• flftKE- t'tj3 • /tJ /:L fJ Y • CCHlBohVla CI9356A • Increasmg Access to FamIly Planmng ServIces m Rural Campesmo Commumtles A PIlot Project FINAL REPORT • July 15, 1993 - September 14, 1994 • • The Population CouncIl seeks to Improve the wellbemg and reproductIve health of current and future generatIOns around the world and to help achieve a humane equItable and sustamable balance between people and resources The Council _ analyzes populatIOn Issues and trends _ conducts bIOmedIcal research to develop new contraceptives, _ work.s With public and pTIvate agencies to Improve the qualIty and outreach of family plannmg and reproductive health services _ helps governments to mfluence demographic behaVIOr, _ communicates the results ofresearch In • the population field to appropTIate audIences _ and helps build research capacItIes m developIng countTIes The Council a nonprofit nongovernmental research organizatIOn established In 1952 has a multInatIOnal Board of Trustees Its New York headquarters supports a global network of regIOnal and country offices ThIS project was funded by the US Agency for InternatIOnal Development Office of PopulatIOn under Contract No AID/DPE-3030-Z-00-90 I9-00 StrategIes for Improvmg ServIce DelIvery/OperatIOns Research and Techmcal Assistance m Latm AmeTIca and the CarIbbean (INOPAL II) Project Number 936-3030, and by USAID/BollVla • under Project Number 511-0568 • • • • FINAL REPORT INCREASING ACCESS TO FAMILY PLANNING SERVICES IN RURAL CAMPESINO COtviMUNITIES A PILOT PROJECT • CCH (CO:MMUNITY AND CHILD HEALTH) Contract Number CI93 56A • Prepared by John P SlabIak Mary McInerney • Carlos Nava G • • USAID Contract No DPE-3030-Z-00-9019-00 • • $l ! I I ,I .1 I • FINAL REPORT INCREASING ACCESS TO FAMILY PLANNING SERVICES IN RURAL CAMPESINO COMMUNITIES A PILOT PROJECT • CCH (COMMUNITY AND CHILD HEALTH) • • • The PopulatIOn CouncIl/INOPAL II Commumty and ChIld Health (CCH) Avemda Ecuador 2249 Calle GOltla 141 CasI1la 3384 La Paz, BolIVia La Paz, BolIVia Tel 37-6331/41/46 Tel 37-3947 Fax 39-1503 Fax 32-7091 •i I -I I I TABLE OF CONTENTS -I I EXECUTIVE SUM:MARY TABLE OF CONTENTS • 1 INTRODUCTION 1 2 GEOGRAPHIC AND SOCIODEMOGRAPIDC CONTEXT 4 KAP Study 4 QualItatIve Study 8 3 OPERATIONS RESEARCH 9 • Study DesIgn 9 DescnptIon of InterventIons 10 Trammg 10 EqUIpment and SupplIes 11 Study Results 12 Pap Exams 12 • DIstnbutlon of FamIly Plannmg Methods 14 Cost Data 17 4 CONCLUSIONS 19 Impact on Programmmg 19 • REFERENCES 21 • • • • .1 I EXECUTIVE SUMMARY • In February 1993, the Secretana RegIonal de Salud/Cochabamba (SRSC) requested technIcal and financIal support from !NOPAL II to Introduce farmly planmng servIces mto the prImary health care program of one of Its most populated and poorest dIStrIcts -- DIstrIct VII, a large, geographically dIverse area encompassIng the provmces of Capmota, BolIvar and Arque Though the SRSC had already successfully Introduced reproductIve health mto Its urban hospItals, domg so wIthm an exclUSIvely rural context Imphed uncertamtIes and deCISIOns for • I whIch there was no precedent m Cochabamba Though aware of the strengths and weaknesses I, of rural health care delIvery m general unknown medIcal barrIers, cultural and ethnIC bIases an absence of accurate cost data and hmlted avmlablhty of relevant field expenence effectlvelv .1I dIscouraged the SRSC from launching theIr first rural reproductIve health program The ultImate goal of the present study, therefore, was to prOVIde an empmcal basIS for assessmg the feasIbIhtv, cost and qualIty of provIdmg a full range of reproductIve health servIces at rural communItv-based health posts The project was carned out In two provmces of DIstnct VII Capmota and Arque and was Implemented under the auspIces ofthe Commumty and ChIld Health Program (CCH) a USAID sponsored project supportIng pnmary health care and Chagas .' preventIOn In rural Cochabamba Over a 14 month penod, the project undertook two demonstratIOn mterventIOns m DIstrIct VII One mItIated famIly plannmg and related reproductIve health servIces at communIty based health posts by tramed nurse alLXIharies The other InterventIOn enabled phySICIan-staffed hospItals to offer the same servIces Demand for these servIces was created through actIVltleS to mcrease commumty awareness and acceptance of famIly plarInIng servIces such as the use of appropnate InfOrmatIOn, educatIOn and commumcatIOn (IEC) matenals and the trammg of communIty based health promoters By analyzmg these mterventIons m terms of famIly planmng acceptance, cost and qualIty of care, thIs project sought to proVIde an empmcal basIS for assessmg the strengths and weaknesses of provIdmg farmlv plarInIng servIces at each level of health care servIce • delIverY Between start-up or servIce aellvery on 16 Novemoe"" 1993 ana the termmatIon of data collectIon actIVItIes on 16 June 1994, a toral of 284 pap exams were perrormed In the project area, over 50 percent by auxIhary nurses alone AUXIlIary nurses were not onlv as equallv competent technIcally as phYSICIans In performmg pap smears, but actually prOVIded hIgher follow-up rates • for paps than phySICIans More than half of all IUD InSertIOns In the project were performed by nurse auxlharles at theIr health posts The Impact of these servIces on overall method chOIce, however, was most eVIdent eVIdent In comparIsons between method dIstrIbutIOn at posts WIth auxIlIanes tramed to msert IUDs and those WIth aUXIlIarIes who were not The study results showed that whIle method dIstnbutlOn among the former clearly favored the IUD, such health posts were nevertheless • extremely successful at dlstnbutmg a full range of contraceptIve methods Where nurses were not tramed to msert IUDs, by contrast, the method mIX was not only deVOId of IUDs, but heaVIly • • bIased towards less relIable methods such as condoms, and expensIve resupply methods such as the pIll • A major assumptIon of the study was that auxilIanes, by resIdmg In and often commg from the communItIes m whIch they work, are more effectIve than phySICIans at reaclung local women and mamtaImng contact WIth them ThIS assumptIOn was clearly borne out In the case of follow-up rates among IUD users Indeed, mnety-five percent of all such users, who receIved IUDs from aillClhanes returned withm 90 days for theIr follow-up VISIt, compared to only 50 percent m the • case of physIcIans With respect to costs of mtroducmg reproductIve health servIces mto rural areas, the study results showed that hlgher InItIal trammg costs for aUXIlIanes were compensated over tIme by the auxIlIanes' permanence wlthm theIr home commumtIes PhYSICIans, on the other hand, because of theIr oblIgatory ana de prOvmCIa, reqUIred constant retrammg In reproductIve health, thereby mamtaImng at an overall hIgher cost per famIly planmng or IUD user By June 1994, the cost per IUD msertIOn for auxIlIanes was only slIghtly lugher than that of phySICIans and IS soon e,<pected to drop below It WIth the next scheduled refresher trammg course for phySICIans • - .~ . • i • • • 1. INTRODUCTION • Though the percentage of BolIvIans lIvmg m rural areas has decreased by almost 28 percent m the last 16 years, more than 42 percent ofthe country stIll lIves In settlements of 2 000 or less - the second highest percentage ofrural mhabltants In all Spanish speakIng Latm AmerIca • For BolIvIa, the consequences of thIS dIstnbutlOn are eVIdent In startling dISparItIeS between the qUalIty of lIfe m the natIOn's rural and urban areas BolIVIa's rural mhabItants are not only poorer and less lIterate than theIr urban counterparts, they also dIe earlIer and at a much faster rate Indeed, poverty, malnutntIOn and an absence of basIC medIcal servIces contrIbute to an average rural hfe expectancv of only 36 7 years -- one ofthe lowest In the world (Unoste 1984 83) Moreover, BolIVIa's mfant and maternal mortalIty rates -- already the mghest In Latm • Amenca -- pale In comparIson to the extremes found, for example, In the country's rural Valle regIOn I As UrIoste (1984) has argued the causes of rural poverty In BolIVIa are both comole'( and pervasIve Yet there IS ample eVIdence to support the argument that current levels of mfant and maternal mortalIty could be reduced sIgmficantly by Increased detectIon and aVOIdance of hIgh • rIsk pregnanCIes and by a reductIOn In the hIgh abortIOn levels charactenstic of the countrY as a whole Unfortunately, the use of family planmng, wlnch could reduce both phenomena remaIns alarrmngly low 2 According to the 1989 Demograplnc and Health Survey (INE 1990), only 12 percent of all Bohvian women of reproductIve age practIce some form of modem contraceptIOn, whlie m rural areas, modern contraceptive prevalence barely exceeds 52 percent Even the awareness of modem contraceptlon remams lImIted The DRS showed that wmle 68 percent of • SpanIsh-spealang mamed women could IdentIfy at least one modem method and Its source, only 23 percent of non SpanIsh-speakmg women could do the same (Schoemaker 1991) Though the few last years have Witnessed a burgeorung mterest and acceptance of reproductIve health m the natlOn s urban areas there still remams much to be done In rural BolIVia • unforrunately, not all of the strategies ana Interventlons responsIble for the success of urban IThIS regIOn which encompasses the Deoartments of Cochabamba, TartJa and ChuqUisaca eVIdences mfant mortahty rates of2383 per thousand births (Unoste 1984 83-90) TIus contrasts With a national rate estImated m 1989 to be 96 per thousand (INE 1990 5) • 2 It IS Widely acknowledged that clandestme abortions