Delivering High-Quality Family Planning Services in Crisis-Affected Settings: Program Implementation and Results

"This article describes lessons learned during the first 2.5 years of implementing the ongoing Supporting Access to Family Planning and Post-Abortion Care in Emergencies (SAFPAC) initiative, led by CARE, which supports government health systems to deliver family planning services in 5 crisis-affected settings (Chad, Democratic Republic of the Congo, Djibouti, Mali, and Pakistan)."

According to this research, SAFPAC draws on strategies that have shown success as public health best practices in more stable settings. "The project works through the Ministry of Health in 4 key areas: (1) competency-based training, (2) supply chain management, (3) systematic supervision, and (4) community mobilization to raise awareness and shift norms related to family planning." The first article (both Program Implementation and Results are published in Global Health: Science and Practice) describes the programme's structure and strategies for delivering family planning services, including long-acting reversible contraceptives (LARCs), in crisis-affected settings. The second article describes research that draws from data collected by project staff summarised in monthly reports from client registers, using hardcopy forms, then recorded electronically in Microsoft Excel for compilation and analysis. [Footnotes have been removed by the editor.]

From the abstract:

"A key approach to ensuring sustained ability to train and supervise new providers has been to build capacity in clinical skills training and supervision by establishing in-country training centers. In addition, monthly supervision using simple checklists has improved program and service quality, particularly with infection prevention procedures and stock management. We have generally instituted a 'pull' system to manage commodities and other supplies, whereby health facilities place resupply orders as needed based on actual consumption patterns and stock-alert thresholds. Finally, reaching the community with mobilization efforts appropriate to the cultural context has been integral to meeting unmet family planning needs rapidly in these crisis-affected settings. Despite the constraints in crisis-affected countries, such as travel difficulties due to security issues, in our experience, we have been able to extend access to a range of contraceptive methods, including long-acting reversible contraceptives, in such settings using best practice approaches established in more stable environments."

Selected aspects of programme development and management include:

• Health facility assessment: a start-up assessment by programme staff conducted in conjunction with staff at Columbia University, New York, United States, the evaluation partner, using a tool they developed to identify gaps in basic infrastructure, equipment and supplies, human resources, and the health information system.
• Tool redesign for collecting and analysing service delivery data: a redesign of family planning registers in two countries and a new postabortion care (PAC) register in all settings. "In addition to creating a monthly form for compiling data and reporting up to district and program levels, we also developed wall charts showing key indicators and oriented facility and district management teams on definitions and ways of using  the indicators for decision making."
• Training: competency-based training of service providers on implant and intrauterine (IUD) insertion/removal using materials developed by Jhpiego, as well as "in-depth family planning counseling training using the Population Council's 'Balanced Counseling Strategy Plus (BCS+)' strategy and the World Health Organization's (WHO's) 'Decision-Making Tool for Family Planning Clients and Providers' (DMT)". Providers also received job aids, such as algorithms, counseling cards, and the WHO Medical Eligibility Criteria Wheel (a quick reference tool to rule out medical contraindications for specific methods). The programme established in-country training centres and provided client volume through social mobilisation.
• Supportive supervision and quality improvement: use by supervisors of a 2-page checklist co-designed by CARE and Columbia University to assess general clinic conditions, including: infection prevention procedures and supplies; stock level verification; collection of data for programme reporting; and assessment of data consistency across forms, registers, and reports. Data is displayed on wall charts for staff analysis and discussion. Supervisors may also assess provider competency on clinical and counseling skills at this time.
• Stock management information system: monthly collection and reporting of data on stock levels in health facilities and re-supply depots to ensure that a wide range of contraceptives and essential medicines and medical supplies are always available. Due to conflict and seasonal weather that impedes deliveries, re-supply depots dispatch or "push" supplies to health facilities at regular intervals. At the same time, health providers place or "pull" new orders whenever stock levels approach the minimum stock level required to prevent stockouts.
• Community partnership: "...awareness-raising via radio, participatory theatre and songs, and large mixed-group dialogue about barriers to women accessing family planning and actions to reduce those barriers. We also work closely with religious leaders across Christian and Muslim faiths not only to raise awareness about services, clarify myths, and share information about the benefits of family planning for women and their families but also to reinforce a woman’s right to access health services." In Chad, due to a law ensuring reproductive health as a right, religious leaders have rallied as champions of family planning, including going house-to-house to counsel couples and working in refugee camps to organise meetings and counseling sessions. Police are involved as supporters of the right to family planning. In Pakistan, municipal and health system leadership were mobilised.
• National policy change: delivery of family planning and post-abortion care services, which has influenced national reproductive health policies in some countries where the initiative is implemented. For example, the Chadian government has approved lower-level cadres of health workers (nurses and midwives) to provide implants and IUDs as well as guidance that allowed this service to be provided at the health center level. This guidance was eventually adopted as national family planning policy.

Recommendations for establishing comprehensive family planning in crisis-affected settings include: 

"1. Prioritize building clinical skills training and supervision capacity to ensure continued ability to train and supervise new providers after the end of a donor-funded project

2. Incorporate selected quality improvement strategies, as feasible, adding additional elements with time

3. Conduct a local participatory situation analysis as early as possible to further refine global best practices in community engagement and social accountability strategies"

The monitoring system focused data collection on the 4 contraceptive methods commonly offered at all health facilities within the study - oral contraceptive pills, injectable contraceptives, implants, and IUDs - as well as permanent methods, which are offered in only a few facilities. Indicators were established for "the number and percentage of new users by contraceptive method, the percentage of new family planning users who adopted long-acting, reversible contraceptives (LARCs), and the number and percentage of PAC clients who adopted contraceptive methods."

Communication aspects of local facility data analysis include use of wall charts, as mentioned above, to track service delivery progress. Regular meetings of project and government staff at both facility and district levels assess service delivery patterns and unexpected changes, in order to adjust programming as necessary. "These teams also hold joint meetings with community leaders monthly or quarterly to discuss trends, develop specific action plans, and document next steps in handwritten supervisory logs. At the health zone/district and country levels, program staff use an Excel datasheet with built-in formulas and automatically generated graphics for data analysis. A globally aggregated datasheet compiles data and generates pivot tables and pivot charts for descriptive analysis."

The data not only made possible the management and provision of family planning to crisis-affected communities, it also allowed programme staff to draw the following conclusions: "These results suggest that it is feasible to work with the public sector in fragile crisis-affected states across diverse settings to offer a wide range of family planning services and methods. Moreover, the project demonstrated that it is feasible to do so in a short time period (about 2 years), resulting in rapid uptake of family planning overall, as well as a dramatic increase in the percentage of users voluntarily choosing highly effective long-acting reversible methods."

Click here to read the full text of part 1 online in PDF format.

Click here to read the full text of part 2 online in PDF format.