© Palladium 2015

Dr Amit Bhanot

January 2016, ICFP

Improving contraceptive choice and equity in rural Bihar and Odisha (India) through private sector partnerships – results from Project Ujjwal social franchising approach

© Palladium 2015

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Recent projects

USAID Innovations in Family Planning Services Technical Assistance

Project (ITAP)/India: 2005-2012

USAID Communications for Behaviour Change: Expanding Access to

Private Health Products and Services/Afghanistan (COMPRI-A): 2006–

2012

DFAT/ AusAID HIV Cooperation Program for Indonesia (HCPI): 2008-

2016

DFID Maternal, Newborn and Child Health (MNCH2) /Nigeria: 2014-

2019

DFID Ghana Adolescent Reproductive Health (GHARH): 2014-2017

DFID Human Development Innovation Fund (HDIF)/Tanzania: 2014–

2019

USAID Social Behaviour Change Communications / Social Marketing

program / Mali: 2015-2020

USAID District Coverage of Health Services Project (DISCOVER-H) /

Zambia: 2016-2021

4

Health System Strengthening and Private Sector Engagement

Palladium, formerly GRM Futures Group

Reproductive Health Framework (DFID)

Reducing Maternal & Child Mortality through Strengthening

Primary Health Care / South Africa: 2012-2015

Delivering Increased Family Planning Across Rural Kenya:

2013-2018

Improved Family Planning and Reproductive Health Services

India (Project Ujjwal): 2013-2016

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Innovations in Family Planning Services Technical Assistance Project (ITAP) 2005-2012 supported by USAID

Innovative and Scalable Public Private Partnership Models

Voucher system

Social marketing

Social franchising

Mobile health vans

ASHA Plus Program

UDAAN Adolescent Health – Uttarakhand

Saloni Swasth Kishori Yojana - UP

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Innovations in FP Services (IFPS) Technical Assistance Project

Project Ujjwal: Improved Family Planning and Reproductive Health Services in India

8

9

The Economist – India Population Summary

The Economist – Indian GDP Summary

10

Source: AHS-2012-13

2.6 3.0 3.0 3.0

3.1 3.1 3.1 3.1 3.1

3.2 3.2 3.2 3.2 3.2

3.3 3.3 3.3

3.4 3.4 3.4

3.5 3.5 3.5

3.6 3.7

3.8 3.8 3.8

3.9 3.9

4.0 4.0

4.2 4.2

4.3 4.3

4.4 4.6

0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 5.0

Patna

Gaya

Aurangabad

Jehanabad

Nawada

Buxar

Munger

Begusarai

Rohtas

Muzaffapur

Bihar

Siwan

Purnia

Samasthipur

Kathiar

Madhepura

Khagaria

Araia

Kishanganj

TFR Inequity at District Level in Bihar

12

…..and a similar case in Odisha

Source: AHS-2012-13

1.8 1.9 1.9 1.9

2 2 2 2 2 2 2

2.1 2.1 2.1

2.2 2.2 2.2

2.3 2.3 2.3 2.3

2.4 2.5 2.5 2.5 2.5

2.6 2.7

2.8 2.9

3.5

0 0.5 1 1.5 2 2.5 3 3.5

Jharsuguda

Bargarh

Baleshwar

Jagatsinghapur

Khordha

Sundargarh

Ganjam

Kendujhar

Odisha

Dhenkanal

Kalahandi

Balangir

Rayagada

Malkangiri

Nabarangapur

Baudh

Rural-Urban Differentials

Bihar State mCPR 38 (AHS 2011-2012)

Urban Rural

(50% population in C&D villages)

11% population Urban mCPR is 48 (AHS 2011-2012)

89% population Rural mCPR 37 (AHS 2011-2012

37 million condom market

38 million condom market

1.85 million OCP 1.95 million OCP

Odisha State mCPR 47 (AHS 2011-2012)

Urban Rural

(60% population in C&D villages)

17% population Urban mCPR 48 (AHS 2011-

2012)

83% population Rural mCPR 47 (AHS 2011-

2012

45 million condom market 21 million condom market

1 million OCP 2.3 million OCP

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?

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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,

4: Generate demand, overcome

barriers to FP uptake, and

address gender norms through

communications and community

outreach

Output 1: Choice of Sites in Rural areas

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Output 1 – Increase choice of sites Social Franchising

“…is an attempt to use franchising methods to achieve

social rather than financial goals, influencing the service

delivery systems of the private sector similarly to the way in

which social marketing has adapted traditional outlets for

commodity sales.”

Social franchising across the world has emerged as an

effective approach for quickly expanding the health care

services in partnership with private providers, often

reaching tens of thousands of poor households

Output 1: Social Health Entrepreneurs

Output 1 – Choice of Sites in Rural Areas

Social Franchising at Scale – Ujjwal Clinics

68 districts, all methods – IUD and Injectable Contraceptive

300 clinics – 71% in rural areas – 217,779 additional users in 27 months - 75% in last 18 months

Ster:IUD:Inj = 40:30:30 (Bihar) and 31:29:40 (Odisha)

Targeted Demand-side Financing/ PPPs

56 Ujjwal Clinics Accredited – 30% of Routine Clients till now

76 Ujjwal Clinics RSBY – Social Health Insurance

20

Equity Analysis - Profile of Sterilisation clients from Routine clinics

55% of sterilisation clients in Bihar and 39% in Odisha were reported to be more than 29 years old 75% and 77% of sterilization clients in Bihar and Odisha, respectively were from SC/ST and OBC; 46 % of sterilization clients in Bihar and 50% in Odisha were BPL

Background characteristic Bihar Odisha Age distribution of clients 15 - 19 0.1 0.2

20 - 24 3.9 13.3

25 - 29 41.3 48.4

30 - 34 42.4 30.3

35 - 39 10.3 6.9

40 - 49 1.9 1.0

Caste

Scheduled Caste 22.5 20.6

Scheduled Tribe 12.6 12.2

Other Backward caste 39.0 44.0

Forward caste 24.2 23.3

Below Poverty Line

Yes 45.9 49.7

No 54.1 50.3

Total clients 55,219 13,109

Equity Analysis - Profile of IUCD clients from Routine clinics

76% and 79 % of IUD clients in Bihar and Odisha respectively, were reported to be less than 29 years old; 80% and 78 % of IUD clients in Bihar and Odisha respectively were from SC/ST and OBC; 51 % of IUD clients in Bihar and 47% in Odisha were BPL

Background characteristic Bihar Odisha Age distribution of clients 15 - 19 1.3 0.9

20 - 24 13.0 33.5

25 - 29 57.7 43.6

30 - 34 22.8 17.0

35 - 39 4.8 4.3

40 - 49 0.3 0.7

Caste

Scheduled Caste 22.6 18.6

Scheduled Tribe 12.8 20.6

Other Backward caste 40.2 38.2

Forward caste 21.5 22.6

Below Poverty Line

Yes 51.0 47.0

No 49.0 53.0

Total clients 32,721 10,552

Equity Analysis - Profile of Injectable clients from Routine clinics

84% of injectable clients in Bihar and 77% in Odisha were reported to be less than 29 years old; 70% and 83% of Injectable clients in Bihar and Odisha, respectively, were SC/ST and OBC; 50 % of injectable clients in Bihar and 52% in Odisha were BPL.

Background characteristic Bihar Odisha Age distribution of clients 15 - 19 0.4 0.8

20 - 24 26.4 29.8

25 - 29 55.6 45.1

30 - 34 14.8 17.4

35 - 39 2.6 6.0

40 - 49 0.2 0.9

Caste

Scheduled Caste 22.4 24.3

Scheduled Tribe 10.5 23.4

Other Backward caste 32.2 34.4

Forward caste 31.5 17.8

Below Poverty Line

Yes 50.0 51.7

No 50.0 48.3

Total clients 36,573 8,666

Demand side financing

Profile of Accredited and Remaining clinics & its services

Clinics Duration (months)

Mean sterilisations per month per clinic

Mean Total clinical services per month per clinic

FP Accredited 26 222 17.0 29.0

Remaining 177 3803 10.0 25.0

Bihar

Odisha

Clinics Duration (months)

Mean sterilisations per month per clinic

Mean Total clinical services per month per clinic

FP Accredited 25 394 9.0 22.0

Remaining 58 953 3.4 13.3

Output 2:

Access to Products in Rural areas

Output 3 – Institutionalizing QA in Rural Clinics

Output 3 – Institutionalizing QA in Rural Clinics

Accreditation – State and District QAC

Medical Audits – State and National FOGSI, FP expert linkages

QI plan development and implementation support

Hands-on training for Paramedics at clinics

Infection Prevention and BWM linkages

FP expert observations

FP QA Reward and Recognition

e-Learning

State and District workshops and meetings

Investments by clinics in improving QA

Installation of Trendlenburg Table Installation of Shadow less lamp

Expansion of infrastructure

Output 4 – Generate Demand – Brand Ujjwal

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

TA BCC – Use of Ujjwal materials in public sector facilities

Output 5 Commercial Sector tools for M&E

• MIS systems – clinics and SM outlets data

• Product Availability/ Outlet Penetration tracking surveys

• Retail audit data / Brand Penetration - AC Nielsen

• Rapid assessments – mHealth, Social Entrepreneur Analysis, FP Counsellors,

Injectable and IUD Follow up study, reach and recall for EE shows, Demand

Side Financing analysis

• Quality and operational audits – medical audit, Periodic Client Satisfaction

Surveys

• Third Party monitoring by DFID through Sambodhi

• Concurrent impact evaluation with tracking of cost-effectiveness for service

delivery models by DFID through OPM

What Next

Opportunities for SF transitioning from donor financing

• Mentoring business models with financial planning and implementation – Ujjwal MerryGold

• Demand side financing. National Health Insurance Programmes.

• Supporting Commercial Health Investments in Rural Areas - Primary Care Hospital Chains to launch

• Innovative or global sources of financing: development impact bonds

33

FP/RH – Is it viable for a franchisee?

• Sterilisation and MTP are major revenue generators

• Only IUD and injectable provisioning not viable for entrepreneur based model – even with upto three times increase from current volume of services

• Inclusion of sterilisation services, twice a month, with an on-call doctor-

• Makes family planning profitable at RSBY reimbursement rates with 1.5 times increase in volume of services

• Makes family planning profitable at GoI reimbursement rates with three time increase

• Doctor based clinics are generating monthly profits at current averages and prices

• Support needs to be provided to the entrepreneur for organising FP fixed day services, twice a month

• Regulatory design affects the sustainability of the model

-

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

45,000

50,000

Option 1 Option 2 Option 3

Co

st a

nd

Rev

enu

e (i

n R

s)

Service Mix Options

Entrepreneur facility without Medical Officer

Costs Revenue - Ujjwal Revenue - GoI

34

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Impact Bonds

35

Outcome Payers

(gov./donor/corp.)

make payments to

investors if

outcomes are

delivered

Service Providers

Often supported by

intermediaries

providing project,

contract and fund

management, deliver

social intervention to

improve community

outcomes

Investors

Provide upfront

capital. They receive

returns only if

outcomes are

achieved

$

Outcomes

• Impact Bonds are a new payment-by-results financing

mechanism with the potential to drive greater efficiency,

results and participation of private and institutional investors

in the delivery of development projects – over the past 5

years almost 50 have been set up across the planet

• The core feature of an Impact Bond is the designation of a

payment metric on which a target value is agreed. If

achieved the investors are paid back their capital plus a

success premium

• The structure gives flexibility to investors and service

providers to be responsive and adapting in order to achieve

the most cost-effective, value-adding solution

• DIBS address social needs of:

• Public budgetary constraints

• Emerging desire to test innovations

• Expanding pool of investors looking to harness

entrepreneurial energy

Rajasthan Reproductive, Maternal, Newborn, Child and Adolescent Health Impact Bond

Lessons Learnt

Multiple players responsible for market development approaches

Implementation partners

HLFPPT

PHFI

JHU CCP

OPM

MSI

Sambodhi

FOGSI

PHSI

Strengthening capacities of local

partners

Bangla Natak

Shadow

Tek Management

Visual House

Nayan Enterprises

Nawastha

Inductus

Partners Consulting

Sigma

AC Nielson

Results sharing to inform programmes

Mckinsey

Care-TSU

BMGF

Amaltas

Packard Foundation

UCSF

UHI

UNFPA/Indonesia

Enabling policy to action

Government of Bihar

Government of Odisha

State Health Societies

Department of Labour

SIHFW

SQAC

DQAC

RSBY Officials

Insurance cos

Corporates and social enterprises

Pregna

Ayzh

Alchemist

GSK

HLL

Famycare

PHSI

Merck for Mothers

Enabling environment

- Building an understanding in state and district governments around private sector

- Need to identify new financing strategies for MDA with social impact-DIBs

- Need for an organizing body to facilitate dialogue among all stakeholders

Rules of the game

- Inclusion of FP/RH services under Insurance coverage

- Strengthening for-profit private sector opens market for competition

Support functions

- A lot of times people do not know what they want until you show it to them

- Capabilities in information gathering around private sector in rural areas required

Capabilities of actors

- Challenge for non-profit to transition to commercial for-profit models

- Establishing trust among suppliers in new markets requires time

Market development approaches