Fixed Day Static Approach to Expand Access to Quality Family Planning Services

Purpose: To provide specific guidance on planning and organizing of effective strategies for implementation of Fixed Day Static (FDS) services (also referred to as Family Planning Day) for expanding access to quality Family Planning (FP) services.

Audience:

  • Chief Medical and Health Officers (CMHO/CDMO/CMO/CS)
  • Chief Medical Superintendents (CMS)
  • Nodal Officer Urban Health
  • Persons In-charge of Private facilities
  • District Program Managers (DPM)

Background: The Fixed Day Static (FDS) (or Family Planning Day [FPD]) approach has been seen to increase access and availability of quality FP services. It helps the government maximize the use of its limited resources and manpower, and increase the provision of services to a large number of beneficiaries. It is a collaborative effort wherein trained manpower, equipment, commodities and supplies at the facility are made available on a pre-announced day and time known to the community.

The FDS/FPD approach is consistent with the government strategy and takes place on a regular basis to offer a range of FP methods on the same day, or a specific method such as No-Scalpel Vasectomy (NSV), female sterilization or Intra Uterine Contraceptive Device (IUCD). The FDS/FPD can be organized in government facilities as well as in accredited private facilities. When organized in the private sector, the service burden on the government health facilities is reduced, thus providing the underserved a greater access to FP methods and services.

How FDS/FPD increases satisfaction and trust in the health facilities amongst consumers

  • Individuals receive the FP services they have come for, unless they are screened out on medical grounds
  • High quality services are provided and appropriate follow-up is encouraged
  • The service schedule is widely publicized and is easy to remember
  • Waiting time is minimal

Evidence of Effectiveness

The Urban Health Initiative’s (UHI) experience revealed that when FDS/ FPD were regularly organized in a facility, they enhanced the quality and utilization of routine FP services in that facility. Similar results have been demonstrated by Population Services International’s (PSI) Expand Access to Quality (EAQ) project, which aims to increase the use of Long Acting Reversible Contraception (LARC) and Long Acting Permanent Methods (LAPMs) by expanding choice and access to people residing in urban slums of 32 districts of Uttar Pradesh.

The above graphs show that an increase in the number of FDS/FPD conducted in selected facilities across 11 cities of UHI and 32 districts in the EAQ project of Uttar Pradesh, resulted in an increase in the number of acceptors of LAPM.

Guidance on Implementing Fixed Day Static Service/Family Planning Day

The following steps need to be taken for organizing an FDS/FPD:

Determining the Schedule of FDS/FPD

Determining the schedule of FDS/FPD for district hospitals, Urban Primary Health Centres (UPHCs), Community Health Centres (CHC), Urban CHCs and accredited private health facilities.

  • The CMHO/CDMO/CMO should issue a directive that facilities share their FDS/FPD calendar, after which a schedule can be drawn up and a joint calendar prepared (Refer FDS/FPD Calendar Format)
  • Accredited private providers are also encouraged to organize FDS/FPD and this should also be included in the respective district/city calendars issued by the CMHO/CDMO/CMO/CS
  • The schedule submitted should include the proposed dates, the FP services to be provided and the FDS/FPD medical team consisting of a doctor, an anesthetist (if available), paramedical staff, a lab technician, a counsellor, a ward boy, a sweeper to be made available. The CMHO/CDMO/CMO/CS would then approve the schedule and budget as required
  • The FDS/FPD calendar should be widely circulated among health staff
  • Community mobilizers and other community members should be informed about the FDS/FPD schedule through handbills, newspaper inserts, and other communication mechanisms
Ensuring Facility Readiness for FDS/FPD
  • The Chief Medical Superintendent (CMS)/Facility-in-charge of accredited private facilities should appoint the FDS/FPD team and assign responsibilities to ensure that commodities, supplies, equipment, manpower, requisite reporting forms, IEC materials and sufficient budget for wage loss compensation (wherever applicable) are available on the given day. Electricity and water supply are also important requirements for quality services. The checklist of facility readiness (Refer Annexure 3a_Check- list for Preparedness of the site during FDS/FPD for Sterilization Procedure) can be used to assess and ensure facility readiness
  • A duty roster should be created by the facility-in-charge for all essential staff i.e. medical and non-medical including anesthetists (if available), staff nurses, lab technicians, counselors, drivers, sweepers etc.
  • Where a facility does not have trained medical / paramedic staff required for providing any particular FP services, such as lack of doctors trained in NSV, female sterilization, injectable contraceptive, Intra Uterine Contraceptive Device (IUCD), the facility-in-charge should seek help and approval from the CMHOs/CMOs to depute qualified staff from another facility or to hire a private sector doctor for FDS/FPD.
  • The CMS of the government facilities and the facility-in-charge of accredited private facilities should ensure that the wage loss compensation is paid to the sterilization clients and incentives are paid to the motivators (wherever applicable).
Facilitating Client Flow on the Day of FDS/FPD

  • The counselor or the designated staff member should establish a separate registration counter for FP clients on the day of the FDS/FPD and client information should be recorded in a register.
  • The counselor should offer pre-service counseling to clients (Refer to Final Draft Handbook on FP for counsellors and paramedics, Chapter No. 2 to 6) and respond to their queries with the help of Information, Education and Communication (IEC) materials (UHI method specific IEC materials)
  • From here the client should be sent to the Out Patient Department (OPD), where a designated/empaneled doctor should examine and screen the woman or man prior to the procedure/service. The doctor may refer the client for any further diagnostic tests.
  • Based on the screening, the client should be offered the FP method of his/her choice and in case the client is not fit for a particular FP method, then appropriate counseling should be done concerning other suitable methods available.
  • All documentation should be completed. In the case of sterilization, the consent form, the medical case record checklist and the client card should be filled out and the client card copy should be given to the client (Refer to the government consent forms & other checklists for sterilization).
  • The accredited private facilities should utilize the government approved client records and reporting forms including the consent forms.
  • The counselor should provide post-procedure counseling to all those who have received the service. This should include information about the necessary follow-up, possible side-effects and early warning signs which require immediate medical attention by a provider (Refer Final Draft Handbook on FP for Counsellors and Paramedics, Chapter No. 13)
  • Condoms (in case of NSV) and medicines for follow-up care should be given along with the client card before the client leaves the hospital.
  • As per the government budget guidelines, the facility-in-charge should arrange for pick-up and drop off for clients willing to use FDS/FPD (Refer ROP 2017-18, NHM-UP for budget guidelines for FDS)
Mobilizing the Community to Participate in the FDS/FPD
  • The CMHO/CDMO/CMO/CS should share the FDS/FPD calendar / handbill with the government and and non-government organizations to inform on the FDS/FPD, activate demand generation teams (community workers) and mobilize potential clients to seek the FP services provided under FDS/FPD.
  • Accredited Social Health Activists (ASHAs), Anganwadi Workers (AWWs), District Urban Development Agency (DUDA) link workers, other developmental partners and NGOs should publicize FDS/FPD through different IEC materials like wall posters and handbills, which carry information about dates and venues of FDS/FPD to mobilize the clients.
  • The FDS/FPD date can be publicized by stamping it on the OPD registration forms of government facilities as well as private and NGO facilities.
  • Media briefs can be provided by the CMHO/CDMO/CMO to publicize the FDS/FPD.

Roles and Responsibilities

Role
Responsibility
CMHO/CMO
  • Send a directive to the persons in-charge of all the rural and urban facilities and accredited private facilities to obtain facility-wise FDS/FPD schedule and to allocate and approve resources
  • Encourage all accredited private facilities to organize FDS/FPD
  • Proactively plan and organize FDS/FPD in the district
  • Ensure that empaneled providers are available for conducting FDS/FPD
CMS/Facility In-Charge (in case of private facilities)
  • Develop the FDS/FPD calendar
  • Establish FDS/FPD teams
  • Supervise facility readiness
  • Ensure that informed choice and method-specific counseling is done as per guidelines
  • Ensure that clients are appropriately screened. In case not eligible for their preferred method, clients should be counseled about other appropriate contraceptive alternatives
  • Ensure that methods are provided with appropriate quality of care including recommended infection prevention practices
  • Monitor the quality of FDS/FPD services and ensure correct reporting. The facility-in-charge is responsible for ensuring quality of services and correct reporting
  • Ensure wage loss compensation for sterilization clients
  • Minimize client waiting time at the facility on the day of FDS/FPD
Nodal Officer Urban Health and FP
  • Lead in planning and organizing FDS/FPD in the district
  • Manage the FDS/FPD operations including team deployment and logistics
  • Coordinate and oversee all quality parameters and work as an interface between district leadership and facilities
  • Ensure methods are provided with appropriate quality of care including recommended infection prevention practices
  • Ensure a smooth supply of commodities and supplies
  • Monitor FDS/FPD for quality and ensure data validity and reliability
  • Ensure client verification for accredited private facilities
Facility Counsellor
  • Develop the FDS/FPD calendar
  • Establish FDS/FPD teams
  • Supervise facility readiness
  • Ensure informed choice and method specific counseling is done as per guidelines
  • Ensure the clients are appropriately screened. If not eligible for preferred method, counsel the client for appropriate contraceptive alternatives
  • Ensure methods are provided with appropriate quality of care including recommended infection prevention practices
  • Monitor the quality of FDS/FPD services and ensure correct reporting.
  • Ensure wage loss compensation for sterilization clients
  • Minimize client waiting time at the facility on the day of FDS/FPD
U-ASHAs/ Mahila Arogya Samiti (MAS), NGOs, Outreach workers
  • Generate awareness and mobilize clients for FP/FPD through home visits and group meetings
  • Prepare potential client list before each FDS/FPD
  • Use IEC materials to provide information to men, women and community leaders about FP and specific contraceptive methods
  • Use handbills to provide information on FDS/FPD schedules and availability of services
  • Accompany clients to the facilities to help them access services
  • Provide feedback to the facility-in-charge on services
  • Support post-procedure follow-up of clients

Monitoring FDS/FPD to Expand Access to Quality Family Planning Services

FDS/FPD can be monitored by including FDS/FPD as a regular agenda item for discussion in the District Quality Assurance Committee (DQAC), District Health Society (DHS) meeting, and monthly meeting of Medical Officers-In-Charge convened by the CMO. The following indicators should be reviewed:

  • Number of FDS/FPD planned, compared to the number of FDS/FPD held
  • Number of family planning clients served through FDS/FPD, by method-mix distribution
  • Percentage of FP clients served through FDS/FPD to the total FP clients served, by method, by month
  • Client-provider ratio for sterilization (so as not to compromise client safety and quality of care)

Further, spot checks by the CMO and the in-charge of private facility should be undertaken to ensure attention to quality parameters and resolution of bottlenecks.

Monitoring the reasons for which women are screened out or service provision is postponed particularly for sterilization can provide important information on quality of care and provider-driven barriers to services. This information can be obtained by noting the reasons for screening out/postponement in the client register.

Data Quality Assurance – Although there is a tendency to collect and report service provision data from FDS/FPD together with the information from routine service days, separate record-keeping for a certain period of time is recommended for monitoring.

Cost Elements

The elements required for FDS/FPD are mentioned below along with their PIP codes for easy reference. They may be covered under existing budget line items (Refer ROP 2017-18, NHM-UP), but if not, they should be incorporated through the Program Implementation Plan (PIP) process. Any additional support can also be sought from the flexi-pool. Specific costs include the following:

Cost Element
FMR Code
Source
Pre- publicity costs such as costs for wall paintings, hoardings at the facility B.10.3.3.1 ROP UP 2017-18, NHM-UP
Necessary kits and surgical equipment and supplies costs B16.1.3 ROP UP 2017-18, NHM-UP
IEC-BCC materials B.10.3.3 ROP UP 2017-18, NHM-UP
Printing of FP Manuals, guidelines A.3.5.6.1 ROP UP 2017-18, NHM-UP
Manpower costs (where a trained doctor is not available or the position is vacant, a contract- in provider can be supported through the PIP. Costs for contracting-in a counsellor for the FDS/FPD team)

A.3.1.1, A.3.1.2, A.3.1.3, A.3.1.4

& for spacing methods A.3.2.2, A.3.2.3, A.3.2.4

ROP UP 2017-18, NHM-UP
POL for Family Planning/others (Including additional mobility support to surgeon’s team if required) A.3.3 ROP UP 2017-18, NHM-UP

This table is indicative and illustrates the manner in which cost elements are provisioned in a government PIP, thus giving guidance to the audience on where to look for elements related to a particular task, such as ‘Fixed Day Static’ or ‘Family Planning Day’ services.

Sustainability

Sustainability of FDS/FPD can be achieved through the following measures:

  • Ensuring that financial resources required for FDS/FPD are included in the annual PIP.
  • Establishing a routine schedule of implementation through an order by the CMHO/CDMO/CMO, and institutionalizing monitoring at monthly meetings.
  • Making a specific staff member accountable for FDS/FPD (for example, a doctor/matron/senior nursing staff of a a District Women Hospital (DWH)or the in-charge of a private accredited facility) at each facility. By making quality FP services more frequently available at a facility, FDS/FPD serves as a first step towards providing comprehensive FP services on a regular basis. FDS/FPD at the DWHs and other accredited private facilities have become a regular practice where a broad range of FP services are provided. Still, the need is to continuously publicize the event in poverty clusters and other urban slum areas to create demand.
  • Ensuring providers have the skills and knowledge to provide all methods (as it decreases the need for contracting-in providers on special days and facilitates routine provision of all methods).
  • Including support for contracted-in- counselors in the PIP facilitates availability of counseling for both FDS/FPD and routine service provision.
  • For sustaining FDS/FPD at private accredited facilities, constant follow-up should be done with private providers by the CMHO/designated nodal officer to motivate them, build their capacity, provide timely reimbursements and support them in generating demand for FP services on the scheduled day of FDS/FPD.

 

Disclaimer: This document is based on the learnings collated from Urban Health Initiative (supported by BMGF), Health of the Urban Poor (supported by USAID) and Expanded Access and Quality (EAQ) to broaden method choice in Uttar Pradesh (supported by BMGF). This document is not prescriptive in nature but provides overall guidance of how this particular aspect was dealt with in these projects for possible adoption and adaptation.