How Can Improved Health Financing Reduce Discontinuation?
By: Paul Abonyo, Atamandike Chingwanda, and Eduardo Gonzalez-Pier
Health financing plays a critical role in explaining the discontinuation of contraceptive use. Data from Demographic and Health Surveys (DHS) have shown that discontinuation rates among women and couples trying to avoid pregnancy have remained stubbornly high in the past decade. In a large study of 60 low- and middle-income countries, between 20–50 percent of women and couples stopped using contraceptives during the first 12 months after initiating, with reasons cited varying widely by country and choice of method. This poses a particularly critical challenge because discontinuation undermines the efficacy of large upfront investments made in helping women and couples begin using contraception and constrains program capacity to reach commitments made to global efforts such as Family Planning 2030 (FP2030) and the Sustainable Development Goals (SDGs).
What are the main reasons for discontinuation that emerge from the DHS? In general, for women still wanting to avoid pregnancy, contraceptive failure — getting pregnant while using a method — was the most common reason cited, followed by method side-effects or health concerns. Then came inconvenient use and wanting to try a different method that was not offered. Surprisingly, reported discontinuations due to cost or access problems came in fourth place. High costs and access barriers as a reason for discontinuation is tricky to interpret. Although while, at a personal level, financial barriers don’t seem to be a major determinant of discontinuation, the same doesn’t hold true when looking at the health system level. The main reasons for contraceptive discontinuation can be directly traced and compounded by health system financing gaps.
“The dominance of out-of-pocket payments is unfair, with low-income groups and women carrying most of the burden and consequently a higher rate of discontinuation.”
Health Financing Gaps as a Root Cause
Weak health financing translates into quality and access gaps in the delivery of family planning services and is key to understanding reasons for discontinuation. Shortfalls in family planning funding are often associated with weak supply chains and shortages of key family planning commodities; an ineffective referral system between community outreach and primary healthcare; suboptimal regulation of family planning commodities with resultant quality issues; and insufficient, or ineffective, use of information for family planning service improvement and policy reformulation. Discontinuation is more likely to take place in poorly resourced health systems.
The source of funds also matters. In 69 of the FP2030 priority countries, almost two-thirds of all family planning expenditure came from individuals paying out-of-pocket, mostly on lower-cost, short-acting methods. These methods are also often lower-quality and more likely to cause side-effects, be associated with contraceptive failure, and thus increase rates of discontinuation. The dominance of out-of-pocket payments is unfair, with low-income groups and women carrying most of the burden and consequently a higher rate of discontinuation. Moreover, when contraceptives are made available through a myriad of public health coverage plans and privately paid service providers, there is limited opportunity to pool funds, implement an efficient and transparent procurement process, and access World Health Organization-prequalified products at bulk prices. The result is that family planning commodities are made available at higher prices and lower quality, further compounding the root causes of discontinuation.
Including a more comprehensive array of family planning services and commodities in national and local health benefits plans or private health insurance coverage can also be a critical factor in reducing discontinuation. Availability of a desired method could be improved if national health plans selected the various family planning methods covered based on need and cost-effectiveness evidence, and that the inclusion of those methods is properly communicated to all stakeholders and users.
The Road Ahead
Unfortunately, it is unlikely that the resources needed to offer sufficient, quality family planning services in the future will be met. The United Nations’ Department of Economics and Social Affairs estimates that in sub-Saharan Africa the number of women aged 15–49 is expected to increase from 262 to 349 million and the prevalence rate of any form of contraception will increase from 27.8 to 32.0 percent between 2020 and 2030. This means demand will increase by about 53 percent. But for the same region, the share of GDP that goes to government health spending has remained low and steady at 2 percent for nearly a decade. Moreover, the pandemic-induced economic crisis reduced budget allocations to health in many poor countries. A recent World Bank report has identified 52 countries, many of which are low-income USAID priority countries, which will not reach pre-pandemic levels of health spending until 2026. To compound the fiscal challenge, donor funding for health has plateaued and is expected to decline in the next decade.
To maintain spending levels and replace external funding, domestic resources need to be mobilized at an unprecedented scale — both from public and private sources. To avoid contraceptive discontinuation, especially by women and couples with limited economic resources, it will be important for governments to scale up sustainable family planning financing strategies, including through budget allocation and execution, evidence-based programming, and establishing an efficient regulatory family planning procurement system.
“HP + has increasingly pushed thinking on how to improve coordinated public and private efforts to deliver equitable family planning services.”
The USAID-sponsored Health Policy Plus (HP+) project has identified and helped governments promote innovative ways to mobilize domestic resources for family planning in pursuit of FP2020 and FP2030 targets. The range of strategies employed include advocating for increased country investments in family planning to accelerate socio-economic development, promoting matching contributions from federal and local governments, and leveraging partnerships through the Global Financing Facility to mobilize additional funds. Sustainability is a core concern of resource mobilization efforts. To secure long-term funding, improve responsiveness of services, and increase equitable access, HP+ has helped countries integrate their family planning programs into universal health coverage schemes and find ways to improve the choice of methods. In addition, performance-based reimbursement mechanisms that encourage better counseling are central to tackling method failure, side-effects, and health concerns as a reason for discontinuation. Nevertheless, the public sector response will not be enough, and countries will need to increasingly rely on the private sector to deliver low-cost responsive family planning services, which can help reduce discontinuation.
HP + has increasingly pushed thinking on how to improve coordinated public and private efforts to deliver equitable family planning services. Attention is being placed on extending blended financing mechanisms whereby public and philanthropic funds are used to make private sector investments in family planning more attractive. In addition, private sector market shaping through well-established regulatory frameworks and fiscal incentives can help respond to gaps in service provision for women and couples that can afford to pay privately, thus better targeting scarce public resources to improve quality service and method choice to prevent contraceptive discontinuation among those less well-off.
We urgently need to better understand pathways on how fair and efficient health financing can help tackle contraceptive discontinuation. While in the next few years the focus might be on how to weather macroeconomic instability to maintain family planning financing levels and sustain gains in modern contraceptive prevalence rate, the longer-term focus on adequate financing for program efforts — especially commodities — will remain a priority and is key to reducing discontinuation as we approach the 2030 deadline for the SDGs agenda.
Palladium’s Paul Abonyo is a health finance officer for the USAID-funded Health Policy Plus (HP+) project based in Kenya. Atamandike Chingwanda, also with Palladium and working on HP+, is a health economist based in Malawi. Eduardo Gonzalez-Pier is a health economist and senior technical director for health financing at Palladium and is based in Washington DC.