Assessing the readiness of health facilities to provide family planning services in low-resource settings: Insights from nationally representative service provision assessment surveys in 10 Countries
Authors: Rahman Mosiur , Islam Md. Jahirul , Adam Izzeldin Fadl , Duc Nguyen Huu Chau , Sarkar Prosannajid , Haque Md. Nuruzzaman , Mostofa Md. Golam 
Published: November 2023

Background
Many low-income countries continue to have high fertility levels and unmet need for family planning (FP) despite progress in increasing access to modern contraceptive methods and in reducing the total fertility rate (TFR). Health facilities in sub-Saharan Africa (SSA) and South Asia (SA) are thought to be unable to adequately deal with the burden of high unmet FP demands due to their weaker health systems. As a result, determining the readiness of health facilities that offer FP services is critical for identifying weaknesses and opportunities for continued development of FP health systems in those regions. Service Provision Assessment (SPA) tools—which break down health systems into measurable, trackable components—are one useful way to assess service readiness and the ability of health institutions to deliver FP services.

Methods
Using data from nationally representative SPA surveys, we conducted a study that aimed to: (1) evaluate healthcare facilities’ readiness to provide FP services; and (2) identify the factors that affect FP service readiness. Using a cross-sectional survey design, we used data from SPA surveys conducted in 10 low-resource SA and SSA countries: Afghanistan, Bangladesh, Kenya, Malawi, Namibia, Nepal, Rwanda, Senegal, Tanzania, and the Democratic Republic of the Congo (DRC). We analyzed data from public and private health facilities in Afghanistan (84), Bangladesh (1,303), Kenya (567), Malawi (810), Namibia (357), Nepal (899), Rwanda (382), Senegal (334), Tanzania (933), and the DRC (1,061) for a total of 6,730 facilities. We used 17 items/indicators recommended by the Service Availability and Readiness Assessment to measure a health facility’s readiness to provide FP services across four domains.

Results
Only 3.6% to 34.1% of the health facilities were reporting at least 75% (12–13 of 17) of the relevant items for FP service provision. Most of the health facilities in the countries under investigation suffered from lack of readiness, meaning that they did not fulfill at least 75% of the standards (12–13 items of 17 items on the availability of trained staff and guidelines, equipment, and commodities components). The factors associated with higher readiness scores varied among the 10 countries analyzed. Regression models showed that increases in the number of FP healthcare providers available at a health facility and infection control measures for FP exams were factors linked to increased readiness scores in all 10 countries. The low readiness of health facilities to provide FP services in the countries studied showed that the health systems in these low-resource settings faced significant problems with providing FP services. Differences in country-specific variability in the characteristics linked with better preparedness ratings could be attributed to data collected across different years in different nations or to country-specific healthcare financing policies.

Conclusions
To increase a health facility’s readiness to offer FP services, country-specific factors must be addressed, in addition to common factors found in all 10 countries. Further research is required to determine the causes of country-level differences in FP tracer item availability to develop targeted and effective country-specific strategies to improve the quality of FP services in the SA and SSA regions and address unmet need for FP.