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

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.

Narrative synthesis systematic review of Pakistani women's health outcomes from primary care interventions

OBJECTIVE

Women living in Pakistan have complex health problems including infectious and non-communicable diseases, accident and injuries, and mental health problems. While a majority of these women rely on primary healthcare services for all of their healthcare needs, there has to date been no overview of the extent of their effectiveness. The objective of this review was to (1) synthesise the available evidence regarding the effectiveness of primary care based interventions aimed at improving women's mental and physical health and (2) identify the factors that promote effectiveness for women's health outcomes.

METHODS

Five academic databases were searched, including PubMed, BMC Medicine, Medline, CINAHL and the Cochrane Library. A search was also made of the grey literature. The quality of included studies was assessed using a standardised critical appraisal tool, and the findings summarised using a narrative synthesis.

RESULTS

In total, 18 studies were included in the review. Eight involved evaluations of counselling interventions, three health education and awareness interventions, two social and psychosocial interventions, and five were evaluations of combination interventions. Twelve of the included studies were randomised controlled trials. Of these 14 reported significant outcomes, and 4 further interventions showed partially favourable results. However, interventions mostly targeted women's mental or reproductive health.

CONCLUSIONS

While the evidence is limited in terms of quality and what has been evaluated, a number of interventions appear to be effective in improving outcomes for women. The three key approaches include the adoption of an active door-to-door and group-based approach; utilisation of community peers who can deliver care cost-effectively and who are more accepted in the community; and the integration of financial vouchers to support uptake in poor populations.

PROSPERO REGISTRATION NUMBER

CRD42020203472.