Close to community provider’s role in strengthening reproductive health service provision: lessons from an implementation research, REACHOUT Bangladesh

Sushama KananSenior Research AssociateJames P Grant School of Public HealthBRAC University, Bangladesh

Background

• REACHOUT, a five year implementation research project to understand and strengthen the role of close-to-community (CTC) health workers

• REACHOUT Bangladesh, led by James P Grant School of Public Health, focusing on CTC providers involved in menstrual regulation (MR) service

• MR: a procedure to safely establish non-pregnancy up to 8-10 weeks after a missed menstrual period

Background

• Rapid urbanization

• Pluralistic nature of health system

• Shortages of qualified health workforce

• Close to community (CTC) health providers bridges

community to health facilities

Objective

• To understand and strengthen the role of CTC providers involved in menstrual regulation (MR) service

• Phases of REACHOUT Bangladesh

Context analysis(Feb 2013-Jun 2014)

Quality Improvement Cycle 1

(Nov 2014-Jan 2016)

Quality Improvement Cycle 2

(Apr 2016-May 2017)

Implementing partners & Study area

• Marie Stopes Bangladesh

• Reproductive Health Services Training and Education Program (RHSTEP)

• Two urban slum settings in Dhaka

Method

Context analysis

• Poor referral and weak supervision system

Intervention

• Training on facilitative referrals and supportive supervision

• Updating referral cards

Data collection

• Data collection in first phase ended in November, 2015

Intervention

Training• Supportive supervision to supervisors of

correspondent CTC provider• Facilitative referral to the CTC provider

Referral card• Updating referral cards to track referred

clients

Tools for data collection

• In-Depth Interview with client• In-Depth Interview with CTC provider• KII

• Observation in terms of training and supervision

• Continual meeting with organization heads

Key findings

• Improved referral and supervision were recognized by CTC providers

“We have distributed referral card among all referrers and also explain its importance.... The referrer is glad to receive the new referral card, now information is recorded when referrer sends patients to our clinic. Previously we didn’t track it ... Now some changes in referral system… this system is effective for us.” -CTC provider

“After training some positive changes has come in supervision style; like in a meeting if I make any mistake or does something wrong he (supervisor) doesn’t give feedback in front of all. When I came back to the office he gives his feedback. Previously he would give feedback in front of all. I must fall in shame.” - CTC provider

Key findings cont…

• Confident about job responsibilities

• CTC providers were able to identify referral gaps and referral network

“Changes happened after the training, MSV who get the training now they can understand their work…How they approach people they can understand by their own. It is helpful for me… if any issue arises they can manage by themselves. They even don’t need me.” - CTC provider’s supervisor

Key findings cont…

• CTC providers’ information package helped to shape MR client’s decision and save them from clandestine operators

“Yes, there is a change in referring process like I am giving cards to the client…. after counseling (information shared with client) they get proper treatment. She is also safe from the broker plus she doesn’t have to pay extra money.” -CTC provider

Key findings cont…

• Exhibited improved follow-up service

“In your training what I learnt that only referring patient is not complete referral, I have to do follow up also… Now I have the address and contact no of the client so I can follow up with her. Previous system was not like that.” - CTC provider

“She (CTC provider) asked me to come after 15 days for checkup. She gave me contact number if I have any problem, I can call them for suggestion. She also suggested me to come if I have any kind of difficulties.” -MR client

Key findings cont…

• New referral card helped in documenting activities, tracking referred clients and ensuring referral fees to the referrer

“(Referral card is) really effective. (We can check with pharmacists that) yes, you have really referred (the client), whether she visit (the clinic) or not. We can identify that. (It gives) mental satisfaction that I do fieldwork and there is some evidence (of that).” -CTC provider

“This referral system is a good process. Though this is a hardship process but it will keep documents that I am referring a client” –CTC provider

Key findings cont…

• Referral card was positively accepted by client group also

• Trust on the CTC providers was the foremost reason of uptaking referral from the client’s perspective.

“Sister (CTC provider) gave me a slip. It had the address. She also guided me the address and told me to call her if there is any problem”- MR client

Key findings cont…

• Improved the relationship between CTC providers and supervisors

“After they have got supervision training, we have noticed the changes of their supervision style, motivation style which we like most. I realize there is a difference now. As I have been working with him since one year, I know how he supervised before…now after he received the training his style of supervision and way of saying thank you has been changed…this makes us motivated in our work.” -CTC provider

Key findings cont…

• Low payment is a demotivating factor

• Commonly faced challenge by the CTCs: – Access to all households– Less time for interacting with client

‘Economic factor is the major cause for me compared to honor As by this I am running my family along with me. In this context, the award they are giving me has no value. Everyone is clapping for me, it is not that much important.’ –CTC provider

Challenges

• Continuous communication with partner organizations due to staff turnover

• Acknowledging CTC provider’s contribution in the process were crucial for successful implementation

• Promoting ownership

Conclusion

• To strengthen CTC providers role and capacity implementation research is important

• Requires innovation and adaptation

• Any intervention implemented needs to be embedded by the implementing organizations