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

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.

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."

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.

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.

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.