Implementing Quality Improvement Initiatives to Improve the Use of Adolescent- and Youth-Friendly Health Services in Zou, Benin

INTRODUCTION

In Benin, the unmet need for family planning services is especially high for adolescent girls and youth aged 15-24 years. The Challenge Initiative (TCI) supported the health system to assess and improve the quality of adolescent and youth sexual reproductive health services and enhance contraceptive uptake in 65 service delivery points (SDPs) of the Zou department.

PROGRAM DESCRIPTION

Between June 2019 and March 2021, TCI supported the health districts in Zou to train an assessment team to complete 3 cycles of quality assessments (QAs) using a QA checklist adapted to the local context. Based on assessment scores, the SDPs were categorized into poor, moderate, or good to excellent quality. The SDP managers developed remedial action plans after each cycle and for each SDP and followed up with supportive supervision.

RESULTS

The first QA cycle showed that 52% of assessed SDPs achieved a good to excellent classification; by the second QA cycle, this reached 74%. However, the quality of adolescent- and youth-friendly health services regressed during the third QA cycle (during COVID-19 pandemic disruptions), when only 40% of SDPs achieved the good to excellent category. Between the first and second QA cycles, contraceptive uptake for adolescents and youth improved in the SDPs that had good or excellent quality of services, compared to the ones that were of lower quality (established significance level of 5% with a P value of .031).

CONCLUSION

Further assessments could deepen our understanding of the internal and external factors that can affect service quality. The findings reinforce the importance of investing in quality improvement strategies to maximize the use of sexual and reproductive health services among adolescents and youth. They also underscore the need for a contextual and nuanced approach to ensure enduring results.

Increasing Contraceptive Use Through Free Family Planning Special Days in Poor Urban Areas in Francophone West Africa

INTRODUCTION

In francophone West Africa (FWA), contraceptive uptake remains limited, often due to geographic, economic, and social barriers. With technical support from The Challenge Initiative (TCI), municipalities and health systems implemented Family Planning Special Days (FPSDs) to improve family planning (FP) uptake and reduce high unmet need. The FPSD intervention consisted of organizing free FP services on a monthly or quarterly basis over 2 to 5 consecutive days within health facilities or sites close to the population. These events helped to educate, inform, and mobilize the community around FP and improve geographic and financial access to FP services. We describe the process of implementing FPSDs in FWA countries and analyze the results.

METHODS

We used several techniques and data sources in our descriptive analysis, including document review of activity reports, analysis of health management information system data, and retrospective data collection on the profile of FPSD users and implementation costs.

RESULTS

Between July 2020 and June 2021, municipalities and health systems collaborated to hold 1,046 FPSDs in 452 health facilities in 10 FWA cities. This collaboration was made possible through the establishment of city-level management and coordination units composed of municipal, health system, and TCI focal points. In the 10 FWA cities, 181,792 people were made aware of the FPSDs and 71,669 contraceptive users were served. The overall cost of organizing the FPSDs was about 145382501 Central African CFA francs (US$252839), 35% of which came from the municipalities' local financial contribution.

DISCUSSION

Results from our analysis showed that, with appropriate financial support from municipalities, the health system could offer high-quality free FP services. Nonetheless, there are still challenges to the sustainability of conducting FPSDs, including the availability of contraceptive products and continued financing of the strategy during system shocks such as the COVID-19 pandemic.

Scaling Access to Contraception for Youth in Urban Slums: The Challenge Initiative's Systems-Based Multi-Pronged Strategy for Youth-Friendly Cities

INTRODUCTION

More than half of all adolescents globally live in Asia, with India having the largest adolescent population in the world at 253 million. In sub-Saharan Africa, adolescents make up the greatest proportion of the population, with 23% of the population aged 10-19. And these numbers are predicted to grow rapidly-particularly in urban areas as rural youth migrate to cities for economic opportunities. While adolescents and youth are subject to high sexual and reproductive health risks, few efforts have been documented for addressing these in urban settings, especially in poor settlements.

METHODS

The Challenge Initiative (TCI) is a demand-driven, family planning platform for sustainable scale and impact that lets city governments-in particular urban slums-lead implementation. It is currently active in 11 countries in Africa and Asia. In June 2018, TCI heightened its focus on adolescent and youth sexual and reproductive health (AYSRH) for youth living in urban slums. It now supports 39 city governments. TCI dedicates technical and program support to married (including first-time parents) and unmarried youth ages 15-24 years. Using an innovative coaching model and an online learning platform (TCI University), TCI supports city governments as they implement AYSRH interventions to accelerate the impact of TCI's model for rapid scale.

RESULTS

TCI has been assessing the performance of cities implementing its AYSRH approaches using its RAISE tool and has found considerable improvement over two rounds of assessments through TCI coaching and support for adaptation of its high-impact interventions between the first and second round.

CONCLUSIONS

TCI's AYSRH approach scaled rapidly to 39 cities and multiple urban slums since 2018, using its evidence-based interventions and coaching model. In the context of universal health coverage, TCI has supported segmented demand generation and improved access to quality and affordable contraceptive as well as youth-friendly health services. It provides a menu of interventions for cities to implement for youth-including such approaches as public-private partnerships with pharmacies and quality assurance using quick checklists-along with an innovative coaching model. This approach has facilitated greater access to contraceptive methods of choice for youth.

Mentoring, Task Sharing, and Community Outreach Through the TutoratPlus Approach: Increasing Use of Long-Acting Reversible Contraceptives in Senegal

Mentoring, task sharing, and community outreach at 100 rural facilities in Senegal led to an 86% increase over 6 months in the number of women choosing long-acting reversible contraceptives (from 1,552 to 2,879). Concurrent improvement of facilities and provider skills, coupled with the application of Senegal’s task-sharing policy, are increasing the range of contraceptive methods available to women throughout the country.

Background:

To broaden access to family planning in rural areas and improve contraceptive prevalence, Senegal, in the context of wide method choice, is promoting implants and the intrauterine device, currently used throughout the country by only 5.6% of women of reproductive age who are in union, primarily urban women.

Methods:

The TutoratPlus performance improvement approach strengthens family planning clinical skills, particularly for long-acting reversible contraceptives (LARCs), through mentoring, task sharing, and community outreach. Following a 2013 baseline situation analysis, 290 participating facilities in 12 of Senegal's 14 regions developed action plans to address gaps identified in 3 areas: provider performance, equipment, and infrastructure. Between 2013 and 2014, 85 trained mentors coached, demonstrated skills, and observed 857 providers, including nurses, nonclinical family planning counselors, and community health workers (CHWs), in LARC service provision through two 5-day visits per facility at 21-day intervals. We used routine service delivery data and TutoratPlus mentoring data to assess changes in contraceptive use, including LARCs, 6 months before and 6 months after the mentoring intervention among 100 of the facilities with complete data.

Results:

The baseline assessment of 290 facilities found that fewer than half (47%) had a provider who could offer at least 1 LARC method, and 64% to 69% lacked kits. Post-intervention, all 290 facilities were adequately equipped and clinically able to offer LARCs. Among the 552 clinical providers, the percentage with acceptable LARC performance (at least 80% of observation checklist items correct) doubled from 32% to 67% over the 2 mentoring visits. In the 100 facilities with available comparison data, the number of new LARC users rose from 1,552 to 2,879 in the 6 months pre- and post-intervention—an 86% increase.

Conclusion:

Success of the TutoratPlus approach in Senegal is likely in part attributable to addressing facility-specific needs, using on-site mentoring to assess provider capacity, and achieving workplace enhancements through community engagement. Without CHW-initiated community outreach, LARC uptake might have been lower. Although task sharing requires institutionalization within national health systems, TutoratPlus demonstrates that provider skills can be improved, facilities can be better equipped, and demand can be promoted using existing government and community resources.