Does an expansion in private sector contraceptive supply increase inequality in modern contraceptive use?

OBJECTIVE To determine whether an expansion in private sector contraceptive supply is associated with increased socio-economic inequality in the modern contraceptive prevalence rate (MCPR inequality). METHODS Multiple rounds of Demographic and Health Surveys data were analysed for five countries that experienced an increase in the private sector supply of contraceptives: Morocco, Indonesia, Kenya, Ghana and Bangladesh. Information on household assets and amenities was used to construct wealth quintiles. A concentration index, which calculates the degree of inequality in contraceptive use by wealth, was calculated for each survey round. RESULTS Socio-economic inequality in the MCPR (MCPR inequality) declined in Morocco and Indonesia, where substantial expansion in private sector contraceptive supply occurred. In both countries, poor women continued to rely heavily on contraceptives supplied by the public sector even as they increased use of contraceptives obtained from the private sector. A marginally significant decline in MCPR inequality occurred in Bangladesh, where the increase in private sector supply was modest. There was no significant overall change in MCPR inequality in Kenya or Ghana. In Kenya, this lack of significant overall change disguised trends moving in opposite directions in urban and rural areas. In urban Kenya, MCPR inequality declined as low-income urban women increased use of contraceptives obtained primarily from the public sector. In rural Kenya, MCPR inequality increased. This increase was associated with a decline in the supply of contraceptives by the public sector and non-governmental organizations to the poorest, rural, women. CONCLUSIONS The study found no support for the hypothesis that an increase in private sector contraceptive supply leads to higher MCPR inequality. The findings suggest that continued public sector supply of contraceptives to the poorest women protects against increased MCPR inequality. The study highlights the role of the public sector in building contraceptive markets for the private sector to exploit.