
Discounts for modern contraceptive methods

COLLAPSE, COMPLICATIONS
Eligible clients who received a FP consultation by a trained provider using the app were offered randomly varying discounts for modern contraceptives. Contraceptive prices and the counseling style are fixed for each client for 1 year per the random allocation at their initial visit, meaning that return clients face the same set of prices if they want to adopt a new method or switch their current one. The four modern contraceptive methods available at the hospital were grouped into two categories: LARCs (i.e., the copper IUD and the implant) or SARCs (i.e., the pill and the injectable). LARCs were offered at five different price levels with equal probability, which we collapse into two bins for statistical power: full price [Central African Francs (CFA) 4000] and discounted price (CFA 2000; 1000; 150; and free). Removals of LARCs are free for all study participants whenever they wish to switch or discontinue their method. SARC prices were cross-randomized at two price levels with equal probability: Full price (CFA 1250 for the injectable and 1500 for the pill) or free. Both short-acting methods need to be renewed every 3 months, and the clients could do so at the same price offered at the initial consultation, which was valid for a period of 1 year, representing three renewals. Note that because of the very low take-up of SARCs among the study population and the lack of impact of offering discounts for SARCs, the study team discontinued offering random discounts for SARCs on 20 January 2021, meaning that they were offered at their full price for the remainder of the study period. For this reason, we do not focus on SARC discounts in the analysis.Two details about the implementation of random discounts might matter. First, the prices for all modern methods were revealed at once and after the client had chosen a method they wanted to adopt unless they inquired about prices earlier on in the counseling session, which happened only 4% of the time. This decision was made after careful deliberation with health care providers at HGOPY: The study team wanted to avoid price discounts possibly skewing the discussion of suitable methods for the clients. Second, the reader might worry about the clients (alone or in collaboration with the providers) trying to “game” the system to receive higher discounts—for example, by asking the counselor to start a new app session or by returning later. Carefully developed study protocols for return clients, monitoring the data from the tablets (including meta- and paradata), and monthly audits of HGOPY’s own administrative data allow us to rule out the possibility of clients redrawing a new set of prices.We can also largely rule out any meaningful bias in our impact estimates due to clients visiting nearby FP clinics to receive the same services at lower prices than those they were offered at HGOPY: First, even the highest LARC prices in our study constitute a nonnegligible discount over the regular prices offered at HGOPY and at other publicly funded hospitals and clinics in Yaoundé. Second, we surveyed nearby private and public-private clinics to get price estimates for contraceptive methods and associated services, which exceeded the costs borne by clients in our study (see table S5). Third, the randomized price of adopting each contraceptive method in our study covers all associated services, which includes FP counseling, removals of LARCs, follow-up services to address side effects and complications, and free provision of condoms. Table S5 shows that separate charges for LARC removals and FP counseling in other facilities can be quite expensive. Last, follow-up surveys we conducted with a later sample of clients, who were recruited during the adaptive experiment, indicate that only a negligible share of HGOPY clients sought FP services elsewhere following their consultation at HGOPY, less than 2.5%.