Using Market Analysis to Help Ethiopia Achieve its Health and

Development Goals

This analysis was conducted by the USAID | DELIVER PROJECT, Task Order 4

A tool to analyze utilization of services and define strategies to segment, focus and improve access to family planning:

What is a market analysis?

- Utilizes Demographic Health Surveys (DHS)

- Groups clients by characteristics, needs, and/or common preferences to understand their family planning needs

- Analyzes use, demand, and provision of contraceptives in the total market (public, NGO, and commercial)

- Uses this data to help inform multi-sectoral strategies to extend family planning services to those in need

Countries face challenges when trying to expand family planning coverage

• FP services: easier to reach and wider choice in urban communities; rural/marginalized communities – little or no access

• Need for coordination among providers of family planning services (public, private, NGOs, SMOs, FBOs, Donors)

• Little coordination between supply side (logistics, procurement, distribution) and demand and access side (FP service providers and customers)

• Lack of adequate services for varied segments of the population (young vs. older, educated vs. non-educated, etc.)

• When to charge? When to provide free? Confusion over user fees vs. free products and services

How can a market analysis help address these challenges?

• By better understanding client needs

• By better understanding family planning coverage and demand

• By better understanding the potential for different sectors to meet this demand/need

• By identifying gaps and overlaps in coverage between different service providers, and even within one sector

• By identifying ways to more efficiently distribute resources between providers to cover the family planning market more equitably

Ethiopia Context

A little background

• Ethiopia is the second most-populous country in sub-Saharan Africa, with an estimated population of 86.9 million (PRB 2012)– Population is growing at a rate of 2.6% (PRB 2012) – 83% of population lives in rural areas

• Very high birthrate- 34 births per 1,000 total population (PRB 2012)

• Under 5 mortality is 88 deaths per every 1000 live births and infant mortality is 59 per 1000 live birth. (EDHS 2011)

• Maternal mortality is 676/100,000 live births (EDHS 2011)– (lifetime risk of dying in childbirth is 1 in 27)

• Nevertheless, Ethiopia has made significant gains in in strengthening family planning and reproductive health – Ethiopian’s Government commitment to family planning continues

as a key strategy for improving health and development

Ethiopia has achieved remarkable gains in expanding family planning service provision

• Impressive gains in modern contraceptive use by all women (women in union and those who are sexually active)

• A decrease of ~ 10% in unmet need since 2000

• TFR has significantly decreased in recent years

DHS 2000 DHS 2005 DHS 20110

5

10

15

20

25

30

35

40

4

4.2

4.4

4.6

4.8

5

5.2

5.4

5.65.55.4

4.8

Current use of mod-ern contraceptive methods among women in union and those sexually active

Unmet need for family planning ser-vices, among women in union and those sexually active

Total fertility rate

Perc

enta

ge

If we have already had success, why should we do a market analysis in Ethiopia?

• To understand where we’ve made the most progress in family planning coverage in recent years

• To identify areas where we can do a better job to meet demand, that are not published in the DHS report

• To use this data to join together and identify new strategies to reach our family planning goals

• To support the GoE in achieving socioeconomic development goals and improve living conditions for families, mothers, and children of the future

Demographic Analysis Results

• Participatory market analysis approach using EDHS demand and other supply data to better understand and satisfy customer needs/preferences

• CPR percentage of women of reproductive age (15-49 years) who are practicing or whose sexual partners are practicing any method form of contraception

• Method Mix distribution of different contraceptive methods used by target population

• Unmet Need percentage of WRA who do not want to become pregnant but are not using contraception

Defining Terms: Key Terms Used in Presentation

20% of households with the lowest socioeconomic indicators

20% of households with the highest socioeconomic indicatorsRichest

Richer

Middle

Poorer

Poorest

Based on goods and services at the household level population is divided into five equal groups.

These quintiles are used as a proxy indicator of socioeconomic status.

Defining Terms: Quintile Analysis

Defining the Population Analyzed

In the DHS women (15-49) are independently categorized as:

For purposes of this analysis “women” refers to women in union and those who are sexually active (in the last 4 weeks).

Marital Status(V502) Never in union

Currently in union/living with a man

Formerly in union/living with a man

Never had sex Active in last 4 weeks

Not active in last 4 weeks*

Recent sexual activity(V536)

2000 2005 20110

1

2

3

4

5

6

7

5.5 5.4

4.8

Total Fertility Rate 2000-2011

UrbanRuralTotal

The total fertility has declined since 2000 primarily due to declines in the rural area

Family planning use has nearly doubled in a short period although is still below the 66 percent by 2015 GoE target

2000 2005 20110%

20%

40%

60%

80%

100%

6.85 14.127.8

Contraceptive Prevalence Rate (CPR) of Women

Modern method Traditional method No method

Unmet need to space16%

Unmet need to limit9%

Using to space17%

Using to limit13%

Method not needed

46%

Unmet need for Family Planning 2011

Overall unmet need is almost as high as the percent of women who are using family planning

There is a huge disparity in use between the poorest and the richest women; although unmet need is consistently high in most quintiles

Poorest Poorer Middle Richer Richest0%

10%20%30%40%50%60%70%80%90%

100%

CPR and Unmet need by Quintile 2011

Modern methods Traditonal methods Unmet Need Method Not Needed

Neither family planning use nor unmet need seems to be influenced by age

15-19 20-24 25-29 30-34 35-39 40-44 45-490%

10%20%30%40%50%60%70%80%90%

100%

CPR and Unmet need by Age 2011

Modern method Traditonal methodUnmet Need Method Not Needed

Family planning use (including traditional methods) is much higher among women with education and in urban areas

No edu-cation

Primary Secondary Higher Urban Rural0%

10%20%30%40%50%60%70%80%90%

100%

CPR by Education and Residence 2011

Modern method Traditonal methodUnmet Need Method Not Needed

Family planning use is highest in Addis Ababa, Amhara, Dire Dawa, Gambella, and Harari

Unmet need is highest in Oromia and SNNPR

Gambela 17%Harari

24%

Dire Dawa 22%

Ben-Gumz 24%

Afar 16%

Addis Abba 11%

Tigray 22%

Somali 24%

SNNP 25%

Amhara 22%

Oromiya 30%

An estimated 3.3 million women have an unmet need for FP. Most of these women reside in Oromiya, Amhara and SNNP

Estimated number of women (15-49) with unmet need by region in 2011(% unmet need)

Of these 3.3 million women with unmet need, an estimated 300,000 are adolescents (15-19)

Estimated number of women (15-19) with unmet need by region in 2011 (% unmet need)

Unmet need among adolescent women in Afar, Amhara, and Harari is 10-15 percent points higher than the average for all women

Dire Dawa 21%

Gambela 22%

Harari 34%

Ben-Gumz 32%

Afar 31%

Addis Abba 11%

Tigray 27%Somali

25%

SNNP 33%

Amhara 32%

Oromiya 36%

Method Mix and Sources of Supply

Pill7%

IUD1%

Injections72%

Condom1%

Female Ster-ilza-tion2%

Im-plant

s12% Traditional methods

5%

2011

Primary method continues to be injectables although implants use has risen while orals have declined in recent years

Method Mix

CPR= 15% CPR=29%

Pill21%

IUD1%

Injections66%

Condom2%

Female Ster-

ilzation1%

Im-plants

1%

other modern1%

Tra-di-

tional methods6%

2005

Injectables are the most commonly used among all age groups. Use of long acting and permanent methods increase with age.

15-19CPR=25%

20-24CPR=36%

25-29CPR=30%

30-34CPR=33%

35-39CPR=29%

40-44CPR=24%

45-49CPR=13%

0%

20%

40%

60%

80%

100%

Pill IUD Injections Condom Female Sterilization Implants Traditional

Injectables are most commonly used among all groups. Urban and more educated women use a greater variety of methods than others.

no ed-ucation

primary secondary higher Urban Rural0%

10%20%30%40%50%60%70%80%90%

100%Method mix by Education and Residence

Injections Pill IUD Condom Female Sterilization Implants other modernTraditional methods

There has been significant increase among users obtaining products from health posts/health extension work

2005 20110%

10%20%30%40%50%60%70%80%90%

100%

54.9 52.6

19.6 28.8

11.010.0

Source of Supply for FP method by Year

Gov't Hospitals Gov't health centers Gov't health posts/HEWPrivate facility Pharmacy/Shop/Friend NGO

Public sector provides most products although condoms and pills are also obtained in pharmacies. Pills IUDs and injections are also obtained in private facilities.

Pill IUD Injections Condom Implant0%

20%

40%

60%

80%

100%

Government Hospital Government health center Government health post/HEW Private facilityPharmacy/Shop/Friend NGO

poorest poorer middle richer richest urban rural0%

20%

40%

60%

80%

100%

Government Hospital Government health centerGovernment health post/HEW Private facilityPharmacy/Shop/Friend NGO

The majority of women regardless of wealth or residence receive their contraception from government sources

The public sector is also the main provider throughout the regions with health posts and HEWs largest in SNNP and health centers predominant in some regions

Tigray

Afar

Amhara

Oromiya

Somali^

Ben-Gumz

SNNPR

Gambela

Harari

Addis Abeba

Dire Dawa

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Gov't Hospital Gov't health center Gov't health post/HEW Private facility

Pharmacy/Shop/Friend NGO DK/missing^ Regional results for Somali should be interpreted with caution as sampling was not representative

There is a large potential for future clients. More than half of those who are not currently using a method intend to do so in the future

Use Later56%

Unsure About Use3%

Does Not Intend41%

Intention to Use of Women Not Currently Using

Most Common Reasons for Non-Use*%

Postpartum Amenorrheic 25Fear of Side Effects 18Breastfeeding 13Fatalistic 12Religious Prohibition 7Husband/Partner Opposed 5Not Having Sex 5Interferes With Body’s Processes 4Infrequent Sex 4Knows No Source 4Knows No Method 4Inconvenient to Use 3

Most women who are not using consider they are not at risk because they have recently had a baby and/or they do not use because they have a fear of side effects

Looking at UNMET NEED

and CPR between surveys

There are still significant differences in use between regions despite use increasing in most areas between years

No Difference=p>0.05

The rate of increase between years is most evident in four regions

Unmet need has also declined at to varying degrees by region

No difference between 2005

and 2011

No Difference=p>0.05

No Difference=p>0.05

Rate of decline in unmet need is similar in most regions although Tigray, Afar and Somali lag behind

Defining Terms: Total Demand and Demand Satisfied• Total Demand for Family

PlanningAll women who are using or have a need for family planning. Women who need FP are not using but are: 1) sexually active 2) fertile 3) and report they do not want any

more children or want to delay the birth of their next child

• Demand Satisfied The percent of the total demand which is met through method use.

CPR

Unmet Need

Total Demand

Total Demand

CPR

2005 2011 2005 2011Urban Rural**

0%

20%

40%

60%

80%

Total Demand for FP by Residence for all Women in 2005 and 2011

using method unmet

Urban Rural**0%

20%

40%

60%

80%

100%

% of All Women with Demand for FP Satisfied in 2005 and 2011

2005 2011**p≤0.001

Total demand is higher and has been best satisfied in the urban areas although major improvement has occurred in the rural areas

**p≤0.001

Total demand among the adolescent population (women 15-19) is higher in urban areas but demand satisfied has declined since 2005. Rural areas made significant improvement between years.

2005 2011 2005 2011Urban Rural**

0%10%20%30%40%50%60%70%80%90%

100%

Total Demand for FP by Resi-dence for Women 15-19 2005

and 2011

Using method Unmet Need

Urban Rural**0%

20%

40%

60%

80%

% of Women 15-19 with Demand for FP Satisfied 2005 and 2011

2005 2011

Total demand is higher and is been best satisfied in richer quintiles but all quintiles have seen major improvement

0%10%20%30%40%50%60%70%80%90%

% of Demand Satisfied in 2005 and 2011

2005

2011

2005

2011

2005

2011

2005

2011

2005

2011

2005

2011

poorest poorer middle richer richest

0%

20%

40%

60%

80%

Total Demand by Quintile 2005 and 2011

using method unmet

Demand generation is important to reach the GoE targets for 2015. In most regions demand was less than 50% in 2005

While total demand for family planning improved in 2011 particularly in Gambella more is needed

Much of family planning demand was not satisfied in 2005

Much more of this demand has been satisfied in 2011 with major improvement in Amhara and Gambella

RURAL CLUSTER ANALYSISUsing SatScan Analysis

2011 National Average

22.5% mCPR

There are five specific areas throughout the country where the rural population uses modern methods at similar rates

There are five specific areas throughout the country with similar patterns for demand satisfied among the rural population

Summary and Recommendations

• Fertility rates have declined; although, they have stagnated in urban areas

• Contraceptive prevalence for all women (women in union + sexually active) has increased substantially in a short period of time (7% in 2000 to 14% in 2005 to 28% in 2011)

• Least wealthy and non-educated women of all ages are using at a lower rate than the rest of the population

• Injectables are still the most common method being used but use of long-acting and permanent FP methods has increased (4% in 2005 to 15% in 2011)

• Highly educated and richer women are using more traditional methods than less educated and poorer women

Key take away points from this analysis

• Nearly 90 percent of all women with unmet need live with in Oromiya, Amhara and SNNPR regions.

• In Amhara, Afar and Harari young women (15-19) have 10-15% higher unmet need compared with other women in the same region

• The public sector continues to provide most products (84% of market), although condoms and pills are also obtained in pharmacies while private facilities are providing pills, IUD and injections.– Almost ⅓ of users are obtaining products from health posts/HEW

(vs. ~1/5 in 2005)

Key take away points from this analysis

• In Dire Dawa, Addis Adaba, Harari, Amhara, Afar, Tigray- health centers are the most popular source for methods. In SNNPR, Ben-Gumz, and Oromiya most women obtain methods from health post/HEW. In Gambela, most women obtain their methods at private facilities.

• The most wealthy women are obtaining most of their methods from the public sector.

• Most women (56%) who are currently not using any method intend to use FP in the future

• The most common reasons for women who are not current using are because: they recently had a baby, are breastfeeding and/or have a fear of side effects.

Key take away points from this analysis

• Demand for FP as well as satisfying this demand has improved substantially since 2005 in the rural areas

• In urban areas, especially among youth (15-19), demand and demand satisfied has stagnated or decreased

• Least wealthy women of all ages have less of their demand satisfied than the rest of the population

• A few geographic areas and segments (urban youth, for example) have a high total demand for contraceptives (66% or more) and others lag behind

• There are areas throughout the country, located across regional boundaries, that display similar use and demand patterns

Key take away points from this analysis

• Use in urban areas, especially among the youngest women, has not increased at the same rate as in rural areas.– Study use preference and determination factors to better

develop messages and services that meet their needs.

– Consider developing strategies that extend services to youth in urban areas and maintain or increase use among all populations living in urban areas.

• Women with unmet need are concentrated in regions with the highest population. – Consider developing services to satisfy the large number of

women with unmet that are concentrated in these areas.

Recommendations

• Most women across all age groups are primarily using injectables.– Continue to support efforts to strengthen the capacity of the

public sector to provide LAPMs and counsel women on more appropriate methods for their point in their childbearing life cycle.

• Gambela and Tigray display use and need patterns that are different from other regions. – Consider further studying these populations to better

understand the factors that affect women’s use in these regions

Recommendations

• Most wealthier women, although they may have an ability to pay for family planning, are obtaining their methods from the public sector.

– Consider carrying out ability and willingness to pay studies to see whether these women could be shifted to NGO or private sector facilities to obtain services.

– Continue efforts to partner with the private sector to expand and coordinate their services with the public sector and attract wealthier clients to services that are better customized to their needs

Recommendations

Benefits of further strengthening family planning

• Increased CPR is indicative of increased levels of service provision, an increase in the availability of contraceptives, and overall, a more robust supply chain.

• These services leave families less vulnerable to unintended pregnancies and births; and reduce abortion rates, maternal and infant deaths, and sexually transmitted infections, including HIV.

• Yet, more work needs to be done to meet Ethiopia’s family planning and development goals

• Accelerating these gains can make a powerful contribution toward the country’s economic growth, poverty reduction, and helping Ethiopia achieve its Millennium Development Goals.

For a better future! Thank you.

This analysis was conducted by the USAID | DELIVER PROJECT, Task Order 4