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

Abstract

Background

Pakistan has a high total fertility and unmet contraceptive need and is the fifth most populous country. This research aims to assess the effectiveness of a subsidized, multi-purpose voucher intervention to enhance the client–provider interaction for improved contraceptive counseling resulting in a potential increase in the modern methods uptake, continued use, and its impact on equity through better targeting, while increasing uptake of postnatal care and child immunization among women from the lowest two wealth quintiles in rural and urban communities of Punjab province, Pakistan.

Methods

We used a quasi-experimental design with pre- and post-phases in intervention and control sites in Punjab province (August 2012–March 2015). To detect a 20% 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. Absolute and relative index of inequality including concentration curves and concentration index are used to describe the magnitude and extent of equity.

Results

With no net increase in modern contraception use, the intervention area, however, reported a low modern method discontinuation rate. Vaccination rates for BCG increased significantly by 14%, and 5% each for DPT, HBV, and measles. Concentration index and slope index of inequalities for first-time use of modern contraceptives, knowledge of contraceptives, receiving ANC, and delivery at health facilities were negative, indicating that the use of these services was more concentrated among the disadvantaged in intervention areas than the wealthy counterparts.

Conclusion

This Greenstar-led multiple voucher model did not significantly increase modern contraceptive use in the intervention study area but positively impacted equity. The integrated approach combining contraception with child immunization led to an increase in immunization coverage. It will be important for public policy decision-makers to assess the usefulness of this approach, as a long-term provision of free contraceptive services may lead to dependency in targeted communities.

Keywords:

• vouchers
• contraceptives
• family planning
• equity
• immunization
• Pakistan

Disclaimer

This paper contains the collective views of an international group of experts, and does not necessarily represent the decisions or the stated policy of the World Health Organization.

Abbreviations

DID, Difference-in-differences; FP, family planning; GSM, Greenstar Social Marketing; HH, household; LMIC, lower-middle income countries; MCH, maternal child health; mCPR, modern contraceptive prevalence rate; MWRA, married women of reproductive age; PNC, postnatal care; PSI, Population Services International; SRS, simple random sampling; SII, slope index of inequality; UC, Union Council; WHO, World Health Organization.

Data Sharing Statement

The data will be available on request from the corresponding author.

Ethics Approval and Consent to Participate

This paper reviewed national policies. The data were completely anonymous with no personal identifiers. The study was reviewed and approved by Population Services International (PSI) Research Ethics Board (REB).^19,20

Consent for Publication

Not applicable.

Acknowledgments

The authors are highly indebted to all the enumerators, field workers; and, above all, to the study participants for their time and enriching this study by sharing their experiences.

Author Contributions

This evaluation was conceptualized and conducted by MA, SKA, HBH, and MMR independently without any consultation with the project implementing organization. All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising, or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Disclosure

The authors have no conflicts of interest.

Additional information

Funding

Funded by The David and Lucile Packard Foundation, this evaluation is conducted by the Department of Reproductive Health and Research, World Health Organization, Geneva. 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, or The David and Lucile Packard Foundation.