Alleviating price and information barriers to long-acting contraception uptake in Kenyan pharmacies using patient and provider incentives: a cluster randomized control trial.

Background: Access to modern family planning impacts women's health, education, and economic well-being. Persistent barriers to accessing long-acting methods, such as price and lack of information, limit adoption. This study highlights the potential of a novel payment and incentive structure for pharmacies, a key access point for contraceptives for young women in particular, to improve access to subcutaneous depot medroxyprogesterone acetate (DMPA-SC). By targeting incentives to either patients or providers through a low-cost digital tool, the intervention aims to enhance contraceptive choice cost-effectively with potential for scale. Methods: We randomized 137 pharmacies in Kenya into three intervention arms, varying patient copay, pharmacy profit, or pharmacy cost to stock DMPA-SC, plus a status quo control group that conducted pharmacy operations as usual. All pharmacies used an app-based platform for sales and inventory tracking, and a digital tool to manage family planning sales, through which client discounts for DMPA-SC, pharmacy cost to stock DMPA-SC, or pharmacy profit for DMPA-SC were experimentally varied in the intervention arms. We used double/debiased machine learning for adjusted models, with the primary outcome being uptake of DMPA-SC, and secondary outcomes being couple-years of protection, and an analysis of price and information mechanisms. Findings: We analyzed data from 26,883 family planning visits (C = 7605, T1 = 7774, T2 = 5009, T3 = 6495) between August 2022 and May 2023. Providing consumer discounts and provider incentives through a pharmacy-facing intervention increases adoption of DMPA-SC by 14 percentage points (control mean: 0.03), while decreasing use of short-acting methods by 13 percentage points (control mean: 0.92), compared to a control group. Interventions alleviated both price and information barriers to access through a 100% price pass through in the consumer discount arm and an increase in comprehensive counseling by 68 percentage points in the provider-side arms, all compared to the status quo control group. Targeted incentives increase couple-years of protection (CYP) for $2.56-$12.50 per CYP. Interpretation: Pharmacy-based interventions that reduce price and information barriers of DMPA-SC can expand women's contraceptive options, with implications for choosing longer-acting methods. Pharmacies are crucial access points for family planning in Kenya and globally. Understanding how pharmacy-specific interventions influence access to modern methods can generate evidence on this understudied and important care setting. Funding: This study was funded by the Children's Investment Fund Foundation and The Weiss Fund for Research in Development Economics at the University of Chicago. This study was prospectively registered with the AEA registry for randomized controlled trials (AEARCTR-0009020) and is registered with the Pan-African Clinical Trials Network (PACTR202506634961987).