Zusammenfassung der Ressource
SRH service delivery
evaluation
- How well does the SRHP deliver its service?
- 3 dimensions to service delivery
- program image/acceptability
- a key determinant of use
- Inter-relationship between access and quality and use
Anmerkungen:
- a client cannot be satisfied with services unless they are accessible
Analytically useful to view access and quality as distinct but complementary elements of the programme
quality can be prioritized over access. Thaddeus
and Maine (1994, too far to walk) "while distance and cost are major obstacles in the decision to seek care, the
relationships are not simple. There is evidence that people often consider the quality of care more important than
cost"
- Access: getting to the door
Anmerkungen:
- 5 dimensions to potential barriers to getting services
- geographic/ physical barriers
- To the extent which
clients can travel to
get services taking
account of travel
time and costs
- As the geographic
density of services
decreases, the journey
time and cost become
less accessible for
more people
- Data source:
Mapping of SDPs
/Reports
by knowledgeable
local informants
- Measure: The #
of different
service
distribution
points located
within a
specified
distance (e.g.:
20kms) or travel
times (e.g.: 2
hours) from a
given reference
location
- economic barriers
- The extent to
which a large
proportion of the
targeted population
can afford the costs
of reaching a
service and
obtaining services
including
opportunity costs
- Measure: Cost of one months'
supply of contraceptives and
transport and time to travel as a
proportion of average monthly
wages/ income
- FPP service and
supply costs
exceeding 1% of
monthly wages for a
significant
proportion of clients
would be considered
an indication of
economic barriers to
contraceptive use
(Ross et al 1992)
- Data source:
Population-based
survey
information Fees
paid from SDP
records Local
transport survey
- affect service use by,
1) discouraging
potential clients from
seeking, 2) making
service continuation
difficult
- eg.
out-of-pocket
payment
- administrative barriers
- Rules and regulations
that restrict use and choice of
method for reasons
unrelated to medical
considerations
- Data source:
Programme
documents
outlining
policies and
regulating
and eligibility
criteria for
services
offered by a
SRHP
- requirements for
spousal consent
for contraceptive
method
- restrictions on
certain methods
based on marital
status/parity
- requirements for
multiple visits to
receive certain
methods e.g.: IUDs
- legal status:
undocumented
immigrants
- restricted clinic
opening hours
- restrictions on the
distribution of
contraceptives
during clinic hours
for other services
e.g.: child
immunisations,
growth monitoring
etc
- adolescents
- (Fallon 2009) Adolescent access to
emergency contraception in the UK.
increased access due to the govt's
measures to reduce teenage
pregnancy. But the tension between:
Adolescent rights to confidential
treatment and advice Professional
anxiety about encouraging secrecy or
parental deception
- (Han & Bennish, 2009)
Condom Access in South
African Schools. Due to the
2007 South Africa Children's
Act, contraceptives available
at school. Controversy: Some
believe availability of
contraception will encourage
sexual activity. Others cite
the early age of sexual debut
and the uselessness of the
measure without addressing
sexually active youth outside
schools
- cognitive
- The extent to
which potential
clients are aware
of the locations or
service/supply
points and of the
services available
at these locations
Anmerkungen:
- •Someone can be unaware of the existence of a service even though it is physically
accessible
- Measure: The
proportion of the
population of
reproductive age
(total, or by sex) that
can name one or
more specific
locations or sources
where services may
be obtained
- Data source:
Population-based
surveys Cannot be
derived from
service statistics
- psycho-social
- Measure: Information on reasons
for non-use of a SRH service
- affect the demand for services
- e.g., societal family
size norms,
demand for
children and the
acceptability of FP
- affect use of services
- e.g.: fears of negative
social stigma
associated with
service use, fears
regarding submitting
to specific procedures
such as pelvic exam,
fear of side-effects,
social restrictions on
women travelling
alone to seek services
- Data source:
Population-based surveys
(limited), Focus group
discussions In-depth
interviews
- quality of care: inside the door
- = the degree to which
health services increase
the likelihood of desired
outcomes (Institute of
Medicine, 1990)
- Experts' perspectives/technical
aspects1) The quality of the care
provision by providers
Anmerkungen:
- •The
provision of care may be deemed of high quality against all recognised
standards of good practice, but unacceptable to the client
Or,
Certain
aspects of provision may be popular with clients but ineffective or even
harmful to health
- Users' perspectives/interpersonal
aspects:The quality of the care as
experienced by users
- Bruce (1990) – Framework of quality of care in FP
Anmerkungen:
- emphasis on users' perspectives
- 6 elements of care, mutually inclusive, non-discrete
- 1) Choice of methods 2) Info given to clients, 3)
Technical competence 4) Interpersonal
relations 5) Mechanisms to ensure continuity
6) Appropriate constellation of services/acceptability ... all
of these lead to utilization of services
- EVALUATION: quality of care should be evaluated from multiple perspectives
(not only clients' perspectives). measuring clients’ perspectives alone could
lead to the inaccurate evaluation of quality of care for SRH services. As Becker
et al. (2007) highlighted, because clients’ perspectives alone is less likely to
fully capture quality standards, various methodologies that incorporate
multiple perspectives would enable researchers to evaluate quality of care
for SRH services more properly.
- Methods to assess quality: given the multidimentional
nature of quality of care, it has to be measured from
multiple perspectives and by employing various
methodologies, qualitative (exit interviews, observations,
patient visits) and quantitative (client- and
provider-surveys, medical record reviews)
- According to Becker et al. (2007), the evaluation of quality of care solely from
client’s perspectives tended to result in inaccurate evaluations, excluding
other perspectives: those of health care providers and program managers. As
the researchers contended, because courtesy bias tend to prevent clients
from accurately evaluating certain aspects of quality, particularly technical
competency, the assessment of quality should include various methodologies,
such as “expert observations, medical record reviews, simulated patient visit
and provider surveys” (p 211). Furthermore, the evaluation based on clients’
perspectives could suffer from measurement validity concerns as researchers
tend to regard clients’ views on quality as the same as their satisfaction with
services.
- Haddad & Fournier (1995)
Quality, cost and utilisation of
health services in developing
countries. A longitudinal study
in Zaire. improved quality of
technical aspects of service
don't necessarily encourage
utilization as services were
economically inaccessible. but
interpersonal relationships at
facilities can compensate for
the negative effects of
accessibility.
- interplay between financial
accessibility, service quality of
technical aspects and of interpersonal
aspects, and use
- both are important, can
complement with each
other, encourage/discourage
use
- accessibility alone cannot guarantee use.
- quality cannot guarantee use unless clients access
- Agha, Gage, Balal (2007) Changes in perceptions of
quality of, and access to, services among clients of a
fractional franchise network in Nepal. due to private
provider's participation in service provision, significant
improvements in perceived quality of care and
perceived access to services -> increased client loyalty
and possibly sustained use
- service use
- data
- qualitative
- in-depth interview
- focus group
- important to look
at clients'
perspectives
- quantiative
- clients record
- surveys
- service output evaluation
- service use
- Gabrysch & Campbell (2009)
"Still too far to walk:
Literature review of the
determinants of delivery
service use"
- Sociocultural
factors
Perceived
benefit/need
of skilled
attendance
Economic
accessibility
Physical
accessibility
- this is important as demonstrating the
interrelationships between accessibility, use,
and program image
- In sum, many factors including quality
of care, accessibility, and service image
all influence/determine the utilization
of skilled birth attendnce
- service delivery have to be evaluated based on three
aspects of service delivery, because all of them are directly
connected with service use (which is the goal of service)