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

Katherine Tumlinson; Sein Kim; Emilia Goland; Brooke W Bullington; Stephanie Chung; Brian Frizzelle; Eunice Kioko; Ginger Golub; Erica Felker-Kantor; Mickael Randriamanjaka; Andry Rabemanantsoa; Daniel Crapper; Sean Sylvia; Tara Templin

doi:10.1016/j.contraception.2026.111521

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

Contraception. 2026 Jun 11:111521. doi: 10.1016/j.contraception.2026.111521. Online ahead of print.

Authors

Affiliations

¹ Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, United States; Carolina Population Center, University of North Carolina at Chapel Hill, United States.
² Department of Global Health and Population, Harvard T.H. Chan School of Public Health, United States. Electronic address: seinkim@fas.harvard.edu.
³ Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, United States.
⁴ Division of Family Planning, Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, United States.
⁵ Carolina Population Center, University of North Carolina at Chapel Hill, United States.
⁶ Innovations for Poverty Action (IPA), Nairobi, Kenya.
⁷ Division of Infectious Disease and Global Health, University of California at San Diego, United States.
⁸ Population Services International, Madagascar.

PMID: 42276444
DOI: 10.1016/j.contraception.2026.111521

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.

Keywords: Contraception; Health services accessibility; Informal payments; Madagascar; Out-of-pocket payments.