Sources of Family Planning: Uganda

Publication date: 2018

Understanding where women acquire their family planning methods is important to increase access to modern contraception and catalyze efforts to meet Uganda’s Family Planning 2020 commitments and Health Sector Development Plan goals. This brief presents a secondary analysis of the 2016 Uganda Demographic and Health Survey to describe where modern contraceptive users obtain their methods and to examine the contribution of the private sector to family planning. Key Findings • Four out of ten modern contraceptive users (40%) rely on the private sector for their method. • Uganda’s modern contraceptive prevalence rate increased from 21% in 2011 to 27% in 2016, due to greater use of injectables and implants. • Among private sector users, most (79%) rely on private hospitals and clinics for their contraception. • Short-acting method users are equally as likely to obtain their contraceptive from the private sector as they are the public sector. • Nearly 3 in 10 of the poorest users go to the private sector for family planning. Sources of Family Planning Uganda Photo: 2017 Laura Wando, Courtesy of Photoshare Source of modern contraceptives 40% 59% 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 Uganda’s modern contraceptive prevalence rate (mCPR) is 27 percent among all women of reproductive age and 35 percent among married women. This brief focuses on all women, married and unmarried, to accurately portray contraceptive sources among all users. The recent growth in Uganda’s mCPR, from 21 to 27 percent, is driven by increases in injectables (from 11 to 14 percent) and implants (from 2 to 5 percent). Injectables remain the most popular contraceptive method, accounting for over half of modern method use. Use of short-acting methods (SAMs) and long-acting reversible contraceptives (LARCs) and permanent methods (PMs) increased from 2011. SAMs increased from 16 to 19 percent and LARCs and PMs from 5 to 8 percent.1 Sources for family planning methods The public sector is the primary source of modern contraceptives in Uganda (59 percent). Yet, 40 percent of users rely on the private sector. Since 2011, private sector use decreased from 51 percent, while public sector use increased from 47 percent. Less than 2 percent of users rely on other sources.2 As a result of Uganda’s population growth and mCPR increase, the public and private sectors combined served approximately 913,000 additional women from 2010 to 2015-16. Private sector’s contribution to method mix More Ugandan women rely on private sources to obtain SAMs (9 percent) than LARCs and PMs (1 percent). Use of public and private sources for SAMs is equivalent (9 percent). This does not hold true for LARCs and PMs. Six percent of women sought LARCs and PM in the public sector in 2016, up from 4 percent of women in 2011. The use of LARCs and PMs obtained from the private sector has not changed between 2011 and 2016 (1 percent). Among users of injectables, 54 percent use public sources and 46 percent use private sources. Among implant users, the majority (83 percent) use public sources and 17 percent use private sources. One-half of condom users and more than three-fourths (76 percent) of pill users obtain their method from the private sector. SAM users are equally likely to go to a public or private source 2011 2016 10% 6% 4% 9% 9% 1% 6% Public Private LARCs and PMs SAMs Other Public Private Uganda’s mCPR increase is largely due to higher use of injectables and implants 21% 27% 2011 2016 11% 2% 3% 2% 2% 14% 2% 3% 5% 2% 1% Implants IUDs Sterilization LARCs and PMs SAMs Condoms Pills Injectables Other Note: Numbers may not add due to rounding. 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, family planning clinics, mobile clinics, and community health workers. Private sector sources include hospitals, clinics, and doctors; faith-based and non-profit organizations including mobile clinics, community health workers, and churches; and pharmacies, drug shops, 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. Rural and urban areas The mCPR is slightly higher in urban (30 percent) than rural (26 percent) areas. More than one-half of urban users (52 percent) rely on the private sector for their family planning method compared with one-third of rural users (35 percent). Less than half of urban users rely on the public sector to obtain their method (46 percent) compared with nearly two- thirds (64 percent) of rural users. Contraceptive source by marital status and age Fifty percent of unmarried contraceptive users rely on private sector sources compared with approximately one-third (37 percent) of married users. Unmarried users are somewhat more likely to use SAMs than married users (77 versus 68 percent). This raises questions as to whether unmarried users are seeking out SAMs such as 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 happen to be more available. Younger contraceptive users ages 15-24 are somewhat more likely than older users ages 25-49 to use private sector sources (47 versus 37 percent, respectively). Use of condoms is more common among users under 25 (21 percent) than users over 25 (8 percent), again suggesting that young women may seek out One-half of unmarried users obtain their method from the private sector Almost half of users under 25 use private sector sources Private sector sources Among private sector users, the majority (79 percent) go to a private hospital or clinic and 16 percent go to a pharmacy. Very few private sector users go to a shop (3 percent) or a nongovernmental or faith-based organization (2 percent). The method most commonly sought from the private sector is injectables. Most private sector injectable users (91 percent) go to a private clinic, and 8 percent obtain injectables from a pharmacy. More than half of urban users rely on private sector sources Private sector Public sector Other Private sector Public sector Other Urban Rural 52% 46% 35% 64% private sector sources where condoms are readily available due to benefits such as convenience or privacy. High condom use among youth could also be due to successful HIV prevention and condom distribution efforts. Unmarried Married 50% 46% 37% 62% <25 25+ 47% 50% 37% 62% 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 The private sector is an important source of contraception, particularly for SAM users, unmarried women, youth, and urban populations. Uganda has one of the youngest and fastest growing populations in the world, and it is rapidly urbanizing. These demographic transitions indicate that the private sector may become increasingly important to ensure contraceptive access and choice. To meet this need, stakeholders should explore mechanisms to increase private sector provision of injectables and implants—methods which have driven recent mCPR increases. Provision of injectables through pharmacies presents one important opportunity to expand access, particularly given the scale up of Sayana Press, an injectable approved for self-injection. Given recent growth in implant use, interventions that expand private sector capacity of implant insertion and removal—such as a recent public-private partnership that trained health workers across sectors in LARC provision—could help more Ugandan women achieve their reproductive intentions.4 The high reliance on the public sector among the wealthiest highlights an opportunity to foster a more efficient overall market and develop better complementarity between the public and private sectors. Redirecting finite government resources away from providing free services to wealthier population segments and toward supporting access for poorer populations, the government can increase its reach and impact while creating opportunity for the private sector to serve segments of the population with the ability to pay. Contraceptive source by socioeconomic status The mCPR is lower among the poorest women than among the wealthiest women (22 versus 30 percent, respectively).3 Among the poorest users, nearly 3 in 10 (27 percent) rely on the private sector, indicating that private sources may offer benefits to these women that outweigh financial costs. The poorest rural users are slightly more likely to go to a private sector source (28 percent) than the poorest urban users (23 percent). The wealthiest users rely equally on public and private sources. The wealthiest contraceptive users rely on the private sector for SAMs (58 percent) more than they do for LARCs and PMs (26 percent), suggesting that the private sector is underused for LARCs. Find Us SHOPSPlusProject.org Nearly 3 in 10 of the poorest contraceptive users in Uganda use private sources Nearly half of the wealthiest contraceptive users obtain their method from public sector sources 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 Ministry of Health (MOH), Uganda. 2014. Uganda Family Planning Costed Implementation Plan, 2015–2020. Kampala: Ministry of Health, Uganda.

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