Ganle et al. International Journal for Equity in Health          (2021) 20:186 
https://doi.org/10.1186/s12939-021-01518-y
SYSTEMATIC REVIEW Open Access
Family planning for urban slums in low-
and middle-income countries: a scoping
review of interventions/service delivery
models and their impact
John Kuumuori Ganle1*, Leonard Baatiema2, Paul Ayamah3, Charlotte Abra Esime Ofori4,
Edward Kwabena Ameyaw5, Abdul-Aziz Seidu6,7 and Augustine Ankomah8
Abstract
Background: Although evidence suggest that many slum dwellers in low- and middle-income countries have the
most difficulty accessing family planning (FP) services, there are limited workable interventions/models for reaching
slum communities with FP services. This review aimed to identify existing interventions and service delivery models
for providing FP services in slums, and as well examine potential impact of such interventions and service delivery
models in low- and middle-income settings.
Methods: We searched and retrieved relevant published studies on the topic from 2000 to 2020 from e-journals,
health sources and six electronic databases (MEDLINE, Global Health, EMBASE, CINAHL, PsycINFO and Web of
Science). Grey and relevant unpublished literature (e.g., technical reports) were also included. For inclusion, studies
should have been published in a low- and middle-income country between 2000 and 2020. All study designs were
included. Review articles, protocols or opinion pieces were excluded. Search results were screened for eligible
articles and reports using a pre-defined criterion. Descriptive statistics and narrative syntheses were produced to
summarize and report findings.
Results: The search of the e-journals, health sources and six electronic databases including grey literature and other
unpublished materials produced 1,260 results. Following screening for title relevance, abstract and full text, nine
eligible studies/reports remained. Six different types of FP service delivery models were identified: voucher schemes;
married adolescent girls’ club interventions; Willows home-based counselling and referral programme; static clinic
and satellite clinics; franchised family planning clinics; and urban reproductive health initiatives. The urban
reproductive health initiatives were the most dominant FP service delivery model targeting urban slums. As regards
the impact of the service delivery models identified, the review showed that the identified interventions led to
improved targeting of poor urban populations, improved efficiency in delivery of family planning service, high
uptake or utilization of services, and improved quality of family planning services.
* Correspondence: jganle@ug.edu.gh
1Department of Population, Family and Reproductive Health, School of
Public Health, University of Ghana, P. O. Box LG 13 Legon, Accra, Ghana
Full list of author information is available at the end of the article
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Ganle et al. International Journal for Equity in Health          (2021) 20:186 Page 2 of 15
Conclusions: This review provides important insights into existing family planning service delivery models and their
potential impact in improving access to FP services in poor urban slums. Further studies exploring the quality of
care and associated sexual and reproductive health outcomes as a result of the uptake of these service delivery
models are essential. Given that the studies were reported from only 9 countries, further studies are needed to
advance knowledge on this topic in other low-middle income countries where slum populations continue to rise.
Keywords: Family planning, Contraception, Reproductive health, Service delivery, Urban slums, Scoping review
Introduction transactional sex and age asymmetry of sexual part-
Globally, people living in informal settlements (slums) in ners as well as high rates of sexual and gender-based
urban areas will reach 2 billion by 2030 [1]. The UN de- violence [6, 13]. These conditions potentially expose
fines slums as areas with high population density, which women and adolescent girls in slums to high risks of
lack one or more of the following conditions: access to unplanned pregnancies [13].
improved water, access to improved sanitation, sufficient A number of factors have been identified to contribute
living area, housing durability, and security of tenure [2]. to poor access to family planning services in slums. First,
It is estimated that, in 2015, the proportion of urban many slum residents are often ‘time poor’, and this
populations living in slums in different regions of the reduces their ability to access services [13]. Poor slum
world were as follows: Northern Africa (11.9 %); Sub- residents may have to travel outside their neighbour-
Saharan Africa (55.9 %); Latin America and the Carib- hoods for high quality and free or low-cost family plan-
bean (21.1 %); Eastern Asia (26.2 %); Southern Asia ning services because government services in the vicinity
(31.3 %) South-Eastern Asia (28.4 %); Western Asia of informal settlements are often in poorer state and lack
(24.9 %); and Oceania. (24.1 %) [2]. key supplies than clinics in other parts of cities [13].
In Ghana, an estimated 37.9 % (5.4 million) of urban Where slum dwellers are served at all, they are often
dwellers live in slums [3]. Within current literature, there served by private informal providers [13]. Besides, in
is consensus that many slum neighbourhoods in Africa some countries private providers in urban slums may
are precarious spaces of human habitation [4–10]. For in- also be poorly regulated and may not be well integrated
stance, slums are often characterized by poor infrastruc- into the public health sector [11, 13]. Private services in
ture, poverty, and violence in addition to frequently not urban slums may also be of poor quality and lacking
being recognized by public authorities as integral parts of basic facilities and supplies [11]. Private providers may
cities [7, 11–13]. This disadvantage transcends several even charge higher user fees for contraceptives. Also,
spheres to include poor access to family planning (FP) and misinformation and rumours can undermine use of con-
contraceptive services [6, 14, 15]. In broad terms, family traceptives even in areas with high unmet need for FP
planning is the voluntary planning and action taken by in- [11]. In addition, the localized networks of slum dwellers
dividuals to prevent, delay or achieve a pregnancy [16]. may further reduce their awareness and knowledge
The ultimate aim of family planning is to help people de- about contraceptive methods and services. The com-
cide freely and responsibly on the number of children they bined effect of this multiple deprivation is high unmet
want to have and when to have them [16]. Thus, family need for FP services [10, 11].
planning enables couples and individuals to delay preg- Over the years, the precarious conditions in slums
nancy, space births, limit family size, prevent unintended have attracted a number of research and policy analyses.
pregnancies and sexually transmitted infections (STIs) Slum populations have also attracted specially designed
including HIV and AIDS, as well as helps couples and interventions to improve access to, and uptake of, qual-
individuals who want to have children achieve their ity and affordable FP services. However, to the best of
desires [16]. In this study, family planning services consid- our knowledge, no review has been conducted to pull to-
ered included family planning information provision, fam- gether the disparate literature in order to better under-
ily planning counselling, contraceptive services, post- stand what FP service delivery models/interventions
abortion family planning services, and STI screening, pre- currently exist and their impact. This knowledge gap
vention and treatment services. could potentially hinder efforts to improve not just
Current scholarly and programmatic literature on reproductive health outcomes in slums but also overall
reproductive health suggest that many slum dwellers sustainable urban development as envisaged under sus-
in low-income settings have the most difficulty acces- tainable development goal (SDG) 11. As previous
sing sexual and reproductive healthcare [6, 7, 11, 13]. researchers have noted, poor access to FP services could
In addition, slum environments are often character- negatively affect overall urban development and govern-
ized by high levels of substance use, early sex, ance via high fertility, rapid population growth and
Ganle et al. International Journal for Equity in Health          (2021) 20:186 Page 3 of 15
urbanisation, increased demand for urban services, and medical subject headings (MeSH) terms. The third
poor health outcomes [13]. The aims of this scoping re- round of search was through manual hand-searching of
view were (1) to identify existing interventions and ser- the reference lists of selected articles. Supplementary file
vice delivery models for providing FP services to slum 1 outlines the MEDLINE database search strategy, which
communities; and (2) to assess their actual and potential was modified and used for each database where
impact. appropriate.
For inclusion, studies should have been published in a
Methods low- and middle-income country between 2000 and
This scoping review was conducted according to Arksey 2020, a time frame to ensure that the eligible studies on
and O’Malley’s framework on evidence synthesis [17]. existing interventions are current and relevant to address
The framework proposed five key steps in iteratively the family planning needs of populations in urban slums.
generating and synthesizing evidence: (1) identification Only articles published in the English language were
of key research questions(s); (2) identification of relevant considered. All study designs were included. For inclu-
eligible studies; (3) selection of eligible studies; (4) data sion, studies were original research articles with focus
charting and; (5) collating, summarizing and reporting of on FP interventions or programmes in urban slums in
results. To ensure rigour and transparency in reporting, low- and middle-income countries. Where relevant, the
this review was conducted according to the Preferred review also considered reports, policy documents, and
Reporting Items for Systematic reviews and Meta- working papers. Review articles, protocols or opinion
Analyses extension for Scoping Reviews (PRISMA-ScR). pieces were excluded though reference may be made to
some of them in the main work. The review also in-
Review questions cluded grey literature relevant to the review topic.
The scoping review was conducted to answer the follow-
ing questions: what FP interventions and/ or service de- Study selection
livery models currently exist in urban slums in low- and All databases were searched individually, and studies
middle-income settings; and what has been their poten- imported into EndNote. Selection of potentially eligible
tial/actual impact in terms of improving access to family studies proceeded as follows. First, duplicates of studies
planning services? To effectively answer these questions, from all databases search results were removed. Second,
a scoping review was favoured over a systematic review titles of articles were assessed by two reviewers (JGK &
because the strict inclusion and reporting criteria of a LB) for relevance using the study inclusion and exclu-
systematic review would make it impossible to incorpor- sion criteria. The third round involved review and
ate otherwise useful materials such as unpublished re- screening of abstracts of retained studies after title rele-
ports on potential impact of FP interventions. In other vance screening. In the fourth stage, full text of articles
words, the methodological approach to a scoping review was reviewed for relevance and where eligibility criteria
is relatively flexible and allows for the inclusion of di- were met, articles were selected for final analysis. Six of
verse study designs and grey literature. the authors (LB, JGK, PA, CAEO, EAN and AA), of this
review paper independently assessed the full text of
Identifying eligible studies these articles to evaluate their potential eligibility. Arti-
A search strategy was developed to facilitate the search cles from reference lists which met the inclusion criteria
and selection of relevant studies to address the two re- were also screened and eligible studies included in the
search questions on existing interventions and service final analysis. A search decision flowchart detailing the
delivery models and their impact. The search sources search process at every stage including duplicates re-
comprised E-journals, health sources and six electronic moval, exclusions at title assessment, abstract and full-
databases including MEDLINE, Global Health, EMBASE, text screening and inclusions after reference screening is
CINAHL, PsycINFO and Web of Science. Grey and un- shown in Fig. 1.
published literature were also searched for relevant
studies.
The literature search process was in three phases. The Extracting and charting the results
first comprised a preliminary search of selected data- A standardized, pre-tested data extraction form was
bases to analyze relevant text words on the subject mat- developed and reviewed by the team to ensure that all
ter reported in potentially eligible studies. The second relevant information in relation to answering the review
search involved electronic search of each of the selected questions were captured. In brief, the data extraction
databases as outlined above using a pre-tested search form captured data on the authors, year of publication,
strategy. The search strategy was modified according to country of study, study designs, aims/objectives of the
each database using the same key search terms and study, study population, sampling and sample size,
Ganle et al. International Journal for Equity in Health          (2021) 20:186 Page 4 of 15
Fig. 1 Evidence Flow Chart
methods, type of intervention, duration of intervention literature and published reports resulted in 84 studies.
and key study findings. Key study outcomes or findings The total number of articles or reports was thus 1,260.
related to any direct effects of the implemented family A total of 496 duplicates were removed and the rest
planning intervention or service delivery model were (764) remained for title relevance and abstract screening.
reported. Following screening of title and abstract for study rele-
vance, a further 703 were removed and 61 papers were
Collating, summarizing and reporting of results considered for full-text screening. Following full-text
Following extraction of the data into an evidence table, screening, only 9 articles and grey reports were
we summarized the main studies and displayed in a considered eligible for the review.
chart to show study locations, FP interventions and bar-
riers to accessing FP services in urban slums. In report- Characteristics of eligible studies
ing the study findings, we adopted the narrative The included studies were conducted in 9 different low-
synthesis approach, a widely used approach to reporting income countries and low-and middle-income countries,
scoping review findings [18]. This approach is particu- namely Bangladesh, Ghana, Nigeria, Uganda, Kenya,
larly suitable for reporting findings from eligible studies Senegal, India, Pakistan, and Nicaragua. The studies
with different study designs [19]. were published between 2005 and 2020. The types of FP
services reported in the study comprised condoms;
Results injectable contraceptives; IUDs; tubectomy; vasectomy;
Overview of studies pill; sterilization; emergency contraception; oral contra-
The search generated a total of 1,176 peer reviewed arti- ceptives; and implants.
cles [MEDLINE = 400; CINAHL = 318; EMBASE = 203; The study designs employed in the eligible studies
PsycINFO = 80; Web of Science = 14; and Global were mixed. For example, most were quasi/experimental
Health = 161]. Search from other sources including grey in design [20–23]; one was a retrospective study [24], a
Ganle et al. International Journal for Equity in Health          (2021) 20:186 Page 5 of 15
Table 1 Characteristics of eligible studies on family planning interventions in urban slums
# Country Authors, Study Aim Study design Family planning FP service Population, Data collection
publication services delivery sample, age methods
year model &
intervention
1 Bangladesh Huda et al. To assess the Quasi- Condom, injection, Married Married adolescent quantitative survey
2019 [21] effectiveness of a experimental IUD, tubectomy, Adolescent girls
married adolescent study vasectomy, implant Girls’ (MAG) Club
girls club in and pill club Sample = 1601
reducing the unmet intervention Age = 14–19
need for family
planning (FP)
2 Pakistan Hennink and To determine the Quasi- Pill, condoms, Franchised Age: <20–40+ Interviews;
Clements, impact of new experimental injectables, the Family descriptive
2005 [20] family planning study IUD, female Planning statistics,
clinics on sterilization Clinics
knowledge, procedures),
contraceptive use, pregnancy testing,
and unmet need termination of
for family planning pregnancy, and
among married advice about
women in poor sexual health.
urban areas
3 Nicaragua Meuwissen to identify the Cross-sectional Oral, injectables, Voucher Sample: 3301 Structured
et al. nature of existing study IUD and condoms scheme Age: 11–20 questionnaire,
2006 [25] unmet needs for descriptive
SRH care through statistics;
voucher multivariable
redemption analysis
4 India Achyut et al., To evaluate the Evaluation Sterilization (female Urban women of interviewer
2016 [27] impact of the study or male) IUD reproductive reproductive age administered
Urban Health (longitudinal Oral contraceptive health (15–49) women facility audit,
Initiative sample of pill Condom initiative: and the sub- provider interviews
women and Other modern sample of poor and exit interviews
health facilities method women
with baseline
(2010) and
endline (2014)
data)
5 Senegal Benson et al. To examine the Evaluation Sterilization (female Urban women of interviewer
2018 [28] impact of the Baseline (2011) or male) IUD reproductive reproductive age administered
Initiative’s demand- and endline Oral contraceptive health (15–49) women facility audit,
and supply-side ac- (2015) pill Condom initiative: and the sub- provider interviews
tivities on modern longitudinal Other modern sample of poor and exit interviews
contraceptive use. data method women
6 Kenya & Arur et al., To improve use, Technical report Implants, female Voucher Poor women in secondary
Uganda 2009 [26] responsiveness, and (review from sterilization, scheme urban centres literature, primary
quality of FP and published and intrauterine data collection, and
Safe Motherhood unpublished contraceptive extensive
services and give secondary devices (IUDs) interviews
clients a choice of literature,
providers. primary data
collection, and
interviews)
7 Nigeria Krenn et al. To determine the Quasi- N/A Nigerian Men and women Interviews,
2014 [22] contribution of experimental Urban of reproductive age secondary data
mobile services to study Reproductive analysis, descriptive
total family Health statistics
planning services Initiative
8 Ghana Henry et al., To generate Retrospective, Male or female The Willows women who were Retrospectively
2020 [24] estimates of the cross-sectional sterilization, reproductive between the ages assessed changes
effect of the design intrauterine device, health of 16 and 44 in in women’s
Willows home- implants, programme 2013 contraceptive use
based counselling injectables, oral 1836 women in Household survey
model as imple- contraceptive pills, each of the
mented in Kumasi, male or female intervention and
Ganle et al. International Journal for Equity in Health          (2021) 20:186 Page 6 of 15
Table 1 Characteristics of eligible studies on family planning interventions in urban slums (Continued)
# Country Authors, Study Aim Study design Family planning FP service Population, Data collection
publication services delivery sample, age methods
year model &
intervention
Ghana from 2013 condoms, comparison areas,
to 2016 in order to lactational which we rounded
guide future pro- amenorrhoea up to a sample of
gramming for method and 2000 women in
community-based emergency each site.
family planning contraception.
behaviour-change
interventions in
urban Ghana and
similar West African
settings.
9 Bangladesh Uddin et al. To assess the Experimental Condom, pill, and Static clinic 800 (400 females Mixed method
2012 [23] effectiveness of two pre-post design injection and satellite and 400 males) approach, a
models to provide clinics street-dwellers, combination of
primary healthcare ever-married fe- both quantitative
(PHC) services to males and males and qualitative
street-dwellers. aged 15 years and techniques, was
above, living within used for data-
the two-kilometre collection. The
radius of the study community survey
locations; and were and qualitative
sleeping in the area components (in-
for at least one depth interviews
week before data- with study subjects
collection. and healthcare
providers)
Fig. 2 Distribution of FP service delivery models for urban slums in low/middle-income countries
Ganle et al. International Journal for Equity in Health          (2021) 20:186 Page 7 of 15
cross-sectional study [25], a technical report [26] and Reproductive-Health Output-Based Approach (RH-
the rest were evaluation/baseline studies [27, 28]. A OBA) voucher pilot programme, were implemented in
summary of the study characteristics is reported in Uganda and Kenya respectively [26]. The RH-OBA pro-
Table 1. ject was implemented in three rural districts and two
slums in Nairobi for eligible beneficiaries to purchase FP
Family planning interventions and service delivery vouchers for both long and permanent methods at $1.25
models and safe motherhood voucher for antenatal, institutional
The studies reported six different types of service deliv- delivery and postnatal care services at $2.50. The RH-
ery models or interventions to improve access to FP OBA provides safe motherhood services at $1.50. Marie
services in urban slums (see Fig. 2). These included (1) Stopes International Uganda was appointed as the Vou-
voucher schemes [25, 26, 29]; (2) married adolescent cher Management Agency. A key feature of the RHVP
girls’ club intervention [21]; (3) franchised FP clinics scheme was that FP services vouchers could only be re-
[20]; (4) urban reproductive health demand-creation and deemable at private for-profit and non-profit providers.
supply programmes [22, 27, 28]; (5) Willows home-
based counselling and referral programme [24]; and (6) Married adolescent girls’ (MAG) club intervention
Static clinic and satellite clinics [23]. Details of the study One study was identified, which reported use of a club-
characteristics are summarised in Table 1. These inter- based service delivery model in Bangladesh [21]. This
ventions and/ or service delivery models are described in was a quasi-experimental study conducted in four urban
detail below. slums in 2016 to examine the effectiveness of MAG in
reducing unmet needs for FP among married girls
between the ages of 14 and 19. The MAG intervention
Voucher schemes and access to FP services was developed and implemented to tackle the unmet FP
Distribution of vouchers for accessing free sexual and needs of adolescents in slums in Bangladesh. This MAG
reproductive health services was identified as a service was rolled out in response to early marriage and child-
delivery model to improve access to FP services in poor bearing often resulting in pregnancy complications,
urban slums. Two separate studies reported the use of spousal violence and low-birth weight of babies in urban
this service delivery model [25, 26]. slums in Bangladesh. The MAG targets married adoles-
The first was a cross-sectional study conducted in cent girls between 14 and 19 years’ old, both pregnant
Nicaragua to identify the nature of existing unmet and non-pregnant and living with their husbands and/or
needs for SRH care through voucher redemption families in four selected urban slums in Bangladesh. The
between September 2000 and July 2001 [25]. This MAG held monthly sessions covering 40 sessions under
scheme provided, at no cost, uninhibited access to the guidance of facilitators recruited on the project.
sexual and reproductive healthcare in 19 primary Some of the activities undertaken as part of the MAG to
healthcare facilities in Managua. The vouchers were its members comprised dance, music and drama ses-
distributed through the Central American Health sions. Services provided under the MAG model com-
Institute (ICAS), NGOs, project clinics, four markets, prised comprehensive information and services on FP.
19 public schools and 22 poor neighbourhoods. To assess the effectiveness of the club-based model, an
Female adolescents were mainly the distributors of intervention and control groups were set up comprising
the vouchers and vouchers were valid for three 799 participants for the intervention group (areas) and
months. The voucher package for beneficiaries com- 802 for the control groups (areas). These participants
prised free-of-charge consultation and a follow-up were drawn from 10 clusters each from the intervention
visit for advice/counselling, contraception, treatment and control groups.
of STIs or reproductive tract infections, pregnancy
testing and/ or antenatal care in any of the four pub- Franchised family planning clinics
lic, five private and 10 NGO clinics. The clinics re- The use of socially franchised clinics for FP was identi-
ceived reimbursement for each adolescent fied as one of the service delivery models for urban poor
consultation. During each consultation, doctors com- communities. The study was commissioned against the
pleted standardized clinical forms. Voucher redeemers background of high fertility rates and unmet needs for
received a booklet on adolescent health, two condoms FP services in Pakistan. Using a quasi-experimental de-
with supportive information, and if required, contra- sign, the study aimed to examine the impact of new fam-
ceptive methods, laboratory tests and syndromic treat- ily planning clinics on knowledge, contraceptive use, and
ment for STIs. unmet need for family planning among married women
The second voucher scheme, which comprised the aged 15–45 years in poor urban areas of six secondary
Reproductive Health Voucher Project (RHVP) and the cities of Pakistan [24]. The services provided as part of
Ganle et al. International Journal for Equity in Health          (2021) 20:186 Page 8 of 15
this project comprised contraceptives (pills, condoms, context of low uptake of FP services among the poor, ac-
injectables, IUD, female sterilization), pregnancy testing, cess to low quality FP services and high maternal and
pregnancy termination and advice about sexual health. child mortalities, the project was designed to increase
Both outreach and clinic-based services were utilized, the use of FP services by the urban poor, improve quality
and the latter was facilitated by teams of community- of FP services, reduce maternal and infant mortality. Key
based distributors. Fees charged for the services provided components of the project comprised provision of post-
at the clinics were relatively lower than the cost at pri- partum and post abortion FP, delivery of training to FP
vate health facilities due to the subsidized treatment providers to improve their technical competence and
funds available to the urban poor community members client-provider interactions, expansion of the role of the
as part of the franchising FP clinic intervention. In the private sector in FP service provision, use of community
study, baseline and end line surveys were conducted to health workers for outreach activities and use of mass-
collect data from a population of 5,338 for the baseline media to promote demand for FP services. Community
and 5,502 for the endline in four intervention sites and health workers were tasked to visit homes within slums
two control sites. The study collected data on knowledge to offer education on FP methods and offer counselling
of modern contraception, contraceptive prevalence, and on postpartum FP; accompany women to a health facil-
unmet need for FP. ity; refer women to a health facility on fixed service days;
and where necessary, provide short-term methods (pills
Urban reproductive health demand-creation and supply and condoms) to interested parties.
programmes The third study was the Nigerian Urban Reproductive
Three studies were identified which reported on inter- Health Initiative (NURHI) – a 6-year comprehensive
ventions seeking to improve uptake of FP services in family planning programme (2009–2015) in 4 cities
poor urban communities [22, 27, 28]. The first study (Abuja, Ibadan Ilorin and Kaduna) [22]. The project
was conducted in a Senegalese context where uptake adopted multiple communication pathways to facilitate
and use of FP services was low, and the prevalence of dialogue on family planning, increase social approval for
modern contraceptive use was only about 20 % [28]. The it, and improve accurate knowledge about contracep-
urban reproductive health initiative is an integrated, tives. As part of the project, mobile service delivery was
multi-dimensional project which seeks to address this later introduced to improve access to clinical methods in
problem among women. The project had both demand- slums. This study analyzed data from representative
side and supply-side components. The former recruited, baseline (2010–11) and midterm (2012) surveys of
trained and used Muslim religious leaders to become FP women of reproductive age in the project cities. The
champions, to promote FP messages in religious settings, findings showed that, between baseline and midterm, the
and debate and campaign for access to FP services in the percentage of women who believed in myths or had mis-
media (radio, television and print media). As part of the conceptions about contraception declined by between 9
intervention, community-health volunteers were re- and 17 % points on outcomes measured. Intention to use
cruited and trained to share information about FP contraception in the next 12 months also recorded an
through individualized discussions with women and increase of between 7.5 and 10.2 % points in all four cit-
other members of the household. The supply-side com- ies. The prevalence of contraception use increased by
ponent sought to ensure sufficient and regular supply of between 2.3 % points (in Abuja) and 15.5 % point (in
FP services in the project sites, improve access to quality Kaduna) from baseline to midterm. The study noted that
FP services, and strengthen the referral system. A cross- several of the NURHI communication interventions
sectional study was subsequently conducted in all the six were significantly associated with higher levels of contra-
cities in Senegal to evaluate the impact of this initiative ceptive use, and propensity score matching found a
using a 2011 baseline and 2015 endline longitudinal 9.9 % point increase in contraceptive use in the 4 cities
data. There was an increase in contraception use be- attributable to project exposure.
tween baseline and endline. First, and for all women,
modern and traditional contraception use rose from 16.9 Willows home-based counselling and referral programme
to 2.0 % at baseline to 22.1 and 2.3 % at endline respect- The Willows reproductive health intervention was a 3-
ively. Second, results for poor women and less poor year home-based counselling and referral programme
women were similar. Third, the proportions of non- for women in low-income urban settlements in the
users saw a decreased from 81.1 to 75.5 % for all women Ashanti region of Ghana [24]. The intervention involves
and 81.4–73.4 % for poor women. information sharing and education, including counsel-
The second study was an Urban Health Initiative, ling, and referral on FP. As part of the programme, visits
which aimed to increase FP use among poor women in are undertaken, counselling and referral targeting
urban areas of Uttar Pradesh, India [27]. Against the 20,000–50,000 women of reproductive age are done. As
Ganle et al. International Journal for Equity in Health          (2021) 20:186 Page 9 of 15
part of the intervention, field educators are recruited, FP service delivery models. These service delivery
trained and deployed to conduct home visits, create models were reported from only 9 low- and middle-
awareness about FP services, and refer women to locally middle income countries, including Senegal, Uganda,
based health services. A retrospective analysis of changes Kenya, Nicaragua, Bangladesh, Pakistan, Ghana, India
in women’s contraceptive use over the 5 years prior to and Nigeria. Of the six service delivery models, the
the survey, including before the Willows programme Urban Reproductive Health Initiative and the voucher
launch, at the end of the programme, and 18 months scheme service delivery models were the most predom-
after the close of the programme was subsequently con- inant. As regards the impact of the above-mentioned FP
ducted. Overall, the intervention resulted in a 10.5 %- service delivery models in urban slums, the review
point increase in use of modern contraceptives from identified that these interventions hold great promise in
baseline to endline (95 %CI: 6.2, 14.8; P < 0.001) and a significantly improving uptake of FP services. For
7.6 % point increase from baseline to follow-up (95 %CI: instance, evidence from this scoping review showed that
3.3, 11.9; P < 0.001). The programme had a significant the identified service delivery models for FP enhanced
impact on modern contraceptive use at end line among targeting of poor urban populations, improved efficiency
women who received some information or counselling in delivery of FP service, and increased utilization of FP
visit. However, only 20.2 % of women in the Willows services.
intervention area reported a visit, hence the intervention
did not achieve its aim to reach all reproductive-aged Findings compared to previous studies
women in the community. Despite increased research and policy interest in the
growing populations in poor urban slums across major
Static clinic and satellite clinics cities in low- and middle-income countries, there is
The static clinic and satellite clinic intervention was evalu- limited information on the range of FP service delivery
ated through an experimental pre-post design study that models or interventions. For example, many studies exist
tested two models: static clinic and satellite clinics, for on improving access to FP services in both rural and
providing primary healthcare services to street-dwellers urban populations [30, 31], but most have paid little at-
through paramedics in Dhaka city from May 2009 to April tention to FP uptake in urban slums. Of the few reviews
2010 using both quantitative and qualitative techniques on this topic, much attention has been focused on evalu-
[23]. An analysis of the longitudinal data shows that the ation of the voucher scheme in improving uptake and
use of healthcare services by female street-dwellers in- utilization [32, 33].
creased by 56 and 31% between baseline and end line in Evidence from the review has also shown that the use of
both the model clinic areas, and the difference was highly voucher schemes was highly impactful in terms of improv-
significant (p < 0.001). The study showed a significant in- ing access to FP services among marginalized groups, a
crease in the use of family planning methods among fe- finding consistent with previous studies [32, 34]. This is
males at end line compared to baseline in both the static unsurprising given the fact that the voucher scheme
and satellite clinics. Use of family planning methods re- model is highly favoured in improving access to general
corded a significant increase among males also at endline healthcare services [34]. The use of the voucher scheme as
compared to baseline in the static clinic. The use of semi- a FP service delivery model suggests a general trend in im-
permanent and permanent methods among males proved access and uptake of FP services in both poor
remained almost same at endline in model clinic 1 areas urban slums and non-slum communities. However, previ-
while it increased in model clinic 2 areas (Table 2). ous studies have highlighted the challenge of targeting
beneficiaries in such schemes using validated tools to en-
Discussion sure the most appropriate and deserving beneficiaries have
Summary of findings access to FP services [25]. Evidence from other studies
This review aimed to identify existing interventions and have presented important lessons which should guide pol-
service delivery models for providing FP and contracep- icy makers and funding agencies in the implementation of
tive services to slums as well as examine actual and policies such as the voucher schemes in urban slums for
potential impact of past and current interventions and optimal results.
service delivery models in improving access to FP and It is also apparent from the review that, despite the
contraceptive services among slum dwellers in low- and range of FP service delivery models, a number of con-
middle-income settings. Overall, only 9 studies and/ or textual factors mediate access to such voucher schemes,
reports were eligible and included in the review, further including cost of FP services, educational level of slum
emphasizing the limited nature of studies on this topic. populations as well as cultural norms and values (Ste-
On the existing service delivery models and interven- phenson & Hennink, 2004). Thus, efforts should be
tions for FP services in slums, the review identified six made to ensure that these services are available and
Ganle et al. International Journal for Equity in Health          (2021) 20:186 Page 10 of 15
Table 2 Summary of evidence on impact of FP interventions/ service delivery models for urban slums
Country Author FP intervention Outcomes measured Impact of family planning service delivery model
Bangladesh Huda et al. Married Adolescent Girls Effectiveness of a married • The percentages of the targeted population using
2019 [21] Club adolescent girls club in reducing any modern method of contraception were
unmet need for family planning significantly higher among respondents in the
intervention areas than those in the control areas
(72.6 % versus 63.5 %).
• The unmet need for FP was significantly lower
among respondents in the intervention areas than
that of the control areas (16.2 % versus 20.7 %).
• The MAG club was a well-received strategy to pro-
vide comprehensive information on FP, which in
turn helped improve contraceptive method practices
and reduced the unmet need for FP among married
adolescent girls in urban slums in Bangladesh
Pakistan Hennink and Franchised family Knowledge, contraceptive use and • The clinics contributed to a 5 % increase in overall
Clements, planning clinics unmet needs for family planning knowledge of family planning methods and an
2005 [20] services increase in knowledge of female sterilization and
IUD of 15 and 7 % respectively.
• Distinct effects were found on contraceptive uptake,
including an 8 % increase in female sterilization and
a 7 % decline in condom use.
• Unmet need for family planning declined in two
sites, whereas impacts on the other sites were
variable.
• Although the new clinics are located within poor
urban communities, users of the services were not
the urban poor, but rather were select sub-groups of
the local population.
Senegal Benson et al. Urban Health Initiative Impact of demand and supply-side • By endline there was increased exposure to radio
2018 [28] activities on modern contraceptive and television programming, religious leaders
use speaking favourably about contraception, and
community-based initiatives.
• In the same period, modern contraceptive use
increased from 16.9–22.1 % with a slightly larger
increase among the poor (16.6–24.1 %)
• Multivariate analysis demonstrate that women
exposed to community-based activities were more
likely to use modern contraception by end line (mar-
ginal effect (ME): 5.12; 95 % confidence interval (CI):
2.50–7.74) than those not exposed.
• Further, women living within 1 km of a facility with
family planning guidelines were more likely to use
(ME: 3.54; 95 % CI: 1.88–5.20) than women without a
nearby facility with guidelines.
• Among poor women, community-based activities,
radio exposure (ME:4.21; 95 % CI: 0.49–7.93) and liv-
ing close to program facilities (ME: 4.32; 95 % ci:
0.04–8.59) impacted use.
India Achyut et al., Urban Health Initiative Impact of demand and supply side • Impact evaluation results show significant effects of
2016 [27] factors influencing access to and exposure to both demand and supply side program
provision of FP activities.
• In particular, women exposed to brochures
(marginal effect: 6.96, pb.001), billboards/posters/wall
hangings (marginal effect: 2.09, pb.05), and FP on
the television (marginal effect: 2.46, pb.001) were
significantly more likely to be using a modern
method at end line.
• In addition, borderline significance for being
exposed to a community health worker (marginal
effect: 1.66, pb.10) and living close to an improved
public and private supply environment where UHI
undertook activities
Nicaragua Meuwissen Voucher scheme Knowledge of contraceptives, • The mean number of problems presented was 1.5
et al. 2006 contraceptive use per consultation: 34 % of the vouchers were used for
[25] method of preference contraceptives, 31 % for complaints related to
factors that influence use of sexually transmitted infection (STI) or reproductive
contraceptives tract infection (RTI), 28 % for advice/counselling,
Ganle et al. International Journal for Equity in Health          (2021) 20:186 Page 11 of 15
Table 2 Summary of evidence on impact of FP interventions/ service delivery models for urban slums (Continued)
Country Author FP intervention Outcomes measured Impact of family planning service delivery model
28 % for antenatal check-up and 18 % for pregnancy
testing.
• A new category of health care users emerged:
sexually active girls who were neither pregnant nor
mothers and who sought contraceptives or STI/RTI
treatment.
• Contraceptive use doubled among the sexually
active non-pregnant voucher redeemers.
• Consultation with a female doctor younger than 36
years was associated with a higher chance of having
contraceptives prescribed
Uganda & Arur et al., Voucher scheme Use, responsiveness, and quality of • In Kenya, uptake of RH-OBA SM vouchers has been
Kenya 2009 [26] FP high. Between June 2006 and October 2008, 78,651
SM vouchers were sold and 60,581 women used SM
vouchers to deliver in a participating facility.
• In contrast, use of FP vouchers was considerably
lower than expected. In the same period, only
25,620 FP vouchers were sold, and 11,296 (41 %) of
these were used.
• Examination of provider claims data reveals that FP
voucher users overwhelmingly prefer implants to
other long-acting and permanent methods. Almost
two-thirds (60 %) of FP voucher users selected im-
plants, compared to a third (35 %) who chose female
sterilization (bilateral tubal ligation, or BTL). Only 5 %
opted for intrauterine contraceptive devices (IUCDs).
• Voucher utilization patterns indicate that the poor in
Kenya prefer to use private for-profit and non-profit
providers. In the area of FP, non-profit providers
were the preferred provider (59 %) across all voucher
site locations.
• Private non-profit providers appear to be a particu-
larly important source of surgical methods of contra-
ception: private non-profit providers submitted 90 %
of all claims for BTLs. Non-profit providers were also
the preferred provider for SM services and
accounted for 45 % of SM claims.
• Between February 2009 and June 2009, 4,034 RHVP
SM vouchers were sold and close to 2,451 (61 %)
used for ANC, institutional deliveries, or PNC services.
• Uptake in the first few months of RHVP may have
been low as voucher systems take a long time to set
up, particularly on the large scale of the RHVP.
However, the gap (61 %) between the number of
vouchers sold and used is now closing.
Nigeria Krenn et al. Nigerian Urban Awareness and utilisation of FP • Between baseline and midterm, the percentage of
2014 [22] Reproductive Health services women who believed in myths or had
Initiative misconceptions about contraception declined
between 9 and 17 % points on outcomes measured
• Intention to use contraception in the next 12
months increased between 7.5 and 10.2 % points in
four cities
• Actual contraception use increased between 2.3 %
points (in Abuja) and 15.5 % point (in Kaduna) from
baseline to midterm
• Reported exposure to several of the Nigerian Urban
Reproductive Health Initiative (NURHI)
communication interventions was significantly
associated with higher levels of contraceptive use.
• Propensity score matching found a 9.9 % point
increase in contraceptive use in the 4 cities
attributable to project exposure
Ganle et al. International Journal for Equity in Health          (2021) 20:186 Page 12 of 15
Table 2 Summary of evidence on impact of FP interventions/ service delivery models for urban slums (Continued)
Country Author FP intervention Outcomes measured Impact of family planning service delivery model
Ghana Henry et al., The Willows home-based Women reported contraceptive use • 10.5 % point increase in use of modern
2020 [24] counselling and referral contraceptives from baseline to close (95 %CI : 6.2,
programme 14.8; P < 0.001) and a 7.6 % point increase from
baseline to end of project (95 %CI : 3.3, 11.9; P <
0.001).
• Only 20.2 % of women in the Willows intervention
area reported a visit. The intervention, therefore, did
not achieve its aim to reach all reproductive-aged
women in the community.
• The programme had a significant impact on modern
contraceptive use at the close of the programme
among women who received an information or
counselling visit
Bangladesh Uddin et al., Clinics near the place of Use of family-planning methods • The use of healthcare services by the street-dwellers
2012 [23] residence (static clinic and among street-dwellers increased at endline compared to baseline in both
satellite clinics) the model clinic areas, and the difference was highly
significant (p < 0.001).
• Institutional delivery among the female street-
dwellers increased at endline compared to baseline
in both the clinic areas.
• The use of family-planning methods among females
also significantly (p < 0.001) increased at endline
compared to baseline in both the areas.
barriers impeding uptake are addressed to reduce the franchising in slums may however be limited by the
huge unmet needs of populations in slums. The use of likelihood that few private practitioners are willing to
vouchers, benefit cards or social franchising schemes are locate in slums. It is also important to note that the
not new within the context of facilitating uptake of FP availability of such FP service delivery models does
services. Previous studies have shown that these schemes not necessarily guarantee uptake, hence factors im-
have been successful in improving uptake of FP services peding access should be considered to ensure optimal
in non-slums areas [32, 33, 35–38]. However, Evidence uptake of available service delivery models. It is there-
of a lasting effect is absent, partly because voucher fore important to account for all these contextual fac-
schemes are funded externally and relatively of short tors in order to ensure success in the implementation
duration. of the various service delivery models for FP services
The findings regarding improved access and targeting slums in the urban centres.
utilization of FP services in slum communities using Although different activities and strategies were
the franchised clinics as a service delivery model are adopted in the urban health initiatives for FP, it was
consistent with evidence reported from non-slum set- clear from this review that the education and aware-
tings. For example, findings from a Kenyan study ness creation initiatives, including the use of posters,
showed that the use of franchised clinics resulted in billboards, engaging religious and traditional leaders,
improved access and use of long-acting or permanent and the media helped in improving knowledge levels
methods of contraception [39]. However, the same on FP services and overall increase in FP service
study did not find increase in access and uptake of utilization. Similarly, some previous studies have
other FP services, a finding which questions the wide- adopted the media, religious and traditional leaders
spread applicability of the franchising model for FP to improve FP knowledge and utilization, underscor-
services in the general population. It also highlights a ing the potential impact of such approaches in
need to explore and consider potential facilitating fac- efforts to improve access and utilization of FP
tors promoting the use of FP services through the services.
franchising model. Similar to a study in Pakistan on
social franchising where there was remarkable im- Implications for research and practice
provement in knowledge on FP services and fulfil- The findings from the present review has important
ment of the unmet needs of people living in urban implications for policy makers, governments, NGOs
slums, evidence from Marie Stopes International on a and donors/funders interested in improving access to
private sector-led social franchising scheme for FP in- FP services in poor urban areas and slums. First, the
dicated an improvement in access to FP services, review has advanced our understanding on the dif-
choice and quality of FP services [37]. Social ferent service delivery models and interventions for
Ganle et al. International Journal for Equity in Health          (2021) 20:186 Page 13 of 15
improving access to FP services in urban slums in their extent of potential impact, this review did not ap-
low- and middle-income countries. It also provided praise the methodological rigour of the individual stud-
insights on the potential impact of existing service ies given the inclusion of reports (grey literature). Future
delivery models for improving access to FP services studies should consider undertaking systematic reviews
in slums. For example, the evidence showed that the with priority given to experimental study designs in
voucher scheme has potential to improve access and order to measure the actual impact and effectiveness of
uptake of FP services among populations in slums the range of FP service delivery models and/ or interven-
[26]. These findings could therefore assist policy tions documented in this study. Assessment of the study
makers and funding agencies to select the most im- findings as reported by the authors was largely relied
pactful and potentially impactful service delivery upon. Policy makers contemplating the use of any of the
models to improve access and use of FP services in identified models of care should therefore do so with
urban slums. While some studies have sought to caution. Further, the findings reported herein were based
evaluate the quality of FP services based on specific on the identified peer-reviewed and grey literature using
types of service delivery models, none of the studies well-defined and broad search terms. Given that the
in the present review evaluated the quality of FP ser- search was restricted to six electronic databases, and
vices provided in urban slums. English language, it is possible some relevant articles
Based on this review, we recommend that full system- and reports were still missed. Again, there are potentially
atic review is conducted to evaluate the evidence about other contraceptive methods that may have been left
the potential impact of each existing service delivery out. For instance, some authors refer to bilateral tubal
model for FP services in urban slums. Although emer- ligation, vasectomy and intrauterine contraceptive device
ging evidence on the impact of service delivery models (IUCD), synonymous with IUD, which is included in our
were reported in this scoping review, this is less optimal. search strategy. Articles or reports yet to be reported
To establish definitive evidence on the extent of impact and not published online could also have been missed,
of the various service delivery models, future studies thus minimizing the extent of the evidence. In this re-
should be restricted to experimental and controlled view, all intervention designs had some effect on FP up-
studies. Future studies should also endeavour to add to take, thus demonstrating the scope for improvement in
existing knowledge on the experiences and lessons learnt slums populations. But no study examined cost-benefit
from implementation of the various FP service delivery or sustainability which is an important limitation worth
models. This information is critical to inform and guide noting.
policy makers and funding agencies in the implementa- In spite of the above limitations, some strengths are
tion of similar projects which target urban slums. notable. First, classical of a scoping review approach, this
Studies may also take interest in examining the imple- review adopted a broad approach in considering eligible
mentation of such service delivery models based on the studies for the review. In other words, the eligibility cri-
sex, educational status, employment status, and age dis- teria were quite open and flexible and thus allowed for
tribution of populations in urban slums. We further call the inclusion of all potentially relevant studies, thus
for more research/interventions past or current to be maximizing the final results. Relatedly, the outcomes
published for the purpose of wider learning. Evidence on variables examined for potential effects of the service de-
the quality, health outcomes and efficiency of the variety livery models were also inclusive and less restrictive.
of service delivery models was scant and thus, this
should take priority in future research activities. Import- Conclusions
antly, the identified six family planning interventions Despite increased policy and research interest in improv-
and service delivery models to improve access to FP in ing access to FP services, service delivery models and in-
urban slums were reported from different countries with terventions to improve uptake in urban slums remain
different contexts, cultural values and family planning limited. The present review revealed 9 eligible studies
policies. There is no doubt these factors influenced the reporting 6 different service delivery models and/ or in-
extent of implementation of these interventions. It is terventions for improving uptake of FP services in urban
therefore important to take this into account in any at- slums. Most of the included studies cited the voucher
tempt to apply or implement these models in other scheme as an intervention to improve utilization of FP
countries. services in urban slums. Thus, the use of voucher system
to improve access remains the predominant service de-
Study limitations and strengths livery model implemented across different countries.
The review acknowledges certain pertinent limitations. This review has identified potential opportunities to in-
First, although evidence about existing service delivery form future research activities to generate more expan-
models for FP in urban slums are presented, including sive and definitive evidence especially on the potential
Ganle et al. International Journal for Equity in Health          (2021) 20:186 Page 14 of 15
effects of the different service delivery models. Further Competing interests
efforts are needed to test the efficacy of such interven- The authors declare that they have no conflict of interests.
tions using controlled study designs. Author details
1Department of Population, Family and Reproductive Health, School of
Public Health, University of Ghana, P. O. Box LG 13 Legon, Accra, Ghana.
2
Abbreviations Department of Health Policy, Planning and Management, School of Public3
ICAS: Central American Health Institute; FP: Family Planning; NGOs: Non- Health, University of Ghana, Accra, Ghana. AIDS Commission, Accra, Ghana.4
Governmental organisations; NURHI: Nigerian Urban Reproductive Health Regional Institute for Population Studies, University of Ghana, Legon, Accra,5
Initiative; MAG: Married adolescent girls; IUD: Intrauterine Device; Ghana. School of Public Health, Faculty of Health, University of Technology
RHVP: Reproductive Health Voucher Project; RH-OBA: Reproductive-Health Sydney, NSW, Sydney, Australia.
6Department of Population and Health,
Output-Based Approach; SDGs: Sustainable Development Goals; STIs: Sexually University of Cape Coast, Cape Coast, Ghana.
7College of Public Health,
Transmitted Infections; UN: United Nations Medical and Veterinary Sciences, James Cook University, Townsville,
Queensland, Australia. 8Population Council, Accra, Ghana.
Supplementary Information Received: 7 January 2021 Accepted: 20 July 2021
The online version contains supplementary material available at https://doi.
org/10.1186/s12939-021-01518-y.
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