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Monitoring and Evaluation: FAMILY PLANNING PROGRAMS Session Objectives • Be able to apply basic M&E concepts (frameworks, indicators, etc.) to family-planning programs • Be able to summarize the main issues in M&E of family-planning programs from a post-Cairo perspective. • Be able to summarize the emerging issues for M&E of family-planning programs in high HIV prevalence countries. Session Overview • Family-planning frameworks • M&E implications of the Cairo agenda • Contraceptive prevalence and unmet need • Monitoring quality of care • Evaluating the impact of quality • Family planning and HIV Family Planning Frameworks Conceptual Framework for FP Demand and Program Impact on Fertility Other intermediate variables Societal & Fertility Value & FP demand individual demand for • Wanted factors • Spacing children • Unwanted • Limiting Contraceptive practice Service outputs: Development programs • Access Service Utilization Other health & FP supply • Quality social improvements factors • Acceptability Source: Bertrand, Magnani, and Rutenberg, 1996. Conceptual framework of family planning supply factors External FP Organizational Operations Development Structure Assistance • Management & • Service supervision Service Outputs infrastructure • Training • Access Political and • Sectoral integration Administrative • Commodity • Quality System • Delivery strategies acquisition & • Acceptability distribution • Political • Public-private support partnerships • IEC • Resource • Research & allocations evaluation • Legal code / regulations Larger societal & Source: Bertrand, Magnani, and political Rutenberg 1996 factors Applying the frameworks for FP M&E • Inputs, e.g. – Types and levels of resources – Qualified personnel – Unit and total costs of program resources • Outputs – functional areas, e.g. – People trained – Performance of people trained – Cost per person trained Applying the frameworks for FP M&E • Outputs – Service outputs, e.g., – Service delivery points providing FP services – Quality of FP services – Cost of increasing access/quality of FP services • Outputs – Service utilization – New FP acceptors, Couple Years of Protection (CYP) – Returning clients – Cost of increasing CYP, etc. Applying the frameworks for FP M&E • Outcome – intermediate outcomes – Contraceptive prevalence rate (CPR) – Unmet need – Costs associated with increased CPR • Outcome – long term outcome – Fertility rates – Unintended pregnancy – Costs of changes in fertility, unintended pregnancy Indicators for FP programs • See Bertrand and Escudero, 2002, Compendium of Indicators for Evaluating Reproductive Health Programs, 2 volumes – Indicators that crosscut program areas – Indicators for specific program areas What is different about M&E of FP programs? • Basic principles are the same as in other health programs • Outcomes relatively well-defined, focused, and measurable • Long history of data collection on FP outcomes through WFS, DHS – document global trends • Attempts to link outcomes to program outputs - evidence of program effects Programme of Action adopted at ICPD, Cairo 1994 Traditional (pre-Cairo) focus of FP program M&E • Demographic impact • Focus on married women • Availability of services • Contraceptive adoption (new users) • Characteristics of women • Cross-sectional measurement Cairo: Objectives of FP Programs • To help couples and individuals meet their reproductive goals • To prevent unwanted and high-risk pregnancies • To make quality FP services affordable, acceptable, and accessible • To improve the quality of family planning IEC, counseling, and services • To increase the participation and sharing of responsibility of men in FP • To promote breastfeeding to enhance birth spacing Exercise 1 • Discuss the implications of the Cairo programme of action for M&E of FP programs. Identify 3 or more ways in which the traditional focus of FP programs listed on the earlier slide should change to respond to the Cairo agenda. What are the implications of these changes for M&E? Contraceptive Prevalence Rate (CPR) • Percentage of (married) women of reproductive age (15-49) who are currently using a contraceptive method. Unmet Need for Family Planning • Percentage of fecund women exposed to the risk of pregnancy who say they want to wait at least two years for another birth (spacing) or do not want any more children (limiting), but are not currently using a method of contraception. Related Indicators • Demand for FP = % (married) women using FP + % (married) women with unmet need for FP • Percentage of demand satisfied = % (married) women using FP / % (married) women with demand for FP Unmet Need Exercise CPR vs Unmet Need CPR Unmet Need • Relatively simple to • Relatively complex to define define • Uni-dimensional • Multi-dimensional – • Consistency over time demand & use • Does not capture • Definition has evolved concept of meeting • Captures concept of needs meeting need Monitoring Quality of Care What is Quality of Care in FP? • General, loosely-defined concept • Different people define quality in different ways • Multi-dimensional • Appropriate standards against which to measure quality vary Bruce-Jain Framework • Choice of contraceptive methods • Information given to users • Provider competence • client/provider relations • re-contact and follow-up mechanisms • appropriate constellation of services Indicators for QOC • No single indicator can capture the different components of QOC • Indicators need to be adapted to specific program context and priorities • Shortlist of 24 QOC indicators (see Bertrand and Sullivan, Evaluation Bulletin No. 1, Table 1 page 2). Facility Surveys for QOC Indicators • Situation Analysis • MEASURE Evaluation Quick Investigation of Quality (QIQ) • MEASURE DHS+ Service Provision Assessments (SPA) • DHS service availability modules and community surveys (SAM) Some Data Collection Issues • Small sample sizes for FP clients, especially in low prevalence countries • Observation in clinics that use a client flow approach • Sampling • Courtesy bias and hawthorn effects • Unit of analysis (client, provider, facility) Case Study: QOC in Turkey Turkey’s Strategic Framework Strategic Objective Increased utilization of FP/RH services Intermediate Result 1 Intermediate Result 2 Strengthened sustainability Expansion of high quality FP/RH services of FP/RH program in the public and private sectors The Quality Index • Method availability • Availability of trained personnel • Perceived quality of FP counseling • Adequate infection-prevention measures • Availability of IEC materials • Physical access to FP services Data Source • Istanbul Quality Surveys – Facility inventory – Client exit interviews • Based on MEASURE Evaluation QIQ The Quality Index • Sum of scores from Private hospitals the 6 components SSK (range 0-6) hospitals Health centers MCH/FP centers MOH hospitals 0 2 4 6 Method Availability • Proportion of facilities Private hospitals that distribute or SSK prescribe 3 or more hospitals modern FP methods Health centers MCH/FP centers MOH hospitals 0 0.2 0.4 0.6 0.8 1 Perceived Quality of FP Counseling • Proportion of clients who Private report hospitals – they were seated SSK hospitals – had sufficient time with the provider Health centers – clearly understood the information provided MCH/FP centers MOH hospitals 0 0.2 0.4 0.6 0.8 1 Adequate Infection Prevention Measures • Proportion of facilities Private that meet the following hospitals standards : SSK – Plastic bucket for CL hospitals solution Health – Unused IUD kits kept centers sterile MCH/FP centers – Medical waste kept in leak-proof containers MOH hospitals with lids – Appropriate containers 0 0.2 0.4 0.6 0.8 1 for sharp objects Evaluating the impact of quality of care Framework for links between quality of family planning services and fertility Quality of services Acceptance •Choice Information to Contraceptive users prevalence Provider competence Client-provider Continuation Fertility relations Follow-up Other Appropriate proximate constellation of determinants services Other factors Known effects Hypothesized effects Source: Jain, 1989 Outcomes of interest • Intention to use • Contraceptive adoption • Contraceptive discontinuation – Failure – Switching – Stopping • Current contraceptive use – Contraceptive choice • Unwanted pregnancy Examples of impact studies • Peru (Mensch, et al., 1996) • Morocco (Steele, et al., 1999) • Bangladesh (Koenig et al., 1997) Morocco Study Design (1) • To explore whether the service environment in which a woman resides affects adoption and continuation of the pill • Linkage of 1995 Demographic and Health Survey calendar with 1992 DHS Service Availability Module • Multi-level hazards models with contraceptive adoption and discontinuation as outcomes • 862 births and 775 episodes of pill use in 107 clusters Morocco Study Design (2) • Explanatory factors - Individual and Community – age, education, residence, community drinking water & toilet facilities, principle economic activity – Contraceptive intention (discontinuation) – Breastfeeding status, last child wanted (adoption) • Explanatory factors – Program – Public health center <10km, pharmacy <5km, outreach services, 3+ methods available at clinic – Source of pills (discontinuation) Predicted percentage of women adopting a modern contraceptive method within 12 months of giving birth by service factors 70 60 50 40 % 30 20 10 0 Yes No <3 3+ Health center <10km No. methods offered at closest set of facilities Predicted 12-month pill discontinuation rate by reason and service factors, Morocco 35% 30% 25% 20% 15% 10% 5% 0% Government Pharmacy or Yes No Yes No other Health center within 10KM Pharmacy within 5KM Source Failure Desired pregnancy Side effects/ health concerns Other method-related Main Findings: Morocco • Relatively strong service effects on post- partum adoption • Service availability associated with both adoption and discontinuation • Number of methods available only associated with adoption • Users of government sources have lower discontinuation Limitations of Impact Studies • Measures of quality inadequate (often limited to access and method choice) • Cross-sectional designs (endogenous inputs) • Linking individual and program data (geographic boundaries, service environment vs. individual service experience) Emerging areas: FP/HIV linkages and integration Context • Considerable progress in preventing unwanted pregnancy but unmet need remains substantial • Rapid increases in HIV in many countries • Changing funding focus to HIV from FP • Integrated vs. vertical programs Synergies between FP and HIV programs • Both are central to reproductive health • “ABC” messages in HIV programs also relevant to FP programs • Youth programs that encourage responsible sexual behavior prevent both HIV and teen pregnancy • Strong RH policies support both HIV and FP programs Dual Protection • Abstinence • Monogamous couples using effective contraception • Correct and consistent condom use FP in high HIV-prevalence countries • Relationship between HIV and fertility desires • FP/RH needs differ for: – HIV- concordant monogamous couple – HIV- concordant non-monogamous couples – HIV discordant couples – HIV+ concordant couples • HIV counseling in FP services FP and VCT • FP counseling opportunity for VCT or general HIV counseling and VCT referral • VCT services could include FP services or FP counseling and referral • Concern over unintended consequences of integration – Provider burn-out – Discourage FP clients – Quality of integrated vs. vertical FP & VCT services FP and PMTCT • Averts child infections by preventing unintended pregnancies among HIV+ women • PMTCT programs provide opportunity for prenatal FP counseling and post-partum contraceptive use • Reduced breastfeeding by HIV+ mothers will lead to shorter birth intervals in the absence of FP FP Counseling of PMTCT clients, Zambia 60 50 40 % 30 20 10 0 ANC visit 3 months PP 6 months PP pregnant women HIV+ HIV- Source: Rutenberg & Baek, 2004 PMTCT-Client FP Use 6 Months Post- partum, Zambia 45 40 35 30 25 % 20 15 10 5 0 Modern Condom Sex active, no method HIV+ HIV- Source: Rutenberg & Baek, 2004 HIV Counseling in FP Sessions, Uganda 40 35 30 % FP sessions 25 20 15 10 5 0 HIV needs HIV risk discussed Dual protection assessed proposed Baseline Follow-up Source: Rutenberg & Baek, 2004 Exercise 3 • Select an area of FP/HIV integration (e.g. PMTCT, VCT, HIV counseling in FP etc.). – Develop a basic input-output-outcome-impact framework for a simple program in this area. – Suggest 3-6 indicators to monitor your program. – What data sources would you propose to collect these indicators?
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