Dr. Min Zaw Dr. Aung Hein Minal Amin Increased quality IUDs services utilization among Sun Quality Health Social Franchises through Supportive Supervision Good morning Ladies and Gentlemen. My name is “Dr. Aung Hein”. I am from PSI/Myanmar, working as Health Services Manager-Operation in HS department. It is an honor to have the opportunity to present our experience in this international conference. Today, I would like to present about “Increased quality IUDs services utilization among Sun Quality Health Social Franchises through Supportive supervision ”. Dr. Min Zaw Dr. Aung Hein Minal Amin

Sun Quality Health Network Private MD networking Serving for the poor Same Quality and Price at service site PSI/Myanmar uses social franchising to reach the poor and vulnerable in Myanmar with high quality products and services. This franchised network named as Sun Quality Health, members are licensed general practitioners (private medical doctors) who most work full time at their own clinic and serve low income people of Myanmar. They provide wide range for services with same quality and price to community. Sun network was established since 2001 and working on 5 major health areas; reproductive health, child health, malaria, HIV and TB. PSI/M currently works together with 1543 SQH doctors in 174 townships. The majority of the clinics is located in urban and peri-urban area and serves for low income people of Myanmar. The sun doctor receives training, communication materials and commodities at highly subsidized prices from PSI/Myanmar in return for providing agreed quality standards to the client. Demand side financing

SQHC and Reproductive Health Reproductive Health in SHQC There are currently 1270 active RH providers who provide up to 5 family planning products: Pills, 3 month injection, emergency contraception, male and female condoms and IUDs. In 2010, there were over million RH consultations. Now I am going to present you about IUD program of PSI/Myanmar. The IUD was launched in the Sun network in 2003 and 104 Sun doctors were trained. But yearly insertion was not more than 200 over 5 year period. But starting from 2008, strategies on long term method program changed and lunched PSI IUD mobile team and event days for IUD services. In November 2009 because of policy barrier, PSI/Myanmar changed its strategies on IUD activities that included stopping the mobile team activities and starting to conduct intensive supportive supervision visit to recently trained providers instead. PSI/M expanded coverage of IUD services by training more IUD providers around the country. We have a yearly target to expand 100 IUD trained providers. Now we have 284 active IUDs providers. RH services Tsp active Providers RH 174 1270 LTM 117 284

In this slide, I would like to present another innovative Sun channel named ‘Sun Primary Channel’. Sun Primary Health providers are village resident and trained by PSI/Myanmar for basic health care and referral services for RH, and TB. We build a strong bridge between SQH and SPH channel for expending of network coverage. In this slide, we can see that most sun quality clinic based in urban and sometimes, in peri-urban area. But services from SQH can be spread through SPH channel in rural area. SQH Sun Primary Health

Clinic assistant or Clinic educator Conduct birth spacing health talk Refer potential birth spacing clients Assist providers in infection prevention procedure Another innovative way of creating demand for IUD services is assistant or clinic educator. PSI/M trains assistant from SQH provider as RH educator. They conduct birth spacing health talk in the community and refer potential birth spacing clients to SQH clinic. Also they assist providers in infection prevention procedure which will take certain amount of time for providers to perform.

Quality accreditation Training (3 days) 2 days: theory and practice with zoe model 1 day practice with client Post training SSV Average 3 SSVs By PSI staffs Quality accreditation By independent QA team In accordance with PSI/M service delivery protocol Annual visit Supportive supervision activities (post training) Now I would like to present current IUD activities in PSI/Myanmar. After November 2009, we started to use more participatory, highly informative and learners focus IUD training curriculum among franchised network. It is designed to cover all the essential skills need for quality IUD services. After training, we conducts post training supportive supervision activities as a part of training. Average three post-training supportive supervision visits must take place before a provider can start IUD insertions freely. SSV was done by franchising staffs of PSI/Myanmar who were trained and certified on IUD insertion and removal according to PSI protocol. There must be client for IUD service during supportive supervision visit to access providers’ technical skills. During supportive supervision visit, franchising staffs need to give intensive support, supervise technical skill and give constructive feedback for improvement. After getting satisfactory practice during SSV, PSI/Myanmar’s independent quality assurance team conducts the quality accreditation visit to certify provider’s competency according to PSI service delivery protocol. To maintain quality services of accredited providers, quality assurance team conducts annual visit to providers. QA team also have responsible to follow up complication cases that arise from IUD insertion by providers. They also established referral network with Ob/gy for complication cases. After quality accredit, PSI/M continue to conduct quality monthly monitoring visit and gives support to provider as needed.

Stop mobile team SSV activities In this graph, you can see the numbers of IUD insertion by PSI mobile team and Sun providers. Since 2008 up to 2011 February, we inserted 61,751 IUDs. The green color is IUD insertion by mobile team and the blue color is insertion by Sun providers. In 2009 november, we stopped mobile team activities and started supportive supervision activities to providers. During this period, only 18 adverse events occurred.

Quality Accredited IUD providers before and with SSV (85.7%) (9.8%) In 2010, 101 Providers were trained on IUD insertion followed by intensive SSV. As of March 2011, 49 out of 101 providers were accredited by Quality assurance team which can be comparable to 2009 trained providers in which only 8 providers were accredited for quality services. It can be clearly seen that intensive SSV is one of the factors that contribute in quality services. Before SSV With SSV

QA passed IUD providers after SSV >86% of providers were certified after 3 SSVs 49 QA accredited providers inserted 1,868 IUDs in 2010 No adverse event on follow-up Out of 49 quality accredited providers, 42 providers (>85.7%) were certified after 3 consecutive SSVs. So, at least 3 consecutive SSVs were needed for providers to become quality accredited providers.

Lesson Learnt Demand creation by SPH Cohesive team approach between supportive supervision team and quality assurance team Strong communication and relationship between SQH providers and franchising staffs Here are some lesson learnt that we found on SSV activities. We found that demand creation activities by sun primary health and clinic assistant can help SSV activities. 2nd thing is cohesive team approach between Supportive supervision team and quality assurance team can help to improve provider’s technical skill effectively. Other thing is strong relationship between SQH providers and franchising staffs during SS activities.

Challenges Maintain quality standards after accreditation How to solve or need to find solutions for providers who haven’t passed quality accredited SSV Vs human resource SSV by peer supervisor

Thanks Thanks you for ur attention.