© Palladium 2015
Dr Amit Bhanot
January 2016, ICFP
Improving contraceptive choice and equity in rural Bihar and Odisha (India) through private sector partnerships – results from Project Ujjwal social franchising approach
© Palladium 2015
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Corporate Presentation © Palladium 2016 3
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Recent projects
USAID Innovations in Family Planning Services Technical Assistance
Project (ITAP)/India: 2005-2012
USAID Communications for Behaviour Change: Expanding Access to
Private Health Products and Services/Afghanistan (COMPRI-A): 2006–
2012
DFAT/ AusAID HIV Cooperation Program for Indonesia (HCPI): 2008-
2016
DFID Maternal, Newborn and Child Health (MNCH2) /Nigeria: 2014-
2019
DFID Ghana Adolescent Reproductive Health (GHARH): 2014-2017
DFID Human Development Innovation Fund (HDIF)/Tanzania: 2014–
2019
USAID Social Behaviour Change Communications / Social Marketing
program / Mali: 2015-2020
USAID District Coverage of Health Services Project (DISCOVER-H) /
Zambia: 2016-2021
4
Health System Strengthening and Private Sector Engagement
Palladium, formerly GRM Futures Group
Reproductive Health Framework (DFID)
Reducing Maternal & Child Mortality through Strengthening
Primary Health Care / South Africa: 2012-2015
Delivering Increased Family Planning Across Rural Kenya:
2013-2018
Improved Family Planning and Reproductive Health Services
India (Project Ujjwal): 2013-2016
© Palladium 2015
Innovations in Family Planning Services Technical Assistance Project (ITAP) 2005-2012 supported by USAID
Innovative and Scalable Public Private Partnership Models
Voucher system
Social marketing
Social franchising
Mobile health vans
ASHA Plus Program
UDAAN Adolescent Health – Uttarakhand
Saloni Swasth Kishori Yojana - UP
Source: AHS-2012-13
2.6 3.0 3.0 3.0
3.1 3.1 3.1 3.1 3.1
3.2 3.2 3.2 3.2 3.2
3.3 3.3 3.3
3.4 3.4 3.4
3.5 3.5 3.5
3.6 3.7
3.8 3.8 3.8
3.9 3.9
4.0 4.0
4.2 4.2
4.3 4.3
4.4 4.6
0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 5.0
Patna
Gaya
Aurangabad
Jehanabad
Nawada
Buxar
Munger
Begusarai
Rohtas
Muzaffapur
Bihar
Siwan
Purnia
Samasthipur
Kathiar
Madhepura
Khagaria
Araia
Kishanganj
TFR Inequity at District Level in Bihar
…..and a similar case in Odisha
Source: AHS-2012-13
1.8 1.9 1.9 1.9
2 2 2 2 2 2 2
2.1 2.1 2.1
2.2 2.2 2.2
2.3 2.3 2.3 2.3
2.4 2.5 2.5 2.5 2.5
2.6 2.7
2.8 2.9
3.5
0 0.5 1 1.5 2 2.5 3 3.5
Jharsuguda
Bargarh
Baleshwar
Jagatsinghapur
Khordha
Sundargarh
Ganjam
Kendujhar
Odisha
Dhenkanal
Kalahandi
Balangir
Rayagada
Malkangiri
Nabarangapur
Baudh
Rural-Urban Differentials
Bihar State mCPR 38 (AHS 2011-2012)
Urban Rural
(50% population in C&D villages)
11% population Urban mCPR is 48 (AHS 2011-2012)
89% population Rural mCPR 37 (AHS 2011-2012
37 million condom market
38 million condom market
1.85 million OCP 1.95 million OCP
Odisha State mCPR 47 (AHS 2011-2012)
Urban Rural
(60% population in C&D villages)
17% population Urban mCPR 48 (AHS 2011-
2012)
83% population Rural mCPR 47 (AHS 2011-
2012
45 million condom market 21 million condom market
1 million OCP 2.3 million OCP
The Total Market Approach (TMA)
Complementing GoI efforts
Health Impact
• The government is making steady progress towards RMNCH+A outcomes. How can we engage the private sector to accelerate progress and supplement govt. efforts?
• Are we growing the category for all FP methods?
Equity
• Do all segments of the population have equal access?
• Are we helping ensure there are options for different income levels and for different age groups?
• Are we improving quality and affordability?
Subsidy
• Are we managing to reduce the subsidy?
• Do we have a longer-term cost recovery strategy?
• Are we creating a situation that could continue without us?
© Palladium 2015
1: Increased choice of sites providing quality clinical FP/ RH services with a
focus on clinic-based services in
rural and underserved areas
2: Increased access to FP/ RH products with a
focus on rural and underserved areas
3: Build FP/ RH capacity of private sector providers,
provide training and mentoring support,
4: Generate demand, overcome
barriers to FP uptake, and
address gender norms through
communications and community
outreach
© Palladium 2015
Output 1 – Increase choice of sites Social Franchising
“…is an attempt to use franchising methods to achieve
social rather than financial goals, influencing the service
delivery systems of the private sector similarly to the way in
which social marketing has adapted traditional outlets for
commodity sales.”
Social franchising across the world has emerged as an
effective approach for quickly expanding the health care
services in partnership with private providers, often
reaching tens of thousands of poor households
Output 1 – Choice of Sites in Rural Areas
Social Franchising at Scale – Ujjwal Clinics
68 districts, all methods – IUD and Injectable Contraceptive
300 clinics – 71% in rural areas – 217,779 additional users in 27 months - 75% in last 18 months
Ster:IUD:Inj = 40:30:30 (Bihar) and 31:29:40 (Odisha)
Targeted Demand-side Financing/ PPPs
56 Ujjwal Clinics Accredited – 30% of Routine Clients till now
76 Ujjwal Clinics RSBY – Social Health Insurance
20
Equity Analysis - Profile of Sterilisation clients from Routine clinics
55% of sterilisation clients in Bihar and 39% in Odisha were reported to be more than 29 years old 75% and 77% of sterilization clients in Bihar and Odisha, respectively were from SC/ST and OBC; 46 % of sterilization clients in Bihar and 50% in Odisha were BPL
Background characteristic Bihar Odisha Age distribution of clients 15 - 19 0.1 0.2
20 - 24 3.9 13.3
25 - 29 41.3 48.4
30 - 34 42.4 30.3
35 - 39 10.3 6.9
40 - 49 1.9 1.0
Caste
Scheduled Caste 22.5 20.6
Scheduled Tribe 12.6 12.2
Other Backward caste 39.0 44.0
Forward caste 24.2 23.3
Below Poverty Line
Yes 45.9 49.7
No 54.1 50.3
Total clients 55,219 13,109
Equity Analysis - Profile of IUCD clients from Routine clinics
76% and 79 % of IUD clients in Bihar and Odisha respectively, were reported to be less than 29 years old; 80% and 78 % of IUD clients in Bihar and Odisha respectively were from SC/ST and OBC; 51 % of IUD clients in Bihar and 47% in Odisha were BPL
Background characteristic Bihar Odisha Age distribution of clients 15 - 19 1.3 0.9
20 - 24 13.0 33.5
25 - 29 57.7 43.6
30 - 34 22.8 17.0
35 - 39 4.8 4.3
40 - 49 0.3 0.7
Caste
Scheduled Caste 22.6 18.6
Scheduled Tribe 12.8 20.6
Other Backward caste 40.2 38.2
Forward caste 21.5 22.6
Below Poverty Line
Yes 51.0 47.0
No 49.0 53.0
Total clients 32,721 10,552
Equity Analysis - Profile of Injectable clients from Routine clinics
84% of injectable clients in Bihar and 77% in Odisha were reported to be less than 29 years old; 70% and 83% of Injectable clients in Bihar and Odisha, respectively, were SC/ST and OBC; 50 % of injectable clients in Bihar and 52% in Odisha were BPL.
Background characteristic Bihar Odisha Age distribution of clients 15 - 19 0.4 0.8
20 - 24 26.4 29.8
25 - 29 55.6 45.1
30 - 34 14.8 17.4
35 - 39 2.6 6.0
40 - 49 0.2 0.9
Caste
Scheduled Caste 22.4 24.3
Scheduled Tribe 10.5 23.4
Other Backward caste 32.2 34.4
Forward caste 31.5 17.8
Below Poverty Line
Yes 50.0 51.7
No 50.0 48.3
Total clients 36,573 8,666
Demand side financing
Profile of Accredited and Remaining clinics & its services
Clinics Duration (months)
Mean sterilisations per month per clinic
Mean Total clinical services per month per clinic
FP Accredited 26 222 17.0 29.0
Remaining 177 3803 10.0 25.0
Bihar
Odisha
Clinics Duration (months)
Mean sterilisations per month per clinic
Mean Total clinical services per month per clinic
FP Accredited 25 394 9.0 22.0
Remaining 58 953 3.4 13.3
Output 3 – Institutionalizing QA in Rural Clinics
Accreditation – State and District QAC
Medical Audits – State and National FOGSI, FP expert linkages
QI plan development and implementation support
Hands-on training for Paramedics at clinics
Infection Prevention and BWM linkages
FP expert observations
FP QA Reward and Recognition
e-Learning
State and District workshops and meetings
Investments by clinics in improving QA
Installation of Trendlenburg Table Installation of Shadow less lamp
Expansion of infrastructure
Output 4: Generate Demand – Brand Ujjwal
360° messaging - inform, persuade and engage
Smart Couples
Positive deviants/ FP acceptor couples’ films
Innovative mobile-based IPC Tool
Follow up through Helplines
Smart Providers
FP corners at health facilities
FP training for counseling
Doctors’ films on FP methods for client motivation
AV materials made available
Smart Community
Entertainment-Educate shows
Community meetings and publicity vans
Market town activities for promotion of FP products
Smart Environment
Use innovative platforms in mass media to reach young couples
Repurpose PSAs for increasing awareness
TV series format for improving social norms
TA BCC – Use of Ujjwal materials in public sector facilities
Output 5 Commercial Sector tools for M&E
• MIS systems – clinics and SM outlets data
• Product Availability/ Outlet Penetration tracking surveys
• Retail audit data / Brand Penetration - AC Nielsen
• Rapid assessments – mHealth, Social Entrepreneur Analysis, FP Counsellors,
Injectable and IUD Follow up study, reach and recall for EE shows, Demand
Side Financing analysis
• Quality and operational audits – medical audit, Periodic Client Satisfaction
Surveys
• Third Party monitoring by DFID through Sambodhi
• Concurrent impact evaluation with tracking of cost-effectiveness for service
delivery models by DFID through OPM
Opportunities for SF transitioning from donor financing
• Mentoring business models with financial planning and implementation – Ujjwal MerryGold
• Demand side financing. National Health Insurance Programmes.
• Supporting Commercial Health Investments in Rural Areas - Primary Care Hospital Chains to launch
• Innovative or global sources of financing: development impact bonds
33
FP/RH – Is it viable for a franchisee?
• Sterilisation and MTP are major revenue generators
• Only IUD and injectable provisioning not viable for entrepreneur based model – even with upto three times increase from current volume of services
• Inclusion of sterilisation services, twice a month, with an on-call doctor-
• Makes family planning profitable at RSBY reimbursement rates with 1.5 times increase in volume of services
• Makes family planning profitable at GoI reimbursement rates with three time increase
• Doctor based clinics are generating monthly profits at current averages and prices
• Support needs to be provided to the entrepreneur for organising FP fixed day services, twice a month
• Regulatory design affects the sustainability of the model
-
5,000
10,000
15,000
20,000
25,000
30,000
35,000
40,000
45,000
50,000
Option 1 Option 2 Option 3
Co
st a
nd
Rev
enu
e (i
n R
s)
Service Mix Options
Entrepreneur facility without Medical Officer
Costs Revenue - Ujjwal Revenue - GoI
34
© Palladium 2015
Impact Bonds
35
Outcome Payers
(gov./donor/corp.)
make payments to
investors if
outcomes are
delivered
Service Providers
Often supported by
intermediaries
providing project,
contract and fund
management, deliver
social intervention to
improve community
outcomes
Investors
Provide upfront
capital. They receive
returns only if
outcomes are
achieved
$
Outcomes
• Impact Bonds are a new payment-by-results financing
mechanism with the potential to drive greater efficiency,
results and participation of private and institutional investors
in the delivery of development projects – over the past 5
years almost 50 have been set up across the planet
• The core feature of an Impact Bond is the designation of a
payment metric on which a target value is agreed. If
achieved the investors are paid back their capital plus a
success premium
• The structure gives flexibility to investors and service
providers to be responsive and adapting in order to achieve
the most cost-effective, value-adding solution
• DIBS address social needs of:
• Public budgetary constraints
• Emerging desire to test innovations
• Expanding pool of investors looking to harness
entrepreneurial energy
Rajasthan Reproductive, Maternal, Newborn, Child and Adolescent Health Impact Bond
Multiple players responsible for market development approaches
Implementation partners
HLFPPT
PHFI
JHU CCP
OPM
MSI
Sambodhi
FOGSI
PHSI
Strengthening capacities of local
partners
Bangla Natak
Shadow
Tek Management
Visual House
Nayan Enterprises
Nawastha
Inductus
Partners Consulting
Sigma
AC Nielson
Results sharing to inform programmes
Mckinsey
Care-TSU
BMGF
Amaltas
Packard Foundation
UCSF
UHI
UNFPA/Indonesia
Enabling policy to action
Government of Bihar
Government of Odisha
State Health Societies
Department of Labour
SIHFW
SQAC
DQAC
RSBY Officials
Insurance cos
Corporates and social enterprises
Pregna
Ayzh
Alchemist
GSK
HLL
Famycare
PHSI
Merck for Mothers
Enabling environment
- Building an understanding in state and district governments around private sector
- Need to identify new financing strategies for MDA with social impact-DIBs
- Need for an organizing body to facilitate dialogue among all stakeholders
Rules of the game
- Inclusion of FP/RH services under Insurance coverage
- Strengthening for-profit private sector opens market for competition
Support functions
- A lot of times people do not know what they want until you show it to them
- Capabilities in information gathering around private sector in rural areas required
Capabilities of actors
- Challenge for non-profit to transition to commercial for-profit models
- Establishing trust among suppliers in new markets requires time
Market development approaches
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