Impact of demand-side financing in

promoting the use of modern

contraception in rural Pakistan

7th Public Health Scientific Conference

Health Services Academy

14th December 2016

Waqas Hameed

Team Lead, Research & Evaluation Division

Marie Stopes Society

Presentation Outline

• Background

• Research question and hypothesis

• Intervention

• Methods

• Key findings

• Conclusion

Background

• Family planning – a cost-effective method in reducing

maternal mortality

• High total fertility rate (3.8)

• Low use of contraception (26%)

• Stagnated use of LARC, despite huge need

• High poor-rich inequities in contraceptive unmet need

and current use

Free voucher scheme

Research question

Whether a free single-purpose voucher intervention is effective in

increasing of modern contraceptive method use among the poor

women (lowest two wealth quintiles)

Hypothesis

Poor women living in sites served by the MSS’ single-purpose

voucher programme will have higher use of modern contraceptives

than in sites not served by the voucher programme.

Voucher had three components: Services (only family planning); follow up /side effect

management; removal services

Intervention component Comparison Group

Suraj provider Peri-Urban provider

Training on FP and post-

training evaluation

Training on FP (including

Femplant) & post-training

evaluation Training on FP

(including Femplant for

Urban private only) and

post training evaluation

Field worker mobilization Field worker mobilization

Vouchers Vouchers

Marketing and Branding

Intervention details

Note: Initially public providers were a part of the program as well but didn’t come onboard at implementation

Methods

Study design Quasi-experimental with control arm

Duration 30 months (June 2012 – Dec 2014)

Sites

Suraj Social

Franchise Peri-Urban Providers Control

Chakwal Bhakkar

Providers 17 6 10

Sample size Endline=1,236 each study arm

Target

audience Married women of reproductive age (15-49)

Voucher Management System

1) MSS

• Develop, print &

distribute vouchers

2) Field Worker

• Mobilize community

• Identify client

• Distribute voucher

4) Providers

• Provide services against vouchers

• Submits redeemed vouchers to

MSS

3) Client

• Receives vouchers &

avails services

6) District Manager

• 5% verification

• Submit to MSS with

supporting documents

Cla

ims

Note: a) MSS has an internal Voucher Management System

b) No cash payment was done for providers

7) MSS - Finance

• Check supporting

documents and release

reimbursement

5) SFS

• 20% verification

• Submits to district

manager

Via DM and SFS

Socio-demographics characteristics

Indicators Chakwal

Mean

Bhakkar

Mean

Age of women (years) 32 30

Husband age (years) 37 34

Women’s age at marriage

(years) 20 20

Household size 6 6

Utilization : Contraceptive use

Chakwal Current user p=<0.0001, b) Bhakkar Current user p= <0.0001

19%

50%

16% 22%

2%

20%

2% 4% 7% 13%

7% 9%

Baseline (n=692) Endline (n=1318) Baseline (n=2583) Endline (n=1296)

Chakwal Bhakker

Modern method Intra-uterine device Condom

50 - 19=31 22 - 16=6 31 – 6 = 25%

Intervention Control Net effect

IUCD = 16%

Condom = 4%

Reducing inequities

Characteristics

Odds ratio (95% Confidence interval)

Contraceptive Knowledge any

one method

Ever use (any method)

Current use (any method)

Modern method use

Wealth quintile

Poorest 1.78 (1.06-2.97) 1.68 (1.16-2.42) 1.67 (1.13-2.46) 1.69 (1.13-2.55)

Poor 1.26 (0.89-1.79) 1.58 (1.23-2.04) 1.37 (1.02-1.85) 1.39 (1.00-1.94)

Average 1.27 (0.90-1.81) 1.29 (1.03-1.62) 1.29 (0.95-1.75) 1.29 (0.93-1.80)

Rich 0.97 (0.76-1.24) 0.96 (0.77-1.20) 0.98 (0.76-1.27) 0.94 (0.68-1.29)

Richest 1.00 1.00 1.00 1.00

Adjusted for respondent age and education, husband’s age and education, baseline and endline time points

Method discontinuation and switching within 12

months

Indicators

Chakwal Bhakkar

n=842

n (%)

n=354

n (%)

Discontinued

modern method 115 (13.7) 95 (26.8)

Switched to

different method 392 (46.6) 47 (13.3)

Conclusion

Free contraceptive vouchers can increase the use

modern contraception especially among women

in lowest two wealth quintiles.

Other lessons learnt

• Use of vouchers to generate demand and

address cost barrier

• Private sector engagement through social

franchising

• Multi-pronged approaches – supply and demand

side

• Improvement in quality of services

Disclaimer: Funded by The David and Lucile Packard Foundation, this study is implemented by Marie Stopes Society (MSS) Pakistan. The paper includes collective views of an international group of experts, and does not necessarily represent the decisions or the stated policy of the World Health Organization, Marie Stopes Society Pakistan, Marie Stopes International or The David and Lucile Packard Foundation.

Principal Investigator: Dr. Moazzam Ali, World Health Organization, Geneva

Co-investigators: Dr. Syed Khurram Azmat, Dr. Hasan-bin-Hamza, and Waqas Hameed

Acknowledgement

Funding: This work was supported by The David

and Lucile Packard Foundation, Grant number:

2011-37284