Should You Have A Vasectomy? One Mans Journey of Discovery
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By drawing attention to the broad range of influences on the health system demonstrated through the analysis of the NSV program, this study assists in providing a proxy framework on how a future MC program could exist within an already vulnerable health system. In this paper we present the findings of a qualitative study conducted to explore lessons from the development and implementation of the NSV program in PNG to understand health system readiness for a potential MC program if it is deemed appropriate.
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An iterative, purposive sampling technique was used to identify potential participants for the KII with upper level health system officials involved in the coordination of the national NSV program. Following identification of the most active NSV services snowball sampling of frontline health workers HWs involved in direct implementation of the selected NSV services was completed.
The interview guide for the KII with upper health system officials followed a number of research themes including options for models of service delivery; human resource capacity, training and accreditation processes; supply and demand; strengths and weaknesses of the national program and funding arrangements. A separate interview guide was developed for the KII with frontline health staff and included further in-depth questioning of how the service operated; experience of being involved in the NSV service; perception of demand of service; and barriers and opportunities for implementing the program.
The interview guides were developed in collaboration with AT, PH, AV, AK, JM and GL and revised on an ongoing basis to elicit more focused responses from participants and to accommodate themes that emerge in the early stages of data analysis.
Two interviews were conducted over the phone to allow contact with key people who would have otherwise been difficult to access due to distance, responsibilities and time constraints. Documentary analysis included the review of raw data from the NSV services, training manuals, government reports, and national and provincial policies surrounding NSV and has been included in the results section.
A field journal was kept during the intensive period of data collection to further ensure accuracy of findings and to record additional observations. Preliminary results were discussed with key members of the NDoH by the authors to ensure trustworthiness of results as the fieldwork progressed.
The building block framework was designed by WHO to promote a common understanding of what a health system is and constitutes the key components necessary for health systems strengthening[ 28 ]. The building blocks include service delivery; health workforce; health information systems; access to medicines, vaccines and technologies; financing and; leadership and governance [ 27 ].
In an iterative process the researchers organised the data into each WHO building block to review how the functioning of the NSV program in the country was impacted on by contextual factors. The themes were discussed with all authors and adjusted where appropriate. Written informed consent was sought from all individuals participating in interviews.
Confidentiality was maintained in the data transcription process, which used pseudonyms to identify respondents. Consideration was given by all researchers to the customs, practices and legal systems in PNG, potential for language barriers and the provision of a clear understanding of research objectives to all participants involved in this study. The NSV program has been integrated within public health services and non-government organizations NGOs , similar services that may be called upon to incorporate a MC program.
Difficulties with transportation, access, staffing, training, financing and resources were all described as barriers. The following results are presented within the WHO building blocks of a health system and include the analysis of key documents including government reports and policy documents. No-scalpel vasectomy NSV provides an important component of the NDoH family planning program for safe motherhood, as well as a strategy to address population growth in PNG an identified concern since independence in The NSV program is overseen by the NDoH with the decentralized health system resulting in provincial governments being responsible for administrating and prioritizing the service at a local level.
However despite this support, the NSV program competes with a number of other priorities within provincial and national health departments. As a result, control of the program as a nationwide effort is often underpinned by provincial and district level priorities resulting in mixed results throughout the country. National level officials acknowledged that there were historical difficulties for effective governance and leadership of the NSV program for various reasons.
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In particular, leadership on strengthening the health system in general was seen as a much needed priority for the success of any program. Because at the moment our health systems are in tatters, they have collapse, anything outside a couple of successful provincial hospitals. And nothing else much works. Being able to translate policy into practice was also acknowledged by one government official as a key issue.
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So in terms of priorities it is in the policy document. Now it is the question of translating it into actual operations and this does rely on the capacity of the facilities. However, you also have got national provincial and district government. So we can come up with a policy or a statement saying that the priority is this, but when it goes to actual service delivery it depends if it is a priority at the other levels. There may be other challenges that they may face. Sustainability of services was often described to be heavily reliant on key drivers within provincial government and frontline health services as well as ongoing financial commitment from both provincial and national governments.
As one provincial health official who worked within a province with a successful NSV program explained:. Vasectomy falls within this. Because now we can see that our population is increasing at a very alarming rate.
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And compared with economic development, the population is just growing miles. We understand this, so in this province one of our priorities is the family planning program. The impact of poor leadership was evident with many of the frontline health workforce. According to frontline HWs interviewed, feelings of poor support from government including difficulties accessing funds and resources was often a problem.
As a result, many had difficulties with maintaining momentum for the service. With funding coordination at national government level, provincial governments are responsible for obtaining money and allocating it to the service accordingly. This was not only described as being due to actual availability of funds, but also to the limited maneuverability of funds through the system, resulting in reported delays:. I am still waiting. I will just wait. In two of the provinces reviewed, NGOs have been able to bridge the gap by providing financial or technical support to the training program or outreach services.
Pathfinder International provides financial support for training and allowances for outreach services in Madang Province. Small user fees were required by one NGO to access the service. Other key factors were poor supervisory support and training for staff; staff migration; inadequate program monitoring and evaluation; poor integration of the NSV program with other health services; and transport and logistical difficulties. High demand and increasing waiting lists for the NSV service were commonly experienced in rural areas.
However, waiting lists also existed in urban settings due to irregular financial support of designated staff, as well as inflexible times at which the service could be offered:. And they are still on the waiting list. Raising expectations within communities for services through promotional activities resulted in a construction of obligation between worker and potential client. With increasing awareness and demand, but no service to support this, creation of dissatisfaction within the community became evident.
For example, one respondent described an incident where he was confronted by a man who was particularly frustrated with waiting for the service. And that made him really angry. That was one of my struggles that I had. According to frontline HWs an increasing demand for NSV services had been observed and was believed to stem from increasing economic pressures and demand for land experienced in communities as people continued to have large families.
One HW also reported that after providing NSV services within a small community, he discovered that some men appeared to have been motivated by a desire to have more sexual partners without the fear of having more children. A challenge with developing efficient and effective health information systems in PNG was a concern for all upper health system officials. And because of the remoteness of our communities it is a great challenge to us.
And try to build up a system that will enable us to get information quickly, to respond to it quickly. But you know it has been a great challenge to us.
This was evident in the review of the NSV program with details of national statistics for NSV services difficult to obtain prior to This raises questions about demand:. That is the general picture, the general statement I can make. But in reality in terms of hard data, I cannot prove that.
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Numbers on waiting lists were also often difficult to ascertain. No data on adverse events, including infection rates or failure rates, appeared to be systematically collected by any of the NSV services reviewed. Post-operative monitoring was also rarely completed due to the difficulties of access, population mobility and limited ability to contact people in PNG e.
These difficulties were noted to be a significant problem by all upper level health officials. All frontline HWs reported that access to essential medicines and equipment for the NSV service was not a real problem despite upper level health officials suggesting that access difficulties were a common problem in PNG and likely had a significant impact on NSV service provision. However frontline HWs did report significant difficulties in accessing drugs for other components of the family planning service.
Now family planning drugs are coming from Moresby. Like the vaccines. And ah we called this morning and they said the person who is in charge for doing the order for the, the family planning orders, he has been sacked or something. So now we are running out of things and have to send people elsewhere. Lack of transport for the NSV program, particularly for outreach visits, was considered more of an important obstacle by all frontline HWs.
To deliver outreach programs, the HWs reported needing to rely on vehicles from other programs to assist. But the biggest problem is that we do not have transport. At one stage, I thought that I was going to get a vehicle so I started planning my program to go from district to district there, and not be restrictive to the district here. However, it was given to someone else.