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:
- Why is a well-trained, supervised and motivated staff so
important to success?
- Why is a well-trained, supervised and motivated staff so
difficult to achieve?
- To make sure that the staff is well-trained, supervised,
and motivated, what is most important thing that a program manager can
do?
- 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:
- From a client’s point of view, what constitutes
client-centered care?
- Why is client-centered care in family planning programs
difficult to achieve?
- How can programs ensure that services cater to all groups,
including youth, men, and unmarried couples? What are the barriers?
- 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:
- What are the steps your program takes to ensure a
continuous supply of contraceptives? What are some common logistics
problems in your setting?
- 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?
- 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?
- 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:
- What is the client’s perspective of integrated services?
What impact does integrated services have on clients?
- What is the provider’s perspective of integrated services?
What impact does integrated services have on providers?
- 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?
- 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:
- 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?
- Should every family planning program strive to offer
methods outside the clinic? What types of situations are best suited
for community-based distribution?
- What are the benefits of offering family planning services
outside the clinic? What are the considerations or limitations?
- 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:
- 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?
- What are the major difficulties that you have faced in
undertaking communication activities? How did you address these
problems?
- 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.)
- 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?
- 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:
- 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?
- How do you monitor and evaluate your program? Do you follow
a specific approach or framework? What indicators do you use?
- 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?
- 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:
- 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?
- 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?
- 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?
- 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:
- How is your program funded? Does your program depend on
donor aid or government subsidies? Is your current funding situation
sustainable?
- Does your program have enough financial resources to meet
the current demand for services?
- 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