Creating the Conditions for Scaling Up the Integration of Reproductive Health Services for Men in Health and Family Welfare Centers in Bangladesh

"Men have substantial reproductive health needs that have not been addressed in the context of the current government health care delivery system in Bangladesh....They are largely ignorant of preventive measures and postpone seeking medical care for chronic health conditions, often resorting to self-medication for acute illness..."

This 32-page report is a follow-up study to a September 2004 paper detailing an operations research (OR) study, supported by the Population Council's Frontiers in Reproductive Health (FRONTIERS) Program, which showed that reproductive health (RH) services for men could be feasibly and acceptably integrated within the Health and Family Welfare Centres (HFWC) in Bangladesh. Given these findings, FRONTIERS worked with the Directorate General of Family Planning (DGFP) and the Institute of Child and Mother Health (ICMH) to create the conditions for scaling up the model. This paper evaluates strategies for scaling up the intervention in 40 HFWCs selected from 4 districts of Dhaka division.

An excerpt from the report follows:

"The scale-up activities were carried out in three phases. The first was a preparatory phase, consisting of a review and revision of the teaching and communication materials developed during the original OR project, which included incorporating the systematic screening instrument to identify clients' unmet needs during the registration process. In the second phase, the revised model was introduced into 40 HFWCs. Activities included orienting program managers, supervisors, and field workers, creating a cadre of master trainers, and providing theoretical, practical, and refresher training to service providers on case management for reproductive tract and sexually transmitted infections (RTIs and STIs). To make people aware of the availability of RTI/STI services, 463 group meetings were conducted at the community level. The third phase entailed assessing the feasibility of scaling up this revised model through analysis of service statistics, exit interviews with clients, and observation of client-provider interactions...

A total of 26 master trainers were trained and 110 service providers successfully completed the training on counseling and treating RTIs/STIs using the syndromic management approach. The results revealed significant improvements in the trainees' knowledge and competence in the management of RTI/STI clients. For example, the proportion of providers who knew how to treat urethral discharge nearly tripled following the training (increasing from 36% to 96%). The refresher training was vital for retaining providers' skills and clarifying their questions, and is strongly recommended for any scale-up process.

As was demonstrated in the pilot OR project, adding services for men increased utilization of the facilities by both men and women. During the six-month scaling up period, approximately 30 percent more clients received services from the 40 HFWCs. Of the adult clients (those over age 14, comprising 71% of clients) attending the clinic, 17 percent were males. The monthly average number of adult male clients visiting increased from 41 to 55 per HFWC over this period; similarly, the average number of adult female clients also increased from 200 to 263 per month at each HFWC.

Approximately 82 percent of adult clients (96% of the men and 79% of the women) visited the HFWCs for general health care. More females received family planning and reproductive health services than males (10% versus 2%). During the scale-up period, service providers diagnosed and treated 1,862 RTI/STI clients, 14 percent of them men. Condom distribution gradually increased over time in areas where the condom supply was regular, but declined where the supply was irregular (condoms were out of stock for almost three months).

The systematic screening instrument, a method developed by FRONTIERS to identify clients' unmet needs, was introduced during the scale-up. In nine percent of cases, systematic screening helped identify one or more unmet needs, most commonly general health care services, followed by RTI/STI treatment and family planning. In most cases, providers were able to administer the additional services during the same visit. However, providers' compliance with the screening procedure varied, with providers following the screening procedures correctly in one-third of the consultations observed. During the initial stages of scale-up, closer supportive supervision and encouragement from senior officials, such as a letter from DGFP, could strengthen compliance.

Exit interviews with clients and observations of client-provider interactions revealed a satisfactory quality of services overall, measured in terms of providers' focusing on the clients' needs, asking the right questions about their problems and service needs, including appropriate questions for RTI /STI clients, and correctly following syndromic management protocols. Most of the clients interviewed were satisfied with the services they had received.

These findings suggest that this model of service delivery and training could be scaled up countrywide, preferably in stages....Training a large number of service providers will be a critical component for the expansion. Classroom-based training is not enough; providers also need practical training, opportunities to observe and examine patients to improve their diagnosis and treatment skills, and refresh their knowledge and skills periodically..."