Proven approaches, new strategies : innovations, best practices and lessons learned from the SEATS II project

SEATS faced many challenges and worked in a remarkable variety of situations, including countries new to USAID"s population portfolio; countries with extreme poverty; countries with high HIV prevalence; countries coping with change, such as war, civil unrest, and health sector reform; countries with relatively longstanding family planning/reproductive health (FP/RH) programs; and countries requiring large-scale national FP/RH efforts. In all, SEATS trained 11,099 people in 632 courses and established or improved 2,982 service delivery points. Through 12/99, 773,943 couple-years of protection (CYP) were provided, 424,828 new users had been served, and 1,143,128 revisits had been attended. The contraceptive prevalence rate (CPR) increased 44% overall in each subproject. SEATS reached underserved clients in all service delivery subprojects, but especially through special initiatives that empowered city leaders, midwives, PVOs/NGOs, and community-based paramedical personnel, peer educators, and policymakers to extend services to adolescents and to the urban and rural poor. SEATS developed many innovative tools, models, and methodologies that constitute its lasting legacy, confirmed the value of documented approaches, and legitimized ideas advanced at the 1994 International Conference on Population and Development (ICPD). SEATS" experience with increasing access underscores the need to implement more comprehensive RH programs -- a key ICPD goal. The project learned that: (1) Access encompasses more than physical availability of services, and barriers to access still exist. (2) All basic components of service delivery should be in place to ensure access and use; some components are so vital that without them other improvements lose their effectiveness. SEATS sought to build a client orientation among service providers, mainstream continuous quality improvement (CQI), and find a workable approach to measuring quality. SEATS learned that: (1) Quality must be built in from the beginning, as must the capacity for CQI. (2) Quality of care has three core aspects: improving the readiness of facilities to provide quality services, improving provider knowledge and skills, and increasing client satisfaction. Attention to quality results in improvements, empowers clients and providers, and ensures that clients will pay more for quality services. SEATS learned that investment from the outset in institutional planning and management capacity is fundamental to sustainability, and that the inherent tensions among rapid service expansion, service to the poor, and long-term sustainability can be managed effectively. Many sustainability issues are effectively addressed through the CQI process of team-based problem solving. SEATS also learned that access to contraceptive commodities is critical for program continuation, public-sector and adolescent programs require special approaches to sustainability, and leveraging additional resources can create new organizational challenges. Crosscutting lessons are as follows: (1) Unmet need is best addressed through simultaneous, synergistic improvements in access, quality, and sustainability. (2) Evidence- based programming encourages community ownership and appropriateness of interventions. (3) Future programming, especially in systems undergoing decentralization, needs to build in a permanent capacity to collect and use data. (4) Integrating FP and other RH services responds better to client and country demand. (5) At the global level, demand is high for a responsive, broad-based capability that combines proven approaches with new strategies. Sufficient time should be allowed for programs to be effective SEATS highlighted the inter-relatedness of access, quality, and sustainability and demonstrated that careful management of all three makes it possible to balance demands to expand access, reach the poor, and achieve long-term sustainability. In SEATS" experience, client focus is key. This concept was new to many in-country partners, but they soon embraced it, creating the possibility for achieving long-term sustainability and making client focus a cornerstone of RH activities everywhere.