Provider Perspective

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Provider Perspective
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Overview

• In order to improve family planning and
  reproductive health programs further, we need to
  see the world through the providers eyes and
  understand them better.

Sources Huezo and Diaz, 1993 Shelton 2001
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Objective

• Consider the healthcare providers perspective
• What personal characteristics or attributes may
  affect provider performance?
• How does medical culture affect provider
  performance?
• How do providers relate to clients and the
  community?
• What systems and social issues affect provider
  performance?
• Why might a provider avoid providing IUDS?

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Providers - Who are they, anyway?
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Thinking About the Provider

• Personal Characteristics
• Technical Competence
• Needs and Rewards
• Control/Convenience/Comfort
• Medical Culture
• Empowerment/Proactivity
• Links to Client/Community
• Systems Issues

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Personal Characteristics

• Personality
• Work Attitude/Inclination
• Altruism/Motivation
• Humanness
• Value System
• Gender, Age etc.

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Technical Competence

• Knowledge
• Skills
• Self-efficacy

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Performance Improvement An Alternative Approach

• Seeks to understand the myriad elements that
  influence provider and organizational performance
  and considers the full range of possible
  interventions to make improvements.

Source Stolovitch and Keeps 1992.
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What Do Providers Need?

• Material Necessities
• Family
• Security
• Psychic fulfillment - status, affiliation etc.
• Other Basic

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Rewards

• Appreciation

• Financial

• Interest/Fun

• Status/Ego

• Helping
• Others

• Accomplishment

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Recognition
Appreciation
Photo by Marianne Elias
Photo by Marianne Elias
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Providers May Face Daunting Constraints

• Problems with reimbursement, supplies, and
  equipment
• Lack of physical space
• Poor training and supervision
• Lack of transportation
• Bureaucratic obstacles
• Scheduling difficulties
• Lack of physical security

Source Khan, Patel and Gupta 1995.
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Control/Convenience/Comfort

• Pace
• Stress
• Easiness
• Timing
• Predictability
• Physical Aspects
• Clinic Flow

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Photo by Lamia Jaroudi
Photo by Sereen Thaddeus
P.M.
A.M.
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Procedural Barriers as Rationale to Reduce
Workload

• Procedural barriers to service delivery, such as
  requiring women to be menstruating to receive
  contraceptives, may allow providers a
  legitimate rationale to regulate and reduce
  their workload, even though it means clients may
  not receive services.
• Source Stanback et al 1997.

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Scheduling and Time Regulation

• Scheduling is a method often used to control
  volume and pace of work.
• In Brazil, a study found appointments only
  accepted on certain days of the week, and clients
  standing in line for hours to get appointments as
  far as one or two months in advance.

Source Diaz et al 1999.
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Medical Culture

• Hierarchical
• Work routines
• Division of labor
• Rituals
• Technical versus Human
• Insulation
• Curative

Source Shelton, Angle and Jacobstein 1992.
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Empowerment/Proactivity
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What Key Provider Attribute Does this Slide
Represent?
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How Does the Provider Link to the
Client/Community?

• Knowledge about the community
• Affinity
• Affiliation/Roots
• Class/Race/Gender, etc.
• Social Distance
• Power Imbalance
• Favoritism

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Key Social Issue for Providers
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What Systems and Social Issues Influence
Providers?

• Creative Financing
• Bureaucracy/Personnel Systems
• Peer/Social Network Influences
• Scarce Resources
• Supervision
• Socio-Cultural Environment

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Provider Social Issue
Photo by Johns Hopkins Center for Communication
Programs
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Two RealitiesHealth District Study

• Health System to Deliver Services (official
  reality)

• Health System to Provide a Job (other reality)

• Training to Improve Performance

• Training to Provide Income

• Personnel System for Rewards and Sanctions

• Informal methods for Rewards and Sanctions

• Right Skills for Each Health Job

• Various Health Jobs Interchangeable

• Reporting for Decision-making/Quality

• Reporting as an End in Itself

Source Aitken J-M. 1994.
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Why might a provider avoid IUDs?

• More work!
• Supplies and equipment required
• Proper training required
• Low FrequencyLow confidence
• Misconceptions about IUDs
• Social distance
• Personal risk (HIV, etc)

Sources Hajii and Laksisir 1996 Stanback,
Omondi-Odhiambo, Omundo 1995 Johnson, Katz and
Janowitz 2000.
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Some Provider Thoughts on the IUD
sometimes we are in a rush and there are many
patientsmany times we choose the easiest
method. A doctor in El Salvador
Well, we have been trained, but I have never had
the opportunity to perform the procedure. Anot
her doctor in El Salvador
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More Provider Thoughts on the IUD
... patients were forced to buy gloves so even
that one contributed to the failures. She will
go because she has no money and does not come
back again. Provider in Kenya
Maybe you have a small cutyou could get
infected. Another provider in Kenya
It is a lot to do if you are busy. Another
provider in Kenya
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Summary Provider Perspective

• We really need to know more about providers.
• Providers are different, but have certain common
  patterns.
• Key motivations are financial, status, helping,
  appreciation, control of environment, and social
  norms of behaviorask yourself whats in it for
  them.
• As with anyone, if we want providers to do more
  work, we need to justify it with them.
• We must be prepared to address the unpopular
  issues that are often not discussed.
• We need to find out more about the providers way
  of looking at the world.

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There are some wonderful providers out there
doing great work!