SRH service delivery evaluation

1. a key determinant of use

Annotations:

• 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"   

1. Access: getting to the door

   Annotations:

   • 5 dimensions to potential barriers to getting services
   1. geographic/ physical barriers
      1. To the extent which clients can travel to get services taking account of travel time and costs
         1. As the geographic density of services decreases, the journey time and cost become less accessible for more people
            1. Data source: Mapping of SDPs /Reports by knowledgeable local informants
            2. 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
   2. economic barriers
      1. 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
         1. Measure: Cost of one months' supply of contraceptives and transport and time to travel as a proportion of average monthly wages/ income
            1. 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)
            2. Data source: Population-based survey information Fees paid from SDP records Local transport survey
         2. affect service use by, 1) discouraging potential clients from seeking, 2) making service continuation difficult
            1. eg. out-of-pocket payment
   3. administrative barriers
      1. Rules and regulations that restrict use and choice of method for reasons unrelated to medical considerations
         1. Data source: Programme documents outlining policies and regulating and eligibility criteria for services offered by a SRHP
            1. requirements for spousal consent for contraceptive method
            2. restrictions on certain methods based on marital status/parity
            3. requirements for multiple visits to receive certain methods e.g.: IUDs
            4. legal status: undocumented immigrants
            5. restricted clinic opening hours
            6. restrictions on the distribution of contraceptives during clinic hours for other services e.g.: child immunisations, growth monitoring etc
            7. adolescents
               1. (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
               2. (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
   4. cognitive
      1. The extent to which potential clients are aware of the locations or service/supply points and of the services available at these locations

         Annotations:

         • •Someone can be unaware of the existence of a service even though it is physically accessible
         1. 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
            1. Data source: Population-based surveys Cannot be derived from service statistics
   5. psycho-social
      1. Measure: Information on reasons for non-use of a SRH service
         1. affect the demand for services
            1. e.g., societal family size norms, demand for children and the acceptability of FP
         2. affect use of services
            1. 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
         3. Data source: Population-based surveys (limited), Focus group discussions In-depth interviews
2. quality of care: inside the door
   1. = the degree to which health services increase the likelihood of desired outcomes (Institute of Medicine, 1990)
      1. Experts' perspectives/technical aspects1) The quality of the care provision by providers

         Annotations:

         • •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
      2. Users' perspectives/interpersonal aspects:The quality of the care as experienced by users
         1. Bruce (1990) – Framework of quality of care in FP

            Annotations:

            • emphasis on users' perspectives
            1. 6 elements of care, mutually inclusive, non-discrete
               1. 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
   2. 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.
      1. 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)
      2. 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.
3. 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.
   1. interplay between financial accessibility, service quality of technical aspects and of interpersonal aspects, and use
4. both are important, can complement with each other, encourage/discourage use
   1. accessibility alone cannot guarantee use.
5. quality cannot guarantee use unless clients access
6. 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

1. in-depth interview
2. focus group
3. important to look at clients' perspectives

1. clients record
2. surveys

1. Gabrysch & Campbell (2009) "Still too far to walk: Literature review of the determinants of delivery service use"
   1. Sociocultural factors Perceived benefit/need of skilled attendance Economic accessibility Physical accessibility
      1. this is important as demonstrating the interrelationships between accessibility, use, and program image
   2. In sum, many factors including quality of care, accessibility, and service image all influence/determine the utilization of skilled birth attendnce