1. STAKEHOLDER MEETING Revitalizing the IUD in [insert country name] City, Country Date Insert MOH logoInsert Project logoInsert USAID logo (Note: Photos have been removed to keep the file size manageable.)

2. Introductions  As we go around the room, say: –Your name –Your position –Where you work

3. 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

4. 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

5. Environmental Scan: Country 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.

6. 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?

7. Mali: General indicators 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 2/23/2005http://www.prb.org/http://devdata.worldbank.org/external/dgcomp.asp?rmdk=110&smdk=473886&w=0 Total midyear population12,291,529 (2005) Population growth rate3.3% (2004) Total fertility rate7.0 (2004) Married women of reproductive age (MWRA) 2,163,000 (2000) Percentage of population under age 15 49 (2004) Physicians/1000 people0.1 (1996)

8. Mali: Family planning Sources: Demographic and Health Surveys, Mali, 2001. Among MWRA, 15-49 yrs Knowledge of any method77.8% Knowledge of any modern method75.6% Knowledge of female sterilization32.5% Knowledge of Norplant25.7% Knowledge of IUDs Knowledge of male sterilization 21.1% 12.6%

9. Mali: Family planning 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.http://www.measuredhs.com Among MWRA, 15-49 yrs CPR (any method)8.4% 181,692 couples CPR (modern method)5.8% 125,454 couples Total demand for FP36.6% 791,658 couples  Demand to space25.9% 560,217 couples  Demand to limit10.7% 231,441 couples

10. Mali: Family planning IndicatorMali 2001Senegal 1997 Guinea 1999 Mauritania 2000/2001 CPR (any method) 8.4%12.9%6.2%8.0% CPR (modern method) 5.8%8.1%4.2%5.1% Demand to space 25.9%33.5%19.6%28.1% Demand to limit 10.7%14.3%10.8%11.5% Total demand for FP 36.6%47.8%30.4%39.5% Source: MEASURE DHS+ STATcompiler. http://www.measuredhs.com, May 10, 2004.http://www.measuredhs.com

11. Mali: CPR among MWRA Source: MEASURE DHS+ STATcompiler. http://www.measuredhs.com, May 10, 2004.http://www.measuredhs.com 1.3 4.5 7.0

12. Mali: CPR among MWRA Contraceptive Prevalence by Region by Year Source: MEASURE DHS+ STATcompiler. http://www.measuredhs.com, February 25, 2005http://www.measuredhs.com

13. Mali: Source of FP supply Modern methods, MWRA, 15-49 yrs Data source: MEASURE DHS+ STATcompiler. http://www.measuredhs.com, February 25, 2005http://www.measuredhs.com

14. 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, 2005http://www.measuredhs.com

15. 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

16. 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

17. 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.

18. Mali: Projected number of LTPM users (All women) Sources: EngenderHealth, Contraceptive Sterilization: Global Issues and Trends, 2002; Ross, Stover and Willard, 1999.. In 1,000s

19. Source : EngenderHealth, 2002; Janowitz, Measham and West, 1999. Sustainability Sustainability Average Cost (US$) to Health Care System Per Year of Protection, by Method (Mombasa, Kenya)

20. Mali: HIV/AIDS  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 HIV/AIDS Snapshot

21. Mali: HIV/AIDS  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 HIV/AIDS Snapshot: Current policies and programming

22. 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.http://www3.who.int/whosis/mmhttp://www.measuredhs.com/countries 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

23. Questions or Comments?

24. Questions for Reflection (2)  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? Note: These are sample questions for illustration.

25. Introduction to the Performance Improvement Approach

26. What is Performance?  The tasks that people do and the results of those tasks

27. Effort  Performance

28. What is Performance Improvement?  A step-by-step methodology for finding out what is needed to ensure good performance, and delivering it

29. Factors Influencing Performance 1.Job expectations 2.Performance feedback 3.Environment and tools 4.Motivation and incentives 5.Skills & knowledge Organizational Support: Using Performance Factors

30. Job Expectations Guidelines, policies, standards, procedures, protocols, and how these are communicated to and understood by providers

31. Performance feedback How providers find out how they’re doing, compared to the standards.

32. Physical Environment The facilities, supplies, materials, tools necessary to do the job.

33. 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.

34. Knowledge and Skills  Systems and interventions to address how to do a job.

35. Over-Arching Consideration Organizational Support The extent to which the organization assures that all the performance factors are in place. --Supervision, policies, communication

36. Lack of data and information Lack of motivation and incentives Lack of tools and equipment Lack of knowledge and skills “ If all you have is a hammer… everything looks like a nail.” Training

37. 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)

38. PI Framework PNA

39. Steps in the PNA Process  Stakeholder agreement  Define desired performance  Determine actual performance  Analyze root causes  Select interventions

40. 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

41. Do you have any questions or comments?

42. Defining Desired Performance

43. Desired Performance We are Here PNA

44. 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

45. 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.

46. 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.

47. 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).

48. 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.

49. Providers will have access to needed supplies. Is This a Desired Performance Statement? The supervisor will make 1 supervision visit per quarter to each health facility in his district.

50. 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. :

51. 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

52. Do you have any questions or comments?