Abstract
Background: High-quality family planning (FP) services have been associated with increased FP service demand and use, resulting in improved health outcomes for women. Community-based family planning (CBFP) is a key strategy in expanding access to FP services through community health workers or Village Health Team (VHTs) members in Uganda. We established the first CBFP learning site in Busia district, Uganda, using a quality improvement collaborative (QIC) model. This process evaluation aims to understand the QIC adaptation process, supportive implementation factors and trends in FP uptake and retention. Methods: We collected data from two program districts: Busia (learning site) and Oyam (scale-up). We used a descriptive mixed-methods process evaluation design: desk review of program documents, program monitoring data and in-depth interviews and focus group discussions. Results: The quality improvement (QI) process strengthened linkages between health services provided in communities and health centers. Routine interaction of VHTs, clients and midwives generated improvement ideas. Participants reported increased learning through midwife mentorship of VHTs, supportive supervision, monthly meetings, data interpretation and learning sessions. Three areas for potential sustainability and institutionalization of the QI efforts were identified: the integration of QI into other services, district-level plans and support for the QIC and motivation of QI teams. Challenges in the replication of this model include the community-level capacity for data recording and interpretation, the need to simplify QI terminology and tools for VHTs and travel reimbursements for meetings. We found positive trends in the number of women on an FP method, the number of returning clients and the number of couples counseled. Conclusions: A QIC can be a positive approach to improve VHT service delivery. Working with VHTs on QI presents specific challenges compared to working at the facility level. To strengthen the implementation of this CBFP QIC and other community-based QICs, we provide program-relevant recommendations.
Highlights
The integration of volunteer community health workers (CHWs), or Village Health Team (VHT) members in Uganda, into family planning (FP) service delivery is one of several proven highimpact practices in family planning and is called communitybased family planning (CBFP)[1]
High-quality FP services have been associated with increased FP service demand and use, resulting in improved health outcomes for women, including reductions in unmet need for FP and rates of unintended pregnancy, abortion, morbidity and mortality[3]
To select participants for focus group discussions (FGDs) and in-depth interviews (IDIs), we purposively identified a subset of pilot and scale-up health centers in Busia and Oyam districts
Summary
The integration of volunteer community health workers (CHWs), or Village Health Team (VHT) members in Uganda, into family planning (FP) service delivery is one of several proven highimpact practices in family planning and is called communitybased family planning (CBFP)[1]. QICs have been implemented across sub-Saharan Africa, focusing on iteratively testing changes in service delivery and analyzing their effects on processes and outcomes[5,6], often using the plan-do-study-act (PDSA) quality improvement model (Figure 1). These quality improvement initiatives are often clinical and disease-focused (e.g., HIV/AIDS), driven by clinical processes (e.g., appropriate treatment, diagnosis) and have occurred at the health center level[7,8]. We established the first CBFP learning site in Busia district, Uganda, using a quality improvement collaborative (QIC) model This process evaluation aims to understand the QIC adaptation process, supportive implementation factors and trends in FP uptake and retention.
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