Maximizing Access and Quality Presentation Graphics Notes |
The purpose of this first module is to present you with an overview of the key concepts that define MAQ and shape activity pursued under the MAQ Initiative. We will answer the following questions:
- What is MAQ?
- Why is MAQ important? and
- How do we go about maximizing access and quality in a program?
Here is a one-sentence description of the MAQ Initiative. (Read the slide aloud)
The Initiative fosters application of state-of-the art practices through a variety of mechanisms that include but are not limited to:
- Activities undertaken by the MAQ Working Group in Washington
- TA and financial support to countries in the development and revision of service delivery guidelines
- Funding of regional conferences and workshops
- And events like this one.
In addition, activities supported by the MAQ Initiative have the following attributes.
Activity under the MAQ Initiative has focused on access and quality in Family Planning. This graphic may be familiar to AID staff …….it depicts the way AID has framed the relationship between FP and an expanded definition of RH. Family Planning has and continues to be the centerpiece of this Initiative as it does for AID as a whole. We also acknowledge, however, that there are important linkages to selected reproductive health issues. For example, in the Exchange curriculum theme of Integration, we look at integrating FP services with PAC and STI prevention and treatment. We have also incorporated issues related to gender throughout our curriculum.
So, why should we work to improve access and quality in our FP programs?
Improved access to and quality of FP services presents a win-win situation.
The interventions necessary to improve program performance in turn result in increased client satisfaction.
A satisfied client is more likely to return to a service delivery point (SDP) that has provided her/him with high quality services and is more likely to continue use of a FP method. This in turn has a positive impact on program performance indicators.
For example, when quality and access were improved in Pakistan through doorstep delivery of FP services, along with the provision of referrals as needed, 6 project sites were able to meet a previously unsatisfied demand.
This approach resulted in a rise in CPR that continued throughout 12 months of follow-up.
This slide shows the CPR that results from varying combinations of increases in adoption and continuation rates.
The first column indicates that if we have a 5% rate of contraceptive adoption and 50% annual continuation rates, the outcome is a CPR of 10.
Comparing columns 2 and 3 we see CPR increase from 33.4 to 40. This is due to increased continuation rates, despite a 50% decrease in new contraceptors.
Although there is only 5% adoption rate for the last bar, the 90% continuation rate results in the highest CPR.
Thus, as we become more effective in meeting the individual client’s needs, our programs will perform better and we will come closer to achieving the USAID Agency goal of........(next slide)
Because many of us in the room are managing programs and involved in service provision, we tend to focus more on the supply side of family planning and reproductive health services. However, in the interest of achieving our ultimate goal of increasing client satisfaction, it is equally important to consider things from the client’s perspective. So, to start, I would like to share with you a simple graphic representation of quality and access issues through the eyes of a client.
Remember that clients may face numerous barriers before even reaching a service delivery point (SDP). For example, there may be sociocultural norms that put use of FP in a negative light. Gender roles may be such that women do not have the decision-making power to seek FP planning services and do not receive support in doing so from their partner. In addition to autonomy in decision-making, women may not control financial resources necessary to cover costs in seeking a method (transport, child care, method, related services….) etc.
When we consider physical access, we need to think about such things as the amount of time it takes to access a SDP. This is affected by the distance the client must travel and the means of transportation available. Is there public transportation? Does s/he own a bicycle or car? What condition are roads in? Is s/he required to walk and if so how far?
(Conduct brainstorming activity)
Once clients reach the SDP, there are numerous additional factors that can affect the quality of services.
For example, does the provider help the client make an informed choice of method? Is the method the client chooses available?
Are the hours the clinic provides services convenient? Does the client receive services on her first visit--or is she required to come back at another time for some or all of the services she seeks? How long is she required to wait?
Do clinic protocols reflect up-to-date international consensus on eligibility for methods? Do providers actually use the protocols?, etc….
How appealing is the physical environment of the SDP? Is it clean and well maintained? Is there a comfortable waiting area with seating that is protected from the elements?
(Continue in same manner for rest of items...)
You can see that there are many factors which play into a client’s perception of the quality of services she has received and the resulting level of satisfaction she has with the services. The MAQ Exchange was created to help us ensure that we are successful in addressing these many factors. It is meant to be a process that facilitates the efforts of providers and program managers to improve their performance and ultimately meet our goal of improving access and quality for our clients.
The 1991 Pariani study shows that clients who receive their method of choice are much more likely to continue using the method.
Approximately 90% or more of the women who received their method of choice were continuing with a FP method one year later.
Whereas, only 20% of the women who had not received their method of choice were still using a method.
So, how often are clients getting their method of choice? The results of this Situational Analysis show that almost 1/2 of the clients who indicated having a preferred method did NOT get that method. Do you think this is a problem in your country, and what might explain this? (One of the factors in this Nigeria study was a problem with stockouts.)
One of several reasons clients may not receive their method of choice is stockouts. Here is one example of the large percentage of SDPs experiencing stockouts of an array of methods in a 6-month period. Note that injectables were unavailable due to stockouts in 53% of the clinics and POPs in 74%.
Another important area in improving quality of services is content of client-provider interaction. These data show us that failure to counsel clients on potential side effects of their chosen method can result in 2-3.5 times higher discontinuation rates.
We see here that among clients not counseled about side effects in Niger, 37% discontinued use of a method whereas only 19% of those who had been counseled discontinued.
The difference is even greater in the data from The Gambia where discontinuation was only 14 percent among those who had been counseled about side effects.
Here is a good visual example of client-provider interaction in which there appears to be very little or no social distance. The provider is clearly engaged, she has good eye contact, is smiling and sitting at the same level as the client...
Let’s take a minute to consider the impact of medical barriers that still exist in many programs...
Age limits on eligibility for a method is but one example of medical barriers.
If you look at OCs, you see that 29% of the providers interviewed would NOT provide pills to women under 25 years of age and 43% of the providers interviewed would not provide pills to women over 30 years of age.
That is a lot of women who wouldn’t be eligible to use the pill based on age alone.
Parity also remains a major barrier to a variety of methods.
These data on parity requirements for injectables show that a large number of providers in these 5 African countries limit access based on this criterion.
Fortunately, much can be done to improve quality and access with existing resources. Evidence shows that existing resources are not always used in the most efficient manner.
Here we see that only 20% of the SDP points are providing approximately 75% of the services.
In most countries you find that some of the clinics are doing a lot of good work. We simply need to get the others to do the same.
So how do we go about achieving the things we’ve just discussed??
Collaboration is key!
Country programs and host-country partners are at the center of efforts to improve service delivery while donors and CAs work together to provide support.
An example of collaboration under the MAQ Initiative is the MAQ Working Group which is made up of representatives from USAID and a large number of cooperating agencies. Within the working group 5 different committees have been formed to produce documentation of lessons learned and best practices from the field and tools useful for improving different aspects of access and quality in FP programs.
The committees review lessons learned in countries around the world and compile the best evidence of what works in reference documents and other tools. These are in turn disseminated to promote and support the application of best practices in program development and service delivery.
This is just a sample of the some of the MAQ publications produced to promote and support best practices.
The Monitoring and Evaluation MAQ Subcommittee has recently completed field testing of a short list of quality of care indicators (24 total). Data are collected with three different instruments: facility audit, observations of CPI and client exit interviews. The Subcommittee’s next task is to put together a user-friendly packet of the instruments with guidance on data collection, analysis and presentation of results.
(Do "Synergy of Interventions" activity described in facilitator’s outline.)
Creating a norm of easy access and good quality service requires a synergy of interventions. This graphic illustrates the various complementary components to consider in efforts to improve access and quality in our programs.
Implementing an intervention to address any one of these components may make a difference; however, impact of interventions is maximized with each additional component we succeed in addressing.
(Talk briefly about each component.)
- e.g. By Supervision, we mean not only overseeing the work/performance of providers and support staff. We are talking about supervision that provides both direction and support to staff in a fashion that is facilitative and inclusive. Good supervisors will help those working under them find solutions to challenges on the job.
e.g. Client and Community Promotion refers to generating demand for higher quality. This entails IEC outreach to both potential and existing clients.
Improving access and quality in our service delivery programs is an art form.
Program managers need to focus on many different aspects of their program simultaneously and adapt to ever-changing environments. They need to take state-of-the art practices and adapt them to the demands and opportunities of their given situation.
In the course of the next three days we will discuss all of the issues touched on in this segment in greater detail. We will be drawing on the varied expertise of all of you in this room. Improving access and quality in our programs requires a group effort and a multidisciplinary approach. In the next three days we will focus on four key themes:
- Access and Quality
- Client-Centeredness
- Selected Integration
- Strengthening systems/Application
During this workshop it is important that we capitalize on the variety of expertise in the room. Each and every person has valuable knowledge and experience to draw from and contribute to the productivity of the sessions.
The purpose of this opening session was to set the stage for the content of the next three days. So, in summary...
Why is MAQ important?
(e.g., MAQ is important because it improves individuals’ lives and makes the world a better place.)
What is it?
(e.g., efficient, well-functioning, service delivery that is responsive to the client’s needs.)
How do we achieve it?
(e.g., through a synergy of interventions.)
This is a list of the 24 quality of care indicators identified and field tested in multiple countries by the Monitoring and Evaluation Subcommittee.
Purpose of developing QC indicators:
- develop a low-cost, practical methodology for measuring QC in clinic-based FP services
- provide USAID Mission with QC indicators for use in the R4 process
- develop an approach to monitoring quality that would be useful to CAs, NGOs and other donors
The final product from the quality of care field-test will be a package of materials for organizations interested in monitoring quality of care. It will cover the following topics:
- short list of indicators
- sampling issues
- instruments for data collection
- field guide for supervisors
- analysis plan
- illustrative presentation formats for data.
In this study, providers at one half of the clinics received special training to improve counseling clients on potential side effects of injectables. The other half did not receive this training.
In clinics where providers were given special training, only 10% of the women discontinued. This is in comparison with 40% of the women in the control clinics.
On average, new clients are told about side effects one-half of the time or less.
This is an index used in a Bangladesh study to assess clients’ perceptions of a fieldworker’s interpersonal skills.
Both first-method and all-method continuation increases when fieldworkers have better interpersonal skills.
Here are the 6 key process and content points that characterize good quality client-provider interaction.
Note that the first point under Process is friendly atmosphere. A friendly atmosphere is created by the provider when s/he is respectful and responsive to the client’s needs.
The document on eligibility criteria uses these four categories.
In the course of the next three days we will discuss all of the issues touched on in this segment in greater detail. We will be drawing on the varied expertise of all of you in this room.
Improving access and quality in our programs requires a group effort and a multidisciplinary approach. In the next three days we will focus on four key themes:
- Access and Quality
- Client-Centeredness
- Selected Integration
- Strengthening Systems/Application
During this workshop it is important that we capitalize on the variety of expertise in the room. Each and every person has valuable knowledge and experience to draw from and contribute to the productivity of the sessions.
