3 -pp rr 2003 4-page layout bw 12-30-03

PRIMEPRIMEPRIMEPRIMEPRIMEPPPPPAGESAGESAGESAGESAGES

PRIMEIntraHealth International, Inc.6340 Quadrangle Drive, Suite 200Chapel Hill, North Carolina [email protected] www.intrahealth.org

Reviewing Results in PRIME IIOct. 2002�Sept. 2003

Policy, Advocacy and Services

� National RH Policy

� Partnership

Knowledge Advancing Best Practices

� PMTCT

� Scaling-Up PI

� Costing

� Supportive Supervision

Support to the Field

� Nicaragua: EONC

� Philippines: HIV/AIDS

� Paraguay: FP/RH Quality

� Mali: FGC

� Senegal: PAC

� Dominican Republic: RTL

� Mali, Benin, Ethiopia: PPPH

� Bangladesh: RTL

November 2003

PRIME II Results Review

Since the PRIME II Project is in its fifth and final year of imple-mentation, a group of senior headquarters and field staff,partner representatives and USAID officials gathered in July2003 to review available and expected results and determinethe key messages and lessons learned emerging from theProject. A spin-off from this group has continued the effort todevelop a comprehensive communications strategy for the finalyear of the Project to ensure that these lessons and messagesare widely shared. This year�s Results Review submission in-cludes an overview of the key messages that emerged from theJuly workshop and a series of Pages highlighting key resultsareas from 2002-2003.

Key MessagesThe Overarching Message:PRIME II has improved primary provider performance byapplying and scaling-up Performance Improvement andsupporting approaches.

Primary Care ProvidersPRIME II has helped expand service delivery and reach morepeople with critical FP/RH services (including HIV/AIDS) byidentifying and building the capacity of a wider range ofprimary providers who respond effectively to growing healthcare needs.

ConsumersPRIME II has increased the quality, accessibility and use ofFP/RH services by integrating consumer perspectives and byfostering consumer-provider partnerships.

Blended LearningPRIME II has improved primary provider performance bydeveloping and implementing practical, cost-effective blendedlearning approaches.

Non-training InterventionsPRIME II is discovering effective ways to improve providerperformance through a range of non-training interventions.

PRIME II Project ManagementPRIME II has demonstrated strong technical leadership andproduced impressive results in primary provider performance;successfully managed a large, complex project with significantfield support contributions using a decentralized managementmodel; maintained strong and supportive working relationshipswith USAID/Washington and missions; and pioneered asuccessful partnership model.

PRIME

This publication was produced by the PRIME II Project and was made possible through

support provided by the U.S. Agency for International Development under the terms

of Grant Number HRN-A-00-99-00022-00. The views expressed in this document are

those of the authors and do not necessarily reflect those of IntraHealth International or

the U.S. Agency for International Development.





� National RH Policy� Partnership


� PMTCT

� Scaling-Up PI

� Costing



� Nicaragua: EONC



� Mali: FGC

� Senegal: PAC



� Bangladesh: RTL

Global Policy

Improving Performancethrough Clear ExpectationsLinking National ReproductiveHealth Policy and PrimaryProvider Performance

Family planning and reproductive health (FP/RH) servicepolicies and protocols can be a powerful facilitating factor increating clear performance expectations for primary provid-ers. This makes policy and protocols development and revi-sion a natural and critical component of the performanceimprovement process.

Interventions and ResultsPRIME II has had significant success in the policy arena.Key results from 2002-2003 include:

In Rwanda, the Ministry of Health (MOH) asked PRIME to helpdraft the first national RH policy since the country�s civil war.To identify national RH priorities PRIME organized a round-table conference in 2000, which launched a collaborative pro-cess with key RH stakeholders. PRIME facilitated this processand helped to finalize the RH policy, which was signed by theminister of health in July 2003. With assistance from PRIME,the Rwandan MOH is now drafting new RH guidelines toensure effective implementation of the national policy.

In Armenia, PRIME organized a national forum, held in Septem-ber 2002, in which over 100 national and internationalexperts reached consensus on the most important actionsneeded to improve FP/RH access and quality using WHOguidelines. These recommendations served as the foundationfor RH legislation passed by the Armenian parliament inDecember 2002 after significant technical review and supportfrom PRIME, UNFPA and the NGO community. The legislationprovides a framework for expanded access to quality FP/RHservices and guidance on women�s reproductive and sexualrights. Early on in its work in Armenia, PRIME also organizeda Ministry of Health working group to draft a national RHpolicy. After the working group prioritized RH needs andservices, PRIME defined roles and responsibilities for FP/RHproviders at all levels of the health care system to matchthese priorities. While not yet officially approved, the draftpolicy is serving as a guide for additional policy work tosupport PRIME�s assistance in expanding the role of primary-level nurses and midwives. Among these efforts are new RHprotocols, which were more easily developed and approvedbecause they were based on the draft national policy.

PRIME






In Paraguay, PRIME designed and implemented the evaluationof the Ministry of Health�s five-year National RH Plan (1997-2001). The evaluation was presented in November 2002 tothe National Reproductive Health Council, a major policybody presided over by the MOH. This was a landmark eventfor Paraguay and Latin America, marking one of the few in-stances when implementation of a national RH plan has beencomprehensively evaluated. The methodology included stake-holder interviews ranging from rural clients to high-levelgovernment officials, observation of providers in varioussettings, and focus groups with clients of different gender andage groups. The results revealed particular problems in thearea of dissemination of the National Plan. PRIME is assistingthe MOH in designing a new National Plan for 2003-2007,through a highly participatory process that includes stake-holder workshops in 17 geographic departments. PRIME hasalso been asked to provide training and assist in disseminatingthe new plan throughout the country.

In Zambia, PRIME gathered input from consumers on theirexpectations for quality nursing services. The Zambia GeneralNursing Council then built this consumer feedback intorevised nursing and midwifery practice standards based on theEast, Central and Southern African College of Nursing draftprofessional regulatory framework. This is one of the firstexamples of provider standards or protocols that reflectconsumer input and promote consumer-oriented care.

Key lessons from these experiences include:� While necessitating an in-depth and sometimes lengthy

process, a participatory approach that ensures the in-volvement and buy-in of local stakeholders and partnersas well as government officials is essential for developingpolicy and protocols that are most likely to be imple-mented and used

� Clearly stated policies and related protocols should formthe basis for clear provider performance expectations, andare a part of the Performance Improvement approach

� It may be useful to gather feedbackfrom consumers on their expecta-tions for quality care as a part ofthe process of developing protocols

� In order to improve implementation,it is important to focus on widedissemination of policies and trans-lation of policies into protocolsand clear provider performanceexpectations.

Suggested citation:Coleman AL, Nelson D.Linking NationalReproductive HealthPolicy and PrimaryProvider Performance11/2003(PRIME PAGES: RR-25)

Photo credit:Kristin Cooney

PRIME








Global Partnership

Prioritizing the Common GoodThe Effective PRIME IIPartnership Model

Like many large USAID global projects, PRIME II is designedfor implementation by a consortium of partners who bringa broad set of complementary skills and capacities rarelyavailable from a single organization. This is a strategy withmany advantages, but it creates a complex structure to leadand manage. From the earliest stages of forming a partner-ship, responding to the Request for Application and thestartup of operations, the five PRIME partner organizationshave shared a powerful vision of the partnership in action.The resulting collaboration has proven unusually reward-ing, and a review of its successes and lessons learned isprovided here.

Partner Leadership GroupComposed of two senior leaders from each partner organi-zation, the Partner Leadership Group (PLG) provides astable and consistent mechanism for direct participation inthe Project�s strategic direction and technical leadership. Thistight-knit group meets four times a year, rotating venuesamong partner offices. These leaders must set the example ofa willingness to prioritize the common good of the Projectand to seek win-win decisions.

Memorandum of UnderstandingAt the outset of the Project, members of the PLG collabo-rated to develop the PRIME II Partnership Memorandum ofUnderstanding. This document, signed by each organization,provides transparent and practical guidance on topics suchas partnership structure and process, annual planning andsubcontracting processes, responding to new work opportu-nities, credit and recognition, representation, and strategicprioritization of technical assistance requests.

Suggested citation:Gormley W, Rabb M.The Effective PRIME IIPartnership Model11/2003(PRIME PAGES: RR-26)

Photo Credit:Marc Luoma

Reviewing Results in PRIME II

Oct. 2002�Sept. 2003



� Partnership


� PMTCT

� Scaling-Up PI

� Costing



� Nicaragua: EONC



� Mali: FGC

� Senegal: PAC



� Bangladesh: RTL

productivity due to chronic ineffective partnership in aglobal project the size of PRIME II would be around$500,000, or about 2.5% of the budget. As this exerciseshows, the investment of time and resources in creating aneffective partnership has paid off in the Project�s overallproductivity. However, the successes of the PRIME II Projectin technical leadership, field support, producing results, andmeeting performance expectations offer the best proof ofthe strength of this partnership.

PRIME

Seconded StaffThe PRIME II partnership operates daily, in a very straightfor-ward way, through seconded staff from the partner organiza-tions based in the Chapel Hill headquarters. In addition, anumber of partner staff are based in PRIME field offices.Many seconded staff hold key decision-making positions onthe Project such as Unit Director and Regional Director.Seconded staff are so fully integrated into the Project that itis often not readily apparent to staff or outsiders whichpartner is their home organization.

Partnership Collaboration in the FieldThe same collaborative relationship established among theUS offices of partner organizations extends to the partners�regional and country offices. These relationships were pur-posefully built at the field level. In the beginning of theProject the organizations came together in the field to planhow they would work together. This collaboration frequentlyproves valuable in identifying new opportunities, helpingstart new country programs (e.g., in Honduras, Rwanda andArmenia) and sharing experiences and resources (e.g., inKenya and Ghana).

Challenges of PartneringNaturally, there have been challenges in building and main-taining the PRIME II partnership. Among the Project�s accom-plishments and lessons learned:

� Establishing and sustaining a trusting, synergistic partner-

ship requires leadership commitment and resources. Thislevel of commitment from all PRIME partner organizations,including USAID, has been exceptional.

� PRIME II has two supporting institutions, the AmericanCollege of Nurse-Midwives and Save the Children. Theseaffiliations were based on the need for specific, project-by-project technical assistance, and the organizations havenot been PLG members. Consequently, the supportinginstitution relationship has not been as well defined asthe partnership model and has proven more challengingto manage.

� The PLG structure has helped to ensure that communi-cation channels are open and that appropriate staff fromeach partner organization stay informed about Projectdevelopments, aware of each partner�s capabilities,and ready to access these competencies to meet theProject�s needs.

� While the PLG has resulted in effective communicationsamong partners, a more regular and formal feedbackmechanism would enable partners to continuously moni-tor and improve partner relationships and performance.

� Each partner organization expects their technical re-sources to be utilized as fully as possible. PRIME�s twingoals have been to assign the most appropriate technicalresources to the job at hand, and to share the work sothat each partner organization contributes to the Project�ssuccess. Decisions on work distribution have been guidedby technical needs, not a predetermined portion ofthe work.

� Partners that initiated or led in developing new projectopportunities, especially in the field, generally receivedlarger portions of the work on those projects. This strat-egy has contributed to the large number of field supportprojects under PRIME.

Advantages of the PartnershipPRIME�s success in creating a model of partner collaborationhas resulted in significant benefits:

� The Project has maintained easy access to the partners�diversity, complementary strengths, technical expertiseand management know-how.

� A sense of common purpose and shared commitment hasencouraged partners to define together the Project�s tech-nical leadership areas and cutting-edge technical agendasin a collaborative and technically synergistic manner.

� PRIME has drawn from all partner organizations to consti-tute its interdisciplinary global teams, developing strate-gies to move technical agendas forward. This has helpedto scale-up new initiatives faster and more successfully.

� The partnership helped the Project expand to new coun-

tries faster, bringing more depth of technical expertise,management experience, understanding of the context,and leveraging of other agency and donor contributions.

� Because the PRIME II partnership is effective, USAID hasbeen less taxed to engage in fostering collaboration,solving problems and negotiating among partners. Thepartnership has played the role of ensuring that the tech-nical competencies of the various agencies are consideredand used to the fullest extent possible.

Value of the PartnershipBuilding and maintaining partnerships requires leadershipattention and resources. PRIME estimates that the annualcost of the partnership is approximately $210,000, whichwhen annualized over the first four years of the Project isabout 1.25% of the Project budget. As one way to gauge thevalue of effective partnering, PRIME estimated the cost of anineffective partnership using both real examples of the costsof problem-solving and hypothetical examples of missedopportunities. PRIME estimates that annual costs of lost

4%

3%

2%

1%

0

PRIME II Partnership

IneffectivePartnership

1.25%

2.50%

Costs of PartnershipAs percentage of

annual project budget

PRIME








Global Partnership

Prioritizing the Common GoodThe Effective PRIME IIPartnership Model

Like many large USAID global projects, PRIME II is designedfor implementation by a consortium of partners who bringa broad set of complementary skills and capacities rarelyavailable from a single organization. This is a strategy withmany advantages, but it creates a complex structure to leadand manage. From the earliest stages of forming a partner-ship, responding to the Request for Application and thestartup of operations, the five PRIME partner organizationshave shared a powerful vision of the partnership in action.The resulting collaboration has proven unusually reward-ing, and a review of its successes and lessons learned isprovided here.

Partner Leadership GroupComposed of two senior leaders from each partner organi-zation, the Partner Leadership Group (PLG) provides astable and consistent mechanism for direct participation inthe Project�s strategic direction and technical leadership. Thistight-knit group meets four times a year, rotating venuesamong partner offices. These leaders must set the example ofa willingness to prioritize the common good of the Projectand to seek win-win decisions.

Memorandum of UnderstandingAt the outset of the Project, members of the PLG collabo-rated to develop the PRIME II Partnership Memorandum ofUnderstanding. This document, signed by each organization,provides transparent and practical guidance on topics suchas partnership structure and process, annual planning andsubcontracting processes, responding to new work opportu-nities, credit and recognition, representation, and strategicprioritization of technical assistance requests.

Suggested citation:Gormley W, Rabb M.The Effective PRIME IIPartnership Model11/2003(PRIME PAGES: RR-26)

Photo Credit:Marc Luoma


Oct. 2002�Sept. 2003



� Partnership


� PMTCT

� Scaling-Up PI

� Costing



� Nicaragua: EONC



� Mali: FGC

� Senegal: PAC



� Bangladesh: RTL

productivity due to chronic ineffective partnership in aglobal project the size of PRIME II would be around$500,000, or about 2.5% of the budget. As this exerciseshows, the investment of time and resources in creating aneffective partnership has paid off in the Project�s overallproductivity. However, the successes of the PRIME II Projectin technical leadership, field support, producing results, andmeeting performance expectations offer the best proof ofthe strength of this partnership.

PRIME








Rwanda, Ethiopia PMTCT

Voluntary Counseling, Testing and TreatmentScaling-Up Services to PreventMother-to-Child Transmission of HIV

Prevention of mother-to-child transmission (PMTCT) of HIVservices at the Byumba and Kibuye district hospitals inRwanda, launched with assistance from PRIME II in March2002, have been successfully sustained, with increasingpercentages of women and their partners agreeing toreceive HIV testing. Scale-up to a third facility, KigomaHealth Center, beginning in December 2002, has producedsimilar achievements. Building on results and lessons learnedfrom this work, PRIME is taking a leadership role in the newpresidential initiative PMTCT program in Ethiopia anddeveloping approaches other projects can use to integratefamily planning into PMTCT services.

BackgroundPRIME�s PMTCT activities in Rwanda, carried out in collabo-ration with the Ministry of Health (MOH), IMPACT/FamilyHealth International (FHI) and the Treatment and ResearchAIDS Center, have striven to build a foundation for im-proved prenatal, obstetric and postpartum care, betteroutcomes for seropositive women and their children, andopen dialogue about HIV/AIDS. The PMTCT sites wherePRIME is working were identified in conjunction with gov-ernment and USAID partners in districts where the Projectalready had an active presence.

Lessons learned and implementation challenges fromPMTCT activities in Rwanda are being incorporated into thedesign of the five-year Ethiopia initiative, the Hareg Project,launched in September 2003. PRIME is serving as the overallcoordinator of Hareg activities for USAID and the Centersfor Disease Control, who will collaborate with UNICEF, theMOH and Ethiopia�s HIV/AIDS Prevention Control Office

Suggested citation:Blyth K, Nelson D.Scaling-Up Services toPrevent Mother-to-ChildTransmission of HIV11/2003(PRIME PAGES: RR-27)

Photo Credit:Amanda Huber


Oct. 2002�Sept. 2003



� Partnership


� PMTCT

� Scaling-Up PI

� Costing



� Nicaragua: EONC



� Mali: FGC

� Senegal: PAC



� Bangladesh: RTL

PRIME

(HAPCO). PRIME�s Ethiopia country director and a MOHcounterpart will travel to Rwanda late this year to observePMTCT service delivery and better understand how PRIME�sapproach in Rwanda is integrated into national FP/RH services.

InterventionsAt the Rwanda sites, PMTCT activities include group andindividual counseling during prenatal care; voluntary counsel-ing and testing (VCT); administration of nevirapine to HIV-positive delivering mothers and their newborns; prenatal,obstetrical and postnatal care; breastfeeding counseling; andfamily planning counseling and services. PRIME has trainedmore than 100 providers in VCT skills and nevirapine adminis-tration, and supported the training of eight laboratory techni-cian in rapid HIV confirmation tests. To promote PMTCTservices and encourage partner involvement and testing,PRIME has also carried out IEC/BCC activities at the commu-nity level. In July 2003, PRIME initiated PMTCT services attwo additional sites, Mugonero Hospital and RubengeraHealth Center, and will expand to two more sites in the re-maining implementation year.

Building on existing PMTCT programs in Ethiopia and target-ing health facility-linked prenatal care as an entry point forwomen�s services, the Hareg Project will expand PMTCT to15 medical centers and their catchment sites. In a countrywhere two thirds of mothers have no access to prenatal careservices, PRIME and partners will use the PerformanceImprovement approach to integrate PMTCT services withbroader efforts to improve safe motherhood. Priorities includestrengthening family planning linkages with PMTCT and en-hancing prenatal, intrapartum and postnatal care by includingservices such as voluntary HIV/AIDS counseling and testing,PMTCT and nutritional support and birth preparedness.

ResultsRwanda: From March 2002 through August 2003, 95.5% ofthe over 3,000 women attending Byumba Hospital forinitial prenatal visits were counseled about HIV/AIDS andPMTCT and 2,912 (95.1%) agreed to be tested for HIV. Ofthose women, 190 (or 6.9%) tested positive for HIV, with142 (74.7%) returning for their test results. Providers haveaccelerated interventions to follow-up with mothers whohave tested positive but have not returned for their resultsthrough infant vaccination activities, which are highly at-tended. Community sensitization activities on partner in-volvement may have contributed to the 8.3% of malepartners who agreed to be tested, a jump from just 1%from March to September 2002. During 1,601 deliveriesrecorded by Byumba Hospital over the intervention pe-riod, 75 HIV-positive women received nevirapine duringlabor and all newborns were also treated with the drug.

At Kibuye Hospital, 99.6% of the 1,286 women visiting thehospital for prenatal care over the 17 months ending inAugust 2003 were also counseled about HIV/AIDS andPMTCT and 1,096 (85.6%) received HIV testing. This is sig-nificantly higher than for March through September 2002during which only 64% agreed to be tested. Of the womentested, 82.4% returned for their test results and 9.3% wereHIV positive. Following intensive community sensitizationactivities, testing of women�s sexual partners has also sig-nificantly increased, from 4% as of September 2002 to15.8% in August 2003. Of the 1,390 deliveries recorded atthe hospital during the 17 months, 61 HIV-positive womenreceived nevirapine during labor and 59 out of those 61newborns were also treated with the drug.

Kigoma Health Center also reported strong results for theperiod from December 2002-August 2003: 99.1% of 683women attending prenatal consultations were counseledabout HIV/AIDS and PMTCT and 83.6% agreed to receivetesting, with 10.4% HIV positive. Partner involvement hasbeen especially encouraging, with 30% tested, of which12.3% were HIV-positive. Out of 189 deliveries at thecenter, 14 HIV-positive women received nevirapine duringlabor and 12 newborns were also treated.

100%

50%

0

85.6% Tested

99.6% Counseled

15.8% TestedPartners

9.3% HIV+

Kibuye Hospital

100%

50%

0

83.6% Tested

99.1% Counseled

Prenatal HIV Testing and Counseling at Rwanda Sites

30% TestedPartners

10.4% HIV+

Kigoma Health Center

100%

50%

0

95.1% Tested

95.5% Counseled

8.3% TestedPartners

6.9% HIV+

Byumba Hospital

March '02 - August '03

March '02 - August '03

December '02 - August '03

PRIME








Rwanda, Ethiopia PMTCT

Voluntary Counseling, Testing and TreatmentScaling-Up Services to PreventMother-to-Child Transmission of HIV

Prevention of mother-to-child transmission (PMTCT) of HIVservices at the Byumba and Kibuye district hospitals inRwanda, launched with assistance from PRIME II in March2002, have been successfully sustained, with increasingpercentages of women and their partners agreeing toreceive HIV testing. Scale-up to a third facility, KigomaHealth Center, beginning in December 2002, has producedsimilar achievements. Building on results and lessons learnedfrom this work, PRIME is taking a leadership role in the newpresidential initiative PMTCT program in Ethiopia anddeveloping approaches other projects can use to integratefamily planning into PMTCT services.

BackgroundPRIME�s PMTCT activities in Rwanda, carried out in collabo-ration with the Ministry of Health (MOH), IMPACT/FamilyHealth International (FHI) and the Treatment and ResearchAIDS Center, have striven to build a foundation for im-proved prenatal, obstetric and postpartum care, betteroutcomes for seropositive women and their children, andopen dialogue about HIV/AIDS. The PMTCT sites wherePRIME is working were identified in conjunction with gov-ernment and USAID partners in districts where the Projectalready had an active presence.

Lessons learned and implementation challenges fromPMTCT activities in Rwanda are being incorporated into thedesign of the five-year Ethiopia initiative, the Hareg Project,launched in September 2003. PRIME is serving as the overallcoordinator of Hareg activities for USAID and the Centersfor Disease Control, who will collaborate with UNICEF, theMOH and Ethiopia�s HIV/AIDS Prevention Control Office

Suggested citation:Blyth K, Nelson D.Scaling-Up Services toPrevent Mother-to-ChildTransmission of HIV11/2003(PRIME PAGES: RR-27)



Oct. 2002�Sept. 2003



� Partnership


� PMTCT

� Scaling-Up PI

� Costing



� Nicaragua: EONC



� Mali: FGC

� Senegal: PAC



� Bangladesh: RTL

PRIME








Suggested citation:Luoma M, Nelson D.Lessons Learned inImproving ProviderPerformance11/2003(PRIME PAGES: RR-28)

Photo Credit:Margaret Rabb

Global Performance Improvement

Applying and Scaling-UpPerformance ImprovementLessons Learned in ImprovingProvider Performance

To ensure intervention packages address provider needsholistically, PRIME II has conducted 28 performance needsassessments (PNAs) in 18 countries. The findings have dem-onstrated that some form of PNA is an essential step thatshould be taken even when the initial client request is fortraining only. When presented with PNA results, clientsquickly appreciate the value gained from the exercise. PNAsneed not take a long time, nor cost much money. Based onthe scope of the situation to be assessed, PRIME�s PNAs havebeen completed in as little as two or three days, with costsas low as less than 1% of a total project budget. Based onthese experiences, PRIME II is able to make recommenda-tions to other organizations on using and scaling-up thePerformance Improvement (PI) approach.

Recommendations forImplementing Successful PI ProjectsIt is possible and necessary to convince even those clientswith a one-intervention mindset to use PI. Prior to the wide-spread use of PI, project designers often attempted to solveprovider performance issues with a single favorite interven-tion, usually training. Because USAID missions and ministriesof health are used to training-only solutions, requests forassistance typically still arrive as a request for training. Attimes, it is appropriate to explain the benefits of PI as a wayto address problems affecting performance that are unlikelyto be solved through training. In other instances, clients maybe resistant and insist on training only. In such cases, PRIMEhas found it useful to agree to the request but gain permis-sion to ask additional questions to �make sure the training


Oct. 2002�Sept. 2003



� Partnership


� PMTCT

� Scaling-Up PI

� Costing



� Nicaragua: EONC



� Mali: FGC

� Senegal: PAC



� Bangladesh: RTL

PRIME

sticks.� In this way, other performance factors may be ad-dressed and providers can get the additional support theyneed. Once this tactic has been used to show the non-training-related needs of providers, such as motivation orpolicy changes that set clear performance expectations,clients usually see the value of the assessment and oftenask for PNAs in future collaborations.

The approach must be tailored for each situation: PIhas been applied in numerous ways and in many contentareas, including family planning, maternal health,postabortion care and preventing postpartum hemorrhage.While the approach consists of a clear, step-by-step method-ology, PRIME has found that the process needs to be tailoredfor each unique situation. In most cases it makes sense to setdesired performance before examining actual performance.In other cases the reverse order is used (e.g., India ISMPproject). Depending on the rigor needed for the expectedresults, one may gather data from an exhaustive sample(800+ providers in the performance factors special study)or from only a few knowledgeable stakeholders (the 2001Armenia PNA). Where target audiences are very large andthe scope of performance is wide, more effort and moneywill be required. Still, even when time is short and budgetsconstrained, completing a PNA before selecting interventionsis a critical investment that cannot be omitted. Moving inquickly with a misguided intervention that fails to improveperformance only wastes much more time and money.

Multiple interventions are necessary: Over the 28PNAs, seldom has one intervention been sufficient to meetthe needs of providers. The graph on the left summarizes thepercentage of needs assessments that found each perfor-mance factor missing. Performance results take time toemerge: Training-only projects have typically presented�results� that consist of the number of people trained alongwith pre- and post-training knowledge test scores. Measuringworkplace performance demands more evaluation rigor (andbudget). In addition, workplace performance changes takelonger to emerge. For example, performance improvementsbrought on by holistic changes in the supervision system innorthern Ghana have taken two years to become fullyevident. Where results have been gathered quickly, becauseof programmatic time constraints, they have been far lesscompelling (e.g., Honduras PI project). Along with carefulinterim monitoring, programs should allow the time andspace for interventions to be effective.

To build capacity in PI, train and then partner: As amethod of scaling-up PI, PRIME has built capacity in usingthe approach. In internal and external capacity buildingefforts, the greatest success has come from initial skill-build-ing and then partnering during a PI project. Skill-building hastaken many forms, including one-on-one introductions,

public instructor-led courses and self-paced learning usingPRIME�s online materials. Partnering during an initial projecthas taken the form of side-by-side work in the field as well asassistance from afar. PRIME�s work with MOH staff in Tanza-nia offers a successful example of PRIME�s PI capacity build-ing. After attending a PI short course sponsored by PRIMEand the Regional Centre for Quality of Health Care inUganda, staff members redesigned several RH programs touse the PI approach. PRIME now works with MOH staff tosupport implementation of these programs.

Future DirectionsWhile significant progress has been made in determiningbetter practices in applying PI, much remains to be learnedand tried:� Broadening the application of PI to offer critical support

to the human capacity development challenges posed bythe HIV pandemic.

� Taking the PI approach to the next level, which includesdeveloping and documenting additional experience innon-training interventions such as motivation, supportivesupervision, human resource allocation, job satisfactionand employee retention.

� Scaling-up the use of approaches that make trainingmore effective and cost-efficient, beginning with perfor-mance needs assessments (PNAs) and including ap-proaches such as implementing complementary trainingand non-training interventions as indicated by PNAs,applying the performance learning methodology, use ofinnovative and blended learning, and improved use ofinformation technology.

100%50%0

Performance Factors Found to be Missing

75%25%

Expectations

Feedback

Environment

Motivation

Skills and Knowledge

n=24 PNAs

PRIME








Suggested citation:Luoma M, Nelson D.Lessons Learned inImproving ProviderPerformance11/2003(PRIME PAGES: RR-28)

Photo Credit:Margaret Rabb


Applying and Scaling-UpPerformance ImprovementLessons Learned in ImprovingProvider Performance

To ensure intervention packages address provider needsholistically, PRIME II has conducted 28 performance needsassessments (PNAs) in 18 countries. The findings have dem-onstrated that some form of PNA is an essential step thatshould be taken even when the initial client request is fortraining only. When presented with PNA results, clientsquickly appreciate the value gained from the exercise. PNAsneed not take a long time, nor cost much money. Based onthe scope of the situation to be assessed, PRIME�s PNAs havebeen completed in as little as two or three days, with costsas low as less than 1% of a total project budget. Based onthese experiences, PRIME II is able to make recommenda-tions to other organizations on using and scaling-up thePerformance Improvement (PI) approach.

Recommendations forImplementing Successful PI ProjectsIt is possible and necessary to convince even those clientswith a one-intervention mindset to use PI. Prior to the wide-spread use of PI, project designers often attempted to solveprovider performance issues with a single favorite interven-tion, usually training. Because USAID missions and ministriesof health are used to training-only solutions, requests forassistance typically still arrive as a request for training. Attimes, it is appropriate to explain the benefits of PI as a wayto address problems affecting performance that are unlikelyto be solved through training. In other instances, clients maybe resistant and insist on training only. In such cases, PRIMEhas found it useful to agree to the request but gain permis-sion to ask additional questions to �make sure the training


Oct. 2002�Sept. 2003



� Partnership


� PMTCT

� Scaling-Up PI

� Costing



� Nicaragua: EONC



� Mali: FGC

� Senegal: PAC



� Bangladesh: RTL

PRIME








Ghana Performance Improvement

Informing Policy DecisionsCosting and Cost & ResultsAnalysis for Effective Approachesand Interventions

PRIME II�s work in Ghana demonstrates the Project�s abilityto help policy-makers and managers better understand thecosts and cost-effectiveness of alternative approaches forimproving provider performance. PRIME assisted the GhanaHealth Service (GHS) to analyze costs of scaling-up theCommunity-Based Health Planning and Services (CHPS)initiative from a successful pilot activity to a nationwidestrategy to reach underserved populations with familyplanning and reproductive health care. The results of thiscosting study are being used by the Ministry of Health todetermine scale-up options and advocate for resources withpartners. PRIME is also helping GHS assess the financial andopportunity costs of two alternative approaches for trainingprimary providers of Safe Motherhood services: an innova-tive self-paced learning (SPL) approach and a more tradi-tional classroom-based approach.

BackgroundCost and results are key factors in determining whether toadopt an innovative training or non-training intervention forwider scale-up. Results are determined by whether anintervention achieves its intended intermediate (e.g., im-proved supervision, better learning) and end indicators (e.g.,improved provider performance, increased service volume).PRIME II developed a Cost and Results Analysis (CRA)

Suggested citation:Killian R, Nelson D.Costing and Cost &Results Analysis forEffective Approachesand Interventions11/2003(PRIME PAGES: RR-29)

Photo Credit:Richard Killian


Oct. 2002�Sept. 2003



� Partnership


� PMTCT

� Scaling-Up PI

� Costing



� Nicaragua: EONC



� Mali: FGC

� Senegal: PAC



� Bangladesh: RTL

PRIME

Strategy and Toolkit to guide analyses of whether alternativesachieve desired results at costs equal to or less than existingapproaches. The two experiences in Ghana are describedbelow.

Intervention: CHPS District Cost AnalysisThe Ghana Health Service and USAID/Ghana requested thatPRIME II assess CHPS scale-up costs and produce financialinformation that had not previously been available for policydialogue and implementation planning. GHS asked PRIMEto work in a sample of 16 CHPS zones from five of thecountry�s ten regions. The sample zones encompassed 140communities with a combined population of about 110,000.The PRIME II/GHS team collaborated with stakeholders todevelop four data collection tools. Teams of data collectorsfrom the regions gathered cost data on start-up activitiesand placement of Community Health Officers (CHOs) thatoccurred in 2000, and costs of service delivery by CHOs in2001, the last full year for which data were available.

ResultsThe cost data produced by this analysis provided the basisfor serious and overdue policy dialogue on issues related tothe level of CHPS implementation the MOH/GHS and itspartners can afford. The data will assist MOH/GHS in formu-lating policy decisions such as the need to downsize imple-mentation goals or encourage adoption of lower cost scale-up strategies (e.g., renovation of buildings versus new con-struction). The team found the average annual operating costfrom the sample zones to be inadequate and made recom-mendations accordingly.

In the absence of financial figures (which are based onaverages from the 16 sample zones), previous plans for scale-up and numbers of CHOs to be deployed were not finan-cially sound. MOH/GHS had never prepared an overallCHPS budget because CHPS is seen as an initiative underdecentralized health service delivery and not a �program.�These figures have served as a �reality check� to MOH/GHSplanners and partners, leading to increased recognition that

better coordination, logistical support and resource mobili-zation are needed to enable decentralized CHPS implemen-tation to succeed and approach scale-up targets.

Intervention: Safe Motherhood Operations Research(OR) on Self-Paced Learning (SPL)PRIME II collaborated with the FRONTIERS Project and theGHS Health Research Unit on the pilot study comparing theSPL and classroom-based approaches. The team measuredthe financial and opportunity costs of the two approachesbased on a sample of 80 learners, 40 for SPL and 40 for thetraditional approach, from the Northern and Upper Westregions. The two approaches were implemented over 18months in 2002-2003. Data collected included hours of timerequired by the learners and persons involved in implement-ing the two approaches, along with direct costs of activitiessuch as travel, per diem, and other allowances and directcosts. These cost data are being linked with baseline andfinal evaluation results to assess the cost-results relationshipsof the two approaches.

ResultsThe financial costs of SPL are about 60% of the cost perlearner of the traditional classroom-based approach. SPLtakes more learner time, by a factor of about 3 to 1, butmuch of the time used by SPL learners is personal time ortime when they are not seeing clients. Also, the �opportunitycost� of the SPL learners� time does not have financialimpact since their salaries and benefits are already beingpaid by the Government of Ghana. Programmatic (effective-ness) results will be available soon through an evaluationconducted by FRONTIERS.

$2000

$1000

$1500

0

SPL Traditional

$1,220

$1,813

Average Financial Cost Per Learner

PRIME








Ghana Performance Improvement

Informing Policy DecisionsCosting and Cost & ResultsAnalysis for Effective Approachesand Interventions

PRIME II�s work in Ghana demonstrates the Project�s abilityto help policy-makers and managers better understand thecosts and cost-effectiveness of alternative approaches forimproving provider performance. PRIME assisted the GhanaHealth Service (GHS) to analyze costs of scaling-up theCommunity-Based Health Planning and Services (CHPS)initiative from a successful pilot activity to a nationwidestrategy to reach underserved populations with familyplanning and reproductive health care. The results of thiscosting study are being used by the Ministry of Health todetermine scale-up options and advocate for resources withpartners. PRIME is also helping GHS assess the financial andopportunity costs of two alternative approaches for trainingprimary providers of Safe Motherhood services: an innova-tive self-paced learning (SPL) approach and a more tradi-tional classroom-based approach.

BackgroundCost and results are key factors in determining whether toadopt an innovative training or non-training intervention forwider scale-up. Results are determined by whether anintervention achieves its intended intermediate (e.g., im-proved supervision, better learning) and end indicators (e.g.,improved provider performance, increased service volume).PRIME II developed a Cost and Results Analysis (CRA)

Suggested citation:Killian R, Nelson D.Costing and Cost &Results Analysis forEffective Approachesand Interventions11/2003(PRIME PAGES: RR-29)

Photo Credit:Richard Killian


Oct. 2002�Sept. 2003



� Partnership


� PMTCT

� Scaling-Up PI

� Costing



� Nicaragua: EONC



� Mali: FGC

� Senegal: PAC



� Bangladesh: RTL

PRIME









Capacity Building to SupportPrimary ProvidersStrengthening Traditionaland Peer Supervision

PRIME II seeks to support an enabling work environmentfor primary providers of family planning and reproductivehealth services to deliver quality care to their clients. Theseefforts include helping supervisors become more effective,particularly in the areas of setting clear work expectationsand offering performance feedback. In addition, PRIME hasencouraged peer networks among providers to create sup-port when formal supervision is insufficient or unavailable.

BackgroundPerformance needs assessments and other studies con-ducted worldwide often find weaknesses in supervision sys-tems, which are frequently overburdened and understaffed.When supervisors adopt supportive approaches and othersupport systems are strengthened, the potential to affect avariety of factors influencing provider performance is high.

InterventionsSenegal: PRIME II provided technical assistance to ten directsupervisors of approximately 70 community health workersand their district-level supervisors in Kebemer district(population 150,000). The assistance included workshops,development of a guide and supervisory tools, and follow-up

Suggested citation:Dohlie MB, Nelson D.StrengtheningTraditional and PeerSupervision11/2003(PRIME PAGES: RR-30)

Photo Credit:Maj-Britt Dohlie


Oct. 2002�Sept. 2003



� Partnership


� PMTCT

� Scaling-Up PI

� Costing



� Nicaragua: EONC



� Mali: FGC

� Senegal: PAC



� Bangladesh: RTL

PRIME

visits to support the supervisors. The intervention comple-mented a study by the Ministry of Health and the PopulationCouncil to explore alternative ways of providing community-based services.

Honduras: In the Olancho health region, PRIME trained 38supervisors of public-sector primary health care workers insupportive supervision as well as 122 providers and supervi-sors in peer support. PRIME identified supportive supervisionas an important intervention area following a performanceneeds assessment (PNA) that revealed poor provider perfor-mance in prenatal care and FP service delivery.

India: Through a cascade of master and lead trainers, PRIMEhas trained and supported more than 1,000 Lady HealthVisitors (LHVs) in 37 districts of Uttar Pradesh. The LHVsoffer supportive supervision to more than 9,500 AuxiliaryNurse-Midwives (ANMs), primary providers offering a rangeof FP services including IUDs.

Kenya: In Nairobi, Central and Rift Valley provinces, PRIME IIhas collaborated with the POLICY Project and local partnersto strengthen four peer support clusters, formal groups thatenable private nurse-midwives trained by PRIME in post-abortion care to supplement the limited support they receivefrom their formal supervisors, District Public Health Nurses.Workshops on peer support and performance improvementwere attended by 46 participating providers.

ResultsSenegal: All direct supervisors improved their performance,as indicated by the finding that 8 of 10 supervisors nowplan and execute supervisory activities in accordance withthe guide, prepare a plan for conducting supervision everytwo months, and use the checklist included with the supervi-sory tools; all of these are new performances. After theintervention, 81% of the 60 community health workerssampled had a performance workplan (compared to noneprior to the intervention) and 89% felt at ease with theirsupervisors (no baseline is available since the providers arenew to these positions). Preliminary data show improvedperformance by community health workers in both interven-tion and control areas.

India: A database on ANM performance reveals that whilescores dropped slightly during an initial follow-up assess-ment a few months after training, they improved at the timeof a second follow-up assessment. This return to higher-levelperformance seems to be due to the support ANMs receivedfrom the trained LHVs. All target districts achieved the super-vision indicator, a minimum of 50% of supervisors perform-ing at least two interactions per month with their super-

visees. Qualitative data indicate agreement among LHVsand ANMs that supervision has improved as a result of theintervention, with more coaching and emphasis on qualitytaking place during interactions.

Honduras: Supervisors� performance was measured throughprovider performance; some areas of performance improvedwhile others did not, but the improvement was not statisti-cally significant. There was no difference between the groupwith traditional supervision and the group with traditionalsupervision plus peer support. This lack of effect is mostlikely due to expecting results and conducting the evaluationtoo quickly after the intervention.

Kenya: Private nurse-midwives report that learning frompeers, problem identification with peers and financial col-laboration are among the primary benefits of peer support.Two of the peer-support clusters have become registeredassociations, with two others in the process of registering.All the clusters have established bank accounts and threeare collecting fees from members. The members have eitherinitiated or increased outreach activities in their communi-ties, including visits to schools to discuss FP, STI/HIV preven-tion and postabortion care services with adolescents.Adolescents had not always been welcome in the privatefacilities, but peer group discussions helped convince provid-ers to encourage adolescents to access their services andmake their facilities more adolescent-friendly. While the finalevaluation has yet to be carried out, preliminary data indi-cate that peer support has been beneficial and that provid-ers see more FP clients because services have improved.

Lessons LearnedKey lessons learned from PRIME II�s work in supportivesupervision include:� Many supervision options are available to ensure provid-

ers get the support they need. However, several systemsneed to be in place for supervision and support-relatedinterventions to be successful.

� Consistent follow-up and a minimum investment of timeto support the supervisors are required before changes insupervisory practices �trickle down� and affect providerperformance.

� While PRIME has explored a variety of supervision alter-natives, much work remains to be done, especially in field-testing additional forms of non-traditional supervision.

� Peer support appears to be a viable alternative in situa-tions where traditional supervision is not available, suchas with private providers.

100%50%0

Community Health Workers Post Intervention

At ease with supervisor

89%

Have performance workplan

81%

100%

50%

0

Pre- test

1st follow up

85.5%82%

88%

Auxiliary Nurse-MidwivesAverage Performance Scores

n=9455

Post- test

2nd follow up

n=9449 n=8050 n=5026

26%

PRIME









Capacity Building to SupportPrimary ProvidersStrengthening Traditionaland Peer Supervision

PRIME II seeks to support an enabling work environmentfor primary providers of family planning and reproductivehealth services to deliver quality care to their clients. Theseefforts include helping supervisors become more effective,particularly in the areas of setting clear work expectationsand offering performance feedback. In addition, PRIME hasencouraged peer networks among providers to create sup-port when formal supervision is insufficient or unavailable.

BackgroundPerformance needs assessments and other studies con-ducted worldwide often find weaknesses in supervision sys-tems, which are frequently overburdened and understaffed.When supervisors adopt supportive approaches and othersupport systems are strengthened, the potential to affect avariety of factors influencing provider performance is high.

InterventionsSenegal: PRIME II provided technical assistance to ten directsupervisors of approximately 70 community health workersand their district-level supervisors in Kebemer district(population 150,000). The assistance included workshops,development of a guide and supervisory tools, and follow-up

Suggested citation:Dohlie MB, Nelson D.StrengtheningTraditional and PeerSupervision11/2003(PRIME PAGES: RR-30)

Photo Credit:Maj-Britt Dohlie


Oct. 2002�Sept. 2003



� Partnership


� PMTCT

� Scaling-Up PI

� Costing



� Nicaragua: EONC



� Mali: FGC

� Senegal: PAC



� Bangladesh: RTL






� Partnership


� PMTCT

� Scaling-Up PI

� Costing



� Nicaragua: EONC� Philippines: HIV/AIDS


� Mali: FGC

� Senegal: PAC



� Bangladesh: RTL

Nicaragua Maternal Health

Linking Primary Providers and CommunitiesImproved Responses to Obstetricand Neonatal Emergencies

The PRIME II Project�s efforts to address maternal health inlow-resource environments often depend not only on improv-ing primary provider performance but also on strengtheningcommunity responsiveness to obstetric and neonatal emergen-cies and ensuring that services at referral facilities are up tostandard. A PRIME II-assisted pilot project in rural Nicaraguahas successfully integrated community members, volunteersand several cadres of providers to improve emergencyobstetric and neonatal care (EONC).

BackgroundNicaragua has among the highest maternal mortality ratios inLatin America and the Caribbean. Over a third of births areattended at home, frequently by a traditional birth attendant(TBA). To help the Ministry of Health (MOH) link communities,TBAs and health centers in the mountainous Jinotega region,PRIME II collaborated with the NicaSalud consortium ofNGOs/PVOs: Project Concern International, Project Hope,Wisconsin-Partners of the Americas and Catholic ReliefServices.

InterventionsThe goal of the consortium�s EONC strategy was building andreinforcing linkages among community-based providers, facil-ity-based providers and community members to raise aware-ness of the danger signs of complicated pregnancies, theconsequences of delays in seeking care and the importance ofa prompt response to postpartum bleeding. TBAs and otherprimary providers received training in community-based life-saving skills (adapted from the American College of Nurse-Midwives� Home-Based Life-Saving Skills model). Communitymobilizers and TBAs from the communities of Wiwili andPantasma learned immediate first-aid for safe delivery requir-ing little or no medical equipment and supplies. Providersfrom Jinotega Hospital were trained in basic emergency skillsincluding administration of drugs and intravenous fluids.Community mobilization activities focused on setting upEONC committees, pooling emergency funds, and establishingtransportation plans to ensure women and newborns reachreferral facilities quickly in the event of an emergency. Comple-menting these community organizing efforts, PRIME facilitatedan ongoing census of pregnant women in the region. PRIME IIstaff also participated in a national commission to developemergency obstetric and neonatal care protocols, which are

PRIME






undergoing evidence-based validation from the nationalreferral hospital, regional and departmental hospitals andhealth centers.

ResultsThe final evaluation demonstrated significant improvement inprovider performance. As defined by a quality index score,care of immediate postpartum women by TBAs improved by87%. Management of postpartum hemorrhage by physicians,nurses and auxiliary nurses improved from 68% to 82%. Thesepositive results for providers have been matched by commu-nity efforts. Of the 32 project communities, 78% reported theestablishment of committees for emergency obstetric andneonatal care. Emergency transportation systems have beenestablished in 56% of communities and emergency funds setaside in a quarter. In one illustrative example, emergency fundsin the community of Venecia are being administered by acommittee, and a community member with a vehicle is now oncall to transport women to the nearest hospital in cases ofemergency at any hour. A census of pregnant women is avail-able in 81% of the communities, and nearly half have imple-mented birth and complications readiness plans.

PRIME II also conducted a qualitative evaluation to assess theintegration of NicaSalud consortium partners in project imple-mentation. The strengths of the partnership were many, withorganizations sharing resources, time, funds and objectives toconduct a successful project. Those interviewed agreed that aprincipal strength was demonstrating to themselves and theMOH that a united group brought added credibility in devel-oping and implementing this pilot at the institutional andcommunity levels.

Suggested citation:Coleman AL, Nelson D.Improved Responsesto Obstetric andNeonatal Emergencies11/2003(PRIME PAGES: RR-31)

Photo credit:Alfredo Fort

100%

50%

0

Baseline End of Pilot

35.2%

65.7%

Care of Immediate

Postpartum Women

Traditional Birth Attendants

n=43n=46

100%

50%

0

Baseline End of Pilot

68%

82%

Management of

Postpartum Hemorrhage

Hospital Providers

n=56n=31






� Partnership


� PMTCT

� Scaling-Up PI

� Costing



� Nicaragua: EONC

� Philippines: HIV/AIDS� Paraguay: FP/RH Quality

� Mali: FGC

� Senegal: PAC



� Bangladesh: RTL

Philippines HIV/AIDS Integration with FP

Encouraging Condomsand Dual ProtectionImproving Sexual Behaviorsamong High-Risk Youth

Working through non-traditional providers, PRIME II builton a successful STI/HIV prevention project in the Philippinesto improve contraceptive use among youth engaging inhigh-risk behaviors. Youth exposed to the intervention weresignificantly more likely to report using condoms and othercontraceptive methods during high-risk behaviors than thosewho were not exposed.

BackgroundThrough the USAID-funded AIDS Surveillance and EducationProgram (ASEP) in the Philippines, PRIME II partner PATH hasbeen promoting safer reproductive health behaviors amonggroups identified at high risk of exposure to STIs and HIV. InJuly 2002, PRIME began working to improve access to familyplanning information and counseling for adolescent commer-cial sex workers, their clients/partners, and other adolescentswho engage in risky sexual behavior. The intervention focusedon encouraging adolescents to use dual protection, but espe-cially to use condoms, through strengthening the capacity ofASEP partner NGOs to deliver information and counseling onSTI/HIV prevention, reproductive health and dual protection,with an emphasis on pregnancy prevention, at four ASEP sites:Angeles, Cebu, Iloilo and Zamboanga. Because high-risk youthsaid they depended on Community Health Outreach Workers(CHOWs) and ASEP peer educators for information andcounseling on STI/HIV prevention and treatment, these non-traditional providers were galvanized to expand outreach tohigh-risk individuals. Youth (the �consumers�), CHOWs andpeer educators offered input into the design and implementa-tion of the intervention.

InterventionsQualitative research conducted with adolescent sex workersand their clients/partners indicated that the sex workers knewlittle about contraception and were reluctant to access gov-ernment-run health clinics. Because of the instrumental rolethat CHOWs play with this elusive and hard-to-reach group,PRIME II provided refresher training to CHOWs from the fourproject sites on pregnancy prevention and reproductive healthneeds of adolescents and strengthened the CHOWs skills fordual protection outreach. Together with ASEP partner NGOsand their CHOWs, PRIME developed a job aid on dual protec-tion that standardized messages to use when talking to youth.

PRIME






100%

50%

0

Exposed Not Exposed

76.2%

51.9%

Condom Use, Last Sex

n=214n=227

100%

50%

0

Exposed Not Exposed

93%84.2%

Modern Contraception,

Last Sex

n=120n=176

Suggested citation:McMahan J, Nelson D.Improving SexualBehaviors amongHigh-Risk Youth11/2003(PRIME PAGES: RR-32)

Photo Credit:PATH/Philippines

Pocket-size educational materials were also designed specifi-cally for youth to convey facts about dual protection and howto locate ASEP�s youth-friendly pharmacists for select forms ofcontraception, including condoms.

ResultsIn May 2003, PATH/Philippines and the ASEP partner NGOsconducted a Behavior Monitoring Survey (BMS) among theadolescent target groups in the four project sites. Findingsfrom the BMS study indicate that young female sex workerswho were exposed to the PRIME-assisted intervention weresignificantly more likely to report condom use (76% versus52%) and overall modern contraceptive use (93% versus 84%),and to seek appropriate treatment for STI symptoms (76%versus 55%) than those with no exposure to the intervention.The project shows that with clear written expectations forhealth workers and simple, targeted messages for clients, non-traditional providers can positively affect health-seeking behav-ior and practice in young female sex workers.

PRIME








Paraguay Family Planning

Improved Performance, Better QualityStrengthening Family Planning andReproductive Health Services

In Paraguay, PRIME II helped to develop and implement acomprehensive provider performance package with theMinistry of Health (MOH), leading to significant improve-ments in the quality of family planning (FP) and other repro-ductive health (RH) services. The components of quality thatimproved include client-provider interaction, counseling,informed consent, technical competence and availability ofcontraceptive methods.

BackgroundParaguay has among the lowest contraceptive prevalencerates in Latin America and the Caribbean, a hard-to-accessrural population, and a comparatively low level of donor andinternational NGO involvement in the FP/RH arena. Theneed to strengthen overall systems and services in FP/RHwith assistance from PRIME II is a high priority for the MOHand USAID/Paraguay.

InterventionsThe objective of the project is to improve the quality of fivecomponents of FP services: effective and appropriate client-provider interaction, effective counseling, informed consent,technical competence and availability of contraceptivemethods. After an initial needs assessment, PRIME II workedwith the MOH to design and implement a quality improve-ment model that included addressing many of the key fac-tors known to improve provider performance: augmentingprovider knowledge and skills in a number of technicalareas, creating clear expectations for providers offering FPservices, developing systems to incorporate client feedback,reinforcing the supervision systems, and maintaining neededsupplies and equipment (e.g., sharp disposal receptacles,

Suggested citation:Coleman AL, Nelson D.Strengthening FamilyPlanning andReproductive HealthServices11/2003(PRIME PAGES: RR-33)

Photo Credit:Juan Britos


Oct. 2002�Sept. 2003



� Partnership


� PMTCT

� Scaling-Up PI

� Costing



� Nicaragua: EONC



� Mali: FGC

� Senegal: PAC



� Bangladesh: RTL

PRIME

privacy curtains, a clean water source). The project was de-signed to gradually phase up to working in 23 service deliv-ery sites in five geographic regions of Paraguay.

ResultsTo measure changes in quality, PRIME started with a baselinesurvey with multiple indicators for each category. The ques-tions required a yes or no answer and the total score for asite was a composite number based on the answer for eachquestion. After up to six months of intervention time, a mid-term evaluation used a similar survey to measure improve-ments in quality in 11 sites where the interventions were inplace (the project is still phasing into the other sites). Thesurvey found that the clinics had realized a more than two-fold increase in their quality score, from 32% to 73%.

Other key results from the mid-term assessment include:� All sites had established separate FP exam rooms with

full-time dedicated staff attending to FP clients; had clearsigns directing people to the FP counseling area and/orexam rooms, which were clean, offered privacy for clientsand had educational materials available, including FPposters and flipcharts.

� All FP staff appeared enthusiastic, motivated and had asense of empowerment to provide FP services. Providerswho attended a PRIME II workshop or on-the-job trainingwere eager to discuss their new knowledge and skills. Asone nurse-midwife stated, �PRIME has been very impor-tant for my work. I am very happy and more secure��

� All FP staff were conversant in FP methods and able todescribe properly how they counsel on the pros and consof each method. All sites properly stored and tracked FPmethods (although a few sites depended on other depotsfor certain methods, so this information was not availablefor those methods).

� All sites implemented consistent standards of infectioncontrol during FP activities, with demonstrable changes inbehavior as well as infrastructure. All sites had separatecontainers with a narrow opening for the disposal ofsharp materials. Many sites had created a separate, closedfresh water container with a spigot, with special soap,towel and bucket for hand washing. All sites have sepa-rate containers with a narrow opening for disposal ofsharp materials. Hydrochlorate solution and instrumentbuckets were available in the examining room and theproviders understood how to mix the solution properly.

� Dramatic changes occurred in interpersonal relationsbetween providers and their clients. Many providersrelated how they treat their clients differently, usingphrases like �we take the time to talk to them and get toknow them,� �we put ourselves in their shoes,� �we greetthe clients in the hallway when we see them� or �whenwe send our clients to other departments on-site, we walkwith them.�

� Counseling skills and techniques improved, with all sitesproviding each client with individualized counseling onavailable methods, presenting the pros and cons of eachmethod before the client makes a choice. All staff usedavailable IEC materials in counseling. In most sites, staffwore name tags and in some sites staff were reorganizedto allow for a fulltime FP counselor.

� All of those sites that have received the appropriate pro-vider training offered postpartum/postabortion FP meth-ods on-site.

Quality Score 11 Service Delivery Sites

Baseline Mid-Term

32%

73%

C

100%

50%

0

PRIME








Paraguay Family Planning

Improved Performance, Better QualityStrengthening Family Planning andReproductive Health Services

In Paraguay, PRIME II helped to develop and implement acomprehensive provider performance package with theMinistry of Health (MOH), leading to significant improve-ments in the quality of family planning (FP) and other repro-ductive health (RH) services. The components of quality thatimproved include client-provider interaction, counseling,informed consent, technical competence and availability ofcontraceptive methods.

BackgroundParaguay has among the lowest contraceptive prevalencerates in Latin America and the Caribbean, a hard-to-accessrural population, and a comparatively low level of donor andinternational NGO involvement in the FP/RH arena. Theneed to strengthen overall systems and services in FP/RHwith assistance from PRIME II is a high priority for the MOHand USAID/Paraguay.

InterventionsThe objective of the project is to improve the quality of fivecomponents of FP services: effective and appropriate client-provider interaction, effective counseling, informed consent,technical competence and availability of contraceptivemethods. After an initial needs assessment, PRIME II workedwith the MOH to design and implement a quality improve-ment model that included addressing many of the key fac-tors known to improve provider performance: augmentingprovider knowledge and skills in a number of technicalareas, creating clear expectations for providers offering FPservices, developing systems to incorporate client feedback,reinforcing the supervision systems, and maintaining neededsupplies and equipment (e.g., sharp disposal receptacles,

Suggested citation:Coleman AL, Nelson D.Strengthening FamilyPlanning andReproductive HealthServices11/2003(PRIME PAGES: RR-33)

Photo Credit:Juan Britos


Oct. 2002�Sept. 2003



� Partnership


� PMTCT

� Scaling-Up PI

� Costing



� Nicaragua: EONC



� Mali: FGC

� Senegal: PAC



� Bangladesh: RTL






� Partnership


� PMTCT

� Scaling-Up PI

� Costing



� Nicaragua: EONC



� Mali: FGC� Senegal: PAC



� Bangladesh: RTL

Mali FGC

Training Providers, Reaching CommunitiesCounseling and Advocacyto Abandon Female Genital Cutting

In Mali, where 92% of women undergo female genital cutting(FGC), a PRIME II-assisted intervention has made encouraginggains in the effort to eliminate the harmful traditional practicethrough counseling and advocacy. Relying on outreach withinand outside of health centers, the intervention was designedto improve primary providers� knowledge, skills and aware-ness related to FGC so that they could both serve as resourcepersons and better identify and manage complicationsfrom FGC.

BackgroundFemale genital cutting in Mali typically occurs before girlsreach the age of five, following the cultural belief that excisingthe clitoris and sometimes other parts of the female genitaliawill keep a young woman chaste and improve her chances ofmarrying a good husband. FGC is associated with immediateand long-term health consequences including hemorrhage,HIV infection, complications during birth, infertility and evendeath. Attempts to persuade traditional practitioners, usuallyolder women, to abandon the practice have not been verysuccessful, and campaigns focused only on the health conse-quences of FGC have not only been ineffective but have led toincreased �medicalization� of the practice by health providers.Targeting men in community campaigns against FGC is essen-tial as they often have the final say in decisions about whethertheir daughters will be cut.

InterventionsPRIME II assisted a Ministry of Health (MOH) and local NGOtechnical working group in developing and field-testing anational FGC curriculum, which was used to train 120 repro-ductive health (RH) providers in Koulikoro and Bougounidistricts and Bamako Commune I. Written knowledge testsadministered six weeks after training showed significant im-provement in provider knowledge about prevention andmanagement of FGC complications. The curriculum is part ofa FGC resource package for providers, which includes job aidsand a 35-minute video that helps providers understand andidentify complications from FGC. Produced with support fromPRIME II, the video has also been distributed to governmentministers, members of parliament and mayors. In addition toincreasing primary providers� knowledge and skills, PRIME hasworked with the MOH and NGOs to expand the providers�role as leaders for community campaigns to eliminate FGC.

PRIME






ResultsAt the 27 health centers in the three PRIME II implementationareas, providers are now three times more likely to ask preg-nant women if they have FGC complications that might affectbirthing. The mean number of FGC complications treated on-site has increased by 26%. While counseling on FGC wasvirtually nonexistent at baseline, an end-of-project review ofhealth center registers showed that 414 female prenatal careclients received private counseling about abandoning thepractice. Nearly three quarters of providers passed the coun-seling skills performance test, up from 12% at baseline. Provid-ers facilitated 473 educational sessions in the health centerson the negative effects of FGC and 958 men who had comefor consultation or to accompany a woman or child partici-pated in waiting-room talks about the practice. At the end ofthe intervention, the percentage of clients who said they werein favor of eliminating FGC rose to 89% from 44%, and thepercentage of clients who intended to excise their daughtersdeclined to 52% from 70% at baseline.

Training providers to prevent and manage complications ofFGC helped to increase the quality of other RH services in thehealth centers, as providers improved their skills in patientreception, counseling and screening. Improved counselingskills and provider comfort level in conducting RH talks paidoff in a dramatic increase in educational sessions on generalreproductive health topics, from 153 at baseline to 2,074 atthe end-of-project review. Health information systems at thetarget sites were also strengthened as a result of tools put inplace to monitor FGC-related visits, complications and refer-rals. Such monitoring activities were nonexistent at baseline.

Of the 1,187 community outreach sessions supported by theintervention, providers were present as resource persons at714 (60%). Due to the intervention�s success, PRIME has re-ceived additional funding to extend FGC abandonment effortsthrough strengthened provider-community partnerships.

Suggested citation:Newman C, Nelson D.Counseling andAdvocacy to AbandonFemale Genital Cutting11/2003(PRIME PAGES: RR-34)


Clients in Favor of Eliminating FGC

Baseline End of Project

44%

89%

C

100%

50%

0

Clients who Intended to Excise Daughters

Baseline End of Project

70%

52%

C

100%

50%

0

PRIME








Senegal Postabortion Care

Increasing Access,Emphasizing Family PlanningA Community Model forPostabortion Care Services

In Sokone district, Senegal, PRIME II has implemented amodel to expand postabortion care (PAC) services beyondfacilities providing manual vacuum aspiration (MVA) to thecommunity level where many women and adolescent girlslive and work. The model relies on high-quality family plan-ning (FP) services to help prevent unintended pregnanciesand repeat abortion. This care meshes with fully functionalreferral and counter-referral systems among rural healthhuts and health posts and the district health center wherewomen needing treatment for complications from unsafe orincomplete abortion can receive MVA.

BackgroundWHO has estimated that unsafe abortion is responsible for30% of maternal deaths in sub-Saharan Africa. With a con-traceptive prevalence rate of 8% and an estimated 33% ofmarried women of childbearing age wanting to delay oravoid another pregnancy but not using contraception (DHS,1997), the situation in Senegal necessitates innovative ap-proaches to reducing the number and minimizing the conse-quences of unsafe abortion. Sokone, a rural district of100,000 people about 200 kilometers from Dakar, was

Suggested citation:Corbett M, Nelson D.A Community Modelfor PostabortionCare Services11/2003(PRIME PAGES: RR-35)

Photo Credit:Maureen Corbett


Oct. 2002�Sept. 2003



� Partnership


� PMTCT

� Scaling-Up PI

� Costing



� Nicaragua: EONC



� Mali: FGC

� Senegal: PAC



� Bangladesh: RTL

PRIME

selected by the Ministry of Health (MOH) for the PRIME IIintervention because PAC/MVA services are available at theSokone health center, which serves as a district hospital.There are 14 health posts in Sokone, each staffed by a nurse(mostly male), and 34 health huts where a matron or tradi-tional birth attendant serves clients. Health post nursessupervise the health huts, with an average of two to threehealth huts linked to each health post.

InterventionsPRIME II used the Performance Improvement approach totarget gaps in provider performance and access to services,including lack of knowledge about PAC/FP and infectionprevention, no supervision, and limited community involve-ment for emergency care. Matrons and community membersworking at health huts have been trained to inform womenwhere to obtain FP, identify danger signs of obstetric emer-gencies, and activate transportation and referral networks.Health post nurses have been trained in FP and to stabilizewomen with postabortion complications for transport to thehealth center. Job descriptions and performance expectationsof providers and supervisors, including members of theDistrict Health Management Team (DHMT), have been clari-fied; training curricula, job aids and supervision checklistsare in use during training and supervision; and monitoringand data collection forms are in place.

Organizational support from the DHMT has also beenstrengthened to clarify task distribution among providersand improve the organization of services; ensure the avail-ability of basic equipment, supplies and FP commodities;and establish the functional referral and counter-referralsystems. Community-provider partnerships established andsupported with assistance from the Center for PolyvalentExpansion, a program of the Senegalese Ministry of theInterior, play a major role in rallying local communities tomaintain transportation plans and funds for obstetric emer-gencies and helping health post nurses convey effective,community-supported messages about FP. In addition, theSokone district medical officer and his team have demon-strated their commitment to addressing the problem ofunsafe abortion by actively advocating for PAC at the pri-mary and community levels and for increased use of FP toprevent unintended pregnancies.

ResultsMonitoring data collected and analyzed on a quarterly basisby the district MOH and PRIME are showing exciting resultsas women with obstetric emergencies begin, for the first time,to be referred from health huts to health posts for stabiliza-tion, treatment as possible, and referral to the Sokone healthcenter for treatment as needed. From May to September2003, 85 women with postabortion complications were seenat the health posts; of these, 11 were referred from matronsin health huts. Of the 85 PAC clients, 39 (45.9%) weretreated by the nurse at the health post, using curage, and 36(42.3%) were referred to the health center for MVA, 7 afterstabilization at the health post. All 39 women treated at thehealth posts were counseled for postabortion FP and 22(56.4%) left the health post with a FP method. In addition, 74matrons at health huts and health posts now understand thatthey can and should re-supply FP clients using contraceptivepills, a task in Senegal�s national FP service policy that ma-trons were reluctant to perform before a PRIME interventionin August 2003.

Reflecting improved provider performance, these preliminarydata offer encouraging signs of what can be accomplishedwhen PAC services are made more available and accessibleto those who can benefit most from them. The MOH expectsto replicate this approach in other districts in Senegal, andlessons learned and recommendations from the pilot initia-tive in Sokone district will have implications beyond Senegalfor better practices in increasing the availability and use ofPAC services to reach more women and adolescent girls whosuffer the consequences of unsafe and incomplete abortion.

PRIME








Senegal Postabortion Care

Increasing Access,Emphasizing Family PlanningA Community Model forPostabortion Care Services

In Sokone district, Senegal, PRIME II has implemented amodel to expand postabortion care (PAC) services beyondfacilities providing manual vacuum aspiration (MVA) to thecommunity level where many women and adolescent girlslive and work. The model relies on high-quality family plan-ning (FP) services to help prevent unintended pregnanciesand repeat abortion. This care meshes with fully functionalreferral and counter-referral systems among rural healthhuts and health posts and the district health center wherewomen needing treatment for complications from unsafe orincomplete abortion can receive MVA.

BackgroundWHO has estimated that unsafe abortion is responsible for30% of maternal deaths in sub-Saharan Africa. With a con-traceptive prevalence rate of 8% and an estimated 33% ofmarried women of childbearing age wanting to delay oravoid another pregnancy but not using contraception (DHS,1997), the situation in Senegal necessitates innovative ap-proaches to reducing the number and minimizing the conse-quences of unsafe abortion. Sokone, a rural district of100,000 people about 200 kilometers from Dakar, was

Suggested citation:Corbett M, Nelson D.A Community Modelfor PostabortionCare Services11/2003(PRIME PAGES: RR-35)

Photo Credit:Maureen Corbett


Oct. 2002�Sept. 2003



� Partnership


� PMTCT

� Scaling-Up PI

� Costing



� Nicaragua: EONC



� Mali: FGC

� Senegal: PAC



� Bangladesh: RTL

PRIME








Suggested citation:Coleman AL, Nelson D.Volunteer PromotersIncrease FamilyPlanning Knowledgeand Use in the Bateyes11/2003(PRIME PAGES: RR-36)

Photo Credits:Alfredo Fort, Lucy Harber

Dominican Republic Responsive Training and Learning

Improved Provider Performance, BetterHealth-Seeking BehaviorVolunteer Promoters IncreaseFamily Planning Knowledge andUse in the Bateyes

While almost all PRIME II interventions measure changes inprovider performance, the Project�s work to improve theknowledge and skills of volunteer health promoters in sevenof the Dominican Republic�s bateyes also included a commu-nity survey of women�s family planning and reproductivehealth (FP/RH) knowledge, attitudes and practices. Thesurvey results reveal encouraging gains in accessibility anduse of contraception.

BackgroundThe most alarming health statistics in the Dominican Re-public are found in the bateyes, isolated communities thatwere originally established to house the Dominican andHaitian migrant workers who toiled in state-run sugarcanefields and refineries. Due to the privatization of the sugarindustry, the bateyes endure a high rate of unemployment;housing and sanitation are poor and health care suffersfrom lack of infrastructure, supplies and trained providers.In collaboration with the Dominican Institute for Commu-nity Action (IDAC), an NGO with 15 years� experienceworking in the bateyes, PRIME implemented a year-longintervention to compare two learning approaches, self-directed learning and classroom-based training, for 35volunteer health promoters.

InterventionsEach learning approach was supported by a referencemanual and client education materials, community radiobroadcasts, a revolving fund for contraceptive supplies,creation of simple referral systems, community talks andhome visits, and facilitated supervision. While the promotersdid not necessarily learn in the manner project designers


Oct. 2002�Sept. 2003



� Partnership


� PMTCT

� Scaling-Up PI

� Costing



� Nicaragua: EONC



� Mali: FGC

� Senegal: PAC



� Bangladesh: RTL

PRIME

Responses to Questions by Women of Reproductive Age (in percentages)

had envisioned, a substantial amount of learning took placeamong promoters in each approach. Increased promoterknowledge and skills and improved performance have beendocumented in the 2002 PRIME II Results Review and otherreporting, including a PRIME Dispatch (Number 6, June 2003)that captures findings and recommendations from the dy-namic process of monitoring and revising the project design.To examine the effects of the intervention on health-seekingbehavior in the bateyes, PRIME carried out a communitysurvey among 390 women of fertile age both before andafter the intervention. The random household surveys in-cluded 62 FP/RH-related questions. The first challenge inconducting the baseline survey was attempting to identifyhouseholds in the bateyes: none had traditional addressnumbers and no neighborhood maps existed, even from thecensus bureau.

To proceed, promoters and PRIME staff drew maps of eachbatey by hand. The mapping exercise became a mini-inter-vention itself�community members were active in the effortand are using the maps to negotiate expanded municipalservices from mayors and community officers. The post-intervention survey was conducted using the same interviewinstrument and methodology.

ResultsThe table below highlights findings from the baseline andpost-intervention community surveys. Particularly notewor-thy are the percentage of women finding contraceptives easyto access (from 19% at baseline to 60% post-intervention)and the percentage of women using contraception (from69% to 81%). Though these results are positive, one limita-tion of the survey design is that it did not include measuringwomen�s behavior in �control� areas, which would haveprovided demonstration of the net effects of the inter-vention.While the post-intervention survey indicates thatimproving health promoter performance in the context of acommunity-based intervention positively affected FP/RHpractices, it is plausible that concomitant interventions in thebateyes may have contributed to the changes in women�sbehavior. However, the project staff is not aware of anymajor government or NGO programs that would haveappreciably influenced FP/RH behavior in these communities.

Question Baseline (1/02) n = 390

Final (3/03) n = 391

Can get contraceptives from promoters

Are using contraception -Injection -Condoms

Know where to get EC(of 100% of sources) -From Promoter

Had PAP smear in last 12 months

Contraception easy to access

Am missing info on contraception

Have attended community talk - By promoter - About contraception

Promoter provides good or excellent quality of care

** difference significant at p < 0.01

59% 79%**

69 81**

48 58**

19 60**

71 52**

40 64**

22 60

57 81

61 70**

1.4 5.4

9.5 26**

27 84

1.4 4.3

PRIME








Suggested citation:Coleman AL, Nelson D.Volunteer PromotersIncrease FamilyPlanning Knowledgeand Use in the Bateyes11/2003(PRIME PAGES: RR-36)

Photo Credits:Alfredo Fort, Lucy Harber

Dominican Republic Responsive Training and Learning

Improved Provider Performance, BetterHealth-Seeking BehaviorVolunteer Promoters IncreaseFamily Planning Knowledge andUse in the Bateyes

While almost all PRIME II interventions measure changes inprovider performance, the Project�s work to improve theknowledge and skills of volunteer health promoters in sevenof the Dominican Republic�s bateyes also included a commu-nity survey of women�s family planning and reproductivehealth (FP/RH) knowledge, attitudes and practices. Thesurvey results reveal encouraging gains in accessibility anduse of contraception.

BackgroundThe most alarming health statistics in the Dominican Re-public are found in the bateyes, isolated communities thatwere originally established to house the Dominican andHaitian migrant workers who toiled in state-run sugarcanefields and refineries. Due to the privatization of the sugarindustry, the bateyes endure a high rate of unemployment;housing and sanitation are poor and health care suffersfrom lack of infrastructure, supplies and trained providers.In collaboration with the Dominican Institute for Commu-nity Action (IDAC), an NGO with 15 years� experienceworking in the bateyes, PRIME implemented a year-longintervention to compare two learning approaches, self-directed learning and classroom-based training, for 35volunteer health promoters.

InterventionsEach learning approach was supported by a referencemanual and client education materials, community radiobroadcasts, a revolving fund for contraceptive supplies,creation of simple referral systems, community talks andhome visits, and facilitated supervision. While the promotersdid not necessarily learn in the manner project designers


Oct. 2002�Sept. 2003



� Partnership


� PMTCT

� Scaling-Up PI

� Costing



� Nicaragua: EONC



� Mali: FGC

� Senegal: PAC



� Bangladesh: RTL



Mali, Benin, Ethiopia PPPH

Reducing Stress, Improving ServicesPreventing Postpartum Hemorrhagewith Active Management of theThird Stage of Labor

Replacing existing practices for delivery of the placenta with anevidence-based new protocol, PRIME II has trained providers inthree African countries in prevention of postpartum hemor-rhage (PPH) through active management of the third stage oflabor (AMTSL). Providers working at all levels of the healthcare systems in Benin, Ethiopia and Mali are demonstratingtheir ability to perform AMTSL. In addition to its value inaverting maternal death and morbidity, providers have foundAMTSL to be safer, cleaner, faster and often less expensive thanprevious practices for both the client and the facility.

BackgroundPostpartum hemorrhage is the single most significant cause ofmaternal mortality worldwide, accounting for half of all mater-nal deaths that occur after childbirth and 24% of maternaldeaths overall, approximately 130,000 women each year. Halfof the women who suffer from PPH have no risk factors, and99% of women who die from PPH are in developing countries.If a woman survives PPH she may be left severely anemic orwith other ongoing health problems. Most cases of PPH occurduring the third stage of labor after the baby has been deliv-ered. Recommended by WHO as a best practice for all vaginaldeliveries, AMTSL has three main components: 1) administra-tion of an uterotonic drug (like oxytocin) within one minute ofbirth of the newborn to induce a strong contraction, 2) con-trolled cord traction of the umbilical cord, which is clampedand cut early, with counter-traction to the uterus, and 3)massage of the uterine fundus through the abdomen. AMTSLshortens the time it takes to deliver the placenta and leads toa decrease in uterine relaxation, which is associated with 90%of PPH.

InterventionIn collaboration with ministries of health and professionalassociations, PRIME began implementing the PPPH specialinitiative in 2003 in partnership with the American College ofNurse-Midwives, Management Sciences for Health/Rapid Phar-maceutical Management Plus and JHPIEGO. The project isunder way at seven pilot sites in Benin, 24 in Ethiopia (locatedin five regions), and 8 in Mali, with more than 250 providerstrained in AMTSL and related areas including patient counsel-ing, infection prevention and oxytocics storage.




� Partnership


� PMTCT

� Scaling-Up PI

� Costing



� Nicaragua: EONC



� Mali: FGC

� Senegal: PAC


� Mali, Benin, Ethiopia: PPPH� Bangladesh: RTL

PRIME






Vaginal Births 24 Pilot Sites, Ethiopia

90% received AMTSL

n=4,586

ResultsMonitoring data from Ethiopia and Mali show promising results.At the 24 sites in Ethiopia, AMTSL has been applied to 4,138 ofthe 4,586 vaginal births since training. Few complications havebeen reported in women who received AMSTL (41, or about1%) and no maternal deaths, with only one case of PPH seriousenough to warrant a transfusion. In Mali, 3,190 women havereceived AMTSL out of 3,933 vaginal births. Three complica-tions have been reported, including one death, which was notattributed to AMTSL. While data from Benin are not yet avail-able, a clear improvement has been noted at the communityhealth center in Akassato, where the head midwife states withpride that they have had no cases of PPH in the four monthssince AMTSL training as compared to nine cases of PPH, includ-ing two resulting in death, in the six months prior to training.

Qualitative data from providers indicate that they are beingexposed to less blood (thus reducing risk of HIV infection), donot have as many bloodstained materials to throw away orclean, are using less oxytocin and other supplies than would berequired by a case of PPH, and do not have to spend as muchtime waiting for delivery of the placenta�leaving them moretime to attend to the newborn and other clients, and for themother to rest and hold her baby immediately after the birth.

Because of such positive results, the Benin Department ofFamily Health has already indicated its interest in scaling-upthe program nationally, even before final evaluation results areavailable in early 2004. Both the Ethiopian Society of Obstetri-cians and Gynecologists and the Ethiopian Midwives Associa-tion have highlighted PPH prevention and AMTSL in theirannual meetings. In addition, USAID/Mali has included PPHprevention as a high-impact service in its new bilateral projects.

Suggested citation:Huber A, Nelson D.Preventing PostpartumHemorrhage with ActiveManagement of theThird Stage of Labor11/2003(PRIME PAGES: RR-37)






� Partnership


� PMTCT

� Scaling-Up PI

� Costing



� Nicaragua: EONC



� Mali: FGC

� Senegal: PAC



� Bangladesh: RTL

Bangladesh Responsive Training and Learning

Creating Change from WithinThe Health and PopulationSector Programme (HPSP)

At the request of USAID/Dhaka, the PRIME II Project workedwith the Bangladesh Ministry of Health and Family Welfare toimplement a national in-service training strategy for the essen-tial services package (ESP). The PRIME I Project had beeninstrumental in drafting Bangladesh�s national strategy, so thefollow-on PRIME II Project was ideally positioned for thisactivity and established an office within the Technical TrainingUnit (TTU) of the Ministry, which worked side-by-side with theTTU staff for three years (2000-2003).

BackgroundPRIME�s goals were to help the TTU operationalize the na-tional in-service training strategy and to create a decentralizednational system to train 54,000 primary providers. Key objec-tives included:

� Strengthen central-level management capacity� Standardize in-service planning, implementation and

follow-up� Strengthen lead training organization (LTO) capacity� Strengthen district and sub-district (upazila) capacity to plan

and monitor training� Conduct training and follow-up� Develop monitoring and evaluation capability at the central

level, including a Training Management Information System.

InterventionsRecognizing that a national training program requires stan-dardization of training quality, PRIME led the process of draft-ing National Training Standards, which the governmentadopted. Building on these standards, PRIME led in developingtraining guidelines for the ESP course, and organizing detailsof all the steps needed to implement an effective trainingprogram for field workers. Both the standards and guidelinesdocuments contributed to the development of a quality check-list tool that was used by the Central Monitoring Team toassess the quality of the training they monitored during visitsto districts and sub-districts.

With PRIME�s assistance, the TTU established a decentralizednetwork of 64 district training coordination committees(DTCCs) and 460 district/upazila training teams (DUTTs).Through interventions identified during a performance needsassessment, the PRIME-TTU team strengthened three of thegovernmental LTOs. The team worked closely with three localNGOs that supported the logistics and administrative manage-ment of the training.

PRIME






ResultsAt the end of the three-year intervention period, the projectproduced the following key results:� 45,000 providers were trained in the basic ESP course

(83% of the target)� Data collected at worksites using stringent observation

scoring criteria for a sample of providers at baseline andend-line showed a threefold increase in average perfor-mance scores on selected tasks

� A national-level computerized Training ManagementInformation System was established, improving the TTUs�ability to plan, monitor and follow-up training

� PRIME developed and piloted a District ManagementInformation System to facilitate supportive supervision anddecision-making at the district level

� All six LTOs met the quality standards established in thenational training standards

� All sample district/upazila training teams reported receivingand using the ESP training guidelines, and 83% of DUTTmembers received follow-up support during the 21-daybasic ESP training at the upazila, compared to 52% atbaseline

� 66% of DTCC members and 41% of DUTT membersrecognized training as one of their major responsibilities,compared with a baseline of 48% and 24%, respectively

� PRIME assisted the Line Director for In-Service Training toincorporate Performance Improvement as a strategicapproach in the conceptual framework of the IST section inthe Ministry�s 2002-2003 Annual Operational Plan.

ConclusionThe HPSP represented the first time PRIME II had played apivotal role in operationalizing a national in-service trainingprogram on such a large scale and developing a nationwideframework for human capacity development. Having PRIMEstaff �embedded� in the Ministry offices facilitated the processof standardizing and ensuring the quality of training through-out the country, and the staff workedconstructively and collegially with theircounterparts to increase the capacityof the TTU.

Suggested citation:McMahan J, Rabb M.The Health andPopulation SectorProgramme (HPSP)11/2003(PRIME PAGES: RR-38)

Photo Credit:Lorraine Bell

100%

50%

0

45,000 Field Workers Trained

83% of target

Basic Essential Services Package Training

100%50%0

District Training Coordination Committees

Decentralized Training Responsibility

District/Upazila Training Teams

75%25%

2000 48%

2003 66%

2000 24%

2003 41%

3 -pp rr 2003 4-page layout bw 12-30-03

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