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