Assessing the sustainability of single versus multiple voucher-based family programs in Pakistan: a 24-months post-intervention evaluation

Assessing the sustainability of single versus multiple voucher-based family programs in Pakistan: a 24-months post-intervention evaluation | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Assessing the sustainability of single versus multiple voucher-based family programs in Pakistan: a 24-months post-intervention evaluation Syed Khurram Azmat, Moazzam Ali, Md. Mizanur Rahman This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2920150/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 22 Aug, 2023 Read the published version in Contraception and Reproductive Medicine → Version 1 posted 7 You are reading this latest preprint version Abstract Introduction Family planning vouchers have emerged as a promising approach to improve coverage of underserved groups or underutilized services. The current study was designed to measure the residual/longer term impact of FP voucher programs on the practices of women beyond the life of the programme. Methods A cross-sectional survey conducted, as part of the larger mixed-method study, approximately 24 months after the close-down of Marie Stopes Society and Greenstar Social Marketing family planning voucher intervention programmes in Punjab, Pakistan. Following necessary ethics approvals, a total of 338 voucher MSS clients & 324 voucher GSM clients were interviewed using a structured questionnaire at the household level. Results Compared with end-line data, a significant decrease in the modern contraceptive uptake in both MSS (90% at endline to current ( or post-endline ) 52%) and GSM (from 84% to current 56%) intervention sites among the voucher clients was noted. Among MSS voucher clients, the highest decline in use was observed in IUCD (54% at endline versus to current 13%); however no change between the surveys was noted among GSM clients. In both projects, following closure of voucher intervention 34% of the discontinued users in MSS and 29% in GSM sites adopted/switched to a new modern contraceptive again. In the post-intervention survey, wealth-based inequality in GSM data depicts more pro-rich utility for modern methods, indicating pro-rich inequality, in contrast, the post-intervention survey in MSS found mixed results such as pro-poor inequality for any method and modern method use. Conclusions The prevalence for contraception in study sites, following closure of voucher intervention remained high than national average. This study provides evidence that family planning vouchers can bring about an enduring positive change in clients’ behaviours in using modern contraceptive methods among poor populations. These results are useful to design family planning programs that will sustain when the donor funding terminates. Introduction Sustainability of healthcare interventions is defined as the ability of a program or implementation strategy to maintain individual behavioral change and produce continued benefits or results over a well-defined period of time even after it evolves or adapts from the initial program intervention , . Sustained use of programme components and activities past their initial funding period and achievement of intended outcomes is vital in ensuring constant and effective health care improvements over time. Evidently, programs that fail to dedicate time and resources towards building sustainability of their interventions, end up wasting the initial investments over unrealized potential . Sustainability of interventions is dependent on the Consultation, Collaboration and Consolidation processes executed throughout intervention implementation. During the consultation process, transparency, client or service provider buy-in and alignment of measures with organizational or community goals are important in sustaining effective programs. The use of contraception has the potential to reduce maternal and child mortality and contribute to poverty reduction and social and economic development, particularly in countries with high fertility and rapid population growth , . However, despite global commitments and targeted efforts to increase the use of contraception, high unmet need for family planning continues to be a major challenge in low- and middle-income countries (LMICs) , with stark poor-rich disparities in many parts of the world. Globally, close to one in five women continue to have an unmet need for family planning in 2023. Several approaches have been used to increase the accessibility of quality family planning services. Demand-side financing (DSF) through vouchers, health insurance and conditional cash transfer 13 , is one approach that has been used in LMICs to improve maternal and reproductive health services, and the basic premise of which is to transfer the purchasing power to the clients.. Among these, family planning vouchers have emerged as a promising approach to improve fertility- and contraceptive services. Vouchers are considered as a tool for improving quality and improving access for poor and underserved communities, including youth and postpartum. Being the fifth most population country, Pakistan is grappling with several challenges, including rapid population and high unmet need for contraception, 19 .. The current use of modern contraception stands at 26% 19 which remained unchanged over the last 5 years , , . Female sterilisation and condom being the predominantly used methods 19 .. A range of demand- and supply-side factors are responsible for low contraceptive use including, but not limited to, sub-standard quality of services, women’s perceived socio-cultural unacceptability of FP and health concerns 19 . Over the last one decade, the country embarked on pro-poor approaches – especially voucher coupons - targeting marginalised communities to improve access to and use of quality maternal and reproductive health services, with promising results in improving maternal and reproductive health outcomes institutional birth 24 and contraceptive use 25,26, . Though effective, voucher programmes sustainability, both at programmatic levels and maintenance of user behaviours (i.e. contraceptive use) following completion of funded-projects are seen as potential challenges 27 . Responding to the concerns regarding sustainability of voucher programmes, a larger study was conducted to generate empirical evidence by examining the residual impact of two voucher programmes – implemented by Marie Stopes Society (MSS) and Greenstar Social Marketing (GSM) - on contraceptive behaviours of voucher recipients and franchised service providers after 24-months post intervention. Both the voucher programmes have shown a substantial increase the knowledge and practices regarding contraception 29,30 . To the best of the authors’ knowledge, limited or scarce research has been conducted to assess the long-term residual impact of voucher programmes either in the context of family planning, especially after project close-out, or in the post-intervention period. This paper reports on the residual impact of the FP voucher programmes on practices of women pertaining to contraception. Description of voucher intervention programmes : a) Marie Stopes Society (MSS) voucher programme: Lack of FP quality and prohibitive cost were the key assumptions behind MSS single-purpose voucher program that restricts women’s access to contraceptive use. The voucher intervention was delivered through an established social franchise network of private service providers. Core components of intervention included: a) pre-paid vouchers for free short- and long-term contraceptive services including method uptake, follow-up for side-effect management and removal of FP; b) provision of FP services through a MSS-trained private sector service providers (mid-level: nurse, midwife, lady health visitor; physician: medical doctor); and c) community outreach workers for distribution of vouchers to women who belonged to poorest two wealth quintiles based on screening criteria. Further details can be found elsewhere. 29, 29 b) Greenstar Social Marketing (GSM) voucher intervention programme: The premise for GSM multi-purpose voucher was lack of awareness among women owing to limited or lack of counselling by service providers. The intervention was to enhance client-provider interaction for improved FP counselling through vouchers. Core components of intervention included: a) booklet of vouchers that offer 13 pre-paid visits over a period of 18 months that comprised of two postnatal care visits, five infant immunisation and six FP visits (including contraceptive); b) cost of the voucher booklet was 50 Pakistan rupee (0.27 cents – USD 1=183 PKR); c) vouchers were distributed through service providers and distributing agencies to women belonging to poorest two wealth quintile as per screening criteria. Further details can be found elsewhere 30 . Methods Study design: This paper reports on a cross-sectional survey conducted, as part of the larger mixed-method study, approximately 24-month after the close-down of MSS and GSM contraceptive voucher programmes. Study settings The survey was conducted during May-June 2017 in the same geographic catchments in districts of Chakwal and Faisalabad where MSS and GSM voucher interventions were implemented, respectively. MSS engaged a total of 25 social franchise providers, of them six service provider sites were randomly selected. In contrast, GSM implemented its voucher intervention through 100 social franchise providers, of which sixteen providers were randomly selected for this survey. Study population Women of reproductive age (15–49 years) who had received a voucher (booklet) during intervention period were eligible to participate in the survey. Sampling We went through multiple steps from the development of list frame of voucher clients to the actual interviews. The same sampling strategy was used for both the programmes. At first, we developed a list frame of all voucher clients served through the programmes (MSS = 7,101 and GSM = 28,000). Second, we randomly selected 12 MSS and 25 GSM service providers. However, of the selected service providers, 6 MSS and 9 GSM couldn’t participate in the survey due to non-availability/shifted/migrated (MSS = 4 and GSM = 5), non-cooperation (MSS = 2 and GSM = 2), and death (GSM = 2). Consequently, the list frame of voucher clients for the remaining active providers reduced to 638 in MSS and 567 in GSM. Finally, the desired sample of 400 participants from each programmes was conveniently recruited from the list frame. Data Collection Tools And Procedures A standardized structured questionnaire was developed for both the MSS and GSM survey. The questionnaire broadly covered: a) socio-economic and demographic characteristics; b) reproductive history; c) fertility preferences and awareness and use of contraception; d) method discontinuation and its reasons; and e) experiences regarding use of voucher-based contraceptive services. The questionnaire was translated into Urdu and revised based on pre-testing conducted among 36 (18 each MSS and GSM) married women of reproductive age. These were not included in the final sample. Data collection and management Face-to-face interviews were conducted by trained data collectors on paper-based structured questionnaire at participants’ home in privacy. On average, each interview took 20–30 minutes. We took several measures to ensure the quality of collected data. In the field, all the forms were checked routinely for completeness and logical errors. Principal Investigators also conducted monitoring visits to ensure that data were collected in adherence with the study protocol. Data were double-entered centrally in Karachi office in a pre-designed data entry software that was developed in Epidata version 3.1. The software was also restricted for the must-filled entries and extreme values. Statistical analysis: Data analysis was performed separately for MSS and GSM. Simple frequencies and percentages were used to explore the socio-demographic and reproductive health characteristics of study participants. The residual impact of the voucher programmes was assessed by comparing the estimates of current survey with the respective endline surveys of each programmes conducted back in 2015. Crude differences between current survey and the endline were tested using Pearson chi-square (for categorical variables) and t-test (for continuous variables). Finally, we applied multivariable logistic regression to observe changes in the use of contraceptive methods between endline (2015) and current survey, after adjusting for potential covariates such as age, number of children, education status and wealth quintile. A p-value of ≤ 0.05 was taken to indicate statistical significance. For the purpose of health equity analysis, the index for the wealth quintile was constructed according to the technique used internationally by the Demographic and Health Survey (DHS) . Households were divided into five wealth quintiles (Q1-Q5) to assess socio-economic status. Slope index of inequality (SII) and relative index of inequality (RII) were calculated to measure absolute and relative measure of inequality, respectively. SII measures the absolute difference between the extreme wealth quintiles (Q5-Q1) and reflects the difference in percentage points in a given family planning indicators, while RII is a measure of ratio and expressed by percentage. Both SII and RII were calculated using linear regression models. Additionally, a concentration curve was constructed to illustrate the socio-economic inequality in the indicators graphically and a concentration index was calculated to measure the extent of socio-economic inequality in each family planning indicators. All statistical analyses were performed using Stata version 14.1/MP (StataCorp, College Station, Texas USA). Ethical consideration The study protocol was approved by the World Health Organization ‘ Scientific and Ethics Review Committee (Project ID: A65911). All enumerators were trained to ensure that they took appropriate measures in order protect the confidentiality of participants to the fullest extent possible. All study participants gave written, voluntary informed consent. Patient and public involvement No patients were involved in this research. The voucher-based contraceptive users' participants were recruited not as patients, but as service users and as citizens. Hence, the development of research questions and outcome measures was not informed by the patients’ priorities, experiences, and preferences. Patients were not involved in the design of the research. Further, this is not clinical research or randomized clinical trial. Results At MSS study sites, a total of 638 clients were approached, 338 (53.0%) were successfully interviewed. The main reasons for non-response were: household could not be located (225, 35.3%), not at home (47, 15.8%) and migrated (26,8.7%). Similar response rate was found at GSM sites where (324, 57.1%) participants were successfully interview of 567 who were approached. The main reasons for non-response were: household not located (119, 21.0%), not at home (34,6.0%), and a few migrated (10, 1.7%). Table 1 compares the characteristics of study participants (who had used vouchers), between endline and post-endline survey across MSS and GSM voucher programmes. With few exceptions, the characteristics of participants differed between the endline and ‘post-endline’ survey across both the programmes. However, it is to note that across both MSS and GSM sites, the actual differences were not substantive for characteristics such as age, age at married, mean number of children and mean household members (see Table 1). Insert TABLE 1 here Table 2 presents the comparison of current contraceptive use among voucher recipients between endline and post-endline survey. At MSS sites, of the voucher clients interviewed at endline survey, 90.8% reported to be using any form of contraceptive method, which has significantly reduced to 58.3% at post-endline survey. This decrease was observed primarily in the use of modern methods (from 90.3–51.8%); interestingly, the use of traditional methods increased from 0.8% in the endline to 5.3% in the post-endline survey. Among modern methods, the highest decline was recorded in the use of IUCD (from 53.6% in the endline study to 13.0% in post-endline), followed by implants (from 7.0–3.0%); whereas, the use of pill, injectable and condom remained more or less the same. Interestingly, a significant increase was noted in the use of tubal ligation (from 0.8–5.3%). Table 2 Comparison of current contraceptive use between endline and post-endline survey, according to MSS and GSM voucher programmes Characteristics MSS – single purpose voucher GSM – multipurpose voucher Endline n = 390 Post-endline n = 338 p-value Endline n = 409 Post-endline n = 324 p-value n % n % n % n % Any method 354 90.8 197 58.3 < 0.001 356 87.0 250 77.2 < 0.001 Any modern method 352 90.3 175 51.8 < 0.001 343 83.9 180 55.6 < 0.001 Oral pill 20 5.1 15 4.4 0.664 33 8.1 11 3.4 0.008 IUCD 209 53.6 44 13.0 < 0.001 126 30.8 100 30.9 0.987 Injectable 40 10.3 38 11.2 0.668 92 22.5 17 5.2 < 0.001 Implant 29 7.4 10 3.0 0.007 1 0.2 0 0.0 N/A Condom 51 13.1 53 15.7 0.317 80 19.6 36 11.1 0.002 Tubal ligation 3 0.8 18 5.3 < 0.001 12 2.9 16 4.9 0.160 Any traditional method 2 0.5 19 5.6 < 0.001 12 2.9 70 21.6 < 0.001 Periodic abstinence 0 0.0 3 0.9 0.062 2 0.5 27 8.3 < 0.001 Lactational amenorrhea 2 0.5 8 2.4 0.032 0 0.0 7 2.2 0.003 Withdrawal 0 0.0 8 2.4 0.002 10 2.4 36 11.1 < 0.001 In contrast, the drop in the proportion of any contraceptive method from endline (87%) to post-endline (77.2%) was comparatively low at GSM sites. This decrease was observed primarily in the use of modern methods (from 83.9–55.6%); interestingly, we observed a substantive increase in the use of traditional methods from 2.9% in the endline survey to 21.6% in the post-endline survey. Among modern methods, the highest decline was recorded in the use of injectables (from 22.5% in the endline survey to 5.2% in the post-endline survey), followed by condom (from 19.6–11.1%) and pill (from 8.1–3.4%). Insert Table 2 here At MSS sites, the provision of information pertinent to contraceptive methods was universal at endline; however, among current users at post-endline, around equal proportion (14%) of the women reported that they were not informed about potential side effects of the method or what to do if they experienced side effects. On the other hand, that provision of information pertinent to contraceptive methods increased significantly from endline to post-endline survey across all three indicators at GSM sites. The provision of information pertinent of contraceptive method was high at MSS and GSM service providers (see supplementary table 1 ). Insert Table 3 here Table 3 Clients’ experiences of quality of FP services Characteristics MSS – single purpose voucher GSM – multipurpose voucher Endline n = 351 Post-endline n = 171 p-value Endline n = 309 Post-endline n = 179 p-value n % n % n % n % Informed about side effect or problems of method use 351 100.0 148 86.5 < 0.001 268 86.7 177 98.9 < 0.001 Informed what to do in case of side effects 350 99.7 148 86.5 < 0.001 261 84.5 176 98.3 < 0.001 Informed about range of contraceptive methods 351 100.0 167 97.7 0.004 286 92.6 178 99.4 < 0.001 Post-endline survey revealed that 85% and 77.2% of the voucher clients of MSS and GSM reported to have discontinued the method they had adopted through voucher two years ago during the intervention period, respectively. Reportedly, IUD was the most commonly cited method that was last discontinued in the 24 months across MSS (44.6%) and GSM (52.1%) clients. Pregnancy desire (MSS = 29.1%, GSM (25.2%), side effects/fear of health concerns (MSS = 22.4%, GSM = 40.5%) constituted the most commonly cited reasons for discontinuation among MSS and GSM clients. Insert Table 4 here Table 4 Contraceptive discontinuation within last 2 years (following the closure of voucher programme) and reasons for discontinuation, according to MSS and GSM voucher programmes MSS – single purpose voucher GSM – multipurpose voucher Post-endline n = 338 Post-endline n = 324 n % n % Clients discontinued the method adopted through voucher 275 85.0 250 77.2 Method discontinued within last 24 months (n = 165) (n = 234) Oral pill 15 9.0 45 19.2 IUD 74 44.6 122 52.1 Injectable 20 12.0 31 13.2 Implant 29 17.5 0 0.0 Condom 27 16.3 36 15.4 Reasons for discontinuation (n = 215) (n = 369) Pregnancy desire 65 29.1 97 25.2 Side effect/Fear of health concerns 50 22.4 156 40.5 Others (accessibility, inconvenient, God's Will, Husband out of country) 32 17.8 49 16.9 Infrequent sex 33 14.8 14 3.6 Hysterectomy 13 5.8 15 3.9 Husband opposition 11 4.9 5 1.3 Method failure 11 4.9 33 8.6 Table 5 presents wealth-based inequalities in access to different contraceptive use by endline and post-endline survey for MSS and GSM voucher programmes separately. At MSS sites, around 90% of the poor population used modern methods in the endline survey, while this declined to around 53% in the post-endline survey. Use of all contraceptive methods was concentrated among poorer families in the endline survey, however at post-endline survey there was pro-poor inequality for any method and modern method. The slope index of inequality indicated that in the post-endline survey, use of modern methods among the rich population was around 9 percentage points lower than among the poor population. The relative index of inequality indicates that the wealthiest respondents were 0.84 times less likely to use modern contraceptives compared to the poorest group. Similarly, the concentration index identified that the use of modern contraceptives was concentrated among the poor group in both surveys. Table 5 Wealth-based inequalities in contraceptive use in endline and post-endline survey, according to MSS and GSM voucher programmes Coverage, (%) Inequality assessment Concentration index (x100) Q1 (Poorest) Q5 (Richest) SII (Q5: Q1, % points) RII (Q5:Q1) MSS – single purpose voucher Endline (2015) Modern method user 90.2 (83.7–94.2) 100 0.9 (-9.0 to 10.9) 1.0 (0.9 to 1.1) -2.4 (-4.2 to -0.5) Traditional use 1.5 (0.38–5.9) 0 -2.3 (-5.8 to 1.1) 0.2 (-0.1 to 0.6) -40.6 (-121.2 to 40.0) Post-endline (2017) Modern method user 52.9 (41.0-64.6) 46.3 (34.6–58.3) -9.4 (-27.8 to 0.1) 0.8 (0.5 to 1.1) -10.0 (-15.8 to -4.2) Traditional use NA NA 4.5 (-4.2 to 13.1) 1.9 (-0.5 to 4.4) 15.3 (-10.0 to 40.6) GSM – multipurpose voucher Endline (2015) Modern method user 97.4 (83.5–99.7) 79.8 (72.0-85.9) -15.7 (-27.2 to -4.1) 0.8 (0.7 to 0.9) -6.3 (-8.7 to -3.9) Traditional use 0.00 2.3 (0.8-7.0) -0.8 (-5.5 to 4.2) 0.8 (-0.2 to 1.9) 10.4 (-22.5 to 43.3) Post-endline (2017) Modern method user 53.8 (41.6–65.6) 58.7 (46.1–70.3) 10.4 (-8.3 to 29.0) 1.2 (0.8 to 1.6) -3.6 (-9.3 to -2.0) Traditional use 23.0 (14.3–35.0) 20.6 (12.3–32.5) -5.6 (-21.1 to 9.9) 0.8 (0.2 to 1.3) -0.3 (-12.4 to 11.8) Note : SII, Slope index of inequality; RII, Relative index inequality; 95% CI, 95% Confidence interval; * First-time contraceptive use; All equity analysis was adjusted for base and endline survey point. The endline survey curve indicated that there is no inequality to regarding the use of modern contraceptive methods among poor and rich, however, greater pro-poor inequality was observed in the post-endline survey (see supplementary Fig. 1). With respect of GSM sites, the use of modern contraceptive methods in the endline survey was higher among the disadvantaged group than the affluent group, but the use of modern contraceptives declined among both groups in the post-endline survey. Pro-poor inequality in the endline survey and pro-rich inequalities were observed for all types of contraceptive user group. The slope index of inequality indicated that the use of modern contraceptive method was about 15-percentage points lower in the wealthiest group in the endline survey than the disadvantaged group. However, in the post-endline survey, the use of modern contraceptives was 10.4 percentage points higher in the wealthiest group than the disadvantaged group. the concentration curve for the use of modern contraceptive in the endline survey was above the line of equality, indicating that modern contraceptives use was more concentrated among the poorest group in the endline survey. In post-endline survey, the concentration curve for modern contraceptive moved far below the line of inequality, indicating pro-rich inequality (see supplementary Fig. 2). Insert Table 5 here Discussion Attention to the sustainability of health intervention programs is increasing, a development program was considered sustainable when it is able to deliver an appropriate level of benefits for an extended period of time after major financial, managerial and technical assistance from an external donor is terminated . There is dearth of evidence to questions like, what happens to the short-term projects funded by government agencies and foundations to foster local improvement in some aspect of health or health promotion? This paper attempts to answer the issues raised here. Family planning vouchers have emerged as a promising approach to improving fertility outcomes 14 . However, no research has attempted to measure the sustainable impact of voucher programmes either in the context of maternal health or family planning. After the closure of voucher intervention for 24 months a considerable decrease was noted in the use of modern contraceptive methods in both MSS (38%) and GSM (26%) study sites. However, our study was unable to capture the exact time of discontinuation; therefore it is possible that these women may have discontinued early after adoption or they may have used the contraceptive method long enough to achieve healthy birth spacing. Previous research from a similar social franchising context in Pakistan showed higher continuation , , compared with national statistics 19 . As the voucher intervention closed, a substantial rise in traditional methods was observed in both the projects – particularly among GSM clients (6% points in MSS and 18% points in GSM). This perhaps signifies an increase in awareness and subsequently the demand but few possible factors such as affordability, lack of proper supervision from field health worker can be cited. However, further research is needed to understand the increase in the use of traditional methods following end of intervention. Despite that huge reduction in the use of modern contraceptive from endline to post-endline in both the projects, however, it was highly encouraging to observe that 34% of the relapsed users in MSS and 29% in GSM sites adopted a modern contraceptive again. This switching proportion is comparatively far higher than the national statistics of 3.4% 19 . Notably, approximately two years after the closure of the voucher programme, the current use of modern contraceptive in both the study sites was higher than the national contraceptive use 19 . Moreover, the use of modern methods at post-endline survey in the MSS project was similar to the proportion observed at endline in the general population (MSS = 50%) 29 ; whereas in the case of GSM, the post-endline modern contraceptive use was far higher than the endline proportion (GSM = 32%) 30 . These results are indicative of an enduring change in the behaviour of communities that occurred as a result of the voucher intervention programme. Among MSS voucher clients, the highest decline was observed in IUCD use. In GSM sites, a considerable decrease was observed in the use of short-acting methods. This discontinuation could have been prevented through engagement of LHWs who are responsible for door-to-door visits for counselling and provision of short-acting methods. It is therefore imperative that for any new initiative, programmatic synergies should be explored with existing system, and where possible, health system linkages should be established accordingly. Among those exposed to voucher program, about half of the contraceptive users in GSM and one-third in MSS adopted the new method from service providers and 25% of the respondent cited MSS/GSM project field worker as the source of the referrals. These findings not only reinforce the importance of demand generation through outreach workers; but at the same time it signifies provision of quality services that establishes a long-term relationship between service providers and the clients. With respect to service quality, in MSS we observed a significant decrease of clients being informed about potential side effects and follow up comparing endline to post-endline survey. This could be that the quality of service provision got comprised in the absence of clinical supervision and monitoring as it was during voucher intervention. On the contrary, a significant increase was observed in the GSM site where provision of this information was nearly universal, irrespective of the source of method. Overall, these results are still better than national estimates where only one-third of the clients are provided with such information 19 . This increase in informed choice may be attributed to the fact that service providers have actually realised the importance of quality counselling and hence have been able to maintain the standard. Health equity analysis showed mixed results for MSS and GSM voucher clients. In GSM at the endline survey, the use of modern contraceptives was higher in the poorer group compared to the wealthiest, which reversed in the post-endline survey where use was higher in the wealthiest group. These findings reinforce the importance of a voucher programme in terms of reducing inequalities in the use of contraceptive methods between rich and poor populations. On the other hand, in MSS study sites, the use was higher in poorer segments of the population than in the wealthiest segments at post-endline. A possible explanation could be that MSS service providers were primarily based in rural areas it is common practice to maintain good rapport with the clients. In addition, the use of free voucher may have changed the behaviour of users in the intervention catchment suggesting ex-voucher user either continuing to use the same method or adopted a new method by paying out-of-pocket. However, this merits further investigation for better understanding. Side effects were cited as the most common reasons for discontinuation among GSM clients (41%) whereas this was the second most common reason among MSS clients (22%). In both the projects, side effects as the reason for discontinuation increased from endline to post-endline survey, highlighting lack of supportive structure that was during intervention. Moreover, high IUCD expulsion rate (9% in GSM and 5% in MSS) was also documented in our study. These findings suggest the need for better counselling of clients, follow-up support for side effect management 35 and enhancement of provider skills (on IUCD) in procedures. Keeping in view of women’s restricted mobility in Pakistan, technological solutions could be considered in the communities such as helpline services where women could call and get information regarding side effect management 35 . Limitations There are some limitations in our study. There is possibility of recall problem in answering questions about their past experiences with service providers such as information of method at the time of uptake, last method discontinued etc; matched pre-post design whereby interviewing same voucher clients would have accounted for the differences in sample characteristics and other unobserved confounders. This was minimized as information on personal identifiers was discarded by the implementing organisations (MSS and GSM); locating households with the support on field teams who are involved in the distribution of vouchers may have introduced a selection bias as they could recall and take data collectors to those household where they have good relationship with women – and this may have skewed the responses positively in favour of the intervention; finally, as contraceptive calendar approach was not used, the study is unable to capture and report exact time of method discontinuation. Conclusion Understanding sustainability of interventions is important in forming a baseline for promoting effective practices that yield desired health outcomes over longer period . Present evidence suggests that vouchers can contribute to the agenda of equitable access in universal health coverage by addressing its three core aspects: 1) Increase access to the poor and vulnerable; 2) Increase the number of services by adding contraceptives to the existing method mix, and 3) provides financial protection by being inclusive and reaching out to the underserved. This study also indicates that vouchers can bring about an enduring positive change in behaviours regarding the use of modern contraceptive methods among poor populations. However, method discontinuation as a result of side effects seems to be a common practice that should be dealt with properly through improved counselling and active follow-up. The findings of this study will provide information to policymakers to plan services to support and sustain positive health behaviour among the population when donor funding goes dry. Declarations Acknowledgements: Authors are highly indebted to all the enumerators, field workers; and above all, to the study participants for their time and for enriching this study by sharing their experiences. Funding: The research project was funded by The David and Lucile Packard Foundation (Grant ID-64569), this evaluation is conducted independently by the Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva. There was no role of the funding organization in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript. Availability of data and materials The data will be available upon request as per the WHO policies. Requests for access to data can be sent to [email protected] Authors contributions: This evaluation was conceptualized and conducted by MA, SKA, MR independently, without any consultation with the project implementing organization. MA, SKA, MR developed the first and final drafts of the manuscript and provided intellectual contribution to the final draft of the manuscript. All authors have read and approved the manuscript, and ensure that this is the final version. Ethics approval and consent to participate: All respondents were informed about survey and their rights. No personal information was entered in the database that could be used to identify specific individual. The study protocol was approved by National Bioethics Committee (NBC) Pakistan. Ref: No. 4–87/12/NBC-92/RDC/3548 All survey participants provided a written informed consent to participate in the survey. This study does not fall within the International Committee of Medical Journal Editors (ICMJE)’ definition of a clinical trial. Consent for publication Not Applicable. Competing interests: The authors declare that they have no competing interests. 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. References Moore JE, Mascarenhas A, Bain J, and Straus SE, “Developing a comprehensive definition of sustainability,” Implement. Sci., vol. 12, no. 1, pp. 1–8, 2017, doi: 10.1186/s13012-017-0637-1. Walugembe DR, Sibbald S, Le Ber MJ, and Kothari A, “Sustainability of public health interventions: Where are the gaps?,” Heal. Res. Policy Syst., vol. 17, no. 1, pp. 1–7, 2019, doi: 10.1186/s12961-018-0405-y. Herkama S, Kontio M, Sainio M, Turunen T, Poskiparta E, and Salmivalli C, “Facilitators and Barriers to the Sustainability of a School-Based Bullying Prevention Program,” Prev. Sci., vol. 23, pp. 954–968, 2022, doi: 10.1007/s11121-022-01368-2 Khalil K and Kynoch K, “Implementation of sustainable complex interventions in health care services: the triple C model,” BMC Health Serv. Res., vol. 21, no. 1, pp. 1–10, 2021, doi: 10.1186/s12913-021-06115-x Mendelson A et al., “The effects of pay-for-performance programs on health, health care use, and processes of care: A systematic review,” Ann. Intern. Med., vol. 166, no. 5, pp. 341–353, 2017, doi: 10.7326/M16-1881. Cleland J, Bernstein S, Ezeh A, Faundes A, Glasier A, Innis J. Family planning: the unfinished agenda. Lancet. 2006;368(9549):1810–27. 10.1016/S0140-6736(06)69480-4 Ahmed S, Li Q, Liu L, Tsui AO. Maternal deaths averted by contraceptive use: an analysis of 172 countries. Lancet . 2012;380(9837):111–25. 10.1016/s0140-6736(12)60478-4 Kantorova V, Wheldon MC, Ueffing P, Dasgupta ANZ. Estimating progress towards meeting women's contraceptive needs in 185 countries: A Bayesian hierarchical modelling study. PLoS Medicine. 2020;17: e1003026. Ross J. Improved Reproductive Health Equity Between the Poor and the Rich: An Analysis of Trends in 46 Low- and Middle-Income Countries. GLOB HEALTH SCI PRACT 2015 Sep 10;3(3):419-45. United Nations Population Division: www.population.un.org/dataportal/home (accessed on April 16, 2023). Mwaikambo L, Speizer IS, Schurmann A, Morgan G, Fikree F. What works in family planning interventions: a systematic review. Stud Fam Plann 2011 Jun;42(2):67-82. Murray S, Hunter B, Bisht R, Ensor T, Bick D. Effects of demand-side financing on utilisation, experiences and outcomes of maternity care in low- and middle-income countries: a systematic review. BMC Pregnancy and Childbirth. 2014;14: 30. Bellows B, Bulaya C, Inambwae S, Lissner CL, Ali M, Bajracharya A. Family Planning Vouchers in Low and Middle Income Countries: A Systematic Review. Stud Fam Plann 2016 Nov 1;47(4):357-70. High Impact Practices in Family Planning (HIP). Family planning vouchers: a tool to boost contraceptive method access and choice. 2020. United Nations Population Fund (UNFPA)., Pathfinder International. The State of Family Planning in Pakistan: Targeting the Missing Links to Achieve Development Goals. Islamabad: UNFPA, Pathfinder International; 2013 Jun National Institute of Population Studies Pakistan, Macro International Inc. Pakistan Demographic and Health Survey 2006-7. 2008. National Institute of Population Studies Pakistan, Macro International Inc. Pakistan Demographic and Health Survey 2012-13. 2014. National Institute of Population Studies (NIPS) [Pakistan] and ICF. Pakistan Demographic and Health Survey 2017-18. 2018. Khan A, Shaikh BT. An all time low utilization of intrauterine contraceptive device as a birth spacing method- a qualitative descriptive study in district Rawalpindi, Pakistan. Reprod Health 2013;10(1):10. Casterline JB, Sathar ZA, Haque Mu. Obstacles to Contraceptive Use in Pakistan: A Study in Punjab. Stud Fam Plann 2001 Jun 1;32(2):95-110. Agha S. Changes in the proportion of facility-based deliveries and related maternal health services among the poor in rural Jhang, Pakistan: results from a demand-side financing intervention. International Journal for Equity in Health 2011;10(1):57. Azmat SK, Shaikh BT, Hameed W, Mustafa G, Hussain W, Asghar J, et al. Impact of Social Franchising on Contraceptive Use When Complemented by Vouchers: A Quasi-Experimental Study in Rural Pakistan. PLoS ONE 2013 Sep 12;8(9):e74260. Azmat SK, Hameed W, Hamza HB, Mustafa G, Ishaque M, Abbas G, et al. Engaging with community-based public and private mid-level providers for promoting the use of modern contraceptive methods in rural Pakistan: results from two innovative birth spacing interventions. Reprod Health 2016 Mar;13(1):1-15. Mehboob G, Shaikh BT. Experience Of Vouchers For Reproductive Health Services In Developing Countries: Making A Case For Pakistan Through A Systematic Review. J Ayub Med Coll Abbottabad 2015;27(3):695-701. Broughton EI, Hameed W, Gul X, Sarfraz S, Baig IY, Villanueva M. Cost-Effectiveness of a Family Planning Voucher Program in Rural Pakistan. Frontiers in Public Health 2017 Sep 22;5:227. Ali M, Azmat SK, Hamza HB, Rahman MM, Hameed W. Are family planning vouchers effective in increasing use, improving equity and reaching the underserved? An evaluation of a voucher program in Pakistan. BMC Health Services Research. 2019;19: 200. Ali M, Azmat SK, Hamza HB, Rahman MM. Assessing Effectiveness of Multipurpose Voucher Scheme to Enhance Contraceptive Choices, Equity, and Child Immunization Coverage: Results of an Interventional Study from Pakistan. J Multidiscip Healthc. 2020;13: 1061-1074. Ali M, Azmat SK, Hamza HB. Assessment of modern contraceptives continuation, switching and discontinuation among clients in Pakistan: study protocol of 24-months post family planning voucher intervention follow up. BMC Health Serv Res. 2018 May 11;18(1):359. doi: 10.1186/s12913-018-3156-0. PMID: 29751807; PMCID: PMC5948711. Azmat SK, Ali M, Hameed W, Mustafa G, Abbas G, Ishaque M, Bilgrami M, Temmerman M. A study protocol: using demand-side financing to meet the birth spacing needs of the underserved in Punjab Province in Pakistan. Reprod Health. 2014;11: 39. Rutstein SO, Johnson K. DHS Comparative Reports 6: The DHS Wealth Index. Calverton, Maryland: ORC Macro; 2004 Jul. US Agency for International Development (1988) Sustainability of Development Programs: A Compendium of Donor Experience. USAID, Washington, DC. Hameed W, Azmat SK, Ali M, Ishaque M, Abbas G, Munroe E, et al. Comparing Effectiveness of Active and Passive Client Follow-Up Approaches in Sustaining the Continued Use of Long Acting Reversible Contraceptives (LARC) in Rural Punjab: A Multicentre, Non-Inferiority Trial. PLoS ONE 2016 Sep 1;11(9):e0160683. Azmat S, Shaikh B, Hameed W, Bilgrami M, Mustafa G, Ali M, et al. Rates of IUCD discontinuation and its associated factors among the clients of a social franchising network in Pakistan. BMC Women's Health 2012;12(1):8. Hameed W, Azmat S, Ishaque M, Hussain W, Munroe E, Mustafa G, et al. Continuation rates and reasons for discontinuation of intra-uterine device in three provinces of Pakistan: results of a 24-month prospective client follow-up. Health Research Policy and Systems 2015;13(Suppl 1):S53. Stirman SW, Kimberly J, Cook N, Calloway A, Castro F, and Charns M, “The sustainability of new programs and innovations: A review of the empirical literature and recommendations for future research,” Implement. Sci., vol. 7, no. 1, p. 17, 2012, doi: 10.1186/1748-5908-7-17. Additional Declarations No competing interests reported. Supplementary Files SupplementaryFigure1.docx SupplementaryFigure2.docx SupplementaryTable1.docx Cite Share Download PDF Status: Published Journal Publication published 22 Aug, 2023 Read the published version in Contraception and Reproductive Medicine → Version 1 posted Editorial decision: Major revision 12 Jun, 2023 Reviews received at journal 31 May, 2023 Reviewers agreed at journal 18 May, 2023 Reviewers invited by journal 17 May, 2023 Editor assigned by journal 12 May, 2023 Submission checks completed at journal 12 May, 2023 First submitted to journal 11 May, 2023 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-2920150","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":200039398,"identity":"c7b9ce38-8b9e-48e0-8d1f-a95696acdb5e","order_by":0,"name":"Syed Khurram Azmat","email":"","orcid":"","institution":"AAPNA-Institute of Public Health, Jinnah Sindh Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Syed","middleName":"Khurram","lastName":"Azmat","suffix":""},{"id":200039399,"identity":"fefe623b-ecdc-47e7-adb8-9b32bd0f1f39","order_by":1,"name":"Moazzam Ali","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAApklEQVRIiWNgGAWjYDACdsYGIGnDYAAkDxCnhRmsJQ2qJYEoLWDyMFgLA1Fa+JuZWzd8qDmfuJ29gfFw4Q8itEgcZmy7OePY7cSdPQcYDs8gymFALbd52G7nbriRwHCYhxgt8mAt/86RoMUApIW37QAJWgxBfpnZl1y/4czBhsM8aURokTve/uzGh292xgbHmw9/5rEhQgsSAMfpKBgFo2AUjAKqAAC3RDzWACcexQAAAABJRU5ErkJggg==","orcid":"","institution":"World Health Organization","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Moazzam","middleName":"","lastName":"Ali","suffix":""},{"id":200039400,"identity":"d49d7502-6f49-43b5-a5ff-a0745ff2dfcc","order_by":2,"name":"Md. Mizanur Rahman","email":"","orcid":"","institution":"Hitotsubashi University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Md.","middleName":"Mizanur","lastName":"Rahman","suffix":""}],"badges":[],"createdAt":"2023-05-11 12:44:29","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-2920150/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-2920150/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s40834-023-00244-w","type":"published","date":"2023-08-22T15:01:06+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":42781013,"identity":"141e7ba8-19ab-46b2-a388-466365fec19f","added_by":"auto","created_at":"2023-09-07 15:06:58","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":518408,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2920150/v1/bcd7be75-7a01-4700-bf06-837f2a49ab1b.pdf"},{"id":37082361,"identity":"bd92bb84-1ad6-46c8-89a5-7071f7ade4f0","added_by":"auto","created_at":"2023-05-16 11:25:35","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":80985,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFigure1.docx","url":"https://assets-eu.researchsquare.com/files/rs-2920150/v1/fec91730df8ac8c708dfe0ed.docx"},{"id":37082044,"identity":"3b7f93e8-ab69-48a6-9554-fa0ff6839b01","added_by":"auto","created_at":"2023-05-16 11:17:35","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":81267,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFigure2.docx","url":"https://assets-eu.researchsquare.com/files/rs-2920150/v1/e2a6b27a7972c776b28684a8.docx"},{"id":37082043,"identity":"25a0bf11-e970-48c4-a4de-e68adbba1f21","added_by":"auto","created_at":"2023-05-16 11:17:34","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":15722,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryTable1.docx","url":"https://assets-eu.researchsquare.com/files/rs-2920150/v1/ef9ae815a9239b746b76c0a0.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Assessing the sustainability of single versus multiple voucher-based family programs in Pakistan: a 24-months post-intervention evaluation","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSustainability of healthcare interventions is defined as the ability of a program or implementation strategy to maintain individual behavioral change and produce continued benefits or results over a well-defined period of time even after it evolves or adapts from the initial program intervention\u003csup\u003e,\u003c/sup\u003e. Sustained use of programme components and activities past their initial funding period and achievement of intended outcomes is vital in ensuring constant and effective health care improvements over time. Evidently, programs that fail to dedicate time and resources towards building sustainability of their interventions, end up wasting the initial investments over unrealized potential .\u003c/p\u003e\n\u003cp\u003eSustainability of interventions is dependent on the Consultation, Collaboration and Consolidation processes executed throughout intervention implementation. During the consultation process, transparency, client or service provider buy-in and alignment of measures with organizational or community goals are important in sustaining effective programs.\u003c/p\u003e\n\u003cp\u003eThe use of contraception has the potential to reduce maternal and child mortality and contribute to poverty reduction and social and economic development, particularly in countries with high fertility and rapid population growth\u003csup\u003e,\u003c/sup\u003e. However, despite global commitments and targeted efforts to increase the use of contraception, high unmet need for family planning continues to be a major challenge in low- and middle-income countries (LMICs) , with stark poor-rich disparities in many parts of the world.\u003c/p\u003e\n\u003cp\u003eGlobally, close to one in five women continue to have an unmet need for family planning in 2023. Several approaches have been used to increase the accessibility of quality family planning services. Demand-side financing (DSF) through vouchers, health insurance and conditional cash transfer\u003csup\u003e13\u003c/sup\u003e, is one approach that has been used in LMICs to improve maternal and reproductive health services, and the basic premise of which is to transfer the purchasing power to the clients.. Among these, family planning vouchers have emerged as a promising approach to improve fertility- and contraceptive services. Vouchers are considered as a tool for improving quality and improving access for poor and underserved communities, including youth and postpartum.\u003c/p\u003e\n\u003cp\u003eBeing the fifth most population country, Pakistan is grappling with several challenges, including rapid population and high unmet need for contraception,\u003csup\u003e19\u003c/sup\u003e.. The current use of modern contraception stands at 26%\u003csup\u003e19\u003c/sup\u003e which remained unchanged over the last 5 years\u003csup\u003e,\u003c/sup\u003e\u003csup\u003e,\u003c/sup\u003e. Female sterilisation and condom being the predominantly used methods\u003csup\u003e19\u003c/sup\u003e.. A range of demand- and supply-side factors are responsible for low contraceptive use including, but not limited to, sub-standard quality of services, women\u0026rsquo;s perceived socio-cultural unacceptability of FP and health concerns\u003csup\u003e19\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eOver the last one decade, the country embarked on pro-poor approaches \u0026ndash; especially voucher coupons - targeting marginalised communities to improve access to and use of quality maternal and reproductive health services, with promising results in improving maternal and reproductive health outcomes institutional birth\u003csup\u003e24\u003c/sup\u003e and contraceptive use\u003csup\u003e25,26,\u003c/sup\u003e. Though effective, voucher programmes sustainability, both at programmatic levels and maintenance of user behaviours (i.e. contraceptive use) following completion of funded-projects are seen as potential challenges\u003csup\u003e27\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eResponding to the concerns regarding sustainability of voucher programmes, a larger study was conducted to generate empirical evidence by examining the residual impact of two voucher programmes \u0026ndash; implemented by Marie Stopes Society (MSS) and Greenstar Social Marketing (GSM) - on contraceptive behaviours of voucher recipients and franchised service providers after 24-months post intervention. Both the voucher programmes have shown a substantial increase the knowledge and practices regarding contraception\u003csup\u003e29,30\u003c/sup\u003e. To the best of the authors\u0026rsquo; knowledge, limited or scarce research has been conducted to assess the long-term residual impact of voucher programmes either in the context of family planning, especially after project close-out, or in the post-intervention period.\u003c/p\u003e\n\u003cp\u003eThis paper reports on the residual impact of the FP voucher programmes on practices of women pertaining to contraception.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDescription of voucher intervention programmes\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003ea) Marie Stopes Society (MSS) voucher programme: Lack of FP quality and prohibitive cost were the key \u0026nbsp;assumptions behind MSS single-purpose voucher program that restricts women\u0026rsquo;s access to contraceptive use. The voucher intervention was delivered through an established social franchise network of private service providers. Core components of intervention included: a) pre-paid vouchers for free short- and long-term contraceptive services including method uptake, follow-up for side-effect management and removal of FP; b) provision of FP services through a MSS-trained private sector service providers (mid-level: nurse, midwife, lady health visitor; physician: medical doctor); and c) community outreach workers for distribution of vouchers to women who belonged to poorest two wealth quintiles based on screening criteria. Further details can be found elsewhere.\u003csup\u003e29,\u003csup\u003e29\u003c/sup\u003e\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;b) Greenstar Social Marketing (GSM) voucher intervention programme: The premise for GSM multi-purpose voucher was lack of awareness among women owing to limited or lack of counselling by service providers. The intervention was to enhance client-provider interaction for improved FP counselling through vouchers. Core components of intervention included: a) booklet of vouchers that offer 13 pre-paid visits over a period of 18 months that comprised of two postnatal care visits, five infant immunisation and six FP visits (including contraceptive); b) cost of the voucher booklet was 50 Pakistan rupee (0.27 cents \u0026ndash; USD 1=183 PKR); c) vouchers were distributed through service providers and distributing agencies to women belonging to poorest two wealth quintile as per \u0026nbsp;screening criteria. Further details can be found elsewhere\u003csup\u003e30\u003c/sup\u003e.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design:\u003c/h2\u003e \u003cp\u003eThis paper reports on a cross-sectional survey conducted, as part of the larger mixed-method study, approximately 24-month after the close-down of MSS and GSM contraceptive voucher programmes.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy settings\u003c/h3\u003e\n\u003cp\u003eThe survey was conducted during May-June 2017 in the same geographic catchments in districts of Chakwal and Faisalabad where MSS and GSM voucher interventions were implemented, respectively. MSS engaged a total of 25 social franchise providers, of them six service provider sites were randomly selected. In contrast, GSM implemented its voucher intervention through 100 social franchise providers, of which sixteen providers were randomly selected for this survey.\u003c/p\u003e\n\u003ch3\u003eStudy population\u003c/h3\u003e\n\u003cp\u003eWomen of reproductive age (15\u0026ndash;49 years) who had received a voucher (booklet) during intervention period were eligible to participate in the survey.\u003c/p\u003e\n\u003ch3\u003eSampling\u003c/h3\u003e\n\u003cp\u003eWe went through multiple steps from the development of list frame of voucher clients to the actual interviews. The same sampling strategy was used for both the programmes. At first, we developed a list frame of all voucher clients served through the programmes (MSS\u0026thinsp;=\u0026thinsp;7,101 and GSM\u0026thinsp;=\u0026thinsp;28,000). Second, we randomly selected 12 MSS and 25 GSM service providers. However, of the selected service providers, 6 MSS and 9 GSM couldn\u0026rsquo;t participate in the survey due to non-availability/shifted/migrated (MSS\u0026thinsp;=\u0026thinsp;4 and GSM\u0026thinsp;=\u0026thinsp;5), non-cooperation (MSS\u0026thinsp;=\u0026thinsp;2 and GSM\u0026thinsp;=\u0026thinsp;2), and death (GSM\u0026thinsp;=\u0026thinsp;2). Consequently, the list frame of voucher clients for the remaining active providers reduced to 638 in MSS and 567 in GSM. Finally, the desired sample of 400 participants from each programmes was conveniently recruited from the list frame.\u003c/p\u003e\n\u003ch3\u003eData Collection Tools And Procedures\u003c/h3\u003e\n\u003cp\u003eA standardized structured questionnaire was developed for both the MSS and GSM survey. The questionnaire broadly covered: a) socio-economic and demographic characteristics; b) reproductive history; c) fertility preferences and awareness and use of contraception; d) method discontinuation and its reasons; and e) experiences regarding use of voucher-based contraceptive services. The questionnaire was translated into Urdu and revised based on pre-testing conducted among 36 (18 each MSS and GSM) married women of reproductive age. These were not included in the final sample.\u003c/p\u003e\n\u003ch3\u003eData collection and management\u003c/h3\u003e\n\u003cp\u003e Face-to-face interviews were conducted by trained data collectors on paper-based structured questionnaire at participants\u0026rsquo; home in privacy. On average, each interview took 20\u0026ndash;30 minutes. We took several measures to ensure the quality of collected data. In the field, all the forms were checked routinely for completeness and logical errors. Principal Investigators also conducted monitoring visits to ensure that data were collected in adherence with the study protocol. Data were double-entered centrally in Karachi office in a pre-designed data entry software that was developed in Epidata version 3.1. The software was also restricted for the must-filled entries and extreme values.\u003c/p\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis:\u003c/h2\u003e \u003cp\u003eData analysis was performed separately for MSS and GSM. Simple frequencies and percentages were used to explore the socio-demographic and reproductive health characteristics of study participants. The residual impact of the voucher programmes was assessed by comparing the estimates of current survey with the respective endline surveys of each programmes conducted back in 2015. Crude differences between current survey and the endline were tested using Pearson chi-square (for categorical variables) and t-test (for continuous variables). Finally, we applied multivariable logistic regression to observe changes in the use of contraceptive methods between endline (2015) and current survey, after adjusting for potential covariates such as age, number of children, education status and wealth quintile. A p-value of \u0026le;\u0026thinsp;0.05 was taken to indicate statistical significance.\u003c/p\u003e \u003cp\u003eFor the purpose of health equity analysis, the index for the wealth quintile was constructed according to the technique used internationally by the Demographic and Health Survey (DHS)\u003ca class=\"FNLink\" href=\"#Fn30\" id=\"#FNLinkFn30\"\u003e\u003c/a\u003e. Households were divided into five wealth quintiles (Q1-Q5) to assess socio-economic status. Slope index of inequality (SII) and relative index of inequality (RII) were calculated to measure absolute and relative measure of inequality, respectively. SII measures the absolute difference between the extreme wealth quintiles (Q5-Q1) and reflects the difference in percentage points in a given family planning indicators, while RII is a measure of ratio and expressed by percentage. Both SII and RII were calculated using linear regression models. Additionally, a concentration curve was constructed to illustrate the socio-economic inequality in the indicators graphically and a concentration index was calculated to measure the extent of socio-economic inequality in each family planning indicators. All statistical analyses were performed using Stata version 14.1/MP (StataCorp, College Station, Texas USA).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEthical consideration\u003c/h3\u003e\n\u003cp\u003e The study protocol was approved by the World Health Organization \u0026lsquo; Scientific and Ethics Review Committee (Project ID: A65911). All enumerators were trained to ensure that they took appropriate measures in order protect the confidentiality of participants to the fullest extent possible. All study participants gave written, voluntary informed consent.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003ePatient and public involvement\u003c/strong\u003e \u003cp\u003eNo patients were involved in this research. The voucher-based contraceptive users' participants were recruited not as patients, but as service users and as citizens. Hence, the development of research questions and outcome measures was not informed by the patients\u0026rsquo; priorities, experiences, and preferences. Patients were not involved in the design of the research. Further, this is not clinical research or randomized clinical trial.\u003c/p\u003e \u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eAt MSS study sites, a total of 638 clients were approached, 338 (53.0%) were successfully interviewed. The main reasons for non-response were: household could not be located (225, 35.3%), not at home (47, 15.8%) and migrated (26,8.7%). Similar response rate was found at GSM sites where (324, 57.1%) participants were successfully interview of 567 who were approached. The main reasons for non-response were: household not located (119, 21.0%), not at home (34,6.0%), and a few migrated (10, 1.7%).\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;1 compares the characteristics of study participants (who had used vouchers), between endline and post-endline survey across MSS and GSM voucher programmes. With few exceptions, the characteristics of participants differed between the endline and \u0026lsquo;post-endline\u0026rsquo; survey across both the programmes. However, it is to note that across both MSS and GSM sites, the actual differences were not substantive for characteristics such as age, age at married, mean number of children and mean household members (see Table\u0026nbsp;1).\u003c/p\u003e \u003cp\u003e \u003cb\u003eInsert TABLE 1 here\u003c/b\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e2\u003c/span\u003e presents the comparison of current contraceptive use among voucher recipients between endline and post-endline survey. At MSS sites, of the voucher clients interviewed at endline survey, 90.8% reported to be using any form of contraceptive method, which has significantly reduced to 58.3% at post-endline survey. This decrease was observed primarily in the use of modern methods (from 90.3\u0026ndash;51.8%); interestingly, the use of traditional methods increased from 0.8% in the endline to 5.3% in the post-endline survey. Among modern methods, the highest decline was recorded in the use of IUCD (from 53.6% in the endline study to 13.0% in post-endline), followed by implants (from 7.0\u0026ndash;3.0%); whereas, the use of pill, injectable and condom remained more or less the same. Interestingly, a significant increase was noted in the use of tubal ligation (from 0.8\u0026ndash;5.3%).\u003c/p\u003e \u003cp\u003e\u003cimg src=\"https://myfiles.space/user_files/122228_c8a1650c59388082/122228_custom_files/img1684235597.png\"\u003e\u003c/p\u003e\u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of current contraceptive use between endline and post-endline survey, according to MSS and GSM voucher programmes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"12\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c6\" namest=\"c2\"\u003e \u003cp\u003eMSS \u0026ndash; single purpose voucher\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c12\" namest=\"c8\"\u003e \u003cp\u003eGSM \u0026ndash; multipurpose voucher\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eEndline\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;390\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003ePost-endline\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;338\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003eEndline\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;409\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003ePost-endline\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;324\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c12\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAny method\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e354\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e90.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e197\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e58.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e356\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e87.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e250\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e77.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAny modern method\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e352\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e90.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e175\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e51.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e343\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e83.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e180\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e55.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOral pill\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.664\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e8.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e3.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0.008\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIUCD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e209\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e53.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e13.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e126\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e30.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e30.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0.987\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInjectable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e11.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.668\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e22.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e5.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImplant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.007\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eN/A\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCondom\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e15.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.317\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e19.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e11.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTubal ligation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e2.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e4.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0.160\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAny traditional method\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e2.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e21.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePeriodic abstinence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.062\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e8.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLactational amenorrhea\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.032\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e2.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWithdrawal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e2.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e11.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn contrast, the drop in the proportion of any contraceptive method from endline (87%) to post-endline (77.2%) was comparatively low at GSM sites. This decrease was observed primarily in the use of modern methods (from 83.9\u0026ndash;55.6%); interestingly, we observed a substantive increase in the use of traditional methods from 2.9% in the endline survey to 21.6% in the post-endline survey. Among modern methods, the highest decline was recorded in the use of injectables (from 22.5% in the endline survey to 5.2% in the post-endline survey), followed by condom (from 19.6\u0026ndash;11.1%) and pill (from 8.1\u0026ndash;3.4%).\u003c/p\u003e \u003cp\u003e \u003cb\u003eInsert\u003c/b\u003e Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cb\u003ehere\u003c/b\u003e\u003c/p\u003e \u003cp\u003eAt MSS sites, the provision of information pertinent to contraceptive methods was universal at endline; however, among current users at post-endline, around equal proportion (14%) of the women reported that they were not informed about potential side effects of the method or what to do if they experienced side effects. On the other hand, that provision of information pertinent to contraceptive methods increased significantly from endline to post-endline survey across all three indicators at GSM sites. The provision of information pertinent of contraceptive method was high at MSS and GSM service providers (see supplementary table \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cb\u003eInsert\u003c/b\u003e Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e3\u003c/span\u003e\u003cb\u003ehere\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClients\u0026rsquo; experiences of quality of FP services\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"12\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c6\" namest=\"c2\"\u003e \u003cp\u003eMSS \u0026ndash; single purpose voucher\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c12\" namest=\"c8\"\u003e \u003cp\u003eGSM \u0026ndash; multipurpose voucher\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eEndline\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;351\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003ePost-endline\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;171\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003eEndline\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;309\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e \u003cp\u003ePost-endline\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;179\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c12\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInformed about side effect or problems of method use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e351\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e148\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e86.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e268\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e86.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e177\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e98.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInformed what to do in case of side effects\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e350\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e99.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e148\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e86.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e261\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e84.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e176\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e98.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInformed about range of contraceptive methods\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e351\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e167\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e97.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.004\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e286\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e92.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c10\"\u003e \u003cp\u003e178\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c11\"\u003e \u003cp\u003e99.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c12\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ePost-endline survey revealed that 85% and 77.2% of the voucher clients of MSS and GSM reported to have discontinued the method they had adopted through voucher two years ago during the intervention period, respectively. Reportedly, IUD was the most commonly cited method that was last discontinued in the 24 months across MSS (44.6%) and GSM (52.1%) clients. Pregnancy desire (MSS\u0026thinsp;=\u0026thinsp;29.1%, GSM (25.2%), side effects/fear of health concerns (MSS\u0026thinsp;=\u0026thinsp;22.4%, GSM\u0026thinsp;=\u0026thinsp;40.5%) constituted the most commonly cited reasons for discontinuation among MSS and GSM clients.\u003c/p\u003e \u003cp\u003e \u003cb\u003eInsert\u003c/b\u003e Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e4\u003c/span\u003e\u003cb\u003ehere\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eContraceptive discontinuation within last 2 years (following the closure of voucher programme) and reasons for discontinuation, according to MSS and GSM voucher programmes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eMSS \u0026ndash; single purpose voucher\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eGSM \u0026ndash; multipurpose voucher\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003ePost-endline\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;338\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003ePost-endline\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;324\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClients discontinued the method adopted through voucher\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e275\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e85.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e250\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e77.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMethod discontinued within last 24 months\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003e(n\u0026thinsp;=\u0026thinsp;165)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e\u003cb\u003e(n\u0026thinsp;=\u0026thinsp;234)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOral pill\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e19.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIUD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e122\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e52.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInjectable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e13.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImplant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCondom\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e15.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReasons for discontinuation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003e(n\u0026thinsp;=\u0026thinsp;215)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e\u003cb\u003e(n\u0026thinsp;=\u0026thinsp;369)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePregnancy desire\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e25.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSide effect/Fear of health concerns\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e156\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e40.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOthers (accessibility, inconvenient, God's Will, Husband out of country)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e16.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInfrequent sex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHysterectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHusband opposition\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMethod failure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e5\u003c/span\u003e presents wealth-based inequalities in access to different contraceptive use by endline and post-endline survey for MSS and GSM voucher programmes separately. At MSS sites, around 90% of the poor population used modern methods in the endline survey, while this declined to around 53% in the post-endline survey. Use of all contraceptive methods was concentrated among poorer families in the endline survey, however at post-endline survey there was pro-poor inequality for any method and modern method. The slope index of inequality indicated that in the post-endline survey, use of modern methods among the rich population was around 9 percentage points lower than among the poor population. The relative index of inequality indicates that the wealthiest respondents were 0.84 times less likely to use modern contraceptives compared to the poorest group. Similarly, the concentration index identified that the use of modern contraceptives was concentrated among the poor group in both surveys.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eWealth-based inequalities in contraceptive use in endline and post-endline survey, according to MSS and GSM voucher programmes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eCoverage, (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eInequality assessment\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eConcentration index (x100)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQ1 (Poorest)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQ5 (Richest)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSII (Q5: Q1, % points)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRII (Q5:Q1)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e MSS \u0026ndash; single purpose voucher\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEndline (2015)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModern method user\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e90.2 (83.7\u0026ndash;94.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.9 (-9.0 to 10.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.0 (0.9 to 1.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-2.4 (-4.2 to -0.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTraditional use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.5 (0.38\u0026ndash;5.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-2.3 (-5.8 to 1.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.2 (-0.1 to 0.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-40.6 (-121.2 to 40.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePost-endline (2017)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModern method user\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e52.9 (41.0-64.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46.3 (34.6\u0026ndash;58.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-9.4 (-27.8 to 0.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.8 (0.5 to 1.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-10.0 (-15.8 to -4.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTraditional use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.5 (-4.2 to 13.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.9 (-0.5 to 4.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e15.3 (-10.0 to 40.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGSM \u0026ndash; multipurpose voucher\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEndline (2015)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModern method user\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e97.4 (83.5\u0026ndash;99.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e79.8 (72.0-85.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-15.7 (-27.2 to -4.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.8 (0.7 to 0.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-6.3 (-8.7 to -3.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTraditional use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.3 (0.8-7.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.8 (-5.5 to 4.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.8 (-0.2 to 1.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10.4 (-22.5 to 43.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePost-endline (2017)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModern method user\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e53.8 (41.6\u0026ndash;65.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58.7 (46.1\u0026ndash;70.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10.4 (-8.3 to 29.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.2 (0.8 to 1.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-3.6 (-9.3 to -2.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTraditional use\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.0 (14.3\u0026ndash;35.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20.6 (12.3\u0026ndash;32.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-5.6 (-21.1 to 9.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.8 (0.2 to 1.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-0.3 (-12.4 to 11.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNote\u003c/b\u003e: SII, Slope index of inequality; RII, Relative index inequality; 95% CI, 95% Confidence interval;\u003c/p\u003e \u003cp\u003e* First-time contraceptive use; All equity analysis was adjusted for base and endline survey point.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe endline survey curve indicated that there is no inequality to regarding the use of modern contraceptive methods among poor and rich, however, greater pro-poor inequality was observed in the post-endline survey (see supplementary Fig.\u0026nbsp;1).\u003c/p\u003e \u003cp\u003eWith respect of GSM sites, the use of modern contraceptive methods in the endline survey was higher among the disadvantaged group than the affluent group, but the use of modern contraceptives declined among both groups in the post-endline survey. Pro-poor inequality in the endline survey and pro-rich inequalities were observed for all types of contraceptive user group. The slope index of inequality indicated that the use of modern contraceptive method was about 15-percentage points lower in the wealthiest group in the endline survey than the disadvantaged group. However, in the post-endline survey, the use of modern contraceptives was 10.4 percentage points higher in the wealthiest group than the disadvantaged group. the concentration curve for the use of modern contraceptive in the endline survey was above the line of equality, indicating that modern contraceptives use was more concentrated among the poorest group in the endline survey. In post-endline survey, the concentration curve for modern contraceptive moved far below the line of inequality, indicating pro-rich inequality (see supplementary Fig.\u0026nbsp;2).\u003c/p\u003e \u003cp\u003e \u003cb\u003eInsert\u003c/b\u003e Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e5\u003c/span\u003e\u003cb\u003ehere\u003c/b\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eAttention to the sustainability of health intervention programs is increasing, a development program was considered sustainable when it is able to deliver an appropriate level of benefits for an extended period of time after major financial, managerial and technical assistance from an external donor is terminated\u003ca class=\"FNLink\" href=\"#Fn31\" id=\"#FNLinkFn31\"\u003e\u003c/a\u003e.\u003c/p\u003e \u003cp\u003eThere is dearth of evidence to questions like, what happens to the short-term projects funded by government agencies and foundations to foster local improvement in some aspect of health or health promotion? This paper attempts to answer the issues raised here.\u003c/p\u003e \u003cp\u003eFamily planning vouchers have emerged as a promising approach to improving fertility outcomes\u003csup\u003e14\u003c/sup\u003e. However, no research has attempted to measure the sustainable impact of voucher programmes either in the context of maternal health or family planning.\u003c/p\u003e \u003cp\u003eAfter the closure of voucher intervention for 24 months a considerable decrease was noted in the use of modern contraceptive methods in both MSS (38%) and GSM (26%) study sites. However, our study was unable to capture the exact time of discontinuation; therefore it is possible that these women may have discontinued early after adoption or they may have used the contraceptive method long enough to achieve healthy birth spacing. Previous research from a similar social franchising context in Pakistan showed higher continuation\u003ca class=\"FNLink\" href=\"#Fn32\" id=\"#FNLinkFn32\"\u003e\u003c/a\u003e\u003csup\u003e,\u003c/sup\u003e\u003ca class=\"FNLink\" href=\"#Fn33\" id=\"#FNLinkFn33\"\u003e\u003c/a\u003e\u003csup\u003e,\u003c/sup\u003e\u003ca class=\"FNLink\" href=\"#Fn34\" id=\"#FNLinkFn34\"\u003e\u003c/a\u003e compared with national statistics\u003csup\u003e19\u003c/sup\u003e. As the voucher intervention closed, a substantial rise in traditional methods was observed in both the projects \u0026ndash; particularly among GSM clients (6% points in MSS and 18% points in GSM). This perhaps signifies an increase in awareness and subsequently the demand but few possible factors such as affordability, lack of proper supervision from field health worker can be cited. However, further research is needed to understand the increase in the use of traditional methods following end of intervention.\u003c/p\u003e \u003cp\u003eDespite that huge reduction in the use of modern contraceptive from endline to post-endline in both the projects, however, it was highly encouraging to observe that 34% of the relapsed users in MSS and 29% in GSM sites adopted a modern contraceptive again. This switching proportion is comparatively far higher than the national statistics of 3.4%\u003csup\u003e19\u003c/sup\u003e. Notably, approximately two years after the closure of the voucher programme, the current use of modern contraceptive in both the study sites was higher than the national contraceptive use\u003csup\u003e19\u003c/sup\u003e. Moreover, the use of modern methods at post-endline survey in the MSS project was similar to the proportion observed at endline in the general population (MSS\u0026thinsp;=\u0026thinsp;50%)\u003csup\u003e29\u003c/sup\u003e; whereas in the case of GSM, the post-endline modern contraceptive use was far higher than the endline proportion (GSM\u0026thinsp;=\u0026thinsp;32%)\u003csup\u003e30\u003c/sup\u003e. These results are indicative of an enduring change in the behaviour of communities that occurred as a result of the voucher intervention programme.\u003c/p\u003e \u003cp\u003eAmong MSS voucher clients, the highest decline was observed in IUCD use. In GSM sites, a considerable decrease was observed in the use of short-acting methods. This discontinuation could have been prevented through engagement of LHWs who are responsible for door-to-door visits for counselling and provision of short-acting methods. It is therefore imperative that for any new initiative, programmatic synergies should be explored with existing system, and where possible, health system linkages should be established accordingly.\u003c/p\u003e \u003cp\u003eAmong those exposed to voucher program, about half of the contraceptive users in GSM and one-third in MSS adopted the new method from service providers and 25% of the respondent cited MSS/GSM project field worker as the source of the referrals. These findings not only reinforce the importance of demand generation through outreach workers; but at the same time it signifies provision of quality services that establishes a long-term relationship between service providers and the clients.\u003c/p\u003e \u003cp\u003eWith respect to service quality, in MSS we observed a significant decrease of clients being informed about potential side effects and follow up comparing endline to post-endline survey. This could be that the quality of service provision got comprised in the absence of clinical supervision and monitoring as it was during voucher intervention. On the contrary, a significant increase was observed in the GSM site where provision of this information was nearly universal, irrespective of the source of method. Overall, these results are still better than national estimates where only one-third of the clients are provided with such information\u003csup\u003e19\u003c/sup\u003e. This increase in informed choice may be attributed to the fact that service providers have actually realised the importance of quality counselling and hence have been able to maintain the standard.\u003c/p\u003e \u003cp\u003eHealth equity analysis showed mixed results for MSS and GSM voucher clients. In GSM at the endline survey, the use of modern contraceptives was higher in the poorer group compared to the wealthiest, which reversed in the post-endline survey where use was higher in the wealthiest group. These findings reinforce the importance of a voucher programme in terms of reducing inequalities in the use of contraceptive methods between rich and poor populations. On the other hand, in MSS study sites, the use was higher in poorer segments of the population than in the wealthiest segments at post-endline. A possible explanation could be that MSS service providers were primarily based in rural areas it is common practice to maintain good rapport with the clients. In addition, the use of free voucher may have changed the behaviour of users in the intervention catchment suggesting ex-voucher user either continuing to use the same method or adopted a new method by paying out-of-pocket. However, this merits further investigation for better understanding.\u003c/p\u003e \u003cp\u003eSide effects were cited as the most common reasons for discontinuation among GSM clients (41%) whereas this was the second most common reason among MSS clients (22%). In both the projects, side effects as the reason for discontinuation increased from endline to post-endline survey, highlighting lack of supportive structure that was during intervention. Moreover, high IUCD expulsion rate (9% in GSM and 5% in MSS) was also documented in our study. These findings suggest the need for better counselling of clients, follow-up support for side effect management\u003csup\u003e35\u003c/sup\u003e and enhancement of provider skills (on IUCD) in procedures. Keeping in view of women\u0026rsquo;s restricted mobility in Pakistan, technological solutions could be considered in the communities such as helpline services where women could call and get information regarding side effect management\u003csup\u003e35\u003c/sup\u003e.\u003c/p\u003e"},{"header":"Limitations","content":"\u003cp\u003eThere are some limitations in our study. There is possibility of recall problem in answering questions about their past experiences with service providers such as information of method at the time of uptake, last method discontinued etc; matched pre-post design whereby interviewing same voucher clients would have accounted for the differences in sample characteristics and other unobserved confounders. This was minimized as information on personal identifiers was discarded by the implementing organisations (MSS and GSM); locating households with the support on field teams who are involved in the distribution of vouchers may have introduced a selection bias as they could recall and take data collectors to those household where they have good relationship with women \u0026ndash; and this may have skewed the responses positively in favour of the intervention; finally, as contraceptive calendar approach was not used, the study is unable to capture and report exact time of method discontinuation.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eUnderstanding sustainability of interventions is important in forming a baseline for promoting effective practices that yield desired health outcomes over longer period\u003ca class=\"FNLink\" href=\"#Fn35\" id=\"#FNLinkFn35\"\u003e\u003c/a\u003e.\u003c/p\u003e \u003cp\u003ePresent evidence suggests that vouchers can contribute to the agenda of equitable access in universal health coverage by addressing its three core aspects: 1) Increase access to the poor and vulnerable; 2) Increase the number of services by adding contraceptives to the existing method mix, and 3) provides financial protection by being inclusive and reaching out to the underserved. This study also indicates that vouchers can bring about an enduring positive change in behaviours regarding the use of modern contraceptive methods among poor populations. However, method discontinuation as a result of side effects seems to be a common practice that should be dealt with properly through improved counselling and active follow-up. The findings of this study will provide information to policymakers to plan services to support and sustain positive health behaviour among the population when donor funding goes dry.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAuthors are highly indebted to all the enumerators, field workers; and above all, to the study participants for their time and for enriching this study by sharing their experiences.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eFunding: \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe research project was funded by The David and Lucile Packard Foundation (Grant ID-64569), this evaluation is conducted independently by the Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva. There was no role of the funding organization in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript. Availability of data and materials The data will be available upon request as per the WHO policies.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Requests for access to data can be sent to [email protected]\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eAuthors contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis evaluation was conceptualized and conducted by MA, SKA, MR independently, without any consultation with the project implementing organization. MA, SKA, MR developed the first and final drafts of the manuscript and provided intellectual contribution to the final draft of the manuscript. All authors have read and approved the manuscript, and ensure that this is the final version.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll respondents were informed about survey and their rights. No personal information was entered in the database that could be used to identify specific individual. The study protocol was approved by National Bioethics Committee (NBC) Pakistan. Ref: No. 4\u0026ndash;87/12/NBC-92/RDC/3548 All survey participants provided a written informed consent to participate in the survey. This study does not fall within the International Committee of Medical Journal Editors (ICMJE)\u0026rsquo; definition of a clinical trial.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eConsent for publication Not Applicable.\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eCompeting interests:\u003c/strong\u003e The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eDisclaimer:\u003c/strong\u003e 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.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMoore JE, Mascarenhas A, Bain J, and Straus SE, \u0026ldquo;Developing a comprehensive definition of sustainability,\u0026rdquo; Implement. Sci., vol. 12, no. 1, pp. 1\u0026ndash;8, 2017, doi: 10.1186/s13012-017-0637-1.\u003c/li\u003e\n\u003cli\u003eWalugembe DR, Sibbald S, Le Ber MJ, and Kothari A, \u0026ldquo;Sustainability of public health interventions: Where are the gaps?,\u0026rdquo; Heal. Res. Policy Syst., vol. 17, no. 1, pp. 1\u0026ndash;7, 2019, doi: 10.1186/s12961-018-0405-y.\u003c/li\u003e\n\u003cli\u003eHerkama S, Kontio M, Sainio M, Turunen T, Poskiparta E, and Salmivalli C, \u0026ldquo;Facilitators and Barriers to the Sustainability of a School-Based Bullying Prevention Program,\u0026rdquo; Prev. Sci., vol. 23, pp. 954\u0026ndash;968, 2022, doi: 10.1007/s11121-022-01368-2\u003c/li\u003e\n\u003cli\u003eKhalil K and Kynoch K, \u0026ldquo;Implementation of sustainable complex interventions in health care services: the triple C model,\u0026rdquo; BMC Health Serv. Res., vol. 21, no. 1, pp. 1\u0026ndash;10, 2021, doi: 10.1186/s12913-021-06115-x\u003c/li\u003e\n\u003cli\u003eMendelson A et al., \u0026ldquo;The effects of pay-for-performance programs on health, health care use, and processes of care: A systematic review,\u0026rdquo; Ann. Intern. Med., vol. 166, no. 5, pp. 341\u0026ndash;353, 2017, doi: 10.7326/M16-1881.\u003c/li\u003e\n\u003cli\u003eCleland J, Bernstein S, Ezeh A, Faundes A, Glasier A, Innis J. Family planning: the unfinished agenda. Lancet. 2006;368(9549):1810\u0026ndash;27. 10.1016/S0140-6736(06)69480-4 \u003c/li\u003e\n\u003cli\u003eAhmed S, Li Q, Liu L, Tsui AO. Maternal deaths averted by contraceptive use: an analysis of 172 countries. \u003cem\u003eLancet\u003c/em\u003e. 2012;380(9837):111\u0026ndash;25. 10.1016/s0140-6736(12)60478-4\u003c/li\u003e\n\u003cli\u003eKantorova V, Wheldon MC, Ueffing P, Dasgupta ANZ. Estimating progress towards meeting women\u0026apos;s contraceptive needs in 185 countries: A Bayesian hierarchical modelling study. PLoS Medicine. 2020;17: e1003026.\u003c/li\u003e\n\u003cli\u003eRoss J. Improved Reproductive Health Equity Between the Poor and the Rich: An Analysis of Trends in 46 Low- and Middle-Income Countries. \u003cem\u003eGLOB HEALTH SCI PRACT\u003c/em\u003e 2015 Sep 10;3(3):419-45.\u003c/li\u003e\n\u003cli\u003eUnited Nations Population Division: www.population.un.org/dataportal/home (accessed on April 16, 2023).\u003c/li\u003e\n\u003cli\u003eMwaikambo L, Speizer IS, Schurmann A, Morgan G, Fikree F. What works in family planning interventions: a systematic review. \u003cem\u003eStud Fam Plann\u003c/em\u003e 2011 Jun;42(2):67-82.\u003c/li\u003e\n\u003cli\u003eMurray S, Hunter B, Bisht R, Ensor T, Bick D. Effects of demand-side financing on utilisation, experiences and outcomes of maternity care in low- and middle-income countries: a systematic review. BMC Pregnancy and Childbirth. 2014;14: 30.\u003c/li\u003e\n\u003cli\u003eBellows B, Bulaya C, Inambwae S, Lissner CL, Ali M, Bajracharya A. Family Planning Vouchers in Low and Middle Income Countries: A Systematic Review. \u003cem\u003eStud Fam Plann\u003c/em\u003e 2016 Nov 1;47(4):357-70.\u003c/li\u003e\n\u003cli\u003eHigh Impact Practices in Family Planning (HIP). Family planning vouchers: a tool to boost contraceptive method access and choice. 2020.\u003c/li\u003e\n\u003cli\u003eUnited Nations Population Fund (UNFPA)., Pathfinder International. The State of Family Planning in Pakistan: Targeting the Missing Links to Achieve Development Goals. Islamabad: UNFPA, Pathfinder International; 2013 Jun\u003c/li\u003e\n\u003cli\u003eNational Institute of Population Studies Pakistan, Macro International Inc. Pakistan Demographic and Health Survey 2006-7. 2008.\u003c/li\u003e\n\u003cli\u003eNational Institute of Population Studies Pakistan, Macro International Inc. Pakistan Demographic and Health Survey 2012-13. 2014.\u003c/li\u003e\n\u003cli\u003eNational Institute of Population Studies (NIPS) [Pakistan] and ICF. Pakistan Demographic and Health Survey 2017-18. 2018.\u003c/li\u003e\n\u003cli\u003eKhan A, Shaikh BT. An all time low utilization of intrauterine contraceptive device as a birth spacing method- a qualitative descriptive study in district Rawalpindi, Pakistan. \u003cem\u003eReprod Health\u003c/em\u003e 2013;10(1):10.\u003c/li\u003e\n\u003cli\u003eCasterline JB, Sathar ZA, Haque Mu. Obstacles to Contraceptive Use in Pakistan: A Study in Punjab. \u003cem\u003eStud Fam Plann\u003c/em\u003e 2001 Jun 1;32(2):95-110.\u003c/li\u003e\n\u003cli\u003eAgha S. Changes in the proportion of facility-based deliveries and related maternal health services among the poor in rural Jhang, Pakistan: results from a demand-side financing intervention. \u003cem\u003eInternational Journal for Equity in Health\u003c/em\u003e 2011;10(1):57.\u003c/li\u003e\n\u003cli\u003eAzmat SK, Shaikh BT, Hameed W, Mustafa G, Hussain W, Asghar J, et al. Impact of Social Franchising on Contraceptive Use When Complemented by Vouchers: A Quasi-Experimental Study in Rural Pakistan. \u003cem\u003ePLoS ONE\u003c/em\u003e 2013 Sep 12;8(9):e74260.\u003c/li\u003e\n\u003cli\u003eAzmat SK, Hameed W, Hamza HB, Mustafa G, Ishaque M, Abbas G, et al. Engaging with community-based public and private mid-level providers for promoting the use of modern contraceptive methods in rural Pakistan: results from two innovative birth spacing interventions. \u003cem\u003eReprod Health\u003c/em\u003e 2016 Mar;13(1):1-15.\u003c/li\u003e\n\u003cli\u003eMehboob G, Shaikh BT. Experience Of Vouchers For Reproductive Health Services In Developing Countries: Making A Case For Pakistan Through A Systematic Review. \u003cem\u003eJ Ayub Med Coll Abbottabad\u003c/em\u003e 2015;27(3):695-701.\u003c/li\u003e\n\u003cli\u003eBroughton EI, Hameed W, Gul X, Sarfraz S, Baig IY, Villanueva M. Cost-Effectiveness of a Family Planning Voucher Program in Rural Pakistan. \u003cem\u003eFrontiers in Public Health\u003c/em\u003e 2017 Sep 22;5:227.\u003c/li\u003e\n\u003cli\u003eAli M, Azmat SK, Hamza HB, Rahman MM, Hameed W. Are family planning vouchers effective in increasing use, improving equity and reaching the underserved? An evaluation of a voucher program in Pakistan. BMC Health Services Research. 2019;19: 200.\u003c/li\u003e\n\u003cli\u003eAli M, Azmat SK, Hamza HB, Rahman MM. Assessing Effectiveness of Multipurpose Voucher Scheme to Enhance Contraceptive Choices, Equity, and Child Immunization Coverage: Results of an Interventional Study from Pakistan. J Multidiscip Healthc. 2020;13: 1061-1074.\u003c/li\u003e\n\u003cli\u003eAli M, Azmat SK, Hamza HB. Assessment of modern contraceptives continuation, switching and discontinuation among clients in Pakistan: study protocol of 24-months post family planning voucher intervention follow up. BMC Health Serv Res. 2018 May 11;18(1):359. doi: 10.1186/s12913-018-3156-0. PMID: 29751807; PMCID: PMC5948711.\u003c/li\u003e\n\u003cli\u003eAzmat SK, Ali M, Hameed W, Mustafa G, Abbas G, Ishaque M, Bilgrami M, Temmerman M. A study protocol: using demand-side financing to meet the birth spacing needs of the underserved in Punjab Province in Pakistan. Reprod Health. 2014;11: 39.\u003c/li\u003e\n\u003cli\u003eRutstein SO, Johnson K. DHS Comparative Reports 6: The DHS Wealth Index. Calverton, Maryland: ORC Macro; 2004 Jul.\u003c/li\u003e\n\u003cli\u003eUS Agency for International Development (1988) Sustainability of Development Programs: A Compendium of Donor Experience. USAID, Washington, DC.\u003c/li\u003e\n\u003cli\u003eHameed W, Azmat SK, Ali M, Ishaque M, Abbas G, Munroe E, et al. Comparing Effectiveness of Active and Passive Client Follow-Up Approaches in Sustaining the Continued Use of Long Acting Reversible Contraceptives (LARC) in Rural Punjab: A Multicentre, Non-Inferiority Trial. \u003cem\u003ePLoS ONE\u003c/em\u003e 2016 Sep 1;11(9):e0160683.\u003c/li\u003e\n\u003cli\u003eAzmat S, Shaikh B, Hameed W, Bilgrami M, Mustafa G, Ali M, et al. Rates of IUCD discontinuation and its associated factors among the clients of a social franchising network in Pakistan. \u003cem\u003eBMC Women\u0026apos;s Health\u003c/em\u003e 2012;12(1):8.\u003c/li\u003e\n\u003cli\u003eHameed W, Azmat S, Ishaque M, Hussain W, Munroe E, Mustafa G, et al. Continuation rates and reasons for discontinuation of intra-uterine device in three provinces of Pakistan: results of a 24-month prospective client follow-up. \u003cem\u003eHealth Research Policy and Systems\u003c/em\u003e 2015;13(Suppl 1):S53.\u003c/li\u003e\n\u003cli\u003eStirman SW, Kimberly J, Cook N, Calloway A, Castro F, and Charns M, \u0026ldquo;The sustainability of new programs and innovations: A review of the empirical literature and recommendations for future research,\u0026rdquo; Implement. Sci., vol. 7, no. 1, p. 17, 2012, doi: 10.1186/1748-5908-7-17.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"contraception-and-reproductive-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"carm","sideBox":"Learn more about [Contraception and Reproductive Medicine](http://contraceptionmedicine.biomedcentral.com)","snPcode":"40834","submissionUrl":"https://submission.nature.com/new-submission/40834/3","title":"Contraception and Reproductive Medicine","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-2920150/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2920150/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFamily planning vouchers have emerged as a promising approach to improve coverage of underserved groups or underutilized services. The current study was designed to measure the residual/longer term impact of FP voucher programs on the practices of women beyond the life of the programme.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA cross-sectional survey conducted, as part of the larger mixed-method study, approximately 24 months after the close-down of Marie Stopes Society and Greenstar Social Marketing family planning voucher intervention programmes in Punjab, Pakistan. Following necessary ethics approvals, a total of 338 voucher MSS clients \u0026amp; 324 voucher GSM clients were interviewed using a structured questionnaire at the household level.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCompared with end-line data, a significant decrease in the modern contraceptive uptake in both MSS (90% at endline to current (\u003cem\u003eor post-endline\u003c/em\u003e) 52%) and GSM (from 84% to current 56%) intervention sites among the voucher clients was noted. Among MSS voucher clients, the highest decline in use was observed in IUCD (54% at endline versus to current 13%); however no change between the surveys was noted among GSM clients. In both projects, following closure of voucher intervention 34% of the discontinued users in MSS and 29% in GSM sites adopted/switched to a new modern contraceptive again. In the post-intervention survey, wealth-based inequality in GSM data depicts more pro-rich utility for modern methods, indicating pro-rich inequality, in contrast, the post-intervention survey in MSS found mixed results such as pro-poor inequality for any method and modern method use.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe prevalence for contraception in study sites, following closure of voucher intervention remained high than national average. This study provides evidence that family planning vouchers can bring about an enduring positive change in clients’ behaviours in using modern contraceptive methods among poor populations. These results are useful to design family planning programs that will sustain when the donor funding terminates.\u003c/p\u003e","manuscriptTitle":"Assessing the sustainability of single versus multiple voucher-based family programs in Pakistan: a 24-months post-intervention evaluation","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-05-16 11:17:30","doi":"10.21203/rs.3.rs-2920150/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2023-06-12T13:48:14+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2023-05-31T18:10:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"1074e2d1-461b-4176-b392-7d124a510baa","date":"2023-05-18T06:19:30+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2023-05-17T11:05:33+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2023-05-13T03:04:22+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2023-05-13T03:04:22+00:00","index":"","fulltext":""},{"type":"submitted","content":"Contraception and Reproductive Medicine","date":"2023-05-11T12:36:58+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"contraception-and-reproductive-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"carm","sideBox":"Learn more about [Contraception and Reproductive Medicine](http://contraceptionmedicine.biomedcentral.com)","snPcode":"40834","submissionUrl":"https://submission.nature.com/new-submission/40834/3","title":"Contraception and Reproductive Medicine","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b8e2eda3-92d7-4bef-b892-c5a11bdb8b94","owner":[],"postedDate":"May 16th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2023-09-07T15:03:32+00:00","versionOfRecord":{"articleIdentity":"rs-2920150","link":"https://doi.org/10.1186/s40834-023-00244-w","journal":{"identity":"contraception-and-reproductive-medicine","isVorOnly":false,"title":"Contraception and Reproductive Medicine"},"publishedOn":"2023-08-22 15:01:06","publishedOnDateReadable":"August 22nd, 2023"},"versionCreatedAt":"2023-05-16 11:17:30","video":"","vorDoi":"10.1186/s40834-023-00244-w","vorDoiUrl":"https://doi.org/10.1186/s40834-023-00244-w","workflowStages":[]},"version":"v1","identity":"rs-2920150","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2920150","identity":"rs-2920150","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}