On September 14-15th 2017, fifty practitioners, consultants, policy makers and researchers came together in Antwerp to work on the ambitious agenda of revising how PBF programs pay for family planning services. Clarisse Uzamukunda reflects on her take-home observations from the two-day meeting, convened by BlueSquare, the Institute of Tropical Medicine, the Performance Based Financing Community of Practice, Population Council and WHO (Reproductive Health Research Department).
Working group on barriers to update of PBF indicators for family planning
As I travelled from Lesotho, the far “Mountain Kingdom”, to Belgium to participate in an international workshop on Performance Based Financing (PBF) and Family Planning (FP), I had mix feelings; I felt quite excited about the workshop but also kept asking myself if I had truly understood the objectives and most importantly what would be my contribution to this important meeting. During the long lay-over at the OR Tambo international airport, I advised myself to go through the workshop materials and reflect on the two main objectives:
- Contribute to the emergence of a collective learning and action agenda on incentivization of quality services in family planning and define how the PBF quality of care tools (checklists and patient feedback) can be improved;
- Develop a research and learning agenda to monitor and study the effectiveness of the recommendations.
Considering the length of the meeting, a question arose to whether these ambitious objectives would be met. Working at the implementation level, providing day-to-day technical support to the Lesotho PBF program, my reflex was to start thinking about details, reminding myself of the usual long in-country process of developing quality measurements. Through that process I always asked myself, are we really addressing the core quality issues? Whether to put more weight on structure or process indicators? Do we know if these indicators have a direct effect on our priority outcomes? What would be the effective way to use patient feedback?
While reading Avedis Donabedian for more insight, I acknowledged the complexity to measure quality! He actually mentioned that not long ago the question of care was considered to be something of mystery and not subject to measurement. He thought that in our time, we actually have moved too far in the opposite direction: “Those who have not experienced the intricacies of clinical practice demand measures that are easy, precise, and complete – as if a sack of potatoes was being weighed”. Peter Eerens shared very similar views in a blog post introducing our meeting.
Family Planning services in PBF Programs at country level
Once at the Institute of Tropical Medicine, I realized that the organizers had brought together an incredible combination of experts: researchers, policy makers, freelance consultants, government representatives, implementers,… There was a very nice balance of PBF experts and FP experts, from the South and from the North. This diversity of experiences resulted in a great knowledge exchange. Allow me to report a few observations that I consider important.
On the first morning, I really appreciated the presentation of the Cameroon case. It emphasized adolescent reproductive health. For many of the PBF experts, the information that 42% of women of reproductive age are between 15-25 years old was an eye opener: are we not missing this group by focusing our PBF systems on generalist health centres only? Cameroon is innovating. They are trying to develop a FP service offer adapted to the specific needs of adolescents (call them ‘youth friendly services’). Jeannette Afounde also provided interesting quantitative data on actual skills available at the facility level (a big bottleneck) and qualitative data on cultural barriers.
As one of the meeting topics was patient feedback, the controversial use of Community Based Organizations (CBOs) to track patients in communities came to light. The issue of confidentiality was once again discussed as non-medical personnel (CBOs) are given access to medical records, track patient to verify if they really received the services as reported by the facility and also administer surveys to measure clients’ satisfaction. Exit interviews were discussed as a alternative option to collect routine patient feedback for FP services. Some argued for a more rigorous satisfaction survey (the existing model is not informative enough) to be planned on a semi-annual basis.
The Antwerp workshop made me aware about the multiple factors to consider when setting up FP indicators. I noticed that the socio-cultural factor is critical. I had a quick chat with one participant on this one. She mentioned that as a mother, she will not support a FP program targeting adolescents as it is seen as encouraging youth to be sexually active at early age. Her other point was a question to whether we should promote use of pills and injections versus condoms at the cost of increasing HIV/AIDS prevalence. Whether the country priority is to decrease the fertility rate or decrease HIV prevalence, there was a common understanding that these programs should as well emphasize behavior change targeting service providers, population, religious leaders, etc.
Quality of care Family Planning Frameworks
At the meeting, I learned that frameworks are essentially conceptual, meaning that when it comes to operational level, realities are different. Hence when developing frameworks, it is important to be cautious and keep in mind contextual realities and other social dimensions. In the Theory of Change (ToC) presentation, there was this powerful statement by Peter Eerens: “Health systems are complex systems. Everything is connected: causality goes through many channels. A ToC is actually a reflexive way to navigate this complexity; a ToC tells as much about ourselves as about the reality under analysis. Our data should trigger action, much more than measure everything”. Before the meeting, I was not very familiar with the Right-Based Approach framework. I learned that PBF programs tend to emphasize only some rights to Sexual and Reproductive Health (SRH) services: availability, accessibility, acceptability. This indicates the need to add a focus on right to equity, non-discrimination, empowerment, participation, accountability, etc. In the effort to improve FP quality measurements, our next steps should include an analysis of existing indicators in PBF to identify sexual and reproductive rights that are not currently fostered.
As for the ToC of PBF, we all came to an agreement that we should recognize the multiplicity of channels in a PBF intervention and our relative ignorance on which one leads to the greatest impact. Both our action and research should better recognize this multiplicity of channels. This is not neutral as for our choice for indicators : should they capture the conversion of the health facility staff to quality improvement or outcomes for instance?
Use of new technologies to improve quality of care
On day 2, I appreciated the presentation by BlueSquare on various existing possibilities to improve quality data collection and analysis using new technologies. It is actually not a secret to anyone that technology is the cornerstone to measure results. It was interesting to learn that quality data can as well be integrated in the national information system and be reported from the source using devices like smart phones and tablets.
A few other innovative ideas were discussed as well, for instance the possibility to include the equity tool in a dashboard to measure socio-economic status of routine patients and to cover preventive and curative quality services of care, health staff, infrastructure, equipment, water access, etc. What really captured my attention, and most likely that of the majority of the participants was the geo map application that provides the ability to measure the time-distance of patients to health centers. I found the idea interesting, considering the long-standing catchment area population challenge that many developing countries are still facing. However, it was worth noting that there is a set of prerequisite work and requirements necessary in order to apply these new technologies in our systems. I learned that integration should be done gradually in order to implement an efficient data system that fully benefits from new technologies.
Family Planning Indicators
So here we are at the stage when we had to brainstorm about measurable FP indicators. Discussions were mainly oriented towards identifying areas and dimensions that stand out, suggesting different views and perspectives. Together, we identified six areas where progress could be made by PBF programs in terms of measurement and incentivization. Two can be categorized as determinants of quality of care: (1) staff knowledge & competencies (e.g. does the staff know how to coach the users on FP options?) and (2) structural inputs (e.g. no stock-outs of contraceptives). Two can be categorized as key components of quality services: (3) the patient experience (e.g. has the user the opportunity to make a fully free choice?) and (4) the outcome (e.g. reduction of FP discontinuation). Eventually, two are a bit broader: (5) equity (e.g. what does PBF do for groups, like adolescents, not using generalist health centres?) and (6) human rights (e.g. how does PBF fair from a rights-based approach perspective?).
These six areas were discussed in parallel groups. Let me just pick four of them. Regarding indicators addressing the competence and knowledge of the providers, I learnt that having been trained in delivering FP services is far from a sufficient condition for quality service. One constraint is that for some methods, one needs a sufficient volume of practice to attain a good level of care. Another issue with FP is providers’ interpersonal skills; they are key to ensure that clients make an informed choice as far as FP is concerned. For PBF programs, the challenge is how to measure this dimension, as it does not rely on medical records but rather on a direct observation.. We learned from social franchising and vouchers programs that for their certification of providers, they do some direct observation. This seems to me a direction that could be further explored in PBF program.
Myself, I participated in the group work dedicated to outcome indicators. We divided them into short term (quarterly), long term (2 to 3 years) and very long term. There was a consensus that most of outcome indicators are population based and measured on long term basis, hence they may not be the best ‘clients’ for PBF checklists. However, it is possible to pay for outcome indicators at the individual level, e.g. continuation, adaptation uptake, client satisfaction (e.g. waiting time, availability of medicines prescribed at the facility X). We agreed that the traditional PBF client survey consisting of Yes/No questions has its limitations. For instance, a client may think that waiting for 2 hours to see a health professional is reasonable when asked to give their judgment on the waiting time X. The questions need to be strengthened to ensure effectiveness and data accuracy.
In terms of equity, some PBF programs incentivize health providers to pay attention to certain categories of people (e.g. indigents). It would be interesting to develop mechanisms encouraging health facilities to cater to the needs of some other minority groups, such as the disabled or adolescents. I like a lot the idea but the challenge will rely on the system to categorize and identify these groups within the population.
The structural indicators were also discussed in length, e.g. training, availability of equipment and commodities, etc. It was interesting to learn that issues relating to stock out and autonomy need to be context specific as countries health system widely differ. In some settings, the sanction for stock-out should maybe fall on somewhere than the health facility (e.g. on some higher level of the supply chain). We know that today, structural indicators represent a significant portion of FP indicators (see this comparison in six countries). There is a need for more research to investigate to what extent structural indicators affect outcomes. We heard about interesting work done by a research group on this.
Future steps
In conclusion, the discussions on PBF and FP were quite rich and intense! I had hoped for more time to discuss the issues at length. Nevertheless, the workshop happened to be an eye opener for me with regards to quality issues, more specifically around FP. It was a revealing experience to exchange views with experts.
Despite the significant progress, we still have a long way to go! A lot of work needs to be done to define FP quality of care measurement and improve standardization. Moving forward, as one of the participant of the Antwerp meeting on PBF and FP, I will surely continue to engage in this task. I look forward to the next steps on Collectivity. Ultimately, I will utilize the acquired knowledge to better advise ways of improving the Lesotho quality measurements tools.
