Out-of-pocket spending for contraceptives in Latin America

Publication date: 2020

Full Terms & Conditions of access and use can be found at https://www.tandfonline.com/action/journalInformation?journalCode=zrhm21 Sexual and Reproductive Health Matters ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/zrhm21 Out-of-pocket spending for contraceptives in Latin America Lucas Godoy Garraza , Federico Tobar & Iván Rodríguez Bernate To cite this article: Lucas Godoy Garraza , Federico Tobar & Iván Rodríguez Bernate (2020) Out- of-pocket spending for contraceptives in Latin America, Sexual and Reproductive Health Matters, 28:2, 1833429, DOI: 10.1080/26410397.2020.1833429 To link to this article: https://doi.org/10.1080/26410397.2020.1833429 © 2020 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group Published online: 02 Nov 2020. 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Correspondence: ftobar@unfpa.org c Consultant Economist, Reproductive Health Commodity Security, United Nations Population Fund (UNFPA), Latin American and the Caribbean Regional Office, Panamá, Panama Abstract: Despite progress in increasing the use of modern contraceptives in most Latin American countries over the last few decades, important challenges remain, including the heavy reliance on out-of-pocket spending to access contraceptives, which may expose consumption to macroeconomic fluctuations. Out-of- pocket spending on contraceptives and/or the proportion of women aged 15–49 who received free contraceptives at a public health facility or as part of statutory health insurance were estimated for 13 Latin American countries using the most recently available household budget surveys and demographic and health or similar household surveys. Data on contraceptive retail sales in 12 countries over the 2006– 2010 period and publicly available macroeconomic indicators were used to examine the relationship between changes in sales and macroeconomic indicators using multiple regression models. On average, women aged 15–49 spent close to US$1 per month out-of-pocket on contraceptives. However, almost three out of five women received them free of charge. A 1% increase in the percentage of the population living on less than US$ 3.2/day (2011 PPP values), or the percentage unemployed in the labour force, predicted about a 2% decrease in the growth of contraceptive retail sales (measured in couple-years of protection, CYP, per capita) the subsequent year. The analysis revealed the sensitivity of contraceptive retail sales to changes in macroeconomic variables, particularly changes in poverty levels. Achieving universal access to family planning by 2030 will require improving contraceptive financing schemes. DOI: 10.1080/ 26410397.2020.1833429 Keywords: contraceptives, out-of-pocket expenses, Latin America, access to care, family planning financing Introduction Despite the progress seen in most Latin American countries in the increased use of modern contra- ceptives, the prevalence of which is estimated to be close to 60%,1 important challenges remain, including large differences between and within countries and persistently high adolescent fertility rates.1–4 Furthermore, most of the increase in con- traceptive prevalence has been driven by an increase in short-acting contraceptives (such as pills, injectables, condoms, and emergency contra- ception) rather than long-acting reversible contra- ceptives (intrauterine devices and subdermal implants) or permanent contraception (male and female sterilisation).5,6 Some of these issues may be partially explained by the way contraceptives are paid for. Indeed, access to contraceptives in the region relies heavily on out-of-pocket expenditures.3,5 As an important part of the health financing landscape in most Latin American countries, out- of-pocket spending can detrimentally affect access to required care and impose undue financial bur- dens on households.7–10 While this negative effect has been highlighted mostly in relation to the so- called catastrophic health events, deleterious effects on access to preventive and reproductive health services have been documented as well.11 Several analysts, for instance, have pointed out that the uptake of long-acting reversible Supplemental data for this article can be accessed at https:// doi.org/10.1080/26410397.2020.1833429. RESEARCH ARTICLE 1© 2020 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (http:// creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. http://orcid.org/0000-0001-8426-9485 http://orcid.org/0000-0002-0660-4935 http://orcid.org/0000-0002-0186-0956 mailto:ftobar@unfpa.org https://doi.org/10.1080/26410397.2020.1833429 https://doi.org/10.1080/26410397.2020.1833429 http://crossmark.crossref.org/dialog/?doi=10.1080/26410397.2020.1833429&domain=pdf&date_stamp=2020-10-30 http://creativecommons.org/licenses/by-nc/4.0/ http://creativecommons.org/licenses/by-nc/4.0/ contraceptives (LARCs) has been lower that could be expected given prevailing reproductive prefer- ences and the evidence of LARCs’ safety and effi- cacy.1,5,12 The high upfront cost of LARCs has been identified as an important barrier for this uptake. Evidence from recent experiences among adolescents in the US suggests that when financial barriers are removed, both LARC uptake and unin- tended pregnancy rates are favourably impacted.13,14 The widespread use of short-acting contracep- tives coupled with the reliance on out-of-pocket spending to pay for them can increase the exposure of contraceptive consumption to macro- economic fluctuations, which tend to be recurrent in the region.15–17 While the negative effect of these fluctuations on the consumption of any kind has been well established,18 their effect on contraceptive use, in particular, has not been examined previously. As the region is set to achieve the Sustainable Development Goal (SDG) 3.7 of ensuring universal access to sexual and reproductive health care services by 2030, it is important to understand how existing contracep- tive financing schemes in the region could hinder this plan. The aim of this study is two-fold. First, we esti- mated out-of-pocket spending for contraceptives, as well as a closely related indicator, the pro- portion of women receiving contraceptives free of charge at a public health facility or as part of the statutory health insurance, for several countries in the region using the most recently available household surveys. Second, we examined the extent to which contraceptive retail sales are sensi- tive to changes in macroeconomic variables, including inflation, growth, and poverty rates, taking advantage of data on retail contraceptive sales from several countries during a period that included the global financial crisis of 2007–2008. Methods Sample We focused on 14 out of the 33 Latin American countries, where close to 90% of the region’s popu- lation is concentrated, for which relevant data were available: Argentina, Brazil, Colombia, Chile, Costa Rica, Ecuador, El Salvador, Guatemala, Hon- duras, Mexico, Panama, Peru, Uruguay, and Vene- zuela. Depending on the analysis, the information required was available for between 9 and 12 out of the 14 countries. In particular, the regression of retail sales on macroeconomic variables did not include Brazil or Mexico. Sales were available from 2006 to 2010. For the out-of-pocket esti- mation, we used the most recent information over the last 15 years. Measures and sources Out-of-pocket spending for contraceptives was esti- mated using the most recently available household budget survey in each country, which ranged from 2005 to 2018. National statistical agencies period- ically conduct this type of survey, which provides important inputs for consumer price indices and national accounts. These household surveys typi- cally involve multiple questionnaires to capture expenditures that occur at different frequencies and are incurred by either the household or its individual members.19 Questions about contracep- tive spending are generally included in an individ- ual questionnaire (except for Colombia, where such questions were included in the household questionnaire). There is some level of harmonisa- tion, with national statistical agencies in this sample building on international classifi- cations.20,21 All surveys distinguish at least between mechanical (e.g. intrauterine device, dia- phragm) and hormonal (e.g. pill, injectable, patch) contraceptives, although some include further dis- tinctions. Additional details on the definitions in each country are provided in Table S1 in the sup- plementary materials. The surveys were implemented in different years and recorded in local currency that we converted to 2011 purchas- ing power parity (PPP) dollars to ensure compar- ability.22 Spending on condoms may be at least partially directed toward sexual transmitted dis- ease prevention rather than contraception. The estimation of women receiving contracep- tives free of charge at a public health facility or as part of statutory or social health insurance was based on the most recent household survey focused on health or reproductive health available in each country, which ranged from 2004 to 2017. This includes the USAID-sponsored Demographic and Health Survey (DHS) and the US Centers for Dis- ease Control-supported Reproductive Health Sur- vey (RHS). In contrast, UNICEF’s Multiple Indicator Cluster Survey (MICS) does not inquire about the source of contraception.23 Local surveys were used in the cases of Argentina, Mexico, and Chile. In the first two cases, the surveys were roughly comparable to the DHS or RHS, with questions about the source of contraception following a set L Godoy Garraza et al. Sexual and Reproductive Health Matters 2020;28(2):1–10 2 of questions about contraceptive knowledge and use. In the case of Chile, the question was embedded in a broader question about the source for drugs currently used by the respondent, included in a survey focused on health issues rather than reproductive health in particular. Additional details on the response items indicating the public source in each country are provided in Table S2 in the supplementary materials. Retail sales data from 2006 to 2010 were obtained from IQVIA (at the time, IMS Health), a global consultancy firm widely recognised as an authoritative source of data by the pharmaceutical industry. While the de facto standard and, fre- quently, at least within the region, the only source for this information, their reliability has occasion- ally been questioned.24 The information for the present study encompassed pharmaceutical pro- ducts in the categories G02B (intrauterine devices and vaginal rings) and G03A (pills, patches, implants and emergency contraception) from the Anatomical Therapeutic Chemical Classification (ATC). Condom retail sales were not included. IQVIA methodology is not publicly available but the estimation in each country is presumably based on sales records from a panel of pharma- ceutical wholesalers and retailers. IQVIA measured pharmaceutical sales volumes in terms of the num- ber of commercial packs, a unit that is difficult to compare across contraceptive methods or even within a single method (e.g. in the case of pills, a package generally but not always corresponds with a single cycle). Based on information on the pharmaceutical form, we re-expressed the volume in terms of the number of couple-years of protec- tion (CYP) rather than the number of commercial packs.25 All the macroeconomic predictors were obtained from publicly available online data- bases.26,27 Table S3 in the supplementary materials provides additional details on the definitions of variables used. Analysis Estimations of out-of-pocket spending and the public provision of contraceptives were based on household surveys that used complex sample designs. As such, information on the design was incorporated into the estimation. While the specific characteristics of these household surveys vary, they are generally based on multistage cluster samples of households (with relatively compact area segments as the primary sampling unit to facilitate fieldwork). The segments are usually stratified before selection, for example, into rural and urban. Micro datasets always include weights that reflect the specific probability of inclusion of each unit as well as additional adjustments such as post-stratification. These weights were incorpor- ated both on point and interval estimations. Clus- ter and stratum identifiers were generally (but not always) released to allow for correct interval estimation. When unavailable, such as in micro- data from Argentina, Panama, and Uruguay, we used alternative indicators (large geographic iden- tifiers, temporal identifiers, and quantiles of income) to approximately incorporate clustering in the interval estimation. To assess the relationship between macroeco- nomic variables and contraceptive retail sales, we used different regression approaches, including ordinary least squares (OLS), mixed-effect models fitted by restricted maximum likelihood (ME), and hierarchical models estimated using a fully Baye- sian approach (BH). We regressed contraceptive sales on each candidate macroeconomic predictor separately, one at a time. In all cases, we used first differences, that is, the change in the value of each variable with respect to the previous year. For the outcome variable (i.e. contraceptive retail sales) as well as for inflation, we focused on the relative change (rather than the absolute change) to deal with more comparable figures across countries. However, we used the absolute difference in the case of unemployment and poverty rates. All pre- dictors are lagged one period (i.e. they correspond to their value in the previous year) since we are interested in assessing the extent to which changes in the purchase of contraceptives can be antici- pated. Using the first difference is a frequent approach to address residual serial correlation, which would otherwise invalidate the OLS esti- mation. Nevertheless, both the ME and BH models incorporated random intercepts by country and a first-order autoregressive process for the residuals. For Bayesian estimation, the choice of prior distri- butions for the model parameters favors simpler models over more complex ones when compatible with the data.28 Posterior distributions were esti- mated using nested Laplace approximation.29 All analysis was implemented with R,30 including the packages survey,31,32 nlme,33 and INLA.29 Results Estimated mean and the 95% confidence intervals of out-of-pocket spending for contraceptives as L Godoy Garraza et al. Sexual and Reproductive Health Matters 2020;28(2):1–10 3 well as the proportion of women aged 15–49 using a modern contraceptive who received it free at a public health facility or as part of statutory health insurance are included in Table 1. On average, they spent about US$ 12 per year on out-of-pocket con- traceptives, although the distribution appears to be bimodal, which translates into a rather wide confidence interval. As a percentage of the GDP per capita, out-of-pocket spending ranged from .01% in Chile or Colombia, to 0.15% in Uruguay. Almost three out of five women obtained them free of charge. Out-of-pocket spending was at or above the median in Argentina, Brazil, Costa Rica, Panama, and Uruguay. Public provision was well below the median in Argentina, Ecuador, and Honduras. The results from the regression of retail contra- ceptive sales on each predictor (i.e. previous year GDP growth rate, inflation, variation in poverty, unemployment rate overall, and female-specific unemployment rate) are summarised in Table 2. The previous year general inflation was not Table 1. Out-of-pocket spending for contraceptives and public provision of contraceptives Country Out-of-pocket spending Proportion of women aged 15– 49 using a modern contraceptive who obtained it free of charge 2011 US$ PPP (95% CI) % per capita GDP Survey, Year % (95% CI) Survey, Year Argentina 12.2 (6.3–18.1) 0.06 (0.03-0.09) ENGHo, 2012–2013 32.2 (28.7–35.8) ENSSyR, 2013 Brazil 12.6 (11.6–13.7) 0.09 (0.08-0.10) POF, 2008–2009 Chile 2.9 (2.1–3.7) 0.01 (0.01-0.02) EPF, 2017 57.8 (47.5–67.5) ENS, 2017 Colombia 2.0 (0.3–3.7) 0.01 (0.00-0.03) ENPH, 2016–2017 56.0 (54.7–57.4) DHS, 2015 Costa Rica 17.2 (14.1–20.2) 0.12 (0.10-0.15) ENIGH, 2013 Ecuador 34.5 (32.7–36.4) RHS, 2004 El Salvador 72.6 (71.0–74.2) RHS, 2008 Guatemala 60.7 (59.2–62.2) DHS, 2014 Honduras 54.1 (52.7–55.5) DHS, 2011 Mexico 1.8 (1.1–2.6) 0.01 (0.01-0.02) ENGASTO, 2013 68.6 (68.0–69.2) ENADID, 2014 Panama 16.0 (8.4–23.5) 0.11 (0.06-0.17) EIGH, 2007–2008 Peru 1.8 (1.3–2.3) 0.02 (0.01-0.02) ENAPREF, 2008–2009 62.0 (60.2–63.8) DHS, 2012 Uruguay 18.8 (15.7–22.0) 0.15 (0.12-0.17) ENGIH, 2005–2006 Median 12.2 (8.4–13.1) 0.06 (0.03-0.09) 57.8 (55.1–61.5) Note: DHS: Demographic and Health Survey; RHS: Reproductive Health Survey; ENGHo: Encuesta Nacional de Gastos de los Hogares; ENSSyR: Encuesta Nacional sobre Salud Sexual y Reproductiva; POF: Pesquisa de Orçamentos Familiares; EPF: Encuesta de Presupuestos Familiares; ENS: Encuesta nacional de salud; ENPH: Encuesta Nacional de Presupuestos de los Hogares; ENIGH: Encuesta Nacional de Ingresos y Gastos de los Hogares; ENGASTO: Encuesta Nacional de Gastos de los Hogares; ENADID: Encuesta Nacional de la Dinámica Demográfica; EIGH: Encuesta de Ingresos y Gastos de los Hogares; ENAPREF: Encuesta Nacional de Presupuesto Familiar; ENGIH: Encuesta Nacional de Gastos e Ingresos de los Hogares. L Godoy Garraza et al. Sexual and Reproductive Health Matters 2020;28(2):1–10 4 predictive of contraceptive sales. Changes in the GDP growth rate were somewhat more predictive, although 95% confidence interval did not entirely rule out a complete lack of association. Variations in poverty and unemployment rates were the most important predictors of variations in contraceptive sales. A one percentage point increase in the per- centage of the population living on less than US$ 3.2 per day (2011 PPP values), or in the percentage unemployed in the labour force, predicted about a two percentage point decrease in contraceptive retail sales growth (measured in CYP per capita) the subsequent year. Finally, Table 3 includes the results from the same regression analysis on a subsample of countries, which includes only countries with above-median out-of-pocket spending on contra- ceptives and/or below-median public provision of contraceptives. The results are somewhat compar- able to the result with the overall sample although estimates are less precise, as could be expected given the substantial reduction in sample size. In Table 2. Contraceptive sales growth regressed on macroeconomic indicators in 12 Latin American countries during 2007–2010 Macroeconomic indicator OLS ME BH Estimate (95% CI) GDP growth rate (%) 0.61 (−0.11–1.32) 0.43 (−0.29–1.15) 0.61 (−0.09–1.30) Inflation (%) −0.05 (−0.51–0.42) −0.14 (−0.69–0.41) −0.05 (−0.50–0.40) Poverty variation (pp) −1.73 (−2.91 to −0.54) −1.51 (−2.72 to −0.29) −2.03 (−3.01 to −1.06) Unemployment rate variation (pp) −2.21 (−4.21 to −0.20) −1.68 (−3.62–0.26) −2.35 (−4.35 to −0.35) Female unemployment rate variation (pp) −1.91 (−3.51 to −0.31) −1.18 (−2.64–0.28) −2.10 (−3.74 to −0.47) Note: OLS: ordinary least square; ME: mixed effect fitted by restricted maximum likelihood; BH: Bayesian hierarch- ical model; pp: absolute difference in percentage points; %: relative percentage difference. Table 3. Contraceptive sales growth regressed on macroeconomic indicators in six Latin American countries with above average out-of-pocket spending Macroeconomic indicator OLS ME BH Estimate (95% CI) GDP growth rate (%) 0.26 (−0.69–1.21) 0.21 (−0.78–1.20) 0.26 (−0.63–1.14) Inflation (%) −0.58 (−1.86–0.69) −0.84 (−2.15–0.47) −0.58 (−1.77–0.61) Poverty variation (pp) −2.91 (−4.72 to −1.11) −2.95 (−4.77 to −1.13) −2.91 (−4.59 to −1.24) Unemployment rate variation (pp) −1.28 (−4.00–1.45) −1.18 (−3.99–1.62) −1.28 (−3.81–1.25) Female unemployment rate variation (pp) −1.29 (−3.14–0.56) −1.09 (−2.95–0.77) −1.41 (−3.30–0.47) Note: OLS: ordinary least square; ME: mixed-effect fitter by restricted maximum likelihood; BH: Bayesian hierarch- ical model. L Godoy Garraza et al. Sexual and Reproductive Health Matters 2020;28(2):1–10 5 most cases, confidence intervals (or credible inter- vals for the Bayesian case) include zero. Only the estimated influences of the changes in poverty are both larger and more precisely estimated in this subsample. Figure 1 represents the regression line estimated using the Bayesian hierarchical model, both for the overall sample and for the countries with above-average out-of-pocket spending. Discussion We obtained estimates of out-of-pocket spending for contraceptives and the proportion of women receiving contraceptives free of charge at a public health facility or as part of statutory health insur- ance for several countries in the region based on recent household surveys. Our estimate of out-of- pocket spending is close to recent estimations of private spending per user in 24 low and middle- income Latin American and Caribbean countries by the Reproductive Health Supplies Coalition (RHSC).34 In contrast, Fagan and colleagues3 esti- mation for seven countries (four of them in our sample), is considerably higher. Their estimation approach, however, is far more indirect than ours, relying on input from key informants at sev- eral steps, and, as the author acknowledged, does not capture reimbursement in the private sector. Our estimation of the proportion of women who received contraceptives free of charge is some- what higher than the one from the RHSC, but con- sistent with the estimation by Ugaz and colleagues,5 who showed the proportion of users obtaining their method from the public sector has slowly increased since the early nineties. Figure 1. Estimated regression line of contraceptive sales growth on previous year change in poverty. Note: Entire sample (black line). Countries with above-average out- of-pocket spending (grey line). Circles are country-year observations; circles from countries with above-average out-of-pocket spending are filled. Increases in poverty were associated with subsequent decreases in the growth of contraceptive retail sales, particularly among countries with above-average out-of-pocket spending. L Godoy Garraza et al. Sexual and Reproductive Health Matters 2020;28(2):1–10 6 The discrepancy between the sources partly reflects differences in focus and definitions. For example, we assumed that a Colombian woman who received contraceptives at an “EPS health center” received them free of charge as part of the statutory health insurance, a mandate intro- duced at the end of 2007.35 The discrepancy is also driven by RHSC projection of a rather low level of public provision of contraceptives in Bra- zil. The latest DHS in Brazil dates back to 1996 and was therefore not included in our study. However, the high estimated out-of-pocket spending we estimated is consistent with low levels of public provision assumed by RHSC. This analysis also reveals the sensitivity of con- traceptive retail sales to changes in macroeco- nomic variables, particularly changes in poverty levels. The sensitivity is likely due to the heavy reliance on out-of-pocket spending to finance access to contraceptives in the region. Indeed, we found evidence of a stronger sensitivity of sales to poverty in countries with above-average out- of-pocket spending on contraceptives and/or below-average public provision. While not possible to test directly with our data, it is reasonable to hypothesise that the poorest and youngest women among private sector users are the most affected, particularly in a context of high-income inequality.2,4 The findings have important implications, par- ticularly regarding the ability of Latin American countries to reach the SDG of universal access to family planning by 2030, as illustrated using a quick back-of-the-envelope calculation. Based on this sample’s average number of CYPs acquired through retail (7.6 million per year) as well as the average yearly change (7%), the estimated change in sales following a one percentage point increase in poverty translates into 155 thousand less CYPs annually (95% CI 81–230) or, equivalently, 1.8 million women aged 15–49 not being able to access protection during a month (95% CI 1–2.8). This may be partially offset by an increase in the provision by the public sector, assuming the resources to respond to this additional demand are available especially during periods of macroe- conomic strain. An array of measures could be implemented to address this situation. For example, in the US, the Affordable Care Act mandates private health insur- ance plans to cover prescription contraceptives with no consumer cost sharing, which was recently shown to deliver large reductions in out-of-pocket spending on contraceptives.36 Whether this measure will result in increased uptake of LARCs, or impact fertility rates, has yet to be assessed. Increasing LARCs uptake, for example, may require concurrent interventions, such as information campaigns beyond the removal of financial barriers.6 The results should be interpreted in the context of the limitations of this study. First, while the sample of Latin American countries is broad and diverse, some information was not available for all of them. Specifically, the two largest pharma- ceutical markets were not included in the regression analysis because it was not possible to obtain sales information. Therefore, while the regression results are suggestive, their generalisa- bility is not guaranteed. Second, the most recent survey available for out-of-pocket spending esti- mation was relatively spread over a ten-year span. Using constant dollars only partially improves the comparability of these figures, par- ticularly in a growing market. This situation should improve as many national statistical agencies are scheduled to update their household budget sur- veys over the next few years. Finally, as previously discussed, while there is considerable harmonisa- tion in the way contraceptive expenditures are col- lected across countries and overtime, there are still substantial differences. This is also the case of the complementary indicator, acquisition of contra- ceptives from a public source, which is not cur- rently collected by one of the large international surveys in the field. Despite the advancement in the region in terms of access to modern contraception, several chal- lenges remain. Financing schemes that heavily rely on out-of-pocket spending can leave family planning at the whim of factors that should not play any role. The achievement of SDG 3.7 will undeniably require improving such schemes. Acknowledgements FT, LGG and IRB conceived the idea for the paper and planned the analysis. LGG advised on and con- ducted the analysis and drafted the paper with input from all authors. All authors approved the final draft. This study did not require ethical approval since it was entirely based on de-identified secondary data. Disclosure statement No potential conflict of interest was reported by the author(s). L Godoy Garraza et al. Sexual and Reproductive Health Matters 2020;28(2):1–10 7 Funding This work was partially funded by the United Nations Population Fund (Latin American and the Caribbean Region) (UNFPA-LACRO). The opinions expressed in this article are the authors’ own and do not reflect the view of the UNFPA LACRO. Data availability statement Country-level data and R code to reproduce the analysis are available from the corresponding author upon reasonable request. Household survey microdata are already accessible from the respective source. ORCID Lucas Godoy Garraza http://orcid.org/0000- 0001-8426-9485 Federico Tobar http://orcid.org/0000-0002-0660- 4935 Iván Rodríguez Bernate http://orcid.org/0000- 0002-0186-0956 References 1. Leon RD, Ewerling F, Serruya SJ, et al. Contraceptive use in Latin America and the Caribbean with a focus on long- acting reversible contraceptives: prevalence and inequalities in 23 countries. Lancet Glob Health. 2019;7: e227–e235. DOI:10.1016/S2214-109X(18)30481-9. 2. Caffe S, Plesons M, Camacho AV, et al. Looking back and moving forward: can we accelerate progress on adolescent pregnancy in the Americas? Reprod Health. 2017;14:83. DOI:10.1186/s12978-017-0345-y. 3. Fagan T, Dutta A, Rosen J, et al. 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Les enquêtes Resumen A pesar del progreso logrado para incrementar el uso de métodos anticonceptivos modernos en la mayoría de los países latinoamericanos en las últi- mas décadas, aún existen retos importantes, entre ellos la gran dependencia de gastos de bolsillo para acceder a los anticonceptivos, que podría exponer el consumo a fluctuaciones macroeconómicas. Los L Godoy Garraza et al. Sexual and Reproductive Health Matters 2020;28(2):1–10 9 https://doi.org/10.1093/wber/lhm017 http://www.who.int/health_financing/documents/cov-dp_e_11_01-oop_errors/en/ http://www.who.int/health_financing/documents/cov-dp_e_11_01-oop_errors/en/ http://www.who.int/health_financing/documents/cov-dp_e_11_01-oop_errors/en/ https://doi.org/10.1787/9789264181809-en https://doi.org/10.1093/ije/dys185 https://www.fda.gov/drugs/drug-safety-and-availability/fda-reports-quality-problems-data-provided-firm-iqvia-were-used-inform-estimates-some-controlled https://www.fda.gov/drugs/drug-safety-and-availability/fda-reports-quality-problems-data-provided-firm-iqvia-were-used-inform-estimates-some-controlled https://www.fda.gov/drugs/drug-safety-and-availability/fda-reports-quality-problems-data-provided-firm-iqvia-were-used-inform-estimates-some-controlled https://www.fda.gov/drugs/drug-safety-and-availability/fda-reports-quality-problems-data-provided-firm-iqvia-were-used-inform-estimates-some-controlled https://doi.org/10.1177/0193841X0002400101 https://doi.org/10.1177/0193841X0002400101 http://interwp.cepal.org/cepalstat/WEB_CEPALSTAT/estadisticasIndicadores.asp?idioma=i http://interwp.cepal.org/cepalstat/WEB_CEPALSTAT/estadisticasIndicadores.asp?idioma=i http://interwp.cepal.org/cepalstat/WEB_CEPALSTAT/estadisticasIndicadores.asp?idioma=i http://iresearch.worldbank.org/PovcalNet/povOnDemand.aspx http://iresearch.worldbank.org/PovcalNet/povOnDemand.aspx https://doi.org/10.1214/16-STS576 https://doi.org/10.1214/16-STS576 https://doi.org/10.1111/j.1467-9868.2008.00700.x https://doi.org/10.1111/j.1467-9868.2008.00700.x https://www.R-project.org/ https://CRAN.R-project.org/package=survey https://CRAN.R-project.org/package=survey https://doi.org/10.18637/jss.v009.i08 https://CRAN.R-project.org/package=nlme https://www.rhsupplies.org/fileadmin/uploads/rhsc/Projects/Global_Commodity_Gap_Analysis/Snapshots-2018/CGA_Snapshot_LAC.pdf https://www.rhsupplies.org/fileadmin/uploads/rhsc/Projects/Global_Commodity_Gap_Analysis/Snapshots-2018/CGA_Snapshot_LAC.pdf https://www.rhsupplies.org/fileadmin/uploads/rhsc/Projects/Global_Commodity_Gap_Analysis/Snapshots-2018/CGA_Snapshot_LAC.pdf https://www.rhsupplies.org/fileadmin/uploads/rhsc/Projects/Global_Commodity_Gap_Analysis/Snapshots-2018/CGA_Snapshot_LAC.pdf https://www.minsalud.gov.co/sites/rid/Lists/BibliotecaDigital/RIDE/DE/DIJ/Acuerdo_380_de_2007.pdf https://www.minsalud.gov.co/sites/rid/Lists/BibliotecaDigital/RIDE/DE/DIJ/Acuerdo_380_de_2007.pdf https://doi.org/10.1377/hlthaff.2015.0127 les plus récentes sur le budget des ménages ou les enquêtes démographiques et de santé ou autres menées auprès des familles ont permis d’estimer les dépenses à la charge des utilisateurs de contra- ceptifs et/ou la proportion de femmes âgées de 15 à 49 ans qui ont reçu des contraceptifs gratuits dans un centre de santé publique ou dans le cadre d’un régime obligatoire d’assurance maladie dans 13 pays latino-américains. Les données sur les ventes au détail de contraceptifs dans 12 pays au cours de la période 2006–2010 et les indicateurs macro-écono- miques disponibles publiquement ont été utilisés pour examiner la relation entre l’évolution des ventes et les indicateurs macro-économiques, au moyen de différents modèles de régression. En moy- enne, les femmes âgées de 15 à 49 ans dépensaient près d’un dollar par mois pour des contraceptifs. Néanmoins, près de trois femmes sur cinq les rece- vaient gratuitement. Une augmentation de 1% dans le pourcentage de la population vivant avec moins de 3,2 dollars par jour (valeurs PPP 2011) ou le pourcentage de chômeurs dans la population active laissait prévoir une diminution de 2% de la croissance des ventes de contraceptifs au détail (mesurée en couple-année de protection, par habi- tant) l’année suivante. L’analyse a révélé que les ventes de contraceptifs au détail étaient sensibles aux modifications des variables macro-économiques, en particulier aux changements des niveaux de pauv- reté. Pour mettre en place un accès universel à la pla- nification familiale d’ici à 2030, sera nécessaire d’améliorer les plans de financement des contraceptifs. gastos de bolsillo en anticonceptivos y/o la proporción de mujeres de 15 a 49 años que reci- bieron anticonceptivos gratuitos en una unidad de salud pública o como parte de seguro médico obligatorio fueron estimados para 13 países lati- noamericanos utilizando las encuestas domiciliar- ias más recientes sobre presupuestos, así como encuestas domiciliarias demográficas y de salud o encuestas similares. Se utilizaron datos sobre las ventas minoristas de anticonceptivos en 12 países durante el período de 2006 a 2010 e indicadores macroeconómicos disponibles públicamente para examinar la relación entre los cambios en ventas y los indicadores macroeconómicos utilizando diferentes modelos de regresión. En promedio, las mujeres de 15 a 49 años gastaron casi un dólar al mes de su propio bolsillo en anticoncepti- vos. Sin embargo, casi tres de cada cinco mujeres los recibieron sin costo alguno. Un aumento del 1% en el porcentaje de la población que vive con menos de US$ 3.2 al día (valores PPP para el año 2011) o en el porcentaje de personas desemplea- das en la fuerza laboral predijo una disminución de un 2% en el crecimiento de ventas minoristas de anticonceptivos (medido por año de protección por pareja, CYP, per cápita) el año subsiguiente. El análisis reveló la sensibilidad de las ventas minor- istas de anticonceptivos a los cambios en variables macroeconómicas, en particular cambios en niveles de pobreza. Para lograr acceso universal a los servicios de planificación familiar para el 2030, será necesario mejorar los esquemas de financiamiento de anticonceptivos. L Godoy Garraza et al. Sexual and Reproductive Health Matters 2020;28(2):1–10 10 Abstract Introduction Methods Sample Measures and sources Analysis Results Discussion Acknowledgements Disclosure statement Data availability statement ORCID References

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