Assessing integration methodology (AIM)

167 Pages·2009·1.34 MB·English

AIM
Assessing Integration Methodology
A Handbook for Measuring and Assessing
the Integration of Family Planning and
Other Reproductive Health Services

Assessing Integration Methodology (AIM)
A Handbook for Measuring and Assessing the Integration
of Family Planning and Other Reproductive Health Services

Frontiers in Reproductive Health
Population Council
M. Estela Rivero-Fuentes
Saumya Ramarao
Ricardo Estrada
Charlotte Warren
Saiqa Mullick
Harriet Birungi
Ian Askew
John Townsend
Susana Medina
2008
The Population Council is an international, nonprofit, nongovernmental institution that seeks to
improve the well-being and reproductive health of current and future generations around the world
and to help achieve a humane, equitable, and sustainable balance between people and resources. The
Council conducts biomedical, social science, and public health research and helps build research
capacities in developing countries. Established in 1952, the Council is governed by an international
board of trustees. Its New York headquarters supports a global network of regional and country offices.
The Frontiers in Reproductive Health Program (FRONTIERS) applies systematic research
techniques to improve delivery of family planning and reproductive health services and influence
related policies. FRONTIERS is funded by the United States Agency for International Development
(USAID) and led by the Population Council in collaboration with Family Health International.
This publication is made possible by the generous support of the American people through the United
States Agency for International Development (USAID) under the terms of Cooperative Agreement
No. HRN-A-00-98-00012-00. The contents are the responsibility of the FRONTIERS Program and
do not necessarily reflect the views of USAID or the United States Government.
This publication may be reproduced in whole or in part without permission of Population Council
provided full source citation is given and the reproduction is not for commercial purposes.
Suggested citation: Rivero-Fuentes, Estela, et al. “Assessing integration methodology (AIM): A
handbook for measuring and assessing the integration of family planning and other reproductive
health services,” FRONTIERS Manual. Washington, DC: Population Council.
Frontiers in Reproductive Health Program (FRONTIERS)
Population Council
4301 Connecticut Avenue, NW, Suite 280
Washington, DC 20008
Telephone: [phone]
Facsimile: [phone]
E-mail: [email protected]
www.popcouncil.org/frontiers
© 2008 The Population Council, Inc.
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Contents
Acronyms .......................................................................................................................................... iv
Background ........................................................................................................................................v
Section 1: Assessing Integration Methodology: Why, what and how? ................................................1
Section 2: Data collection instruments for the integration of family
planning and antenatal care services .................................................................................................. 21
Section 3: Data collection instruments for the integration of family
planning and postnatal care services ...................................................................................................59
Section 4: Data collection instruments for family planning in
postabortion ca r e s e r v i c e s .................................................................................................................103
Section 5: Data collection instruments for the integration of family
planning and HIV and STI prevention and detection . ....................................................................129
AIM Handbook i ii
Acronyms
AIM Assessing Integration Methodology
ALVA Consultoria y Asesoria
ANC Antenatal Care
CDPHC Center for Development in Primary Health Care
CERA Centre d’Evaluation et de Recherche Apliquee
CIOMS Council for International Organizations of Medical Sciences
C&T Counseling and Testing
DHS Demographic and Health Surveys
ERC Ethical Review Committee
ESIC Employees’ State Insurance Corporation
FANC Focused Antenatal Care
FASQ Facility Audit of Service Quality
FP Family Planning
FGD Focus Group Decisions
FRONTIERS Frontiers in Reproductive Health Program
HFC Health Facility Census
HIV Human Immunodeficiency Virus
ICU Integral Care Units
IRB Institutional Review Board
JICA Japan International Cooperation Agency
M&E Monitoring and Evaluation
MCH Maternal and Child Health
MEASURE Monitoring and Evaluation to Assess and Use Results
MODE Taylor Nelson Sofres Mode Pvt. Ltd.
MOH Ministry of Health
MSH Management Sciences for Health
PAC Postabortion Care
PNC Postnatal Care
PMTCT Prevention of Mother to Child Transmission
PSAM Prevention Service Availability Mapping
RA Rapid Assessment Tool for Sexual and Reproductive Health and HIV Linkages
SA Situation Analysis
SPA Service Provision Assessment
SRH Sexual and Reproductive Health
STI Sexually Transmitted Infections
SyS Systematic Screening
VCT Voluntary Counseling and Testing
WHO World Health Organization
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Background

The origins and purpose
critical components of any postabortion care
of this handbook (PAC) service (Postabortion Care Consortium
2002). Since the advent of the AIDS pandemic,
Several international statements over the past two especially in Africa, considerable attention is
decades have endorsed the integration of family being paid to both integrating FP information
planning (FP) services with other reproductive and services into services for the prevention,
health services as a means of expanding management, and treatment of HIV/AIDS and
availability and access for potential users. Initially, other sexually transmitted infections (STIs), as
the focus was on integrating FP with maternal well as integrating these services with FP services
and child health (MCH) services; indeed, in (WHO, UNFPA, UNAIDS, and IPPF 2005).
virtually all African countries, FP services were
initially introduced through integrating their The World Health Organization (WHO) defines
provision into existing MCH service programs. integrated service delivery as:
Although FP services were introduced in Africa
through organizing their provision within “The management and delivery of health services
existing MCH programs, rather than creating so that clients receive a continuum of preventive
separate programs as had largely been the case in and curative services according to their needs over
Asia, they still tended to be provided separately time and across different levels of the health system.”
from, rather than integrated with, the antenatal, (WHO 2008)
delivery, postnatal, and child health services
offered by these programs. Many rationales underlie the move toward
integrating FP with other services. First among
More recently, there has been tremendous these is that combining the provision of one
interest in exploring ways of integrating the or more services provides a number of benefits
provision of FP information and services with to both the client and the program. Moreover,
other relevant services. For example, counseling there is the expectation (although evidence is
during antenatal care (ANC) on the importance still scarce) that the costs to the health system
of using FP after delivery for spacing births of configuring two or more services to be
and the subsequent provision of contraceptive provided either jointly at the same time and by
methods in the postpartum period during the same provider or through referral will be
postnatal and child health consultations are less than providing these services independently
widely recommended as ‘postpartum FP’ services (Das et al. 2007). These benefits include: (1)
(Vernon 2008). Efforts to incorporate FP meeting multiple reproductive health needs
counseling as an integral component of focused of a client simultaneously, (2) reducing the
antenatal care (FANC) (WHO 2002; Birungi stigma associated with providing a service
et al. 2006; Birungi and Onyango-Ouma 2006) independently, (3) combining several services
and to develop integrated postnatal-FP service needed for a multifaceted health condition, and
packages during the series of consultations (4) achieving cost efficiencies through sharing
during the 12-month postpartum period, all staff skills, infrastructure, and equipment.
demonstrate the increasing interest in integrating Experience indicates, however, that creating
FP with MCH services (Mwangi, Koskei, and service configurations for integrated services is
Blanchard 2008). For more than a decade, the usually not straightforward; can place a strain on
value of offering FP services to women receiving the underlying logistics, training, supervisory, and
postabortion services has been recognized and management systems, especially if the services are
endorsed, with FP being seen as one of the provided through different programs (as is the
AIMv Handbo ok v
case with sexual and reproductive health [SRH] Reproductive Health Program (FRONTIERS).
and HIV/AIDS services); and may overstretch This methodology derives from the Situation
service providers with limited skills and support. Analysis (SA), a methodology originally devised
by the Population Council in the 1990s through
However, there is still remarkably little empirical its USAID-funded Africa OR/TA Project, to
evidence available about integration of services better understand the range of programmatic
to guide policy makers, program managers, factors that influence the quality of care received
those providing technical assistance, and those by a client during facility-based FP services
responsible for financing health care. The (Miller et al. 1997; Miller et al. 1998).
following questions are critical, but the answers
remain largely unknown, or are uncertain in a Since the SA methodology was first developed
particular country or program context: and used in Kenya in 1990, the means by which
FP and other SRH services are delivered have
• Which service combinations are feasible?
increased and changed substantially, most notably
• Which services are acceptable to clients and through the integration of FP with other services.
providers? Offering services in a combined fashion requires
appropriate methodologies for determining the
• Which services can effectively increase
feasibility of various combinations, assessing and
access to one or both services without
monitoring the quality of service received, and
compromising the quality or safety of their
evaluating their effect on utilization. Responding
delivery?
to this need, FRONTIERS has adapted and
• Does their joint provision lead to a revised the SA methodology to create and use
synergistic impact on both the individual AIM to help health programs in many countries
client’s health status and that of the to address the questions concerning integration
population served? posed above.
In part, this knowledge gap exists because there Over the past decade, FRONTIERS has
has been little attention paid to assessment implemented more than 15 projects in a dozen
methodologies to generate such information. countries that have assessed the feasibility,
Over time, a number of methodologies for acceptability, and effectiveness of integrating
undertaking what are known as health facility FP services with maternal and child health,
assessments (HFAs) of service delivery have been postabortion, and HIV/STI prevention. The
developed and field-tested (Measure/Evaluation purpose of this handbook is to serve as a
2006; International Health Facility Assessment reference for organizations and individuals that
Network 2008), but none of these focus would benefit from methodological guidance
specifically on measurement of the integration of when describing, measuring, or assessing
services.
Map of FRONTIERS country projects using AIM
This handbook presents a
methodology that seeks to address
this gap. Termed the Assessing
Integration Methodology, or
AIM, it has been developed
from experience gained by the
Population Council in undertaking
assessments of various combinations
of integrated services in many
developing countries, most of
which was undertaken through
the USAID-funded Frontiers in
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integrated services. The handbook (a) explains the Sections 2 to 5 present generic data collection
basic principles of conducting studies using AIM, instruments for implementing AIM studies that
(b) provides tips for the data collection, and address the integration of FP with four services:
(c) makes available data collection instruments ANC, postnatal care (PNC), PAC, and STI/HIV
that have been validated in projects throughout services. Each section includes:
the developing world. The map on the previous
• A facility inventory of services,
page highlights those countries in which
infrastructure, equipment, and supplies
FRONTIERS carried out projects utilizing the
AIM strategy. Additionally, a detailed list of these • An observation guide for recording
projects can be found in Appendix 3. provider-client interactions
How to use the materials in this • A standardized questionnaire for exit
interviews with clients
handbook
• A questionnaire for interviews with
The focus of this handbook is on the AIM and providers
the instruments that can be used to collect
data at health facilities offering, or considering The questions included here have been tested
offering, integrated services. Data analysis will and validated in more than one setting. The
depend on the specific objectives of each study instruments are intended to be comprehensive
and so will not be reviewed here; most HFAs and therefore include some topics that will
such as AIM use primarily univariate or bivariate not be relevant for every context or study; to
descriptive statistics, so advanced statistical skills facilitate adaptation of the instruments, items
are usually not required. Examples of the types of that are fundamental for all AIM studies are
analyses that can be undertaken with AIM data distinguished from those that are specific for a
can be found in the reports from the completed particular combination of services.
studies (all available on the Population Council’s
website). Once the context and objectives of the
study have been specified, the data collection
instruments provided here can be adapted and
adjusted to ensure that they cover only the issues
of interest so that unnecessary data are not
collected.
The handbook is organized in five sections. The
first section describes the overall methodology in
terms of:
• Uses for AIM
• Components of an AIM study
• Data collection instruments
• Conducting an AIM study
• Limitations of AIM
• Comparison of AIM with other HFA
methodologies
AIMvii Handbo ok vii
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