DOI: 10.7910/dvn/23811
title: Belize (2012): Assessment of Quality of Service Provision to Most-at-Risk Population by Private Sector Providers in Central America.

description: Abstract In Central America, HIV/AIDS is remains concentrated among most-at-risk populations (MARPs), primarily in and around networks of men who have sex with men (MSM), transgender populations, male and female sex workers (SW), and certain mobile and ethnic groups (e.g., migrants, uniformed services, individuals of Afro-Caribbean descent). A USAID-funded HIV Combination Prevention Program for MARPs in Central America and Mexico is being implemented by PSI/PASMO, together with partners IPPF/WHR, Cicatelli Associates and Milk and Cookies in the period 2010-15, which aims to i) reduce prevalence of high-risk behaviors among MARPs and people living with HIV, ii) decrease homophobia, stigma and discrimination related to sexual orientation, occupation or HIV status, iii) increase access by MARPs to a minimum package of essential health services, and iv) use strategic information to design or modify prevention activities. As part of the Program, we plan to assess the quality of service provision to MARPs at health facilities participating in the program with the goal of ensuring that these populations receive high-quality care, free of stigma and discrimination. Our descriptive study will use mystery clients to collect data. Our findings will provide guidance to participating facilities on improving services to MARPs. Introduction and Rationale The HIV/AIDS epidemic in Central America remains concentrated among MARPs, primarily in and around networks of men who have sex with men (MSM). Throughout the region, the HIV prev
alence among MSM is approximately 10% (UNAIDS 2009). Sexual transmission accounts for the vast majority of HIV infections in the region. Other populations with a notable burden of infection include transgender populations (Trans), male and female sex workers (SW) and their clients, and certain mobile and ethnic groups (e.g., migrants, uniformed services, individuals of Afro-Caribbean descent). Social stigma, however, has kept many of these epidemics hidden and unacknowledged (UNAIDS 2010). In 2010, PSI/PASMO, together with partners IPPF/WHR, Cicatelli Associates and Milk and Cookies, was awarded a grant from USAID to implement the HIV Combination Prevention Program for MARPs in Central America and Mexico (2010-15) beginning on October 1, 2010. The program uses a combination prevention approach, which comprises a mixture of behavioral, structural and biomedical interventions and is based on scientifically-derived evidence and ownership of communities. The programÃÂÃÂs approach has been developed with guidance from the U.S. Government ÃÂÃÂs ÃÂÃÂPartnership Framework Document to Support Implementation of the Central American Regional HIV/AIDS Response (March 2010)ÃÂÃÂ and embodies several key principles from that document, including using evidence-based approaches to decision making, prioritizing interventions targeting MARPs, involving MARPs more actively in programming, considering gender, increasing local capacity to mount an effective response, increase coordination among stakeholders and implementing agencies, and sharing best practices widely and actively (PSI/PASMO). Over the period 2010-15, the program seeks to achieve the following results: Result 1: Reduced prevalence of high-risk behaviors among MARPs and PLHIV. Result 2: Increased effective interventions implemented to decrease hostility in social environments that foment and tolerate homophobia and stigma and discrimination attitudes related to sexual orientation, occupation or status. Result 3: Increased access by MARPs to a minimum package of essential prevention and health services , that includes but is not limited to access to condoms, VCT services and STI diagnosis and treatment, emphasizing in the involvement of private health providers. Result 4: Strategic information obtained through the research and monitoring process, being used to design or modify prevention activities. As part of Results 2 and 3, the Program aims not only to increase access by MARPs to essential health services but also to ensure that these populations receive high-quality care, free of stigma and discrimination, beginning with private-sector facilities participating in the Program. Objectives The specific objectives of this evaluation are to: 1. Assess the quality of service provision to MARPs by private-sector health-service providers participating in the HIV Combination Prevention Program for MARPs funded by USAID in Central America (Belize, Costa Rica, El Salvador, Guatemala, Nicaragua and Panama). 2. Compare the quality of services provided to MARPs to the quality of services provided to the general population by private-sector health-service providers participating in the Program in the countries of interest. 3. Identify areas for improvement in service provision to MARPs at participating facilities and provide recommendations. Study Design This is a descriptive, mystery client study that will be conducted annually over the course of the USAID HIV Combination Prevention for MARPs Program. We plan to begin the first annual assessment process in the first quarter of 2012. We will use mystery clients to gather data. Mystery clients will visit selected health facilities for HIV VCT services or an STI consultation and will complete a standardized closed-format questionnaire upon completion of each health facility visit. Study Population The study aims to assess the quality of service provision to the primary MARPs targeted by the Program: Trans, SW,
MSM, as well as the experience of people living with HIV (PLHIV). As such, mystery clients will be recruited primarily from these populations to fulfill the role of researchers. An additional subgroup from the general population will be included in order to allow for comparison of experiences between the general and MARP populations. This will allow us to determine whether the attitudes towards or treatment of MARP clients at participating facilities varies systematically from that of general population clients. Sampling and Data Collection Sites In most countries, given the small number of participating facilities, the study will include all participating facilities and, as such, no sampling will be necessary. However, in countries in which a larger number of facilities will be participating in the project (more than 19), we will apply lot quality assurance sampling (LQAS). LQAS was originally developed as a quality control technique for goods produced in factories, but its sampling concepts have universal applicability, and in public health, it has been used for assessing immunization coverage, antenatal care, use of oral rehydration therapy, growth monitoring, family planning, disease incidence, and the technical skills and knowledge of health workers (Robertson and Valadez 2006). This method requires a small sample, yet provides reliable results. According to the literature, a sample of 19 correctly identifies under-performing or over-performing lots or supervision areas at least 92% of the time. It thus provides an acceptable level of error for making management decisions. Sample sizes larger than 19 do not result in substantial increases in statistical precision. It can therefore be used as a rapid assessment technique to identify areas where intervention is necessary. Given that the purpose of the present assessment is to monitor the quality of service provision and identify improvements on an ongoing basis for programmatic purposes, this sampling method is appropriate. The first step in LQAS is to define a ÃÂÃÂlotÃÂÃÂ or supervision areaÃÂÃÂ that will serve as the unit of analysis. For the purposes of this study a ÃÂÃÂsupervision areaÃÂÃÂ is a health facility. The assessment will include or sample up to 19 facilities from each of two groups in each study country: 1) health facilities of IPPF/WHR member associations (MAs) participating in the USAID HIV Combination Prevention Program and 2) other private-sector health facilities participating in the Program, as listed in the following section Data Collection Facilities. As mentioned above, in the case where the number of actual facilities in a given group in a given country is lower than 19, the full number of facilities in the group will be included and no sampling will be necessary.