Meeting need vs. sharing the market: a systematic review of methods to measure the use of private sector family planning and childbirth services in sub-Saharan Africa

Abstract

Background: Ensuring universal access to maternal and reproductive health services is critical to the success of global efforts to reduce poverty and inequality. Engaging private providers has been proposed as a strategy for increasing access to healthcare in low- and middle-income countries; however, little consensus exists on how to estimate the extent of private sector use. Using research from sub-Saharan Africa, this study systematically compares and critiques quantitative measures of private sector family planning and childbirth service use and synthesizes evidence on the role of the private sector in the region.

Methods: We conducted a systematic review of the Medline, Global Health, and Popline databases. All studies that estimated use of private sector of family planning or childbirth services in one or more sub-Saharan African countries were included in this review. For each study, we extracted data on the key study outcomes and information on the methods used to estimate private sector use.

Results: Fifty-three papers met our inclusion criteria; 31 provided outcomes on family planning, and 26 provided childbirth service outcomes. We found substantial methodological variation between studies; for instance, while some reported on service use from any private sector source, others distinguished private sector providers either by their profit orientation or position within or outside the formal medical sector. Additionally, studies measured the use of private sector services differently, with some estimating the proportion of need met by the private sector and others examining the sector's share among the market of service users. Overall, the estimates suggest that the private sector makes up a considerable portion (> 20%) of the market for family planning and childbirth care, but its role in meeting women's need for these services is fairly low (< 10%).

Conclusions: Many studies have examined the extent of private sector family planning and childbirth service provision; however, inconsistent methodologies make it difficult to compare results across studies and contexts. Policymakers should consider the implications of both private market share and coverage estimates, and be cautious in interpreting data on the scale of private sector health service provision without a clear understanding of the methodology.

Keywords: Africa; Family planning; Maternal health; Private sector; Systematic review.

Fig. 1

PRISMA flow diagram

Fig. 2

Number of included studies by publication date

Fig. 3

Classification of private sector providers

Fig. 4

Denominators for measuring private sector coverage and market share in included studies

Fig. 5

(a) Family planning coverage among women married or in union; (b) Family planning coverage among women in need of contraception; (c) Childbirth care coverage among all births; (d) Childbirth care coverage among most recent births

Fig. 6

(e) Family planning market share among all current users of modern contraception; (f) Family planning market share among married/in union current users of modern contraception; (g) Family planning market share among all current users of modern contraception from a source with a classifiable sector

Fig. 7

(h) Childbirth care market share among deliveries that received appropriate care; (i) Childbirth care market share among deliveries that occurred in a facility; (j) Childbirth care market share among deliveries that received appropriate care by a provider with a classifiable sector