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REPRODUCTIVE, MATERNAL AND CHILD 2. Major Findings 2.1 Service statistics comparison between DISH 80 sentinel sites and other institutions providing reproductive, maternal and child health services 2.1.1 Comparison with a non-DISH district The DISH sentinel sites and Mukono HMIS data shared similar trends. Figures 4 and Figure 5 show these trends. Both figures beginning in 1999 show a declining trend in use of family planning services. The antenatal care and assisted delivery trends are also similar between DISH and Mukono. Similar to DISH sites trends, Mukono ANC and assisted deliveries declined beginning 1999.. 2.1.2 Comparison with an NGO Hospital Mengo hospital data, similar to that from DISH sites and Mukono district, show declines in number of antenatal care and assisted delivery clients. (Figure 6)However, the Mengo hospital declines began much earlier, by 1997, and appear more steady . The similarity between DISH sentinel data, Mukono district and Mengo hospital suggests that in 1999 public sector facilities were experiencing similar trends. They registered declined in utilization of family planning, antenatal care and assisted delivery services. 2.1.3 Comparison with UPMA Differences existed in antenatal and assisted delivery care client load trends between DISH sentinel sites and UPMA sites. For example, before beginning to decline the DISH antenatal care and assisted delivery clients increased by 8% and 13% respectively between 1997 and 1998. In comparison, the UPMA number of antenatal and assisted delivery clients increased by 42% and 52% respectively. However, trend of family planning use were similar DISH and UPMA. The latter also expwerienced declines in use of family planning servcies, as Figure 7, showing the number of new family planning acceptors suggests. 2.1.4 Comparison with CMS A sharp contrast existed between DISH sentinel sites FP trends and those of the CMS project. In 1999, during the period the DISH FP trends declined, the CMS pills and injectable sales increased sharply as shown in Figure 8. The comparison of service utilisation trends between the DISH sentinel sites and other public institutions versus the private institutions, namely, UPMA and CMS reveals an interesting situation. For instance, the 1999 trends show that while the public sector institutions experienced service utilisation declines, the private sector experienced, specifically the social marketing program, experienced remarkable increases. This evidence suggests that a shift occurred; clients purchasing family planning supplies from social marketing instead of seeking the service from public facilities.
Following up suggestions from the comparisons presented above, DISH II proceeded to survey private sector facilities and to interview clients seeking reproductive, maternal and child health services from these facilities. Results from these surveys constitute the next section. 2.2 Private Sector Facility Interviews The private health facility survey covered 400 private health facilities and 277 drug shops/pharmacies in Jinja (Jja) district and in the two divisions- Kawempe and Makindye in Kampala(Kla). Table 1 shows the facilities covered. TABLE 1: Private Sector Study coverage
It is notable that while Kampala had more facilities than drug shops, with a ratio of 1 to 0.4, Jinja had less facilities than drug shops, with a ratio of 1 to 2.8. This difference possibly suggests that drug shops play a bigger role that private clinic in the more rural setting. It is also notable that in Jinja district the ration of Government to Private facilities was almost 1 to 1. In Kampala this ration was 1 to 59, suggesting that the role of government sector facilities increases in the more rural set up. 2.2.1 Reproductive Health Services in the private sector Most (72%) private facilities surveyed provided reproductive health services. Mainly they sold pills, condoms and injectables. Almost all drug shops sold contraceptives, mainly pills and condoms. Facilities providing RH services responded to a questionnaire (see Annex I) that collected further details about their services. More and more facilities had introduced RH services during the period 1997 to 2000. Figure 9 shows the number of facilities providing reproductive health services by year. It shows that the number providing family planning services doubled between 1997 and 2000. 2.2.2 Record Keeping in the Private sector Many private sector facilities do not keep reliable data. Among the facilities visited, only 43% had records that could be used to extract client load information for the period 1997 to 2000. Higher level facilities and those run by UPMA members were significantly more likely to have records. 2.2.3 Trends in client load 1997 to 2000 Data from facilities with records was used to calculate the average number of clients per facility. As Figure 10 shows, the average number of family planning clients per facility remarkably increased while that for antenatal care and deliveries stagnated between 1997 and 2000 The average number of FP clients doubled between 1997 and 2000, posting in 1998 a sharp increase that apparently coincides with the beginning of the declining trends reported by the DISH sentinel sites data. However, their average ANC and Delivery clients hardly increased. These results suggest the private sector family planning clientele is growing much faster than that of antenatal and deliveries. The total number of clients served by Government compared to that served by the private sector reveals further evidence of the dominance of the latter in Kampala. For instance, the Makindye division of Kampala had only 3 Government facilities which had served less than 500 family planning clients planning clients between January and June 2000. In comparison, the 69 private sector facilities in Makindye that had records had served 4,167 family planning clients on pills and injectables alone. 2.2.4 Staffing and Training in Private Facilities Most facilities (84%) had a nurse or midwife. Very few (26%) had a permanent doctor. However, permanency in this case was difficult to interpret because some doctors who own clinics and only report for work in the evenings were also reported as permanent. Most facilities (78%) had no staff who had ever attended DISH training. But 38% reported at least one member of staff who had attended reproductive health training in the previous two years. Client-exit interviews at 44 private health facilities covered 750 women who had come for reproductive, maternal and child health services. Most of these were family Planning clients (34%), followed by child health (28%), antenatal (20%) and STD (11%) clients. The majority of clients (52%) had Secondary or Higher education, while 35% had Primary education and 13% had no education or higher education level. Most women (52%) were below the age of 25, 33% were 25 to 30 years and 15% were over 30 years. The majority (81%) were married. 2.3.1 Shifting from Government, NGO to Private sector facilities Clients were asked whether they had ever sought from Government or NGO the services they had come for at the private facility. One in five (22%) percent of clients interviewed had ever gone to seek services from a Government facility. But only 8% had ever sought service from an NGO. The percentage reporting ever attendance at Government facilities was higher (44%) among Child Health Care clients, followed by ANC (31%), FP (22%) and STD(12%) clients, as shown in Figure 11. The percentage of clients who had ever gone to Government facilities was higher among the educated than among the non educated, among the older than among the younger clients and among the married than among the unmarried, as Table 2 shows Table 2: Private clinic clients ever gone for same service at Government facilities, by education, age and marital status.
Results in Table 2 suggest that the uneducated women, young women and unmarried women are less likely to have ever sought services from government facilities. This is consistent with the common notion that these women tend to shy from the more formal health facilities such as Government facilities and prefer the less formal set up that is likely to prevail in their neighbourhood clinics. (Figure 12) Clients who had ever sought services from a Government or NGO facility were asked why they had not returned to that facility for the current visit. (Figure 14) Clients most frequently mentioned "Location" as one of the reasons they were attending a private clinic instead of returning to Government or NGO facility. The next most frequently mentioned reasons were: waiting time, drug availability, good service and credit facilities, as shown in graph below. Major reasons for shifting did not vary much by clients seeking different services, except that waiting time, good service and drug availability are slightly more important to clients seeking child health care than to clients seeking ANC or Family Planning. It is notable that "Good Service" was less important among Family Planning clients than among ANC or Child Health Care clients. Figure 13 shows reasons for switching differentials by type of service. Reasons for shifting differed by education. Educated women most frequently mentioned "Location" followed by "Waiting time". In contrast, women with no education most frequently mentioned "Good Service". It is ironical that the least educated were more concerned with quality of service than the educated ones. Figure 15 shows that young women did not return to Government facilities primarily because of accessibility and long waiting time at these facilities. Older women had a different reason, they did not return to a Government facility primarily because private clinics offer "Good service". Reasons for not returning to a Government facility did not vary by marital status. Irrespective of marital status, the major reasons was "Location" followed by "Waiting time" , "Good service", "Availability of Drugs" and "Credit facilities." Overall, location is the major factor driving clients to the private clinics. Clients end up at clinics largely because of accessibility. Focus Group Discussants, while mentioning all the other factors mentioned in exit interviews, also emphasised the issue of location. Discussants mentioned that private clinics are near and, therefore, one incurred no transport costs and can seek services anytime including at night. In contrast, seeking services at Government facilities involves transport costs, long waiting time before getting from sometimes rude providers. Focus Groups also mentioned the other factors mentioned by exit interview respondents. The survey asked questions to assess the quality of service offered at private clinics. These questions focused on quality of client-provider interaction and the overall satisfaction of the client. New and re-visiting family planning clients and ANC clients were asked questions about their interaction with the provider during the counselling session. Results in Figures 16, Figure 17 and Figure 18 show that family planning and antenatal care clients were satisfied with services received from private clinics and received good client-provider interactions. However, 34% of revisiting family planning clients were not asked whether they were experiencing problems with the contraceptive method they were using. Irrespective of type of service sought, most clients considered the cost of services at private clinics as fair. Figure 19 illustrates this finding. On average clients paid Shs 1,498 for a family planning visit, Shs 3,310 for an antenatal visit, Shs 3,007 for a child health visit, and Shs 6,928 for an STD visit. Interestingly, while clients considered private clinics costs as fair, they complained at costs charged by Government facilities. Participants in Focus Group Discussions complained that Government facilities charge for everything including registration cards. Yet, they believed, services in Government facilities should be very cheap or even free. 2.3.5 Ideal source of services Clients were asked what they consider the ideal source of the service they had come for at the private clinics. Not surprising, the majority, similarly across different types of services, considered the private sector as the ideal source of service, as Figure 20 shows. This pattern did not vary by education, age or marital categories. The majority of clients believed that private clinics are ideal for providing the services they were seeking. Similar sentiments were expressed in Focus Group Discussion where discussants mentioned that because of competition private facilities are forced to offer better services. However, discussants also acknowledged private sector shortcomings such as lack of medical equipment and, regarding family planning, dissatisfactory handling of contraceptive side effects related problems. 2.3.6 Recommendations for improvement of services to attract more clients. Clients were asked for suggestions that would improve services at Government, NGO and Private sector facilities. Figures 21, 22 and 23 show the responses by clients seeking the different services. Family planning clients The Family Planning clients’ major recommendations that were mentioned by at least 20% of the clients are as follows in order of priority for each category of facilities.: Government facilities:
NGO:
Private Facilities:
Antenatal care clients Antenatal care clients’ recommendations by and large were similar to those made by Family planning clients. The first three recommendations were similar. However, antenatal clients, unlike family planning clients, mentioned qualified staff as an area Government needs to address. They also mentioned accessibility. For NGOs, antenatal clients’ recommendation slightly differed from those mentioned by Family planning clients. Both types of clients equally mentioned "Waiting time" and "accessibility". But unlike Family planning clients, antenatal clients complained about provider behaviour and drug availability at NGO facilities. At private clinics, antenatal care clients had similar recommendations with family planning clients, only that the former more strongly recommended that private clinics improve drug availability.
Child health care clients’ recommendations reflected problems similar to those mentioned by family planning and antenatal care clients. For Government it was again "Waiting time and "Provider behaviour". But Child Health clients, compared to any other category of clients, more strongly mentioned availability of drugs at Government facilities. For private clinic, child health care clients were mostly concerned with staff qualification. Like all other clients, to Government facilities, STD clients were also concerned with provider behaviour, waiting time, drug availability and accessibility. And, similar to antenatal care clients, they raised concern about staff qualification at Government facilities. Regarding NGO facilities, STD clients recommendation mainly focused on accessibility and drug availability. For private facilities, STD clients recommended better drug availability, infrastructure and staff qualification. It is notable that STD clients more strongly mentioned the issue of infrastructure for the private facilities than for the other types of facilities. The above results suggest that provider behaviour and waiting time are major issues to be addressed by Government facilities. In addition Government needs to improve accessibility of its services. NGO facilities need to increase accessibility and also check on provider behaviour especially for the antenatal and STD clients. (Figure 24) Private facilities need to address staff qualification. This was echoed in the FGD. Discussants accused private practitioners of using their unqualified relatives as service providers. Government and private facilities need to address the problem of drug availability. This problem prevails for all types of services in Government facilities. In private facilities this problems is relatively less with respect to child health services.
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