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Strengthening Community-based Family Planning MARCH 2017 Systems through Collaborative Improvement in Busia District, Uganda QUALITY IMPROVEMENT BRIEF - ISSUE 2 Busia District’s contraceptive prevalence rate has increased Introduction 1 from 16% to more than 30% Uganda’s first learning site for community-based family planning (CBFP) — established since the CBFP improvement in Busia District by the Advancing Partners and Communities (APC) project in partnership effort began, the District Health with the Ministry of Health (MOH) — aims to increase uptake and sustained use of family Office reports. planning services among women of reproductive age. At all three pilot CBFP In this second issue of the APC Quality Improvement Brief, we describe the progress to date improvement sites, 70% of in systematic efforts to improve the quality of CBFP in Busia District and plans to scale up clients return for follow-up visits these efforts in two other districts in Uganda. — a return rate much higher than the national average of 53% percent. The Improvement Effort In Busia, 14 midwives and 118 community health workers known as village health team members (VHTs), in-charges and midwives from seven health centers, and a principal CHANGE PACKAGE TO nursing officer work together to implement a quality improvement (QI) effort based on the IMPROVE CBFP Collaborative Improvement Model.2 With APC technical assistance, the nursing officer serves • To ensure adequate as a district-level QI mentor, and each health center catchment area has a QI team consisting counseling: Use the FP of VHTs, who function as QI champions, midwives, who coach the VHTs, and clients, who counseling book as a participate in learning sessions. reminder. • To improve FP counseling: Midwife and VHTs hold Midwives conduct QI sessions that include monthly facility- observation of and feedback on based QI coaching counseling. and FP mentoring • To increase male sessions where involvement: Use two- they guide the minute FP “elevator speech,” VHTs in using a basic script developed by improvement collaborative representatives principles and for the VHTs’ use. processes to • To improve retention on FP: identify and Engage expert clients to dispel implement changes myths. Conduct home visits to to improve remind clients about follow- service delivery. VHTs, midwives, a QI mentor, an APC project member, and HC in-charges discuss ideas for up visits and (with a client’s improving CBFP. The midwives also permission) talk to partners. mentor VHTs through either direct observation of FP counselling and service delivery or role plays. Progress reviews between midwives and VHTs provide additional opportunities to educate and support the VHTs in problem solving. The improvements developed during the sessions are tested through the Plan-Do-Study-Act (PDSA) Model (see box on following page) and become the basis for a validated package of changes that have proved effective in the local context (see blue box to the left). www.advancingpartners.org Ac is more ownership of them among the QI teams and greater FHI Quality Improvement Model sustainability of community-based QI. • QI coaching sessions have led to greater involvement in FP issues among midwives and in-charges compared to What are we trying I. I. IncreaseIncrease uptake uptake to accomplish? that of other districts in Uganda, report those who provide andand sustained sustained supportive supervision. VHT interaction with and support useuse of of family family for clients have increased, and critical support to VHTs’ has planningplanning servicesservice improved among HC-based QI mentors (midwives). How will we know a change II.II. IncreasesIncreases in: in: is an improvement? %% of of women women • The improvement effort started with three HCs and has now adequatelyadequately been scaled-up to four new HCs, covering the entire district. counseled on counseled on The Busia CBFP learning site teams have played an active FP by VHTs FP by VHTs role in the scale-up of the collaborative QI effort in Oyam What change can we make that will result in improvement? III.III. Changes Changes to to District, and a delegation from Oyam District participated in ImproveImprove CBFP CBFP the November 2016 learning session in Busia. • The APC QI team and the Busia District officials gave ACT PLAN IV. Tes t/implement three presentations at the National Quality Improvement system changes Conference in Kampala in August 2016. STUDY DO Results V. Sustain and An analysis of the QI data collected by the VHTs in Busia District spread the from June 2015 to December 2016 shows progress in the three new system pilot sites (Buteba, Buhehe, and Bulumbi) and the four sites in which the QI initiative has been scaled up (Lunyo, Lumino, Source: GL Langley, KM Nolan, TW Nolan, CL Norman, and LP Provost, The Improvement Guide: A Practical Approach to Enhancing Organizational Performance Busitema, and Mbehenyi). (San Francisco: Jossey-Bass, 1996). OBJECTIVE 1: Ensure all female clients (new and returning, 15-49 years old) receive adequate counseling from VHTs on the side effects of FP methods, including LARCs. Ahievements and Lessons from Findings (see graph 1): By December 2016, VHTs in all the pilot Busia District sites reported following all the steps in the FP counseling checklist • Frequent QI coaching sessions in the three pilot HCs with 90% of clients, and the scale-up sites reported doing so (14 conducted from June 2015 to December 2016) with 60% to 80% of clients. In the scale-up sites, VHTs began to involving stakeholders at all levels strengthened common record providing adequate counseling in February 2016 after they understanding, started using a counseling flip book as a job aid. The VHTs also provided practical increased the time spent counseling clients, which helped them feedback, and What VHTs in Busia say realize that whether and how to disclose FP use to partners should facilitated the success about being part of be incorporated into counseling sessions to help women gain the of QI processes. CBFP Learning Center support of their partners for sustained use of FP methods. of Excellence: • By December 2015, OBJECTIVE 2: Increase the percentage of female clients all three sites were “Ordinary people can do counseled with their partners by VHTs. monitoring QI extraordinary things.” measures and plotting “Complicated and advanced Findings (see graph 2): Reaching FP clients and their partners them on run charts for me, but I understood” as couples is the most challenging objective for the VHTs. Some (see graphs on page VHTs report that they use follow-up visits to clients’ homes (with 3). The practice of prior permission from the FP client) to counsel women with their self-monitoring and husbands and record the couples counseling in the VHT registers. interpretation of graphs in team meetings has increased VHTs also counsel couples when partners accompany women on interest in QI and innovation among the VHTs. hygiene, immunization, and antenatal care days. The VHTs have found that reaching out to younger couples is easier; efforts to • A change package (see blue box on page 1) that is counsel this group explain, in part, the slight improvement in the continuously updated guides new VHTs and the scale-up of percentage of couples reached. VHTs do not talk to a partner if the QI. Because the changes are simplified and localized, there woman does not want her partner to know she uses contraception. 2 www.advancingpartners.orgwww.advancingpartners.org OBJECTIVE 3: Increase the number of GRAPHIPercentage 1 - PERCENTAGE of Clients OF CLIENTS Adequately ADEQUATELY Counseled COUNSELED FOR for FP FP BY by VHT VHT (PILOT AND SCALE-UP SITES) male clients receiving (pilot and scale-up sites) FP information and counseling during 100% Flip book interactions with VHT. 80% Flip book Findings (see graph 3): Various changes 60% tested by VHTs in both the pilot and 40% scale-up sites appear to have contributed 20% to an increase in the number of men 0% reached per month, which rose from 50 to over 300 within a year. VHTs learned that compared to older men, young men Pilot sites Scale up sites were more willing to support their wives’ use of FP methods, in several cases, so that they could go back to school.To GRAPHIC 2 - PERCENTAGE OF FEMALE CLIENTS COUNSELED AS COUPLES WITH THEIR HUSBANDPercentage (PILOT of female AND SCALE-UP clients counseled SITES) as couples with their partners reach these men, VHTs began giving FP 16% “elevator speeches” during village savings Encouraging and loan association (VSLA) meetings, 14% di s closure Friend Couple men’s drinking group (MALWA) meetings, 12% to couple Visits gatherings of church congregations, and even through meetings convened by 10% Home Visits the local counsel chairperson. Recently 8% APC conducted informal small group 6% Encouragingwomen to 4% come with their husbands on next visit FP Elevator Speech (excerpt) 2% Integrating FP in sanitation “I and my wife have been using FP for home visits and talk to men 0% the last 9 years and in between we have had two children….We need to have families that we can look after.” GRAPHIC 3 - NUMBER OF MEN REACHED WITH FP SERVICES AFTER SCALE-UP IN discussions in all seven sites, which also BUSIA NumberDISTRICT of (PILOT Men reachedAND SCALE-UP with FP SITES) services after scale up in Busia District 350 helped involve more men. VHTs from the Targeting young seven HCs were able to counsel a total of 300 men in Video halls 1,793 males, or an average of 149 men per 250 couple to couple Reach men month, in 2016. home visits Meeting men in on Boda 200 use of Malwa groups Boda stages elevator OBJECTIVE 4: Increase the number of 150 speech female clients who return to the VHTs for No.

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