Assessment of a Community Based Distribution (CBD) Model for Increasing Demand and Utilization of Family Planning Services in 49 Districts of Pakistan

Abstract

The performance of the Marie Stopes Society’s (MSS’) Community Based Distribution (CBD) project that provided Family Planning (FP) and Reproductive Health (RH) information and services to the doorstep of the clients is illustrated in this analytical report. Baseline registration of Married Women of Reproductive Age (MWRA (15-49 years of age) was carried out during August 2008-Febuary 2009 in 49 project districts before the inception of the project. The Services were started in March 2009. Eighteen months into project implementation, the End-Line survey was conducted in 40 project districts (during August-September 2010). Over the course of the project approximately half a million MWRA from a catchment population of over 3 million were provided FP/RH information and services. This analysis includes baseline survey results and comparison of these with end of the project survey results; and trend changes in contraceptive use and behavior for a cohort of half a million MWRA.The project increased CPR from 38% at baseline to 51% at endline in 18 months.The results show that the contraceptive prevalence rates increased from 38% at baseline to 51% at the end of project, with modern methods accounting for 41% increase and representing a 52% increase over baseline. The annual change in CPR brought about by the CBD Project intervention at 13% in 18 months is almost 10 times higher than the annual change in national CPR between 2000 and 2007. Substantial increases were seen in all modern methods by 67% to 200% except female sterilization.While CPR rose, the rate of currently pregnant women fell from 11% to 7% - or by 36% over baseline - representing 20,000 fewer pregnancies among half a million women reached by the project. If CBD were to be implemented all over Pakistan, with a similar extrapolation of the project findings points towards a likely increase in national CPR to 45% with a reduction of 2 million (40%) pregnancies nationwide.True to its roots in the Willows Foundation Model of community based information and distribution, MSS CBD workers were the source of provision of current contraception method for nearly 2 in 5 (39%) users, followed by a friend or relative and a government facility (13%). It is interesting to note that in comparison to the PDHS 2006-7 where 52% of contraception commodities were self-procured (usually from a store or chemist directly by clients), the CBD had replaced self-procurement as the main source of family planning. The project may have implications and lessons for the government’s very large Lady Health Worker program in aspects of training and outreach.Women (and to some extent their spouses) consider family planning a necessary service.This project strongly demonstrates that quality services, delivered to women directly, can significantly increase CPR and that women (and to some extent their spouses) consider family planning a necessary service. However, research is required to further elaborate the effectiveness or not, of a number of aspects of the intervention. One is the involvement of men: a small proportion amongst non-users is men-centric refusal to use family planning. Research must elaborate if this is relevant and if so how to overcome it. Further research should explore how this model can be replicated and scaled up by other NGOs or civil society groups rather than the public sector. Operations research would be required to ascertain if the model can be adopted within government health structures (such as LHWs, CMWs and fixed facilities) and if so what would be the modalities. Exploring/ascertaining the potential impact/role of incentives (demand and supply side) in reaching nonusers, provision of transport to clients to reach family planning centers and performance based incentives for the project teams is required.