Intrauterine Contraceptive Device (IUD) in Gujarat and Rajasthan - Transforming Service Delivery of and Access to
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Transforming Service Delivery of and Access to Intrauterine Contraceptive Device (IUD) in Gujarat and Rajasthan Experiences of Expanding Access to Intrauterine Contraceptive Device Services in India (EAISI) Project
Vision
A gender-equal world where all people
achieve their sexual and reproductive
health and rights.
Mission
To implement high-quality, gender-
equitable programs that advance
sexual and reproductive health and
rights.
Values
As we work toward our vision, our strategy and our
programs are built on the following values:
•
Diversity, equity, and inclusion
•
Evidence and innovation
•
Engagement and collaboration
•
Leadership and learning
•
Organizational effectiveness
2
Our efforts on
strengthening internal
capacities of public
health systems
combined with focus
on quality of services
delivered has created
sustainable demand for
contraceptive services.
India is home to 340 million women who are on the threshold of reproductive years
and have continuous need for family planning services. Family planning has been
widely recognized as one of the most cost-effective solutions to achieve Universal
Health goals, provided women are given the right agency and knowledge to exercise
their rights. Thus, access to quality family planning is not only a human right but
also extremely important for individual as well as societal well-being, and for the
nation’s development as a whole.
EngenderHealth is a leading global health organization working to improve Sexual
and Reproductive Health and Rights (SRHR) for women and girls in the world’s
poorest communities. EngenderHealth, through EAISI project, empowered facilities
as well as communities in Rajasthan and Gujarat with knowledge, skill, and access to
provide SRH services including high quality counselling.
We made inroads to transform even the remotest public health facilities by building
the capacity of providers and enabled them to provide quality family planning
services. We strengthened the systems to sustain quality services through supportive
supervision and created demand for services by mainstreaming professional
counseling into public health.
Our mission was set out with a greater goal of transitioning out the facilities in a way
that the government continues to own and support these facilities, even after the
project ends.
Dr. Sunita Singal
Technical Director & DCR India
Country Office
3
Maternal Mortality Systemic Challenges Improving Access to
IUD Services
An estimated 35,000 women The lack of a
died of pregnancy related trained and skilled Working across public
events in India in 2017. This is workforce, supportive health systems, with a focus
the largest number of maternal infrastructure, and on the most remote parts
deaths globally. Additionally, systems to monitor of Gujarat and Rajasthan,
two-thirds of Indian women and respond to the EngenderHealth provided
have an unmet need for family demands of clients technical assistance to
planning in their first year seeking family improve access to quality
postpartum. planning services IUD services and ensure they
Source: Levels and trends 2000 to 2017 remains a challenge are as available as other
(WHO, UNICEF, UNFPA & World Bank report) in India. contraceptive methods.
4
Fig 1 EngenderHealth enabled providers to reach
Results from the
EAISI Project 490,135 4,34,437 8,580
(2014-2019) women with IUD selected selected post
services, of which: postpartum IUD abortion IUD and
47,118
selected interval IUD
Gujarat and Rajasthan are among the of India, EngenderHealth initiated
six priority states identified by the Expanding Access to IUD Services in
Government of India for strengthening India (EAISI) project in 2014 in these
postpartum family planning services two states. EAISI aimed to promote
to counter high incidence of maternal healthy timing and spacing among
and infant morbidity. In collaboration women with unmet family planning
with the Ministry of Health and Family needs by increasing awareness and
Welfare and the Government access to IUDs.
Fig 2
Key Highlights Rajasthan
from Gujarat Phase I
and Rajasthan 138 facilities from 25 districts
Phase II
92 facilities from 8 districts
Gujarat
Phase I
38 facilities from 25 districts
Phase II
91 facilities from 8 districts
Gujarat and Rajasthan Facilities
State Districts Facilities
Rajasthan 33 230
Gujarat 33 129
http://mmr2017.srhr.org/
Total 66 359
5
India has a large population between public health facilities through
the ages of 19 and 24 year old. training service providers to deliver
This group, in the prime of their high quality family planning services,
reproductive years is in dire need strengthening the systems to sustain
of contraceptive services. While quality services, and creating demand
public health facilities provide by mainstreaming professional
family planning services, they do not counseling into public health efforts.
include all methods and lack effective
counseling, a barrier to allowing We set out on a mission to prepare
clients to make informed decisions. intervention facilities that could
easily transition ownership of
Through the EAISI project, programming to the Governments of
EngenderHealth provided expertise on Gujarat and Rajasthan. By the end of
Sexual and Reproductive Health the project, we were able to confirm
(SRH) to empower facilities and approximately 87% facilities as self-
communities in Gujarat and Rajasthan sustainable. Thanks to the continued
with the knowledge and skills needed support of both state governments,
to provide SRH services including EngenderHealth was able to foster
rights-based counseling. We helped sustainable improvements in family
transform even the most remote planning services.
By project end,
approximately
87%
of facilities were
self-sustainable.
601 The Trajectory Towards Transformation
Phase
I
June 2014 – March 2017
Data had revealed an inequitable from the Large Anonymous Donor
EAISI built upon distribution of contraceptive (LAD) supported implementation of
the Government’s service availability, particularly the EAISI project in two phases. In
success efforts with respect to postpartum and 2014, EngenderHealth introduced
to increase postabortion family planning, activities in 38 facilities across 25
institutional with more availability in urban districts in Gujarat and 138 facilities
deliveries, which areas. The project built upon the across 25 districts in Rajasthan.
has increased to Government’s tremendous success Activities during this period focused
75%
in increasing institutional deliveries, on increasing demand for and
which have risen to 75% in semi- improving availability, quality,
in semi-urban and urban and rural facilities in the and sustainability of IUD services,
rural facilities. target states, as most women had including Postpartum IUD (PPIUD),
an unmet need for postpartum Postabortion IUD (PAIUD), and
contraception. A generous grant Interval IUD (IIUD) services.
7Fig 3 Our guiding principles for EAISI included leveraging existing health systems and
Key Strategies platforms as much as possible and introducing local innovations to strengthen the
cultural, infrastructural, and administrative environment. The strategies we used were:
PROVIDE technical BUILD the TRAIN providers
assistance to state capacity of to ensure rapid
and district health the districts scale up of quality
systems to improve to provide IIUD, PAIUD, and
access of IUD quality PPIUD services.
services. trainings to
providers.
SUPPORT facilities in
districts to become
IMPROVE
self-reliant in improving
SAFEGUARD knowledge of
service quality by
clients right and SRH and cultivate
strengthening
informed choices demand for
monitoring,
through skill-based services.
supportive supervision,
counseling.
and evidence-based
decision making.
8Phase
II
In this phase, we April 2017 – March 2020
expanded to The second phase of the project This phase focused on building
183
facilities, thereby
was designed to facilitate the
institutionalization and sustainability
internal training capacities,
supporting the Government of India’s
of EAISI interventions. efforts in improving services in
ensuring coverage high caseload facilities, improving
of all health During this period, we also expanded counseling services, activating
facilities in our two to 183 facilities (91 in Gujarat and 92 in quality circles to ensure facility level
target states. Rajasthan), thereby covering all health monitoring of quality of IUD services,
facilities in the two states. and strengthening data management.
9The EAISI project EAISI graduated EAISI completed By the end of the project,
313 95%
significantly approximately
86.7%
increased the
availability and facilities (84% of of expected trainings.
100%
uptake of IUD and all intervention of intervention facilities were
other family planning facilities) to operating quality circles,
services by building state ownership of trainers were deemed indicating continued efforts
the capacity of by the end of competent to deliver to improve the quality of
service providers in the project. IUD services. Further, family planning counseling,
99.7%
of intervention
district trainers are
continuing to conduct
robust record-keeping, and
institutionalized project
interventions within the
IUD trainings using
facilities. Government resources. public health system.
1002 The Keystones of Transformation
Building on Health Staff Task Module and Practicum (SLIM-P)
Shifting training approach.
Staff nurse and Auxiliary Nurse a. Structured On-the-Job Training
Midwives (ANMs) conduct most (SOJT):
facility deliveries. Aligning with the Most peripheral health facilities are
government of India’s vision for task understaffed and it is difficult to get
shifting, which supports the provision providers out of their facilities to
of postpartum family planning participate in trainings. Therefore,
services to staff nurses and ANMs, EAISI conducted Structured On-the-
EAISI trained and supported nurses to Job Trainings (SOJTs) in intervention
deliver quality PPIUD services. We also facilities. Benefits of SOJTs include:
trained one doctor in each facility to 1. Facilities are saturated with trained
support PPIUD insertions for complex providers. This is especially
cases, while staff nurses and ANMs beneficial for the provision of
focused on routine cases. PPIUD and PAIUD services.
As most clients opt for an IUD
EAISI brought an Innovative Training immediately after delivery or
innovative training Methodology abortion, 24-hour, 7 day-a-week
methodology: services need to be available.
Structured On- EAISI contextualized our training
the-Job Training approach and applied a mix of three 2. Providers learning IUD service
to intervention provision skills in their own
innovations: Structured On-the-Job
environment, thus helping build
facilities. Trainings; Centralized Trainings,
their competence and confidence
and the Self-Learning Instructional
quickly.
113. Other services are not hindered by untrained providers or with newly
staff leaving their posts for long transferred, untrained providers), EAISI
periods of time. offered centralized trainings in district
facilities. These providers received
EngenderHealth’s mobile clinical additional support from previously
team conducted trainings in trained colleagues upon returning to
the intervention facilities using their home facilities.
Government of India’s approved
five-day model for IIUD, PPIUD, c. Self-Learning Instructional Module
and PAIUD service delivery. In and Practicum (SLIM-P):
addition to extensive practice with EAISI piloted application of
anatomical models, we required all EngenderHealth’s SLIM-P approach in
providers to practice with clients few facilities with very few untrained
during the training or soon thereafter. providers. This approach, which was
The training package also included more cost-effective and time-efficient
infection prevention sessions to than sending a full training team to
improve the quality of family a centralized facility, allowed one
EAISI trained
planning services for the entire provider to attend a centralized training
2,793 facility staff. and then, with support from the district-
level, mentored colleagues in their
providers to deliver b. Centralized Trainings: facility.
IUD, PPIUD, and For intervention facilities with fewer
PAIUD services. staff in need of training (for instance, In total, 2,793 providers have completed
facilities with a mix of trained and EAISI IIUD, PPIUD, and PAIUD trainings.
12Integrating Effective recognize and address gender and
Counseling with Service sociocultural barriers to family
Delivery planning uptake, including myths
and misconceptions related to
Effective family planning counseling various contraceptive methods. In
is paramount to protecting client’s total, EAISI trained 5,021 service
rights, improving service quality, providers to deliver effective
and ensuring client satisfaction, all counseling.
of which contributes to continuation
rates. However, most facilities 2. Using a localized, facility-based
lacked the basic requirements for approach to create infrastructure
quality counseling: trained human for family planning counseling:
resources, adequate infrastructure, and EASI used local resources to
institutional capacity to sustain the establish spaces for counseling
services. EAISI thus focused on three with auditory and visual privacy
key strategies: and created job aids for counselors
1. Task shifting to ensure service to use with clients.
availability: Where family
planning counselors were 3. Collaborating with the State
not readily available, EAISI Institute of Health and Family
trained staff nurses to provide Welfare (SIHFW): EAISI
EAISI trained family planning counseling. collaborated with SIHFW to
802
We trained nurses using conduct online orientations for
EngenderHealth’s REDI (Rapport 400 facilities across 33 districts.
service providers Building, Exploring, Deciding,
in effective and Implementing) approach. All trainings were gender-neutral and
counseling. The REDI module focuses on EAISI offered equal opportunities for
enhancing the soft skills needed to all to participate in the trainings.
13Focusing on Client’s Key Program Activities
Satisfaction:
a. Integrating IUD Services into
EAISI built capacity in client-centered Primary Healthcare:
service delivery in order to improve EAISI sought to increase IUD
overall client satisfaction. As a result, the uptake by integrating with primary
project demonstrated increased uptake healthcare services. The project
in family planning services in intervention supported 143 facilities in offering
facilities. PAIUD services, 95 facilities in
offering PPIUD services, and 33
facilities in offering IIUD services.
Further, all 358 intervention facilities
EngenderHealth conducted a survey to measure
are now providing PPIUD and IIUD
client satisfaction at participating facilities following
services and 227 of those facilities
training interventions. Clients surveyed included
are also offering PAIUD services. As
those aged 18 to 24 (47.7%), 25 to 30 (45.6%), and
a result, PPIUD insertion rates have
older than 30 (6.6%).
increased from 17.5% to 23.9% and
PAIUD insertion rates have increased
79.3% 100%
of women of women decided to
from 3.9% to 14.3%. In total, 490,135
clients have adopted an IUD.
expressed adopt family planning either
satisfaction with alone (58%), in conjunction
the service they with their partner (33.3%),
received at the or with their service Fig 4
95
Number of facilities PPIUD services
health facilities. provider (8.3%).
Facilities
and Services
89.2% 97.6%
33 IIUD services
Supported by facilities
EAISI
felt that auditory are informed about
privacy was possible side effects 143 PAIUD services
facilities
maintained during of IUD adoption and
conversations 61.9% are aware of
with the service protocols in case any
358 PPIUD and IUD services
provider. side effects manifest. facilities
95.2%
out of which
of those with questions
felt they were given the 227 PAIUD services
opportunity to freely facilities
ask the service provider
any queries they had.
Total 4,90,135 women adopted IIUD, PPIUD, PAIUD services
14Fig 5
Improvements in family planning counseling trends for IUD insertions in the postpartum,
Family Planning
postabortion, and interval periods.
Counseling
Touch Points
Data collected across the field illustrates how clients were
Postpartum
counseled about family planning at multiple touch points.
18%
97.2% of clients who chose to adopt Postpartum Intrauterine
Devices received counselling at least once, while 10.3%
19% ANC
received counseling two or more times (e.g., during ANC/
63% Early Labour/PNC).
Early Labor
b. Ensuring Quality through Flexible patients quickly, thereby easing their
Supportive Supervision Visits and workloads.
Using Local Resources to Address
Challenges: EAISI also advocated for the inclusion
EngenderHealth built a system of family planning counseling
of accountability into the health 1
information in Mamta Cards . This
facilities by introducing clinical enabled improved monitoring of
monitoring and coaching visits clients receiving counseling on various
using standard checklist to record contraceptive methods.
observations. These visits were used
to assess clinical and counseling skills d. Improved client follow-up:
of providers, facility readiness, quality Client follow up is a measure of
The focus of of counseling, data digitalization, quality of services. It helps to address
each visit was to record keeping, reporting, and stock any challenge that the client may
immediately management. The focus of each be facing- medical, psychosocial or
resolve visit was to mitigate any challenges emotional. The client follow up was
immediately using local resources, extremely low at 0.4% in the initial
challenges
including through engaging district period of project. As a result of project
using local
interventions in total, 71,354 clients
resources. health officials to conduct those visits,
received follow up consultations (92%
wherever possible.
of whom visited health facilities in
person). The remaining 8% received
c. Sustainability of Effective: follow-up calls via telephone. The
Counseling Services EAISI trained follow-up data revealed that 73%
family planning counselors, staff of clients reported no complaints,
nurses, and ANMs to provide high- 21% had their IUDs removed, 1%
quality counseling services. We also reported expulsion, and 5% had other
provided job aids to help counselors miscellaneous issues.
deliver medically accurate, clear
messages when discussing family 1
Mamta Card, or Mother and Child Protection
Card, is a tool instituted to disseminate positive
planning choices. These job aids also health practices towards the wellness of pregnant
helped providers attend to more women, young mothers, and children.
15Fig 6
Percentage of Deliveries/Abortions
23.9
PPIUD and PAIUD 21.7 21.6
Uptake from 2014 20.2
to 2020 17.5 17.1
16
15 14.3
12.8
10.3 10.2
9.2
3.9
Percentage of PPIUD insertion
Percentage of PAIUD insertion Baseline Apr 17-Sep 17 Oct 17-Mar 18 Apr 18-Sep 18 Oct 18-Mar 19 Apr 19-Sep 19 Oct 19-Feb 20
The percentage of women who chose multiple partner meetings with
to adopt a PPIUD (out of the women these three institutions to support
who delivered at an intervention coordination and collaboration.
facility) increased from 17.5% during These meetings served as a platform
the baseline period to 23.9% during for representatives from all these
this reporting period (Figure 6). agencies to share experiences and
learning over the course of the project.
e. Improved Outcomes through EAISI also developed software to
Evidence-Based Decision Making, capture family planning statistics
Collaboration and Coordination: (including IUD service and client
The EAISI project is implemented satisfaction data). All partners used
by EngenderHealth in partnership this software to track project results.
with Ipas Development Foundation
(IDF) and Jhpiego. The Ministry of EngenderHealth introduced method-
Health and Family Welfare organized specific IUD insertion registers and
16follow-up registers at intervention the family planning program together
facilities. By the end of the project, with the district officials.
99.7% of facilities demonstrated
completed insertion registers and In appreciation of these efforts,
68.8% demonstrated completed EngenderHealth was felicitated at
follow-up registers. The data collected World Population Day celebration in
helped state and district officials, the district of Dungarpur in Rajasthan.
facility in-charges, and service
providers make decisions to improve g. Enabling System Self-Sufficiency:
family planning service quality. Ensuring high-quality clinical
delivery of IUD services requires
f. Reducing Inequities in the continuous training for service
Provision of Service Delivery: providers, as providers are often
In districts with particularly transferred to other departments.
poor family planning uptake,
EAISI supported the respective EngenderHealth created a pool
State Governments to scale up a of master trainers at the district
comprehensive family planning and block levels and trained these
package in the selected districts. This master trainers in the clinical aspects
package included an orientation of IUD services and key teaching
for frontline workers, assistance methodologies. We also provided
to district officials in planning for these master trainers with training
family planning service delivery in all tools, such as anatomical models and
facilities, and support for monitoring teaching aids.
17Fig 7 Method-Mix Comparison
Comparison of (Apr’ 2015 - Sep’ 2015 & Oct’ 2019 - Feb 2020)
the Contraceptive 100%
Method-Mix (%)
32.4 38.2
IUD
Female sterilization
19.6%
Male sterilization
MPA
44.8 Condom
23%
OCP
24.3% 5.6
2.3
8.9
0%
Apr’ 15-Sep’ 15 Oct’ 19-Sep’ 20
18EAISI focused on improving the h. Institutionalization and
training skills as well as the skills Sustainability of Quality IUD
with which these master trainers Services:
would conduct follow-up site visits to A key contribution of the EAISI
the participants they train. We used a project was the integration of quality
cascade model, through which each counseling into family planning
master trainer provided training to services. At the request of the State
peer member and co-workers. Government in Rajastan, we helped
enhance the program through the
As a result, EAISI helped establish a following:
pool of 190 in-house trainers within
the public health system. By the • EngenderHealth developed
end of the project, district trainers a three-hour, comprehensive
were conducting trainings and had counseling curriculum, complete
cascaded learning to 373 providers. with preparatory materials,
Further, health departments assumed including a pretest questionnaire.
ownership of the trainings and
have allocated resources for venues, • EngenderHealth collaborated
trainers, and training centers. with SIHFW to organize a video
19conference on family planning group size will allow every member
counseling in 2019 to provide to actively participate. Thanks to a
additional support to 500 high guideline from the State requiring
caseload facilities. the formation of Quality Circles to
monitor and review health programs,
EAISI successfully sensitized the most of the districts and facilities
local health system (at state, district, had formed Quality Circle; however,
and block levels) on the importance functionality was a challenge. EAISI
of counseling. The Government now facilitated Quality Circles at state,
considers counseling an important district, and facility levels to ensure
aspect of family planning service the monitoring of quality of IUD
delivery and recognizes its role services. We also revived district
in clarifying common myths and quality assurance committees to
misconceptions. As a result of this monitor service quality.
intervention, EngenderHealth
collaborated with the Government of Functional Quality Circles yielded
Rajasthan in planning and conducting significant improvements in
additional trainings on IUDs as well addressing facility-level knowledge
as injectable contraceptives, such as gaps. By the end of the project, we
Antra. recorded nearly 87% of intervention
health facilities operating their own
i. Quality Circles: Quality Circles.
EngenderHealth recommends
By the end of the forming Quality Circles comprising a j. Improved Infection Prevention (IP)
project, nearly medical superintendent, paramedical, and Waste Management Practices:
87%
and other support staff (depending EAISI trained service providers on
on the size of the institution being infection prevention (IP) and waste
of intervention monitored) to review service quality management practices to ensure
health facilities periodically at various health facilities quality of services. Our IP trainings
were operating and institutions. We suggest that the emphasized key components of IP
their own Quality optimum number of members in for family planning, such as wearing
Circles. Quality Circle to be four or five, with sanitized gloves, sterilize instruments,
the philosophy being that this small using antiseptic for cervix cleaning,
20Fig 8
100
100
96.9
Improvement in
FP Counseling
81.3
Availability of infrastructure for FP counseling
Service Quality Information on FP methods displayed
(% of facilities) Clients recieved unbiased counseling tailored to their needs
Clients allowed and encouraged to make their own decisions
and washing hands before and after level to collaboratively identify and
EAISI trained IUD insertion. The training also implement solutions.
5,706
included guidance for preparing
bleaching solutions, segregating Factors contributing to our success
facility staff in waste using color-coded bins, and include:
IP and waste managing spills. We delivered these Documentation and knowledge
management trainings to all health facility staff, sharing.
practices. including laboratory staff and Safai Rigorous follow up at various
karamcharis, for a total of 5,706 levels.
staff trained. Motivation of staff and
stakeholders in sustaining and
EAISI provided IP and waste scaling operations.
management training to 82% of
intervention facilities. Of those
facilities, 100% demonstrated
adherence to at least some IP practices
(such as the no-touch technique) and
95% demonstrated use of an autoclave
or boiler for sterilizing equipment.
k. Leadership and Project
Management:
EngenderHealth’s approach to
implementing and institutionalizing
the EAISI approach resulted in
significant positive results.
Our team continuously reviewed and
reflected upon project activities to
identify any gaps hindering impact.
We worked with service providers at
the facility level and decision-makers
at the state management and policy
2103 Key Challenges
Understaffed facilities and overworked staff: Facilities have far fewer
doctors and nurses than needed. This problem is further compounded
in facilities that are situated far away from cities, thus exacerbating the
inequities that clients experience in those areas.
Frequent changes in leadership at the State Government level:
Shifts in priorities and implementation strategies, resulting from
frequent leadership changes in both States, affected program delivery.
EngenderHealth staff oriented new officials on occasion to continue to
ensure Government support for project activities.
Intra and inter facility attrition of trained service providers: Trained
service providers were often transferred to non-family planning wards and
departments outside the intervention facilities. This resulted in a continual
need for training to maintain the necessary pool of trained providers, which
is not cost-effective.
Abortion service are not universally and consistently available:
The lack of available comprehensive abortion care services contributed
considerably to the limited uptake of PAIUD (14%).
2204 Key Learnings
Task shifting of IUD service provision is practical and needs to be
undertaken on a large scale: Through the EAISI project, we demonstrated that
nurses can be effective family planning counselors and service providers if
they receive comprehensive training and are supported by doctors within
their facilities.
Integrating postpartum family planning with primary healthcare is feasible
and does not dilute service quality: In addition to recognizing that primary
healthcare services are critical for ensuring universal access to family
planning, EAISI demonstrated satisfaction among clients receiving family
planning services from primary healthcare facilities.
Scaling up postabortion family planning requires integration of family
planning counseling within comprehensive abortion care: We were unable
to achieve desired results in increased uptake of PPIUD due to the limited
availability and quality of abortion services. Improving PPIUD access,
quality, and uptake will require similar improvements in abortion care
services.
Self-sustainable facilities: By using a graduation approach, EAISI helped
to improve resource allocation, strengthen documentation practices, and
enhance IUD clinical and counseling skills among providers. The graduation
process also supported institutionalization of the program approaches by
engaging Government officials, facility in-charges, and other stakeholders in
participating in periodic reviews and supportive supervision visits.
23EngenderHealth First Floor, Plot Number 18, Ramnath House Yusuf Sarai Community Centre New Delhi-110049, India www.engenderhealth.org © Photo credits: Teki Vishy/CRC
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