Using Market Analysis to Help Ethiopia Achieve its Health and Development Goals

1. Using Market Analysis to Help Ethiopia Achieve its Health and Development Goals This analysis was conducted by the USAID | DELIVER PROJECT, Task Order 4

2. What is a market analysis? A tool to analyze utilization of services and define strategies to segment, focus and improve access to family planning: • 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

3. 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

4. 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

5. Ethiopia Context

6. 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

7. 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

8. 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

9. Demographic Analysis Results

10. Defining Terms: Key Terms Used in Presentation • 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

11. Defining Terms: Quintile Analysis 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. 20% of households with the highest socioeconomic indicators Richest Richer Middle Poorer 20% of households with the lowest socioeconomic indicators Poorest

12. Defining the Population Analyzed Marital Status (V502) Never in union Currently in union/living with a man Formerly in union/living with a man In the DHS women (15-49) are independently categorized as: Recent sexual activity (V536) Never had sex Active in last 4 weeks Not active in last 4 weeks* For purposes of this analysis “women” refers to women in union and those who are sexually active (in the last 4 weeks).

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

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

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

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

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

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

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

20. Unmet need is highest in Oromia and SNNPR

21. 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) Oromiya 30% Amhara 22% SNNP 25% Somali 24% Tigray 22% Addis Abba 11% Afar 16% Ben-Gumz 24% Dire Dawa 22% Gambela 17% Harari 24%

22. 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) Oromiya 36% Amhara 32% SNNP 33% Tigray 27% Somali 25% Afar 31% Ben-Gumz 32% Gambela 22% Unmet need among adolescent women in Afar, Amhara, and Harari is 10-15 percent points higher than the average for all women Addis Abba 11% Harari 34% Dire Dawa 21%

23. Method Mix and Sources of Supply

24. Primary method continues to be injectablesalthough implants use has risen while orals have declined in recent years Method Mix CPR=29% CPR= 15%

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

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

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

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

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

30. 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 ^ Regional results for Somali should be interpreted with caution as sampling was not representative

31. 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

32. 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 Most Common Reasons for Non-Use*

33. Looking at Unmet need andCPRbetween surveys

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

35. The rate of increase between years is most evident in four regions No Difference=p>0.05

36. Unmet need has also declined at to varying degrees by region No difference between 2005 and 2011 No Difference=p>0.05

37. Rate of decline in unmet need is similar in most regions although Tigray, Afar and Somali lag behind No Difference=p>0.05

38. Defining Terms: Total Demand and Demand Satisfied Total Demand for Family Planning All women who are using or have a need for family planning. Women who need FP are not using but are: sexually active fertile 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.

39. 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

40. 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. **p≤0.001

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

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

43. While total demand for family planning improved in 2011 particularly in Gambellamore is needed

44. Much of family planning demand was not satisfied in 2005

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

46. Using SatScan Analysis Rural Cluster Analysis

47. There are five specific areas throughout the country where the rural population uses modern methods at similar rates 2011 National Average 22.5% mCPR

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

49. Summary and Recommendations

50. Key take away points from this analysis • 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