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

Financing for equity for women's, children's and adolescents' health in low- and middle-income countries: A scoping review

Over the past few decades, the world has witnessed considerable progress in women's, children's and adolescents' health (WCAH) and the Sustainable Development Goals (SDGs). Yet deep inequities remain between and within countries. This scoping review aims to map financing interventions and measures to improve equity in WCAH in low- and middle-income countries (LMICs). This scoping review was conducted following Joanna Briggs Institute (JBI) guidance for conducting such reviews as well as the PRISMA Extension for Scoping Reviews (PRISMA-ScR) for reporting scoping reviews. We searched Medline, PubMed, EMBASE and the World Health Organization's (WHO) Global Index Medicus, and relevant websites. The selection process was conducted in duplicate and independently. Out of 26 355 citations identified from electronic databases, relevant website searches and stakeholders' consultations, 413 studies were included in the final review. Conditional cash transfers (CCTs) (22.3%), health insurance (21.4%), user fee exemptions (18.1%) and vouchers (16.9%) were the most reported financial interventions and measures. The majority were targeted at women (57%) and children (21%) with others targeting adolescents (2.7%) and newborns (0.7%). The findings highlighted that CCTs, voucher programs and various insurance schemes can improve the utilization of maternal and child health services for the poor and the disadvantaged, and improve mortality and morbidity rates. However, multiple implementation challenges impact the effectiveness of these programmes. Some studies suggested that financial interventions alone would not be sufficient to achieve equity in health coverage among those of a lower income and those residing in remote regions. This review provides evidence on financing interventions to address the health needs of the most vulnerable communities. It can be used to inform the design of equitable health financing policies and health system reform efforts that are essential to moving towards universal health coverage (UHC). By also unveiling the knowledge gaps, it can be used to inform future research on financing interventions and measures to improve equity when addressing WCAH in LMICs.

A study protocol for integrating outpatient services at the primary health care level as part of the universal health coverage benefit package within the national health insurance program of Pakistan through private health facilities

Introduction and aim

Pakistan has a mixed-health system where up to 60% of health expenditures are out of pocket. Almost 80% of primary healthcare (PHC) facilities are in the private sector, which is deeply embedded within the country's health system and may account for the unaffordability of healthcare. Since 2016, the existing national health insurance program or Sehat Sahulat Program (SSP), has provided invaluable coverage and financial protection to the millions of low-income families living in Pakistan by providing inpatient services at secondary and tertiary levels. However, a key gap is the non-inclusion of outpatient services at the PHC in the insurance scheme. This study aims to engage a private provider network of general practitioners in select union councils of Islamabad Capital Authority (ICT) of Pakistan to improve access, uptake, and satisfaction and reduce out-of-pocket expenditure on quality outpatient services at the PHC level, including family planning and reproductive health services.

Methods and analysis

A 24-month research study is proposed with a 12-month intervention period using a mixed method, two-arm, prospective, quasi-experimental controlled before and after design with a sample of 863 beneficiary families from each study arm, i.e., intervention and control groups (N = 1726) will be selected through randomization at the selected beneficiary family/household level from four peri-urban Union Councils of ICT where no public sector PHC-level facility exists. All ethical considerations will be assured, along with quality assurance strategies. Quantitative pre/post surveys and third-party monitoring are proposed to measure the intervention outcomes. Qualitative inquiry with beneficiaries, general practitioners and policymakers will assess their knowledge and practices.

Conclusion and knowledge contribution

PHC should be the first point of contact for accessing health services and appears to serve as a programmatic engine for universal health coverage (UHC). The research aims to study a service delivery model which harnesses the private sector to deliver an essential package of health services as outpatient services under SSP, ultimately facilitating UHC. Findings will provide a blueprint referral system to reduce unnecessary hospital admissions and improve timely access to healthcare. A robust PHC system can improve population health, lower healthcare expenditure, strengthen the healthcare system, and ultimately make UHC a reality.

Effective strategies for increasing the uptake of modern methods of family planning in South Asia: a systematic review and meta-analysis

BACKGROUND

Family planning (FP) interventions have improved the use of modern contraceptives, yet a high unmet need for contraception still exists in South Asia. This systematic review of existing research was conducted to identify effective FP interventions that led to an increase in the uptake of modern methods of contraception in South Asia.

METHODS

Five electronic databases were searched for relevant studies published between January 1st, 2000 and May 4, 2023. Experimental studies that reported data on the impact of FP interventions on modern contraceptive use among women of reproductive age (15-49 years) in the South Asian region were included. A random-effects Inverse Variance weighted model was employed to pool the adjusted odds ratio (OR) on modern contraceptive use and unmet need for contraception. In addition, we computed subgroup meta-estimates based on intervention type and the urban-rural divide.

RESULTS

Among 643 studies identified, 21 met the inclusion criteria. The overall pooled odds ratio for modern contraceptive use was significantly higher (OR 1.51; 95% CI 1.35-1.70; heterogeneity; I2 = 81%) for FP interventions with a significant reduction in unmet need for contraception (OR 0.86; 95% CI 0.78-0.94, I2 = 50%). The subgroup analysis revealed demand-generation (OR 1.61; 95% CI 1.32-1.96), health system integrated (OR 1.53; 95% CI 1.07-2.20), and franchised FP clinic interventions (OR 1.32; 95% CI 1.21-1.44) had promoted the modern contraceptive uptake. Further, FP interventions implemented in urban settings showed a higher increase in modern contraceptive use (OR 1.73; 95% CI 1.44-2.07) compared to rural settings (OR 1.46; 95% CI 1.28-1.66). Given the considerable heterogeneity observed across studies and the low degree of certainty indicated by the GRADE summary for the primary outcome, caution is advised when interpreting the results.

CONCLUSION

The review collated experimentally evaluated FP interventions that increased modern contraception use and reduced the unmet need in South Asia. The demand generation interventions were the most effective in increasing the uptake of modern contraceptive methods. Furthermore, the urban environment provides a conducive environment for interventions to improve contraceptive usage. However, further studies should assess which aspects were most effective on attitudes towards contraception, selection of more effective methods, and contraceptive behaviors.

Implementation strategies, facilitators, and barriers to scaling up and sustaining demand generation in family planning, a mixed-methods systematic review

BACKGROUND

Demand generation aims to increase clients' desire to use family planning. The aim of this work was to systematically summarize strategies, facilitators, and barriers to scaling up and sustaining demand generation in family planning.

METHODS

We searched electronic bibliographic databases from inception to October 2022. We included quantitative, qualitative, and mixed methods reports on demand generation strategies in family planning, regardless of country, language, publication status, or methodological limitations. We assessed abstracts, titles and full-text papers according to the inclusion criteria, extracted data, and assessed methodological quality of included reports. We used the convergent integrated approach and a deductive thematic synthesis to summarize demand generation themes and subthemes. We used the health system building blocks to synthesize the factors affecting implementation (barriers and facilitators). We used GRADE-CERQual to assess our confidence in the findings.

RESULTS

Forty-six studies (published 1990-2022) were included: forty-one quantitative, one qualitative, and four mixed methods). Three were from one high-income country, and forty three from LMIC settings. Half of reports were judged to be of unclear risk of bias. There were unique yet interrelated strategies of scaling-up demand generation for family planning. Interpersonal communication strategies increase adoption and coverage of modern contraceptive methods, but the effect on sustainability is uncertain. Mass media exposure increases knowledge and positive attitudes and may increase the intention to use modern contraceptive methods. Demand-side financing approaches probably increase awareness of contraceptives and the use of modern contraceptive methods among poor clients. Multifaceted Demand generation approaches probably improve adoption, coverage and sustainability of modern methods use. Factors that influence the success of implementing these strategies include users knowledge about family planning methods, the availability of modern methods, and the accessibility to services.

CONCLUSIONS

Demand generation strategies may function independently or supplement each other. The myriad of techniques of the different demand generation strategies, the complexities of family planning services, and human interactions defy simplistic conclusions on how a specific strategy or a bundle of strategies may succeed in increasing and sustaining family planning utilization.

TRIAL REGISTRATION

Systematic review registration: Center for Open Science, osf.io/286j5.

Assessing the sustainability of two independent voucher-based family planning programs in Pakistan: a 24-months post-intervention evaluation

INTRODUCTION

Family planning vouchers have emerged as a promising approach to improve coverage of underserved groups or underutilized services. The current study was designed to measure the residual/longer-term impact of two-independent FP voucher programs on women's practices beyond the program's life program.

METHODS

A cross-sectional survey conducted, as part of the two-independent larger mixed-method studies, approximately 24 months after the close-down of Marie Stopes Society and Greenstar Social Marketing family planning voucher intervention programs in Punjab, Pakistan. Following necessary ethics approvals, 338 voucher MSS clients & 324 voucher GSM clients were interviewed using a structured questionnaire at the household level.

RESULTS

Compared with end-line data, a significant decrease in the modern contraceptive uptake in both MSS (90% at endline to current (or post-endline) 52%) and GSM (from 84% to current 56%) intervention sites among the voucher clients was noted. Among MSS voucher clients, the highest decline in use was observed in IUCD (54% at endline versus to current 13%); however no change between the surveys was noted among GSM clients. In both projects, following closure of voucher intervention 34% of the discontinued users in MSS and 29% in GSM sites adopted/switched to a new modern contraceptive again. In the post-intervention survey, wealth-based inequality in GSM data depicts more pro-rich utility for modern methods, indicating pro-rich inequality, in contrast, the post-intervention survey in MSS found mixed results such as pro-poor inequality for any method and modern method use.

CONCLUSIONS

The prevalence for contraception in two-independent study sites, following closure of voucher intervention remained high than national average. This study provides evidence that family planning vouchers can bring about an enduring positive change in clients' behaviours in using modern contraceptive methods among poor populations among both intervention models. These results are useful to design family planning programs that will sustain when the donor funding terminates.

Choices and Challenges: Visualizing Contraceptive Use Dynamics Data in 15 Low- and Middle-Income Countries

Interactive data visualization tools, particularly Sankey diagrams, are an effective approach for showing high-level trends in contraceptive adoption, switching, and discontinuation.

Barriers to family planning use in the Eastern Democratic Republic of the Congo: an application of the theory of planned behaviour using a longitudinal survey

OBJECTIVE

In the Democratic Republic of the Congo, there is a low adherence of the population to the use of family planning (FP) due to various social barriers. This study aimed to understand the drives from social barriers to the use of FP in women in the Kivu, a region particularly affected by poverty and many years of conflicts. A theory of planned behaviour (TPB) using a generalised structural equation modelling has been applied to understand the complex sociocultural drivers to the intention and the ultimate decision to use FP.

DESIGN

Longitudinal study.

SETTING

A community-based approach was used to investigate FP use in the North and South-Kivu regions.

PARTICIPANTS

Overall, 1812 women 15 years and older were enrolled in the baseline study and 1055 were retrieved during the follow-up.

PRIMARY AND SECONDARY OUTCOMES

FP use and intention to use FP.

RESULTS

The mean age was 36±12.9 years, with a minimum of 15 years old and a maximum of 94 years old. Among sexually active participants, more than 40% used a modern contraceptive method at the last sexual intercourse. Education was positively and significantly associated with intention to use FP (β=0.367; p=0.008). Being married was positively and marginally significantly associated with intention to use FP (β=0.524: p=0.050). Subjective norms were negatively and significantly associated with intention to use FP (β=-0.572; p=0.003) while perceived control was positively associated with intention to use FP (β=0.578; p<0.0001). Education and perceived control were positively and significantly associated with the use of FP (respectively, β=0.422, p=0.017; and β=0.374; p=0.017), while Intention to use FP was positively and marginally significantly associated with the use of FP (β=0.583; p=0.052).

CONCLUSION

TPB helped understand sociocultural barriers to FP use and it can be useful to define adapted strategies in different contexts.

Use of implementation science to advance family planning programs in low- and middle-income countries: A systematic review

Objective

As environmental and economic pressures converge with demands to achieve sustainability development goals, low- and middle-income countries (LMIC) increasingly require strategies to strengthen and scale-up evidence-based practices (EBP) related to family planning (FP). Implementation science (IS) can help these efforts. The purpose of this article is to elucidate patterns in the use of IS in FP research and identify ways to maximize the potential of IS to advance FP in LMIC.

Design and methods

We conducted a systematic review that describes how IS concepts and principles have been operationalized in LMIC FP research published from 2007-2021. We searched six databases for implementation studies of LMIC FP interventions. Our review synthesizes the characteristics of implementation strategies and research efforts used to enhance the performance of FP-related EBP in these settings, identifying gaps, strengths and lessons learned.

Results

Four-hundred and seventy-two studies were eligible for full-text review. Ninety-two percent of studies were carried out in one region only, whereas 8 percent were multi-country studies that took place across multiple regions. 37 percent of studies were conducted in East Africa, 21 percent in West and Central Africa, 19 percent in Southern Africa and South Asia, respectively, and fewer than 5 percent in other Asian countries, Latin America and Middle East and North Africa, respectively. Fifty-four percent were on strategies that promoted individuals' uptake of FP. Far fewer were on strategies to enhance the coverage, implementation, spread or sustainability of FP programs. Most studies used quantitative methods only and evaluated user-level outcomes over implementation outcomes. Thirty percent measured processes and outcomes of strategies, 15 percent measured changes in implementation outcomes, and 31 percent report on the effect of contextual factors. Eighteen percent reported that they were situated within decision-making processes to address locally identified implementation issues. Fourteen percent of studies described measures to involve stakeholders in the research process. Only 7 percent of studies reported that implementation was led by LMIC delivery systems or implementation partners.

Conclusions

IS has potential to further advance LMIC FP programs, although its impact will be limited unless its concepts and principles are incorporated more systematically. To support this, stakeholders must focus on strategies that address a wider range of implementation outcomes; adapt research designs and blend methods to evaluate outcomes and processes; and establish collaborative research efforts across implementation, policy, and research domains. Doing so will expand opportunities for learning and applying new knowledge in pragmatic research paradigms where research is embedded in usual implementation conditions and addresses critical issues such as scale up and sustainability of evidence-informed FP interventions.Systematic Review Registration: https://www.crd.york.ac.uk/prospero/, identifier: CRD42020199353.

Free Access to a Broad Contraceptive Method Mix and Women's Contraceptive Choice: Evidence from Sub-Saharan Africa

Financial barriers may restrict women's ability to use their preferred contraceptive methods, especially long-acting reversible contraceptives (LARC). Providing free access to a broad contraceptive method mix, including both LARC and short-acting reversible contraceptives (SARC), may increase contraceptive use, meet women's various fertility needs, and increase their agency in contraceptive decisions. Linking facility and individual data from eight countries in sub-Saharan Africa, we use a propensity score approach combined with machine learning techniques to examine how free access to a broad contraceptive method mix affects women's contraceptive choice. Free access to both LARC and SARC was associated with an increase of 3.2 percentage points (95 percent confidence interval: 0.006, 0.058) in the likelihood of contraceptive use, driven by greater use of SARC. Among contraceptive users, free access did not prompt women to switch to LARC and had no effect on contraceptive decision-making. The price effects were larger among older and more educated women, but free access was associated with lower contraceptive use among adolescents. While free access to contraceptives is associated with a modest increase in contraceptive use for some women, removing user fees alone does not address all barriers women face, especially for the most vulnerable groups of women.

Assessing Effectiveness of Multipurpose Voucher Scheme to Enhance Contraceptive Choices, Equity, and Child Immunization Coverage: Results of an Interventional Study from Pakistan

Background

Pakistan has a high total fertility and unmet contraceptive need and is the fifth most populous country. This research aims to assess the effectiveness of a subsidized, multi-purpose voucher intervention to enhance the client–provider interaction for improved contraceptive counseling resulting in a potential increase in the modern methods uptake, continued use, and its impact on equity through better targeting, while increasing uptake of postnatal care and child immunization among women from the lowest two wealth quintiles in rural and urban communities of Punjab province, Pakistan.

Methods

We used a quasi-experimental design with pre- and post-phases in intervention and control sites in Punjab province (August 2012–March 2015). To detect a 20% 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. Absolute and relative index of inequality including concentration curves and concentration index are used to describe the magnitude and extent of equity.

Results

With no net increase in modern contraception use, the intervention area, however, reported a low modern method discontinuation rate. Vaccination rates for BCG increased significantly by 14%, and 5% each for DPT, HBV, and measles. Concentration index and slope index of inequalities for first-time use of modern contraceptives, knowledge of contraceptives, receiving ANC, and delivery at health facilities were negative, indicating that the use of these services was more concentrated among the disadvantaged in intervention areas than the wealthy counterparts.

Conclusion

This Greenstar-led multiple voucher model did not significantly increase modern contraceptive use in the intervention study area but positively impacted equity. The integrated approach combining contraception with child immunization led to an increase in immunization coverage. It will be important for public policy decision-makers to assess the usefulness of this approach, as a long-term provision of free contraceptive services may lead to dependency in targeted communities.

Impact of home-based family planning counselling and referral on modern contraceptive use in Karachi, Pakistan: a retrospective, cross-sectional matched control study

OBJECTIVES

To assess: (1) the impact of a reproductive health program on modern contraceptive use from baseline to program close; (2) the sustained impact from baseline to follow-up 36 months later; and (3) the exposure-adjusted impact at program close and follow-up.

DESIGN

Retrospective, cross-sectional matched control study.

SETTING

Karachi, Pakistan.

PARTICIPANTS

2561 married women aged 16-49 years.

INTERVENTIONS

The Willows Program, a community-based family planning counselling and referral program implemented from 2013 to 2015.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was community-level modern contraceptive prevalence rate (mCPR), measured for January 2013 (baseline), June 2015 (program close) and at follow-up 36 months later. A secondary outcome was exposure-adjusted mCPR (among women reporting a family planning home visit) at program close and at follow-up.

RESULTS

There was no significant effect on community-level mCPR at program close (2.4 percentage point increase in intervention over comparison; 95% CI -2.2 to 7.0) or at follow-up (1.9 percentage point decrease; 95% CI -6.7 to 2.8). Only 18% of women in the intervention area reported receiving a family planning visit in the preceding 5 years. Among those reporting a visit, we observed a significant 10.3 percentage point increase (95% CI 4.6 to 15.9) from baseline to close, and a non-significant 2.0 percentage point increase (95% CI -3.8 to 7.8) from baseline to follow-up, relative to matched women in the comparison area. The cost per new modern method user was US$1089, while the cost per user-year during the intervention period was US$455.

CONCLUSIONS

The program had a positive short-term effect on women who received a family planning visit; however, this effect was not sustained. Program coverage was low and did not significantly increase community-level family planning use. Findings highlight the need to increase community coverage of high-quality counselling and contextually relevant interventions for family planning demand generation.