Syed Khurram Azmat, Moazzam Ali, Waqas Hameed, Muhammad Ali Awan


Background: Studies have documented the impact of quality family planning services on improved contraceptive uptake and continuation, however, relatively little is known about their quality of service provision especially in the context of social franchising. This study examined the quality of clinical services and user experiences among two models in franchised service providers in rural Pakistan. Methods: This facility-based assessment was carried out during May-June 2015 at the 20 randomly selected social franchise providers from Chakwal and Faisalabad. In our case, a franchise health facility was a private clinic (mostly) run by a single provider, supported by an assistant. Within the selected health facilities, a total 39 user-provider interactions were observed and same users were interviewed separately. Results: Most of the health facilities were in the private sector. Comparatively, service providers at Greenstar Social Marketing/Population Services International (GSM/PSI) model franchised facilities had higher number of rooms and staff employed, with more providers’ ownership. Quality of service indices showed high scores for both Marie Stopes Society (MSS) and GSM/PSI franchised providers. MSS franchised providers demonstrated comparative edge in terms of clinical governance, better method mix and they were more user-focused, while PSI providers offered broader range of non-FP services. Quality of counselling services were similar among both models. Service providers performed well on all indicators of interpersonal care however overall low scores were noted in technical care. For both models, service providers attained an average score of 6.7 (out of the maximum value of 8) on waste disposal mechanism, supplies 12.5 (out of the maximum value of 15), user-centred facility 2.7 (out of the maximum value of 4), and clinical governance 6.5 (out of the maximum value of 11) and respecting clients' privacy. The exit interviews yielded high user satisfaction in both service models. Conclusion: The findings seem suggesting that the MSS and GSM/PSI service providers were maintaining high quality standards in provision of family planning information, services, and commodities but overall there was not much difference between the two models in terms of quality and satisfaction.  The results demonstrate that service quality and client satisfaction are an important determinant of use of clinical contraceptive methods in Pakistan.

Keywords: Family planning; Pakistan; Rural; Service quality

Full Text:



Goldie SJ, Sweet S, Carvalho N, Natchu UC, Hu D. Alternative Strategies to Reduce Maternal Mortality in India: A Cost-Effectiveness Analysis. PLoS Med 2010;7(4):e1000264.

Bongaarts J. The impact of family planning programs on unmet need and demand for contraception. Stud Fam Plan 2014;45(2):247–62.

WHO. Family Planning/Contraception Geneva: WHO; 2015 [cited 2015 Aug 5]. Available from:

Singh S, Darroch JE. Adding it up: Costs and benefits of contraceptive services. Guttmacher Inst UNFPA 2012.

UN. Sustainable Development Goals. New York: United Nations, 2016 [cited 2017 July]. Available from:

UN Foundation. Family Planning 2020 Washington, DC: United Nations Foundation; 2016 [cited 2016 Sep 10]. Available from:

Kamugumya D, Olivier J. Health system’s barriers hindering implementation of public-private partnership at the district level: a case study of partnership for improved reproductive and child health services provision in Tanzania. BMC Health Serv Res 2016;16(1):596.

Basu S, Andrews J, Kishore S, Panjabi R, Stuckler D. Comparative Performance of Private and Public Healthcare Systems in Low- and Middle-Income Countries: A Systematic Review. PLoS Med 2012;9(6):e1001244.

WHO. Public policy and franchising reproductive health: current evidence and future directions Guidance from a technical consultation meeting. Geneva: World Health Organization, 2007.

Ensor T, Weinzier S. Regulating health care in low- and middle-income countries: Broadening the policy response in resource constrained environments. Soc Sci Med 2007;65(2):355–66.

Mackintosh M, Channon A, Karan A, Selvaraj S, Cavagnero E and Zhao H. What is the private sector? Understanding private provision in the health systems of low-income and middle-income countries. Lancet. 2016 Aug 6;388 (10044):596-605

Chapman, A. The Impact of Reliance on Private Sector Health Services on the Right to Health. Health Hum Rights 2014;16(1):122–33.

Beyeler N, York De La Cruz A, Montagu D. The impact of clinical social franchising on health services in low- and middle-income countries: a systematic review. PLoS One 2013;8(4):e60669.

Koehlmoos TP, Gazi R, Hossain SS, Zaman K. The effect of social franchising on access to and quality of health services in low- and middle-income countries. Cochrane Database Syst Rev 2009;21(1):CD007136.

WHO. Quality of Care: a process of making strategic choice in health systems. Geneva: World Health Organization, 2007.

Nishtar S, Boerma T, Amjad S, Alam AY, Khalid F, ul Haq I, et al. Pakistan's health system: performance and prospects after the 18th Constitutional Amendment. Lancet 2013;381(9884):2193–206.

NIPSI. Pakistan Demographic and Health Survey 2012–13. Second Pak Demogr Health Surv. 2012;13:2013.

Ngo AD, Alden DL, Pham V, Phan H. The impact of social franchising on the use of reproductive health and family planning services at public commune health stations in Vietnam. BMC Health Serv Res 2010;10(54).

Montagu D, Yamey G, Visconti A, Harding A, Yoong J. Where do poor women in developing countries give birth? A multi-country analysis of demographic and health survey data. PLoS One 2011;6(2):e17155.

Mumtaz, Z. Social franchising: whatever happened to old-fashioned notions of evidence-based practice? The Lancet Global Health , Volume 6 , Issue 2 , e130 - e131

Azmat SK, Ali M, Ishaque M, Mustafa G, Hameed W, Khan OF, et al. Assessing predictors of contraceptive use and demand for family planning services in underserved areas of Punjab province in Pakistan: Results of a cross sectional baseline survey. Reprod Health 2015;12:25.

Cleland J, Conde-Agudelo A, Peterson H, Ross J, Tsui A. Contraception and health. Lancet 2012;380(9837):149–56.

Azmat SK, Hameed W, Hamza HB, Mustafa G, Ishaque M, Abbas G, et al. Engaging with community-based public and private mid-level providers for promoting the use of modern contraceptive methods in rural Pakistan: results from two innovative birth spacing interventions. Reprod Health 2016;13(25):1–15.

Hogan MC, Foreman KJ, Naghavi M, Ahn SY, Wang M, Makela SM, et al. Maternal mortality for 181 countries, 1980-2008: a systematic analysis of progress towards Millennium Development Goal 5. Lancet 2010;375(9726):1609–23.

Planning Commission. Pakistan Millennium Development Goals Report 2013. Islamabad: Government of Pakistan, 2013. [Internet]. [cited 2017 July]. Available from:

Nishtar NA, Sami N, Alim S, Pradhan N, Hasnain FU. Determinants of Contraceptives Use amongst Youth: An Exploratory Study with Family Planning Service Providers in Karachi Pakistan. Glob J Health Sci 2013;5(3):1–8.

Donabedian A. The quality of care: How can it be assessed? JAMA 1988;260(12):1743–8.

Bhutta ZA, Hafeez A, Rizvi A, Ali N, Khan A, Ahmad F, et al. Reproductive, maternal, newborn, and child health in Pakistan: challenges and opportunities. Lancet 2013;381(9884):2207–18.

Schlein K, De La Cruz AY, Gopalakrishnan T, Montagu D. Private sector delivery of health services in developing countries: a mixed-methods study on quality assurance in social franchises. BMC Health Serv Res 2013;13:4.

Munroe E, Hayes B, Taft J. Private-Sector Social Franchising to Accelerate Family Planning Access, Choice, and Quality: Results From Marie Stopes International. Global Health Sci Pract 2015;3(2):195–208.

Azmat SK, Ali M, Hameed W, Mustafa G, Abbas G, Ishaque M, et al. A study protocol: using demand-side financing to meet the birth spacing needs of the underserved in Punjab Province in Pakistan. Reprod Health 2014;11(1):39.

Miller G, Babiarz KS. Family planning program effects: Evidence from microdata. Popul Dev Rev 2016;42(1):7–26.

Sprockett A. Review of quality assessment tools for family planning programmes in low- and middle-income countries. Health Policy Plan 2017;32(2):292–302.

Malik FR. Quality family planning services provision at private clinics of Khyber Pakhtunkhwa province, Pakistan. Gomal J Med Sci 2015;13(3):177–82.

Agha S, Fareed A, Keating J. Clinical training alone is not sufficient for reducing barriers to IUD provision among private providers in Pakistan. Reprod Health 2011;8:40.

Agha S, Do M. The quality of family planning services and client satisfaction in the public and private sectors in Kenya. Int J Qual Health Care 2009;21(2):87–96.

Hutchinson PL, Do M, Agha S. Measuring client satisfaction and the quality of family planning services: a comparative analysis of public and private health facilities in Tanzania, Kenya and Ghana. BMC Health Serv Res 2011;11:203.


  • There are currently no refbacks.

Contact Number: +92-992-382571

email: [jamc] [@] []