ANNEX A: ICV Compliance Monitoring and Reporting Flow Chart

NATIONAL
ICV Compliance Committee

NCDPC - FHO

REGIONAL ICV COMMITTEE

 RD/ARD
 LHAD Chief REGIONAL VALIDATION
 Family Health Cluster Head TEAM
 Regional FP Coordinator
and Monitoring Team which
NCF Report reported non-compliance
CF Report ReReRReR  NGO or Private Sector
PROVINCE/CITY PROVINCIAL/CITY MONITORING eport
PHO/CHO and PHTL TEAM
 FP Coordinator/ Technical staff
(HEPO)
 PHTL/DOH reps.

Legend:

CF - Complying Facility
NCF - Non-Complying Facility
VCF - Validated Complying Facility CF NCF
VNCF - Validated Non-Complying Facility

Monitoring Line

Reporting Line
VCF
Validation Line VNCF

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ANNEX B-1: ICV Compliance Monitoring tool for Service Providers/Service Delivery Sites

Instructions to Interviewer:

The purpose of this Assessment Tool is to facilitate the gathering of information related to
compliance with the Department of Health legislative and policy requirements to ensure quality of
care in family planning service delivery. This tool is intended to serve as a rapid assessment of
compliance to the National Family Planning Program policies by the service providers at service
delivery sites or outlets at the regional, provincial, municipal or barangay levels. It is not necessary
to follow this tool verbatim, but rather during the course of conversation, to obtain the information
requested below, it may be necessary to ask additional questions and probe deeper to obtain details
about a given issue. It is the responsibility of the interviewer to continue the in-depth discussion to
the point necessary to gather all the necessary information and provide a comprehensive report to
the appropriate level of DOH office. If during the use of the tool there is a ‘red flag’ that indicates
non compliance, it is necessary to report this immediately to the appropriate level of DOH office to
initiate in-depth investigation. The results of this tool must be reported jointly with the results of
the Assessment Tool for Family Planning Clients. If the results obtained by the two tools do not
match, further investigation will be required.

When all pertinent questions in the interview have been asked and answered, all feedback and
comments have been taken, BE SURE to address the service provider’s questions, issues or concerns.
DO NOT leave without addressing issues that you had picked up during the interview.

How to use this instrument:

The instrument is divided into 10 sections that examine different aspects of family planning and
abortion-related issues and concerns. Each section has several questions which are designed to elicit
the information necessary to determine whether there is cause for concern related to that particular
issue. Each section contains a space to record answers to the specific questions and a space for
additional comments based on the information provided.

This tool is intended to serve as a guide to the interviewer. For record keeping purposes, please fill
in the tool immediately following the interview and submit the form to the appropriate entity within
your respective office.

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 ICV Compliance Monitoring Questionnaire for Service Providers/Service Delivery Sites

Date : ________________________________________

Name of Interviewer : ________________________________________

Position and Office : ________________________________________

Name of Health Facility : ________________________________________

Address of health facility : ________________________________________

Name of individual interviewed : ________________________________________

Position/Title : ________________________________________

Interviewees include: Doctors, nurses, midwives and barangay health workers.

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Introduction:
My name is _______________ and I work for _____________________ as a ___________________. I
am here to collect some information about family planning services in this region/province/ city/
municipality/ baranggay. I will ask you some questions about family planning services at this facility.
Thank you for your assistance in helping us better understand the family planning services in this
facility.

Do you have any questions? Yes  No 

1. Broad range of contraceptive methods available at the health facility

No. Question

1.1 What family planning (FP) methods are currently available and offered to clients in
this health facility?

 Pills  NFP (what method? ________________)

 Injectables  Bilateral Tubal Ligation (BTL)
 Intra-Uterine Device (IUD)  Vasectomy
 Condoms  Other (specify)____________________

1.2 If methods are not available, are clients referred elsewhere? Yes  No 

If yes, a) what methods ___________ and b) where referred? ______________

Comments

2. Numerical Targets
Answer
No. Question
Yes No

2.1 Do you have planned FP targets/goals?

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 2.2 If yes, for what purpose/s?

 Planning
 Logistics (forecasting, procurement and distribution)
 Performance evaluation
 Other, please specify: ____________________________

2.3 Are you required to achieve any assigned specific numbers of

any of the following?

If yes, please check all that apply:

______ total number of FP acceptors

______ number of acceptors of specific methods as

follows:
______ for IUD
______ for injectables
______ for modern NFP (BBT, CM, ST, LAM, SDM)
______ for vasectomy
______ for pills
______ for condoms
______ for tubal ligation
______ for others, specify pls: _______________

2.4 What happens if you meet your targets?

What if you fail to meet your targets?

Comments

3. Incentives/Financial Rewards
Answer
No. Question
Yes No

Incentives/Financial rewards for Service Providers/Clients

3.1 Aside from your salary, do you get paid (money or in kind) for
FP services and/or referrals?

If yes, how much and explain for what.

3.2 Are financial rewards/incentives provided when you achieved

your individually assigned predetermined FP numerical
targets?

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 3.3 Does the facility offer anything to clients in exchange for
accepting family planning (e.g., food, money)?

If yes, how much and for what?

Comments

4. Denial of Benefits
Answer
No. Question
Yes No

4.1 If a client decides not to use family planning, are any

benefits or rights withheld from the client or their family?

4.2 If yes, what is withheld?

Comments

5. Comprehensible Information
No. Question

5.1 What information do you give to clients about the FP method he/she has chosen
(check)
___ Risks and benefits
___ Side effects
___ Advantages/Disadvantages
___ How to use the methods/procedures
___ Conditions that would render method inadvisable?

6. Family Planning IEC Materials Available

Answer
No. Question
Yes No

6.1 Is there a wall chart with all FP methods visible? (where is/are
posted and in what language)?
____________________________________________________

6.2 Are other family planning IEC materials available- flipcharts,

brochures, leaflets, etc)
Comments

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7. Abortion
Answer
No. Question
Yes No

7.1 Have there been times when you were consulted for missed
or delayed menstruation?

7.2 What do you do when such clients ask you to help them regain menstruation?

7.3 What do you do if pregnancy is confirmed?

Comments

8. Voluntary Surgical Sterilization (VSS)

Answer
No. Question
Yes No

8.1 VSS Information Giving

8.2 Do you provide counseling to clients who want VSS services

(BTL /Vasectomy)?

8.3 Does this health facility have informed consent forms for VSS?

8.4 Are informed consent forms signed prior to any VSS

procedure?

8.5 Compensation to Clients/Providers services

8.6 If VSS is provided at this health facility, do VSS clients

receive any type of compensation?

If so, how much? ________________

8.7 If VSS is provided at this health facility, are referral agents or

service providers paid on a per case basis related to VSS?
Comments

9. Document Review
Answer
No. Question
Yes No

Request for permission to review the service provider’s service records/statistics

(3-6 months) and referral records (ex. FP Form 1, FP clients’ logbook; target
client list; FHSIS monthly/quarterly reports; O.R. logbook; others). Use the

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 guide questions below to determine compliance with FP policies.

9.1 Are there any sharp increases that might indicate more emphasis
on increasing number of acceptors/users of any one particular
method (note or record any observations)?

9.2 Are there any kind of inconsistency in the data (ex. Anything that
looks unusual; supply vs. utilization reports)?

10. Coercion
Answer
No. Question
Yes No

10.1 Is there any evidence of coercion in the family planning

program?

If yes, please describe and explain.

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ANNEX B-2: ICV Compliance Monitoring Tool for FP Clients

Instructions to Interviewer:

The purpose of this Assessment Tool is to facilitate the gathering of information related to
compliance with the Department of Health legislative and policy requirements to ensure quality of
care in family planning service delivery. This tool is intended to serve as a rapid assessment of
compliance to the National Family Planning Program policies from family planning clients. It is not
necessary to follow this tool verbatim, but rather during the course of conversation, to obtain the
information requested below, it may be necessary to ask additional questions and probe deeper to
obtain details about a given issue. It is the responsibility of the interviewer to continue the in-depth
discussion to the point necessary to gather all the necessary information and provide a
comprehensive report to the appropriate level of office of the DOH. If during the use of the tool
there is a ‘red flag’ that indicates non-compliance, it is necessary to report this immediately to the
appropriate level of office of the DOH to initiate in-depth investigation. The results of this tool must
be reported jointly with the results of the Assessment Tool for Service Providers. If the results
obtained by the two tools do not match, further investigation will be required.

When all pertinent questions in the interview have been asked and answered, all feedback and
comments have been taken, BE SURE to address the FP clients’ issues or concerns. DO NOT leave
without addressing issues that you had picked up during the interview.

This tool is intended to serve as a guide to the interviewer. For record keeping purposes, please fill
in the tool immediately following the interview and submit the form to the appropriate entity within
your respective office.

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 ICV Compliance Monitoring Questionnaire for Family Planning Clients

Date : ___________________________________

Name of Interviewer : ___________________________________

Position and Office : ___________________________________

Place of Interview/address : ___________________________________

Client (circle one) : Male Female

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Introduction

My name is ____________________ and I work for ___________ as a ______________________ I am

here to collect some information about the family planning services in this area. I will ask you some
questions about the family planning services you have received and your impressions about family
planning services in general. The results of our interview and data collection will be used to better
understand the current situation in this LGU and to identify areas that might be strengthened or
improved. I am not recording your name or any other information that could be linked to you. The
responses you give me are confidential and will be summarized with the responses of other clients
from different sites around the country. In addition to our discussions with clients, we will also be
gathering information from health facility staff.

Do you have any questions? Yes  No 

Do you agree to participate in this interview? Yes  No 

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1. Client Feedback on the Quality of FP Services

No. Question Answer

1.1 What family planning method are you

currently using?

1.2 Where do you get family planning

supplies and/or services?

2. Voluntary decision making

2.1 How did you decide/choose the FP method that you are using now?

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2.2 Who decided/chose the family planning method that you are using now?
 A. Myself
 B. My husband/partner
 C. My in-laws/parents
 D. Others: (pls specify.)________________________________________

3. Knowledge of complete and accurate information on FP method

Answer
No. Question
Yes No

3.1 Did the service provider share with you the information about
the method you selected.

 advantages/disadvantages
 possible side effects
 how to use the method/procedures
 conditions that made method inadvisable

3.2 Did the service provider explain what to do and where to go if

you experienced side effects?

3.3 Do you think that you received all of the information necessary
to make a decision about your family planning needs?

4. Coercion/Denial of Benefits
Answer
No. Question
Yes No

4.1 Did you feel any pressure from anyone to use family planning,
or to use a particular method?

5. Incentives/Financial Rewards
Answer
No. Question
Yes No

5.1 Did someone give you anything, in exchange for using family
planning or using a particular method (i.e. food, money, gift,
access to a particular program)?

If yes, what or how much?

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6. Voluntary Sterilization (for BTL/NSV Clients only)
Answer
No. Question
Yes No

6.1 Before you had the procedure, did you sign a form saying you
understand what bilateral tubal ligation (BTL)/vasectomy is
about?

6.2 Did you receive anything (money, food, gift, etc) for having
BTL/vasectomy done?

If yes, what or how much?

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Annex C: ICV Reporting Form for Service Provider/Service Delivry Sites and Clients Monitoring Results

Center for Health Development: _________________________

Province/City: _________________________
Date Submitted: __________________________
Report for the Month of: __________________________

Part A: Technical Assistance, Inputs and Other Activities

Specific Activity Date of Place of Conducted Number of Participants Remarks

Activity activity By Whom
(Topic or Content) M F

Total Number of Orientation/Training Activities conducted: _______

Total Number of Participants Trained or Oriented: _______
Males: _______
Females: _______

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Part B. Summary Matrix of Service Providers/Facilities Monitored and Family Planning Clients Interviewed

Date Name of Location Name/Designation No. of FP Monitored Results/Findings Steps Taken/

Monitored Facilities of of Service Providers Clients by Recommendations (be
facilities Interviewed (be as detailed as as detailed as possible
possible pls and pls and indicate
indicate separately separately for service
for service providers and FP
providers and FP Clients)
Clients)

Total number of Facilities Monitored: __________ Number of facilities noted to be compliant to policies: _______
Total number of Service Providers Monitored: __________ Number of facilities noted to not compliant _______
Total number of FP clients interviewed: __________

Part C. General Recommendations and Next Steps

Good points determined during this monitoring:
________________________________________________________________________________________________

________________________________________________________________________________________________
Points to improve on and recommendations/next steps:
________________________________________________________________________________________________

________________________________________________________________________________________________

Prepared by: _____________________________________ Designation _________________ Contact Number _________

(Signature over printed name)
Date:_________

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Annex D:

Narrative Report of Non-compliance with FP Policies

Date of monitoring:

Name of Unit (RHU/Hospital/private clinic, etc)

Location/Exact Address of Unit:

Reported by:

Witnessed by:

Complete Name/s of Service Providers or Source of Info:

________________________________________________________

Nature of the incident/possible non-compliance:

Specific FP Policy possibly not complied with:

Evidence/result or outcome of the possible non-compliance committed, if any:

Action taken by reporter/eyewitness:

Printed name and signature of eyewitness or reporter: ________________________

Printed name and signature of the FP Compliance Focal Person: _______________

Noted by (Signature of) the Reporter's immediate superior: ___________________

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