Effect of blue star healthcare network on family planning service uptake

THE EFFECT OF BLUESTAR HEALTHCARE
NETWORK ON FAMILY PLANNING SERVICES
UPTAKE IN MEMBER PRIVATE CLINICS
IN ETHIOPIA
By
Fikru Tessema (BSc, MSc & MBA)
June, 2015
Addis Ababa, Ethiopia

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ACKNOWLEDGMENT
I am grateful with program officers and Sales & Supply Officer of central area office for
their facilitation in data collection.
Finally, it is my pleasure to extend my sincere gratitude to Desalegn, M&E/IT Senior
Officer for his support in providing me secondary data, so as to compare with it the data
collected in the field.

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TABLE OF CONTENTS
Content Page
ACKNOWLEDGMENT ------------------------------------------------------------------------------ i
TABLE OF CONTENTS----------------------------------------------------------------------------- ii
LIST OF TABLES ------------------------------------------------------------------------------------iv
LIST OF FIGURES ----------------------------------------------------------------------------------- v
ACRONYMS -------------------------------------------------------------------------------------------vi
ABSTRACT -------------------------------------------------------------------------------------------vii
CHAPTER ONE: INTRODUCTION-------------------------------------------------------------- 9
1.1 Background ----------------------------------------------------------------------------------- 9
1.2 Statement of the Problem------------------------------------------------------------------15
1.3 Objectives of the Study---------------------------------------------------------------------18
1.3.1 General Objective ----------------------------------------------------------------18
1.3.2 Specific Objectives ---------------------------------------------------------------18
1.4 Research Questions -------------------------------------------------------------------------18
1.5 Scope and Limitation of the Study-------------------------------------------------------19
1.5.1 Scope of the Study ----------------------------------------------------------------19
1.5.2 Limitations of the Study----------------------------------------------------------19
1.6 Significance of the Study-------------------------------------------------------------------20
1.7 Definition of Key Terms -------------------------------------------------------------------21
1.8 Structure of the Thesis ---------------------------------------------------------------------21
CHAPTER TWO: LITERATURE REVIEW---------------------------------------------------22
2.1 Theoretical Framework--------------------------------------------------------------------22
2.2 Empirical Literature------------------------------------------------------------------------26
CHAPTER THREE: METHODOLOGY--------------------------------------------------------30
3.1 Description of the Study area -------------------------------------------------------------30
3.2 Research Design and Approach ----------------------------------------------------------31
3.3 Data Source and Method of Data Collection-------------------------------------------31
3.3.1 Inclusion and exclusion criteria:-----------------------------------------------31
3.3.2 Sampling technique and sample size-------------------------------------------32
3.3.3 Data collection instruments-----------------------------------------------------32
3.3.4 Data collection procedure ------------------------------------------------------32

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3.3.5 Study project management ------------------------------------------------------33
3.4 Method of Data Analysis-------------------------------------------------------------------33
3.4.1 Definition of Variables-----------------------------------------------------------33
3.4.2 Econometrics models and Specification of Variables-----------------------33
3.4.3 Data quality management -------------------------------------------------------34
3.4.4 Ethical Consideration------------------------------------------------------------34
3.4.5 Report writing plan---------------------------------------------------------------35
3.4.6 Findings dissemination plan and publication --------------------------------35
CHAPTER FOUR: STUDY RESULTS AND DISCUSSION --------------------------------36
4.1 Findings ---------------------------------------------------------------------------------------36
4.1.1 Socio-Demographic Characteristics of the Study Population -------------36
4.1.2 BlueStar Healthcare Network Implementation-------------------------------37
4.1.3 The rate of increase in number of FP clients of member clinics since
membership------------------------------------------------------------------------39
4.1.4 The rate of increase in FP service volume of member clinics since
membership------------------------------------------------------------------------41
4.1.5 Challenges/factors hindering FP service uptake of member clinics since
membership------------------------------------------------------------------------44
4.2 Discussion-------------------------------------------------------------------------------------47
CHAPTER FIVE: CONCLUSIONS AND RECOMMENDATIONS ----------------------51
5.1 Conclusions-----------------------------------------------------------------------------------51
5.2 Summary of Findings-----------------------------------------------------------------------51
5.3 Recommendations---------------------------------------------------------------------------52
REFERENCES----------------------------------------------------------------------------------------55

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LIST OF TABLES
TABLE 1: NUMBER OF FP SERVICE PROVIDERS IN BLUESTAR HEALTHCARE NETWORK MEMBER
PRIVATE CLINICS BY TRAINING ON FP AND THEIR EDUCATION STATUS, 2015....................37
TABLE 2: NUMBER OF BLUESTAR HEALTHCARE NETWORKED PRIVATE CLINICS BY YEAR OF
JOINING THE NETWORK AND REASON FOR JOINING THE NETWORK, 2015...........................37
TABLE 3: NUMBER OF PRIVATE CLINICS WHO REPORTED THAT BLUESTAR HEALTHCARE
NETWORK MET THEIR EXPECTATION IN FP SERVICES, 2015.................................................38
TABLE 4: RATE OF INCREASE IN CLIENT NUMBER VISITING MEMBER CLINICS FOR FP SERVICES
SINCE MEMBERSHIP TO BLUESTAR HEALTHCARE NETWORK, 2015 ....................................40
TABLE 5: RATE OF INCREASE IN CLIENT NUMBER VISITING MEMBER CLINICS FOR FP SERVICES
SINCE MEMBERSHIP FROM MSIE SECONDARY DATA BY TYPE OF CLINICS, 2015 ...............40
TABLE 6: NUMBER OF PRIVATE CLINICS WHO REPORTED THAT THEY MET THEIR EXPECTATION
WITH THE INCREASE IN NUMBER OF FP CLIENTS, 2015.........................................................41
TABLE 7: RATE OF INCREASE IN FP SERVICE VOLUME IN MEMBER CLINICS SINCE MEMBERSHIP
TO BLUESTAR HEALTHCARE NETWORK, 2015 .....................................................................42
TABLE 8: NUMBER OF PRIVATE CLINICS WHO REPORTED THAT THE NETWORK MET THEIR
EXPECTATION AS COMPARED TO RATE OF INCREASE IN FP SERVICE VOLUME, 2015............43
TABLE 9: DATA ANALYSIS PRACTICE IN UNDERSTANDING THE INCREASE IN NUMBER OF
CLIENTS AND FP SERVICE VOLUME BY EDUCATION STATUS OF THE INTERVIEWEES, 201544
TABLE 10: FACTORS FOR INSIGNIFICANT INCREASE IN CLIENT NUMBER AND SERVICE VOLUME
FOR FAMILY PLANNING SERVICE UPTAKE, 2015..................................................................45
TABLE 11: NUMBER OF BLUESTAR HEALTHCARE NETWORKED PRIVATE CLINICS PRACTICING
FAIR METHOD MIX, ADEQUATE TIME FOR COUNSELING, 2015............................................46
TABLE 12: NUMBER OF BLUESTAR HEALTHCARE NETWORKED PRIVATE CLINICS PRACTICING
GOOD CLIENT HANDLING AND CONFIDENTIALLY RECORDING CLIENTS' MEDICAL RECORDS
FOR FAMILY PLANNING, 2015...............................................................................................46

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LIST OF FIGURES
FIGURE 1: BLUESTAR HEALTHCARE NETWORK BRAND MARK, 2015 ..........................................12
FIGURE 2: THEORETICAL FRAMEWORK, 2015 ...............................................................................25
FIGURE 3: GEOGRAPHIC DISTRIBUTION OF BLUESTAR HEALTHCARE NETWORK MEMBER
PRIVATE CLINICS, 2015.........................................................................................................30
FIGURE 4: NUMBER OF RESPONDENTS BY THEIR SEX AND EDUCATION STATUS, 2015................36
FIGURE 5: REASON/EXPECTATION OF PRIVATE CLINICS FOR JOINING BLUESTAR HEALTHCARE
NETWORK, 2015....................................................................................................................38
FIGURE 6: TYPE OF SUPPORTS OFFERED BY MSIE THAT ACKNOWLEDGED BY PRIVATE CLINICS
NETWORKED IN BLUESTAR HEALTHCARE NETWORK, 2015 ................................................39
FIGURE 7: RATE OF INCREASE OF FP SERVICE VOLUME IN MEMBER PRIVATE CLINICS, 2015......43

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ACRONYMS
BCC : Behavioral Change and Communication
BS : BlueStar
BSHN : BlueStar Healthcare Network
CFP : Comprehensive Family Planning
CSA : Civil Society Agency
EDHS : Ethiopian Demographic and Health Survey
FMHACA : Food, Medicine, Healthcare Administration and Control Authority
FP : Family Planning
HEWs : Health Extension Workers
HNP : Health, Nutrition, and Population
IAC : Internal Audit Checklist
IUD : Intrauterine Device
MoH : Ministry of Health
MoT : Ministry of Trade
MSI : Marie Stopes International
MSIE : Marie Stopes International Ethiopia
PD : Program Department
PMS : Pre-menstrual Syndrome
QTA : Quality Technical Assurance
SF : Social Franchise
SS : Supportive Supervision
TA : Technical Assistance
UNFPA : United Nation Fund Population Association
USAID : United States AID
WHO : World Health Organization

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ABSTRACT
Background: Contraceptive prevalence among currently married women increased by
an impressive 46% in the last three years, from 29% in 2011 to 42 % in 2014. The overall
private sector contribution of FP service uptake is about13.4% and the unmet need for
Family Planning in Ethiopia is still about 25% with 42% contraceptive prevalence rate
(Mini EHDS, 2014). MSIE is one of the largest contributing organizations to the efforts
made by the government and other stakeholders in increasing access to quality FP
services. BlueStar Healthcare Network that has been designed to alleviate lack of access
to family planning services, it has not received adequate attention by partners in the past
and has not progressed far (MSIE, 2014).
Study objective: The overall objective of this assessment is to assess the effect of BlueStar
Healthcare Network on family planning service uptake in member private clinics since
membership in Central Area of Ethiopia.
Methods: This study employed a cross-sectional survey with questionnaire based and
secondary data collection techniques. The study was conducted from March to April,
2015. A Probability sampling methods have been used in selection of respondents for the
study (G. Jay Kerns, 2010). The quantitative data has been entered in to SPSS version
20.0 with coding for analysis.
Study results and discussion: A total of 222 participants were invited and 211 responded
to the survey. The response rate, 95% is high in this survey with 82% Male and 18%
Female participants. In this study it was evident that most private clinics joined the
network for ensuring their quality services provision and ultimately meet serving more
users and maximizing their social commitment. About 13% the BS clinics have strongly
agreed in meeting their expectations of joining the network and very few (3%) were
strongly disagreed. A technical assistance (TA) through supportive supervision was
acknowledged only by 36% of the member clinics.

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The majority (78%) of the member clinics have the rate of increases greater than 10-30%
in number of clients for FP service uptake since membership. The rate of increase in FP
service volume also indicates that the majority (73%) of the member clinics have
increases greater than 40%.
Conclusion: The rate of increase in number of clients for FP service uptake indicates
that the majority (78%) of the member clinics have increases greater than 10-30% and
very few (3%) of the member clinics have increases greater than 30% in number of
clients for FP service uptake since membership.
The rate of increase in FP service volume also indicates that the majority (73%) of the
member clinics have increases greater than 40% and about16% of the member clinics
have increases between 20-40% in FP service volume since membership.
Recommendations: MSIE has to intensify its technical assistance (TA) through
supportive supervision and check the TA practice of its program officers. MSIE program
officers have to give priority for member clinics with the experience of no significant
increases in number of FP service uptake and FP service volume since membership.

CHAPTER ONE: INTRODUCTION
1.1 Background
In the Constitution of the Federal Democratic Republic of Ethiopia, Article 35.9, the right
of women in accessing family planning stated as “to prevent harm arising from
pregnancy and childbirth and in order to safeguard their health, women have the right to
Family Planning (FP) education, information, and capacity” (EFDR (1995), “Family
planning saves lives of women and children and improves the quality of life for all. It is
one of the best investments that can be made to help ensure the health and well-being of
women, children, families and communities” (WHO, 1995).
Following Ethiopia’s adoption of a Population Policy in 1993, local and
international institutions partnered with the government in expanding FP programs and
services. The National Office of Population was then established to implement and
oversee the strategies and actions related to the Population Policy. In 1996, the Federal
Ministry of Health (FMOH) released Guidelines for FP Services in Ethiopia to
guide stakeholders, as well as to expand and ensure the quality of FP services. In
this guideline, the FMOH designated new outlets for FP services in addition to the
preexisting facility-based and outreach FP services. Moreover, other policy and
strategic documents have emphasized integration and the linkage of FP services with
other RH services, to enhance FP utilization (FMOH, 2010).
Knowledge of FP has increased to 87% among currently married women. However, FP
use is still lagging, at 13.9% in 2005-though a recent survey with representative
samples from Ethiopia’s four most populous regions demonstrated the
Contraceptive Prevalence Rate (CPR) to have reached 32% there (The L10K Project,
2009). This can for the most part be attributed to the FMOH’s new Health Extension
Program (HEP), which has worked to increase access to preventive and promotive
health services, including FP services at the community and household levels
(FMOH, 2010).

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At the international level, several milestones have left footprints in population, women’s
status, RH, and FP. In 1994, the International Conference on Population and
Development (ICPD) focused on the close link between population, sustained economic
growth, and sustainable development. ICPD recommended actions to help couples and
individuals to meet their reproductive goals (FMOH, 2010).
Family planning (FP) saves the lives of women and children and improves the quality of
life for all. It is one of the best investments that can be made to help ensure the health and
well-being of women, children, and communities. FP reduces mortality and morbidity
from pregnancy and childbirth. Spacing childbirth at intervals of three to five years
significantly reduces maternal, prenatal , and infant mortality rates. Use of FP
prevents the depletion of maternal nutritional reserves and reduces the risk of anemia
from repeated pregnancies and births (WHO, 1995).
Pregnancy and childbirth pose special risks for some groups of women—adolescents,
women older than 35, women with more than four previous births, and women
with underlying medical diseases. It is estimated that if all of these high-risk
pregnancies were avoided through the use of FP, 25% of maternal deaths could
be prevented (Royston & Armstrong, 1989). Moreover, unwanted pregnancy can
lead to unsafe abortion, with its resultant short-term and long-term complications,
including death. Suffering and deaths from complications of unsafe abortion can be
prevented with the use of FP.
The provision of FP services is dependent upon the integration of services throughout the
health care system, starting from the community level to specialized referral hospitals. In
addition to outpatient clients, FP counseling and services should be made available to
postpartum women, post-abortion women, and individuals with special needs. All health
workers providing FP services should have contraceptive clinical and counseling skills.
The Family Planning Methods are classified as short term, long term and permanent
methods (HNP, 2013).

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Public sector contraceptive coverage of FP services accounts for 82% while private sector
contribution is about13.4% and the unmet need for Family Planning in Ethiopia is about
25% with contraceptive prevalence rate of 42% (Mini EDHS, 2014).
Apart from limiting and spacing births, FP methods have other, non-contraceptive
benefits. If properly and consistently used, the condom provides protection from
sexually transmitted infections (STIs), including HIV. The lactational amenorrhea
method (LAM) provides special nutritional benefits to the infant and protects the infant
from infections. In addition, LAM establishes mother-child bonding early in life, the
benefits of which continue through later life. It also reduces the risk of breast cancer in
the mother (FMoH, October, 2011).
Family Planning
The FMOH recognizes the important role and contribution of NGOs and the
private sector to health. HSDP IV recognizes the proactive involvement of NGOs
and the private sector, which significantly complement the public sector’s capacity to
tackle public health problems. NGOs will partner with FMOH and shall continue to
take part in FP programs, as depicted in the harmonization manual of the
HSDP(FMOH, 2005).
Women’s knowledge of family planning methods provides a measure of the level of
awareness of contraception in the population and indicates the success of existing
information, education, and communication programmes. Knowledge of at least one
family planning method and a positive attitude toward contraception are prerequisites for
the use of contraception.
Knowledge of contraceptive methods is nearly universal in Ethiopia. Four in every ten
currently married women (42%) are using a method of contraception, mostly modern
methods (40%). By far the most popular modern method, used by 31% of currently
married women, is injectables. Use of modern methods among currently married women
has increased from 6% in 2000 to 40% in 2014-largely due to the sharp increase in the
use of injectables, from 3% to 31% (Mini EDHS, 2014).

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BlueStar Healthcare Network
BlueStar (BS) Healthcare Network is a brand name for social networking through social
franchise program that Marie Stopes International Ethiopia (MSIE) is setting a new trend
to create access to family planning services by combining social service-provision goals
with a franchise model. It aims to increase access to quality services in urban and semi-
urban areas of Ethiopia. BS network operates in many regions of Ethiopia except the
peripheries where there are few or no clinics that meet the minimum standard for BS
Network Membership.
Figure 1: BlueStar Healthcare Network Brand Mark, 2015
MSIE fill quality gap by providing training on Comprehensive FP to providers of the
private clinics, monitoring after training and conducting regular supportive supervision to
the clinics. MSIE also fill supply gap by facilitating FP commodity supplies. Regarding
premises quality gap, MSIE branded the facility of the private clinic. MSIE also provides
marketing and BCC services to overcome gap in client uptake (MSIE, 2013).
As much of the developing world has to rely on private sector healthcare to provide
contraceptives and sexual and reproductive healthcare, MSIE has pioneered the use of
social franchising under the BlueStar brand to significantly expand access to high quality
services through existing local providers.

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BlueStar has expanded significantly over the last year, and has now reached almost more
than 600 clients across eight countries. This has not only resulted in vital services
reaching more communities faster than via organic growth; it has also empowered social
businesses in a replicable and sustainable model that provides hope to reach even more of
the underserved population in Ethiopia (MSIE, 2013).
Social Franchising Vs Social Marketing
- Social Franchising
Social franchise is a mechanism in which the private clinic agrees to provide a service in
accordance with an overall blue print devised by MSIE. It encompasses a network of
private clinics linked through contracts to provide socially beneficial services under a
common brand (BlueStar). It is an innovative way to reach women largely in urban and
semi-urban areas where MSIE couldn’t reach through its other two outlets (MSIE, 2013).
- Social Marketing
Social marketing is a strategy that promotes, distributes, and sells contraceptives at
affordable price through existing commercial channels. Social marketing promotes FP
services through multimedia IEC. Social marketing is already being used for the
promotion and sales of condoms, pills, and injectables. Other FP commodities (e.g.,
emergency contraceptives pills [ECPs]) can be distributed through social marketing,
which complements the services that are rendered in the public, private, and NGO
health institutions. Social marketing also involves pharmacies, drug stores, and rural
drug vendors (FMoH, October, 2011).
MSIE identifies local health providers who have the skill and the will to upgrade to a new
level of service delivery in sexual and reproductive health. They are provided training,
access to relevant products and association with an increasingly recognized network. On-
going monitoring ensures high standards that conform to the BlueStar name. In BlueStar,
MSIE is encouraged by the progress of a potentially winning formula for everyone
involved (MSIE, 2013).

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First and most importantly, the targeted population gets access to an international quality
standard of sexual and reproductive healthcare services at an accessible cost, right within
their community and from local healthcare professionals they recognize. For the
dedicated independent health provider on the ground, the BlueStar programme provides a
way to take their healthcare practice to the next level. They receive access to excellent
training, marketing expertise and great value family planning products – including
contraceptives and pregnancy kits that can be co-branded with their practice, and help
them build their practice further (MSIE, 2013).
For the investment in time and resources, MSIE is able to reach communities at a scale
that would not have been possible through MSIE clinics, while maintaining a high level
of service delivery. The BlueStar brand not only provides a recognized asset for the local
healthcare provider that they help build, but also retains an appropriate distance from the
brand of MSIE’s own managed clinics. “Quality of care is everything!” says BlueStar
Ghana Manager. “It goes far beyond technical competence in terms of clinical service
delivery into areas such as state of the outlet, customer care, and staff management”
(MSIE, 2013).
Promising progress
MSIE launched BlueStar in Ethiopia in 2009. Increasingly, independent health providers
are realizing the benefits of a facilitated social network through a streamlined central
organization and highly devolved decision-making and operation, MSI has been able to
bring together everyone from private clinicians, pharmacists, midwives, non-government
organizations and government representatives for the sharing of ideas, plans and
knowledge (MSIE 2013). The forum provides expert advice and direction and strengthens
advocacy for the BlueStar network. MSIE is energized by the success of achieving even
greater impact through increased access through the BlueStar social franchise network.
This sustainable model provides hope that this positive impact will only increase further
in the future (Donna, etal, 2010).

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1.2 Statement of the Problem
In Ethiopia, like many other African countries, provision of family planning services is
hindered by poverty, traditions favoring high fertility, cultural barriers, and limited
involvement of male. Generally, the existing family planning services are not inadequate
and large number of community is not reached by family planning services (WHO,
2003).
Individual: Pregnancy and childbirth pose a risk to the life of the woman.
Repeated pregnancies and childbirth limit women’s education, employment, and
productivity, resulting in low status in the community, with a resulting poor living
standard. FP enables women to pursue an education, to attain a better employment
opportunities.
Family: Increased family size leads to income-and resource-sharing. Having too many
pregnancies close together can entail early weaning, with consequent high levels
of infant morbidity and mortality, as well as the high cost of alternative infant
feeding options. In addition, children in such families tend to be underfed, ill-
housed, and undereducated, culminating in future unemployment and being a burden to
the family and the community at large. The death of a mother results in the disruption of
the family.
Community and national: Increase in population size leads to an increased ratio
of people to land, as well as reduced production and income, with consequent
increased migration to urban areas. Furthermore, increased population size results in
poor social services, poor education, compromised women’s empowerment, an
increase in the nonproductive segment of the population, deforestation, and
overconsumption of resources (which aggravates poverty).
Global: Uncontrolled population growth intensifies famine, war, and migration,
which are collectively termed ― demographic entrapment‖ (King, 1993). Moreover,
deforestation, erosion, and resource depletion and global warming are consequences of
the population explosion. All of these individual, family, community, and global effects

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of uncontrolled population growth can be minimized through strong FP programs
and services that respect the rights and informed decisions of women and men. FP is
one of the most powerful health interventions with which to achieve MDGs (King, 1993).
BlueStar Healthcare Network that has been designed to alleviate lack of access to family
planning services, it has not received adequate attention by the partners in the past and
has not progressed so far.
Moreover, lack of FP led to unwanted pregnancy that can lead to unsafe abortion, with its
resultant short-term and long-term complications, including death. Suffering and deaths
from complications of unsafe abortion can be prevented with the use of FP (Mini EDHS,
2014).
Lack of availability of commodities, equipment and supplies, and training of service
providers at private health facilities is a persistent barrier to the use of long acting
methods in Ethiopia. Short-acting methods are widely available through Health Extension
Workers (HEWs) and commercial outlets especially in rural areas where most people
live. Many potential clients in Ethiopia lack information or have misconceptions about
long acting methods. In countries where most people know about family planning, fewer
people have knowledge of long acting and permanent methods. Myths and
misconceptions are also widespread for these methods (Mini EDHS, 2014).
Knowledge of family planning is a prerequisite to obtaining access to and using a suitable
contraceptive method in a timely and effective manner. The knowledge of contraceptives
are still specific to FP methods. In the consequence, the overall contraceptive prevalence
rate is 29% for all women and 42% for currently married women, which is still low. The
use of modern methods than traditional methods is much better, but it is about 40% of
currently married women are using a modern method compared with just 1% using a
traditional method. The most commonly used modern method is limited to injectables,
currently used by 31% of currently married women. 5% of currently married women use
implants and 3% use the pill (Mini EDHS 2014).

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In many parts of the world, women do not have the decision making power,
physical mobility, or access to material resources to seek family planning services.
Women's use of contraceptives is often strongly influenced by spousal or familial support
of, or opposition to family planning. Research in northern Ghana found that women who
chose to practice contraception risked social ostracism or familial conflict. In some
areas, women need their husband's permission to visit a health facility or to travel
unaccompanied, which may result in either clandestine or limited use of contraceptives
(Biddlecom A, and Fapohunda BM, 1998).
The current contraceptive use is lower among currently married women age 40 and above
(some of whom are no longer productive) than younger women. For example, 20% of
currently married women age 45-49 % current use of a contraceptive method compared
with more than 40% of currently married women less than 40 years of age. Contraceptive
use is highest among currently married women age 20-24 (46%). Current use of
contraceptive methods is much lower among all women, and particularly among that age
15-19, than among currently married women, primarily because the all women category
includes unmarried women and women who are separated, divorced or widowed, for
whom use is relatively low (Mini EDHS 2014).

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1.3 Objectives of the Study
1.3.1 General Objective
The overall objective of this study is to assess the effect of BlueStar Healthcare Network
on family planning service uptake and service volume in member private clinics since
membership, so as to make recommendations based on the findings of the study.
1.3.2 Specific Objectives
1.3.2.1 To assess the changes in FP clients uptake of the member private clinics since
membership to the BlueStar Healthcare Network.
1.3.2.2 To assess the changes in FP services volume in member private clinics since
membership to the BlueStar Healthcare Network.
1.3.2.3 To identify possible challenges hindering the FP service uptake in member
private clinics since membership to BlueStar Healthcare Network.
1.4 Research Questions
One key characteristics of BlueStar Healthcare Network will result in member private
clinics the retention of existing clients; attracting more clients with maximum satisfaction
so as to earn more money with sustainable service provision and ultimately increase in
family planning service uptake and service volume. So that, the basic research questions
to be answered in this regard by the findings of this study are:
Qus-1: What is the effect of BlueStar Healthcare Network on family planning
services uptake and service volume in the member private clinics since
membership?
Qus-2: What are the contributing factors for significant increase or hindering factors
for insignificant increase in family planning services uptake and service
volume in the member private clinics since membership?

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1.5 Scope and Limitation of the Study
1.5.1 Scope of the Study
This study is mainly targeted to assess FP service uptake of the franchisees (BS private
clinics) since membership to BlueStar Healthcare Network with understanding of how
the franchisees rationalize the support of the franchisor’s (MSIE’s) in facilitating FP
service uptake towards reaching the target group in need of FP services.
In the provision of family planning services in the context of social networking of
BlueStar Healthcare Network member private clinics, there may be a change in family
planning service uptake and service volume since membership, which might be
significant in some BlueStar Healthcare Network member private clinics or might not be
significant FP service uptake and service volume in some other member clinics.
The potential relationship between family planning service uptake and social networking
is most likely moderated by quality of the service provision, technical assistance and
sustainability of family planning commodity supply system. The availability of family
planning commodities, family planning method choice and training on family planning
for service providers at private health facilities are key factors in the use of FP services
by the community.
1.5.2 Limitations of the Study
The information will be collected from the respondents at a single period in time and
dependent on respondents, their honest and frank response. The information will be
collected from the respondents at a single period in time and dependent on respondents,
their honest and frank response. There is lack studies carried out related to the network to
make comparison with the findings of this study.

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1.6 Significance of the Study
The findings of this study will greatly contribute in understanding the effect of BlueStar
Healthcare Network on FP service uptake in member private clinics and helpful in
deciding which activities should be retained or improved in FP service provision to the
community.
BlueStar is a brand name for network and operates under social franchise program of
MSIE. It is a partial franchise and partnership between private sector clinics and Marie
Stopes International Ethiopia in the provision of quality FP services to the community
with an affordable prices.
Marie Stopes International Ethiopia provides all the support necessary for the franchisee
(the private clinic) to run its business in the same way it is done by the franchisor. It
works by establishing a contractual relationship between a franchisee (private clinics) and
a franchisor (MSIE) in which the former agrees to produce or market a product or service
in accordance with an overall ‘blueprint’ devised by the franchisor. It is a ‘chain’ or
‘network’ that promises a consistent FP services to the community. The social franchise
is non-profit for the franchisor (MSIE, 2013).
The whole aim of MSIE is social goals rather than financial goals. On the other hand, the
franchisee’s objective is more of serving target group with affordable/ subsidized better
FP services so as to attract more clients with maximum satisfaction and ultimately earn
more money.
The core issue to be addressed through the network is showing commitment to the quality
of services provided and maximum care for the clients (WAO, 2013). So that, this study
is important to know whether the aim of Franchisor and expectations of the Franchisee is
achieved or not in reaching the target group with quality FP services.

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1.7 Definition of Key Terms
BlueStar: A brand name for social networking designed by Marie Stopes International
Ethiopia to enhance family planning service access and increase service uptake
at private clinics.
Private Clinics: medium or primary clinics those voluntarily join the BlueStar
Healthcare Network.
Social Franchise: a mechanism in which the private clinic agrees to provide a service in
accordance with an overall blue print devised by Marie Stopes International
Ethiopia.
Franchiser: Marie Stopes International Ethiopia who designed BlueStar Healthcare
Network
Franchisee: a private clinic that voluntary join the network to be benefited from social
networking.
1.8 Structure of the Thesis
The report divided in to five chapters. Each chapter comprises subtitles. Chapter one is all
about introduction part. The main components of this chapter are introduction with
background information, problem statement, research questions and objectives with
justification and definition of key terms.
Chapter two is dealing with review of related literatures. Chapter three is all about
methodology of the study. Chapter four is study findings with data presentation, analysis
and discussion. Chapter five is more of conclusions and recommendations. The reports
ended with references and annexes.

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CHAPTER TWO: LITERATURE REVIEW
2.1 Theoretical Framework
In essence, a framework is a structured organization of ideas supported by evidence so as
to produce a valid explanation. In does so, by establishing a relationship between more
than one conceptor variable. A theoretical framework is a casual orientation toward the
contemplated study. As such, it formulates a detailed model of the given program. It also
furnishes a supportive framework for the model, based on the empirical evidence
gathered from prior research/study and/or experiences (May, T., 2001).
Social Franchising Vs Social Marketing
- Social Franchising
Social franchise is a mechanism in which the private clinic agrees to provide a service in
accordance with an overall blue print devised by MSIE. It encompasses a network of
private clinics linked through contracts to provide socially beneficial services under a
common brand (BlueStar). It is an innovative way to reach women largely in urban and
semi-urban areas where MSIE couldn’t reach through its other two outlets (MSIE, 2013).
- Social Marketing
Social marketing is a strategy that promotes, distributes, and sells contraceptives at
affordable price through existing commercial channels. Social marketing promotes FP
services through multimedia IEC. Social marketing is already being used for the
promotion and sales of condoms, pills, and injectables. Other FP commodities (e.g.,
emergency contraceptives pills [ECPs]) can be distributed through social marketing,
which complements the services that are rendered in the public, private, and NGO
health institutions. Social marketing also involves pharmacies, drug stores, and rural
drug vendors (FMoH, October, 2011).

23
Basically Family Planning (FP) is voluntary service utilization practiced by the
community and hence, a base to initiate social franchise program for FP services and
define the context of BlueStar Healthcare Network. The context of BlueStar Healthcare
Network encompasses franchiser, franchisees, the program/network, inputs and
stakeholders.
The theoretical framework presents all these in relatively abstract terms. It identifies,
defines and elaborates the concepts reflected in the program. It may be thought of as a
mental diagram, or map, which interrelate these concepts, showing where, when and how
they fit together. The written statement of the theoretical framework is, therefore, the
analyst's description and explanation of this conceptual map (Mayer, R. R. and E.
Greenwood, 1980).
Whilst any theoretical framework is distinction so far as it specifies a relationship or sets
of relationships, it does not operate in a vacuum- it derives from previous research and or
experience. So that, the social franchise program implementation needs MoU among
franchiser and franchisees. It is a pre-requisition for the establishment of the network and
the membership, which is crucial for the operation of the network. The needs of clients
and providers are the initiator of the FP services, which lead to identify the availability of
service input that determines available resources.
A theoretical framework specifies relationships of franchisees and franchiser in
interconnectional terms. Even when concepts are operationalized it still remains
hypothetical. Only proof from empirical work (irrespective of whether this evidence is
from primary or secondary data) can validate the argument contained in the theoretical
framework. Because a theoretical framework derives from prior knowledge, the
validation of the argument contained in it naturally lends itself to adding value to
theoretical or empirical knowledge (May, T., 2001).
This mean, Supportive Supervision (SS)/Technical Assistance (TA) and Quality
Technical Assurance (QTA)/Internal Audit Checklist (IAC) from the franchiser side are

24
continuing to examine how well support was implemented and resources utilized and
insure service accessibility and meeting franchisees expectations; the compliance of
program outputs with intended outcomes: Increase in number of FP clients uptake;
Increase in FP service volume; Sustainability of FP services; and Quality FP services
The franchisees regularly reported its performances of FP services to franchiser and
stakeholders. The data is recording in the database of MSIE. It is analyzed for
performance tracking by involving its partners and stakeholders and taking corrective
measures required in the future within the larger framework of the implementation
process of social franchise program.
Depending solely on empirical data collection to provide an explanation runs the risk of
not only reproducing assumptions of everyday actions and outcomes but also of closing
our mind to other factor that may have an influence on the program outcomes. It also
specify a relationship between more than one concept or variable - either in a qualitative
or a quantitative manner or a combination of the two.
This theoretical framework provides a structure for argument. It normally follows from a
literature review and the research question. An exception is when a grounded
methodology is adopted. In this case, the findings arising from grounded research may be
explained by the use of a theoretical framework that relates the findings to the wider
literature. The key point being made here is that whilst variables are easily measured,
concepts are not so easily measurable. However, attempts have been made to measure
concepts - but only by operationalizing them.
The use of this theoretical framework can produce theoretical outcomes at the same time
as producing outcomes for franchisees and franchiser concerned with social issues of FP
services. However, the key points to note about research that is a-theoretical is: Research
that does not theorize depends on facts to speak for themselves. In this essay or
dissertation, this is often related to a literature review that is issue-based (see the
literature review component).

25
Figure 2: Theoretical Framework, 2015
Increase in # of FP clients
Program Input:
- Training
- Supply
- Promotion
- Branding/infrast
ructure
Social
Franchise
Program
BlueStar
Healthcare
Network
Franchiser: MSIE
Franchisees: Private
Clinics
Stakeholders:
- CSA
- FMHACA
- MoH
- Clients
Expectation
Need of ClientsMoU
Membership Access to FP
services
SS/TA
Reporting/
Recording/Info Use
Reporting/
Recording/Info Use
Increase in FP service volume
Sustained FP services
Quality FP services

26
2.2 Empirical Literature
2.2.1 Definition of Family Planning
Family planning is defined as the ability of individuals and couples to anticipate and
attain their desired number of children and the spacing and timing of their births. It is
achieved through the use of contraceptive methods and the treatment of involuntary
infertility. FP is a means of promoting the health of women and families and is part of a
strategy to reduce the high levels of maternal, infant, and child mortality (MoH, FP
Guidelines, 2011).
2.2.2 Family Planning: Voluntary Services
The United Nations Population Fund (UNFPA) estimates that one out of three maternal
deaths can be prevented by just addressing the unmet need for family planning. Family
planning is a smart investment. For every dollar that is invested in contraception, one can
expect a social sector saving of twice that amount (MoH, FP Guidelines, 2011).
While countries like Ethiopia are making remarkable progress in improving access to and
use of contraception, the progress has stalled in many low income countries. People
should be offered the opportunity to determine the number and spacing of their own
children. Information about FP should be made available, and access to FP services
should be actively promoted for all individuals desiring them (Fantahun M, Chala F,
Loha M (1995).
FP reduces mortality and morbidity from pregnancy and childbirth. Spacing childbirth at
intervals of three to five years significantly reduces maternal, perinatal, and infant
mortality rates. Use of FP prevents the depletion of maternal nutritional reserves and
reduces the risk of anemia from repeated pregnancies and births (Royston & Armstrong,
1989).
Pregnancy and childbirth pose special risks for some groups of women-adolescents,
women older than 35, women with more than four previous births, and women with
underlying medical diseases. It is estimated that if all of these high-risk pregnancies were

27
avoided through the use of FP, 25% of maternal deaths could be prevented (Royston &
Armstrong, 1989).
In efforts to promote FP, programs are guided by the principles of voluntarism and
informed choice, so that: People have the opportunity to choose voluntarily whether to
use FP or a specific contraceptive (FHI, 2005). Individuals have access to information on,
and full opportunity to choose from, a full range of FP choices. Clients choosing
sterilization have their voluntary and informed consent documented in a signed written
consent (USAID, 2006).
The most common reasons for unmet need are: Difficult access to modern contraceptive
methods; Low quality health care services; and Little perceived risk of becoming
pregnant - the stated reason for one- to two-thirds of women with unmet need are due to
Opposition from husbands, families, communities; Fears about contraceptive side effects;
and Lack of knowledge about contraceptive methods or sources of supply (WHO, August
2006) and USAID, 2006).
Young women are another special group with unmet need. Adolescent women often have
less access to contraception, less knowledge about pregnancy risk, and less understanding
of contraceptive options. Unintended pregnancies may have important adverse effects for
the future education and lives of adolescents. Preventing unintended pregnancies among
young women (under age 18) also helps prevent the formation of vesicovaginal fistulas
that result if the pelvis is too small (USAID, 2006).
2.2.3 Factors affecting individual's use
Several studies have been done in the different countries in the past to find out the factors
that affect individual's use or non-use of contraceptives. Literature shows an interaction
of individual, societal and reproductive health service factors affecting young people's
ability to access contraception. Based on the studies undertaken elsewhere the factors are:
Individual Factors, Socio-cultural factors, Reproductive Health Service Factors, Method

28
Choice and Availability, Information and Counseling, Affordability of Services,
Providers’ Attitude and Actions (MSIE, September, 2014).
The effectiveness of a method, or "how well the method works," is often the most
important consideration for the client. The "effectiveness" of a method is the number of
pregnancies per 100 women using the method in one year. There are short and long term
and permanent methods (USAID, 2006).
2.2.4 Short Term Method
Combined pill and Progesterone-only pill (mini pill): The contraceptive pill or oral
contraception is a common form of contraception for women. This is the most common
type of contraceptive use by most women(MSIE 2013). Combined pill contains two
hormones – oestrogen and progestogen, which prevent an egg from being released from a
woman’s ovary each month. The combined pill can reduce pre-menstrual syndrome
(PMS) and period pain. There is evidence that it also offers some protection against
cancer of the uterus and ovaries (MSIE 2013).
Progesterone-only pill (mini pill): Unlike the combined pill, this only contains the
hormone progestogen. It works by thickening the cervical mucus, which acts as a barrier
to stop sperm entering the womb. It also makes the lining of the womb thinner, to prevent
it accepting a fertilized egg. This type of pill is good for women who are breast-feeding,
older women, smokers and others who cannot use the combined pill. It can also help with
pre-menstrual syndrome (PMS) and painful periods (MSIE, 2013).
Contraceptive injection: It’s an injection of hormones that provides a longer-acting
alternative to the pill. It works by slowly releasing the hormone progestogen into the
body to stop ovulation. Each injection lasts for 12 weeks. Injections may reduce heavy or
painful periods and may give some protection against cancer of the uterus (MSIE, 2013).
2.2.5 Long Term Method
The Intrauterine device (IUD): An IUD is also known as a Coil, small plastic and
copper device, usually shaped like a ‘T’, which is fitted into the woman’s uterus by a

29
doctor using a simple procedure. It works by preventing an egg from settling in the
womb. An IUD can stay in place for five years – sometimes for 10. It can also be used as
an emergency method of contraception within five days of unprotected intercourse
(Mendoza, S., August 2004). The doctor who fits the device should show how to check it
by feeling for the threads.
Contraceptive implant: It’s a small stick containing the hormone progestogen which is
inserted under the skin in the arm. The hormone is slowly released into the body,
preventing eggs from being released from the ovaries, sperm from reaching an egg or an
egg settling in the womb (WHO, UNFPA, 2003).
2.2.6 Adolescents and youth
Adolescents and youth-limited knowledge of sexual physiology, early marriage, limited
use of contraceptives, limited access to reproductive health information, and girls’ limited
agency over [their] sex lives all contribute to the high rate of unwanted pregnancy.
National Adolescent and Youth Reproductive Health Strategy Fewer than 10% of
married girls aged 15–19 years use any modern FP method. Almost one-third (31.1%) of
adolescents experienced an unwanted mistimed live birth (Central Statistical Agency and
ORC Macro, 2006), indicating limited access to FP services or access to less youth-
friendly services. All contraceptives can safely be used by adolescents. However, specific
attributes of the different FP methods for use by adolescents should be discussed during
counseling (William, R., 2000).
Unmarried and married youth may have different sexual, FP, and other SRH needs. FP
services can create an opportunity to discuss STIs, HIV, GBV, and other SRH issues.
Because of ignorance and psychological and emotional immaturity, adolescents’
and youths’ compliance with the use of FP methods may not be optimal (FMOH, 2006).

30
CHAPTER THREE: METHODOLOGY
3.1 Description of the Study area
The study area will be major areas of Ethiopia where BlueStar Healthcare Network is
more operational, namely: Central, West, East, South and North part of the country. This
classification is done based on the strategic management of MSIE for its BlueStar
Healthcare Network.
There are about 400 BlueStar Healthcare Networked private clinics in the year 2012. The
year 2012 is the baseline year and it is the year when database established and data
recording on family planning service was started for each BlueStar Healthcare Network
member private clinics at National level. Currently, the number of member clinics
reached more than 600 clinics. They are fairly distributed all over the country, and less
populated in the emerging regions (MSIE, 2013).
Figure 3: Geographic Distribution of BlueStar Healthcare Network Member Private
Clinics, 2015
Key:
 BlueStar Clinics

31
3.2 Research Design and Approach
This study will employ a descriptive cross-sectional survey with self-administered semi-
structured questionnaire and secondary data collection techniques. The information will
be collected from the respondents at a single period in time. Survey is the most basic type
of study design and extensively used for assessing results of programs/projects in detail
(Mark Saunders, 2009; G. Jay Kerns, 2010).
This study period covered three months, in which May, 2015 was the period for data
collection. June to July, 2015 was also the period for data analysis, report writing,
submission to advisor & department and for dissemination of results.
Surveys and use of secondary data represent one of the most common types of
quantitative, social science research design. In survey research, the researcher selects a
sample of respondents from a population and administers a standardized questionnaire to
them.
The questionnaire can be a written document that is completed by the person being
surveyed, a self-administered semi-structured questionnaire. It will enable the
investigator to explore, in great detail, about the network effects (Mark Saunders, 2009;
Lynda B., 2007).
3.3 Data Source and Method of Data Collection
The source populations for this study are all private clinics that joined BlueStar
Healthcare network in Ethiopia. The study populations are the head of the private clinics.
3.3.1 Inclusion and exclusion criteria:
Inclusion criteria: Private clinics, which joined BlueStar Healthcare Network for more
than three years and active in the Network will be included in the study.

32
Exclusion criteria: Private clinics, which area joined BlueStar Healthcare Network after
2012 and not active will be excluded from the study. The year 2012 is also the baseline
year when data recording for family planning services for each member clinics.
3.3.2 Sampling technique and sample size
Probability sampling methods will be used in selection of respondents for the study (G.
Jay Kerns, 2010). The sample size was calculated by using EpiInfo version 7.1.5,
StatCalc Utility, considering the following parameters: according to an estimates for the
family planning service uptake growth rate in BlueStar Healthcare Network is about
50%, 95% confidence level and worst acceptable value + 5%. Accordingly from the total
population of 528 active private clinics networked in BlueStar Healthcare Network, the
required sample size is 222.
The total sample size distributed to all regions from sampling frame, by using randomly
generated MS Excel RAND. All assigned clinics have been invited and interviewed to
participate in the survey.
3.3.3 Data collection instruments
The semi-structured questionnaires are standard questionnaires used in this study. It has
been tested in the field for its consistency and clarity. Finally, the corrected tool has been
used for data collection (Annex 1).
There has been also secondary data source for reviewing of database/ performance
records of private clinics networked in the BlueStar Healthcare Network of Marie Stopes
International Ethiopia (MSIE). The year 2012 is the baseline year and it is the year when
database established and data recording on family planning service for each franchise was
started at National level.
3.3.4 Data collection procedure
The principal investigator did the overall control and follow up of data collection process
with checking the completeness of the filled questionnaire daily. He also approached
MSIE for quantitative secondary data collection from records of the performances of the

33
clinics. Two supervisors and four data collectors have been hired to do surveying of
private clinics, member of BlueStar Healthcare Network.
The supervisors were senior and at least bachelor holders. The data collectors were also
bachelor holders with health/social science background. They have been assigned into
four areas to complete data collection in maximum of ten days.
3.3.5 Study project management
The principal investigator will have overall project coordination with the assistance of
supervisors. All administrative and logistics issues will be the responsibility of the
coordinators. The payment will be man-days based on the agreement made between the
principal investigator and supervisors and data collectors. MSIE should sign a letter of
support for cooperation and legal support.
3.4 Method of Data Analysis
3.4.1 Definition of Variables
The independent variables are age, sex, religion, education status, location/geography and
level of clinics. The dependent variables are year of membership, reason for membership,
MSIE supports, number to FP clients, volume of FP services, FP method mix, adequate
for counseling for FP, client handling, and medical records practices.
3.4.2 Econometrics models and Specification of Variables
The study variables, divided into four categories: (1) moderating variables (David A.
Kenny, 2011), (2) general information related variables, (3) family planning service
uptake related variables, (4) Service penetration practices related variables.
The quantitative data first checked for completeness and internal consistency. Then the
data has been entered in to SPSS version 20.0 with coding. The entered data has been
cleaned by using data utility of SPSS to work on clean data for analysis. It has been
analyzed by running simple frequency distribution for demographic data and statistical
tests. The results have been presented using tables with cross tabulations and graphs.

34
3.4.3 Data quality management
Pre-test: A pre-test study has been conducted to maximize validity and reliability of the
study instruments. A questionnaire for surveying has been tested by taking private clinics
networked in BlueStar Healthcare Network, which were not included in the survey.
Accordingly corrections have been made after testing for appropriate wording, clarity and
consistency of questions. At the end of the pretest, discussion has been held with the
respondents on skipping pattern, sensitiveness of the questions, and their honest and frank
response, the relevance of the study and other additional opinions they may had.
Training: Data collectors have been familiarized with the instruments through training.
They have been given two days training on surveying techniques including pre-testing by
using training guide (Annex 4).
Supervision: A daily supervision and follow up has been done by principal investigator
with the assistance of supervisors. Data collectors have been submitted the completed
questionnaires every day to supervisors and have been checked for completeness with
principal investigator.
3.4.4 Ethical Consideration
Ethical clearance: Ethical clearance for the protocol has been made by RVUC, Bole
Campus Ethical Clearance Committee prior to its implementation.
Confidentiality: Respondents’ view and opinion treated as confidential and anonymous.
With regard to protecting participants’ confidentiality, participants’ identities were
protected and respected during final presentation of the data in public dissemination
events, as well as in printed publications.
Informed consent: Informants informed about the research in a way they can
understand, finally reached on consensus and have got verbal consent with data
collectors. The information to informants included: the purpose of the study, how
confidentiality protected and expected benefits.

35
3.4.5 Report writing plan
A report has been prepared and submitted to advisors for their comments. The result has
been presented with discussion and interpretation. This study will help for decision
making in relation to program improvement and expand best experiences for the future
scale up of the network. A check list was prepared for reviewing reports for its
completeness and appropriateness (Annex 4).
3.4.6 Findings dissemination plan and publication
The dissemination plan comprises presenting the study results to different stakeholders
by approaching them through seminars, workshops, and distributing hard copies of the
study result reports.
The final report has been prepared in electronic (PDF format) and hard copies. One hard
copy with electronic copy submitted to RVU.
The principal investigator will also publish the findings of the study in Journals to
maximize the use of findings for the improvement of the network.

36
CHAPTER FOUR: STUDY RESULTS AND DISCUSSION
4.1 Findings
4.1.1 Socio-Demographic Characteristics of the Study Population
A total of 222 BlueStar Healthcare Network member private clinics invited to participate
in the survey carried out in Ethiopia. A total of 211 responded to the survey with
response rate of 95%. Of the total respondents 16% were lower /primary clinics, 82%
were medium clinics and 2% were higher clinics. Hence, the final analysis was made
based on 211 completed questionnaires.
About 50% of respondents were in the age range of 40 – 49 years; about 47% of the
respondents were also in the age range of 30 – 39 years; and about 3% of respondents
were in the age range of 50+ years. Most respondents (97%) were in the age range of 30
– 49 years. Of the total respondents 105 were in the age range 40 – 49 year and 70 were
in the age range 30 – 39 years.
Of the total participates in the survey, 172 (82%) were Male and 39 (18%) were Female.
By location of respondents, 50% of the participants were from Oromia Region; 16% from
Amhara Region; 16% from Addis Ababa City, 13% from South Nations & Nationalities
Peoples Region, 5% from Tigray Region and 1% from Dir Dawa City Administration
(see Figure 4 below).
Figure 4: Number of Respondents by their Sex and Education Status, 2015

37
Regarding service providers, the interviewees reported that 97% were trained on family
planning and only 3% not trained. About 64% of the providers were college diploma
holders, 32% bachelor holders and 5% were medical doctors (see Table 1 below).
Table 1: Number of FP Service Providers in BlueStar Healthcare Network Member
Private Clinics by Training on FP and their Education Status, 2015
Se.
No
Level of clinics
Training status of service
providers
Total
Education status of service providers
Trained
on CFP
Not trained on
CFP
College
diploma
Bachelor Medical
doctor
Total
1 Higher 5 0 5 1 3 1 5
2 Lower 30 4 34 34 0 0 34
3 Medium 169 3 172 94 67 11 172
Total 204 7 211 129 70 12 211
4.1.2 BlueStar Healthcare Network Implementation
About 60% of the respondents reported that they joined the network between 2011 and
2012; almost 25% of them joined between 2009 and 2010 and the rest about 15% joined
before 2009 (see Table 2 below).
Table 2: Number of BlueStar Healthcare Networked Private Clinics by Year of
Joining the Network and Reason for Joining the Network, 2015
Se
No
Level of clinics
Year of joining the network
Total
Before 2009 2009-2010 2011-2012
1 Higher 0 0 5 5
2 Lower 15 4 15 34
3 Medium 16 49 107 172
Total 31 53 127 211
Almost all (98%) of the private clinics were joined the network for quality services
provision; the majority 80% for serving more users, 70% for becoming competitors and
26% for maximizing social commitment in the market (see Figure 5 below).

38
Figure 5: Reason/Expectation of Private Clinics for Joining BlueStar Healthcare
Network, 2015
Regarding BlueStar Healthcare Network meeting the expectations the Member clinics,
significant number of respondents (72%) were agreed; some 13% were strongly agreed,
12% were disagreed and 3% were strongly disagreed in meeting their expectations.
Significant number of respondents (76%) was also reported that they provided family
planning service free of charge for clients not affording fees for FP services (see Table 3
below).
Table 3: Number of private clinics who reported that BlueStar Healthcare Network
met their expectation in FP Services, 2015
Se
No
Level of
clinics
BlueStar Healthcare Network met the Expectation of Member
private clinics
Provide services
for free
Strongly
agree
Agree disagree Strongly
disagree
Total Sometimes
1 Higher 0 1 4 0 5 5
2 Lower 3 30 1 0 34 20
3 Medium 24 120 20 8 172 137
Total 27 151 25 8 211 161
Almost all respondents (100%) reported that Marie Stopes International Ethiopia (MSIE)
provided supports through training for their providers on family planning, supply
provision and others like branding, promotion, quality control, etc. Only about 36% of

39
the respondents reported that MSIE offered technical assistance though supportive
supervision to FP service providers (see Figure 6 below).
Figure 6: Type of Supports Offered by MSIE that Acknowledged by Private Clinics
Networked in BlueStar Healthcare Network, 2015
4.1.3 The rate of increase in number of FP clients of member clinics since
membership
The majority (99.5%) of the respondents mentioned that the client number visiting their
clinics increased since membership. In mentioning the rate of increase in number of
clients, about half (49%) were reporting that there is somehow an increase; about 25% of
the respondents mentioned that they do not know or have no analysis for the rate of
increase in number of clients; about 14% reported that the increase is significant; about
12% explained that the rate of increase is not significant. (see Table 4 below).
The qualitative findings also indicated that competitors are the one who contributed to
low FP service uptake for some member clinics. On the other hand, most frequently
mentioned reasons were differences in the level of clinics in which medium clinics have
more uptake than lower clinics in the vicinity of the clinics.

40
Table 4: Rate of Increase in Client Number visiting Member clinics for FP Services
since Membership to BlueStar Healthcare Network, 2015
Se
No
Level of
clinics
Clinics with increased client
number for FP services
since membership
Rate of increase in number of clients for FP
services since membership
Total
Yes No Total Not
significant
Somehow
there is
change
There is
significant
change
I don't know
or Have no
analysis
1 Higher 5 0 5 0 4 0 1 5
2 Lower 34 0 34 2 18 3 11 34
3 Medium 171 1 172 24 82 26 40 172
Total 210 1 211 26 104 29 52 211
The analysis of secondary data from MSIE database indicates that the rate of increase in
number of FP clients visiting the member clinics for FP service since membership
showed that 10-30% in 78% of the surveyed clinics. About 19% of surveyed clinics have
less than 10% rate of increase in number of FP clients. In some (3%) of the member
clinics, the rate of increase is greater than 30% (see Table 5 below).
Table 5: Rate of Increase in Client Number visiting Member clinics for FP Services
since Membership from MSIE Secondary Data by Type of Clinics, 2015
Se No
Level of
clinics
Rate of increase in number of FP clients from MSIE data
Total
Less than 10% 10-30% Greater than 30%
1 Higher 1 4 0 5
2 Lower 2 32 0 34
3 Medium 37 128 7 172
Total 40 164 7 211
Among the respondents, about 78% of the respondents who agreed that the network met
their expectation have less than 10% of the rate of increase in number of FP clients since
membership. About 22% of the respondents who disagreed that the network met their
expectation have less than 10% of the rate of increase in number of FP clients since
membership.

41
their expectation have 10-30% of the rate of increase in number of FP clients since
expectation have also 10-30% of the rate of increase in number of FP clients since
membership.
Among the respondents, about 100% of the respondents who agreed that the network
met their expectation have greater than 30% of the rate of increase in number of FP
clients since membership. There were no respondents who were neutral and disagreed
with the rate of increase greater than 30% in number of FP clients since membership
(refer Table 6 below).
Table 6: Number of private clinics who reported that they met their expectation
with the increase in number of FP clients, 2015
Se
No
Met their
expectation
Rate of increase in number of FP clients from MSIE data
Total
1 Strongly agree 7 18% 17 10% 3 43% 27
2 Agree 24 60% 123 75% 4 57% 151
3 Disagree 7 17% 18 11% 0 0% 25
4 Strongly disagree 2 5% 6 4% 0 0% 8
Total 40 164 7 211
4.1.4 The rate of increase in FP service volume of member clinics since
membership
All respondents mentioned that the FP service volume at their clinics increased since
membership. In mentioning the rate of increase in service volume, a significant number,
about 40% of the respondents mentioned that they do not know or have no analysis to
know the level of increase in FP service volume; about 34% were reported that there is
somehow an increase; about 25% reported that the increase is significant increase in FP

42
service volume; and the rest 1% explained that the increase in service volume is not
significant (see Table 7 below).
Table 7: Rate of Increase in FP Service Volume in Member Clinics since
Membership to BlueStar Healthcare Network, 2015
Se
No
Level of
clinics
Clinics with increased
FP service volume
since membership
Rate of Increase in volume of services
Total
Yes No Total
No
significant
change
Somehow
there is
change
There is
significant
change
I don't know
or Have no
analysis
1 Higher 5 0 5 0 3 1 1 5
2 Lower 34 0 34 0 11 4 19 34
3 Medium 172 0 172 3 57 47 65 172
Total 211 0 211 3 71 52 85 211
The analysis of secondary data from MSIE database indicates that the rate of increase in
FP service volume since membership showed that 73% of the surveyed clinics have the
rate of increase in FP service volume greater than 40%. About 16% of the surveyed
clinics also have 20-40% rate of increase in FP service volume; and the rest 11% of the
surveyed clinics have less than 20% increase in FP service volume (see Figure 7 below).

43
Figure 7: Rate of Increase of FP Service Volume in member private clinics, 2015
their expectation have less than 20% of the rate of increase in FP service volume since
expectation have less than 20% of the rate of increase in FP service volume since
membership.
their expectation have 20-40% of the rate of increase in FP service volume since
expectation have also 20-40% of the rate of increase in FP service volume since
membership.
their expectation have greater than 40% of the rate of increase in FP service volume since
expectation have greater than 40% of the rate of increase in FP service volume since
membership (refer Table 8 below).
Table 8: Number of private clinics who reported that the network met their
expectation as compared to rate of increase in FP service volume, 2015
Se
No
Met their
expectation
Rate of increase in FP service volume from MSIE data
Total
1 Strongly agree 2 9% 8 24% 17 11% 27
2 Agree 16 70% 20 59% 115 75% 151
3 Disagree 2 9% 4 12% 19 12% 25
4 Strongly disagree 3 12% 2 5% 3 2% 8
Total 23 34 154 211

44
Based on the education status of interviewees, about 23% of the total respondents who
don't know or have no analysis for the rate of increase in number of clients for FP service
uptake were Bachelor holders; 2% were Diploma holders and 1% was Medical doctors.
Regarding rate of increases in FP service volume, about 37% of the total respondents
who don't know or have no analysis for the rate of increase in service volume were
Bachelor holders; 3% were Diploma holders and 3% were Medical doctor.
Overall, who doesn't know or have no data analysis for the rate of increase in number of
clients visiting the member clinics, accounts for 43% and who doesn't know or have no
analysis for the rate of increase in services volume in their clinics also accounts for 27%
of the respondents (see Table 9 below).
The qualitative findings also revealed the causes of no information utilization in member
clinics. One of the major causes no information utilization is lack of skill in data analysis
with mainly focus on generating data for reporting purpose.
Table 9: Data Analysis Practice in Understanding the Increase in Number of Clients
and FP Service Volume by Education Status of the Interviewees, 2015
Se
No
Education Status
of Interviewees
Who doesn't know
or have no analysis
for changes in
number of clients
%
Who doesn't know or
have no analysis for
changes in volume of
services
%
1 Bachelor 48 23% 78 37%
2 College diploma 6 3% 6 3%
3 Medical doctor 4 2% 7 3%
Total 58 27% 91 43%
4.1.5 Challenges/factors hindering FP service uptake of member clinics since
membership
About 44% of the respondents mentioned that trained staff turnover is as one of the
causes of insignificant rate of increases in FP service uptake since membership to
BlueStar Healthcare Network. Most frequently mentioned causes were also supply

45
interruptions/shortages by 27% of the respondents and competitors by 25% of the
respondents and low promotions by 3% of the respondents (see Table 10 below).
The qualitative findings also identified the reasons for trained staff turnover. Among
reasons that frequently mentioned for trained staff turnover was mainly salary and high
cost & shortage of transportation to the site. In this regard, most respondents also
remarked that MSIE has to provide gap filling trainings to replace trained staff left the
clinics.
Most frequently mentioned reason for supply interruption/shortage was lack of medical
supply on their request as fast as possible from MSIE. Most respondents suggested that
MSIE has to strengthen its supply provision system to reach timely the clinics on their
request as fast as possible.
Table 10: Factors for Insignificant Increase in Client Number and Service Volume
for Family Planning Service Uptake, 2015
Se
No
Factors
Frequency
(Yes)
Percent
(%)
1 No significant increase due to staff turnover 26 44%
2
No significant increase due to supply
interruptions/shortage
16 27%
3 No significant increase due to competitors 15 25%
4
No significant increase due to other (low
promotion)
2 3%
Total 59 100%
With regard to practicing fair FP method mix, about 96% of the respondents either
strongly agreed or agreed on practicing fair FP method mix in their clinic and about 4%
of the participants also disagreed on practicing fair FP method mix. All respondents
either strongly agreed or agreed on giving adequate time for counselling of clients on FP
(see Table 11 below).

46
Table 11: Number of BlueStar Healthcare Networked Private Clinics Practicing
Fair Method Mix, Adequate time for Counseling, 2015
Se
No
Level of
clinics
Practice fair FP method mix Adequate time for counseling on FP
Strongly
agree
Agree Disagree Total
Strongly
agree
Agree Disagree Total
1 Higher 0 5 0 5 0 5 0 5
2 Medium 4 23 7 34 6 28 0 34
3 Lower 11 160 1 172 18 154 0 172
Total 15 188 8 211 24 187 0 211
% 7% 89% 4% 11% 89% 0%
Regarding client handling, of the total participants, 78% of the respondents agreed with
practicing good client handling by FP service providers and about 22% strongly agreed
with practicing good client handling by FP service providers.
About 71% also strongly agreed with practicing clients' history recording confidentially
for FP services and bout 29% agreed with practicing clients' history recording
confidentially for FP services (see Table 10).
Table 12: Number of BlueStar Healthcare Networked Private Clinics Practicing
Good Client Handling and Confidentially Recording Clients' Medical
Records for Family Planning, 2015
Se
No
Level of
clinics
Good client handling by providers
Confidential clients' medical records
for FP
Strongly
agree
Agree Total Strongly
agree
Agree Total
1 Higher 0 5 5 2 3 5
2 Lower 7 27 34 17 17 34
3 Medium 40 132 172 131 41 172
Total 47 164 211 150 61 211
% 22% 78% 71% 29%

47
4.2 Discussion
The response rate (95%) was high in this survey with male (82%) and female (18%)
participation. The age range of the majority (97%) of the respondents is 30 – 49 years
with age median 40 years.
The majority (73%) of the respondents were bachelor holder. More than half (64%) of the
service providers are college diploma holder. The rate of trained service providers in FP
is very high, about 97%.
This study revealed that the increase in number of private clinics that joining the network
indicates a growth rate of more than double for each period since launching of social
franchising program. But more than half (60%) of the private clinics joined the network
between 2011 and 2012.
It was evident that most member private clinics were joined the network for ensuring
their quality services provision and ultimately meet serving more users and maximizing
their social commitment. Not only ensuring service quality but also they want to become
a competitor in the market. This study result is the same with a study done on what drives
family planning use in Ethiopia (Donna E, Jenny R, etal, 2010). Significant number
(72%) of member clinics agreed with that the network met their expectation in FP
service provision to their clients.
Almost all respondents acknowledged that Marie Stopes International Ethiopia (MSIE)
provided a support on training for their providers on family planning, supply provision
and others like branding, promotion, etc. MSIE technical assistance (TA) through
supportive supervision was acknowledged only by 38% of the respondents. This result
showed that MSIE TA is less recognised by BS healthcare network member private
clinics.

48
Overall, it was evident that there is an increase in FP service uptake in member private
clinics since membership. With regard to the rate of increase in number of FP clients,
few (12%) member clinics experienced no significant increases in number of clients for
FP service uptake. Only few (14%) of the member clinics have a significant increase in
number of clients for FP service uptake.
The analysis of secondary data from MSIE database regarding the rate of increase in
number of clients for FP service showed less than 10% in 19% of the member clinics
since membership. An increase between 10-30% in number of clients for FP service was
also experienced in the majority (78%) of the clinics. Only in about 3% of the member
clinics, the increase in number of clients for FP service was also greater than 30%.
All member clinics experienced an increase in FP service volume. With regard to the rate
of increase in FP service volume, few (1%) of the member clinics experienced no
significant increases in FP service volume. Some (25%) of the member clinics have a
significant increase in FP service volume.
The analysis of secondary data from MSIE database regarding the level of increase in FP
service volume showed that about 66% of the member clinics have also an increase in FP
service volume greater than 40%. This is very similar with the analysis made for 2013
annual strategic planning process of MSIE (unpublished document).
In this study, it is evident that the rate of increase in number of FP clients uptake is
between 10 -30% and very few (2%) of the member clinics have greater than 30%.
Regarding the rate of increase in FP service volume, it is also evident that it is greater
than 40%
Overall, a significant number (40%) of the member clinics also do not know or have no
analysis of data they generate to understand the rate of increase in FP service volume.
They generate data only for reporting purpose to the government and MSIE, which a
similar findings with qualitative results.

49
Member clinics who doesn't know or have no data analysis for the level of increase in
number of clients visiting their clinic for FP services, accounts for 27% and who doesn't
know or have no data analysis for the rate of increase in FP services volume in their
clinics also accounts for 43%.
It was also evident that 37% were Bachelor holders respondents who don't know or have
no data analysis for the rate of increase in FP service volume, College diploma holders
were 3% and Medical doctor were 3%.
Among factors causing insignificant increases in FP service uptake since membership,
staff turnover is the major (44%) contributor and followed by supply
interruptions/shortage 27% and competitors (25%), which a similar findings with
qualitative results, which a similar findings with qualitative results.
The qualitative findings also revealed similar results. The main cause of staff turnover is
salary. Supply interruptions/shortage is due to lack of timely supply provision by MSIE;
and high competition is also due to differences in level of clinics (medium, lower, etc.).
The study results showed that member private clinics that have fair FP method mix
practice with agreed account for about 86% and who also practicing an adequate time for
counselling of clients on FP with agreed account for about 89%. This study result is the
same with a study done on Broad Counseling for Adolescents about Combined Hormonal
Contraceptive Methods: The Choice Study in Switzerland (Gabriele S. Merki and Isabel
M. L. Gruber (2012).
It is also evident that practicing good client handling by FP service providers in member
clinics with strongly agreed account for about 21% and agreed account for 79%. Member
private clinics that are strongly agreed with confidentially recording of FP history of
clients account for about 78% and agreed account for about 22%.

50
About 86% of the member private clinics were agreed in practicing fair FP method mix
practice. About 89% were also agreed in practicing counselling on FP with adequate
time for counselling. About 79% of member private clinics were also agreed in practicing
good client handling. About 78% of member private clinics were also agreed with
confidentially recording of FP history of clients.

51
CHAPTER FIVE: CONCLUSIONS AND RECOMMENDATIONS
5.1 Conclusions
The overall social franchise program implementation came up with significant increases
in number of clients for family planning services uptake and family planning service
volume in member private clinics.
The information reported here also presents valuable guidance on the improvement of
BlueStar Healthcare Network under social franchise program implantation of Marie
Stopes International Ethiopia.
5.2 Summary of Findings
5.2.1 All member private clinics acknowledged supports that MSIE offered like
training, supply provision, and promotions, but, TA is less recognised by BS
healthcare network member private clinics.
5.2.2 Most member private clinics joined the network for ensuring their quality services
provision and ultimately serving more users and maximizing their social
commitment and becoming competitors in the market.
5.2.3 High number of member private clinics were strongly agreed that the BlueStar
Healthcare Network met their expectations with very few (3%) were strongly
disagreed in meeting their expectations from of BlueStar Healthcare Network.
5.2.4 A secondary data from MSIE database regarding the rate of increase in number of
clients for FP service uptake indicates that very few (3%) of the member clinics
have increases greater than 30% and the majority (78%) of the member clinics
have increases greater than 10-30% in number of clients for FP service uptake
since membership.

52
5.2.5 A secondary data from MSIE database regarding the rate of increase in FP service
volume also indicates that the majority (73%) of the member clinics have
increases greater than 40% and about16% of the member clinics have increases
between 20-40% in FP service volume since membership.
5.2.6 There were significant number of member clinics who didn't know or have no
analysis of data they generate to know and monitor the rate of increase in number
of clients visiting their clinic for FP services, and high number of clinics also did
not know or have no data analysis for the level of increase in FP services volume
in their clinics.
5.2.7 Among leading factors causing insignificant increases in FP service uptake since
membership are staff turnover, supply interruption/shortage and competitors.
5.2.8 Very high number of member private clinics practicing fair FP method mix with
adequate time for counselling of clients for FP services with good practice in
client handling by FP service provider; with good confidentially recording of
clients' history for FP services and with significant number of visit by youths.
5.2.9 High number of member private clinics was practicing sometimes the provision of
FP services for free for FP clients who do not affording fees for FP service
charges.
5.3 Recommendations
In this study it is evident that there have been activities to be retained, improved and
included in the process of implementing BlueStar Healthcare Network under Social
Franchising program. Based on the findings of this study results the following points are
recommended.

53
Need for improving practices
5.3.1 MSIE has to intensify its support in the area of technical assistance (TA) through
supportive supervision and check the TA practice of its program officers.
5.3.2 MSIE program officers have to give priority for member clinics with the
experience of no significant increases in number of FP service uptake and FP
service volume since membership.
5.3.3 Since the majority of the member clinics have 10-30% of increases in number of
clients for FP services uptake, they have to retain their clients with good quality
of services and capacity to increase the current rate and join those have achieved
greater than 30% of increases in number of clients for FP services uptake.
5.3.4 Since a significant of the member clinics (27%) have less than 40% of increases
in FP service volume, they have to retain their clients with good quality of
services and capacity to increase the current rate and join those have achieved
greater than 40% of increases in FP service volume.
5.3.5 MSIE has to assess expectations of the BlueStar Healthcare Networked private
clinics, so as to meet their expectations and attempt to satisfy their needs.
5.3.6 To overcome factors affecting the service uptake: MSIE has to provide gap filling
trainings to overcome trained staff turnover; MSIE has to strengthen its supply
provision system to reach timely the clinics on their request as fast as possible;
and MSIE has to support member clinics in improving business skill to be become
competitors.
Need for retaining/scaling up of best practices
5.3.7 MSIE has to create a forum or experience sharing mechanism, so as to make that
member clinics with significant increase in number of clients for FP service

54
uptake and increases in FP service volume have to share their experiences to other
member clinics.
5.3.8 MSIE has to continue in recognizing BS Healthcare Network member private
clinics performing best in FP method mix practice with adequate time for
counselling of clients on FP; with good practice in client handling by FP service
provider; with good confidentially in recording of clients' history for FP services
and with significant number of visit by youths, so as to empower them to continue
with these practices.
5.3.9 The member clinics have to continue with their practices in the provision of FP
services free of charge for FP clients who do not afford fees for FP service.
Need for including initiatives
5.3.10 The SF program should address the issue of data analysis at the member clinics
level, so as to empower them to monitor the rate of increase in FP service uptake
instead of focusing only data generation for reporting purpose.
5.3.11 The SF program should also address the issue of making the member clinics more
competitors in the market by improving their business skill with tailored
promotions.
5.3.12 Further comparative study, which addresses both BS clinics and non-BS clinics in
the sample is important, so as to know clearly the impact of the BlueStar
Healthcare Network in FP service uptake in BS clinics.

55
REFERENCES
Biddlecom A, and Fapohunda BM (1998), "Covert Contraceptive Use: Prevalence,
Motivations, and Consequences." Studies in Family Planning 29, no. 4: 360-72.
CSA (2012), Ethiopia Demographic and Health Survey 2011, pp. 78-89
CSA (2014), Ethiopia Mini Demographic and Health Survey 2014, pp. 39-60
Division of Medical Affairs, MSD Merck Sharp and Dohme AG, Luzern, Switzerland, Article
History: Received December 10, 2012;
Donna E, Jenny R, etal (2010), What Drives Family Planning Use in Ethiopia? pp. 42-59
EFDR (1995), The Constitution of the Federal Democratic Republic of Ethiopia. Addis
Ababa, pp. 23-30
Fantahun M, Chala F, Loha M (1995), Knowledge Attitude and Practice of Family planning
among high school students in North Gondar. Ethiopian Medical Journal; 33(1): 19-30.
Federal Democratic Republic of Ethiopia Ministry of Health (October, 2011), National
guideline for family planning Services in Ethiopia, pp. 26-40
FHI (2005), Iringa Adolescent Behavior Survey – Findings and Report, (Dar es Salaam), pp.
8-10
FMOH (2006), National Adolescent and Youth Reproductive Health Strategy 2007–2015,
Addis Ababa, pp. 15-20
FMOH (2010), Health Sector Strategic Plan (HSDP-IV) 20010/11-20014/15, Addis Ababa,
pp. 12-15
G. Jay Kerns (2010), Introduction to Probability and Statistics, First Edition, pp. 32-39

56
Gabriele S. Merki and Isabel M. L. Gruber (2012), Broad Counseling for Adolescents About
Combined Hormonal Contraceptive Methods: The Choice Study, Division of Reproductive
Endocrinology, University Hospital, Zurich, Switzerland
HNP (2013), Results-based Financing for Family Planning, pp. 90-122
Kenny, D. A., & Judd, C. M. (2011), Estimating the nonlinear and interactive
effects of latent variables, Psychological Bulletin, 96, 201-210
Lynda B. (2007), Survey Research, Johns Hopkins University, pp. 80-102
Mark Saunders, Philip Lewis and Adrian Thornhill (2009), Research methods for business
students, fifth edition, pp. 44-50
May, T., 2001), Social Research: Issues, Methods and Process. Buckingham: Open University
Press, p. 21.
Mayer, R. R. and E. Greenwood, 1980), The Design of Social Policy Research, Englewood
Cliffs, N.J: Prentice-Hall, p 121
Mendoza, S. (August 2004), Straight Talk—HIV and Young People, (International
Adolescent Leadership Council,) pp. 2-4, Retrieved from www.advocatesforadolescent.org on
28th
May, 2015.
MSIE (2013), Overview of Marie Stopes International Ethiopia, pp. 23-28
MSIE (2013), Overview of Social Franchising Program, pp. 23-27
MSIE (2014), BlueStar-Network of Private Providers in Ethiopia, pp. 60-78
MSIE, Integrated Marketing Department (2014), A Study on Barriers to Contraceptive Use of
Adolescents in Some Selected Major Urban Ethiopia, pp.8-16
Royston & Armstrong (1989), FP Reduces Mortality and Morbidity from Pregnancy and
Childbirth, pp. 56-68
USAID (2006), Family Planning 101, pp. 36-66

57
WAO (2013), Family Planning and Development Linkage, pp.5-12
WHO (1995), Family Planning and Investment in Family Planning, pp. 60-64
WHO (2003), Essential Drugs and other Commodities for RH Services, pp. 10-20
WHO (August 2006), Progress in Reproductive Health Research) pp. 2-8, Retrieved from
www.who.org on 28th
of May, 2015.
William, R.(2000), Sex Education Helps Prepare Young Adults: Reproductive Health
Education can Succeed in Various Settings, Including Schools and Community Centers,
Volume 20, Number 3, FHI, pp. 2-11

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