Service Delivery Network
With a population of more than 200 million, Pakistan is ranked as the sixth most populous country in the world. High rates of population growth are largely the result of frequent childbearing or high fertility-often corresponding to high unmet need for family planning. With a contraceptive prevalence rate of only 35%, the total unmet need for FP services is at 25%. Maternal mortality rate is 350-400/ 100,000 live births. The current population growth rate is 2 percent. According to estimates, Pakistan will become the fifth most populous country in 2050 at its current rate of population growth (Government of Pakistan, 2013). This scenario presents a picture that could be devastating for the country’s already-scarce national resources. At present, the population density in Pakistan is 231 persons per square kilometer. Although birth and death rates have fallen in Pakistan over the past several decades, the decrease in death rate is much more rapid than the decrease in birth rate. Subsequently, life expectancy at birth has increased: from 63.4 years in 1981 to 66.5 years in 2013 for females and from 62.4 years in 1981 to 64.6 years in 2013, for males (Government of Pakistan, 2013). Rural population (% of total population) in Pakistan was last measured at 63.12 in 2013, according to the World Bank.
Pakistan has 71,000 nurses and midwives, 19,000 other health service providers and 126,000 physicians. For every 10,000 people, there are 5 midwives, one other health service provider and 12 hospital beds. 70% of healthcare is provided through the private sector. The public sector is large but does not work efficiently; problems occur with supplies and staffing, and facilities often tend to be poorly maintained. Frequent changes in government also lead to frequent changes in staff at all levels. Salaries within the government health sector tend to be low, while private practice is much more lucrative, hence preferred by most providers. Access to healthcare thus tends to be very expensive for the average Pakistani who relies on private sector facilities.
Rahnuma-FPAP and Greenstar Social Marketing, are leading organizations in Pakistan for family planning and contraceptives services. They play a significant role in providing access to family planning services for the poor; however their outreach tends to be primarily urban and semi-urban. There are several associations for private providers such as the Pakistan Medical Association, the Pakistan Nursing Council, the Pakistan Society of Obstetricians and Gynecologists, and the Midwifery Association of Pakistan. There is little interaction between private and public providers; however, due to recent efforts by the NGO sector, especially through advocacy with the Ministries of Health and Population Welfare, both at the Federal and Provincial levels, this picture is slowly changing. Many private providers who are also engaged in the NGO sector have begun interacting with senior officials within these Ministries to advocate for policy change and implementation. Nevertheless, relationships that are being developed between the private and the public sector are largely individual driven; for example, the current Health Secretary is supportive of public-private partnerships as are several senior officials within the Ministry of Population Welfare. If any of these individuals are transferred, there is no guarantee that their successors will be interested in continuing to build these relationships; thus, at present, public private relationships are being developed, rather than institutional public-private partnerships. The public sector, being the chief player in the health sector, cannot do much to turn around the situation in Pakistan, for it serves only 15% of total population of Pakistan. Whereas private sector caters to 85% of the population it contributes just 15% to all Family Planning services in Pakistan. It is thus the need of the hour to engage private health sector in the provision of FP and SRH services.
Rahnuma-FPAP, with its wide service delivery network, is one of the significant providers of SRH & FP services. Currently, services are provided through ten fully functional Family Health Hospitals, more than one hundred Family Health Clinics, and more than twenty five hundred Private Practitioners (PPs) and Community Based distributors (CBDs) across Pakistan. Rahnuma-FPAP’s SRH infrastructure is well-equipped to respond to the unmet need of family planning among the marginalized, poor and underserved men, women and youth. During 2015, Rahnuma-FPAP strived to double SRHR services provided, while focusing on social franchising and increased the number of aligned Private Practitioners (PPs) and Community Based Distributors (CBDs) across Pakistan. Comprehensive capacity building programs were carried out for these PPs and CBDs and provided them with different value added services, including sign boards, stationary and regular replanting of contraceptives, resulting in strengthening their performance and service provision for target communities. SRH referral mechanism at all levels was strengthened while enrolling new PPs, CBDs and TBAs. Regular follow up and coordination meetings were conducted, and contraceptives supplies, BCC and IEC material on SRH and FP were shared with them.
Rahnuma-FPAP also integrated SRH and HIV and AIDS prevention services at our selected SDPs. These Drop-In and VCT centers provided SRH and HIV & AIDS related services to target population groups, such as street based female sex workers, male sex workers, injectable Drug Users (IDUs). The SDPs established in Lahore, Quetta and Faisalabad provide SRH awareness, counseling and rehabilitation services with the collaboration of Provincial AIDS Control Programs (Punjab & Balochistan). BCC and IEC Toolkits were also disseminated among the above mentioned target populations to protect them from contracting STIs/STDs.
In order to cater to the SRH needs of young people, Rahnuma-FPAP provides Youth Friendly Services (YFS) to young people through its static clinics. The objective of the YFS component is to increase the provision of quality, youth-friendly adolescent sexual and reproductive health services through well trained service providers (Doctors and Counselors). At Rahnuma-FPAP’s Youth Friendly Centres young people have access to voluntary counseling and testing (VCT) centers, HIV/AIDS/STI, management and care, post abortion care related services and laboratory services. To attract a large number of youth for these services, timings were changed from morning to evening. This has resulted in considerable increase in the number of youth availing services in YFCs. Furthermore Rahnuma-FPAP also provides SRHR Services to youth through mobile health camps in outreach areas, including communities, education institutions, etc.
We have enrolled more than one hundred and twenty private practitioners as a referral partners and MOUs were signed with them to provide SRH services to young people. Prior to formally allowing them to execute their services, capacity building trainings on Youth Friendly Services were conducted for their benefit. In this regard, a Quality of Care (QoC) Manual titled “How to Ensure Quality Youth Friendly and Reproductive Health Services” was piloted at Service Delivery Points. This private practitioner engagement model has resulted enhanced capacity building of thirty new service providers. The model has also brought about an increase in the number of beneficiaries received; (both male and female school students) now receive Micro-nutrients and medicines that are distributed among 5-10th grade students. More than 1373 families of school students (male and female) were registered for the provision of SRHR information and services.
Furthermore, forty referral meetings were conducted with different organizations to enhance service delivery referral mechanism and increase access to specialized SRH and other health care services for young people and their families’, especially male family members.
Integrated package of essential services (IPES) includes contraceptives, HIV and AIDS, STI/RTI, Gynecology, Obstetrics, Urology/Andrology and counseling services. All these services are available at Youth Friendly Clinics and are accessed by young people especially young married girls at Rahnuma-FPAP’s service delivery points. Performance data clearly reveals an increase in the uptake of services and outreach activities.
The implementation of IPES is supported by the Quality of Care assurance system to ensure that SRH services are of high quality, are integrated and rights-based. IPPF has made considerable progress in implementing the IPES across South Asia Region. All Member Associations (MAs) provided IPES services which included sexuality counseling, contraceptive services including emergency contraception, safe abortion care, and reproductive tract infections/sexually transmitted infections (RTIs/STIs), HIV, gynecology, prenatal and postnatal care and sexual and specialized care for gender-based violence.
To increase the outreach of services especially in far-flung rural areas where the mobility of women and youth is restricted, mobile camps were set up to provide access to SRHR services and information to marginalized groups such as young mothers and out of school youth. We have set up more than four hundred mobile camps and they remained very effective in registering more clients and provided them with SRHR services. Young people discussed their SRHR issues with qualified staff and received services. These mobile health camps were arranged with the coordination of Rahnuma-FPAP’s young peer educators. It benefited Poor Marginalized Socially Excluded Under Served (PMSEUS) group of people, female prisoners residents of Dar-ul-Aman (young girls & women protection center), Sex workers and Transgenders who felt ashamed, and hesitant to visit clinics received quality services through mobile camps. Resultantly, their medical and reproductive health needs were effectively addressed.
Counselling is one of the most important components of Sexual Reproductive Health Services and IPES package. Approximately 50% of women and young clients access counseling services through Rahnuma-FPAP’s health infrastructure. Service Providers provide counselling services on an individual basis. Counsellors provide free information, counselling and referral services regarding sexual reproductive health while ensuring complete privacy and confidentiality. In 2015, a wide range of SRHR services were provided to registered families and their family members; 100,723 services catered to the health needs of registered families, 25,573 counselling services were rendered, 52,510 general health services, 19,522 SRH and 938 family planning services were provided.
Youth Helpline is another youth focused SRHR empowerment initiative project operational in six cities of Pakistan. These helplines are mandated to provide SRHR awareness and counseling services to adolescent and young people through well trained male and female counselors.
As government has the largest set up of service provision and no private institute has a comparable infrastructure, it is very imperative to make links with the public health department for massive coverage. In spite of a challenging task, Rahnuma-FPAP has started advocating with the government to institutionalize Youth Friendly Services within the public health care system, aligning them with national protocols. As a result, the Department of Health Government of Punjab and Sindh proposed to provide training for Basic Health Unit (BHU) staff on Youth Friendly SRH Services at our different locations. Therefore, a capacity building training was organized for service providers of Government (Basic Health Unit). This initiative shows that there is significant scope to expand these interventions across Pakistan through public private partnerships.
In order to publicize to youth friendly services different strategies were adopted, including wall paintings, sign boards, radio and cable messages at project locations. Radio and cable messages remained an effective means of publicizing and proved quite successful in reaching out to young people in far-flung areas. The process included development and airing of radio messages. FM radio messages on youth friendly SRH services were aired in local languages in the project locations. Service statistics report clearly reveals that clientele and the number of services have gradually increased. Publicizing services remains an important contributing factor in rural areas, and is an effective approach in order to reach out to young people in far flung areas.
To monitor strict compliance with quality of care standards in Rahnuma-FPAP’s service delivery network, Quality Assurance Doctors are placed at all five regions. These doctors visit each SDP quarterly and conduct client exit interviews, informal interviews and FGDs. These QADs also conduct QoC trainings at each Program Management Office (PMO). To keep service providers updated with state of the art information regarding SRH and FP, QoC training workshops are also organized for Quality Assurance Doctors, Gynecologists and LHVs from all five regions at Rahnuma-FPAP’s Head Office.
Poverty Alleviation Program (PAP) is being successfully implemented by Rahnuma-FPAP at 24 locations across the country. Rahnuma-FPAP aimed to provide loan services to 31410 women. Over the course of 2015, 25,206 women were given loans, fulfilling the target upto 80%. Trainings on FP and SRH were also provided to 25206 borrowers by field staff of Rahnuma-FPAP. Through another ongoing intervention, PAP program was integrated with Rahnuma-FPAP’s RH & RE and SRH services programs.
Most poor people in developing countries get healthcare from private rather than public service providers. For SRH, the strongest evidence for market interventions showed that franchising can expand private sector access to family planning services for the poor; social marketing of FP messages and products can improve access for everyone and raise awareness and knowledge; private sector community-based workers can be trained to administer injectable contraceptives with a high quality of care. Social marketing is as or more cost-effective than other channels for getting contraceptives to those who want them, for increasing demand, and especially in reaching out to adolescents. Social franchising aims at ensuring access (increase the number of providers and services offered); and cost effective and provision of services in line with quality standards equitable. It thus seems imperative to harness the potential of private sector health providers who are willing to upgrade their knowledge and skills in order to add family planning to the services they offer and in this way, contribute to increased contraceptive use by making high-quality family planning services and commodities available and accessable throughout urban and peri-urban Pakistan.
It calls for partnerships between the franchisers and selected providers (franchisees) with the agreement that these providers would integrate a defined package of services, and deliver them according to the high-quality standards established by the former. In return, the franchisee receives specialized support, training, and rights to the franchise brand for as long as the franchisee maintains minimum quality standards. The franchisee also benefits from brand equity, indicating quality and reliability, created by the franchiser.
Delivering good quality care to all clients, wherever they are, is a fundamental principle of IPPF’s work. Good quality of care enhances clients’ satisfaction and their use of services. It increases job satisfaction and motivation among service providers, and it leads to greater sustainability of service provision.
IPPF promotes good quality of care by ensuring that clients have the right to information, access to services, choice, safety, privacy and confidentiality, dignity and comfort, and continuity of services and opinion.
To fulfill clients’ rights, the needs of service providers must be met as well. These needs include training, information, infrastructure and supplies, guidance, respect and encouragement, feedback and opportunities for self-expression.
IPPF’s ongoing efforts to improve quality assurance among its Member Associations aim to ensure:
High quality integrated services that, depending on the context, may include: counseling, provision of contraceptives and family planning, safe abortion care, care for sexually transmitted infections and reproductive tract infections, HIV, gynecology, gender-based violence services, adolescent sexual and reproductive health services, and maternal and child health care services.
- Increased coverage for poor, marginal, vulnerable and under-served groups by strengthening their broader service delivery system.
- A client-centric approach that is sensitive, confidential and respects sexual rights and diverse needs.
- Health services are implemented according to best practices and in adherence to quality assurance measures.
- Lessons learnt are shared with the broader community and integrated in advocacy work to inform broader policy objectives.
- Rahnuma-FPAP has worked to increase access to SRH services through static service delivery points (SDPs), mobile and outreach clinics, associated clinics and community-based distributors (CBDs).
- Concerted efforts have been made to reach remote and under-served areas by deputing a mobile team of doctors, nurses and paramedics. Mobile service delivery has been provided through sexual reproductive health service awareness sessions, special family planning sessions and services through mobile vehicles on specific days.
- Strengthened service delivery, building capacity of service providers on newer services, advanced techniques, integrated counseling, and investment in frontline workers to provide higher level of services. These strategies are combined with initiatives for education, awareness, leveraging the government system, building community ownership, developing key partnerships, upgrading infrastructure and commodities management.
There are 30 franchisees in 3 districts of Punjab which includes Lady Health Visitors and doctors, who are referred to as private service providers. The objective of the Franchisee Model is to increase access to the SRH services, through Social Franchising, with Private Practitioners (PPs), residing in peri-urban and rural areas of Pakistan. The strategy adopted was to build capacity of the selected number of PPs (30), so that they can provide additional SRH services, which they were not providing earlier (apart from the Family Planning Services). Capacity building was complemented by community mobilization, development of infrastructure, expansion of service packages and quality assurance, which was maintained and monitored by Rahnuma-FPAP.
b) Uninterrupted supply of Commodities:
Private Practitioners were supplied with commodities through Family planning representatives. The latter were responsible for the Continuous Medical Education of the providers.
c) Target population:
The target population for franchises is rural and poor, mostly married women. The market rate for Intra-Uterine Contraceptive Device (IUCDs) in the areas where these franchisees operate is Rs. 400-500, which is at least five times the cost of short term methods such as pills, injectables and condoms. Therefore, those who wish to use IUCDs and because of subsidized rates they are able to have access to long term family planning methods.
Rahnuma-FPAP spearheaded humanitarian services for marginalized and vulnerable sections of society affected by natural disasters and emergencies. Poor reproductive health compounds hardships faced by the underserved, poor and marginalized. Rahnuma-FPAP’s minimum Initial Service Package (MISP) and Standard Operating Procedures (SOPs) were formulated to aid disaster management efforts and minimize suffering.
MISP is a minimum standard set in the 2004 Sphere Guidelines, the 2009 IASC Global Health Cluster Guidance, as well as a CERF minimum life-saving criterion. In line with MISP Guidelines, we have carried out extensive MISP advocacy and lobbying efforts, launched the Research and Advocacy Fund (RAF) funded initiative during 2011/2012 and got MISP incorporated in Standard Operation Procedures (SOPs) of National and Provincial Disaster Management Plans (DMPs) of National and Provincial Disaster Management Authorities, including AJK, FATA and Gilgit Baltistan. The MISP (Minimum Initial Service Package.) is a set of priority activities designed to prevent maternal and neonatal mortality and morbidity, reduce HIV transmission, prevent and manage the consequences of sexual violence, and plan for comprehensive SRH services. The MISP includes equipment and supply kits, which complement a set of priority activities that must be implemented at the onset of an emergency in a coordinated manner by trained staff. The MISP can be implemented without a new needs assessment because documented evidence already justifies its use.
To further strengthen the advocacy success achieved, Rahnuma-FPAP launched SPRINT (I and II) Initiatives to institutionalize effective coordination amongst all stakeholders including NDMA, PDMAs and DDMAs through advocacy at large and trainings of the concerned personnel to improve health outcomes of crisis affected populations by reducing preventable sexual and reproductive health mortality and morbidity. The main objectives of this initiative are to build a supportive environment for SRH in crisis settings, to increase capacity for implementation of the MISP in humanitarian settings and to deliver a well-managed program underpinned by robust internal systems, monitoring & evaluation systems and lessons learned. We are actively working with National Health Emergency Preparedness and Response Network (NHEPRN), through its Reproductive Health Working Group, to strengthen the public sector’s capacity on MISP related SOPs.