continued from pg. 1
The Proceedings of the East and Southern Africa (ESA) Regional Workshop: Improving
Quality of Care and Access to Contraception: Reducing Medical Barriers (featuring
highlights of the five-day workshop, six country action plans, preworkshop medical barrier
questionnaire results, and workshop evaluation) were distributed to all delegates and
cooperating and donor agency representatives in September 1994. An additional 500 copies
were produced in October 1994 for distribution worldwide.
A six-month follow-up questionnaire was sent out in September 1994 to the 44
delegates who attended the East and Southern Africa MAQ workshop. This was the first in a
series of three follow-up questionnaires that will be distributed to the ESA MAQ workshop
delegates. The purpose of these questionnaires is to gather delegates' assessments of the
workshop's programmatic impact over the 18-month period following the workshop. To date,
ten of the 44 six-month follow-up questionnaires have been returned to JHPIEGO: three from
Botswana; one from Kenya; one from South Africa; three from Uganda; two from Zimbabwe.
HHRAA/SARA and the JHPIEGO MAQ Task Force look forward to hearing from the remaining 34
delegates. The following are highlights of responses to these questionnaires.
What was the workshop's primary objective? (response highlights)
To assist delegates to identify the barriers to family planning (FP)
access in their countries and plan strategies for removing the barriers
To share information in order to improve the quality of FP programs and
the quality of care
To improve quality in training services
Was the workshop's primary objective met? (ten respondents)
Are workshops of this kind an effective means of helping health officials improve
the quality of their family planning programs? (ten respondents)
80% responded that these regional workshops are a very effective means
of helping health officials improve the quality of their FP programs.
20% responded that these regional workshops are a somewhat
effective means of helping health officials improve the quality of their FP programs.
How could the effectiveness of future regional MAQ workshops be increased?
(response highlights)
Follow-up workshops could be conducted to allow countries to share their
experiences in removing the barriers.
Countries further along in implementation could serve as role models and
inter-country discussion could be improved.
Country-level workshops could be conducted.
Prior to workshops, each country group could prepare a document of their
perceived problems.
ESA regional workshop proceedings could be widely distributed.
What was the most useful aspect of the workshop? (nine respondents)
66% indicated the development of specific action plans to address
barriers to improved FP services in their countries.
22% indicated the update on contraceptive information.
11% indicated the opportunity to discuss issues with others in the
country/region.
Which of the workshop reference materials were of most interest/relevance to
colleagues upon returning home? (nine respondents)
JHPIEGO's PocketGuide for FP Service Providers was selected nine
times.
FHI's Injectables Module was selected seven times.
FHI's Network was selected one time.
Eight delegates selected presenter materials. Norplant presenter
materials were selected five times as being of interest/relevance and each of the other
presenter materials listed (oral contraceptives, IUDs, injectables, barrier methods, and
voluntary sterilization) were selected twice.
How many times have delegations met to discuss action plans and strategies for
implementation since the workshop?
Delegations (or sub-groups) have met anywhere from one to three times to "more
than 3" times since the end of the ESA regional workshop in February.
Are action plans developed still reasonable and/or appropriate given the resources
available? (ten respondents)
- 80% responded yes.
- 10% responded no.
- 10% responded do not know.
In-depth workshop follow-up interviews in Botswana and Zimbabwe recently have been
conducted to assess progress made toward country action plan objectives formulated during
the ESA MAQ workshop in Zimbabwe. Similar interviews will be conducted in Kenya, Tanzania,
South Africa and Uganda. The following are highlights of achievements made toward action
plan goals in Botswana and in Zimbabwe.
Botswana
In September 1994, two family planning leadership conferences were held in
Gaborone and Francistown for a total of approximately 175 participants, including policy
makers, district health leaders from the Ministry of Health, local governments and private
institutions. The following members of the ESA MAQ workshop Botswana delegation took part
in these national-level conferences: Dr. A.A. Hogewoning, Ms. L.G. Mogapi, Ms. N.
Mokgautsi, Ms. K.M. Motswaledi and Ms. P. Mudongo, Dr. J.K.M. Mulwa .
As a result of these two conferences, policy makers and managers from both the northern
and southern parts of the country came to consensus on a wide variety of revisions to the
Botswana Family Planning General Policy Guidelines and service standards, including
removal of most of the barriers that were identified by the Botswana delegation at the ESA
regional MAQ workshop in Zimbabwe.
Agreed Changes to Botswana Family Planning Policy Guidelines
Age and parity restrictions removed
- Age and parity restrictions will be removed for all reversible methods.
Inappropriate contraindications removed
- Method-specific contraindication checklists will be revised/updated per USAID's guidance
document.
Process hurdles decreased
- Process hurdles will be decreased by reducing the unnecessary requirements for physical
exams, laboratory tests and revisit schedules per USAID's guidance document.
Oral Contraceptives (OCs)
- Community-based distribution of OCs by family welfare educators prior to physical exam
was approved for six months (up from one month).
IUDs
Trained nurses and physicians will be able to insert IUDs both interval
and postpartum (change in the physician-only rule).
Training strategy approved for immediate post-partum IUD insertion, even
after caesarian section.
IUD training will include STD/HIV risk assessment, diagnosis and
treatment.
Norplant®
- Upon completion of the preintroduction trial currently under way, midwives will be
trained in Norplant insertion and removal.
Tubal Ligation (TL)
Standardized approach to informed choice and consent approved (reversed
the prevalent practice of routine TLs under general anesthesia on women undergoing a third
caesarian section).
A training strategy for minilap under local anesthesia was developed to
replace the "Cape to Cairo" incision under general anesthesia.
Next Steps
Botswana's Family Health Division will appoint a committee to review and ratify the
agreed changes in the policy guidelines. The new, revised guidelines will be used to
revise the family planning procedures manual. Pre- and in-service training curricula will
be harmonized with the new policy norms. Beginning in January 1995, the new in-service
family planning curriculum will be used for Ministry of Health (MOH) training. The new
training approach will be competency-based and participatory to replace the classroom,
didactic approach.
Zimbabwe
In July 1994 a national medical barriers workshop, organized by the Zimbabwe National
Family Planning Council (ZNFPC) with USAID, was held for 20 participants. All sectors were
invited (including provincial medical officers, provincial nursing officers, Ob/Gyn
lecturers, MOH, ZNFPC) to revise service guidelines and IEC materials. At this meeting, a
medical barriers task force was formed. The task force has met three times since the
national meeting to highlight existing barriers in family planning documents and to list
recommended revisions.
From November 7–18, 1995, 18 participants attended a workshop sponsored by the
ZNFPC in Harare to review national policy and service delivery guidelines and to
incorporate changes recommended by the medical barriers task force. The following key
documents were reviewed and revised: service delivery guidelines, clinical procedures
manual, clinical training manual, CBD procedures and CBD training manual, the IUD/GTI
reference manual, trainer's notebook and participant handbook. Final editing to these
manuals, under the supervision of the ZNFPC's Chief Training Officer and Chief Nursing
Officer, is ongoing and will be completed by the end of January 1995.
Agreed Changes to Zimbabwe Family Planning Service Guidelines, Procedures and
Policies
Process hurdles reduced
- Physical examination is required for new family planning (FP) clients on the first visit
only (used to be required annually as a prerequisite for receiving FP methods).
Provider limitations decreased
- Trained provider (physician/nurse/midwife) can provide any reversible method (reversed
the physician-only rule).
Oral Contraceptives (OCs)
- Disbursement of OCs should be as follows:
Clinic: three packets at initial visit; 12 cycles (up from three cycles) at
follow-up. CBD: three packets at initial visit; six cycles (up from three cycles)
at follow-up. Depot Holder: three packets at initial visit; six cycles (up from
three cycles) at follow-up. Youth Centre: three packets at initial visit; six
cycles (up from three cycles) at follow-up.
IUDs
- No backup method necessary as IUD is effective upon insertion (reversed recommendation
that backup method be used for seven days).
- IUDs can be inserted or removed at any time in a woman's menstrual cycle, as long as
pregnancy is ruled out by history and vaginal exam (reversed practice of insertion/removal
only during menses).
- A six-week checkup postinsertion is the only return visit necessary if no
problems/complaints.
Voluntary Sterilization (VS)
- Age and parity should not be limiting factors in the provision of VS services. Critical
factor is thorough counseling to rule out indicators of possible regret.
Next Steps
Revised training manuals will be pretested during an upcoming training course, during
which additional changes will be recommended. Final revisions to family planning service
delivery guidelines, procedures and policies will be reviewed and ratified by a committee
of family planning experts by the end of May 1995.
continued on pg. 3
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