Scaling Up a Strengthened Youth-Friendly Service Delivery Model to Include Long-Acting Reversible Contraceptives in Ethiopia: A Mixed Methods Retrospective Assessment

Document Type: Original Article

Authors

1 Evidence to Action/PATH, Washington, DC, USA

2 Pathfinder International, Addis Ababa, Ethiopia

Abstract

Background
Donor funded projects are small scale and time limited, with gains that soon dissipate when donor funds end. This paper presents findings that sought to understand successes, challenges and barriers that influence the scaling up and sustainability of a tested, strengthened youth-friendly service (YFS) delivery model providing an expanded contraceptive method choice in one location – the YFS unit – with additional units in Amhara and Tigray, Ethiopia.
 
Methods
This retrospective mixed methods study included interviews with key informants (KIs) (qualitative arm) and analysis of family planning (FP) uptake statistics extracted from the sampled health facilities (quantitative arm). A multistage convenience purposive sampling technique was adopted to randomly select 8 health facilities aligned with respective woredas, zones and regional health bureaus (RHBs). A semi-structured interview guide soliciting information on 6 scaling-up elements (stakeholder engagement, roles and responsibility, policy environment, financial resources, quality of voluntary FP services and data availability and use) guided the interviews. Fifty-six KI interviews were conducted with policy-makers, program managers, and clinic staff. Recurring themes were triangulated across administrative levels and implementing partners. Relevant FP data (acceptor status, age and method uptake) were extracted from the 8 sampled health facilities for a thirteen-month period. Qualitative findings triangulated with FP service statistics assessed the influence of the 6 scaling-up elements with trends in long-acting reversible contraceptive (LARC) uptake before and after training.
 
Results
Our findings depict that respondents were knowledgeable and supportive of an expanded method mix. Statistically significant increases in long-acting contraceptive uptake were noted at 2 of the 8 health centers. Fidelity to the tested model was operationally constrained; respondents frequently mentioned trained staff absences and turnover as obstacles in offering quality FP services.
 
Conclusion
Despite conducive policy environment, supportive stakeholders, favorable environment, and financial support for trainings, statistically significant increases in LARC uptake occurred at only 2 of the 8 health centers; indicating the influence of weak health systems, poor quality of voluntary FP services and a ceiling effect. Scale-up processes must consider potential bottlenecks of weak health systems and availability of financial resources by addressing these as crucial elements in any systematic scale-up framework.

Keywords

Main Subjects


  1. ExpandNet, World Health Organization (WHO). Nine steps for developing a scaling-up strategy. Geneva: WHO; 2009. Geneva: WHO; 2012.   http://apps.who.int/iris/bitstream/handle/10665/44432/9789241500319_eng.pdf.  Accessed October 10, 2018.
  2. Paina L, Peters DH. Understanding pathways for scaling up health services through the lens of complex adaptive systems. Health Policy Plan. 2012;27(5):365-373. doi:10.1093/heapol/czr054
  3. Pérez-Escamilla R, Curry L, Minhas D, Taylor L, Bradley E. Scaling up of breastfeeding promotion programs in low- and middle-income countries: the "breastfeeding gear" model. Adv Nutr. 2012;3(6):790-800. doi:10.3945/an.112.002873
  4. Yamey G. Scaling up global health interventions: a proposed framework for success. PLoS Med. 2011;8(6):e1001049. doi:10.1371/journal.pmed.1001049
  5. Huaynoca S, Chandra-Mouli V, Yaqub N Jr, Denno DM. Scaling up comprehensive sexuality education in Nigeria: from national policy to nationwide application. Sex Education. 2014;14(2):191-209. doi:10.1080/14681811.2013.856292
  6. Balabanova D, Mills A, Conteh L, et al. Good Health at Low Cost 25 years on: lessons for the future of health systems strengthening. Lancet. 2013;381(9883):2118-2133. doi:10.1016/s0140-6736(12)62000-5
  7. Hainsworth G, Engel DM, Simon C, Rahimtoola M, Ghiron LJ. Scale-up of adolescent contraceptive services: lessons from a 5-country comparative analysis. J Acquir Immune Defic Syndr. 2014;66 Suppl 2:S200-208. doi:10.1097/qai.0000000000000180
  8. Chandra-Mouli V, Gibbs S, Badiani R, Quinhas F, Svanemyr J. Programa Geração Biz, Mozambique: how did this adolescent health initiative grow from a pilot to a national programme, and what did it achieve? Reprod Health. 2015;12:12. doi:10.1186/1742-4755-12-12
  9. Carai S, Bivol S, Chandra-Mouli V. Assessing youth-friendly-health-services and supporting planning in the Republic of Moldova. Reprod Health. 2015;12:98. doi:10.1186/s12978-015-0088-6
  10. Chandra-Mouli V, Baltag V, Ogbaselassie L. Strategies to sustain and scale up youth friendly health services in the Republic of Moldova. BMC Public Health. 2013;13:284. doi:10.1186/1471-2458-13-284
  11. Renju J, Andrew B, Nyalali K, et al. A process evaluation of the scale up of a youth-friendly health services initiative in northern Tanzania. J Int AIDS Soc. 2010;13:32. doi:10.1186/1758-2652-13-32
  12. Halperin DT. Scaling up of family planning in low-income countries: lessons from Ethiopia. Lancet. 2014;383(9924):1264-1267. doi:10.1016/s0140-6736(13)62032-2
  13. Billings DL, Crane BB, Benson J, Solo J, Fetters T. Scaling-up a public health innovation: a comparative study of post-abortion care in Bolivia and Mexico. Soc Sci Med. 2007;64(11):2210-2222. doi:10.1016/j.socscimed.2007.02.026
  14. Nguyen G, Costenbader E, Plourde KF, Kerner B, Igras S. Scaling-up Normative Change Interventions for Adolescent and Youth Reproductive Health: An Examination of the Evidence. J Adolesc Health. 2019;64(4s):S16-S30. doi:10.1016/j.jadohealth.2019.01.004
  15. Gotsadze G, Chikovani I, Sulaberidze L, Gotsadze T, Goguadze K, Tavanxhi N. The Challenges of Transition From Donor-Funded Programs: Results From a Theory-Driven Multi-Country Comparative Case Study of Programs in Eastern Europe and Central Asia Supported by the Global Fund. Glob Health Sci Pract. 2019;7(2):258-272. doi:10.9745/ghsp-d-18-00425
  16. Family Planning 2020.  Family Planning Summit 2017. http://ec2-54-210-230-186.compute-1.amazonaws.com/wp-content/uploads/2017/09/FP_Summit_2017_Commitment_Summary_Update-V18-Clean.pdf  Accessed September 24, 2018.
  17. Darroch JE, Woog V, Bankole A, Ashford LS. Adding it up: costs and benefits of meeting the contraceptive needs of adolescents. Guttmacher Institute; 2016.
  18. Hubacher D, Mavranezouli I, McGinn E. Unintended pregnancy in sub-Saharan Africa: magnitude of the problem and potential role of contraceptive implants to alleviate it. Contraception. 2008;78(1):73-78. doi:10.1016/j.contraception.2008.03.002
  19. Biddlecom A, Riley T, Darroch JE, Sully E, Kantorová V, Wheldon M. Future scenarios of adolescent contraceptive use, cost and impact in developing regions. New York: Guttmacher Institute; 2018.
  20. Central Statistical Agency (CSA) Ethiopia, ICF International. Ethiopia Demographic and Health Survey 2016. Addis Ababa, Ethiopia, and Rockville, Maryland, USA: CSA and ICF; 2016. https://dhsprogram.com/pubs/pdf/FR328/FR328.pdf.  Accessed February 11, 2019.
  21. Central Statistical Agency (CSA), Ethiopia and ORC Macro. Ethiopia Demographic and Health Survey 2000. Addis Ababa, Ethiopia, and Calverton, Maryland, USA: CSA and ORC Macro; 2001.
  22. Federal Democratic Republic of Ethiopia; Ministry of Health. National Adolescent and Youth Reproductive Health Strategy: 2007-2015. http://www.nationalplanningcycles.org/sites/default/files/planning_cycle_repository/ethiopia/ayrh_strategy.pdf.  Accessed February 8, 2018.
  23. Federal Democratic Republic of Ethiopia; Ministry of Health. National Adolescent and Youth Health Strategy (2016-2020). http://corhaethiopia.org/wp-content/uploads/2016/08/NATIONAL-ADOLESCENT-AND-YOUTH-health-strategy-.pdf Accessed November 13, 2018.
  24. Federal Democratic Republic of Ethiopia Ministry of Health: Health Sector Development Program IV 2010/11 – 2014/15. Final draft 2010. http://phe-ethiopia.org/admin/uploads/attachment-721-HSDP%20IV%20Final%20Draft%2011Octoberr%202010.pdf Accessed November 12, 2018.
  25. Health Care Financing Reform in Ethiopia: Improving Quality and Equity. https://www.hfgproject.org/wp-content/uploads/2015/02/Ethiopia_Health_Care_Reform_Brief1.pdf Accessed November 12, 2018.
  26. Fikree FF, Abshiro WK, Mai MM, Hagos KL, Asnake M. Strengthening Youth Friendly Health Services through Expanding Method Choice to include Long-Acting Reversible Contraceptives for Ethiopian Youth. Afr J Reprod Health. 2017;21(3):37-48. doi:10.29063/ajrh2017/v21i3.3
  27. Fikree FF, Abshiro WK, Mai MM, Hagos KL, Asnake M. The Effect of Peer Education in Dispelling Myths and Misconceptions about Long-Acting Reversible Contraception among Ethiopian Youth. Afr J Reprod Health. 2018;22(3):90-99. doi:10.29063/ajrh2018/v22i3.10
  28. Family Planning 2020. Commitment: Government of Ethiopia. http://ec2-54-210-230-186.compute-1.amazonaws.com/wp-content/uploads/2018/02/Govt.-of-Ethiopia-FP2020-Commitment-2018-Update.pdf Accessed November 13, 2018.
  29. Nelson EC, Batalden PB, Huber TP, et al. Microsystems in health care: Part 1. Learning from high-performing front-line clinical units. Jt Comm J Qual Improv. 2002;28(9):472-493.
  30. Hanson K, Ranson MK, Oliveira-Cruz V, Mills A. Expanding access to priority health interventions: a framework for understanding the constraints to scaling-up. J Int Dev. 2003;15(1):1-14. doi:10.1002/jid.963
  31. World Health Organization (WHO). Global standards for quality health-care services for adolescents: a guide to implement a standards-driven approach to improve the quality of health care services for adolescents. Volume 1: Standards and criteria. WHO; 2015.
  32. Madon T, Hofman KJ, Kupfer L, Glass RI. Public health. Implementation science. Science. 2007;318(5857):1728-1729. doi:10.1126/science.1150009
  33. Hanson K, Cleary S, Schneider H, Tantivess S, Gilson L. Scaling up health policies and services in low- and middle-income settings. BMC Health Serv Res. 2010;10 Suppl 1:I1. doi:10.1186/1472-6963-10-s1-i1
  34. Rosenberg NE, Bhushan NL, Vansia D, et al. Comparing Youth-Friendly Health Services to the Standard of Care Through "Girl Power-Malawi": A Quasi-Experimental Cohort Study. J Acquir Immune Defic Syndr. 2018;79(4):458-466. doi:10.1097/qai.0000000000001830
  35. Federal Democratic Republic of Ethiopia Ministry of Health. August 2017. Ethiopia Health Accounts, 2013/14. Addis Ababa, Ethiopia.  https://www.hfgproject.org/ethiopia-health-accounts-201314/
  36. Mays N, Pope C. Rigour and qualitative research. BMJ. 1995;311(6997):109-112. doi:10.1136/bmj.311.6997.109
  37. Onwuegbuzie AJ, Leech NL. Validity and Qualitative Research: An Oxymoron? Qual Quant. 2007;41(2):233-249. doi:10.1007/s11135-006-9000-3