Abstract
BackgroundLow 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.MethodsA 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.ResultsCompared 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.ConclusionVouchers can substantially expand contraceptive access and choice among the underserved populations. Vouchers are a good financing tool to improve equity, increase access, and quality of services for the underserved thus contributing towards achieving universal health coverage targets.
Highlights
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
Marie Stopes Society (MSS) used a combination of social franchising and voucher program to reach out to the underserved in selected areas in Punjab province, Pakistan to increase access to all methods with a special focus on long acting reversible contraceptives (LARCs)
Difference in difference analysis for contraceptive use shows the net effect for any contraceptive current user and modern method user was 16 and 26%, respectively, which was significant
Summary
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. Pakistan has a high total fertility rate (TFR) of 3.8 [2] and low modern contraceptive prevalence rate (mCPR) i.e. 26% [2], combined with a high unmet need of about 20%. The modern contraceptive uptake was 23 and 20% in the rural and in the poorest populations, respectively along with a high unmet need [1,2,3]. According to Pakistan Demographic Health Surveys from 1990 onwards the private sector provision of share of family planning services in the country increased from 34 to 52% specially in the rural and poorest populations [2, 4,5,6]
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