July 19, 2013

Catalysing Private Sector for

Improved Family Planning

and Reproductive Health

Services in Bihar and Odisha

Dr Amit Bhanot

The Total Market Approach (TMA)

Complementing GoI efforts

Health Impact

• The government is making steady progress towards RMNCH+A outcomes. How can we engage the private sector to accelerate progress and supplement govt. efforts?

• Are we growing the category for all FP methods?

Equity

• Do all segments of the population have equal access?

• Are we helping ensure there are options for different income levels and for different age groups?

• Are we improving quality and affordability?

Subsidy

• Are we managing to reduce the subsidy?

• Do we have a longer-term cost recovery strategy?

• Are we creating a situation that could continue without us?

Source: AHS-2010-11 Districts/ State

2.83.33.3

3.43.43.43.4

3.53.53.53.53.53.5

3.63.63.63.6

3.73.73.73.7

3.83.83.83.8

3.944

4.14.14.1

4.34.3

4.44.54.54.5

4.7

0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5

Patna

Bhojpur

Lakhaisarai

Aurangabad

Gaya

Jehanabad

Nawada

Banka

Kaimur

Mungar

Nalanda

Rohtas

Saran

Buxar

Jamui

Madhubani

Vaishali

Bihar

Begusarai

Gopalganj

Muzaffapur

Bhagalpur

Samasthipur

Siwan

Supaul

Sitamarhi

Dharbhanga

Sheikpura

Madhepura

P.Champaran

Purnai

Kathiar

PurbiChamparan

Araia

Khagara

Kishanganj

Saharsa

Sheohar

TFR Inequity at District Level in Bihar

…..and a similar case in Odisha

22222

2.12.12.12.12.1

2.22.22.2

2.32.32.32.3

2.42.4

2.52.5

2.62.62.6

2.72.82.8

33

3.13.7

0 0.5 1 1.5 2 2.5 3 3.5 4

Angul

Bargarh

Debagarh

Jharsuguda

Puri

Baleshwar

Jagatsinghapur

Jajapur

Khordha

Sundargarh

Cuttack

Kendrapara

Sambalpur

Odisha

Dhenkanal

Ganjam

Kendujhar

Bhadrak

Mayurbhanj

Gajapati

Kalahandi

Balangir

Kandhamal

Nayagarh

Rayagada

Malkangiri

Sonapur

Nabarangapur

Nuapada

Koraput

Baudh

Source: AHS-2010-11

Trends in Contraceptive Prevalence Rate

Modern Methods, Bihar – DLHS-3 and AHS

5 Sources: AHS, 2010-11 and DLHS, 3 2007-08

29.4

26.1

0.4 0.4 0.9 1.3 0.1

33.9

29.4

0.2 0.5 1.5 1.6 0.1

0

5

10

15

20

25

30

35

40

An

y M

od

ern

met

ho

d

F St

erili

sati

on

M s

teri

lisat

ion

IUC

D

Pill

s

Co

nd

om

s

ECP

s

DLHS-3 AHS

Trends in Contraceptive Prevalence Rate

Modern Methods, Odisha – DLHS-3 and AHS

6 Sources: AHS, 2010-11 and DLHS, 3 2007-08

39.6

27.9

1.2 0.4

8

1.7 0.1

44

30.1

0.3 0.3

11.1

2.1 0.1

0

5

10

15

20

25

30

35

40

45

50

An

y M

od

ern

met

ho

d

F St

erili

sati

on

M s

teri

lisat

ion

IUC

D

Pill

s

Co

nd

om

s

ECP

s

DLHS-3 AHS

Unmet Need for Family Planning by Quintile

Bihar Odisha

9.1

17.8

26.9

3.9

12.7

16.6

0

5

10

15

20

25

30

35

40

45

For Spacing For Limiting Total

Lowest Highest

7 Source: DLHS, 3 2007-08

13.7

28.1

41.9

7.8

13.8

21.6

0

5

10

15

20

25

30

35

40

45

For Spacing For Limiting Total

Lowest Highest

Source of Modern Contraception

Spacing Methods

Bihar

11.6 7.9 10 8.7 7.8

40.9 44.9 42.7 44.7 43.4

47.5 47.2 47.4 46.6 48.8

0

10

20

30

40

50

60

70

80

90

100

Lowest Low Medium High Highest

Government Private Other

Odisha

8 Source: DLHS, 3 2007-08

46.6

30.7

19.614.6

9.6

33.3

48.4

59.563.4

64.9

20.2 20.9 20.9 22 25.5

0

10

20

30

40

50

60

70

80

90

100

Lowest Low Medium High Highest

Government Private Other

Source of Modern Contraception

Limiting Methods

Bihar

66.3 63.7 61.155.3

46.3

32.2 34.6 3843.6

52.1

1.5 1.7 0.9 1.1 1.6

0

10

20

30

40

50

60

70

80

90

100

Lowest Low Medium High Highest

Government Private Other

Odisha

9 Source: DLHS, 3 2007-08

97.3 97.295.5

93.8

84.4

1.4 1.53

4.2

13.5

1.3 1.3 1.5 2 2.1

75

80

85

90

95

100

Lowest Low Medium High Highest

Government Private Other

Demand Side– Audience Insights

• No demand, Negative beliefs, myths and

misconceptions for spacing methods – especially for

clinical methods for spacing – IUDs, Injectable

• Sterilization is usually the first modern method and

after high parity

• Misuse of MTP kits and unsafe abortions

• High awareness and utilization of the benefits and

reimbursements available for institutional deliveries

and sterilization

• In younger age-groups – awareness about spacing

methods is lower than older age group

• Low reach of media in villages but high ownership in

urban centres

• Use of mobile phones is increasing

Ph

oto

: F

utu

res G

roup

• Some public facilities are under resourced

• Few trained to provide quality FP services and then demand

• Committees like PC&PNDT & accreditation need to be activated

• Limited knowledge of indemnity insurance schemes

• Supply disruptions in contraceptive products

• Private sector data not reported (services and products)

• Rural Medical Practitioners (RMPs) serving poor – 2-3 in every

village – could be engaged to follow national guidelines

• Availability of qualified providers at the block level

• Negligible availability of condoms, oral contraceptive pills and

emergency contraceptive pills at the C&D village level

• Supply chain does not reach lower than block level

• Retailers not aware of proper use of methods including MTP kits

Public Sector

Private Sector

Supply Side – Audience Insights

Programme Goals and Objectives

Increase in modern CPR to 42% in Bihar and 48% in Odisha

Generate around 3 million CYPs in 2 years

Avert 1657 maternal deaths

Estimated 780,000 new FP users

Provide 300,000 RH services

Establish 280 franchisees

Set up 18000 social marketing outlets

12

1: Increased choice of sites providing

quality clinical FP/ RH services with a focus

on clinic-based services in rural and underserved areas

2: Increased access to FP/ RH products

with a focus on rural and underserved

areas

3: Build FP/ RH capacity of private sector

providers, provide training and mentoring support, and facilitate

improved implementation of

PCPNDT Act

4: Generate demand, overcome barriers to

FP uptake, and address gender norms through

communications and community outreach

Output 1: Increasing Sites - Quality FP/ RH Services

• Tiered network of 280 private clinics with 6000 community based workers

• Efforts towards government accreditation for sustainability

• Building capacities of providers on technical and business management aspects

Social Franchising

• Operationalised for select districts and urban poor

Targeted demand-side

financing

• Supplement public healthcare service delivery efforts

• Private agency contracted

• Enhance capacities of public facilities for sustained service provision

Fixed Days Services at

Public Facilities

• Enable BPL clients to avail free of cost quality services through private facilities

• Provide choice of spacing methods and services

Fixed day Services at

Private facilities

• Integrated helpline to ensure client satisfaction

• ICT for client education and behaviour change, data collection, electronic decision support and maintain electronic health records

Helpline

Tiered Network : Hub and Spoke Model

L1 L2

L2

L2

L2

L3 L3

L3

L3

L3 L3

L3

L1 L3

SERVICES L1 CLINICS

(80)

L2 CLINICS

(200)

Family Planning Counselling

a) Counselling Available

Spacing Methods

• Injectables

• IUCD (Interval IUCD &

PP IUCD)

Permanent Methods

•Male Sterilization (NSV)

•Female Sterilization (Minilap)

•Female Sterilization (Laparoscopic)

Abortion Services

• First Trimester

• Second Trimester

Post Abortion Family Planning Services

Comprehensive Abortion Care

Output 2: Social Marketing

Basket of Products Penetration tracking

• Male condoms

• Female condoms

• Oral contraceptive pills

• Emergency Contraceptive Pills

• Medical Termination of Pregnancy Kit

• IUCD

• Safe Day Method

• Injectable Contraceptives

• Pregnancy Test Card

• Sanitary Napkins

• Establish 18,000 new outlets in underserved areas and groups

• Traditional outlets

• Non-traditional outlets

• Linkages with NGOs, SHGs, youth clubs

• Strengthening social marketing skills of ASHAs for community based SM

• Retailer and depot holders strengthened through training on products and FP counselling

• Engage commercial sector and local SMOs for products and social marketing

Overall approach: Expanding overall market for FP products

Output 3: Capacity Building and Quality Assurance

Capacity Building

• Increased pool of trained providers

• Collaboration with medical colleges and distinguished professional bodies (FOGSI)

• Series of CME sessions for both public and private doctors Orientating network clinics on PC&PNDT compliance

• Training ANMs on technical skills for IUCD and PPIUCD insertion

• Mentoring public sector providers through partnerships

Quality Assurance

• Adapt Government of India guidelines for accreditation of private clinics

• Develop comprehensive standards for QA, adapting the government guidelines

• Creating a pool of QA monitors in partnerships with DQAC

• Establishing Centres of Excellence to serve as state apex centres for training cum demonstration in FP service provision

Output 4: Generate Demand

360° messaging - inform, persuade and engage

One Brand – connecting demand and supply

Correct knowledge, addressing fears and concerns

K

Doctors Peers / Community

Mass and Mid-Media

Community Health

Workers

Community level role models / positive deviants who have overcome barriers

Access to correct information , products and services

Creating an enabling environment, aspirational role models

Info

rmat

ion

do

mai

n

Persuasio

n d

om

ain

Output 4: Generate Demand – Brand Ujjwal

360° messaging - inform, persuade and engage

Smart Couples

Positive deviants/ FP acceptor couples’ films

Innovative mobile-based IPC Tool

Follow up through Helplines

Smart Providers

FP corners at health facilities

FP training for counseling

Doctors’ films on FP methods for client motivation

AV materials made available

Smart Community

Entertainment-Educate shows

Community meetings and publicity vans

Market town activities for promotion of FP products

Smart Environment

Use innovative platforms in mass media to reach young couples

Repurpose PSAs for increasing awareness

TV series format for improving social norms

19

Monitoring and Evaluation

• MIS systems – clinics and SM outlets data

• Penetration Tracking Surveys – reach in C&D villages

• Market Research and Retail Audit Data

• Operational research and Rapid Assessments

• Concurrent Impact Evaluation

• Quality and operational audits

• Tracking cost effectiveness for service delivery models

Sustainability

• Institutionalising processes for PPP • Accreditation of private clinics and streamlining reimbursement

• Facilitating JSK strategy for sterilisation/IUCD/safe abortion (Santushti scheme)

• Activating DQACs and DLCs

• Institutional capacity building of state governments to manage PPPs

• Scale up models through inclusion in state PIPs and NRHM funds

• Market based partnerships with commercial sector by creating shared value (such as depot holders among FMCG retailers)

• Professional associations and Centres of Excellence for ownership of key activities beyond the project

• Knowledge sharing and process documentation

• Sharing data with state governments

• Linkages with non-health rural marketing and development programmes for creating distribution and communication points