1.   Background and Problem Statement

Marie Stopes International (MSI) works around the world to ensure that every woman and girl, whatever their age, religion, income or ethnicity, is empowered to decide if and when she wants to have children. Comprehensive and sustainable access to sexual and reproductive health services can redress gender inequalities, remove barriers to education and vocational opportunities, decrease the care burden, and increase participation and leadership opportunities for women and girls in public and political life. Control over family size and fertility can increase household and community resilience to climatic stresses, by giving families control over the number of dependents supported by working family members (the dependency ratio) and increasing household food security. By enabling families to control their family size, contraception is one of the most effective ways of addressing household vulnerabilities to climate, food insecurity and health challenges.

In order to achieve these gains, MSI delivers services through a flexible and adaptive range of service delivery channels, including static clinical centres; mobile clinical outreach teams that operate on a roaming basis to serve hard-to-reach communities; the BlueStar social franchising network to build quality through private sector facilities; and our newest channel, ‘Marie Stopes Ladies’, which trains and equips nurses, midwives or community health workers to become midwife, nurse entrepreneurs (MNEs) and set up local health services in their own communities.

The role of the MNE service delivery channel is to provide community based, easily accessible, quality assured and affordable contraception and SA/PAC services whilst generating fees for the services. The MNEs (and in some countries, men) receive training, supportive supervision and equipment from their Marie Stopes Country Support Office. MNEs can be operated entirely utilising donor funding to the channel, allowing for free or heavily subsidised service provision [impact model]. Alternatively, MNEs can charge fees for their services and work towards the sustainability of the channel [entrepreneurial model]. Overall, the channel approach is rooted in the principles of entrepreneurship. The model works towards sustainability whilst increasing access to family planning for women in areas where other services might not be readily available. The MNE channel promotes the independence and socio-economic well-being of the MNE and strengthens communities by addressing unmet need for contraception.

MSION MNEs in Nigeria

The MNE service delivery model is now operational in 15 MSI countries. Marie Stopes International Organisation Nigeria (MSION) first launched the MNE model in June 2015 to increase uptake of contraceptives in Nigeria, which has a low modern contraceptive prevalence rate (mCPR) of 13.8% amongst all women. What began as a cohort of five MNEs has now grown to a network of more than 180. In Nigeria, MNEs are skilled professional, independent medical practitioners who are trained to provide FP services targeting underserved women of reproductive age through community-based service provision in rural and urban slum settings. MSION trains, equips, supports and supplies MNE with FP commodities and consumables and supports them through standard supportive supervision visits and quality control assessments.

The majority of MNEs in Nigeria provide mobile family health services through door-to-door visits or through their drug shops known as Proprietary Patent Medicine Vendors (PPMVs).

1. Mobile (door to door) providers

These are MNEs who do not own any form of shop but move from one location/community to another while providing services. This could be a midwife or CHEW (community health extension worker); though CHEWs are preferred given the fact that by training, they are equipped to provide mobile health care services within their communities and are more able to integrate within the community structure.  

1. PPMVs

The PPMVs (Patent and Proprietary Medicine Vendor) are those MNEs who own drug shops and only provide SRH services from their shops. They can also be midwives or CHEWs.

To date, MSION has received support from several donors to continue this service delivery model, including MSD for Mothers, the Bill and Melinda Gates Foundation, and the Department for International Development (DFID). With support from the Fondation Chanel, Inc., MSION has expanded the model to include an additional 67 MNEs providing services in Benue, Federal Capital Territory (FCT), Niger and Nasarawa states. Since the start of the Fondation Chanel, Inc. project, the MNEs supported have served more than 35,000 clients, averting an estimated 7,000 unsafe abortions and 81 maternal deaths.  

Table 1: Number of MNEs per state

2. Evaluating the MSION MNE service delivery model

As the MNE service delivery channel has evolved, it has become increasingly apparent, that as well as contributing to improvements in reproductive health outcomes (through the delivery of quality family planning services), the programme can also contribute to key outcomes related to the economic empowerment of the MNEs.

By economic empowerment, we understand: a woman is economically empowered when she has both the ability to succeed and advance economically and the power to make and act on economic decisions. Specifically:

• To succeed and advance economically, women need the skills and resources to compete in markets, as well as fair and equal access to economic institutions;
• To have the power and agency to benefit from economic activities, women need to have the ability to make and act on decisions and control resources and profits.[1]

Existing evidence shows that when women have the right skills and opportunities, they can help business and markets grow and that empowering women economically is one of the most effective ways for women to achieve their potential and advance their rights.

While MSI has robust systems in place to monitor and evaluate key family planning indicators, health outcomes and impacts among the clients we serve, we have less data available in terms of outcomes related to women’s economic empowerment.[2] [3]

Incentivising the MSION MNEs and piloting new approaches

Performance based incentives have proved an effective way to increase performance when market forces are not well aligned with MSION priorities, e.g. reaching the poor and youth. Using incentives helps remove some of the financial barriers MNEs face in delivering services to those less able to pay. Incentives also help ensure the MNEs feel valued by MSION and foster motivation.

MSION first implemented financial, performance based, incentives in July 2018. Incentives are paid monthly, based on the MNE’s performance against four key performance indicators (KPIs):

• # of medical post- abortion care cases
• % of FP client visits who were adopters (not using FP at the time of their visit)
• % of FP/PAC client visits who were adolescents (aged under 20)
• # of Couple Year of Protection (CYP) delivered

A base incentive is paid if targets for each KPI is met, further payment is available relative to how much targets are exceeded (see Table 2 below).

MSION is eager to gather additional learning on the most effective approach to incentivising the MNEs. Therefore, this evaluation will include piloting, and exploring the impact, of two alternative approaches to incentivising the MNEs. These pilots will run for 10 months, from August 2019 – May 2020. The two approaches:

• Cohort 1: For the new MNEs in Jigawa, a non-monetary incentive which may include commodities, consumables or other support which the MNEs normally have to fund themselves.
• Cohort 2: For existing MNEs Benue/ Nasarawa we will transition from current financial incentives based on a broader set of performance indicators (to include data quality, clinical quality and possibly client satisfaction as well as service statistics), from a fixed available budget for all MNEs each month.
• Cohort 3: No change to incentives.

Overall Evaluation Questions

1. What is the impact of the different incentive models on MNE productivity and profile of clients served?
2. What are MNE perceptions towards the MNE model of service delivery and the support provided to MNEs by MSI?
3. Does working as an MNE provide participants with distinct skills and resources that in turn allow them to improve their socio-economic status?

Proposed Outcomes Areas and Indicators to Explore

[for the MNE channel overall, and by incentive cohort]

• MNE productivity and profile of clients served
  • Number of clients visits
  • Number of CYPs generated
  • Cost per CYP
  • % of client visits from adolescents
  • % of client visits from FP adopters
  • FP method mix delivered
  • Number of MPAC (medical post abortion care) cases

• Socio-economic status of the MNE:
• Additional income generated via MNE activities
• Contribution of MNE generated income to overall household income
• How any additional income generated through MNE activities is spent (or saved)
• MNE involvement in household decision-making and spending
• MNE ownership of assets

• MNE power and agency:
• MNE capacity for leadership and business skills
• MNE self-efficacy and confidence to make decisions
• MNE time allocation and workload
• MNE group participation
• MNE perceptions of community support for work of MNEs
• MNE perceived barriers to the success of their business

• Perceptions of the service delivery model/ MSION support:
• Value placed on different training provided by MSION
• Value placed on working under MSION brand
• Benefits of working as an MNE compared to other types of provider

3. Study Design and Method

The study will take a multi-method approach, with primary data collection at baseline and endline as well as the collection of routine monitoring data throughout the pilot and evaluation period.

Operational baseline survey of MNEs [August 2019]

MSION, with the support from the MSI London Evidence to Action team, will complete a quantitative operational baseline survey with their MNE network. The survey will consist a short telephone questionnaire with a census of the MNEs. The questionnaire will collect baseline data (pre-pilot incentive introduction) related to the outcome areas 2 - 4 above (MNE income, household decision-making, satisfaction with being part of the MNE network etc.).

Analysis of monitoring data capturing FP/PAC services delivered and incentives paid [ongoing]

MSION collects monthly data on the FP/PAC services provided by the MNEs (see outcome area 1 above). MSION will also track the incentives paid monthly to each MNE. Analysis will be undertaken to compare key indicators (related to outcome area 1 above) over time, and between the various cohorts of MNEs.

Endline Study [Q2 2020]

The Consultant, in collaboration with MSION and the support of MSI London, will be responsible for finalising the methodological approach and design of the endline study.

We expect the endline evaluation to include the following:  

• Primary data collection: quantitative telephone survey of the MNEs (which should be an expanded version of what is completed at baseline) as well as qualitative interviews or group discussions with a sample of MNEs.
  • Additional data collection with key informants and MNE clients may also be included in the endline evaluation.
• Analysis of the baseline survey and monitoring data, comparing key outcome indicators over time, and for the various cohorts of MNEs.

4.    Scope of Work for the Evaluation Consultancy

The consultancy will include the following key tasks and activities:

• Participation in an inception meeting with MSION and MSI London to discuss the terms of reference, study objectives and refine the research questions and outcomes to explore and finalise an appropriate methodology;
• Development of an endline study protocol, which should lay-out in detail methodologies to respond to the research objectives, a brief review of the literature, ethical considerations of data collection, a data management and analysis plan, and include all relevant data collection tools, participant information sheets and informed consent documents;
• Secure all required local and international ethical approvals for the study;
• Manage field work activities as outlined in the endline study protocol and share regular updates with MSI (if necessary the consultant or their team may work from the MSION country office during this time);
• Completion of the analysis of the primary data collected as well as the monitoring and baseline data to be made available to the consultant by MSION;
• Produce and submit a draft report with findings from the study and proposed recommendations. Gather MSI and MSION comments and inputs, address comments as needed to finalize the report and PowerPoint
• Present findings via PowerPoint presentation/ Skype meeting and submit a final report.

5.    Consultant Deliverables

The following outputs should be delivered by the Consultant/ Company:

• Detailed work plan for the endline study, with milestones and timelines.
• Full endline study protocol, laying-out in detail methodologies used to respond to research questions, a brief review of the literature, ethical considerations of data collection, a data management and analysis plan, and include all relevant data collection tools, participant information sheets and informed consent documents. Depending on agreed methodologies, there may be a need for local and MSI Ethics Review Committee approval of the research protocol.
• Final study datasets (qualitative and quantitative, including transcripts and any analytical output (syntax/.do files etc.).
• Final evaluation report in Word, not to exceed 20 pages. As well as final summary presentation (in PowerPoint).

. Submission of Proposals and Selection Process

Interested individuals/ companies should submit the following documents:

• Short concept note (of no more than 3 pages) addressing the above terms of reference;
• A comprehensive preliminary budget including all costs and fees in GBP. Please provide a detailed breakdown, before any VAT or other charges, of all estimated costs, including but not limited to; total fee as a lump sum or standard daily or hourly rates, (if applicable), work materials; anticipated travel costs etc.
• Capability statement: relevant experience to the assignment, contacts of organizations previously worked for and curriculum vitae of key personnel.

These documents should be sent to:  hr@mariestopes.org.ng on or before midnight, 12 December 2019.

6. Consultant Skills and Qualifications

The Individual / Company should have the following relevant experience:

• Master’s degree or equivalent in public health, social sciences or a related relevant discipline;
• Sector experience of reproductive health and / or women’s economic empowerment (ideally both);
• Experience of implementing research in the Nigerian context;
• Proven experience of the design, implementation and analysis of qualitative and quantitative research methodologies;
• Substantial experience of conducting evaluations;
• Excellent drafting and report writing capacity;
• Be pro-choice and committed to Marie Stopes International’s goal and mission.

MSI is committed to safeguarding and promoting the welfare of children, young people and vulnerable adults. MSI also takes a zero-tolerance approach to fraud and bribery, terrorism and money laundering as well as modern slavery and any unethical behaviour. To ensure consultants’ values and conduct align with MSI’s, consultants will need to undergo several checks prior to contracting.