Delivering reproductive health services through non-state providers in Pakistan:understanding the value for money of different approaches

Background:Delivering Reproductive Health Results(DRHR)programme used social franchising(SF)and social marketing(SM)approaches to increase the supply of high quality family planning services in underserved areas of Pakistan.We assessed the costs,cost-efficiency and cost-effectiveness of DRHR to understand the value for money of these approaches.Methods:Financial and economic programme costs were calculated.Costs to individual users were captured in a pre-post survey.The cost per couple years of protection(CYP)and cost per new user were estimated as indicators of cost efficiency.For the cost-effectiveness analysis we estimated the cost per clinical outcome averted and the cost per disability-adjusted life year(DALY)averted.Results:Approximately£20 million were spent through the DRHR programme between July 2012 and September 2015 on commodities and services representing nearly four million CYPs.Based on programme data,the cumulative cost-efficiency of the entire DRHR programme was£4.8 per CYP.DRHR activities would avert one DALY at the cost of£20.Financial access indicators generally improved in programme areas,but the magnitude of progress varies across indicators.Conclusions:The SF and SM approaches adopted in DRHR appear to be cost effective relative to comparable reproductive health programmes.This paper adds to the limited evidence on the cost-effectiveness of different models of reproductive health care provision in low-and middle-income settings.Further studies are needed to nuance the understanding of the determinants of impact and value for money of SF and SM.