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Chapter 2. Assessment Methology
Chapter 2. Assessment Methology
2.1. Assessment team
The assessment team consisted of 23 members, representatives of the main institutions dealing with the reproductive health, including three representatives of the Ministry of Health and Social Protection, out of whom one consultant in preventive medicine, three representatives of the National Scientific Practical Center of Reproductive Health, Medical Genetics and Family Planning, two representatives of the Republican Society of Family Doctors, one representative of the Ministry of Justice, two representatives of Mother and Child Health Care Research Institute, coordinator of the Safe Motherhood WHO mission to Moldova, representatives of the main non-government organizations and abortion services providers, and mass-media. Two experts, representatives of the World Health Organization Department of Research and Reproductive Health and one expert from Ipas (international US-based organization specialized in the promotion of safe abortion) provided technical consultancy to the assessment team. The list of assessment team members is presented in Annex 1.
The team developed the pattern for assessment, carried out the field activities, analyzed the obtained data, drafted the assessment report and disseminated the results to decision makers and the main institutions dealing with the reproductive health.
The involvement of the government decision makers, responsible of program management, is a guarantee that the formulated recommendations will be implemented. The team also included representatives of the non-government sector, such as family planning associations, organizations for women and young people, interested research institutions active in the field of reproductive health and sexuality. The foreign experts provided specialized assistance and shared their experience of conducting assessments on the basis of a strategic approach.
They offered new experiences, knowledge, and opinions on certain issued that might have been regarded and uninteresting and/or impossible-to-be-changed by the local investigators. The local and judetz public and health authorities, managers, and service providers actively collaborated during the assessment.
2.2. Discussion Document
According to the recommendations from the WHO guidelines for strategic assessment, during the first month the team prepared and distributed among the participants in the national planning workshop a discussion document, which presents a summary of the existing data, available literature, unpublished research reports, and the national legal framework on abortion and contraception. The discussion document presented the current situation in reproductive health in the Republic of Moldova, permitted to identify the existing gaps, helped generate some key questions to be approached during the further assessment and research, helped the assessment team and health facilities dealing with the reproductive health to exchange their knowledge, promoted debates and discussions among participants in the planning workshop. This document helped the team focus on the key issues and provided access to relevant literature and information during the field work, analysis and drafting of the assessment report.
2.3. The Initial Planning Workshop
An one-day national planning workshop was organized in Chisinau in June 2005, attended by representatives of all relevant institutions dealing with the reproductive health. This workshop aimed at identifying the priorities and program issues to be evaluated during the assessment. It was attended by members of the consulting group, service managers, health service providers, representatives of women’s organizations, representatives of youth organizations, researchers, mass-media.
The planning workshop had the following objectives: to inform the involved institutions about the strategic approach, make them aware of the assessment goal and process, examine the discussion document and identify the gaps and key problems to be studied during the assessment, exchange ideas and opinions about abortion services, identify the strategic problems, which the assessment will be based on, identify the geographical area for assessment, operate as an open forum, present the assessment team to the main institutions dealing with the reproductive health.
As the strategic assessment is not a research study and the approached strategic issues are crucially important, they offered enough time to make sure the issues to be approached were well defined and a consensus was reached in this respect. The WHO guidelines for strategic assessment was closely respected and the discussion document was analyzed attentively. The discussions targeted at identifying the critical issues that called for deep examination during the assessment.
During the planning workshop they selected the regions for data collection. The regions and localities to be visited were selected on the basis of the following criteria: existence of health care facilities of all levels from rayon hospitals to community family doctors offices, existence of a wide range of high or low quality health care services, high or low access to health services; reflection of the regional, cultural and program life (for instance, urban and rural regions, regions with a high or low prevalence of maternal mortality, community-based services, services in municipal centers, with a potential to identify the existing gaps (for instance, regions were people are pretty unaware of sexual practices and reproductive health).
2.4. Preparatory Activity
After the planning workshop the assessment team met for a one-week preparatory seminar to examine all technical details. During this meeting they determined the structure of the two sub-teams and appointed their coordinators. Based on the recommendations and priorities identified during the planning workshop they drafted the agenda. The team members planned the process of collecting data about the current state of the abortion services, gaps in the staff knowledge and recommendations for the next research stages and potential programs aimed at improving the abortion service in the Republic of Moldova. They identified the places to be visited (medical offices, communities, etc.), team members that will visit the respective localities, discussions, arranged for the meetings and drafted the preliminary report. At this meeting they also settled the technical problems related to the field activity. The coordinator of the assessment team and director, backed by the Ministry of Health and Social Protection and rayon and municipal authorities, arranged the meetings with the people to be interviewed.
The team also identified the key groups of people to be interviewed during the field activities, developed and tested the questionnaires, and selected the localities, judets and localities for the interview. Check-lists were developed to facilitate the data collection process and monitor the abortion services provided by different facilities.
During the preparatory meeting the team got familiarized with their tasks and procedures of field research and the motivations underlying each question from the questionnaire. As the field research is a quality exercise, the availability of a printed list of questions offered more confidence to the team members. Structured questionnaires were not used for data collection in order to provide interviewers with the freedom to direct and adjust the discussions to the specific circumstances, which might have been not planned initially.
After and thorough examination of the “critical” aspects, identified during the planning workshop, the team identified the group of people that might provide relevant information. The interviewed representatives of all relevant institutions involved in the reproductive health field, including managers, service providers, administrators, representatives of groups of women and young people, as well women and young people from local communities. Distinct interview guidelines were developed for each group of interviewed people in order to facilitate the systematic data collection and allow interviewers solicit clarifications, more detailed explanations and additional information. The assessment instruments were pre-tested in Chisinau.
2.5. The Field Activity
The field activity was carried out in 9 rayons (Edinet, Soroca, Soldanesti, Orhei, Ungheni, Cahul, Hincesti, Comrat şi Causeni), and in municipalities of Balti and Chisinau. The assessment team was divided in two sub-teams with a similar structure. The two sub-teams traveled into different locations and divided in other two or three groups consisting of two-three people, who worked independently and then gathered at the end of the day.
Specific places were selected within each rayon (big or small towns) in order to assure a full coverage of the respective geographical area. Unlike the research studies with randomized samples, the qualitative approach was based on a non-probable sample. The assessment team defined the selection criteria of the visited places in order to collect enough data and find answer to any question. On the field the team consulted with rayon managers, who helped them select the appropriate communities. The details about the visited places and institutions and interviewed people are presented in Annex 2. As a whole, 589 interviews were conducted with representatives of institutions, professional groups and current or potential users of abortion and contraception services.
2.6. The data collection instrument:
Thee data collection methods were used during the field visits:
- Individual interviews and group discussions with managers of reproductive health programs, local public authorities, representatives of NHIC, public and private abortion services providers, representatives of organizations for women and young people, non-government organizations and didactic personnel dealing with reproductive health. These are the main actors who work for the improvement of the abortion services; the previous studies reveal that most Moldovan women (men) have certain experience in issues related to abortion and contraception.
- Individual interviews with women who had an abortion in order to find out their opinions about contraception and abortions, as well their experience and attitude towards the existing system.
- Observation of institutions and abortion services provided at different levels of the public health system, as well at private clinics from different Moldovan localities. The observation was carried out by one or two members of each subgroup of the assessment team.
The key informers were selected on the basis of their experience, position, knowledge and their readiness to participate in the assessment. One interview usually lasted 30 minutes and the information received were written down and discusses on a daily basis, in accordance with the WHO guidelines. All team members met each evening in order to discuss the experiences and observations of the respective day. They compared and integrated their notes, introduced the data in the computer and presented them subsequently for examination.
2.7. Data Analysis and Report Drafting
The data analysis was a part of the data collection process. At the end of each day, as mentioned above, the sub-teams met to discuss the data collected during the respective day and analyze their compliance with the key assessment issues. They debated the new ideas, appeared during the data collection process, and adjusted the structure of interviews, if needed. After the first week of field activity the entire assessment team met for a day to exchange experience and opinions about the collected data and start the data analysis process. When the field activity came to a close the entire assessment team rallied for a two-day meeting in Chisinau to complete the analysis of the collected data and structure the information. During this meeting they drafted the first version of the preliminary report that contained information and recommendations of the assessment team.
During a joint exercise they prioritized the field observations on the basis of their own perceptions and the priorities established during the planning workshop. Each team member identified the most stringent issued identified during the field activity, expressing his/her viewpoint and concrete examples; then they compared the individual observations during group discussions.
The key issues, approached during the discussions, were divided by categories, which subsequently formed separate chapters in the final assessment report. They developed the content of each chapter. Each team member was assigned to write one or more divisions from each chapter. The preliminary report was distributed to all team members to be studied and commented upon. The assessment coordinator incorporated the suggested comments and was responsible for the issuance of the preliminary report; after a number of consultations with the team members he corrected the gaps, identified during his discussions with representatives of the institutions dealing with the reproductive health and with consultants.
2.8. Distribution
The national distribution workshop was organized to present the main findings of the assessment team and facilitate the discussion of the preliminary report and recommendations of the assessment team. The workshop was attended by many representatives of program managers, service providers, organizations for women and young people, relevant non-government organizations and foreign donors, as well representatives of the institutions visited by the assessment team.
The workshop had the following goals:
- to distribute preliminary recommendations and data and check with the workshop participants the accuracy of obtained data;
- to allow participants evaluate the relevancy of information obtained at the respective institutions or rayons;
- to discuss, change, and agree on the recommendations, obtain additional information from the participants for the final assessment report;
- to make recommendations about policies, programs and research issued on the basis of the feasibility study and assess their impact on the respective policies, programs and operational responses to the obtained information, including action-oriented research projects and other interventions;
- to assure the involvement of service providers and program managers.