NPO performance in reproductive health sector of low and middle income countries: what is the influence of the wider policy context

Non-ProfitOrganizations (NPOs) are increasingly being promoted as preferred providers toreplace weak government services in Low and Middle Income Countries (LMIC) butresults on ground show mixed performance. The variation in national policycontexts is one explanation for uneven NPO performance but has beenunder-explored in reproductive health literature. This paper collates gray andpublished literature providing an overview of how policy context impacts on NPOperformance in reproductive health. Socio-political context, state policies anddonor dependency indirectly influence NPO working by shaping operational space,autonomy, networking and mandate. These influences need to be recognized andmodified so as to enable NPOs to better achieve their attributedcharacteristics of client responsive and quality services aimed at marginalizedpopulations. Policy measures are needed to build better policy space and regulatoryframeworks for NPOs, state-NPO collaboration forums, and greater reliance oninternal funding

Parallel NGO networks for HIV control: risks and opportunities for NGO contracting.

Policy measures for preventive and promotive services are increasingly reliant on contracting of NGOs. Contracting is a neo-liberal response relying on open market competition for service delivery tenders. In contracting of health services a common assumption is a monolithic NGO market. A case study of HIV control in Pakistan shows that in reality the NGO market comprises of parallel NGO networks having widely different service packages, approaches and agendas. These parallel networks had evolved over time due to vertical policy agendas. Contracting of NGOs for provision of HIV services was faced with uneven capacities and turf rivalries across both NGO networks. At the same time contracting helped NGO providers belonging to different clusters to move towards standardized service delivery for HIV prevention. Market based measures such as contracting need to be accompanied with wider policy measures that facilitate in bringing NGOs groups to a shared understanding of health issues and responses

Struggling with long-time low uptake of modern contraceptives in Pakistan

Background: Efforts to expand access to reproductive health care in Pakistan date as far back as the early 1950s. Despite such efforts, the fertility rate has declined at a slower pace compared to that in neighbouring countries.Aims: To explore the underlying reasons and challenges for long-time low contraceptive use among female clients and key service providers of community-based family planning programmes in Pakistan.Methods: A qualitative study was carried out with a total of 10 focus group discussions and 7 in-depth interviews with female clients and key service providers. The data were analysed using qualitative content analysis.Results: The intra-family dynamics, that is, influence of husbands and mothers-in-law, were significant in shaping the decision-making and choice of family planning methods. In addition, inadequate counselling skills, insufficient training for service providers, weak supportive supervision, interrupted supply of contraceptives, and delays in salary disbursement were among the key family planning programme challenges.Conclusion: Despite a well-designed community-based FP programme, providers\u27 counselling skills need to be enhanced. However, this has to be combined with sufficient training, supportive supervision and contraceptive availability

A study protocol for an mHealth, multi-centre randomized control trial to promote use of postpartum contraception amongst rural women in Punjab, Pakistan

Background: Provision of family planning services during the immediate post-partum phase is considered effective and cost-efficient for promoting healthy timing and spacing of pregnancies. This research aims to test the effectiveness of mobile phone-based interventions in promoting use of postpartum contraception. Moreover, it will also test the non-inferiority of text and voice messages compared to interactive phone-based counselling.Methods: A three-arm, 10-month, multicentre, randomized controlled trial will be conducted at 15 social franchise (SF) health facilities in Punjab province of Pakistan. Pregnant women aged 15-44 years who are in their first or second trimester and have a mobile phone for their own use will be eligible to participate in this study. The participants will be randomly allocated to one of three study arms: a) voice and text messages; b) interactive telephone-based counselling; or c) control arm (no additional phone-based support). The intervention counselling module will be developed based on the Integrated Behaviour Model which was recently adapted, and tested for the family planning context in Pakistan. It will broadly cover birth-preparedness, importance of birth spacing, and postnatal care. The phone-based intervention aims to improve women\u27s ability to use contraception by providing them with information about a range of methods, access to family planning methods through outlets such as Suraj SF providers, connecting them with MSS field health educators to help them reach the centres, motivation by re-enforcing the benefits of contraceptive use on women\u27s quality of life, and dispelling myths and misconceptions about modern contraceptive methods. Risk differences will be used as the measure of effect of the intervention on the outcomes.Discussion: The study findings will highlight effectiveness of mobile phone in raising awareness of maternal health and contraception, which in turn, is expected to be translated into increased proportion of: at least four antenatal visits, skilled birth or institutional delivery, postpartum contraceptive use, postnatal check-up, child immunization, and breastfeeding. Moreover, if the text and voice messages approach is proven to be non-inferior to interactive calls, it will provide evidence to making promotion of healthcare less resource intensive, and thereby contribute in improving the efficiency of the healthcare system.Trial registration: This trial was prospectively registered with the Clinical Trials registry ( NCT03612518 ) on August 2nd, 2018

Does courtesy bias affect how clients report on objective and subjective measures of family planning service quality? A comparison between facility- and home-based interviews

Purpose: Despite a general understanding that exit interviews being conducted at service providers\u27 facilities may influence clients\u27 responses favorably to health professionals, there is very little evidence available that demonstrates the extent to which this problem exists. This study aimed at assessing and comparing clients\u27 perceptions of the quality of family planning services and their satisfaction levels between facility- and home-based interviews.Methods: A cross-sectional survey was conducted among clients receiving family planning services across three service delivery channels - nongovernmental organization (NGO) clinics, social franchise (SF) centers, and outreach camps. The survey took place from December 2015 to January 2016 in 70 districts across all four provinces of Pakistan. A total of 2,807 clients were interviewed, of whom 1,404 clients were interviewed at health facilities after receiving services and 1,403 were interviewed at their homes within 3 days of method uptake.Results: Overall, we found no significant differences between the characteristics of study participants interviewed at health facilities or at home. The findings suggested that experiences reported in exit surveys at facilities were strongly biased positively. This was true for both experiential (service quality) and perception-based (satisfaction) questions in the context of SF centers, while at NGO clinics the interview location only affected clients\u27 responses regarding service quality. However, in outreach settings, clients are more likely to share bad experiences in exit interviews than in home-based interviews on objectively asked questions (service quality).Conclusion: Our study indicates signs of courtesy bias and possibly the Hawthorne effect in exit interviews. Program implementers could opt for home-based interviews for women receiving services at NGO clinics or SF center, whereas exit interviews could be used in outreach settings

Population Challenges in a Changing World: An Overview of the 22nd Annual Research Conference of the Population Association of Pakistan

The Population Association of Pakistan (PAP), established in 2000, continues to emphasize the crucial relationship between population and development. The population and development programs in Pakistan have not progressed as steadily as in most of the countries in the region or other Muslim-majority countries such as Egypt, Indonesia, Iran, and Turkey. PAP provides a platform that offers an opportunity to bridge the various social sciences disciplines including economics, public and social policy, statistics, demography, public health, sociology, geography, and anthropology to deliberate upon solutions for pressing population and development related issues of Pakistan in this changing worl

Cost-effectiveness of a family planning voucher program in rural Pakistan

Introduction: This study reports on the effectiveness and efficiency from the program funder\u27s perspective of the Suraj Social Franchise (SSF) voucher program in which private health-care providers in remote rural areas were identified, trained, upgraded, and certified to deliver family planning services to underserved women of reproductive age in 29 districts of Sindh and 3 districts of Punjab province, Pakistan between October 2013 and June 2016.Method: A decision tree compared the cost of implementing SSF to the program funder and its effects of providing additional couple years of protection (CYPs) to targeted women, compared to business-as-usual. Costs included vouchers given to women to receive a free contraceptive method of their choice from the SSF provider. The vouchers were then reimbursed to the SSF provider by the program.Results: A total of 168,206 married women of reproductive age (MWRA) received SSF vouchers between October 2013 and June 2016, costing $3,278,000 ($19.50/recipient). The average effectiveness of the program per voucher recipient was an additional 1.66 CYPs, giving an incremental cost-effectiveness of the program of $4.28 per CYP compared to not having the program (95$3.62-5.31).Conclusion: The result compares favorably to other interventions with similar objectives and appears affordable for the Pakistan national health-care system. It is therefore recommended to help address the unmet need for contraception among MWRA in these areas of Pakistan and is worthy of trial implementation in the country more widely

What influences family planning in rural Pakistan: Franchised service provider and community health worker perspective

Background: Pakistan has a low modern contraceptive prevalence rate, 26%, leading family planning (FP) programmes to explore partnerships with local private providers to improve access to quality FP services. This study aims to understand the socio-cultural and organizational factors that influence delivery of quality family planning services. Methods: This qualitative study was conducted with private service providers and community health workers (CHW) in Marie Stopes Society\u27s (MSS) social franchise network. A total of 31 providers and 28 CHWs from Sindh, Punjab, and Khyber Pakhtunkhwa provinces of Pakistan were purposively selected for in-depth interviews. The study used thematic content analysis to understand providers\u27 and health workers\u27 perspectives of family planning service provision. Results: This study found that normative environment, propagation of myths and misconceptions, and health concerns remain major barriers to service provision in rural communities. Findings showed that CHWs were instrumental in increasing awareness and positive attitudes towards family planning in the catchment areas. Moreover, social franchising was effective in increasing access to high-quality, subsidised family planning services amongst economically marginalised and low-awareness communities. Providers and health workers expressed satisfaction with the franchising approach, and revealed that being part of this network substantially increased their client volume and ability to serve poorer segments of the population. Conclusion: The study found that franchising private service providers in rural areas enhances their ability to serve clients, and when coupled with demand-generation elements, such as vouchers and community health workers, it substantially increases their client volume. Albeit effective, the franchising approach currently lacks the element of long-term service provision at the current scale, and may require further strategizing by the franchisor. Moreover, alternate strategies should be explored to ensure continued provision of FP services without vouchers and CHWs

Improving community case management of diarrhoea and pneumonia in district Badin, Pakistan through a cluster randomised study--the NIGRAAN trial protocol

BACKGROUND: Diarrhoea and pneumonia contribute 30% of deaths in children under 5 in Pakistan. Pakistan\u27s Lady Health Workers Programme (LHW-P) covers about 60% of the population but has had little impact in reducing morbidity and mortality related to these major childhood killers. An external evaluation of the LHW-P suggests that lack of supportive supervision of LHWs by lady health supervisors (LHSs) is a key determinant of this problem. Project NIGRAAN aims to improve knowledge and skills of LHWs and community caregivers through supervisory strategies employed by LHSs. Ultimately, community casemanagement (CCM) of childhood pneumonia and diarrhoea will improve. METHODS/DESIGN: NIGRAAN is a cluster-randomised trial in District Badin, Pakistan. There are approximately 1100 LHWs supervised by 36 LHSs in Badin. For this study, each LHS serves as a cluster. All LHSs working permanently in Badin who regularly conduct and report field visits are eligible. Thirty-four LHSs have been allocated to either intervention or control arms in a ratio of 1:1 through computer-generated simple randomisation technique. Five LHWs from each LHSs are also randomly picked. All 34 LHSs and 170 LHWs will be actively monitored. The intervention consists of training to build LHS knowledge and skills, clinical mentorship and written feedback to LHWs. Pre- and post-intervention assessments of LHSs, LHWs and community caregivers will be conducted via focus group discussions, in-depth interviews, knowledge assessment questionnaires, skill assessment scorecards and household surveys. Primary outcome is improvement in CCM practices of childhood diarrhoea and pneumonia and will be assessed at the cluster level. DISCUSSION: NIGRAAN takes a novel approach to implementation research and explores whether training of LHSs in supervisory skills results in improving the CCM practices of childhood diarrhoea and pneumonia. No significant harm to participants is anticipated. The enablers and barriers towards improved CCM would provide recommendations to policymakers for scale up of this intervention nationally and regionally

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