Mobilizing male opinion leaders' support for family planning to improve maternal health: a theory-based qualitative study from Pakistan

Syed Khurram AzmatTechnical Services and Research and Metrics, Marie Stopes Society, Karachi, Sindh, PakistanPurpose: Pakistan is a patriarchal society in which male opinion leaders play an important role in determining health-seeking behaviors pertaining to family planning (FP) among their respective communities. This research focuses on cataloguing the perceptions of opinion leaders (clergymen, health professionals, and social workers) about the barriers for using services and practical solutions for promoting FP in the slums of Karachi, Pakistan.Materials and methods: A qualitative study using an open-ended, semistructured interview schedule with hypothetical scenarios and in-depth interviews with a purposive sample of 45 opinion leaders (25 mosque imams/clergymen, 12 nonallopathic health professionals, and eight social workers/activists) was conducted in 2006–2007 in Karachi, Pakistan. Transcripts were coded thematically utilizing NVivo by using an adapted constant comparison analysis process as described by Strauss and Corbin.Results: Seven key themes were derived from the in-depth interviews. Five themes provide insight into the opinion leaders' perceptions of barriers to FP and modern contraception methods. Among the barriers religious taboos and cultural pressures were particularly noteworthy. Two themes offered opportunities for more effective development and implementation of FP programs.Conclusion: It is evident from the study that opinion leaders in the community and the clergy lack the understanding of the importance of birth spacing. However, because they have a great deal of influence on the community at large, it is imperative to interact with them to build their capacity in order to propagate the messages of FP and improve maternal health and reproductive health in general.Keywords: religious leaders/community imams/clergyman, health professionals, social worker

The logistics of voucher management: the underreported component in family planning voucher discussions

Moazzam Ali,1 Madeline Farron,2 Syed Khurram Azmat,3,4 Waqas Hameed5 1Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland; 2School of Public Health, University of Michigan, Ann Arbor, MI, USA; 3Department of Uro-Gynecology, University of Ghent, Ghent, Belgium; 4Department of Health Information Systems, Hospital for Sick Children, Toronto, ON, Canada; 5Research, Monitoring and Evaluation Department, Technical Services, Marie Stopes Society, Karachi, Sindh, Pakistan Background: The purpose of health care vouchers or coupons is to receive a health service in exchange which is fully or partially subsidized, such as any treatment offered for communicable disease; for immunization; antenatal care-/postnatal care-related maternal health services; a family planning (FP) service; or to get a health commodity like a medicine. Vouchers are targeted for a group of people who can benefit the most such as on the basis of poverty ranking, marginalized or living in rural areas. According to the World Health Organization, voucher schemes in the area of sexual and reproductive health are considered of high value if they are implemented to address the issues of contraceptive commodity or service unavailability or to address the barriers to access such services through contracting out health services, for example, through social franchising (SF). FP vouchers can substantially expand contraceptive access and choice and empower the underserved populations. Literature cites voucher’s effectiveness in better targeting, increasing use, and improving program outcomes in FP programs; however, there is little research or explanation of how voucher management is done in practice.Discussion: The paper attempts to describe various components of voucher management system and its functioning using example of a voucher program in Pakistan. There are challenges such as high upfront cost, targeting the appropriate clients, validation of vouchers, and quality assurance, but these can be managed with better preparation at the planning and design stage. Strong monitoring and evaluation are integral to successful implementation of the voucher program. Also, voucher interventions that are targeted and adopt a pro-poor strategy have been found to improve access to care within poor and marginalized populations. Such programs have the capacity to bridge health inequities in developing nations. Targeted voucher schemes such as those which are designed as pro-poor or pro-rural are known to reduce barriers to access for those living with poverty or for the ones considered as marginalized population. Hence, such interventions have the capacity to fulfill the gaps in health inequities, especially, in low- and/or middle-income countries.Conclusion: Voucher programs should report the voucher logistics and management to build a larger evidence base of best practices. All voucher schemes must be designed, implemented, and evaluated on the basis of set objectives through addressing the local context. But any voucher implementing organization also conducting the in-house voucher management simultaneously may be considered as a weakness in program design, in turn providing rationale for either failure or success of that particular voucher intervention. Therefore, separating implementation and management of a voucher initiative can lead to enhanced transparency, improved accountability, allow for independent validation of services, and facilitate compliance for payments. Keywords: voucher management, contraception, validation, Pakista