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

Posted by Maria Codina on April 8, 2019 at 12:00 pm



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.

Discussion

Vouchers can be a highly effective tool to increase access to and use of family planning and reproductive health services, especially for underserved populations including the poor, youth, and postpartum women [25]. The experience in Pakistan shows that vouchers can facilitate access to modern contraceptive services where supply-side approaches don’t work. In line with other studies, the results of this study also confirmed that when vouchers are targeted towards poor beneficiaries who otherwise would not capitalise on a service – they are particularly effective at improving equity [25, 26]. Voucher programmes improve access to institutional delivery, as shown by a Cambodian voucher scheme. It has been associated with an increase of 10 percentage points in the probability of institutional delivery, and among the poorest 40% of households, the increase in the prevalence of the probability of child birth in a public health-care facility was 15.6 percentage points [38], similar results were shown in a study in Kenya [19] and Bangladesh and Pakistan [10, 28].


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