Provider Perspective Slide 1 Hello, I am Doctor Jim Shelton, Senior Medical Scientist with the Global Bureau for Health, US Agency for International Development in Washington, DC, and author of a paper published in International Family Planning Perspectives called "The Provider Perspective: Human After All." Slide 2 We have learned that in order to have successful family planning and reproductive health programs that serve clients well, we need a better understanding of the people being served. But providers also are pivotal to how services are provided. Why they provide services and how they do it is crucial, because they are human too. In order to improve programs further, we need to see the world through their eyes and understand them better. But who are providers? How do they see their jobs, their roles, and their programs? What are their needs and motivations? How do their work environments challenge them? What is the human dimension of their overall lives, and how can we best enlist their help to improve access to services and the quality of programs? Slide 3 This tutorial will help you consider service provision from the healthcare provider's perspective. You may be or may have been a provider yourself. If we can understand providers better, we can better enlist their support. •During this tutorial we will consider: •What personal characteristics or attributes may affect provider performance? •How does medical culture affect provider performance? •How do providers relate to clients and the community? •What systems and social issues affect provider performance? •Why might a provider avoid providing IUDs? Slide 4 Who are providers, anyway? A wide variety of staff can be considered "providers"-from the clerk who first greets clients in a clinic, to the surgeon performing a vasectomy, from the peer educator promoting safe sex practices and providing contraceptives, to the shopkeeper selling condoms or antibiotics for sexually transmitted infections. We tend to think of providers' technical skills and knowledge, but their opinions, attitudes and advice strongly influence what services clients receive and their clients' subsequent behavior. The provider's role as "gatekeeper" can profoundly affect how and when clients receive services, or even whether clients receive services at all. In addition, different staff may have conflicting interests in the way work is designed. For example, a manager may be interested in streamlining clinic flow, whereas a nurse providing services may be interested in having flexibility in working with clients. Slide 5 Please think for a few minutes about the various characteristics and attributes that may affect a provider's performance. Here are some examples of factors that may affect a provider's performance. • Like all of us, providers have their personal characteristics. • And like most of us, providers are trained to achieve the technical competence they need to do their jobs. • Like us, providers have needs and they usually like to receive rewards for the work they do. • Also like us, providers tend to want a certain amount of control, convenience, and comfort while they are doing their work. • Providers do their work within an existing medical culture. • Empowerment and proactivity can help providers perform better. • Providers need links to the client and the community. • And there are numerous systems issues that affect the organizations in which providers work. Slide 6 Consider this figure. Can you guess what it depicts and what it has to say about providers? This is a normal bell curve, which suggests that providers are different. They may be different in lots of ways-morning people versus night people. Optimistic people versus grumpy people, and so forth. So, we can't just think of one image of a provider. We need to consider the whole population of different providers. Slide 7 Please think for a few minutes about some of the personal characteristics that may affect providers' provision of services. This slide gives some examples. •Personality •Work attitude/inclination •Altruism/motivation •Humanness •Their value system •Gender/age, and so forth Can you think of other examples? We all have preconceived notions of providers, from the cold and aloof physician, to the dedicated, self-sacrificing nurse-midwife. Yet providers are individuals with a full range of human characteristics. They have gender, age, race, and social class. They have families, neighbors, and communities. They have dreams and aspirations. They have needs, values, cultural orientations, and political views. They have likes, dislikes, fears, biases, superstitions, and much more. Still, certain characteristics lead to better provider performance, including altruism, a strong work ethic, technical competence, a proactive problem-solving mindset, self-efficacy, organizational skills, and the ability to interact with clients on a caring, connected human basis. Slide 8 Technical competence is obviously a key provider attribute. It is supported by knowledge, skills, and self-efficacy. The standard way to improve the way providers work is through training, which is generally aimed at skills and knowledge. But are skills and knowledge the only things that influence performance? Slide 9 Actually, in recent years our field has come to realize that training alone, which often focuses only on skills and knowledge, is often ineffective in improving provider performance, and thereby service delivery. Rather, an alternative approach is "performance improvement," which seeks to understand the myriad elements that influence provider and organizational performance and considers the full range of possible interventions to make improvements. If provider behavior is key to performance improvement, then understanding providers is also key. Slide 10 Please think about some of the things providers need. •Providers need material necessities such as food, clothing, and shelter. They also need: •Family •Security •Psychic fulfillment such as status, affiliation, and so forth. •And they have other basic needs. What other needs can you think of? Try to put yourself in the shoes of a real provider. For example, imagine that you are a single female provider in an isolated rural setting. In this situation, would your personal security be important to you? Slide 11 Why do providers do the work that they do? Let's think about what providers may perceive as their "rewards" for doing their job. Examples are: •Financial •Status or ego •Helping others •Appreciation •Interest or fun •And accomplishment A central question to ask is, why do people choose to be providers? For most, it cannot be because of the salary. Their pay is so low, especially in the government sector, that many providers augment their incomes in a variety of ways, such as by unofficially charging for "free" services, by having private practices, or by receiving compensation through travel and per diems. In all likelihood, the appreciation and satisfaction received from helping others are primary motivations for many providers. Personally, I love feeling appreciated. Think of some of the things that motivate you to do a good job. Slide 12 What key concept in provider performance does this slide represent? It represents status. Another important motivation for providers is the social status and respect that come with their positions. This social status has high value in itself, but also may enhance the legitimacy of the provider's private clinical practice. Moreover, many providers are women, and the health field may be one of the few opportunities available to them for a career or other out-of-the-house activity. Thus, many women appear willing to act as volunteer community-based distribution agents or depot holders, with little or no monetary compensation. They seem motivated largely by their own altruism and other rewards such as the enhanced social status of their positions. Slide 13 What key elements of provider motivation does this slide represent? The slide on the left depicts "recognition." The slide on the right depicts "appreciation." Feeling that they are appreciated will help providers perform better. Can you think of ways that providers in your country know that they are appreciated? Slide 14 Providers face many constraints. For example, a study from Sitapur District in India provides a poignant insight on the daunting constraints that confront auxiliary nurse-midwives attempting to provide family planning and reproductive health services. These include: •Problems with reimbursement, supplies, and equipment •Lack of physical space •Poor training and supervision •Lack of transportation •Bureaucratic obstacles •Scheduling difficulties •And even lack of physical security After reading the study, you wonder how the auxiliary nurse-midwives were able to deliver any substantial amount of service at all. Slide 15 Like all of us, providers try to control their work environment. Try to think of the aspects of work they might try to influence. Here are some •The pace of the work •The stress •How easy or hard the work is •The timing •The predictability •The various physical aspects •And how the clinic flows Consider how these elements might vary for different providers. For example, many people prefer an environment in which work is continuous and predictable. Others like a lot of variety. Providers strive for an environment that is both physically and psychically comfortable. They too want their breaks, their perks, and their diversions. To a large extent, they also seek control over the timing, pace, volume, ease, stress, and predictability of their jobs. This is not necessarily easy, because the nature of healthcare is often unpredictable. To help achieve control, providers use a variety of formal and informal regulatory mechanisms. Slide 16 What element of control does this slide represent? Here's a hint. Try adding the letters A.M. under the left side and P.M. under the right side. This slide represents "clinic flow." The crowded waiting room on the left represents the typical client overflow in the morning. The picture on the right represents the quiet, sometimes empty clinic in the afternoon. Have you ever witnessed this scene? Why do you think it exists? Is this system conducive to good client access and service provision? Client flow in clinics is often strongly dictated by the convenience of the provider and longstanding practice, rather than by optimal service provision. For example, clinics may follow the convention of weighing every client in the clinic. It is almost universally true in developing countries that in busy clinics, the vast majority of clients are seen in the morning, and often after an elaborate system of queuing. In contrast, few clients are seen in the afternoon, even though the same services are theoretically offered. In their role as gatekeepers, providers strongly influence their clients' behavior patterns, thus regulating their own workload in the afternoon. Slide 17 One way that providers regulate workload is through procedural barriers. For example, requiring women to be menstruating to receive contraceptives allows providers a "legitimate" rationale to regulate and reduce their workload, even though it means clients may not receive services. Slide 18 Scheduling is a method that is often used to control the volume and pace of work. In a striking example of such time regulation from Brazil, appointments were only accepted on certain days during the week, and clients had to stand in line for hours just to get appointments as far as one or two months in advance. Fortunately, subsequent revisions of scheduling procedure, along with a major reorganization of work procedures, resulted in a substantial improvement of access for clients. Slide 19 The medical field has its own culture that strongly influences most health workers. Medical culture is often not conducive to the "humanness" that we would like to see in providers. Providers are accustomed to the idea of "doing" and "solving" rather than relating to a client. Four specific attributes can help us understand the provider's perspective. First, medical culture is hierarchical and conservative, with traditionally strong norms for work routines, division of labor, and even rituals. These attributes make it difficult to introduce changes or to stimulate empowerment and decision-making at "lower" levels. Second, medical culture strongly values various technical procedures involving the laying on of hands or technology. Thus, providers may give a large amount of attention to physical exams, lab tests, and technical procedures, but little attention to the "human" aspects of communicating well with clients. Third, medical culture insulates health staff from clientele. Although other groups of employees remove themselves from their clientele, partly for reasons of practical logistics, medical staff do it partly out of emotional self-preservation. Without some distance, dealing with large numbers of sick and distressed people would be extremely draining emotionally. Lastly, the predominant mindset of the medical field is curative. It views providers as the decision-makers; they decide what therapy to prescribe. This mentality may not be conducive to providing preventive care and to promoting healthy behavior and decision-making-all central to reproductive health interventions. Recognizing these aspects of medical culture not only helps us understand why providers behave in certain ways, but also helps us understand the challenge that exists in promoting the flexible, proactive, humane, and connected provider we would like to see. Slide 20 What key concept of medical culture is this? This slide depicts the concept of "ritual." The preference providers have for habit and ritual, such as with routine pelvic exams and much of current antenatal care practice, may partly be explained because these practices, although often of no real use, promote a controlled and predictable work environment. Slide 21 What aspect of the medical environment does this slide represent? This photo represents hierarchy. Medical culture is hierarchical. Slide 22 Empowerment is another key attribute for providers. For example, do they actively study their surroundings to see what needs to be done? Do they feel empowered to take responsibility, solve problems, make things work, and look for better ways of doing things? For example, if a window gets broken, do providers figure out how to get it fixed themselves? Or, do they expect someone else to take care of it? Do providers try to improve clinic flow so clients do not have to wait so long? Or, do they just keep things working the way they always have? Slide 23 This slide depicts the key concept of empowerment! Are providers in your country empowered to take responsibility, solve problems, take risks, make things work, and look for better ways of doing things? If not, how might they be empowered? Consider potential interventions such as policy change, supportive supervision, and rewarding proactive behavior. Slide 24 One important point to discuss is how much the provider really KNOWS about and RELATES TO the specific community in which he or she works and how this may affect his or her work. It is also important to think about how providers relate to clients. Here are some examples: • Do providers know about the community? • Do they have affinity for or sympathy with the community? •Do they have connections or roots in the community? • How well does the provider's class, race, and gender match that of the community? • How much social distance is there between clients and providers? • Typically, providers maintain a power imbalance as they provide clinical services. The environment and routine are familiar to them, but are foreign to the client. • Lastly, are there elements of favoritism or nepotism involved in service delivery? Many providers may like social distance and power imbalance because it is safer and gives them control. Interestingly, when providers do make strong links with clients and communities, they can increase their job satisfaction substantially. Slide 25 What key issue does this slide represent? This picture shows "horse power" versus "nuclear power," and thus is a representation of: power imbalance. The issue of power imbalance has to do with how providers relate on a social basis to the communities and clients they serve. Providers are not immune from class, caste, race, and gender issues in their society. Service providers are often of a higher socioeconomic status than their clientele, and the medical culture only serves to increase that social distance. Moreover, because providers often do not come from or even live near the communities to which they are assigned, they are disconnected even further from their clients. On the other hand, service delivery programs that recruit staff from within the villages and towns in which they serve tend to be more successful. Slide 26 What key concept does this slide represent? This picture represents the concept of "links" or linkage to the community. Are the providers in your country closely linked? If not, how might better links be made? Slide 27 This slide lists "systems and social issues" that can have a profound effect on providers. To understand providers, one must also consider the systems and social context in which they work. Low salaries may cause providers to resort to "creative financing." For example, a provider may be able to work only half a day in a public facility so that he or she can generate additional income in the afternoon, from a "second" job such as a private practice. Or, a provider might need to use "per diems" to augment salary. Likewise, bureaucratic and personnel systems and policies influence a provider's behavior. They can lead to inspiration and motivation, or they can lead to disillusionment and alienation. How often do clients bear some of the repercussions of a provider's disgruntled feelings toward "the system"? Relationships to supervisors and co-workers are also important, because providers are influenced by their peers and their social network. Resource-poor environments promote a scarcity mentality, which makes providers highly protective of supplies. Understanding this phenomenon helps us understand a variety of provider behaviors, such as providing only a few cycles of pills or a few condoms at a time, or resisting providing multiple antibiotics for syndromic management of reproductive tract infection symptoms. Supervision and the socio-cultural environment also affect provider behavior. Slide 28 What social issue does this slide represent? This picture represents a kind of social network. The social network of supervisors, peers, and other program personnel is pivotal. As in any organization, the social norms of behavior among providers are very strong. For example, when staff are trained off-site and then return to their work sites, they find that pressure from other staff, as well as other situational constraints, may undermine their ability to implement newly acquired skills and knowledge. Similarly, if the common unofficial practice calls for staff to leave the clinic at 2:00 pm rather than at the official time of 4:00 pm, few individual providers are likely to try hard to go against the established social norm. Slide 29 Another look into the provider's perspective comes from an anthropological study from Nepal showing that the health staff's views of their jobs often differed from the official program views. A co-existing and contradictory value system was found to exist within the healthcare system. One reality was the official value system and the other reality was the unofficial value system. Both were "valid" in a certain sense, but we must recognize and understand both and address both. For example, the "official reality" said that: •The health system existed to deliver services •Training was conducted to improve performance •The personnel system provided a basis for rewards and sanctions •Each health job required a specific set of the "right" skills •And, the function of reporting was to support decision-making and improve quality However, the "unofficial reality" said that: •The health system existed to provide a job for the provider •Training was conducted to provide income •Rewards and sanctions were based on informal methods •Various health jobs were interchangeable •And, reporting was an end in itself Slide 30 A good example of the importance of provider perspective relates to IUD insertion. Many efforts have been made to increase the availability and use of various "underused methods" over the years, mainly with training. But the provider perspective is often overlooked. From the provider perspective, IUD provision has many disadvantages. Can you think of some reasons why providers might avoid IUDs? A few studies have specifically addressed providers' views of IUDs and IUD insertion. •It appears that many physicians prefer oral contraceptives over IUDs partly because providing an IUD entails more work than providing the pill. •Studies from El Salvador and Kenya have found that IUD service delivery is less attractive to providers because IUD insertion requires time and a variety of supplies and equipment. •IUD service provision also requires proper training. • And, the low frequency of IUD insertion can lead to low confidence among providers in their ability to perform the procedure. •In addition, providers often have misconceptions about IUDs. •Sometimes the social distance between the client and the provider inhibits the provider from performing an intimate physical exam. •Sometimes providers perceive themselves at personal risk of infection. Slide 31 Here are some provider quotes about providing IUD services to clients: A doctor in El Salvador said that "sometimes we are in a rush and there are many patients...many times we choose the easiest method." Another doctor in El Salvador said, "Well, we have been trained, but I have never had the opportunity to perform the procedure." Slide 32 A provider in Kenya noted that patients were forced to buy gloves for IUD procedures. A woman may go home without the procedure because she has no money, and then never return to the clinic. Another provider in Kenya commented that if the provider has a small cut, he or she could get infected. And a third provider said that providing an IUD is a lot to do if the provider is busy. Slide 33 We need to see the world through the provider's eyes. What does the provider see in this picture? We may either see a young woman looking backward, or an old woman looking forward. So, we may see two pictures in the picture on this slide. But if we want to improve provider performance, we need to find out what the providers are actually seeing. They may see something else entirely. Slide 34 And so, in summary: We really need to know more about providers. But we do know that, although individual providers are different, they have certain patterns of behavior that can help us understand what motivates them. Some of the key motivators for providers are financial reward, status, the sense that they are helping others, feeling appreciated, having some control over their environment, and the influence of social norms on their behavior. A key question to ask is: What's in it for them? As with anyone, if we want providers to do more work, we need to justify it with them. We must be prepared to address the unpopular issues that are often not discussed, such as compensation for low pay. And finally, we need to find out more about the provider's way of looking at the world. Slide 35 The good news is that there are many wonderful service providers out there doing great work under very difficult circumstances. As we design and implement programs, we need to listen more to the providers who are on the front line and build on their views. And, we need to do more research to understand providers better. As our field continues to advance, we must remember that providers are human after all, and must be full partners as we further improve reproductive healthcare.