Sources of Family Planning: Afghanistan
Publication date: 2019
Understanding where women obtain their family planning methods can help programs to better target their resources and increase overall access to modern contraception. This brief is one in a series of country briefs that examines where women obtain modern contraception by method, geography, age, and socioeconomic status. Through a secondary analysis of the 2015 Afghanistan Demographic and Health Survey, the brief explains where married modern contraceptive users obtain their method and examines the contribution of the private sector to family planning in Afghanistan. Key Findings • One-half of married modern contraceptive users rely on the private sector for their method. • Nearly two-thirds (62%) of women who use pills, the most popular method in Afghanistan, obtain their method from the private sector. • More than 40% of the poorest users go to private sector sources for their family planning method. • 41% of the wealthiest family planning users rely on the public sector for their method. Sources of Family Planning Afghanistan Photo: Naimat Rawan This is one in a series of briefs that examines sources of family planning methods in USAID priority countries. View the data at PrivateSectorCounts.org. Source of modern contraceptives 50%47% Private sector Public sector Other 3 Implants IUDs Sterilization LARCs and PMs SAMs Condoms Pills Injectables 19% 3% 7% 5% 2% Modern contraceptive prevalence rate and method mix Among married women of reproductive age in Afghanistan, nearly one in five (19 percent) use modern contraception. This brief focuses on currently married (as opposed to ever-married) women. Due to the lack of source information for the lactational amenorrhea method, the method is excluded from the analysis, resulting in a slightly lower modern contraceptive prevalence rate (mCPR) than in the Demographic and Health Survey (20 percent). Modern contraceptive use is dominated by short-acting methods (SAMs). Seven percent of women use pills, 5 percent use injectables, and 3 percent use condoms. Use of long-acting reversible contraceptives and permanent methods (LARCs and PMs) is considerably lower: 2 percent of women are sterilized, and 1 percent use IUDs.1 Sources for family planning methods Afghan family planning users rely on the public and private sectors almost equally. One-half of modern contraceptive users rely on the private sector, and 47 percent use the public sector. Three percent use other sources.2 LARC and PM use is relatively low and the public sector is the dominant source for these methods—serving twice as many women as the private sector (2 versus 1 percent). Similar to the overall source mix, women rely on both the private sector (8 percent) and the public sector (7 percent) to obtain SAMs. In line with global patterns, private sector reliance is higher among pill and condom users compared with injectable users. Among users of Afghanistan’s leading method—pills—nearly two-thirds (62 percent) rely on private sources. While this source pattern is similar for condoms, it looks different for injectables: 62 percent of injectable users rely on the public sector for their method, while 36 percent rely on the private sector. 1 SAMs include injectables, contraceptive pills, male condoms, female condoms, and fertility awareness methods. LARCs and PMs include IUDs, implants, and male and female sterilization. The lactational amenorrhea method and “other modern” methods are excluded from this analysis, as the Demographic and Health Survey does not systematically ask women about sources for these methods. This analysis shows which methods women use. It does not reflect which methods women might choose if they had access to all methods. 2 Public sector sources include hospitals, health centers and sub-centers, health posts, mobile clinics, and community health workers. Private sector sources include hospitals, clinics, and doctor’s offices; nongovernmental organizations including field workers, charity foundations, Marie Stopes Afghanistan, Afghan Family Guidance Association, and Red Cross; and pharmacies and shops. Other sources include friends, relatives, refugee camps, and women who did not know or report the source. This analysis shows where women obtained their most recent method. It does not reflect where women might choose to go if they had access to all sources of care. Percent of users that rely on private sources by method SAMs, the dominant methods in Afghanistan, are obtained nearly equally from the public and private sectors Note: Numbers may not add due to rounding. Condoms Injectables 65% 36% Pills IUDs 62% 38% Sterilization 25% Other Public sector Private sector LARCs and PMs SAMs Other Public sector Private sector 8% 7% 2% Urban Rural 57% 46% 51% 40% Urban users are more likely to use the private sector than rural users Private sector use is higher among younger women Private sector Public sector Other <25 25+ 39%59% 49%48% Percent of users in each group who obtain modern contraception from each source Percent of users in each group who obtain modern contraception from each source Private sector Public sector Other Contraceptive source by geography The mCPR is higher in urban (28 percent) than in rural (16 percent) areas. This inequity is primarily due to differential condom use (7 percent in urban areas versus 2 percent in rural areas), likely resulting from the limited number of pharmacies—the primary source for condoms—in rural areas. Urban contraceptive users are more likely to purchase their method from the private sector (57 percent) compared with rural users (46 percent). Market segmentation analysis shows that nearly half of potential family planning users are concentrated in five provinces: Balkh, Herat, Kabul, Kandahar, and Nangarhar. In these five more urbanized provinces, the average mCPR (28 percent) is higher than the average of all other provinces (13 percent) and private sector use is substantially higher than that of the rest of the country (58 versus 39 percent). Contraceptive source by age Contraceptive users 25 and older are less likely to use the private sector (48 percent) compared with younger users ages 15 to 24 (59 percent). The method mix varies slightly between women 25 and older compared with women younger than 25 years. While pills are the most popular method across age categories (34 percent among older users and 49 percent among younger users), younger women are more likely to use condoms (27 versus 16 percent), while older women are more likely than younger women to use injectables (29 versus 13 percent). Pharmacies and shops 31% Nongovernmental organizations Hospitals and clinics 67% 2% Pharmacies and shops are the primary private sector sources Private sector sources Among private sector users, 67 percent obtain their method from a pharmacy or shop, 31 percent from a private hospital or clinic, and 2 percent from a nongovernmental organization, including Marie Stopes Afghanistan and the Red Cross. The two methods most commonly sought from the private sector are pills and condoms. Most private sector pill and condom users (73 and 76 percent respectively) obtain their method from a pharmacy. Sustaining Health Outcomes through the Private Sector (SHOPS) Plus is a five-year cooperative agreement (AID- OAA-A-15-00067) funded by the United States Agency for International Development (USAID). The project strategically engages the private sector to improve health outcomes in family planning, HIV, maternal and child health, and other health areas. Abt Associates implements SHOPS Plus in collaboration with the American College of Nurse-Midwives, Avenir Health, Broad Branch Associates, Banyan Global, Insight Health Advisors, Iris Group, Population Services International, and the William Davidson Institute at the University of Michigan. This brief is made possible by the generous support of the American people through USAID. The contents are the responsibility of Abt Associates and do not necessarily reflect the views of USAID or the United States government. September 2019 Implications Afghanistan’s public and private sectors are key sources for most population segments. Social marketing, which contributes more than 20 percent to the mCPR, is an important complement to the public sector in helping to achieve Afghanistan’s ambitious Family Planning 2020 commitment to increase the mCPR from 20 to 30 percent (Government of Afghanistan 2018). Social marketing can help address normative barriers and knowledge gaps that are critical to increasing use. Further, social marketing can contribute to improving access and choice in large urban provinces, which account for nearly half of Afghanistan’s potential family planning users (Ganesan 2017). Such resource segmentation would allow the government to prioritize its efforts in rural provinces lacking private sector infrastructure and increase access to LARCs. The latter is particularly important as many SAM users wish to limit, rather than space, their births, indicating LARCs or PMs may better meet their needs (Ganesan 2017). There are also opportunities to better target government resources away from the wealthiest and toward the poorest women who are most in need of free services. These strategies would help foster a more efficient and equitable market and provide greater opportunity for the private sector to serve segments of the population with the ability to pay for contraceptive services. Contraceptive source by socioeconomic status In Afghanistan, the mCPR is lower among the poorest than wealthiest women (15 versus 25 percent).3 The private sector plays an important role for both poor (42 percent) and wealthy (56 percent) contraceptive users. Four in ten (41 percent) of the wealthiest rely on public sources. More than 4 in 10 of the poorest contraceptive users in Afghanistan rely on the private sector Find Us SHOPSPlusProject.org More than 4 in 10 of the wealthiest contraceptive users in Afghanistan use the public sector 3 The poorest women are those in the lowest two wealth quintiles as defined by the Demographic and Health Survey’s asset-based wealth index. The wealthiest women are those in the top two wealth quintiles. References Government of Afghanistan. 2018. Family Planning 2020 Commitment. Ganesan, R. 2017. “Opportunities to Increase Uptake of Family Planning Products” (PowerPoint presentation, meeting at the Afghanistan Ministry of Public Health, Kabul, August 2017).