DFID Malawi
The Malawi Family Planning Programme
Business Case
November 2011
Acronyms
BLM
CHAM
CMS
CPR
CYP
DALY
DHS
DPs
FP
GDP
GOM
HMIS
IUD
JSI
KPI
LAPM
MDG
MFPP
MICS
MMR
MNCH
MoH
RH
MSI
SP
SRH
STM
TFR
UNFPA
USAID
VFM
WHO
Banja La Mtsogolo
Christian Health Association of Malawi
Central Medical Stores
Contraceptive Prevalence Rate
Couple Years of Protection
Disability-Adjusted Life Year
Demographic and Health Survey
Development Partners
Family planning
Gross Domestic Product
Government of Malawi
Health Management Information System
Inter-uterine device
John Snow International
Key Performance Indicators
Long acting and permanent methods
Millennium Development Goal
Malawi Family Planning Programme
Multiple Indicator Cluster Survey
Maternal mortality ratio
Maternal, neonatal and child health
Ministry of Health
Reproductive Health
Marie Stopes International
Service Provider
Sexual and reproductive health
Short-term method
Total Fertility Rate
United Nations Population Fund
United States Agency for International Development
Value for Money
World Health Organisation
Intervention Summary: The Malawi Family Planning Programme
(the MFPP)
What support will the UK provide?
The UK will provide £25.20 million over five years (2011-2016) to increase the coverage and use of
effective family planning in Malawi, with a focus on rural, poor, and young women. Approximately
£19m will go to family planning service delivery and the remaining £6m will be spent on contraceptive
commodities. £200,000 is allocated for research and evaluation.
Why is UK support required?
What need is this intervention going to address?
Despite several years of strong economic growth, Malawi remains one of the poorest nations in the
world with 52% of the population living below the poverty line.i At present, amongst the health MDGs,
it is likely that Malawi will only attain the child mortality MDG.
This intervention will address a number of inter-related concerns. First, Malawi’s high maternal
mortality ratio of 675 per 100,000 live births.ii Second, Malawi’s high fertility rate – an average family
size of 5.7 per womaniii and a rate of natural increase at 2.9% per annum.iv This means that the
population of Malawi (currently 15.4 million) will be 37 million people by 2050 (more than doubling) v.
This high rate of population growth means that Malawi has a young population with 45% of the
population under the age of 15.vi Third, Malawi’s high abortion rate, currently 38 per 1,000 women. vii It
is estimated that abortions (in the main unsafe) account for 17% of Malawi’s maternal mortality.viii
Fourth, Malawi’s high HIV prevalence rate: currently 10.6%. Fifth, Malawi’s high under five mortality
rate of 112 per 1,000 children.
The intervention will expand the coverage of high quality accessible family planning. This will impact on
the above concerns in the following ways:
First, in general access to family planning reduces maternal deaths by around one third (the other two
thirds reduction is through access to emergency obstetric care and skilled attendance at birth). ix This is
partly because there are safer times to be pregnant (between 18 and 35) and because of the benefits
of birth-spacing.x
Second, contraceptive prevalence and fertility are closely related. Although there are many other
determinants of fertility, contraceptive use (especially modern contraceptives) is a key driver in the
contemporary fertility transition—whereby fertility decreases begin to match the decreases in mortality
that have already taken place.xi
Third, family planning will reduce the need to resort to (most often unsafe) abortion. Fourth, it will
reduce the risk of death from pregnancy related complications for HIV positive women which may be as
much as double that for HIV-negative women.xii Ensuring equitable access to contraception to women
irrespective of their HIV status is both important in its own right and should play a key role in reducing
transmission from mother-to-child.
Fifth, in reducing the child mortality rate. Babies born less than two years after their older sibling are
twice as likely to die before they reach their first birthdays as those born more than three years apart,
have less care and support from their mothers and, because of large family sizes, may have higher
incidence of stunting because of less food availabilityxiii.
What will DFID do to respond to the need?
The proposed intervention will increase the use of effective family planning methods with an emphasis
on reaching rural, poor women, especially young women. There will also be activities that stimulate
positive behaviour change around family planning. In addition, the intervention will procure
approximately one quarter of Malawi’s public sector contraceptive needs for the next five years.
Expanding access to family planning is one of the two strategic priorities in DFID’s Choices for women:
planned pregnancies, safe births and healthy newborns, which commits DFID to enabling at least 10
million more women to use modern methods of family planning by 2015. This Business Case (BC)
contributes to this commitment by addressing each of its four pillars. It also responds to DFID’s
Business Plan action 5.2 to lead international action to improve maternal health. Increasing
contraceptive prevalence is a component of DFID Malawi’s Operational Plan (OP) results for women
and girls.
Who will deliver? A contract will be given to the successful Service Provider (SP) from a mini
competition under the DFID Reproductive Health Framework. In addition, UNFPA will be contracted to
procure commodities.
What are the expected results?
The programme will contribute to reducing maternal mortality and achieving MDG5 in Malawi. This
will be measured at impact and outcome level by:



Reducing maternal mortality from a ratio of 675 (deaths per 100,000 live births) in 2010 to 425
in 2015/16
reducing the total fertility rate from 5.7 in 2010 to 4.2 in 2015/2016; and
increasing the national contraceptive prevalence rate (CPR) from 42% (use of modern
methods by married women) in 2010 to 55% in 2015/16.
This programme will directly deliver through the Reproductive Health Framework (undiscounted
results):
 3.0 million couple years of protection (CYPs)1 ;
 1.0 million fewer pregnancies;
 148,000 fewer abortions (most unsafe);
 3,700 fewer maternal deaths; and save 729,000 disability adjusted life years (DALYS)2.
In addition, DFID will cover the costs of approximately one quarter of the Government of Malawi’s
contraceptive procurement needs between 2011/2-2015/16. Allocating a share of the benefits from this
important contribution to family planning services in public and church run services will provide a
further:
 646,000 CYPs;
 229,000 fewer pregnancies;
 32,000 fewer abortions (most unsafe);
 800 fewer maternal deaths; and save 160,000 DALYS.
In total, the programme will enable an additional:
 3.6 million CYPs;
 1.27 million fewer pregnancies;
1
CYPs are a way to measure the volume of contraception provided through different methods. For
these estimates of results, the CYPs are estimated in the year the family planning service is provided,
although the protection for long acting methods runs into future years.
2
One DALY can be thought of as one year of "healthy" life. The sum of these DALYs across the population, or
the burden of disease, can be thought of as a measurement of the gap between current health status and an
ideal health situation where the entire population lives to an advanced age, free of disease and disability .


180,000 fewer abortions (most unsafe);
4,460 fewer maternal deaths; and save 888,000 DALYS.
If DFID’s existing family planning support to the Programme of Work (2009-2015) of Banja La Mtsogolo
(BLM) is included, DFID will be supporting in total over the five years 2011/12-2015/16 (undiscounted):
 4.8 million CYPs;
 1.7 million fewer pregnancies;
 239,000 fewer abortions (most unsafe);
 5,900 fewer maternal deaths; and save 1.2 million DALYS.3
Not intervening would mean that women who want to use family planning would not have access or
would only have access to a limited range of methods due to contraceptive shortages. Use of family
planning in Malawi would remain at or below current levels and women would continue to use less
effective methods. Maternal mortality would not be significantly reduced and continued high population
growth would have a negative impact on Malawi’s social and economic development.
STRATEGIC CASE
A. CONTEXT AND NEED FOR A DFID INTERVENTION
CONTEXT
1. Malawi is a poor country with major health status concerns. Malawi is one of the poorest
countries in the world and one of the most densely populated in Africa. Its GDP per capita is $310, the
fourth lowest in the world.xiv. Poverty in Malawi has decreased from 52% in 2004 to 39% in 2009, and
the proportion of ultra – poor decreased from 22% in 2004 to 15% in 2009.xv
Malawi has performed well in health gains for a considerable period of time and by 2005, health
outcomes were better than the average for Least Developed Countries.xvi However, there is still a long
way to go as at present, amongst the health MDGs, it is probable that Malawi will only attain the child
mortality MDG.
2. Maternal mortality in Malawi is very high and family planning can help reduce it. Malawi
continues to struggle with high maternal mortality, with a ratio that has shown some evidence of decline
in the past ten years, but remains high at 675 per 100,000 live births.xvii Malawi has one of the highest
rates of maternal mortality in sub-Saharan Africa. Family planning can reduce maternal mortality by up
to one third.
3. Malawi’s maternal mortality is related to high rates of unsafe abortion and HIV- related
maternal deaths.
When women are unable to practise family planning, they have unintended
pregnancies and these pregnancies are more likely to end in abortion. In Malawi, where abortion is
3
Results (undiscounted and actual – not rounded as in the text) attributed to DFID inputs
Programme
element
RH
Framework to
support private
service
delivery
Procurement
of
contraceptives
(via UNFPA)
Subtotal for this BC
Existing DFID
support to BLM
Total DFID support
to FP
CYPs
Pregnancies
averted
Abortions
averted
Maternal
deaths
averted
DALYS saved
2,950,000
1,044,300
645,640
228,557
3,595,640
1,272,857
1,192,961
422,308
4,788,601
1,695,590
147,500
32,282
179,782
59,648
239,490
4,459
1,479
5,939
3,658
728,947
801
159,473
888,420
294,661
1,183,081
illegal under most circumstances, this abortion is likely to be unsafe and extremely risky for women.
Unsafe abortion is estimated to be responsible for 17% of Malawi’s maternal mortality (the international
average is 13%)xviii. Recent estimates suggest that there were 70,500 induced abortions in Malawi in
2009.xix Malawi’s abortion rate is estimated at 38 per 1,000 women compared to the global average of
29 per 1,000 women. Over half of the women who suffer complications of unsafe abortion are below the
age of 25 years and 81% are married, which indicates a high rate of unwanted or unplanned
pregnancies even within marriage.xx Not only does unsafe abortion result in maternal deaths, there are
also high rates of maternal morbidity related to the practice sometimes leaving women unable to bear
children.
HIV/AIDS is also contributing to maternal deaths. Malawi has an HIV prevalence of 10.6%.xxi Risk of
death from pregnancy-related complications for HIV positive women may be as high as double that for
HIV-negative women.xxii Ensuring equitable access to contraception for women irrespective of their HIV
status is both important in its own right and should play a key role in reducing transmission from
mother-to-child.
4. Malawi has rapid population growth. Fertility remains high in Malawi with an average family size
of 5.7 per woman and a rate of natural increase at 2.9% per annum.xxiii This means that the population
of Malawi (currently 15.4 million) will be 37 million people by 2050 (more than doubling). xxiv This high
rate of population growth means that Malawi has a young population, with 45% of the population under
the age of 15.xxv
The Ministry of Development Planning and Cooperation (MDPC) has published projections of
population growth from 2008 to 2040 based on two hypothetical population scenarios and using 2008
census data.xxvi One scenario assumes that women in Malawi will continue to have six children on
average during their lifetime, while the other scenario assumes a gradual decline to three children per
woman. Both scenarios take into account the effect of AIDS-related deaths. The first scenario with
continued high fertility shows the population growing from about 13 million people in 2008 to 41 million
people in 2040. By contrast, the second scenario with lower fertility shows an increase to only 31 million
people—a difference of 10 million people.
Population
40 Million People …
Population Triples by 2040
Current Fertility Rate
13 to 40
million people
Sources: 2008 Malawi Census, Spectrum
5
5. A sustained rapid population growth will impede national development. The same
demographic modelling exercise carried out by the Government of Malawi (GoM) found that the lower
scenario would result in major social and economic gains, including 3.2m fewer primary school age
children and 5,126 fewer primary schools with a saving of $900m to the education sector. In the health
sector, thirty per cent fewer health workers would be needed yielding savings of $1.8 billion. This
translates to 4m fewer young people seeking jobs.xxvii
6. There are significant gender related social issues in Malawi. Only 1 in 4 girls completes primary
school (8 years). Only 45% of pupils enrolled in secondary school are girls and this reduces to 34% at
tertiary level. Girls are 5.5 times more likely to be enrolled in non-formal education than boys.xxviii Girls
perform worse in the national school leaving exams at both primary and secondary level. In Malawi,
women’s bodies are subject to a range of social control mechanisms, notably around reproduction. xxix.
7. There is significant unmet need in Malawi for family planning. In Malawi, an estimated 26% of
women have an unmet need for family planningxxx, implying that there is a high demand for family
planning. Malawi is similar to other Eastern African countries with high unmet need (see chart).
Reasons for unmet need are generally lack of knowledge, difficult access to supplies and services,
financial costs, and fear of side effects.xxxi Poor, rural women with the least education are the most likely
to have an unmet need for family planning. It is this rising level of expressed need for family planning
that it is critical to respond to – as the MFPP will do – that will address the major problems described
above.
Unmet Need for Family planning: a cross country comparison
Source: DHS data; Note: Unmet need to limit births implies that women want no more children. Unmet need to
space means that the women wish for a longer time between births.
8. Family size remains high even with high CPR. Malawi’s total fertility rate of 5.7 children per
woman is high considering that the proportion of women using family planning (the CPR) to be 46%.
The strong negative association between women using contraception and fertility found worldwide has
never been as strong in sub-Saharan Africa. This would imply that Malawi, along with several other
African countries, is on the brink of its demographic transition.xxxii (This means that falling death rates
would be answered with falling birth rates). All other regions in the world have had a demographic
transition while sub-Saharan Africa lags behind.xxxiii
9. Aside from this it remains the case that Malawi’s family planning programme is not effective as
it needs to be. There are a number of reasons for this. First, the family planning programme is
currently unable to provide a full range of methods due to frequent stock outs of commodities linked to
suboptimal procurement and distribution practice and inadequate numbers of skilled health workers
(albeit that there has been “task shifting” over recent years with health surveillance assistants now
providing injectables). When the full range of contraceptive methods is not available, women are more
likely to discontinue contraceptive use.
Second, the balance between the use of commodities needs redressing. Malawi is at the vanguard in
Africa in the use of injectables – currently 25.8% of modern contraception is by injectables. It accounts
for the largest share of the increase in contraceptive use - from 13% to 46% (all methods) over an 18
year periodxxxiv. It is probable that the demand for injectables will increase. There is a need to ensure
the national programme responds to this need (and avoids the aforementioned stock outs) but also a
major need to increase the range of methods available, in particular of longer acting methods
(contraceptive implants and inter-uterine devices) and permanent methods (male and female
sterilisation) - collectively termed long acting and permanent methods (LAPM). In particular there are
good prospects for a rapid increase in the use of implants.
Malawian women have one of the lowest rates of switching from one method of contraceptive to
another in the world (only 8% of women switch to another method within three months).xxxv A
programmatic implication of this would be to train healthcare providers to counsel women to consider
switching from injectable contraceptives to a more long-acting method from the onset of their choice to
use an injectable. This would give women time to think about other options when they choose to stop
using injectables (median use of injectable in Malawi is 10 months).xxxvi
Third, there is a need to focus more on the needs of younger women.
Table 1: Use of contraception by age: Malawi
Age
15-19
20-24
25-29
30-34
35-39
40-44
Source:
Any
family
planning method
28.8
41.8
47.8
50.4
53.5
50.4
MDHS, 2010
Modern methods
Injectables
Female Sterilisation
26.4
38.0
45.0
46
49.1
45.0
21.4
31.8
33.7
27.0
22.0
12.8
0.0
0.6
2.8
10.0
19.7
28.5
Young people in Malawi initiate sexual activity and childbearing at a young age. Twenty six percent of
young women (aged 15-19) have already begun child bearing, with 20% being mothers and an
additional 6% being pregnant with their first child. Young motherhood is more common in rural areas
than urban areas; young women with no education are more than eleven times more likely to have
started child bearing by age 19 than those with secondary education. Six in ten women and 41% of
men age 25-49 were sexually active by the age of 18 with 19% of women having had sex by age 15,
one and half years earlier than men.xxxvii In addition to encouraging younger women to use
contraception, it will be important for Malawi to adopt policies that seek to increase the age at marriage,
and delay early childbearing – this includes keeping girls in school longer to delay as modern
contraceptive use increases with education: 49% of women with more than secondary education use
modern methods of contraception compared to 37% of women with no education.xxxviii Common
barriers to access for young women include myths and misconceptions around family planning, and
social norms relating to young unmarried women in particular.
11. As a country with high HIV prevalence, Malawi must stress dual protection.
Condoms
prevent HIV and yet, among married women in high HIV prevalence countries like Malawi, condom use
is low.xxxix This means that HIV is spread within marriage, partly because condom use within committed
relationships is stigmatised due to its relationship with extra-marital and commercial sexxl and may not
be considered an appropriate form of family planning for marital relations.xli Family planning
programmes should stress the need for ‘dual protection’ whereby women used a long-acting more
effective family planning method in addition to use of condoms (although this implies female power in
the relationship to insist on use of condoms within marriage and is not always possible).
National response: Malawi’s Family Planning Policy and Programme
National policy environment: The draft Malawi Growth and Development Strategy II 2011-2016
promises to ‘enhance the provision, access, delivery and utilization of sexual and reproductive health
services to all including the vulnerable and disadvantaged groups’. Malawi’s National Health Bill and
the draft National Health Policy will provide the policy framework. The operationalisation of the
programme will be primarily governed by the new 5 year national health programme: the Health Sector
Strategic Plan (HSSP). The results produced by the MFPP will feed into the HSSP.
The National Reproductive Health Strategy has ambitious maternal health targets. It aims to achieve
these through reducing the number of children women bear and by ensuring that they are more likely to
have skilled attendance at delivery. In order to reach these targets the Reproductive Health Unit (RHU)
of the Ministry of Health (MoH) developed a Road Map for Accelerating the Reduction of Maternal and
Newborn Mortality and Morbidity in Malawi’. This covers nine strategy areas. The Road Map is currently
being revised and now places family planning as the first strategy with an emphasis on LAPM.
Translation of policy into practice in Malawi is sometimes weak. The reasons are many and inter-related
and are described below.
The national family planning programme. Public sector. Public sector family planning services are
delivered as part of the primary healthcare system whereby women can receive family planning at their
local health centre, if contraceptive supplies are available and healthcare personnel are able to deliver
them. District health officers (DHO) have a drug budget and procure from the Central Medical Stores
(CMS). The CMS is a parastatal which is managed as a revolving fund. It procures with public funds
and has a supply chain to deliver to government and the private non profit making agencies (discussed
below). However, Malawi is experiencing a national drug shortage for three reasons. First there is a
national shortage of foreign exchange to procure internationally. Second, the DHOs have often not paid
the CMS and hence the CMS is heavily in debt. Third, CMS has been poorly managed both in relation
to procurement and in supply chain management. xlii CMS procures around $43m per year.xliii In
response to this crisis, DFID Malawi (with Norway and Germany) is developing a BC for the emergency
provision and distribution of essential drugs for 18 months. During this period CMS will undergo
significant reform in order to restore its integrity. The Global Fund are sourcing an international supply
chain management agent for two years to co-manage the distribution network and other development
partners (DPs) will provide a procurement agent to likewise support procurement practice.
Contraceptive commodities supply chain. A RH Commodity Security Working Group was formed in
2010 which includes most family planning organisations and has met twice so far. Family planning
commodities for the public sector are purchased by the CMS or provided by DPs. CMS’s procurement
of DMPA injectables (depo) is proving expensive, which coupled with CMS’s 12.5% handling charge
discourages the DHOs from purchasing injectables. Hence DHOs often, with their limited budget, do not
prioritise contraceptives and choose curative drugs instead.xliv UNFPA procurements are distribution by
CMS (who charge a 5% handling charge). USAID procure but distribute through a parallel system
managed by JSI/DELIVER.
Table 2: Family planning commodities needs for Malawi have been forecast by the MOH as follows:
Malawi family planning procurement requirements (excludes shipping), 2011-2013 (US$/£s totals)
FP Commodities
IUCD
Implants
Male condoms
Female condoms
Combined oral pills
Progestin-only pills
DMPA injectables (depo)
2011
2012
2013
$597
$2,455
$2,400
$854,557
$1,572,687
$1,517,561
$0
$308,647
$980,434
$0
$0
$409,632
$218,764
$160,174
$159,016
$0
$19,128
$23,218
$2,917,764 (UNFPA will $3,411,418 (UNFPA will $3,316,110
procure $1m worth – to procure $1m worth – to
be confirmed
be confirmed)
Emergency contraception
$13,171
$9047
$9047
Family planning TOTAL £2,683,250
£3,673,982
£4,299,738
COSTS (£/$)
$4,004,852
$5,483,556
$6,417,519
Source: MOH The Malawi Government 2011 National Quantification and Supply Planning Report .
The current commodity supply situation in Malawi, based on a June 2011 consultancy, means that the
above requirements are largely not assured. UNFPA will soon confirm the supply of $1m worth of depo
for this year and the next and USAID are likely to procure pills.
Beyond the current pipeline there are no funding commitments. Total contraceptive needs for 20112013 will cost £10,657,000. The MOH’s RHU does not prepare procurement estimates beyond three
years. Therefore, estimating (based on 2011-2013 trends) contraceptive needs for 2014 as
approximately £5m and for 2015 as £5.8m, this would imply that family planning procurement
requirements for 2011-2015 would total around £21,500.000. This means that DFID’s contribution to
Malawi’s contraceptive procurement needs (£5.8m) for the five years 2011-2016 would cover a little
more than one quarter of the total need.
It is critical to ensure effective forecasting and well coordinated procurement in order to maximise the
value for money in procurement and maintain security in supplies. There is an understanding that
USAID will focus future support on the purchase of long-term methods (IUDs and implants) and UNFPA
will complement this by a focus on short and medium methods (condoms, pill, and injectables). The
choice of who buys which commodity is partly driven by value for money as UNFPA buys injectables at
lower prices than USAID, for example (as discussed further in the procurement case).
The not-for-profit and private sectors. Christian Hospital Association of Malawi (CHAM). CHAM
is a national NGO and serves as an organisation to manage Christian based health care. CHAM has
signed an MOU with the Government and all CHAM employees get a Government salary. In addition,
CHAM trains many public sector health providers and Government pays for many of the training
facilities. CHAM consists of two arms: the Episcopal Conference of Malawi (Catholic) and the Malawi
Council of Churches (Protestant). Only the Protestant arm of CHAM promotes family planning services
- it is also attempting to provide family planning services in the areas where only the Catholic arm of
CHAM is operating. Medical supplies, including family planning, are supplied to CHAM via the CMS.
Banja La Mtsogolo (BLM). The major private sector provider in Malawi of family planning is Banja La
Mtsogolo, a partner of Marie Stopes International (MSI). BLM is currently implementing a Programme
of Work (POW) to deliver sexual and reproductive health (SRH) services throughout Malawi. DFID is
the lead donor and funds 32% of the POW with £11.8m committed for 2009-2015. BLM’s POW aims to
reach 12 million people through BLM’s own static clinic network (covering 22 districts), expanding to
provide community outreach services in all 29 districts. The POW also stimulates positive behaviour
change around family planning and HIV, and combats HIV/AIDS by providing people with information
on prevention, treatment and care, and access to condoms and HIV testing and counselling services
within the context of an integrated family planning, reproductive health, and HIV/AIDS framework.
BLM provides nearly 16% of all family planning methods in Malawi, including 50% of all female
sterilisations. In 2010, BLM estimated that their services provided 774,918 CYPs in Malawi. According
to MSI REACH Modelling, as of 2010, 18.9% of Malawi’s CPR - now at 42% (modern methods) - is
attributable to BLM.
BLM’s BlueStar franchise enables SRH services to be accredited, provided and quality assured though
the private sector, in areas beyond BLM’s catchment. There are currently 34 BlueStar private providers
or franchisees and there will be an estimated 300 by 2015. BLM also socially market their family
planning commodities.
Other private sector players include Population Services International (PSI) managing a social
marketing programme, the Family Planning Association of Malawi (FPAM) which has four centres and
five clinics and has a special emphasis on services for youth, Engender Health which trains health care
workers, JSI Deliver, and the Futures Group which focuses on policy.
RATIONALE FOR DFID SUPPORT FOR FAMILY PLANNING IN MALAWI.
DFID’s Business Plan (2011-2015)xlv commits DFID to supporting actions to help achieve the MDGs,
and lead international action to improve maternal health and family planning. Specifically, DFID has
committed to embed in every relevant bilateral programme plans to double our impact in terms of the
number of maternal and newborn lives saved, enable more couples to access modern methods of
family planning over the next five years, and scale up our efforts to restrict the spread of major diseases
like HIV/AIDS, tuberculosis and malaria.
DFID Malawi is a lead partner in the health sector and was instrumental in the development and
implementation of the first health sector wide programme (SWAp). DFID is developing a BC (the
Malawi Health Sector Programme, MHSP), for support to the next health sector wide programme: the
Malawi Health Sector Strategic Plan 2011-2016 (HSSP). MHSP is under design at present: maternal
health may be an element of the technical assistance component of the programme
However, there are compelling reasons why an additional family planning stand-alone programme is
justified. First, the importance of addressing high maternal mortality and high population growth is
central to Malawi’s growth and social development and requires concerted efforts. It is likely that
accelerated progress will better be achieved by using a mix of providers. Investing in service delivery
via the private sector provides excellent value for money.
Second, family planning is a recognised “best buy” in global health and is one of the most cost-effective
ways to reduce maternal mortality as it is far cheaper to prevent than treat complications of unintended
pregnancy. A recent study calculated that by reducing fertility and pressure on services, one dollar
invested in family planning saves $2 to $6 which can be used to provide other interventions such as
health and education for fewer children, maternal health services, and improvements in water and
sanitation.xlvi
Third, donor support for family planning appears precarious, with a major commodity shortage looming.
And, with an estimated funding in the HSSPxlvii of only $26 per capita, nor is a major scale up of
provision through the public sector likely.
Fourth, although DFID is already a major player in the national family planning programme, through
funding 32% of the BLM programme, this is not yet sufficient as explained above.
In addition to DFID’s two bilateral programmes: the MFPP and the MHSP, Malawi is one of the
countries covered by two regional DFID-funded maternal health programmes: Preventing Maternal
Death due to Unsafe Abortion (PMDUP) and the Evidence for Action programme. These bilateral and
regional programmes will produce more than the sum of their parts by positioning DFID Malawi to
identify and support public and private sector alliances that expand coverage of family planning, as well
as supporting other opportunities to address reproductive health holistically, and ensuring attention is
given to reproductive health needs that do not receive adequate policy support from other DPs - such
as addressing unsafe abortion.
UNFPA and USAID are the only other donors involved in providing family planning commodities and
technical assistance. Neither plan to scale up activities over the next five years. Increased DFID
support is important for two reasons: first, MFPP will provide for the much needed predictable
procurement of commodities, and second, MFPP will uniquely address two needs at the same time (i)
strengthening a core health system - commodity forecasting, procurement and distribution and (ii)
supporting a whole-market approach to service provision, by maximising the potential of the not-forprofit sector.
The MFPP will address the highest family planning programmatic priorities which are: ensuring
adequate stocks at national level of highest demand commodities (injectables); increasing demand for
and availability of longer acting methods; increasing the coverage of service provision to rural areas;
and addressing the needs of young women.
B. IMPACT AND OUTCOME THAT WE EXPECT TO ACHIEVE
The programme will contribute to reducing maternal mortality and achieving MDG5 in Malawi. This will
be measured at impact and outcome level by:



Reducing maternal mortality from a ratio of 675 (deaths per 100,000 live births) in 2010 to 425 in
2015/16;
reducing the total fertility rate from 5.7 in 2010 to 4.2 in 2016; and
increasing the national contraceptive prevalence rate (CPR) from 42% (modern methods for
married women) in 2010 to 55% in 2015/16.
The benefits directly delivered by the MFFP are detailed in the Intervention Summary above. In total,
the programme will enable an additional:




3.6 million CYPs;
1.27 million fewer pregnancies;
180,000 fewer abortions (most unsafe);
4,460 fewer maternal deaths; and save 888,000 DALYS
If DFID’s existing family planning support to the Programme of Work (2009-2015) of Banja La Mtsogolo
(BLM) is included, DFID will be supporting (in total over the five years 2011/12-2015/16 undiscounted):
 4.8 million CYPs;
 1.7 million fewer pregnancies;
 239,000 fewer abortions (most unsafe);
 5,900 fewer maternal deaths; and save 1.2 million DALYS.
The MFFP’s outcome is to increase the use of effective family planning methods, especially the young,
the rural population and the poorest. There are five outputs as follows:
1) Effectiive family planning and other sexual and reproductive health services used, especially by the
young, the rural population and the poorest. ;
2) Access, awareness and knowledge of family planning and SRH services at the individual, household
and community levels;
3) Strengthened national proficiency in SRH policy, planning and implementation;
4) Strengthened programme cost-effectiveness, quality and accountability ; and
5) Contraceptive commodity security improved for short-term methods (including injectables) for public
sector .
APPRAISAL CASE
A. WHAT ARE THE FEASIBLE OPTIONS THAT ADDRESS THE NEED SET OUT IN THE
STRATEGIC CASE?
Brief on the options
Option 1: Do Nothing
Option 2: Public sector scale up and commodity provision
Option 3: Non-for-profit-private sector scale up and commodity provision
Description of the options
Option 1: DO NOTHING: No additional funding for family planning (beyond £11.8m already committed
for BLM). Other DPs, CHAM, and other NGOs are already supplying family planning in rural Malawi with
limited coverage. There would continue to be high unmet need for family planning, and contraceptive
use would remain less effective with a high dependence on short term methods. There could be
shortages of commodities in the public sector.
Option 2: PUBLIC SECTOR SCALE UP AND COMMODITY PROVISION: Scale up family planning
service coverage and efficiency through public sector services, and provide 25% of the estimated
contraceptive commodity requirement.
The mechanism would have two components.
Component one: public sector scale up: (£19.2m) DFID Malawi would provide additional earmarked
financial aid to the MHSP to ensure family planning is delivered as part of the public sector primary
healthcare system. This would be managed by the MOH who would determine how the funding will result
in increased service provision: for example, more training, more staff recruited, more funding to the
DHOs to specifically purchase commodities.
Component two: commodity procurement: (£5.8m) DFID Malawi would fund UNFPA to procure a range
of commodities. These would be distributed through the CMS network. Funding for family planning
commodities would allow DFID to complement its support to HSSP and help to ensure there are a range
of family planning commodities available for service delivery. An estimated 25% of Malawi’s commodity
needs would be met for the next 5 years. This would be a major contribution to ensuring both
government and non-government providers can draw on supplies of family planning commodities. There
is a particular need for more injectables as this is the preferred method for Malawian women and the
demand is likely to increase. The component would provide a cost saving of £3.66m over 5 years for
depo needs alone as UNFPA procure more cheaply than CMS and the CMS handling fee for UNFPA
depo is lower.4
Distribution would be tracked through a dedicated Contraceptive Distribution Logistics and Management
Information system which UNFPA supports. In addition, UNFPA is supporting the CMS with installation
of CHANNEL, a warehousing software for tracking commodities as well as generating consumption data.
This support would be further strengthened by the Global Fund supported new Supply Chain
Management Agent.
Resource cost: £25m - £19.2m for service delivery and £ 5.8m for commodities
Option 3 NOT-FOR-PROFIT PRIVATE SECTOR SCALE UP (THE REPRODUCTIVE HEALTH
FRAMEWORK) AND COMMODITY PROVISION : Scale up family planning service coverage and
efficiency through the private not-for- profit provider, and provide 25% of the estimated contraceptive
commodity requirement.
The mechanism would have two components.
Component one: not-for-profit-private sector scale up. (£19.2m) DFID is committed to the expansion of
the private sector and building on their different strengths and capabilities. The not-for-profit private
sector in Malawi have shown they can expand delivery of family planning services quickly, and there are
existing providers with the human resources and infrastructure to deliver more effective LAPM.
Encouraging the not-for-profit private sector while continuing to support the public sector via the HSSP
would encourage a Total Market Approach, whereby Malawians have both good public and private
sector options from which to choose.
DFID Malawi would use DFID’s Reproductive Health (RH) Framework (a Global Framework Agreement
for Delivery of Reproductive Health Services and Products) to run a mini-competition in Malawi to identify
an appropriate private service provider. The RH Framework, which became operational in September
2011, enables DFID country offices to run smaller, quicker in-country mini competitions to hire pre
4
CMS procure/import one vial of depo for $1.10, combined with the 12.5% handling charge by CMS,
this vial cost the DHOs (or CHAM or central hospital), $1.23. UNFPA procure/import the same vial for
$0.95, combined with a 5% handling charge by CMS, this vial cost the DHOs $1. Thus every 1 million
vials, there is a cost saving of $230,000.
qualified service providers. The pre qualified providers already in Malawi would include MSI (BLM), IPPF
(FPAM), the Futures Group and PSI. (DFID Procurement Group rules preclude the automatic
enhancement of the current project with BLM.)
The service provider (SP) would do the following:
- increase the use of modern family planning methods (with an emphasis on LAPM). It is expected that
the programme would be able to deliver in the region of 2.95 million additional CYPs through family
planning provided in the 5 years (undiscounted). The expected outputs/milestones in terms of
contraceptive provision would lead to total CYPs delivered in the year as follows (although tenders could
suggest a different profile): 2011/12: 150,000 2012/13: 400,000 2013/14: 500,000 2014/15: 700,000
and 2015/16 1,200,000 CYPs5;
- provide services to rural poor in all districts of Malawi with a focus on districts where MOH facilities do
not exist or are suboptimal;
- enhance positive behaviour change around family planning and combat HIV/AIDS within the context of
an integrated family planning, reproductive health, and HIV/AIDS framework;
- deploy a range of appropriate service delivery mechanisms: static and mobile clinics, social marketing
and social franchising;
- procurement of commodities as appropriate;
- expand community outreach clinics which will deliver family planning and HIV counselling and testing
in collaboration with the MoH and CHAM health facilities that lack capacities. This may include the use
of Reproductive Health Assistants (RHAs) to provide services at community level
- strengthen the capacity of the private sector to deliver SRH services;
- ensure a focus on accessing young women and men;
- provide services including integrated FP/HIV services, tailored SRH services and behaviour change
interventions to high-risk groups including prison populations, commercial sex workers, construction site
workers and truck drivers;
- strengthen national proficiency in SRH policy, planning and implementation.
Component two: (£5.8m) as for option 2. Although the SP in component one will undertake some
procurement, this will relate to smaller quantity needs, such as implants, and one major efficient procurer
is still needed.
Resource cost: £25m - £19.2m for service delivery and £ 5.8m for commodities (figures based on
DFID’s assessment of local absorptive capacity)
5
Numbers of CYPs estimated based on services provided in that year - with all the CYPs counted in
the year of service delivery.
B. ASSESSING THE STRENGTH OF THE EVIDENCE BASE FOR EACH FEASIBLE OPTION
EXAMINING THE OPTIONS
THE EVIDENCE for the options
Option 1: Do Nothing (the counterfactual)
Negative benefit: the negative impact on health indicators set out in the Strategic Case. Poor women in
Malawi will continue to have limited access to family planning even when they would use it, if it were
available. The level of unintended pregnancies and abortions (especially among young women) would
remain high.
Risk: Malawi’s high maternal mortality persists and population growth rate remains high.
Evidence strength: Strong Malawi’s poor maternal health statistics and high birth rate among young girls
are well documented by MDHS and other sources
OPTION 2: PUBLIC SECTOR AND COMMODITY PROCUREMENT: THEORY OF CHANGE
Inputs
Outputs
Outcomes
Direct
Wider
Wider
Impact
Health
Societal
Impact
Impact
DFID earmark
funds for family
planning as
part of financial
aid to HSSP.
Funds will be
earmarked for
family planning
as a
component of
HSSP’s
essential
health care
package.
Funds will be
used for (i)
DHOs to
purchase
commodities
from CMS (ii)
demand
creation
activities and
(iii) training.
Funds to
UNFPA to
procure
commodities to
be managed
by CMS.
Family
planning
services
available as
part of a full
range of PHC
services to all
Malawians.
Reliable
supply of
family
planning
commodities
at national and
provider level
through
government
services and a
fully functional
supply system.
Increase in
use of
effective
family
planning for
all
Malawians
Fewer
unwanted
pregnancies
Fewer
unsafe
abortions
Better
spaced
births
More equity
in access to
family
planning,
including in
rural areas,
& for
adolescents.
Improved
maternal
health
and lower
maternal
mortality
rates
Reduced
infant
mortality
rates and
improved
infant
health
Reduced
costs of
dealing
with
deliveries
and
unsafe
abortions
Slower
population
growth
Lower
costs of
health &
education
services
More
females
stay in
education
and
participate
in
economic
and
political
life.
What is the evidence that the public sector can scale up fast? Not strong. There are positive benefits of
using the public sector in terms of systems strengthening and sustained change beyond DFID funding.
Public sector facilities are able to deliver some family planning methods and provision is free to the user.
The public sector is gradually increasing coverage – for example by engaging Health Surveillance
Assistants (HSAs) to provide short-term methods. However, further scale up will take time – and there is
a strong case, as presented in the Strategic Case, to accelerate progress which arguably has to be at a
faster pace than the public sector alone can manage. In addition, the public sector does not have the
capacity to increase the focus on young women.
What is the reason for earmarking and what is the evidence for using it? The Malawi public health
system is resource constrained (spending is around $19 per capita per annumxlviii). Government
spending data over time shows limited commitment to family planning commodities and DHOs
prioritising spending of limited drug funds on curative services over preventative ones (as the population
often demands curative care). Whilst limited resources and the tension between choices to spend on
curative or preventive care continue, family planning will probably not be prioritised by the MOH or the
DHOs. Hence the case for DPs to earmark funds for family planning. Broadly, unearmarked financial aid
is recommended over earmarking. Earmarking should generally only be used when the regular budget
process is unlikely to produce desirable allocations, and generally also requiring equivalent resources
provided by the Government.xlix Additionally, management of earmarked financial aid can be onerous for
the recipient government and for the DP.
What is the evidence that the CMS procurement and distribution system can well use earmarked
financial aid? Not strong. CMS’s performance is a major area of concern as presented in the Strategic
Case. DFID and other DPs are working with the CMS to improved its efficiency but at present, given
there are alternative procurement methods open to DFID, it is not advisable to use CMS.
What is the evidence that more commodities will be used? Strong. There is an increasing use of
injectables (and pills to a lesser degree) and an anticipated increased demand for implants - as
presented in the Strategic Case.
What is the evidence that UNFPA can deliver and will provide value for money? UNFPA is the second
major (following CMS) procurement agency and, as presented above, has proved significantly cheaper
than CMS. The Commercial Case presents the evidence that large sale procurement through a single
global agency offers economy and quality in procurement. Use of CMS’s distribution system would be
supported by UNFPA technical assistance and the Global Fund’s Supply Chain Management Agency. .
Assumption: That CMS reforms into an effective and efficient distribution agency and that the public
sector services will grow stronger and expand through HSSP and gradually be able to serve more rural
communities.
Evidence strength: medium.
OPTION 3: NON-FOR-PROFIT-PRIVATE SECTOR SCALE UP (RH FRAMEWORK) AND
COMMODITY PROCUREMENT:
THEORY OF CHANGE FRAMEWORK
Inputs
Outputs
Outcomes
Direct
Wider
Wider
Impact
Health
Societal
Impact
Impact
Expand family
planning
service
coverage,
especially to
rural and to
younger
women
through a
range of
service outlets
(static clinics,
outreach
clinics, social
Family
planning
services
available
closer to
people
especially in
rural areas,
including long
acting
methods.
Increase
in use of
effective
family
planning,
especially
for young
women
and rural
populations
Young women
aware of and
Increased
use of
Fewer
unwanted
pregnancies
Fewer
unsafe
abortions
Better
spaced
births
More equity
Improved
maternal
health
and lower
maternal
mortality
rates
Reduced
infant
mortality
rates and
improved
Slower
population
growth
Lower
costs of
health &
education
services
More
females
stay in
marketing).
Education and
communication
to generate
demand for
family planning
especially
among young
people and to
shift demand to
LAPM.
able to access
family planning
Reliable
supply of
family planning
commodities at
national and
provider level.
LAPM
compared
to short
term
methods
in access to
family
planning,
including in
rural areas,
& for
adolescents.
infant
health
Reduced
costs of
dealing
with
deliveries
and
unsafe
abortions
education
and
participate
in
economic
and
political
life.
Funds to
UNFPA to
procure
commodities
to be managed
by CMS.
What is the evidence that the not-for-profit private sector can scale up? Strong. BLM is the largest
service provider. Using its performance as evidence of the not-for-profit sector’s capacity to scale up,
there is strong evidence of both current good performance (for example BLM ‘s programme scores 1 or 2
for its DFID annual reviews) as well as evidence of capacity to scale up (the POW is ambitious but based
on evidence of ability to deliver). In addition, the non-for-profit agencies have access to the rural areas at
present and have established networks to address specific groups such as young women.
What is the evidence for a need amongst young women? Strong. This is presented in the Strategic
Case. In summary although 26% of young women (aged 15-19) have already begun child bearing, only
28% are using family planning.
What is the evidence of capacity to scale up in LAPM? The demand for LAPM is likely to increase. The
not-for-profit private agencies are already responding by procuring implants themselves as well as
procuring from CMS. In addition these use a range of methods to expand access to LAPM such as social
marketing and franchising commodities.
Risks: A SP relatively new to Malawi would face substantial start-up costs and a steep learning curve. It
would take time to develop an effective network of service delivery points and policy influence at the
MoH level.
Assumptions: (i) Sufficient organisations in Malawi will be able to compete; (ii) A new SP would either
have a ready service deliver network or be able to quickly develop a service delivery network and RH
policy influence at required scale; (iii) GOM continues to welcome private sector NGO support to
supplement public sector family planning delivery ; (iv) HSSP will include training for health workers in
family planning and strengthen supervision, to encourage and enable health workers to deliver a wider
range of family planning methods; (vi) that there is close coordination between the SP and the MOH and
the DHOs to avoid service overlap and duplication of service provision.
Evidence: Strong
There is compelling global evidence of the relationship between outcomes to direct impact, to
wider health impact, and to wider societal impact. This evidence is presented in Annex 2.
Rating of evidence :The table below rates the quality of evidence for each option: Strong, Medium
or Limited
Option Evidence rating
1
Strong
2
Medium
3
Strong
ENVIRONMENTAL AND CLIMATE CHANGE EFFECTS
The programme is likely to have a potentially substantial positive environmental impact and a limited
direct detrimental environmental impact.
Positive impact. There is a significant benefit associated with higher uptake of family planning services
and smaller family sizes in relation to climate change and pressure on natural resources. Increased
contraceptive use will result in a lower fertility rate, which in turn results in slowed population growth.
There is strong evidence that changes in population dynamics (e.g. age structure, urbanisation rate,
household size etc) play a role in green house gas emissions, and that the contribution of population to
climate change models has been underestimated.l
Reducing population growth decreases vulnerability to environmental stresses, and many developing
countries identify population pressures as a determinant of their vulnerability to climate changeli . There
is increasing evidence, used in national adaptation planning, of how reducing population growth will have
a positive impact on climate change.lii This increasing attention to family planning in addressing climate
change has been boosted by analysis from the Centre for Global Development, which identifies family
planning as the best single intervention to reduce green house gas emissionsliii . If family planning is
combined with girls’ education there are even more significant gains. It has been argued that this
combination may be a better investment than Reducing Emissions from Deforestation and Forest
Degradation (REDD), which currently aims to spend $30 billion a year on incentives for developing
countries to reduce deforestation and forest degradation.”liv
Table B1 : Saving CO2 emissions by development intervention (source: Centre for Global Development)
Intervention
Tonnes of CO2 saved
FP & girls' education combined
250,000
FP alone
222,222
Girls education alone
100,000
Reduce slash and burn of forests
66,667
Pasture management
50,000
Geothermal energy
50,000
Energy efficient buildings
50,000
Pastureland afforestation
40,000
Nuclear energy
40,000
Reforestation of degraded forests
40,000
Plug-in hybrid cars
33,333
Solar
33,333
Power plant biomass co-firing
28,571
Carbon Capture and Storage (new)
28,571
Carbon Capture and Storage (retrofit)
26,316
Malawi’s environment is already under stress due in part to its high population density. If the high fertility
scenario (41 million by 2040) is realised there will be 1,657 people per square kilometre of arable land.
This is likely to accelerate deforestation, soil erosion, and the loss of soil fertility. Furthermore, under this
scenario, vulnerability to climate and weather related shocks will be greatly increased, with 9 million
people unable to meet their daily food needs. .lv
Potential detrimental environmental impact. The MFPP may have two possible negative impacts on
the environment:
 The release of carbon dioxide through transport of the outreach teams; and
 Waste generated as a result of used contraceptive commodities.
These will be minimised by:
1) Reducing emissions: reduced number of outreach visits though more detailed planning. Planning
should take account of carbon emissions. Training in the use of carbon calculators will be
provided to the preferred bidder and UNFPA staff.
2) Waste disposal will follow carefully-designed protocols.
The MFPP is not likely to be negatively affected by climate change, or to have a significant negative
impact on climate change or the environment. Evidence indicates that family planning services, through
their impact on population growth rates, will have a positive impact on climate change (reducing both
emissions and vulnerability) and on environmental degradation. Based on this evidence we feel that the
‘Do nothing’ option poses a significant risk to the environment, and to the impact of climate change on
vulnerable populations. Both options 2 and 3 may have a significant positive impact on the environment,
and reduce climate change impact and emissions. These are clearly important issues to consider when
deciding on the need for the programme. However, climate and environment considerations are not
central to the assessment of these options, and hence we have decided to categorise the programme as
C regards to these impacts given that relevant actions are included the business case.
Option
1
2
3
C.
Climate change and environment risks Climate
change
and
environment
and impacts, Category (A, B, C, D)
opportunities, Category (A, B, C, D)
DO NOTHING B
C
PUBLIC SECTOR + COMMODITIES C C
RH FRAMEWORK + COMMODITIES C C
WHAT ARE THE COSTS AND BENEFITS OF EACH FEASIBLE OPTION?
APPRAISAL OF OPTIONS
Economic appraisal
The headline findings are provided here. Annex 3 provides a detailed account of the economic
appraisal. This includes the methodology, assumptions and sensitivity analysis.
Tables C1 and C 2 below summarise the results from the cost effectiveness and cost benefit analysis. It
is clear that both Options 2 and 3 are cost effective given that the average cost per DALY averted
is £35.35 for Option 2 and £33.55 for Option 3 (Table C 1). This is significantly below the GDP per
capita of Malawi of $791 (in international 2005 dollars). Where average cost is below this measure of
GDP per capita this is considered to be very cost effective by WHO, and thus offers good value for
money. Option 3 is estimated to be more cost effective than Option 2 under this analysis, and
under the other scenarios considered, unless the discount rate is increased to more than 13%.
Table C 1: Cost effectiveness of the options reviewed (with discounting)
£
Cost per DALY
Option 1 - Do nothing
£0
Cost per CYP
£0
Option 2 - Public sector (inc CHAM)
£35.35
£8.70
service delivery and commodities
Option 3 - private (NGO) service delivery
£ 33.55
£8.30
and commodities
Estimates allow for effects of inflation and discounting of costs and benefits in the future (at 10%)
In terms of cost benefit analysis, Option 3 gives a positive Net Present Value (NPV) net of costs of
£108m and a Benefit to Cost Ratio (BCR) of 7.3. It thus offers good value for money.
Table C 2: Cost benefit analysis of Options
Option
Net present
NPV of
Net
Benefit:
Cost per
value (NPV)
of costs £
0
£17.0m
benefits
£
0
£117.9
benefits
£
0
£100.9
cost ratio
DALY saved
in £
0
£35.4
Option 1: Do Nothing
Option 2. Public sector
6.9
services and commodities
Option 3. Private sector
£ 17.0m
£125.1
£108.0
7.3
£33.5
services and commodities
Note: Costs and benefits discounted at 10% per year. This is the discount rate set for Malawi for DFID Business
Cases.
Table 3 summarises the impacts of the proposed intervention in terms of unwanted pregnancies,
maternal deaths, and unsafe abortions averted and the resulting impact in terms of DALYs saved.
Numbers are not discounted. It shows that with the same level of funding, option 3 is expected to deliver
greater benefits than option 2.
Table C 3: Estimated Benefits of the options, undiscounted
Option
Total CYPs
Pregnancies Maternal deaths
averted
averted
Abortions
averted
DALYs
saved
Option 1: Do
0
0
0
0
0
Nothing
Option 2: Public
sector +
commodities
2,707,750
958,540
3,360
135,390
668,820
Option 3: Not for
profit services +
commodities
3,596,840
1,273,280
4,460
179,840
888,420
Notes: Totals for 5 years are shown here, with benefits undiscounted. Rounded to nearest 10.
IMPACT OF FAMILY PLANNING
SOCIAL IMPACT
Family planning improves health for women, their infants, their families, and for society. If women can
control their fertility, we seelvi:
Outcome
Improved women’s education
Increased female labour force
participation
Increased political participation
Higher status for women
Increased family well-being
Increased child well-being
In addition, society can see:
Outcome
Reduced public-sector spending on
health
Reduced public-sector spending on
education, water and sanitation
Improved productivity and higher income,
greater savings and investment
Potential for faster economic growth
Reduced pressure on natural resources
Reason
Girls can stay in school and finish their education
Family sizes smaller, giving women increased
flexibility to work
Women have more freedom to participate in
society
Women are not always pregnant and have
increased control over their lives
Mother has survived to care for her family
More time and income for each child
Reason
Healthier mothers & babies & slowing fertility
means reduced numbers
Slowing fertility means reduced numbers of
students and smaller class sizes
More people in working age population with fewer
children to support
Working population has fewer children to support
Fewer people to be sustained by the land
ECONOMIC AND POLITICAL CONTEXT AND IMPACT
Malawi’s economic growth has been strong in recent years, averaging 7% in the 5 years to 2010.
However concerns over future economic performance have been growing since the start of 2011. The
tobacco industry faces an uncertain future. And in the short term foreign exchange shortages have led to
fuel shortages, and a range of problems for the private sector. In June the IMF programme was in effect
suspended (declared as ‘off track’). Malawi’s society is inequitable: the richest 10% have eight times
greater income per capita than the poorest 10%. Addressing growth in Malawi – and ensuring it is pro
poor – needs to be complemented by access to quality social services, protection for those who cannot
engage in market based economic activities, good governance and addressing human rights. It is hoped
that the next Malawi Growth and Development Strategy (MGDS) will address these issues.
Development and service delivery depends on effective governance. Malawi’s governance situation has
been on an upward trajectory since the return to multi-party politics in 1994. However this has not been a
linear route, with contrasting periods of deterioration and improvement linked to the political cycle. At the
current time, in President Mutharika’s second and final term, political instability has increased due to a
perceived decline in democratic governance standards and increased public discontent fuelled by an
acute economic crisis. This situation is likely to have a negative impact on Malawi’s development, and
could affect the ability of the government to maintain public service delivery. This makes the contribution
of Malawi’s DPs all the more important to keeping vital services and reform programmes on-track.
The centrality of population growth to the national discourse on development is gaining ground. The
draft Malawi Growth and Development Strategy addresses rapid population growth as an impediment to
development. The new Population Reference Bureau IDEA programme will support population policy
development through the provision of Malawi-specific educational materials to opinion leaders particularly the media and parliamentarians. The President of Malawi, a Catholic, is supportive of family
planning. The First Lady is the National Coordinator for Maternal, Infant and Child Health, HIV, Nutrition,
Malaria and TB. In addition, she is patron to the Malawi Family Planning Association. On the other hand,
the Catholic church is strong in Malawi and the Catholic branch of CHAM will not deliver family planning
services.lvii
OPTION SELECTED
Based on this analysis, the selected option is Option 3. Under this option the most appropriate private
sector SP will be selected by tender through the RH Framework to carry out the service delivery; and
UNFPA will be supported to fill the commodity gap for a range of providers, public and non-for-profit.
D. WHAT MEASURES CAN BE USED TO ASSESS VALUE FOR MONEY FOR THE INTERVENTION?
It is proposed that value for money will be measured in the following ways:
Economy in procurement of supplies - through comparison of unit costs of family planning commodities
purchased, by commodity, with others procured in Malawi and with unit costs for DFID supported
procurement in other countries.
Efficiency in service delivery, through assessment of:
 unit costs of service delivery for different target groups reached in different ways, e.g. comparison of
cost per rural woman reached with family planning for one year through private sector services; MOH
clinics; or community services (e.g. HSAs). Costs can also be assessed for reaching young women
as a critical target group. This could be compared across DFID programmes in the region;
 The impact of scale on unit costs can also be reviewed in this analysis;
 The data on method mix by provider can be analysed to see whether there is progress in moving
towards a more efficient method mix;
 Efficiency in service delivery, through indicators of availability (or stock outs) for different types of
provider and by commodity.
Effectiveness can be assessed by estimating the additional CYPs achieved through different funding
channels and services and looking at whether the intended target groups have been reached. This
would ideally require a population based survey to identify whether people have switched provider
versus whether they are new users of contraception, and how far target groups are reached. This could
be built into planned monitoring surveys under HSSP or via separate Knowledge, Attitude and Practice
surveys on reproductive health. These surveys could also assess whether equity in service use is
improving.
Cost effectiveness - estimates of cost per additional CYP delivered can be calculated for different types
of providers - public sector, CHAM and the selected private provider. Marginal costs per CYP for
reaching target groups such as women in rural areas and adolescents can also be analysed to see
whether the expected cost effectiveness has been achieved.
The intervention would no longer represent good value for money if there is a major increase in service
and commodity costs, or if there are disappointing results in terms of the target groups benefitting from
the services (poor, rural and young women).
E. SUMMARY VALUE FOR MONEY STATEMENT FOR THE PREFERRED OPTION
The proposed option 3 indicates excellent value for money. The benefits have been valued at over 8
times the costs. Even on pessimistic assumptions for the extent of benefits achieved and their value, the
benefits outweigh costs by a factor of over 4 times. This is consistent with the strong and well
documented international evidence that family planning is a good investment that is cost effective, has
clear benefits for maternal and child health, and facilitates demographic transition.
COMMERCIAL CASE
DIRECT PROCUREMENT
A. CLEARLY STATE THE PROCUREMENT/COMMERCIAL REQUIREMENTS FOR INTERVENTION
COMPONENT ONE: NOT-FOR-PROFIT PRIVATE SECTOR SCALE UP (THE REPRODUCTIVE
HEALTH FRAMEWORK)
The SP will be selected through a competitive tender process, which will be limited to pre-qualified
providers identified under the global DFID Reproductive Health Framework Agreement.
Direct procurement will be through a commercial contract with the selected SP for five years. The SP will
also be responsible for some procurement of commodities.
B. HOW DOES THE INTERVENTION DESIGN USE COMPETITION TO DRIVE COMMERCIAL
ADVANTAGE FOR DFID?
DFID’s expectations of the contract are set out in the expected results to be delivered by the programme
- see Logical Framework (Annex 1) and the Terms of Reference for the SP (Annex 4).
In brief, the SP will be expected to:






Deliver in the region of 3 million additional CYPs through family planning provided over the 5 years
(undiscounted);
Recruit and train outreach teams to deliver family planning services;
Procure vehicles and equipment for outreach services;
Deliver family planning services at scale through the deployment of a range of appropriate service
delivery mechanisms : social marketing, franchising, static clinics and outreach clinics;
Expand access to and uptake of LAPM;
Improve access to and uptake of family planning services for young women;








Provide training and mentoring support on family planning, including LAPM, and on provision of
adolescent friendly services to government health providers;
Work with community structures and leaders to reduce barriers to family planning and increase
uptake of services;
Manage procurement of commodities required to support expansion of family planning services,
including ensuring that commodities meet international quality standards and national standards;
Collaborate with other cooperating partners supporting family planning services to avoid duplication
of effort;
Develop and implement a monitoring and evaluation plan;
Contribute to effective commodity forecasting, procurement and distribution;
Report on programme progress to MOH at central and district levels;
Build the capacity of government staff and services, as well as the service provider’s own, to sustain
provision of quality, comprehensive family planning services in rural areas.
Pre-qualified providers will have existing experience in delivering family planning programmes at scale.
Competitive bidding among pre-qualified providers is expected to deliver value for money. While quality,
technical expertise and innovation will be critical considerations in selection of the service provider, DFID
Malawi will give high priority to efficiency and the ability to deliver CYP at the lowest cost.
C. HOW DO WE EXPECT THE MARKET PLACE WILL RESPOND TO THIS OPPORTUNITY?
Potential bidders will be identified at global level by DFID’s Procurement Group. There is likely to be a
limited range of pre-qualified service providers with an established presence in Malawi and the capacity
to manage service delivery and procurement at scale.
D. WHAT ARE THE KEY COST ELEMENTS THAT AFFECT OVERALL PRICE? HOW IS VALUE
ADDED AND HOW WILL WE MEASURE AND IMPROVE THIS?
The main cost drivers are: personnel; outreach services; training; equipment and supplies; and family
planning commodities.
Outreach services are labour intensive and personnel costs reflect the staff required to deliver services.
Outreach service costs also reflect the cost of vehicles, fuel and per diems for staff and the distances
required to reach rural communities.
Costs will be minimised through competitive tendering for the SP and for procurement of equipment and
supplies, as well as through careful planning and monitoring of the SP budget and expenditure. DFID
will:
 Review the programme budget annually to monitor efficiency and identify cost savings;
 Ensure that the SP has an efficiency savings plan for year on year cost savings;
 Review the SP ’s procurement processes to ensure that these provide VFM;
 Conduct formal annual reviews to monitor progress, efficiency and VFM.
E. WHAT IS THE INTENDED PROCUREMENT PROCESS TO SUPPORT CONTRACT AWARD?
DFID Malawi will procure the SP through a competitive tender process, which will be limited to prequalified providers identified under the global DFID Reproductive Health Framework Agreement. Terms
of Reference are annexed (in Annex 4). Pre-qualified providers will be invited to submit expressions of
interest and those that meet the essential selection criteria will be invited to submit a full proposal and
budget.
F. HOW WILL CONTRACT & SUPPLIER PERFORMANCE BE MANAGED THROUGH THE LIFE OF
THE INTERVENTION?
DFID will:

Discuss and agree detailed Key Performance Indicators (KPIs) and milestones with the SP during the
programme inception period, to be reflected in the Logical Framework;





Conduct an annual review to assess SP‘s performance against the agreed KPIs, and milestones;
Track programme performance and budget execution through quarterly narrative and financial
reports and quarterly update meetings with the SP;
Ensure that the SP has quality assurance procedures in place to ensure goods and services are fit
for purpose;
Negotiate management charges as part of programme budget negotiation to ensure these charges
are set at an appropriate level to deliver programmes in the Malawian context;
Agree and monitor a risk strategy, which sets out specific responsibilities of DFID and the SP for
managing and mitigating risk.
The contract with the SP will incorporate steps to be taken in the event of poor performance and failure
to deliver the expected results and value for money.
INDIRECT PROCUREMENT
A. WHY IS THE PROPOSED FUNDING MECHANISM/FORM OF ARRANGEMENT THE RIGHT ONE
FOR THIS INTERVENTION, WITH THIS DEVELOPMENT PARTNER?
COMPONENT TWO: COMMODITY PROCUREMENT
UNFPA is the lead UN organisation working in family planning. UNFPA will be single sourced to provide
the procurement services under component two. A Memorandum of Understanding (MoU) will be drawn
up which will include conditions and payment schedule for the five year period. UNFPA will provide
procurement services for all contraceptives commodities.
In Malawi UNFPA is a long established third party procurer of commodities in Malawi. It works closely
with the MoH to address RH commodity security. UNFPA Malawi adheres to and utilizes standardized
procurement guidelines from both the Government of Malawi and UNFPA HQ. This arrangement
harmonizes national and international procurement standards thereby ensuring that quality RH
commodities are procured. UNFPA has also assisted in building the capacity of government staff to
store, distribute and deliver family planning commodities. For example, it has installed a Contraceptive
Distribution Logistics and Management Information System and is currently supporting CMS with new
software to track commodities movement and consumption. UNFPA are therefore well established in
health systems strengthening in Malawi.
DFID’s March 2011 multilateral aid review of UNFPAlviii concluded that it:
 reinforces country-led approaches and incorporates beneficiary voice in policies and
programmes
 has strong partnerships with civil society, partner countries and other agencies.
With respect to procurement, the review found that UNFPA generally has a good track record on
procurement. However there were some negatives on financial management in-country: that it did not
report systematically on prices achieved or track procurement savings, and that clearer reporting of
results are needed. DFID’s MoU with UNFPA will specify KPIs to ensure sufficient performance in these
respects.
UNFPA’s prices are comparable with other suppliers and it is the only UN agency to be certified as
compliant with best practice in this area by the International Organisation for Standardisation (ISO).
UNFPA is also one of the largest procurers of contraceptives to developing countries.
Procurement for UNFPA funded projects may be undertaken by UNFPA’s country office personnel (local
country office procurement) or by headquarters (headquarters procurement). About 85% of the total
procurement volume is carried out by headquarters. Procurement on behalf of external entities such as
other UN Agencies, Governments and NGOs, is the sole responsibility of Headquarters Procurement
Unit. UNFPA procurement guidelines aim to:





Maximize economy and efficiency ;
Encourage a wide solicitation of proposals to promote competition;
Encourage sources of supply from developing countries;
Encourage sources of supply from underutilized major donor countries; and
Promote integrity and fairness and maintain the transparency of the procurement process.
B. VALUE FOR MONEY THROUGH PROCUREMENT
Advantages of Procuring Through UNFPA
UNFPA has established itself as a global contraceptive procurement agent. The savings through
economies of scale in procurement, its adherence to UN standards and its technical expertise make
UNFPA an ideal partner for the MFPP.
Because of the large volume it purchases, UNFPA has negotiated very competitive prices for
contraceptives with manufacturers, passes the lower prices to recipient countries and can maintain
prices at at the same level for long periodslix. It can also offer countries lower prices for products that do
not comply with secondary regulations (such as required inserts, the phrase “not for sale” written on the
items, or labels written in English). Many countries have saved significant amounts of money by
procuring contraceptives through UNFPA.lx
Through its website, MyAccessRH.org, scheduled for launch later in 2011, UNFPA will provide direct
access to information on UNFPA products, prices, quality standards, and tendering processes. In
addition, the website offers the RHInterchange (RHI), which provides consolidated data on contraceptive
orders and shipments from multiple sources, including such organizations as IPPF, PSI and USAID. The
site facilitates sharing of information among decision makers across supply chain functions, thus helping
to ensure reliable management of contraceptive supplies.
UNFPA prices have been compared to USAID/Deliver prices as per the UNFPA catalogue. All prices are
valid on a 30 day basis. Where long term agreements have been established prices are generally fixed
for longer periods. The favourable price for DMPA by UNFPA is important as this is the main commodity
to be ordered for the MFPP.
Comparison of Catalogue Prices for Family Planning Commodities
Product
USAID Cost (US$)
IUCD
0.49 per item
Implants (Jadelle)
21.00 complete set
M/Condoms
0.2797 per piece
F/Condoms
0.55 per piece
COC’s
0.28 per cycle
POPs
0.28 per cycle
DMPA (injectable)
0.95 per vials
Syringes
Emergency Contraceptives
Price Not available
UNFPA Cost (US$)
0.37 per item
21.00 complete set
0.2708
0.59 per piece
0.32 per cycle
0.456 per cycle
0.68 per vial
0.075
0.25 (set of 2)
NB: Prices at 26/09/12
UNFPA undertakes contraceptive procurement on behalf of governments, other UN agencies and NGOs
that are not funded by UNFPA core resources. This enables these partners to benefit from UNFPA’s
Long Term Agreements covering the procurement of high quality goods at low cost (i.e. a way of
aggregating demand and reducing prices). UNFPA offers a procurement service for public-sector
purchasers that includes: quality assured products; competitive pricing and a fixed overhead cost;
access to impartial expert advice; a transparent and auditable procurement process; the ability to
respond to urgent, emergency requests using stock items; long product shelf lives; and long term
partnerships with strategic suppliers.
Through its newly launched AccessRH initiative (with funding from DFID), UNFPA maintains a stock of
condoms in order to reduce lead times by at least 10 weeks, and is in the process of building inventory of
other key contraceptive items.
UNFPA guarantees the quality of the products it provides, as well as the credentials of
manufacturers. It ensures that its products have the proper certifications and requirements and, in
the case of manufacturers, that they follow the standards established by the World Health
Organization (see table).
UNFPA ’s Criteria for Contraceptive Quality Product
Manufacturer
General
Listed in the Pharmacopoeia of Great Britain or the United
States
Inspected and
certified by the WHO
Certificate of analysis
Good Manufacturing
Practices and
International
Standards
Organization
Certificate (in the last
two years)
Independent
sampling by a
monitoring company
International quality
control in a
laboratory qualified
by the WHO in a
third country
Certificate of compliance
Authorization for sale in the country of origin
Registration certificate in the destination country
Compliance with WHO specifications
Certified by the
national authority
At least 80 percent of shelf-life remaining
Label that includes the date of manufacture, expiration date,
and lot number
Plant authorized to
manufacture the
product
Insert with instructions for use
PowerPoint presentation made by David Smith, Chief of Procurement, UNFPA Procurement Services, to the Peru
Contraceptive Security Committee in 2004.
UNFPA procures on the client’s behalf and charges a 5% handling fee based on the total amount of
commodities procured. UNFPA procurement branch also charges an insurance fee of 0.132%. Freight
charges will also be added. Suppliers’ prices are included in the UNFPA procurement catalogue.
Disadvantages of Procuring Through UNFPA
There are two disadvantages. First, budgeting and planning of commodity procurements have to be
done well in advance in order to accommodate sometimes rather slow procurement processes.
Agreements have to establish the types of currency acceptable and provision needs to be made to
include the payment of fees for customs, transportation, and other expenses. Second, procurement
processes can be slow. The time taken from placing an order to receiving the commodities in
country can be many months. Without effective long-term planning this can lead to shortages,
dissatisfied users, and barriers to improving family planning.
To a certain extent, UNFPA has established delivery times for its products based on its experience.
Delivery times vary by product. The agency claims that agreed-on delivery times “can vary
significantly,” given market conditions, the time of year, delays in shipments, and the impounding of
products.
Example of Projected Product Delivery Times Product Delivery time
Condoms
24 weeks
Injectables
10 weeks
Pills
12–20 weeks
Intrauterine devices
16 weeks
Based on a PowerPoint presentation made by David Smith, Chief of Procurement, UNFPA Procurement Services,
to the Peru Contraceptive Security Committee in 2004.
How will DFID Malawi ensure UNFPA performs well?
The MOU will contain the following:
 key performance indicators (KPIs) which will include: forecasting accuracy (on quantities and
prices), compliance with delivery times, prices achieved, compliance with agreed financial
(including audit) administrative costs and responsiveness to client requirements;
 details of key staff responsible for managing the procurement process,their experience and
relevant qualifications;
 schedule for financial and procurement reports on a six monthly basis;
 schedule for regular (six monthly) reviews by DFID and UNFPA to monitor performance;
 DFID prerogative to request an audit of the funds provided to UNFPA to establish if they have
been used appropriately and that the correct procurement procedures have been followed
 DFID’s right to withdraw from the agreement should UNFPA not perform as required.
Payments to the supplier will be linked to the achievement of key milestones.
FINANCIAL CASE
WHAT ARE THE COSTS, HOW ARE THEY PROFILED AND HOW WILL YOU ENSURE
ACCURATE FORECASTING?
The MFPP’s budget is £25.2m and is designed for a 5 year period to align with the HSSP.
2011/12
2012/13
2013/14
2014/15
2015/16
RH
1,100,000
3,000,000
3,400,000
4,600,000
7,100,000
FRAMEWORK
UNFPA
1,200,000
2,000,000
1,600,000
400,000
600,000
Review and
evaluation
(DFID
200,000
managed)
Total
2,300,000
5,000,000
5,000,000
5,000,000
7,900,000
Total
19,200,000
5,800,000
200,000
25,200,000
The large increase in RH Framework funding in the final year reflects the fact that the existing Banja
La Mtsogolo project finishes in 2015, so additional funding will be required to maintain the total level
of services supported in the absence of GOM commitment to fund. Given Malawi’s poverty levels
and dependence on donor support, it is assumed that follow-on donor support will be required to
maintain services beyond 2015/16.
We will ensure accurate forecasting by ensuring realistic initial estimates by the providers, and close
monitoring during the life of the programme.
B. HOW IT WILL BE FUNDED: CAPITAL/PROGRAMME/ADMIN
All required resources will be programme funded - covering procurement of goods and services.
Funds are available from the DFID Malawi Framework. There are no contingent or actual liabilities.
C. HOW WILL FUNDS BE PAID OUT?
COMPONENT ONE: NOT-FOR-PROFIT PRIVATE SECTOR SCALE UP (THE REPRODUCTIVE
HEALTH FRAMEWORK DFID Malawi will disburse funds to the SP on a quarterly basis in arrears
linked to performance against the KPIs in the MOU.
COMPONENT TWO: COMMODITY PROCUREMENT .Funds will be disbursed according to the
terms of the MOU between DFID and UNFPA.
D. WHAT IS THE ASSESSMENT OF FINANCIAL RISK AND FRAUD?
COMPONENT ONE: NOT-FOR-PROFIT PRIVATE SECTOR SCALE UP (THE REPRODUCTIVE
HEALTH FRAMEWORK The level of risk is assessed to be low. DFID has direct knowledge of the
nature and scale of risk associated with one potential SP (BLM) and can draw on this knowledge
when monitoring the performance of the SP.
COMPONENT TWO: COMMODITY PROCUREMENT The risk level is assessed to be low.
The bulk of funding is for commodities through international procurement.
E. HOW WILL EXPENDITURE BE MONITORED, REPORTED, AND ACCOUNTED FOR?
COMPONENT ONE: NOT-FOR-PROFIT PRIVATE SECTOR SCALE UP (THE REPRODUCTIVE
HEALTH FRAMEWORK DFID and the SP will agree an annual work plan, with KPIs and an annual
budget. Monitoring and evaluation costs have been included in the programme budget. The SP will
submit quarterly financial and progress reports. In addition, annual financial reports and a certified
annual audit statement will be provided to demonstrate funds received and expended. The SP will
also maintain an assets register. Financial management costs have been included in the programme
budget.
COMPONENT TWO: COMMODITY PROCUREMENT UNFPA will provide six monthly
forecasts for all procurement, and funding will be in advance upon receipt of financial and progress
reports of the previous six months. No funds will be released before the previous advance is
liquidated.
MANAGEMENT CASE
A. WHAT ARE THE MANAGEMENT ARRANGEMENTS FOR IMPLEMENTING THE INTERVENTION?
The MFPP’s governance structure, will include a programme steering committee (SC) which will
convene annual reviews. Members of the SC will include the Director of Planning, MOH, Director of the
SWAp, MOH, Director of the Reproductive Health Unit, MOH, CMS, DFID, USAID, UNFPA and the SP
for component one plus the Chair of the Health Development Group.
The annual programme review will be held before the annual HSSP review.
The SP and UNFPA will collaborate with the MOH and the RH commodity security committee, the CMS,
UNFPA and JSI Deliver.
At district level, the SP will work in partnership with the DHOs and the district health management teams
and other related agencies.
Within DFID Malawi, the MFPP will be managed by a Health and HIV/AIDS Adviser. The adviser will
ensure that the MFPP:- adheres to corporate reporting requirements;
- delivers against its annual targets;
- manages the annual review, with partners as described above;
- ensures effective relationships are established with other national family planning; and
reproductive health programmes including the regional DFID programmes, in particular the
Prevention of Maternal Deaths from Unwanted Pregnancy and the Evidence for Action
programmes.
Additional inputs will be provided, on financial and administration issues, by the DFID Malawi Deputy
Programme Manager and the Programme Finance Group.
COMPONENT ONE: NOT-FOR-PROFIT PRIVATE SECTOR SCALE UP (THE REPRODUCTIVE
HEALTH FRAMEWORK) DFID Malawi will draw up a bilateral agreement (Accountable Grant), where all
conditions in terms of reporting, financial disbursement and asset management will be specified.
COMPONENT TWO: COMMODITY PROCUREMENT DFID Malawi will be responsible for the
management oversight of the MoU with UNFPA which will contain all management requirements.
B. WHAT ARE THE RISKS AND HOW THESE WILL BE MANAGED?
Risk
Impact
Likelihood Risk mitigation
Output 1:Quality family planning and other services delivered, especially to the rural poor
1. Method mix
High
Medium
The SP and UNFPA will work closely with USAID
available does not
and the MOH’s RHU on commodity projections.
match demand for
The SP and UNFPA will monitor demand and
different family
adjust projections accordingly.
planning methods
2. Programme fails to
reach young women,
especially in rural
areas
High
Medium
SP to establish good networks and strategies to
address young women, closely monitored by
DFID.
3. Side effects, injury
or death resulting from
family planning
High
Low
Training of clinical staff, establishment of clinical
standards, quality assurance and monitoring.
4. Shortage of health
workers at rural health
facilities
Medium
Medium
The SP will engage its own staff. It is also to train
and support MoH staff where there are nurse
shortages. The HSSP will be addressing retention
schemes.
Output 2: Awareness and knowledge of family planning and SRH services at the individual ,
household and community levels
5. Community
High
Low
Community sensitisation and collaboration with
opposition, from
community leaders, Chiefs and community health
traditional/ religious
workers. National engagement with
leaders and men to
parliamentarians, Chiefs and religious leaders.
family planning
6. Limited demand for High
Medium
Provision of information about long-term methods.
long term methods
Demand creation strategies
Output 3: Strengthened national proficiency in SRH policy planning and implementation
7. Lack of support
High
Low
Well established relationships in place at present
from MoH for the SP
between leading RSH NGOs (such as BLM) and
the MOH. The SC of the MFPP will work to ensure
an effective relationship.
Output 4: Strengthened programme cost-effectiveness, quality and accountability
Output 5: Contraceptive commodity security for short term methods (including injectables) for
public sector
8. Weaknesses in
High
High in
DFID and other DPs are supporting major reforms
supply chain for
short term
to the Central Medical Stores. This will include
commodities to district
then
procurement management support (contracted by
and facility level
reducing
DFID) and distribution management support
(contracted by GF) for up to 18 months. CMS
reforms will include a new financing mechanism
and new functioning arrangements.
Risk matrix summary: Provided that these risks are monitored and appropriate action is taken by
the service provider, these risks are considered to be manageable.
IMPACT
PR
OB
ABI
LIT
Y
HIGH
HIGH
8
MEDIUM
LOW
MEDIUM
1,2,6
LOW
3,5,7
4
C. WHAT CONDITIONS APPLY (FOR FINANCIAL AID ONLY)
Not applicable, as the MFPP does not involve financial aid to government.
D. HOW WILL PROGRESS AND RESULTS BE MONITORED, MEASURED AND EVALUATED?
MONITORING MECHANISMS
The programme Logical Framework has been completed so far to impact and outcome level. Output
milestones and targets will be added during the inception period, following selection of the Service
Provider and agreement on specific deliverables.
COMPONENT ONE: NOT-FOR-PROFIT PRIVATE SECTOR SCALE UP (THE REPRODUCTIVE
HEALTH FRAMEWORK). The SP will develop and implement a monitoring and evaluation plan, based
on the MFPP Logical Framework plus a specific logframe for this component. Monitoring systems will be
designed to ensure that the programme can capture data about new users of family planning, demand for
different methods, users switching methods, and the age profile of clients. Monitoring will also need to
capture data in response to Appraisal Case section D: measuring economy, efficiency and effectiveness.
Where baseline data is not available, this will be collected at the start of the programme. Data to assess
progress will be drawn from the SP’s monitoring system, the MoH’s Health Management Information
System, UN data and modelling, and periodic surveys including the Demographic and Health Survey.
Modelling will be used to measure maternal deaths, unintended pregnancies and unsafe abortions
averted.
The SP will provide quarterly and annual narrative reports to DFID Malawi. The SP will also report
programme data to the MOH through the established mechanism for NGOs to respond and present at the
annual HSSP review.
COMPONENT TWO: COMMODITY PROCUREMENT. UNFPA will develop and implement a
monitoring and evaluation plan, based on the MFPP Logical Framework as well as the specific
component two MOU and accompanying logframe. UNFPA will report to DFID on a bi-annual basis
against the component’s own logframe and the MFPP Logframe. UNFPA will also report to the MOH
through its established mechanism and will present at the annual MFPP reviews.
EVALUATION
DFID will conduct a mid-term review and an independent end of programme evaluation. Particular
attention will be given to identifying lessons learned in relation to Appraisal Case section D: measuring
economy, efficiency and effectiveness, as well as the following:
- effectiveness of outreach services in scaling up access to family planning, especially LAPM;
- strategies to address social and cultural barriers to family planning;
- strategies to increase demand and uptake among young women ;
- discontinuation rates of short-term and LAPM users and appreciation of the factors influencing
discontinuation.
DFID will allocate £200,000 to track the programme through annual reviews and an independent
end of programme evaluation which will cover the issues above. The programme will generate
knowledge of wider value and DFID Malawi will ensure that lessons learnt are shared nationally with
other partners as well as through regional and global Reproductive Health networks.
Annex 1: Logical framework
The programme Logical Framework has been completed so far to impact and partially at
outcome level. Logframe targets and milestones will be finalised and agreed with the
service provider within six months of the contract being awarded. .
ANNEX 2: EVIDENCE SUPPORTING THE THEORY OF CHANGE
Will increased access, equity, and behavior change lead to increased use of
contraception? What is the evidence? One of the most well known examples of an
intervention to increase contraceptive prevalence through both stimulating demand and
increasing supply is the Matlab experiment in Bangladeshlxi. Nearly two decades after the
programme was begun, exposure to the programme was associated with a statistically
significant 13% reduction in fertility.lxii
Access: Outreach service delivery has potential for meeting the unmet need for a range of
contraceptive methods. Evidence from a recent systematic review suggests that outreach in
an effective and acceptable way of increasing access to contraceptives, particularly longacting and permanent methods.lxiii
Equity: Enabling women to have choices in their lives, especially the right to determine the
number, timing and spacing of their children free of discrimination, coercion or violence is
key to women’s empowerment and gender equality. lxiv Evidence has shown that those most
likely to be affected by user fees are rural residents, for whom targeted assistance may be
required to maintain contraceptive use.lxv
Behaviour change to create demand: Analysis of DHS data in the late 1980s shows that
one of the most frequently reported reasons for not using modern methods of contraception
was a lack of accurate information about different contraceptive methods, how to use them,
and potential side effects.lxvi A systematic review of media campaigns from 1970-1999lxvii
drew the following conclusions: a) family planning campaigns can generate an immediate
demand for family services; b) exposure to family planning messages through mass media
campaigns is associated with approval of family planning, partner communication about
fertility and family planning, and increased contraceptive use; and c) exposure to general
and targeted mass media messages about family planning influences social norms through
stimulating group, interpersonal and spousal communication, thereby indirectly affecting
reproductive behaviours. Messages for older married women will be different to those for
the
younger
ones.
What are the macro health benefits of family planning? In addition to the international
evidence already provided in the Context section above, the health benefits of family
planning to women and their children are multiple. Unfortunately, pregnancy and childbirth
are risky. In developed countries, 1 in 7,300 women will die in childbirth or from pregnancy–
related causes. In Malawi, the lifetime risk of dying is 1 in 18.lxviii No statistic demonstrates
the disparities between developed and developing countries more than this one. And most
of these deaths are preventable. If every woman had the number of children she wanted
when she wanted them, maternal mortality would drop by one third. This is partly because
there are safer times to be pregnant (between 18 and 35 rather than earlier or later) and the
benefits of birth-spacing. Babies born less than two years after their older sibling are twice
as likely to die before they reach their first birthdays as those born more than three years
apart, have less care and support from their mothers and, because of large family sizes,
may have higher incidence of stunting because of less food availability.
How does family planning impact on maternal mortality? Maternal health is affected by
inequitable access to health services, lack of healthcare providers, an early age of first
pregnancy and a high unmet need for contraception. There is now international consensus
that reducing maternal mortality requires three interventions, each one accounts for reducing
maternal mortality by one third: a) access to emergency obstetric care 24/7; b) skilled
attendance at birth; and c) access to family planning and safe abortion.lxix Family planning
impacts on reducing maternal deaths in two ways. First, international evidence shows that,
by reducing the number of births, the number of times a woman is exposed to the risk of
mortality from pregnancy related causes is reduced. Second, family planning also enables
both the youngest and oldest women, for whom pregnancy and childbirth is most risky, to
either delay or limit childbearing. In addition, family planning can help a woman space her
births. One third of the total maternal deaths can be attributed to non-use or lack of
availability of contraceptionlxx. Increased birth intervals have a positive effect on outcomes
for both the child born and the older sibling.lxxi Longer spaces between births avoids
maternal depletion syndromelxxii, sibling competition for resourceslxxiii,lxxiv, and reduces the
child’s exposure to infectious disease because of longer breastfeeding.lxxv
How does family planning impact on population growth. Contraceptive prevalence and
fertility are closely related. Although there are many other determinants of fertility,
contraceptive use (especially modern contraceptives) is a key driver in the contemporary
fertility transition—whereby fertility decreases begin to match the already happening
decreases in mortality. Population growth is almost entirely due to differences in fertility
behaviour over average lives lived: it is far more important for population growth whether a
woman has two or eight children than if she lives for 35 or 70 years. Additionally, as desired
fertility drops, the main driver behind population growth is going to be unmet need for family
planning.lxxvi Another factor, often overlooked, linking fertility and population growth is how
old women are on average when giving birth. Even if completed fertility is the same, a
population where women are having their babies earlier will grow faster than one where
women have their children later. Reducing adolescent fertility is good for maternal and child
health – and also reduces population growth, regardless of whether overall fertility is
reduced. This effect also means that the reduction in the population growth rate resulting
from a reduction in the Total Fertility Rate (TFR) is proportionate rather than absolute – in
terms of its impact on long-term growth rates, fertility reduction clearly has increasing
returns.lxxvii
How does family planning enhance the status of women? Family planning enables girls
to stay in school and continue their educations and results in increased statuslxxviii,lxxix. Good
reproductive and maternal health services results in greater equality between men and
women and less discrimination against girlslxxx,lxxxi This effect is also illustrated by looking at
the relationship between female labour force participation, per cent of women workers who
receive wages and fertility. As women spend less time looking after their children, they
spend more time in work, thus boosting income and reducing poverty.lxxxii
What is the evidence for the need for effectiveness and a range of methods?
Contraceptive effectiveness is a measure of the success of typical use of a method. It
incorporates efficacy (how well a method works when used consistently and correctly) with
ease of compliance.lxxxiii No modern contraceptive approach is 100% perfect in reducing
unwanted pregnancies but in general, LAPM are the most effective (>99% protection against
pregnancy over a year of use). An advantage of these methods is that they are independent
of the user once initiated and are the most effective contraceptives (between 3 and 60 times
more effective than short acting methods during a year of typical use). Yet, despite these
advantages, they are often difficult for clients to access and are not used as widely as other
methods, particularly in Africa.lxxxiv
In addition, women’s preference for spacing births versus limiting their total number of births
influences their choices of contraceptive methods. Those wanting to stop childbearing are
likely to use one of the most effective methods while those wishing to postpone a birth
choose among short-acting reversible methods.lxxxv It is well documented that a family
planning programme must offer the full range of methods to all women.lxxxvi
What is the evidence that family planning is good value for money? At a global level,
the Guttmacher Institute has undertaken research which demonstrates that increasing the
coverage of modern family planning methods is a highly cost effective intervention.lxxxvii It
calculates that meeting the need for family planning methods for 818 million women in
developing countries would cost:



$ 28 to avert an unintended pregnancy
$ 3050 to save the life of a woman or newborn
$ 62 to save a DALY (women and newborns combined)
Putting this in the context of other common health care interventions in developing countries
they demonstrate that such a cost-benefit figure represents relatively good value for money:
Cost per DALY by intervention
Intervention
Insecticide-treated bed nets
Malaria prevention for pregnant women
Tuberculosis treatment (epidemics)
Modern contraceptive methods
Antiretroviral therapy (Africa)
BCG vaccination of children
Oral rehydration therapy
Cholera immunisation
Cost per DALY saved in US$
13-20
29
6-60
62
252-547
48-203
1268
3516
Furthermore, the Guttmacher Institutelxxxviii demonstrated that in Sub-Saharan Africa,
providing modern contraceptives to all women who need them would more than pay for
itself, saving $1.30 in the cost of maternal and newborn care for each dollar invested.
ANNEX 3: ECONOMIC APPRAISAL
This economic appraisal looks at
a) The unit costs for the options;
b) Estimation and valuation of the health benefits compared to the costs;
c) Other benefits of cost savings due to reduction in other services;
d) The impact on the private for profit sector;
e) Incidence of benefits; and
f) Summary of the economic rationale for public funding for family planning in Malawi.
a) Unit costs for the options
To calculate the cost of family planning, it is necessary to add up all the components
required in to get the family planning service to the user. At its simplest, this includes:
a) the cost of the commodity (e.g. condom or implant), its procurement and freight into the
country;
b) the costs of logistics (including transport and storage in country);
c) the cost of marketing the services and educating potential users; and
d) the cost of service delivery.
In order to look at the output of family planning programmes, it is common to use the
measure of a couple year of protection (CYP). A CYP is the amount of contraception
necessary to protect one couple for one year. The CYP calculation provides an immediate
indication of the volume of programme activity and can be used to estimate unit costs. For
the estimates below, standard conversion factors are used from UNFPA’s proposal to DFID,
see table 3.1 belowlxxxix. Where the benefits of the programme are being discounted for the
cost benefit analysis, then these benefits are discounted accordingly.
Table 3.1: Conversion factors to CYPs by method
Contraceptive method
CYP provided
Sterilisation
8.0
Implants
3.5
Intra-uterine device (IUD)
3.5
Injectable depo
0.25
Male or female condoms
120 condoms to 1 CYP
Pills
15 cycles for 1 CYP
Emergency contraception
0.05
Source: UNFPA proposal to DFID.
For the options considered in this appraisal, the following approach to costing was used:
Option 2: Public sector scale up and commodity provision: it is assumed that the costs
of service delivery in Malawi are proportional to the costs of contraceptives provided.
UNFPA at global level has estimated that typically, the costs of commodities is one sixth of
the total costs of family planning service delivery (source Friedman, UNFPA, personal
communication, data drawn from the 2009 Guttmacher report ‘Adding it up’). For the specific
case of Malawi, and the planned procurement of commodities, this ratio has been adjusted
to assume that the cost of contraceptives is 25% of the cost of service delivery. This higher
share for contraceptives relative to non-commodity costs is based on the following:
- low incomes and wages in Malawi, below the regional average;
- relatively high cost of the methods procured in this option, with 60% for injectable
contraceptives, which are the most popular in Malawi;
- procurement and international freight costs are included in the commodity costs.
The sensitivity of this assumption is checked in the sensitivity analysis below. This provides
an estimated cost of service delivery for the contraceptives provided.
UNFPA has provided estimates of the volumes of family planning commodities it will provide
and the timing of their procurement by year. This was used to convert the procurement plan
into CYPs. In order to allow for delivery and distribution time lags, it is assumed that
commodities procured in 2011 will be used in the financial year 2011/12, etc.
Once the contraceptives supplied have been converted to CYPs, this can be used to derive
the average cost per CYP. This average cost of service delivery in the public sector was
then used to estimate the total CYPs of the support for service delivery.
Inflation was assumed to be 3% on costs denominated in $ or £ (inflation in Malawi Kwacha
is higher, but it is assumed that the exchange rate will adjust for this).
Option 3: Non-for-profit-private sector scale up and commodity provision the costs
have been based on two elements
- the procurement of commodities estimate was as above, as provided by UNFPA. It
assumed that commodities make up 25% of service delivery costs in this case.
Therefore when it comes to attribution, DFID can claim 25% of the CYPs and
resulting health benefits from the commodities provided.
- the costs of the services delivered in the RH Framework contract, which will be
delivered by a private provider based on tendering. The costs and contraceptives to
be provided were taken from the proposed Programme of Work that was submitted
to DFID by BLM, a private sector provider, in June 2011 for 2011/12-2015/16. These
figures are taken as indicative of what could be done by a private sector provider.
The number of CYPs was estimated using the total family planning service delivery
planned in the proposed programme of work, by method. The CYPs were calculated
in the same way as for option 2 (as a result, the estimate of CYPs to be delivered do
not exactly match the projected CYPs according to the BLM proposal). Again,
discounting of future CYPs is included.
Attribution to DFID: Attribution of benefits to DFID was pro rata to the share of total
delivery costs funded by DFID. Thus:
- For commodity funding in option 2 and 3, 25% of total CYPs are attributed to DFID.
- For the service delivery costs in option 2, DFID is assumed to have funded the noncommodity costs - 75% of the total service costs.
- For service delivery in option 3, the share of total programme funding from DFID is
used to attribute a share of the CYPs delivered by the programme to DFID. This
may underestimate the benefits attributed to DFID support since there may be lower
marginal costs in expanding an existing programme, if a bidder with an existing
programme wins the tender. Since the programme will be put out to tender so
another provider may be selected, this more conservative estimate has been used.
The resulting estimate of unit costs is as follows, in constant prices (adjusted for inflation but
not discounted):
Table 3.2: Estimated unit costs per CYP by option, in real £, undiscounted.
Option
2011/12
2012/13
2013/14
2014/15
Option 2. Public sector +
8.20
8.91
8.52
8.60
commodities
Option 3. Private sector +
7.66
7.97
6.99
6.29
commodities
2015/16
8.59
5.31
This estimate suggests that option 3 has lower unit costs per CYP. The private sector
can achieve low costs because they will provide a higher proportion of female sterilisation,
and this and other long acting methods tend to have lower unit costs per CYP. Secondly, the
costs are based on a family planning private sector provider that already operates on a
substantial scale in Malawi and can benefit from scale economies in management and
service delivery. This private provider also purchases its commodities at low costs, including
importing a low cost contraceptive implant from Chinaxc. The potential for reducing
procurement costs further through using national or UNFPA procurement could also be
explored in the medium term.
b) Estimation and valuation of the health benefits compared to the costs
This economic appraisal concentrates on the benefits from increased use of family planning
leading to reduced maternal mortality and reduced maternal morbidity, due to both fewer
pregnancies and fewer unsafe abortions. This is contrasted with the estimated costs of the
family planning services (not just those costs funded by DFID). Other types of benefits,
including direct benefits to families and wider social and environmental impacts are not
within the calculations.
The benefits of the options have been estimated based on standard estimates of the
numbers of pregnancies, abortions, and maternal deaths that will be averted per CYP. The
estimates used for converting CYPs to pregnancies, deaths, abortions and DALYs averted
are taken from the recently updated MSI Impact Estimatorxci. This tool estimates the
benefits of family planning.
Table 3.3: Estimated benefits: pregnancies, maternal deaths, abortions and DALYS averted by
option, undiscounted
Option
Total
Pregnancies
Maternal deaths Abortions
DALYs
CYPs
averted
averted
averted
saved
0.354
0.00124
0.05
0.247
Conversion
factor
per CYP
Option 2: Public
sector
+
commodities
2,707,752
958,544
3,358
135,388
668,815
Option 3: Private
sector
+
commodities
3,596,842
1,273,282
4,460
179,842
888,420
Notes: Totals for 5 years are shown here, with benefits undiscounted.(as in BC guidance note).
Table uses MSI Estimator conversion factors. UNFPA has suggested ratios that were lower for
maternal deaths averted (0.00032).
These estimates assume that all CYPs are additional. This seems reasonable in this case
where a) there is substantial unmet demand and b) the supply of services is supply
constrained - either by location or by limited availability of commodities in public services.
On the understanding that the private sector provider will be targeting its services to meet
the demand from people in areas that are not served by public sector or CHAM services,
and elsewhere will be targeting high risk groups such as young people not already using
services, then this assumption of full additionality seems reasonable. It will be important to
continue to encourage the private sector provider to provide services to un-served areas and
groups and to monitor that this is happening. Longer term it will be important to encourage
BLM and others to aim for increasing total coverage, rather than increasing their own client
numbers, and to increase the availability of integrated reproductive health services.
In order to value the benefits in money terms, the standard approach of valuing one DALY
as the average GDP per capita is usedxcii. A discount rate of 10% is applied to discount the
costs and benefits incurred in later years. This is the discount rate set by the DFID country
office for Malawi and is consistent with the rate used by World Bank in Malawi. Costs have
been adjusted for inflation assuming 3% p.a. inflation on costs calculated in £ or $. Using
these figures gives the following results in terms of costs and benefits of the options:
Table 3.4: Costs and benefits of the different options, discounted
Option
Net present NPV
of Net benefits
value (NPV) benefits
£
of costs £
£
1: Do nothing
0
0
0
2. Public sector £17.0 m
£117.9m
£100.9m
services
and
commodities
3. Private sector £ 17.0 m
£125.1m
£108.0m
services
and
commodities
Note: Costs and benefits discounted at 10% per year.
Benefit: cost
ratio
6.9
Cost
per
DALY saved
in £
0
£35.35
7.3
£33.55
These calculations suggest that both options are good value for money in terms of benefits
substantially greater than the costs. These are estimates based on various assumptions and
some may be over-generous, but even if the benefits were half what is predicted, both offer
excellent value.
Option 3 offers better value for money on the assumptions made. This reflects the higher
use of more cost effective family planning methods in option 3, and the existence of a low
cost private provider in Malawi (which was used as the basis for costing the RH framework
contract in option 3). The commodity procurement component within option 3 provides an
important complementary input to the private sector component, as the public sector and
CHAM services remain a major source of family planning and they need supplies. They are
complementary to the private sector, offering services in different areas. The longer term
sustainable strategy is to increase the delivery of family planning through public and CHAM
services and balance this with use of the private sector. Option 3 is therefore proposed
as the preferred option.
Sensitivity analysis
Sensitivity analysis was carried out on the level of benefits and valuation of benefits, in order
to allow for uncertainty in the estimates of costs and benefits.
- To allow for over-optimism in the estimation of benefits, which could in practice be
lower due to inefficiency in service delivery, or dual use of contraceptives, the
sensitivity analysis looks at a reduction in the number of CYPs by 20%.
- In addition if it is assumed most beneficiaries will come from below average income
households, the valuation of benefits at average GDP per capita may overstate the
benefits. A valuation at 67% of the average GDP is used to allow for this.
- The sensitivity of the assumption that commodities are 25% of family planning
service costs is tested by using one sixth of service costs. This reduces the value for
money of option 2 as services cost more to deliver. If commodities are assumed to
make up a higher share of costs (30%) then the options both indicate higher value
for money with less difference between the options.
- Finally, a lower discount rate (3%) is assessed to see the effects. 3% is the discount
rate used in many international analyses of effectiveness of health interventions,
such as by WHO and the Disease Control Priorities Project.
The table below shows the results for these scenarios, and demonstrates that even with
lower estimates of benefits, the benefits substantially outweigh costs and the programme
offers good value. It also shows that option 3 remains the better performing option in these
estimates. A 3% discount rate increases the difference in benefit: cost ratio between the
options, as the higher use of long term methods under option 3 counts for more with a lower
discount rate. It would require a discount rate over 13.3% for option 2 to perform better than
option 3 on this measure of cost effectiveness.
Table 3.5: Benefit: cost ratio for different scenarios
Scenario
Option 2
Original estimate
6.9
Lower benefits - 20% fewer CYPs
5.5
Lower valuation of benefits (by a third) and
3.7
20% lower CYPs
Assume commodities costs are 16.7% of
4.6
service costs
Assume commodities costs are 30% of service
8.3
costs
Lower discount rate (3%)
7.0
Option 3
7.3
5.9
3.9
6.8
7.7
8.7
Other benefits of cost savings due to reduction in other services
The Guttmacher reports argue that increasing family planning to eliminate unmet needs will
result in a cost saving, because the fall in unwanted pregnancies will reduce health service
costs for maternity and newborn care. They estimate that “providing modern contraceptives
to all women who need them more than pays for itself, saving $1.30 in the cost of maternal
and newborn care for each dollar invested”xciii.
In Malawi, there should be lower demand for health care than without this intervention, due
to reducing numbers who need care for severe consequences of unsafe abortions as well as
fewer deliveries. However this may not result in actual cost savings to the health sector most costs are not variable with the number of deliveries. Savings for families who would
otherwise have sought antenatal and delivery care or post abortion care could be significant,
but there is insufficient data to quantify these savings.
Some of the modelling of impact of family planning estimates the savings in terms of
reduced expenditure required on education and other services. These have not been
quantified in this appraisal, mainly because: it is difficult to quantify the net impact - fewer
births but better child survival; there may not be actual savings to the education budget but
rather better quality of education due to fewer children per class; and it ignores the potential
loss in future output of children not born. However, as discussed elsewhere, a reduction in
fertility has been associated with increasing investment and the ‘demographic dividend’ due
to lower dependency.
Impact on the private for profit sector
There is likely to be little impact on the private for profit sector as the family planning
services will be targeted to poorer and unreached groups.
Incidence of benefits
At present urban contraceptive prevalence rate (CPR) is higher than the rural CPR (50%
urban vs 41% rural for all methods found in the 2010 Malawi Demographic and Health
Survey). This reflects higher demand in urban settings as well as easier access to services
and more choice of services available. Option 2 should benefit rural populations, where the
majority of GOM and CHAM facilities are located, and hence help redress the urban/rural
imbalance. The commodities could also be distributed through NGOs that target vulnerable
groups such as adolescents and those with HIV.
Option 3 - Expanding support through the private sector with a specific remit to reach
additional rural areas will also help to expand effective family planning use in rural areas.
The private provider will also be contracted to target activities for young people among
whom pregnancy is more risky and other high risk groups for HIV, which should improve the
effectiveness in terms of the health benefits and hence cost effectiveness.
The economic rationale for public funding for Family Planning in Malawi
The economic rationale for DFID and other public funding for family planning in Malawi is
based on both market failure and equity arguments:
 market failures arise in terms of inadequate knowledge among the population on the
health benefits of family planning, and on the range, safety and effectiveness of methods
available. This is the justification for expansion of advocacy and promotion activities,
especially targeting young people.
 Externalities arise as the costs of dealing with unwanted pregnancies fall not only on the
family concerned, but also on wider society in terms of funding for the health care and
other services involved, and the wider impact of rapid population growth. This justifies
public investment to contribute to increased access to family planning.
 Equity issues arise in enabling access to services by poor people, especially in rural
areas, who would not otherwise be able to afford family planning, especially some of the
more long term, modern methods.
The analysis of costs and benefits suggests that benefits far outweigh costs, even on
the more conservative assumptions in the sensitivity analysis.
Annex 4: Draft Terms of Reference – Service Provider for increasing family planning
effectiveness in Malawi
1. Introduction
DFID wishes to secure the services of a non-state provider to scale up family planning
services in Malawi, working in partnership with the Ministry of Health (MoH). These Terms of
Reference provide the background to the programme and set out the services required.
2. Scope
To scale up the provision of family planning and related sexual health interventions in
Malawi. The service provider (SP) will provide quality family planning services to increase
the use of effective family planning methods, especially by rural, poor, and young women.
This is one component of the Malawi Family Planning Programme (MFPP). It will be
complemented by the other component which is the procurement of commodities for Malawi
which UNFPA will be contracted to manage.
3. Background
The DFID Reproductive Health Framework
In December 2010, DFID published its Global Framework for Results for improving
reproductive, maternal and newborn health in the developing world and set out the following
objectives to be achieved by 2015:




Save the lives of at least 50,000 women during pregnancy and childbirth and 250,000
newborn babies by 2015.
Enable at least 10 million more women to use modern methods of family planning by
2015, contributing to a wider global goal of 100 million new users.
Prevent more than 5 million unintended pregnancies.
Support at least 2 million safe deliveries, ensuring long-lasting improvements in quality
maternity services, particularly for the poorest 40%.
As summarised in the Framework, there are four pillars for action:




Empower women and girls to make healthy reproductive choices and act on them.
Remove barriers that prevent access to quality services, particularly for the poorest and
most at risk.
Expand the supply of quality services, delivering cost-effective interventions for family
planning, safe abortion, antenatal care, safe delivery and emergency obstetric care,
postnatal and newborn care – delivered through stronger health systems with public and
private providers.
Enhance accountability for results at all levels with increased transparency.
To support delivery of these objectives, DFID has established a global Reproductive Health
Framework Agreement with pre-qualified providers for the supply of clinical services and
commodities for reproductive health by non-state providers in DFID bilateral programmes.
Key service delivery mechanisms include social marketing, procurement of commodities,
direct provision, community-based distribution and outreach. The choice of these delivery
mechanisms and the inclusion of other services will depend on the specific requirements at
country level.
Scaling up family planning in Malawi
Family planning in Malawi
See Annex 1: The Family Planning Situational Analysis report by Carol Bradford, HLSP,
2011.
The Malawi Family Planning programme
DFID wants to support the scale up of family planning services in Malawi over the next five
years (2011/12-2015/16). The programme will focus on reaching adolescents and couples in
underserved rural communities and ensuring the method mix is more appropriate by
increasing the uptake of long term reversible methods of contraception.
There are two components to the programme. The first is to scale up service coverage by
extending family planning services and the range of methods available to poor people and in
rural areas and to increase use of family planning by young people. It includes some
procurement. These TORs pertain to this component.
The second component is to procure commodities for the country. DFID will contract UNFPA
Malawi to procure, and the commodities will be provided to both government and the
Christian Health Association of Malawi (CHAM) through the Central Medical Stores (CMS)
distribution channels. It is anticipated that this component (£5.8m) will deliver 25% of the
commodity needs for the next 5 years.
This programme will complement other areas of DFID Malawi’s health portfolio, including
support to the next health sector wide programme, the Health Sector Strategic Plan (HSSP),
a small malaria programme and an emergency drug procurement project.
The impact of the MFPP will be to reduce maternal mortality and achieve MDG5 in Malawi.
The outcome will be to increase the use of effective family planning methods, especially by
rural, poor, and young women.
The programme has four outputs:
1) Quality family planning and other services delivered, especially to the rural poor and
young women;
2) Awareness and knowledge of family planning and sexual and reproductive health (SRH)
services at the individual, household and community levels;
3) Strengthened national proficiency in SRH policy, planning and implementation); and
4) Strengthened programme cost-effectiveness, quality and accountability.
Quantification of output 1: Number of additional CYPs resulting from the additional
contraception to be provided by the RH Framework grant
It is expected that the programme will be able to deliver in the region of 2.95 million
additional CYPs through family planning provided in the 5 years (undiscounted).
The expected outputs/milestones in terms of contraceptive provision in the year that will lead
to the total CYPs as follows (although tenders could suggest a different profile):
2011/12 150,000
2012/13 400,000
2013/14 500,000
2014/15 700,000
2015/16 1,200,000
These figures are estimated based on counting CYPs in the year the service is delivered.
See the annex below for details of the approach to calculation.
The requirements – pertaining to component one
The SP will address the demand side and the supply side of needs in Malawi. Supply side
issues include ensuring the availability of a range of family planning methods and skilled
service providers, and access to services, including adolescent friendly services. Demand
side issues include raising awareness of family planning options and community
sensitisation to address social and cultural barriers that prevent service utilisation. The exact
methodology is to be proposed by the implementing partner. However, it is envisaged that
the programme will:














Recruit and train outreach teams to deliver a range of family planning services in areas
not served by other providers.
Procure vehicles and equipment for outreach services.
Deliver family planning services at scale through the deployment of a range of
appropriate service delivery mechanisms: social marketing, franchising, static clinics and
outreach clinics.
Expand access to and uptake of LAPM.
Improve access to and uptake of family planning services by young women.
Provide training and mentoring support on family planning, including LAPM, and on
provision of adolescent friendly services to government health providers.
Work with community structures and leaders to reduce barriers to family planning and
increase knowledge of family planning and AIDS prevention methods, leading to
increased uptake of services.
Manage procurement of commodities required to support expansion of family planning
services including ensuring that commodities meet international quality standards and
national standards.
Collaborate with other cooperating partners supporting family planning services to avoid
duplication of effort.
Develop and implement a monitoring and evaluation plan.
Contribute to effective commodity forecasting, procurement and distribution.
Report on programme progress to MOH at central and district levels
Build the capacity of government staff and services, as well as the service providers
own, to sustain provision of quality, comprehensive family planning services in rural
areas.
Influencing national policy.
Family planning services will be free of charge, planned and delivered in partnership with the
MoH, district health management teams and other local NGOs.
The programme will build the capacity of government health providers to deliver quality
services, including a comprehensive choice of family planning methods and adolescent
friendly services. Training will be provided to update their knowledge and skills including the
provision of long-term family planning methods. The SP will agree an exit strategy with each
district and health facility that it works with to ensure the sustainability of services beyond
the programme. Over time, responsibility for family planning service delivery would be
handed over to government health workers, with the service provider providing ongoing
mentoring.
The SP will procure family planning commodities in response to identified gaps by the MoH
commodity security committee to enable implementation of its programme. The SP will
develop an annual procurement plan and seek agreement from DFID and the MoH before
placing the orders.
The SP will work with the MoH to develop an exit strategy and strengthen their capacity to
sustain expanded delivery of family planning services beyond the life of the programme. The
programme’s annual reviews will consider the scope to progressively integrate programme
activities within MoH systems.
Detailed Scope of Services Required
The service provider will be expected to:
Programme implementation

Conduct a needs assessment and design an implementation plan.
The Plan will demonstrate how it will








Add value to existing programmes by the SP
Support the provision of services by the government
Support the capacity development of the public sector (training opportunities, mentoring
support to government service providers on family planning, including long-term
methods, and on provision of adolescent friendly services)
Be integrated into the SP existing or planned programmes addressing other aspects of
reproductive health and sexual health
Redress Malawi’s ineffective contraceptive use by better advocacy and better
programming and ensure a more appropriate mix of contraception.
Support procurement. The SP will liaise with the MoH’s Reproductive Health Commodity
Security Committee to ascertain how the programme will contribute to the commodity
gaps. The SP will, in particular, liaise with the UNFPA with respect to component two of
the MFPP. It will agree a procurement plan with DFID and MoH, to purchase family
planning commodities required to support expansion of family planning services and in
accordance with commodity gap forecasts. The SP will be responsible for ensuring that
commodities meet international standards and are registered with Malawi’s
Pharmaceutical Regulatory Authority. The SP will manage all aspects of the
procurement process
Sensitise the community and work with community structures to reduce barriers to family
planning and increase uptake of services
Develop an exit strategy with health facilities, District Health Management Teams and
Ministry of Health to ensure the long-term sustainability of family planning and
adolescent friendly services.
Programme partnerships




Establish effective working relationships with all stakeholders at the national and
decentralised level
Collaborate with the MOH at central and district level on planning, delivery and
monitoring of family planning services and implications for policy
Collaborate with other cooperating partners supporting family planning services to avoid
duplication of effort and enhance programme effectiveness. In particular, work closely
with UNFPA.
Collaborate with other DFID programmes operating in Malawi including DFID’s regional
Prevention of Maternal Deaths form Unwanted Pregnancy Programme and the regional
Evidence for Action.
Programme management









Establish transparent financial and procurement systems based on international best
practice and in accordance to DFID’s contract requirements
Agree with DFID and the MoH, an annual work plan and monitoring and evaluation plan
that include Key Performance Indicators and milestones in line with the project’s
logframe. If this programme is complementing an existing one, address how the
combined programme monitoring system will demonstrate results for overall CYPs,
estimated CPY coverage, profile of users of family planning, demand for different
methods, users switching methods, and the age profile of clients
Strengthen existing MoH data collection mechanisms or establish systems to allow the
measuring and reporting of programme results
Provide quarterly progress updates to DFID and annual narrative reports. Share reports
and data with MoH’s Reproductive Health Unit
Ensure systems are in place to capture lessons learned, document and disseminate
findings that have the potential to contribute to global learning
Prepare an annual budget with DFID and identify cost efficiencies. Demonstrate value
for money across all activities, especially on the procurement of reproductive health
commodities
Provide DFID with quarterly financial reports, monthly financial forecasts, annual
financial reports, and a certified annual audit statement showing funds received and
expended
Maintain an assets register.
Agree and monitor a strategy for managing and mitigating risk.
5. Procurement, contracting and performance monitoring
Procurement process
DFID Malawi will contract the SP through a mini-competitive tender process (see timeframe
below). Pre-qualified providers will be invited to submit a detailed proposal and budget. The
MoH will be involved in finalising these ToR, evaluating the bids and choosing a suitable SP.
Finalise ToR with MoH
Call for proposals
Deadline for proposals
Evaluation of proposals and request for additional information
Negotiation and award of contract
Eligibility
Pre-qualified providers identified under the global DFID Reproductive Health Framework
Agreement are eligible to bid. Pre-qualified providers will have met DFID’s requirements
which include:






Capacity to supply reproductive health services or commodities at scale.
Capacity to work in partnership with the public sector, partner governments, other
donors and other relevant stakeholders.
Capacity to work with commercial, formal, and informal providers to create a strategy to
develop the local capacity and provider networks.
Capacity to provide behaviour change and communications management.
Compliance with quality assurance standards and processes for services and
commodity procurement.
Ensuring value for money and health outcomes are delivered from all interventions.



Monitoring of the development effectiveness of intervention through ‘before and after’
evaluations.
Capability to target the poor and to disaggregate, measure and report regularly on
service use.
Provision of data on service costs to enable benchmarking.
Selection criteria
DFID has used the following criteria to identify potential partners at the prequalification
stage:










Registration and established presence in Malawi
Technical capacity to deliver high quality services that are accessible and appropriate.
Demonstrated ability to reach under-served rural areas and groups with particular needs
including adolescent girls.
Organisational capacity to deliver services at scale.
Strong financial management systems and sound audit track record.
Strong procurement systems and experience of providing procurement services.
Track record of working with different levels of government and with donor and NGO
partners.
Track record of working in partnership with the public health sector.
Demonstrated ability to adopt innovative approaches to service delivery.
Experience of programme monitoring and evaluation, and managing for results.
DFID Malawi will work with the MoH to finalise evaluation criteria for selecting a pre qualified
SP. These will include an examination of the:







Proposed methodology for delivering the desired programme results, with particular
focus on methodology for reaching remote and unserved communities and adolescent
girls
Proposed methodology for working with the community to overcome opposition to Family
Planning and increasing utilisation of services, including how they will work with existing
community structures and programmes.
Proposed sequence for implementation and geographical roll out.
Proposed methodology for measuring and monitoring the results of the programme,
including evaluation criteria. Costings for this should be included in the budget.
Proposed methodology for ensuring capacity building for delivery of different FP
methods and longer term sustainability of services at the health facility, district and
national level.
Quality and availability of personnel
Commercial case
Contract
DFID Malawi will award a contract to the successful bidder. The contract will be awarded for
5 years, subject to annual reviews of performance. The commodity procurement component
of the contract will be awarded initially for 2 years, with two possible extensions of 12
months each.
Performance monitoring
DFID Malawi will be responsible for contract management and oversight of the implementing
partner.
The contract with the implementing partner will set out key performance indicators (KPI) in
line with the logical framework. Programme performance will be assessed against the KPI,
annual work plans, and the indicators, milestones and targets in the Logical Framework.
DFID will conduct an annual review of the programme including assessment of
implementing partner’s performance. DFID will also track programme performance and
budget execution through quarterly narrative and financial reports and quarterly update
meetings with the implementing partner.
DFID will conduct a mid-term review and an independent end of programme evaluation.
Particular attention will be given to identifying lessons learned about the effectiveness of
outreach services in scaling up access to family planning; the effectiveness of strategies to
address social and cultural barriers to family planning and to increase demand; to increase
uptake among adolescent girls;, and to expand availability/uptake
of long-term
contraceptive methods.
Annex (for the appraisers of the bids) to the TORs: Methodology use to estimate
CYPs
Notes on CYP calculation method used for this calculation:
CYPs are estimated by method using the following conversion factors to CYPs
Contraceptive method
CYP provided
Sterilisation
8.0
Implants
3.5
Intra-uterine device (IUD)
3.5
Injectable depo
0.25
Male or female condoms
120 condoms to 1 CYP
Pills
15 cycles for 1 CYP
Emergency contraception
0.05
Count the full CYPs in the year when the FP was delivered.
Calculate the number attributed to DFID's support pro rata to the share of the programme funded
from this grant.
Do not include the CYPs from services delivered in earlier years.
Data needed: numbers of FP services delivered by method by year.
This is a method to show total CYPs that DFID has provided, although some of the protection is
occurring in years after the end of the grant.
Example: In year x the total programme delivered 1000 sterilisations (8 CYP each) and 1000 IUDs
(3.5 CYP).
Calculation of total CYPs for year x is 8,000 + 3,500 = 11,500
If DFID funded say 80% of the programme then CYPs attributed to DFID is 80% of 11,500 = 9,200
CYPs.
Additionality: Contraception is additional if it is not substituting for another provider. So it will be
important to demonstrate that the program is reaching additional people, e.g. from unserved areas,
and not substituting - reducing the numbers getting FP services from other providers. The service
provider should be able to demonstrate that this is achieved. It does not mean some individuals
cannot switch e.g. to get permanent methods, but does mean that there should not be competition for
clients leading to reduced numbers getting FP from the public sector and other providers. This need
for additionality is because DFID wants to help Malawi increase total FP use, not just to increase use
through a particular provider.
ANNEX 5 Framework for action – addressing Reproductive, Maternal and
Newborn Health in Malawi (DFID Malawi and DFID regional support)
PILLAR 1:
Empower women and
girls to make healthy
reproductive choices
Political commitment to
girl and women and their
health at all levels
Legal frameworks for girl
& women’s rights and
protection

The Justice for
Vulnerable
Groups (20112014)
Girls’ education –
including lower secondary
level
 The Keeping Girls in
School (2011-2016)
PILLAR 2:
Remove barriers that
prevent access to
services, particularly
for the poorest and
most at risk.
Financial barriers to
services removed,
increasing purchasing
power and choice and
incentivising use
where appropriate:
services free at point
of use, cash transfers,
vouchers, cash
incentives, social
health insurance –
including family
planning in packages
of care.

The MFPP
(making
commodities
free)
PILLAR 3:
Expand the supply of quality
services
PILLAR 4:
Enhance accountability
for results at all levels
Increased coverage of health
services that provide high
impact, cost effective
interventions for family
planning, safe abortion, antenatal care, safe birth,
emergency obstetric care, post
natal care, newborn care with
PMTCT, HIV prevention,
nutrition, malaria, water,
sanitation and hygiene

BLM POW 2009-2015

The MFPP (2011-2016)

The MHSP (2011-2016)
Data & information
systems for registering
births/deaths, better
planning & tracking results

The Evidence for
Action programme
Economic opportunities:
employment, income for
healthy choices

Innovative
approaches to
referrals & transport
(to emergency
obstetric care)
Health workers – midwives
and community health workers
trained, deployed, managed &
supervised,

The MHSP (2011-2016)
Locally-led social change
of norms that constrain
women’s choice, control
over resources & body (eg
early marriage, FGM/C,
cultural preferences for
sons); working with
men/boys

The MFPP (the
2011-2016)
Tackling
discrimination and
treatment of women in
services. Includes
adolescent friendly
services that reach
married girls and
unmarried at risk
Commodities – innovation (eg
for long acting FP) – getting
supplies in right place at right
time – commodity security –
making affordable & available,
social marketing

The MFPP
Girl, women and wider
communities’ action for
RMNH

The MFPP (20112016)
Culturally sensitive
information, especially
about family planning, to
meet unmet need and
stimulate demand

The MFPP (20112016)

The MFFP
(2011-2016)
More efficient and effective
delivery of quality services
by public or private
providers (quality assurance,
management, regulation,
performance based funding)

BLM POW 2009-2015

The MFPP (2011-2016)
Working with private sector
providers (including NGOs)
when appropriate, cost
effective and pro-poor - through
social marketing, accreditation,
innovation

BLM POW 2009-2015

The MFPP (2011-2016)
Enhanced accountability
and transparency
between citizens,
communities, civil society
and providers

The Evidence for
Action programme
Accountability for better
performance in RMNH
services

The MFPP (20112016)
Enabling & ensuring the
multilateral system
delivers for reproductive,
maternal and newborn
health

The MFPP (20112016)
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ii
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xxiii
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xxv
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xxvi
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xxviii
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xxix
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xxxiv
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xxxv
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xxxvi
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xxxvii
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lxxxvii
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lxxxviii
Singh, S et al 2009 Adding it up: the benefits of investing in sexual and reproductive
healthcare. UNFPA and Guttmacher Institute.
lxxxix
These CYP conversion factors are based on how a method is used, failure rates, wastage, and
how many units of the method are typically needed to provide one year of contraceptive protection for
a couple. The calculation takes into account that some methods, like condoms and oral
contraceptives, for example, may be used incorrectly and then discarded, or that IUDs and implants
may be removed before the end of their life span.
xc
The Chinese implant is called Sino-plant, and is a third of the cost of most implants, ($7 vs $23).
DFID is currently researching the prospect of being able to fund this low-cost implant. Permission to
do this is likely to be granted in late autumn 2011.
xci
Marie Stopes International, May 2011, Impact estimator version 1.2,
http://www.mariestopes.org/Resources/Tools.aspx This takes each CYP to be equivalent to 0.247
DALYs per CYP, based on estimates from the PSI DALY calculator for Malawi.
xcii
GDP per capita based on IMF April 2011 figures, estimated as follows:
GDP per capita in real £
xciii
2011/12
2012/13 2013/14
2014/15 2015/16
223.2
233.0
242.9
252.7
262.9
Guttmacher and UNFPA (2010) In Brief: Facts on investing in family planning and MNH, SubSaharan Africa, updated Nov 2010. http://www.guttmacher.org/pubs/FB-AIU-Africa.pdf