ContraceptionOverview of the DCPP

Chapter

Gaverick MathenyDept Health Policy & Mgmt

Johns Hopkins University

World Bank, 12 July 2007

Outline Disease Control Priorities Project Contraceptive use and health Patterns of fertility and contraceptive use Meeting the demand Cost-effectiveness of contraception Research priorities

Disease Control Priorities Project

Cost-effectiveness analysis to inform priority-setting in international health

1993: DCP1, WB WDR 2006: DCP2, Priorities in Health Contraception (Levine, Langer, Birdsall,

Matheny, Wright, Bayer) http://www.dcp2.org/pubs/DCP/57/

Health Benefits of Contraceptive Use

Prevent unsafe abortions Prevent pregnancies that are:

Underspaced To women too young or too old High parity

25-50% reduction in maternal mortality 10-29% reduction in infant mortality 21-35% reduction in <5 mortality

WHO, 2001; Conde-Agudelo and Belizan, 2000; Fraser, Brockert, and Ward, 1995; Rutstein, 2003, Conde-Agudelo and Belizan, 2003; Muhuri and Menken, 1997; Tsui, Wasserheit, and Haaga, 1997; Walsh et al., 1993; Trussell and Pebley, 1984.

Health Benefits of Contraceptive Use

STIs Condoms for dual-protection

FP: 10-15% of all condoms Some groups: low risk perception of STIs, high risk

perception of pregnancy PMTCT via FP

$5 / DALY (Stover 2003)

UNAIDS, 1999; Agha, 2002; Van Rossem and Meekers, 2000; Stover, 2003; Marseille et al., 1999; King et al., 1995.

Health Benefits of Contraceptive Use

Population growth linked to environmental health: Urban air pollution (1% of global mortality) Urban water pollution Global climate change

Pop growth ~half of increase in greenhouse gas emissions over next 25 yrs

Health effects: infectious diseases, cardiovascular and respiratory disease from thermal extremes, malnutrition from crop losses

WHO, 2002; Shi, 2001; Brockerhoff and Brennan, 1998; Bongaarts, 1992; Birdsall, 1994.

Health Benefits of Contraceptive Use

Health affected by economic development / economic outcomes affected by pop growth:

Dependency ratios Dilution of natural capital Costs of environmental remediation However, pop size = source of labor & taxes

Bloom, Canning, Sevilla, 2002; Nordhaus and Boyer, 1998; Lee and Miller, 1991.

Current Total Fertility Rates by RegionAmong Women Ages 15-49

5.3

4.3

3.5 3.5

2.1

4.5

0

1

2

3

4

5

6

Sub-SaharanAfrica

Near East &North Africa

Asia Latin America& Caribbean

EasternEurope &

Central Asia

UnweightedAverage*

Region

Tota

l Fer

tilit

y R

ate

*Among 60 developing countries(excludes data from Eastern Europe & Central Asia).

Contraceptive Use Grows in Developing Countries

Percent* of Married Women in Developing Countries

Currently Using Contraception

3341

55

0102030405060708090

100

1983 1990 2000

Year

Pe

rc

en

t

*Weighted by population size.

Estimate of Contraceptive Use Worldwide Among Married Women ages 15-49, 2000

0102030405060708090

100

Any Method Any Modern Method Any Traditional Methoda

Type of Method

Pe

rce

nt

Cu

rre

ntl

y U

sin

g

Developing Areas Developed Areas Worldwide

Percentages are weighted by population size and use the most recentdata from the DHS and RHS and, for countries without these surveys, datafrom the United Nations, the US Census Bureau’s International Database,and other nationally representative surveys.a Includes periodic abstinence and withdrawal.

Fertility Levels Closely Correspondto Levels of Contraceptive Use

Percent with Unmet Need for Family Planning Among Married Women Ages 15-49, 1990-2001

24 21 20 1612

0

10

20

30

40

50

60

70

80

90

100

Sub-SaharanAfrica

Near East &North Africa

Asia Latin America &Caribbean

E. Europe &Central Asia

Region

Pe

rce

nt

Contraceptive Method Mix

Four methods account for almost 75% of total contraceptive use among married women:

Female sterilization Oral contraceptivesInjectablesIntrauterine device

Other methods are used littleVaginal method use averages <1% of total contraceptive useMale sterilization use generally less than 1%Implant use highest in Indonesia (6%) and Haiti (1%)Female condom use <1%

Cost-Effectiveness Analysis Why CEA? Resources are finite Have to make difficult choices Where is the “biggest bang for the buck”?

How can I prevent the most misery with $XB?

If every life has equal value, should spend $ on most cost-effective projects

Cost-Effectiveness Analysis

Dearth of FP CEAs Most programs measure average costs,

not marginal costs Most programs measure output (CYPs),

not impact (lives saved) Brand/method substitution: need client-

intercepts

Data

Alan Guttmacher Institute et al (2000) Used country-level data for 68 developing

countries Variety of interventions, settings, scales Estimated public sector FP costs per

maternal and infant death averted

Data Traditional method users moving to modern methods No method users moving to modern methods % of unintended pregnancies that end in birth % of unintended pregnancies that end in abortion % of unintended pregnancies that end in miscarriage Estimated number of unintended births averted Estimated number of induced abortions averted Estimated number of miscarriages averted Non-abortion maternal mortality per 100,000 births Estimated non-abortion maternal deaths averted Abortion mortality per 100,000 abortions Estimated abortion deaths averted Infant mortality per 1,000 births Maternal deaths averted Infant deaths averted

Methods Regional averages: country data population-

weighted by # rep age women in each country Converted deaths into DALYs, using regional

death-DALY ratios for FP-related conditions, regional life expectancies, 3% discount rate and no age-weighting

Adjusted to 2001 dollars

Cost-effectiveness of FP

Region Infant death Maternal death DALYEAP 4,907 12,880 60LAC 2,316 34,564 53MNA 1,989 18,917 49SAR 1,577 5,172 30SSA 1,367 10,231 34

Average cost per averted

2001 US dollars. Based on AGI et al (2000). Costs per deaths averted into cost per DALY using regional life expectancies and death-DALY ratios, with 3% discount rate and no age-weighting.

Included in CEA

Preventing unsafe abortions Preventing pregnancies that are:

Underspaced To women too young or too old High parity

Excluded from CEA Condoms for dual-protection PMTCT via FP Population links to environmental health Economic effects of fertility

Implementation Should not over-generalize Identify local needs through market research

Who has unmet need? Where do they receive health services/products? What are barriers to their contraceptive use?

Target through market segmentation Non-poor currently receive most subsidized services Geographical and media targeting How does commercial sector reach this group?

Offer several methods

Contraceptive methods

No single method is best Simple cost-per-CYP measures aren’t

measuring impact Offer choice

Reducing unmet need Most common causes of “unmet need”:

Lack of knowledge Health concerns Social disapproval Not price

Information is key IEC/BCC activities are cost-effective: $1-$3 per new user

(price subsidies: ~$100) Educate couples about child health benefits of birth spacing Encourage private sector supply/service (social marketing,

social franchising)Matheny 2004

Research Priorities “You control only what you measure” Standardized O.R. instruments useful to local

programs: Tools to identify local barriers to contraceptive use

(current misfit between reported barriers and programs) Marketing research to develop program strategies and

materials Market segmentation to reduce leakage Accounting to measure programs' marginal costs Monitoring & evaluation to measure programs' marginal

effectiveness

Research Priorities Biomedical

Better contraceptives so women can protect themselves from pregnancy and HIV

Policy Relationships between economic outcomes and

population dynamics - macro and micro levels Stakeholder analysis: How can local governments be

encouraged to increase their investments in FP? What info do they need?

FP: lessons learned Decline in unmet need: great success story in

public health Key elements:

Education (esp of men) Choice of many methods Donor commitment

Future progress will depend on keener use of private sector, effective communication to men, better targeting, and integration with STI services/supplies

Levine 2004

Integration in RH

More profitable services can subsidize less profitable services

Increases # of clients, reducing fixed costs per client

Offer FP at prenatal, delivery, post-partum, (post-)abortion care sites

Offer FP at STI care sites

Thank you!

jmatheny@jhsph.edu

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•Attanayake N, Fauveau V, Chakraborty J. Cost-effectiveness of the Matlab MCH-FP Project in Bangaldesh. Health Policy and Planning 1993;8(4):327-338.

•Birdsall N. Another look at population and global warming. In United Nations, Population, Environment, and Development. New York: United Nations; 1994. p. 39-54.

•Bloom D, Canning D, Sevilla J, The Demographic Dividend: A New Perspective on the Economic Consequences of Population Change. Rand Population Matters series, 2002.

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•Rutstein SO. Effect of Birth Intervals on Mortality and Health. Calverton, MD: Measure/DHS+/Macro International; 2003.

•Stover J. Costs and benefits of providing family planning services at PMTCT and VCT sites. Washington, D.C.: Futures Group; 2003.

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•Walsh JA, Naschuk, CN, Meaham AR, Gertler PJ. Maternal Health. In Jamison DT, Mosley WH, Measham AR, Bobadilla JL, editors. Disease Control Priorities in Developing Countries. Oxford: Oxford University Press; 1993. p. 363-390.

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