Elements of Successful Family Planning
Interview with Ricky Lu
Interview conducted on March 6, 2008 by Rose Reis
Rose Reis: What role does training play in family planning success?
Ricky Lu: Well the way I see it, one of the performance factors for providers to be able to provide quality services is that they need updated information about the contraceptive methods that they are going to be providing to their clients. They also need the skills in order to provide them safely. Training can also be motivational for them, that if they know they are being supported to improve their performance, if they need information, if they need to update their skills, there is always a way to do that. So, to me, I think training is important but we have to be looking at other performance factors that support a provider's provision of services.
RR: What, in fact, is a successful program, and how do you define a successful family planning program?
RL: The way I define a successful family planning program is that it is able to meet the needs of its clients who are coming from the community that the FP service is serving. It also means that the providers in the family planning clinic have the knowledge and the skills to deliver these services in a high quality way. It also means that there are supplies, there are commodities and that they can give it clients correctly when they need it.
RR: What are some of the most important things that program managers can do to make sure that their staff is well-trained and motivated?
RL: I think the role of the program manager here is critical in identifying how well the providers are performing according to the standards that they have set for the clinic. Part of the role of the program manager is also to provide support so that when providers are not meeting their performance standards or the standards of care that the clinic is offering, that they are able to access or identify ways to support this provider. I'll give you an example. For example a provider has been well-trained or has just come back from training on IUCD. When they arrive in the clinic, what the program manager can do it actually make sure that the equipment, the instruments, the supplies are available to this newly trained provider. The second part is to take a look at the policies, are the policies and guidelines there in the clinic that allow this provider to provide these services. How about supply? Supply of the IUCD. Is it available in the clinic for this newly trained provider to use for the clients. The other aspect is also taking a broader look at whether there are opportunities for them to practice. This also means how to figure how they will reach out to the community, how to communicate that there are new services that are available in the clinic. In this case, like IUCD, so it is working with other cadres in the clinic, the health educators, the community health workers or the voluntary health workers to get out the message that we have a newly-trained provider who can insert the IUD, a long-term method, safely and it will be good for you. If you want these services, come to the clinic and you will be taken care of. So there a lot of things a program manager can do to support the performance of a family planning provider.
RR: Could you talk about this in terms of one particular country program where you have seen this happen? Just within one scenario where they would be supportive of this.
RL: There are actually several examples of programs where you see program managers and providers working collaboratively in order to provide high quality services. For example, we had a program in Brazil back at that time. The program involved working with the program managers, taking a look at the performance measures or clinical guidelines or standards of care for the clinic. Now, the standard of care for the clinic establishes how services are going to be provided. Now, in order for these standards of care to be complied by everyone it is critical that the providers themselves have an understanding, have an input and know what the standards are. So, in this program we worked to bring the program manager or the administrators together with the providers to work together into looking at the standards and adapting them into the level of care. So both the provider and the administrator are looking at the same standard of care and when there is supervision, when there is monitoring of practices, when there is a feed-back on their practices, you are actually measuring them at the same standard. So that is one example.
Another way to look at this is our work in Indonesia which is aimed at looking at what would be the standards of care for IUCD insertion and removal. Then identifying what are the gaps between the stated standard and the current practice and what are the root causes for these gaps. And from there identifying solutions and then defining how these solutions are going to implemented and then setting a time-line and a goal. What would be the initial level of performance that they would try to meet in order to comply with the standards? So yes, there are a number of examples of program managers and providers working together in order to have a common understanding of how services should be provided, how they can be improved and how they can be maintained.
RR: How long does this process to implement, this standards-based management?
RL: So how long does the Standards Base Management Recognition (SBMR) take from start to finish? The way I see it, it is a very continuous process. The initial phase may take a little bit of time, because it requires identifying what are the standards you are looking at, working with providers and program managers to identify how the standards are going to be adapted to their situation, and then measuring the difference between what they have agreed on as standards and what the current practices are and then identifying the solutions. There are some standards which are easy to accomplish, and the whole idea of the SBM is to go for, what we call, the low-hanging fruit. Going for the low-hanging fruit is not only that you create or solve a problem immediately but it also creates a sense of motivation that you can solve the problem. An example of a low-hanging fruit in a clinic is putting up a sign. Now, if one of the standards of the clinic is that the clinic, in order to be offering quality services, needs to have a list of what is available in the clinic or when care is going to be provided. Now, this is quite a low hanging fruit because all you need is a board, paint and the effort to write down the services. Now compare this to a clinic that wants to be able to do a pelvic examination, which would require a gynecologic table. With that one, in a clinic, you need to be able to figure out where to get the resources, order the bed, pay for it, get it delivered and set it up, so it take a little bit more time. So, the way to go for a standards based management type of activity is identify what are some of the problems that you can solve immediately, solve it, and then go for the more complex ones.
RR: In what areas do providers lack training and in your opinion, what are some of the most importance skills and knowledge that a provider can possess?
RL: So what are some of the deficiencies in skills, knowledge or even attitude that a provider has in a typical family planning clinic? And I guess it varies because there are providers who are very new and would just need a basic overview of the different methods that are available in the clinic in terms of its benefits, mechanisms of action, advantages, disadvantages, limitations, how to use it, etc. There are skills which need to be developed which are particular for a method. Some of the skills are common across different methods, for example, counseling. Counseling involves both a message for a particular method as well as the process for interpersonal communication skills. Now, for a new provider, this has to be developed as a new skill, as an attitude on how to interact with client. For providers who have been providing services for quite sometime, it maybe that their deficiency or need when it comes to training would be a refresher. So, what is new with this particular method? What is new, for example, with Depo-Provera? So when you look at some of these, they require more of the refresher type of training in terms of knowledge. Going back again to new providers, so for example you are training a new provider on permanent contraception, for example, vasectomy. So that would involve training them to do the correct counseling, the correct infection-prevention practices as well as the skills for performing the vasectomy. So there is a variety of skills depending on the method and depending on the type of providers- whether they are new providers or they are current providers who need a refresher.
RR: Are there any particular deficiencies that you see frequently in low-resource areas in terms of provider skills?
RL: One of the most common deficiencies is in counseling, in terms of communication skills and using their limited time to get the maximum out of the interaction between the provider and their client. The other deficiency that I frequently see is in the area of infection prevention practices, whether it is the routine hand washing that you need to do after seeing a client or the processing of instruments correctly from used instruments down to storing these processed instruments. There is a definite path as to how these instruments need to be handled so that it is safe for the cleaners, and it is also going to be safe for the clients when they are re-used and also safe for the provider when they use it. These are the two common deficiencies that I see. Another thing, which may not be a deficiency but rather an approach to working with clients, which is attitude- the attitude of being supportive, friendly and helpful to their clients. Again, we have to take this into context of their work more often that not in low-resource settings. There is just a large number of things that they need to be doing in a limited period of time. But we also do see a lot of providers who are happily and satisfactorily doing their work.
RR: What advice would you give to a manager who is confronting a motivated and ill-trained staff?
RL: So what advice would I give to a program manager to encourage a staff who is not performing well? As a program manager I think we are going to encounter different performance level from our staff on a daily basis. And I guess the basic rule that we usually follow is to try to engage this provider, engage in the sense, not with an accusatory tone, engage in the sense ask them how they are and figuring out where the problem is. This means probably taking this provider to an area where they can have a private and confidential conversation about what is happening. More often than not, there are other factors that are involved in their performance. It may be some problems at home, it may be a personal issue, it may be that they just don't have the skills or the knowledge to perform the procedure. All of these things need to come out through a conversation with a program manager. Now, it takes time but I think it is more productive than penalizing or getting angry at your provider. So the very first thing I would suggest is to invite your provider to talk privately about what they see as the problem and how the program manager can support or address the problems of the provider.
RR: One of the experts we spoke to told us about providers, who, because they were not trained in the method, were injecting clients daily with Depo. Do you have any examples to share from programs you have worked on or read about that demonstrate the importance of quality training experience?
RL: So the question is have I encountered unusual practices in providers because they lacked training? The practice you just mentioned daily injection of Depo-Provera which is not supposed to be happening because it's a method that has to be injected every 3 months. Yes, there have been cases that I have encountered and one clear example that I can think of is for example the use of the IUD, particularly the Copper D83A. Most of us load the IUD in the non-touch technique: using the packaging of IUD to load the IUD and not physically touching the IUD. What I've seen among untrained providers is that they put on a pair of gloves, open the entire pack, and take the IUD directly into their finger and load it into the inserter tube. Now ideally, you can do that as long as you maintain sterility but it wastes the precious gloves you have in the clinic. When it fact you can do this without the gloves using the no-touch technique for loading the IUD. This part of the training for providers for IUD: how to load the IUD using the no touch technique. Another example is no-touch insertion technique. Once it has been loaded using the no touch technique, you insert the IUD into the cervix without touching the vaginal wall without touching the instrument speculum that was used to view the cervix. Again if the provider is not trained to do the no touch technique, they may touch the speculum, the cervix or the vaginal wall inadvertently, possibly contaminating the IUD before it gets into the uterus. So those are two examples I can think of. There are still some but we can go on and on with these examples.
RR: How did you become focused on training?
RL: By training I am a physician and by specialization I am a gynecologist. I started in training providers when I was asked to work with a group of surgeons and obstetricians training to do laparoscopic tubal ligation—a high tech type of tying the tubes. What you do is tubal ligation using a laproscope.
Over a period of years I've been involved in training of trainers, teaching residents as well as medical students and eventually working with in service with providers needing additional skills development. With JHPIEGO, my work comprises both training as well as looking to improve provider performance. I do training work and I also do a lot of work that supports training largely in area: 'How do we make sure providers are able to perform what they are asked to do?' Part of my work is in in-service training, part of my work is in pre-service, program development and management. I do a number of things but training is always exciting because it involves you directly with providers, it gives you a sense of what is happening at the point of care. When you look back developing standards guidelines, is to have a grasp of what is happening at the level providers and clients.
RR: Where were you practicing as an OB/Gyn?
RL: I am originally from the Philippines. I have completed my status and training in the Phillipines. I had my fellowship here, at Hopkins School of Public Health part of fellowship program that I had with JHPIEGO doing post graduate program as well as applying what I'm learning to program activities. I was involved in the Nepal programs as well as those in the former Soviet Union; a lot in women's health particularly reproductive health.
RL: How has clinical training evolved since I started? There are a number of things that have changed actually. One of the biggest changes is in the area of communications and particularly information technology. But the approaches that we are using for our clinical skills training have essentially remained the same, which is competency based, adult education, humanistic approaches (a lot of simulations and models to allow providers or participants in their training activities to learn and master skills first on models before we allow them to work on clients). A lot of training has been group-based activity, so we bring in a group about 10-15 participants to central place. You work with them in the classroom both in a lecture or small group activity, you work with them on models and then you go to a practice site to practice those skills, assess them and then tell them: “Yes, you are now ready to do this procedure.”
I've also seen as needs in the field change I've seen trend toward on the job training or self-based learning: developing capabilities. In a number of low resource settings, training where participants are taken out, even 3 days or 1 week for training in IUD, means that particular clinic is going to lose the services of that provider for training on IUD. So we should take a look at some of the different ways that we can maximize their training and at the same time minimize the disruption in their services. I mentioned one of the biggest changes has actually been in information technology, we’re seeing more and more of what we call blended learning, using both group based activities and multimedia or distance learning approaches. We blend them together as a learning approach. One example of that one would be for knowledge transfer. Let’s say you want to teach them on IUD, before they come to the training sight you can send them CD with orientation and exercises to complete knowledge transfer. So when they arrive at your training, you review key points and messages in terms of knowledge and then focus your attention in developing those skills using as models and clients. So yes, we are using more and more trying to leverage what information technology can offer in terms of maximizing training, minimizing disruption of services and at the same time satisfying the needs of participants as providers to perform a particular skill.
RR: What kinds of resources do you use for ICT for training providers?
RL: There's a combination of things we use and it’s actually driven by what is actually available in a particular country. In some countries, for example in Asia, the internet may be quite reliable and stable and easily-accesible, we can probably use web-based approaches. Whereas in certain countries in Africa where it may really be a challenge when it comes to connecting to the internet, we may want to use CD-ROM based material. We may send it out and give participants instructions on how to use it and then let them use it at their site and then call them back again for practice. So we blend them depending on what’s available in the country.
RR: Are you familiar with the Global Health eLearning website?
RL: Absolutely. It's been used by USAID staff. I believe it's open to everyone with a good enough internet access to be able to use existing materials. What I've heard is that these topics are well received by people who have accessed it so far.
RR: You mentioned the Standards Based Management and Recognition process to performance improvement; can you bring us up to speed on what that is?
RL: The way I see it, it is an approach for a continuous quality improvement for health services. In my particular case, since I work a lot in women’s health, it’s used in family planning, maternal health as well as neonatal health, and cervical cancer prevention. The same approach can be used for other clinical services.
It looks at working collaboratively with providers and developing common standards for a particular procedure and then measuring their current practices to agreed standards so that they can address deficiencies that are going to come out between current practice and agreed upon standards. It's not as if they are picking out standards from thin air. They are usually evidenced-based, based on best practices and then adapted to local situation and these are set for the standards of care for that particular produced. It provides you with a yard stick as to "how well are you meeting those standards that you yourself have agreed upon".
It doesn't stop there. The next step is identifying why you're not meeting those standards and what are some of the problems with meeting those standards? It goes to the level of identifying the root cause. The root cause, at first glance, is that there may be no supply for the IUD. If you do a root cause analysis, there might be a deeper problem than that: there are just no policies or guidelines at the clinic to decide who, how and when the IUD is going to be provided in that clinic. So, having a clear understanding of the deficiency allows you to the next step which is “what is the solution, the next step to address this deficiency?”
Once you have done that, it’s setting priority to solve these problems. How and when should we do this one? How do we measure that we are meeting those standards? The nice thing about the standards based managements is it develops a sense of ownership among the providers, that this is a standard we ourselves agreed upon. There’s a common theme that we have said we can meet those standards. The additional advantage is the recognition part. There is motivation for them to do well because they'll be recognized for the work and the effort put in to meet those standards. This can come in a number of ways. In some countries where we have started SBMR, this means every quarter or once a year there is a meeting that brings in all the providers or institutions or clinics and given plain certificate that you have meet your standards. He may be the local district manager or the local health minister. In some countries they give t-shirts or tokens. It's not like you're working your butt off and not being acknowledged, but having someone say we're watching or we're concerned and happy that this is happening and you are doing a good job.
My word of caution it's a process that needs to work iteratively and needs to be supported and requires commitment from everyone in order for this to work. It's not like JHPIEO alone initiated this one; it's a combination of agencies its a development that used a number of resources both from the commercial industrial sector as well as work in quality assurance and quality improvement.
RR: Do you have any other comments you want to go back to?
RL: Do I have anything else to ... In order to have high trained providers providing quality services, we need to look at the issue of preparing providers in a very broad perspective. We have discussed only one segment in this interview is just one segment: in service training. The other critical component is taking a look at pre-service education. A lot of things, knowledge and critical skills can be developed from pre-service. From a health service and a health cost perspective, we can be more cost effective in terms of preparing providers if we link what is happening at the service delivery points if to how we prepare providers during their pre-service education, and then use the in-service training as a way to add, as a way to upgrade, refresh and add new skills at their clinics.
RR: Thanks very much for your time.
RL: No problem.
