catalysing private sector for improved family planning and...
TRANSCRIPT
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