Background: To effectively deliver on proposed objectives, it is vital that practitioners, policymakers, and other stakeholders are able to clearly understand how strongly their large-scale program is being implemented. This study sought to test the feasibility, cost-effectiveness, and validity of a phone-based method as an innovative and cost-efficient approach to assessing program implementation strength (through an Implementation Strength Assessment-ISA), alternative to the traditional in-person field methods. Methods: We conducted 701 mobile phone and 356 in-person interviews with facility in-Charges and two types of community health workers who provide family planning services in the Dowa and Ntcheu districts in Malawi. Responses received via the phone interview were validated through in-person review of records and inspections. Sensitivity and specificity were calculated to determine validity. Results: Most indicators at the health facility and community health worker levels were above a 70% threshold for sensitivity. However, there were fewer indicators that met this threshold for specificity. The primary reason for lower specificity was due to poor recordkeeping. Collecting data via mobile phone was found to be feasible and twice as cost-efficient as collecting the same data via in-person inspections. Conclusions: The rapid increase in mobile phone ownership and network availability in lower income countries could offer an alternative, cost-effective avenue to collect data for a better understanding of program implementation. Through rigorous assessment, this study found that using mobile phones could be a low-cost alternative to collect data on health system delivery of services, especially in places where routine data quality is poor and traditional, in-person methods are costly.
To explore the association between the strength of implementation of family planning (FP) programs on the use of modern contraceptives. Specifically, how strongly these programs are being implemented across a health facility’s catchment area in Malawi and the odds of a woman in that catchment area is using modern contraceptives. This information can be used to assess whether the combined impact of multiple large-scale FP programs is leading to change in the health outcomes they aim to improve. We used data from the 2017 Implementation Strength Assessment (ISA) that quantified how much of family planning programs at the health facility and community health worker levels were being implemented across every district of Malawi. We used a summary measure developed in a previous study that employs quantitative methods to combine data across FP domains and health system levels. We tested the association of this summary measure for implementation strength with household data from the 2015 Malawi Demographic Health Survey (DHS). We found that areas with stronger implementation of FP programs had higher odds of women using modern contraceptives compared with areas with weaker implementation. The association of ISA with use of modern contraception was different by education, marital status, and geography. After controlling for these factors, we found that the adjusted odds of using a modern contraceptive was three times higher in catchment areas with high implementation strength compared to those with lower strength. Metrics that summarize how strongly FP programs are being implemented were used to show a statistically significantly positive relationship between increasing implementation strength and higher rates of modern contraceptive use. Decisionmakers at the various levels of health authority can use this type of summary measure to better understand the combined impact of their diverse FP programming and inform future programmatic and policy decisions. The findings also reinforce the idea that having a well-supported and supplied cadre of community health workers supplementing FP provision at the health facility can be an important health systems mechanism, especially in rural settings and to target youth populations.
17 18 19 20 21 22 49 statistically significantly positive relationship between increasing implementation strength and 50 higher rates of modern contraceptive use. Decisionmakers at the various levels of health 51 authority can use this type of summary measure to better understand the combined impact of 52 their diverse FP programming and inform future programmatic and policy decisions. The 53 findings also reinforce the idea that having a well-supported and supplied cadre of community 54 health workers supplementing FP provision at the health facility can be an important health 55 systems mechanism, especially in rural settings and to target youth populations. 56 57 58 59 60 61 62 63 64 65 66 Page 5 of 25 91 multiple national and subnational FP programs. 17,18,19 This is evident in their recent national 92 strategy policies and initiatives, such as their Youth-Friendly Health Services (YFHS) 93 program. 20,21 94 95 The Malawi FP delivery system includes government, faith-based (Christian Health Association 96 of Malawi -"CHAM"), and NGO facilities, as well as two types of community health workers: 97 paid Health Surveillance Agents (HSAs) who can provide male condoms, oral contraceptive pills 98 (OCPs), and injectables (the most popular form of FP in Malawi) and voluntary Community-99 Based Distribution Agents (CBDAs), who can provide male condoms and OCPs directly to 100 women. 101102 Previous studies have shown mixed results in demonstrating a clear association between 103 structural quality or readiness (an analogue to implementation strength) and contraceptive 104 use. 22,23,24 Yet, very few of these studies include outreach services or analyze the combined 105 impact of the implementation of multiple FP programs at the national scale. 25,26,30 We conducted 106 an Implementation Strength Assessment (ISA) in 2017 to measure the strength of FP programs 107 delivered across the community and facility levels in Malawi and developed a summary measure 108 that reflects the combined implementation strength of FP programs across these levels. 27 Using 109 this summary measure, this paper reports on the association between the implementation strength 110 of FP programs and modern contraceptive use among Malawian women. 112 Materials and Methods 113 This study draws from two data sources from Malawi: the 2017 ISA of FP programs and the 114 2015 Malawi Demographic and Health Survey (DHS). 115 116 Data source for independent variable 117 We reported previously on the methods the ISA conducted in Malawi in 2017. 27 The ISA was a 118 cross-sectional, mobile phone-based survey conducted from May to July 2017 that aimed to 119 understand how strongly FP programs, especially those directed at youth, were being 120 implemented at the health facility and CHW levels across all 28 districts of Malawi. Data were 121 collected across five domains: training of health workers, supervision of health workers, 122 contraceptive method and supply availability, FP demand generation, and accessibility of FP 123 services. 124 125...
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