Are family planning vouchers effective in increasing use, improving equity and reaching the underserved? An evaluation of a voucher program in Pakistan

Ali et al. BMC Health Services Research (2019) 19:200 https://doi.org/10.1186/s12913-019-4027-z RESEARCH ARTICLE Open Access Are family planning vouchers effective in increasing use, improving equity and reaching the underserved? An evaluation of a voucher program in Pakistan Moazzam Ali1* , Syed Khurram Azmat2,3, Hasan Bin Hamza4, Md. Mizanur Rahman5 and Waqas Hameed6 Abstract Background: Low modern contraceptive prevalence rate and high unmet need in Pakistan aggravates the vulnerabilities of unintended pregnancies and births contributing to maternal morbidity and mortality. This research aims to assess the effectiveness of a free, single-purpose voucher approach in increasing the uptake, use and better targeting of modern contraceptives among women from the lowest two wealth quintiles in rural and urban communities of Punjab province, Pakistan. Methods: A quasi-interventional study with pre- and post-phases was implemented across an intervention (Chakwal) and a control district (Bhakkar) in Punjab province (August 2012–January 2015). To detect a 15% increase in modern contraceptive prevalence rate compared to baseline, 1276 women were enrolled in each arm. Difference-in-Differences (DID) estimates are reported for key variables, and concentration curves and index are described for equity. Results: Compared to baseline, awareness of contraceptives increased by 30 percentage points among population in the intervention area. Vouchers also resulted in a net increase of 16% points in current contraceptive use and 26% points in modern methods use. The underserved population demonstrated better knowledge and utilized the modern methods more than their affluent counterparts. Intervention area also reported a low method-specific discontinuation (13.7%) and high method-specific switching rates (46.6%) amongst modern contraceptive users during the past 24 months. The concentration index indicated that voucher use was more common among the poor and vouchers seem to reduce the inequality in access to modern methods across wealth quintiles. Conclusion: Vouchers can substantially expand contraceptive access and choice among the underserved populations. Vouchers are a good financing tool to improve equity, increase access, and quality of services for the underserved thus contributing towards achieving universal health coverage targets. Keywords: Vouchers, Contraceptives, Family planning, Equity, Pakistan * Correspondence: 1 Department of Reproductive Health and Research, World Health Organization, Avenue Appia 20, CH-1211 Geneva 27, Switzerland Full list of author information is available at the end of the article © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Ali et al. BMC Health Services Research (2019) 19:200 Background High population growth and fertility rates affect human development and adversely impact the health and lives of women and children [1]. Pakistan has a high total fertility rate (TFR) of 3.8 [2] and low modern contraceptive prevalence rate (mCPR) i.e. 26% [2], combined with a high unmet need of about 20%. Short-term methods are widely known and used compared to long-term methods [2]. The health system in Pakistan suffers from significant urban-rural disparities in healthcare delivery [1]. Data from the 2012–13 Pakistan Demographic Health Survey (PDHS) described that the poorest people in Pakistan, in particular rural residents, experience significant difficulty in gaining access to essential health services, including FP provided by public and private sectors [2]. The modern contraceptive uptake was 23 and 20% in the rural and in the poorest populations, respectively along with a high unmet need [1–3]. According to Pakistan Demographic Health Surveys from 1990 onwards the private sector provision of share of family planning services in the country increased from 34 to 52% specially in the rural and poorest populations [2, 4–6]. Traditionally the health sector focus has been to improve supply side with a lesser focus on utilizing demand side approaches in FP [7, 8]. Recently the emphasis has shifted towards improving the physical, financial and social access of marginalized populations to FP services using social franchising approaches including vouchers [8–19]. However, the current evidence on the effectiveness of voucher approaches seems limited [15, 17], thus highlighting the need to fill the knowledge gaps. [2, 15, 20, 21]. As most of the modern contraceptive method users obtain services through the private sector in Pakistan the lack of financial resources at the individual level can be a major impediment in acquiring FP services [2, 4]. The Family Planning 2020 (FP2020) goals are to reach 120 million more women with voluntary family planning services through the expansion of global access to family planning [22]. The intended outputs of the FP2020 goal are universal access, efficiency, quality and equity [18]. Demand Side Financing (DSF) approaches, including vouchers, aim to address some of the economic and structural barriers that limit the uptake of FP [15, 25– 28] which involves transferring purchasing power to specified groups for the purchase of defined goods or services. [25, 27]. Some voucher schemes have been shown to be limitedly effective in countries like Bangladesh, India, Kenya, Indonesia, Pakistan, Ethiopia and Uganda [4, 11, 12, 15, 17, 20, 23–25, 29–31]. The paper reports a study conducted by Marie Stopes Society (MSS) Pakistan (the local affiliate of Marie Stopes International (MSI) in Pakistan) to assess the Page 2 of 12 effectiveness of a free, single-purpose voucher approach (MSS model) in increasing the access, uptake, improving equity and better targeting of modern contraceptives among women from the lowest two wealth quintiles in rural and urban communities of Punjab province, Pakistan [8, 17, 32, 33]. Methods MSS used a combination of social franchising and voucher program to reach out to the underserved in selected areas in Punjab province, Pakistan to increase access to all methods with a special focus on long acting reversible contraceptives (LARCs). It had a quasi-interventional study design with pre and post phases implemented through an intervention, with a control arm. For the pre-intervention phase an independent cross-sectional baseline survey was conducted in May 2012 in the intervention and control arms. The intervention phase ended in January 2015, followe (...truncated)