A Successful National Program for Expanding Vasectomy Services: The Experience of the Instituto Mexicano del Seguro Social
Terrence W. Jezowski, Francisco Alarcón, Consuelo Juárez, Alcides Estrada, Fernando Gómez
Historically, vasectomy has not been an important contraceptive method in the Mexican family planning program. Until recently, the number of vasectomies performed annually in Mexico has increased slowly compared with growth in the use of other methods, notably female sterilization and IUDs. However, in 1989, the Instituto Mexicano del Seguro Social (IMSS), Mexico's largest provider of health and family planning services, with the technical support of AVSC International, launched a long-range strategy to increase the number of vasectomies performed in Mexico. The immediate results were that within two years, the number of vasectomies performed in IMSS facilities more than doubled, and the number has continued to increase. IMSS now provides more vasectomies than any other institution in Latin America.
This paper describes the innovative strategies adapted by IMSS to improve the availability and use of vasectomy. These strategies included: introducing and adopting no-scalpel vasectomy as the program's standard technique; conducting training at the service sites for all personnel involved with vasectomy services using a novel "site training" approach; removing barriers by providing access to vasectomy at the primary-care level; and providing ongoing supervision and technical support to the local service delivery sites.
The authors believe that the continuation of these strategies within IMSS and the adaptation of the IMSS strategy by other institutions will further increase vasectomy use in Mexico. The success of the IMSS program highlights the importance of leadership by health professionals in the expansion and use of vasectomy services.
Although IMSS has maintained accurate vasectomy records since 1972, vasectomy records from other institutions throughout Mexico are generally incomplete except for in very recent years. Nevertheless, contraceptive prevalence surveys suggest that the number of vasectomies performed nationwide each year has been very modest. For example, in 1987, vasectomy was the method of choice for only 1.5% of the married women of reproductive age who practiced contraception (Secretaría de Salud 1987).
Since 1974, the government of Mexico has developed clearly articulated policies and has implemented increasingly effective programs to extend the country's family planning and reproductive health services and to limit population growth. These efforts have been successful: contraceptive prevalence in Mexico grew from 30% in 1976 to an estimated 63.1% in 1992, and Mexico's population growth rate declined from more than 3% in the 1970s to about 2% in 1992. Recent and current government plans have included ambitious goals, such as achieving contraceptive prevalence of 68% by 1994 and a population growth rate of 1% by the year 2000 (Consejo Nacional de Población 1991a and 1991b). Another objective included in the government plans is to increase men's participation in family planning.
Profile of IMSS
More of Mexico's family planning services are provided by IMSS facilities than by any other institutions, public or private. In 1992, IMSS served 41.6% of family planning users; all other public-sector institutions served a total of 24.6%, [see footnote 1] and private-sector sources served 33.8% (Instituto Nacional de Estadística, Geografía e Informática 1994).
IMSS's mission is to provide a broad range of social, health, and economic benefits to the population it serves. IMSS's programs, which are coordinated nationally from the District of Mexico, are decentralized through 36 delegations (delegaciones) that provide basic administration of IMSS facilities. With the exception of the Federal District of Mexico, which has four delegations, and the State of Veracruz, which has two, there is one delegation in each Mexican state.
[Table 1] summarizes IMSS's health care facilities and human resources. In urban areas, IMSS provides medical services at the primary-care level through Unidades de Medicina Familiar (UMF).[see footnote 2] The number of UMFs in a delegation depends on the size of IMSS's enrolled population in that delegation. Except for emergencies, enrolled clients go to UMFs for all health services and are referred to hospitals, if necessary. Each delegation has general hospitals that handle emergencies and referrals from the UMFs. At the tertiary level, there are 39 specialized hospitals to which referrals from hospitals and UMFs are made. Other than female sterilization and postpartum IUD insertion, which are provided in hospitals, the bulk of family planning services, including vasectomy, is provided in UMFs.
Vasectomy Performance at IMSS
[Table 2] shows the number of vasectomies and female sterilizations performed by IMSS facilities from 1972 to 1993. Until the late 1970s, standard incisional vasectomy was offered in IMSS hospitals by a few urologists. In 1978, IMSS decided to make services more accessible by making vasectomy services available in the outpatient, primary-level UMFs. However, the impact of this decision was modest; female sterilization services were more easily and widely available and, therefore, were more often used.
In the late 1980s, two new developments rekindled IMSS's interest in vasectomy services. The first was that two institutions in Latin America, PROPATER in Brazil and PROFAMILIA in Colombia, had well-publicized success with their vasectomy services. The success of these programs demonstrated that Latin American men will use high-quality vasectomy services that are accessible and geared to men's needs (Rogow 1990).
The second development was that AVSC began to introduce no-scalpel vasectomy (NSV) around the world. NSV, which was developed in China by Dr. Li Shunqiang, is a more refined technique than standard incisional vasectomy. NSV involves less bleeding and surgical trauma, fewer complications, and less pain than the standard procedure and therefore appeals to both clients and providers (Family Health International 1991; Li et al. 1991; Nirapathpongporn et al. 1990). In Latin America, both PROPATER and PROFAMILIA adopted NSV as their program technique. In 1988, IMSS and AVSC began planning to introduce NSV in Mexico.
As [Table 2] shows, the number of vasectomies performed by IMSS nearly tripled between 1989 and 1993 as the revitalized vasectomy program took hold. IMSS has continually increased its position as the foremost provider of vasectomy services in Mexico--both in terms of the number of vasectomies performed and the ratio of vasectomies to female sterilizations. In 1993, IMSS performed 17,015 vasectomies (about one vasectomy for every 12 female sterilizations).[see footnote 3] In contrast, the Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado (ISSSTE) and the Secretaría de Salud (SSA), the other major institutions that provide family planning in Mexico, performed 1,326 and 1,189 vasectomies, respectively, with corresponding vasectomy to female sterilization ratios of 1 to 21 and 1 to 56.
THE IMSS VASECTOMY STRATEGY AND PROGRAM
The long-term goal for IMSS's vasectomy program is to increase vasectomy performance in IMSS facilities to between 30,000 and 35,000 annually by 1997, thereby realizing a vasectomy-to-female sterilization ratio of between 1 to 7 and 1 to 6. IMSS intends to make vasectomy services widely available in all delegations--by training local service-delivery teams in no-scalpel vasectomy services, IMSS plans to make vasectomy services available in 260 UMFs by 1997.
To achieve these goals, IMSS has adopted a strategy of four interrelated and mutually reinforcing elements.
Introducing NSV and Training Personnel
Based on the positive experiences reported in other countries, IMSS adopted NSV as its program technique. From 1989 to 1993, IMSS conducted a program to systematically introduce the NSV technique in selected IMSS facilities throughout Mexico. The four phases of NSV introduction presented below are summarized in [Figure 1].
In the first phase, five IMSS doctors received NSV training in Brazil in 1989. Three of these doctors were certified to become trainers during a follow-up visit to Mexico by the Brazilian trainer in 1990.
In the second phase, the first group of trained IMSS doctors set up demonstration service centers in selected UMFs in Mexico City in 1990. These activities were crucial in demonstrating the effectiveness of NSV in Mexico and in gaining practical experience before extending services to other sites.
In the third phase, IMSS conducted in-country training of service providers. Between late 1991 and mid-1993, IMSS trainers from the demonstration centers and IMSS headquarters trained service-delivery teams from selected UMFs in each of the 36 IMSS delegations. This clinical training was one component of a more comprehensive site-training program developed to integrate vasectomy at the primary health care level. This phase consisted of site and trainee selection, surgical training, and trainee follow-up.
Site and trainee selection
Because this phase involved the national expansion of vasectomy services in primary-care facilities, careful selection of both the UMF sites and trainees was critical. In each delegation, the first UMF chosen was one that served a relatively large population and therefore had a large base of eligible clients. Because of the need for adequate staff and space to accommodate the service, all of these UMFs had 20 or more doctors on staff, and most had a consultation room that could be converted into a vasectomy surgery room. The UMFs chosen were centrally located so that referrals from other UMFs and hospitals in the delegation could be easily arranged. In each delegation, local officials agreed to allow the site to serve as the base for future training in NSV for other UMFs in that delegation.
In the majority of sites, the first trainees were two family medicine or general practice doctors. These doctors, selected by the delegation's medical director and family planning coordinators, had some surgical experience, an interest in providing vasectomy services, and a willingness to act as trainers for other doctors.[see footnote 4]
As one component of the comprehensive site-training program (see discussion below), surgical training was conducted at each UMF over two days. Training at the service site included demonstrations by the trainer, assisted and unassisted practice by the trainees, and extensive informal coaching on different aspects of service delivery and technique. By the end of the two days, the goals were for each trainee--assisted by another trainee--to have directly performed between 5 and 10 procedures and to have correctly performed the procedure without coaching from the trainer.[see footnote 5] At the end of the second day, the trainer met with the trainees, their supervisors, and UMF officials to review the training, make recommendations, and, if the trainees demonstrated sufficient proficiency, to present the NSV instruments.
The trainer returned to conduct a "verification" visit after the trainees had each performed 20 or more procedures (usually after a few weeks or months). The trainers observed the trainees and gave additional training and coaching if needed. If necessary, the trainer recommended additional practice and planned a return verification visit or suggested that the trainee improve his or her skills at a practical training session at a demonstration center in Mexico City that had a larger caseload. If the trainees demonstrated sufficient knowledge, competence, and confidence, the trainer certified them to train other UMF doctors in the delegation.
At this writing, the fourth phase of the introduction strategy is underway. During this phase, additional training conducted in each delegation allows NSV services to expand to additional sites. The current priority is to consolidate the program in the initial sites and complete the follow-up and verification of the trainees. This will require the development of additional training guidelines and materials and special workshops to further develop training skills.
Results of NSV training
[Table 3] summarizes the progress of the training program through December 1993. Now that the third phase of the program is complete, at least one service site with a trained surgical team has been established in each delegation, and all 36 delegations have at least one doctor who is certified to conduct training for other surgical teams in the delegation. By the end of 1993, 97 of the targeted 260 UMFs were capable of performing vasectomy services on demand.
Using "Site Training" to Develop Local Vasectomy Services
Training doctors is only a part of IMSS's objective. The broader objective is to help delegations and service sites establish and integrate effective vasectomy service-delivery systems. Thus, instead of conducting short-term surgical training courses in central or regional training sites for the doctors alone--who then often face serious obstacles while introducing the technology and changing the knowledge, attitudes, and behavior of their fellow workers--IMSS developed a novel "site-training" approach.
Site training involves developing the knowledge and skills and improving the teamwork of all of the UMF personnel who are involved in providing vasectomy services. This includes the doctors and nurses who actually perform vasectomies, staff who might be involved in providing clients with related medical services (such as medical examination, postoperative instructions, follow-up examination, and treatment of complications), and staff who provide family planning information and counsel vasectomy clients.
IMSS also involves other personnel from the delegation who are in a position to provide support. These are the top delegation managers, including the delegation chief (delegado), the medical director, and UMF directors; the delegation's coordinators for reproductive health and family planning (a doctor, a nurse, and, in some cases, a social worker) who have supervisory and technical support responsibility throughout the delegation; and the managers, doctors, nurses, and social workers from hospitals and other UMFs in the delegation who may provide information to clients or refer them to the vasectomy service site.
IMSS's site training for vasectomy introduction is a comprehensive intervention. It involves several activities conducted in steps over a period of weeks. The interventions treat the local service-delivery site as a system and the personnel as members of a team that make the system function. Training is conducted on site under the conditions the trainees will later face. Thus, the goals for site training are not only to transfer knowledge and develop critical skills but also to forge an effective, smoothly functioning service-delivery system and effective local teamwork. The intended results are that services will be more effectively integrated, the services themselves will be of higher quality, and more clients will be served than if only the doctors were trained.
As conducted by IMSS, site training for vasectomy involves the four steps outlined below.
Step 1. Selection and initial planning
Several months before on-site training, IMSS headquarters staff meet with delegation officials to:
Step 2. The mini-workshop--initial on-site training and orientation
Several weeks before training, a team of IMSS headquarters staff that includes a physician and a counseling trainer visits the delegation to conduct a three-day "mini-workshop."
On the first day, the trainers meet with the delegation's top administrative, medical, and family planning officials and the UMF's principal staff to orient them to the vasectomy program and to clarify their roles and responsibilities during and after training.
On the second day, the trainers conduct a seminar for doctors, nurses, social workers, and medical assistants from the selected UMF and other nearby UMFs in the delegation. This seminar is held to orient participants to the vasectomy service, to provide accurate information and answer questions and concerns about vasectomy, to give a basic orientation on how to counsel clients interested in vasectomy, and to enlist participants' support for the vasectomy services.
On the third day, the trainers meet with the vasectomy service-delivery team at the UMF to review the physical site for vasectomy services and training. The trainers explain the preparations for surgical training in terms of equipment and supplies needed, infection-prevention techniques, and scheduling of clients. They define roles and responsibilities for the surgical training.
The mini-workshops also prompt local health personnel to begin giving information about vasectomy to the local population. This is important for generating sufficient clients for the practical training.
Step 3. Surgical team training
About six to eight weeks after the mini-workshop (once a sufficient number of clients have been scheduled for vasectomy), the trainers conduct two-day NSV surgical training for the service-delivery team at the UMF. The trainers meet with trainees and key delegation and UMF supervisory officials before and after the surgical training to review the objectives and to discuss overall management and local supervision of the program.
Step 4. Verification and certification visits
The trainers conduct follow-up visits several weeks after the surgical training to verify the skills of the local trainees and to certify them as local trainers within the delegation. These visits are not merely to review surgical skills, but to review the completeness, effectiveness, and quality of the different components of the overall local service-delivery system (scheduling, client flow, facilities management, client information and referral, counseling, recordkeeping, infection prevention, and supervision). The trainers continue follow-up visits and technical assistance until they feel that the surgical trainees are ready to be certified as local trainers.
Removing Barriers to Services
IMSS's decision in 1978 to make vasectomy services available at the primary-care level is consistent with their philosophy of simplifying medical services, reducing their cost, and providing them at the lowest level in the system where they can be safely performed.
Although the introduction of vasectomy services at the primary-care level resulted in only modest increases in the number of vasectomies, after the introduction of NSV and the accelerated extension of vasectomy services to UMFs, the number of vasectomies performed dramatically increased [ see Figure 2]. Although the majority of the 3,844 vasectomies performed by IMSS in 1982 were done in hospitals, that number had nearly quadrupled by 1992, and 90% of these vasectomies were provided in UMFs. As the number of trained doctors in UMFs increases, it is expected that virtually all vasectomies will be done in UMFs.
The advantages of providing vasectomy services in UMFs rather than hospitals merit closer examination. First, the number of primary-level UMFs exceeds that of the secondary-level hospitals by a wide margin (in 1993, there were 1,476 UMFs and 222 secondary-level hospitals). Providing services in UMFs permits a considerable expansion in the total number of vasectomy service-delivery points available, thereby making vasectomy services more accessible.
Another advantage is that clients have fewer barriers to vasectomy services in UMFs than in hospitals. To have a vasectomy in a hospital, the client must be referred from a UMF, and the procedure must be scheduled in advance in accordance with the available time and operating space. Thus, clients who have vasectomies in hospitals usually require at least three visits to a health facility: first, to a UMF to request the vasectomy and be referred to a hospital; second, to a hospital to schedule the vasectomy; and third, to the hospital for the surgery. In contrast, at a UMF that has trained vasectomists on staff, clients may obtain vasectomies at their first visit.
The availability of vasectomy services at UMFs has yet another advantage. In the IMSS system, clients go to UMFs for virtually all reproductive health and family planning information and counseling and, with the exception of female sterilization and postpartum IUD insertion, for all contraceptive methods. Because of this, placing vasectomy services within UMFs raises the visibility and awareness of the method among both health care personnel and clients.
Providing Ongoing Supervision and Technical Support
IMSS supervisors at all levels are involved in routine supervision of vasectomy services as part of their overall supervisory responsibilities. For many supervisors, providing technical support during supervisory and staff development activities is an important part of their job. Supervision and technical support from the national level of IMSS include the following:
Supervision and technical assistance at the delegation level are more frequent and direct. Delegation-level supervision includes:
ISSUES AND FUTURE NEEDS
Despite the achievements of the IMSS vasectomy program, there are still considerable challenges to meet in extending services, assuring and improving the quality of services, and improving the effectiveness of the program as a whole.
There are two critical concerns regarding the use of decentralized training to extend vasectomy services within delegations. First, the certified doctors in each delegation must be supported and encouraged to train teams from other UMFs. The keys for success will be for IMSS to continue both to assign a high priority and to provide ongoing supervision and technical support to male programs.
Second, IMSS must set clear standards for the training provided within delegations by UMF staff who have been designated as trainers. Because they do not ordinarily do surgical training, these trainers need special materials and support from IMSS headquarters. This support might include a simplified training curriculum (or guidelines) that can be adapted to the working environment of UMFs and further practical instruction in performing NSV and in the fine points of training others to do the technique. In addition, IMSS should develop or adapt instructional guides and reference materials to help reinforce trainee knowledge and skills.
Even for a doctor experienced in performing vasectomy, NSV requires considerable skill and delicateness to ensure maximum client comfort and a minimum of complications. In the first years after NSV was introduced, there was considerable debate as to whether nonsurgeons or surgeons who did not already have skills in standard incisional vasectomy should be trained in NSV. But as NSV's superiority to incisional vasectomy and its potential to become the standard technique for programs have become apparent, trainee selection restrictions have generally relaxed.
IMSS's guidelines for NSV trainee selection do not require family medicine doctors to have extensive surgical experience. Yet, because many of the family medicine doctors trained in vasectomy will be designated as trainers of others, there are concerns about whether medical safety and effectiveness can be maintained and assured as services are further extended. IMSS will continue to monitor services through on-site supervision and routine collection of data about services and complications. Nevertheless, this may need to be supplemented with specific research and clinical field assessments to verify the quality of the training and services being provided.
Client Needs and Satisfaction
The success of this program shows that many Mexican men will request vasectomy when information and services are available. Yet little is known about Mexican men's knowledge, motivations, needs, and concerns regarding vasectomy. To design better communications, counseling, and services that are attentive to the needs of Mexican men, research on these issues is still needed.
IMSS and AVSC are currently conducting a study of Mexican couples to identify the steps Mexican men typically go through in deciding to have a vasectomy and the role of partners in decisions about vasectomy. [see footnote 6] Other client studies that are needed include:
Learning more about client satisfaction should not remain solely in the domain of the researchers. Local service providers can do much to better understand the needs, perceptions, and satisfaction of their clients. IMSS plans to encourage service sites to design and conduct investigations that require little additional cost and effort. For example, sites can conduct short, structured interviews with clients before and after surgery and at follow-up, hold informal focus-group discussions in UMF waiting rooms, send short questionnaires to clients a few weeks or months after vasectomy, and investigate the reasons clients fail to show up for a scheduled vasectomy.
Client Information and Referral Sources
To date, information from within the IMSS health care facilities accounts for the majority of referrals for vasectomy. An analysis of unpublished service statistics reports for vasectomies performed in UMFs between 1989 and 1993 shows that four out of five vasectomy clients were referred by their family doctor, by other persons within a UMF, or by another health institution.
As the program evolves and expands, there will be a continuing need to test new ways to provide information within the IMSS health care network and to improve information provision and referrals. IMSS is currently collaborating with the Population Council on an operations research project to test alternative client information and referral strategies in selected sites. The strategies include orienting satisfied vasectomy clients to serve as promoters of vasectomy, providing improved orientation to vasectomy services for the health workers in peripheral UMFs who refer clients for vasectomy, and providing information through videos to clients in UMF waiting rooms.
Promotion through Mass Media
As high-quality vasectomy services become more extensively available throughout Mexico, it is appropriate to begin using mass media to provide information about vasectomy services. The Mexican government is planning to include information about vasectomy in a mass-media program. The client-focused research discussed above could provide very useful guidance in planning, targeting, and conducting mass-media messages.
DISCUSSIONS AND CONCLUSIONS
More than a decade ago, family planning professionals from around the world gathered at the First International Conference on Vasectomy to review the international experience with vasectomy (Atkins and Jezowski 1983). The objective was to better understand why vasectomy, which has many advantages in terms of effectiveness, cost, and safety, is not used more extensively throughout the world. An underlying concern was that, if men generally do not want vasectomy, family planning programs might be better off investing their resources in promoting other, predominantly female, methods of contraception. They reviewed the available research and the experiences of the few programs in which vasectomy had been successful.
What the experts said was both sobering and encouraging. They concluded that the principal reason for the poor record of vasectomy services in much of the world was not men's resistance to the method, but rather the failure of health professionals to make vasectomy services available. This failure was often a result of lack of knowledge, misinformation, a personal dislike of vasectomy, or untested presumptions about what men thought and wanted. The simple truth was that vasectomy was not an important method because information and services were not adequately available and accessible.
The experts' conclusions suggested that if health and family planning programs made vasectomy services easily available, and if health care and family planning professionals had accurate information about vasectomy and shared this information with their clients, many more men would request vasectomy. The experts also concluded that, in an environment where vasectomy information and services are widely available, men will tell others about their vasectomies. They also recognized that, like women, men have special needs; vasectomy services that pay attention to these needs are likely to be more frequently used.
The considerable success of IMSS's still-young vasectomy program provides ample support to the conclusions the international experts reached over a decade ago. IMSS's initiative has effectively targeted the health and family planning professionals working at the levels closest to its client population, has provided these staff with orientation and training, and has engaged them in providing information and services to clients. While more must be done to make services accessible to more of the population, IMSS has established a strong foundation in each of its delegations. In setting up this network, IMSS has developed an innovative training model that targets the surgical teams, managers, and health care and family planning staff from the entire delegation. As a result, vasectomy services are becoming well integrated into overall services, vasectomies are now performed in many more sites, and there has been a substantial increase in the number of vasectomies performed.
NSV has played an important role in the current success of the program. However, whatever NSV's attraction and advantages to prospective clients (a subject that requires further study), its principal contributions may have been that it has interested doctors in becoming trained in the technique and has served as a catalyst for expanding and managing the overall training effort.
The IMSS vasectomy program can serve as a model that can be adapted by other Mexican public sector institutions and can provide inspiration and hope for many other countries that are now beginning to plan vasectomy services. The IMSS program shows that men will use vasectomy services if health professionals provide the leadership in making services available.
Working Paper #8 Authors:
Terrence W. Jezowski, Alcides Estrada, and Fernando Gómez are staff members of AVSC International. Francisco Alarcón and Consuelo Juárez are staff of Jefatura de Servicios de Salud Reproductiva y Materno Infantil, Instituto Mexicano del Seguro Social. Alarcón and Juárez are currently preparing a Spanish version of this paper for publication in Mexico.
Phase I: International training (1989 to 1990)
Phase II: Establishing future models and guidelines (1990 to 1991)
Phase III: Introducing vasectomy services to all IMSS delegations (1991 to 1993)
Phase IV: Expanding and consolidating services in delegations (1992 and beyond)
The purpose of AVSC Working Papers is to capture on paper AVSC's experience and to disseminate the results of AVSC-supported research. We welcome your comments and suggestions.
The authors wish to recognize the initiative of Drs. Jorge Martínez-Manautou and Sergio Correu in introducing the no-scalpel technique as part of IMSS vasectomy services in 1989. The authors would also like to recognize two trainers in the program, Dr. Juanita Martínez and Dr. Magdalena Lozano, who allowed us to observe them during site training and who answered our many questions. This study could not have been completed without the assistance of IMSS personnel at the Subjefetura de Planificación Familiar who assisted with the data collection and analysis. The following AVSC staff reviewed and provided many helpful comments on early drafts of this paper: Nicholas Danforth, Pamela Harper, Jeanne Haws, Evelyn Landry, and Cynthia Steele Verme. Joanne Tzanis edited the manuscript and Amy Van Hoogstraat and Stephanie Greig assisted with final production.
This publication may be reproduced without permission, provided the material is distributed free of charge and the publisher and authors are acknowledged. This publication was made possible, in part, through support provided by the Office of Population, U.S. Agency for International Development (AID) under the terms of cooperative agreement HRN-A-00-98-00042-00. The opinions expressed herein are those of the authors and do not necessarily reflect the views of AID.
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