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Information Resources"Health
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REPRODUCTIVE, MATERNAL AND CHILD 1. INTRODUCTION The Delivery of Improved Services for Health Project aims at increasing use of reproductive, maternal and child health services in order to improve general health of the population in 12 out of the 45 districts in Uganda. These districts which include Jinja, Kampala, Kamuli, Kasese, Luwero, Masaka, Masindi Mbarara, Nakasongola, Ntungamo, Rakai and Ssembabule account for about 20% of Uganda’s total population and host the major urban centres in the country. The DISH project began in 1994 and completed phase one in October 1999. The second phase immediately followed and will end in September 2002. The project strategy is to improve quality and increase quantity of services through in-service training and supervision of service providers, and training and supporting health unit management systems to ensure sustainability of services. At the same time, through behaviour change communications, the project aims at improving health seeking behaviour in order to increase use of the improved and increasingly available reproductive, maternal and child health services.
As a result of this strategy, the DISH II project has five main components:
1.1 Monitoring DISH II Project The DISH project has a set of indicators to monitor trends in use of reproductive, maternal and child health services. Among the key indicators are: Use of Family Planning services- measured by Couple-Year-Protection (CYP); number of antenatal care clients; number of institutional deliveries; Child DPT3 immunisations and Vitamin A supplementation. These indicators are compiled from monthly health unit Health Management Information System (HMIS) reports from the project area. However, because of data collection limitation, the project collects data from 80 sentinel sites to ensure similar reporting coverage every month. All the sentinel sites are either Government or NGO facilities, none is a private-for-profit facility. 1.2 Trends reported from the 80 sites Through its sentinel surveillance system, the DISH II project observed declining trends in use of services, particularly beginning from the end of 1998. Figure 1 below shows this decline. The declining trends raised concern, leading to several possible explanations including:
Available data and information was explored to investigate these explanations. At the preliminary stages of this investigation the following consensus emerged. Evidence from the 1999 DISH evaluation survey did not support the likelihood of declining use of services. For instance, this survey that covered all DISH districts except Kasese found increased use of family planning services - Contraceptive Prevalence (CPR) had increased from 19% in 1997 to 21% in 1999. It also found no decline in use of antenatal or delivery services. The percentage of mothers attending antenatal services increased from 90% to 93% while the percentage delivering from health units from 50% to 53%. On accuracy of the data, a random spot check to reconcile information in daily registers against information reported on the monthly HMIS forms was conducted to validate accuracy of monthly data from health facilities. This exercise found monthly reported data consistent with records in the facilities’ daily registers.
Regarding the shift from government to the private sector, data from the 1999 DES presented supportive evidence. It showed that in the DISH districts, the percentage of clients seeking family planning from the private sector had increased from 39% in 1997 to 45% in 1999. In contrast, the percentage seeking from government decreased from 39% to 34%, as Figure 2 shows. Data on child health care seeking patterns showed more spectacularly this increased preference for the private sector over the government sector. Children care takers were more likely to seek child treatment for fever or cough from private/NGO facilities rather then from Government (see Figure 3)
Figures 2 and 3 strongly suggest that there is a shift from the Government sector to the private sector. The suggestions mentioned above warranted further investigations; more evidence was needed to confirm the shift from the private to the public sector.. For example, besides population based data that would best show this trend, supplementary information confirming an increased client load in the private sector would further provide evidence of the increased role of the private sector. In addition, a match between the timing and magnitude of the decline in the public sector with the increase in private sector client would confirm that clients were shifting from the former to the latter. In pursuit of further evidence, while waiting for population level survey results from the 2000 Uganda Demographic and Health Survey that would best examine the shifting, the DISH project commissioned a Private Sector Study (PSS) The findings of this (PSS) study constitute the rest of the report. Subsequent sections present the objectives, methodologies, major findings and recommendations of the PSS study. The Private Sector Study had four main aims:
This study used two different methodologies, namely, 1) comparing public versus private sector trends of service utilisation indicators and 2) conducting a facility-level private sector survey. 1.3.2.1 Comparison of service statistics between public sector (including DISH sentinel facilities) and private sector instituions.. In this phase, family planning, antenatal and delivery services statistics from the DISH sentinel sites for the period 1997 to 2000 were compared with those from other institutions providing reproductive, maternal and child health services. These included Mokono district - a non-DISH district; Mengo Hospital – a major NGO hospital in the capital city (Kampala); Uganda Private Midwife Association (UPMA) – an umbrella organization for private-for-profit midwives; and the Commercial Marketing Strategies (CMS) project. DISH sites, Mukono district and Mengo hospital represent the more formal health care system referred to as public in this report, while UPMA and CMS represent the less formal and private-for-profit sector. This report compared the above-specified public and private sector service utilization trends. 1.3.2.2 Facility-based Private Sector Survey i. Facility listing and Interviews The next phase involved a survey of private facilities. First in this phase, all private sector facilities and drug shops in the selected areas, namely, Jinja district and Kawempe and Makindye divisions of Kampala were listed, noting those that provided reproductive services. A short questionnaire was administered to those providing reproductive health. This questionnaire covered reproductive health services offered and year when this service was introduced; the client load trends between 1997 and 2000; the staffing and whether any staff had received DISH training or training in reproductive health provided by other institutions. ii. Client Exit-Interviews and Focus Group Discussions (FGDs) Secondly, under the Private Facility survey, clients seeking reproductive, maternal and child health services in selected private facilities responded to a Facility-exit interview administered by a trained interviewer. Facilities were selected based on Family Planning client load to ensure at least one interview per day at a facility. This criterion, using twenty four interviewers for 10 days would result into at least 240 respondents. In addition, because some facilities had records while others had no record, the sample was designed to equally cover either group of these facilities. Hence in Kampala each of the 20 enumerators spent 5 days at one of the 20 highest volume facilities with records, and 5 days at the 20 highest volume (based on estimates) facilities without records. In Jinja, because of low volumes the each of the four enumerators covered one facility for 10 days. During the same period of the exit interviews, Focus Group Discussions (FGDs) were conducted for clients who had purchased family planning supplies from either drug shops or private clinics during the month preceding the survey. To trace FGD participants, facilities had kept a list of all clients willing to participate in our study. FGD participants were selected from these lists. Both the structured questionnaire and FGD included questions on sources of services, opinion about quality of services at the different sources, shifting from public to private sources, and reasons for shifting. Respondents were also asked to recommend ways to improve services in the Government, NGO and private sector. The two methodologies described above examined evidence of a shift from public to private sector, the reasons for this shift and recommendations to improve the reproductive, maternal and child health services at Government, NGO and private facilities. Based on this evidence this study made recommendations for the way forward regarding interventions to improve reproductive, maternal and child health status.
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