Background: As of 2013, Ethiopia had an HIV prevalence rate of around 1.3% with around 760,000 million people living with HIV in the country (UNICEF, 2013). The HIV/AIDS Prevention and Control Office (FHAPCO) in Ethiopia claimed that adult HIV prevalence level had fallen from 2.1% in 2011 to 1.3% in 2013 due to a strong push on procurement of HIV-related supplies, procedures of quality assurances and policy on HIV prevention, treatment, care and support (HAPCO, 2013).
Ethiopian women tend to marry young, with more than half of women bearing children by the age of 20. Many Ethiopian women continue to have very limited access to and choice of modern contraceptives. The unmet need for family planning in Ethiopia is highest among women aged between 15 and 19 years old (MSIE, 2012). The Ethiopian government has set an agenda to increase the uptake of reproductive health and family planning services across the country. The following case study shows the potential of an SMS-based eVoucher programme to provide linkages to contraceptive services, but also other services aimed at HIV prevention such as free condom provision, voluntary testing and counselling on HIV, and STI screening and treatment.
Marie Stopes International (MSI) has been providing subsidised vouchers to low-income or high-risk individuals who are not using reproductive health or family planning services. Eligible clients can present the voucher they have received at selected health facilities in order to receive free or discounted sexual and reproductive health services, including contraceptives, HIV testing and counselling etc. The eVoucher program is also used as a linkage to other services, including the MSI helpline which is used to access information on sexual and reproductive health.
The voucher programme was implemented to empower clients to increase their use of health services and address the high unmet need for sexual and reproductive health services in the country. Traditionally, voucher programmes use paper vouchers, which can present some challenges such as loss of vouchers or high implementation of designing, printing, storing and dispatching the vouchers.
In August 2012, MSI Ethiopia launched a four year subsidised voucher programme aimed at young people between 15 and 29 years old, particularly those in poor and marginalised communities. With funding from the Dutch government, the programme focused on the Ethiopian government’s reproductive health and family planning targets of increasing young people’s access to and choice of contraceptive methods. As part of the programme, MSI Ethhiopia piloted eVouchers to replace traditional paper vouchers.
The goal of the program was to make it easier for young people to redeem the vouchers, to reduce the ongoing costs of implementing a voucher programme, and to simplify the monitoring process.
The eVoucher program was piloted in five towns in Ethiopia – Assela, Nekemte, Debre Markos, Shashemene and Dessie – for 18 weeks. In each town, community health workers were trained by MSI Ethiopia to increase young people’s awareness of contraception services and to offer advice on sexual and reproductive health, as well as giving a subsidised eVoucher to young women who expressed an interest in modern contraception.
The voucher system was also extended to integrate with other services provided by MSI, such as a call centre to allow vouchers to be generated and communicated through other channels. Once generated, the voucher is redeemed and recorded through the same process as with community health workers. The same call centre also operates as a helpline for these clients. The service receives more than 6,000 phone calls per month, around 80% of which are young people aged 20-29 years old. They call seeking advice on contraception, safe abortion, HIV/AIDS and other sexual health issues. In 2012, MSI Ethiopia managed to obtain the toll-free number ‘8044’ for its hotline which led to higher call numbers and resulted in an increase in staff number at the call centre. The languages spoken by the staff include Amharic, Oromo, Tigrigna and English.
Target Population: Adolescents and Young People, Particularly Female, Rural and Urban, Ages 15-29 years
Technology: Apposit used their custom-built ‘Connect Platform‘ to develop the eVoucher system for MSI. Connect allows clients to collect data easily and accurately from end users. All information collected via mobile tools can be accessed through a secure browser-based portal.
Technology Use: Clients are given a voucher by MSI Ethiopia free of charge. These randomly assigned voucher codes are sent directly to the client’s mobile phone through an SMS message. Women who redeemed a voucher at one of the health facilities attached to the programme receive a free counselling session on all contraceptive methods, as well as sexual and reproductive health including HIV counselling, testing and treatment, to ensure they are making a voluntary and well-informed choice.
In addition to promoting the use of contraceptive methods, the voucher system is used to follow up on patients that have received care. With information on the type of service received and the date on which the service was received, the system is able to extend follow up services through CHWs to those young women who have received treatment. The system alerts CHWs of services received by people they have referred and alerts them at scheduled intervals to follow up with those patients.
Using the same smartphone, these CHWs complete simple follow up questions and submit their results electronically to ensure proper follow up of patients. This helps to create an effective monitoring system of patients using timely data directly from the communities.
Organization and Partners: Marie Stopes International (MSI) is a global organization headquartered in London, UK. They currently provide contraception and safe abortion services in 37 countries around the world.
Challenges and Lessons Learned: MSI Ethiopia’s pilot of eVouchers demonstrates that this system offers a viable and realistic alternative to the paper vouchers traditionally used by subsidised voucher programmes. Between 15th August 2012 and 28th February 2013, MSI Ethiopia issued 2,521 eVouchers. By the end of this period, 1,278 eVouchers (51%) had been redeemed.
The eVouchers that were issued benefitted the group they were aimed at – young people. In total, 92% of the issued vouchers were redeemed by individuals aged between 15 and 29 years old. The eVouchers also appear to have increased young people’s access to and choice of contraceptive methods, while also increasing their uptake of information on HIV/AIDS and STIs.
According to Apposit, as of 2013, over 19,000 vouchers had been issued, with around 100 CHW and over 30 clinics participating in the program. MSIE has been able to meet its objectives of reaching marginalized populations through a system that is scalable, efficient, reduces fraud and provides real-time insight into the performance of the program.
This case study was compiled using the following sources from Marie Stopes International and UNICEF:
- Statistics Ethiopia (2013). Retrieved from https://www.unicef.org/infobycountry/ethiopia_statistics.html. Accessed on 22 March 2017.
- HIV Prevalence level shows a drastic Fall in Ethiopia. Retrieved from http://www.hapco.gov.et/index.php/media-room/news/item/12-hiv-prevalence-level-shows-a-drastic-fall-in-ethiopia. Accessed on 22 March 2017.
- Retrieved from https://mariestopes.org/media/2120/evouchers-in-ethiopia.pdf. Accessed on 22 March 2017.
- eVouchers in Ethiopia: Using mobile phones to increase young people’s access to contraception (2012). Promoting Reproductive Health Using eVouchers. Retrieved from http://www.apposit.com/marie-stopes-international-ethiopia.html. Accessed on 22 March 2017.