Increasing FP access for young people through the private sector: Youth vouchers in Madagascar Lalaina Razafinirinasoa Country Director, Marie Stopes Madagascar

Why a youth voucher? Young people often express preference for seeking FP from the private sector But proportion of clients under 20 remains low in MSI franchises Learning that supply-side interventions such as youth- friendly franchisee training have more lasting results when matched with demand-side component such as vouchers Marie Stopes International

Madagascar: country context Population: 22 million 92% live on < $2/day 64% of the population are < 25 years old 48% of girls are married by 18 32% of 15-19 year olds have children 27% have an unmet need for FP Marie Stopes International

Marie Stopes Madagascar Provides FP across all 22 regions of Madagascar, including 80% of LARC/PM services countrywide Reached 800,000 clients in 2014 through mobile outreach, clinics, mobile midwives, and BlueStar social franchise network Implements poverty voucher linked to BlueStar, using m-health for voucher claims, reporting and reimbursements Marie Stopes International

How does the voucher program work? BlueStar Network of 150 private providers, supported by MSM; previously only providing short term FP methods, now also providing LARCs Vouchers sold by Community Health Educators (cost client USD $0.10) to poor women; BlueStar providers then reimbursed per service Reporting and reimbursements via mobile money - fast and cost-effective Over 100,000 women have used FP vouchers (Oct11- Sep14), the majority choosing voluntary LARCs Marie Stopes International

Youth voucher program: design & development Only 12% of franchisee clients were 15-19 Cost barrier for young people to access quality SRH services Opportunity to deliver vouchers via SMS MSM experienced in voucher programs Rationale Training CHEs and franchisees in youth friendly services Adapted existing voucher management software Preparation Launch of the youth voucher for FP and STI services for 15-19 year olds distributed by Community Health Educators (CHEs) and available for redemption at BlueStar franchisees Launch Marie Stopes International

Service package covered by the voucher FP counselling Provision of short term FP methods Provision of LARCs (3 year implant, 10 year IUD) STI screening and counselling Removal of LARCs A young person can obtain a combination of services under one voucher, eg. an FP method and STI counselling Marie Stopes International

Youth voucher distribution: step by step MSM Field Coordinator distributes vouchers to CHE Young person identified by a CHE at community level SMS sent to MSM server by the CHE Young person receives voucher code via SMS to their phone or on paper from the CHE's phone Young person redeems the voucher at a BlueStar franchisee Marie Stopes International

Voucher reimbursements to BlueStar providers Franchisee sends voucher claim to MSM server Server validates that the voucher code matches the code of voucher distributed Daily report of voucher claims generated and sent to Voucher Manager Voucher Manager groups franchisees claims together Reimbursements sent via mobile money to franchisees Set reimbursement rates for each service, or combination of services Marie Stopes International

58,417 vouchers were distributed Results (July 2013-Dec 2014): 58,417 vouchers were distributed 43,352 young people used vouchers to take up a service 78% chose to take a voluntary LARC 51% had STI counselling

Results by service Marie Stopes International

Who are the voucher clients?

69% had never previously used a method of family planning July 2015 snapshot client profile data: 69% had never previously used a method of family planning 96% of clients were aged 20 or younger 47% had one or more children

Lesson learned from the pilot: evolving the voucher format to include a paper voucher E-vouchers were not being frequently used due to: a high number of young people interested in receiving a service but who did not own a mobile phone Reluctance to provide mobile number due to the sensitive nature of the SMS content New distribution strategy was established: Paper-based voucher distributed at community level E-vouchers via MSM’s Call Center (toll-free number) Marie Stopes International

Monitoring & Evaluation Real-time monitoring of the voucher program through daily tracking of voucher codes distributed and redeemed, and reimbursement claims Verification of validity of voucher claims: CHE level Client level Franchisee level Marie Stopes International

Feedback from franchisees Youth-friendly training helped equip them to provide confidential, non-judgemental information and services Increased youth client load improved provider confidence and willingness to provide services, including voluntary LARCs, to young people Marie Stopes International

Conclusion Results demonstrate that vouchers can be an effective tool to reach adolescents at scale, provide them with FP choice, and leverage existing private health infrastructure When young people have the choice, many of them choose LARCs Holistic demand and supply side intervention key to success E-voucher not appropriate in all contexts MSM continuing to scale up program - anticipates reaching 50,000 young people in 2015 Marie Stopes International

Thank you! Marie Stopes International