The impact of franchised family planning clinics in poor urban areas of Pakistan

Effective strategies for increasing the uptake of modern methods of family planning in South Asia: a systematic review and meta-analysis

BACKGROUND

Family planning (FP) interventions have improved the use of modern contraceptives, yet a high unmet need for contraception still exists in South Asia. This systematic review of existing research was conducted to identify effective FP interventions that led to an increase in the uptake of modern methods of contraception in South Asia.

METHODS

Five electronic databases were searched for relevant studies published between January 1st, 2000 and May 4, 2023. Experimental studies that reported data on the impact of FP interventions on modern contraceptive use among women of reproductive age (15-49 years) in the South Asian region were included. A random-effects Inverse Variance weighted model was employed to pool the adjusted odds ratio (OR) on modern contraceptive use and unmet need for contraception. In addition, we computed subgroup meta-estimates based on intervention type and the urban-rural divide.

RESULTS

Among 643 studies identified, 21 met the inclusion criteria. The overall pooled odds ratio for modern contraceptive use was significantly higher (OR 1.51; 95% CI 1.35-1.70; heterogeneity; I2 = 81%) for FP interventions with a significant reduction in unmet need for contraception (OR 0.86; 95% CI 0.78-0.94, I2 = 50%). The subgroup analysis revealed demand-generation (OR 1.61; 95% CI 1.32-1.96), health system integrated (OR 1.53; 95% CI 1.07-2.20), and franchised FP clinic interventions (OR 1.32; 95% CI 1.21-1.44) had promoted the modern contraceptive uptake. Further, FP interventions implemented in urban settings showed a higher increase in modern contraceptive use (OR 1.73; 95% CI 1.44-2.07) compared to rural settings (OR 1.46; 95% CI 1.28-1.66). Given the considerable heterogeneity observed across studies and the low degree of certainty indicated by the GRADE summary for the primary outcome, caution is advised when interpreting the results.

CONCLUSION

The review collated experimentally evaluated FP interventions that increased modern contraception use and reduced the unmet need in South Asia. The demand generation interventions were the most effective in increasing the uptake of modern contraceptive methods. Furthermore, the urban environment provides a conducive environment for interventions to improve contraceptive usage. However, further studies should assess which aspects were most effective on attitudes towards contraception, selection of more effective methods, and contraceptive behaviors.

How a co-design process led to more contextually relevant family planning interventions in emerging urban settings in Eastern Uganda

Voluntary, rights-based family planning upholds women's right to determine freely the number and spacing of their children. However, low-resource settings like Uganda still face a high unmet need for family planning. And, while urban areas are often indicated to have better access to health services, emerging evidence is revealing intra-urban socio-economic differentials in family planning utilization. To address the barriers to contraceptive use in these settings, understanding community-specific challenges and involving them in tailored intervention design is crucial. This paper describes the use of co-design, a human-centred design tool, to develop context-specific interventions that promote voluntary family planning in urban settings in Eastern Uganda. A five-stage co-design approach was used: 1) Empathize: primary data was collected to understand the problem and people involved, 2) Define: findings were shared with 56 participants in a three-day in-person co-design workshop, including community members, family planning service providers and leaders, 3) Ideate: workshop participants generated potential solutions, 4) Prototype: participants prioritized prototypes, and 5) Testing: user feedback was sought about the prototypes. A package of ten interventions was developed. Five interventions targeted demand-side barriers to family planning uptake, four targeted supply-side barriers, and one addressed leadership and governance barriers. Involving a diverse group of co-creators provided varied experiences and expertise to develop the interventions. Participants expressed satisfaction with their involvement in finding solutions to challenges in their communities. However, power imbalances and language barriers were identified by the participants as potential barriers to positive group dynamics and discussion quality. To address them, participants were separated into groups, and medical terminologies were simplified during brainstorming sessions. These changes improved participation and maximized the contributions of all participants. It is therefore important to consider participant characteristics and their potential impact on the process, especially when engaging diverse participant groups, and implement measures to mitigate their effects.

How well are Indonesia's urban poor being provided access to quality reproductive health services?

Accommodating the needs of Indonesia’s rapidly growing urban population is essential to reaching national reproductive health goals and international commitments. As in other rapidly urbanizing low- and middle-income countries, satisfying the needs of Indonesia’s urban poor is both a high priority and a significant challenge. In this study, we assessed both how being from urban poor or near-poor households affects the quantity and quality of family planning and maternal health services received and the extent to which differentials had narrowed during the 2012–2017 period. This time interval is significant due to the introduction of a national social health insurance scheme in 2014, establishing the foundation for universal health care in the country. Data from the 2012 and 2017 Indonesian Demographic and Health Surveys were analyzed using logistic and multinomial logit regression. Poverty status was measured in terms of urban household wealth quintiles. For family planning, although urban poor and near-poor women made different method choices than non-poor women, no substantial 2017 differences in contraceptive prevalence, unmet need for family planning or informed choice were observed. However, urban poor women and to a lesser extent near-poor women systematically lagged non-poor urban women in both the quantity and quality of maternal health services received in connection with recent pregnancies. Significant maternal health service gains were observed for all urban women during the study reference period, with gains for poor and near poor urban women exceeding those for non-poor on several indicators. While the deployment of pro-poor interventions such as the national social health insurance scheme is likely to have contributed to these results, evidence suggesting that the scheme may not be influencing consumer health-seeking behaviors as had been anticipated along with continued limitations in public health sector supply-side readiness resulting in service quality issues suggest that more will have to be done.

Family planning for urban slums in low- and middle-income countries: a scoping review of interventions/service delivery models and their impact

Background

Although evidence suggest that many slum dwellers in low- and middle-income countries have the most difficulty accessing family planning (FP) services, there are limited workable interventions/models for reaching slum communities with FP services. This review aimed to identify existing interventions and service delivery models for providing FP services in slums, and as well examine potential impact of such interventions and service delivery models in low- and middle-income settings.

Methods

We searched and retrieved relevant published studies on the topic from 2000 to 2020 from e-journals, health sources and six electronic databases (MEDLINE, Global Health, EMBASE, CINAHL, PsycINFO and Web of Science). Grey and relevant unpublished literature (e.g., technical reports) were also included. For inclusion, studies should have been published in a low- and middle-income country between 2000 and 2020. All study designs were included. Review articles, protocols or opinion pieces were excluded. Search results were screened for eligible articles and reports using a pre-defined criterion. Descriptive statistics and narrative syntheses were produced to summarize and report findings.

Results

The search of the e-journals, health sources and six electronic databases including grey literature and other unpublished materials produced 1,260 results. Following screening for title relevance, abstract and full text, nine eligible studies/reports remained. Six different types of FP service delivery models were identified: voucher schemes; married adolescent girls’ club interventions; Willows home-based counselling and referral programme; static clinic and satellite clinics; franchised family planning clinics; and urban reproductive health initiatives. The urban reproductive health initiatives were the most dominant FP service delivery model targeting urban slums. As regards the impact of the service delivery models identified, the review showed that the identified interventions led to improved targeting of poor urban populations, improved efficiency in delivery of family planning service, high uptake or utilization of services, and improved quality of family planning services.

Conclusions

This review provides important insights into existing family planning service delivery models and their potential impact in improving access to FP services in poor urban slums. Further studies exploring the quality of care and associated sexual and reproductive health outcomes as a result of the uptake of these service delivery models are essential. Given that the studies were reported from only 9 countries, further studies are needed to advance knowledge on this topic in other low-middle income countries where slum populations continue to rise.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-021-01518-y.

Reaching rural communities through 'Healthy Entrepreneurs': a cross-sectional exploration of community health entrepreneurship's role in sexual and reproductive health

The purpose of the current study was to explore the association between community health entrepreneurship and the sexual and reproductive health status of rural households in West-Uganda. We collected data using digital surveys in a cluster-randomized cross-sectional cohort study. The sample entailed 1211 household members from 25 randomly selected villages within two subcounties, of a rural West-Ugandan district. The association between five validated sexual and reproductive health outcome indicators and exposure to community health entrepreneurship was assessed using wealth-adjusted mixed-effects logistic regression models. We observed that households living in an area where community health entrepreneurs were active reported more often to use at least one modern contraceptive method [odds ratios (OR): 2.01, 95% CI: 1.30–3.10] had more knowledge of modern contraceptive methods (OR: 7.75, 95% CI: 2.81–21.34), knew more sexually transmitted infections (OR: 1.86, 95% CI: 1.14–3.05), and mentioned more symptoms of sexually transmitted infections (OR: 1.83, 95% CI: 1.18–2.85). The association between exposure to community health entrepreneurship and communities’ comprehensive knowledge of HIV/AIDS was more ambiguous (OR: 1.27, 95% CI: 0.97–1.67). To conclude, households living in areas where community health entrepreneurs were active had higher odds on using modern contraceptives and had more knowledge of modern contraceptive methods, sexually transmitted infections and symptoms of sexually transmitted infections. This study provides the first evidence supporting the role of community health entrepreneurship in providing rural communities with sexual and reproductive health care.

Using Evidence to Drive Impact: Developing the FP Goals Impact Matrix

When designing a family planning (FP) strategy, decision‐makers can choose from a wide range of interventions designed to expand access to and develop demand for FP. However, not all interventions will have the same impact on increasing modern contraceptive prevalence (mCP). Understanding the existing evidence is critical to planning successful and cost‐effective programs. The Impact Matrix is the first comprehensive summary of the impact of a full range of FP interventions on increasing mCP using a single comparable metric. It was developed through an extensive literature review with input from the wider FP community, and includes 138 impact factors highlighting the range of effectiveness observed across categories and subcategories of FP interventions. The Impact Matrix is central to the FP Goals model, used to project scenarios of mCP growth that help decision‐makers set realistic goals and prioritize investments. Development of the Impact Matrix, evidence gaps identified, and the contribution to FP Goals are discussed.

How equitable is social franchising? Case studies of three maternal healthcare franchises in Uganda and India

Substantial investments have been made in clinical social franchising to improve quality of care of private facilities in low- and middle-income countries but concerns have emerged that the benefits fail to reach poorer groups. We assessed the distribution of franchise utilization and content of care by socio-economic status (SES) in three maternal healthcare social franchises in Uganda and India (Uttar Pradesh and Rajasthan). We surveyed 2179 women who had received antenatal care (ANC) and/or delivery services at franchise clinics (in Uttar Pradesh only ANC services were offered). Women were allocated to national (Uganda) or state (India) SES quintiles. Franchise users were concentrated in the higher SES quintiles in all settings. The percent in the top two quintiles was highest in Uganda (over 98% for both ANC and delivery), followed by Rajasthan (62.8% for ANC, 72.1% for delivery) and Uttar Pradesh (48.5% for ANC). The percent of clients in the lowest two quintiles was zero in Uganda, 7.1 and 3.1% for ANC and delivery, respectively, in Rajasthan and 16.3% in Uttar Pradesh. Differences in SES distribution across the programmes may reflect variation in user fees, the average SES of the national/state populations and the range of services covered. We found little variation in content of care by SES. Key factors limiting the ability of such maternal health social franchises to reach poorer groups may include the lack of suitable facilities in the poorest areas, the inability of the poorest women to afford any private sector fees and competition with free or even incentivized public sector services. Moreover, there are tensions between targeting poorer groups, and franchise objectives of improving quality and business performance and enhancing financial sustainability, meaning that middle income and poorer groups are unlikely to be reached in large numbers in the absence of additional subsidies.

Impact of the Urban Reproductive Health Initiative on family planning uptake at facilities in Kenya, Nigeria, and Senegal

Background

The 2012 London Summit on Family Planning set ambitious goals to enable 120 million more women and adolescent girls to use modern contraceptives by 2020. The Urban Reproductive Health Initiative (URHI) was a Bill & Melinda Gates Foundation funded program designed to help contribute to these goals in urban areas in India, Kenya, Nigeria, and Senegal. URHI implemented a range of country-specific demand and supply side interventions, with supply interventions generally focused on improved service quality, provider training, outreach to patients, and commodity stock management. This study uses data collected by the Measurement, Learning & Evaluation (MLE) Project to examine the effectiveness of these supply-side interventions by considering URHI’s influence on the number of family planning clients at health facilities over a four-year period in Kenya, Nigeria, and Senegal.

Methods

The analysis used facility audits and provider surveys. Principal-components analysis was used to create country-specific program exposure variables for health facilities. Fixed-effects regression was used to determine whether family planning uptake increased at facilities with higher exposure. Outcomes of interest were the number of new family planning acceptors and the total number of family planning clients per reproductive health care provider in the last year.

Results

Higher program component scores were associated with an increase in new family planning acceptors per provider in Kenya (β = 18, 95% CI = 7–29), Nigeria (β = 14, 95% CI = 8–20), and Senegal (β = 7, 95% CI = 3–12). Higher scores were also associated with more family planning clients per provider in Kenya (β = 31, 95% CI = 7–56) and Nigeria (β = 26, 95% CI = 15–38), but not in Senegal.

Conclusions

Supply-side interventions have increased the number of new family planning acceptors at facilities in urban Nigeria, Kenya, and Senegal and the overall number of clients in urban Nigeria and Kenya. While tailoring to the local environment, programs seeking to increase family planning use should include components to improve availability and quality of family planning services, which are part of a rights-based approach to family planning programming.

Incorporating elements of social franchising in government health services improves the quality of infant and young child feeding counselling services at commune health centres in Vietnam

BACKGROUND

Although social franchising has been shown to enhance the quality of reproductive health services in developing countries, its effect on nutrition services remains unexamined. This study assessed the effects of incorporating elements of social franchising on shaping the quality of infant and young child feeding (IYCF) counselling facilities and services in Vietnam.

METHODS

Process-related data collected 12 months after the launch of the first franchises were used to compare randomly assigned Alive & Thrive-supported health facilities (AT-F, n = 20) with standard facilities (SF, n = 12) across three dimensions of service quality: 'structure', 'process' and 'outcome' that capture the quality of facilities, service delivery, and client perceptions and use, respectively. Data collection included facility assessments (n = 32), staff surveys (n = 96), counselling observations (n = 137), client exit interviews (n = 137) and in-depth interviews with mothers (n = 48).

RESULTS

Structure: AT-F were more likely to have an unshared, well-equipped room for nutrition counselling than SF (65.0% vs 10.0%).

PROCESS

Compared with SF providers, AT-F staff had better IYCF knowledge (mean score 9.9 vs 8.8, range 0-11 for breastfeeding; mean score 3.6 vs 3.2, range 0-4 for complementary feeding). AT-F providers also demonstrated significantly better interpersonal communication skills (score 9.6 vs 5.1, range 0-13) and offered more comprehensive counselling sessions.

OUTCOME

Overall utilization of franchises was low (10%). A higher proportion of pregnant women utilized franchise services (48.9%), compared with mothers with children 6-23.9 months (1.4%). There was no quantitative difference in client satisfaction with counselling services between AT-F and SF, but franchise users praised the AT-F for problem solving related to child feeding.

CONCLUSIONS

Incorporating elements of social franchising significantly enhances the quality of IYCF counselling services within government primary healthcare facilities, particularly their structural and process attributes. Provided that service utilization is improved through demand generation, this model has the potential to impact IYCF practices and child nutrition.

Attitudes, beliefs and norms relating to contraceptive use among young migrant and non-migrant adults in urban Dar es Salaam, Tanzania

The young urban population of Tanzania is growing rapidly, primarily due to rural-urban migration. More information is needed on the challenges facing young adult urban women and men in using family planning (FP). The purpose of this study is to identify perceptions, interpersonal and familial attitudes, and sociocultural norms regarding FP among young adults (18-25 years) in Dar es Salaam, Tanzania, comparing responses by sex, marital status and migration status. We conducted 12 focus groups with young adult men and women (n=74) in Dar es Salaam in December 2009. Participants knew of modern contraceptive methods, but had serious concerns about side effects. Single men and women preferred condoms. Female migrants stated that traditional methods were ineffective, yet commonly used in rural areas. Men's desires for more children frequently led female migrants not to use FP, while many married long-term residents used FP discreetly. Single women sometimes received the support of their parents/boyfriends to access and use contraception. Findings highlight differences in experiences among young adult men and women based on their migrant and marital status at the individual, interpersonal and normative levels. Future efforts to promote FP should engage existing social support systems and cultivate new ones in response to barriers.

The impact of clinical social franchising on health services in low- and middle-income countries: a systematic review

BACKGROUND

The private sector plays a large role in health services delivery in low- and middle-income countries; yet significant gaps remain in the quality and accessibility of private sector services. Clinical social franchising, which applies the commercial franchising model to achieve social goals and improve health care, is increasingly used in developing countries to respond to these limitations. Despite the growth of this approach, limited evidence documents the effect of social franchising on improving health care quality and access.

OBJECTIVES AND METHODS

We examined peer-reviewed and grey literature to evaluate the effect of social franchising on health care quality, equity, cost-effectiveness, and health outcomes. We included all studies of clinical social franchise programs located in low- and middle-income countries. We assessed study bias using the WHO-Johns Hopkins Rigour Scale and used narrative synthesis to evaluate the findings.

RESULTS

Of 113 identified articles, 23 were included in this review; these evaluated a small sample of franchises globally and focused on reproductive health franchises. Results varied widely across outcomes and programs. Social franchising was positively associated with increased client volume and client satisfaction. The findings on health care utilization and health impact were mixed; some studies find that franchises significantly outperform other models of health care, while others show franchises are equivalent to or worse than other private or public clinics. In two areas, cost-effectiveness and equity, social franchises were generally found to have poorer outcomes.

CONCLUSIONS

Our review indicates that social franchising may strengthen some elements of private sector health care. However, gaps in the evidence remain. Additional research should include: further documentation of the effect of social franchising, evaluating the equity and cost-effectiveness of this intervention, and assessing the role of franchising within the context of the greater healthcare delivery system.

Is franchising in health care valuable? A systematic review

BACKGROUND

Franchising is an organizational form that originates from the business sector. It is increasingly used in the healthcare sector with the aim of enhancing quality and accessibility for patients, improving the efficiency and competitiveness of organizations and/or providing professionals with a supportive working environment. However, a structured overview of the scientific evidence for these claims is absent, whereas such an overview can be supportive to scholars, policy makers and franchise practitioners.

METHODS

This article provides a systematic review of literature on the outcomes of franchising in health care. Seven major databases were systematically searched. Peer-reviewed empirical journal articles focusing on the relationship between franchising and outcomes were included. Eventually, 15 articles were included and their findings were narratively synthesized. The level of evidence was rated by using the Grading of Recommendations Assessment, Development, and Evaluation scale.

RESULTS

The review shows that outcomes of franchising in health care have primarily been evaluated in low- and middle-income countries in the reproductive health/family planning sector. Articles about high-income countries are largely absent, apart from three articles evaluating pharmacy franchises. Most studies focus on outcomes for customers/clients and less on organizations and professionals. The evidence is primarily of low quality. Based on this evidence, franchising is predominantly positively associated with client volumes, physical accessibility and some types of quality. Findings regarding utilization, customer loyalty, efficiency and results for providers are mixed.

CONCLUSIONS

We conclude that franchising has the potential to improve outcomes in healthcare practices, but the evidence base is yet too weak for firm conclusions. Extensive research is needed to further determine the value of healthcare franchising in various contexts. We advocate more research in other healthcare sectors in both low- and middle-income countries and high-income countries, on more types of outcomes with attention to trade-offs, and on what factors produce those outcomes.

What works in family planning interventions: a systematic review

This study presents findings from a systematic review of evaluations of family planning interventions published between 1995 and 2008. Studies that used an experimental or quasi-experimental design or used another approach to attribute program exposure to observed changes in fertility or family planning outcomes at the individual or population levels were included and ranked by strength of evidence. A total of 63 studies met the inclusion criteria. The findings from this review are summarized in tabular format by the type of intervention (classified as supply-side or demand-side). About two-thirds of the studies found were evaluations of programs focusing on demand generation. Findings from all programs revealed significant improvements in knowledge, attitudes, discussion, and intentions. Program impacts on use of contraceptives and use of family planning services were less consistently found, and fewer than half of the studies that measured fertility or pregnancy-related outcomes found an impact. Based on the review findings, we identify promising programmatic approaches and propose directions for future evaluation research of family planning interventions.