Expanding Access to Intrauterine Device Services in India (EAISI) Project

Recognising the impact of provider attitudes, biases, behaviours, and practices on the delivery and uptake of quality FP services, EngenderHealth conceptualised an intervention that aligned with the four pillars of health system: service delivery, health workforce, information for decision-making, and leadership and governance. They assessed the underlying causes of negative provider attitudes and practices at different levels of the health system and identified opportunities to address these challenges. While conventional strategies for addressing provider bias often rely on the provision of training and updated standards and guidelines, EngenderHealth decided to focus instead on:

• Advocacy with policymakers and programme managers: EngenderHealth discussed service providers' failure to understand and respect clients' rights and choices and the consequent poor use of FP methods at government facilities with state- and district-level programme managers. EngenderHealth advocated use of every available forum wherein these programme managers engaged with providers to stress voluntary, noncoercive FP service delivery. EngenderHealth also sensitised district-level programme managers to the need for monitoring service provision, providing supportive supervision, and using data and evidence for programmatic decision-making. Further, they trained these programme managers to use a clinical monitoring and coaching (CMC) toolkit during supervisory visits to identify gaps in the infrastructure and within service delivery and to provide feedback and recommendations to providers using non-adversarial approaches. By determining action items collaboratively and in consideration of providers' concerns and challenges, these visits thus shifted from serving as fault-finding missions to becoming facilitative interventions that aimed to ensure safety, efficiency, informed and voluntary decision-making, and client and provider satisfaction in the delivery of healthcare services.
• Sensitisation and capacity-building of providers: EngenderHealth's capacity-building approach focused on enhancing the clinical and counseling skills of service providers, ensuring continued mentoring assistance and provision of job aids, and supporting skills updates and retention. The organisation worked with service providers to expand their understanding of SRHR and built their counseling and clinical skills to ensure delivery of high-quality services. They established stringent criteria for qualifying a service provider as "competent" and conducted follow-up visits. EngenderHealth also provided a competency-based training to service providers, especially facility-based FP counselors, to support client-centred counseling. This training focuses on enabling providers to help clients make full, free, and informed decisions by establishing relationships with clients in which they can explore the client's individual circumstances (including their social and gender context), identify any challenges they may experience in implementing FP decisions, and determine approaches to address such challenges. This training incorporates case studies and vignettes, interactive sessions, and value clarification exercises highlighting the power imbalances that clients face within their households and communities and at facilities in a patriarchal society like India. Through activities illustrating the varying contraceptive needs of different types of clients (e.g., unmarried adolescents), providers reflect on how their personal attitudes, beliefs, and preferences - which are entrenched in these patriarchal social norms - impact their clients' reproductive rights and contraceptive choices. To facilitate a holistic, rights-based approach to demand creation and service delivery, EngenderHealth included frontline workers and other facility staff in select EAISI trainings. For example, recognising the role accredited social health activists (ASHAs) play in motivating clients in their respective communities to use FP, EngenderHealth trained ASHAs to conduct outreach and counseling about the contraceptive choices available at local facilities.
• Use of data for decision-making: EngenderHealth country office and state teams underwent informed consent and voluntarism and FP compliance orientations and actively participated in safeguarding rights working group meetings to reinforce internal monitoring and reporting on FP compliance for service providers. The staff conducted CMC visits, routinely analysed related data and facility service statistics, and carefully reviewed information generated from client exit interviews. They used this information to provide feedback to the respective facilities as well as to relevant mentoring field team.