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?