Bill & Melinda Gates Institute for Population and Reproductive Health Using new technologies to track access, choice, and quality dimensions of service delivery Accountability Workshop, EuroNGO Conference October 29, 2014, Madrid
PMA 2020 Overview Responds to: Need for more frequent data to mark progress Evolution of smart-phone technology & cell provider reach 2 linked mobile-assisted, sentinel surveys Household & Female Survey measuring demand and use Service Delivery Point Survey measuring supply and access Implementation in 10 countries Ghana DR Congo Ethiopia Uganda Kenya Burkina Faso Nigeria Niger Indonesia India
PMA2020 Survey Features Innovative mobile technology Annual indicators of progress Survey fielded in 4-6 week timeframe Provides consistency with DHS measures and introduces new indicators of quality, choice, access Creates a community feedback loop to prompt program improvement Establishes a platform that is expandable to other health sectors Strengthens local capacity Network of partner universities/research institutions Network of resident enumerators
Data validation & analyses Data management Community feedback: key indicators, visuals transferred via GPRS Data transfer via GPRS networks Real-time update of tables, graphs, maps (available at different aggregation levels) interface for external data access: reports, graphs,maps Service Delivery Point Mobile Data collection Households Sentinel Enumerator
Open Data Kit (ODK) Screen shots
Measuring access, equity, quality, choice All indicators can be disaggregated by age, marital status, wealth quintile, education, region, urban/rural For Users ( most recent visit) Did you obtain the method you wanted? If not, why not? Who made the final decision on the method you received? Did you pay anything for the services received? If yes, how much? Were you told of other methods? Were you told of side effects of your method? What to do if you experienced side effects? Would you return to this provider? Refer relative/friend to provider? If sterilized, were you told that this method was permanent? For Discontinued Users Female Survey (51 questions/31 on FP) What was your method? When did you stop using? Why did you stop using? For Women with Unmet Need Reason for not using a method?
Measuring access, equity, quality, choice Service Accessibility How many days a week is FP offered? Are services offered today? What methods are counseled? Provided? Referred? Charged? Have any methods been out of stock in the last 12 months? Which methods? If implants provided, are there trained personnel to insert? Remove? Are key supplies in place? (repeated for IUDs) Are unmarried adolescents counseled, offered, referred for contraceptive methods? Are CHWs supported from facility? If so, how many? What FP services do they offer? Has mobile outreach team worked from facility? How many times in last year? Does facility charge fees for FP services? How much by method? Service Quality Does facility have system for client feedback? Ask to see. Has there been change? When was the last time a supervisor from outside this facility came here to visit? Integrated services SDP Survey (56 questions/42 on FP) If delivery/maternity: Is FP counseled during the post-partum visit? Are services offered/referred? (repeated for post-abortion, HIV-related services)
Survey status Country Implementing Partner Enum. Areas Status Ghana KNUST + UDS 100 Round 1 & 2 complete DR Congo* Univ. of Kinshasa 60 Round 1 complete/round 2 underway Ethiopia Addis Ababa Univ. + 200 Round 1 complete Uganda Makerere Univ. 110 Round 1 complete Kenya ICRH + 120 Round 1 complete Nigeria U Ibadan, Ife & Bayero 200+ Data collection underway Burkina Faso ISSP, U Ouagadougou 53 Enumerator training completed Indonesia BKKBN + 300+ Survey preparations underway India & Niger tbd tbd Assessment visits complete * DR Congo survey is managed by Tulane University and initially is implemented in Kinshasa only.
Kenya Launch Trainings: Mombasa TOT Bungoma REs Mapping/listing field practice by: RE s Supervisors Data collection using ODK Field Interview Practice
A few topline observations REs: the backbone of PMA2020 Recruit, train, support, reward, retain No phones, no program The right phones, in the right place, at the right time Govt interest in sub-national detail/added modules Need to first build the platform/prove the concept
What we are learning Learning: REs can be trained to conduct mobile-assisted surveys, with support Survey rounds can be completed in 4-6 weeks Cascade training is highly effective ODK performs well and can aggregate data instantly Monitoring data as it comes in is important for identifying problems early Preliminary indicators in line with those of recent surveys Surprises: More front-end training than envisioned Greater number of supervisors/support team required Elevated level of effort needed for mapping/listing phase Few smart phones meet our requirements/special shipments needed Yet to learn: Resilience of resident enumerator network Feasibility of using this network for community feedback
Key Indicators Brief* * supplemented by detailed indicator report.
Select results from: Kenya Ethiopia Uganda Ghana
Ethiopia: Method Mix Sterilization 0.4% IUD 1.9% Pills 5.6% Condoms 0.5% Other Modern 0.4 % Implants 15.9% mcpr:33.8% (among married contraceptive users) Injectables 75.5% EDHS, 2011 Injectables 76.2% Implants 12.5% Pills 7.7% IUD 1.1% Condoms 0.7% Sterilization 1.8% Other Modern 0.0%
Ethiopia: Method Mix (among sexually, active unmarried women) Emergency Contraception 1.4% IUD 4.9% Other Modern 0.2% Implants 7.4% Pills 8.6% mcpr: 42.3% Condoms 13.5% Injectables 64.1 % EDHS, 2011 Injectables 61.1% Condoms 20.6% Pills 10.3% Implants 4.6% Sterilization 2.5% IUD 0.4% EC 0.0% Other Modern 0.6%
Percentage Ethiopia: % demand satisfied by wealth quintile 90 80 70 60 50 40 EDHS 2011 PMA2014/Ethiopia 30 20 10 0 Q1 Q2 Q3 Q4 Q5 Poorest Wealth Quintile % demand satisfied = modern CPR/(CPR+ unmet need) Wealthiest
Uganda Fertility Indicators UDHS 2011 PMA2014/Uganda Total Fertility Rate (all women age 15-49) 6.2 5.9 Adolescent Birth Rate (per 1000, age 15-19) 134 146 Recent Births Unintended (%) 43.7 53.0 Wanted Later 31.8 33.9 Wanted No More 11.9 19.2 Ratio of Lowest vs. Highest Wealth Quintiles of % Births Unintended -- 69 : 28
Indicators of Access, Equity, Quality & Choice Ghana Ethiopia Obtained method of choice 94% 95% Method Chosen By Woman Alone or Jointly 90% 79% Paid for services 66% 19% Told of other methods 57% 50% Counseled on side effects 48% 40% If Counseled, told what to do 78% 80% Sterilized users told that the method was permanent (n=10/15) Would return to provider and would refer a friend or family member 100% 100% 70% 68%
Ghana Unmarried women are more likely to pay for family planning. Rural women are more likely to pay. Average payment: 11 cedis; 10: injectables, 8: pills, 17: implants.
Kenya: Indicators across 9 counties County mcpr Unmet Need % Satisfied Bungoma 57 22 72% Kericho 52 26 67% Kiambu 67 9 88% Kilifi 33 32 50% Kitui 53 18 75% Nairobi 57 21 73% Nandi 58 23 71% Nyamira 63 15 81% Siaya 50 24 67%
Ethiopia: Service Delivery Points (n=392: 347 Public, 45 Private) Public Private Percent Offering Family Planning 98 96 Average Number Of Days Per Week 5.5 4.2 Offering The Following Family Planning Methods: % % Pill 90 91 Male condoms 97 88 Injectable 99 86 Implants 82 7 IUDs 57 7 Female Sterilization 15 0
Ghana: SDPs characteristics (n=149: 106 public, 43 private) Public Private Offer FP counsel/service to adolescents 100 89 Charging fees for FP services 91 73 With client feedback system 100 61 Mobile outreach support in last 12 months 31 0 Integrating FP into: Maternal health services 90 19 Post-abortion services 91 19 HIV services 87 26
Percentage of Service Delivery Points Kenya: stock-outs in last 12 months, by method 25 20 15 10 5 0 Condoms IUDs Injectables Implants Pills Male
Bill & Melinda Gates Institute for Population and Reproductive Health Thank you Find PMA2020 on the web: www.pma2020.org www.facebook.com/gates.pma2020 www.twitter.com/pma2020jhu
Kenya Resident Enumerator: Profile 35 + < 25 2 or more No children Single 30-34 25-29 Married 1 child Secondary Unemployed In EA Far Tertiary Full-time Part-time Near