STAKEHOLDER MEETING
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Transcript of STAKEHOLDER MEETING
STAKEHOLDER MEETINGSTAKEHOLDER MEETING
Revitalizing the IUD in [insert Revitalizing the IUD in [insert country name]country name]
City, CountryCity, Country
DateDate
Insert MOH logo Insert Project logoInsert USAID logo
(Note: Photos have been removed to keep the file size manageable.)
IntroductionsIntroductions
As we go around the room, say:– Your name
– Your position
– Where you work
Meeting ObjectivesMeeting Objectives
Discuss the context for IUD services and family planning within Country
Reach consensus on importance of the IUD within FP method mix and the need to improve the utilization of the IUD
Determine desired performance for IUD services
AgendaAgenda
Welcome and Opening Remarks Current situation of FP and IUD in Country Questions for Reflection Break Overview of the PI Approach and PNA Lunch Desired performance for IUD services Questions and Next Steps
Environmental Scan: CountryEnvironmental Scan: Country
Note: The slides shown are taken from a PNA conducted in Mali. The information presented would need to be adapted for each country’s particular context and include as much IUD dataas is available. You can decide how many RH areas to include.
Questions for Reflection (1)Questions for Reflection (1)
What is your impression of the use of family planning in Mali? For example, – What methods are most used in Mali? Least
used? How about the IUD?– What has happened with the IUD?—was it used
before and is declining, or has it never been popular?
– What are the reasons for this?
Mali: General indicators
Data source: U.S. Bureau of the Census, International Data Bas, 2005; Population Reference Bureau, http://www.prb.org/ TemplateTop.cfm?Section=Data_by_Country&template=customsourc…, cited on 2/23/2005; UN/ESA World
Contraceptive Use, 2003; World Bank, World Development Indicators Database, http://devdata.worldbank.org/external/dgcomp.asp?rmdk=110&smdk=473886&w=0, cited on 2/23/2005
Total midyear population 12,291,529 (2005)
Population growth rate 3.3% (2004)
Total fertility rate 7.0 (2004)
Married women of reproductive age (MWRA)
2,163,000 (2000)
Percentage of population under age 15
49 (2004)
Physicians/1000 people 0.1 (1996)
Mali: Family planning
Sources: Demographic and Health Surveys, Mali, 2001.
Among MWRA, 15-49 yrs
Knowledge of any method 77.8%
Knowledge of any modern method 75.6%
Knowledge of female sterilization 32.5%
Knowledge of Norplant 25.7%
Knowledge of IUDs
Knowledge of male sterilization
21.1%
12.6%
Mali: Family planning
Sources: Demographic and Health Surveys, Mali, 2001; UN/ESA World Contraceptive Use wall chart, 2003; ORC Macro, 2004. MEASURE DHS+ STATcompiler. http://www.measuredhs.com, February 23, 2005.
Among MWRA, 15-49 yrsCPR (any method) 8.4%
181,692 couples
CPR (modern method) 5.8%
125,454 couples
Total demand for FP 36.6%
791,658 couples Demand to space 25.9%
560,217 couples Demand to limit 10.7%
231,441 couples
Mali: Family planning
Indicator Mali 2001 Senegal 1997
Guinea 1999
Mauritania 2000/2001
CPR (any method)
8.4% 12.9% 6.2% 8.0%
CPR (modern method)
5.8% 8.1% 4.2% 5.1%
Demand to space
25.9% 33.5% 19.6% 28.1%
Demand to limit
10.7% 14.3% 10.8% 11.5%
Total demand for FP
36.6% 47.8% 30.4% 39.5%
Source: MEASURE DHS+ STATcompiler. http://www.measuredhs.com, May 10, 2004.
Mali: CPR among MWRA
0
2
4
6
8
1987 1995/96 2001
Pill IUD
Injections Condom
Female sterilization Male sterilization
Implants Diaphragm/foam/jelly
Source: MEASURE DHS+ STATcompiler. http://www.measuredhs.com, May 10, 2004.
1.3
4.5
7.0
Mali: CPR among MWRA
Contraceptive Prevalence by Region by Year
Source: MEASURE DHS+ STATcompiler. http://www.measuredhs.com, February 25, 2005
05
10152025
1995
/96
2001
1995
/96
2001
1995
/96
2001
1995
/96
2001
1995
/96
2001
1995
/96
2001
1995
/96
2001
Kayes Koulikoro Sikasso Segou Mopti Gao/Kidal/Timbuktu
Bamako
Pill IUD Injections
Diaphragm/foam/jelly Condom Female sterilization
Implants Foam or jelly
Mali: Source of FP supply
Modern methods, MWRA, 15-49 yrs
0%
20%
40%
60%
80%
100%
Fem s
ter
IUD
Inje
ct Pill
Condom
Diaphr
agm
Foam o
r jel
ly
DK/Missing
Other
Other private
Private medical
Public
Data source: MEASURE DHS+ STATcompiler. http://www.measuredhs.com, February 25, 2005
Mali: FP snapshot – attitudes
2001 DHS– Women
• Respondent and spouse approve: 29.7%• Respondent approves, unsure about spouse: 22.2%• Respondent unsure: 7.2%•
– Men• Respondent and spouse approve: 41.5%• Respondent approves, unsure about spouse: 20.5%• Respondent unsure: 7.9%
Data source: MEASURE DHS+ STATcompiler. http://www.measuredhs.com, March 2, 2005
Mali: FP snapshot – attitudes
Guèye and Konaté (Draft, 2004)– Women’s approval of FP: 53.0% (26.6% were
unsure)– Men’s approval of FP: 62.6%– Reasons for disapproval of FP
• Religion• Side effects (e.g. sterility, menstrual problems,
nervousness)• Dislike of methods• Desire for children
Mali: FP snapshot – attitudes
Konaté, Djénépo and Sidibé (June 2004)– Reasons for not using modern methods
• Opposition from spouse and/or family• Lack of knowledge re: modern methods• Religion• Rumors• Lack of funds• Lack of a service delivery structure
Mali: FP snapshot – IUDs
EngenderHealth 1994 evaluation of a Post Partum IUD (PPIUD) program, Hamdallaye Maternity, Bamako– Who were the PPIUD users?
• More likely to be married• Less likely to want more children• Among those wanting more children, more likely to want a
longer spacing time– IUD acceptance associated with number of living children– PPIUD users were more likely to have had a method suggested
to them during their prenatal visit– Reasons for not choosing PPIUD: desire to wait before choosing
FP and preference for other method– Nearly all clients (97%) were satisfied: convenient lack of
interference with breastfeeding, and lack of side effects were cited as reasons.
Mali: Projected number of LTPM users(All women)
1532
56
90
1 2 4 624
92
187
323
0
50
100
150
200
250
300
350
2000 2005 2010 2015
Female Sterilization Use Male Sterilization Use IUDs
Sources: EngenderHealth, Contraceptive Sterilization: Global Issues and Trends, 2002; Ross, Stover and Willard, 1999.
.
In 1,000s
Source:EngenderHealth, 2002; Janowitz, Measham and West, 1999.
SustainabilitySustainability
Average Cost (US$) to Health Care System Per Year of Protection, by Method (Mombasa, Kenya)
0 5 10 15 20 25 30 35
Condoms
Depo Provera
Norplant
Pills
Female Sterilization
Vasectomy
IUD
US$
Mali: HIV/AIDS
1.9% adult HIV prevalence (2003)– 140,000 adults and children are living
with AIDS– 12,000 AIDS deaths in 2003
90.3% of MWRA have ever heard of AIDS
17.7% of MWRA know of no ways to avoid AIDS
Data source: UNAIDS, 2004 Report on the Global AIDS Epidemic, as cited in UNAIDS country profile, cited March 1, 2005
HIV/AIDS Snapshot
Mali: HIV/AIDS
Policies– New National Multisectoral HIV/AIDS Policy– National AIDS Control Programme
Active groups– People living with HIV– Locally elected officials– Parliamentary network
Services for prevention and treatment– 15 VCT centers in Bamako– In Bamako, health centers and 1 hospital with PMTCT services and 3
health centers with antiretroviral treatment services– Peer education, social marketing, BCC activities through NGOs
Data source: UNAIDS, 2004 Report on the Global AIDS Epidemic, as cited in UNAIDS country profile, cited March 1, 2005
HIV/AIDS Snapshot: Current policies and programming
Mali: Maternal health
Maternal mortality ratio is 588 per 100,000 live births (DHS 2001)
Estimated maternal deaths is 6,800 per year Maternal morbidity is difficult to assess
– Out of 2,000 villages near Mopti, half have at least one woman living with fistula
– Women with fistula are often hidden by their family FP seen as key in reducing maternal mortality
and morbidity
Sources: WHO, Revised 1995 Estimates of Maternal Mortality, http://www3.who.int/whosis/mm ORC Macro, 2004. Country statistics: Guinea. http://www.measuredhs.com/countries, February 19, 2004;; Hyjazi & Diallo, 1996.
Sources: WHO, UNICEF, and UNFPA, 2004, Maternal mortality in 2000: Estimates developed by WHO, UNICEF and UNFPA; Doctors of the World, as cited in UNFPA and EngenderHealth, 2003, Needs assessment report: findings from nine African countries
Questions or Comments?Questions or Comments?
Questions for Reflection (2)Questions for Reflection (2)
Systemic issues in regards to the IUD: – What cadre of personnel are allowed to insert IUDs? – What training do providers receive in IUD insertion and
removal? – What is the MOH view on the IUD—i.e. what are the
messages they are giving to providers?– What do the norms and policies say about the IUD?– What is the national supply of IUD commodities like?– How well does the national distribution system work?
What should be done to improve the use of the IUD in Mali?
Note: These are sample questions for illustration.
Introduction to the Introduction to the Performance Improvement Performance Improvement
ApproachApproach
What is Performance?What is Performance? What is Performance?What is Performance?
The tasks that people do and the results of those tasks
Effort Performance
What is Performance Improvement?What is Performance Improvement?
A step-by-step methodology for finding out what is needed to ensure good performance, and delivering it
Factors Influencing PerformanceFactors Influencing Performance
1. Job expectations
2. Performance feedback
3. Environment and tools
4. Motivation and incentives
5. Skills & knowledge
Organizational Support: Using Performance
Factors
Job ExpectationsJob Expectations
Guidelines, policies, standards, procedures, protocols, and how these are communicated to and understood by providers
Performance feedbackPerformance feedback
How providers find out how they’re doing, compared to the standards.
Physical EnvironmentPhysical Environment
The facilities, supplies, materials, tools necessary to do the job.
Motivation/IncentivesMotivation/Incentives
Do staff have a reason to perform as they are asked to perform? Does anyone notice?
--Internal motivation or external incentives to perform up to standard.
Knowledge and SkillsKnowledge and Skills
Systems and interventions to address how to do a job.
Over-Arching ConsiderationOver-Arching Consideration
Organizational Support
The extent to which the organization assures that all the performance factors are in place.
--Supervision, policies, communication
Lack of data and information
Lack of motivation and incentives
Lack of tools and equipment
Lack of knowledge and skills
“If all you have is a hammer…everything looks like a nail.”
Training
PI asksPI asks
What performance do we want? (Desired) What performance do we have now?
(Actual) What is the difference? (Gap) Why is there a difference? (Root causes) What should we do about it?
(Interventions)
PI Framework
CONSIDERINSTITUTIONAL
CONTEXT
MISSION
GOALS
STRATEGIES
CULTURE
CLIENT ANDCOMMUNITY
PERSPECTIVES
OBTAIN AND MAINTAIN STAKEHOLDER AGREEMENT
MONITOR AND EVALUATE PERFORMANCE
DEFINE DESIREDPERFORMANCE
FIND ROOTCAUSES
WHY DOES THEPERFORMANCE
GAP EXIST?
SELECTINTERVENTIONS
WHAT CAN BE DONETO CLOSE THE
PERFORMANCE GAP?
DESCRIBE ACTUALPERFORMANCE
PERFORMANCEGAP
IMPLEMENTINTERVENTION
PNA
Steps in the PNA ProcessSteps in the PNA Process Steps in the PNA ProcessSteps in the PNA Process
Stakeholder agreement Define desired performance Determine actual performance Analyze root causes Select interventions
A PNA ExampleA PNA Example
Based on PNA conducted in the Dominican Republic Desired: 100% adherence to client-provider
interaction norms Actual: 60% adherence to norms Gap: 40% of providers not adhering to norms Root causes: unclear expectations,
lack of CPI skills, no feedback Interventions: CPI norms training,
feedback from clients
Do you have any questions or Do you have any questions or comments?comments?
Defining Desired PerformanceDefining Desired Performance
Desired PerformanceDesired Performance
CONSIDERINSTITUTIONAL
CONTEXT
MISSION
GOALS
STRATEGIES
CULTURE
CLIENT ANDCOMMUNITY
PERSPECTIVES
OBTAIN AND MAINTAIN STAKEHOLDER AGREEMENT
MONITOR AND EVALUATE PERFORMANCE
DEFINE DESIREDPERFORMANCE
FIND ROOTCAUSES
WHY DOES THEPERFORMANCE
GAP EXIST?
SELECTINTERVENTIONS
WHAT CAN BE DONETO CLOSE THE
PERFORMANCE GAP?
DESCRIBE ACTUALPERFORMANCE
PERFORMANCEGAP
IMPLEMENTINTERVENTION
We are HereWe are HerePNA
Define Desired PerformanceDefine Desired PerformanceDefine Desired PerformanceDefine Desired Performance
Definition: What the organization would like to see happening – Program goals– What the target group should be doing
Defined by stakeholder consensus using specific, measurable terms
Desired Performance StatementsDesired Performance StatementsDesired Performance StatementsDesired Performance Statements
Identify the performer State accomplishments or behavior of the
performer Observable Measurable Can be agreed upon by independent
observers Are under the control of the performer
Example: All FP providers counsel FP clients on HIV risk and prevention according to MOH guidelines.
Performance Measures…Performance Measures…
Quality– Does the performance match the standard?
• Provider should follow all 5 steps of FP counseling with each client.
– Does the performance meet the expectations of clients/community?
• Clinic should achieve 90% client satisfaction on MOH client satisfaction survey form.
Quantity– Does the performance happen as much as it should?
• Each provider sterilizes 4 sets of instruments at the beginning of each day.
Performance Measures…Performance Measures…
Timeliness– Does the performance happen on time?
• The provider should be ready to see clients by 9:00 a.m., every day.
– Does the performance happen as often as it should? • The provider should do family planning
counseling with all eligible women and couples (100% of the time).
Is This a Desired Performance Is This a Desired Performance Statement?Statement?
For new family planning clients, the nurse will discuss all family planning methods available at the clinic.
Prenatal care providers will fill out 100% of prenatal history.
Providers will have access to needed supplies.
Is This a Desired Performance Is This a Desired Performance Statement?Statement?
The supervisor will make 1 supervision visit per quarter to each health facility in his district.
Small Group ExerciseSmall Group Exercise We will divide into 3 small groups to define desired
performance from the: Client perspective Provider perspective Institutional or organizational perspective
Review the written instructions and the background materials.
Be sure your Desired Performance Statements are observable, measurable, and under the control of the provider.
Please use 60 minutes, and then we will present and discuss in plenary.
:
Next StepsNext Steps
Collect additional data in the field as part of Performance Needs Assessment
Conduct Stakeholders Intervention Selection Workshop on Date:– Discuss performance gaps– Analyze root causes– Select interventions
Do you have any questions or Do you have any questions or comments?comments?