FLAG A
Family planning and reproductive health services
in Bihar and Odisha – a total market approach
Business Case
July 2012
1
Contents
Pages
Acronyms
Intervention Summary
4-5
1. Strategic Case
6-13
2. Appraisal Case
14-27
3. Commercial case
28-30
4. Financial Case
31-33
5. Management Case
34-35
6. Annexes
FLAG B: Logical Framework
FLAG C: TOR for implementing agency
FLAG D: Annex 5: Climate and Environment assurance note
FLAG E: Replies to earlier HoO comments
ACKNOWLEDGEMENTS
Section
Intervention
summary
Writers
Rashmi Kukreja, Health Adviser
Strategic case
Rashmi
Mamta Kohli, Social Development
Adviser
Shantanu Das, Economist
Rashmi, Shantanu,
Renu Deshpande, Governance
Adviser
Mamta
Ritu Bhardwaj, Environment Adviser
Shantanu
Appraisal case
Economic
Appraisal
Commercial case
Financial case
Management
case
Benazir Patil, Programme Manager
Benazir
Renu
Rashmi
Quality Assurers
Billy Stewart, Senior Health
Adviser
Emma Spicer,
MDG Team Leader
Billy
Emma
Billy
Emma
Roli Asthana
Rashmi
Emma
Rashmi
Emma
Emma
2
Acronyms
ASHA
ANMs
BCR
CHC
CPR
CYP
DFID
DALY
DANIDA
DoHFW
DLHS 3
DMPAA
FP
GDP
IUD
KPI
MBBS
MDGs
M&E
MMR
MSI
MTP
MWRA
NFHS 3
NRHM
Ob/Gyn
OCP
PHC
PCPNDT
PIP
PPP
RMNHFfR
RHSFA
SF
SM
SMART
SRS
STI
TFR
ToR
UNFPA
VfM
WHP
Accredited Social health Activist
Auxiliary Nurse Midwives
Benefit to Cost Ratio
Community Health Center
Contraceptive Prevalence Rate
Couple Year of Protection
UK’s Department for International Development
Disability-Adjusted Life Year
Danish International Development Agency
Department of Health and Family Welfare
District Level Health Survey 3
Depo Medroxy Progesterone Acetate
Family Planning
Gross Domestic Product
Intra-Uterine Device
Key Performance Indicators
Bachelor of Medicine and Bachelor of Surgery
Millennium Development Goals
Monitoring and Evaluation
Maternal Mortality Ratio
Marie Stopes International
Medical Termination of Pregnancy
Married Women of Reproductive Active
National Family Health Survey 3
National Rural Health Mission
Obstetrics and Gynaecology
Oral Contraceptive Pill
Primary Health Center
Pre- conceptual and prenatal diagnostic tests act
Project Implementation Plan
Public Private Partnership
Reproductive Maternal and Newborn Health Framework for Results
Reproductive Health Services Framework Agreement
Social Franchising
Social Marketing
Specific Measurable Attainable Realistic Timely
Sample Registration System
Sexually Transmitted Infections
Total Fertility Rate
Terms of Reference
United Nations Population Fund
Value for Money
World Health Partners
3
Intervention Summary
Family planning and reproductive health services in Bihar and Odisha
What support will the UK provide?
£18 million over 3 years (2012-2015) to catalyse the private sector to scale up the choice of good
quality, affordable family planning and reproductive health services for poor women in Bihar and
Odisha.
Why is UK support required?
What need is the intervention trying to address?
Less than half of married women in India use modern contraception. 50% of Indian women get married
before the age of 18 and have frequent, poorly spaced births. One fifth of all pregnancies are
unwanted. More than 6 million induced abortions take place annually1 and about half of these are
unsafe – performed in unhygienic conditions by untrained providers2. In two states where DFID works
– Bihar and Odisha – rates of mother and infant deaths are alarmingly high. Better access to family
planning could avert 40% of maternal and 10% of infant deaths. It would also meet women’s desire
for smaller families and address unmet need. The estimated rate of contraceptive prevalence is only
32% in Bihar and 38% in Odisha3.
The main family planning method in India is female sterilisation, accounting for 71% and 88% of
contraceptive users in Odisha and Bihar. Young people and poor rural women find it hard to obtain a
choice of modern family planning; and the quality of reproductive health care is very variable. Private
health care providers can play a key role in addressing this gap. At the same time, India’s female sex
ratio has been declining rapidly. More stringent regulation is required to ensure that ultrasound
technology is not used illegally for sex selective abortion.
New opportunities to expand and enhance family planning are emerging. A broader mix of modern
family planning methods is available in India; and women are increasingly choosing family planning
from the private sector, especially birth spacing methods. The Government of India has brought in a
new family planning ‘service guarantee’, for a wide range of FP spacing methods through public and
private channels including: social marketing through over 800,000 community volunteers (ASHAs) and
reimbursing costs for sterilisations and IUDs through accredited private clinics.
What will DFID do to tackle this problem?
The private sector market for family planning is growing. DFID wants to make sure that as many poor
people as possible benefit from the opportunity to choose the family planning services that suit them.
We will use our funds to expand five-fold the number of accredited private clinics and social marketing
outlets that serve neglected populations and under-served areas. We will aim to ensure that far more
poor, young and newly married women have the opportunity to choose the number and timing of their
children.
1
National Commission on Population 2002
Duggal R, Ramachandran V. The Abortion Assessment Project-India; Key Findings and Recommendations.
Reproductive Health Matters, Volume 12, Issue 24, 2004. 122-129
3
Projected CPR from DLHS 2008 assuming the past trajectory continues
2
4
How will it be done?
DFID will mobilise private providers to join a network of social marketing outlets and social franchising
clinics offering good quality family planning (FP) and reproductive health services. The project will
expand services in areas with the highest unmet need for contraception, train providers and monitoring
the quality of private clinics. It will also promote community outreach and demand for family planning
services.
The project will expand the choice of birth spacing methods on offer and reach adolescent girls and the
poorest women. It will work with community health workers to raise awareness among men and
families about family planning and provide accurate information to dispel myths and misconceptions.
The franchisee clinic network will offer family planning counselling, referrals and cashless services to
poor clients through government subsidy. Linking the private clinic network with the public sector is an
opportunity to drive improvements in the skills of around 10% of existing frontline govt health providers
and strengthen the quality of care on a large scale.
What are the expected results?
We estimate that this project will reach about 780,000 new family planning users over a three year
period. This would be roughly 25% of the additional new users, if the contraceptive prevalence rate
(CPR) of both states increases by 10 percentage points during the project period. It will seek to scale
up the coverage of franchisee network clinics almost five times.
The impact: Reduce maternal death from unwanted pregnancy and reduce fertility rates. By 2015, this
project will help to increase:
 the contraceptive prevalence rates in Bihar from 32% in 2011 to 42% in 2015.
 the contraceptive prevalence rates in Orissa from 38% in 2011 to 48% in 2015.
The outcome is to increase use of family planning methods, reduce the unmet need for family planning
and prevent unsafe abortion.
Outcome and output level indicators4 :
 Number of new contraceptive users: 780,000
 No. of CYPs (couple years of protection): about 3.5 million
 300,000 women provided safe reproductive health services
 280 fully functional social franchisee outlets providing reproductive health services
 18,000 social marketing outlets providing family planning products and advice on healthy
behaviours
 About 700,000 unintended pregnancies averted
 About 1,700 maternal deaths averted in the programme period and beyond
 About 37,000 infant deaths averted in the project period and beyond
4
Outcomes are modelled using the MSI Impact Estimator
5
1.
Strategic Case
A. Context and need for a DFID intervention
Set the scene and provide the overarching context for why DFID is doing this.
1.
Less than half (48.5%)5 of currently married women in India use any modern
form of contraception. The Government of India estimates that up to 40% of
maternal deaths, and 10% of infant deaths, could be averted by allowing women
access to information, skills and technologies to delay motherhood, space births,
avoid unintended pregnancies and unsafe abortions, and stop childbearing when
they have reached their desired family size.
2.
Data from India’s latest National Family Health Survey shows that 21% of all
pregnancies (about 5.6 million per year) are unintended6 and that 13% of currently
married women – 30 million women - have an unmet contraceptive need. The same
survey shows a growing desire for smaller families: nearly 70% of women consider
two or fewer children to be the ideal number, and only 9% of women desire more
than three children.
3.
With 27 million births each year, India’s population is forecast to grow by 371
million in the first quarter of this century (2001-2026). Half of this growth will be seen
in 7 poor states, which include DFID’s priority states of Bihar, Orissa and Madhya
Pradesh. India’s total fertility rate (TFR) has declined from 3 in 2003 to 2.6 in 2008
and 14 affluent states have reached replacement fertility levels. But it likely to take
several decades for India’s population to stabilize, mainly because half the
population is in the reproductive age group (15-49 years).
4.
Bihar and Odisha are two of India’s poorest states. Odisha has a GDP per
head of £577 and 37% of Oriyas live below the poverty line. In Bihar GDP per head
is £163 and 60 million live in poverty (60%). Health indicators in both the states are
alarming: maternal mortality - 305 deaths per 100,000 births in Bihar and 275 deaths
per 100,000 births in Odisha - are much higher than the Indian average and
comparable to many low-income African nations7. At 3.9, Bihar’s fertility rate is the
highest in India, while Odisha’s TFR of 2.4 remains well below above that of
southern Indian states8. The rate of contraceptive prevalence (CPR) is 32% in Bihar
and in 38% in Odisha9, which is 10 percentage points lower than neighbouring
Bangladesh. Access to a choice of family planning methods in these states could
improve maternal and child health outcomes significantly.
5
6
NFHS 3, 2005/2006
10 percent were wanted later and 11 percent were not wanted at all
7
WHO, UNICEF, UNFPA, and World Bank, ‘Trends in Maternal Mortality 1990-2010’, puts countries with a
maternal mortality ratio of over 300 into the higher MMR bracket, including most sub-Saharan African countries.
8
9
For example, the TFR in Tamilnadu and Kerala was 1.7; 1.9 in AP, and 2.0 in Karnataka in 2009.
The CPR in Bangladesh is 48 (2006-2010), UNFPA Annual Report 2011
6
Situation analysis: challenges and opportunities in family planning and reproductive
health
5.
India’s family planning situation is characterised by a predominance of
permanent methods (i.e. female sterilisation), negligible use of spacing and male
dependent methods, substantial levels of discontinuation and a high burden of
maternal mortality (8%) due to unsafe abortion. There is an urgent need to expand
the contraceptive method mix. Reducing reliance on sterilisation would have the
biggest benefit for the 50% of Indian women who get married before 18 and have
frequent, poorly spaced child births. A typical Indian woman's first contact with FP
services is after she’s given birth; and, if she’s had several births, mainly to be
offered a permanent FP method. Until recently, the public sector has paid less
attention to methods to delay and space births, but now more priority is being given
to promote spacing methods. Social and cultural factors have meant that young
people, especially young, newly married, low parity women but also young men,
have not sought family planning services from the public sector.
6.
These characteristics are exacerbated in India’s poorer states. In Bihar and
Odisha unmet need for birth control among non-users is substantial - about one
quarter in both states. 88% and 71% of contraceptive users in Bihar and Odisha
respectively report sterilisation as the method. Unmet need is greatest in 15-19 year
olds, in the less educated and in the poorest households, largely due to a significant
gap in services, supplies and counselling. Pervasive discrimination against women
is an underlying factor, as women are often unable to exercise reproductive choice.
A strong son preference in the majority of communities also leads to large number of
unwanted births often until a male child is born.
7.
Opportunities to expand and enhance family planning are emerging in
India and globally. Contraceptive uptake has doubled worldwide in the last two
decades. Evidence suggests that the countries which have achieved most progress
have expanded the choice of contraceptives but also scaled up a diverse network of
private and public sector clinics and community outreach channels. Over the last 20
years, new contraceptive users through social marketing – which uses traditional
commercial marketing to make contraceptives widely available in commercial retail
outlets10 and promotes awareness of socially beneficial behaviours through mass
media11 - have increased nine-fold. Social franchising (SF), a way of contracting
private providers to join a branded franchised chain, is being taken up in many
developing countries, leading to improvements in service quality, usage rates and
client perceptions12. In exchange, the franchising agent offers demand generation
activities such as communication and mass media; training; and product supply.
10
Rothschild ML 2010. Using Social Marketing to manage population health performance. Pre Chronic Disease (7) 5
A96
11
Levine R, Langer A, Birdsall N et al. Contraception. In : Jamison DT et al. Disease Control Priorities in Developing
Countries. 2nd ed. World Bank, Oxford University Press. 2006.
12
Montagu D. Franchising of health services in low-income countries. Health Policy and Planning. 2002; 17: 121–30.
7
8.
In India care-seeking in the private sector is substantial13, as for Asia as a
whole. Evidence shows that when people first seek FP advice they often visit a
private pharmacist, drug seller or clinic. One quarter of Indian women are already
seeking RH services from the private sector (private clinic, hospital or pharmacy)
indicating that there is some ability to pay. Increasing urbanisation and high unmet
demand continue to increase preference for private sector services. In Bihar and
Odisha 46% and 23%14 of women respectively are seek family planning services
from the private sector. What is important to note is that spacing-method users are
overwhelmingly seeking private sector services (about 50% to 80%)15.
9.
It is well known that Government of India and the state governments are
investing huge resources under National Rural Health Mission (NRHM) to expand
FP coverage and to promote spacing methods. However the need is enormous and
it not possible for government alone to address the diverse requirements of the vast
rural and peri-urban poor population. Unmet need can be feasibly addressed
through complementary efforts of the private sector and diverse service channels.
Recent policy developments demonstrate the Government of India’s commitment to
provide a wider range FP spacing methods. A new ‘service guarantee’ – announced
by Government of India at the 2012 Family Planning Summit - is in design that
includes social marketing of oral pills, condoms and emergency contraceptives
through community volunteers; training nurse midwives to insert IUDs; and
reimbursing the cost of sterilisations and IUDs insertion through social franchisee
channels. Under the ‘Universal Health Coverage scheme’16, there is a strong focus
on private sector provision of services through accreditation and regulation. At the
same time, the number of social marketing outlets and social franchising clinics
ready to offer a basket of choice, good quality of care and to work with the public
sector is growing. Janani, a registered society in Bihar and affiliate of the donor
agency DKT is one such example. Janani and other social marketing agencies such
as Population Services International, Abt Associates, and Marie Stopes
International, combine a market-based approach with a community-based
distribution system that is increasingly able to provide quality family planning
services at an affordable price in rural areas (Gopalakrishnan et al. 2002).
10.
India faces particular challenges of unsafe abortion and sex selection,
which need to be recognised and addressed. An estimated 6.7 million induced
abortions take place ever year in India17.Half of these (around 3.5 million) are
performed in unhygienic conditions by untrained providers18. Unsafe abortion is a
major cause of maternal mortality globally, leading to some 7% of maternal deaths.
In India an estimated 8% of 68,000 maternal deaths annually are attributed to
13
Madhaven S et al. Engaging the private sector in maternal and neonatal health in low and middle income countries.
FHS Working Paper 12; 2010.
14
NFHS 3
15
NFHS3
12th Plan 2012 – Planning Commission
16
17
National Commission on Population 2002
Duggal R, Ramachandran V. The Abortion Assessment Project-India; Key Findings and Recommendations.
Reproductive Health Matters, Volume 12, Issue 24, 2004. 122-129
18
8
unsafe abortion19. More than 80% women in India do not know that safe abortion is
legal or available20. While there are 11,000 government-approved facilities providing
legal abortion, these clinics are overwhelmingly distributed in richer states and in
urban areas 21. In poorer states, the majority of private clinics remain uncertified for
conducting legal safe abortions2223. The vast majority of women - particularly poor
rural women in Bihar and Orissa – have no access to safe abortion24 and continue to
have recourse to illegal, backstreet providers. The World Health Organisation
recommends that safe abortion services – emergency contraception, medical
abortion, abortion counselling and comprehensive abortion care - should be made
available as part of a package of comprehensive reproductive health services which
promote choice and informed consent. DFID also believes that family planning is a
key intervention to reduce unintended pregnancy; that abortion should be rare and
safe; and that women should be able to choose abortion within the laws of the
country concerned.
11.
India’s sex ratio has declined to the alarming level of 917 girls for every
1,000 boys25. There is no current evidence to show that increased access to safe
abortion has a negative impact on gender ratios. However, what is known is that the
provision of abortions in the second trimester of pregnancy after a sex determination
test by unscrupulous providers (reportedly, mainly private providers) is widespread,
and increasing in many parts of the country. India has strong laws that outlaw
prenatal sex-selection – notably the PCPNDT 26Act – but the implementation of the
law is weaened by severe restrictions in certifying and monitoring private facilities.
This has the dual effect of making safe abortion harder to access, and also driving
more abortion providers out of a regulated system which could better monitor
inappropriate use of sex selection technologies. Most experts conclude that better
access to safe abortion services and more stringent implementation of PCPNDT act
are both required.
Present evidence that clearly justifies the need for the intervention
12.
Benefits for health: India contributes one fifth of global maternal and child
deaths, and remains off track for MDGs 4 and 5. Promoting family planning in could
19
SRS data 2004
20
Banerjee et al. 2009. Knowledge and Care seeking behavior in four selected districts of Bihar and Jharkhand.
India. Presented at Population Association of America (PAA). April-May 2009. Available online at
paa2009.princeton.edu/sessionViewer.aspx?SessionId=153
21
Barge S. Situation analysis of medical termination of pregnancy in Gujarat, Maharashtra, Tamil Nadu and Uttar
Pradesh. Paper presented at MTP workshop, Ford Foundation, 20 May 1997. In: Bandewar S, Ramani R, Asharaf A,
editors. Health Panorama
No.2. Mumbai7 CEHAT, 2001. p.25–34.As cited in: Hirve S. Abortion Law, Policy and Services in India: A Critical
Review. Reproductive Health Matters. 2004; 12 (24 Suppl): 114-121.
22
IPAS report situation analysis on MTPs in Bihar 2011
23
Paramita Guha, 2004. Abortion assessment project - India: State level dissemination meeting, Uttar Pradesh.
Lucknow, India: Kriti Resource Centre.
24
Paramita Guha, 2004. Abortion assessment project - India: State level dissemination meeting, Uttar Pradesh.
Lucknow, India: Kriti Resource Centre.
25
Census 2011 shows that the numbers of girls in the 0-6 years age group has further declined from 927 in 2001 to
917.
26
PCPNDT Act: Pre- conceptual and prenatal diagnostic tests act
9
avert 40% of maternal deaths and nearly 10% of childhood deaths27. Recent
analysis of DHS data from 68 countries estimates that the drop in total fertility rates
from 1990 to 2005 resulted in 1.2 million fewer maternal deaths – 15% fewer than
would have occurred with no fertility decline28. Birth spacing saves infant lives:
babies born less than two years after their next oldest sibling are twice as likely to
die in the first year as those born after an interval of three years29.
13.
Benefits for women and girls: There is wide consensus that women’s ability
to regulate their own fertility is fundamental to autonomy and choice in other areas
of their lives30. Reductions in family size are associated with significant household
economic benefit. When a family has fewer children, they are able to invest in the
children’s nutrition, health and education, which then lead to higher incomes31.
Fertility declines are also associated with increases in women’s paid labour force
participation. Unwanted pregnancy can cause girls to drop out of school, and push
women and their families into poverty.
14.
Economic benefits A recent DANIDA paper estimates that ‘for each
percentage point of fertility reduction in developing countries, per capita GDP growth
will likely increase by 0.25%32. The prevention of unintended pregnancies can also
generate large savings to the health and education sectors, and wider development
investments. A 2008 study33 estimates: for every US dollar spent on family planning
can save governments US$31 on health care, water, education, and housing: a
return of investment of more than 3000%. Similarly Speigal et al34 estimates large
returns on investments from family planning spending. The economic case for action
on unsafe abortion is also strong. About five million women are hospitalised each
year in developing countries due to complications from unsafe abortion, with poor
women more likely to experience abortion complications than non-poor women35,
costing an estimated $375 and $838 million a year to health systems.36
Is intervention feasible?
15.
Intervention is readily feasible for three reasons: First, richer Indian states
such Andhra Pradesh, Punjab, Maharashtra, Karnataka and Tamilnadu have
reached replacement level fertility, with low TFR, high contraceptive use rates, and
27
The Lancet : John Cleland, Stan Bernstein,Alex Ezeh, Anibal Faundes, Anna Glasier, Jolene Innis. Family planning: the
unfinished agenda. The Lancet Sexual and Reproductive Health Series, October 2006.
28
Stover J, Ross J. How contraceptive use has reduced maternal mortality. Matern Child Health J.
2009;14:687-695
29
Macro International Inc., Demographic and Health Surveys, various years. In Smith R et al, Family
Planning Saves Lives: 4tth Edition. Population Reference Bureau: 2009.
30
Naila Kabeer et al. Gender Equality and the MDGs. DFID/IDS 2010
31
Bongaarts J, Sinding SW. Family planning as an economic investment: a comment. Unpublished
mimeograph. 2010.
32
Dalgaard C J, Hansen H. Evaluating Aid effectiveness in the aggregate, a critical assessment of the evidence.
DANIDA; January 2010.
33
Guttmachers Institute, UNFPA, Contraception: An investment in lives, health and development,
2008 series.
34
Speidel JJ, Sinding S, Gillespie D, Maguire E, Neuse M. Making the case for US international family planning
assistance.. Washington, DC: United States Agency for International Development, 2009.
35
36
Singh S et al, (2009), op.cit.
The Global Burden of Disease, 2004 Update – WHO Geneva 2008, p.60 Table A2.
10
good access to private sector with wider family planning choices available.
Neighbouring countries like Bangladesh and Sri Lanka are also showing good
results, where provision of wider contraceptive method choice (especially
injectables, IUD and implants) has resulted in better use rates and reduced fertility.
There is no reason to believe that poor states of India cannot follow suit.
16.
Secondly, technology is available - There are now at least half a dozen
modern contraceptive technologies available which are safe, effective and reliable
and approved by the Drug Controller of India. Several temporary and permanent
methods (such as injectables, implants, intrauterine devices and voluntary
sterilisation) are effective and they require little action by the client. However there is
limited distribution and access for younger low parity37 women, particularly within the
public sector. This ismainly because the government providers reach woman only
during pregnancy or when they have completed their families, to provide
sterilisations.
17.
Thirdly, successful private sector models exist in India, both of scaling up
spacing methods through social marketing as well as provision of clinical family
planning and reproductive health services through social franchising. DKT’s Janani
network in Bihar reaches about half the districts in the state, and other strong socal
franchising agencies (World Health Partners, Population Services International,
Marie Stopes International) are active in other parts of India.
State why DFID intervention is justified
18.
DFID has limited discretionary funding for health remaining under this
country plan and has prioritised an investment in family planning for four main
reasons:
Meeting strategy and policy commitments: DFID India’s Operational Plan (20012015) highlights a set of inter-connected outcomes that can break the cycle of intergenerational poverty for women and girls in India’s poorest states: increasing the
age of first pregnancy, secondary schooling, improved nutrition and improving
choice for family planning. This intervention will also support DFID’s Reproductive
Maternal and Newborn Health Framework for Results (RMNH FfR)38, which commits
to promoting reproductive choice for women by 2015. It will also support the Indian
Government’s new ‘Service Guarantee’ which they presented at the Global Family
Planning Summit in July 2012.
Making markets work for the poor people: This is an opportunity for DFID to
catalyse private sector engagement in preventive health care in India’s poorer
states, expanding services for the growing number of women opting for private FP
37
Parity refers to the number of children borne by a woman. Woman with one or two children are
called low parity.
38
Choices for Women: planned pregnancies, safe births and health newborns; The UK’s Framework for Results for
improving reproductive, maternal and newborn health in the developing world. DFID, Dec, 2010
11
services. A private sector response is appropriate since the public sector’s offer on
spacing methods needs to be supplemented to tackle vast and diverse needs.
Younger and vulnerable women who are most at risk of death and disease due to
frequent, poorly spaced childbirths can be effectively reached through private sector
providers.
Transformational impacts: Intervening is an opportunity for DFID to encourage
four transformational shifts in family planning services: towards spacing methods
and away from sterilisation; towards younger women; towards quality of care,
improved counselling and informed choice; and towards more efficient and
effective joint working between the public and private sectors to improve health
outcomes.
Maximising VFM with other DFID programmes. DFID India is supporting maternal
health through state health programmes in the high-need states of Bihar, Orissa and
Madhya Pradesh. Complementing this support with family planning investments
through private sector providers can maximise value for money and achieve higher
impact, especially where DFID is positioned to strengthen linkage between public
and private sectors, and test and strengthen new collaborative PPP approaches.
Tackling difficult issues: DFID’s £18 million intervention can make a small but
critical contribution to safe choices for women who would otherwise only have
recourse to unsafe abortion or have unintended births. By supporting the expansion
of quality-assured clinics that provide comprehensive abortion service DFID can
play a small part in better implementation of the PCPNDT act, ensuring its providers
operate under stringent monitoring and quality assurance and reducing the space
for sex selective abortion.
19.
If DFID does not intervene, government FP programmes in Bihar and Odisha
will continue to make marginal improvements in access and quality and CPR will
increase by about 5% points by 2016, compared to 10% in our estimated preferred
intervention scenario. About 780,000 couples will miss out on FP services and the
demographic transition of Bihar and Odisha will be further delayed. The public
sector’s ability to delivery spacing methods to younger women is likely to develop
only slowly. DFID will forego the opportunity to leverage and grow the private
sector, where currently almost a quarter of women are already seeking services.
Without investment of the scale recommended, we can assume that the impact and
costs of unwanted pregnancy in the Evidence section will continue.
B. Impact and Outcome that we expect to achieve
20.
Regular services, supplies, and counselling for informed choice are all
needed to increase contraceptive users, reduce unintended pregnancies and unsafe
abortions and, contribute to a reduction in maternal mortality. The proposed
investment will support rapid scale-up of family planning and reproductive health
services for under-served areas and populations through private sector providers.
12
Geographically focussed in Bihar and Orissa, the project will ensure that poor,
young and low parity women are able to prevent unwanted pregnancy.
B2. Impact and outcome
21. The impact: Reduce maternal death from unwanted pregnancy and reduce
fertility rates. The outcome is to increase use of family planning methods,
improve birth spacing practices, and prevent unsafe abortion. This project will
help to increase the contraceptive prevalence rates in:


Bihar from 32% in 2011 to 42% in 2015
Orissa from 38% in 2011 to 48% in 2015
22. Outcome and output level indicators39 attributable to DFID support:








No. of CYPs (couple year protection): about 3.5 million
No. of women provided safe reproductive health services: 300,000
Number of new contraceptive users: 780,000
About 700,000 unintended pregnancies averted
No. of functional social franchisee outlets for RH services: 280
No. of functional Social marketing outlets: 18,000
About 1,700 maternal deaths averted in the programme period and
beyond
About 37,000 infant deaths averted in the programme period and
beyond.
23. The service package will be delivered through clinics and community based
channels and includes provision of: IUDs, Injectables, OCPs, Condoms,
tubectomy, vasectomy: reproductive health services like pregnancy detection,
emergency
contraception,
medical
abortion,
Post
abortion
care
and
Comprehensive abortion services: with counselling, referrals, quality monitoring,
myth busting and reduce discontinuation.
This Table shows the service package delivered through various channels:
Clinic based services (at Govt hospitals and Community/Village based services (Govt
private Social Franchisee clinics)
ASHAs/ANMs, and Social Marketing outlets)
Pregnancy detection
Limiting methods
Sterilisations
Pregnancy detection
like
Male
and
Female
Nil
Spacing methods like IUD, Injectable, Oral Pills, Spacing methods like Oral Pills, Condoms and
Condoms and Emergency contraception
Emergency contraception.
IUD
39
and
Injectables
are
not
provided
Outcomes are modelled using the MSI Impact Estimator
13
at
community levels
Safe abortion services include:



Nil
Medical abortion (with Mifepristone and
Misoprostol)
Manual Vacuum aspiration
Post abortion care and Comprehensive
abortion services
Note: Injectables are not provided at public health facilities, but only provided at private clinics.
Evidence from DLHS/NFHS shows that 90% of limiting methods are provided at Public facilities and
90% of spacing methods are provided at private clinics and private pharmacies/chemist/village
grocers etc.
Sustainability
24.
Project funds are needed to achieve greater reach and coverage of rural remote
areas and for demand generation. The expenses include a) mobility costs for setting up
franchisee and SM outlets, b) costs for distribution and replenishment of contraceptives, c)
training and quality assurance and c) cost of demand generation. There will be some
revenue accruing to franchise clinics and SM outlets; however it will not be able to cover
costs. Over time, the increasing scale, use rates and volumes will drive down the costs, and
therefore the need for subsidy. In addition the govt of India and the state govts are also
setting up systems for reimbursing costs for free and subsidized delivery of Family planning
services and products. At the Family Planning Summit in July 2012 India committed to
provision of services free at the point of use to all reproductive age couples, and
adolescents. Planning and delivery of this project will consider sustainable strategies, so
that the benefits continue after withdrawal of DFID resources.
14
2.
Appraisal Case
A. What are the feasible options that address the need set
out in the Strategic case?
25. Use of contraception is increasing in Bihar and Odisha and is projected to grow
4-5 percentage points in the next three years without DFID intervention. Feasible
options that address the needs described in the Strategic Case would:
 accelerate this trend by expanding the number of suppliers to reach the
untapped market for modern, good quality family planning choices;
 provide a full package40 of safe, quality assured family planning and reproductive
services, products and counselling, including pregnancy detection, emergency
contraception and comprehensive abortion care (CAC) services;
 target services to younger women and men especially in under-served rural
areas and urban slums;
 increase uptake of long-term reversible methods (IUDs, injectable, male
sterilisations), thereby reducing over-dependence on permanent methods;
 address social and gender barriers to accessing family planning services;
 Develop sustainable local capacity for service delivery, in anticipation of DFID’s
exit.
Evidence indicates that a stand-alone public sector option, reliant on permanent
methods and limited reach for young women would not deliver all six success
criteria and so we did not appraise this funding route. Our appraisal instead
compares two private provider-led options, which are assessed against a
counterfactual/do nothing scenario.
Option 1: A network of private sector social franchising (SF) clinics and social
marketing outlets delivering services independently of government.
Option 2: A total market approach in which the same network of private social
franchising clinics and social marketing outlets deliver services ‘standalone’ and
through a range of PPP approaches with government involving contracting in,
contracting out, referral and voucher schemes.
In both options DFID project funds are not used long-term to provide services
directly but instead to: mobilise private providers to join franchising networks; train,
accredit and set and monitor quality of care standards at providers; create
awareness and demand for family planning including community outreach
campaigns; and to monitor and evaluate project performance. In other words to
facilitate private provisioning rather than pay the recurring costs associated with it.
40 Package includes provision of both spacing and permanent family planning methods eg. IUDs, Injectables,
OCPs, Condoms, No scalpel vasectomy, tubectomy, vasectomy: provision of reproductive health services like
pregnancy detection, emergency contraception, medical abortion, Post abortion care and Comprehensive
abortion services: and focus on counselling, referrals, quality monitoring, myth busting and reduce
discontinuation rates.
15
Option 1: An independent network of private sector social franchising (SF)
clinics and social marketing (SM) outlets, with direct outreach and
communication campaigns and no referrals from the public sector.
26.
Social marketing and social franchising generates funds for services and
products, however DFID funds are needed to achieve greater reach and coverage of
rural remote areas and for demand generation. These expenses include i) mobility
costs for setting up franchisee and SM outlets, ii) costs for distribution and
replenishment of contraceptives, iii) training and quality assurance and iv) cost of
demand generation. Over time, the increasing scale, use-rates and volumes will
drive down the costs, and therefore the amount of subsidy. In addition the
government of India and the state governments are setting up systems for
reimbursing costs for free/subsidised delivery of family planning services and
products. These schemes will eventually make the social provision sustainable
without DFID support.
27.
In this option, private sector implementing partner would provide FP/RH
services by expanding networks of private clinics and social marketing outlets, with
no referrals from the public sector. We estimate that a network of 280 Social
franchisee (SF) clinics and 18000 Social Marketing (SM) could be set up during the
project period, serving mainly rural and underserved areas and urban slums. This
means almost a five-fold increase in franchisee clinics from current 48 to 280.
28.
Social marketing would take place through pharmacies and non-conventional
retail outlets and concentrate on condoms, pills and injectables. Social franchising of
private clinics would be scaled up to provide family planning methods that require a
trained provider and a clinic setting (i.e. IUDs, injectable; male and female
sterilisations; safe, legal abortion). A systematic plan would be followed for training
and quality assurance for all SM/SF providers. All project participants would receive
intensive training on the standard operating procedure and quality assurance for all
FP / RH services. Community based health workers attached to NGOs and/or
franchised clinics would provide short-term FP products such as oral pills and
condoms, counselling for informed choice, create demand for services and make
referrals to facilities for longer-term and clinical methods. Demand generation
through communication and social mobilisation campaigns would be used to expand
demand for services.
Channels
Private clinics
Social marketing outlets: Chemists,
Pharmacies, non-traditional, Grocer
shops, Pan shops, Barbar
Community based workers and
outreach
Services
IUD, Injectables, Sterilisations, OCP,
Condoms,
Medical
and
Surgical
abortions
OCPs,
Condoms,
Emergency
contraceptives
OCPs, Condoms,
demand generation
counselling
and
16
Figure 1: Theory of change for Option 1
Impact
Long-term
outcomes
Intermediate
outcomes
Outputs
DFID investment
of £18 million
Risk: sustainability beyond
project period is doubtful due to
lack of partnership with
government
Wider Impact
Healthy well
nourished
children
Reduced
Health
expenses
Reduced
Poverty
Enhanced
economic
opportunities
for women
Due to bias
towards limiting
methods and
inequity, huge
unmet need
remains
unaddressed
600,000 new
users - Method
mix in favour of
spacing
methods
Health care
costs reduced
by £39 million
Market gets
partially
reshaped with
better choices
to poor and
under-served
people
Associated
DALY and
economic
benefits
280 Franchisee
Clinics
Outreach Teams
0.3 million
DALY at low
cost
Economic
benefit £138
million from
gained DALYs
Inputs
2 million CYP
generated
1268 Maternal
deaths averted,
27066 infant
deaths averted,
0.5 million
births averted,
0.05 million
unsafe
abortions
averted, 0.4
million
unintended
pregnancies
averted
Substantial
health
outcomes
achieved for
public
clients
18000 Social
Marketing Outlets
Quality
Assurance
Demand driving
linkages
established in
rural areas
Demand
Generation
Quality
assurance
mechanism
established
Training +
Supervision
SF / SM
providers
receive
extensive
training
Public
sector
initiatives
continue
parallely
without
linkage
effect
Increased
utilization of
limiting
method due
to NRHM
initiatives .
How would it work? Assessing the theory of change for Option 1
29.
Option 1 will help private providers penetrate the huge untapped market for
FP / RH services and open up an accessible and affordable assortment of FP
choices to underserved groups. This option will substantially scale up the existing
SF and SM network, which is already delivering about a quarter of FP services;
hence the unit costs of providing services could be reduced by tapping economies of
scale. The capacity of local private providers would be strengthened resulting in a
more responsible and quality-assured delivery system. Initiatives to generate
demand through effective communication are expected to trigger the uptake of
spacing methods (especially IUDs and injectables) and safe, legal abortion care.
30.
The implementing agency would introduce an economically viable price
structure based on market segmentation, which would offer low-end brands to the
poor at a low cost. At the same time, it will make expensive brands available for
high-end and less poor consumers to maintain viability of the business model. So
far, the on-going interventions in Bihar have a well-planned pricing policy based on
market segmentation41. This discriminatory pricing policy to some extent helps bring
41
The products and services offered by Janani come with a broad price range; the low end condoms, targeted
primarily to poor users, are sold at as low as Rs. 0.33 (or, £0.004) while the high-end brands are sold at a competitive
commercial price at Rs. 5 (£0.06). MTPs (in first trimester) are often conducted free for poor clients, with govt
reimbursement, but, for less poor, the price may converge to the commercial price (Rs. 2000 or £23).
17
equity as well as viability of the business model, through cross subsidy. Quality
standards for the contraceptives used for each market segment will be the same but
packaging will differ.
31.
Theory of change: As a result of expanding service sites (280 clinics and
18000 SM outlets) and demand generation activities, an estimated 600,000
additional clients will access FP/RH services. The theory of change is underpinned
by three assumptions. First, the current method mix will change in favour of spacing
methods for the additional users; and the current high share of limiting methods
(89% in Bihar and 71% in Orissa) would reduce. Among spacing methods, the share
of IUD and injectables would increase most compared to other methods, especially
amongst new users. This assumption is based on evidence from Bangladesh,
Pakistan and several other developing countries. Second, is also assumed that the
government would continue to perform at the same pace with respect to delivering
permanent FP methods, allowing DFID’s franchisees to concentrate on spacing
methods. This is a reasonable assumption given global evidence that franchisees
have been able to generate substantial CYPs primarily by focusing on new spacing
technologies targeted to low income people42. Instead of crowding in the public
sector domain, the implementing private partners would therefore target new lowincome private clients with DFID support. Third, a corollary of the above is that
there will be change both in provider and method mix. The private share will
decrease in the limiting methods but will increase for spacing methods. This
assumption is borne out by the trend in both Odisha and Bihar that reflects
substantial potential demand for spacing methods which publicly-funded
programmes are failing to translate into actual demand. We expect that with
concentrated attention to demand generation, the private sector can generate
considerable demand for spacing contraceptives.
32.
The weaker evidential links in the theory of change relate to the ability of
poor clients to pay and be comfortable entering private facilities, and to
sustainability. The SF clinics are likely to largely attract clients who have some
capacity to pay and therefore exclude the poorest two quintiles from the private
sector net, unless costs are reimbursed by the government or donors. The
sustainable elements of SF/SM models largely relate to payment made against the
cost of products and services, which may be paid either by the clients or the donor
or the government. More difficult to sustain elements are demand generation,
outreach, communication expenses. The sustainability of FP programmes without
donor support is difficult when they fail to tap internal public sector resources. For
example, the DKT/Janani programme in Bihar still depends heavily on donor support
and has reduced donor dependence only 10 percentage points (from 74% to 64%)
in last eight years. However, it is expected that over longer term with social and
economic development demand should increase with its own momentum, and that
government will increasingly take on even these elements of donor funded
42
See Schlein K et al (2011). Clinical Social Franchising Compendium: An Annual Survey of Programs, 2011. San
Francisco: The Global Health Group, Global Health Sciences, University of California, San Francisco.
18
operations (such as behaviour change communications) as their own health budgets
grow.
Summary results’ projection for Option 1:
33.
DFID funds will help increase franchisee clinics from current 48 to 280: set
up additional 18,000 social marketing outlets; and support communication and
demand generation campaigns. Based on past trends from similar projects and
service provisioning capacity, conservative estimates were calculated for number of
clients serviced per clinic/outlet annually. An estimated 600,000 new contraceptive
users and about 300,000 safe abortion services will be provided under option 1.
Among the 600,000 new contraceptive users, about 520,000 will be using spacing
methods and about 80000 will be for sterilisation, generating 2.02 million CYPs.
Table 1.1: Projected achievement of Option 1
Number of Franchisee clinics
280
Number of additional Social
marketing outlets
18,000
Number of new contraceptive
users
600,000
Number of safe abortion
services provided
300,000
Total CYPs generated:
2.02 million
19
Option 2: Total market approach: This option would require the implementing
agency to set up a network of 280 SF clinics and 18000 SM outlets, as for Option 1.
In addition, it would test and scale-up hybrid models of social franchising by situating
private doctors and counsellors in government health facilities, thus allowing network
operators to access public sector clients, especially those in the two lowest income
quintiles and draw on the human, physical, and financial resources of the public
sector and make a contribution to improved skills of public sector FP providers.
Figure 2: Theory of change for Option 2
Impact
Long-term
outcomes
Intermediate
outcomes
Outputs
Inputs
DFID investment
of £18 million
Risk: Sustainability risk is
reduced subject to effective
partnership with government
Wider Impact
Healthy well
nourished
children
Reduced
Health
expenses
Reduced
Poverty
Enhanced
economic
opportunities
for women
780,000 new
users - Method
mix in favour of
spacing
methods
Health care
costs reduced
by £55 million
Outreach Teams
0.4 million
DALY at low
cost
Economic
benefit £207
million from
gained DALYs
Market
reshaped
through total
market
approach
280 Franchisee
Clinics
3.6 million CYP
generated
1775 Maternal
deaths averted,
37817 infant
deaths averted,
0.8 million
births averted,
0.09 million
unsafe
abortions
averted, 0.8
million
unintended
pregnancies
averted
18000 Social
Marketing Outlets
Quality
Assurance
Demand driving
linkages
established in
rural areas
Demand
Generation
Quality
assurance
mechanism
established
Training +
Supervision
SF / SM
providers
receive
extensive
training
Public private
partnerships to
reimburse cost
of sterilisation
and IUD,
counsellors in
PHCs, train
ANMs on IUDs
Voucher scheme
used for
financing
The bias
towards limiting
methods and
inequity is
counterbalanced by
private
initiatives
Associated
DALY and
economic
benefits
Substantial
health
outcomes
achieved for
public
clients
Increased
utilization of
limiting
method due
to NRHM
initiatives .
Parallel Public
sector initiatives
especially in
limiting methods
34.
In this Option, public sector resources deployed/shared by the implementing
agency would be:
 Physical space in sub district public health facilities used for counselling and
promoting referrals. Assuming a conservative target, the project will cover 2025% of govt sub district hospitals for counselling, or roughly 0.4 million of
institutional births per year. Assuming a success rate of 5% (i.e., 5% of women
adopt IUD after counselling), there will be about 20,000 IUD insertions per year
(or, about additional 0.1 million CYP) through this process.
 Training infrastructure and materials shared between state and non-state
agencies to expand capacity building initiatives. For instance, we estimate that
50% of SF units could be trained jointly with the public sector workers.
 Frontline staff – the implementing agency would train public sector auxilliary
nurse midwives (ANMs) in IUD insertions. It is estimated that about 1000 ANMs
(i.e. 1,000 out of 15,000) could be covered through this training, who will then
promote IUD within the community, generating an estimated 25,000 new IUD
users. Other frontline workers in the public health care system such as
20


Accredited Social Health Assistants (ASHAs) would be linked for demand
generation and establishing referral linkages.
Social mobilization campaigns jointly organized to promote economies of
scope43.
Financial – increased uptake of government voucher schemes (subsidy)
that reimburse sterilisation and IUD service costs. We expect 0.1 million IUDs
and 0.12 million sterilizations (the expected users in SF clinics) to be reimbursed
by the public sector in the DFID supported SF clinics.
How would it work? Assessing the theory of change for Option 2
35.
The theory of change for Option 2 relies on the same basic principles and
assumptions as Option 1 in terms of projected change in method and provider mix.
The key difference is the extent to which existing use of public sector facilities is
used as a platform to engage new users of spacing methods. This assumption is
based on clinical evidence that 80% of women in Bihar and Odisha deliver in
government clinics and that post-partum counselling is a key opportunity to influence
future reproductive health behaviours. It is also based on documented international
evidence that well tested private models stewarded by the public sector are a cost
effective way to improve maternal and child health outcomes and make markets
work better for the poor.
36.
Adopting a ‘total market’ approach will require project implementers to plan
their service delivery strategy in collaboration with the government health
departments. Quality indicators will be incorporated in monitoring to ensure that all
franchisee clinics – whether stand-alone or situated in public facilities – are meeting
quality standards (provide a full method mix to poorer clients and younger woman;
monitor discontinuation and switching rates). Emerging competition between public
and private providers may possibly drive up quality and informed choice. Through
careful planning between implementing partners and the public sector, greater
programme coverage will be achieved. A total market approach therefore has the
potential to maximise the overall impact of DFID’s investments.
37.
We see five main outcomes resulting from collaboration between public and
private sector. First, increase use of spacing methods in both public sector and
private facilities due to counsellors placed in sub-district hospitals and increased
capacity of frontline workers for IUD insertions. NRHM guidelines place new
emphasis on spacing methods: and we estimate that this option will bring about the
proposed change in method mix at a faster rate than Option 1.
Secondly, a drive towards improved quality of services and informed choice can be
managed more effectively through a ‘total market’ approach. This is because
43
Economies of scope is gained when it becomes cheaper to provide different services / products jointly by a
number of organizations than providing them independently.
21
product differentiation in SF/SM channels and better quality services for poor and
under-served couples is expected to exert competitive pressure on the frontline
public sector workers. A portion of publicly-provided FP services in less accessible
areas can be handed to SF clinics to run. This provides opportunities to improve
counselling and use of post-partum contraceptive by poor clients, who tend to use
public services. In addition, the clients, especially the poorest two quintiles would
also find it easier to redeem vouchers for free private FP services, which
government will offer on a reimbursement basis.
38.
Thirdly, cost savings. We envisage that the unit costs of providing private
services would decline because project clinics would not require a subsidy from
DFID/other donors to provide free services to the poorest groups. Similarly, the
investment required by Option 1 for communication and training would be partially
saved if frontline workers and resource persons in the public system are used.
Discussions with the key government officials and the present collaboration with
Janani in Bihar suggest that the resource sharing is quite feasible. However training
monitoring and cost of community outreach will be continued to maintain quality.
39.
Fourthly, partnership with public sector has a significant implication on the
sustainability of project benefits. For example, there is a strong possibility that
project clinics (franchisee) can be empanelled and accredited during the project
period and will continue to receive voucher-based reimbursements from the
government for sterilization and IUDs when DFID funding ends. At a minimum, the
additional coverage of sterilization and IUDs will extend to 2017, the end of the
current five year plan for Government of India, and two years beyond the project
period. The costs for demand generation and communication expenses can also be
sustained if the government increasingly funds elements of behaviour change
communications. In conjunction with DFID health sector budget support projects,
systematic efforts will be made to earmark DFID Financial aid for communications
and demand generation activities. This will help influence the use of public health
budgets to softer non-tangible elements of demand generation and communications.
The influencing agenda will also include continued engagement with the Franchiser
agency to manage public private partnerships beyond DFID funding.
40.
However the potential benefits in increased efficiency described are
contingent on government openness to effective private sector partnerships and
willingness to share their resources with the market players. At present voucher
financing faces several bottlenecks, most due to poor contract enforcement. Many
of the current accredited private clinics do not receive voucher reimbursements in
time. Clearly, a new system of partnerships with more effective contracting is
required to enable the implementation of this option. While the implementing agency
would help build government’s capacity to manage and monitor private partnerships,
in terms of quality, coverage and payment mechanism, the risk of poorly functioning
PPPs is a major limitation of this Option. This is also an issue, which DFID’s sector
support programmes can help address.
41.
Summary results projection for Option 2: As in option 1, DFID funds will
help increase franchisee clinics from current 48 to 280 and set up 18,000 social
22
marketing outlets and carry out communication and demand generation activities. In
addition, under option 2 the implementing agency will catalyse government support
for reimbursements, counselling provision within public facilities and other training
and communications inputs. As a result, we estimate about 780,000 new users
resulting in about 3.6 million additional protected couple years (CYP), of which 75%
are due to spacing methods. The additional CYP gains of Option 2 over Option 1 are
largely due to additional sterilisations and IUDs to poor clients in DFID supported
private clinics whose costs will be met by the government. Also referrals to DFID
clinics will take place from counsellors at public clinics and ASHAs and ANMs
supported by DFID inputs44. The results projections are conservative estimates and
are limited to only the three year project funding period. The benefits are likely to go
beyond the three years as the franchisee clinics will continue to service clients and
possibly the govt will continue to reimburse services in the private clinics beyond
DFID funding. With growing demand and desire for small family size, new private
sector market will emerge and sustain the momentum.
Table 1.2: Projected achievement of Option 2
Number of Franchisee clinics
280
Number of additional Social
marketing outlets
18,000
Number of new contraceptive
users
780,000
Number of safe abortion
services provided
300,000
Total CYPs generated:
3.6 million
Option 3: Do nothing
42.
Both Bihar and Orissa are amongst the poorest states in India. Without this
intervention these states’ trajectory for achieving MDG 4 and 5 is likely to remain
substantially off track. Evidence shows that promoting family planning in countries
with high birth rates has the potential avert 32% of all maternal deaths and nearly
10% of childhood deaths45 and avert poverty and hunger. Doing nothing would
further delay the demographic transition of Bihar and Odisha.
44 It is also projected, that because of additional counselling inputs in public clinics, training of ANMs and ASHAs,
there will be more uptake of both spacing and limiting methods at public facilities: these benefits have not been
quantified. For the porpose of calculations, only the clients served by DFID supported private clinics have been
considered
45
The Lancet : John Cleland, Stan Bernstein,Alex Ezeh, Anibal Faundes, Anna Glasier, Jolene Innis. Family planning: the
unfinished agenda. The Lancet Sexual and Reproductive Health Series, October 2006.
23
43.
DFID’s present health sector support to these two states will continue but no
support will reach the private providers directly for the FP/RH services. The CPR will
increase by about 4-5% points, as against and estimated 8-10% points in the
preferred intervention scenario.
44.
Failing to link to a significant latent market will be a missed opportunity:
currently almost a quarter of women seek private sector services. It is likely that the
two state governments will upscale their FP/RH based on the centrally-funded
NRHM programme, without further developing PPP approaches. Because it is
difficult for the public sector to provide recurrent, on-going service as compared to
one time service, government provides more of sterilisation and limiting methods.
There will be limited progress in access for young newly married women and
spacing method use.
45.
Without DFID investment on the scale recommended, we can assume that
the impact and costs of unwanted pregnancy will continue in terms of high fertility,
maternal and infant mortality, as outlined in the strategic case.
46.
Based on our evidence based theory of change, we assess that Option
2 has several important advantages over Option 1, which will lead to higher
results. Option 2 is superior on the grounds of reach to poor women, potential to
effective a transformation in the quality of services offered through the public sector,
and sustainability. However the additional cost of option 2 will be in the transaction
costs of support to state health departments for designing, managing and monitoring
private sector partnerships. There is a risk of slow change and inefficiency of
mobilising the public sector. It is likely that in the worst case scenario, public private
partnerships will not be mobilised. Under this scenario, the project will implement
option 1 by default. The economic rates of returns for option 1 are also good in
comparison with similar global models and would still warrant DFID intervention.
Table 2: Option 2 has several advantages over Option1
Advantages of Option 1 over the do
nothing scenario
Advantages of Option 2 over and above
option 1
Increased access and larger number of
service points. However, cost may be a
barrier for the poorest
Poorest of the poor and lower two quintiles can
use both public and private services, because
the cost of services at private clinics will be
reimbursed by the Government
Increased choice of FP methods –
more of spacing methods uptake at
private clinics
Existing Government hospitals (PHCs and
CHCs) which are understaffed will have FP
counselling corners, where more spacing
methods can be provided.
24
Younger women and men access
services for delaying and spacing births
Training infrastructure and materials can be
shared between state and non-state agencies to
expand capacity building initiatives to benefit
both public and private sectors.
The vast network of frontline workers of the
public health care system (e.g., ASHA workers)
will be linked to the project for demand
generation and establishing referral linkages.
Penetration of services in underserved
rural and urban areas
Potentially transformative effect on the public
sector: better capacity to manage PPP; informed
choice and quality improvements for sterilisation
services; shift in spacing method use in public
sector clinics.
Risks and opportunities in implementing different options
Political Risks and Opportunities
Option 1: implement the FP/RH
services through standalone
private sector approaches like
social
marketing,
social
franchising, direct outreach and
communication campaigns.
Option 2: to deliver services through
public private partnership and test
hybrid models to support public
sector to ‘contract out’ or ‘contract in’
private sector, or use voucher
schemes or help public sector
expand social marketing initiatives.
Risks
Risks
Risks
Limited political ownership
Perception that the public resources
are being used for private sector
support
Limited improvement of
maternal and child health
indicators and high unmet
FP need leading to political
dissatisfaction
Potential opposition to safe
abortion service through a nonstate providers due to fear of
misuse of sex determination
techniques
Opportunities
Expanding access and rapid
scale up of services can be used
for political gain
Potential political fallout and
reputational risk due to inappropriate
quality of services in private sector
such as failed sterilisations.
Opportunities
Positive Public perception and image
of the government for addressing the
unmet need and greater client
satisfaction.
Option 3: Do nothing
Lack of political will to scale
up and collaborate with
private sector
Opportunities
Institutional Risks and Opportunities
Option 1: implement the FP/RH
services through standalone
private sector approaches like
social
marketing,
social
franchising, direct outreach and
communication campaigns.
Option 2: to deliver services through
public private partnership and test
hybrid
models
where
the
implementing agency will support
public sector to ‘contract out’ or
‘contract in’ private sector, or use
voucher schemes or help public
Option 3: Do nothing
25
sector expand
initiatives.
social
marketing
Risks
Risks
Risks
Existing government resources
(eg. FP commodities and
infrastructure) not optimally used
Limited interest within government to
work with private partners
Slow progress on MDG goals
4 and 5
Inadequate govt capacity for contract
management and delayed payments
Difficult to scale up govt
collaborations with non-state
agencies
Public sector unable to expand
spacing methods
High transaction costs, slowness and
inefficiency in project delivery,
because of complex govt systems
Lack of sustainability
Inadequate capacity of the
private partners
Opportunities
Vested Interest to push clients to
private clinics even where govt clinics
are well functioning.
Opportunities
Rapid scale up to meet the
unmet demand
Conflict of interest, bias and selective
preference of a few private clinics
over others
Establishing protocols and
standardisation of services
leading to better services and
satisfaction to the population
Opportunities
Leverage and optimum use of
governments existing infrastructure
and resources
Strengthen existing private
sector to deliver services
Using total market approach leading
to enhanced private and public
capacity to deliver FP services
Better probability of sustainable
project benefits beyond the project
Opportunity to include PPPs as part
of SBS reform plan and earmark
DFID Funds for this support
Strengthening overall capacity of the
government for procurement of
private services and managing PPPs
Better implementing PCPNDT Act
and MTP Act
Social Risks and Opportunities
Option 1: implement the FP/RH
services through standalone
private sector approaches like
social
marketing,
social
franchising, direct outreach and
communication campaigns.
Risks:
limited reach to women and
young people in rural areas;
Profit orientation may exclude
Option 2: to deliver services through
public private partnership and test
hybrid models where the
implementing agency will support
public sector to ‘contract out’ or
‘contract in’ private sector, or use
voucher schemes or help public
sector expand social marketing
initiatives.
Risks:
skewed focus on service delivery
with little focus on:
 Spacing methods;
Option 3: Do nothing
Risk: Limited awareness and
access to services by poor
women.
26
several poor women;
Weak implementation of the
PCPNDT Act.
Service delivery not geared to
respond to demand generation.
Opportunities: a more improved
basket of choice with less focus
on terminal methods.
Deepen the private providers
network in rural and
underserved areas;
360 degrees communication
campaign can be catalytic in
questioning norms and
behaviours.



young couples
involving men and boys;
quality of services
Opportunities:
Opportunities
With govt reimbursement of FP
services at SF clinics, the poorest
quintile benefits.
Service delivery in place to respond
to demand generation;
Improve the implementation of the
PCPNDT Act through improved
record keeping and greater scrutiny
on quality of safe abortion services.
Improved quality, client focus, and
better adherence to informed consent
in public services.
27
B. Assessing the strength of the evidence base for each
feasible option
Results
Pathway
Confidence in Evidence Base
Evidence for
method bias
in public
provision
Strong. The evidence for traditional over-emphasis on permanent FP
method – more specifically on female sterilization. Very low utilization
of the spacing methods is seen in several surveys (e.g., NFHS 3 200506, and DLHS 2007-08)). About 88% of FP users in Bihar and 68% in
Orissa reported female sterilization as their method of modern
contraception as compared to about 20 to 30 % in developed countries.
Evidence
inequity:
for
Strong. The inequity in the use or access to FP / RH services is quite
significant; for example, in Bihar, only 21%of eligible women in the
poorest quintile adopted any modern method of contraception,
compared to about 52 % in the richest quintile (DLHS 3). There is also a
sharp rural-urban disparity – only 27% and 36% of women used
contraception among rural populations respectively in Bihar and Orissa,
compared to 41% and 49% among their urban counterparts.
Evidence for
unmet need
Strong. National surveys indicate that about a quarter of the eligible
couples have an unmet FP need. .This may be an underestimation
since the need remains unfelt for many women due to weakinformation
campaigns. Unmet need is heavily concentrated among young, poor,
and rural women. For example, the unmet need in Bihar is almost
double among the poorest quintile (42%) than that among their richest
counterparts (21.6%) (DLHS 3).
Evidence for
scaling up
social
marketing
Strong. Comprehensive evidence reviews indicate that the non-state
sector can increase access to FP services in developing countries. The
private sector care is particularly significant in Asia46, where as much as
79% of all health care in South Asia is provided through non-state
Madhaven S et al. Engaging the private sector in maternal and neonatal health in low and middle
income countries. FHS Working Paper 12; 2010.
46
28
and
social
franchising
through the
private sector
providers.47 India’s non-state providers (NGO facilities as well as
private pharmacies and doctors) deliver services to about 25% of the
family planning clients48. Social marketing and social franchising has
increased significantly over recent years and made sizeable
contributions to global health49.
Between 1985 and 2005, CYPs from social marketing increased ninefold, whereas overall CYPs globally only doubled50. A comprehensive
review of global evidence commissioned by DFID in 2010 also makes
the case that non-state providers have a key part to play in improving
the access and quality in most RH areas, particularly FP51. Recent
studies in Pakistan have also indicated that franchised facilities provide
better quality of care than non-franchised private clinics52.
Several agencies which are now providing FP / RH services in several
Indian states. In Bihar, non-state providers in family planning services is
quite visible primarily due to the presence of Janani, an organization
affiliated to DKT International, since 1996. Despite being a smaller
market player (compared to the government), the impact of the
organization is notable; it has generated about 2 million protected
couple years (CYP) in Bihar in the last 5 years (2007-11)53. The
presence of private actors in Orissa is less visible although the evidence
from other comparable states (e.g., UP) indicate that market penetration
is quite feasible for private agencies.
Studies commissioned by DFID indicate that health interventions
through non-state providers are generally good value for money, in
particular social marketing of family planning products, which often cost
47 Madhavan, S. and Bishal, D., Private Sector Engagement in Sexual and Reproductive Health and
Maternal and Neonatal Health: A Review of the Evidence, 2010
48 NFHS 3 2006
49 Madhavan, S. and Bishal, D., Private Sector Engagement in Sexual and Reproductive Health and
Maternal and Neonatal Health: A Review of the Evidence, 2010
50 Harvey, P.D. Social Marketing: No Longer a Sideshow, 2008, Shah, N., Wang, W., Bishai, D.
Measuring Multiple Impacts of Social Franchised vs. Private Clinics in Pakistan and Ethiopia, 2009
51 Ibid.
52 Shah, N., Wang, W., Bishai, D. Measuring Multiple Impacts of Social Franchised vs. Private Clinics
in Pakistan and Ethiopia, 2009
53
Source: Data received from Janani
29
less than $100 per DALY gained. When compared with the cost
effectiveness of public sector services, the non-state sector is in most
cases as cost effective, with lower unit cost and better quality of care54.
Recent reviews suggest that equity can be achieved through non-state
providers where it is explicitly built into programming objectives,
although the evidence on this is not conclusive55. It is clear, however,
that to effectively reach the poor, programme will often incur additional
costs5657. Subsidised vouchers that target the poor and enable them to
receive free or heavily subsidised services from private providers can to
lead to a higher overall usage FP58, especially among the poor due to
costs.
A DFID systematic review of 29 social marketing programmes
concluded that there was strong evidence of a positive impact from
social marketing to increase access to FP products but limited evidence
on access by poor people. We will build stronger evaluation of uptake
by the poorest into the monitoring and evaluation framework for this
project.
Evidence for
Feasibility and
sustainability of
private public
partnership
Medium on feasibility; low on proven models In Bihar, under the
government-sponsored
and
National Rural Health Mission (NRHM),
voucher financing is going to SF units, accredited by Janani at a small
scale. In Orissa, the recent action plan of the Department of Health and
Family Welfare has included a budget item for the same purpose.
Consultations with the key government officials and UNFPA in both the
states indicate a positive and open intention to expand the private
partnerships for FP / RH services. However there is weak evidence to
show success of such models.
National surveys indicate that nearly 80% of woman deliver in public
hospitals as a result of the government’s cash incentives scheme. This
is one of the very few contacts they have with the formal health
systems, and there is an important opportunity to use this opportunity
to deliver FP counselling and services.
54 Walford, V., Value for Money in Working with the Non-State Sector in Health – What do we know from DFID
Experience?, 2010
55 Ibid.
56 Meadley, J., Pollard, R. and Wheeler, M. Review of DFID Approach to Social Marketing, 2003
57 The Impact of Vouchers on the Use and Quality of Health Goods and Services in Developing Countries: A
Systematic Review. Venture Strategies for Health and Development, 2010.
58 Madhavan, S. and Bishal, D., Private Sector Engagement in Sexual and Reproductive Health and
Maternal and Neonatal Health: A Review of the Evidence, 2010
30
Medium on sustainability: The sustainable elements of SF/SM models
largely relate to cost of products and services, which may be paid either
by the clients or the donor or the government. Therefore sustainability of
donor supported projects will improve if govt subsidies are utilised.59
The non-sustainable elements are demand generation, outreach,
communication expenses. The sustainability of FP programmes without
donor support is difficult when they fail to tap internal public sector
resources. For example, the DKT/Janani programme in Bihar still
depends heavily on donor support and has reduced donor dependence
only 10 percentage points (from 74% to 64%) in last eight years. While
there is weak evidence that the non-sustainable elements continue after
donor support, it is expected that over the longer term with social and
economic development demand should increase with its own
momentum.
Climate change: What is the likely impact (positive and negative) on climate
change and environment for each feasible option?
47.
According to the United Nations medium variant projection, the world population will
have increased from today's seven billion to over nine billion by 2050, surpassing ten billion
by the end of the century60. The majority of this growth is projected to take place in
developing countries: the countries that have contributed the least to climate change, but
are the most vulnerable to its impacts. With 27 million births each year, India will see a
forecast additional population of 371 million between 2001 and 2026. Half of this growth will
be seen in 7 poorest states, (including Bihar, Orissa and MP). While struggling to adapt to
climate change the poorest states face the additional burden of feeding and providing for
their growing populations.
48.
Thirty-seven (37) of the forty-one (41) national plans for climate change adaptation
submitted by Least Developed Countries to the United Nations Framework Convention on
Climate Change recognise rapid population growth as a factor that either exacerbates the
impacts of climate change or impedes their ability to adapt61, 62. Climatic impacts identified
as being exacerbated by population growth include soil degradation, freshwater scarcity,
migration, deforestation and loss of biodiversity63.Research has shown that availability of
choice of FP can improve the health and well-being of women and families, increasing resilience
59 The Impact of Vouchers on the Use and Quality of Health Goods and Services in Developing Countries: A
Systematic Review. Venture Strategies for Health and Development, 2010.
60
United Nations Population Division World Population Prospects: The 2010 Revision (United Nations,
2011)
Mutunga C, Hardee, K. Population and Reproductive Health in National Adaptation Programmes of
Action (NAPAs) for Climate Change, Working Paper WP 09‐ 04. Population Action International 2009
61
62
IPCC Climate Change 2007: Impacts, Adaptation and Vulnerability (eds Parry, M. L., Canziani, O.
F., Palutikof, K. P., van der Linden, P. J. & Hanson, C. E.) (Cambridge Univ. Press, 2007)
63
Bryant, L., Carver, C. & Anage, A. B. World Health Organisation, 87, 852–857 (2009)
31
in the face of climate change and slowing population growth, which is associated with rising
greenhouse-gas emissions64.
49.
As stated in the strategic case, in India, about 5 million pregnancies are
unintended, and an estimated 30 million women have an unmet need for contraception.
Access to family planning products will help to prevent unplanned pregnancies and space
births according to choice. Addressing the need for family planning that respects and
protect women’s and men’s rights offers a cost-effective strategy for supporting climate
change adaptation65, 66. Analysis by climate change experts at the Centre for Global
Development has identified family planning a cost-effective intervention to reduce carbon
emissions67.
50.
Family planning commodities, such as condoms, hypodermic syringes, needles,
hormonal preparations, expired medicines, and sanitary towels pose potential risks to
people and the environment. These risks include infections with HIV, hepatitis, sexually
transmitted infections (STIs), and other diseases transmitted via body fluids or
environmental pollution. According to a World Health Organization Situation Analysis
Regarding Health-Care Waste, such risks are greatest among health care workers, waste
handlers, scavengers retrieving items from dumpsites, people receiving injections with
previously used needles or syringes, and children who may come into contact with
contaminates by playing in areas without restricted access to waste disposal sites. The
programme would ensure adherence to appropriate waste disposal by effective
communication and management through contracted providers, and this would be built into
the quality indicators used to monitor the service providers.
51.
In the table --, the likely risk-impact on climate change and environment are
presented.. These categorises as A, high potential risks / opportunity; B, medium /
manageable potential risk / opportunity; C, low / no risk / opportunity; or D, core contribution
to a multilateral organisation.
Table--: Likely impacts on climate change and the environment
Option
1
2
3
Climate change and environment
and impacts, Categories (A, B, C, D)
C
C
C
risks
Climate
change
and
environment
opportunities, Categories (A, B, C, D)
B
B
C
Population Action International, by Mogelgaard, K. at
bonn-climate-change-is-sexist .
64
http://www.grist.org/article/2009-06-01-
65
Stephenson, J., Newman., K. & Mayhew, S. J. Public Health 32, 150–156 (2010)
66
Costello, A. et al. Lancet 373, 1693–1733 (2009)
See Wheeler D and Hammer D The Economics of Population Policy for Carbon Emissions Reduction
in Developing Countries. Centre for Global Development Working Paper 22. 9 November 2010
67
32
C. Economic Appraisal
52.
The economic appraisal evaluates the benefits and feasibility of both the
Options.

Option 1: A network of private sector social franchising clinics and social
marketing outlets delivering services independently of government.

Option 2: A total market approach in which the same network of private
social franchising clinics and social marketing outlets deliver services
‘standalone’ and through a range of PPP approaches with government
involving contracting in, contracting out, referral and voucher schemes.
53.
The main difference between the options is that in Option 2, in addition to
setting up of 280 SF clinics and 1800 SM outlets, as in Option1, it will also test and
scale up hybrid models of social franchising by situating doctors and counsellers in
government facilities. This will allow network operators to access public sector
clients, especially those in the two lowest income quintiles and draw on the human,
physical, and financial resources of the public sector. It is expected to make a
contribution to improved skills of public sector FP providers.
54.
This would result in reaching additional number of people and thereby higher
CYPs, CPR and DALY gains, as seen in the table below. Also Option 2 will lead to a
reduction in costs due to sharing of resources with Government facilities.
Option 1
Option 2
Total cost (PV)in £m
18.2
17.7
Benefit (PV) in £m
138.3
206.7
Benefit to Cost Ratio in £
7.59
11.66
Economic Cost Per CYP in £
9.01
4.98
Economic Cost Per DALY gained £
65.33
43.85
2
3.5
CYPs attributable to the Project
(adjusted) in million
33
Unintended pregnanies averted
437112
768,878
Births averted
542361
760,466
1268
1,775
Infant deaths averted
27066
37,817
Unsafe abortion averted
48568
85,431
Maternal deaths averted
What are the benefits and costs of each feasible option?
55.
The benefits arising from the intervention areDemographic and health Impacts:

Pregnancies and birth averted

Maternal deaths saved

Abortions and unsafe abortions averted

DALYs Saved
Economic Impacts:
56.

Cost savings to families and health care systems

£s saved per pound invested
For the economic appraisal, we have estimated and compared the
incremental benefits arising from both the demographic and health impacts and
economic impacts under Options 1 and 2.
57.
Assumptions behind calculation of impacts/benefits:
The impacts and benefits have been calculated based on past trends and a field
level scoping study to estimate the number of service channels and their service
provision capacity. Literature evidence and field level experiences shows that there is
huge unmet need and limited capacity of public sector alone to meet the increasing
demand for FP services especially for spacing methods and younger woman.
58.
The intervention will increase supply and demand and thus lead to change in
method mix (from sterilisation to modern spacing methods). The current method mix
will change in favour of spacing methods for the additional users. It is expected that
34
the current high share of limiting methods will reduce due to a balancing emphasis on
spacing methods within the DFID supported programmes. Governments will continue
performing at the same pace in regards to permanent method and the project will
encourage the private players (franchisees) focus more on spacing methods. This is
a reasonable assumption since the recent global evidences show that most of the
franchisees have been able to generate substantial CYPs primarily by focusing on
new spacing technologies targeted to low income people. The logical corollary to
above assumption is that there will be some change in the provider mix. The private
share will decrease in the limiting methods but will increase in the spacing method.
Among spacing methods, the share of IUD and others (injectables) will increase
more compared to other methods.
59.
Based on available data of use rates, method mix, trends from other state/
country and local capacity of social franchises/marketing channels it is estimated that
DFID support would reach about 600,000 new users under Option 1 and 780,000
new users under option 2. This would be roughly 25% of the additional new users, if
the CPR of both the states increases by 10 percentage points during the project
period.68
Quantification of Benefits:
60.
Based on the above assumptions, CYPs have been calculated for both the
options. The difference between the options is in-terms of calculating the benefits
accruing due to project’s success in penetrating the private market. It has been
assumed that under Option 2, because of the public –private partnership approach,
the service channels (i.e., the franchise clinics, marketing outlets, outreach teams,
etc.) would be able to serve more poor people because of leveraging resources and
support from the Government’s NRHM scheme. Therefore, Option 2 would result in
higher CYPs and DALYs gained as seen in the table below. (Details of estimation are
in Annexe and excel sheet)
68
Excel sheets and detailed economic appraisal available on request
35
Estimated CYPs, DALYs under different Options69
DALYs
DALYs
Adjusted
gained
gained
Total
Total
total
due to
Total
due to
Daly
Discounted
CYP
CYPs
FP
CAC
CAC
Gained
Daly (10%)
1
2236098
2023669
289385
300000
85800
375185
279019
2
3933284
3559622
509026
300000
85800
594826
404442
Option
61.
Based on the above CYPs, the incremental demographic and health
benefits for both the options have been calculated based on standard MSI Impact
estimator.
Estimated health outcome (including CAC) under different
options
Option 1
Option2
Unintended pregnancies averted
437112
768878
Births averted
542361
760466
1268
1775
Infant deaths averted
27066
37817
Unsafe abortion averted
48568
85431
279019
404442
Maternal deaths averted
DALY gained (discounted)
62.
Apart from estimating the health benefits we have estimated the economic
benefits arising from the FP interventions.
Economic benefits were estimated from two different angles:
69
Calculated based on MSI Impact estimator1.2; Adjusted CYPs calculated factoring in
discontinuation rate and switching rate as per DLHS data; Total CYPs for each option were
obtained by adding the CYP accrued in each year
36

savings in health care costs

the income or productivity gains due to DALYs gained because of
interventions
63.
The economic benefits under different options are70-
Estimated economic benefits under different Options (£m)
Option 1
Option 2
Income loss averted
99.3
151.6
Health Cost saving
39.0
55.2
138.3
206.8
Total benefits
Costs:
64.
It has been assumed both the options will provide FP / RH services primarily
through five channels: (1) Own clinic (cum Training Centre), (2) Franchisee clinic run
by general practitioners (MBBS doctor), (3) Franchisee clinics run by specialists
(Ob/Gyn), (4) Outreach team consisting of technical experts and field workers, and
(5) Social marketing outlets (pharmacies, etc.).
65.
It is expected that the proposed DFID support will be used primarily to enable
the environment for the process of scaling up of non-state operations.
More
specifically, the larger part of the support will go to build training capacity,
communication and establishing rural referral linkages, managerial and qualityassurance support structure, and frontline field operations. The cost items were
delineated accordingly and corresponding unit costs for all items were estimated
based on the field cost data collected from Janani and MSI as well as through
consultations with experienced program leaders of these organizations.
70
The health cost savings were estimated using the conversion rates (India) from MSI Impact
estimator. The income gained were estimated in the following way: First, the current Net State
Domestic Product (NSDP) (in 2004-05 prices) for each of the two states were used as the base. The
future NSDPs for next 15 years (17 years for Option 2) were calculated by using a 6% real growth
rate. In the next step, the weighted average of NSDPs of two sates in each year was calculated by
using the state’s share of CYP in the proposed DFID project. Finally, the total gain per year was
obtained by multiplying discounted DALYs with the discounted NSDPs in each year-
37
66.
Based on the unit cost, total costs were calculated. Assuming that the project
would reach its peak from the second year, the total cost has been distributed in
20:40:40 proportion over the project period. Finally, the costs were discounted by
10% rate.
70.
The distinguishing feature between Option 1 & 2 is the possibility drawing on
government resources under Option 2.
The three areas where the support is
expected from Government are
(i) in service delivery: leveraging existing voucher schemes for the clients in
own centres; (assuming 50% of support)
(ii) training: using physical and human resources of government facilities for
training; ( 25% of support)and
(iii) establishing rural linkage and access: using government facilities and
frontline workers. (25% of support)
71
All these support from Government would lead to substantial savings of DFID
resources leading to reduced net cost for Option 2 as shown in the table below.
(Details in Annexe and excel sheet). However, costs identified for some service
channels (e.g., outreach services) under Option 2 will be higher than that under
Option 1 due to more number/volumes, but lower unit costs. There will also be higher
transaction costs of setting up and managing the partnership, PPP processes,,
contract management, slowness and inefficient decision making, which have not
been quantified.
Estimated total discounted costs ( £m)
Total Discounted costs
Option 1
Option 2
18.2
17.7
What measures can be used to assess Value for Money for the intervention?
38
72.
73.
Value for money of the proposed intervention has been calculated based on –

Benefit cost ratios

Economic costs per CYP

Economic costs per DALY gained
Our analysis shows that the Option 2 i.e. delivering FP/RH services through
public –private partnership is most cost effective delivering most CYPs ( (3.6m) and
return of about £12 per £1 invested, as seen in the table below.
Summary results
Option
Option1
2
Total Discounted costs
£18.2m £17.7m
Total discounted Benefits
£138.3
£206.7
Benefit to Cost ratio
7.59
11.66
Economic Cost per CYP
9.01
4.98
£65.33
£43.85
2.02
3.55m
Economic Cost per DALY gained
CYP attributable
74. The cost- effectiveness of the intervention has also been assessed from other
angles. WHO’s benchmark for xost effectiveness is that if an intervention saves a
DALY for less than per capita GDP it is deemed to very cost effective. This analysis
shows Option 2 ( and even Option 1) is very cost effective against this benchmark.
75.
In comparison to evidences from other countries, the cost per CYP under
Option 2 tends to be in the middle zone; for example, a study on 14 developing
countries found that the cost per CYP (for all methods of delivery combined) was
lowest in the Middle East which roughly £2.0871. The highest cost was found in
Africa - $11.20 or £6.92 per CYP. The proposed DFID intervention comes closer to
the lowest range (£4.98).
71
Barberis M and P D Harvey “Costs of family planning programmes in fourteen developing countries by
method of service delivery” J. Biosoc. Sci (1997) 29, 219-233.
39
76.
The cost-effectiveness measured in terms cost per DALY in the proposed
intervention works out roughly to £44 or $ 71 and compares quite favourably with
most common health interventions as well as DFID India’s own health portfolio..
Sensitivity Analysis
77.
Two alternative scenarios were considered for sensitivity analysis of Option 2:
Scenario 1: The assumed cost saving due to sharing financial resources of the
governments is nil (i.e., no cost saving from sharing voucher scheme, training, and
referral scheme)
Scenario 2: The real growth rate of income is half (3% instead of 6%).
78.
As the following table shows, the Benefit-Cost ratio is still higher than that of
Option 1 even under such extremely unlikely cases implying that the value for money
is robust under Option 2 (see details in Annex and Excel Sheet).
Sensitivity Analysis
Benefit-Cost ratio
Scenario 1
Scenario 2
11.14
9.91
Summary value for money statement for the preferred option
79.
Both the appraised options show a high benefit-cost ratio. However, the
proposed Option 2 indicates better value for money. The benefits have been
valued at over 11 times the costs. Sensitivity analysis (two different scenarios) also
confirms the robustness of the results. This is consistent with the strong and well
documented international evidence that FP / RH interventions led by well-tested
private models and in partnership with the public sector is a good investment that is
cost effective, has clear benefits for maternal and child health, and makes the total
market work for the poor. In the unlikely scenario that Governments are not willing to
work with the private sector, the project would shift by default to Option 1 which
would remain cost effective and still merit DFID intervention.
40
3.
Commercial Case
Direct procurement
A. Clearly state the procurement/commercial requirements for intervention
80.
The implementing partners will be selected through a competitive tender process,
which will be limited to 7 pre-qualified providers who are operational in India and have been
identified under the DFID’s Global Reproductive Health Services Framework Agreement
(RHSFA). There will be a mini-competition under this Agreement, focusing on implementing
social marketing/franchising and PPP approach for two states of Bihar and Odisha.
81.
Direct procurement will be through a commercial contract with the successful bidder
possessing credibility and substantial experience in the field of Family Planning. The
successful bidder will be required to work closely with DFID sector support programme in
Bihar and Orissa to maximise overall results of this programme as well as close
cooperation with state govt and , district health department
B. How does the intervention design use competition to drive commercial advantage
for DFID?
82.
The mini-competition process will attract proposals from 7 pre-qualified providers at
best commercial prices. The pre-qualified providers have existing experience in delivering
RH and FP programmes at scale. Competitive bidding among pre-qualified providers under
the mini-competition is expected to deliver value for money.
While quality, technical
expertise and innovation will be critical considerations in selection of the service provider,
DFID India will give high priority to efficiencies, the ability to deliver FP Commodities at the
lowest cost, and Competitiveness of fee rates in relation to the market. 40 % weightage will
be given for financial capacities of the provider so as to ensure good value for money.
83.
DFID will use output based terms of reference such that the responses from
applying agencies have clearly stated methodologies and delivery focussed solutions. One
of the key expectations from the implementing partners will be to have commercial
capacity/capability in order to ensure smooth operations and delivery of the programme.
41
84.
DFID’s expectations of the contracts are set out in the expected results to be
delivered by the project (see the Logical Framework - Flag A) which gives the overall
results for the project and the draft Terms of Reference for the implementing partner (see
Flags B ).
C. How do we expect the market place will respond to this opportunity?
85.
Seven potential bidders (multi-stakeholder consortia) have been prequalified at
global level by DFID’s Procurement Group. There are a number of well qualified potential
bidders with significant India experience and in-country presence within this group, giving
us a good potential filed for competitive bidding, ensuring good value for money and quality
of execution. Prequalified suppliers have extensive global experience which could bring
innovative approaches to this programme. Most have expressed interest in working in India
through their global framework tender documentation.
D. What are the key cost elements that affect overall price? How is value added and
how will we measure and improve this?
86.
The main cost drivers under the contracts are: personnel; communications,
marketing and promotion; training; monitoring and Quality assurance.
87.
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. Long-term methods
(like IUDs, Injectables and sterilisations) are more expensive than short-term methods of
family planning to deliver as they require a clinical setting (although they are longer lasting
in their effects).
88.
Costs will be minimised through competitive tendering and ensuring VFM of key
inputs. DFID will:

Review the budget annually to monitor efficiency and identify cost savings.

Ensure that the contractor has an efficiency savings plan for year on year cost savings.

Review the implementing partner’s procurement processes to ensure VFM.

Conduct formal annual reviews to monitor progress, efficiency and VFM.
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E. What is the intended Procurement Process to support contract award?
89.
DFID India will procure the services through a mini competitive tender process,
which will be limited to pre-qualified providers identified under the global DFID Reproductive
Health Framework Agreement. Terms of Reference and selection criteria are attached as
Flags B and C.
90.
The procurement capacity and procedures of the prequalified bidders has been
evaluated during their selection under DFID Reproductive Health Services Framework
Agreement. Procurement practice, efficiency and value for money achieved by the
implementing partners will be continually assessed as part of the contract and programme
monitoring.
F. How will contract & supplier performance be managed through the life of the
intervention?
91.
Results-oriented ToRs that include SMART deliverables and outputs, key
performance indicators and clear delineation of responsibilities will be used as the basis for
a contract with the provider. A clear log-frame and milestone chart will be included in the
contract in order to ensure anticipated results.
92.
The contract with the service provider will set out Key Performance Indicators (KPI),
linked to annual programme work plans and the indicators, milestones and targets in the
logical framework. DFID will:

Conduct an annual review of the programme focusing on performance against targets

Track programme performance and budget execution through quarterly narrative and
financial reports and quarterly update meetings with the implementing partners.

Negotiate management charges as part of programme budget to ensure these charges
are set at an appropriate level to deliver programmes in the India context.

Agree and monitor a risk strategy, which sets out specific responsibilities of DFID and
the implementing partner for managing and mitigating risk.
93.
The contracts will incorporate steps to be taken in the event of poor performance
and failure to deliver the expected results and value for money.
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94.
DFID would retain sole right to terminate the contracts should performance be
considered inadequate, and an exit clause would enable DFID to withdraw from this phase.
These strategies will help in getting best value for money and achievement of results.
Indirect procurement
A. Why is the proposed funding mechanism/form of arrangement the right one for
this intervention, with this development partner?
Not applicable
B. Value for money through procurement
Not applicable
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4.
Financial Case
A. What are the costs, how are they profiled and how will you ensure accurate
forecasting?
95.
£18 million has been allocated to the delivery of RH results through non-state
providers in India over 3 years from 2012/13 to 2014/15 to cover all programme costs and
programme evaluation. Out of this total amount approximately £ 17 million will be spent
through the implementing partner. The remaining £ 1 million will be used for hiring an M&E
firm (see Management Case), external audit of the implementing partner and for any urgent
TA needs. From experience of similar interventions in India and elsewhere, it is anticipated
that this approach will show significant results, and will represent opportunity for scale up
and further programming impact. Flexibility will be retained, and as components prove
successful and worthy of scale up, should additional funds be available, coverage may be
extended and the programme extended beyond 2014/15.
96.
Bidders will submit a budget and cost breakdown as part of their commercial
proposals during the tendering process. A finalised budget will be negotiated with the
contracted implementing partners.
Approximate breakdown of costs, 2012/13 to 2014/15
97.
2012/13
2013/14
2014/15
TOTAL
£4m
£6m
£7m
£17m
A rough estimate of the component-wise breakup of costs for this three year project
is presented below. To note, the £17m budget includes: setting up and mobilising
franchising networks, social marketing outlets; train, accredit and set and monitor quality of
care standards at providers; create awareness and demand for family planning including
community outreach campaigns, training related expenditure, management support,
frontline field operations, costs for establishing rural linkages and access and technical
support.
Approximate breakdown of costs by project component:
Components
Amount
(£ mil)
Own centres
£1.5
Franchise+Outreach+SM
£7
Training
£2
Management and technical Support
£1.5
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98.
Frontline field operations
£4
Establishing rural linkage and access
£1
TOTAL
£17
Monthly review of spending and forecasts will be adhered to. Any significant
changes will be tracked early on and remedial measures taken accordingly. Monthly
payments will be made in arrears for both the phases. DFID will review and approve
contracted agencies annual work plans and budget to ensure that the proposed plans are
feasible and the budget estimates as realistic as possible.
B. How will it be funded: capital/programme/admin?
99.
The full contribution will be drawn from the DFID India programme resource
allocation.
100.
Funds for the programme will be drawn from the programme resources budget
approved under the DFID India’s operational plan. The year-wise outlay for this programme
is provided for within the DFID India Aid framework for 2011 -15. No contingency reserve is
required.
C. How will funds be paid out?
101.
Contracts will be signed between DFID and the selected implementing partner.
After the workplan development inception activities, recruitment, team mobilisation, and
training, a proportion of the funding will be reimbursed on a quarterly or six-monthly basis,
conditional on achieving milestone performance targets. Disbursement will be on
reimbursable expenditures plus a performance based element which will be based on
achieving Key Performance Indicators drawn from the log frame (subject to contract
negotiations):

Couple Year Protection (CYPs) delivered and numbers of new users reached Number
of new non-state providers/ clinics providing services in target locations.

Number of clinics accredited for quality standards against the target.
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102
The chosen KPIs will ensure that the implementing partners meet both the equity,
location, scale and method choice objectives of this programme and will be finalised during
contract negotiations stage.
103.
The DFID appointed member of the Task Team and the project officer will authorise
payments on the basis of certified financial statements accounting for previous
disbursements and utilisation.
D. What is the assessment of financial risk and fraud?
104.
Experience indicates that choice of managing institution is important. The
programme will be implemented by a partner selected through a competitive tender
process, from the list of pre-qualified providers identified under the DFID’s Global
Reproductive Health Services Framework Agreement (RHSFA). The framework agreement
indicates that all the prequalified suppliers have robust financial management ,accounting
and monitoring procedures and the commercial capacity and the capability to administer
the programme.
105.
The risk exposure to DFID funds is limited as all payments to the agency will be on
reimbursement basis as per agreed milestones/deliverables. The agency will be
responsible for establishing operational internal controls associated with establishing
eligibility, processing applications, making payments to the contracted private sector
partners. The agency and DFID will review the principal controls in place to ensure that they
are sufficient to minimise fiduciary risk. To verify that the incentives and services reach the
intended beneficiaries periodic third party monitoring will be undertaken. The preliminary
Fiduciary Risk related to the TC Fund at this stage is assessed as “Moderate”.
106.
Any equipment or asset procured under this programme during both the phases will
be treated in accordance with DFID procedures. The agencies will be required to maintain
inventory list which will be updated with frequent periodicity. Any assets remaining at the
end of the phase will follow an agreed transfer/disposal strategy with DFID.
E. How will expenditure be monitored, reported, and accounted for?
107.
DFID and the contracted implementing partner will agree an annual work plan, with
Key Performance Indicators in line with the finalized log frame, and an annual budget. The
implementing partner will submit quarterly financial reports and provide monthly updates of
47
financial forecasts. In line with DFID guidance, they will be required to submit annual
financial reports and certified annual audit statement showing funds received and
expended.
The implementing partners will also maintain assets registers.
Financial
management costs will be included in the programme budget.
108.
DFID and each contracted provider will agree on an implementation roll out plan,
annual work plan with Key Performance Indicators from the log frame, and an annual
budget.
Monitoring and evaluation costs have been included in the project budget,
including for third party monitoring of results.
109.
DFID will have the right to conduct external audit from a certified chartered
accountancy firm.
110.
The contract with the implementing partner will incorporate measures in the event of
poor performance and failure to deliver the expected results and VFM.
5.
Management Case
A. What are the Management Arrangements for implementing the intervention?
111.
DFID India will be responsible for overall contract management and performance
oversight of the selected Implementing partners and all activities planned and executed.
112.
The implementing partners will collaborate and coordinate with the two State
Governments of Bihar and Odisha. The project activities will be planned to complement the
National Rural Health Mission Project implementation plan (PIP) and will help address
service gaps in areas not served by public facilities. The state govts will consider options of
contracting private services through the existing franchising models as well as use private
providers for counselling and provision of contraceptives. Implementing partners will
provide progress reports and service delivery results to the relevant district, state and
National government and attend any technical and operational coordination meetings.
Implementing partners will pay particular attention to links with DFID’s state health sector
projects to strengthen coordination of activities across the entire state health programme.
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113.
The reports produced by the implementing partners outlining progress and
achievement of targets and measures taken for quality assurance will be presented on
quarterly basis to DFID and state govt officials.
114.
Performance oversight and technical monitoring for the proposed intervention will be
the primary responsibility of the DFID India Task team. Management and monitoring of the
intervention, as per the Logical Framework and annual work plan, will be carried out by the
Task team through scheduled quarterly meetings and annual verification of results by a
third party. Social Development and Governance advisers will also be provide inputs into
selected technical components that are concerned with wider social development and
Governance issues. Accountability for these inputs will rest with the Bihar- Odisha
Programme Manager and inputs will be ensured by having a performance management
objective/ success criteria for the task team members. Performance and Annual Review
reports of the intervention will be presented to the DFID India Head of the Office for final
approval.
The results projections given in the draft log frame are rough estimates based on desk
review and broad stakeholders analysis. More accurate results projections will be done
during the inception phase informed by a rigorous situational analysis, mapping of private
clinics and detailed micro-planning. It is also expected that more updated survey data will
be available by early 2013, based on which the results forecast will be revised. In case the
project approval and roll out gets delayed, and three years of implementation time is not
available: the results projection will be scaled down during inception phase. Alternatively,
options to extend the project timeline up to two years will be considered, subject to project
performance and the existing DFID aid framework.
115.
During inception phase, the implementing partners will plan an exit strategy to work
towards the sustainability of services beyond the project. Over time, we will seek to ensure
shift of responsibility for regulating family planning service delivery through non-state
providers over to government.
B. What are the risks and how these will be managed?
SOCIAL POLITICAL INSTITUTIONAL AND FINANCIAL RISKS
Risk
Impact
Likelihood
Risk mitigation
Programme fails
Medium
Medium

Intervention will be implemented in locations
49
to reach the
where poor people live: underserved rural areas
poor
and urban slums

Will implement pro-poor interventions such as
voucher schemes, free services and subsidies
across the range of FP products and services
Social and
Medium
Low

Community outreach, family based
cultural barriers
counselling, call centers and helplines will be
to demand for
used for myth busting.
IUD and spacing

methods among
young newly married couples will be planned
young women

Special campaigns for adolescent girls and
Providers will be trained and incentivised to
provide a full basket of choice of FP methods
and on myth busting.
Quality clinical
Medium
Medium
services are not

Minimum standards of services as per
international protocols will be established
maintained

Implementing partners will be required to use
quality assurance protocols

Strong training and follow up supervisions for
frontline providers and close monitoring of client
satisfaction to the population

Mystery client visits will record any bias, and
results will be widely disseminated

Regular clinical quality audits will be carried
out and the results shared with implementing
agency and the govt
Opposition to
Medium
Medium

Wide communications and training of
Franchisee clinics on provisions of PCPNDT acts
private sector
and MTP acts
delivery of
FP/RH due to

misuse of sex
private clinics with close scrutiny of 2nd trimester
determination
abortions
techniques

Regular record keeping and monitoring of
Close collaboration with state and district
committees for PCPNDT act.
Limited interest
within
government to
work with
private partners
Medium
Low
Implementing agency will work closely with state
government to share evidence of effectiveness of
the private sector models
Exposure visits and pilots of SF/SM will be
demonstrated to govt officials especially in
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Orissa, where private sector experience is low.
Demand generation activities will push the govt
officials to expand supply channels.
Inadequate govt
capacity for
contract
management
and delayed
payments
Medium
High
Handholding, training and mentoring support for
PPP contract management will be provided
In house TA to build capacity for better contract
management.
Frequent meetings and collaborative interactions
between public and private sector to generate
mutual trust and problem solving
Fraud and
mismanagement
of funds and
Govt resources:
Conflict of
interest, bias
and selective
preference of a
few private
clinics over
others
Medium
Low
 Independent monitoring of services and funds
disbursal
 Third party annual audits will be carried out
 Only organisations with strong financial and
management controls will be selected to
implement the programme
C. What conditions apply (for financial aid only)?
116.
Not applicable, as the project does not involve financial aid to government.
D. How will progress and results be monitored, measured and evaluated?
117. A robust programme monitoring and evaluation (M&E) system will track
performance against agreed targets as well as keeping DFID informed on the progress of
interventions. The M&E system will be two tiered: programme level monitoring and
verification, and third party evaluation. Third party performance monitoring will be used to
verify on a sample basis the reported KPI.
118
Programme Level: The contractors will develop and implement a comprehensive
M&E plan, based on the indicators, targets and milestones agreed in the Logical
Framework. Monitoring systems will be designed to ensure that the programme is capable
of measuring age (in particular girls aged between 15 and 19); income quintile; quality of
care; types of RH services delivered; users switching methods, and the reasons for
switching methods. Special steps will be taken to ensure data quality by integrating a data
quality management mechanism as component of the proposed M&E system.
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119. Data to assess progress on CYPs and other key indicators will be drawn from all
levels of the service delivery, collated and analyzed by the implementing partners.
Modelling will be used to measure number of maternal deaths averted, unintended
pregnancies averted, and unsafe abortions averted.
120. A set of standardized reporting tools will be developed for collecting information on
monthly basis which will be consolidated on monthly and quarterly basis for reporting to
DFID. The contracted organisations will be required to establish baselines for all the key
indicators from the very beginning of the project ensuring consistencies in terms of
acceptability and standardization and consistency with DFID’s Framework for Results
indicators.
121
Quarterly performance and annual narrative reports to DFID will report on progress
against KPI and all other milestones (annually) as identified in the Logical Framework. The
implementing partners will also share information with state and district health department.
122. Third Party Monitoring: The programme will contract the services of an
organisation on a retainer basis, to validate the monitoring information collected by the
implementing partners on biannual basis.
123. This organisation will be responsible for checking data validity through process of
data audit of monitoring reports, spot checks, evaluation studies and peer reviews. They will
provide periodic guidance to the implementing partners on the gaps identified and the
proposed recommendations. They will also validate the baselines established by the
contracted organizations, ensuring their triangulation with national figures. Where baselines
are not available, they will undertake studies to establish these using standardized
techniques and make the figures available to respective organizations.
124. Evaluation DFID will conduct annual reviews of the programme. In addition, an
independent and end of programme evaluation in 2015 will be contracted out. Particular
attention will be given to identifying lessons learned about the role of non-state provider’s
effectiveness in scaling up access to quality RH services for girls and MWRA including
effectiveness of strategies to address social and cultural barriers to family planning
services, how to increase demand, choices/method mix and uptake of FP services.
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