Expanding Access to Quality FP/RH Services
While reproductive health indicators have improved in Paraguay over the past decade, the total fertility rate is high for the region and over 17% of women in union have an unmet need for family planning. After designing and implementing an evaluation of the Ministry of Health’s five-year national reproductive health (RH) policy, PRIME II helped to design a new RH/sexual health national policy for 2003-2008. In five regions—Central, Misiones, Itapua, Cordillera and Asuncion—PRIME focused on expanding access to family planning (FP)/RH services among rural and low-income women and improving the quality of FP/RH care offered in 22 hospitals and health centers. PRIME used the Performance Improvement (PI) approach to select interventions including training doctors and nurses in FP, informed consent, client-provider interaction, infection prevention and postabortion care; clarifying job expectations through review and analysis of RH protocols and norms; giving performance feedback to providers during on-the-job training; and applying EngenderHealth’s COPE tool to institute changes in clinic environments and structure of services.

Key Results: A sampling of trained providers (n=27 at baseline, n=23 at final evaluation) showed significantly improved performance in five priority areas, from 36% of tasks performed to standard to 80%. Achievements were especially dramatic in the areas of informed consent (40% to 94%) and client-provider interaction (60% to 98%). Acceptance of modern contraception among samples of FP clients (n=36 at baseline, n=232 in December 2003) increased from 42% to 75.5%.

Improving Maternal and Newborn Health Care
Lack of access to the services of trained providers is one of the main reasons that Paraguay has the third highest maternal mortality ratio in Latin America. In rural areas, where approximately 70% of Paraguayans live, an alarming 60% of women deliver their children at home with only the assistance of traditional birth attendants. PRIME II worked to improve the knowledge and performance of primary providers of maternal health services in the Caaguazu region by assessing clinical services and community needs, creating a network of services through health committees, and designing and implementing a training curriculum based on the needs of different levels of services.

Key Results: Observation scores showed significant improvements in many areas of prenatal care for facility-based providers (mostly nurses) between baseline (n=25) and post-intervention (n=28) including listening to fetal beats (61% to 100%), breast examination (21% to 64%) and informing women about danger signs (4% to 48%). Similar improvements were noted between baseline (n=24) and post-intervention (n=22) in areas of postpartum care including controlling temperature (33% to 91%), pinching the umbilical cordon properly (37% to 85%) and evaluating postpartum bleeding (75% to 95%). Overall performance observation scores for midwives improved from 35% at baseline (n=64) to 61% post-intervention (n=30) with 100% scores in all areas of partum care. Client satisfaction with postpartum services increased from 52% (n=26) to 77% (n=28).

Client Feedback on Provider Performance
Clients are uniquely positioned to evaluate provider performance during their care, and client satisfaction is the most important determinant of their willingness to return for future services. Yet providers and their supervisors are often unaware of clients’ expectations and uninformed about clients’ perceptions. Dissatisfied clients simply fail to come back. At 16 Paraguayan hospitals and health centers, PRIME II compared two strategies for client feedback: group meetings with clients and providers (10 facilities) and feedback cards that clients can leave in an “opinion box” (6 facilities). Both approaches featured public display of client communication posters to summarize the good things clients said about services, their suggestions on ways to improve services, and the changes providers were making in response to the feedback.

Key Results: Observations of provider performance in components of prenatal care included in feedback showed significant improvement at the intervention facilities—from 21% to 57% for the group approach and 24.5% to 35% for the feedback card approach—as compared with an improvement of 23% to 23.5% for providers at a control facility.