1. Prof. Abul Barkat Human Development Research Centre 1

2. Contraceptive Prevalence Rate (CPR): Goal & Current Status Population & Family Planning (FP) target in MDG (by 2015): Bangladesh  NRR=1  TFR=2.2  CPR=70-75 Current Status of CPR: Bangladesh  CPR=61.2 (BDHS 2011)  CPR=62.6 (BMMS 2011) Highest Performing Division  Rajshahi (CPR=69.5) Lowest Performing Division  Sylhet (CPR=44.7) 2

3. Study Objectives General objective: To determine the social, economic and cultural factors that influence FP acceptance in low performance-areas in Bangladesh Specific objectives: a.To investigate the characteristics that are influencing low performance b.To find-out the determinants of low performance c.To determine what need to be done to increase acceptance of FP in low performing areas. 3

4. Study Locations and Sample Size Low performance districts  Habigonj (Sylhet Div.) – 264 Eligible couples  Brahmanbaria (Chittagong Div.) – 266 Eligible couples Comparison (High performance) district  Thakurgaon (former Rajshahi Div.) – 192 Eligible couples Selected Slums  Slum from Dhaka City Corp. – 177 Eligible couples  Slum from Chittagong City Corp. – 77 Eligible couples Total Sample Size =976 Eligible couples Study Locations and Sample Size Low performance districts  Habigonj (Sylhet Div.) – 264 Eligible couples  Brahmanbaria (Chittagong Div.) – 266 Eligible couples Comparison (High performance) district  Thakurgaon (former Rajshahi Div.) – 192 Eligible couples Selected Slums  Slum from Dhaka City Corp. – 177 Eligible couples  Slum from Chittagong City Corp. – 77 Eligible couples Total Sample Size =976 Eligible couples Methodology & Implementation Overall Sample Design Quantitative and exploratory qualitative approaches with a focused (targeted) and comparable groups Overall Sample Design Quantitative and exploratory qualitative approaches with a focused (targeted) and comparable groups

5. Methodology & Implementation … contd… Study Respondents MWRAs of the sample households (both user and non-acceptors) Frontline FP service providers (FWAs) Programme Managers Techniques and Tools Household Structured Interview with MWRAs Focused one-to-one In-depth Discussion with users and non-users Focus Group Discussion (FGD) with FWAs Key Informant Interviews (KIIs) with UFPOs 5

6. FINDINGS 6

7. Characteristics Influencing Low Performance Household Size 7

8. Characteristics Influencing Low Performance …contd… Education of MWRAs (%) 8

9. Characteristics Influencing Low Performance …contd… Education of Husbands (%) 9

10. Characteristics Influencing Low Performance …contd… Religion (%) 10

11. Characteristics Influencing Low Performance …contd… Poverty (%) 11

12. Characteristics Influencing Low Performance …contd… Fertility History 12

13. Characteristics Influencing Low Performance …contd… Previous Practice and Discontinuation of FP Methods (%) 13

14. Characteristics Influencing Low Performance …contd… Sources of Receiving FP methods and/or Services (%) 14

15. Characteristics Influencing Low Performance …contd… Quality of FP Services Quality IssuesLPAHPA Mobility of FP field workerLimitedHigher Communication systemDifficultBetter Misbehavior of service providerMoreLess Client’s motivation towards visiting FWC/CC Not motivatedMotivated Religious fanaticismHigherLess 15

16. Characteristics Influencing Low Performance …contd… Intention to Accept FP in Future among non-users Intention FactorsLPAHPA Have intention to use FP in Future79%97% Reasons for not willing to use FP in future Want more children Unfavourable health condition Opposition from husband Religion does not permit use of FP 29% 28% 15% 13% 16

17. Characteristics Influencing Low Performance …contd… Household Decision Maker for Acceptance of FP (%) 17

18. Determinants of Low Performance Results of Hypothesis testing and Odds ratio estimates Couples more likely to use any modern FP method are- Middle class households (third quintile) Educated women Women married at age of 20 years and above Couples taking family planning decisions together Husbands not opposing use of FP methods Religious norms not confronting FP use Less travelling time to CCs, NGO Clinics or FWCs Regular visitation of family planning workers. 18

19. Factors Influencing Low Performance Programmatic Factors Field worker visitation to HHs Location of SDPs (FWC, CC, SC, NGO Clinic) Location of SDPs (FWC, CC, SC, NGO Clinic) Client’s motivation to visit SDP Non-availability of contraceptives methods Non-Programmatic Factors Social factors –  Education of husband/wife Social factors –  Education of husband/wife Cultural -  Religiosity,  Non-cooperation from family Cultural -  Religiosity,  Non-cooperation from family Demographic –  Age at marriage,  Son/daughter preference,  Wants more children Demographic –  Age at marriage,  Son/daughter preference,  Wants more children Economic-  Poor / Rich Economic-  Poor / Rich 19

20. Actions Suggested to Increase Performance Suggestions from low performance areas FWC/CC should be set up nearby/common place & opened timely FWA/HA should visit home more frequently Motivate males to use FP method Inform people that FP method is not harmful for female Early marriage should be discouraged Delayed pregnancy after marriage should be encouraged Extensive services should be provided through mobile outreach Post-partum counseling on FP during PNC/Neonatal care 20

21. CONCLUSIONS 1.Weakness exists in program management, leadership and commitment. 2.Weaknesses persist in terms of shortage of manpower at field level, and inadequacy and non-availability of contraceptives at grass-root level. 3.Social factors such as family (husband and elders) support towards FP is weak, and community cooperation is almost non-existent. 4.A large part of society are still not practicing the marriageable age of 18 years for girls, and being mothers before knowing anything of FP. 5.Religious misconception (FP is sin) is still a factor influencing FP acceptance in low performing areas. 6.Motivation (in other words, BCC) on FP is not much effective. 7.Performance monitoring on a regular basis and supportive supervision appeared weak and not up to the mark. 8.Activities of field force, as it was observed and as reported, was less than satisfactory. They lack skill and empathy in dealing with the clients. 9.Role of local government bodies and also NGOs appeared to be marginal. 21

22. RECOMMENDATIONS 1.Launch effective behavioral change communication (BCC) campaign with greater focus on low-performing areas (including urban slums). 2.Establish a chain of quality FP services and follow-up care to counter fears of side-effects and misconceptions. 3.Create a social movement to stop marriage of girls below the age of 19 years. 4.Increase number of service-providers (FWAs, FWVs) and other field- level staff. 5.Ensure uninterrupted availability of FP methods near the community/family. 6.Involve local government institutions and NGOs. 7.Enhance rates of compensation package to the acceptors of FP terminal methods. 8.Promote the cause of education in a wider-scale. 9.Hold a workshop with all concerned stakeholders to develop an implementable Action-Plan to meet the study objectives. 22

23. RECOMMENDATIONS …contd… Activities to be accomplished within short & medium-term period 1.Fill up all (100%) vacant posts within 3-4 months. 2.Recruit village-level volunteers as supporting hand to FWA and deploy them after proper training within a period of 6 months. 3.Take out-sourcing as an interim approach to provide field level services in some low performing areas with shortage of field staff. Activities to be carried out as a continuous process (non-stop) 1.Ensure need-based procurement and supply of FP methods both for reserve stock as well as for regular consumption. 2.Ensure strong monitoring of FP method use and growing needs of contraceptives, so as to avert stock-out situation. 3.Make available FP methods at FWC and CC and ensure that these facilities remain open as per given time schedule. 4.Involve private sector/NGOs in strengthening supply line of FP methods at the periphery. 5.Involve local government bodies in promotion of FP. 23