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Elements of Successful Family Planning Programs


10-21 December, 2007
http://my.ibpinitiative.org/elementsoffpsuccess

Discussion Statistics


Number of participants: 280
Number of participants' countries: 19
Number of contributions: 88
% of contributions from developing countries: 84%
Number of countries contributing: 19 countries

Contributing countries: Bangladesh, Canada, Ethiopia, Fiji, Germany, Ghana, India, Iran, Jamaica, Kenya, Malawi, Mongolia, Mozambique, Nigeria, Pakistan, Philippines, Senegal, Uganda, United States.



Purpose and Objectives

The purpose of this forum was to reach consensus on the key elements contributing to the success of family planning program. The forum also explored why certain program elements are so important and how they can be achieved, even when that is difficult.
                                                                        
Day 1. Well-trained, supervised and motivated staff  

Questions:

  1. Why is a well-trained, supervised and motivated staff so important to success?
  2. Why is a well-trained, supervised and motivated staff so difficult to achieve?
  3. To make sure that the staff is well-trained, supervised, and motivated, what is most important thing that a program manager can do?
  4. What are examples of programs that succeed at having well-trained, supervised, and motivated staffs?

Emerging themes and issues:

  • According to our survey respondents, this is one of the most important elements of FP success (chosen by 41%). Why is this one of the most crucial elements? Although few studies have been conducted that carefully measure how training family planning providers affects clients satisfaction, evaluations of training programs demonstrate that training has improved services and helped to attract more clients. Anecdotal evidence from today’s contributions also supports this conclusion.
  • It is generally understood that motivated providers who are well-trained in clinical procedures, have up-to-date knowledge of contraceptive technology, and who have good interpersonal communication skills deliver good quality family planning services. In addition, clients who receive such services are more likely to be satisfied.
  • A lack of resources and lack of adequate compensation and recognition for family planning providers are the root of the problem. Other factors that may affect a program’s workforce, and thus the ability to provide quality FP services, include the HIV/AIDS epidemic, labor migration (brain drain), and a lack of investment in human resources. Further comments are welcome.
  • To make sure that the staff is well-trained, supervised, and motivated, a program manager should have good leadership qualities and the ability to identify areas for improvement, such as offering incentives or financial adjustments. In addition, other actions that managers can take include: (1) updating and properly introducing service delivery guidelines; (2) refresher courses conducted at frequent intervals; and (3) monitoring and evaluation, which enables managers to identify problems.
  • Training, both in-service and pre-service, can help keep staff up-to-date on the latest family planning guidance. An excellent resource is, “Family Planning: A Global Handbook for Providers,” which offers the latest family planning guidance for providers and program managers. Another helpful way to update skills is to take an online-learning course at the USAID Global Health e-Learning Center. These courses are available free of charge to all those who register at: www.globalhealthlearning.org. The following three courses are especially relevant to this topic: “Family Planning 101,” “Family Planning Counseling,” and “IUDs.”                                             
                                                
Day 2. Client-centered care and services  

Questions:

  1. From a client’s point of view, what constitutes client-centered care?
  2. Why is client-centered care in family planning programs difficult to achieve?
  3. How can programs ensure that services cater to all groups, including youth, men, and unmarried couples? What are the barriers?
  4. What are specific examples of programs that have improved client-centered services?

Emerging themes and issues:

  • Although cultural norms may differ by setting, there seems to be universal expectations about what client-centered care should involve. Clients know good treatment when they experience it, and they certainly know when they are treated badly.
  • From clients’ point of view, not only the technical quality of services is important, but so are the other aspects that the contributors noted above. One contributor noted that it may be helpful for service providers to put themselves in the client’s shoes to better understand the client’s point of view.
  • Client-centered care is often hindered by lack of technical and human resources, governmental guidelines, and an adequate budget to support staffing.

Day 3. Contraceptive security 

Questions:

  1. What are the steps your program takes to ensure a continuous supply of contraceptives? What are some common logistics problems in your setting?
  2. What methods are currently available in your program? Are there certain methods that clients request that are not available? Why aren’t these methods currently available?
  3. How much effort should a program make to have a wide range of methods available? Is it possible to have too many methods to offer?
  4. Please share any additional program examples, experiences, or stories on this topic.

Emerging themes and issues:

  • Family planning programs can succeed only if the clients they serve have access to contraceptive supplies when they are needed.
  • The objective of logistics management is simple: to deliver the right product, in the right quantity, in the right condition, to the right place, at the right time, for the right cost. In practice, however, managing family planning logistics is often complex.
  • Examples of common logistic problem from our contributors include: gaps in supply, insufficient funds, late orders, unreliable transportation, late payments, and funds that are not readily available.
  • Contributors shared that their programs generally have a good mix of contraceptive methods, although there is room for improvement.
  • Is possible to offer a full range of methods if all the key players are well-coordinated at both central and district levels, and if the program has a well-functioning logistics system and a plan for monitoring and evaluation. In some primary health care facilities, it may be better to provide 3 or 4 methods well, rather than trying to provide 8 methods and risk stockouts and poor quality of care. Programs must be able to provide a continuous supply of the method and staff should be up-to-date on guidance and service provision guidelines. Still, it is important to offer the methods in the “top tier of effectiveness” (implants, the IUD, and male and female sterilization).                 
                                                    
Day 4. Integration with related health services

Questions:

  1. What is the client’s perspective of integrated services? What impact does integrated services have on clients?
  2. What is the provider’s perspective of integrated services? What impact does integrated services have on providers?
  3. In what types of situations is it helpful to integrate family planning with other services? When is it not helpful? Are there certain health services that are more suited to integration with family planning than others?
  4. What advice would you give to a program manager who is considering integrating family planning with related health services? Are there any tools, job aids, or resources you would recommend? Are there any gaps in resources?

Emerging themes and issues:

  • In general, contributors thought that integrated services (offering several services in one location) were a positive thing for clients. Integrated services increase client access to more comprehensive services, reduce client waiting times, and reduce costs to the client.
  • Several contributors pointed out the inconvenience clients face if they are required to travel to several locations to receive different types of services. In some situations where services are not integrated, clients are required to visit several different facilities (for example, to receive laboratory results), which can lead to method discontinuation or failure to follow up.
  • Contributors also noted that integrated services save the client time and resources. They are convenient to the client and her family because they can find different services that suit each of their unique needs. Offering several services under one roof can help ensure that a client does not have to choose one type of service at the expense of the others.
  • According to our contributors, integrated services are often more beneficial for clients than they are for providers. On one hand, integrating services is beneficial for providers because it is cost effective and saves time and resources and enables easier client follow-up. On the other hand, providers who deliver integrated services often take on many roles, which increases their workload. Integration requires providers to acquire a greater variety of skills, and may increase the amount of time a provider needs to spend with each client. When providers are told to offer multiple services, they often become overburdened, and some services are ignored or overlooked.
  • There are several types of services that are frequently integrated, for example, family planning and HIV/STI services. It may be less stigmatizing to attend a family planning clinic than an STI clinic. Combining the two sets of services can significantly increase a program’s reach.
  • Three principles of integration: First, interventions being integrated should be effective. Second, interventions need a common field of operation as well as common audiences. Third, there should be synergies between the two interventions that enhance the impact of both.
  • A system’s capacities, staff capacity, health priorities, and the perspective of managers and policy makers, should be considered before integrating services. It is also important to review and observe other country experiences and lessons learned.                                                   
                                                  
Day 5. Mix of service delivery points  

Questions:

  1. If you are part of a family planning program, where does your program offer services? Are services exclusively clinic-based or are they also provided by community-based distribution workers, pharmacists, or other retailers?
  2. Should every family planning program strive to offer methods outside the clinic? What types of situations are best suited for community-based distribution?
  3. What are the benefits of offering family planning services outside the clinic? What are the considerations or limitations?
  4. Several programs have recently begun to offer injectable contraceptives in community-based distribution programs. Does your program have experience offering injectables outside the clinic or has it considered this approach? What strategies have worked? What challenges are faced?

Emerging themes and issues:

  • Family planning programs in many areas of the world have found that offering services outside the clinic is an effective way to increase access to and acceptability of family planning, particularly in rural areas where health care infrastructure is weak.
  • Family planning services are available in many locations, including primary health care centers, community health care centers, government hospitals, chemist shops, and private practitioners. The methods and services offered in these diverse outlets also vary by setting. For example, some offer only counseling and referrals, while others offer more comprehensive services such as counseling, oral contraceptives, condoms, and, in some areas, injectable contraceptives.
  • Multiple service delivery points are not always seen as positive, however. Private pharmacies and retailers are competitors who often offer contraceptives at a discounted price. These outlets may not follow the same quality standards as public sector clinics. Clients who receive methods through pharmacies may not receive enough counseling to ensure informed use.
  • Programs can benefit from offering services in the community, but only if the service offered are suitable for the specific locale or situation. There were conflicting views about whether or not every program should strive to offer services outside the clinic.

Day 6. Effective communication & outreach

Questions:

  1. What type of communication activities or materials do you most commonly use to reach your clients? How do you decide what types of activities or materials are going to reach your clients? Are you using any newer technologies to reach clients, such as cell phones or Web sites?
  2. What are the major difficulties that you have faced in undertaking communication activities? How did you address these problems?
  3. In your country currently, what are the most important reasons for family planning programs to undertake communication activities? What does communication need to accomplish at this time? (e.g. influence attitudes and social norms, address myths and misconceptions, move people to use contraception, make use of HIV testing, etc.)
  4. How much of your family planning budget do you invest in behavior change communication (BCC)? Is it enough to ensure behavior change? Do you have any examples of low-budget BCC programs that have had measurable effects on behavior?
  5. How do you involve community members in the design, implementation, and evaluation of your behavior change communication (BCC) programs? Does community involvement help assure results?


Emerging themes and issues:

  • Some programs rely mostly on interpersonal communication, while others use a combination of three approaches: interpersonal communication, mass media channels, and community channels.
  • Contributions on reasons to undertake communication activities included several common themes, such as addressing myths and misperceptions, increasing contraceptive use, and decreasing unplanned pregnancy.
  • There is diversity in the amount of resources that are allotted to communication activities. Some programs spend a good portion of their overall budget on communication activities, while other programs spend very little.
  • Most contributors shared that their programs involve community members in planning and evaluating BCC programs.                                                                 
                                        
Day 7. Research, M&E

Questions:

  1. Do you currently use research to guide your program? If so, what resources do you use to find research? How do you put the research into practice? Are there any research gaps that you have identified?
  2. How do you monitor and evaluate your program? Do you follow a specific approach or framework? What indicators do you use?
  3. How does your program decide which data to collect? What data collection instruments do you use? Who collects the data? How do you analyze and interpret data? Do you have any examples of how a management information system helped you with program planning, reporting, or other decision-making?
  4. What resources are needed to make monitoring and evaluation easier? What resources are needed to better manage and interpret data?


Emerging themes and issues:

  • Contributors report using several types of research to guide programming, including pilot projects, comparative national surveys, and operations research.
  • Virtually all family planning programs can benefit from evaluating their operations. Programs evaluate their activities both during the course of operations, to help manager’s improve operations, and also at the end of projects, to derive lessons for future use. Measuring how program activities affect client behavior such as clinic attendance, contraceptive use, and continuation rates is particularly valuable.
  • Information management tools help managers collect, interpret, and use essential information easily and effectively. Today’s contributors point out, however, that health information systems in many countries are far from perfect. An effective management information system (MIS) need not be complex, however.                                                                 
                       
Day 8. Management, leadership and supportive policies

Questions:

  1. How important are supportive government policies to family planning program success? Who plays a role in developing supportive government policies? Are supportive government policies in place for your program?
  2. What constitutes good leadership in family planning programs? Who do you consider to be the “leaders” in your program? Can good program management succeed without strong leadership?
  3. In recent years concerted international effort has gone into developing evidence-based guidelines for family planning practice and service delivery. What efforts are being made to implement this guidance at the program level? How often does your program update service delivery guidelines?
  4. In the recent online survey, up-to-date service delivery guidelines received the fewest votes as an important element of family planning programs. Why would this be so? Aren’t up-to-date guidelines important to achieve a high quality of care?


Emerging themes and issues:

  • Family planning programs need political support to operate successfully.
  • Supportive government policies are important to program success because they help program planners to establish frameworks, service guidelines and protocols, and to establish required resources for service delivery.
  • Many people play a role in developing supportive government policies, including program managers, mass media, policy makers, clients, service providers, researchers, and religious leaders.
  • Good leadership is an essential component of family planning programs. Different types of leadership are required at different levels. For example, strong leadership at the Ministry of Health level requires an expert, well-informed management group committed to family planning. At the clinic level, strong leadership requires well-informed and committed service providers.
  • In some contexts, influential religious leaders who support family planning are just as important as ministry-level leadership.
  • Keeping service delivery guidelines up-to-date is not an easy task.                                            
                                                  
Day 9. Financial resources

Questions:

  1. How is your program funded? Does your program depend on donor aid or government subsidies? Is your current funding situation sustainable?
  2. Does your program have enough financial resources to meet the current demand for services?
  3. How important is offering free or subsidized services for the poor? Do you find that people prefer to purchase services because they associate price with quality?


Emerging themes and issues:

  • A variety of funding sources for their programs, ranging from government subsidies to assistance from foreign aid agencies.
  • A few contributors consider their current funding situation to be sustainable, but most do not. Several contributors mentioned frequent lapses in funding, which negatively affects programs.
  • Some contributors believe their programs have enough financial resources to meet current demand for services, while others do not.
  • On one hand, some contributors believe that programs should offer family planning services free of charge. On the other hand, some are against the concept of offering free services.
  • People may prefer to purchase services because they associate them with good quality, whereas free services are associated with poor quality and are stigmatized.
  • Acceptance of free services may depend on what service is being offered. For example, in areas where the female condom is not readily available, offering these products for free is welcome. For the widespread male condom, however, clients prefer to buy commercial brands over the subsidized products, claiming that they “offer greater satisfaction.”                                            
                                    
Post-forum survey results

N° of surveys completed 45

  • % who have passed content to others 30%
  • % who have or will use in their work    95% 
  • % very satisfied with forum content     76%

                      

References and resources
-- ACQUIRE Brief, A Focus on the Fundamentals of Care: provides a synthesis of ACQUIRE’s approach and an example of how it has been applied in Bolivia: http://www.acquireproject.org/fileadmin/user_upload/ACQUIRE/Publications/ACQUIRE_Knowledge_FOC_final.pdf 

--COPE (Client-Oriented, Provider Efficient) methodology and tools. COPE has been adapted for use in service sites as well as in communities. EngenderHealth has produced several key programmatic tools to promote knowledge and skills in the areas of informed choice, client-provider interactions, and counseling—all of which focus on identifying and meeting the client’s needs. http://www.engenderhealth.org/ia/sfq/qcope.html 

--Choices in Family Planning: Informed and Voluntary Decision Making, (EngenderHealth 2003). This tool helps policymakers, managers and service providers take a more client-centered approach to service delivery to enable individuals to exercise their right to make and act on their own decisions about their health and reproduction. http://www.engenderhealth.org/res/offc/ic/choices/index.html 

--Comprehensive Counseling for Reproductive Health: An Integrated Curriculum (EngenderHealth 2003). This tool responded to the need for counseling and communications training to prepare service providers to perceive the client as a whole person with a range of interrelated RH needs, to address sensitive issues of sexuality with greater comfort, and to support and protect the client’s sexual and reproductive rights. http://www.engenderhealth.org/res/offc/counsel/ccrh/index.html 

--Global Health Technical Brief, Client-Provider Interaction: Key to Successful Family Planning. http://www.maqweb.org/techbriefs/tb10interaction.pdf
Another helpful resource is the Decision-Making Tool for Family Planning Clients and Providers, one of the World Health Organization's 4 cornerstones of family planning guidance. This tool helps clients and providers in counseling sessions with choosing and learning to use family planning methods. This counseling tool is an illustrated flip chart offering suggestions tailored for the individual client. To see the Decision-Making Tool and to download it from the Internet, go to http://www.infoforhealth.org/pubs/dmt/.

The RHInterchange Web site:http://www.rhsupplies.org 
The RHInterchange standardizes regular transmissions of data from donor agencies, allowing users to create reports either at a global, regional or country level for user-defined periods of time. Information at any of the geographic levels includes quantity, value, and method.

-The Logistics Handbook: A Practical Guide for Supply Chain Managers in Family Planning and Health Programs (JSI/DELIVER, 2004)
http://portalprd1.jsi.com/pls/portal/docs/PAGE/DEL_CONTENT_PGG/DEL_PUBLICATION_PG1/DEL_GUIDE_HANDBK_PG1/LOGISTICSHANDBOOK.PDF 

-Population Reports, “Strengthening the Supply Chain” (Johns Hopkins, 2002)
http://www.infoforhealth.org/pr/j51edsum.shtml 

-The Pocket Guide to Managing Contraceptive Supplies (CDC, 2000)
http://www.cdc.gov/reproductivehealth/Products&Pubs/PDFs/PocketGuide/pref_ack_pg.pdf 

-PipeLine Software Tool (JSI)
http://portalprd1.jsi.com/portal/page/portal/DELIVERWEBSITE/HomePage/DEL_TOOLS_TAB

A useful M&E resource is the “Handbook of Indicators for Family Planning Program Evaluation.” This Handbook provides a comprehensive listing of the most widely used indicators for evaluating family planning programs in developing countries. The framework described in the resource specifies how programs are expected to achieve results both at the program and at the population level. This resource is available here: http://www.cpc.unc.edu/measure/publications/pdf/ms-94-01.pdf 

Another useful resource is the online USAID e-learning course, “M&E Fundamentals.” This course will help you understand what M&E is, why it is important, and the basics of what it entails. To access the course, simply register at http://www.globalhealthlearning.org

Reports and publications Organizing groups 
The INFO Project based at Johns Hopkins Bloomberg School of Public Health's Center for Communication Programs, WHO, partners of the Implementing Best Practices (IBP) Initiative.

Contributing experts/facilitators 

Catherine Richey & Ward Rinehart, INFO Project, Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs

Moderators
Catherine Richey, INFO Project, Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs