RESEARCH, MONITORING & EVALUATION

Findings of an 18-month assessment of the effectiveness of a rural-based social franchising

programme using vouchers of long-term family planning services in Pakistan
Dr. Syed Khurram Azmat

ISSN 2076-0000
Working Paper Series No. 3, 2012

Research, Monitoring & Evaluation

Marie Stopes Society, Pakistan

RESEARCH, MONITORING & EVALUATION

Findings of an 18-month assessment of the effectiveness of a rural-based social franchising programme using
vouchers of long-term family planning services in Pakistan
Dr. Syed Khurram Azmat
The opinions reflecting in this paper are solely the authors and do not reflect the opinion of Marie Stopes Society
Pakistan.

Email: mariestopes@msspk.org
Website: www.mariestopespk.org

Acknowledgement

Acknowledgement
It gives me great pleasure to present this Working Paper, third (03) of a series from Marie
Stopes Societys (MSS) Research, Monitoring and Evaluation (RME) department. The Working Paper is based on the findings of the 18-months assessment of MSS Social Franchise
(SF) model to enhance access to and utilization of modern contraception among underserved women in rural areas of Pakistan. Branded as Suraj, meaning Sun in English, MSS
launched its SF model in 2008 and initially forged a partnership with 100 mid-level Private
Sector Providers (PSPs) in eighteen (18) districts of the two most populous provinces of
Pakistan that include Sindh and Punjab. The effectiveness of this model was evaluated via
baseline and endline population based surveys in four (4) intervention and control districts.
The study prolonged over 24 months including 18 months of intervention period. Based on
the impact and quality of care it maintained throughout, the Suraj model is being further
expanded to more districts. It also gives me immense delight to inform that this Suraj SF
model was awarded the 2011 International Quality Award by the Global Health Group,
University of California, San Francisco.
The RME department was mainly responsible for designing the surveys, managing collection
of data, data analysis, report writing, dissemination of results at various forums and development of this working paper. My special thanks go to Dr. Syed Khurram Azmat Deputy Director Technical Services, for his strong leadership and technical assistance throughout the
project period. In addition, I am greatly thankful to the entire RME team especially, Mr. Waqas
Hameed Senior Manager RME, Mr. Ghulam Mustafa Manager RME, Mr. Ishaque Sheikh
Assistant Manager RME, Mr. Wajahat Hussain, Mr. Safdar Ali and Mr. Aftab Ahmed. I
acknowledge the contribution of each one of them with appreciation as without their support,
immense help and technical assistance this endeavor would not have been possible!
Moreover, I would like to acknowledge and thank all of the persons who strongly supported
and facilitated us at various phases of the surveys. First of all, I would like to thank all of the
respondents across the two provinces of Pakistan who participated in the surveys. I am also
highly thankful to the entire social franchise and operations teams at support, regional and
district offices including Director Operations Dr. Shafqat Ijaz, Senior Project Manager Social
Franchise Mr. Jamshaid Asghar, Regional Managers Operations (RMOs), Regional Executives Social Franchise (RESFs), District Project Officers (DPOs), Suraj service providers, and
Field Workers Marketing (FWMs)/Senior Field Supervisors (SFSs) for their support during
various stages of the surveys. Finally, I would like to thank Communication and New Business Development (CNBD) department at MSS for reviewing the final draft of the Working
Paper (WP) and providing valuable feedback.

Mohsina Bilgrami
Country Director
Marie Stopes Society, Pakistan

Marie Stopes Society, Pakistan - Working Paper Series No. 3, 2012

Abbreviations

List of Abbreviations
CNBD

Communication and New Business Development

CPR

Contraceptive Prevalence Rate

DPO
DSF

District Project Officer

Demand Side Financing

FP

Family Planning

FWM

Field Worker Mobilization

IUCD

Intra-uterine Contraceptive Device

LHV
LTM

Lady Health Visitor

Long Term Method

MDGs

Millennium Development Goals

MSS

Marie Stopes Society

MWRA Married Women of Reproductive Age

PDHS
PSPs

Pakistan Demographic Health Survey

Private Sector Providers

RESFs Regional Executives Social Franchise

ii

RH

Reproductive Health

RME

Research, Monitorining and Evaluation

RMO
SES

Regional Manager Operations

Socio-economic Status

SF

Social Franchise

SFS

Senior Field Supervisor

WHO

World Health Organization

WP

Working Paper

Marie Stopes Society, Pakistan - Working Paper Series No. 3, 2012

Contents

Contents

iii

List of Tables

List of Figures

Abstract

Background and Introduction

The context and rationale

Study objectives

Methods

Statistical Analysis

Results

10

Effect of intervention

11

Ever use and Current use of contraception

12

Contribution of voucher and FWM in uptake of contraception

13

Satisfaction with Social franchise services

13

Discussion and Conclusion

14

References

15

Marie Stopes Society, Pakistan - Working Paper Series No. 3, 2012

Tables & Figures

List of Tables
Table 1: Study sites and sampling details

Table 2: Percent distribution of study participants by selected socio-demographic

10

characteristics according to study arms at baseline

Table 3: Awareness about contraceptive methods

11

Table 4: Ever and current use of contraceptive methods

12

List of Figures
Figure 1: Main intervention components

Figure 2: Percent distribution of women who received contraceptive services

13

from social franchise, by their source of motivation

Marie Stopes Society, Pakistan - Working Paper Series No. 3, 2012

Abstract

Abstract
Introduction
Nearly 14,000 women die each year in Pakistan from causes
related to pregnancy. This number is projected to have been
1.7 times higher without contraceptive practice. Family planning is known to be one of the most cost-effective ways to
reduce maternal deaths, but currently only 29.3% use contraceptives. This paper evaluates the effectiveness of a twopronged approach using social franchising and vouchers
designed to increase contraceptive utilization, especially long
term birth spacing methods, among underserved women in
rural areas of Pakistan where the use of contraceptives is very
low in order to improve maternal health.
Methods
A quasi-experimental study design with controls was used.
One intervention and one control district were purposively
(based on socio-demographic and reproductive health indicators) selected each from two provinces of Pakistan; and each
district had a total of four providers. All providers in intervention groups were franchised, trained, and have demand generated through field workers (social franchising intervention) and
vouchers (free voucher intervention); while control providers
continued with their routine practices without changes. A
population-based, cross-sectional survey was carried out
among 4992 married women of reproductive age group
(MWRA) in Feb 2009 within the catchment areas of each
provider and after 18 months, an endline survey was
conducted among 4003 MWRA. Multiple logistic regressions
were used to estimate net effect (difference in interventiondifference in control) using Stata 11.2.
Results
The intervention significantly increased the awareness of
modern contraception by 5% (p-value <0.001) when adjusted
for control. The ever use of modern contraceptive was
increased by 28.5% (p-value <0.001). A substantial increase of
19.6% (p-value <0.001) was observed in contraceptive prevalence, with modern contraceptive use increasing by 22.7%
(p-value <0.001); while the use of traditional method was
reduced by 3% (p-value <0.001). Among modern methods, the
highest change was recorded in IUCD with 11.1% (p-value
<0.001) as the intervention was promoting long-term method
use; and among IUCD users 76.4% had it inserted from Suraj
SF centre including 34.7% women who received it through
vouchers of all women interviewed, nearly 28% reported that
they had received contraceptive services from MSS social
franchise provider and were referred by MSS demand generation field workers including: 8.9% with voucher (for IUCD) and
nearly 20% without voucher (for any contraceptive service) .

Marie Stopes Society, Pakistan - Working Paper Series No. 3, 2012

Conclusion
The two-pronged social franchising approach implemented by
MSS Pakistan, that generates demand (field workers and
vouchers) and addresses the supply gap (trained providers),
can effectively increase awareness and uptake of contraceptives that would ultimately improve maternal health.

Background & Introduction

Background and Introduction

Public Health development and promotion can be efficiently
carried out via Family planning (FP) activities. FP services can
serve as a cornerstone in achieving MDGs, for they have the
potential to reduce poverty and hunger resulting from
unplanned population growth. And about 30% of maternal and
10% of child deaths can be reduced by adopting effective FP
methods (Cleland, Bernstein et al. 2006). In countries with
limited resources, FP is a cost effective intervention. It
improves populations health along with socio-economic
indicators and the overall pace of development in a country.
Countries having weak public health provision infrastructures
are faced with numerous challenges of governance, scarcity of
human resources and financial constraints. In such situations
private providers can contribute significantly to family planning
services (Bank; 1993; Swan and Zwi 1997; Winfrey W et al
2000; Marek, OFarrell et al. 2005).The World Health Organization (recognizing the need for effective FP service provision)
emphasizes on the need to set up partnerships with FP private
practitioners using a range of methods, including social
franchising (WHO 2007). Africa and Asia both show records of
successes in franchising of sexual and reproductive health
services, stating it as a viable solution for the growing
demands for health care from the public(Prata, Montagu et al.
2005; Frost 2006).Thus several methods for direct delivery of
the FP healthcare services have emerged by engaging the
private sector in Asia and Africa. These include contracting
out, voucher schemes, insurance schemes, provider accreditation, and social marketing (Kumaranayake, Mujinja et al.
2000; Smith, Brugha et al. 2001; Mills, Brugha et al. 2002;
Stephenson, Tsui et al. 2004). A social franchise network is a
kind of business model, in which independent providers or
service delivery outlets are provided licenses by a franchising
organization to operate under its brand name (Qureshi 2010).
Developing countries like Pakistan have shown a great deal of
interest in employing social franchising models to promote
family planning and reproductive health services in resource
poor and underserved areas (Mills, Brugha et al. 2002; Chandani and Sulzbach 2006).
Voucher programmes are a kind of demand-side financing
(DSF) in which subsidy is directly or indirectly given to the
targeted people and Vouchers have been found to be an effective way to address the issue of cost involved (Montagu and
Graff 2009). Many countries have demonstrated large scale
impact through these schemes (Hecht, Batson et al. 2004;
Eichler 2006; Gold 2010; Shah, Wang et al. 2011). In service
models with social franchising, vouchers can be used to pay
for providers services like consultation fee, cost of contraceptives, follow up and treatment of complication, etc. A major
challenge in DSF remains to be the identification of target
group and assuring delivery of services to them. For
approaches, in which subsidies are provided to the
client/patients instead of service deliver, are difficult to monitor
as they are more prone to corruption problems due to lesser
education among the people offered a subsidy. However, well
established and controlled/monitored demand side subsidies
6

Marie Stopes Society, Pakistan - Working Paper Series No. 3, 2012

can change the health-seeking behavior and may offer a

greater potential for population benefit compare to supply side
programmes(Montagu and Graff 2009).For many potential
and willing family planning users would not be able to afford
these services if they were to pay for them out of their own
pockets. Thus their inability to afford will result in their exclusion and further add their number to the unmet need. In addition to FP services, more clientele for family planning can be
an added benefit to the providers income, who might consult
him/her for other ailments too.

Context & Rationale

Context & Rationale

For over the last one and half decade, Pakistan has not been
able to show a significant change in the fertility and population
growth rate. Countrys population exceeded 174 million in
2011 and is growing at rate of 1.9% per annum which is much
higher than that of its South Asian neighbours. Majority of its
population (65%) lives in rural areas and 61% earns less than
2 US$ a day. The modern contraceptive users in Pakistan
about 22% (who already have 4-5 children) and the most
common contraceptive method is Condom (besides tuballigation). And condoms are short term male dependent
method having a high failure rate (National Institute of Population Studies and Macro International 2008). The unmet need
for family planning in Pakistan stands at 25% among currently
married woman and it is the highest in the women of its rural,
underdeveloped regions who are poor and have no education
(National Institute of Population Studies and Macro International 2008). Promotion and utilization of Long term birth
spacing methods require improvement by removing and
addressing the existing constraints and access barriers
respectively.
Long term contraceptive methods such as Intrauterine
Contraceptive Device (IUCD) are highly reliable - in averting
unwanted pregnancies (Lassner, Chen et al. 1995) and have
a high efficacy of >98%. In Pakistan, IUCD use has been as
low as 2% with accompanying reasons to explain such little
utilization. One of these reasons is the minimal number of
facilities which offer long term contraceptive methods
(accompanied with the necessary qualities and standards).
Government health facilities are rarely visible and seldom
provide FP services to the clients and their overall state of
responsiveness is poor. Further aggravation is caused by
intermittent availability of contraceptive supplies(Shaikh
2010) and the unsympathetic attitude of the providers. Thus
the clients look toward the private sector where they find a
totally opposite picture. They perceive that services (on
payment) from a private provider are more trustworthy and
reliable. However, keeping in mind the current poverty trends
in Pakistan, a major question of affordability comes into play.
Nonetheless, it is essential not to ignore the demand for quality services and spacing in pregnancies which has been documented on multiple occasions.
The
providers
on
the
other
hand,
lack
the
communication/counselling skills. Majority of the family planning centres and health facilities lack in aspects of environment (ensuring confidentiality services and aseptic conditions) for IUCD insertion(Shaikh 2010). In addition they have
not been provided adequate incentives nor are acknowledged
for their services; therefore, they show low motivation levels.
The other issue include side effects and fears/fallacies related
to the use of IUCD which prevents many potential users of
this long term method to adopt it as a birth spacing method
(Azmat, Shaikh et al. 2012). Many national studies and
governments own surveys have documented that more than
80% of the people prefer private providers for first level care
7

Marie Stopes Society, Pakistan - Working Paper Series No. 3, 2012

(inclusive of prevention) and for advice on common health

problems (Shaikh 2008; Government of Pakistan 2011).
Furthermore, franchising family planning services at the
private providers outlets has shown optimistic results as
regards the contraceptives utilization rates in Pakistan(Shah,
Wang et al. 2011). Thus it is important that a mechanism to
overcome the financial barrier at the users end is essential to
facilitate use of private services of family planning.
In response to this high unmet need and low contraceptive
prevalence in underserved rural areas of Pakistan, Marie
Stopes Society (MSS) established Social Franchise model in
2008, branded as Suraj which means sun in English. This
network forged partnerships with 100 mid-level Private Sector
Providers
(PSPs)
which
includes
Lady
Health
visitors/midwives/nurses(Marie Stopes Society 2010; Azmat,
Shaikh et al. 2012). These PSPs were trained and accredited
to provide condoms, emergency contraceptives, injectable,
oral contraceptives and to insert and remove intrauterine
devices IUCDs (refer to figure 1). The IUCD component of
Suraj also includes a voucher scheme which provides
payment to the service provider in case a client is unable to
pay.Under MSS DSF integrated social franchise model, the
potential FP client is given a free voucher for IUCD which the
client can redeemed at the respective SF provider with no
money to incur by the client. Later, the amount of the service
charges is reimbursed to the SF provider upon her claim. The
MSS Suraj model recognises the fact that economic and
access barriers are indeed major hurdles and need to be overcome in order to provide the much needed FP services to the
underserved communities.

Study Objectives

Study Objectives
To evaluate the effectiveness of this two-pronged social franchising approach in increasing contraceptive utilization, especially
long term birth spacing methods, among underserved women in rural areas of Pakistan.

Figure 1: Main intervention components

1. Training on RH/FP and post training

evaluation
Medical: RH and FP counselling, quality of
services, and IUCD insertion/removal;
Business: basic budgeting skills, record
keeping, stock management, branding,
marketing, and the voucher management.
The training is followed by post
training evaluation conducted
by external consultant
(medical doctor).

2. Voucher for LTM (IUCD)

Voucher worth US$ 2.10* and is only for
IUCD (insertion, follow-up and removal).
The voucher is distributed by FWM to
eligible women, identified through poverty
scale. It is redeemed at Suraj PSP. The
reimbursement is sent to PSP against her
claim.
*Conversion rate USD1 = 95PKR

Suraj Social Franchise

Components
3. Field Worker
Marketing (FWM)
FWM is a local resident
of the community;
undergoes training on FP
methods, voucher distribution
system, and data recording. Pays door
to door visits, provides FP information,
generates referrals, distribute vouchers for
IUCD to eligible women using a poverty
ranking scale.

Marie Stopes Society, Pakistan - Working Paper Series No. 3, 2012

4.Branding/Marketing
PSPs are branded as
Suraj while marketing is
done through FWM, posters,
wall paintings, leaflets, etc.
The Suraj logo is displayed
prominently in Urdu outside all clinics.

Methods

Methods
Employing a before and after design with a control arm, the
study was conducted with target population in four districts of
Punjab and Sindh provinces of Pakistan. Two districts were
selected in each province with equivalent comparison population where one district served as an intervention site whereas
the other one served as a control site.
A total of four Private Sector Providers (PSPs) were selected
as franchise in each districts including the comparison
districts. The selection criteria for PSP was i) mid-level female
provider ii) located in rural areas iii) interested in providing
family planning and birth spacing services iv) willing to comply
with standard medical and business protocols. On the whole,
sixteen PSPs were taken on-board for this study and all of
them were Lady Health Visitors (LHVs) . All PSPs were
located in hard to reach rural areas at a distance of 30 kms
from the district head quarter hospital and covered a population of 16,000 to 20,000. The providers were located at large
enough distance from each other to avoid contamination.
Baseline survey was conducted during February 2009 in both
of the intervention and control districts with 4992 Married
Women of Reproductive Age (15-49 years) residing within the
catchment area of the study provider. The first household was
randomly selected and after that every second household was
included in

the survey using a systematic approach. If more than one

MWRA were present in any household, only one MWRA was
selected for the interview using a lottery method. The endline
survey was conducted with 4003 MWRA after eighteen
months of intervention during July/August 2010 in the same
intervention and control areas. Same sampling strategy was
used except that every fourth household was included in the
endline survey instead of every second household as during
the baseline to insure sample representativeness (Table 1).
Moreover, the sample was equally divided between the study
arms and within each providers catchment area.
The baseline household questionnaire was adopted from
PDHS 2006-07 structured questionnaire and was divided into
three sections i) socio-economic status (SES): possession of
household assets, education, household member, construction of house, source of drinking water ii) reproduction: parity,
current pregnancy, outcomes of pregnancies, source of antenatal care, desire for children; and iii) contraception: awareness, ever use, current use, future intention, method switching
behaviour, source of contraceptive method reason for not
practicing contraception and ever use of free contraceptive
services. The same baseline household questionnaire was
used for the endline survey with a few added questions
concerning the intervention. Each interview took half an hour
on average. The data was double entered in Visual FoxPro
version 6.0.

Table 1: Study sites and sampling details

Description
Systematic sampling
Total Sample size
Sample size for Control
(Dadu and Khanewal)
Sample size for Intervention
(Jhang and Badin)
Sample size for providers
catchment area

Baseline
Every 2nd household
4,992
2,509

Endline
Every 4th household
4,003
2,019

2,483

1,984

312/PSP (approx.)

250/PSP (approx.)

Statistical Analysis
Frequencies and proportions for continuous variables were
used for analysis of general characteristics and multiple logistic regressions was used to test the net effect of intervention
accounting for observed and unobserved time-in-variant characteristics as well as time-varying factor between intervention
and control sites. Individual outcome was regressed against a
dummy variable [created by taking the product of time
(baseline
9

Marie Stopes Society, Pakistan - Working Paper Series No. 3, 2012

and endline) by study arm (intervention and control)]. The

analysis was adjusted for other socio-demographic indicators
such as SES quintiles, women education, number of members
living in the house, and number of live children and also the
province. STATA version 11.2 was used for descriptive analysis and models estimation.

Results

Results
Table 2 shows the characteristics of women interviewed at baseline in intervention and control arm. In both arms distribution of
women age, number of children, education and working women were similar whereas small differences were seen between
mother tongue, religion, number of household members and socio-economic quintiles. In both arms, mean age was around 31
years having majority of housewives along with no formal education and had. 0-2 live children.

Table 2: Percent distribution of study participants by selected socio-demographic

characteristics according to study arms at baseline

10

Characteristics

Intervention (%)
(n=2483)

Control (%)
(n=2509)

Mean age of women in years (SD)

Mother tongue
Urdu
Sindhi
Punjabi
Others (Balochi, pushto, hindko, siraiki)
No of alive children
0-2
3-4
5+
Education Categories
No education
Primary
Middle
Secondary
Inter and post
Working women
Yes
No
Religion
Islam
Hinduism
Christianity
Median household member
Socio-economic quintiles
First/(poorest)
Second
Third
Fourth
Fifth/Least poor

30.5 (5.8)

31.9 (6.6)

6.2
32.9
55.5
5.4

8.5
48.5
30.9
12.2

38.9
29.8
31.3

37.0
26.9
36.2

59.5
14.7
7.3
10.4
8.1

66.6
13.9
4.7
7.5
7.8

10.5
89.5

9.7
90.3

92.5
7.3
0.2
9

99.8
0.2
0.04
6

25.1
19.9
17.3
16.6
21.0

14.9
20.1
22.6
23.4
19.0

Marie Stopes Society, Pakistan - Working Paper Series No. 3, 2012

Effects of Intervention

Effect of Intervention
In control site at baseline awareness of any modern contraceptive (91.0%) was higher than intervention sites (88.4%) whereas
awareness of traditional methods was higher in intervention (69.2%) in comparison to control site (58.7%). Table 3 shows the
increase in awareness of each method within intervention (column 5) and control sites (column 6). However, Contraception
awareness was much higher in intervention sites as compared to the control sites in which the difference was 6.4% (p-value
<0.001) for any method and 5.0% (p-value <0.001) for modern method whereas male sterilisation with 8.4% (p-value <0.001)
and injection with 7.7% (p-value <0.001) were amongst the highest increase in intervention site.

Table 3: Awareness about contraceptive methods

Intervention Sites

Control Sites

(%)

(%)

Baseline

Any method
Modern Method
Traditional Method
Pills
Condom
IUCD
Injection
Female Sterilization
Male Sterilization
Periodic Abstinence
Withdrawal
Number of cases

Endline

Baseline

(1)

(2)

(3)

88.7
88.4
69.2
86.7
78.7
84.4
85.1
80.9
62.3
67.2
68.0
2483

96.6
96.6
84.4
95.8
82.6
94.6
96.3
90.1
71.5
73.4
72.7
1984

92.7
91.0
58.7
90.0
85.1
87.4
89.8
79.4
31.0
52.9
48.4
2509

Absolute Difference
(% change)

Endline

Intervention

(4)

94.2
94.2
64.5
93.7
86.6
93.1
93.3
84.9
31.8
54.2
50.5
2019

(5)

7.9
8.2
15.2
9.1
3.9
10.2
11.2
9.2
9.2
6.2
4.7

Net Effect
(% change)

Control
(6)

(7)

1.5
3.2
5.8
3.7
1.5
5.7
3.5
5.5
0.8
1.3
2.1

6.4***
5.0***
9.4***
5.4***
2.4
4.5***
7.7***
3.7***
8.4***
4.9***
2.6***

Absolute difference is the percentage changes from baseline to endline. 2Net effect is the percentage change in intervention group adjusting for the
percentage change in control group. Statistical significance is calculated using multiple logistic regressions adjusting for socio-economic quintiles, women
age, and number of children, working women, women education and province. P-value: ***<0.001 **<0.01*<0.05

11

Marie Stopes Society, Pakistan - Working Paper Series No. 3, 2012

Use of Contraception

Ever and Current use of Contraception

Table 4 shows the changes in the ever use, contraceptive prevalence rate (CPR), method mix and unmet need for contraception. The CPR in intervention and control was similar at baseline; while 18.3% and 23.9% were modern and 8.9% and 4.6%
were traditional at intervention and control site respectively. At endline, the CPR had increased to 48.0% (column 2) and use of
modern method to 43.2%; the net effect (column 7) showed 19.6% (p-value <0.001) increase in CPR and 22.7% (p-value
<0.001) increase in modern use after adjusting by control sites. In addition, the use of traditional method reduced in intervention
by 3.1% (p-value 0.003). The highest percentage change within modern method was observed in IUCD at 11.4% (p-value
<0.001). Column 7 in Table 4 also shows that there was a statistical significant increase in ever use of any contraceptive method
at 25.2% and ever use of any modern method at 28.4% whereas a reduction is clearly apparent in the unmet for contraception
in both study arms However, the intervention substantially reduced the unmet need by 7.6% (p-value <0.001) adjusting for
control arm.

Table 4: Ever and Current use of contraceptive methods

Intervention Sites

Control Sites

(%)
Baseline

(% change)
Endline

Intervention

Net Effect
(% change)

Endline

Baseline

(2)

(3)

0.3

57.3

37.8

39.6

27.0

1.8

25.2***

22.1

53.4

32.8

35.7

31.3

2.9

28.4***

27.2
18.3
8.9
1.9
5.4
1.9
2.1
7.0
0.0
0.04
8.5
0.4

48.0
43.2
4.8
5.3
11.4
13.7
6.3
6.5
0.0
0.9
3.6
0.4

28.5
23.9
4.6
2.2
5.8
3.0
4.2
8.9
0.0
0.2
4.1
0.3

29.7
26.1
3.6
3.3
5.3
3.4
5.0
9.2
0.1
1.1
2.1
0.3

20.8
24.9
-4.1
3.4
6.0
11.8
4.2
-0.5
0.0
0.9
-4.9
0.0

1.2
2.2
-1.0
1.1
-0.5
0.4
0.8
0.3
0.1
0.9
-2.0
0.0

19.6***
22.7***
-3.1**
2.3***
6.5***
11.4***
3.4***
-0.8**
-0.1
0.0*
-2.9***
0.0

35.0
2483

22.2
1984

35.7
2509

30.5
2019

-12.8

-5.2

-7.6***

(1)

Ever use of any

contraception
Ever use of any
modern Method
Contraceptive
Prevalence Rate
Modern Method
Traditional Method
Pills
Condom
IUCD
Injection
Female Sterilization
Male Sterilization
Periodic Abstinence
Withdrawal
Others
Unmet need for
contraception
Number of cases

Absolute Difference

(%)
(4)

(5)

Control
(6)

(7)

Absolute difference is the percentage changes from baseline to endline. 2Net effect is the percentage change in intervention group adjusting for the
percentage change in control group. Statistical significance is calculated using multiple logistic regressions adjusting for socio-economic quintiles, women
age, and number of children, working women, women education and province. P-value: ***<0.001 **<0.01*<0.05

At baseline, in intervention, the services of govt. health facility were used by majority of the contraceptive users at (44.2%) along
with private health facility (32.5%), drugstore (9.3%), outreach worker (5.8%) and (8.2%) other sources. At endline, 52.2% of
the contraceptive users mentioned Suraj Provider as the main source of services followed by govt. health facility (15.6%) and
private health facility 14.0%.

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Marie Stopes Society, Pakistan - Working Paper Series No. 3, 2012

Voucher and FWM

Contribution of voucher
and FWM in uptake of contraception
At endline, in intervention, amongst the interviewed women, 28% had received contraceptive services from Social franchise
provider. Of the total women, 8.9% received IUCD services through voucher and nearly 20% referred by FWM without voucher
(for any contraceptive service). 3.8% were walk-in-clients as shown in the figure 2.

Figure 2: Percent distribution of women who received contraceptive

services from Social franchise, by their source of motivation
Endline survey (n=1984)
50
Women received services through voucher

40

Women received serivces from SF provider

and referred by FWM with no voucher

28.4%

30

Women received services from SF and were

referred by FWM with or without voucher

19.6%

20

Walk-in client to SF

10

8.9%
3.8%

Satisfaction with Social franchise services

Ninety Six Percent (96%) of the women were satisfied from the services they received from Social franchise. The quality of
advice/information received was the most cited reason of satisfaction for 31.4% clients followed by affordable/cheap price at
27.3%. Majority of clients 98% would recommend social franchise services to their friends/relatives.

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Marie Stopes Society, Pakistan - Working Paper Series No. 3, 2012

Discussion & Conclusion

Discussion
Social franchising with demand-side financing approaches
has gained increasing attention in the recent years in low
income countries, yet the existing evidence is not considered
sufficient enough to promote the concept (Frost 2006;
Eldridge and Palmer 2009; Basinga, Mayaka et al. 2011).DSF
has also been used widely in the United States and United
Kingdom to drive quality improvements in health care service
delivery (Eldridge and Palmer 2009) and now it has been gaining increasing attention as a means to achieve national goals
in low-income countries(Hecht, Batson et al. 2004; Eichler
2006). This pilot study attempted to assess the effectiveness
of DSF integrated social franchising to promote family planning, (especially long term contraceptive methods) in the rural
areas of Pakistan. Despite differences in the socio-economic
and demographic characteristics between intervention and
control population, the multivariate analysis accounting for all
these differences showed a very substantial effect of intervention on almost all the key outcome indicators including contraceptive awareness, ever use, current use, and unmet need for
family planning. The awareness of modern contraceptive at
baseline was quite low in intervention (88.4%) compared to
what is reported for the rural population nationally i.e.
94.4%(National Institute of Population Studies and Macro
International 2008). Later, the intervention significantly
increased the awareness of modern contraceptive by 5%.
This present study showed a considerable increase in all
modern contraceptive methods where most notable change
was observed in IUCD use by about 11% whilst its national
use is only 2.3%(National Institute of Population Studies and
Macro International 2008). Moreover, a significant reduction in
traditional method by 3.1% was also documented. Higher
(35%) unmet need for family planning was recorded at baseline in both study arms while the intervention exerted a considerable reduction in it. With respect to sources of contraceptive
method, presence of social franchise clinics considerably
reduced the share of the government and other private health
facility from baseline to endline in intervention sites. However,
the share of drugstore, outreach worker and other sources did
not reduce much, which may be due to the fact that such
sources are normally used to acquire the short term contraceptives such as condoms or pills etc. (National Institute of
Population Studies and Macro International 2008).Community
health workers have been on the frontline in providing care to
the disadvantaged groups for decades(Gold 2010). In this
study too, the FWM has played a key role in referring clients to
the social franchise provider with and without voucher. Moreover, the high level of satisfaction of the women who received
contraceptive services from social franchise can be considered as the outcome of medical and business training and
continuous monitoring.
Between August 2008 and September 2011, the Suraj social
franchise model was able to deliver 148,419 IUCDs with 35%
share of vouchers, across 18 districts of Pakistan(Azmat,
Hameed et al. 2011). A recent study conducted amongst the
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Marie Stopes Society, Pakistan - Working Paper Series No. 3, 2012

SURAJ social franchise IUCD clients revealed 81% continuation rates - with 74% citing field worker marketing as the
source of information for the SF centre(Azmat, Shaikh et al.
2012). Nearly 80% of the providers were found to be complying with organisational clinical standard(Azmat, Hameed et al.
2011). This resulted in higher level of client satisfaction with
around 80% showing willingness to use SF services in future,
in case of need; and 97% said that they would recommend SF
services to friend or relative(Azmat, Shaikh et al. 2012). The
increase in knowledge and use of contraception (particularly
IUCD), higher level of satisfaction, quality of care, and role of
FWM were acknowledged by SF clients in the qualitative
interviews(Azmat, Hameed et al. 2011). Moreover, similar
perceptions regarding increasing awareness of contraception,
importance of voucher, role of FWM and training for providing
quality services were documented during in-depth interviews
conducted with SF provider and FWMs (Azmat, Hameed et al.
2011).

Conclusion
The findings of this pilot study support the idea regarding the
ability of the two-pronged social franchising approach in
promoting the awareness and use of modern contraception
through increasing the accessibility to quality and affordable
family planning services for the underserved communities.
The results reinforce the two pronged approach i.e. generating the demand (through FMW and voucher) and addressing
the need (through trained FP providers and uninterrupted
supplies of contraceptive products). These findings can be
generalized in similar settings. The results of the pilot
research and the monitoring data of SF project across 18
districts helped to understand the impact of this DSF model in
the country. However, it would be desirable to have an
assessment of health outcomes associated with social
franchise services along with an economic evaluation of this
model as well. This would help in ascertaining the effectiveness, limitations and potential of scaling up this DSF model in
Pakistan

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Marie Stopes Society, Pakistan

Email: mariestopes@msspk.org | Website: www.mariestopespk.org