TABLE OF CONTENTS Page EXECUTIVE SUMMARY...... iv A. INTRODUCTION...... l 13. PROJECT RESUL,TS ...... 2. Bl. IR l INCREASED AVAILABILITY AND REACH OF COMMODITY...... 2 Bl.l INCREASED SALES AND DISTRIBUTION BY PRIVATE SECTOR NETWORKS. .... 2 B 1.2. EXP ANDED PRIVATE SECTOR NETWORK...... 9 B2. IR 2: IMPROVING KNOWLEDGE AND HEALTHY BEHAVIORS...... 11 B2. l IMPROVED HEAL TH COMMUNICATION ACTIVITIES ...... 11 B2. l. l NOTUN DIN COMMUNITY MOBILIZATION PROGRAM...... 11 B2.l.l.l ACTMTIES THROUGH IPC AND GROUP MEETINGS...... 12 B2.1. l .2 ENGAGING WOMEN AS ENTREPRENEURS AND EFFECTIVE BEHAVIORAL CHANGE AGENTS...... 17 B2.l.l.3 ACTIVITIES THROUGH OTHER COMMUNICATION CHANNELS...... 19 B2.1.1.4 PROGRAM PLANNING AND PERFORMANCE REVIEW MEETING . . . .. 21 B2.1.2 MASS MEDIA CAMPAIGN...... 22 B3. IR3: IMPROVE AND SUSTAIN PROGRAM QUALITY ...... 22 B3.l INCREASED TRAINING AND REFERRALS...... 22 B3.1.1 BLUE STARPROGRAM...... 22 B3.l.2 LONG ACTING REVERSIBLE CONTRACEPTIVE PROGRAM...... 26 B3 .1.3 PRIVATE COMMUNITY HEAL TH PROVIDERS TRAINING PROGRAM ...... 29 B3.2 STRENGTHENED LINKAGES WITH PUBLIC AND PRIVATE SECTOR ...... 30 C. CONTRIBUTION OF SMC TO THE NATIONAL PROGRAM...... 32 D. TECHNICAL ASSISTANCE OF PROJECT PARTNERS AND OGSB...... 33 E. MONITORING, RESEARCH AND EVALUATION...... 36 El MONITORING ACTIVITIES...... 36 E2 QUALITY ASSURANCE INITIATIVES...... 40 E3 RESEARCH ACTIVITIES ...... 42 E4EVALUATION ...... 45 F. FAMILY PLANNING COMPLIANCES...... 46 G. ENVIRONMENT COMPLIANCE...... 47 H. CAPACITY DEVELOPMENT ACTIVITIES...... 47 I. IMPLEMENTATION CHALLENGES...... 48 J. LESSONS LEARNED...... 50 K. RECOMMENDATION FOR FUTURE PROGRAM...... 54 L. FINANCIAL ANALYSIS OF MIH...... 57 ANNEX 1...... 59 ANNEX2...... 60 ANNEX3...... 68 ANNEX4...... 69

MIH Final Report Pagei

ACRONYM LIST

ARI Acute Respiratmy Infection BCC Behavior Change Communication BRAC Bangladesh Rural Advancement Committee BS Blue Star BSP Blue Star Provider BTV Bangladesh Television CA Cooperative Agreement CSA Community Sales Agent CM Community Mobilization CBA Community Birth Attendant coc Combined Oral Contraceptive CPR Contraceptive Prevalence Rate CYP Couple Year of Protection CWFD Concerned Women for Family Development DOTS Directly Observed Treatment Short Course DGFP Directorate General of Family Planning DQA Data Quality Assessment ECP Emergency Contraceptive Pill EH EngenderHealth FP Family Planning FY Fiscal Year GOB Government of Bangladesh HTSP Healthy Timing and Spacing of Pregnancy IEC Information, Education and Communication IMCI Integrated Management of Childhood Illness IUD Intra Uterine Device IPA Iron Folic Acid IR Intermediate Result LAPM Long Acting and Permanent Method LARC Long Acting Reversible Contraceptive MAMA Mobile Alliance for Maternal Action MOU Memorandum of Understanding MFP Mobile Film Program MCH Maternal and Child Health MIH Marketing Innovation for Health MNP Micronutrient Powder MWRA Married Women of Reproductive Age M&E Monitoring and Evaluation NGMP Non Graduate Medical Practitioner NGO Non Government Organization NTP National TB Program OCP Oral Contraceptive Pill ORS Oral Rehydration Salts OGSB Obstetrical and Gynaecological Society of Bangladesh PCHP Private Community Health Provider POP Progestin Only Pill

Page ii PO-TSD Program Officer-Training and Service Delivery PSTC Population Services and Training Center PSI Population Services International RFP Request for Proposal RH Reproductive Health RDC Radio Conunercial SBCC Social and Behavior Change Communication SDK Safe Delivery Kit SMC Social Marketing Company TB Tuberculosis TOT Training of Trainers TVC Television Conunercial USAID United States Agency for International Development WHO World Health Organization

MIH Final Report Page iii EXECUTIVE SUMMARY

Social Marketing Company (SMC) implemented the Marketing Innovation for Health (MIH) Program funded by USAID from 26 July 201 2 to 25 July 2016. The program aimed to support the Government of Bangladesh's efforts to further reduce fertility rate and address critical public health concerns such as high maternal, neonatal and child morbidity and mortality, spread of tuberculosis (TB) and poor malnutrition. The goal of the MIH program was to "contribute to sustained improvements in the health status of women and children in Bangladesh by increasing access to and demand for essential health products and services through private sector." Under the MIH program, SMC delivered 16.08 million couple years of protection (CYPs) which helped ave1t 3.29 million unintended pregnancies, 0.57 million deaths of children under-5, and 49 .43 million disability adjusted life years (DALY s) . Some of the key results, contributions and accomplishments of the program by Intermediate Results (IR.s) are elaborated below:

IR 1: Increased availability and reach through expanded commodity sales and distribution through private sector networks

SMC ensured wide reach of its health products and services across Bangladesh through expansion of three major distribution channels: i) commercial outlets, wholesale and retail; ii) local NGOs and community-based distribution points; iii) private sector health facilities and health provider networks. Some of the major achievements in this IR during the life of MIH (FY 2013 to FY 2016) are as follows:

~ Over 16 million couples protected from unwanted pregnancies mostly through sales of 150 million cycles of oral contraceptive pills (OCPs) and over 525 million condoms and 5.7 million injectables. As per the 2014 BDHS, SMC contraceptives contributed to 34% of all contraceptive use nationally, having increased its share of oral contraceptive use to above 44% and condom use to 61 %. ~ During the program period, SMC introduced a number of new products and brands to provide wider choices to family planning consumers. These include two long acting contraceptive methods - IUD and Implant and a new injectable Sayana Press, all donated by USAID; an emergency contraceptive pill branded as N01ix; two new combined oral pill brands; and a premium condom brand, all supported through SMC's own funds. ~ Sold almost 2 billion sachets of its ORS brand ORSaline-N to cater to an increasing demand stemming from use to treat dehydration due to diaIThea as well as excessive sweating. Of these, 1,080 million sachets or 56% of the total sales quantity were manufactured at its own production facility while the remaining were sourced through contract manufacturing. Around 60% of all SMC revenues are generated through ORS sales. ~ Introduced a low priced sanitaiy napkin that has sold over 6.5 million packets and has reached a share of more than 13% of the market since its launch in 2013. Because of its quality, affordable price and wide availably, its use and acceptance among adolescents and first time pad users have been impressive. ~ Sold over 48.3 million sachets of its micronutrient powder brand MoniMix, thus making slow and steady inroads into the hugely important child nutrition market. ~ Introduced a community based distribution model engaging over 800 rural women as entrepreneurs which is showing a strong promise for growth and sustainability in rnral and hard-to-reach areas.

Page iv IR 2: Improved knowledge and healthy behaviors, reduced harmful practices and increased care-seeking practices

MIH implementing partners worked to increase knowledge of health products and healthy behaviors through a community mobilization and behavior change communication (BCC) program called 'Notun Din' and mass media communication to create national level awareness and reinforce the community mobilization activities. The target audiences were married women ofreproductive age (MWRA), caregivers of children under-five, men, school adolescents, community birth attendants (CBA), workplace workers and community influencers. The major interventions included group sessions, interpersonal communications (IPCs), school health education sessions, interactive mobile film shows and floating information, education and communication (IEC) center. The core communication package included messaging on healthy timing and spacing of pregnancy (HTSP), the first 1000 days of pregnancy care, adolescent health and hygiene, and TB. MEASURE Evaluation conducted a baseline and end line study commissioned by USAID to determine what impact if any has been achieved by the MIH program. Key findings from their survey related to IR 2 indicators reveal the following:

• Much improvement in knowledge in program areas ~ 22.5 percentage points (pp) increase in awareness of at least two specific risks/complications related to pregnancies before age 20 as compared to no change in non-intervention areas. ~ 25.5 pp increase in knowledge ofECP as an effective way of preventing unintended pregnancy as compared to 1.6 pp in non-intervention areas. ~ 34.6 pp increase in knowledge of at least two specific benefits of micronutrient powder on children under-5 years as compared to only 5.6 pp increase in non- intervention areas.

• Sharp increase in use ~ 23.6 pp increase in use of safe delive1y kit at last birth outcome during last three years as compared to only 6.5 pp increase in non-intervention areas. ~ 28.2 pp increase in the use of sanitary napkin by unmarried women aged 10-25 years as compared to 7.5 pp increase in non-intervention areas. ~ Contraceptive prevalence of modem method in intervention areas increased by 2.8 percentage points in intervention areas. ~ MNP use among children under-five years increased by 25 .2 percentage points in intervention areas as compared to 9.8 pp in non-intervention areas.

IR 3: Improved and sustained the delivery of quality family planning, reproductive and child health services

SMC created networks of knowledgeable and reliable providers through training who can be accessed and ttusted to provide high-quality services. Providers are motivated to actively reach out to their customers with a wide range of products, services and provide accurate information on FP, RH, MCH, nutrition and TB, as well as to make referrals for LAPMs, TB and other infectious diseases, as needed. Following are the key achievements under IR 3 during the duration of the MIH program:

~ Trained 2,907 Non-Graduate Medical Practitioners (NGMPs) and included them in the Blue Star network and thereby expanding the number of providers in the network to

Page v 5,881 active providers. Over 7,600 Blue Star providers were given refresher training to help improve quality of services and referral mechanism. )> The Blue Star providers made over 100,000 referrals for suspected TB cases to GoB and NGO clinics. Over 36,000 refenals were made for LAPM services to the nearest service delivery centre. )> Over 900 individual graduate doctors received training on IUD, Implant and Injectable through project partner EngenderHealth during the program pe1iod. In addition, 308 doctors received refresher training and 225 assistants of these doctors received training on FP counseling and infection prevention practices. )> Approximately 20,000 Private Community Health Providers (PCHP), mostly drug sellers received basic training in the 19 p1iority districts during the project period to improve their knowledge and OTC counseling skills on basic health matters and create awareness on rational use of drugs. )> More than 2,000 PCHPs received training on SOMA-JECT follow-up doses to explore the possibility of involving them in greater numbers in order to increase access to the method. )> SMC successfully established and strengthened linkages with public, private, NGO and professional bodies to ensure favorable policy and programmatic supports. )> Several promotional activities were undertaken to promote provider and create demand for products and services through both national and local media. I

Key lessons learned

MIH program implemented several activities to achieve its results. Some of these activities were new and innovative and fine-tuned during the project pe1iod through pilot testing. Following are some of the key lessons learned during the implementation of its activities:

)> Organizing awareness-raising group sessions with a combination of audio drama and flipchart helped to increase knowledge of target audiences. School health education also stimulated adolescents to change their behavior. It is observed that innovative media such as mobile film show and floating IEC center are also useful to reach the target audience in underserved areas. )> Involvement of women entrepreneurs ensures easy access to female RH products at the household. Private sector entrepreneur model can increase utilization of public health products in hard-to-reach areas. )> Physical presence of CSAs at community mobilization activities can ensure easy access of infotmation and products to the community people including adolescents. They are the promising new product distribution channel and behavior change agents of future. )> Patiicipation of community stakeholders helps to sensitize community people and to identify cornnmnity-level women entrepreneurs or community sales agents (CSAs). )> Strategic expansion of private sector provider networks helped to increase access and utilization of SM C's contraceptive and health products. )> Creating brand image through strong marketing efforts helps to counter negative image resulting from past experiences, word of mouth or low prices. )> The private sector network is one of the best channels to introduce new public health products and increase access of health care services. These providers or dmg sellers can increase access to contraceptive and injectables at hard-to-reach areas. )> Strong collaboration and pa1iicipation with NGO, GoB and relevant professional authorities such as Obstetrical and Gynaecological Society of Bangladesh (OGSB) can accelerate the achievement of project goal.

Page vi A. Introduction

Social Marketing Company (SMC) is one of the largest privately managed social marketing organizations in healthcare globally. SMC started its journey in 1974 as a project with funding from United States Agency for International Development (USAID). SMC uses commercial marketing techniques to make products and services widely available at an affordable price and motivate people to practice socially beneficial behaviors.

SMC's mission is to improve the health and wellbeing of women, children and families by creating demand for and increasing access to products and services in family planning, nutrition and other socially beneficial areas in partnership with private sector, development partners and public sector.

From 26 July 2012 to 25 July 2016, SMC implemented the USAID funded Marketing Innovation for Health (MIH) Program (Cooperative Agreement - Ref: AID-388-A-12-00003). The program aimed to support the Government of Bangladesh's efforts to further reduce fertility rate and address critical public health issues related to high maternal, neonatal and child morbidity and mmiality, tuberculosis (TB) and malnutrition. The goal of MIH program was the "contribute to sustained improvements in the health status of women and children in Bangladesh by increasing access to and demand for essential health products and services through private sector."

Under the MIH project, SMC and its implementing partners - BRAC, Concerned Women for Family Development (CWFD), Population Services and Training Center (PSTC), Shimantik and EngenderHealth (EH) employed an integrated social marketing program to provide a comprehensive range of products and services to the target populations in Bangladesh, while PSI provided technical assistance to SMC. Project funding included US$ 15 .0 million grant from USAID, $ 113.39 million cost share from SMC and$ 2.23 million program income from sale of USAID donated contraceptive commodities.

The program objectives by Intermediate Results (IRs) and Sub Intermediate Results (Sub­ IRs) are as follows:

IR 1: Increased availability and reached through expanded Commodity Sales and Distribution through private sector networks, including Non-Governmental Organizations (NGOs), at an affordable price to support family planning and other healthy practices especially focused on low income populations.

Sub-IR 1.1 Increased commodity sales and distribution by private sector networks Sub-IRl .2 Expanded private sector networks

IR 2: Improved knowledge and healthy behaviors, reduced haimful practices and increased care-seeking practices while reaching out to new audiences through creative Behavior Change Communication (BCC).

Sub-IR 2.1: Improved health communication activities to reach new user populations

IR 3: Improved and sustained the delivery of quality family planning, reproductive and child health services, referrals/DOTS services for Tuberculosis (TB), and referrals for higher-level

Page 1 clinical services, including Long Acting and Permanent Methods (LAPM) through capacity building of local formal and non-formal private providers.

Sub-IR 3.1: Increased training and refenals for long-tenn and permanent family planning methods, institutional delivery, management of sick newborns and reducing delays in diagnosing and treating Tuberculosis Sub-IR 3.2: Strengthened linkages with other public and private sector partners

This Final Report outlines the detailed description of program as well as its results and key challenges covering the period July 2012 to July 2016 under each of the IR. Lessons learned and recommendations for future programming are also included in the final report.

B. Project Results

Under the MIH program, SMC has reached targets related to expanding and developing private sector provider's sales outlets, reaching target populations with key health messages, and selling SM C's essential health, nutrition, and hygiene products. SMC has accomplished this through three intermediate results: IRl) expanded commodity sales and distribution through the private sector nationwide; IR2) conducted community mobilization and BCC through local implementing partners in 19 low perfo1ming districts; and IR3) strengthened capacity of private sector networks.

Bl. IR 1: Increased Availability and Reached through Expanded Commodity Sales and Distribution

SMC planned to increase the proportion of target population using family planning, maternal, child, nutrition and hygiene products by increasing product availability through an expanded distribution channel. The available quantitative and qualitative research used to develop a profile of the target audience and identify the most important and unique benefits of products and services. Under IR 1, SMC ensured wide reach of health products across Bangladesh through three main distribution channels to increase reach of its products and services: i) commercial distribution through wholesale and retail outlets; ii) local NGOs and community­ based disttibution points; iii) private health facilities and health provider networks. In addition, demand creation strategies were employed to increase use of products through both behavior change communications and brand specific adve1iising.

Bl.1 Increased commodity sales and distribution by private sector networks

SMC started distribution of contraceptive products in 1975, CYP Trend, FY 2012 - FY 2016 when the concept of social marketing first arrived in Bangladesh. SMC is one of the largest contraceptive social marketing organizations, I! 1~•~•-01 ~·~·~·27 ~i~1 ranked second globally in 2015 FY2012 FY2013 FY2014 FY20 '15 FY2016 in terms of numbers of CYPs (Baseline) (10months) delivered.1 According to the

10lson D, (2015) Social Markeli11g Co11tribu/es lo 20% of conlraceplion in developing counlries, Huffington post article, 2015

Page2 Bangladesh Demographic and Health Survey (BDHS) 2014, 62% of condom users, 44% of pill users and more than 18% of all injectable users rely on SMC contraceptives.

SMC made a contribution of 16,081,057 CYPs to the national program over program period, representing 91 % of total project target. The figure shows a gradual increment of CYPs during FY 2012-2014 and slightly decreased in FY 2015 and FY 2016. The main factor for lower achievement is the new entrants of different commercial contraceptive brands (pill, injectables and low pticed condom) and pilferage of government contraceptives. The expected achievement of CYPs from LARC was low due to inadequate number of LARC providers across the country, lack of confidence to administer, inadequate counseling and promotional activities resulting in a fall of 9% below the anticipated target. In terms of method mix contribution, 62% were delivered through sales of OCPs, 27% from condoms, 9% from Injectable contraceptives, one per cent from Emergency Contraceptive Pills (ECP), and one per cent from Long Acting Reversible Contraceptives (LARC-IUD and Implant). SMC contributed 105,529 CYPs to the national program from LARC over the program period. Under this agreement, SMC averted 3.29 million unintended pregnancies, 0.57 2 million deaths of children under-5 and 49 .43 million (disability-adjusted life year) DALYs •

Sales of family planning products and demand generation activities

Oral contraceptive pills

SMC marketed seven oral contraceptive pills (Femicon, Femipil, Naret 28, Minicon, Mypill, Ovacon Gold and Combination 3 or C3) to complement national family planning program. In FY 2014, SMC discontinued USAID-donated pill C3 distribution after receiving complaints regarding cracking and breakage of pills from purchasers. Laboratory tests by FHI 360 confirmed the problem and concluded that the most likely cause for the product defect was long exposure to high humidity and temperature. In FY 2016, SMC introduced two new combined oral pills in its product portfolio namely Mypill and Ovacon Gold to offer more choice of progestin for higher socio-economic class.

During the MIH project OCP Sales Status, FY 2012 ·FY 2016 pe1iod, SMC sold 150.35 million cycles of oral contraceptive pills (OCPs), which is 98% of its projected sales volume. Sales by brands included 91.21 million Femicon; FY2012 FY2013 FY2014 FY2015 FY2016 37.62 million Femipil; 12.66 (Baseline) (10 months) million Noret-28, 0.51 million C3, 0.09 million Mypill, 0.19 million Ovacon Gold and 8.04 million cycles of Progestin Only Pill (POP) - Minicon. Of the total pill sold dming the period, 57% were sold in urban areas and the rest were sold in rural areas. An availability study conducted between September and December

2 The disability-adjusted life year (DALY) is a measure of overall disease burden, expressed as the number of years lost due to ill-health, disability or early death. DALYs for a disease or health condition are calculated as the sum of the Years of Life Lost (YLL) due to premature mortality in the population and the Years Lost due to Disability (YLD) for people living with the health condition or its consequences.

Page 3 2015, show that SMC's brands are leading among 31 OCP brands available in the market. Findings also show that 94% of pharma outlets were carrying at least one SMC brands.

SMC introduced its Emergency Contraceptive Pill "N01ix" in February 2013 to widen its OCP portfolio with a post-coital formulation. Since its launch SMC has sold 2.22 million cycles ofNorix, exceeding the project target by 12%.

SMC developed and aired a number of mass media campaigns to support demand creation of all its OCP brands. SMC aired brand specific TV and Radio commercials through popular channels and complemented its TV advertising with billboards, informational brochures for providers, both formal and non-formal, as well as various point of purchase and sales (POS) materials like danglers, stickers and calendars. Press campaigns were utilized to promote its premium brands and progestin-only formulations including emergency contraceptive pill. SMC also launched a dedicated website and Facebook fan page for selective OCP brands.

Condoms

SMC has been social marketing condoms for over four decades. It cun-ently markets six condom brands (Raja, Hero, Panther, Sensation, U&ME and Extreme) in multiple variants (dotted, ribbed, scented, ultra-thin, etc). In 2014, SMC introduced a premium branded condom named 'Xtreme' to improve its overall condom profitability.

Over 525 mi Ilion condoms were sold during the project period, representing 87% of its project target. The following figure shows a gradual increment of condom sale during FY 2012-2014 and slightly decreased in FY 2015 Condom Sales Status, FY 2012 - FY 2016 and FY 2016. The main 155.78 reason for low condom (;)' 160 ~ sale (mainly Raja) is due . ~ 120 Q.. to wide availability of :§. 80 GOB Nirapod at ~ ~ 40 commercial outlet and · ~ 0 many other low-priced .s FY201 2 FY 2013 FY2014 FY2015 FY 2016 imported condoms that (Baseline) (10months) offer high profit margins to retailers. During the project period, SMC sold 196.76 million Raja, 136.79 million Panther, 103.51 million Sensation, 50.83 million Hero, 34.35 million U&ME and 2.72 million Xtreme condoms. 52% of all SMC condoms were sold to pharmacy outlets and 48% to groceries and NGOs. The Availability Study of 2015 shows that 32% ofnon-pharma outlets and 87% of all pharma outlets sell at least one SMC condom brand. Sales invoices show that SMC sold 39% condoms in rural areas and 61 % in urban areas.

TV commercials were developed and aired to promote profitable brands like Panther, Sensation and U&Me In addition, billboards were extensively used as a reminder media. SMC conducted a consumer-based online campaign on U&ME through Facebook. SMC also continued the online promotional activities of Xtreme condoms in four popular websites and news portals.

Page4 Injectables

SMC launched its over-branded injectable DMPA brand SOMA-JECT in March 2003. The product is manufactured by Pfizer and has been donated by USAID. SOMA-JECT is positioned as a high-quality 3-month contraceptive protection administered mostly by a SMC trained non-fo1mal healthcare provider under a network called Blue Star (BS). SOMA-JECT is now widely available in urban, peri-urban and rural areas throughout through 5,881 BS providers, drug sellers, and NGOs. During the MIH period, SMC sold 5.7 million vials of SOMA-JECT which represent 98% of its four years projection. The following figure illustrates a gradual increment of SOMA-JECT sales from FY 2012 to FY 2016.

SMC introduced Sayana Press SOMA-JECT Sales Status,FY2012 -FY 2016 injectable in February 2015 as 2 1.54 another alternative choice for 13 3 1.41 1.37 potential injectable users. en c Sayana Press is a Q subcutaneous injection prefilled with 104 mg of depot 0 medroxy progesterone acetate FY2012 FY2013 FY2014 FY2015 FY2016 (Baseline) (10monlhs) popularly known as DMP A. The Blue Star providers are the primary channel of distribution of Sayana Press injectable. In addition, graduate providers offering SMC's LARC methods also dispense this injectable brand through their practice. Since its launch, SMC has sold 174,933 vials of Sayana Press injectable and its popularity is gradually increasing.

Mass media including television and radio has been extensively utilized to promote at its own production facility SOMA-JECT injectable as well as create a favorable image of Blue Star service providers. All Blue Star outlets are branded with an attractive signboard so they are easily identifiable. Extensive community awareness is created through loud speaker announcement and mobile show programs.

Various promotional materials have also been developed and utilized to support sales of Sayana Press such as billboards, posters, display boards, provider detailing matetials and danglers.

LARC

SMC has been offering IUD, implant and injectable services through a network of trained private sector graduate providers, clinics and hospitals since FY 2012. During the project duration, it sold 6,945 implants, 17,204 IUDs, 44,958 SOMA-JECT injectables and 3,120 Sayana Press through these networks.

Television advertising was extensively utilized to create awareness of SMC branded IUD, Relax and Implant I plant and encourage potential users to call the SMC Tele-Jiggasha number know about their closest SMC trained LARC providers. Additionally, billboards on IUD an:d implant were strategically displayed near service provider's place of practice.

Page 5 MCH and nutritional products

Oral Rehydration Salt (ORS)

SMC initiated the Oral Rehydration Therapy project under the Child Survival Program in 1985 with funding from USAID to help decrease child mortality and morbidity due to diarrheal diseases. Under the program, SMC first introduced a pre- packaged oral rehydration salt in the brand name ORSaline and launched an extensive campaign to increase knowledge of diarrheal management and promote effective use of ORT. SMC ORSaline-N today continues to be the number one and most trusted ORS in the count1y and it is widely available through commercial outlets countrywide. SMC is also the largest manufacturer of ORS in the country having a production capacity of 380 million sachets a year. Against the projection of 1,756 million sachets during the program period, SMC sold 1,927 million sachets, thereby representing an increase of 10% over the target. SMC strengthened own ORS production capacity due to increased demand of ORS for non-diarrheal purposes. Therefore, sale of ORS has increased over last four years petiod. The figure illustrates a gradual increment of ORS sales from FY 2012 to FY 2016:

About 64% of ORS sold were ORS Sales Status, FY2012-FY2016 through outlets in urban areas 56189 and 36% in mral areas. Study en findings show that SMC's ~400 0 ORS is available at 90% of "'(j) pharma and 66% of non­ (j) c pharma outlets. ~ 0 E FY2012 FY2013 FY2014 FY2015 FY2016 (Baseline) (10 months) ORSaline-N, one of the most trusted names in the country and much loved by millions, was showcased in a much appreciated TV commercial which was aired during the project period. Billboards were placed at strategic locations across the country. A print campaign on ORS was implemented through major national dailies to create awareness of fake ORS.

Sales ofSafe Delivery Kit

SMC's branded Safe Delivery Kit (SDK) titled "Safety Kit" was introduced in FY 2008 to ensure use of clean and sterile equipments during the child bitth at the household level. During the MIH period, SMC sold 0.57 million SOK Sales Status, FY 2012- FY 2016 Safety Kits through 200 177 171 pharmacies, NGOs and 150 traditional birth attendants. The sales volume is 87% 100 of its four years projection. so Of the total SDKs sold, 0 67% were sold in rural FY 2012 FY 20B FY 2014 FY 2015 FY2016 areas and 33% in urban (Baseline\ (10 months\ areas. The figure demonstrates sales achievements of SDK from FY 2012 to FY 2016. Home deliveries are prominent in rural areas where limited number of sales forces hardly gets opportunity to

Page 6 supply SDK especially in remote rural areas. In addition, inadequate promotional campaigns also caused for low sales achievement of SDK.

TV commercials were aired through both BTV and satellite channels to promote use of Safety Kit. Brochure on Safety Kit was developed and distributed through pharmacies and SMC's Blue Star outlets. Various promotional activities were run targeting the Traditional Bi11h Attendants (TBAs) who are the primary influencers for this product. SMC developed Safety Kit branded bag and umbrellas as promotional materials for TBA's.

Zinc tablets

The World Health Organization (WHO) and UNICEF recommend the use of zinc as an adjunct therapy to ORS for reducing m011ality and morbidity caused by dianhea. Zinc also reinforces a child's immune system thereby reducing the likelihood of contracting pneumonia. It also lessons the length and severity of episodes of diarrhea. SMC Zinc was launched in 2008 as a response to make available a more affordable choice for treating diarrhea in low income households. During the MIH period, SMC sold 2.24 million blisters of zinc tablets, representing 80% of the project target and a decreasing trend of sales from FY 2014. The figure illustrates sales achievements of Zinc tablet from FY 2012 to FY 2016. Lack of awareness about the benefits of using Zinc as a combined therapy to treat child diaiThea is one of the important reason for low uptake of Zinc. Zinc Tablet Sales Status, FY 2012 - FY 2016

In addition, the study reveals ~ (]) that ORS is also used for other purposes such as regain energy 0.4 due to sweat and this market is gradually increasing. fH0.1 _L__j -----i ------i - ----1--­ Therefore, it was a challenge to ·~::> i i 0) meet the sales target of Zinc u: FY 2012 FY20'13 FY2014 FY2015 FY2016 (Baseline) {10months) tablet during the project pe1iod.

To promote ORS+Zinc as combined therapy to treat child diarrhea, a billboai·d design was developed and displayed in overhead water tanks and strategic outdoor locations. Besides, digital banner and direct mailing items (letter, sticker, information card & envelope) were distributed amongst Rural Medical Practitioners all over the country. A pack design for a combo pack containing ORS and Zinc tablets was developed and submitted to the drug administration, which is awaiting approval.

Micronutrient JJowder (MNP)

SMC launched its Micronutrient Program through inh·oduction of "MoniMix" in 2008. MoniMix is a micronutrient powder for simple and convenient in~home I r ,-. food fortification of complementary food to address ~ - childhood Iron Deficiency Anemia (IDA). The objective of the micronutrient program is to help improve the nutritional status of under-five children, particularly iron levels an1ong .... ~~ those 6-24 months old, increase knowledge and awareness ...... among parents and health service providers about the imp011ance of micronutrient containing food and adequate Poster on MoniMix

Page 7 dietary intake, and promote exclusive breastfeeding and proper complementary feeding of nutrition rich foods. SMC sold 48.37 million sachets of 'MoniMix' during the project period, which exceeds target by 7%. The sales volume of MNP shows a significant growth over the last four years mainly due to promotional campaign, sales by CSAs, BSPs and PCHPs. From the findings of the Availability Study, MoniMix was available at 32% pharma outlets during the survey period. The following figure illustrates sales achievements of MoniMix for four year period:

SMC developed various mass MNP Sales Status, FY 2012-FY 2016 media campaigns on MoniMix 16 12.8 12.89 13.51 to create awareness of IDA and = 12 the role of micronutrient ~ ~ = -5 8 powder in the prevention and ·=., ~ ... = cure of IDA among children ~= 4 u: under 5. Two TVC's on 0 MoniMix were aired in the FY 2012 FY2013 FY 2014 FY 2015 FY 2016 major TV channels including (Base line} (10 monthsl BTV and popular satellite channels. Wall paining, water tank painting and press adve1iisement were utilized to create understnding and demand ofMoniMix. Besides, a range of promotional materials, e.g. poster, brochw-e, banner, pen pot, paper weight were developed targeting both graduate and non­ graduate medical practitioners.

Sanitary napkin

SMC launched "JOYA" a low-priced sanitary napkin (belt type only) in FY 2013. The purpose behind introducing SMC's own brand was to provide a good quality low-priced brand to attract non-user women and adolescents thus leading to improved female hygiene and increase social inclusion during menstruation. JOYA is the first scented sanitary napkin available in the market. SMC launched wings panty pad under the same brand name in May 2014 after receiving several feedback from the trade channels. This has provided a widened opportunity for non-users, cmTent belt users as well as low quality wings users with more benefits and a more healthy and comfmiable expe1ience. SMC sold 6.51 million packs of JOYA sanitary napkin since its launch. This represents an increase of 9% over its projections. The figure shows sales achievements of JOYA from FY 2013 to FY 2016. The sales volume of JOYA shows significant growth over the last three Sanitary Napkin Sales Status, FY 2014- FY 2016 years due to introducing new 2.77 3 2.58 vaiiant (wing), low price, special product attribute 2 1.55 (smell), extensive promotional campaign as 1 new entrant into the market and sales by CSAs at 0 community level and school FY 2014 FY 2015 FY 2016 (10 health education sessions. months)

JOYA sales have been extensively supp01ied through a number of media campaigns on television, radio and the print media with messages developed based on intensive research among women, both current and non- user of sanitary napkins. Jn addition, billboards for

Page 8 JOY A were also displayed in the major strategic locations across the country and wall paintings on JOY A were displayed in the waiting sheds for parents of high schools.

Project Accomplishments

SMC introduced Sayana Press through the outlets of Blue Star and LARC providers across the country. These providers are also administering SOMA-JECT. However, sales of SOMA­ JECT did not decrease due to the availability of Sayana Press at the same outlets. The unique experience is that Sayana Press not only broadens the choice of clients but also created new users of contraceptive. The following table shows sales volumes of SMC products by targets and actual achievements over the life of the MIH project.

Table 1: Product sales volume by targets and achievement during the MIR project period

SJ. Product Sales Achievem %of CYPs Unintended DALYs Deaths no. Targets ent target provided pregnancies averted averted achieved averted I. OCP 153 m* 150m 98% !Om 2.29 Dl 1.16m 14,371 2. Condom 603 m 525m 87% 4.37 m 0.63 m 0.32 m 3934 3. Injectable 6.03 m 5.87 m 97% 1.46 m 0.33 m 0.16 m 2089 a) SOMA-JECT 5.83 m 5.7m 98% b) Sayana Press 200,000 174,000 87% 4. ECP l .99m 2.21 m 111 % 0.11 m 9,984 5069 63 5. IUD 40,000 17,204 43% 0.08 m 24,823 12,297 151 6. Implant 23,000 6,945 30% 0.03 m 8,084 4046 50 7. ORS 1,756 m l,927m 110% NA NA 47.72 m 0.54m 8. MNP 45 m 48m 107% NA NA NA NA 9. Zinc tablet 2.79m 2.21 m 79% NA NA 8,317 95 10. Safe delivery 0.66m 0.58m 87% NA NA 37,379 438 kit 11. Sanitary napkin 6.2m 6.52m 108% NA NA NA NA Total 16.08 m 3.29m 49.43 m 0.57m *m stands for million

Bl.2 Expanded Private Sector Network a) Private sector outlets

SMC has one of the largest private sector distribution networks in the country. Its wide reach across Bangladesh is possible because of its efficient supply chain system: from product sourcing to packaging, warehousing, transportation, and distribution to the last mile of the chain which are the private sector delivery points. SMC's Central Warehouse (CWH) in Bhaluka, Mymensingh receives all incoming products, whether imported or locally manufactured which are then packaged through contracting NGOs and SM C's own packaging unit.

Sales and distribution of SMC products Page 9 SMC has already started to restructure its field operations by establishing four regional offices and warehouses. The Bogra office and warehouse is already operational while the ones in Comilla and Dhaka are under construction and will be fully functional by 2018. The regional warehouse will act as a depot and help SMC ensure continued availability of commodities of a growing number of products within the region and reduce reliance on more frequent, time-consuming and expensive distribution from the central warehouse.

Furthe1more, SMC will explore other private sector distribution models to complement its existing systems. Currently, SMC makes direct sales to almost 290,000 outlets through its sales officers working through 12 area offices across the country. Of these, 40% are pharmacy outlets and 60% are non-pharmacies. In addition, products were sold to 1,230 institutions including NGOs, hospitals and clinics. Many of these outlets also purchase directly from stockiest/wholesalers in the open marketplace. In some areas, SMC also engages sales persons on bicycles to reach outlets in areas where SMC sales officers and distribution vans cannot penetrate. SMC trained 5,881 providers under the Blue Star network, as well as 400 active LARC providers. Besides, 45 private clinics/hospitals who are providing injectables and LARC services also depend on direct supplies from sales officers and program officers.

The Availability Study conducted by SMC in 2015 shows that 94% of the retail pharmacies are carrying at least one brand of SMC pill and 87% at least one brand of SMC condom. SMC's ORS was available in 90% of all pharmacies. While the scenario looks impressive for pharmacies, the same is not true for non-pharmacies where availability figure was 66% for SMC ORS and 32% for condoms. This is more prominent among pharmacies in rural areas. b) Community distribution

The community women entrepreneurs called community sales agents (CSAs) under the MIH Notun Din program have become an impmtant new channel of distribution for SMC who directly reaching household in underserved areas where direct distribution in many cases is not economically viable. CSAs are females with primary level education who have the financial ability to make cash purchase of the initial stock. CSAs visit households and disseminate health messages and sell SMC products to underserved populations in semi urban and rural areas earning a margin on sales. SMC does not pay any salary or incentives, but motivates and builds the capacity of CSAs, supplies products and helps them to build their business. CSAs are assigned for an average of 1,000 households as catchment area so that they have the potential to generate sizable sales proceeds from selling products and sustain their interest to continue her business as an entrepreneur. The cmTent basket of the products for CSA include different brands of contraceptive pills, condoms, sanitary napkins, ORS, micronutrient powder MoniMix, safe delivery kits and Zinc. In addition, SMC has also piloted the provision of other common products through these agents.

Project Accomplishments

The unique experience under IRl is the wide reach of its health products and services by expanding distribution channels (commercial outlets, wholesale, retail, NGOs and private sector health facilities and health provider networks) across the country and by engaging rural women entrepreneurs as a community-based distribution point in the project areas. The following table shows changes in the coverage and penetration of outlets by type during the life of the MIH project.

Page 10 Table 2: Baseline and project end targets and achievements of private sector distribution networks

Indicator Baseline Target Achievement % increase 1 #of private sector outlets directly covered by SMC Total: 268,640 261,781 273,230 1.7 Pharmacy outlets: 106,195 104,711 113,902 7.3 Non-pharmacy outlets: 161,496 155,948 158,201 -2.0 NGO distribution outlets: 949 1,122 1,127 18.7 2 % of non-pharmacy outlets canying SMC-branded 40% 60% 66% 65.0 ORS 3 % of non-pharmacy outlets carrying SMC-branded 23% 40% 32% 39.l condom 4 # of CSA involved to create demand and sell SMC - - 840 na products 5 # of BSPs recrnited and trained for injectable 3,791 6,000 5,881 55.l services 6 # ofLARC providers recruited and trained 28 700 927 7 # of intuitions involved to offer LARC and 0 66 injectables services

B2 IR 2: Improve Knowledge and Healthy Behaviors

The Mlli project worked to increase knowledge of health products and healthy behaviors through a community mobilization and BCC program called 'No tun Din ' and mass media coJ:nmunication to create national level awareness and reinforce the community mobilization programs.

B2.1 Improved Health Communication Activities

The aim of the program is to increase healthy behavior on family planning, maternal and child health, adolescent health and hygiene, 19 Priority Districts of MIH and TB among the community people through Priority Distriets or MIH

BCC campaign. The target audiences are 8ANGL.AO&tH. .._,_...... , ... __ ~ women of reproductive age, caregivers of "'"~~ ..- ..: ·-~...... children under five, men, school adolescents, --·"""""".-,. . community birth attendants (CBA), workplace workers and community influencers.

B2.1.1 Community Mobilization and Behavior Change Communication

In collaboration with four national partners­ BRAC, CWFD, PSTC and Shimantik, SMC implemented the community mobilization program 'Notun Din' in the 81 MIH upazilas of 19 priority districts where CPR is comparatively low and child mortality rates are higher than the national average. These partners implemented an integrated social marketing program to provide comprehensive

Page 11 information, education, distribution of products and services to the target populations.

The major interventions utilized for disseminating health infonnation in the community were group meetings, orientation sessions, school sessions, mobile film shows and floating IEC sessions. The project staff and 'community mobilizers' were responsible to disseminate infmmation in the community among the target audiences. They used audio-based drama to communicate key health messages on HTSP and first 100 days of pregnancy in each group sessions. Along with the audio drama, field staff also used flipcharts to make participants understand the core messages. With the help of PSI, SMC modified messages and redesigned communication materials in the first quarter of 2015 based on field observation and staff feedback. On August 2014, a workshop was organized with pminers and relevant stakeholders to redefine project activities and processes based on lessons learned. Based on the feedback of participants in the workshop, SMC developed a new execution style using rival folk singers, locally known as "pala gan" to communicate the core messages in a more interesting fmmat. It is a common entertainment medium for villagers known popularly as "Gaane Gaane Lorai (fight betvveen songs)". The following table shows core communication packages, primary target audiences and primary channels under community mobilization activities.

Major areas Primary target audiences Primary communication channel Repositioning FP MWRAs,Husbands Group sessions First 1000 days of Caregivers of children under Group sessions Pregnancy five Healthy Pregnancy TB As Orientation meetings Adolescent Health Adolescents (Boys and girls) School health education sess10ns TB prevention and All populations Group sessions through Management Floating IEC boat and MFP shows

B2.1.1.1 Activities through Interpersonal Communication (IPC) and Group Meetings a) Advocacy and program sharing meeting

Implementing partners conducted advocacy and program sharing meetings with community influential at union and ward levels to generate suppmi for the program and disseminate messages to the community. A total of 3,843 advocacy meetings were held and 118, 657 community advocates and influencers attended the meeting. The achievement stands at 28% more than the actual projection. The participants included local level government officials, elected representatives, local leaders, teachers, health and family planning field staff, religious leaders, youth leaders and other community level personalities. The project achieved more than the anticipated targets because project partners also invited former local government representatives and other influential identified during organizing advocacy sessions. b) Group meeting with MWRA and caregivers ofunder-5 children

The most impmiant target groups to reach through the community mobilization programs were MWRAs, their husbands and caregivers of children under 5. The community mobilizers

Page 12 organized group sessions and IPC activities with the core target audiences in their intervention areas. The project staff of 3 partners (CWFD, PSTC and Shimantik) organized group meetings with approximately 15-20 participants during each session. They used audio player to disseminate core messages and used flipcharts in order to reinforce the messages. On the other hand, BRAC conducted the same session through their own Shastha Kormis (SKs) using flipcharts only to communicate key messages and ideas. A pre-post assessment was conducted at the beginning and end of each session to assess knowledge and message retention level. A total of 6.45 million MWRA's were reached through 1,134,569 group meetings. It represented 6% more than the actual project targets. Simultaneously, 3.81 million caregivers of children or 5% over the projected target also received the core messages on importance of nutrition, exclusive breastfeeding and other relevant topic.

Meeting with MWRA Meeting with husband of MWRA Meeting with workplace workers c) Group meetings with husbands ofMWRA

During the project pe1iod, the four implementing partners reached a total of 1.56 million men, mostly husbands of MWRA in the communities through 89 ,865 group sessions which represents 101 % of its projected target. The purpose was to desensitize them on key health issues affecting their families and engage them in greater discussion with their spouse. d) Adolescent health sessions at school

'Notun Din' community mobilization program reached out to adolescents school girls and boys to encourage adoption of healthy behaviors and practices in their daily life. A total of 0. 77 million school going boys and girls were reached by implementing partners with messages on adolescent health through over 14,000 school sessions druing project period.

The target achievement stands at 3% more than the School session with adolescent girls project target. Of them, 30% were boys and 70% were girls. Separate sessions were organized for.boys and girls. A quiz competition was held at the end of each session to draw attention and reinforce message retention among adolescents. The winer received promotional gifts. In addition, every adolescent received leaflet in the session to remind them about key health and hygiene issues.

Page 13 e) Group meetings with workplace workers

Three implanting partners - BRAC, CWFD and PSTC organized meetings with workplace workers in their intervention areas. They organized over 1,700 group meetings with 31 ,144 workplace workers. The total achievement stands at 11 % more than the actual target. f) Orientation for community birth attendants (CBAs)

'Notun Din' partners organized orientation and follow up meetings with the CBAs to ensure healthy pregnancy and safe delivery at the household level. They were also encouraged to use SDK during delivery at household and to refer complicated cases at nearest health facilities. A total of 3,217 orientation sessions were organized with 45,983 CBAs which is 24% more than the project target. Initially, project planned to orient traditional birth attendants only and target was set accordingly. Considering the important role of their assistants (who are potential to become as a CBA in future), project partners also invited these assistants in the orientation session which shows 24% more achievements than the actual target.

Project Accomplishments

The unique feature of community mobilization was to organize awareness-raising group sessions with the target audiences using a combination of audio drama and flipchaii on HTSP, the first 1000 days of pregnancy care, adolescent health and hygiene. School health education also stimulated adolescents to change their behavior. It is observed that innovative media such as mobile film show and floating IEC center are also useful to reach the target audience in underserved areas. In addition, involvement of mral women as entrepreneur ensures easy access to female RH products at the household. The following table shows targets and achievements in community mobilization during the four year MIB period by the various target groups:

Table 3: Project end targets and achievements ofNotun Din Program

SI. Target Achievement O/o Indicators no. FY (2013-2016) FY (2013- 2016) Achieved 1 MWRAs reached (in millions) 6.03 6.45 106% 2 Caregivers reached (in millions) 3.627 3.81 105% 3 Husbands ofMWRA reached (in millions) 1.547 1.56 101% 4 Adolescents reached (in millions) 0.741 0.766 103% 5 Community Birth Attendants reached 37,100 45,983 124% 6 Workplace Workers reached 28,000 31,144 111% 7 Community Advocates reached 93,000 118,657 128% g) Innovative activities in the MIH intervention areas:

SMC conducted a number of innovative activities at the district, upazila and union level through its four implementing paiiners.

Wall painting: Wall paintings on HTSP and first 1000 days of care, MoniMix and SDK were displayed at strategic places. Wall paintings are used to reinforce the messages disseminated through IPC and group sessions. During the period, SMC reinforced core messages through 1,072 wall paintings in the selected intervention areas.

Page 14 Dissemi11ation of 'Notun Din' message through loudspeaker announcement: In FY 2015, BRAC arranged loud speaker announcement in 59 upazilas of seven distticts, PSTC in five upazilas, and CWFD in six upazilas to inform about Notun Din program, health messages and schedule of mobile film shows.

School debate competition: CWFD organized school debate competitions in collaboration with upazila education department to create awareness among school going adolescents on health and hygiene, pube1ty, early ma1riage and early pregnancy. Sixteen schools in Shawrupkathi Upazila and eight schools in Bhanga Upazila in Faridpur participated in the debate competition during FY 2015.

Exposure visits: The PSTC team members made exposure visits at the intervention areas of CWFD and Shimantik to share and gain current program experiences and lessons learned among them. They met field level staff and stakeholders and also visited 'Notun Din' offices. These exposure visits strengthened relationship between partners and created an opportunity to share best practices for redesigning and improving their own activities and qualities.

Palagaan at community level: Live palagaan shows were organized by local folk team in all upazilas to increase awareness on health and family planning messages of 'Notun Din' program. A total of 351 shows were held where over 40,000 participants participated.

Participation in local cultural fair: The implementing partners PSTC and Shimantik participated in local level fairs to increase awareness about 'Notun Din' activity and to disseminate messages on key public health issues. Notun Din organized a stall on the occasion of Pahela Baisakh, a Bangla Mela was organized at Acharya Sir Jagadish Chandra

A local fair organized by Shimantik A Palagan show at Perojpur

Bose's memorial palace in Sreenagar Upazila in Munshiganj during 2014 to 2016. Different community members visited the stall and the event was also an opportunity to increase awareness and to promote and sell SMC's commodities. Implementing partner Shimantik participated in local level fair "Shisu Mela" (children's fair) to inform people about Notun Din activities and disseminate messages on health issues on 28th December 2014 in a Tea Estate under Srimangal Upazila under Moulvibazar. Shimantik set up a stall in the fair where approximately 1,000 people visited the fair.

Using cable TV network to disseminate messages: All the four implementing partner organizations used local cable TV network to disseminate health messages in all the intervention upazilas. They aired short drama on HTSP, first 1000 days of pregnancy and adolescent health to disseminate messages during the last quarter of FY 2015.

Page 15 Ideal couple award program: The best couple award program was organized in two 'Nottm Din' partners (CWFD and PSTC) intervention areas during 201 5. A total of 102 ideal couples were selected from 11 upazilas using a standard set of criterion (the woman got maITied after the age of 18 and had her first child birth after age 20, had three years gap between pregnancies, and has completed two-child family by age of 3 5 years). The events were organized by involving GOB functionaries from the districts and upazilas. The couples received crest as award for ideal or best couple in the program. The objective of the event was to recognize best practices at the community level and to encourage other couples to follow.

h) Observation of special daysloccasio11s

SMC celebrated the following national and international days in the MIH intervention areas in collaboration with the GoB and other stakeholders during the program period every year: World TB day: The 'Notun Din' community mobilization partners celebrated the World TB day on 24 March every year in their intervention areas. Different community mobilization activities were carried out at the grassroots levels through rallies with BCC materials, seminars and meetings, paper advertisements, film shows by mobile film units in an effort to reinforce the messages disseminated through group sessions. These events received media coverage in the local/national print media and TV channels.

Safe Motherhood Day: The Safe Motherhood Day has been observed on 28 May each year with an aim to create awareness on proper healthcare and maternity facilities to pregnant and lactating women. SMC conducted a number of activities at district and upazila level to observe the day through its implementing partners. Activities included group meetings with pregnant and lactating mothers and provide them information, rally, debate competition, etc.

Safe Motherhood Day 2014 Art competition at TB day 2013 World TB Day 2015

World population day: The World Population Day has been observed on 11th July in the Notun Din program areas every year. Different community mobilization activities were carried out through rallies, seminars and meetings to reinforce the messages disseminated through other activities.

World Breastfeeding Week: The World Breastfeeding Week was observed from 1 - 7 August each year to increase awareness about the impo1tance and benefits of breastfeeding. Different community mobilization activities were carried out at the grassroots levels through rallies with BCC materials, seminars and meetings, paper advertisements, film shows by mobile film units in an effo1t to reinforce the messages disseminated through other channels. These events have received media coverage in the local/national print media and TV channels.

Page 16 B2.1.1.2 Engaging Women as Entrepreneurs and Effective Behavioral Change Agents

Background and rationale

It was observed that demand creation of products and services only was not enough to bring the desired behavioral change unless the related products are easily accessible at the community level. For example, the BDHS 2014 shows that the cmTent CPR of the country is 62.4% but an additional 12% of cunently manied women in Bangladesh have unmet need for family planning services.

According to the 2014 BDHS 1 in 10 women reported having being visited by a government family planning field worker and 5% by an NGO field worker in the six months prior to the survey. The rnral communities also depend on public sector workers who conduct door-to­ door distribution ofFP products, but only one-fourth ofMWRA who have been visited by a field worker received a FP method from the worker. The contraceptive prevalence rate in rural areas is 61 % while the rate for urban areas is 66% (BDHS, 2014 ). In addition, more than half of ever married women in rnral areas have no exposure to any of the mass media (newspaper, television and radio) whereas the rate in urban areas is one in every five (BDHS, 2014). Therefore, making public health products available at the household level through involving community level women entrepreneurs can significantly contribute to increased access and utilization of health products especially at hard-to-reach areas.

CSAs are promoting essential health products to the community women

As part of extensive community mobilization activities conducted by more than 150 Community Mobilizers (CMs), the MIH program has initiated an innovative strategy to create women entrepreneurs called Community Sales Agents (CSA) who disseminate health information, sell health products at the household level and refer potential clients of long acting and permanent family planning (FP) methods to the nearest service delivery facilities. They are not directly paid by the project, but they purchase SMC products at the trade price and sell them at the retail price, earning additional income in the process. The intervention started in July 2013 and focuses on rural areas considering the significant urban-rural disparity in terms of healthcare in Bangladesh.

Involvement of CSAs

More than 830 CSAs are engaged through a competitive selection process by the local level stakeholders in selling health and FP products at the household level and in promoting healthy behaviors. CSAs are pe1manent residents of their communities, have at least a p1imaiy level of education, and ai·e willing to visit households to create demand, sell products and disseminate health messages. The CSAs received training on maternal, child health and family planning as well as job aids, such as pictorial booklets. In order to increase the

Page 17 visibility of CSAs at points of sale, their residences have been branded with the project logo and they have been provided with uniforms (saris). Each CSA covers between 800 and 1000 households. Essential health products distributed by CSAs include OCPs, ECPs, condoms, ORS, zinc tablets, MNP, safe delivery kits and sanitary napkins. The CSAs get their supply from the Upazila project offices when they attend the monthly meetings. SMC sales officers supply the products to the project offices as per their requirements. This ensures a consistent supply of the products throughout the supply chain.

CSAs closely support CMs in mobilizing the target audiences in their respective areas through different activities, including group meetings and school education programs for adolescent boys and girls. Being actively engaged in community mobilization activities allows CSAs to better understand the target audience's needs, the key barriers to behavioral change, and to address them through their intervention at the household level.

During the community level events, organized by CMs, CSAs have the opportunity to introduce themselves and display their basket of products. SMC is also using another popular media channel, the Mobile Film Program (MFP), which reaches remote rural communities with entertaining and educational drama and films. During these gatherings CSAs are introduced by the MFP teams. The project also organizes meetings with influential community leaders to enlist their participation in the program. CSAs attend those meetings, are introduced and they seek cooperation and support from community leaders to continue their business. Brand image of SMC products has helped CSAs to increase their sales volume within a short time.

Systematic planning

The pa1tner organizations were actively involved during the planning and development phase of the program for brand development and design of promotional materials. Their feedback was continuously solicited through monthly meetings to refine strategies and improve program activities. V aiious improvements were also made to the program after consultation with CSAs during monthly meetings. A monitoring and evaluation process has been established in collaboration with the local and central level supervisory staff. SMC has created an MIS system, which provides detailed performance repo1ts.

Key results

SMC conducted a study at the mid of the fourth year of the project implementation to assess the performance and level of knowledge of the CSAs and to identify further support that would be required to improve program impact and increase the CSA's sales volumes.3 The findings show that the average last month income of CSAs is 5,360 during survey. The average working hour as CSA is 5 and on average each CSA works 5 days in a week. More than 95% of CSAs mentioned that they refer clients for injectable contraceptives, IUDs, implants or permanent FP methods.

The findings also show that CSAs have a high level of knowledge related to key program themes. For example, 96% of CSAs mentioned that the maximum age for safe pregnancy is 35 years and 93% of CSAs know conectly birth spacing should be at least 3 years or more. The majority of respondents stated that their sales volume has increased over the last few

3 Assessing the Strengths, Weaknesses and Opportunities ofNotun Din Community Agent Model conducted by RCS

Page 18 months. This is backed up by MIS sales data as shown below. Most of the respondents mentioned that they regularly attend monthly meetings at the Upazila level and 99% of respondents mentioned that they are somewhat satisfied, or very satisfied being a CSA under the program. Sales data indicates a steep increase in sales volumes showing that the program is promising in reaching the desired behavioral changes in the targeted communities. The PSI Impact calculator shows that CSAs provided 0.13 million CYPs, ave1ted 27,237 unintended pregnancies, averted 0.42 million DALYsand 4,789 deaths.

Table 4: Sales achievements by involving CSAs

Product name Sales in '000 CYPs Unintended DALYs Deaths 2013 2014 2015 2016 Total provided pregnancies averted averted averted OCP (in cycles) 30 294 672 550 1,546 103,098 23,554 11,958 147 Condom (in pieces) 127 663 1,290 886 2,966 24,727 3,543 1,799 22 ECP (in dose) 2 6 14 9 31 1,563 141 71 1 ORS (in sachets) 134 3,182 7,127 5,723 16,166 NA NA 400,280 4,569 MoniMix (in sachets) 195 525 867 2020 3,607 NA NA NA NA SMC Zinc tablet (in 6 48 101 68 223 NA NA 838 10 blister) Safe delivery kit (in 3 11 23 14 51 NA NA 3,418 40 pieces) Sanitary napkin (in 0 75 210 218 503 NA NA NA NA packs) Total 129,389 27,237 418,364 4,789

B2.l.1.3 Activities through Other Communication Channels a) Mobile Film Program (MFP)

One of the most effective social marketing approaches of SMC is Mobile Film Program (MFP) which is operating to educate people on family planning, TB, maternal and child health, child nutrition and other social priory issues through enter-education films. Currently, SMC is operating eight mobile film units focusing in 19 priority dish·icts of the country where access of mass media is comparatively poor. A one and half hour long program is shown at different strategic points in the evening. Each of the units reaches a village at the afternoon and makes announcements about fiim show which is held later at the specified place in the evening. The program shows four short enter educating dramas on HTSP, First 1000 Days Care, Adolescent Reproductive Health and TB. In addition, SMC also showed advertisements on HTSP, 1000 days, Healthy Pregnancy to raise awareness among the target population. SMC projected 4,230 MFP shows across the country to reach approximately 3,740,000 people in the 19 districts and met 93% of its target.

Announcement before show MFP vehicle rnnning for program MFP show after sunset

Page 19 The following table shows the year wise coverage ofMFP.

Table 5: MFP show performance

Year FY 2013 FY 2014 FY2015 FY2016 Total #of shows 873 l,273 1,112 1,102 4,360 # of participants 710,040 1,013,168 910,160 811,413 3,444,781 b) Floating IEC Center

SMC's 'Floating IEC Centre' is which is a branded motor launch, provides people ofriverine areas with TB messages for several years. A Floating IEC center reaches the pre-scheduled harbor of the riverine areas as part of its daily activities. A power point presentation performs consisting messages on TB diagnosis, referral and treatment. In addition, three short dramas on HTSP, First 1000 Days of Pregnancy and Adolescent Health as well as an inter-educative drama on TB also project in the session.

Two Floating IEC launches travelled through different intervention areas. Through the floating IEC launches, SMC organized 3,954 sessions, reaching over 264,000 people. The achievement stands at 83% of the target. The operation of one floating IEC boat in Sylhet area was stopped in Febrnaty 2015 and cost was shifted to pe1form other priority activities.

Announcement before show Floating IEC Centre at Barisal Indoor show inside the center

The following table shows the year-wise coverage of the floating IEC Centre:

Table 6: Floating IEC show performance

Year FY 2013 FY 2014 FY2015 FY 2016 Total #of shows 989 1,532 942 491 3,954 # of male participants 41,448 64,116 31,523 15,422 111,061 # of female participants 22,315 40,243 33,083 16,333 89,659 # of total participants 63766 104,359 64,606 31,755 264,486 c) Te/e-Jiggasha program

'Tele-Jiggasha' is the hotline tele-counseling program of SMC. It provides necessary and appropriate information and counseling to female and male callers throughout the day on different health issues. The areas of counseling are family planning including LARC, maternal health, adolescent health, tuberculosis, child health, psycho-sexual, HIV-AIDS and others. Under the Counselor responding to queries under Tele-Jiggasba l'rogram Page 20 MIH program, three counselors of the Tele-Jiggasha program are engaged to respond to the queries posed by the clients with adequate information, counsel for referral care, send SMS among stakeholders and collect customer's opinion/feedback about SMC's services.

This wing is also used to understand health behavior of clients as well as to monitor sales and program activities. In June 2014, 'Tele-Jiggasha' transformed manual operation to call centre solution (partial) in which two new IP connections dedicated to Tele-Jiggasha and can accommodate 6 calls at a time. This call center is operated through a short code for Tele- J iggasha (16387), which has been parked to all mobile operators (Grameenphone, TeleTalk, banglalink, Airtel and Robi) as well as state-rnn BTCL. SMC published the short code number in all IEC mate1ials of products and TVC/billboards to popula1ize the number. Besides, stickers have been developed and advertisement published in the daily newspaper to inform people about its contact number. A total of 18, 119 calls were received by both male and female during MIH period where 55% calls were received from females. Following is the breakdown of call by sex during this period:

Table 7: Performance of Tele Jiggasha Program

Type of Number of Calls Received in FY 2012-FY2016 TOTAL Counselor FY 2013 FY 2014 FY 2015 FY2016 Male 1,577 3,270 2,193 1,210 8,250 Female 934 2,151 3,614 3,170 9,869 Total 2,511 5,421 5,807 4,380 18,119

B2.l.l.4 Capacity Building and Program Performance Review Meeting a) Capacity building ofpartner's staff

SMC conducted a series of orientation program as a part of technical assistance to increase sldlls and knowledge of the Notun Din staff for effective implementation of the program throughout the MIH period.

);;> Basic and refresher training for program staff: Partner NGOs organized basic training for their newly recruited staff as well as refresher training for all staff periodically where all levels of staff were in attendance. ~ Refreshers orientation for CSAs: The CSAs are playing a vital role at the community level to increase the knowledge of the community on FP methods, maternal and child health, hygiene, and other health issues. They also ensure that health products are easily available and accessible at the community level. In order to enhance their capacity on IPC and sales techniques, the paitner NGOs atTanged refresher training sessions for them during the project yeai·s. ~ ToT for the sells skills development: SMC organized Training of Trainers (ToT) for the respective partner's staff on selling skills during FY 2015. The purpose of the TOT was to develop the selling skills of Sashthay Sebika (SS) and CSAs. b) Program review meetings

Monthly, quarterly and yearly program activity review meetings were held at the head office level as well as district office levels. The major discussion issues were: performance evaluation and progress review, activities planning, sharing experiences and best practices, challenges faced as well as monitoring and evaluations of the program activities. SMC

Page 21 organized a total of 40 review meetings at SMC head office during the project period with the partner's key staff. The four implementing partners conducted more than 900 monthly and quarterly review meetings at their head offices and field level offices during the same period. Regular staff development capacity building activities, periodic performance review meetings and experience sharing gatherings are crucial for smooth implementation of program activities as well as to improve perfmmance of staff.

B2.1.2 Mass Media Campaign

SMC extensively uses mass media, particularly television and radio to create awareness on key public health issues. The major focus ofTVCs to achieve IR2 were HTSP; First 1000 Days of Pregnancy and Tuberculosis (Hashi Mukh and Jatra). These TVCs were aired in popular television channels to incresae awareness of the target groups. Each of the TV Cs was aired for at least one month.

Two RDC's on TB (Cough Guru and Puthi) were aired in popular radio channels of Bangladesh. SMC also aired TB drama (Rongila Bao) focusing on different TB messages in a popular satellite TV channel ATN Bangla on the occasion of word TB day.

A national level awareness campaign in favor of a clean cooking solution popularly called 'Clean Cook Stove (CCS)' was aired in major satellite TV channel. The TVC highlighted the hazards of the smokes emitted from the traditional cook stove and the benefits of using CCS.

B3 IR3: Improved and Sustained Service Quality through Capacity Building of Local Formal and Non-formal Private Providers

SMC created networks of knowledgeable and reliable providers that can be easily accessed and trusted to provide high-quality products and services. Providers were motivated to actively reach out to their customers with a wide range of products, services and provide accurate information about FP and RH, MCH, nutrition and TB, as well as to make referrals for LAPMs, TB and other infectious diseases, as required.

B3.1 Increased Training and Referrals

B3.1.1 Blue Star Program

The Blue Star Program is a social franchising network of 5,881 community-level non-formal health providers who are trained on family planning, reproductive and child health, nutrition, TB with other public health priority areas to offer quality services to the customers. The vision of Blue Star is to create a network of skilled community level health providers offering a wide variety of public health products/services and refenals to improve health, family planning and nutrition related indicators within the community. Following are the major accomplishments of the Blue Star Program during the LOP:

Capacity building of the BSPs

SMC provided training to 2,907 new NGMPs and brought them under the Blue Star network across 12 SMC area offices during the MIH period. A total of 7,607 BSPs received refresher training at the same period. SMC trained more BSPs than the anticipated target considering the attrition rate and to remain the BS number at 6,000 at the end of the project. The number

Page 22 ofrefresher trainings was also revised after introducing Sayana Press. SMC emphasized to organize Sayana Press administration session for additional number ofBSPs as many BSPs were not confident to administer Sayana Press. This together resulted 127% achievement of refresher training. SMC planned to expand services, ensure quality of services and improve refenal services by the BSPs under MIH program. Therefore, SMC revised existing training culTiculum at the beginning of the training. The cuniculum includes FP methods such as injectable, referral for LAPM, counseling skills, HTSP, maternal health, specifically antenatal care, safe delivery, postnatal care, A training session with BSPs essential new born care, IMCI focusing on acute respiratory infection (ARI)/pneumonia, diarrhea, tuberculosis, child nutrition, record keeping and reporting. Training also covered detailing of all SMC products. Basic training sessions were conducted with the assistance of private sector training agency AIT AM Welfare Organization while OGSB along with its consortium (EngenderHeal th and Eminence) were selected to conduct the refresher training. SMC introduced FP Injectable Sayana Press during the FY 2015. Through the 'Refresher Training including Sayana Press of Blue Star Providers' SMC has provided 3 days refresher training to 5,881 BS providers during the program period.

Regional workshops

SMC organized eight regional workshops dwing the project peliod to recognize and build further goodwill with the blue Star Providers. More than 2, 100 providers participated in the workshops. Senior government officials and representatives of partner NGOs also attended these workshops. These workshops played an important role in motivating these providers and enhancing their commitment to the mission of improving health and wellbeing of the communities. During these workshops, a total of 138 BSPs from 40 districts were recognized for their perfmmances and awarded by the local government and SMC officials.

Regional workshop with BSP A BSP is sharing his expeliences to be a best performer at Regional workshop

Training on Sayana Press through regional workshop for BSPs

Sayana Press is a new entrance to the Blue Star program. Field observation demonstrated that some BS providers were not confident to administer Sayana Press. Therefore, SMC emphasized to organize a further Sayana Press administration session. In FY 2015, as an opportunity SMC reorganized the regional workshop modality to make it more interactive

Page 23 and effective for BSP. The first half of the workshop focused on Sayana Press administration technique and the second half focused to review performances like refe1Tal for LAPM, TB, timely reporting, proper documentation and best practice sharing. In FY 2015-16, a total of 3,480 existing BSPs were trained on Sayana Press administration through regional workshop. The following table shows targets and achievements of training conducted for Blue Star providers dming MIH period: Table 8: Number of BSPs received training under MIH program

Subject Target FY FY FY FY Total 'Yo 2013 2014 2015 2016 Basic training 2,600 800 1,548 358 201 2,907 112% Refresher training 6,000 1,315 1,644 2,109 2,539 7,607 127% Training through regional 4,000 1,881 1,599 3,480 87% workshop

Referral and directly observed treatment short course for TB

SMC in collaboration with the National TB Program (NTP) introduced DOTS services through selected providers within the BS network to increase coverage of TB services. As part of the initiative, DOTS implementation has been undergoing in the network under Dhaka West and Dhaka East area offices of SMC where a total of 157 patients received TB drugs through three BSPs under Dhaka East and West Area Offices.

Partnership with Mobile Alliance for Maternal Action project (MAMA)

SMC is a partner of the MAMA project, which is a public-private health sector initiative to create a mobile phone messaging program for pregnant women in 35 countries. The objective of the project is to improve awareness of health services through messages for pregnant and lactating mothers as well as for newborns and infants. In partnership with MAMA, a total of 244 Blue Star providers received training of Aponjon service (SMS services) and successfully registered 2,883 clients in selected districts during the program pe1iod.

Mobile interaction with BSPs

SMC created a detail profile of BSPs, PCHPs, CSAs and LARC providers to facilitate communication with them through frequent mobile messaging. This created a pathway for transmitting in1portant programmatic information and exchanging views with the providers. As part of the process, a number of communications with the providers such as messages on different health days was made during the program period.

Referral of TB and LAPM cases by BSP

The Blue Star providers are refeITing suspected TB cases for sputum test and necessary treatment and LAPM services to the nearest service delivery centre. During the program period, over 98,000 suspected cases of TB were referred to GoB and NGO clinics. Besides, 32,017 cases were referred for LAPM services to the nearest service delivery centre. The following graphs show targets and achievements of TB and LAPM referral services that were made by BSPs from FY 2013 to FY 2016:

Page 24 TB referral made by BSPs: FY 2013-2016 LAP Mreferral made by BSPs: FY2013 -2016

600 160 450 476 120 120 0 g 400 0 ~ !=> 80 i:: .E - 200 95 94 40 9 9 0 0 FY2013 FY2014 FY2015 FY2016 FY2013 FY2014 FY20 ·15 FY2016

• Target • Achievement • Target • Achievement

Demand creation activities

During the period, TV Cs and RDCs on SOMA-JECT injectable was aired in leading television channels in order to significantly improve awareness of the brand among clients. SMC conducted loudspeaker announcements to create awareness about the providers and their services at the community level. This activity proved to be an effective and quick initiative to improve the coverage especially for SOMA-JECT and Sayana Press Injectable. Besides, all Blue Star outlets have been branded with an SMC Blue Star signboard and provided with promotional materials.

Several communication and marketing tools and materials have been developed as part of the launching campaign of Sayana Press. Different promotional materials like poster, leaflet, display board, detailing card and dangler on Sayana Press have been developed for providers during FY 2015-2016. Besides these, mass media campaigns on Sayana Press were can-ied out through leading national newspaper to reach target audiences. A semi-annual newsletter "Alap" were published for Blue Star providers with an objective to improve knowledge of BS providers and quality of services by providing necessary information and suppo1is. SMC has reached out to this large providers group with consecutive seven issues of"Alap" news letter.

Contribution of BSPs

Strong collaboration and participation with NGOs, GoB and relevant professional authorities such as OGSB can accelerate the achievement of BS program and its goal. SMC successfully established and strengthened linkages with public, private, NGO and professional bodies to ensure favorable policy and programmatic supports. It is evident that the private sector network is one of the best channels to introduce new public health products and increase access of health care services. These providers or drug sellers can increase access to contraceptive and injectables at bard-to-reach areas. The following table shows contribution ofBSPs during the 4 year periods of different contraceptives, maternal, child and hygiene products:

Table 9: Contributions ofBSPs to CYPs, DALYs, unintended pregnancies and death averted

SL Products Achievement Sales tontribution CYPs Unintended DALYs Deaths No. achievement ~o national provided pregnancies averted averted of BS providet ~ale by BSP nverted l OCP 153.lm 21 .36 m 14% 1.42 m 0.33 m O.l7m 2042 2 Condom 603m 28.45 m 55% 0.24m 0.03 m 0.017 m 213 3 SOMA-JECT 5.83m 5.04 IIl 86% 1.26m 0.28 lil 0.14m 1779

Page 25 SI. Products Achienment Sales Contribution CYPs Unintended DALYs Deaths No. achievement to national provided pregnancies ~verted averted of BS provider sale bv BSP averted 4 Savana Press 0.2m 0.16m 80% 0.040m 0.009 m 0.005 m 57 5 ECP l.99m 0.25 ll1 13% 0.012 ll1 0.0012 m 0.0006 m 8 6 ORS 1756m 193.96m 11% 4.8m 54,807 7 MoniMix 45m 30.34 m 67% 8 SMC Zinc 2.79111 0.74m 27% 0.0027 32 tablet 9 Safe delivery 0.66m 0.18 m 27% 0.012 m 136 kit 10 Sanitary 6m 0.58 m 10% napkin Total 2.97m 0.65m 5.14m 59,074

B3.1.2 Long Acting Reversible Contraceptive Program

Although Contraceptive Prevalence Rate (CPR) has increased impressively over the last decade, little or no growth has been observed in the use of long acting method like IUD and implants. According to BDHS 2014, only 8% of currently married couples use a Long Acting Reversible Contraceptive (LARC) or Permanent Method (PM). The use ofLAPM has increased by less than one percentage points during the last decade. SMC has initiated a program to promote Long Acting Reversible Contraceptives by making them available and accessible through graduate medical practitioners, clinics, hospitals and NGOs as private sector initiatives.

USAID has donated substantial quantities of IUDs, Implants and Injectables to support this initiative. SMC is implementing this program in partnership with EngenderHealth through a collaborative effort of DGFP and the Obstetrical and Gynecological Society of Bangladesh (OGSB). SMC also worked closely with SHOPs in implementing the LARC program since inception to February 2014. SMC has over-branded IUD (TCu 380A, Optima) as Relax and Implant (Jadelle-75 mg X 2 sticks) as i-plant to create a favorable brand image.

In order to become eligible to be a SMC LARC provider, one needs to be a doctor practicing in a private chamber; has adequate number of women clients; space for counseling and provision of maintaining privacy; and willing to comply with the infection prevention practices. The selected doctors who were willing to provide LARC services, they were required to sign a consent fonn in order to participate in the training program and to be enlisted in the network.

Training of the graduate providers and distribution of contraceptives

EngenderHealth has provided necessary training to the private doctors and were responsible to ensure quality assurance of this program. Over nine hundred individual graduate doctors received training on IUD, implant and injectable during the program period. In addition, 308 doctors received refresher training and 225 assistants of these doctors received training on FP counseling and Infection Prevention Procedure (IPP). The basic training performance was 32% more than the anticipated target. The main reason was to engagement of OBGYN (Obs and Gynae Specialist) at the mid of program in FY2016. Therefore, instead of 22 refresher trainings, SMC organized basic training for these new members. Over 60 facilities/

Page 26 institutions (hospitals, clinics, private medical college and hospitals) were also involved to offer LARC services throughout the country.

Out of total LARC providers, 829 doctors were individual providers and 98 were under institution. In the network, 88% were female and the rest of them were male. The network is now covering 61 districts in 7 divisions. The following table shows targets and achievements of basic and refresher training for LARC providers planned under Mlli program:

Table 10: Number of LARC providers received basic and refresher training in four years period

Category of iLOP Target FY FY FY FY Total Yo Trainine 2013 2014 2015 2016 achievement Basic trainin_g 700 197 259 191 1280 927 132% Refresher training 500 94 127 ~7 308 62% Assistant training 200 1I7 108 225 113%

Sales performance

A total of 17,204 Relax-nJDs, 6,945 I-Plants (implants), 44,958 SOMA-JECT and 3,120 Sayana Press injectables have been sold to graduate doctors and private institutions and NGOs. The following figure illustrates the sales trends of Relax and I-plant during FY 2013 to FY 2016: Relax and I-plant Sales Status FY '13-'16

8.. 000 5,681 6,385 6,000 4,000 3,277 1,335 2,052 2,532 2,000 1,026 0 Relax I-plant • FY2013 • FY2014 • FY2015 • FY2016

Evidence Based Management Workshop with Doctors ofLARC network

In FY 2014-2015, SMC organized 14 Evidence Based Management (EBM) workshops with doctors of LARC program with a view to review program performance; share best practices and discuss the way forward. A discussion about the global status of LARC was conducted by the expert panel in the meeting. Departmental Head of GYN &OBS of Shaheed Suhrawardy Medical College, Professor Farhana Dewan, chaired the question-answer session. Representatives from CCSD and local FP officials attended the workshop and assured to provide all smts of suppmt from the CCSDP/DGFP.

Best perfonners of the LARC Program shared their experience in the context of client selection, motivation and service delivery. The expert panel presented various instances to motivate providers and to remove confusion on IUD and implants.

Page 27 This experience sharing workshop helped to motivate and build confidence among the poor or layperson LARC providers for administe1ing LARC. As a result, administration ofLARC is gradually increasing.

Engagement ofOGSB to enhance LARC service delivery and advocacy

OGSB is a national forum of Obstetricians and Gynecologists of Bangladesh. OGSB is mandated to improve maternal and neonatal health along with reproductive health in Bangladesh with 1,300 members in 13 branches around the country. In January 2015, SMC signed a MOU with OGSB in an effort to strengthen the delivery ofLARC services across the country. In March 2015, SMC organized a National Planning and Advocacy workshop with central OGSB branch where presidents and secretaries of 12 branches were also present.

EBM workshop at Dhaka AGM and conference ofOGSB at Signing ceremony between OGSB and Cox's Bazar SMC Regional planning and advocacy workshops

During FY 2015-16, with support from SMC/USAID, OGSB organized twelve Regional Planning and Advocacy Workshops with the members of OGSB branch offices. The objectives of the workshop were to engage OGSB members in the OGSB-adopted initiative on LARC activities of SMC through p1ivate sector, planning activities for detailed in1plementation, advocacy for LARC by OGSB members as well as service delivery and identify the way forward. The expected output of involving OGSB members was to increase utilization of LARC method by the private sector health system network.

Demand crelltion activities

A comprehensive demand creation and brand promotion activities were implemented in order to increase utilization of services through LARC network of p1ivate graduate doctors.

SMC focused in outlet promotion through signboard/banner and product branding through brochures/leaflets and posters to create demand on LARC. Brochures and leaflets have been distributed to the providers for distribution among the clients. SMC also developed promotional materials (pen, key ring, and purse) with brand logos of Relax and I-plant for LARC providers and their attendants as promotional item to remind them about LARC.

TVC on LARC methods, Relax and i-plant, were aired in popular television channels. Jn addition, billboards were installed in strategic location of the countty throughout the program period to promote the LARC method and brands. Advertisements on SMC's Tele-Jiggasha

Page 28 services were also published periodically in daily newspapers in an effort to attract potential users of LARC for meeting their queries over telephone.

SMC conducted loudspeaker announcement within the territory of LARC provider with a view to promote doctors under the LARC network and create local level awareness for availability ofLARC services at the provider's chamber.

B3.1.3 PCHP Training Program

The PCHP training program is creating a network of informal health providers (drng sellers) in the community to offer over the counter information and services. Under the MIH program, SMC has revised its PCHP training strategy to make it more intensive by reaching out to providers only in the 19 priority districts. PCHPs play a vital role in health care delivery system of Bangladesh. They provide most of the primary health services to the community.

The PCHP training program has been initiated to develop a cadre of motivated and proactive informal providers so that they can provide quality information/services to the customers they se1ve and limit the irrational use of drugs including the misuse of antibiotics. SMC has four teams under its Dhaka East, Comilla, Barisal and Sylhet Area Offices to execute the task. SMC has selected OGSB as training organization to assist modifying training curriculum and facilitate the training sessions.

Provider selection through mapping exercise

A mapping exercise was conducted dming the 1st and 2nd quarter of FY 2013 and FY 2014 through which over 30,000 providers were selected from 19 priority districts in two phases to bring them under the network. SMC has developed a database to keep track of the program activities. The providers were selected based on selection criteria: providers who are selling drugs permanently sitting in phannacy (may or may not be owner) and who is either doing practice or providing over the counter information; preferably has minimum SSC level of education; has willingness to attend training sessions and to act as referral agent for public health primity services.

Basic and refresher training ofPCHP

SMC scheduled to conduct basic training for 20,000 new PCHPs and refresher Training Receiving Status of PCHP: FY 2013-2016 training for 15,000 PCHPs across 19 10,912 priority districts during the project 12,000 period. More than 20,000 PCHPs received basic training and 13,245 PCHPs received refresher training across 4,000 the country. The target of organizing 0 refresher h·aining was not met due to FY2013 FY2014 FY2015 FY2016 countrywide political unrest during 1st quarter of FY 2015. The figure shows the number of participants who received basic and refresher training from FY 2013 to FY 2016:

Page 29 Increasing access to injectable contraceptives through PCHP

In FY 2015, SMC aimed at increasing access to injectable contraceptives through PCHP. PCHPs linked with Blue Star and/or other trained providers who gave the first dose and PCHP providers administered subsequent doses. The Directorate General of Family Planning (DGFP) issued the approval for piloting the follow up doses of SOMA-JECT injectable through PCHP. More than 2,000 PCHPs have been trained on SOMA-JECT follow-up doses from the 19 priority districts during FY 2015-16.

Tablell: Training achievement of PCHP program

Category of training Target FY FY FY FY !Achievement % 2013 2014 2015 2016 Basic 20,000 5,371 8,665 6,225 20,261 101% Refresher 15,000 2,333 10,912 13,245 88% SOMA-JECT follow up dose 2,000 1,580 511 2,091 105%

B3.2 Strengthened Linkages with other Public and Private Sector Partners

Collaboration with SHOPS for IUD and Implant services through private hospitals and facilities: SHOPS project was primarily responsible for developing network for IUD and Implant at the institution level. In collaboration with SHOPS for TIJD and Implant, SMC has provided promotional materials to the facilities supported by SHOPs during FY2013- 2014. SHOPS project ended during Febmary 2014.

Collaboration with NTP for introduction ofDOTS: SMC in collaboration with National TB Program (NTP) introduced DOTS services through selected providers within BS network to increase coverage of TB services as a part of the national program. As part of the initiative, DOTS implementation has been undergoing in the network under Dhaka West and Dhaka East Area Offices of SMC where a total of 22 Blue Star providers received training to provide DOTS services to TB patients.

Collaboration with DGFP for basic training ofBlue Star provider, and conducting workshop and advocacy meeting: The MIH program ensured involvement of senior government officials (Divisional Director-PP, Deputy Director-PP, Line Director- CCSDP and others) for generating support and effective implementation of the basic training and regional workshops of the Blue Star program and Evidence Based Management workshops of the LARC program. The Community Mobilization partners organized advocacy meetings at the upazila and district level where high government officials such as Deputy Commissioner, Civil Surgeon, DDFP, District Education Officer and other relevant stakeholders were engaged in that event during the program period.

Collaboration with Ministry ofEducation: SMC received approval letter from the Ministry of Education to implement the School Adolescent Health Program in 19 priority distticts. This approval, with directive to the school authority to arrange such orientation, had become ve1y instrumental to implement the program.

Collaboration with mobile alliance for maternal action project (MAMA): SMC is a partner in MAMA, a public private health sector initiative to create a mobile phone messaging program for pregnant women in 35 countries. Through the partnership with MAMA, a total

Page 30 of 244 BSPs received training to provide messages to pregnant mothers during their antenatal period.

Collaboration with Catalyzing Clean Energy in Bangladesh (CCEB): SMC conducted demand creation activities for increasing the uptake of Clean Cook Stove (CCS) among the public. In this effort, SMC is pursuing a collaborative approach with the major player in this arena among which are: GIZ, Grameen Shakti and Catalyzing Clean Energy in Bangladesh (CCEB). SMC has signed a formal Memorandum of Understanding (MOU) with CCEB on 12 November, 2013 with a focus on joint approaches ofBCC where SMC would leverage its communication activities with that of the CCEB and vice versa. As a part of collaboration, SMC developed a TVC to promote use of improved clean cook stove rather than traditional cook stove for ensuring healthy life and environment.

Collaboration with OGSB to strengthen LARC services: SMC signed a MOU with OGSB to strengthen LARC service delivery. Govt. high officials ofDGFP and DGHS attended the signing ceremony. Line Director CCSDP ofDGFP was also present during the National Planning and Advocacy Workshop.

Collaboration with CCSDP to involve volunteer in LARCIPM: A working group has been formed under the leadership of CCSDP of DGFP to involve volunteers at the local level to improve the situation of LARC/PM in Bangladesh. In this regard, representatives from SMC, BRAC, NHSDP, Engender Health and CCSDP worked periodically together to develop a strategy and training curriculum to engage volunteers and 01ient them at the local level.

Increase access to injectable contraceptive through PCHP: In order to increase access of injectables through PCHP, DGFP issued the approval for piloting the follow-up doses of SOMA-JECT injectable through PCHP.

Collaboration with DGFP for basic training ofBSP and LARC provider on Sayana Press: In FY 2015, SMC received approval from CCSDP ofDGFP to initiate Sayana Press administration through BS and LARC providers.

Participating in the team for developing the joint USAID FP BCC campaign: SMC worked in the team for developing the joint USAID FP BCC campaign along with BCCP, BKMI, Engender Health and Save the Children. The objective of the team was -

• To develop a shared vision for the new campaign by USAID implementing partners • To prepare a campaign matrix that includes intended audience, current behavior, desired behavior and barrier to desired behavior • Develop a robust and highly visible Family Planning (FP) Campaign.

The new FP campaign is not a stand-alone initiative and it would help revitalize the countiy's overall family planning program. The team considered the big picture of the overall health sector while conceptualizing and designing the campaign so that it complements and supplements other reproductive health programs in Bangladesh.

Page 31 C. Contribution of SMC to the National Program

SMC is an integral part of the national program in achieving the goals of the health and population programs in Bangladesh. Population science experts used three critical measures of contraceptive effectiveness - Total Fertility Rate (TFR), Couple Year of Protection (CYP) and Contraceptive Prevalence Rate (CPR). Between 1975 and 2014, the total feitility rate of the country dropped from 6.3 to 2.3, and the overall contraceptive prevalence rate among currently manied women rose from 8% to 62%, with modern contraceptive use at 54 percent (BDHS, 2014). SMC is significantly contributing in the modern contraceptive methods to achieve national contraceptive goals.

According to BDHS 2014, over one-third of all couples adopting family planning use SMC marketed contraceptives. Slightly over 62.0% of condom users, 43.5% of pill users and more than 18.0% of all injectable users rely on SMC contraceptives to protect themselves from Contribution to the National Program having unplanned pregnancies. A recent audit Couples using SMC contraceptives survey also revealed that SMC is enjoying 61 % "BOHS, 2014 market share of condom, 74% OCP and 50% national market of ECP. SMC is one of the largest contraceptive social marketing organizations, ranked second globally in 2015 in te1ms of numbers of CYPs delivered. 4 SM C's ORSaline has proven itself as a major contributor to achievement of the health and population objectives of the Government of Bangladesh. ORSaline was launched in late 1985 to enhance the availability of ORS to address mortality and morbidity due to diarrhea among under 5 year children in Bangladesh. SMC sold 562 million sachets of ORS in 2015 which represents over 55% share of all ORS purchased nationally. The usage of packaged ORS in diarrheal cases among the under five year children has increased from 61%in2000 to 77% in 2014 (BDHS, 2014).

SMC is leading the effort to increase the use of micronutrient powder among children, and ORS and Zinc as an adjunct therapy to treat diarrheal episodes of children. In the female hygiene market, SM C's JOY A sanitary napkins have quickly become the third most popular brand in the cotmtry (enjoying 13% percent market share) with wide appeal among low­ income women and adolescents due to its quality and low price. Under MIH, SMC provided 16.08 million CYPs, sold 1,927 million sachets of ORS, 2.24 million Zinc Tablets, 48.37 million sachets MNP, 6.51 million sanitary napkins and 0.57 million Safe Delivery Kits.

A baseline and end line study was conducted by MEASURE Evaluation to determine impact achieved by the MIH program. Findings show that knowledge and behaviors of certain indicators have increased significantly in experimental areas than comparison. For example, the use of sanitary napkin by unmarried women of age 10-25 years increased 28 .2 percentage points in intervention areas as compared to 7.5 percentage points in non intervention areas;

40lson D, (2015) Social Marketing Contributes to 20% of contraception in developing countries, Huffington post article, 2015

Page 32 23 .6 percentage points increase in use of safe delivery kit at last birth outcome during last three years as compared to only 6. 5 percentage points increase in non-intervention areas; contraceptive prevalence of modem method in intervention areas increased by 2.8 percentage points in intervention areas; MNP use among children under-five years increased by 25.2 percentage points in intervention areas as compared to 9.8 percentage points in non­ intervention areas.

SMC operations during the MIH period have averted 3.29 million unintended pregnancies, 0.57 million deaths of children under-5 and 49.43 million disability adjusted life years (DALYs).

D. Technical Assistance of Project Partners and OGSB

Population Service International (PSI)

PSI has provided technical assistance to SMC covering a range of programmatic areas and operational needs, with a focus on marketing suppmi. Following are the major activities of PSI conducted during the MIH program period:

Research

PSI provided technical assistance to qualitative study, using PSI's FoQuS methodology, quantitative study; an availability study and a consumer panel research. The PSI regional researcher visited Bangladesh several times during the program period and worked closely with the research and sales team to define the scope of the study, including objectives and the methodology, developing the RFP for a local research agency as well as receiving approval from Research Ethics Board (REB).

Marketing and sales planning

Like SMC, PSI makes extensive use of private sector marketing techniques for product distribution as well as communication. It has created a marketing planning process, called DELTA, which is an easy-to-implement package of private sector marketing concepts combined with social objectives. The process emphasizes brevity, tight consumer focus, and attention to the 4 P's of marketing (price, place, product and promotion).

Global social marketing collaboration

PSI and SMC have been able to rekindle their longstanding relationship, and to share social marketing best practices, to the benefit of both organizations. PSI's President and CEO, Karl Hofmann, visited Bangladesh for three days in May 2013. He had the opportunity to meet senior staff from USAID/Dhaka and the SMC Board of Directors, and to share experiences and challenges in global social marketing. He also visited SMC's ORSaline factory in Bhaluka, which is one of the few examples of vertical integration in the social marketing world.

The participation of two senior SMC staff members, GM-Program and Head of Marketing, in a PSI regional social marketing conference in August 2013 also significantly contributed to the exchange of social marketing ideas. The meeting was attended by PSI senior staff from PSI/Washington and 14 country programs in Asia and Eastern Europe.

Page 33 Deputy Manager for BSN participated in the workshop on Integrated Service Delivery (ISD) and Social Franchising (SF) organizing by PSI in April 2016 in Nairobi, Kenya. The goal of the meeting was to define and design social franchise models that have quality, cost­ effectiveness, health impact and equity at its core. Participants learned to identify action points that will improve their understanding on how PSI SF metrics can help improve SF network perfom1ance; learned more about the Tunza new business model; build capacity on ISD, including an introduction to the integrated quality assurance framework.

A provider behavior change communication (PBCC) workshop was conducted in Cambodia to equip participants with knowledge of PBCC as a means to persuade providers to adopt new behaviors and with skills to utilize planning tools to effectively manage provider interactions for maximum productivity and to develop messaging targeting providers. SMC's Marketing Manager attended the workshop.

Mr. David Walker, Global Director of Social Marketing came to Bangladesh in mid­ November 2013, he got the chance to meet extensively with SM C's senior staff members. He was able to share inf01mation on a new tool, called the Sales and Distribution Tool, which PSI has developed to improve the efficiency of social marketing sales networks. The tool helps social marketers to focus their sales efforts on the highest opportunity sales channels.

Sub award management

A team from PSI's Grants and Contacts (G&C) department visited Bangladesh in March 2014, to conduct training on sub awards management. Correct management of sub awards is crucial for successful partnering and for compliance with donor policies. PSI has significant experience managing sub awards globally, in over 60 country platforms, and has been able to share its expertise with SMC through video conference calls and an in-country workshop. The G&C training began with a series of preparatory video chats between the PSI and SMC teams. Two of PSI's G&C team members came to Bangladesh for a week in March 2014 for training and experience sharing. They covered topics such as solicitation and assessment of potential sub award partners, monitoring and evaluation of sub awardees, and the development of a sub-awards management policy manual.

Interpersonal communication assessment

The IPC sessions of community mobilization program are designed to reduce the barriers to better family planning, adolescent health, and maternal and child health and encourage uptake of SMC and BRAC social marketing products. PSI and SMC conducted a joint assessment of the IPC program during 2014, in order to maximize the effectiveness of communication teams. The purpose was to increase the capacity of key leaders within the MIH program to assess this important communication medium.

A senior consultant and former PSI employee, Neil Boisen, visited Bangladesh for 10 days during early May 2014 to guide the assessment. Neil Boisen compiled the information into a final report, which comprised two video presentations, an IPC program evaluation tool, and short list of key recommendations. The final repo1t includes 40 key recommendations, divided into four categories: focus, engagement, exposure and supp01t. An overarching recommendation is to reduce the number of messages. There are approximately 32 separate behaviors in the program, making it difficult to achieve measurable change. The repo1t recommends reducing the number of behaviors, and suggests eight key ones, based on

Page 34 estimated health impact, links with SMC's products and services, and the likelihood of impacting behavior.

Capacity building: During the fiscal year 2015, PSI provided SMC with several opportunities for staff and institutional capacity building:

Writing skill workshop: In order to assist middle and senior SMC staff to improve their skills at business writing and presentations, PSI organized a series of short workshops by engaging an international consultant.

Innovation workshops: In December 2014, PSI conducted two innovation workshops. The first was an innovation session with SMC's leadership team focusing on how innovation can be best supported within the organization and providing innovation tools to SMC senior management. The second was Performance Improvement Process (PIP) workshop with a diverse group of managers and officers at SMC. The PIP focused on generating solutions that helped achieve the goal to "Grow SMC through expansion into new health areas". The workshop helped to develop the group's innovation capabilities in a real world situation and to generate innovative solutions to meet challenges.

Provider behavior change communications workshop: PSI conducted provider behavior change communication (PBCC) workshops for SMC's Program Officers (POs), Program Coordinators (PCs) and Sales Promotion Officers (SPOs) during April - May, 2016. The goal of the workshop was to increase effectiveness of communications with providers by integrating PBCC techniques into the job aids of field staff. Through this workshop, participants learned how to build productive and long-lasting relationships with the providers, how to address individual provider needs and barriers to behavior change, as well as provide innovative solutions, how to effectively listen to provider and incorporate their feedback into a tailored approach, and how consistent and timely to provide follow-up visits.

PBCC message development training: A one-day training where the team learnt to identify provider needs and barriers and then develop messages to handle the same. Team was also guided on creating visual aids and tools. Supervision and Coaching Training where, participants learned how to provide coaching, supervision and essential feedback to the field officers.

Data-driven decision making workshop: In July 2016, PSI organized a two-day workshop for SM C's senior management team and implementing partners to improve data management and analysis for decision-making. Through the workshop, participants discussed the results of the MIH project, analyzed the data from the MIH project evaluation repo1t, and identified main barriers, success and lessons learned. In addition, participants identified the decisions they need to make for their programs, as well as actionable ways on how they can use data to inform their work.

Use of technology

To streamline and standardize the monthly repo1ting system for 6,000 BS Providers, PSI together with a local IT company set up the Interactive Voice Response (IVR) mobile technology that allows a computer to interact with humans through the use of voice and to input data via keypad. The new IVR Reporting System was set up in the SMC office and launched at the end of June 2016.

Page 35 New Business Development (NBD)

PSI provided technical assistance in building the capacity of SMC staff appointed to be focal points in new business development approach. PSI Regional NBD Manager conducted several workshops, where she provided information on donor mapping, proposal development process - pre-proposal preparation, NBD tools to get the process started, annex development, initiating proposal writing and learn how to review proposals. The main vision of this initiative was to build the ability of country staff to be proactive in business development, proficient in positioning for bids and be skilled in leading proposal processes.

Marketing

PSI and SMC have engaged with Fmward Business Network (FBN), the developers of Movercado, a simple, yet powerful technology that has the power to link organizations, markets and populations together into one self-organizing eco-system. FBN has worked closely with SMC in identifying priority areas, establishing connectivity with a local aggregator, and creating a local interface for Movercado that can be customized and used in future programs in Bangladesh.

EngenderHealth

EngenderHealth, being the training partner ofMIH, is providing training to the providers on IUD, implant and injectable services. SMC is also working closely with the Obstetrical and Gynaecological Society of Bangladesh (OGSB) and the DGFP/MOHFW in the implementation of its LARC program.

Obstetrical and Gynaecological Society of Bangladesh (OGSB)

OGSB is the national forum of obstetricians and gynaecologists of Bangladesh. OGSB is mandated to improve maternal and neonatal health along with reproductive health in Bangladesh with 1,300 members in 13 branches around the country. In January 2015, SMC signed a MOU with OGSB in an effort to strengthen the delive1y of LARC services in Bangladesh through involving physicians of OGSB. In March 2015, SMC organized a National Planning and Advocacy workshop with central OGSB branch where presidents and secretaries of 12 branches were present. A total of 213 OGSB members were trained on IUD, implant and injectable and they entered into the network ofLARC program. During FY 2015-16, with support from SMC and USAID, OGSB organized 12 Regional Planning and Advocacy Workshops with the members of OGSB branch offices. The objectives of the workshops were to engage OGSB members in the OGSB-adopted initiative on LARC activities of SMC through private sector, planning activities for detailed implementation, advocate for LARC by OGSB members as well as service delivery and identify the way fo1ward.

E. Monitoring, Research and Evaluation

El. Monitoring activities under MIH

The monitoring and evaluation plan is designed to evaluate the impact of the project and get continuous feedback on the use of products and services, practice of behaviors changes in

Page 36 behavioral factors, and availability of health products at the national and district level for priority areas. SMC monitored its program operation activities in the following ways:

Routine Data Collection

Integrated Management Information System (/MIS): SMC has its own automated integrated management and information system (IMIS) to capture sales and distribution activities of products. The project used the IMIS to monitor activity level indicators such as sales by brand, geographic location, and type of outlet. Using the IMIS information, SMC generated different information brief and shared it among the relevant stakeholders to inform them about the progress of activities. SMC ensured rep01iing on sales performance data to USAJD through quaiierly and annual repo1is and monthly to the national MIS of the government during the reporting period.

Customized Software/NGO MIS: SMC collected program data from the field for community mobilization, Blue Star, PCHP and LARC activities and compiled, analyzed and shared the data with its senior management, program staff, relevant partners, donors and other stakeholders.

An excel sheet was prepared to track the monthly sales of Community Agents. This information is generated by the field staff of partner NGOs. The findings are shared with the partner NGOs at local offices. SMC tracked the progress status by this sheet.

In addition, another platform has been developed for PCHP where detailed background profile of PCHP (age, name, training history, professional history, etc.) are recorded including number of training, selected training paiiicipants, training evaluation score of individuals etc. The LARC team also developed a data sheet for tracking the progress of Relax and Implant sales by individual providers and institutions. SMC tracked progress through these customized software.

Performance tracking tool: A tracking tool (graphical presentation of sales and services by month) has been developed for all programs under Mlli Project. Every month, program activities and sales related information is entered into the system to review the progress of the program implementation. Each month, after reviewing the tracking system, necessary feedback was given to respective managers to act accordingly, if required.

Use of technology: To streamline and standardized monthly reporting system for 6,000 BS Providers, SMC together with a local IT company and with the support of PSI set up Interactive Voice Response (IVR) mobile technology. The new IVR Reporting System was set up at the SMC head office and launched at end of June 2016.

Program Review Meetings

SMC organized review meetings with all program staffs (BS, LARC, CM, MFP, Floating IEC and PCHP) to share best practices, challenges faced, ensure mutual learning among the partners, as well as to know the program status. Program and research data presented for informed decision making in the meeting.

SMC organized 40 review meetings with its community mobilization partners at its head office during the period. The four implementing partners of community mobilization also

Page 37 organized monthly and quarterly meetings at their head office and field office during the same period.

SMC organized 11 quarterly meetings with MFP and five for Floating IEC team to know the performance and challenges faced at the field level during the program period.

In addition to this meeting with community mobilization partners, SMC also organized a retreat workshop for review and refine 'Notun Din' community mobilization program in 2014. Beside, SMC also organized five program performance review meetings with Program Officers and 12 meeting with PCHP team members to review the perfom1ance status, identify gaps and way forward and share future plans.

Workshops for BSP and LARC

In 2013, SMC organized eight regional workshops to recognize and build goodwill with the Blue Star providers at different region. This workshop played an important role in motivating providers and enhancing their commitments to the mission of improving health and well­ being of the communities.

SMC organized 14 Evidence Based Management workshops during 2014-2015 with the LARC providers with a view to review program performance; share best practices and discuss the way forward.

OGSB organized 12 planning and advocacy workshops with the member of OGSB branch offices during 2015-2016 with suppoti from SMC/USAID. The objectives of the workshop were to engage OGSB members in the OGSB adopted initiative in LARC activities of SMC through the private sector, planning activities for detailed implementation and identify the way forward.

Survey/study conducted to track the progress

SMC conducted a series of studies at regular intervals to monitor and track progress, outputs of program and sales activities. After completing research/evaluation, a dissemination presentation was held with relevant stakeholders to utilize insights for program improvement. Research brief developed for each of the studies so that all concerned managers can use it as a ready reference. The following studies were conducted during MIH period to track the progress of program activities:

• Tracking survey (TRaC) carried out for two times to understand the progress of community mobilization program at intervention areas. The main purpose of the survey was to monitor and evaluate progress in changing knowledge, attitude and behaviors of MWRA and caregivers of <5 years children on critical program indicators as well as to measure the exposure of target audiences on community mobilization activities.

• SMC initiated a consumer panel audit study among a representative panel of manied women of reproductive age and husbands of selected MWRA. This study will help to identify SMC product users and to determine the usage patterns; satisfaction with SMC products; brand and methods continuity and switching patterns etc. On the other hand, consumer panel will also help to understand the media behavior of the target audience.

Page 38 • SMC conducted availability and market size estimation studies of SMC and its competitors products with an objective to provide regular estimates of market penetration, market share and market size across a range of product categories. An audit survey was done to understand the market size and market share of four products, Condom, OCP including ECP, ORS and Sanitary Napkin.

• SMC conducted two surveys in order to assess quality of Blue Star (BS) and Long Acting Reversible Contraceptive (LARC) outlets. In addition, the study collected information from exit clients of BS and LARC providers to understand their health seeking behavior from the BS and LARC providers respectively.

Field Activities Monitoring

SMC ensured to monitor the activities and progress at every tier by supervisory visits in the project areas through field and head office level staff.

• Program Coordinators, Community Mobilization, located at the SMC area offices work with community mobilization paiiners to implement the program. They coordinate the mobilization activity, give promotional suppo1ts and monitor the program implementation and validate performance output report of the partners. During the project period, Program Coordinators, Community Mobilization conducted 1,753 visits to the program intervention areas and the SMC program team from head office conducted 361 field visits to monitor program related activities.

• In addition to SMC staff, project staff of four partner NGOs located at their central offices have conducted monitoring and supervision field visits (Regional Managers of BRAC made 1,067 visits, Project Managers made 530 visits, PO-BCC 843, PO-MIS 540, Accounts and Admin Officer 442 and Technical Officer-Monitoring and MIS made 167 visits). A total of 5,261 monitoring and supervision visits were conducted during this peliod.

• During the MIR period, program officers visited 35,220 (multiple visits) times to Blue Star Providers as a part of routine monitoring process. They monitored the overall compliance level of the providers with regards to: 1) Condition ofBSP signboard, 2) Injectable contraceptive stock, 3) Record keeping and 4) Monthly performance report. In addition, six quality assurance associates (QAAs) have been recrnited during FY 2016 for a six-month period to assess service delivery of BSPs as well as to provide technical assistance to improve knowledge and skills of BSPs. They visited 1, 100 BS outlets during their tenure.

• Program Officers made 2013 visits (multiple) to LARC providers to monitor the program activities and reviewed stock status of Relax, i-plant and SOMA-JECT, as well as to ensure smooth implementation of the activities.

• SMC has developed a facility audit checklist to assess readiness of an outlet to offer quality LARC services. Process of this audit is observation and scoring. Program Officers and Head Office staff used the tool while visiting facilities. The LARC Team members at SMC-Head Office visited outlets 250 outlets (including institutions) and field staff visited 2,013 individual providers to monitor the program activities in the reporting period.

Page 39 Data Quality Assessment (DQA)

In consultation with USAID, SMC ensured routine data quality audit and compliance with US government policies on family planning and other services.

SMC bead office and field office officials visited MIH upazilas to conduct DQA of community mobilization activities during the period. A total of 553 DQA were conducted by head office and field level office staff dming this period. DQA team collected recorded information of group sessions conducted with MWRAs, caregivers and husbands under community mobilization activities from dish·ict offices of partner NGOs. In order to ensure the validity and reliability of the data, the team verified the data collected from the office at village and household level and took appropriate measure on the findings ofDQAs.

E2. Quality Assurance Initiatives

SMC carried out several activities to assure quality of care under the MIH program for closing the gap between actual performance and the desirable outcomes.

Establish quality assurances system for BS and LARC networks

SMC assessed the quality assurance status of the providers under the Blue Star and LARC network through periodical assessment in the following key components:

• Technically competence to perform the tasks required • Proper screening of clients • Provision of comprehensive infmmation to ensure that clients have all the information they need to make an informed choice and never coerced into accepting the method. • Whether the providers recognize and respect the need for client's ptivacy and deliver services in a way that protects the client from being seen or heard by others if they desire. • Whether the clients receiving services have access to follow-up care.

All the quality assurance related activities were undertaken in order to get providers knowledge and practice through KAPP and client satisfaction through interviews of clients of the respective private sector health care providers like Blue Star, PCHP and LARC.

Recruitment: There are many ways in which quality performance can be assessed and assured beginning with the rigorous standards applied at the provider recruitment stage.

• Certification: Each of the providers under the network gets a signed certificate from approp1iate authority • Assessment ofthe physical quality ofthe clinic: Evaluation the ventilation system, lighting, cleanliness of the floors and power supply also been considered during recruitment of the providers under different networks. In addition the project also assured that the clinic has the proper space to ensure p1ivacy, a functioning toilet and hand washing facilities.

Training: Training and re-training are essential components by which SMC assured quality. SMC organized basic and refresher b"aining for the private sector health care providers in periodical interval.

Page 40 Monitoring of clinical quality: Regular monitoring and also assessment of clinical quality had been done both for BSPs and LARC providers.

Abstraction of medical records: This is the most common way of evaluating provider's practices. During regular monitoring visits the PO-TSD reviewed the service delivery registers maintained by Blue Star providers and provided onsite coaching to improve the system.

Monitoring of non-clinical quality: PO-TSDs used a checklist to review non-clinical quality indicators for improving the overall quality of service delivery such e.g. stock situation of products and supply, relevant job aids, posters and leaflets.

Feedback loop

A number of quality assurance systems not only include the guidelines and monitoring on quality, but also initiatives to motivate and engage behaviors of target audience in achieving high quality. In order to do that SMC organized regional workshop with the BSPs, advocacy meeting with LARC providers to keep the motivation upwards and to make the network live.

Quality assurance surveys

SMC conducted two surveys in order to assess quality of Blue Star (BS) and Long Acting Reversible Contraceptive (LARC) outlets in terms of its physical environment, available Logistics, equipment, BCC materials, counseling guideline, safety measures and record keeping system. In addition, study collected information from exit clients (MWRAs) of BS and LARC providers to understand their health seeking behavior from the BS and LARC providers respectively as well as to know their perceptions and satisfactions level regarding available services at the BS and LARC outlets. Qualitative data was collected through observation and quantitative data through exit-client interviews. This finding helped program staff of SMC to understand whether outlets of private sector networks are meeting minimum standard of service quality as per guideline as well as to identify gaps that exist to meet the standard quality requirement of the outlets.

Quality assurance campaign for Blue Star network

In 2016, SMC recruited six Quality Assurance Associates (QAA) with medical background for a sho1t period of time to assess the service quality of BSPs and also find out the areas need to improve as a patt of ensuring future quality focus areas. They visited 1, 100 BS outlets under ten area offices during December 2015 to June 2016. The main objectives of the visits were: assess knowledge ofBSPs; build technical capacity of BSPs; assess physical environment of outlet, observe availability of equipments/logistics and healthy behavior; organize on-site technical training and detailing and discuss product/service consumption.

Each QAA visited selected BSPs and completed assessments/interviews by using prescribed checklist/questionnaire and then entered into the pre-designed computerized database system. QAAs then conducted on-site coaching and feedback to the BSPs on the checklist. SMC produced a Quality Evaluation Repmt (QER) based on the findings of the visits of QAAs and generated recommendations for further learning to strengthen the BS Network. Project staff then immediately addressed all weaknesses or gaps identified through the visits of QAAs.

Page 41 E3. Research Activities under MIH

General Objective of the Research Department is to support and strengthen marketing and program efforts by providing managers with timely and appropriate information in a form that they can use it efficiently and easily for the decision making process. The market research will be able to flag key issues or concerns that show up in the data and inform marketing, sales and program team on such important changes. Following are the major research activities that have been undertaken by SMC during MIH period:

K ey R esearc h es w1"th Ob'1ec tive an d Its Util"1za f IOU STUDY NAME OBJECTIVE UTILIZATION OF FINDINGS FY 2013 Blue Star Census The overall objective of the study This finding helped to monitoring the 2012 was to create a complete profile pe1formance ofBSPs and accordingly field database ofBSPs and their SOMA- officials intervened to improve the JECT administration status. performance ofBSPs with special focus to poor performers. KAPP study among The main purpose of the study was Study findings were utilized to develop MWRA, eligible to explore information regarding BCC materials for improving knowledge men, and health knowledge and misconceptions of and removing misconceptions on LARC providers from contraceptive especially LARC and andECP. specific districts ECP. where CPR is relatively low. Pre-testing contents The main objective of the study was Based on client's feedback, scripts were of audio drama to test the contents of two drama modified to make it more user-friendly and based on scripts (HTSP and I ,000 Days) understandable to the target audiences. communication developed for community messages. awareness in terms of information, understanding languages and theme of drama. Availability study of The prime objective of the study This helped SMC's sales and marketing SMC and its was to assess the product team to find out the areas of improvement competitor availability status of SMC as well as to intensity the sales coverage and product products. its competitor products (OCP, distribution as well as to strengthen their Condom, ORS, micronutrient sales and marketing strategies. powder, Zinc and Safe delivery kit) to the outlets all over the country. Feasibility study to The main purpose of the study was SMC planned to introduce a premium know the market to know the current market situation branded bottled mineral water. However, status of bottled of different bottled mineral water this decision has been deferred and will be mineral water. and its estimated market size. considered in future to introduce bottled mineral water. Feasibility study of SMC call'ied out feasibility study to SMC planned to introduce an Artificial introducing know the present market status of Sweetener in the market. However, SMC artificial sweetener. artificial sweetener in Bangladesh. management decided to postpone due to low market size. FY2014 Understand the The objective of the study was to Findings reveal that Tasty Saline is mainly tasty saline market understand the Tasty Saline market used for non-diarrheal purposes and SMC more effectively to more effectively to position has an opporttmity to introduce an position upcoming upcoming SMC electrolyte drink. electrolyte drink to reduce thirsty and regain SMC electrolyte energy. SMC is working to develop this drink product. FoQus study to The prime objective of the stt1dy Based on study findings, the MJH program understand health was to understand how women gave more emphasis to reach and motivate care decisions make decisions about family other influential family members (husbands,

Page 42 STUDY NAME OBJECTIVE UTILIZATION OF FINDINGS during the first 1000 planning and birth spacing. The mother, mother-in-laws, etc.). In addition, days and healthy study also collected information project staff understood priority health timing and spacing regarding understanding health care messages for the community and tailored of pregnancy decision-making of caregivers of accordingly during mobilization sessions. children up to 2 years (1,000 days), particularly related to healthy pregnancy, and child nutrition and to the treatment of diarrhea and pneumonia among the target audience. Knowledge, The main purpose of the study was Study findings helped to identify areas attitude, and to assess knowledge, attitude and where gaps are still exists in terms of practice of trained practice of private community knowledge and attitude of providers. The private community health providers related to FPRH Program team modified training curricula health care provider issues as well as to examine the based on findings and ensured presence of effectiveness of training. SMC staff at every training session organized by other party for ensuring uniform knowledge dissemination and maintaining quality of training. Evaluation of the The purpose of the study was to The findings helped MIH mobilization team knowledge and gather information from the to understand knowledge of CS As on effectiveness of Community Sales Agents (CSAs) to FPRH, their activities, sales volume, Community Sales strengthen and sustain the demand baniers, challenges, way to increase profit Agent activities in generation and income generating margin, suggestions for sustainability etc. MID priority efforts of community level Based on findings, CSAs received adequate districts commercial sales agents. infomiation about health issues and products during monthly sharing meetings. They received opportunity to participate in the project events to be acquainted in the community to sell products and future interactions. Developing list of The purpose of the study was to The database was used to reach potential eligible clients of create a database of clients from acceptors ofLARC methods through Long Acting LARC network providers for telephone calls by the Tele-Jiggahsa team. Reversible identifying potential eligible Contraceptive acceptors of long acting reversible Methods contraceptive methods (IUD and Implant). Brand Awareness The prime objective of the study The findings helped SMC to improve its Trial and Usages was to assess the level of awareness marketing and promotional strategy in order Study (BA TU) on and usage ofMoniMix, Zinc and to increase awareness, purchase and sustain MoniMix, Zinc & Norix. use ofMoniMix, Zinc and ECP. Based on Norix the findings, SMC increased its efforts both at conununity mobilization activities and TVC campaigns. Conduct quality The purpose of the study is to assess Finding helped to understand whether assurance surveys of quality of outlets in terms of its outlets of private sector networks are the BSP and Longer physical environment, available meeting minimum standard of service Acting Method logistics, equipment, BCC quality as per guideline and targets set networks materials, counseling guideline, under MIH. Relevant team members safety measures and record keeping identified gaps and supported BSPs to meet system. the standard quality requirement. Household level The main purpose of the survey was The findings helped to identify the progress TRaC survey on to monitor and evaluate progress in of knowledge and behavior related critical program changing knowledge, attitude and indicators. Findings were utilized to identify indicators in 19 behaviors of married women of strong and weak areas where program priority districts reproductive age and caregivers of demands more and extensive efforts. Based under five years children on critical on identification, communication messages program indicators as well as to were redesigned to focus to the point. Also

Page 43 STUDY NAME OBJECTIVE UTILIZATION OF FINDINGS measw-e the exposure of target it helped to strengthen monitoring activities audiences on community to achieve expected results. mobilization activities. FY 2015 Conduct quality The purpose of the study is to assess Finding helped to understand whether assurance surveys of quality of outlets in terms of its outlets of private sector networks are the BSP networks. physical environment, available meeting minimum standard of service logistics, equipment, BCC quality as per guideline and targets set materials, counseling guideline, under MIH. Relevant team members safety measures and record keeping identified gaps and supp01ted BSPs to meet system. the standard quality requirement. Conducting a SMC planed to explore the Finding showed positive response from the Feasibility Study of possibility to enter into the potential graduate and non-graduate Pharma product pharmaceuticals business under the providers. Therefore SMC started its new marketing by the banner "Medicine for all." Before journey initially with toll manufacturing Social Marketing venturing into this new initiative, facilities which will be gradually shifted to Company SMC did a study to gather insights own manufacturing facilities. Currently from the market, assess providers' SMC has signed an agreement with a toll view ofSMC's decision to enter manufacturing company and subsequently into the prescription drug market, pmchased land for establishing a state-of-art the overall SMC marketing strategy pharmaceutical manufacturing facility by including pricing, potential list of 2020. drugs that they SMC will prefer to consider and any other challenges that SMC should be prepared for. Therefore, SMC has planned to undertake a study among providers and Medical Representatives. Consumer feedback SMC wanted to explore the Findings clearly indicated that there is an on Xtreme condom possibility of introducing a new opportunity to introduce a high-priced premium brand condom with high condom in the market for making profits as price. Before launching the new well as to serve higher socio-economic brand of condom, the marketing people. SMC is working for the new brand department wanted to get feedback and planning to introduce immediately. on SMC's premium brand condom Findings also identified consumers' need as well as competitors' brand, for any other product attributes. Moods and Dw-ex . The purpose of the study was to gather feedback, such as motivating factors, reasons for preference and identify the satisfaction level of the consumers with their cunent condom brands. Post launch study The purpose of post-launch study The findings helped to increase number of on Saya11a Press was to understand the acceptability providers for administering Sayana Press through BSPs. of Sayana Press among the through them considering its acceptability potential users as well as to get among the pill and non users. Findings also feedbacks from the providers who helped to do an analysis of consumption and received training on Sayana Press. projection pattern of Sayana Press.

FY2016 Understanding The objective of the survey was to Findings showed a positive response from SOMA-JECT assess the feasibility of the clients and providers. The Program team administration administering follow up dose of is utilizing findings to monitor the status by Private SOMA-JECT by PCHJ>. performance of PCHPs for improving Community administration status and to provide Healthcare technical supports to poor perfonners. In Providers (PCHP) addition findings helped to program staff for searching a way of enswing unintem1pted product supply. Findings also

Page 44 STUDY NAME OBJECTIVE UTILIZATION OF FINDINGS opened a door for improved access of SOMA-JECT by the PCHP across the country. Assessing the The purpose of the study was to Study identified several strengths, weakness Strengths, assess the strength, weakness and and opportunities to sustain this initiative. Weaknesses and opportunity ofNotun Din CSA Program team is utilizing study findings to Opportunities of Model and to understand how identify and select potential CSAs, to Notun Din community sales agents are improve capacity of CSAs, to introduce Community Agent performing and what changes and potential new products for increasing profit Model opportunities need to be addressed margins for CSAs, and to examine a to create a sustainable CSA sustainable product supply channel. program. Understanding The objective of the survey was to Findings guided to develop a motivational experiences of Long w1derstand source of awareness on campaign for clients and providers. It was Acting Reversible LARC, current use status, found that a motivational and practical Contraceptive influencing factor, service cost and session for providers is crncial to be (LARC) users satisfaction ofLARC services proactive and confident for offering LARC through telephone received from LARC provider. by providers. The Program team is working call on findings for its maximum utilization. Consumer Panel The aim of the consumer panel audit The first round of data collection has been Audit (1st phase): survey is to examine the usage completed and the second round will be patterns; satisfaction with SMC started soon. Already SMC is utilizing products; cotTect usage; brand and media behavior related information for methods continuity and switching airing TVCs. The study will provide patterns; reasons for discontinuation guidelines to strengthen marketing and and reasons for not using SMC communication strategy for SMC's products product, etc. both from maiTied and brands immediate after getting women and men. On the other hand, comparative findings of two episodes of the consumer panel will help to panel information. understand the media behavior of the target audience. Availability and The purpose of the study was to SMC is utilizing findings to identify low- Market Size understand availability of SMC performing geographical areas by product Estimation Study of and its competitor products across availability to strengthen marketing SMC Products the country both at pharrna and strategies. In addition, SMC is exploring non-pharma outlets. In addition, an innovative strategies for increasing its audit survey was done to market share of selected products. understai1d the market size and market share of four products, Condom, OCP including ECP, ORS and Sanitary Napkin.

E4. Evaluation

USAID involved Measure Evaluation to see the impact of interventions of IR2 designed under MIH. They collected baseline and endline information both from intervention/ experimental and comparison areas. Measure Evaluation has shared preliminary findings of Mlli key indicators with SMC and implementing partners. The following table shows changes occurred into key indicators due to interventions using difference (D) and difference­ in-difference (DID) analysis.

Page 45 Table 12: Findings of DID analysis using baseline and endline survey information

Key indicators Experimental f;?roup Comparison group DID Baseline Emiline D Baseline Endline D % ofMWRA who accurately report at least two 44.0 66.2 22.2 39.5 39.2 -0.3 22.5 specific risks/complications related to pregnancies before age 20 % of MWRA who accurately report at least three 22.6 37.8 15.2 20.0 15 .9 -0.41 19.3 possible/potential danl!;er si!!lls ofpreE!llancy % ofMWRA who are aware of the need of at 29.8 47.1 17.3 31.0 31.1 0.1 17.2 least four visits for health check-up during Ipregnancy % of MWRA who can specify correctly at least 7.5 27.1 19.6 5.6 9.9 4.3 15.3 two specific benefits of using safe delivery kits % of MWRA who are aware of ECP as an 1.8 27.3 25.5 2.1 3.7 1.6 23.9 effective way of preventing possible unintended conception % ofMWRA who accurately report at least two 8.5 43 .1 34.6 6.5 12.1 5.6 29.0 specific benefits of giving Micronutrient powder to children under 5 % ofMWRA who have a under-five children and 55 .7 80.7 25.0 50.9 60.6 9.7 15.3 are aware of U1e benefits of the use of Zinc with ORS as an adjunct therapy to treat diarrhea % ofMWRA who had a birth outcome in last 12.4 36.0 23.6 8.9 15.4 6.5 17.1 three years preceding the smvey delivered last time in home were assisted through safe delivery kit % ofMWRA who use(d) sanitary napkins 8.9 25.2 16.3 8.3 15. l 6.8 9.5 currently or last time % ofunmruTied women of age 10-25 years who 13.4 41.6 28.2 15.5 23.0 7.5 20.7 use(d) sanitary napkins currently or last time % ofMWRA who are CUJTently using a modem 46.9 49.7 2.8 46.9 48.9 2.0 0.8 contraceptive method % of children under-five who used MNP 2.8 28.0 25.2 1.9 11.7 9.8 15.4

Findings show that knowledge and behaviors of certain indicators have increased too many folds in experimental areas than comparison. The results using DID indicates that concerted efforts under MIH program brought a positive change in several knowledge and behavior related indicators. For example, the use of sanitary napkin by unmarried women of age 10-25 years increased 28.2 percentage points in experimental and 7.5 percentage points in compa1ison areas which shows 20.7 percentage points higher DID in expe1imental areas due to set of interventions.

F. Family Planning Compliance

USAID is committed to ensuring that women and couples in developing countries have access to voluntary family planning services and are free to make informed decisions about their reproductive lives. SMC involved a dedicated and experienced senior official as the 'Team Leader' to train new staff on FP legislative and policy requirements, as well as to comply and maintain records of all FP Compliance related issues. Under the MIH, SMC has implemented and monitored several activities in order to meet the terms ofUSAID Family Planning Compliance which are as follows:

• SMC oriented all new recruited staff on FP legislative and policy during Mil-I period.

Page 46 • Team leader discussed about FP compliance issue among relevant staff at every quarter. • All relevant MIH staff participated to complete the online course of FP legislative and policy requirements every year. • During basic and refresher training of Blue Star providers, 10,514 providers (multiple reach) trained on FP compliance related issues. • During basic and refresher training of LARC provider, FP compliance issues were discussed and a total of 1,235 graduate providers received orientation on FP compliance during training. • Dming basic and refresher training of PCHP, program staff discussed about FP compliances. A total of 33,506 PCHPs received training regarding this. • Program officers made several visits (including multiple visits) to BS outlets during MIH period. They assessed knowledge of the providers on the policy, observed the availability of TIAHRT poster, counseling provision and job aid in the outl.et. They provided correct and adequate information on all FP methods to user and service providers where needed. They also ensured the BCC materials (especially TIAHRT poster) in case they need the new one.

G. Environmental Compliance

Under MIH, SMC developed several guidelines and checklist and used as a part of quality of care and ensure infection prevention as a part of waste disposal protocol. Following are the activities SMC ensured as a part of the environmental compliance during MIH period:

• SMC developed a guideline for disposal of used syringes and needles of injectable contraceptives for the providers. A total of 9 ,514 BSPs were made aware during basic and refresher training sessions of Blue Star regarding this matter. • 5,530 sharp boxes were distributed to BSPs to ensure safe disposal of used syringes and needles and it ensured a clean environment inside the service delivery premises. • Dming MIH period, 927 and 308 graduate providers received basic and refresher training on IUD, implant and injectable respectively. Besides, 225 assistants of graduate doctors received infection prevention training. All of them were oriented on waste disposal system for used syringes and needles of injectable contraceptives. • More than 2,000 PCHPs received training on SOMA-JECT Injectable administration. During the training they were oriented about waste disposal system. • Dming monitoring visit of Program Officer and other relevant staff ofMIH, they assessed the knowledge of provider on waste disposal (part of Infection Prevention) and observed the availability of infection prevention poster and availability of sharp box. They discussed about waste disposal system and ensured the sharp box where needed.

H. Capacity Building of Staff

One of the core strength of SMC is to facilitate its staff for strengthening professional skills and capacity through need assessment on different issues. SMC provided opportunity among 21 staff to attend international training/workshops/conferences and 29 staff to attend at national level training/workshops/conferences under MIH program.

The capacity building areas were: Communication, Monitoring and Evaluation, Geographic Information System (GIS), Demographic Analysis, Financial Management, new USAID & CDC financial & compliance rnles and regulation, Strategic Customer Service

Page 47 Management, Project Management and implementation, marketing in health care organization, Provider Behavior Change Communication, Movercado, Environment and others. Besides, PSI as a technical partner organized several in -house capacity building trainings for SMC personnel using their international resources during MIH period which area as follows:

• Innovation workshops for SMCs leadership team focusing on how innovation can be best supported within the organization and providing innovation tools to SMC senior management. • Performance Improvement Process (PIP) workshop with a diverse group of managers and officers at SMC. • Organized a series of short workshops in order to assist middle and senior SMC staff to improve their skills at business writing and presentations. • Workshops on presentation and writing skills for journal articles, research writing, and wtiting technical briefs. • Provider behavior change communication (PBCC) workshops for Program Officers (POs), Program Coordinators (PCs) and Sales Promotion Officers (SPOs). • PBCC message development training for project staff to create visual aids and tools. • Supervision and coaching training where, participants learned how to provide coaching, supervision and essential feedback to the field officers. • Data management and analysis workshop for SMC senior management team and implementing partners to improve data management and analysis for decision-making.

During MIH period, SMC representatives paiticipated in the World Social Marketing Conference, Asia and Eastern Europe Regional meeting, seminar on "Voice of Leadership," American Public Health Association (APHA)-141 st Annual Meeting and Exposition, 3rd International Conference on Family Planning (ICFP), Developing Executive Leadership, Third International Conference of Asian Population Association (APA) and Social Franchising at Nairobi.

The following table shows the training accomplishment by year:

Table 13: Training accomplishment ofMIH program

Participants attended in International Participants attended in Local Year Trainin2/Confercnce/Workshop Trainin2 FY 2013 5 14 FY 2014 5 3 FY 2015 6 4 FY 2016 5 8 Total 21 29

I. Implementation Challenges

In the implementation of the MIH program activities, SMC and its partners had to face and overcome some major challenges, a few of which are highlighted below:

• Reach to male and out ofschool adolescents: It was a major challenge to organize awareness and demand creation group sessions with male participants as majority stay outside of home for income generating activities at day time. Project partners organized

Page 48 group sessions at the evening mostly at market places to gather adequate number of male participants together. In many cases, IPC was organized at the household in the morning and evening to catch male participants. On the other hand, project staff also experienced problem to reach out of school adolescents for increasing their knowledge and changing health behaviors. Out of school adolescents were invited to participate in the courtyard group sessions with MWRA and to watch MFP shows. In addition, CSAs were instructed to pay special attention to the out of school adolescents.

• Product supply: Ensuring regular and unintenupted product supply, especially to providers in hard-to-reach areas sometimes led to out of stock situations. In order to resolve this problem, SMC initiated a pilot scheme of cycle van distribution channel at the hard-to-reach areas. On the other hand, community sales agents in the Notun Din program are dependent on adequate availability of supplies from their NGOs which on occasion has created stock problems. Realizing this situation, NGOs generated revolving fund to purchase additional products for meeting sudden requirements of CSAs. However, this supply chain needs to be ftu1her strengthened to avoid out of stock situations, resulting in dissatisfaction among the sales agents.

• Pilferage of GoB contraceptives and availability ofpoor quality brands: Pilferage of free GoB condoms and injectables to at commercial outlets that provide much higher return to retailers since they can be purchased at a very nominal price, poses serious problems especially for SMC's effort to market low-priced condoms through non­ pharmacy outlets. SMC had several meetings with GOB authority to stop pilferages of contraceptives at commercial outlets. On the other hand, different low-quality branded ORS with higher trade margin is now available across the country, which is also affecting the sales of SMC ORSaline-N brand. SMC aired TVC in order to create awareness about the lookalike fake saline brands and remind about the quality associated with child's life.

• Permission for over branded product: The lack of over branding of Sayana Press injectable marketed by SMC poses a serious threat to the investment being made in the brand if the GOB decides to introduce the product in the same brand name from the same manufacturer in the public sector at a much lower ptice. This would thus affect sales of SMC-marketed Sayana Press through the private sector providers. SMC initiated a discussion with USAID, UNFPA and producers to facilitate over branding process of Sayana Press.

• Approval for product marketing from DGDA: SMC had a plan to offer a combo pack of ORS+Zinc as a combined therapy to treat child diarrhea. SMC had taken initiatives to obtain approval from the DGDA, but didn't get the approval due to lengthy administrative procedure of DGDA. SMC is still working with DGDA.

• Product modification: Lack of awareness about the benefits of using Zinc as a combined therapy to treat child dian·hea and availability of only solid form of Zinc are the important reasons for low uptake of Zinc. Therefore, SMC initiated a discussion to produce liquid form of Zinc in near future under its' pha1maceutical division.

Page 49 J. Lessons Learned

MIH program implemented several activities to achieve its IRs and sub-IRs. Some of the activities were new or innovative which were tailored during the project pe1iod through pilot testing. The following key lessons were learned under MIH during implementing its activities:

Recruiting rural women as entrepreneur to sell public health products empower them

Engaging rural women to become entrepreneurs and effective behavioral change agents - is one of the success interventions to create demand and sell SMC products at the community. The project does not offer any financial benefits to CSAs except the sales margin. This initiative not only empowered rnral women but also demonstrated a sustainable model to make public health products available and accessible to hard-to-reach areas. However, the pilot test showed that adding higher margin consumer products such as energy drink, diapers, wet tissue, toilet tissue, limited food products, etc., medical equipment (blood pressure cuffs, thermometers, glucose testers) and phannaceutical products (paracetamol, pregnancy test, calcium, vitamins, etc.) in the portfolio of CSAs will help to sustain their interest and increase the acceptability of the program among the targeted communities. This intervention demands scale up at national level with special focus to hard-to-reach areas.

Involvement of women entrepreneurs ensures easy access offemale RH products at the household

CSAs can also play a major role in reducing women's baniers, which prevent them to access some SMC products. For example, feedback from the field revealed that women feel more comfortable in buying condoms, emergency contraceptive pills and sanitary napkins distributed from a female CSA at their household level because most pharmacists in Bangladesh are men. Moreover, another reason among girls and women for not using sanitary napkins is the shame of being seen buying the product, which could be reduced by selling the product directly at their household. Involving CSAs at larger scale can ensure healthy life of women.

Private sector entrepreneur model can increase utilization ofpublic health products at hard-to-reach areas

Product distribution at the door-step level by the CSAs not only ensures repeat and consistent use o'.f products but also provides opportunity to motivate new users or disadvantaged people to chail;l ge their behaviors especially who reside at hard-to-reach areas. The experience from the program has shown that if supply and demand creation are combined and products are supplied through regularly stocked CSAs better health impact can be ensured. CSAs have the opportudity to become financially independent, while contributing to the improvement of the health of their communities and becoming effective behavioral change agents. Using a private sector entrepreneur model reduces cost and increases access to essential health products in hard to reach rural areas. Finally, regular access to products will ensure adoption of healthy behaviors. This model can be implemented at wider scale to ensure increase use of public health products.

Page 50 On-site technical assistance can help to increase utilization ofLARC services

Graduate providers, especially gynecologists, and institutions (private clinics and hospitals) are appropriate channel to offer LARC services. The administration of contraceptive injectables, illDs and Implants by LARC providers are steadily increasing and many of them have become inactive. Basically, it is quite cumbersome to anange free time of providers for attending extensive training sessions ananged with the provision of adequate practical demonstration facilities. This inhibits to build confidence of providers for administeiing LARC. However, our experience shows that qualified monitoiing officers (preferably physicians) can only motivate LARC providers by supporting them through on-site technical assistance of administering LARC until providers are confident enough to handle cases.

Strategic expansio11 ofprivate sector provider networks helped to increase access and utilization ofpublic health products

MIH program helped to expand sales and distribution network of public health products. Existing sales forces increased number of outlet overage (visits) to sale products more. Beyond, program successfully increased number of BSPs (ensuring at least one in each union) for appropiiate infmmation dissemination and wider accessibility of products at rural areas. Inclusion of PCHPs also brought success to make public health products available at community level especially at hard-to-reach areas. All providers received adequate training to increase their knowledge and skills to offer correct information and services.

Creating brand image is critical in social marketing program to make any product more popular and accessible

Extensive ATL and BTL communication campaign helped SMC to create brand image of its products. For example, SMC introduced ECP 'Norix' and sanitaiy napkin' JOY A' during MIH phase, where Norix has become the market leader and JOY A has become the third market leader (considering market share) in Bangladesh. The sale of MoniMix also increased due to extensive brand promotional campaign and concerted efforts of BSPs and CSAs.

Participation of community stakeholders helps to sensitize community people and to identify CSAs

Involvement of community stakeholders provided an opportunity to identify and select appropiiate women as CSAs to be more acceptable in the community and to sustain their,' business activities. They also played a vital role to sensitize and motivate community p ~ ople for changing health behaviors. They paiticipated in different local level activities such ps MFP shows, fair, folk Song, etc.

Innovative media such as Mobile Film Shows are essential to reach larger audiences

The MFP shows are crucial to reach people residing in rural and remote areas. Large number of audience and active paiticipation of community people in the event brought attention to organize film shows in areas. These shows improve knowledge and change health behaviors of people in rural ai·eas.

Page 51 Floating IEC Center are important vehicle to reach population in riverine areas

The floating IEC Center for TB control is a cost effective way to visit water front communities, many of which are cut off from roads for months at a time during periods of high water. The IEC center has been particularly successful in increasing awareness and referrals for TB treatment. Pilot result shows that IEC center can be utilized to disseminate other health messages among the target audiences.

Physical presence of CSAs at community mobilization activities can ensure easy access of information and products

Participation to organize project activities and the physical presence of CSAs at each activity, such as organizing MFPs and courtyard group sessions provided opportunity to introduce CSAs as sales and information hub. This collaborative effort also helped to ensure easy access of products to the clients at the household level. Organizing school health education sessions was also found to be more effective to increase knowledge of adolescents on different health issues and hygiene. These sessions provided an opportunity to the CSAs for selling more of MoniMix and sanitary napkins among the adolescents.

CSAs are the promising product distribution channel and behavior change agent model

Household visits of CSAs helped to improve knowledge, create demand and sell of public health products in the community. The CSAs who are actively involved in the project activities and frequently visited households they earn more money by creating demand and selling products. Gradual increase of sales volume by the CSAs shows that they are a promising product distribution channel and behavioral change agent model. However, CSAs need to select cautiously and their knowledge and skills need to improve at optimal levels through adequate and effective training for sustaining their efforts.

Field pretested BCC materials are useful to improve knowledge and healthy behaviors

All type of BCC mate1ials under the MIR program were field pre-tested before final production. Courtyard group sessions utilizing field pretested audio drama and flipcharts by the project staff brought success to increase knowledge on health issues and to change healthy behaviors among the target audiences. Mobile film shows and floating IEC centers utili2ling filed pre-tested video drama on HTSP and 1000 days encouraged populations of hard-to-reach areas to improve their knowledge and healthy behaviors.

Capacity building training to formal and non-formal providers is critical to disseminate technical knowledge and referral care

Basic and refresher training for BSP, PCHP and LARC providers provided an opportunity to update their knowledge and skills on different health issues and to offer quality services with rational use of drugs. This training facility also helped to increase referral care for TB and LAPM. Onsite technical assistance to BSPs by the Quality Monitoring Associate (physicians) helped to improve the confidence and performance of BSPs in terms of counseling on FPM and administering injectables (SOMA-JECT and Sayana Press).

Page 52 Private providers play a vital role to ensure accessibility and availability ofpublic health products at hard to reach areas

Private sector providers can ensure accessibility, availability, referral care and utilization of public health services at areas where the presence of public health facilities are inadequate (especially hard-to-reach areas). They can also complement to achieve the national goal of public health programs at a minimum cost.

Private sector network is one ofthe best channels to introduce new public health products and increase access of health care services

Inviting and recruiting more providers in the BS network, particularly in the union where BSP is absent, increased availability, accessibility and utilization of public health products at mral areas. Involvement of OBGYN members to offer LARC through an MOU between SMC and OGSB bas increased its utilization rather recruiting general physicians. They also had opportunity to promote PPIUD. A series of training, planning and advocacy workshops with all 13 branches of OGSB members increased awareness on LARC among private sector physicians and their contribution in delivering LARC. Introduction of Sayana Press by the BSPs and LARC providers found feasible and acceptable to the clients, especially among pill, condom and non users of FPM. However, it was noticed that practical demonstration of administering Sayana Press in the training may help build confidence of BSPs.

Tele-Jiggasha is useful to motivate and receive feedback from clients and providers as well as to collect information about product supply situation and disseminate information

Tele-Jiggasha was set primarily to address que1ies of clients and providers through telephone by the trained counselors. Frequent telephone and physical communication with LARC providers have increased their attachment with the LARC program. This approach not only helped to build confidence, rapport and recall about LARC but also helped to understand product availability and barriers of providers to offer LARC. Counseling through Tele­ Jiggasha also increased knowledge and confidence of clients to accept public health products and increase the level of use retention. This program also helps to collect information regarding product feedback, stock situation and disseminate messages on health events, issues, encouragement news, etc.

Private community health providers or drug sellers can increase access of contraceptive injectables at hard-to-reach areas

As a pilot initiative, SMC recruited selected PCHPs preferably where BSPs are absent and received approval from GoB to participate in the training on SOMA-JECT for administering follow-up doses. The pilot result showed that PCHPs can be another channel of administe1ing follow-up dose of SOMA-JECT. This approach helped to increase availability and accessibility of contraceptive injectables through the private sector channel, especially at hard-to-reach areas.

Strong collaboration and participation with NGO, GoB and relevant professional lluthorities can accelerate to achieve project goal

Active involvement and collaborative efforts of relevant private, NGO, professional and GoB authority helped to implement project activities smoothly. For example, DGFP officials

Page 53 endorsed and attended in the training sessions ofBSP, PCHP and LARC networks. The government's stamp of approval on the trainings increases their value for the providers as they feel part of a larger endeavor, which is bigger even than SMC. Many NGOs purchase public health products from SMC and serve clients who are refen-ed by BSP/PCHP/CSA. Professional bodies such as OBGYN participated actively to make LARC services available across the countty through the private sector.

Automated reporting system helps to identifY gaps and generate remedial ideas

SMC introduced a performance rep011ing system of BSPs through a mobile platform utilizing both IVR and messages. At the end of a month, each BSP sends sells and stock report through mobile phones. This infonnation is then automatically compiled and reports generated by different indicators at the head office. This platform helped project staff ofBSP to understand more in-depth and analytical issues by identifying gaps and to take remedial actions for improving performances ofBSPs.

K. Recommendations for Future Program

Based on program implementation experiences, research and monitoring findings, mid-term pe1formance and impact evaluation report ofUSAID, the MIH project achieved most of its targeted indicators. However, following are few realistic recommendations for the program to address in future. The summarized recommendation provides suggestions for improvements and identifies matters for scale-up/follow- on program. a) Strengthen marketing strategies and plans

• Comprehensive behavior change, marketing and community mobilization strategies need to be developed for each targeted behavior and specific health or nutrition issue, based on findings of situation analyses or client centered approach. In addition, a marketing strategy need to be developed for each branded product or service, recognizing that competition includes competing behaviors utilizing SMC's marketing expertise and private and NGO networks to the SBCC design process. • BCC messages need to be developed and tailored as needed for local situations to meet needs of targeted groups, ensuring these are age-appropriate and gender-sensitive, addr~cssing social or cultural baniers, fears and contributing factors to non-use or low or suboptimal utilization. Fmmative studies are required to develop SBCC messages to learn more about the target population's factors affecting their behaviors. • As a new investment, it is recommended that USAJD invest in district-level planning and public/NGO/private partnerships to provide products and services as part of focused campaigns, e.g., TB or NCD screening and risk reduction. SMC may explore to introduce TB and NCD screening by the BSP in collaboration with local-level GoB and NGO facilities with a strong refe1rnl mechanism. • To be better prepared for designing programmatic strategies, program staff, SMC marketing staff and partners need to have to a good understanding of demand creation ("push and pull") and of SBCC theory. SMC needs to organize a workshop for program and marketing staff and partners in collaboration with USAID-funded Health Communication Collaborative to fu11her develop strategic planning knowledge and skills.

Page 54 b) Support use of mass media campaigns

• Create demand and adoption of preventive health products and practices, support the use of mass media campaigns linked with campaigns that are using community-based marketing and sales promotion. The use of mass media is essential when addressing the lack of perceived need or as an emergency or timely reminder, e.g., the use of emergency contraception if unplanned sexual encounters or contraceptive misuse/failure occur, or the proper use of products during seasonal outbreaks, such as ORS and zinc during the diarrheal seasons. Training in interpersonal communication skills for BCC facilitators, field personnel and CSAs needs to be well developed through a training need assessment. Continue to engage providers and community workers to help evaluate the effectiveness of campaigns and to monitor how specific audience segments are responding to local activities. • LARC campaigns are often focused on method benefits, but research has indicated that audiences did not trust the competency of providers for these methods. Instead of emphasizing the product for LARCs, emphasize the provider as part of a Blue Star or LARC provider network quality branding campaign. A series of dramas may be developed in a mass media campaign, showing the provider to be professional, safe and reliable and highlighting the positioning of quality providers. In addition, it will also show newly married couples being provided with counseling, leading them to choose

implants to be better prepared for parenthood. I • Given the high demand for visual BCC and the success in gathering large crowds, it is I recommended that Mobile Film Shows (by road or water) be supp01ted paiticularly for communities where outlets or services are new or being revised, including sales agents, BSP, PCHP or LARC providers. Because of the high cost of implementing this intervention, as well as geographical access issues (poor road systems, l1igh waters), alternative channels may be needed, e.g., digitalizing the dramas to reach people in smaller groups and small-screen showings in remote areas or on the floating barges. • Select staff and CSAs who can best communicate with and encourage engagement of the targeted populations. Encourage male involvement in promoting family planning. In reaching the 12 percent of the population with unmet need and in promoting longer­ acting contraceptive methods, it is critical to understand household decision-making dynamics, gender-related roles and common attitudes about family size, methods and fears of both males and females about products or services. It is highly recommended that process, output and outcome indicators, disaggregated by sex and age group, are measured and used for monitoring project targeting and evaluating results. c) Explore new marketing and BCC techniques

• As a new investment, USAID supports adolescent/youth wellness initiatives for development of low-cost sustainable life skills training for female and male youth. This could be based in communities or workplaces or take place after school. Topics to be considered are: preparing for motherhood and fatherhood, knowing and respecting your body, understanding reproductive health, prevention of gender-based abuse and violence, disease and injury risk-reduction skills, and skills for appropriate use of new technologies (internet/phones). • There is an opportunity to offer bundled products for expectant mothers by the p1ivate sector, including skilled CBAs, with a maternity kit: progestin-only pill, safe delivery kit,

Page 55 zinc/ORS, MoniMix and provision of life-saving misoprostol and chlorhexidine. In addition, the project can develop an adolescent wellness kit incorporating calcium/iron/folic pills, sanitary napkins, and other hygiene products such as deodorant etc. to promote through CSA and providers. d) Improve SMC logistics, recording, reporting, referral and follow-up systems

•It is recommended that the project may adopt electronic systems and mobile technologies for logistics, reporting product sales and/or administration of medium and long-acting methods, a practical reminder system (using symbol or text via SMS) for injectable contraceptive clients, and monitoring activity and performance of sales agents and providers. e) Develop new service delivery modalities for improved access and equity

• To support government priorities for greater availability and equity to services, work at the district level, using mapping data to address gaps in availability of private sector services in mral, underserved or hard-to-reach locations. Services could be expanded to provide other women's health services: breast exams, pap smears, diet counseling and NCD and TB screening for the wider population. USAID is also encouraged to explore social marketing of innovative community-based maternity service modalities, e.g., privatized birthing huts, or birthing centers in the country or region. j) Intensify development ofprivate provider networks and capacities

• System development should include: development of a quality assurance system to ensure quality hotline/counseling services (suggest using external evaluators), performance appraisals of private providers/outlets with action plans for improvement, and joint medical detailing led by a specific technical/training partner, e.g., EngenderHealth, with an SMC program officer/sales agent and optimally the DGFP/DGHS (technical expert) to ensure that family planning practice standards are adhered to by the network partners. • A qualified training institute needs to be engaged for capacity building activities and emollment of institutions and providers. The following are recommended as new or replicated certified training programs: i) early identification through screening, referral and follow-up of clients with NCDs-specifically hypertension and diabetes; ii) customer education and follow-up to promote proper usage, compliance and adherence to specific products/regimens; iii) IMCI certification training for BSP/PCHP by experienced government practitioners/trainers; iv) reproductive health counseling with emphasis on LAPM and couple-counseling skills for counselors and hotline staff; iv) refresher h·aining for networks to promote their involvement in early identification of suspected TB and referral as well as providing DOTS. g) Performance assessment and system for staff development

• After staff and volunteers were recmited, their petformance was not evaluated systematically or they did not receive refresher training or on-the-job training. This made it difficult to work effectively and efficiently and led to lower-than-optimal perfoimance by many staff members. It is recommended to design and introduce a system that includes improved orientation and regular refresher and professional development trainings for staff. This will help to improve performance, enhance morale and increase commitment of staff as well as may also reduce turnover rate.

Page 56 L. Financial Analysis of MIH F igure in USdo llars

BUDGET FY2013 FY 2014 FY 2015 FY 2016 Expenditure DESCRIPTION 26 J uly, 2012- July26, 2012 - In% BYLINE ITEM 25 J uly, 2016 J uly'12- Oct'13- Oct'l4- Oct' IS- July25, 2016 Sept't3 Sept't4 Sept'15 July'16 A. Direct Labor 880,559 167,823 212,801 268,435 210,346 859,405 98% B. Travel and Per Diem 237,318 38,883 54,582 67,302 64,623 225,390 95% C. Supplies aud Equipment 461,098 98,1] 8 323,365 14,133 12,978 448,593 97% D. Other Direct Cost 6,734,206 1,493,105 1,808,585 1,389,090 1,865,203 6,555,982 97% E. Sub contracts/ aj?reements 6,686,819 1,404,130 1,909,864 2,125,288 1,471,348 6,910,630 103% El-PSI 886,668 274,898 328,927 251,040 234,837 1,089,702 123% E2-BRAC 2,175,000 427,880 564,469 725,302 457,949 2,175,600 100% E3-SHIMANTIK 1,139,151 243,188 304,561 353,032 247,856 1,148,637 101% E4-PSTC 988,001 193,285 262,811 321,693 213,812 991 ,600 100% E5-CWFD 898,000 190,012 248,529 279,098 186,722 904,361 101% E6-ENGENDER HEALTH 600,000 74,867 200,568 195,124 130,172 600,730 100% TOTAL USAID CONTRIBUTION 15,000,000 3,202,059 4,309,196 3,864,249 3,624,497 15,000,000 100% (A+B+C+D+E) USAID - Program 2,234,571 459,356 798,487 769,385 2,027,228 91% Income - SMC - Cost Share 113,394,341 29 , 778 , 56 ~ 35,209,935 34,439,082 19,769,685 119,197,265 105% Total Expenses: 130,628,912 32,980,622 39,978,487 39,101,818 24,163,566 136,224,493 104% I

Budget expenses by items/heads MIH program is primarily designed to improve health status of women and children in Bangladesh by increasing access to and demand for products and services on family planning, maternal, child health and TB. The budget ofMIH was expensed under the following major i terns/heads.

A. Direct labor: Staff salaries are charged to MIH project staff of SMC. All Salaries are charged on a monthly basis and are increased by 5% in each year after the completion of each year according to annual increment policy of SMC. The personnel, compensation rate and level of effort fully charged to the project.

B. Travel and per diem Local travel expenses of MIH project staff are charged under the budget item of Travel and Per Diem. The expenditure includes transportation costs within Bangladesh over the project period. This travel cost is incurred for program management staff for supervisory, training, community mobilization, financial oversight, and monitoring and evaluation activities.

Page 57 C. Supplies and equipment Supplies and equipment costs are charged based on historical bum rates and purchased according to the need of new and replacement equipment for the program. The cost of Network printer, Laser Printer, Laptops, Desktop Computer, Notebook computer, Multimedia Projector, Photocopier, UPS, Office Furniture, LED TV, Scanner, Laminating Machine, Generator, Jeep, Motorbike Floating IEC Center Equipment, MFP Equipment etc. are charged under the budget item Supplies and Equipment.

D. Other direct cost This category includes a wide range of program activity and support costs incurred during the project period. The expenses are charged to Other Direct Cost include General Operating Costs, Bank Charges, Office Rent, Maintenance etc., PCHP Training Prograin Cost, BSN­ Training and Service Delive1y cost, LARC-Training and Service Delivery cost, Advertisement and Promotion Cost, Health Communication/Community Mobilization Cost, Research and M&E Cost, Staff Professional Development Cost, Audit Fee etc.

E. Sub contracts/agreements MIH project had six sub partner and the expenses by sub-partners during the project period are charged under this budget item. The partners include: PSI, BRAC, PSTC, CWFD, Sbimantik and EngenderHealth. They also used the budget items that has been followed by SMC.

Essential features on financial management

Sub-grant management monitoring tools: In order to strengthen financial management systems of partner organizations, SM C's finance team members regularly visited partners head office and field offices to provide supports. For instance, CWFD did not have standard financial manual where SMC provided technical support to develop financial manual and it is used in MIH program. In addition, SMC staff reviewed audit recommendations and guided project partners to comply it. Due to frequent interventions, overall financial management systems of partners improved significantly.

Budget modification: The initial budget was prepared based on the assumption, previous experiences and resources allocation against the line items. Considering the program requirement, USAID revised the Cooperative Agreement budget through modification# 01.

Budget performance: SMC conducted continued monitoring on the budget utilization and was able to fully utilize allocated resources to achieve the program goal and objectives. Due to ensuring strong monit01ing and follow up on the budget line items, SMC experienced that there was hardly minimum deviation in the expenditure of budgeted line items.

RC audit: After completion of each project year, RC audit has been conducted according to RCA guideline and Government Auditing Standard (GAS) by the eligible Audit films approved by RIG/Manila. Initially there were some audit findings which has been improved significantly in the subsequent years. There were few question-cost through audit and all have been resolved.

Besides these, SMC did not face any major budget related obstacles in implementation of the MIH program.

Page 58 ANNEX 1.

Working areas of Community Mobilization Partners

CWFD Barisal & Barisal 10 2 Goumadi Dhaka Jhalokati 04 1 Rajapur, Katbalia Pirojpm 07 2 Kawkhali, Nesarabad Faridpur 09 1 Bhanga

Sub total 02 04 30 06

PSTC Dhaka Kishoreganj 13 2 Katiadi, Bajitpur Narsingdi 06 1 Monohordi Mtmshiganj 06 1 Sreenagar Madaripur 04 1 Rajoir

Sub total 01 04 29 05

Shimantik Sylhet Sylhet 12 03 Golapgonj, Fenchugonj, Sunamgonj 11 02 Balagonj Hobigonj 08 03 Chattak, Bisharnbarpur Moulvibazar 07 03 Bahubal, Chonaroghat, Madabpur Sreemongal, Kulaurn, Kamalgonj

Sub total 01 04 38 11

BRAC Chittagong Comilla 16 16 All upazilas of 7 selected B.Baria 08 08 distticts Chandpur 08 08 Laxrnipur 05 05 Feni 06 06 Noakbali 09 09 Bandarban 07 07

Sub total 01 07 59 59 Total 04 19 156 81

Page 59 ANNEX2

Indicator achievement table by project year

Indicator Target Achievement Achievement Achievement Achievement Achievement % Means of Life of Project FY 2013 FY 2014 FY 2015 FY 2016 Life of Verification (Oct 12- July 16) (Oct '12-Scp (Oct '13-Sep (Oct' 14-Sep (Oct'l 5- Project (Oct '13) '14) '15) July'l6) '12-July '16) 1.1 Number of CYPs ) Total 17.34m 4.0 1 m 4.32m 4. 24m 3.41 m 15.98 m 92% SMC-MIS Urban 9.25 m 2.20m 2.45 m 2.36m 1.86 m 8.87 m 96% Rural 8.09 m 1.81 m l.87 m 1.88 m 1.58 m 7.15 m 88% 1.2 Number of CYPs from LARC6 271,000 12,459 20,147 33,930 38,993 105,529 39% SMC-MIS delivered through private sector providers 1.3 Number of OCP sold 153.l m 36.96 m 39.58 m 41.09 m 32.72 m 150.35 m 98% 1.4 Number of combined OCP (COC) 145.5 m 35.1 m 37.57 m 38.82 m 30.82 m 142.31 m 98% SMC-MIS sold 1.5 Number of Progestin only Pill (PoP) 7.6m 1.86 m 2.01 m 2.27 m 1.9 m 8.04m 106% SMC-MIS sold 1.6 Number of Condom sold 603 m 141.75 m 155.78 m 127.14 m 100.33 m 525 m 87% SMC-MIS 1.7 Number of SOMA-JECT injectable 5.83 m 1.38 m 1.41 m 1.54 m 1.37 m 5.7m 98% SMC-MIS sold 1.8 Number of Sayana Press injectable 200,000 89,162 85,771 174,933 87% SMC-MIS sold 1.9 Number of ORS sold l,756 m 392.18 m 469.47 m 561.89 m 503.95 m 1,927 m 110% SMC-MIS 1.10 Number of micronutrient powder 45m 9.17 m 12.8m 12.89 m 13.51 m 48.37 107% SMC-MIS MoniMix sachets sold 1.11 Number of Zinc tablets sold 2.79 m 0.65 m 0.62m 0.57 m 0.4 m 2.24m 80% SMC-MIS 1.12 Number of SMC Safe Delivery Kit 0.66m 0.14m 0.18 m 0.17 m 0.084 m 0.574m 87% SMC-MIS sold 1.13 Number ofECPs sold 1.99 m 0.34m 0.55 m 0.72 m 0.61 m 2.22m 112% SMC-MIS 1.14 Number of IUDs sold 40,000 1,861 3,277 5,681 6,385 17,204 43% SMC-MIS

5 One CYP calculated as 15 cycles ofOCP, 120 pieces ofcondoms, 4 vials ofinjectables or 20 doses ofECP 6 4.6 CYP per IUD inserted and 3.8 CYP per Implant inserted

Page 60 Indicator Target Achievement Achievement Achievement Achievement Achievement % Means of Life of Project FY 2013 FY 2014 FY 2015 FY 2016 Life of Verification (Oct 12- July 16) (Oct '12-Scp (Oct '13-Sep (Oct'14-Sep (Oct' IS- Project (Oct '13) '14) '15) Julv'16) '12-Julv '16) 1.15 Number of Implants sold 23,000 1,026 1,335 2,052 2,532 6,945 30% SMC-MIS 1.16 Number of Sanitarv N aokin sold 6m 0.013 m l.15 m 2.58 m 2.77 m 6.51 m 109% SMC-MIS 1.17 Number of bundled ORS and Zinc NA 0.850 0 0 0 0 0 kits sold7 1.18 Number of new branded electrolyte NA 48m 0 0 0 0 0 drink sold8 1.19 Number of private sector outlets directly covered by SMC Total 261 , 120 278,513 286,762 274,016 273,204 273,204 25 .6% SMC-MIS Pharmacy outlets 105,060 109,581 110,127 111,508 113,902 113,902 Non-Pharmacy outlets 156,060 167,658 175,521 161,305 158,204 158,204 NGOs 1,122 1,004 1,114 1,203 1,127 1,127 1.20 Increase availability of SMC product Availability/ in non pharmacy outlets Market NA ORS 60% 57% 66% 66% 66% penetration Condoms 40% 27.5% 32% 32% 32% study 1.2 1 Number of active Blue Star providers 6,000 5,881 5,881 NA SMC-MIS 1.22 Number of active, individual private sector LARC providers in the 700 400 400 NA SMC-MIS network 2a % of women who delivered at home Baseline and within last 3 years and were assisted end line 20.0 12.4 36.0 36.0 NA through safe delivery kit (brand name survey9 if possible ) in targeted areas % women who use( d) sanitary Baseline and 2b napkins currently or last time in 15.0 8.9 25.2 25.2 NA end line targeted areas survey 2c % of children under 5 who used Baseline and 8.0 2.8 28.0 28.0 NA MNP in targeted areas end line

7 SMC Could not launched combo pack of ORS+Zinc as DGDA did not provide approval for this product. However, SMC has a plan to launch this product in the upcoming

~ears. Launched of Electrolyte drink could not possible due to delayed approval of DGDA. It is expected that this product will be launched in the next fiscal year. 9 Baseline and Endline survey conducted by Measure Evaluation.

Page 61 Indicator Target Achievement Achievement Achievement Achievement Achievement % Means of Life of Project FY2013 FY 2014 FY2015 FY 2016 Life of Verification (Oct 12- July 16) (Oct '12-Sep (Oct '13-Sep (Oct'14-Sep (Oct'lS- Project (Oct '13) '14) '15) Julv'16) '12-Julv '16) survey 2d % ofMWRA who are currently using Baseline and a modern contraceptive method in 51.0 46.9 49.7 49.7 NA end line targeted areas survey 2.1 % ofMWRA who accurately report Baseline and at least two specific end line risks/complications related to 56.0 44.0 66.2 66.2 NA survey pregnancy before age 20 years in targeted areas 2.2 % ofMWRA who accurately report Baseline and at least two specific endline risks/complications related to 40.0 37.6 42.4 42.4 NA survey pregnancy after age 35 years in targeted areas 2.3 % ofMWRA who accurately repo1i Baseline and at least two specific risks endline /complication related to pregnancies 76.0 66.5 68.1 68.1 NA survey that occur Jess than 2 years after the last childbirth in targeted areas 2.4 % of MWRA intend to use Long Baseline and Acting Reversible Contraceptive end line 2 0.8 2.1 2.1 NA Methods in the future in targeted survey areas 2.5 % of MWRA who accurately report Baseline and at least three possible/potential endline 33 .0 22.6 37.8 37.8 NA danger signs of pregnancy in targeted survey areas 2.6 % of MWRA who can specify Baseline and correctly at least two specific endline 17 7. 5 27.l 27.1 NA benefits of using safe delive1y kits in survey targeted areas 2.7 % ofMWRA who accurately report Baseline and at least four initiatives related to birth 28.0 17.6 25.l 25.l NA endline preparedness to ensure safe delivery survey

Page 62 Indicator Target Achievement Achievement Achievement Achievement Achievement % Means of Life of Project FY2013 FY 2014 FY2015 FY 2016 Life of Verification (Oct 12- July 16) (Oct '12-Sep (Oct '13-Sep (Oct'14-Sep (Oct' IS- Project (Oct '13) '14) '15) Julv'16) '12-Julv '16) in targeted areas 2.8 % ofMWRA who are aware of the Baseline and need of at least four visits for health end line 50.0 29.8 47.1 47.1 NA check up during pregnancy in survey targeted areas 2.9 % of MWRA who accurately report Baseline and at least two specific benefits of end line 20.0 8.5 43 .1 43.1 NA giving Micronutrient powder (MNP) survey to children under 5 in targeted areas 2.10 % of MWRA accurately identify the Baseline and most important symptom of TB in 95.0 87.9 87.2 87.2 NA end line targeted areas survey 2.11 % ofMWRA who have a under-five Baseline and children and are aware of the benefits end line of the use of Zinc with ORS as an 70.0 55.7 80.7 80.7 NA survey adjunct therapy to treat diarrhea in tar.geted areas 2.12 % ofMWRA who are aware ofECP Baseline and as an effective way of preventing endline 10.0 1.8 27.3 27.3 NA possible unintended conception in survey targeted areas 2.13 Number of people reached through NA SMC-MIS the mo bile film pro gram in 19 4,040,000 1,050,000 1,013,168 910160 773,919 3,747,247 priority districts 2.14 Number ofMWRA and husbands reached with HTSP-related messages in priority districts (comm. NGO/SMC- mobilization) MIS MWRA 6.03 0.81 1.83 2.09 l.72 6.45 106% Husbands 1.547 0.19 0.63 0.43 0.31 1.56 101% 2.15 Number of caregivers of children NGO/SMC- under 5 reached with message on 3.627 0.55 1.06 1.21 0.99 3.81 105% MIS first 1000 days in priority district

2.16 Number of adolescent boys and girls ·,

Page 63 ---

Indicator Target Achievement Achievement Achievement Achievement Achievement % Means of Life of Project FY2013 FY 2014 FY 2015 FY 2016 Life of Verification (Oct 12- July 16) (Oct '12-Sep (Oct '13-Sep (Oct'14-Sep (Oct'l5- Project (Oct '13) '14) '15) Ju)y'l6) '12-July '16) ( 13 -19) reached with the adolescent 0.741 0.1 0.269 .244 0.15 0.763 103% NGO/SMC- health package of messages through MIS school programs in priority districts 2.17 Number of CB.A.s reached with the healthy pregnancy package of 37,100 9,866 12, 108 14,152 9,857 45,983 124% NGO/SMC- messages in priority districts MIS 2.18 Average Monthly sales of the NGO/SMC- 5,000 659 1,834 4,721 5,327 5,327 Conununitv Agents MIS 2. 19 Community Agents Sales Performance NGO/SMC- Sanitary Napkin 267,974 0 75,974 180,000 217,603 473,577 171% MIS MoniMix 1,781,470 66,345 524,580 748,000 2,020,8601 3,359,785 189% SDK 33,283 996 11,034 20,000 4,388 46,418 139% 2.20 Number of people reached with the TB Prevention and Management package of messages in priority 319,560 63,766 104,359 64,606 31,755 264,486 83% SMC-MIS districts through community mobilization (Floating IEC Center) 10 2.21 Number of workers reached with messages on FP and health through 28,000 6,114 10,173 9,821 5,036 31,144 111% SMC-MIS worknlace programs 2.22 Number of community advocates reached through advocacy meetings 93,000 26,985 37,156 30,709 23,807 118,657 128% NGO/SMC- in priority districts MIS R3.l Number ofNGMPs trained through the PCHP Program Training Basic 101% MIS Refresher 20,000 5,371 8,665 6,225 20,261 - 88% PCHP trained on SOMA-JECT 15,000 2331 10,9 12 13,245 105% administration 2,000 l,580 511 2,091

10 The achievement is lower due to one Floating IEC Center-Sylhet, which was closed in January 2015.

Page 64 Indicator Target Achievement Achievement Achievement Achievement Achievement % Means of Life of Project FY2013 FY 2014 FY 2015 FY 2016 Life of Verification (Oct 12- July 16) (Oct '12-Sep (Oct '13-Sep (Oct'14-Sep (Oct'l5- Project (Oct '13) '14) '15) Julv'16) '12-Julv '16) R3 .2 Number of GMPs trained on LARC Training Basic 700 259 191 280 927 132% MIS Refresher 500 197 94 127 87 308 62% R3.3 Number of Advocacy meeting held SMC-MIS 12 4 8 12 100% in coordination with OGSB R3.4 Number of Evidence Based Training management workshops with 14 7 7 14 100% MIS provider of LARC network held R3 .5 Number of BSPs trained on new curriculum (referrals for LARCs, injectables, FP counseling, MCH, Training ARI and nutrition) MIS Basic 2,600 800 1,568 358 201 2,907 112% Refresher 6,000 I ,315 1,644 2,109 2,539 7,607 127% R3.6 Number of BS providers trained on TB DOTS in collaboration with NTP 11 R3.7 Sayana Press injectable Training administration training through 4,000 1,881 1,599 3,480 87% MIS regional workshop R3 .8 Number of clients to be referred for SMC-MIS 23 ,500 909 6,41 7 12,030 16,786 36,142 106% LAPMs by the BSP trained providers R3.9 Number of referrals of suspected TB Training 101,500 9,367 13,249 47,634 36,942 107,192 154% cases by BSPs MIS R3 .10 % increase in the number of QA and providers passing quality standards provider (outstanding and very good) Na Survey12 BSP 94% 92.7% 50% 50% LARC 95% - 72% 72% R3.ll % of providers who can tell about the 97.0 96.0 99.7 99.7 Na QA and

11 It was planned that NTP and TB care project supposed to arrange the training during MIH period, but it was not organized by them. 12 Quality assurance and Provider baseline survey conducted in FY 2014 and FY2015.

Page 65 ---- Indicator Target Achievement Achievement Achievement Achievement Achievement % Means of Life of Project FY2013 FY2014 FY 2015 FY 2016 Life of Verification (Oct 12- July 16) (Oct '12-Sep (Oct '13-Sep (Oct'14-Sep (Oct' IS- Project (Oct '13) '14) '15) July'l6) '12-July '16) referral center provider Survey R3 .12 % of BS providers who are able to QA and tell correctly specify the main provider symptom (persistent cough for more 99.0 98.0 98.0 98.0 Na Survey than 2 weeks) for identifying suspected TB case R3.13 % of BS providers who are able to QA and tell correctly at least three major provider 65.0 56.2 65. l 65.1 Na signs and symptoms of sick child (U- Survey 5) for immediate referral R3.14 % of BS providers who are able to QA and tell correctly at least three danger 75.0 67.5 76.9 76.9 Na provider sil!lls of prernancv Survey R3.15 % of BS providers who are able to QA and report at least two possible provider 75.0 68.7 99.4 99.4 Na risks/complications related to Survey pregnancy after age of3 5years R3 .16 % of BS providers accurately QA and specified at least two potential health provider 80.0 74.3 95 .2 95.2 Na problems with early pregnancy Survey (Below age 19) R3.17 % of BS providers who are able to QA and tell at least two specific benefits of provider 80.0 71.8 92.3 92.3 Na giving Zinc with ORS to treat Survey diarrhea R3.18 % of BS providers who are able to QA and accurately at least two benefits of 80.0 75.7 93 .9 93 .9 Na provider giving MNP to children under 5 Survey

R3.19 % of BS providers correctly tell the QA and regimen for MNP 85.0 83.3 74.0 74.0 Na provider Survey

Page 66 Indicator Target Achievement Achievement Achievement Achievement Achievement % Means of Life of Project FY2013 FY 2014 .FY 2015 FY2016 Life of Verification (Oct 12- July 16) (Oct '12-Sep (Oct '13-Sep (Oct'14-Sep (Oct' IS- Project (Oct '13) '14) '15) Julv'16) '12-Julv '16) R3 .20 Number of private sector providers SMC-MIS detailed on information package on FP/Spacing, ORS, Zinc and 40,000 12,319 13,301 14,165 10,687 50,472 126% micronutrients by SMC sales promotion officers

Page 67 ANNEX3

List of Supplies & Equipment Purchased by Partner NGOs from 26 July, 2012 to 25 July, 2016 For MIH Program

Amount BRAC CWFD PSTC Shimantik EngenderHealth Total SI USD Item Amount in # Amount Amount Amount Amount Amount (average Qty Qty Qty Qty Qty Taka Taka Taka Taka Taka Taka rate) 1 Laptop 3 177,084 1 59,000 2 104,550 - l 77,012 417,646 5,077 2 Desktop PC & Accessories 7 466,490 4 495,468 7 361 ,998 6 307,200 5 276,650 1,907,806 23,194 3 IPS /UPS 3 21,000 5 311,029 5 184,957 4 187,050 704,036 8,559 4 Camera - l 16,000 2 20,000 4 67,009 103,009 1,252 5 Furniture & Fixture 542,786 986,223 1,302,973 818,423 3,650,405 44,379 6 Printer and Scanner - 69,188 78,499 1 26,957 174,644 2,123 Sign/ Display & White 7 - 96,200 62,275 8 Board 58,000 216,475 2,632 8 Electric Fan 8 27,600 4 14,850 42,450 516 Grand Total in BDT 1,207,360 1,963,920 2,133,541 1,531,031 380,619 7,216,471 87,733

Grand Total in USD 14,678 - 23,876 - 25,938 - 18,613 - 4,627 87,733

Page 68 ANNEX4

List of Supplies & Equipment Purchased by SMC from 26 July, 2012 to 25 July, 2016

For Marketing Innovation for Health (Miii) Program

SI.# Item Qty AmountUSD 1 Laptop 23 18,041 2 Desktop PC & Accessories 37 29,020 3 Notebook computer 1 497 4 IPS /UPS 45 2,688 5 HP LaserJet printers 21 6,863 6 Ptinter 2 4,621 7 Photocopier 1 3,303 8 Multimedia projector 5 4,962 9 Digital Camera 2 790 10 Scanner 8 482 11 Generator 10 8,164 12 Vehicle (Jeep) 3 270,897 13 Vehicle (Motorbike) 15 28,295 14 LED TV for HO 1 2,519 15 Laminating Machine 1 57 16 Fmniture & Fixtme 37,785 17 Electric fan 7 226 18 Floating IEC Center Equipment 1,270 (Sound system, Battery & DVD player) 19 Equipment for MFP 20,841 20 Display board 18 986 21 Interactive white board Hitachi 1 2,045 22 Flip Cha1i Stand 2 354 Grand Total 444,705

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