By Moazzam Ali, Regional Manager for Asia and Pacific Regions at the Department of Reproductive Health and Research, World Health Organization, and Jean José Nzau Mvuezolo, Senior Regional Advisor/SAF PAC Initiative, CARE USA 

What keeps women from accessing family planning services? In Pakistan, as in many low-income countries, one of the obstacles is cost.

Pakistan’s state-run health program is intended to ensure that everyone has access to free or low-cost healthcare, including family planning. But the system is overburdened, leaving millions of people to seek services and supplies in the private sector instead. Steep out-of-pocket costs can mean that poor women are simply priced out of care.

The concept of demand-side financing offers a promising solution. Demand-side financing puts purchasing power directly in the hands of individuals, usually in the form of vouchers that can be redeemed with private health care providers.

In Pakistan, the Packard Foundation is underwriting voucher programs with the Marie Stopes Society and Greenstar Social Marketing, both of which run private networks of reproductive health care providers. The Marie Stopes vouchers entitle women to free family planning services, while the Greenstar program offers reduced-cost vouchers for family planning combined with postnatal care and childhood immunizations. Both approaches are helping to make high-quality health care accessible to disadvantaged populations.

Accessibility is a key concept in rights-based healthcare. According to the World Health Organization, “the fulfillment of human rights obligations requires that health commodities, including contraceptives, be physically accessible and affordable for all” (Ensuring Human Rights in the Provision of Contraceptive Information and Services: Guidance and Recommendations, WHO, 2014).

This is echoed by Family Planning 2020’s Rights & Empowerment Principles for Family Planning, which lists accessibility among the core principles for rights-based reproductive healthcare:

Accessibility: Health care facilities, trained providers and contraceptive methods are accessible—without discrimination, and without physical, economic, socio-cultural or informational barriers.

But as this definition suggests, cost isn’t the only obstacle women face. Sometimes even the most well-intentioned of government policies can be the greatest barrier to access.

In Chad, 78 percent of the population is rural. Many women and girls get their family planning services from nurses and midwives at the district level. The closest functional health center is frequently two hours or more away by foot.

In order to ensure the provision of high quality services to women in Chad, in 2012 the Ministry of Health issued national standards for reproductive health care. Unfortunately those standards made it so that only doctors—who are few in number, overwhelmingly male, and concentrated in urban areas—were authorized to insert and remove contraceptive implants and intrauterine devices. The standards also restricted these services to hospitals, which are far less common than health centers.

CARE (Cooperative for Assistance and Relief Everywhere) Chad recognized that the new rules, while designed to ensure that women would receive services only from highly-trained providers, would in reality make family planning inaccessible for many women and girls.

CARE had already successfully trained nurses and midwives at health centers to provide contraceptive implants and IUDs. CARE worked closely with the government of Chad to show that these mid-level providers could, in fact, provide high quality services, and that implants and IUDs did not have to be restricted to hospitals.

By demonstrating that decentralized service delivery would make it easier for women to obtain the contraceptive method of their choice, CARE and its partners—including the World Health Organization (WHO) and the United Nations Population Fund (UNFPA)— helped convince the Chadian government to change its policy. The Ministry of Health issued new guidelines in January 2014, lifting the previous restrictions and making the full range of family planning options accessible at the local level.