A study protocol for integrating outpatient services at the primary health care level as part of the universal health coverage benefit package within the national health insurance program of Pakistan through private health facilities.

Introduction and aim: Pakistan has a mixed-health system where up to 60% of health expenditures are out of pocket. Almost 80% of primary healthcare (PHC) facilities are in the private sector, which is deeply embedded within the country's health system and may account for the unaffordability of healthcare. Since 2016, the existing national health insurance program or Sehat Sahulat Program (SSP), has provided invaluable coverage and financial protection to the millions of low-income families living in Pakistan by providing inpatient services at secondary and tertiary levels. However, a key gap is the non-inclusion of outpatient services at the PHC in the insurance scheme. This study aims to engage a private provider network of general practitioners in select union councils of Islamabad Capital Authority (ICT) of Pakistan to improve access, uptake, and satisfaction and reduce out-of-pocket expenditure on quality outpatient services at the PHC level, including family planning and reproductive health services. Methods and analysis: A 24-month research study is proposed with a 12-month intervention period using a mixed method, two-arm, prospective, quasi-experimental controlled before and after design with a sample of 863 beneficiary families from each study arm, i.e., intervention and control groups (N = 1726) will be selected through randomization at the selected beneficiary family/household level from four peri-urban Union Councils of ICT where no public sector PHC-level facility exists. All ethical considerations will be assured, along with quality assurance strategies. Quantitative pre/post surveys and third-party monitoring are proposed to measure the intervention outcomes. Qualitative inquiry with beneficiaries, general practitioners and policymakers will assess their knowledge and practices. Conclusion and knowledge contribution: PHC should be the first point of contact for accessing health services and appears to serve as a programmatic engine for universal health coverage (UHC). The research aims to study a service delivery model which harnesses the private sector to deliver an essential package of health services as outpatient services under SSP, ultimately facilitating UHC. Findings will provide a blueprint referral system to reduce unnecessary hospital admissions and improve timely access to healthcare. A robust PHC system can improve population health, lower healthcare expenditure, strengthen the healthcare system, and ultimately make UHC a reality.

Uptake, satisfaction, and quality of family planning services in Pakistan: before and during Covid-19 outbreak: Stocktaking with clients of a private sector organisation.

OBJECTIVE: To report the uptake, satisfaction, and quality of family planning services in the clients of a private sector organisation during Covid-19 in Pakistan and compare it with the situation before Covid-19 pandemic. METHODS: This paper is based on the client exit interview data collected before and then after the outbreak of Covid-19, using a structured questionnaire. Clients were chosen at the exit of the social franchise (SF) clinics, situated in rural and peri-urban areas, and beneficiaries of the outreach services delivery channel in the remote rural area. Descriptive analysis was carried out in SPSS, and frequencies and percentages were computed. RESULTS: All respondents were married women of reproductive age (MWRA) with an average age of 30 years, with either no or very low literacy levels. During the pandemic, overall utilization of the intrauterine contraceptive devices (IUCDs) declined, while the condom remained popular. Client satisfaction remained high in both service delivery channels during a pandemic. However, some results varied vis-à-vis the residence of the client. CONCLUSIONS: All respondents were married women of reproductive age (MWRA) with an average age of 30 years, with either no or very low literacy levels. During the pandemic, overall utilization of the intrauterine contraceptive devices (IUCDs) declined, while the condom remained popular. Client satisfaction remained high in both service delivery channels during a pandemic. However, some results varied vis-à-vis the residence of the client.

Men's perceptions of child-bearing and fertility control in Pakistan: insights from a PEER project.

Notions of masculinity, which promote the role of men as providers and decision-makers, alongside men's opposition to modern forms of contraception, have long been assumed to be a barrier to women's use of contraception in Pakistan. There has been little in-depth exploration of varieties of masculinity and how these may influence men's views of child-bearing or fertility preferences. This study used Participatory Ethnographic and Evaluation Research to explore married men's (aged 18 to 45 years) perceptions of marriage, child-bearing and fertility control. A total of 31 men were recruited as researchers in two provinces (Punjab and Khyber Pakhtunkhwa), who, in turn, each interviewed two male friends. Men overall supported a 'smaller' family size and use of contraceptive methods. Drivers of this preference included perceived economic constraints, the desire to invest in children's education, and wider acceptability of contraceptive use. Limiting family size was associated with both the value of competent male providers taking care of their children, as well as being poor. Men wanted to have better access to information through a range of channels. Understanding the sociocultural contexts in which masculinities are constructed is essential before involving men in family planning programmes, so that gender inequalities are not reinforced.

Does courtesy bias affect how clients report on objective and subjective measures of family planning service quality? A comparison between facility- and home-based interviews.

PURPOSE: Despite a general understanding that exit interviews being conducted at service providers' facilities may influence clients' responses favorably to health professionals, there is very little evidence available that demonstrates the extent to which this problem exists. This study aimed at assessing and comparing clients' perceptions of the quality of family planning services and their satisfaction levels between facility- and home-based interviews. METHODS: A cross-sectional survey was conducted among clients receiving family planning services across three service delivery channels - nongovernmental organization (NGO) clinics, social franchise (SF) centers, and outreach camps. The survey took place from December 2015 to January 2016 in 70 districts across all four provinces of Pakistan. A total of 2,807 clients were interviewed, of whom 1,404 clients were interviewed at health facilities after receiving services and 1,403 were interviewed at their homes within 3 days of method uptake. RESULTS: Overall, we found no significant differences between the characteristics of study participants interviewed at health facilities or at home. The findings suggested that experiences reported in exit surveys at facilities were strongly biased positively. This was true for both experiential (service quality) and perception-based (satisfaction) questions in the context of SF centers, while at NGO clinics the interview location only affected clients' responses regarding service quality. However, in outreach settings, clients are more likely to share bad experiences in exit interviews than in home-based interviews on objectively asked questions (service quality). CONCLUSION: Our study indicates signs of courtesy bias and possibly the Hawthorne effect in exit interviews. Program implementers could opt for home-based interviews for women receiving services at NGO clinics or SF center, whereas exit interviews could be used in outreach settings.

The impact of a reproductive health franchise on client satisfaction in rural Nepal.

This study evaluates the impact of a nurse and paramedic reproductive health franchise in rural Nepal on client satisfaction and utilization of services. A quasi-experimental study design, with baseline and follow-up measurements on nonequivalent control groups, was used to assess the effects of the intervention. The study collected data from exit interviews with male and female clients at clinics and from household interviews with married women. Our assessment covers the project's performance for about a year of actual implementation. Client satisfaction with the quality of services increased across a range of indicators at intervention clinics but not at control clinics. Overall satisfaction with services also increased only at intervention clinics but not at control clinics. Consistent with these changes, loyalty increased among clients of franchised clinics. The analysis showed a positive relationship between client satisfaction and loyalty. Although the project's implementation was examined over a relatively short period of time, there appears to have been a net positive effect of the intervention on obtaining family planning products from medical stores/pharmacies. The study shows that franchising reproductive health services increases a provider's interest in delivering better quality services in rural areas of a developing country.

Changes in perceptions of quality of, and access to, services among clients of a fractional franchise network in Nepal.

With declining levels of international donor funding for financing reproductive health programmes, developing country governments and international donors are looking towards private sector strategies to expand the supply of quality reproductive health services. One of the challenges of a health franchise is to improve the quality of services provided by independent private practitioners. Private providers are more likely to abide by the quality standards set by a franchiser if they see a financial benefit resulting from franchise participation. This study was conducted to measure whether (a) there were improvements in perceived quality of care and perceived access to health facilities once these facilities became part of a franchise and (b) improvements in perceived quality and perceived access were associated with increased client loyalty to franchised clinics. Franchisees were given basic reproductive health training for seven days and services marketing training for two days. Exit interviews were conducted with male and female clients at health facilities. A pre-test measurement was taken in April 2001, prior to the start of project activities. A post-test measurement was taken in February/March 2002, about 9 months after the pre-test. Multilevel regression analysis, which takes the hierarchical structure of the data into account, was used for the analysis. After taking provider-level variation into account and controlling for client characteristics, the analyses showed significant improvements in perceived quality of care and perceived access to services. Private provider participation in a franchise network helps improve client perceptions of quality of, and access to, services. Improvements in client perceptions of quality and access contribute to increased client loyalty to franchised clinics. Once increased client loyalty translates into higher client volumes, providers are likely to see the benefits of franchise participation. In turn, this should lead to increased provider willingness to remain part of the franchise and to abide by the standards of quality set by the franchiser.

The impact of a microfinance program on client perceptions of the quality of care provided by private sector midwives in Uganda.

OBJECTIVE: To assess the impact of a microfinance program that provided business skills training and revolving loans to private sector midwives on perceived quality of services and client loyalty. STUDY DESIGN: A quasi-experimental study with a pretest, posttest design was used to evaluate the impact of the intervention. Exit interviews were conducted at 15 clinics that received the intervention and 7 clinics that did not. Baseline exit interviews were conducted between November and December 2000. Five days of business skills training were provided to midwives, and loans (averaging $454) were given during January and February 2001. A follow-up clinic visit was made to assess whether midwives were implementing what was emphasized during the training. The loans were to be repaid with interest within 6 to 12 months, at an interest rate that is standard within the local commercial market. For those who repaid the first set of loans (11 clinics), a second set of loans (averaging $742) was provided after June 2001. Follow-up exit interviews were conducted at the same clinics between February and March 2002. We assessed the effect of the intervention at both clinic and client levels. T-tests, the analysis of variance, and multivariate logistic regression analysis were conducted. PRINCIPAL FINDINGS: These findings should be interpreted cautiously since secular trends were observed during the study period. The intervention was associated with improvement in clients' perceptions of the quality of care received at intervention clinics. The intervention was also associated with a higher level of client loyalty. CONCLUSIONS: The enthusiastic response of midwives and the high loan repayment rate indicate that midwives were very receptive to the microfinance program. Overall, these findings suggest that microfinance may have an important role in strengthening private sector health services by increasing private providers' business skills and clients' satisfaction with services.