Evaluating the impact of social franchising on family planning use in Kenya

Background: In Kenya, as in many low-income countries, the private sector is an important component of health service delivery and of providing access to preventive and curative health services. The Tunza Social Franchise Network, operated by Population Services Kenya, is Kenya\u2019s largest network of private providers, comprising 329 clinics. Franchised clinics are only one source of family planning (FP), and this study seeks to understand whether access to a franchise increases the overall use or provides another alternative for women who would have found FP services in the public sector. Methods: A quasi-experimental study compared 50 catchment areas where there is a Tunza franchise and no other franchised provider with 50 purposively matched control areas within 20 km of each selected Tunza area, with a health facility, but no franchised facility. Data from 5609 women of reproductive age were collected on demographic and socioeconomic status, FP use, and care-seeking behavior. Multivariate logistic regression, with intervention and control respondents matched using coarsened exact matching, was conducted. Results: Overall modern contraceptive use in this population was 53 %, with 24.8 % of women using a long-acting or permanent method (LAPM). There was no significant difference in odds of current or new FP use by group, adjusted for age. However, respondents in Tunza catchment areas are significantly more likely to be LAPM users (adj. OR = 1.49, p = 0.015). Further, women aged 18\u201324 and 41\u201349 in Tunza catchment areas have a significantly higher marginal probability of LAPM use than those in control areas. Conclusions: This study indicates that access to a franchise is correlated with access to and increased use of LAPMs, which are more effective, and cost-effective, methods of FP. While franchised facilities may provide additional points of access for FP and other services, the presence of the franchise does not, in and of itself, increase the use of FP in Kenya

Who Serves the Poor? An Equity Analysis of Public and Private Providers of Family Planning and Child Health Services in Kenya

Understanding differences in the wealth status of patients can inform planning decisions aimed at providing affordable access to high quality care to all. This study assesses differences in the wealth status of clients of family planning and child health services by health sector. It also describes reason for facility choice, cost of services, and the proportion of additional clients of these services, and assesses if there are any differences by health sector.A cross-sectional survey of 2,173 clients from 96 health facilities in urban areas of 6 counties in Kenya was conducted, stratified by health facility type. The 4 strata were public, faith-based, private for profit, and social franchise. Client wealth was benchmarked to the national and urban population of the 2014 Kenya Demographic and Health Survey (DHS), and assessed using the EquityTool.There were significant differences in the client wealth distribution between facility types, and public sector facilities served a significantly higher proportion of poor clients than other types of facilities. In all three non-public facility types, more than 25% of clients were from the poorest two wealth quintiles, without significant differences between facility types. No facility type stands out as expanding access to health services more than another.Results show that social franchises do better at reaching the poor than earlier studies have indicated, though not as well as faith-based and public facilities. Findings suggest that private providers remain important within the larger health system, more so for family planning than childhood illness management. In urban areas with significant facility choice, this study quantifies differences in client wealth across four health sectors. Incorporating these findings into policy and programmatic interventions can improve equity in access to and use of quality health services

Measuring service quality and assessing its relationship to contraceptive discontinuation: A prospective cohort study in Pakistan and Uganda

Background: The quality of contraceptive counseling that women receive from their provider can influence their future contraceptive continuation. We examined (1) whether the quality of contraceptive service provision could be measured in a consistent way by using existing tools from 2 large-scale social franchises, and (2) whether facility quality measures based on these tools were consistently associated with contraceptive discontinuation.Methods: We linked existing, routinely collected facility audit data from social franchise clinics in Pakistan and Uganda with client data. Clients were women aged 15-49 who initiated a modern, reversible contraceptive method from a sampled clinic. Consented participants completed an exit interview and were contacted 3, 6, and 12 months later. We collapsed indicators into quality domains using theory-based categorization, created summative quality domain scores, and used Cox proportional hazards models to estimate the relationship between these quality domains and discontinuation while in need of contraception.Results: The 12-month all-modern method discontinuation rate was 12.5% among the 813 enrolled women in Pakistan and 5.1% among the 1,185 women in Uganda. We did not observe similar associations between facility-level quality measures and discontinuation across these 2 settings. In Pakistan, an increase in the structural privacy domain was associated with a 60% lower risk of discontinuation, adjusting for age and baseline method (PP=.005).Conclusions: We were not able to leverage existing, widely used quality measurement tools to create quality domains that were consistently associated with discontinuation in 2 study settings. Given the importance of contraceptive service quality and recent advances in indicator standardization in other areas, we recommend further effort to harmonize and simplify measurement tools to measure and improve contraceptive quality of care for all

The multiple meanings of prosperity and poverty : a cross-site comparison from Tanzania

Assets are important to local definitions of poverty and wealth in rural Africa. Yet their use in asset indices can miss locally valued change. We present data from 17 villages across Tanzania to explore differences in the meaning of wealth and poverty across the country. Despite limitations in our site selection we found considerable diversity that makes a single asset index difficult to compile. Current abbreviated asset indices risk counting assets that do not matter locally

Use of family planning and child health services in the private sector: an equity analysis of 12 DHS surveys

Abstract Background A key component of universal health coverage is the ability to access quality healthcare without financial hardship. Poorer individuals are less likely to receive care than wealthier individuals, leading to important differences in health outcomes, and a needed focus on equity. To improve access to healthcare while minimizing financial hardships or inequitable service delivery we need to understand where individuals of different wealth seek care. To ensure progress toward SDG 3, we need to specifically understand where individuals seek reproductive, maternal, and child health services. Methods We analyzed Demographic and Health Survey data from Bangladesh, Cambodia, DRC, Dominican Republic, Ghana, Haiti, Kenya, Liberia, Mali, Nigeria, Senegal and Zambia. We conducted weighted descriptive analyses on current users of modern FP and the youngest household child under age 5 to understand and compare country-specific care seeking patterns in use of public or private facilities based on urban/rural residence and wealth quintile. Results Modern contraceptive prevalence rate ranged from 8.1% to 52.6% across countries, generally rising with increasing wealth within countries. For relatively wealthy women in all countries except Ghana, Liberia, Mali, Senegal and Zambia, the private sector was the dominant source. Source of FP and type of method sought across facilities types differed widely across countries. Across all countries women were more likely to use the public sector for permanent and long-acting reversible contraceptive methods. Wealthier women demonstrated greater use of the private sector for FP services than poorer women. Overall prevalence rates for diarrhea and fever/ARI were similar, and generally not associated with wealth. The majority of sick children in Haiti did not seek treatment for either diarrhea or fever/ARI, while over 40% of children with cough or fever did not seek treatment in DRC, Haiti, Mali, and Senegal. Of all children who sought care for diarrhea, more than half visited the public sector and just over 30% visited the private sector; differences are more pronounced in the lower wealth quintiles. Conclusions Use of the private sector varies widely by reason for visit, country and wealth status. Given these differences, country-specific examination of the role of the private sector furthers our understanding of its utility in expanding access to services across wealth quintiles and providing equitable care

Translating international guidelines for use in routine maternal and neonatal healthcare quality measurement

Background Improving facility-based quality for maternal and neonatal care is the key to reducing morbidity and mortality rates in low- and middle-income countries. Recent guidance from WHO and others has produced a large number of indicators to choose from to track quality. Objective To explore how to translate complex global maternal and neonatal health standards into actionable application at the facility level. Methods We applied a two-step process as an example of how the 352 indicators in WHO’s 2016 Standards for Improving Quality of Maternal and Newborn Care in Health Facilities might be reduced to only those with the strongest evidence base, associated with outcomes, and actionable by facility managers. We applied Hill criteria and assessed whether indicators were within the control of facility managers. We next conducted a rapid review of supporting literature and applied GRADE analysis, retaining those with scores of ‘moderate’ or ‘high’. To understand the utility and barriers to measuring this limited set of indicators in practice, we undertook a case study of hypothetical measurement application in two districts in Bangladesh, interviewing 25 clinicians, managers, and other stakeholders. Results From the initial 352 indicators, 56 were retained. The 56 indicators were used as a base for interviews. Respondents emphasized the practical challenges to the use of complex guides and the need for parsimonious and actionable sets of quality indicators. Conclusions This work offers one way to move towards a reduced quality indicator set, beginning from current WHO guidance. Despite study limitations, this work provides evidence of the need for reduced and evidence-based sets of quality indicators if guides are to be used to improve quality in practice. We hope that future research will build on and refine our efforts. Measuring quality effectively so that evidence guides and improves practice is the first step to assuring safe maternal and neonatal care

Client-reported quality of in-facility medication abortion compared with pharmacy-based self-managed abortion in Bangladesh

Objective: We used the newly developed Abortion Care Quality (ACQ) Tool to compare client-reported quality of medication abortion care by modality (facility-based versus pharmacy-based self-managed abortion (SMA)) in Bangladesh. Study Design: We used the abortion client ACQTool exit and 30-day follow-up surveys and bivariate statistics to compare 18 client-reported quality indicators grouped in six domains and eight abortion outcomes, by service modality. We used multivariable logistic regression to identify factors associated with selected quality indicators and outcomes (abortion affordability, information provision, and knowing what to do for an adverse event), controlling for client socio-demographic characteristics. Results: Of 550 abortion clients, 146 (26.5%) received a facility-based medication abortion and 404 (73.5%) had a pharmacy-based SMA. Clients reported higher quality in facilities for five indicators; higher in pharmacies for two indicators; the remaining 11 indicators were not different by modality. Compared with facility-based clients, pharmacy clients had higher odds of reporting that the cost of abortion was affordable (aOR = 3.55; 95% CI 2.27-5.58) but lower odds of reporting high information provision (aOR = 0.14; 95% CI 0.09-0.23). Seven of eight abortion outcomes showed no differences; pharmacy clients had lower odds of knowing what to do if an adverse even occurred (aOR = 0.45; 95% CI 0.23-0.82). Conclusions: In Bangladesh, there is no difference in client-reported quality of medication abortion care between health facilities and pharmacies for the majority of quality and outcome indicators. However, information provision and preparedness were higher quality at facilities, while pharmacies were more affordable

Association between the quality of contraceptive counseling and method continuation: Findings from a prospective cohort study in social franchise clinics in Pakistan and Uganda

Quality of family planning counseling is likely associated with whether or not women continue to use the same contraceptive method over time. The Method Information Index (MII) is a widely available measure of contraceptive counseling quality but little is known about its association with rates of method continuation. The index ranges from 0 to 3 based on a client\u27s answer to whether she was told about other methods, potential side effects with her chosen method, and what to do if she experienced side effects. Using data from a prospective cohort study of 1,998 social franchise clients in Pakistan and Uganda, we investigated the relationship between reported baseline MII and the risk of method continuation over 12 months using survival analysis and Cox proportional hazard models. At baseline, about 65% of women in Pakistan and 73% of women in Uganda reported receiving information about all 3 MII aspects. In Pakistan, 59.4% of the 165 women who stopped using their modern method did so while still in need of contraception. In Uganda, of the 77 women who stopped modern method use, 64.9% discontinued while in need. Despite important differences in the demographics and method mix between the 2 countries, we found similar associations between baseline MII and discontinuation: in both countries as the MII score increased, the risk of discontinuation while in need decreased. In Pakistan, the risk of contraceptive discontinuation was 64% lower (crude hazard ratio [HRcrude]=0.36; P=.03), and 72% lower (HRcrude=0.28; P=.007), among women who were told about any 2, or any 3 aspects of MII, respectively. After adjusting for additional covariates, only the difference in the risk of contraceptive discontinuation between MII=3 and MII=0 remained statistically significant (HRadj=0.35; P=0.04). In Uganda, women who reported being informed about all aspects of MII were 80% less likely to discontinue while in need (HRadj=0.20; P\u3c.001), women informed about any 2 aspects of MII were 90% less likely (HRadj=0.10; P\u3c.001), and women who were informed about any 1 aspect of MII were 68% less likely (HRadj=0.32; P\u3c.02) to discontinue contraceptive use while in need as compared to women who reported not being informed about any aspect of MII. Baseline MII scores were positively associated with method continuation rates in our sample of clients from social franchises in both Pakistan and Uganda and could potentially be used as an indicator of contraceptive counseling quality