1. OPERATIONAL RESEARCH ON INTEGRATION OF FAMILY PLANNING SERVICES IN EPI CLINICS IN KALIKOT DISTRICT OF NEPAL 6 June 2014 Authors: Dr. Senendra Raj Uprety, Rachel Cullen, Dr. Maureen Dariang, Dr. Sushil Baral, Ramila Bhandari, Bishnu Dulal

2. Presentation Outline Rationale for integration General background of the study district Step taken for operational research Integration model Monitoring and evaluation model Findings of the OR Enabling factors for high family planning uptake Challenges Lesson learnt Recommendations

3. Rationale for Integration

4. Unmet need of postpartum FP and consequences Unmet need of Post-partum FP (low demand) Birth to pregnancy duration of <24 months Unwanted pregnancy Increased maternal, newborn and infant mortality and poor health outcomes Poor awareness on fertility return; poor access to services

5. Fertility behaviour, risk of pregnancy and use of family planning among post-partum women Source: NDHS 2011 further analysis

6. Unmet need for Family Planning (women 0-23 months post-partum period) Source: NDHS 2011 further analysis Unmet need among MWRA: 27% Limiting: 17%, spacing: 10% Unmet need among MWRA: 27% Limiting: 17%, spacing: 10%

7. Population: 134,000 Expected under one children: 3500 MWRA: 29,350 CPR: 23%

8. Kalikot District Background Kalikot district is one of the most remote and poorest district of Nepal Ranks 73th out of 75 districts Kalikot district has 30 VDCs – 1 district hospital – 1 PHCC – 13 HPs – 15 SHPs – 111 EPI outreach clinics – 68 PHC ORC clinics

9. Step taken for operational research Context specific planning in Kalikot district recommends for integration of FP services in EPI clinics Development of integration materials in Kathmandu in consultation with various stakeholders Design workshop at Kalikot district, staff training and orientation- May-June 2012 Implementation from mid-July 2012 to mid-July 2013 Monitoring and data collection (12 months) Evaluation

10. Group health education on HTSP to persons accompanying the child to the EPI clinic Ask what the mother thinks of spacing/limiting during child vaccination Need identification and individual counselling of women Recording and Reporting. Recording and Reporting. Referral services Mothers whose pregnancy status is not confirmed for pregnancy test Mothers wanting long term methods Referral services Mothers whose pregnancy status is not confirmed for pregnancy test Mothers wanting long term methods Undecided Information and counselling during next visit Undecided Information and counselling during next visit At EPI clinics While vaccinating the child, to all mothers Women interested in further information Service provision Based on the informed decision, devices provided to clients (condoms, pills and depo) Service provision Based on the informed decision, devices provided to clients (condoms, pills and depo) Integration Model

11. Monitoring and Evaluation Model Routine monitoring: out of 30 VDCs, a focused monitoring was conducted in EPI (Expanded Program of Immunization) clinics of 20 VDCs through three field monitoring officers Data collection: EPI FP (family planning) data were collected by the field monitors for FY 2068-69 and 2069-70 from the EPI, FP registers Evaluation: An evaluation was carried out in May-June 2013. Both qualitative and quantitative designs were used in the final evaluation

12. Routine Monitoring Collected routine service delivery statistics (related to EPI, FP and PHC-ORC) Exit interview with clients of EPI clinics and local stakeholders The key objectives of routine monitoring were: To understand the functionality and provision of FP services To understand the overall supply (vaccine, devices) status in the clinics and the issues encountered while providing FP services To record the EPI and FP services provided by EPI clinics To know the perception of women on integrated EPI FP services, etc.

13. Evaluation The objectives of final evaluation were: To explore the knowledge about EPI FP integration To identify the clients participation in various process of integration in the EPI clinics To determine the use of FP services from the EPI clinics To explore the reasons for not using FP services To explore family planning history

14. Findings- July 2012 to July 2013

15. Findings – Service delivery

16. Findings – The model successfully increased access to family planning: Two-thirds of the women attending EPI clinic reported to have attended the group health education session 1539 clients received FP devices from EPI clinics (48% of post-partum women) At household interview 32% of women reported using a family planning method with 56% of them having received the method from the integrated clinics. ( 18% of current users of post-partum women received FP from EPI clinics)

17. Findings – Information is critical to the success of the integrated model especially as many women who access EPI services are unaware that they are at risk of getting pregnant Majority of women knew recommended duration of birth to pregnancy interval 50% of women interviewed did not realise that they were at risk of pregnancy although they do not practice exclusive breast feeding during post-partum 6 months

18. Findings – Underserved groups are using the service: 26% of family planning users were Dalit (lower caste), who represent 24% of Kalikot’s population. This suggests that this group is not marginalised from the service — rather the integration increased their access to family planning services.

19. Findings – The integrated service did not affect the uptake of EPI EPI performance did not suffer as a result of the integrated family planning/EPI service, with performance remaining in line with or above the previous year’s performance for the duration of the research.

20. Findings – Women liked accessing family planning at the EPI clinics: Majority (94%) of the women mention that EPI clinic is convenient location for them to get FP devices The women clients reported that integration had no negative impact on their experiences of the service. In fact they reported a better experience of immunisation services. “I prefer this integrated EPI clinic as I can complete my child immunisation as well as get FP service for myself from the same clinic” (women of Kumalgaun VDC)

21. Enabling factors for high family planning uptake and good service provision were: More than one health worker staffing the clinic; there being at least one female member staffing the clinic (to encourage women to adopt and use family planning methods); all staff having received training on this approach; and Support by Female Community Health Volunteers.

22. Challenges: Consistent availability of health workers to conduct EPI clinics due to retirement of Village Health Workers Management and motivation of health workers at local level to provide regular services – group health education, individual counselling Privacy difficult to maintain in crowded EPI clinics with limited infrastructure Availability of IEC materials (handover among HW to new recruits) Differentiation from the usual HMIS reporting in this pilot

23. Lessons learnt: Orientation of all health workers involved in providing EPI services is necessary Simple flow chart for screening for pregnancy risk would make it easier for health workers

24. Recommendations Scale up the approach in remote districts where EPI service users are small (less than 10 per clinic) Mobilise and enable health workers to provide quality services by assessing the availability of necessary human resources prior to implementing integrated services, orientating staff on the approach and awarding multi-year contracts to locally contracted health workers Develop the skills of health workers to deliver group heath education

25. Recommendations cont… Review infrastructure requirements for integrated clinics and use community networks to improve accommodation for EPI and PHC- ORC clinics Market the services available at integrated clinics, especially to marginalised group people. Involve and seek support from FCHV Ensure availability of LTFP methods at health facility level Review and revise IEC material used based on this study findings (example- focused message on timing of fertility return)

26. Few glimpse of pilot