STAKEHOLDER MEETING

Revitalizing the IUD in [insert

country name]

City, Country
Date
(Note: Photos have been removed to keep the file size manageable.)

Insert MOH logo Insert USAID logo Insert Project logo

 Introductions

 As we go around the room, say:

– Your name
– Your position
– Where you work
 Meeting Objectives

 Discuss the context for IUD services and

family planning within Country
 Reach consensus on importance of the
IUD within FP method mix and the need to
improve the utilization of the IUD
 Determine desired performance for IUD
services
 Agenda

 Welcome and Opening Remarks

 Current situation of FP and IUD in Country
 Questions for Reflection
 Break
 Overview of the PI Approach and PNA
 Lunch
 Desired performance for IUD services
 Questions and Next Steps
Note: The slides shown are taken from a PNA conducted in Mali.
The information presented would need to be adapted for
each country’s particular context and include as much IUD data
as is available. You can decide how many RH areas to include.

Environmental Scan: Country

 Questions for Reflection (1)

 What is your impression of the use of family

planning in Mali? For example,
– What methods are most used in Mali? Least
used? How about the IUD?
– What has happened with the IUD?—was it used
before and is declining, or has it never been
popular?
– What are the reasons for this?
 Mali: General indicators

Total midyear population 12,291,529 (2005)

Population growth rate 3.3% (2004)
Total fertility rate 7.0 (2004)
Married women of 2,163,000 (2000)
reproductive age (MWRA)
Percentage of population 49 (2004)
under age 15
Physicians/1000 people 0.1 (1996)

Data source: U.S. Bureau of the Census, International Data Bas, 2005; Population Reference Bureau, http://www.prb.org/ TemplateTop.cfm?
Section=Data_by_Country&template=customsourc…, cited on 2/23/2005; UN/ESA World
Contraceptive Use, 2003; World Bank, World Development Indicators Database, http://devdata.worldbank.org/external/dgcomp.asp?rmdk=110&smdk=473886&w=0, cited on 2/23/2005
 Mali: Family planning

Among MWRA, 15-49 yrs

Knowledge of any method 77.8%

Knowledge of any modern method 75.6%
Knowledge of female sterilization 32.5%
Knowledge of Norplant 25.7%
Knowledge of IUDs 21.1%
Knowledge of male sterilization 12.6%

Sources: Demographic and Health Surveys, Mali, 2001.

 Mali: Family planning
Among MWRA, 15-49 yrs
CPR (any method) 8.4%
181,692 couples
CPR (modern method) 5.8%
125,454 couples
Total demand for FP 36.6%
791,658 couples
 Demand to space 25.9%
560,217 couples
 Demand to limit 10.7%
231,441 couples
Sources: Demographic and Health Surveys, Mali, 2001; UN/ESA World Contraceptive Use wall chart, 2003; ORC Macro, 2004. MEASURE
DHS+ STATcompiler. http://www.measuredhs.com, February 23, 2005.
 Mali: Family planning
Indicator Mali 2001 Senegal Guinea Mauritania
1997 1999 2000/2001
CPR (any 8.4% 12.9% 6.2% 8.0%
method)
CPR 5.8% 8.1% 4.2% 5.1%
(modern
method)
Demand to 25.9% 33.5% 19.6% 28.1%
space
Demand to 10.7% 14.3% 10.8% 11.5%
limit
Total 36.6% 47.8% 30.4% 39.5%
demand for
FP

Source: MEASURE DHS+ STATcompiler. http://www.measuredhs.com, May 10, 2004.

 Mali: CPR among MWRA

8
7.0
6
4.5
4
1.3
2
0
1987 1995/96 2001

Pill IUD
Injections Condom
Female sterilization Male sterilization
Implants Diaphragm/foam/jelly

Source: MEASURE DHS+ STATcompiler. http://www.measuredhs.com, May 10, 2004.

 Mali: CPR among MWRA
Contraceptive Prevalence
by Region by Year

25
20
15
10
5
0
1995/96

2001

1995/96

2001

1995/96

2001

1995/96

2001

1995/96

2001

1995/96

2001

1995/96

2001
Kayes Koulikoro Sikasso Segou Mopti Gao/Kidal/ Bamako
Timbuktu

Pill IUD Injections

Diaphragm/foam/jelly Condom Female sterilization
Implants Foam or jelly

Source: MEASURE DHS+ STATcompiler. http://www.measuredhs.com, February 25, 2005

Mali: Source of FP supply

Modern methods, MWRA, 15-49 yrs

100%

80%

DK/Missing
60% Other
Other private
40% Private medical
Public

20%

0%
er t ll lly
st IU
D ec Pi m gm e
In
j do a j
m on hr or
Fe C iap
am
D
Fo

Data source: MEASURE DHS+ STATcompiler. http://www.measuredhs.com, February 25, 2005

 Mali: FP snapshot – attitudes

 2001 DHS
– Women
• Respondent and spouse approve: 29.7%
• Respondent approves, unsure about spouse: 22.2%
• Respondent unsure: 7.2%
•
– Men
• Respondent and spouse approve: 41.5%
• Respondent approves, unsure about spouse: 20.5%
• Respondent unsure: 7.9%

Data source: MEASURE DHS+ STATcompiler. http://www.measuredhs.com, March 2, 2005

 Mali: FP snapshot – attitudes

 Guèye and Konaté (Draft, 2004)

– Women’s approval of FP: 53.0% (26.6% were
unsure)
– Men’s approval of FP: 62.6%
– Reasons for disapproval of FP
• Religion
• Side effects (e.g. sterility, menstrual problems,
nervousness)
• Dislike of methods
• Desire for children
 Mali: FP snapshot – attitudes

 Konaté, Djénépo and Sidibé (June 2004)

– Reasons for not using modern methods
• Opposition from spouse and/or family
• Lack of knowledge re: modern methods
• Religion
• Rumors
• Lack of funds
• Lack of a service delivery structure
 Mali: FP snapshot – IUDs
 EngenderHealth 1994 evaluation of a Post Partum IUD
(PPIUD) program, Hamdallaye Maternity, Bamako
– Who were the PPIUD users?
• More likely to be married
• Less likely to want more children
• Among those wanting more children, more likely to want a
longer spacing time
– IUD acceptance associated with number of living children
– PPIUD users were more likely to have had a method suggested to
them during their prenatal visit
– Reasons for not choosing PPIUD: desire to wait before choosing
FP and preference for other method
– Nearly all clients (97%) were satisfied: convenient lack of
interference with breastfeeding, and lack of side effects were cited
as reasons.
Mali: Projected number of LTPM users
(All women)
In 1,000s
350
323
300

250

200
187
150

100
92 90
50 56
24 32
15 6
0 1 2 4
2000 2005 2010 2015
Female Sterilization Use Male Sterilization Use IUDs

Sources: EngenderHealth, Contraceptive Sterilization: Global Issues and Trends, 2002; Ross, Stover and
Willard, 1999.
 Sustainability
Average Cost (US$) to Health Care System Per Year of
Protection, by Method (Mombasa, Kenya)

IUD
Vasectomy
Female Sterilization
Pills
Norplant
Depo Provera
Condoms

0 5 10 15 20 25 30 35
US$

Source:EngenderHealth, 2002; Janowitz, Measham and West, 1999.

 Mali: HIV/AIDS
HIV/AIDS Snapshot
 1.9% adult HIV prevalence (2003)
– 140,000 adults and children are living
with AIDS
– 12,000 AIDS deaths in 2003
 90.3% of MWRA have ever heard
of AIDS
 17.7% of MWRA know of no ways
to avoid AIDS

Data source: UNAIDS, 2004 Report on the Global AIDS Epidemic, as cited in UNAIDS country profile, cited March 1, 2005
 Mali: HIV/AIDS
HIV/AIDS Snapshot: Current policies and programming
 Policies
– New National Multisectoral HIV/AIDS Policy
– National AIDS Control Programme
 Active groups
– People living with HIV
– Locally elected officials
– Parliamentary network
 Services for prevention and treatment
– 15 VCT centers in Bamako
– In Bamako, health centers and 1 hospital with PMTCT services and 3 health
centers with antiretroviral treatment services
– Peer education, social marketing, BCC activities through NGOs

Data source: UNAIDS, 2004 Report on the Global AIDS Epidemic, as cited in UNAIDS country profile, cited March 1, 2005
 Mali: Maternal health

 Maternal mortality ratio is 588 per 100,000

live births (DHS 2001)
 Estimated maternal deaths is 6,800 per year
 Maternal morbidity is difficult to assess
– Out of 2,000 villages near Mopti, half have at least
one woman living with fistula
– Women with fistula are often hidden by their family
 FP seen as key in reducing maternal mortality
and morbidity
Sources: WHO, Revised 1995 Estimates of Maternal Mortality, http://www3.who.int/whosis/mm ORC Macro, 2004. Country statistics: Guinea. http://www.measuredhs.com/countries,
February 19, 2004;; Hyjazi & Diallo, 1996.

Sources: WHO, UNICEF, and UNFPA, 2004, Maternal mortality in 2000: Estimates developed by WHO, UNICEF and UNFPA; Doctors of the World, as cited in UNFPA
and EngenderHealth, 2003, Needs assessment report: findings from nine African countries
Questions or Comments?
 Questions for Reflection (2)
Note: These are sample questions for illustration.
 Systemic issues in regards to the IUD:
– What cadre of personnel are allowed to insert IUDs?
– What training do providers receive in IUD insertion and
removal?
– What is the MOH view on the IUD—i.e. what are the
messages they are giving to providers?
– What do the norms and policies say about the IUD?
– What is the national supply of IUD commodities like?
– How well does the national distribution system work?
 What should be done to improve the use of the
IUD in Mali?
 Introduction to the
Performance Improvement
Approach
 What is Performance?

 The tasks that people do and the

results of those tasks
Effort  Performance
 What is Performance Improvement?

 A step-by-step methodology for finding

out what is needed to ensure good
performance, and delivering it
Factors Influencing Performance
Organizational Support: Using Performance
Factors
1. Job expectations
2. Performance feedback
3. Environment and tools
4. Motivation and incentives
5. Skills & knowledge
 Job Expectations

Guidelines,
policies, standards,
procedures,
protocols, and how
these are
communicated to
and understood by
providers
 Performance feedback

How providers find out

how they’re doing,
compared to the
standards.
 Physical Environment

The facilities, supplies, materials, tools

necessary to do the job.
 Motivation/Incentives
Do staff have a reason to perform as they are
asked to perform? Does anyone notice?

--Internal motivation or
external incentives to
perform up to standard.
Knowledge and Skills

 Systems and
interventions to
address how to do a
job.
 Over-Arching Consideration
Organizational Support
The extent to which the organization assures
that all the performance factors are in place.

--Supervision, policies, communication

 “If all you have is a hammer…
everything looks like a nail.”

Lack of tools and

equipment

i n g Lack of knowledge

ain
and skills

Tr
Lack of motivation
Lack of data and and incentives
information
 PI asks
 What performance do we want? (Desired)
 What performance do we have now?
(Actual)
 What is the difference? (Gap)
 Why is there a difference? (Root causes)
 What should we do about it?
(Interventions)
 PI Framework

OBTAIN AND MAINTAIN S TAKEHOLDER AGREEMENT

PNA
DEFINE DES IRED
P ERFORMANCE

CONS IDER
FIND ROOT S ELECT
INS TITUTIONAL IMP LEMENT
CAUS ES INTERVENTIONS
CONTEXT INTERVENTION
P ERFORMANCE
MIS S ION GAP
WHY DOES THE WHAT CAN BE DONE
P ERFORMANCE TO CLOS E THE
GOALS
GAP EXIST? P ERFORMANCE GAP ?
S TRATEGIES

CULTURE
DES CRIBE ACTUAL
CLIENT AND P ERFORMANCE
COMMUNITY
P ERS P ECTIVES

MONITOR AND EVALUATE P ERFORMANCE

 Steps in the PNA Process

 Stakeholder agreement
 Define desired performance
 Determine actual performance
 Analyze root causes
 Select interventions
 A PNA Example
Based on PNA conducted in the Dominican Republic
 Desired: 100% adherence to client-provider
interaction norms
 Actual: 60% adherence to norms
 Gap: 40% of providers not adhering to norms
 Root causes: unclear expectations,
lack of CPI skills, no feedback
 Interventions: CPI norms training,
feedback from clients
Do you have any questions or
comments?
Defining Desired Performance
 Desired Performance

OBTAIN AND MAINTAIN S TAKEHOLDER AGREEMENT

PNA
We are Here
DEFINE DES IRED
P ERFORMANCE

CONS IDER
FIND ROOT S ELECT
INS TITUTIONAL IMP LEMENT
CAUS ES INTERVENTIONS
CONTEXT INTERVENTION
P ERFORMANCE
MIS S ION GAP
WHY DOES THE WHAT CAN BE DONE
P ERFORMANCE TO CLOS E THE
GOALS
GAP EXIST? P ERFORMANCE GAP ?
S TRATEGIES

CULTURE
DES CRIBE ACTUAL
CLIENT AND P ERFORMANCE
COMMUNITY
P ERS P ECTIVES

MONITOR AND EVALUATE P ERFORMANCE

 Define Desired Performance
 Definition: What the organization would like to
see happening
– Program goals
– What the target group should be doing
 Defined by stakeholder consensus using
specific, measurable terms
 Desired Performance Statements
 Identify the performer
 State accomplishments or behavior of the
performer
 Observable
 Measurable
 Can be agreed upon by independent
observers
 Are under the control of the performer
Example: All FP providers counsel FP clients on HIV risk
and prevention according to MOH guidelines.
 Performance Measures…
 Quality
– Does the performance match the standard?
• Provider should follow all 5 steps of FP counseling with each client.
– Does the performance meet the expectations of
clients/community?
• Clinic should achieve 90% client satisfaction on MOH client
satisfaction survey form.
 Quantity
– Does the performance happen as much as it should?
• Each provider sterilizes 4 sets of instruments at the beginning of
each day.
 Performance Measures…

 Timeliness
– Does the performance happen on time?
• The provider should be ready to see clients by 9:00
a.m., every day.
– Does the performance happen as often
as it should?
• The provider should do family planning
counseling with all eligible women and
couples (100% of the time).
Is This a Desired Performance
Statement?
For new family planning clients, the
nurse will discuss all family planning
methods available at the clinic.

Prenatal care providers will fill out 100%

of prenatal history.
Is This a Desired Performance
Statement?
Providers will have access to needed
supplies.

The supervisor will make 1 supervision

visit per quarter to each health facility in
his district.
 Small Group Exercise
:
 We will divide into 3 small groups to define desired
performance from the:
 Client perspective
 Provider perspective
 Institutional or organizational perspective
 Review the written instructions and the background
materials.
 Be sure your Desired Performance Statements are
observable, measurable, and under the control of the
provider.
 Please use 60 minutes, and then we will present and
discuss in plenary.
 Next Steps
 Collect additional data in the field as
part of Performance Needs Assessment
 Conduct Stakeholders Intervention
Selection Workshop on Date:
– Discuss performance gaps
– Analyze root causes
– Select interventions
Do you have any questions or
comments?