Abstract
To achieve the global Family Planning 2020 (FP2020) goal of reaching 120 million more women with voluntary family planning services, rapid scale-up of services is needed. Clinical social franchising, a service delivery approach used by Marie Stopes International (MSI) in which small, independent health care businesses are organized into quality-assured networks, provides an opportunity to engage the private sector in improving access to family planning and other health services. We analyzed MSI's social franchising program against the 4 intended outputs of access, efficiency, quality, and equity. The analysis used routine service data from social franchising programs in 17 African and Asian countries (2008-2014) to estimate number of clients reached, couple-years of protection (CYPs) provided, and efficiency of services; clinical quality audits of 636 social franchisees from a subset of the 17 countries (2011-2014); and exit interviews with 4,844 clients in 14 countries (2013) to examine client satisfaction, demographics (age and poverty), and prior contraceptive use. The MSI "Impact 2" model was used to estimate population-level outcomes by converting service data into estimated health outcomes. Between 2008 and 2014, an estimated 3,753,065 women cumulatively received voluntary family planning services via 17 national social franchise programs, with a sizable 68% choosing long-acting reversible contraceptives (LARCs). While the number of social franchisee outlets increased over time, efficiency also significantly improved over time, with each outlet delivering, on average, 178 CYPs in 2008 compared with 941 CYPs in 2014 (P = .02). Clinical quality audit scores also significantly improved; 39.8% of social franchisee outlets scored over 80% in 2011 compared with 84.1% in 2014. In 2013, 40.7% of the clients reported they had not been using a modern method during the 3 months prior to their visit (95% CI = 37.4, 44.0), with 46.1% (95% CI = 40.9, 51.2) of them reporting having never previously used family planning at all. Analysis of age and poverty levels of clients indicate mixed results in bridging equity gaps: 57.4% of clients lived on under US$2.50/day in 2013 (95% CI = 54.9, 60.0) and 26.1% were 15-24 years old (95% CI = 23.8, 28.4), but only 15.1% lived on less than $1.25/day (95% CI = 13.8, 16.4) and 5.0% were 15-19 years old (95% CI = 3.9, 6.1). The services provided via social franchising are estimated to avert 4,958,000 unintended pregnancies and 7,150 maternal deaths. Social franchising through the existing private sector has the ability to rapidly scale-up access to high-quality family planning services, including LARCs, for the general population as well as young women and the poor, providing a promising model to help achieve the global FP2020 goal.
Highlights
Global Health: Science and Practice 2015 | Volume 3 | Number 2 modern contraceptive methods for 120 million more women and girls by 2020.1 By 2013, an additional 8.4 million women and girls were using contraception in the 69 Family Planning 2020 (FP2020) focus countries
For short-acting contraceptive methods, such as pills and condoms, franchisees record the number of commodities distributed or sold to the end user, whereas for long-acting reversible contraceptives (LARCs) and permanent methods, they record each service provided. (Family planning counseling resulting in no service provision is captured through routine data collection but was not used in this analysis.) Reporting procedures and formats vary between countries, but at a minimum all franchisees periodically report the number of contraceptive commodities and services provided to the central support office in each country
The number of clients receiving LARCs was obtained from the number of voluntary IUD and implant insertion services delivered, and the number of clients receiving voluntary permanent methods was obtained from the number of tubal ligation and vasectomy services provided
Summary
Global Health: Science and Practice 2015 | Volume 3 | Number 2 modern contraceptive methods for 120 million more women and girls by 2020.1 By 2013, an additional 8.4 million women and girls were using contraception in the 69 FP2020 focus countries. Almost 60% of health care expenditures in the least-developed countries is spent in the private sector,[2] and almost two-fifths of women using modern contraceptive methods report obtaining them from the private sector.[3] While this represents a significant proportion of family planning service delivery, the quality of services provided by the private sector and the range of contraceptive method choices available are often limited. Clinical social franchising is a service delivery approach in which small, independent health care businesses are organized into quality-assured networks. Social franchising presents an opportunity to engage private providers in health care delivery to increase access to high-quality family planning and other services.[4]. A service delivery approach used by Marie Stopes International (MSI) in which small, independent health care businesses are organized into quality-assured networks, provides an opportunity to engage the private sector in improving access to family planning and other health services
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