Informal and out-of-pocket payments for public-sector contraceptive care in remote Madagascar.

Abstract

Objectives: Informal payments at public facilities can undermine contraceptive access, yet little is known about how often women pay out of pocket (OOP) for family planning-or how much.

Study design: We conducted a descriptive analysis using data collected in 2023 from Alaotra Mangoro, Atsinanana, and Vatovavy Fitovinany in Madagascar. We triangulated: (1) a population-based survey of women aged 15-49 [n = 1199]; analytic subsample: current modern method users who obtained methods in the prior 12 months from public facilities [n = 219] or community health workers (CHWs) [n = 91]; (2) client exit interviews with women seeking contraception at public facilities [n = 118]; (3) CHWs interviews on typical charges [n = 214]; and (4) 107 facility audits. Outcomes were any OOP payment and the amount paid. Population-survey respondents were also asked if any payment was "unofficial."

Results: Among facility-sourced users in the population survey, 86% reported paying OOP (median USD 0.56; range 0-1.8). Amounts varied by method (higher for implants, lower for pills). Among CHW-sourced users, 99% paid with amounts broadly similar to facilities overall. In client exit interviews, 53% of clients reported paying, with amounts also lower (median USD 0.11). About 40% of facility-sourced users perceived their payment as unofficial; reports of "unofficial" payments were lower among CHW users.

Conclusions: Informal payments for contraception appear common and non-trivial in remote Madagascar, despite free-of-charge contraception policy in public-sector facilities. Program responses could include transparent fee charters, strengthened supervision and grievance mechanisms, and routine monitoring of OOP payments across facilities to safeguard contraceptive autonomy.

Implications: Informal and out-of-pocket payments create significant financial barriers to family planning, even under free-of-charge contraception policies in public-sector facilities. To ensure equitable access and support contraceptive autonomy, policy efforts should prioritize accountability mechanisms, including standardized fee disclosure, routine verification of client payments, and rigorous supervision of community-level service delivery.