2011 International Conference on Family Planning
29 November–2 December 2011
"Integration of family planning into health service departments: Facility-based performance needs assessment in Ashanti and Eastern regions of Ghana"
Placide Tapsoba, Abisola Noah, Eunice Sefa, and Nicholas Kanlisi
Unintended pregnancies contribute to the risk of death posed by unsafe abortion, which can stem from limited access to family planning (FP). In Ghana, the contraceptive prevalence rate among married women is 17%, despite near-universal knowledge of FP. The Ghana Health Service recognizes the importance of integrating FP services to improve FP access.
A Performance Needs Assessment across several departments in four facilities in the Ashanti and Eastern regions was conducted to assess client interest in obtaining FP services and determine facility/provider readiness for FP service provision.
After defining desired performance in a first stakeholder workshop, a quantitative cross-sectional study was conducted using the Population Council’s Assessing Integration Methodology (AIM). The convenience sample of four facilities represented different levels of the health system with high patient volumes. Data collection was conducted November 15–19, 2010, concentrating on eight core units: antenatal, maternity, postnatal, child welfare, pediatrics, prevention of mother-to-child transmission of HIV/voluntary counseling and testing, outpatient, and FP.
The total sample size included 32 unit inventories, 123 provider-client observations, 712 client exit interviews, and 133 provider interviews. All providers available during the study period were interviewed. Clients (men aged 15–59 years and women aged 15–49 years) were selected at random from all eight core units.
Results showed that 95% of clients with at least one child expressed a desire to limit or space childbearing; however, only 25% of these were currently using any FP method. Twenty-five percent of clients reported that their providers had talked about FP; among the remaining 75%, 7 in 10 said they would have liked their providers to have spoken about FP. While half of providers gave FP information, fewer provided referrals (42%), counseling (42%), and methods (19%). Regardless of current practice, when asked whether they were willing to provide a range of FP services in the future, the majority of providers wanted to provide FP information (97%), counseling and referral (94%), short-term methods (84%), and long-term methods (71%). Almost one-third (31%) of providers were not satisfied with the organization of FP services at their facilities. Most providers had job descriptions; however 23% of these were verbal, while 62% did not include FP. The FP Protocol and/or the FP Global Handbook was available in 10 units; providers were often (65%) not aware that there were written guidelines on FP services. Fewer than one-third of providers (32%) said that supervisors discussed FP and gave feedback specifically on FP performance. Only one non-FP unit motivated staff for performance in FP. Most providers were knowledgeable enough to counsel clients on natural FP or fertility awareness; lactational amenorrhea method; and short-term methods such as pills, injectables, and condoms. A substantial proportion did not know about long-term methods. Few providers were able to insert an IUD (11 providers) or implants (14 providers) or perform a tubal ligation (4 providers) or vasectomy (1 provider). From observations, few providers asked new clients basic questions about fertility and FP. Across facilities, few units had private counseling rooms with visual and audio barriers, enough chairs/benches in waiting areas, or working latrines/toilets. Visual aids, counseling flip charts, models for demonstrating male and female condom use, handheld uterine models, counseling guides, and information leaflets were available in fewer than one-third of units sampled. All 4 FP units had most requisite contraceptives. Contraceptives were much less likely to be available in non-FP units. Levonorgestrel IUDs were unavailable at all facilities. All units had either a register or client cards for keeping records; however, the overwhelming majority of non-FP units did not keep records on FP services. Where available, records were often incomplete or inaccessible. Strikingly, no FP services—information, referral, counseling, or methods—were given in the outpatient department, which had by far the highest patient volume. As expected, the FP unit was the main source of all FP services, except referrals. Curiously, there were still a few referrals from the FP unit.
Based on clients’ significant unmet need for limiting and spacing and demand for FP information during consultations, as well as physicians’ substantial dissatisfaction with how FP is currently organized in the facilities and their willingness to incorporate FP into their duties, integration of FP into a wide range of health services should be further explored. At a second stakeholders meeting, consensus was reached on the priority interventions to be designed and implemented based on the baseline FP performance results and a root cause analysis of performance gaps. These included developing job descriptions to include FP; procuring FP commodities and logistics; conducting in-service training on FP information and basic counseling (for all health workers) and on comprehensive counseling and methods (for all nurses); and setting criteria, developing tools, and establishing plans for monitoring staff performance in FP and FP-related supervision. Implementation is ongoing with endline planned for November 2011.
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