RESEARCH, MONITORING & EVALUATION

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1 RESEARCH, MONITORING & EVALUATION Findings of an 18-month assessment of the effectiveness of a rural-based social franchising programme using vouchers of long-term family planning services in Pakistan Dr. Syed Khurram Azmat ISSN Working Paper Series No. 3, 2012 Research, Monitoring & Evaluation Marie Stopes Society, Pakistan

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3 RESEARCH, MONITORING & EVALUATION Findings of an 18-month assessment of the effectiveness of a rural-based social franchising programme using vouchers of long-term family planning services in Pakistan Dr. Syed Khurram Azmat The opinions reflecting in this paper are solely the author s and do not reflect the opinion of Marie Stopes Society Pakistan. mariestopes@msspk.org Website:

4 Acknowledgement Acknowledgement It gives me great pleasure to present this Working Paper, third (03) of a series from Marie Stopes Society s (MSS) Research, Monitoring and Evaluation (RME) department. The Working Paper is based on the findings of the 18-months assessment of MSS Social Franchise (SF) model to enhance access to and utilization of modern contraception among underserved women in rural areas of Pakistan. Branded as Suraj, meaning Sun in English, MSS launched its SF model in 2008 and initially forged a partnership with 100 mid-level Private Sector Providers (PSPs) in eighteen (18) districts of the two most populous provinces of Pakistan that include Sindh and Punjab. The effectiveness of this model was evaluated via baseline and endline population based surveys in four (4) intervention and control districts. The study prolonged over 24 months including 18 months of intervention period. Based on the impact and quality of care it maintained throughout, the Suraj model is being further expanded to more districts. It also gives me immense delight to inform that this Suraj SF model was awarded the 2011 International Quality Award by the Global Health Group, University of California, San Francisco. The RME department was mainly responsible for designing the surveys, managing collection of data, data analysis, report writing, dissemination of results at various forums and development of this working paper. My special thanks go to Dr. Syed Khurram Azmat Deputy Director Technical Services, for his strong leadership and technical assistance throughout the project period. In addition, I am greatly thankful to the entire RME team especially, Mr. Waqas Hameed Senior Manager RME, Mr. Ghulam Mustafa Manager RME, Mr. Ishaque Sheikh Assistant Manager RME, Mr. Wajahat Hussain, Mr. Safdar Ali and Mr. Aftab Ahmed. I acknowledge the contribution of each one of them with appreciation as without their support, immense help and technical assistance this endeavor would not have been possible! Moreover, I would like to acknowledge and thank all of the persons who strongly supported and facilitated us at various phases of the surveys. First of all, I would like to thank all of the respondents across the two provinces of Pakistan who participated in the surveys. I am also highly thankful to the entire social franchise and operations teams at support, regional and district offices including Director Operations Dr. Shafqat Ijaz, Senior Project Manager Social Franchise Mr. Jamshaid Asghar, Regional Managers Operations (RMOs), Regional Executives Social Franchise (RESFs), District Project Officers (DPOs), Suraj service providers, and Field Workers Marketing (FWMs)/Senior Field Supervisors (SFSs) for their support during various stages of the surveys. Finally, I would like to thank Communication and New Business Development (CNBD) department at MSS for reviewing the final draft of the Working Paper (WP) and providing valuable feedback. Mohsina Bilgrami Country Director Marie Stopes Society, Pakistan i Marie Stopes Society, Pakistan - Working Paper Series No. 3, 2012

5 Abbreviations List of Abbreviations CNBD Communication and New Business Development CPR Contraceptive Prevalence Rate DPO District Project Officer DSF Demand Side Financing FP Family Planning FWM Field Worker Mobilization IUCD Intra-uterine Contraceptive Device LHV Lady Health Visitor LTM Long Term Method MDGs Millennium Development Goals MSS Marie Stopes Society MWRA Married Women of Reproductive Age PDHS Pakistan Demographic Health Survey PSPs Private Sector Providers RESFs Regional Executives Social Franchise RH Reproductive Health RME Research, Monitorining and Evaluation RMO Regional Manager Operations SES Socio-economic Status SF Social Franchise SFS Senior Field Supervisor WHO World Health Organization WP Working Paper ii Marie Stopes Society, Pakistan - Working Paper Series No. 3, 2012

6 Contents Contents List of Tables 4 List of Figures 4 Abstract 5 Background and Introduction 6 The context and rationale 7 Study objectives 8 Methods 9 Statistical Analysis 9 Results 10 Effect of intervention 11 Ever use and Current use of contraception 12 Contribution of voucher and FWM in uptake of contraception 13 Satisfaction with Social franchise services 13 Discussion and Conclusion 14 References 15 iii Marie Stopes Society, Pakistan - Working Paper Series No. 3, 2012

7 Tables & Figures List of Tables Table 1: Study sites and sampling details 9 Table 2: Percent distribution of study participants by selected socio-demographic 10 characteristics according to study arms at baseline Table 3: Awareness about contraceptive methods 11 Table 4: Ever and current use of contraceptive methods 12 List of Figures Figure 1: Main intervention components 8 Figure 2: Percent distribution of women who received contraceptive services 13 from social franchise, by their source of motivation 4 Marie Stopes Society, Pakistan - Working Paper Series No. 3, 2012

8 Abstract Abstract Introduction Nearly 14,000 women die each year in Pakistan from causes related to pregnancy. This number is projected to have been 1.7 times higher without contraceptive practice. Family planning is known to be one of the most cost-effective ways to reduce maternal deaths, but currently only 29.3% use contraceptives. This paper evaluates the effectiveness of a twopronged approach using social franchising and vouchers designed to increase contraceptive utilization, especially long term birth spacing methods, among underserved women in rural areas of Pakistan where the use of contraceptives is very low in order to improve maternal health. Conclusion The two-pronged social franchising approach implemented by MSS Pakistan, that generates demand (field workers and vouchers) and addresses the supply gap (trained providers), can effectively increase awareness and uptake of contraceptives that would ultimately improve maternal health. Methods A quasi-experimental study design with controls was used. One intervention and one control district were purposively (based on socio-demographic and reproductive health indicators) selected each from two provinces of Pakistan; and each district had a total of four providers. All providers in intervention groups were franchised, trained, and have demand generated through field workers (social franchising intervention) and vouchers (free voucher intervention); while control providers continued with their routine practices without changes. A population-based, cross-sectional survey was carried out among 4992 married women of reproductive age group (MWRA) in Feb 2009 within the catchment areas of each provider and after 18 months, an endline survey was conducted among 4003 MWRA. Multiple logistic regressions were used to estimate net effect (difference in interventiondifference in control) using Stata Results The intervention significantly increased the awareness of modern contraception by 5% (p-value <0.001) when adjusted for control. The ever use of modern contraceptive was increased by 28.5% (p-value <0.001). A substantial increase of 19.6% (p-value <0.001) was observed in contraceptive prevalence, with modern contraceptive use increasing by 22.7% (p-value <0.001); while the use of traditional method was reduced by 3% (p-value <0.001). Among modern methods, the highest change was recorded in IUCD with 11.1% (p-value <0.001) as the intervention was promoting long-term method use; and among IUCD users 76.4% had it inserted from Suraj SF centre including 34.7% women who received it through vouchers of all women interviewed, nearly 28% reported that they had received contraceptive services from MSS social franchise provider and were referred by MSS demand generation field workers including: 8.9% with voucher (for IUCD) and nearly 20% without voucher (for any contraceptive service). 5 Marie Stopes Society, Pakistan - Working Paper Series No. 3, 2012

9 Background & Introduction Background and Introduction Public Health development and promotion can be efficiently carried out via Family planning (FP) activities. FP services can serve as a cornerstone in achieving MDGs, for they have the potential to reduce poverty and hunger resulting from unplanned population growth. And about 30% of maternal and 10% of child deaths can be reduced by adopting effective FP methods (Cleland, Bernstein et al. 2006). In countries with limited resources, FP is a cost effective intervention. It improves population s health along with socio-economic indicators and the overall pace of development in a country. Countries having weak public health provision infrastructures are faced with numerous challenges of governance, scarcity of human resources and financial constraints. In such situations private providers can contribute significantly to family planning services (Bank; 1993; Swan and Zwi 1997; Winfrey W et al 2000; Marek, O Farrell et al. 2005).The World Health Organization (recognizing the need for effective FP service provision) emphasizes on the need to set up partnerships with FP private practitioners using a range of methods, including social franchising (WHO 2007). Africa and Asia both show records of successes in franchising of sexual and reproductive health services, stating it as a viable solution for the growing demands for health care from the public(prata, Montagu et al. 2005; Frost 2006).Thus several methods for direct delivery of the FP healthcare services have emerged by engaging the private sector in Asia and Africa. These include contracting out, voucher schemes, insurance schemes, provider accreditation, and social marketing (Kumaranayake, Mujinja et al. 2000; Smith, Brugha et al. 2001; Mills, Brugha et al. 2002; Stephenson, Tsui et al. 2004). A social franchise network is a kind of business model, in which independent providers or service delivery outlets are provided licenses by a franchising organization to operate under its brand name (Qureshi 2010). Developing countries like Pakistan have shown a great deal of interest in employing social franchising models to promote family planning and reproductive health services in resource poor and underserved areas (Mills, Brugha et al. 2002; Chandani and Sulzbach 2006). can change the health-seeking behavior and may offer a greater potential for population benefit compare to supply side programmes(montagu and Graff 2009).For many potential and willing family planning users would not be able to afford these services if they were to pay for them out of their own pockets. Thus their inability to afford will result in their exclusion and further add their number to the unmet need. In addition to FP services, more clientele for family planning can be an added benefit to the provider s income, who might consult him/her for other ailments too. Voucher programmes are a kind of demand-side financing (DSF) in which subsidy is directly or indirectly given to the targeted people and Vouchers have been found to be an effective way to address the issue of cost involved (Montagu and Graff 2009). Many countries have demonstrated large scale impact through these schemes (Hecht, Batson et al. 2004; Eichler 2006; Gold 2010; Shah, Wang et al. 2011). In service models with social franchising, vouchers can be used to pay for providers services like consultation fee, cost of contraceptives, follow up and treatment of complication, etc. A major challenge in DSF remains to be the identification of target group and assuring delivery of services to them. For approaches, in which subsidies are provided to the client/patients instead of service deliver, are difficult to monitor as they are more prone to corruption problems due to lesser education among the people offered a subsidy. However, well established and controlled/monitored demand side subsidies 6 Marie Stopes Society, Pakistan - Working Paper Series No. 3, 2012

10 Context & Rationale Context & Rationale For over the last one and half decade, Pakistan has not been able to show a significant change in the fertility and population growth rate. Country s population exceeded 174 million in 2011 and is growing at rate of 1.9% per annum which is much higher than that of its South Asian neighbours. Majority of its population (65%) lives in rural areas and 61% earns less than 2 US$ a day. The modern contraceptive users in Pakistan about 22% (who already have 4-5 children) and the most common contraceptive method is Condom (besides tuballigation). And condoms are short term male dependent method having a high failure rate (National Institute of Population Studies and Macro International 2008). The unmet need for family planning in Pakistan stands at 25% among currently married woman and it is the highest in the women of its rural, underdeveloped regions who are poor and have no education (National Institute of Population Studies and Macro International 2008). Promotion and utilization of Long term birth spacing methods require improvement by removing and addressing the existing constraints and access barriers respectively. Long term contraceptive methods such as Intrauterine Contraceptive Device (IUCD) are highly reliable - in averting unwanted pregnancies (Lassner, Chen et al. 1995) and have a high efficacy of >98%. In Pakistan, IUCD use has been as low as 2% with accompanying reasons to explain such little utilization. One of these reasons is the minimal number of facilities which offer long term contraceptive methods (accompanied with the necessary qualities and standards). Government health facilities are rarely visible and seldom provide FP services to the clients and their overall state of responsiveness is poor. Further aggravation is caused by intermittent availability of contraceptive supplies(shaikh 2010) and the unsympathetic attitude of the providers. Thus the clients look toward the private sector where they find a totally opposite picture. They perceive that services (on payment) from a private provider are more trustworthy and reliable. However, keeping in mind the current poverty trends in Pakistan, a major question of affordability comes into play. Nonetheless, it is essential not to ignore the demand for quality services and spacing in pregnancies which has been documented on multiple occasions. (inclusive of prevention) and for advice on common health problems (Shaikh 2008; Government of Pakistan 2011). Furthermore, franchising family planning services at the private providers outlets has shown optimistic results as regards the contraceptives utilization rates in Pakistan(Shah, Wang et al. 2011). Thus it is important that a mechanism to overcome the financial barrier at the users end is essential to facilitate use of private services of family planning. In response to this high unmet need and low contraceptive prevalence in underserved rural areas of Pakistan, Marie Stopes Society (MSS) established Social Franchise model in 2008, branded as Suraj which means sun in English. This network forged partnerships with 100 mid-level Private Sector Providers (PSPs) which includes Lady Health visitors/midwives/nurses(marie Stopes Society 2010; Azmat, Shaikh et al. 2012). These PSPs were trained and accredited to provide condoms, emergency contraceptives, injectable, oral contraceptives and to insert and remove intrauterine devices IUCDs (refer to figure 1). The IUCD component of Suraj also includes a voucher scheme which provides payment to the service provider in case a client is unable to pay.under MSS DSF integrated social franchise model, the potential FP client is given a free voucher for IUCD which the client can redeemed at the respective SF provider with no money to incur by the client. Later, the amount of the service charges is reimbursed to the SF provider upon her claim. The MSS Suraj model recognises the fact that economic and access barriers are indeed major hurdles and need to be overcome in order to provide the much needed FP services to the underserved communities. The providers on the other hand, lack the communication/counselling skills. Majority of the family planning centres and health facilities lack in aspects of environment (ensuring confidentiality services and aseptic conditions) for IUCD insertion(shaikh 2010). In addition they have not been provided adequate incentives nor are acknowledged for their services; therefore, they show low motivation levels. The other issue include side effects and fears/fallacies related to the use of IUCD which prevents many potential users of this long term method to adopt it as a birth spacing method (Azmat, Shaikh et al. 2012). Many national studies and government s own surveys have documented that more than 80% of the people prefer private providers for first level care 7 Marie Stopes Society, Pakistan - Working Paper Series No. 3, 2012

11 Study Objectives Study Objectives To evaluate the effectiveness of this two-pronged social franchising approach in increasing contraceptive utilization, especially long term birth spacing methods, among underserved women in rural areas of Pakistan. Figure 1: Main intervention components 1. Training on RH/FP and post training evaluation Medical: RH and FP counselling, quality of services, and IUCD insertion/removal; Business: basic budgeting skills, record keeping, stock management, branding, marketing, and the voucher management. The training is followed by post training evaluation conducted by external consultant (medical doctor). 2. Voucher for LTM (IUCD) Voucher worth US$ 2.10* and is only for IUCD (insertion, follow-up and removal). The voucher is distributed by FWM to eligible women, identified through poverty scale. It is redeemed at Suraj PSP. The reimbursement is sent to PSP against her claim. *Conversion rate USD1 = 95PKR Suraj Social Franchise Components 3. Field Worker Marketing (FWM) FWM is a local resident of the community; undergoes training on FP methods, voucher distribution system, and data recording. Pays door to door visits, provides FP information, generates referrals, distribute vouchers for IUCD to eligible women using a poverty ranking scale. 4.Branding/Marketing PSPs are branded as Suraj while marketing is done through FWM, posters, wall paintings, leaflets, etc. The Suraj logo is displayed prominently in Urdu outside all clinics. 8 Marie Stopes Society, Pakistan - Working Paper Series No. 3, 2012

12 Methods Methods Employing a before and after design with a control arm, the study was conducted with target population in four districts of Punjab and Sindh provinces of Pakistan. Two districts were selected in each province with equivalent comparison population where one district served as an intervention site whereas the other one served as a control site. A total of four Private Sector Providers (PSPs) were selected as franchise in each districts including the comparison districts. The selection criteria for PSP was i) mid-level female provider ii) located in rural areas iii) interested in providing family planning and birth spacing services iv) willing to comply with standard medical and business protocols. On the whole, sixteen PSPs were taken on-board for this study and all of them were Lady Health Visitors (LHVs). All PSPs were located in hard to reach rural areas at a distance of 30 kms from the district head quarter hospital and covered a population of 16,000 to 20,000. The providers were located at large enough distance from each other to avoid contamination. Baseline survey was conducted during February 2009 in both of the intervention and control districts with 4992 Married Women of Reproductive Age (15-49 years) residing within the catchment area of the study provider. The first household was randomly selected and after that every second household was included in Table 1: Study sites and sampling details the survey using a systematic approach. If more than one MWRA were present in any household, only one MWRA was selected for the interview using a lottery method. The endline survey was conducted with 4003 MWRA after eighteen months of intervention during July/August 2010 in the same intervention and control areas. Same sampling strategy was used except that every fourth household was included in the endline survey instead of every second household as during the baseline to insure sample representativeness (Table 1). Moreover, the sample was equally divided between the study arms and within each provider s catchment area. The baseline household questionnaire was adopted from PDHS structured questionnaire and was divided into three sections i) socio-economic status (SES): possession of household assets, education, household member, construction of house, source of drinking water ii) reproduction: parity, current pregnancy, outcomes of pregnancies, source of antenatal care, desire for children; and iii) contraception: awareness, ever use, current use, future intention, method switching behaviour, source of contraceptive method reason for not practicing contraception and ever use of free contraceptive services. The same baseline household questionnaire was used for the endline survey with a few added questions concerning the intervention. Each interview took half an hour on average. The data was double entered in Visual FoxPro version 6.0. Description Baseline Endline Systematic sampling Every 2nd household Every 4th household Total Sample size 4,992 4,003 Sample size for Control 2,509 2,019 (Dadu and Khanewal) Sample size for Intervention 2,483 1,984 (Jhang and Badin) Sample size for provider s 312/PSP (approx.) 250/PSP (approx.) catchment area Statistical Analysis Frequencies and proportions for continuous variables were used for analysis of general characteristics and multiple logistic regressions was used to test the net effect of intervention accounting for observed and unobserved time-in-variant characteristics as well as time-varying factor between intervention and control sites. Individual outcome was regressed against a dummy variable [created by taking the product of time (baseline and endline) by study arm (intervention and control)]. The analysis was adjusted for other socio-demographic indicators such as SES quintiles, women education, number of members living in the house, and number of live children and also the province. STATA version 11.2 was used for descriptive analysis and models estimation. 9 Marie Stopes Society, Pakistan - Working Paper Series No. 3, 2012

13 Results Results Table 2 shows the characteristics of women interviewed at baseline in intervention and control arm. In both arms distribution of women age, number of children, education and working women were similar whereas small differences were seen between mother tongue, religion, number of household members and socio-economic quintiles. In both arms, mean age was around 31 years having majority of housewives along with no formal education and had. 0-2 live children. Table 2: Percent distribution of study participants by selected socio-demographic characteristics according to study arms at baseline Characteristics Intervention (%) Control (%) (n=2483) (n=2509) Mean age of women in years (SD) 30.5 (5.8) 31.9 (6.6) Mother tongue Urdu Sindhi Punjabi Others (Balochi, pushto, hindko, siraiki) No of alive children Education Categories No education Primary Middle Secondary Inter and post Working women Yes No Religion Islam Hinduism Christianity Median household member 9 6 Socio-economic quintiles First/(poorest) Second Third Fourth Fifth/Least poor Marie Stopes Society, Pakistan - Working Paper Series No. 3, 2012

14 Effects of Intervention Effect of Intervention In control site at baseline awareness of any modern contraceptive (91.0%) was higher than intervention sites (88.4%) whereas awareness of traditional methods was higher in intervention (69.2%) in comparison to control site (58.7%). Table 3 shows the increase in awareness of each method within intervention (column 5) and control sites (column 6). However, Contraception awareness was much higher in intervention sites as compared to the control sites in which the difference was 6.4% (p-value <0.001) for any method and 5.0% (p-value <0.001) for modern method whereas male sterilisation with 8.4% (p-value <0.001) and injection with 7.7% (p-value <0.001) were amongst the highest increase in intervention site. Table 3: Awareness about contraceptive methods Intervention Sites Control Sites Absolute Difference Net Effect (%) (%) (% change) (% change) Baseline Endline Baseline Endline Intervention Control (1) (2) (3) (4) (5) (6) (7) Any method *** Modern Method *** Traditional Method *** Pills *** Condom IUCD *** Injection *** Female Sterilization *** Male Sterilization *** Periodic Abstinence *** Withdrawal *** Number of cases Absolute difference is the percentage changes from baseline to endline. 2Net effect is the percentage change in intervention group adjusting for the percentage change in control group. Statistical significance is calculated using multiple logistic regressions adjusting for socio-economic quintiles, women age, and number of children, working women, women education and province. P-value: ***<0.001 **<0.01*< Marie Stopes Society, Pakistan - Working Paper Series No. 3, 2012

15 Use of Contraception Ever and Current use of Contraception Table 4 shows the changes in the ever use, contraceptive prevalence rate (CPR), method mix and unmet need for contraception. The CPR in intervention and control was similar at baseline; while 18.3% and 23.9% were modern and 8.9% and 4.6% were traditional at intervention and control site respectively. At endline, the CPR had increased to 48.0% (column 2) and use of modern method to 43.2%; the net effect (column 7) showed 19.6% (p-value <0.001) increase in CPR and 22.7% (p-value <0.001) increase in modern use after adjusting by control sites. In addition, the use of traditional method reduced in intervention by 3.1% (p-value 0.003). The highest percentage change within modern method was observed in IUCD at 11.4% (p-value <0.001). Column 7 in Table 4 also shows that there was a statistical significant increase in ever use of any contraceptive method at 25.2% and ever use of any modern method at 28.4% whereas a reduction is clearly apparent in the unmet for contraception in both study arms However, the intervention substantially reduced the unmet need by 7.6% (p-value <0.001) adjusting for control arm. Table 4: Ever and Current use of contraceptive methods Intervention Sites Control Sites Absolute Difference Net Effect (%) (%) (% change) (% change) Baseline Endline Baseline Endline Intervention Control (1) (2) (3) (4) (5) (6) (7) Ever use of any contraception *** Ever use of any modern Method *** Contraceptive Prevalence Rate *** Modern Method *** Traditional Method ** Pills *** Condom *** IUCD *** Injection *** Female Sterilization ** Male Sterilization Periodic Abstinence * Withdrawal *** Others Unmet need for contraception *** Number of cases Absolute difference is the percentage changes from baseline to endline. 2Net effect is the percentage change in intervention group adjusting for the percentage change in control group. Statistical significance is calculated using multiple logistic regressions adjusting for socio-economic quintiles, women age, and number of children, working women, women education and province. P-value: ***<0.001 **<0.01*<0.05 At baseline, in intervention, the services of govt. health facility were used by majority of the contraceptive users at (44.2%) along with private health facility (32.5%), drugstore (9.3%), outreach worker (5.8%) and (8.2%) other sources. At endline, 52.2% of the contraceptive users mentioned Suraj Provider as the main source of services followed by govt. health facility (15.6%) and private health facility 14.0%. 12 Marie Stopes Society, Pakistan - Working Paper Series No. 3, 2012

16 Voucher and FWM Contribution of voucher and FWM in uptake of contraception At endline, in intervention, amongst the interviewed women, 28% had received contraceptive services from Social franchise provider. Of the total women, 8.9% received IUCD services through voucher and nearly 20% referred by FWM without voucher (for any contraceptive service). 3.8% were walk-in-clients as shown in the figure Figure 2: Percent distribution of women who received contraceptive services from Social franchise, by their source of motivation Endline survey (n=1984) % Women received services through voucher Women received serivces from SF provider and referred by FWM with no voucher % Women received services from SF and were referred by FWM with or without voucher % 3.8% Walk-in client to SF 0 Satisfaction with Social franchise services Ninety Six Percent (96%) of the women were satisfied from the services they received from Social franchise. The quality of advice/information received was the most cited reason of satisfaction for 31.4% clients followed by affordable/cheap price at 27.3%. Majority of clients 98% would recommend social franchise services to their friends/relatives. 13 Marie Stopes Society, Pakistan - Working Paper Series No. 3, 2012

17 Discussion & Conclusion Discussion Social franchising with demand-side financing approaches has gained increasing attention in the recent years in low income countries, yet the existing evidence is not considered sufficient enough to promote the concept (Frost 2006; Eldridge and Palmer 2009; Basinga, Mayaka et al. 2011).DSF has also been used widely in the United States and United Kingdom to drive quality improvements in health care service delivery (Eldridge and Palmer 2009) and now it has been gaining increasing attention as a means to achieve national goals in low-income countries(hecht, Batson et al. 2004; Eichler 2006). This pilot study attempted to assess the effectiveness of DSF integrated social franchising to promote family planning, (especially long term contraceptive methods) in the rural areas of Pakistan. Despite differences in the socio-economic and demographic characteristics between intervention and control population, the multivariate analysis accounting for all these differences showed a very substantial effect of intervention on almost all the key outcome indicators including contraceptive awareness, ever use, current use, and unmet need for family planning. The awareness of modern contraceptive at baseline was quite low in intervention (88.4%) compared to what is reported for the rural population nationally i.e. 94.4%(National Institute of Population Studies and Macro International 2008). Later, the intervention significantly increased the awareness of modern contraceptive by 5%. This present study showed a considerable increase in all modern contraceptive methods where most notable change was observed in IUCD use by about 11% whilst its national use is only 2.3%(National Institute of Population Studies and Macro International 2008). Moreover, a significant reduction in traditional method by 3.1% was also documented. Higher (35%) unmet need for family planning was recorded at baseline in both study arms while the intervention exerted a considerable reduction in it. With respect to sources of contraceptive method, presence of social franchise clinics considerably reduced the share of the government and other private health facility from baseline to endline in intervention sites. However, the share of drugstore, outreach worker and other sources did not reduce much, which may be due to the fact that such sources are normally used to acquire the short term contraceptives such as condoms or pills etc. (National Institute of Population Studies and Macro International 2008).Community health workers have been on the frontline in providing care to the disadvantaged groups for decades(gold 2010). In this study too, the FWM has played a key role in referring clients to the social franchise provider with and without voucher. Moreover, the high level of satisfaction of the women who received contraceptive services from social franchise can be considered as the outcome of medical and business training and continuous monitoring. SURAJ social franchise IUCD clients revealed 81% continuation rates - with 74% citing field worker marketing as the source of information for the SF centre(azmat, Shaikh et al. 2012). Nearly 80% of the providers were found to be complying with organisational clinical standard(azmat, Hameed et al. 2011). This resulted in higher level of client satisfaction with around 80% showing willingness to use SF services in future, in case of need; and 97% said that they would recommend SF services to friend or relative(azmat, Shaikh et al. 2012). The increase in knowledge and use of contraception (particularly IUCD), higher level of satisfaction, quality of care, and role of FWM were acknowledged by SF clients in the qualitative interviews(azmat, Hameed et al. 2011). Moreover, similar perceptions regarding increasing awareness of contraception, importance of voucher, role of FWM and training for providing quality services were documented during in-depth interviews conducted with SF provider and FWMs (Azmat, Hameed et al. 2011). Conclusion The findings of this pilot study support the idea regarding the ability of the two-pronged social franchising approach in promoting the awareness and use of modern contraception through increasing the accessibility to quality and affordable family planning services for the underserved communities. The results reinforce the two pronged approach i.e. generating the demand (through FMW and voucher) and addressing the need (through trained FP providers and uninterrupted supplies of contraceptive products). These findings can be generalized in similar settings. The results of the pilot research and the monitoring data of SF project across 18 districts helped to understand the impact of this DSF model in the country. However, it would be desirable to have an assessment of health outcomes associated with social franchise services along with an economic evaluation of this model as well. This would help in ascertaining the effectiveness, limitations and potential of scaling up this DSF model in Pakistan Between August 2008 and September 2011, the Suraj social franchise model was able to deliver 148,419 IUCDs with 35% share of vouchers, across 18 districts of Pakistan(Azmat, Hameed et al. 2011). A recent study conducted amongst the 14 Marie Stopes Society, Pakistan - Working Paper Series No. 3, 2012

18 References References Azmat, S., W. Hameed, et al. (2011). Evidence to innovate: Reproductive health social franchising through output-based aid Vouchers in the Rural Areas of Pakistan. International Conference on Family Planning: Research and Best Practices Nov 29-Dec 02. Dakar, Senegal. Azmat, S., W. Hameed, et al. (2011). Perspectives and practices of client, provider and marketing worker of an effective family planning social franchise intervention in rural Pakistan: qualitative enquiries. International Conference on Family Planning: Research and Best Practices Nov 29-Dec 02. Dakar, Senegal. Azmat, S. K., B. T. Shaikh, et al. (2012). "Rates of IUCD discontinuation and its associated factors among the clients of a social franchising network in Pakistan." BMC Womens Health 12: 8. Bank;, W. (1993). Investing in health. World Development Report 1993, Investing in health. Washington, World Bank. Basinga, P., S. Mayaka, et al. (2011). "Performance-based financing: the need for more research." Bull World Health Organ 89(9): Chandani, T. and S. Sulzbach (2006). Private Provider Networks: The Role of Viability in Expanding the Supply of Reproductive Health and Family Planning Services. Bethesda, MD, Private Sector Partnerships-One project, Abt Associates Inc. Cleland, J., S. Bernstein, et al. (2006). "Family planning: the unfinished agenda." Lancet 368(9549): Eichler, R. (2006). Can ''Pay-for-Performance'' increase utilization by the poor and improve the quality of health services? Discussion paper for the first meeting of the Working Group on Performance-Based Incentives Washington DC, Centre for Global Development Eldridge, C. and N. Palmer (2009). "Performance-based payment: some reflections on the discourse, evidence and unanswered questions." Health Policy Plan 24(3): Frost, N. (2006). Social franchising of sexual and reproductive health services in Honduras and Nicaragua. London, UK, Marie Stopes International. Gold, R. (2010). " 'I Am Who I Serve' Community Health Workers In Family Planning Programs." Guttmacher Policy Review 13(3). Government of Pakistan (2011). Pakistan Survey of Living Standards Measurement Islamabad, Federal Bureau of Statistics. Hecht, R., A. Batson, et al. (2004). Making Health Care Accountable - Why performance based funding of health services in developing countries is getting more attention. Finance and Development 41: Kumaranayake, L., P. Mujinja, et al. (2000). "How do countries regulate the health sector? Evidence from Tanzania and Zimbabwe." Health Policy Plan 15(4): Lassner, K. J., C. H. Chen, et al. (1995). "Comparative study of safety and efficacy of IUD insertions by physicians and nursing personnel in Brazil." Bull Pan Am Health Organ 29(3): Marek, T., C. O Farrell, et al. (2005). Trends and Opportunities in Public-Private Partnerships to Improve Health Service Delivery in Africa. Africa Region Human Development: Working Paper Series. Africa, The World Bank. Marie Stopes Society (2010). SURAJ - A PRIVATE PRO- VIDER PARTNERSHIP.. CASE STUDY. R. Saeed and F. Khan. Karachi, Pakistan, Marie Stopes Society. Mills, A., R. Brugha, et al. (2002). "What can be done about the private health sector in low-income countries?" Bull World Health Organ 80(4): Montagu, D. and M. Graff (2009). "Equity and financing for sexual and reproductive health service delivery: current innovations." J Fam Plann Reprod Health Care 35(3): National Institute of Population Studies and Macro International (2008). Pakistan Demographic and Health Survey Islamabad, Government of Pakistan. Prata, N., D. Montagu, et al. (2005). "Private sector, human resources and health franchising in Africa." Bull World Health Organ 83(4): Qureshi, A. M. (2010). "Case Study: Does training of private networks of Family Planning clinicians in urban Pakistan affect service utilization?" BMC Int Health Hum Rights 10(1): 26. Shah, N. M., W. Wang, et al. (2011). "Comparing private sector family planning services to government and NGO services in Ethiopia and Pakistan: how do social franchises compare across quality, equity and cost?" Health Policy Plan 26 Suppl 1: i Shaikh, B. T. (2008). "Marching toward the Millennium Development Goals: what about health systems, health-seeking behaviours and health service utilization in Pakistan?" World Health Popul 10(2): Marie Stopes Society, Pakistan - Working Paper Series No. 3, 2012

19 References Shaikh, B. T. (2010). "Unmet need for family planning in Pakistan-PDHS : It s time to re-examine déjà vu." Open Access J Contracept 1: Smith, E., R. Brugha, et al. (2001). Working with Private Sector Providers for Better Health Care--An Introductory Guide. London, London School of Hygiene and Tropical Medicine, Options Consultancy Services. Stephenson, R., A. O. Tsui, et al. (2004). "Franchising reproductive health services." Health Serv Res 39(6 Pt 2): Swan, M. and A. Zwi (1997). Private practitioners and public health: close the gap or increase the distance. London, London School of Hygiene and Tropical Medicine. WHO (2007). Public Policy and Franchising Reproductive Health : Current Evidence and Future Directions Guidance from a technical consultation meeting. Geneva, World Health Organization. Winfrey W et al (2000). Factors Influencing the Growth of the Commercial Sector in Family Planning Service Provision. POLICY Project Working Paper Series No. 6. Washington DC. 16 Marie Stopes Society, Pakistan - Working Paper Series No. 3, 2012

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