Vouchers in Fragile States: Reducing Barriers to Long-Acting Reversible Contraception in Yemen and Pakistan

Abstract

In conflict-affected states, vouchers have reduced barriers to reproductive health services and have enabled health programs to use targeted subsidies to increase uptake of specific health services. Vouchers can also be used to channel funds to public- and private-service providers and improve service quality. The Yamaan Foundation for Health and Social Development in Yemen and the Marie Stopes Society (MSS) in Pakistan-both working with Options Consultancy Services-have developed voucher programs that subsidize voluntary access to long-acting reversible contraceptives (LARCs) and permanent methods (PMs) of family planning in their respective fragile countries. The programs focus on LARCs and PMs because these methods are particularly difficult for poor women to access due to their cost and to provider biases against offering them. Using estimates of expected voluntary uptake of LARCs and PMs for 2014 based on contraceptive prevalence rates, and comparing these with uptake of LARCs and PMs through the voucher programs, we show the substantial increase in service utilization that vouchers can enable by contributing to an expanded method choice. In the governorate of Lahj, Yemen, vouchers for family planning led to an estimated 38% increase in 2014 over the expected use of LARCs and PMs (720 vs. 521 expected). We applied the same approach in 13 districts of Punjab, Khyber Pakhtunkhwa (KPK), and Sindh provinces in Pakistan. Our calculations suggest that vouchers enabled 10 times more women than expected to choose LARCs and PMs in 2014 in those areas of Pakistan (73,639 vs. 6,455 expected). Voucher programs can promote and maintain access to family planning services where existing health systems are hampered. Vouchers are a flexible financing approach that enable expansion of contraceptive choice and the inclusion of the private sector in service delivery to the poor. They can keep financial resources flowing where the public sector is prevented from offering services, and ensure that alternative sources are available for reproductive health services such as family planning. Programs should consider using vouchers in fragile states to facilitate access to family planning services and support the countries' health systems.

FIGURE 1.

Voucher Movement and Funds Flow Abbreviations: FP, family planning; VMA, voucher management agency.

A distribution agent gives a family planning voucher to a woman in rural Pakistan.

FIGURE 2.

Wealth Index Distribution of the Rural Population in Pakistan and of MSS Voucher Clients for LARCs and PMs (N=1,557), 2014 Abbreviations: LARCs, long‐acting reversible contraceptives; MSS, Marie Stopes Society; PMs, permanent methods. Source: Wealth index distribution of the rural population from the 2012-13 Pakistan Demographic and Health Survey; of voucher clients, from the MSS annual client exit interview survey conducted in December 2014.

FIGURE 3.

Vouchers Redeemed in Pakistan by Contraceptive Method, 2014

A voucher distribution agent in Yemen gives a family planning voucher to a client.