Sources of Family Planning: Ghana

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 of 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 2014 Ghana Demographic and Health Survey, the brief explains where modern contraceptive users obtain their method and examines the contribution of the private sector to family planning in Ghana. Key Findings • More than one-third (35%) of modern contraceptive users rely on the private sector for their method. • In line with global patterns, the private sector is the primary source for condoms (94%) and pills (84%), though reliance on the private sector for these methods is higher in Ghana than in many neighboring countries. • More than 6 in 10 adolescent users (ages 15–19) obtain contraception from private sector sources. • Nearly 3 in 10 of the poorest users rely on the private sector for family planning. • More than one-half (55%) of the wealthiest users obtain their contraceptive method from the public sector. Sources of Family Planning Ghana Photo: Jessica Scranton This is one in a series of briefs that examines sources of family planning methods in USAID priority countries. View the data at Source of modern contraceptives 35% 64% Private sector Public sector Other Modern contraceptive prevalence rate and method mix Nearly one in five (18 percent) women of reproductive age in Ghana use modern contraception. Among married women, the modern contraceptive prevalence rate (mCPR) is 22 percent. This brief focuses on all women, married and unmarried, to accurately portray contraceptive sources among all users. Between 2008 and 2014, Ghana’s mCPR increased from 13 to 18 percent, largely driven by implant and injectable increases. Short-acting methods (SAMs) are most commonly used in Ghana (12 percent), although SAM use has not increased since 2008. While fewer women use long-acting reversible contraceptives and permanent methods (LARCs and PMs), their use tripled between 2008 and 2014 (from 2 to 6 percent).1 Sources for family planning methods Among modern contraceptive users, the public sector is the primary source (64 percent). More than one-third of users (35 percent) rely on the private sector.2 Women in Ghana are equally likely to seek SAMs from private and public sources (6 percent each). Women are more likely to go to public than private sources for LARCs and PMs (5 percent versus less than 1 percent, respectively), likely due to availability of specialized health workers in public facilities who are required by the government to provide LARCs and PMs (GSS, GHS, and ICF, 2015). The private sector contribution to the mCPR has remained stable over time, at approximately 6 percent. The public sector’s role has increased since 2008 in provision of SAMs (from 4 to 6 percent) and LARCs and PMs (from 1 to 5 percent). This shift is likely a reflection of method mix changes: condom use—for which private pharmacies and shops are the dominant source—halved, while injectable and implant use—primarily obtained from public sources—increased. Similar to neighboring countries, the private sector is the dominant source for pill (84 percent) and condom users (94 percent). Injectable contraceptives, Ghana’s leading method, are primarily sourced from the public sector (90 percent). 1 SAMs include injectables (depot medroxyprogesterone acetate intramuscular [DMPA-IM]), 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, clinics, polyclinics, health centers, health posts, Community-based Health Planning and Services facilities, family planning clinics, mobile clinics, field workers, and outreach and peer educators. Private sector sources include hospitals, clinics, and maternity homes; NGOs including community volunteers and Planned Parenthood Association of Ghana clinics; and pharmacies, drug stores, shops, and markets. Other sources include friends, relatives, 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. Use of the public sector for LARCs and PMs increased substantially 2008 2014 6% 6% 5% 4% 6% Public Private LARCs and PMs SAMs Other Public Private Ghana’s mCPR increase is largely due to higher use of implants and injectables 13% 18% 2008 2014 Implants IUDs Sterilization LARCs and PMs SAMs Condoms Pills Injectables Other 2% 4% 6% 4% 4% 4% 4% Note: Numbers may not add due to rounding. Contraceptive source by marital status and age Unmarried contraceptive users are nearly twice as likely as married users to obtain their modern contraceptive method from the private sector (52 versus 27 percent, respectively). Unmarried Ghanaian users are also more likely to use condoms than married users (26 versus 5 percent, respectively), while injectables and implants are more common among married than unmarried users. Contraceptive users ages 15–19 and 20–24 are more likely to use the private sector (61 and 45 percent, respectively) than women 25 and older (30 percent). Condom use is also correlated with youth: 40 percent of the youngest users rely on condoms, compared with 20 percent of those ages 20–24 and 7 percent of those 25 and older. Pill use is less common among 15–19-year-olds (13 percent) than among those ages 20–24 and 25 and older (22 and 23 percent, respectively). One-quarter (26 percent) of adolescent users rely on injectables, compared to more than one-third of older users (38 percent among ages 20–24 and 34 percent among ages 25–49). Over half of unmarried users obtain their method from the private sector Younger contraceptive users are more likely to use the private sector than older users Private sector sources Among private sector users, 86 percent obtain their method from a private pharmacy or shop, 11 percent from a private hospital or clinic, and 2 percent from a NGO. More than 95 percent of private sector condom and pill users obtain their method from a pharmacy. Rural and urban areas The mCPR is higher in rural (20 percent) than in urban (15 percent) areas, perhaps due to Ghana’s Community- based Health Planning and Services program, which primarily targets rural areas (GoG, 2015). Urban contraceptive users are more likely to purchase their method from the private sector (41 percent) than rural users (29 percent). Contraceptive sources vary by region, as well: private sector reliance is highest in the Western region (45 percent) and lowest in the Upper West (16 percent). Urban users are more likely to use the private sector than rural users Urban Rural 41% 70%29% 57% 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 Percent of users in each group who obtain modern contraception from each source Private sector Public sector Other Private sector Public sector Other Unmarried Married 47%52% 71%27% 61% 38% 45% 54% 30% 68% 15-19 20-24 25+ 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. May 2019 vb Implications Ghana’s public sector is a key source of modern contraception and has facilitated increased uptake of injectables and implants. The private sector is also an important source, particularly for younger women and condom and pill users. For injectables and LARCs, the two methods showing increases in uptake, the majority of users rely on public sources. The private sector could contribute more to provision of these methods, particularly for urban and wealthier women. Strategies to improve availability through the private sector include increasing access to lower-priced generic DMPA-IM products, expanding injectable provision through drug shops, and scaling up private sector social franchising programs with access to implants under price guarantees. One of the Government of Ghana’s (GoG) six strategic family planning priorities is to ensure full financing for commodity security in the public and private sectors (GoG, 2015). The GoG aims to undertake a comprehensive market segmentation analysis to better allocate government services away from the wealthiest and towards the poorest women using a total market approach (GoG, 2015). This will provide greater opportunity for the private sector to serve population segments with the ability to pay for contraceptive services, fostering a more efficient and sustainable market. Contraceptive source by socioeconomic status The mCPR is slightly higher among the poorest than wealthiest women (19 versus 15 percent).3 Nearly three in ten of the poorest users (27 percent) rely on private sources. More than half of the wealthiest users rely on public sources (55 percent), and 42 percent use private sources. The wealthiest users rely on the private sector for SAMs (60 percent) much more than they do for LARCs and PMs (5 percent). Nearly 3 in 10 of the poorest contraceptive users in Ghana rely on the private sector Find Us More than half of the wealthiest contraceptive users in Ghana 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 Ghana (GoG). 2015. Accra: Ghana Health Service. Washington, DC: Futures Group, Health Policy Project. Ghana Family Planning Costed Implementation Plan. Ghana Statistical Service (GSS), Ghana Health Service (GHS), and ICF International. 2015. Ghana Demographic and Health Survey 2014. Rockville, Maryland, USA: GSS, GHS, and ICF International.

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