Introduction

In developing regions, an estimated 214 million women have unmet need for family planning. Several global initiatives recognize the importance of modern contraceptive use, including the Sustainable Development Goals (2016–2030) which include universal access to family planning as one of nine sub-goals within health, and Family Planning 2020 (FP2020), a global commitment to provide an additional 120 million women and girls with universal access to a range of safe and effective modern contraceptive methods in the world’s least-developed countries.[1] The 2017 Family Planning Summit in London reasserted family planning as one of the ‘best buys’ in development, but recognized that most countries, are far from achieving their SDG and FP2020 goals and must accelerate progress.[2,3]

Engagement of the private sector is a critical strategy for accelerating progress towards these goals, [2,4] particularly in sub-Saharan African (SSA) countries with high unmet need and underserved geographies and populations. [5,6] More than one-third of all women currently using modern contraceptives in SSA report obtaining them through the private sector, the preferred source for many women. [6–9] Preference for the private sector is linked to perceptions of higher quality, specifically product availability, convenience, timeliness, and privacy. [8,10] Engagement of the private sector is often weak or strained and government policies can limit cooperation with the public sector. [11]

Achieving global SDGs and FP2020 commitments will depend on the success of countries with large populations and high unmet need. In SSA, key countries include Ethiopia, Nigeria, and Democratic Republic of Congo (DRC), each with a unique family planning policy environment and contraceptive method mix (see S1 Table). Ethiopia has made substantial financial investments in family planning and regulates public and private sector provision of methods and services. It has also managed to strengthen public-private engagement in the provision of injectables and long-acting reversible contraceptives (LARCs). [12,13] Social franchising has also increased provision of short-acting methods in the private sector. [14] Such initiatives have contributed to an increase in mCPR in Ethiopia and progress on FP2020 commitments. [15] In Nigeria [16] and DRC [17], large regional variations and inequalities in contraceptive access, lower use of LARCs, and a largely unregulated private sector have stymied progress toward national goals. Both countries have historically depended on condoms, short-acting methods, and traditional methods of family planning. [18,19] Recent initiatives have focused on private sector engagement through social franchising and mobile outreach service delivery, with pilot programs for LARC provision launched in 2015 in Nigeria[20,21] and DRC. [22] However, the current lack of formal policy and regulation as it relates to the private sector in each of these countries hinders the partnership and cooperation that is needed to strengthen public-private engagement. [16–18]

The field would benefit from systematically collected data on total contraceptive markets in the world’s least-developed countries, enabling policymakers’ to improve method diversity and choice. In this study, we measure contraceptive availability, market share, and price to highlight the potential of the private sector to increase access and meet client demand for short-acting methods and LARCs. We identify where national contraceptive policies could be expanded to promote greater partnership and cooperation with the private sector and decisions about funding streams strengthened to increase the role of the private sector in family planning provision.

Methodology

The FPwatch Project, funded by the Bill & Melinda Gates Foundation, was designed to fill knowledge gaps in contraceptive markets by providing estimates for key family planning indicators. In SSA, this included Ethiopia, Nigeria and DRC. FPwatch surveys generate nationally- and regionally-representative data from a cross-section of outlets. These surveys complement other health facility surveys, such as the Performance, Monitoring and Accountability 2020 (PMA2020) surveys, [23] by providing a rigorous, robust, and in-depth look at contraceptive markets.

Study design and sample selection

Data were collected in the second half of 2015. In Ethiopia, the geopolitical areas included the four most populous regions where 85% of the country’s population resides: Amhara, Oromia, Southern Nations, Nationalities, Peoples’ Region (SNNP) and Addis Ababa. The Nigerian survey was nationally representative: outlets from all six geopolitical zones were included. Two provinces were intentionally sampled in DRC to ensure the inclusion of one primarily urban and one primarily rural province, Kinshasa and Katanga, respectively. In 2015, DRC’s 11 original provinces were divided into 26. FPwatch used the pre-2015 boundaries in province selection.

Sample size requirements were based on estimates for the proportion of outlets with three or more modern methods of contraception in stock on the day of the survey at 95% confidence. This indicator was selected for its high relevance to FP2020 commitments (see S1 Table). One or two-stage sampling was conducted using Probability Proportional to Size in each study country, [24] with representative clusters of approximately 10,000 to 15,000 people. In DRC, a booster sample was included for public health facilities and pharmacies to adjust for insufficient numbers of these outlet types. A detailed sampling strategy is included in S2 and S3 Tables: Selected Clusters by Geopolitical Zones.

Data collection lasted six to eight weeks and field teams used a full census approach to identify potential outlets: data collectors met with local authorities to produce sketch maps of the areas’ potentially eligible outlets or walked down all streets and paths of selected administrative units to find them. Every public and private sector outlet with the potential to sell or distribute modern methods was screened for eligibility. Public sector outlets included hospitals, health centers, and community health workers and, in the case of DRC, representative private clinics in areas with no public facility. The private sector included private for-profit clinics, pharmacies, drug shops and general retailers, except in DRC where general retailers were not surveyed (Table 1).

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Table 1. Outlet category description by country.

https://doi.org/10.1371/journal.pone.0192522.t001

Outlets must have met one of the following criteria to be eligible for a full interview and product audit: 1) stocked at least one modern contraceptive method other than condoms (oral contraceptives, emergency contraceptives, injectable contraceptives, contraceptive implants, or IUDs) on the day of the survey; 2) had one or more types of modern contraceptives other than condoms available within the three months preceding the survey; or 3) offered provider-dependent contraceptive services, including contraceptive injections, implant insertions, IUD insertions, and or male/female sterilization.

Results

Potential market and actual market composition

The potential market for modern contraceptive provision was dominated by the private sector: 85% of 8,295 screened outlets in Ethiopia including general retailers, 96% of 13,367 outlets in Nigeria including general retailers, and 80% of 2,207 outlets in DRC (Fig 1). General retailers were not screened in DRC because it was known at the time of the survey that these outlets did not stock contraceptives other than condoms. General retailers were screened in Ethiopia and Nigeria and made up approximately three-quarters of the potential market. However, they were excluded from subsequent analysis because they did not sell modern contraceptives other than condoms. Drug shops were the greatest proportion of private outlets screened in DRC (60%).

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Fig 1. Total outlets screened (potential market) and eligible (actual market), by country and outlet type.

https://doi.org/10.1371/journal.pone.0192522.g001

After excluding general retailers, 96% of all potential outlets in Ethiopia, 55% in Nigeria, and 41% in DRC had modern contraceptive methods on the day of the survey and made up the actual contraceptive market (solid pie slices on the left-hand side of Fig 1). In selected outlets in Ethiopia, the private sector was smaller than the public sector (41% vs. 59%); and private clinics (25%) were the largest group of private outlets. In Nigeria and DRC, private sector outlets were over 80% of the market with drug shops, also referred to as patent and proprietary medicine vendors (PPMVs) in Nigeria, making up 71% and 72% of the total actual market, respectively.

Availability of short-acting methods on the day of the survey

The private sector had higher availability of short-acting methods (oral contraceptives, emergency contraceptives, or injections) than the public sector in each country, particularly for emergency contraceptive pills (ECP). Ethiopia had the highest availability of short-acting methods in private sector outlets (56%-97% across methods, except for ECPs in private clinics 30%). In Nigeria, short-acting methods were more frequently available in pharmacies (61.6%-78.0%) than in other private sector outlets (8%-51%). In DRC, availability of all three short-term methods was less than 50% across the private sector (Fig 2). Stock-outs were observed in the private sector across all countries (1–21%).

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Fig 2. Availability of selected short-acting methods on the day of survey among all screened outlets excluding general retailers, by country and outlet type.

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In the private sector, pharmacies, followed by drug shops, had the highest availability of short-acting methods, particularly for commodities that do not require service provision. Oral contraceptive availability was highest in pharmacies in Ethiopia and Nigeria at 97% and 78%, respectively, and was just under half in DRC. The pattern was similar for oral contraceptives in drug shops. ECPs were concentrated in pharmacies, although availability was moderate: 68% in Ethiopia, 64% in Nigeria, and 44% in DRC. ECP availability was less than 20% in other private sector outlets in Nigeria and DRC as well as in all public sector outlets across all three countries.

Availability of LARCs on the day of the survey

In the private sector, LARC availability (implants or IUDs) was low overall. When LARCs were available, they were found in private clinics where services can be rendered (3–24%) across all countries. Pharmacies and drug shops were not common outlets for LARCs, likely because they can only sell the commodity (<6%) (Fig 3). LARC availability in the public sector was higher in Ethiopia (17–74%) and DRC (13–20%) than their respective private sector counterparts. In Nigeria, LARC availability was slightly higher in private clinics (20–24%) than in the public sector (13–18%).

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Fig 3. Availability of selected LARC methods on the day of the survey among all screened outlets excluding general retailers, by country and outlet type.

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Availability of choice: Three or more methods and three or more methods including LARC/PM on the day of the survey

In Ethiopia and DRC, the private sector had lower availability of any three or more methods other than condoms (3+ methods) than the public sector. Conversely, in Nigeria, the private sector had greater method diversity than the public sector (Fig 4). Private sector outlets in Ethiopia and private clinics and pharmacies in Nigeria had moderate availability of 3+ methods (33–51% and 25%-43%, respectively) and were mostly limited to short-acting methods. Availability of 3+ methods in the private sector in DRC and drug shops in Nigeria was extremely low (<8%).

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Fig 4. Percentage of outlets with 3+ methods and 3+ methods including LARC/PM on the day of the survey among all screened outlets excluding general retailers, by country and outlet type.

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Private sector availability of 3+ methods including LARC/PM was low. The most common combination was oral contraceptives, injectables, and implants, and this pattern was fairly consistent across private sector outlet types. Private clinics in all countries had a more variable method mix that included permanent methods. Consistent with policy, no drug shops or pharmacies in any country had permanent methods.

Price of modern contraceptives in the private sector

Contraceptive methods that are priced beyond an affordable range limit choice. All methods in Ethiopia were less expensive than in Nigeria and DRC. In Nigeria and DRC, prices per oral contraceptive and ECP dose were 25–166% higher in pharmacies than in drug shops. Prices per-dose for injectables were highest in private clinics across all countries, potentially due to the inclusion of an administration service fee (Table 2).

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Table 2. Median consumer per-unit price of short-acting and LARC methods in USD in the private sector^*, by country and outlet type.

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It is important to consider cost-effectiveness in addition to the cost to consumer. Long-term use of each method changes its cost effectiveness; over time, LARCs are more cost effective. For example, in Nigerian drug shops, oral contraceptives had the lowest cost per unit ($0.40) versus injectables ($1.00) and implants ($2.50) that have higher per-unit costs. Over time, however, oral contraceptives were a less cost-effective means of family planning ($6.00 per CYP) compared to injectables ($4.50 per CYP) and implants ($0.83 per CYP), highlighting the need to overcome the high initial costs of LARCs. For a breakdown of price in USD per CYP by country and outlet type see S5 Table.

Discussion

There is a missed opportunity in each country for modern contraceptive provision through the private sector. Low availability of methods and limited access to modern contraceptive stocking outlets make it difficult for women to adopt and use modern contraception consistently and plan the families they desire. Lack of access to a range of methods, short-acting, and LARC methods, and high prices limit choice and constrain a woman’s ability to make the most appropriate and cost-effective decision. In Ethiopia, short-acting methods are readily available in the private sector but LARC availability is more limited. The private sectors in Nigeria and DRC have low availability of both short-acting and LARC methods.

The ubiquity of drug shops within the potential market, but under-utilization in the actual market, present the greatest opportunity to increase access and expand choice in Nigeria and DRC. Although drug shops constitute nearly three-quarters of all outlets, half or less carry oral contraception, and even fewer carry other short-acting methods; almost none stock LARCs. Current evidence highlights the popularity of drug shops as preferred access points for young and unmarried women, youth, and underserved populations, [7,26,27] and supports leveraging these facilities to reach populations with unmet need. The higher availability of short-acting methods observed in pharmacies and drug shops compared to private clinics and the public sector suggests that they fill import gaps in the market.

Promoting access to an expanded range of short-acting methods has been consistently cited as a ‘high-impact practice’. [27] Unfortunately, there is currently little choice available within the private sector. Availability of oral contraceptives, ECPs, and injectables was low, particularly in Nigeria and DRC. Less than 10% of drug shops had three or more methods available in Nigeria and DRC. Lack of access to a preferred method is associated with inconsistent use or method discontinuation, which places women at greater risk for unintended pregnancy. [22] Short-acting methods require little-to-no service provision and are an appropriate fit for outlets without formally trained providers. Increasing short-acting method availability within drug shops would improve access and satisfy demand among discontinued or inconsistent users who prefer short-acting methods. Wider availability of short-acting methods is necessary to promote informed choice and is also particularly relevant for first-time users in contexts where either contraceptive information and counselling are available through trained providers but the supply is lower, or where provider training in drug shops can feasibly be facilitated.

High cost also limits choice. The price for ECPs was prohibitive in most private sector settings. Likewise, the high price of LARCs in Nigeria and DRC may present an obstacle to consumer access and choice. Making methods more widely available could create competition on the market and benefit consumers by decreasing high mark-ups caused by limited supply. Keeping costs down would also allow consumers to make more cost-effective choices. Subsidies across sectors, such as those in Ethiopia, likely offer the best short-term solution for reducing cost to consumers and increasing access to commodities with high-upfront costs such as LARCs.

In Ethiopia, a country that has a tightly regulated market and substantial financial commitments for family planning, pharmacies and drug shops have succeeded in providing affordable access to a variety of short-acting methods through strong social franchise networks. Pharmacies and drug shops have outperformed private clinics and the public sector, locations where greater emphasis has been placed on service provision as opposed to stocking self-administered commodities. [28] These outlets, through expanded provider training for counselling on both LARCs and short-acting methods, could also be leveraged to promote informed choice and affordable access to LARC commodities with referral to private clinics for services and counselling. Promoting market development through training and social franchising initiatives in the private sector are key strategies for reaching populations with unmet need with contraceptive methods and are showing promise for accelerating and sustaining FP2020 progress in SSA. [12,23,29,30]

Subsidized commodities have contributed to Ethiopia’s success in increasing access to LARCs among trained providers in the public sector and short-acting methods across sectors, and offer promise for other countries. Access to modern contraception at affordable prices could be offered through social marketing, including subsidizing methods with a service component, like LARCs. LARCs could be sold in drug shops and pharmacies with a referral for service delivery in private clinics with trained providers on LARC delivery. It is important, however, to incorporate new strategies to sustain access without over-relying on subsidies, like social business enterprise models that offer cross-subsidization of commodities.

Methods that are easy to administer, such as Sayana Press® injectables and Implanon NXT® implants, provide an opportunity to introduce service delivery for injectables and implants at private sector outlets. Social marketing projects, such as those piloted by Association de Santé Familiale DRC and Society for Family Health in Nigeria, that educate providers on the full range of methods already available and others that create demand for injectables and LARCs are promising for improved access to and utilization of a range of modern contraceptive methods in drug shops. [27,29,31,32]

Countries should adopt policies that permit drug shops to fill gaps in the public sector and private clinics. In Nigeria and DRC, private sector stakeholders are working with the public sector to improve the range of methods in drug shops and provider capacity for counselling and referral. [33] However, it is crucial to ensure that the regulatory environment can accommodate such measures. Steps taken by Tanzania’s Ministry of Health to incorporate drug shops into the private sector via targeted provider training and licensing as accredited drug dispensing outlets and other similar policy initiatives targeting drug shops in Uganda, can serve as models for Nigeria and DRC. [34,35]

Conclusion

There is a missed opportunity for modern contraceptive provision through the private sector, particularly in drug shops. Increasing choice and controlling price are essential for improving women’s access to and use of modern contraception. Strategies like social franchising, social marketing, and subsidizing products offer promise for opening up the private sector. Training providers and offering methods that are easier to administer are also important. National contraceptive policies should be expanded to promote greater partnership and cooperation with the private sector, including more strategic decisions about funding streams, to facilitate the role of the private sector in helping countries achieve their SDG and FP2020 commitments.

Supporting information

Acknowledgments

The authors are grateful to the entire FPwatch Group (2015–2017), members as follows: Andrew Andrada; Eric Auko; Dr. Katie Bates; Dr. Nirali Chakrabory; Dr. Desmond Chavasse; Keith Esch; Danielle Garfinkel; Tarryn Haslam; Catherine Hurley; Tabeth Jiri; Aliza Lailari; Dr. Megan Littrell; Godéfroid Mpanya; Julius Ngigi; Dr. Kathryn O’Connell; Ricki Orford; P Prabhu; Jen Pope; Stephen Poyer; Justin Rahariniaina; Christina Riley; Mac Shoen; Dr. Bryan Shaw (Principal Investigator 2015–2017 and lead author on behalf of FPwatch group); Habtamu Tamene; Katherine Thanel; May Me Thet; Chinazo Ujuju. The authors are grateful to the Ministries of Health, PSI platform teams, and for their support during the survey: Dr. Tadele Kebede, Dr. Ephrem Tekle Lemango, and Dr. Berhane Assefa, Ethiopia Ministry of Health; Dr. Woldemariam Girma and the PSI Ethiopia platform team; Dr. Wapada I. Balami, Dr. Kayode Afolabi. Dr. Gabriel Ortonga, Nigerian Federal Ministry of Health; Chinazo Ujuju and the SFH Nigeria team; Dr. Thérèse Kyungu, the DRC Ministry of Health; and Gaby Kasongo and the ASF DRC team. The authors would like to thank Veronique Dupont, Janine Hum, Amy Lin, Dr. Scott Radloff, and Dr. Prashant Yadav of the FPwatch Technical Advisory Group, and Dr. Amanda Kalamar, Sarah Thurston, Coley Gray, and the PSI Family Planning and Reproductive Health team for their technical input and support throughout the FPwatch program. Finally, the authors are deeply grateful to country teams in Ethiopia, Nigeria, and DRC who undertook the surveys and to the study participants for their time and participation.