure 2: Source Mix among Condom Users in Ukraine (1999) 18.6 13.5 3 1.4 1.1 30 Figure 3: Method Mix among Users of Family Planning in Ukraine (1999) Figure 1: Source Mix among Users of Modern Methods in Jordan (2002) Public 34 Priv. provider 27 Pharmacy 11 NGO 20 Other 8 100 Figure 2: Method Mix among Users of Family Planning in Jordan (2002) IUD 43 Traditional 26 OCs 13 Condom 6 Steril. 5 LAM 5 Other mod. 2 0 0 0 0 0 Figure 1: Source Mix among Users of Modern Methods in Jordan (2002) 0 0 0 0 0 0 0 Figure 2: Method Mix among Users of Family Planning in Jordan (2002) Other mod. 2% Figure 1: Source Mix among Users of Modern Methods in Egypt (2003) Public 55.6 Priv provider 23.3 Pharmacy 15.6 NGO 4.9 Other 0.7 100.1 Figure 2: Method Mix among Users of Family Planning in Egypt (2003) IUD 60 OCs 15 Injectables 13 Traditional 6 Steril 2 Condom 2 Implant 2 100 0 0 0 0 0 0 0 Figure 2: Method Mix among Users of Family Planning in Egypt (2003) 0 0 0 0 0 Figure 1: Source Mix among Users of Modern Methods in Egypt (2003)

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