i
Strengthening Family Planning
Project 
تعزيز تنظيم األسرة
Lessons from a Contraceptive Health 
Insurance Coverage Pilot
Submitted to:
Dr. Nagham Abu Shaqra 
Agreement Officer’s Representative
Population & Family Health Section
USAID/Jordan
Submitted by:
Timothy Irgens
Chief of Party
Prepared by: 
Josef Tayag
August 2015
Strengthening Health Outcomes through the Private Sector 
(SHOPS)
Associate Cooperative Agreement No. 278-A-00-10-00434-00
The information contained in this document is considered 
CONFIDENTIAL and is intended for the recipient and their 
authorized representatives only. Any unauthorized distribution is 
strictly prohibited without the prior written consent of submitter.
i
TABLE OF CONTENTS
Table of Contents.........................................................................................................................i
List of Tables and Figures...........................................................................................................ii
Introduction................................................................................................................................ 1
Overview of the Contraceptive Coverage Pilot ........................................................................... 3
Assessment Methodology .......................................................................................................... 5
Beneficiary Surveys................................................................................................................ 5
Cost Analysis.......................................................................................................................... 5
Process Evaluation................................................................................................................. 6
Data Limitations...................................................................................................................... 6
Characteristics of the Beneficiaries ............................................................................................ 8
Pilot Implementation .................................................................................................................14
Challenges Related to Disseminating Information .................................................................14
Challenges Related to Measuring Unmet Demand ................................................................16
Conclusions and Lessons Learned ...........................................................................................20
Bibliography ..............................................................................................................................22
ii
LIST OF TABLES AND FIGURES
Table 1. Characteristics of respondents to Ta’ziz beneficiary survey.......................................... 8
Table 2. Summary comparison of cost and utilization statistics of maternity claims...................16
Table 3. Cost and frequency of modern family planning claims by type reported to Ta’ziz from 
RSS beneficiaries .....................................................................................................................18
Figure 1. Hypothesized result chain for the contraceptive coverage pilot ................................... 4
Figure 2. Reasons for not using modern family planning............................................................ 9
Figure 3. Percent of MWRA using modern family planning against the estimated 57 percent 
required modern contraceptive use condition for break-even ....................................................10
Figure 4. Among respondents using a family planning, distribution of the method used............11
Figure 5. Among users of family planning, the type of provider used.........................................12
Figure 6. Among respondents reporting willingness to use contraceptive coverage, distribution 
of method type ..........................................................................................................................13
Figure 7. Chain of communications to reach MWRA beneficiaries for the contraceptive coverage 
pilot...........................................................................................................................................15
1
INTRODUCTION
Research studies show that ensuring a population’s access to modern family planning leads to 
improved population health outcomes. Between 1990 and 2010, access to modern family 
planning helped cut worldwide maternal deaths in half (Osotimehin, 2012). Access to modern 
family planning is estimated to prevent as many as one in every 11 child deaths (Osotimehin, 
2012). Globally, researchers have estimated that addressing unmet need for family planning 
would reduce unwanted pregnancies by two-thirds, resulting in 21 million fewer unplanned births 
and 26 million fewer induced abortions (Singh & Darroch, 2012).
Studies also show that access to private health insurance positively influences the use of family 
planning in a many developing countries (Comfort, Peterson, & Hatt, 2013). It is estimated that 
every one dollar (JD 0.71) spent on family planning saves USD 1.40 (JD 0.99) in maternal and 
newborn health care costs (Singh & Darroch, 2012). In theory, because health insurance 
providers carry the monetary risk of financing health care for their beneficiaries, such savings 
may also benefit private health insurance funds.
In Jordan, the contraceptive prevalence rate (CPR) has been relatively stagnant over the past 
10 years (Department of Statistics, MOH of Jordan and ICF International, 2013). Currently, an 
estimated 42 percent of married women of reproductive age (MWRA) are using modern family 
planning methods, and 19 percent are using traditional methods (Department of Statistics, MOH 
of Jordan and ICF International, 2013).
1
In addition, 12 percent of MWRA have an unmet need 
for family planning services (Department of Statistics, MOH of Jordan and ICF International, 
2013). Jordan has become more reliant on the private sector as a source for contraceptives,
with 56 percent of all contraceptives being procured from the private sector.2 Given the reliance 
upon the private sector, private sector strategies may help address stagnant CPR and unmet 
need for family planning in Jordan. However, working with the private sector requires a business 
case: evidence that demonstrates that implementing a strategy is financially sustainable or 
profitable for the company undertaking the strategy. 
In Jordan, an estimated 70 percent of the population is covered by health insurance (World 
Health Organization). Thus, mobilizing priority services such as modern family planning holds 
great potential for growing the CPR. Employers—health insurance companies’ main 
customers—have expressed their interest in expanding insurance coverage for their employees
 
1
The intrauterine device (IUD) is the most widely adopted modern method (21 percent), followed by the 
pill and male condom (8 percent each), female sterilization (2 percent), and long acting methods (LAM) 
and injectables (1 percent each). Withdrawal (14 percent) and rhythm (4 percent) are the most common 
traditional methods (Department of Statistics, MOH of Jordan and ICF International, 2013). In the past 22 
years, there has been a decline in the use of long-term methods such as female sterilization and IUD and 
an increase in the use of short-term methods like condoms (Department of Statistics, MOH of Jordan and 
ICF International, 2013).
2
The majority of pills (52 percent), IUDs (62 percent), and male condoms (58 percent) are procured 
through the private sector (Department of Statistics, MOH of Jordan and ICF International, 2013).
2
to include modern family planning. In a study conducted by the Higher Population Council 
(HPC), 87 of the 100 private- and public-sector employers interviewed by HPC reported a 
willingness to pay up to a two percent additional premium3
to expand coverage to include
modern family planning services (Tarawneh, Tarawneh, & Ayyoubeen, 2011). In the same 
study, HPC estimates that this would only require an increase of 1.3 to 1.6 percent in overall 
health insurance premium (Tarawneh, Tarawneh, & Ayyoubeen, 2011). This means that 
employers are willing to pay more than what would be required hypothetically to offer family 
planning benefits to their employees. Despite interest from customers, very few health 
insurance providers in Jordan offer family planning benefits. At the start of this study, only one 
health insurance company offered modern family planning benefits to the employees of the 
Embassy of the United States.
In recent years, health insurance has been limited to low profitability attributed to intense 
competition and low barriers to market entry (Yaghmour, Masri, & Kamhieh, 2011). These 
factors created pressure for health insurance providers to keep the price of their premiums low
while the costs of medication and medical services increase. The loss ratio for the health 
insurance industry stood at 91 percent in 2009, up from 83 percent in the previous year; this 
means that 91 percent of all revenues collected for health insurance were used for medical 
care, leaving only a small margin of profit for the industry (Yaghmour, Masri, & Kamhieh, 2011). 
This is evidence to support that the health insurance industry as a whole is in need of strategies 
to control its costs. Offering contraceptive coverage may help alleviate this pressure.
The Strengthening Family Planning Project in Jordan (in Arabic, Ta’ziz Tanzim al-Usra, or Ta’ziz
for short) implemented a pilot program to test the cost-benefit of offering coverage of modern 
family planning methods through private health insurance schemes in Jordan. Funded by the 
United States Agency for International Development (USAID), Ta’ziz seeks to expand the 
availability, quality, and use of modern family planning services and products through 
partnership with the private sector. Through this pilot, Ta’ziz sought to investigate whether
offering coverage of modern family planning methods and services through private health 
insurance companies would increase contraceptive use among MWRA while at the same time
decrease maternity-related costs related to unplanned pregnancies. 
This report describes the pilot program implemented by Ta’ziz and the methodology used to 
conduct the assessment. It also presents information on pilot beneficiaries, discusses the pilot 
implementation and derives lessons learned. 
 
3
Premium refers to the money required to be paid to health insurance providers in exchange for 
coverage. In Jordan, premiums are usually paid by employers in whole or in part, with the remainder paid 
by the employee receiving coverage.
3
OVERVIEW OF THE 
CONTRACEPTIVE COVERAGE 
PILOT
Ta’ziz estimated that health insurance providers could profit from covering modern family 
planning services if:
4
 Overall utilization of modern family planning methods among beneficiaries reached at least 
57 percent
 Beneficiaries opted to use the most cost-effective methods (such as IUDs)5
 Beneficiaries reduced their reliance on less cost-effective methods such as condoms that 
are high-cost to the insurer, but relatively available to beneficiaries outside of health facilities
(Tayag, 2013).
Thus, Ta’ziz piloted contraceptive coverage to assess if these conditions were feasible in a real￾world scenario and if these conditions would allow health insurance companies to, in fact, 
break-even financially (see Figure 1).6
 
4
Prior to the start of the pilot, Ta’ziz used cost data and utilization rates from HPC’s 2011 study on health 
insurance and family planning to estimate the factors that would lead to a health insurance company to 
break-even in costs. The model used data from the 2009 Jordan Population Family Health Survey 
(JPFHS) for the business case model: a general fertility rate of 127 births per 1,000; average modern 
family planning method effectiveness of 96 percent; 71 percent of births as normal deliveries, 17 percent 
of births as caesarian sections, and 12 percent of births as miscarriages or others; and 2.6 percent of 
MWRA as having been sterilized women (Department of Statistics [Jordan], 2010). Ta’ziz also assumed a 
MWRA population of 2,000 (as estimated by health insurers prior to the start of the pilot); total increase in 
modern family utilization of 16 percent; and a modern family planning utilization of 35 percent using IUDs,
two percent using injectables, nine percent combined pill, one percent implants, three percent opting for 
female sterilization surgery, and seven percent using male and female condoms. See Annex 1 for the 
complete Excel-based model.
5
The cost-effectiveness of modern methods is different for each type of method. IUDs and implants are 
the most cost-effective methods; to prevent a single pregnancy it costs JD 8.60 annually using IUD and 
JD 10.10 using implants. Injectables are less effective at JD 29.7 annually; while female sterilization, birth 
control pills, and condoms are the least effective at JD 73.50, JD 87.40, and JD 96.10, respectively 
(Tarawneh, Tarawneh, & Ayyoubeen, 2011).
6 Result chains represent a program or intervention as a linear process with activities at the front and 
long-term outcomes at the end. Such a visual display helps to explain how intermediate results relate to 
longer term intended results and identify steps to be monitored or assessed by program implementers 
(Funnel & Rogers, 2011).
4
Figure 1. Hypothesized result chain for the contraceptive coverage pilot
Ta’ziz approached eight health insurance companies and only two companies agreed to 
participate in the pilot. Mediterranean and Gulf Insurance Co. P.L.C. Jordan (MedGulf) and Al 
Nisr Al Arabi Co. Ltd. (Al Nisr) both signed memoranda of understanding (MOU). Ta’ziz
committed to cover modern family planning services. The companies committed to grant Ta’ziz
access to needed de-identified claims data and inform their network doctors of the coverage. 
Ta’ziz would deliver educational materials to help promote the contraceptive coverage. The pilot 
was designed such that health insurance companies would cover modern contraceptives for 
existing employer clients. The health insurance companies identified two current clients, the 
Royal Scientific Society (RSS) and Manaseer Group, to participate in the pilot. The employers 
committed to providing contact lists for MWRA beneficiaries. Also, the employers committed to 
allow Ta’ziz to distribute announcement cards and educational materials about family planning 
and conduct educational lectures for employees’ families to promote the coverage.7 At the start 
of the pilot, the insurers estimated that there would be more than 2,000 MWRA beneficiaries; 
however, after collecting the beneficiary lists, only 891 MWRAs (545 from Manaseer Group and 
346 from RSS) were employees or wives of employees and were beneficiaries under the 
employees’ insurance. 
 
7
Ta’ziz signed non-disclosure agreements with each of the stakeholders noted above. Ethical approval 
for this study was obtained from the Abt Associates Inc.’s Institutional Review Board (IRB).
Ta’ziz facilitates the 
pilot design and 
undertakes business 
case analysis
Ta’ziz delivers 
educational materials 
to raise awareness of 
contraceptive 
coverage
Health insurance 
companies include
family planning into 
their benefit packages
Employees are 
aware of
contraceptive 
coverage
Utilization of modern 
family planning 
increases; unplanned 
pregnancies decrease; 
insurers save money
Employers 
distribute 
information
5
ASSESSMENT METHODOLOGY
This section describes the approach used to assess the pilot implementation. Ta’ziz conducted
beneficiary surveys to estimate demand for and use of contraceptives among pilot beneficiaries, 
a cost analysis to estimate changes in maternity- and family planning-related costs to insurance 
companies, and key informant interviews to evaluate the pilot implementation process.
BENEFICIARY SURVEYS
Ta’ziz conducted a baseline beneficiary survey to identify patterns of contraceptive use prior to 
the coverage. The beneficiary survey was conducted via telephone with 891 MWRA 
beneficiaries. Ta’ziz used a structured questionnaire designed to collect information associated 
with use of modern family planning, provider preferences for family planning, and interest in 
modern family planning. The questionnaire also probed perceptions of whether insurance 
coverage would affect contraceptive method use, method choice, and provider choice. There 
were 444 total responses (279 from Manaseer Group and 165 from RSS) for an overall 
response rate of 50 percent. 
Nearly a year after the start of the coverage, Ta’ziz conducted a follow-up telephone survey. 
The follow-up survey consisted of a structured questionnaire designed to collect information on 
awareness of the coverage, use of the benefit, reasons for not using the benefit, and interest in 
learning more about the benefit. A total of 515 MRWA beneficiaries were contacted, but only 
283 MWRA participated in the survey for a response rate of 55 percent.8 All interviewees were 
asked to provide verbal consent before participating in the study and were free to decline to 
participate.
COST ANALYSIS
At the start of the pilot, Ta’ziz analyzed historical claims data related to maternity care 
(consisting of pregnancy, maternal, or post-natal care) from health insurance companies’ pilot 
participants. Ta’ziz compared this data to the data on incidence of claims incurred under the 
contraceptive coverage pilot. Ta’ziz received de-identified historical data from maternity care 
claims made by Manaseer Group beneficiaries insured by MedGulf (July 2011 to May 2013) and
from RSS beneficiaries insured by Al Nisr (January 2010 to August 2013). Ta’ziz analyzed the 
data for the number of MWRA who made claims, total annualized cost of claims, and per capita 
cost of claims. Furthermore, Ta’ziz conducted a more detailed analysis into the frequency and 
cost per completed term of pregnancy using this dataset (Annex 2 and 3).
 
8
At the start of the pilot, health insurance companies identified 891 MWRA beneficiaries. During the 
follow-up survey, health insurers identified only 515 beneficiaries. This decrease could be attributed to 
changes in the number of policyholders registered as well as the removal of inactive beneficiaries from 
insurers’ membership lists.
6
At the end of the pilot, Ta’ziz collected claims data related to maternity care and family planning 
from beneficiaries of both the Manaseer Group and RSS for a period of 15 months and 18 
months, respectively (Manaseer Group’s coverage began three months after RSS’ coverage 
started). This data was analyzed for the frequency of unique MWRA making claims, total 
annualized cost of claims, and per capita cost of claims; in addition, Ta’ziz estimated the cost 
and frequency of family planning services utilized under the pilot for RSS claims. Ta’ziz was 
unable to analyze Manaseer Group claims for family planning because MedGulf, the insurance 
company covering the employer, did not identify family planning services claims as originally 
agreed at the start of the pilot.
PROCESS EVALUATION
Ta’ziz conducted a series of semi-structured key informant interviews to evaluate the 
implementation process and better understand reasons behind the use or non-use of the 
contraceptive coverage. The evaluation used the Consolidated Framework for Implementation 
Research (CFIR) (Damschroder, Aron, Keith, Kirsh, Alexander, & Lowery, 2009). CFIR is 
composed of five domains of implementation:
1. Characteristics of the intervention
2. External influences such as policies or programs that are outside of the intervention that 
may affect implementation
3. The culture surrounding the implementation of the intervention
4. Characteristics of the individuals implementing the pilot
5. The process of implementation.
Ta’ziz interviewed two pilot program managers, six human resources managers from Manaseer 
Group, one senior executive from Al Nisr, and two medical managers from MedGulf. Though 
RSS officially agreed to participate in the process evaluation, it provided no representatives to 
be interviewed. All interviewees were asked to provide verbal consent before participating in the 
study and were free to decline to participate. The interview guides were designed to gather 
information pertaining to each of the five domains of implementation outlined in the CFIR. The
information obtained was contextualized with gray literature, the beneficiary surveys, and the 
claims data provided by the health insurance companies.
DATA LIMITATIONS
There are many limitations associated with the data available for the pilot assessment. Firstly, 
delays from partners shortened the timeline to observe changes in pregnancy patterns. 
Originally the pilot coverage was supposed to run for more than 24 months; however, coverage 
was only available to Manaseer Group for 15 months and to RSS for 18 months. Secondly, 
when signing the MOUs with Ta’ziz, insurers estimated the number of MWRAs as beneficiaries 
to be greater than 2,000, yet the pilot started with only 891 MWRAs. Claims data were for a 
relatively small number of full pregnancies observable within the claims data (113 pregnancies 
observed with Manaseer Group and 191 pregnancies observed RSS beneficiaries) and longer 
7
term trends were not available. Further, Ta’ziz was unable to distinguish family planning claims 
for Manaseer Group which prevented a comprehensive analysis of cost. Due to turnover or 
unavailability, Ta’ziz was unable to interview six of the anticipated 16 key informant interviewees
that were planned for the process evaluation. Ta’ziz, despite these issues, was able to derive 
important lessons that will inform the implementation of future similar programs in Jordan.
8
CHARACTERISTICS OF THE 
BENEFICIARIES
As presented in Table 1, the mean age of MWRA was slightly higher for respondents from RSS 
at 34.2 years old as compared to respondents from Manaseer Group who were on average 31.2 
years old. Respondents from RSS also had more children on average with 2.9 children as 
compared to 2.4 for Manaseer Group respondents. Among RSS respondents, more women 
reported that they were the primary policyholders for their health insurance policy (as opposed 
to being a dependent on the insurance policy). RSS respondents also tended to have more 
years of education compared to respondents of Manaseer Group. This may be related to the 
types of industries in which the companies are involved. RSS is a research and technical 
support service provider, whereas companies in Manaseer Group focus on labor-oriented 
industries such as manufacturing and infrastructure.
Table 1. Characteristics of respondents to Ta’ziz baseline beneficiary survey
Manaseer 
Group
(n=279)
RSS
(n=165)
Combined
(n=444)
Mean age 31.2 34.2 32.3
Average number of children 2.4 2.9 2.6
Percent of policyholders 13.6% 23.6% 17.3%
Average number of years of education 12.9 14.3 13.4
Percent currently pregnant 12.5% 13.3% 12.8%
Before the pilot began, 62 percent of Manaseer Group and 56 percent of RSS respondents
reported not using a family planning method. The most common reasons for not using a family 
planning method included: being currently pregnant, being medically unfit or having health 
concerns, preferring a traditional method, planning to get pregnant, wanting rest from the 
method, and fear of side effects (Figure 2). Thirteen percent of Manaseer Group and nine 
perecent of RSS respondents reported preferring traditional methods. Seven percent of 
Manseer Group and 13 percent of RSS respondents reported fear of side effects for not using a 
family planning method. These proportions suggest that MWRAs who were not currently using 
modern contraceptive may have benefited from additional information about the advantages of 
modern family planning versus traditional methods and about concerns related to side-effects.
Furthermore, a significant proportion of employees (79 percent of Manaseer Group and 81 
percent of RSS respondents) expressed an interest in learning more about contraceptive 
benefits. 
9
Figure 2. Reasons for not using modern family planning
At baseline, neither company had the 57 percent modern contraceptive prevalence that was 
estimated as one of the conditions for insurance companies to break-even. Thirty percent of
Manaseer Group and 44 percent of RSS respondents were using a modern family planning 
method at the time of the baseline beneficiary survey. This means that both Manaseer Group 
and RSS beneficiaries would have to increase their modern contraceptive use by 19 and 13 
percentage points, respectively, to reach the estimated level at which contraceptive coverage 
would be profitable for the insurance companies (Figure 3).
20%
16%
13%
11%
10%
7%
10%
10%
1%
0%
1%
0%
0%
1%
23%
10%
9%
11%
9%
13%
6%
5%
3%
4%
2%
1%
1%
3%
0% 5% 10% 15% 20% 25%
Currently pregnant
Medically unfit/health concerns
Prefers traditional method
Planning to get pregnant
Wanted rest from method
Fear of side effects
Postpartum
Difficult to get pregnant
Respondent opposed
Spouse absent/no sex
Husband opposed
Costs too much
Other
Don't know
RSS Manaseer Group
10
Figure 3. Percent of MWRA using modern family planning against the estimated 57 
percent break-even condition 
The most popular modern methods used by respondents in both the Manaseer Group and RSS
were IUDs (35 percent and 49 percent, respectively) and oral contraceptives (19 percent and 26 
percent, respectively). Twenty-eight percent of Manaseer Group and 17 percent of RSS 
respondents preferred to use traditional methods (Figure 4). Hypothetically, if these users of 
traditional methods converted to modern methods, then the groups of beneficiaries would have 
surpassed the hypothesized 57 percent CPR condition estimated for breaking even, financially.
Furthermore, as figure 3 presents, the percent of non-users who reported being interested in 
using a modern through the insurance also suggests a likelihood of attaining the 57 percent 
contraceptive prevalence.
38%
44%
33% 21%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Manaseer Group RSS
Non-users interested in using a
modern method with
insurance
Currently using modern family
planning
57 percent break-even 
threshold
11
Figure 4. Distribution of methods among respondents using any form of family planning 
Among those currently using modern family planning, 86 percent of Manaseer Group and 82 
percent of RSS respondents reported being satisfied with their current method of choice. Among 
those that reported being dissatisfied with their current method, the main reasons for 
dissatisfaction were side effects and inconvenience. Only seven percent of Manaseer Group 
respondents and no RSS respondents reported being dissatisfied with their method choice 
because of cost reasons. 
Among users of modern family planning, 30 percent of Manaseer Group respondents and 19 
percent of RSS respondents prefer to switch their method if family planning was covered by 
health insurance. Of these, 45 percent of Manaseer Group respondents and 50 percent of RSS 
respondents would switch to IUDs; 16 percent of Manaseer Group and 14 percent of RSS 
respondents would switch to oral contraceptives; and six percent of Manaseer Group and seven
percent of RSS respondents would switch to injectables.
The most common source of modern family planning services was a private doctor, hospital, or 
clinic (29 percent among Manaseer Group and 43 percent among RSS respondents), followed 
by pharmacies (25 percent among Manaseer Group and 19 percent among RSS respondents). 
Government health centers and maternal child health (MCH) clinics were also widely chosen for 
modern family planning (34 percent among Manaseer Group and 24 percent of among RSS 
respondents) (Figure 5).
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Manaseer Group RSS Combined
Injectable
Implants
Female sterilization
Condoms
Pills/Oral contraceptives
IUD
Traditional methods
12
Figure 5. Type of provider used among modern family planning users
Thirty-three percent of Manaseer Group and 32 percent of RSS group respondents preferred to 
switch provider types if family planning was covered by health insurance. Among these, 97 
percent of Manaseer Group and 74 percent RSS respondents preferred to switch to private 
providers.
Among respondents who were not currently using modern family planning, 54 percent of 
Manaseer Group and 38 percent of RSS respondents reported that they would use a modern 
family planning method if family planning was covered by their insurance. Among these, 50 
percent of Manaseer Group and 60 percent of RSS respondents preferred to use their coverage 
to finance their IUDs. Nineteen percent of Manaseer Group and 14 percent of RSS respondents
preferred to use their coverage to finance oral contraceptives. Twenty-one percent of Manaseer 
Group and 17 percent of RSS respondents reported that they do not know what type of method 
on which they preferred to use their health insurance coverage (Figure 6).
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Manaseer Group RSS Combined
Others
Jordan Association for Family
Planning and Protection
Government clinic or hospital
Pharmacy
Private doctor, hospital, or
clinic
13
Figure 6. Distribution of methods among respondents reporting willingness to use 
contraceptive coverage
Prior to the start of coverage, fairly large proportions of respondents reported willingness to use 
their contraceptive coverage, with most wanting to use it for IUDs. These results supported 
Ta’ziz’s hypothesis that there may be unmet demand for modern family planning that may be 
met through health insurance coverage.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Manaseer Group RSS Combined
Condoms
Implants
Injectable
Pills/Oral contraceptives
Don’t know
IUD
14
PILOT IMPLEMENTATION
Two conditions were needed to see an increase in modern family planning use among 
beneficiaries in the pilot program: (1) MWRA beneficiaries being aware of their modern family 
planning insurance coverage and (2) contraceptive coverage meeting an otherwise unmet 
demand for modern family planning. As this section describes, meeting these two conditions 
proved to be challenging.
CHALLENGES RELATED TO DISSEMINATING INFORMATION
Ta’ziz planned to conduct an interpersonal campaign incorporating posters, marketing collateral, 
educational lectures, and family-oriented events. However, companies eventually prevented 
Ta’ziz from conducting the interpersonal activities and limited Ta’ziz to distributing brochures 
and educational information through employer human resource representatives. 
Ta’ziz provided human resources representatives with brochures, a small gift, and cards 
welcoming members to the coverage. Human resource representatives reported that they sent 
news about the coverage through employees’ supervisors. Supervisors were then held 
responsible for disseminating the news to employees. However, according to Ta’ziz’s 
beneficiary survey, only 17 percent of MWRA respondents were policyholders; most (83 
percent) of MWRA respondents were dependents to policyholders. Getting messages to MWRA 
beneficiaries about the contraceptive coverage required a lengthy chain of communication 
(Figure 7). 
News about the coverage had to travel from health insurance companies to employers’ human 
resources representatives, to employee supervisors, to employees, and finally to dependents if 
the MWRA was not the primary policyholder (only 17 percent of MWRA respondents were
primary policyholders). Furthermore, health insurance companies needed to communicate to 
their provider networks to inform them that the coverage was now available to their patients.
15
Figure 7. Chain of communications for news on the contraceptive coverage to reach 
MWRA beneficiaries 
Unfortunately, Ta’ziz discovered that employers had not communicated with the MWRA 
beneficiaries directly. Nearly a year after Ta’ziz delivered the gift announcing the new benefits, 
Ta’ziz called beneficiaries and discovered that 89 percent of Manaseer Group and 87 percent of 
RSS respondents recalled receiving the gift.9 Two percent of Manaseer Group and 10 percent of 
RSS respondents reported being informed by someone about the benefit through an 
interpersonal conversation. One company, RSS, distributed new member identification cards 
that included a sticker on the cards announcing the coverage to ensure that policyholders were 
informed. However, key informant interviews revealed that this approach did not directly reach 
MWRA beneficiaries who were married to the main policyholder because only the main 
policyholder was responsible for picking up the new cards.
Key informant interviews revealed that human resource representatives viewed health 
insurance coverage as essential to recruiting and retaining their employees. However, human 
resource representatives did not believe that the family planning benefit was important for 
retaining their employees. Human resources representatives from Manaseer companies 
 
9
As noted in the limitations section, the response rate for this telephone survey was fairly low at 55
percent. Thus, these proportions are not fully generalizable to the whole population of beneficiaries. 
Furthermore, the beneficiaries were surveyed nearly a year after the gifts and announcements were 
distributed which likely influences how the respondents recalled the announcements. It is unclear if the 
small sample size and recall bias influenced responses positively or negatively.
Health 
insurers
Employer 
HR Reps
Supervisors
Employees/ 
Policyholders
Married to 
policyholder
17
% 
83
% 
Percent of MWRA 
beneficiaries in pilot
Communicated to 
provider network to 
inform them of 
coverage
16
reported that most of their employees were male laborers and had health risks related to injury 
that would have been of greater financial concern to the company than family planning. 
Employers also reported that while they actively promoted the coverage of pregnancy-related 
services, family planning was not seen as a priority because lower proportions of their 
employees were MWRAs. Further, representatives from Manaseer Group and RSS reported 
feeling that family planning was a private matter; they felt the work place was not the proper
venue to have family planning conversations. This likely explains why Ta’ziz was prevented 
from conducting educational lectures at workplaces and why such small proportions of MWRA 
reported having conversations related to their coverage.
These communication challenges prevented potentially useful information from reaching MWRA 
beneficiaries. As of one year after the start of the benefit, five percent of Manaseer Group and 
22 percent of RSS respondents reported using the modern family planning benefit.
CHALLENGES RELATED TO MEASURING UNMET DEMAND
Claims utilization and cost data were to reveal if a rise in the utilization of contraceptive 
coverage could be associated with a reduction in the number of maternity claims. However, 
Ta’ziz faced challenges related to obtaining a sufficient sample of claims structured in sufficient
detail. Health insurance companies originally estimated a population of nearly 2,000 MWRA 
beneficiaries to participate in the pilot; however, only 891 were eventually included in the pilot 
due to the lack of interest from employers. Also, health insurance companies were not able to 
provide beneficiary and detailed encounter data (as originally prearranged in the MOUs) which
limited Ta’ziz’s ability to draw conclusions from analyzing claims. Ta’ziz had originally planned 
to analyze claims frequency for a minimum of 24 months but encountered frequent delays in 
getting administrative approvals from health insurance companies and participating employers. 
Ta’ziz analyzed claims utilization and cost for a period of 15 months with employees of 
Manaseer Group and 18 months with employees of RSS. These delays limited the range of 
claims available for analysis. At the start of the pilot, Manaseer Group recorded 545 and RSS 
recorded 346 MWRA in their beneficiary lists (Table 2). The health insurance companies did not 
provide Ta’ziz with the total number of MWRAs at the end of the pilot despite several requests 
and follow-ups. These challenges prevented Ta’ziz from fully conducting the intended analysis. 
However, the information related to annualized maternity claims cost and the unit cost of 
providing family planning services may be useful for planning future executions of contraceptive 
coverage, which is why the information is presented here. 
Manaseer Group and RSS each had 112 MWRAs make maternity claims per year based on 
historical trends; thus, RSS had higher proportions of MWRAs making maternity claims
compared to Manaseer Group. By the end of the pilot, 180 of Manaseer Group and 125 of RSS 
beneficiaries made maternity claims per year. The increase in maternity claims may be due to 
changes in the number of MWRA beneficiaries in both companies. However, Ta’ziz is unable to 
assess this without the total number MWRAs at the end of the pilot from both companies.
Manaseer Group and RSS saw an increase in the total annualized cost of all maternity claims 
between the start of the pilot and the end of the pilot. Without the total number of MWRAs at the 
17
end of the pilot, Ta’ziz is unable to determine if this increased cost of maternity claims is related 
to an increase in the number of MWRA beneficiaries or if MWRAs were utilizing their health 
insurance benefits more frequently. 
Table 2. Summary comparison of cost and utilization statistics of maternity claims
Start of 
pilot
End of 
pilot
Number of MWRAs in membership lists provided by insurance 
companies
Manaseer Group 545 N/A
Royal Scientific Society 346 N/A
Number of unique MWRAs making maternity claims per year
Manaseer Group 112 180
Royal Scientific Society 112 125
Annualized cost of all maternity-related claims (in JD)
Manaseer Group 57,109.00 64,736.96
Royal Scientific Society 46,875.75 50,684.78
Per capita annualized cost of all maternity-related claims (in JD)
Manaseer Group 509.90 359.65
Royal Scientific Society 418.53 405.48
Both Manaseer Group and RSS saw a decrease in per capita annualized cost for maternity 
claims during the pilot. Annualized per capita cost of Manaseer Group claims decreased from 
JD 509.90 to JD 359.65, and RSS annualized per capita claims cost decreased from JD 418.53 
to JD 405.48. Theoretically, access to modern family planning may reduce annualized per 
capita cost of maternity claims for a population because individuals who have a higher risk of 
birth complications (e.g., MWRAs who have had multiple births and older MWRA) would have 
access to family planning for limiting or spacing. However, without more detailed information 
about beneficiaries, claim encounters, and a larger sample, Ta’ziz is unable to comment if the 
pilot contributed to the observed decrease per capita cost of maternity claims.
At the end of the pilot, Ta’ziz analyzed the family planning claims from RSS beneficiaries. Ta’ziz
was not able to analyze utilization of the benefit among Manaseer Group beneficiaries because 
MedGulf, the insurer administering the benefit was not able to disaggregate family planning 
claims from its maternity claims as originally agreed upon and documented in the MOU. A total 
of 26 MWRA RSS beneficiaries used the benefit in the period between March 2014 and 
February 2015. This population generated a total of 58 individual claims. Regarding cost of 
claims, the cost of addressing complications such as abdominal pain, vaginal bleeding, or 
vertigo associated with a modern family planning service was on average JD 7.00. The average 
cost of contraceptive management was JD 14.14, JD 9.67 for a family planning consultation, JD 
46.65 for an IUD insertion, and JD 5.31 for an oral contraceptive (Table 3). The small sample of 
18
modern family planning claims available poses limitations for the applicability of this data in 
other settings.10
Table 3. Cost and frequency of modern family planning claims by type reported to Ta’ziz
from RSS beneficiaries
Type of family planning service Min. Avg. Max. Count
Complication 2.57 7.00 10.00 6
Abdominal pain 5.17 6.01 6.86 2
Vaginal bleeding 2.57 5.29 8.00 2
Vaginitis or vulvovaginitis 10.00 10.00 10.00 1
Vertigo 9.38 9.38 9.38 1
Contraceptive management11 1.92 14.14 66.85 23
Family planning consultation 8.00 9.67 13.00 3
IUD Insertion 8.00 46.65 110.02 12
Family planning consultation 8.00 8.00 8.00 1
IUD insertion 10.73 43.17 69.00 7
Mirena 104.10 107.06 110.02 2
Nova T 16.20 17.78 19.35 2
Oral contraceptive 2.04 5.31 12.00 14
Belara 3.34 3.34 3.34 1
Cerazette 3.54 5.99 12.00 4
Marvelon 2.04 5.62 12.00 3
Yasmin 4.00 5.04 6.13 6
All family planning services 1.92 17.76 110.02 58
In sum, the pilot reveals that future executions of contraceptive coverage may encounter 
numerous challenges related to data management practices of health insurers. Health 
insurance companies in Jordan find it difficult to provide detailed claims encounter data, 
restructure coding systems to disaggregate medical services like family planning, and maintain 
updated beneficiary lists. These data elements would be required to fully assess the profitability 
of contraceptive coverage.
 
10 Presenting this data on claims may help to contextualize HPC’s calculations of annual cost per users 
based on service provider interviews. The claims analysis also informs the estimated averted cost of 
pregnancies that HPC used for its 2011 study. The HPC study found the expected cost per pregnancy to 
be JD 809, which assumed claiming for all pregnancy-related visits and events and used the cost ceilings 
reported by health insurance companies. However, Ta’ziz’s claims cost analysis revealed that the 
average amount paid by the insurance company in this pilot is about JD 653 for a Caesarian Section and 
JD 269 for a normal delivery, as opposed to the insurance ceiling JD 816 and JD 656, respectively, used 
in the HPC report. This may be because many women do not make claims at the end of a pregnancy 
event. They may be giving birth at a non-network facility or abroad or may choose to instead pay-out-of￾pocket for reasons that were outside the bounds of this study. 
11 Without detailed encounter data, Ta’ziz is unable to determine what is included in the service category, 
“contraceptive management.”
19
Challenges related to the limited data have been compounded by the perspective shared 
among health insurance representatives that the pilot was low-priority. On one hand, health 
insurance companies saw the social value in modern family planning coverage. On the other 
hand, these same individuals were not convinced of the cost-benefit of offering family planning 
coverage and therefore held contraceptive coverage as lower priority compared to other forms 
of coverage that are in great demand from their clients (such as maternity benefits). As the 
Chief Executive Officer of Al Nisr stated, “[modern family planning] is just not in our best 
interest, financially.”
20
CONCLUSIONS AND LESSONS 
LEARNED
At the start of the pilot, Ta’ziz hypothesized that there was an unmet need for modern family 
planning services among MWRA beneficiaries of private health insurance programs in light of 
DHS survey findings. Ta’ziz also hypothesized that these needs could be met through education 
about modern family planning as well as by covering the cost of contraception through health 
insurance. From the perspective of health insurance providers, contraceptive coverage may 
save insurers the cost of financing unwanted pregnancies. In Jordan, the execution of 
contraceptive coverage had never before been piloted to assess its cost-effectiveness for 
private health insurers. During its execution, the Ta’ziz contraceptive coverage pilot identified 
numerous challenges between the theoretical cost-benefit of offering coverage and the practical 
realities of ensuring informed choice to modern family planning.
One lesson learned was that contraceptive costs were not the primary barrier to family planning 
use and that attitudinal or knowledge barriers may be more significant. Ta’ziz’s beneficiary 
surveys revealed that large proportions of MWRA beneficiaries were still interested in using 
contraceptive coverage and learning more about modern family planning methods. Common 
reasons for not using modern family planning included fear of side-effects as well as preference 
for traditional methods of contraception. These attitudinal reasons may be better addressed 
through education and information sharing. Employers and health insurance providers needed
to prioritize contraceptive coverage in order to effectively use their communications channels to 
promote the benefits.
Regarding communication, strategies for disseminating culturally-sensitive information about 
contraception have long been developed. The challenge lies in gaining buy-in throughout the 
chain of communications required to reach beneficiaries. Employers have the most influence in 
raising awareness of coverage and ensuring that beneficiaries are informed. However, cultural 
stigma and misunderstanding around modern contraception must be addressed. Future 
executions of contraceptive coverage could benefit from gaining buy-in from human resource 
officers representing employers. While Ta’ziz first sought buy-in from executive level 
management at the employer companies, getting buy-in from individual human resource 
managers about the financial value of contraceptive coverage is equally important. This would
facilitate better communication, problem-solving, and identify alternative ways of reaching 
MWRA beneficiaries.
Despite the challenges encountered in the pilot implementation, health insurance companies 
decided to continue providing contraceptive coverage beyond the life of the pilot.
Representatives from health insurance companies explained that this was a social benefit they 
would like to continue promoting. This may incentivize other competing health insurance 
companies to offer similar coverage in the future. Future executions of contraceptive coverage 
could be strengthened by assessing the profitability of such strategies to reinforce the social 
21
rationale. To measure profitability and better assess contraceptive coverage, future executions 
will need to build the capacity of health insurance providers to manage their claims and 
membership data. Data on active beneficiaries, detailed data on claims encounters, 
disaggregate coding for family planning services, as well as larger samples over longer time 
periods will strengthen the evidence for the profitability of contraceptive coverage.
Future executions of contraceptive coverage should use the lessons documented in this study 
to inform communication plans, assessment timelines, sampling, and activities related to 
updating health insurer claims and membership management databases. With an estimated 70
percent of the population covered by health insurance, mobilizing priority services such as 
modern family planning holds great potential for growing the CPR (World Health Organization).
Furthermore, executing strategies such as contraceptive coverage may assist the health 
insurance industry in controlling its overall costs. Realizing these benefits, however, hinges on 
overcoming the challenges documented in this study.
22
BIBLIOGRAPHY
Comfort, A., Peterson, L., & Hatt, L. (2013). Effect of Health Insurance on the Use and Provision 
of Maternal Health Services and Maternal and Neonatal Health Outcomes: A Systematic 
Review. Journal of Health, Population, and Nutrition(31), 81-105.
Damschroder, L. J., Aron, C. D., Keith, E. R., Kirsh, R. S., Alexander, A. J., & Lowery, C. J. 
(2009). Fostering implementation of health services research findings into practice: a 
consolidated framework for advancing implementation science. Implementation Science.
Department of Statistics [Jordan]. (2010). Jordan Population and Family Health Survey 2009.
Calverton, Maryland: Department of Statistics and ICF Macro.
Department of Statistics, MOH of Jordan and ICF International. (2013). Jordan Population and 
Family Health Survey 2012. Calverton, MD: Department of Statistics and ICF 
International.
Funnel, S., & Rogers, P. (2011). Purposeful Program Theory: Effective Use of Theories of 
Change and Logic Models . San Franciso: John Wiley & Sons.
Osotimehin, B. (2012). Family Planning Saves Lives, Yet Investments Falter. Lancet, 82-83.
Singh, S., & Darroch, J. (2012). Adding It Up: Costs and Benefits of Contraceptive Services￾Estimates for 2012. New York: Guttmacher Institute.
Tarawneh, M., Tarawneh, B., & Ayyoubeen, Y. (2011). Feasibility of Family Planning Services 
Inclusion within Public and Private Employers Health Insurance Plans. Amman: Higher 
Population Council.
Tayag, J. (2013, April). Jordan Modern Family Planning Coverage Insurance Business Case 
Scenarios. Amman, Amman, Jordan.
World Health Organization. (n.d.). Jordanian experience: Keeping out-of-pocket spending under 
control (Jamal Abu Saif). Retrieved August 6, 2015, from http://www.emro.who.int/about￾who/universal-health-coverage/jordanian-experience-keeping-out-of-pocket-spending￾under-control.html
23
Annexes
Annex 1: Health Insurance Business Case Model
Annex 2: Manaseer Group Claims Data: Baseline Cost Summary
Annex 3: Al Nasr Al Arabi Group Claims Data: Baseline Cost Summary