Effect of an Expansion in Private Sector Provision of Contraceptive Supplies on Horizontal Inequity in Modern Contraceptive Use: Evidence from Africa and Asia

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<title>Effect of an expansion in private sector provision of contraceptive supplies on horizontal inequity in modern contraceptive use: evidence from Africa and Asia</title>
<dc:title>Effect of an expansion in private sector provision of contraceptive supplies on horizontal inequity in modern contraceptive use: evidence from Africa and Asia</dc:title>
<dc:creator>Hotchkiss, David R</dc:creator>
<dc:creator>Godha, Deepali</dc:creator>
<dc:creator>Do, Mai</dc:creator>
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<dc:source>International Journal for Equity in Health 2011, 10:33</dc:source>
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<meta name="citation_authors" content="David R Hotchkiss; Deepali Godha; Mai Do" />
<meta name="citation_title" content="Effect of an expansion in private sector provision of contraceptive supplies on horizontal inequity in modern contraceptive use: evidence from Africa and Asia" />
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<meta name="title" content="Effect of an expansion in private sector provision of contraceptive supplies on horizontal inequity in modern contraceptive use: evidence from Africa and Asia" />
<meta name="description" content="One strategic approach available to policy makers to improve the availability of reproductive and child health care supplies and services as well as the sustainability of programs is to expand the role of the private sector in providing these services. However, critics of this approach argue that increased reliance on the private sector will not serve the needs of the poor, and could lead to increases in socio-economic disparities in the use of health care services. The purpose of this study is to investigate whether the expansion of the role of private providers in the provision of modern contraceptive supplies is associated with increased horizontal inequity in modern contraceptive use." />

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<meta name="dc.creator" content="Godha, Deepali" />
<meta name="dc.creator" content="Do, Mai" />
<meta name="dc.description" content="One strategic approach available to policy makers to improve the availability of reproductive and child health care supplies and services as well as the sustainability of programs is to expand the role of the private sector in providing these services. However, critics of this approach argue that increased reliance on the private sector will not serve the needs of the poor, and could lead to increases in socio-economic disparities in the use of health care services. The purpose of this study is to investigate whether the expansion of the role of private providers in the provision of modern contraceptive supplies is associated with increased horizontal inequity in modern contraceptive use." />
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<h1>Effect of an expansion in private sector provision of contraceptive supplies on horizontal inequity in modern contraceptive use: evidence from Africa and Asia</h1>

        
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        																																																																																																				        <strong>David R Hotchkiss</strong><sup>&#42;</sup><sup>&#134;</sup>, <strong>Deepali Godha</strong><sup>&#134;</sup> and <strong>Mai Do</strong>	</p>

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									 Corresponding author:										            David R Hotchkiss <a href='mailto:david.hotchkiss@tulane.edu'>david.hotchkiss@tulane.edu</a>    					</p>
      
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						                                        Department of Global Health Systems and Development, School of Public Health and Tropical Medicine, Tulane University, New Orleans, USA
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    <p><em>International Journal for Equity in Health</em> 2011, <strong>10</strong>:33&nbsp;<span class="pseudotab">doi:10.1186/1475-9276-10-33</span></p>	
		
    
    		
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		<p>The electronic version of this article is the complete one and can be found online at: <a href="http://www.equityhealthj.com/content/10/1/33">http://www.equityhealthj.com/content/10/1/33</a></p>
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        <tr><td>Received:</td><td>20 December 2010</td></tr>                <tr><td>Accepted:</td><td>19 August 2011</td></tr>        <tr><td>Published:</td><td>19 August 2011</td></tr>        </tbody>
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            &copy; 2011 Hotchkiss et al; licensee BioMed Central Ltd. <br />
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				This is an Open Access article distributed under the terms of the Creative Commons Attribution License (<a href='http://creativecommons.org/licenses/by/2.0'>http://creativecommons.org/licenses/by/2.0</a>), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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    <a name="abs"></a><h3>Abstract</h3>
<h4>Background</h4>
<p style="line-height:160%">One strategic approach available to policy makers to improve the availability of reproductive
   and child health care supplies and services as well as the sustainability of programs
   is to expand the role of the private sector in providing these services. However,
   critics of this approach argue that increased reliance on the private sector will
   not serve the needs of the poor, and could lead to increases in socio-economic disparities
   in the use of health care services. The purpose of this study is to investigate whether
   the expansion of the role of private providers in the provision of modern contraceptive
   supplies is associated with increased horizontal inequity in modern contraceptive
   use.
</p>
<h4>Methods</h4>
<p style="line-height:160%">The study is based on multiple rounds of Demographic and Health Survey data from four
   selected countries (Nigeria, Uganda, Bangladesh, and Indonesia) in which there was
   an increase in the private sector supply of contraceptives. The methodology involves
   estimating concentration indices to assess the degree of inequality and inequity in
   contraceptive use by wealth groups across time. In order to measure inequity in the
   use of modern contraceptives, the study uses multivariate methods to control for differences
   in the need for family planning services in relation to household wealth.
</p>
<h4>Results</h4>
<p style="line-height:160%">The results suggest that the expansion of the private commercial sector supply of
   contraceptives in the four study countries did not lead to increased inequity in the
   use of modern contraceptives. In Nigeria and Uganda, inequity actually decreased over
   time; while in Bangladesh and Indonesia, inequity fluctuated.
</p>
<h4>Conclusions</h4>
<p style="line-height:160%">The study results do not offer support to the hypothesis that the increased role of
   the private commercial sector in the supply of contraceptive supplies led to increased
   inequity in modern contraceptive use.
</p><a name="sec1"></a><h3>Background</h3>
<p style="line-height:160%">One strategic approach available to policy makers to improve the availability of reproductive
   and child health care services in low- and middle-income countries is to expand the
   role of the private sector in providing these services. There are a number of arguments
   that are used to support this type of strategy. First, the private sector may be more
   efficient than the public sector in the provision of services to those households
   who are willing and able to pay, particularly those who live in urban areas. Secondly,
   a strategy that involves working with the private sector can help mobilize additional
   resources for reproductive and child health programs. Third, increasing the private
   sector's market share can potentially allow population and health programs to better
   target the poor and other vulnerable households who have limited physical and financial
   access to services. However, critics of this approach argue that increased reliance
   on the private sector will not serve the needs of the poor, and could lead to increases
   in socioeconomic disparities in the use of services.
</p>
<p style="line-height:160%">Family planning services is one example of a reproductive and child health care service
   where there has been much attention on the role of the private sector. Over the past
   ten years, the demand for family planning services has increased dramatically, as
   evidenced by large increases in modern contraceptive prevalence rates (MCPR) and growing
   numbers of women entering childbearing ages in many low- and middle-income countries
   <a name="d12118e138"></a>[<a onclick="LoadInParent('#B1'); return false;" href="#B1">1</a>]. However, during the same period, donor financing for family planning programs has
   diminished and, in some countries, been phased out <a name="d12118e142"></a>[<a onclick="LoadInParent('#B2'); return false;" href="#B2">2</a>]. Taken together, both trends can potentially threaten the continuation of current
   levels of MCPR as well as progress towards the long-term sustainability of family
   planning programs. In response, many countries have turned to the private sector for
   the provision of contraceptive supplies and services. This may be due to a shortfall
   of public resources for the health sector, poor governance, and a deliberate strategy
   to engage the private sector <a name="d12118e146"></a>[<a onclick="LoadInParent('#B3'); return false;" href="#B3">3</a>].
</p>
<p style="line-height:160%">There is little research available that investigates the relationship between the
   expansion of the private sector in the provision of contraceptive supplies and socioeconomic
   disparities in modern contraceptive use. One exception is a recent study by Agha and
   Do <a name="d12118e152"></a>[<a onclick="LoadInParent('#B4'); return false;" href="#B4">4</a>], which employed population-based survey data from five countries-Morocco, Indonesia,
   Kenya, Ghana, and Bangladesh. The authors found no support for the hypothesis that
   an increase in the private sector supply of family planning services leads to socioeconomic
   inequality in the MCPR.
</p>
<p style="line-height:160%">In this study, we revisit the question of whether the expansion of the role of private
   providers in selected countries in Africa and Asia has led to increased socio-economic
   disparities in modern contraceptive method use. The countries included in the analysis
   are Uganda, Nigeria, Bangladesh, and Indonesia, all of which have experienced an increase
   in the share of women using the private commercial sector for their contraceptive
   supplies.
</p>
<p style="line-height:160%">The study methods build on those of Agha and Do <a name="d12118e160"></a>[<a onclick="LoadInParent('#B4'); return false;" href="#B4">4</a>]. Like that study, we use multiple rounds of Demographic and Health Survey (DHS) data
   for selected countries where there was an increase in the private sector supply of
   contraceptives to estimate concentration indices, whch are used to assess the degree
   of inequality in contraceptive use by wealth groups, across time. However, we extend
   their analysis by also investigating whether the expansion of the role of private
   providers is associated with increased horizontal inequity in modern contraceptive
   use.
</p>
<p style="line-height:160%">We define inequality as differences in contraceptive use between wealth groups. Inequality
   is different from inequity, which we define as unequal use for equal need (horizontal
   inequity), the standard definition used in the health equity literature <a name="d12118e166"></a>[<a onclick="LoadInParent('#B5'); return false;" href="#B5">5</a>]. In our case, inequality is unequal contraceptive use between wealth groups, regardless
   of the need for family planning, while inequity is unequal contraceptive use for equal
   need for family planning. For example, if women in richer households are more likely
   to use a modern contraception method than women in poorer households, then the inequality
   does not necessarily mean that there is inequity because the variation in contraceptive
   use between wealth groups might be explained by socioeconomic variation in the need
   for family planning. In order to measure the extent of MCPR inequity in each of the
   study countries, the study controls for differences in the need for family planning
   (FP) services in relation to household wealth. This allows us to measure the extent
   of horizontal inequity in contraceptive use. The analysis is based on DHS data from
   Uganda, Nigeria, Bangladesh, and Indonesia. In the latter two countries, also analyzed
   by Agha and Do <a name="d12118e170"></a>[<a onclick="LoadInParent('#B4'); return false;" href="#B4">4</a>], we incorporate into our analysis of trends data from a more recent DHS round.
</p>
<p style="line-height:160%">This paper is organized as follows. After this introductory section, section 2 describes
   the data and methods used in the study. Section 3 presents study the empirical results
   of our analysis. Finally, section 4 presents a discussion of the results and the policy
   implications for family planning decision-makers interested in improving the availability
   of FP services as well as the sustainability of FP programs.
</p><a name="sec2"></a><h3>Methods</h3>
<h4>Data sources</h4>
<p style="line-height:160%">This study utilizes data from DHS, which are nationally representative population-based
   surveys of women of reproductive age (15 to 49 years of age). The use of standardized
   questionnaires in the DHS makes it possible to examine changes in the variables of
   interest across multiple countries. For each country included in the study, the final
   sample consists of women of reproductive age who are either currently married or living
   in union.
</p>
<h4>Inclusion criteria</h4>
<p style="line-height:160%">For the purposes of this study, countries were initially selected if: a) there were
   at least three rounds of DHS available; and b) there was an expansion in the private
   commercial sector as source of supply for modern contraceptives in three consecutive
   surveys. The initial search for countries that met our criteria was conducted using
   STAT COMPILER, which includes data from all DHS <a name="d12118e192"></a>[<a onclick="LoadInParent('#B6'); return false;" href="#B6">6</a>]. This was followed by accessing each of the available DHS data sets for countries
   that were identified and then eliminating those countries where the private commercial
   sector share did not expand, using the study's definition of the private commercial
   sector (which does not include nongovernmental organizations [NGOs]). After applying
   these criteria, the following seven countries remained: Nigeria, Uganda, Namibia,
   Zimbabwe, Morocco, Indonesia, and Bangladesh. Due to the budget constraint of the
   study, we selected four of these countries: Nigeria, Uganda, Bangladesh, and Indonesia.
   Of the four, two countries were not included in the analysis by Agha and Do <a name="d12118e196"></a>[<a onclick="LoadInParent('#B4'); return false;" href="#B4">4</a>]. For the two countries also included in Agha and Do <a name="d12118e200"></a>[<a onclick="LoadInParent('#B4'); return false;" href="#B4">4</a>], Bangladesh and Indonesia, more recent DHS had been conducted and made available
   for each country, which provide an opportunity to test the robustness of their results.
   Table <a name="d12118e203"></a><a onclick="popup('http://www.equityhealthj.com/content/10/1/33/table/T1','',800,470); return false;" href="http://www.equityhealthj.com/content/10/1/33/table/T1">1</a> in the appendix lists the surveys used for the four study countries and their respective
   sample sizes.
</p><div class="figs">
<div class="table"><p><a onclick="popup('http://www.equityhealthj.com/content/10/1/33/table/T1','T1',800,470); return false;" href="http://www.equityhealthj.com/content/10/1/33/table/T1"><strong>Table 1.</strong></a> Surveys Used in the Analysis
</div></div>
<h4>Variables</h4>
<p style="line-height:160%">The variable of primary interest in the study is current modern contraceptive use,
   a binary variable derived from the responses to the question, "Are you currently doing
   something or using any method to delay or avoid getting pregnant?" and, for those
   women who answered yes, "Which method are you using?". The methods classified as modern
   are male condoms, pills, intrauterine device (IUD), injections, diaphragm/foam/jelly,
   female sterilization, male sterilization, and Norplant. Lactational amenorrhea method
   (LAM) was not classified as a modern method.
</p>
<p style="line-height:160%">Also of interest is an indicator of whether the woman received her contraceptive supplies
   from a private commercial provider. This indicator is based on the response to the
   question asked to women who were using a contraceptive method, "Where did you obtain
   [current method] the last time?" For the purposes of this study, we define the private
   commercial sector as consisting of those commercial outlets that sell contraceptive
   supplies and services, including chemists, shops, pharmacies, traditional healer/doctor,
   midwife, and private health care facilities and workers<sup>1</sup>. This excludes NGOs and faith-based organizations (FBOs). Based on this definition,
   we generated an indicator of the source of supply with three categories: the private
   commercial sector, the government sector, and other sources (NGOs, relatives, friends,
   and others). We then used this variable to assess changes over time in the extent
   to which women received FP supplies from a private commercial sector outlet "the last
   time" the method was obtained<sup>2</sup>.
</p>
<p style="line-height:160%">In order to control for need in the equity analysis, a variable on the need for family
   planning services was generated from the responses to questions on the desire for
   more children at the time of the survey. A woman was classified as having a need for
   family planning if she: 1) wanted a child no sooner than two years following the survey,
   2) wanted a child but was unsure of the timing, 3) was undecided on whether she wanted
   more children, 4) did not want more children, 5) was sterilized at the time of the
   survey, 6) was currently pregnant at the time of the survey but had wanted the current
   pregnancy later or not at all, or 7) was postpartum amenorrhic and who had wanted
   the last birth later or not at all. Like the commonly used measure of unmet need,
   we classified women who wanted a child within the next two years and women who were
   "infecund" (barren) as not being in need of contraception. Furthermore, all contraceptive
   users who had missing information on the "desire for more children" were also classified
   as women in need<sup>3</sup>. Note that the indicator of need does not consider whether the woman is using a contraceptive
   method, which makes our definition different than that used in the DHS.
</p>
<p style="line-height:160%">In order to assess variation in the use of modern contraception by socioeconomic status,
   a composite measure of household wealth was generated based on questions on household
   assets and living conditions using principal components analysis, which was then used
   to rank and assign households to wealth quintiles, along the lines suggested by Filmer
   and Pritchett <a name="d12118e445"></a>[<a onclick="LoadInParent('#B7'); return false;" href="#B7">7</a>].
</p>
<h4>Analytical approach</h4>
<p style="line-height:160%">To quantify socioeconomic inequality in modern contraceptive use in the analysis,
   a concentration index (CI) was calculated for each survey round. The values of the
   CI can range from -1.0 to +1.0, with 0 indicating no inequality, a negative value
   indicating increased concentration of modern contraceptive use among the poor, and
   a positive value indicating increased concentration among the rich.
</p>
<p style="line-height:160%">A potential problem with the CI approach above is that it does not consider differences
   in women's need for family planning services by socioeconomic status, and therefore
   limits the extent to which one can measure inequities in modern contraceptive use,
   as opposed to inequalities. In order to investigate horizontal inequity<sup>4 </sup>in modern contraceptive use in each of the surveys, we standardized the measure of
   modern contraceptive use for family planning need in relation to household wealth.
   This was done using the indirect method of standardization, as suggested by the World
   Bank Institute <a name="d12118e460"></a>[<a onclick="LoadInParent('#B8'); return false;" href="#B8">8</a>].
</p>
<p style="line-height:160%">The following steps were carried out to assess horizontal inequity. First, need-predicted
   modern contraceptive use is estimated using probit regression models. The dependent
   variable in the models is a dichotomous indicator measuring whether the woman is currently
   using a contraceptive method. Two types of independent variables were included in
   the models. The first type is composed of "need variables" measuring the need for
   modern contraception. Need variables in this study consist of the dichotomous indicator
   of need described above, as well as the age and the educational attainment of the
   woman. The second type is composed of "non-need" variables, which are correlates of
   utilization of modern contraception that may bias the coefficients of the need variables
   if omitted from the models<sup>5 </sup><a name="d12118e468"></a>[<a onclick="LoadInParent('#B8'); return false;" href="#B8">8</a>]. The non-need variables, which are non-confounding variables as they are theoretically
   related only to modern contraceptive use and not to family planning need, consist
   of a household wealth score, the partner's educational attainment, woman's employment
   status, and region (urban vs. rural).
</p>
<p style="line-height:160%">Second, the results of the model are used to estimate the woman's need-predicted probability
   of modern contraceptive use by setting the non-need variables at their means, and
   then generating predicted values.
</p>
<p style="line-height:160%">Third, need-standardized modern contraceptive use is obtained by adding the overall
   sample mean of the indicator of modern contraceptive use to the difference between
   actual and need-predicted modern contraceptive use.
</p>
<p style="line-height:160%">Fourth, once need-expected and need-standardized use were obtained, we calculate their
   respective concentration indices. The method of indirect standardization "corrects"
   the actual distribution by comparing it with the distribution that would be observed
   if all women had not their levels of the non-need variables but the same mean values
   of the non-need variables as the entire population <a name="d12118e478"></a>[<a onclick="LoadInParent('#B8'); return false;" href="#B8">8</a>]. The CI of need-standardized contraceptive use provides a measure of horizontal equity.
</p>
<p style="line-height:160%">A key assumption of this analysis is that once observable need indicators have been
   controlled, "any residual variation in utilization is attributable to non-need factors"
   <a name="d12118e484"></a>[<a onclick="LoadInParent('#B8'); return false;" href="#B8">8</a>]. This may be a strong assumption, given that the variables used to measure need were
   based on information on the desire for more children, age, and educational attainment.
   If there is unobserved variation in need correlated with wealth, then the procedure
   will result in biased measurement of horizontal inequity. Unfortunately, the modeling
   approach used in the study does not allow us to test this assumption with our data.
</p><a name="sec3"></a><h3>Results</h3>
<p style="line-height:160%">This section presents the empirical results for the four study countries. We first
   describe changes in the share of who report relying on the private commerical sector
   for their contraceptive supplies and in the modern contraceptive prevelance rate over
   time. We then present changes in the values of the concentration indices both for
   actual and need-standardized MCPR. Finally, to help explain changes in MCPR inequity,
   we explore changes in the extent to which poor women relied on the private commercial
   sector for their contraceptive supplies. Comparisons between countries should be made
   with caution due to variation in the policy, economic, political, and cultural context
   as well as the length of the study period. An overview of the context in each of the
   study countries can be found in Hotchkiss et al. <a name="d12118e494"></a>[<a onclick="LoadInParent('#B9'); return false;" href="#B9">9</a>].
</p>
<h4>Share of all women relying on the private sector</h4>
<p style="line-height:160%">Figure <a name="d12118e503"></a><a onclick="popup('http://www.equityhealthj.com/content/10/1/33/figure/F1','',800,470); return false;" href="http://www.equityhealthj.com/content/10/1/33/figure/F1">1</a> presents the study results on the changes in the share of women who report obtaining
   the contraceptive supplies from the commercial private sector. As mentioned in the
   methods section, a country must have experienced an increase in the role of the private
   sector to be eligible for the study. In each of the four study countries, the increase
   in the private commercial share was substantial, ranging from 69 percent over the
   1999 to 2008 period in Nigeria to 476 percent over the 1987 to 2007 period in Indonesia.
   The explanation for why the private commercial share increased in the study countries
   is not entirely clear. In Nigeria and Uganda, and Indonesia the increase may have
   been the result of both an explicit programmatic strategy to socially market contraceptive
   supplies, as well as a fluctuating public sector support for family planning due to
   political and macro-economic forces <a name="d12118e507"></a><a name="d12118e509"></a><a name="d12118e511"></a><a name="d12118e513"></a><a name="d12118e515"></a><a name="d12118e517"></a><a name="d12118e519"></a><a name="d12118e521"></a>[<a onclick="LoadInParent('#B10'); return false;" href="#B10">10</a>-<a onclick="LoadInParent('#B17'); return false;" href="#B17">17</a>]. In Bangladesh, the increase may have been the result of the government's strategy
   to increase the role of private sector <a name="d12118e525"></a><a name="d12118e527"></a>[<a onclick="LoadInParent('#B18'); return false;" href="#B18">18</a></a>,<a onclick="LoadInParent('#B19'); return false;" href="#B19">19</a>].
</p><div class="figs">
<div class="fig"><p><a onclick="popup('http://www.equityhealthj.com/content/10/1/33/figure/F1','F1',800,470); return false;" href="http://www.equityhealthj.com/content/10/1/33/figure/F1"><img align="top" src="/content/figures/1475-9276-10-33-1.gif" alt="thumbnail" class="thumbnail"><strong>Figure 1.</strong></a> <strong>Percent of women who report relying on the private commercial sector for their contraceptive
      supplies, by country and by year</strong>.
</div></div>
<h4>Modern contraceptive prevalance rate</h4>
<p style="line-height:160%">Figure <a name="d12118e549"></a><a onclick="popup('http://www.equityhealthj.com/content/10/1/33/figure/F2','',800,470); return false;" href="http://www.equityhealthj.com/content/10/1/33/figure/F2">2</a> presents the MCPR over time in each of the study countries. As the private commercial
   share of contraceptives increased, the MCPR increased in Uganda, Bangladesh, and Indonesia,
   and stagnated in Nigeria. Changes in the mix of methods used by the sample women was
   not investigated in the study.
</p><div class="figs">
<div class="fig"><p><a onclick="popup('http://www.equityhealthj.com/content/10/1/33/figure/F2','F2',800,470); return false;" href="http://www.equityhealthj.com/content/10/1/33/figure/F2"><img align="top" src="/content/figures/1475-9276-10-33-2.gif" alt="thumbnail" class="thumbnail"><strong>Figure 2.</strong></a> <strong>Current use of modern contraceptive methods, by country and by year</strong>.
</div></div>
<h4>MCPR inequality and inequity</h4>
<p style="line-height:160%">Figures <a name="d12118e571"></a><a onclick="popup('http://www.equityhealthj.com/content/10/1/33/figure/F3','',800,470); return false;" href="http://www.equityhealthj.com/content/10/1/33/figure/F3">3</a>, <a name="d12118e574"></a><a onclick="popup('http://www.equityhealthj.com/content/10/1/33/figure/F4','',800,470); return false;" href="http://www.equityhealthj.com/content/10/1/33/figure/F4">4</a>, <a name="d12118e577"></a><a onclick="popup('http://www.equityhealthj.com/content/10/1/33/figure/F5','',800,470); return false;" href="http://www.equityhealthj.com/content/10/1/33/figure/F5">5</a>, and <a name="d12118e580"></a><a onclick="popup('http://www.equityhealthj.com/content/10/1/33/figure/F6','',800,470); return false;" href="http://www.equityhealthj.com/content/10/1/33/figure/F6">6</a> present for Nigeria, Uganda, Bangladesh, and Indonesia, respectively, the estimated
   concentration indices for actual, need-predicted, and need-standardized contraceptive
   use. As described in the methods section, the indicator of MCPR inequality is the
   concentration index for actual modern contraceptive use. The study results suggest
   that in Nigeria and Uganda, actual modern contraceptive use was concentrated among
   the rich during the study period, with the CI relatively stable in Nigeria from 1999
   to 2008 but declining in Uganda from 1988 to 2006. In the two Asian countries, Bangladesh
   and Indonesia, actual modern contraceptive use was only slightly pro rich, with the
   CI declining from 0.04 in 1994 to 0.01 in 2007 in Bangladesh and declining from 0.07
   in 1987 to 0.02 in 2007 in Indonesia.
</p><div class="figs">
<div class="fig"><p><a onclick="popup('http://www.equityhealthj.com/content/10/1/33/figure/F3','F3',800,470); return false;" href="http://www.equityhealthj.com/content/10/1/33/figure/F3"><img align="top" src="/content/figures/1475-9276-10-33-3.gif" alt="thumbnail" class="thumbnail"><strong>Figure 3.</strong></a> <strong>Concentration indices for actual, need-predicted and need-standardized current use
      of modern contraceptives-Nigeria</strong>.
</div>
<div class="fig"><p><a onclick="popup('http://www.equityhealthj.com/content/10/1/33/figure/F4','F4',800,470); return false;" href="http://www.equityhealthj.com/content/10/1/33/figure/F4"><img align="top" src="/content/figures/1475-9276-10-33-4.gif" alt="thumbnail" class="thumbnail"><strong>Figure 4.</strong></a> <strong>Concentration indices for actual, need-predicted and need-standardized current use
      of modern contraceptives-Uganda</strong>.
</div>
<div class="fig"><p><a onclick="popup('http://www.equityhealthj.com/content/10/1/33/figure/F5','F5',800,470); return false;" href="http://www.equityhealthj.com/content/10/1/33/figure/F5"><img align="top" src="/content/figures/1475-9276-10-33-5.gif" alt="thumbnail" class="thumbnail"><strong>Figure 5.</strong></a> <strong>Concentration indices for actual, need-predicted and need-standardized current use
      of modern contraceptives-Bangladesh</strong>.
</div>
<div class="fig"><p><a onclick="popup('http://www.equityhealthj.com/content/10/1/33/figure/F6','F6',800,470); return false;" href="http://www.equityhealthj.com/content/10/1/33/figure/F6"><img align="top" src="/content/figures/1475-9276-10-33-6.gif" alt="thumbnail" class="thumbnail"><strong>Figure 6.</strong></a> <strong>Concentration indices for actual, need-predicted and need-standardized current use
      of modern contraceptives-Indonesia</strong>.
</div></div>
<p style="line-height:160%">In Nigeria and Uganda, the results for need-standardized CI, which measures MCPR inequity
   as opposed to MCPR inequality, shows a lower pro-rich distribution in modern contraceptive
   use than the actual distribution. This is indicated by the CI for the need-standardized
   distribution being lower than that of the actual distribution in each of the three
   survey years. For example, in 1999, the CI for the need-standardized distribution
   was 0.39, compared to the CI of 0.49 for the actual distribution (please see Table
   <a name="d12118e637"></a><a onclick="popup('http://www.equityhealthj.com/content/10/1/33/table/T2','',800,470); return false;" href="http://www.equityhealthj.com/content/10/1/33/table/T2">2</a> in the appendix for 95 percent confidence intervals for each of the concentration
   indices estimated). It should be noted that, in each of the survey years in both Nigeria
   and Uganda, MCPR inequity was relatively high while the MCPR among poor women was
   quite low (results not shown).
</p><div class="figs">
<div class="table"><p><a onclick="popup('http://www.equityhealthj.com/content/10/1/33/table/T2','T2',800,470); return false;" href="http://www.equityhealthj.com/content/10/1/33/table/T2"><strong>Table 2.</strong></a> Estimates of Concentration Indices and 95% Confidence Intervals, by Survey
</div></div>
<p style="line-height:160%">In contrast to the two sub-Saharan African countries, there was relative little difference
   between the actual and need-standardized distributions in Bangladesh and Indonesia.
   This is due to the need-expected probability of modern contraceptive use among currently
   married women being relatively uniform across the five wealth groups in each of the
   survey years. Overall, the level of MCPR inequity, based on the need-standardized
   distribution, remained relatively constant during a time when the private commercial
   sector was expanding in Bangladesh and Indonesia.
</p>
<h4>Share of poor women relying on the private sector</h4>
<p style="line-height:160%">Figure <a name="d12118e1347"></a><a onclick="popup('http://www.equityhealthj.com/content/10/1/33/figure/F7','',800,470); return false;" href="http://www.equityhealthj.com/content/10/1/33/figure/F7">7</a> presents the share of contracepive users in the poorest wealth quintile who report
   relying on the private commercial sector over time. As can be seen, in each of the
   study countries, poor women became increasingly reliant on the private commercial
   sector over time. Moreover, in Nigeria and Indonesia, the private commercial sector
   became the most important source of contraceptive supplies to women in poorest wealth
   quintile group. In addition to the the poorest quintile, women in better off wealth
   quinties also became increasingly reliant on the private commericial sector in each
   of the four study countries.
</p><div class="figs">
<div class="fig"><p><a onclick="popup('http://www.equityhealthj.com/content/10/1/33/figure/F7','F7',800,470); return false;" href="http://www.equityhealthj.com/content/10/1/33/figure/F7"><img align="top" src="/content/figures/1475-9276-10-33-7.gif" alt="thumbnail" class="thumbnail"><strong>Figure 7.</strong></a> <strong>Percent of poor women who report relying on the private commercial sector for their
      contraceptive supplies, by country and by year</strong>.
</div></div><a name="sec4"></a><h3>Discussion</h3>
<p style="line-height:160%">The purpose of this study is to investigate whether the expansion of the private commercial
   sector in the provision of contraceptive supplies leads to MCPR inequity. By facilitating
   the expansion of the role of the private sector, governments can potentially better
   target those women who are in need of family planning services, but lack the ability
   and willingness to pay. This can improve the likelihood that family planning programs
   will be financially sustainable, and help withstand fluctuations in donor assistance
   earmarked for family planning services. On the other hand, one could argue that if
   countries increasingly rely on the private sector without appropriate adjustment of
   the targeting of services to the poor and other vulnerable groups, the availability
   of contraceptives to those groups could potentially deteriorate, and as a result,
   lead to MCPR inequality (and inequity). Because the relationship between increased
   private market share and MCPR inequity is not obvious, empirical evidence on this
   issue is needed by reproductive health policy makers in low- and middle-income countries
   who are responsible for improving contraceptive security.
</p>
<p style="line-height:160%">Overall, the results of the study suggest that the expansion of the private commercial
   sector supply of contraceptives in the two African study countries (Nigeria and Uganda)
   and the two Asian study countries (Bangladesh and Indonesia) did not lead to increased
   MCPR inequity. In fact, in Nigeria and Uganda, MCPR inequity actually decreased over
   time, while in Bangladesh and Indonesia, MCPR inequity, which was already quite low,
   fluctuated.
</p>
<p style="line-height:160%">There are a number of important contextual differences between the four study countries
   that make it difficult to make definitive policy recommendations based on the results
   of the study.
</p>
<p style="line-height:160%">First, in some of the countries, the expansion of the private commercial sector was
   not always part of an explicit government strategy. For example, the increased reliance
   of women on the private commercial sector for their contraceptive supplies was in
   part due to political and economic instability (i.e., Nigeria during the 1990s, Indonesia
   during the late 1990's and early 2000's, where the public sector's role diminished
   significantly) and in part due to family planning receiving lower priority in the
   population and health sectors (i.e., Nigeria during the 1990s, Uganda during 1990s,
   and Indonesia during the 2000s). This indicates that the private commercial sector
   helped fill a void that resulted from these macro-level forces. On the other hand,
   in Bangladesh, the expansion of the private sector seemed to be part of a deliberate
   policy strategy that shifted from a target-driven approach to a facility-based approach.
</p>
<p style="line-height:160%">Second, the role of socially marketed contraceptives, which are included in our definition
   of the private commercial sector, may have also varied across the study countries.
   While social marketing played an important role in the family planning program in
   all four of the study countries, we do not have information on the degree to which
   the social marketing programs received price subsidies as well as the reach of the
   programs.
</p>
<p style="line-height:160%">Third, while countries that increasingly relied on the private commercial sector for
   their family planning supplies should have had a greater ability to target public
   subsidies to poor women, the study results suggest that poor women's reliance on the
   public sector for their supplies did not increase over time. On the contrary, in each
   of the four study countries, women in the poorest wealth quintile increased their
   reliance on the private commercial sector while achieving higher rates of modern contraceptive
   use over time<sup>6</sup>. These results imply that the private commercial sector can play an important role
   in improving the availability and use of family planning supplies not only among better
   off women, but among poorer women as well.
</p>
<p style="line-height:160%">In exploring the relationship between the expansion of the private commercial sector
   and MCPR inequity, a contribution of the study is that we control for the need for
   family planning services, which could potentially vary by socio-economic status and
   as a result, lead to differences between MCPR inequality, which is based on actual
   use, and MCPR inequity, which is based on need-standardized use. We control for need
   by deriving need-expected probabilities of using modern contraceptives, which are
   then used to calculate need-standardized concentration indices. We find that there
   are often substantial differences between the actual and need-standardized probabilities
   of modern contraceptive use, and as a result, the degree of MCPR inequity and the
   degree of MCPR inequality. This is particularly true in the two African countries
   included in our study.
</p>
<p style="line-height:160%">There are a number of limitations to the study. First, we do not attempt to empirically
   attribute differences in MCPR inequity over time to differences in the private commercial
   supply. The family planning supply environment is one of many factors that can influence
   a woman's choice of where to obtain family planning supplies and services, along with
   other community-level factors and household- and individual-level factors. Second,
   the study is at the national level, and as such, may mask increases in MCPR inequity
   that may have occurred in some regions and districts of the study countries. Third,
   the study does not investigate whether the increased role of the private sector influences
   access to and use of long acting and permanent methods (LAPM) and short-term methods.
   Other limitations of the study include the relatively small number of women currently
   using contraception in Nigeria and Uganda, which may make it difficult to interpret
   changes over time, and the inclusion of socially marketed product provision in the
   definition of the private sector, which may have resulted in an overestimate of the
   size of the private commercial sector and, as a result, an underestimate of the true
   association between the private commercial sector's share of contraceptive supply
   and inequity.
</p><a name="sec5"></a><h3>Conclusions</h3>
<p style="line-height:160%">Our findings that the expansion of the private commercial sector did not lead to increased
   MCPR inequity in the four study countries are consistent with the conclusions of Agha
   and Do <a name="d12118e1393"></a>[<a onclick="LoadInParent('#B4'); return false;" href="#B4">4</a>]. While the public sector remains an important source of supply for poor women, who
   may lack the physical and financial accessibility to private outlets that sell modern
   contraceptives, our results also suggest that the private commercial sector can also
   be an important source of supply to poor women without leading to increased MCPR inequity.
   Social marketing programs are likely to have played an important role in expanding
   the use of private suppliers among poor women.
</p><a name="sec6"></a><h3>Competing interests</h3>
<p style="line-height:160%">The authors declare that they have no competing interests.</p><a name="sec7"></a><h3>Authors' contributions</h3>
<p style="line-height:160%">The study was conceived by DRH, DG, and MD, designed and undertaken by DRH, DG, and
   MD, and written by DRH and DG. All the authors have read and approved the final manuscript.
</p><a name="sec8"></a><h3>End-notes</h3>
<p style="line-height:160%"><sup>1 </sup>It is possible that private workers may be public workers who are moonlighting, but
   our data does not allow us to investigate the importance of moonlighting in the study
   countries.
</p>
<p style="line-height:160%"><sup>2 </sup>For Indonesia, the PPKBD (village family planning posts), posyandus (health posts),
   and polindes (delivery posts) have been classified as public facilities in the 1987
   and 1991 DHS but as 'other private' sources in 1994, 1997, 2003 and 2007 DHS. A similar
   classification was used in this study with these facilities being classified as 'public'
   sources in 1987 and 1991 survey data and as 'NGO and other' sources for all other
   surveys.
</p>
<p style="line-height:160%"><sup>3 </sup>The number of missing cases is, for the most part, small. Each survey used but one
   had seven or fewer missing cases. The one survey used that has more than seven missing
   cases is the 1999 Nigeria DHS, which has 30 missing cases.
</p>
<p style="line-height:160%"><sup>4 </sup>Horizontal equity is defined as equal contraceptive use for women with equal need
   for contraceptives.
</p>
<p style="line-height:160%"><sup>5 </sup>This provides partial correlation of the standardizing variable with the variable
   of interest conditional on the presence of the non-confounding variables.
</p>
<p style="line-height:160%"><sup>6 </sup>In Bangladesh, the public sector share among the poorest fluctuated a bit but increased
   from 1994 to 2007. This is the only country where the public sector remains the main
   supplier for the poor while the private sector is increasingly the main provider for
   the rich.
</p><a name="ack"></a><h3>Acknowledgements</h3>
<p style="line-height:160%">This paper was made possible with financial support from the United States Government's
   Agency for International Development (USAID) under the MEASURE Evaluation PRH Award
   (cooperative agreement associate award number GPO-A-00-09-00003-00). We are grateful
   for the insightful comments of two anonymous reviewers who reviewed a previous version
   of the manuscript.
</p>
<p style="line-height:160%">The views expressed in this publication are those of the authors only and do not necessarily
   reflect the views of the United States Government.
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