How family planning supply and the service environment affect contraceptive use: Findings from four East African countries

This report uses data from Demographic and Health Surveys (DHS) and Service Provision Assessment (SPA) surveys conducted in Kenya Rwanda Uganda and Tanzania during the period of 2003-2010. Random-effects logit regression models are fitted to examine the extent to which contraceptive use is associated with the regional family planning supply and service environment and to assess the regional variability in contraceptive use that is explained by these two factors. Contraceptive use information is from the DHS surveys and family planning supply and service environment data are provided in the SPA survey that was conducted within a year of the DHS in each country. The analysis indicates that based on the Kenya 2008-09 DHS Kenya has the highest level of modern contraceptive use among the four countries studied at 39 percent of women of reproductive age. Contraceptive use is lowest in Uganda at 18 percent in the 2006 DHS and only slightly higher in Tanzania at 20 percent in the 2004-05 DHS. Regional variation in contraceptive use within countries is evident but less so in Rwanda than in the other three countries. In Uganda women rely primarily on private-sector sources while in the other three countries they primarily use public sources. Over half of health facilities provide at least one contraceptive method ranging from 60 percent in Uganda in 2007 to 81 percent in Kenya in 2010. Regional variations in method availability are apparent in all four countries but are most striking in Uganda. In terms of infrastructure and resources to support high-quality family planning services the majority of facilities in all four countries ensure visual and auditory privacy for counseling and provide visual aids for their family planning clients. Health facilities providing family planning services often have written national family planning guidelines. In Rwanda and Tanzania facilities have limited capacity in infection control. Running water in particular is missing at most of the facilities in these two countries. In all four countries fewer than 10 percent of facilities contain all of the items specified for quality of care in pelvic examinations including a private room offering visual and auditory privacy an examination bed or table an examination light and vaginal speculums. The lack of routine staff training for family planning providers cuts across all four countries with one-tenth or fewer of facilities in Uganda and Tanzania and one-third or fewer in Kenya and Rwanda providing routine staff training for family planning providers. In all four countries however family planning providers generally receive routine supervision. There are important regional or provincial variations in the various family planning service components. Multivariate regression analysis finds that an average increase of one contraceptive method available in a region increases women’s odds of using modern contraception by 50 percent if family planning facility density in the region and other individual-level variables are held constant. Women in regions with a more favorable service environment (as measured by a higher service environment score) in facilities are more likely to use a modern contraceptive method. The analysis also suggests that regional-level factors significantly contribute to the between-region variation in contraceptive use. The increased proportion of variation explained by adding regional contraceptive supply and service environment variables to the model is 18 percent and 27 percent respectively. Simulation results in the North East province in Kenya and the North region in Uganda suggest that a much higher proportion of women would be using a modern contraceptive method if method availability or the service environment or both could be brought up to the national average level. In light of increasing interest and program efforts to improve contraceptive use in sub-Saharan Africa these findings may assist donors and program planners to assess the effectiveness of existing programs and to plan for future investment in family planning.