Training of providers and the introduction of a decision-support tool
Formative qualitative work that the study team has conducted over the past two years, combined with the efforts of a multi-disciplinary working group (comprised of Cameroonian nurses, doctors, researchers, and adolescent health experts; regional and national health officials; as well as economists and public health specialists from the World Bank) revealed a number of barriers to the uptake of modern contraceptives - both on the supply and the demand sides. On the supply side, lack of formal training of health providers on family planning, inexperience in the administration and removal of LARCs, and provider bias against recommending LARCs (especially to adolescents, unmarried women, and nulliparous women) have been identified as the main barriers. Given that follow-up services (such as management of side effects and removal of implants and IUDs) are also of inadequate quality, the government has decided to tackle these supply-side issues first – before trying to increase demand for contraceptives among adolescent females. This was a deliberate decision as the formative qualitative work also indicated a non-negligible risk of young women having negative experiences with the health system, which could influence the willingness of other young women to adopt modern contraceptives.
Therefore, on the supply-side, the study team is proposing to evaluate the effectiveness of two (cumulative) interventions, which were recently developed by the government of Cameroon, over and above business as usual, with respect to family planning services provided at health facilities: (a) training of nurses using a newly-developed curriculum on MC methods (theory, practice, and counseling), and (b) the introduction of a tablet-based job aid (or a decision-support tool) for nurses to counsel female clients. This design implies a cluster-RCT with three arms implementing the following interventions:
C: No formal training on MCs (business as usual): The comparison group includes facilities that continue business as usual (no FP training or tablet-based job aid). Each facility in this group will receive a tablet equipped with basic data collection software and a one-day training to use the tablets. The study will also serve the purpose of piloting a transition of health facilities from paper-based records and PBF declarations to digital ones.
S1: Training of nurses using a new curriculum on MCs: Health facilities assigned to this group will receive a two-week training intervention on modern contraceptive methods and counseling techniques – aimed at nurses conducting family planning services. This new curriculum was developed by a large group of experts convened by the Ministry of Health in February 2018. The cascade training that is developed by the national government (cascading down to regions, districts, and finally health facilities) is a 15-day training module that targets family planning nurses, covering theory, practical knowledge (practicing administrations and removals), and counseling of clients. The training of regional and district trainers in the East is currently underway and the training sessions for health facilities, which will take place after random assignment of each facility to an intervention arm, are tentatively scheduled for January 2019. Each facility, like the control group (C), will also receive a tablet equipped with basic data collection software and a one-day training to use the tablet.
S2: S1 + the introduction of a tablet-based decision-support tool for nurses to counsel female clients: Health facilities assigned to this group will receive the same programming as the facilities in S1, but they will also be provided with tablets equipped with the “job aid,” which subsumes the basic data collection software used by the remaining facilities. They will also receive additional training on the use of the tablet-based “job aid.” The “job aid” (or the “decision-support tool” or simply the “app”) was developed by a multi-disciplinary working group formed in Cameroon and comprised of nurses, doctors, and researchers from HGOPY, public health and adolescent health specialists from the Department of Family Health in the Ministry of Health, public health and economics researchers focusing on adolescent health from the World Bank, members of local NGOs focused on the sexual and reproductive health of adolescent females and young women (such as ACMS), as well as a digital health consultant who programmed the “app”.
The “app,” which takes a patient-centered approach to counseling, is designed to explicitly and fully incorporate the life goals, fertility plans, needs, and preferences of the client regarding contraceptive methods into the counseling session, which is not only recognized as having utmost importance for her to be able to make an informed decision, but is also empowering – endowing her with agency and making her feel respected. At the same time, the working group also acknowledged that clients, especially adolescent ones, may need some guidance from the health provider in terms of the contraceptive methods that are most suitable to their needs and preferences, but that the providers also have their own biases. Hence, the “app” is a tablet-based decision-support tool, which is designed for use by the family planning nurse conducting counseling sessions and records the answers to a series of questions that elicit the client’s life goals, fertility plans, needs, and preferences regarding contraceptive methods, as well as her medical eligibility (birth history, pregnancy check, breastfeeding status, blood pressure, medications, etc.). Based on the client’s answers to these questions, the “app” then ranks contraceptive methods (that are not contra-indicated) from most suitable to least suitable for the client. The nurse then uses these rankings to discuss these methods in order until the client decides to adopt a method (or refuse all of them). The questions included in the “app” and the language used by the nurse to discuss options with the client can be found in Section 21.
Optimizing PBF payments to facilities for family planning services
Under the PBF system that Cameroon has in place, each facility enrolled in PBF signs a quarterly contract with the government and is paid a price (an incentive) for each unit of eligible services it provides that are covered under that contract, subject to the verification of its declaration of quantity of services provided and an independent audit of the quality of those services. Each PBF contract has two line items specifying payment amounts per LARC and SARC administered by the facility.
The study team hypothesizes that the social cost of unwanted and mistimed pregnancies to young women in Cameroon is such that the current level of PBF payments for SARCs and LARCs (at 1,500 and 2,250 CFA Francs, respectively) are sub-optimal. Specifically, we believe that the level of payments for LARCs is too low – both in absolute value and relative to the level of payments for SARCs.
The study aims to test this hypothesis by randomly varying these two PBF payments across facilities. Block stratified by the main interventions (C, S1, and S2) described above – i.e. within each of study arm of C, S1, and S2 – facilities will be randomly assigned to receive one of three types of PBF contracts at the start of 2019 that fixes the PBF payments for SARCs fixed at their current (status quo) level, but adjusts the PBF payments for LARCs as follows:
• low (the status quo payment of 2,250 CFA francs per LARC administered),
• medium (4,000 CFA francs per LARC administered), and
• high (6,000 CFA francs per LARC administered).
Optimizing PBF payments to facilities for family planning services
Finally, the government would also like to answer the question of whether providing family planning services to adolescents (females aged 24 or younger) would be more cost-effective than allowing health facilities to set their own prices for these services. Currently, under the PBF model, facilities are allowed to set their own prices for each method of contraceptive, although many facilities charge prices recommended by the Ministry of Health or non-governmental organizations they work with. As adolescent females are less likely to have their own money to seek family planning services and purchase contraceptives, free services for them may improve outcomes.
To test this hypothesis, the PBF contracts for half of the facilities in the study sample will require the facility to provide family planning services to adolescents for free in order to receive the stipulated PBF payments (Low, Medium, or High – depending on their treatment status described above). The other half will be free to set their own prices as usual. The comparison of these two groups (approximately 90-95 facilities each) will reveal which approach is more successful (and cost-effective) in increasing the number of adolescent clients adopting reliable modern contraceptive methods.