Increasing Contraceptive Access for Hard-to-Reach Populations With Vouchers and Social Franchising in Uganda

Bellows, Benjamin; Mackay, Anna; Dingle, Antonia; Tuyiragize, Richard; Nnyombi, William; Dasgupta, Aisha

doi:10.9745/ghsp-d-17-00065

Cited by 17 publications

(23 citation statements)

References 32 publications

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“…Prior studies demonstrated that subsidized or free reproductive health vouchers improve uptake of modern contraception among women in lower-resourced settings [14,15,34,35]. A combination of a social franchise and family planning voucher program to provide family planning counseling and a broader contraceptive choice, inclusive of long-acting and permanent methods, increased contraception access and uptake in Ugandan hard-to-reach populations [36]. However, prior evidence has been limited by variability in designs and measured outcomes.…”

Section: Discussionmentioning

confidence: 99%

Provision of family planning vouchers and early initiation of postpartum contraceptive use among women living with HIV in southwestern Uganda: A randomized controlled trial

et al. 2019

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Background Unwanted pregnancies remain a burden for women living with HIV (WLWH). Family planning prevents unplanned pregnancies while promoting longer birth intervals, key strategies to eliminate perinatal transmission of HIV and promote maternal and child health. We evaluated the effect of a family planning voucher, inclusive of immediate postpartum counseling, on uptake, early initiation, and continuation of modern contraceptive methods among recently postpartum WLWH delivering at a publicly funded regional referral hospital in rural, southwestern Uganda. Methods and findings We performed a randomized controlled trial between October, 2016 and June, 2018 at a referral hospital in southwestern Uganda. This interim analysis includes adult WLWH randomized and enrolled equally to receive a family planning voucher or standard of care (control). Enrolled postpartum WLWH completed an interviewer-administered questionnaire at enrollment and 6 months postpartum. Our primary outcome of interest for this analysis is initiation of a modern family planning method within 8 weeks postpartum. Secondary outcomes included family planning initiation at 12, 14, 16, and 20 weeks postpartum, family planning discontinuation and/or change, pregnancy incidence, and mean time without contraception. The trial was registered with clinicaltrials.gov (NCT02964169). At enrollment, half of the women in both the voucher (N = 87, 55%) and control (N = 86, 54%) groups wanted to have a child in 2 years postpartum. Over 80% of referent pregnancies in the voucher (N = 136, 86%) and control (N = 128, 81%) groups were planned. All women were accessing ART. The mean CD4 count was 396 cells/mm 3 (SD = 61) for those enrolled in the control group versus 393 cells/mm 3 (SD = 64) in the family planning voucher group. By 8 weeks postpartum, family planning was initiated in 144 (91%) participants in the voucher group and 83 (52%) participants in the control group (odds ratio [OR] 9.42; CI 4.67–13.97, P < 0.001). We also found high family planning uptake rates for both groups, with higher rates among the intervention group at 12 weeks (OR 5.66; CI 2.65–12.12, P < 0.001), 14 weeks (OR 2.51; CI 1.31–4.79, P < 0.001), 16 weeks (OR 4.02; CI 1.66–9.77, P = 0.001), and 20 weeks (OR 3.65; CI 1.40–9.47, P = 0.004) postpartum. The average time to family planning initiation was reduced to 5.9 weeks (SD = 2.4) for those in the voucher group compared to 9.3 weeks (SD = 5) in the control ( P < 0.001). One pregnancy was recorded in the group receiving standard of care; none were reported in the voucher group. Method mix did not differ by group: injectables were selected by most women (N = 150, 50%), and 52% of this proportion were in the experimental arm, with <10% in each arm selecting condoms, oral contracepti...

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Section: Discussionmentioning

confidence: 99%

Provision of family planning vouchers and early initiation of postpartum contraceptive use among women living with HIV in southwestern Uganda: A randomized controlled trial

et al. 2019

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“…A review of available literature and implementation experience shows that vouchers can be an effective programmatic tool as well as a financing mechanism for family planning and reproductive health. 2 , 7 , 9 , 13 , 14 Key benefits and comparative advantage of voucher programs are summarized in the Table and outlined in more detail below.…”

Section: The Advantages Of a Well-implemented Voucher Programmentioning

confidence: 99%

“…From 2011 to 2014, Marie Stopes Uganda implemented a voucher program in private franchised clinics to provide family planning services to more than 325,000 clients; 66% were not using a contraceptive method before the program and nearly 80% had no education or only primary education (a proxy indicator for low income). 9 …”

Section: The Advantages Of a Well-implemented Voucher Programmentioning

confidence: 99%

Vouchers: A Hot Ticket for Reaching the Poor and Other Special Groups With Voluntary Family Planning Services

Menotti

Farrell

2016

Glob Health Sci Pract

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Vouchers can be a highly effective tool to increase access to and use of family planning and reproductive health services, especially for special populations including the poor, youth, and postpartum women. Voucher programs need to include social and behavior change communication with clients and quality assurance for providers, whether in the private or public sector. In the longer term, voucher programs can strengthen health systems capacity and provide a pathway to strategic purchasing such as insurance or contracting.

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“…We focused our promotions on the IUD because it is the least well-known method in sub-Saharan Africa, including in Rwanda 21, [39][40][41][42] , which explains the relatively high uptake of the IUD relative to the implant. Other LARC implementation studies have observed that the implant is more popular than the IUD 43,44 but that this trend shifts after focused IUD educational and counseling efforts, community-based and media efforts, and provider refresher IUD trainings 24,45 . Thus, though the IUD is less well-known versus the implant in much of sub-Saharan Africa 21,39,40,42,46 and providers may have lower baseline comfort promoting and inserting IUDs [17][18][19] , concerted promotional counseling and training efforts can be successfully employed as was achieved in these examples and our study to increase IUD demand.…”

Section: Discussionmentioning

confidence: 99%

Cost per insertion and couple year of protection for postpartum intrauterine devices and implants provided during service scale-up in Kigali, Rwanda

et al. 2019

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Introduction: In two high-volume government hospitals, their two affiliated health facilities, and two additional health facilities, we developed and implemented postpartum intrauterine device (PPIUD) and postpartum (PP) implant promotional counseling and service delivery procedures between May-July 2017 in Kigali, Rwanda. Between August 2017 and July 2018, 9,073 pregnant women received PPIUD/PP implant promotions who later delivered in one of our selected facilities. Of those, 2,633 had PPIUDs inserted, and 955 had PP implants inserted. The goal of the present analysis is to detail implementation expenditures and estimate incremental costs per insertion and couple years of protection (CYP) for PPIUD and PP implant users. Methods: We detail the incremental costs during the implementation from the health system perspective (including both the implementation costs and the cost of contraceptive methods) and use of standard methods to estimate the cost per insertion and CYP for PPIUD and PP implant users. In addition to the incremental costs of labor and supplies, the costs of promotional activities are included. Research costs for formative work were excluded. Results: A total of $74,147 USD was spent on the implementation between August 2017 and July 2018. The largest expense (34% of total expenses) went toward personnel, including doctoral-level, administrative, data management and nurse counseling staff. Training for PPIUD and implant providers and promoters comprised 8% of total expenses. Recruitment and reimbursements comprised 6% of expenses. Costs of implants to the government comprised 12% of the expenses, much higher than the cost of IUDs (1%). Costs per insertion were $25/PPIUDs and $77/PP implant. Costs per CYP were $5/PPIUDs and $20/PP implant. Conclusion: Understanding the cost per PPIUD/PP implant inserted and CYP can help to inform the cost of scaling up PPIUD/PP implant service implementation activities and resource allocation decision-making by the Rwandan Ministry of Health.

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Increasing Contraceptive Access for Hard-to-Reach Populations With Vouchers and Social Franchising in Uganda

Abstract: Between 2011 and 2014, the program provided more than 330,000 family planning services, mostly to rural women in the informal sector with little or no education. 70% of the voucher clients chose an implant and 25% an intrauterine device.

Cited by 17 publications

References 32 publications

Provision of family planning vouchers and early initiation of postpartum contraceptive use among women living with HIV in southwestern Uganda: A randomized controlled trial

Provision of family planning vouchers and early initiation of postpartum contraceptive use among women living with HIV in southwestern Uganda: A randomized controlled trial

Vouchers: A Hot Ticket for Reaching the Poor and Other Special Groups With Voluntary Family Planning Services

Cost per insertion and couple year of protection for postpartum intrauterine devices and implants provided during service scale-up in Kigali, Rwanda

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