Sources of Family Planning: Malawi
Publication date: 2018
Understanding where women acquire their family planning methods is important to catalyze efforts to meet Malawi’s Family Planning 2020 commitments and Health Sector Strategic Plan II goals. In addition, Malawi’s Costed Implementation Plan for Family Planning (2016-2020) calls for a better understanding of the private sector’s role, and makes a commitment to create more opportunities for public-private partnerships to strengthen family planning service delivery. This brief presents a secondary analysis of the 2015–16 Demographic and Health Survey to describe where modern contraceptive users obtain their method and to highlight the contribution of the private sector to family planning. Key Findings • The public sector is the primary supplier of implants and other long-acting reversible methods. • Malawi’s modern contraceptive prevalence rate increased from 33% in 2010 to 45% in 2015-16, largely due to increased use of implants. • One-fifth of modern contraceptive users rely on the private sector for their method. • Among private sector users, most (63%) rely on nongovernmental and faith-based organizations for their contraception. • More than 70% of the wealthiest users go to public sector sources for family planning. Sources of Family Planning Malawi Photo: Lindsay Mgbor/DFID Source of modern contraceptives 20% 79% Private sector Public sector Other 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. Modern contraceptive prevalence rate and method mix Malawi’s modern contraceptive prevalence rate (mCPR) among all women of reproductive age is 45 percent. Among married women, the mCPR is 58 percent. This brief focuses on all women, married and unmarried, to accurately portray contraceptive sources among all users. The substantial growth in Malawi’s mCPR, from 33 to 45 percent, is largely driven by increases in two methods: a nine-fold increase in implants (from 1 to 9 percent) and a more modest increase in Malawi’s most popular method, injectables (from 19 to 22 percent). More Malawian women rely on short-acting methods (SAMs, 27 percent) compared with long-acting reversible contraceptives and permanent methods (LARCs and PMs, 18 percent), though nearly all of Malawi’s mCPR increase is attributable to growth in use of LARCs and PMs (from 9 to 18 percent).1 Sources for family planning methods The public sector is the primary source of modern contraceptives in Malawi (79 percent). One-fifth of users rely on the private sector. Less than one percent use other sources.2 Since 2010, use of the private sector declined slightly from 25 percent, while public sector use increased from 74 percent. As a result of Malawi’s population growth and mCPR increase, the public and private sectors combined served approximately 743,000 additional women from 2010 to 2015-16. Private sector’s contribution to method mix Women in Malawi rely on the private sector to obtain SAMs and LARCs and PMs in similar proportions (4 and 5 percent, respectively). Use of the public sector for these methods is substantially higher. The percentage of women obtaining LARCs and PMs from the public sector nearly tripled since 2010 (from 5 to 14 percent). The private sector’s increase in LARC and PM distribution has been more modest (from 4 to 5 percent). Among injectable users, 13 percent use private sources. Reliance on the private sector is slightly higher among implant users (19 percent). While fewer women in Malawi use condoms than injectables or implants, more than two out of every five condom users (44 percent) obtain their method from 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 Surveys do 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, health posts, mobile clinics, community based distributors, and health surveillance assistants. Private sector sources include hospitals, clinics, and doctors; faith-based and nonprofit organizations such as mobile clinics, mission hospitals and health centers, community-based distributors, churches, and youth drop-in centers; and pharmacies and shops. 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 of care. Private sector LARC and PM growth lags behind public sector increases 2010 2015-16 5% 19% 4% 5% 4% 22% 5% 14% Public Private LARCs and PMs SAMs Other Public Private Malawi’s mCPR increase is largely due to higher use of implants and injectables 33% 45% 2010 2015-16 19% 2% 3% 8% 22% 2% 3% 9% 8% Implants IUDs Sterilization LARCs and PMs SAMs Condoms Pills Injectables Other Note: Numbers may not add due to rounding. Unmarried Married 81%19% 73%26% Rural and urban areas The mCPR is similar in urban (43 percent) and rural (45 percent) areas. Urban contraceptive users are more than twice as likely to obtain their method from the private sector (37 percent) compared with rural users (16 percent). Nearly two-thirds (63 percent) of urban users go to the public sector to obtain their method, while 83 percent of rural users rely on public sector sources. Contraceptive source by marital status and age Unmarried contraceptive users are somewhat more likely than married users to go to a private sector source to obtain their method (26 versus 19 percent, respectively). Use of condoms is more popular among unmarried users versus married users (19 versus 3 percent), while injectables are more common among married contraceptive users (52 versus 40 percent). This raises questions as to whether unmarried users are seeking out condoms, which leads them to the private sector, or if they are seeking out the private sector for particular benefits such as privacy, where SAMs like condoms happen to be more available. Contraceptive users under 25 and those 25 and over use the private sector in similar proportions (17 and 21 percent, respectively). Injectables are much more common among Unmarried users are somewhat more likely to use the private sector than married users Use of the public and private sectors are similar across age groups Private sector sources Among private sector users, 63 percent obtain their method from a nongovernmental or faith-based organization; almost half of whom (44 percent) go to a mission hospital or the Christian Health Association of Malawi. More than one-fourth (27 percent) of private sector users go to a private hospital or clinic, and one in ten women go to a pharmacy (1 percent) or a shop (9 percent). The method most commonly sought from the private sector is injectables. Private sector injectable users rely on nongovernmental or faith-based organizations (53 percent) and private clinics and hospitals (46 percent) in similar proportions. Urban users are more than twice as likely to use the private sector as rural users Private sector Public sector Other Private sector Public sector Other Urban Rural 63%37% 83%16% <25 25+ 82%17% 78%21% users ages 15-24 (64 percent) compared with older users (45 percent). More than one-fourth (26 percent) of older users are sterilized, while less than 1 percent of younger contraceptive users are sterilized. Despite these differences in method mix, use of the public and private sectors for family planning services are similar across age categories. Percent of urban and rural users who obtain method from each source Percent of married and unmarried users who obtain method from each source Percent of younger and older users who obtain method from each source 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. November 2018 Implications Malawi’s public sector is the primary source of modern contraceptives for all population segments. Large growth in mCPR, which was primarily driven by an increase in implant use, indicates that efforts to strengthen family planning delivery through public sector outlets were successful. However, nongovernmental and faith-based organizations are an important source for those who access family planning from the private sector, as they often provide family planning services that are free or highly subsidized, which is important to serve the needs of poor Malawians. Efforts that focus on expanding provision of implants through these networks could help more Malawian women achieve their reproductive intentions. The high reliance of the wealthiest on the public sector highlights an opportunity to move wealthier segments of the population away from free services using a total market approach. A better understanding of and enhanced collaboration with the private sector will result in increased family planning sustainability, as the Malawian government itself has voiced.4 For example, increasing the capacity of the private sector to provide SAMs to women who are able and willing to pay for them represents an opportunity to expand contraceptive access and use. This will foster a more efficient market and provide greater opportunity for the private sector to serve those segments of the population with the ability to pay for contraceptives, particularly in urban areas, while allowing the public sector to allocate its limited resources towards rural and other underserved communities, helping Malawi achieve a more equitable and sustainable family planning approach. Contraceptive source by socioeconomic status In Malawi, the poorest and wealthiest women are equally likely to use a modern contraceptive method (45 and 44 percent, respectively).3 Among the poorest modern contraceptive users, 13 percent rely on private sources. Use of the private sector is slightly higher among the poorest urban contraceptive users (15 percent). Nearly one-third (28 percent) of the wealthiest contraceptive users obtain their method from the private sector, while 72 percent go to public sector sources. The wealthiest contraceptive users rely on the private sector for LARCs and PMs (34 percent) more than they do for SAMs (24 percent), perhaps demonstrating that these methods are not sufficiently available or easily accessible from private sector sources. Find Us SHOPSPlusProject.org More than 1 in 10 of the poorest contraceptive users rely on the private sector Nearly three-fourths of the wealthiest contraceptive users rely on 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. 4 Government of Malawi. 2015. Malawi Costed Implementation Plan for Family Planning, 2016–2020. Lilongwe: Government of Malawi.