Voices for Health Project: Improving Sexual and - HEPS

VOLUME 001
JAN-MARCH 2016
Results of a Community Score Card in Selected Public
Health Facilities in Kiboga and Isingiro districts
Voices for Health Project: Improving
Sexual and Reproductive Health
Access in Ugandan Communities
FOREWORD
W W W . heps . or . u g
Despite government efforts in improving sexual and reproductive health, the SRH indicators remain weak with
high infant and maternal mortality rates, high fertility rates, high rates of teenage pregnancies, unsafe abortions
and low uptake of contraceptives. The main reasons for this have been given as widespread disempowerment
of youth and women, myths and misconceptions on FP methods, and the lack of awareness of SRH due to
cultural determinants that bring about silence, stigma and discrimination. This in turn limits the choice of
youth and women when making decisions on Family Planning or contraceptive choices generally, and sexual
and reproductive rights, generally. This is compounded by the challenges in chain management that lead
to persistent stock-outs of key contraceptives due to several reasons including delays by districts to submit
orders to the National Medical Stores (NMS), poor forecasting and irregular distribution by the NMS that fail
to meet demand even where the orders come in on time. Private users also contribute to stock- outs owing to
the barrier of poor demand caused by the lack of information or capacity to create demand. As a result, many
would-be consumers’ especially young people rely on self medication, traditional healers and birth attendants
who operate, often unchecked, outside the formal health system.
i n form a t io n :
V I S I T
HEPS Uganda with support from Planned Parenthood Global (PPG) is implementing the Voices for Health
Project: Improving Sexual and Reproductive Health Access among Communities in 2 districts of Kiboga and
Isingiro in Uganda. In this project, We are building on our experience and relations with other stakeholders to
continue spearheading campaigns to address the gaps in access to Family Planning services and contraceptive
commodities and stock-outs in the country. Working through campaigns and capacity building, HEPS is targeting
policy makers and other relevant stakeholders at both national and district level to address gaps on budget
allocation and the supply barriers that lead to stock-outs. HEPS is also generating demand at the community
level by empowering women and youth to make informed decisions and choices on Family Planning and
contraceptives and demand government accountability for effective service provision.
F O R
M O R E
The project is using the Community Scorecard (CSC) strategy to engage communities in Kiboga and Isingiro
districts to address contraceptive stock outs and increase contraceptive choice. In the instant report, we
present the findings of the second round of scorecard activities carries out in Kiboga and Isingiro Districts in
the first quarter of 2016.
DENIS KIBIRA
Deputy Executive Director
This report was prepared by:
Coalition for Health Promotion and Social Development (HEPS-Uganda)
Plot 351A, Balintuma Road, Namirembe Hill
Recommended citation:
Coalition for Health Promotion and Social Development(2016). Improving Sexual and Reproductive Health Access among Communities
in Uganda. Results of a Community Score Card on selected Public Health Facilities in Kiboga and Isingiro districts
2
Contents
F O R
M O R E
i n form a t io n :
V I S I T
W W W . heps . or . u g
3
Contents........................................................................................................... 3
Abbreviations..............................................................................................................4
Introduction....................................................................................................... 5
Background to the Application of the Community Score Card................................................................ 5
Family planning in the national context................................................................................................... 5
W W W . heps . or . u g
Objectives of the Community Score Card............................................................................................... 7
Coverage of the Score Card and Participants......................................................................................... 8
The community Score Card Process. ....................................................................... 8
Introduction. ............................................................................................................................................ 8
Preparation.............................................................................................................................................. 9
V I S I T
The Interface Meetings. ........................................................................................................................ 11
i n form a t io n :
Score Card by Community Members and Health Workers..................................................................... 9
Action Plan Implementation and Progress Monitoring.......................................................................... 13
Development of Action Plans................................................................................................................ 12
Results of the Scorecard at the 10 Health Facilities.................................................... 13
Introduction. .......................................................................................................................................... 13
Availability of FP supplies and commodities. ........................................................................................ 13
M O R E
Staffing Levels and Staff Performance.................................................................................................. 15
Availability of infrastructure for the delivery of FP services................................................................... 17
F O R
User perception of Family Planning Services. ...................................................................................... 18
Male involvement in Family Planning.................................................................................................... 20
Level of youth uptake of family planning services................................................................................. 21
Perception of distance as a barrier to the uptake of family planning services. .....................................21
Conclusions and Recommendations...................................................................... 22
Conclusions........................................................................................................................................... 22
Recommendations................................................................................................................................ 22
4
Abbreviations
District Health Team
EMHS
Essential Medicines and Health Supplies
GoU
Government of Uganda
HC
Health Centre
HEPS
Coalition for Health Promotion and Social Development
HSSIP
Health Sector Strategic and Investment Plan
HUMC
Health Unit Management Committee
MoH Ministry of Health
NMS
National Medical Stores
VHT
Village Health Team
UDHS Uganda Demographic and Health Survey
CPR Contraceptive Prevalence Rate
i n form a t io n :
DHT
M O R E
Community Score Card
F O R
CSC
V I S I T
W W W . heps . or . u g
5
Introduction
Background to the Community Score Card
W W W . heps . or . u g
A Community Score Card (CSC) is an ongoing two-way participatory tool for the assessment, planning,
monitoring and evaluation of services. The CSC brings together the demand side (“service user”) and the supply
side (“service provider”) of a particular service or program to jointly analyze issues underlying service delivery
problems and find a common and shared way of addressing those issues. It is an exciting way to increase
participation, accountability and transparency between service users, providers and decision makers. This CSC
report was prepared by Coalition for Health Promotion and Social Development (HEPS-Uganda) and provides
an assessment of health care users and providers and the actions taken to address access to and utilisation of
sexual and reproductive health services in 10 public health facilities in Kiboga and Isingiro districts.
The CSC methodology is being implemented by HEPS under the Voices for Health Project, whose goal is to,
“improve access to reproductive health commodities and choice for marginalized women, men, (youth) of
reproductive age in rural settings in Uganda by 2020.” The CSC contributes primarily to Objective2 of the
project, which was set to, “monitor the availability of essential family planning services and commodities at
public and private health facilities in the two target districts.”
V I S I T
Family Planning in The National Context
i n form a t io n :
The national contraceptive prevalence rate-CPR-(proportion of married women of reproductive age- 15–49
years-using at least one family planning method) has increased from 23% in 2006 to 30% in 2011 against the
Health Sector Strategic and Investment Plan (HSSIP) target of 43% in FY 2014/15 was 43%(MOH, 2015). The
2011 Uganda Demographic and Health Survey (UDHS) revealed significant disparities in contraceptive use by
age, marital status, education, socioeconomic status, and rural-urban geographic location.
M O R E
Unmarried women of reproductive age have a substantially higher use of modern contraceptive methods
compared to married women. CPR is higher amongst those with higher schooling, at 38% for those with
secondary education and only 16% amongst those with no education. The poorest women have the lowest
levels of use, 13% of women in the lowest wealth quintile compared to 39% of women in the highest wealth
quintile (UBOS and ICF International, cited in MOH, 2014).Women in Kampala have the highest CPR at 40%,
while those in Karamoja in the Northeast region have the lowest at 7% (Ibid).
F O R
The unmet need (the percentage of women who want to but are not using contraception) was 34% in 2011,
decreasing from 41 percent in 2006 (UBOS and ICF International, cited in MOH, 2014). Poor access to quality
family planning services characterized by few skilled providers and inadequate commodities that give the
client little or no choice of methods of family planning and undermines the ability of men and women to
freely decide on the number and spacing of their children contributes to high levels of unmet need in the
country (MOH, 2014).
The high unmet need also contributes to unplanned pregnancies—43 percent of all pregnancies in Uganda
are unplanned (UBOS and ICF International, cited in MOH, 2014). Women in rural areas report higher levels of
unmet need at 37% compared to their counterparts in urban areas at 23%, while women in the lowest wealth
quintile have the highest levels of unmet need at 42% compared to women in the highest wealth quintile at
23% (Ibid).
The low uptake of family planning services is attributed to ignorance of the youth about family planning and
contraception, limited engagement of parents in the sexual education of their children and the perception
among men that family planning is a women’s issue (Ibid). Other challenges include myths and misconceptions
6
about modern family planning methods, cultural and religious values that undermine modern contraceptives
(CIP, cited in MOH, 2014) and gender inequalities that undermine women’s ability to make decisions in the
household (National Planning Authority, 2013).
F O R
The above challenges are compounded by supply-side challenges, such as limited access among rural and
the poorest populations in urban areas (CIP, cited in MOH, 2014), limited access to health facilities providing
family planning services and persistent stock-outs of key contraceptives (Reproductive Health Uganda,
2009). Although primary health service delivery is decentralised, districts face several challenges, including
the recruitment and retention of human resources for health, especially at lower levels of health facilities
(CIP, cited in MOH, 2014) which severely hampers the scale-up of FP service delivery (CIP, cited in MOH,
2014; MOH, 2007.). The low number of skilled family planning providers in Uganda further impacts the
access, coverage, and distribution of FP services in addition to insufficient resources for in-service training,
insufficient coverage of FP topics in pre-service curricula, and transitioning of trained providers to other
health services (CIP, cited in MOH, 2014).
M O R E
i n form a t io n :
Uganda has increased its funding for family planning from US$200 million in FY2005/06 to US$6.9 million
FY 2013/14, thus exceeding its global commitment of US$5 million. However, donor fatigue (MOH, 2014),
lack of funding for FP services for youth remain key challenges funding (CIP, cited in MOH, 2014). There is
also weak integration of FP services in other health services, weak referral systems, and bottlenecks in the
supervision, monitoring, and coordination because of limited dedicated staffing resources at the national
and district levels (Ibid).
In November 2014, the Government of Uganda published the Uganda Family Planning Costed Implementation
Plan, 2015–2020, which sets five strategic priorities:
ii.
iii.
W W W . heps . or . u g
i.
ii.
Increase age-appropriate information, access, and use of family planning amongst young people,
ages 10–24 years
Promote and nurture change in social and individual behaviour to address myths, misconceptions,
and side effects and improve acceptance and continued use of family planning to prevent unintended
pregnancies
Implement task sharing to increase access, especially for rural and underserved populations.
Mainstream implementation of FP policy, interventions, and delivery of services in multisectoral
domains to facilitate a holistic contribution to social and economic transformation.
Improve forecasting, procurement, and distribution and ensure full financing for commodity security
in the public and private sectors.
V I S I T
i.
HEPS Uganda designed this project to contribute to the redress of the above supply-side and demand-side
challenges in the delivery and utilisation of SRH services in the districts of Kiboga and Isingiro through a tiered
set of interventions at the community, local government and national level.
Objectives of the Community Score Card
1.1.1 Overall Objective
The overall objective of this CSC is to provide evidence to inform policy and practice changes necessary to
improve the availability and utilisation of family planning services among marginalized women, youth and
men living in poor communities (ruralandurban) of Uganda.
7
Figure 1: The Steps involved in the Community Scorecard Exercise
W W W . heps . or . u g
1.1.2 Specific Objectives
i.
To assess and report on the availability and level of access to SRH services in 10 public health
facilities in Kiboga and Isingiro districts.
ii.
To highlight the contribution of the Community Score Card process to addressing family planning
service delivery concerns in 10 public health facilities in Kiboga and Isingiro districts.
iii.
To document and report on local family planning service delivery issues that call for improvements in
the wider health system in order to increase access to family planning services among marginalized
women, youth and men living in poor communities (ruralandurban) of Uganda.
iv.
To provide lessons and good practices of the community score card process that can inform the
future application of the social accountability approach in health and other sectors in Uganda.
Coverage of the Score Card and Participants
V I S I T
The CSC was applied in the two districts of Kiboga (Central Uganda) and Isingiro (Western Uganda). A total
of 10 public health centers, one in each of the 10 sub counties were assessed in the two rounds of CSC. The
CSC participants included health workers from the targeted health facilities, members of Village Health Teams
(VHTs), Local council one Chairpersons and other men and women in the community. All the CSC sessions
were facilitated by staff of HEPS Uganda, with the support of community monitors and the sub county leaders.
The list of Sub counties and Health centers involved in the CSC is provided in Table 1 below.
i n form a t io n :
Table 1: Sub counties and Heath Centers targeted in the CSC
Kiboga District
Sub County
Kibiga
Kapeke
Muwanga
Isingiro District
Health Facility
Kambugu HCIII
Nyamiringa HCIII
Muwanga HC III
F O R
M O R E
Lwamata
Lwamata HCIII
Bukomero
Bukomero HC IV
Source: HEPS Project Documents
Sub County
Isingiro T/C
Birere
Ngarama
Health Facility
Rwekubo HC IV
Kasana HC III
Ngarama HC III
Nyamuyanja
Rugaaga
Nyamyanja HC IV
Rugaaga HC IV
The Community Score Card Process
Introduction
The CSC was conducted following the conventional stages, which includes, preparation; input tracking;
identification of issues affecting access to and utilisation of sexual and reproductive health services,scoring by
the women, men, and health workers; interface meeting and action plan development; implementation and
progress monitoring. This process is illustrated in Figure 1 below and further elaborated in the sections that
follow.
8
F O R
M O R E
i n form a t io n :
Preparation
V I S I T
Thorough preparation for a CSC process is crucial for its success. HEPS Uganda began the CSC process by
identifying the health sector and geographic scope of the exercise as well as the health facility entitlement
for sexual and reproductive health. This was followed by orientation meetings with the targeted district
and sub-county officials on the CSC methodology as most of the officials had no prior understanding of the
approach.
W W W . heps . or . u g
The visits also helped HEPS to rally for political support of the leadership and guarantee the success of the
community score card.This was followed by the identification, selection and training of community monitors
who then carried out community sensitization meetings on health rights and responsibilities; advocacy for
health rights; health care service standards; the CSC approach; and the medicines supply system (Kit system
Vs Pull system).
Upon conclusion of the community sensitization meetings, community members were informed of the
impending CSC exercise and were encouraged to participate in the process. When the dates for the CSC were
set, community members were invited by the community monitors. Community members were adequately
briefed about the exercise and that their participation would be on a voluntary basis. HEPS was able to mobilize
and engage the same community members in the two phases of the Score Card.
Score Card by Community Members and Health Workers
Both community members (women’s and men’s groups) and health workers participated in the two rounds
of the score card exercise. The participants and the facilitators agreed on the family planning service delivery
issues and related indicators and the scoring scale. This was followed by the eventual scoring of the identified
issues, basing on the perceptions of group members. All the three categories of participants (women, men and
health workers) identified issues such as the level of awareness of family planning,level of male involvement,
availability of commodities, side effects, myths and misconceptions about family planning and the availability
of staff at the health facilities.
9
The results of the first Score Card conducted in October 2015 were then compared with those of the second
Score Card carried out in March 2016 to assess the changes in thedelivery of family planning services.
The Interface Meetings
W W W . heps . or . u g
Following the conclusion of the scoring sessions by each group, a consolidation exercise was conducted during
which the representatives of the community and the health workers presented their group’s assessment and
recommendations to the participants present at these interface meetings. The main purpose of the interface
meeting was to share the Scores generated by service users and service providers to ensure that feedback
from the community is taken into account, and that concrete measures are taken to improve access to and
utilization of family planning services at the targeted health facilities.
Development of Action Plans
i n form a t io n :
V I S I T
After the discussions in the interface meetings,a consensus was reached on the priority issues and the short
term and long-term actions to be taken to improve family planning services. Action planning also involved
identifying persons/institutions with the mandate to address the issues and the time frame for realising the
desired changes. For example, participants at Kambugu HCIII in Kiboga district put emphasis on creating
awareness of the community members of FP services to increase client flow as only one client visited the
facility per week. The members also agreed that community monitors should conduct home visits to boost
awareness on family planning.At Kasana HC in Isingiro district, members agreed to target male action groups,
such as Bataka and Kweyamba groups as an entry point to change changingmen’s negative attitude towards
family planning.
Action Plan Implementation and Progress Monitoring
M O R E
It is important to recognize that the Score Card process does not stop immediately after generating a round
of scores and joint action plans. Follow-up actions were taken as outlined in the action plans. A follow-up
Score Card was conducted in March 2016 to assess if there were any improvements resulting from the
implementation of the action plans.
F O R
Scorecard Results
Introduction
The consumers (women and men) and health workers assessed the availability and access to family planning
servicesand commoditiesbased ona scale of 1-5 (very bad, bad, fair, good and very good). A zero score means
that the group did not rate the variable of interest during the CSC. The scoring and analysis of the various
variables related to family planning availability and utilization is limited to the health facilities in which the CSC
participants mentioned them. The rated scores and the qualitative assessment were based on the relevant
MOH norms for the various levels of health facilities.
10
Availability of FP supplies and commodities
The Government of Uganda (GoU) has a mandate of ensuring universal access to the essential family planning
services, which requires an adequate stock of family planning commodities and supplies.Uganda has an
Essential Medicine and Health Supplies List (EMHSLU) that contains all contraceptives classified by level of
care. In both the 2015 and 2016 CSC exercise, the participants audited the availability and quality offamily
planning commodities and equipment and supplies.
Kiboga
Men
Health
Workers
Consensus
Score
Kambugu
Nyamiringa
Muwanga
Oct
2015
4
2
2
March
2016
3
5
3
Oct
2015
1
3
3
March
2016
2
4
2
Oct
2015
2
4
1
March
2016
1
4
2
Oct
2015
1
3
1
March
2016
2
4
2
Lwamata
3
4
3
4
1
4
3
4
Bukomero
Rwekubo
3
2
4
1
2
2
1
3
4
4
3
5
0
4
2
4
Kasana
4
3
3
1
1
2
1
2
Ngarama
3
2
2
2
3
3
3
1
Nyamuyanja
1
3
1
1
4
4
4
4
W W W . heps . or . u g
Women
V I S I T
Isingoro
Health
facility
i n form a t io n :
District
M O R E
Table 2: CSC participants’ rating of the availability of FP supplies and commodities
F O R
The results of the second round of the Score Card show a minor improvement in the perceived availability
of family planning commodities ina half of the health facilities, namely, Kambugu, Nyamiringa, Muwanga,
and Lwamata in Kiboga district and Kasana HC in Isingiro district(Table 1). There was an improvement in the
consensus and women’s rating in five health facilities. The rating by men and health workers also improved
or remained goodin threeof the 10health facilities, namely Nyamiringa and Lwamata in Kiboga district and
Rwekubo in Isingiro district. There was a significant improvement in the rating at Lwamata HC because the
commodities for most of the family planning methods were available during the second CSC cycle. The
consensus score and the score of health workers at Nyamuyanja HC in Isingiro district rated the availability of
FP commodities as “good” during the two CSC cycles.
Source: HEPS Field Reports
The stock-out or complete lack of family planning commodities at some of the health facilities was reported
as a major hindrance to the uptake of family planning services. For example,CSC participants at Bukomero
and Kambugu health facilities in Kiboga and Kasana HC in Isingiro reported the lack of commodities for long
term family planning methods, such as Intra Uterine Device (IUD) and Implants.In some health facilities, such
as Bukomero HC, it was reported that the demand for family planning commodities had increased as a result
of the HEPS uganda project, leading to stock-outs. On the other hand, low demand for long term methods
was cited at Rugaaga HC in Isingiro district despite an adequate supply of the needed commodities. The rating
of availability of FP commodities at Ngarama HC declined because only commodities for one family planning
method were available during the second round of the CSC.
This validates previous findings that the current system for quantification, ordering, and distribution from
national to district level, and from districts to health facilities and end users faces challenges. This includes
inability to align the forecasting of demand with the budgeting cycles and the challenges of quantification
caused by lack of programme data on distribution, demand, and use (CIP, cited in MOH, 2014).
11
Staffing Levels and Staff Performance
1.1.3 Adequacy of staff at the health facilities
F O R
M O R E
i n form a t io n :
V I S I T
W W W . heps . or . u g
The availability of an adequate number of qualified staff is crucial for the delivery of sexual and reproductive
health services. The CSC established that there were glaring staffing shortfalls in some of the health facilities
when compared to the MOH staffing norm (49 staff members for HC IV and 19 for HC III). The staffing details
(as shown in Table 2 below) indicate that only four of the 10 health facilities (Rwekubo in Isingiro district and
Rwamata, Muwanga and Bukomero in Kiboga district) had staffing levels commensurate with or above the
HSSIP 2014/15 national staffing target of 75% during the second round of CSC.
There was an increase in the number of staff at four of the health facilities, namely Rwekubo, Kasana, Bukomero
and Rwamata. However, six of the health facilities comprising Rugaaga, Ngarama, Nyamuyanja in Isingiro
district and Nyamiringa, Kambugu, and Muwanga in Kiboga district experienced a reduction in the number
of health workers because of transfers, study leave and absconding from duty. Staff shortages are further
compounded by staff absenteeism, a concern raised at Ngarama HC in Isingiro district. Some Health workers
are given transfers to other busy HCs within the district because community members prefer private health
facilities thinking that they have better services, a concern raised by the In-charge Nyamiringa HCIII.
Table 3: Proportion of Filled Staffing Positions at the 10 Health Facilities
District
Health facility
MOH standard
Isingiro
Kiboga
No Oct15
% Oct15
No
16
Mar-
% Oct15
Nyamuyanja HC IV
Rugaaga HC IV
49
49
23
21
47%
43%
18
20
37%
41%
Rwekubo HC IV
49
51
104%
55
112%
Ngarama HC III
19
14
74%
9
47%
Kasana HCIII
Rwamata HC III
Nyamiringa HC III
Kambugu HC III
Muwanga HC III
Bukomero HC IV
19
19
19
19
19
49
7
16
10
14
16
34
37%
84%
53%
74%
84%
69%
9
17
8
12
15
42
47%
89%
42%
63%
79%
86%
Source: HEPS Field Report
Of the five health facilities (listed in Table 3 below) where low staffing was identified,only two, Kambugu
in Kiboga district and Kasana in Isingiro district recorded an improvement in the consensus rating on staff
adequacy between Oct 2015 and March 2016.The rating remained at 3 (fair)Muwanga HC in Kiboga district.
The consensus rating at Nyamiringa in Kiboga district declined from good to fair.
Table 4: CSC participants’ rating of the adequacy of staff at the facilities
District Health
facility
Kiboga
Women
Men
Kambugu
Health
Consensus
Workers
score
Oct
March Oct
March Oct
March Oct
March
2015 2016
2015 2016
2015 2016
2015 2016
3
1
3
4
4
4
3
4
Nyamiringa
Muwanga
2
4
0
4
3
3
3
3
4
3
5
4
4
3
3
3
Isingiro
Kasana
Rugaaga
1
0
4
0
1
0
2
3
3
0
3
0
2
0
3
2
Source: HEPS Field Reports
The staff shortage affected service delivery. For example, CSC participants at both Kambugu HC in Kiboga district
and Rugaaga HC in Isingiro district acknowledged that the few health workers attend to many clients and they
get overwhelmed. Moreover, staff cadres such as midwives gave less attention to family planning services
because they had to provide “priority” services comprising Antenatal (ANC) and Postnatal care (PNC).
1.1.4 Adequacy of health worker’s skills to provide family services
Health
facility
Women
Men
March
2016
4
Oct
2015
4
March
2016
3
Health
Workers
Oct
March
2015 2016
3
4
Consensus
score
Oct
March
2015 2016
3
3
Muwanga
Isingiro
Rwekubo
3
3
0
0
0
0
3
3
Nyamuyanja
3
4
0
0
0
0
3
4
Rugaaga
4
5
1
3
2
2
3
5
Source: HEPS Field Reports
V I S I T
Kiboga
Oct
2015
3
i n form a t io n :
District
M O R E
Table 5: CSC participants’ rating of the skill level of staff to deliver family planning services
F O R
The delivery of family planning services requires staff with the requisite skills set. The CSC revealed that
the consensus rating of the skilllevel of health workers either improved or remained fair between 2015 and
2016 in each of the five facilities where the variable was rated. An improved rating was recorded at Rugaaga
(from fair to very good) and Nyamuyanja (from fair to good) health facilities in Isingiro district. The perceived
improvement in the skill set of health workers at both facilities was attributed to the training provided.
W W W . heps . or . u g
1.1.5 Staff attitude towards family planning clients
The attitude of staff towards clients was rated at two health facilities (Table 5 below). The consensus rating of
health workers’ attitude improved at Muwanga HC in Kiboga district from fair to good while it declined from
good to bad. During the interface meeting for the second cycle of the CSC, one VHT member noted that he had
referred 66 clients to Ngarama HC III, but the health workers failed to attend to them and the In-charge did
not take any action when the issue was reported. At Muwanga HC, women reported that the incoming (new)
health workers are good and approachable. The same women observed that the newly posted health workers
were friendly and approachable.
Table 6: CSC participants’ rating of the staff attitude towards family planning clients
District
Kiboga
Isingiro
Health
facility
Muwanga
Ngarama
Women
Men
Oct
2015
0
2
Oct
2015
3
4
March
2016
0
2
March
2016
4
0
Health
Workers
Oct
March
2015 2016
1
4
0
0
Consensus
score
Oct
March
2015 2016
3
4
4
2
Source: HEPS Field Reports
13
The MOH recognises that guidelines and service protocols for service providers need updating (MOH, 2014).
The ministry stresses that these policy updates are necessary to strengthen counselling skills and address
provider bias and attitudes and to ensure that services are provided in accordance with human rights and
quality of care standards.
Availability of Infrastructure for Delivering FP Services
W W W . heps . or . u g
The findings of the first round of the CSC revealed that six of the 10 health facilities had space or room/
sdesignated for the provision of family planning services. By March 2016, the management of two other health
facilities (Muwanga and Bukomero in Kiboga district) had committed to partition rooms for the provision of FP
services. Muwanga HC improvised space within the maternity department. Women participants at Bukomero
HC committed to buying a curtain for partitioning the room for providing family planning services to ensure
privacy.
Table 7: Availability and Status of infrastructure for the provision of FP services
District Health
Availability of adequate infrastructure
facility
Oct 2015
March 2016
i n form a t io n :
V I S I T
Kiboga
Kambugu
The fence, FP space, and
accommodation are inadequate
No change has occurred so far
Nyamiringa
The structures
appropriate
No improvement registered.
Muwanga
There is no special room for FP
services
A resolution to purchase curtains to partition a
room for FP services was made after a meeting
between HEPS and the HC management.
Lwamata
No designated room at the HF for FP
services
The In charge of the HC committed to
participation the building to create a room for
the provision of FP services.
Bukomero
F O R
M O R E
Isingiro
are
not
very
The space is there, but not partitioned
to create separate rooms for FP, ANC,
and PNC services
Health Centre management has committed to
partition the available space.
Rwekubo
Lack of space for FP services
No action has been taken by the H/C
management
Kasana
The HC has a Permanent building
with rooms designated for FP
It’s still in a good condition
Ngarama
The health unit has enough space for
offering FP services
There is need for renovation of the building
Nyamuyanja
Rugaaga
The health unit lacks space for FP
services
The has space for FP services within
the maternity ward
No space has been allocated for FP services
The room is small and the whole building
requires renovation
Source: HEPS Field Reports
User perception of Family Planning Services
In both rounds of the CSC, negative perception of family planning services was cited by the CSC participants.
This covered myths and misconceptions, the fear of the side effects and cultural and traditional values that
undermine modern family planning methods.
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1.1.6 Myths and misconceptions on family planning services among users
The consensus score on this variable improved in four (Lwamata and Bukomero in Kiboga district and Kasana
and Rugaaga in Isingiro district) of the seven facilities where it was rated. By March 2015, the consensus score
for Bukomero was 4 and the health workers attributed this change to counselling services provided to women/
couples on family planning. However, the women’s group in Nyamuyanja HCIV in Isingiro district observed
that myths and misconceptions hinder people from utilising family services because they create fear.
Table 8: CSC participants’ rating of user myths and misconceptions on family planning services
District
March
2016
2
4
1
Men
Oct
2015
2
1
2
March
2016
4
2
2
Health Workers
Oct
March
2015
2016
1
1
2
4
3
2
Consensus score
Oct
March
2015
2016
1
2
2
4
2
1
Kasana
Ngarama
Nyamuyanja
Rugaaga
2
3
2
2
2
1
3
1
1
1
2
0
2
1
2
0
1
1
3
1
1
1
2
1
2
1
2
3
i n form a t io n :
Source: HEPS Field Reports
1
1
1
3
M O R E
Isingiro
Lwamata
Bukomero
Rwekubo
Women
Oct
2015
1
4
2
F O R
Kiboga
Health
facility
1.1.7 Side effects of family methods
V I S I T
The side effects of family were mentioned as a major hindrance to the uptake of family planning services.
The side effects identified included excessive bleeding, headache, loss of libido, obesity, and “dryness among
women during sex”. The CSC participants at Lwamata and Bukomero (Kiboga district) and Rwekubo, Kasana
and Rugaaga (Isingiro district) reported an improvement in the user perception of family planning services
because of the sensitization conducted with the support of HEPS Uganda.
W W W . heps . or . u g
Two VHT members at Nyamuyanja HC in Isingiro district mentioned that 15 and 10 women, respectively,
had enrolled on family planning after their referral.At Rugaaga HC, men noted that health workers have
sensitised people and there is increased knowledge that the side effects of family planning are manageable.
At Bukomero HC, the health workers reported that they offer comprehensive counselling on the management
of side effects.
Table 9: CSC participants’ rating of users’ fear of the side effects of family planning services
District Health
facility
Kiboga
Nyamiringa
Lwamata
Bukomero
Isingiro Rwekubo
Kasana
Ngarama
Nyamuyanja
Rugaaga
Women
Oct
2015
0
3
1
1
3
4
4
0
March
2016
3
3
3
3
3
3
2
0
Men
Oct
2015
0
2
2
1
1
0
2
3
Source: HEPS Field Reports
March
2016
3
3
3
1
3
0
0
5
Health Workers
Oct
March
2015
2016
0
2
3
3
4
4
1
1
2
2
0
1
0
3
3
3
Consensus Score
Oct
March
2015
2016
0
3
2
3
2
3
1
2
2
3
4
3
3
2
3
4
15
Despite the improved rating, it was noted that myths and misconceptions still existed and undermined the
uptake of family planning services. Women at Kambugu HC noted that the health workers seemed too busy to
allocate adequate time for counselling clients on family planning.
1.1.8 Religious and Cultural Values
Of the seven health facilities where religious and cultural values were rated, four (Kambugu, Nyamiringa and
Bukomero in Kiboga district and Rugaaga in Isingiro district) recorded an improvement in the scores during
the second cycle (Table 9 below).
Table 10: CSC participants’ rating of the influence of religious and cultural biases on the uptake of family planning services
W W W . heps . or . u g
District
Health
facility
Kiboga
Kambugu
Nyamiringa
Lwamata
Bukomero
Isingiro Ngarama
Nyamuyanja
Rugaaga
Women
Oct
2015
2
2
3
3
0
0
3
March
2016
3
1
3
4
2
3
4
Men
Oct
2015
2
1
1
2
0
0
0
March
2016
3
4
1
3
2
0
4
Health Workers
Oct
March
2015
2016
1
2
3
4
2
2
2
3
0
0
0
2
0
4
Consensus score
Oct
March
2015
2016
1
3
2
4
2
2
2
3
2
0
3
2
3
4
V I S I T
Source: HEPS Field Reports
i n form a t io n :
The recorded improvement was attributed to awareness creation. None the less, some participants pointed
that unsupportive religious and cultural values still persist. For example, a few households across all religions
were identified by health workers at Nyamiringa HC decampaigning the use of FP while male participants at
Rugaaga HC in Isingiro district cited members of the Born-again faith as those encouraging parents to produce
many children (Muzare Tukanye).
Male Involvement in Family Planning
F O R
M O R E
The consensus rating on the level of male involvement in increasing the uptake of FP services improved in
five of the 10 health facilities (Kambugu in Kiboga district and Rwekubo, Kasana, Nyamuyanja and Rugaaga in
Isingiro district) over the intervention period. However, its rating by women improved in only three facilities
(Kambugu and Nyamiringa in Kiboga district and Kasana in Isingiro district) and remained static in four health
facilities (Lwamata and Bukomero in Kiboga district and Rwekubo and Kasana in Isingiro district) as shown in
Table 10 below.
Table 11: CSC participants’ rating of the level of male involvement in Family planning
District
Kiboga
16
Health
facility
Kambugu
Nyamiringa
Muwanga
Lwamata
Bukomero
Women
Men
Oct
2015
1
2
0
2
1
Oct
2015
2
3
0
1
2
March
2016
3
3
1
2
1
March
2016
3
4
2
1
1
Health
Workers
Oct
March
2015 2016
0
0
2
2
2
2
1
2
1
2
Consensus
score
Oct
March
2015 2016
1
3
2
2
2
1
1
1
0
2
Isingiro
Rwekubo
Kasana
Ngarama
Nyamuyanja
Rugaaga
1
3
2
0
2
1
3
0
0
3
4
2
0
2
0
4
3
1
1
0
1
2
4
2
1
1
3
0
0
3
1
2
2
1
1
2
3
2
2
3
Source:HEPS Field Reports
F O R
The rating by men also showed improvement in three health facilities (Kambugu and Nyamiringa in Kiboga
district and Kasana in Isingiro district) while the rating by workers revealed a lack of improvement in any of
the facilities between October 2015 and March 2016. At Rugaaga and Ngarama health facilities, the improved
rating was because some men had become supportive of their wives’ usage of family planning. However, it
was noted at Ngarama HC in Isingiro district that men with wives on long term family methods were having
children with other women, which destabilised their marriages.
M O R E
Level of youth uptake of family planning services
Table 12: CSC participants’ rating on youth uptake of Family Planning services
Health
facility
Isingiro
Kasana
Ngarama
Women
Oct
March
2015
2016
1
1
0
0
Men
Oct
2015
1
1
March
2016
00
01
Health Workers
Oct
March
2015
2016
1
2
1
0
Consensus score
Oct
March
2015
2016
1
1
1
1
V I S I T
District
i n form a t io n :
The CSC participants at Ngarama and Kasana health facilities in Isingiro district observed that the youth uptake
of family planning services is very low. Both heath centres had a consensus score of 1 (very bad). While female
CSC participants at Ngarama HCcited fear of family planning services by the youth, men noted that the youth
are difficult to mobilise.
W W W . heps . or . u g
During the interface meeting, the CSC participants at Kasana HCattributed the low uptake of family planning
services by youth to the fear among parents to talk to their children about family planning services.
Perception of distance as a barrier to the uptake of family planning services
The distance that clients have to travel to access a health facility has a bearing on the utilisation of family
planning services. The influence of distance on the utilisation of services was rated as fair at Kasana, Ngarama
and Rugaaga heath indicates in Isingiro district, while the consensus score in Nyamuyanja was 2 (bad).
Table 13: CSC participants’ rating of distance to the health facilities to access Family Planning services
District
Isingiro
Health
facility
Kasana
Ngarama
Nyamuyanja
Rugaaga
Women
Oct
March
2015
2016
1
3
0
3
2
0
3
0
Men
Oct
2015
2
0
1
3
March
2016
2
2
1
5
Health Workers
Oct
March
2015
2016
1
2
0
3
Consensus score
Oct
March
2015
2016
2
3
0
3
1
3
0
2
0
3
2
3
The women’s group at Kasana HCIII noted that clients resident in Kyera parish move long distances to access
the only HC III in the sub county located in Kasana parish.
17
Conclusions and Recommendations
1.1Conclusions
W W W . heps . or . u g
The CSC process that HEPS has facilitated has yielded remarkable improvements at the community and health
facility level. On the demand side, the changes include increased knowledge of family planning services and
available options, changed negative religious and cultural values that dissuade users. On the supplyside, the
infrastructural setup of health facilities has been modified to create room for the delivery of family planning
services, the skills of health workers in the provision of family services has improved service provider-client
relationship has also been strengthened.
Yet, as HEPS, there are important lessons at this stage of the project. The attitudes and values of the current
and potential family planning users take time to change and require continuous engagement and dialogue.
There are also issues that require the intervention of the district local governments and central government
agencies, including MOH and NMS. Many of these issues, around which our future engagements will focus,
are captured in the recommendations herebelow.
Recommendations
i n form a t io n :
V I S I T
Based on the experience of HEPS Uganda and the findings of the community score card, HEPS Uganda makes
the following recommendations to improve access toand the utilisation of family planning services in the 10
health facilities in Kiboga and Isingiro districts and beyond.
1.1.9 To the community members
1. Rely on family planning information provided by health workers at the health facilities to reduce the risks
of being misled by non-professionals.
M O R E
2. Actively participate in monitoring the availability and quality of family planning services and give appropriate
and timely feedback to the duty bearers to improve family planning services. This includes follow-up of the
Action Plans developed after the second round of the CSC.
F O R
1.1.10To Health Centre Staff and HUMC
1. The health facility In-charges should ensure timely requisition of FP supplies and commodities to build
the confidence of the consumers of family planning services to visit the health facilitiesregularly for the
services.
2. Continue raising the awareness of community members on the benefits of FP and the available family
methods, including the management of side effects.
3. Strengthen referrals to ensure that there is a comprehensive delivery of family planning services.
4. Develop and ensure adherence to a staff duty roster, providing that at least one relevant staff is retained
to provide family services.
5. Monitor staff adherence to the health workers’ professional ethics and public service code of conduct to
create a conducive environment for the utilization of family planning services.
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SCORE CARD IN PICTURES
F O R
Men score inputs of the second scorecard in Muwanga subcounty, Kiboga
M O R E
HEPS Uganda’s Joan Kilande talks to participants in Bukomero, Kiboga.
i n form a t io n :
V I S I T
Men score inputs of the second scorecard in Muwanga subcounty, Kiboga
19
W W W . heps . or . u g
Women score inputs of the second scorecard in Muwanga subcounty, Kiboga
W W W . heps . or . u g
V I S I T
i n form a t io n :
M O R E
F O R
For More Information, Contact Us :
Plot 351A Balintuma Road,Namirembe Hill
Telephone: +256-(0)41-4270970
Email : [email protected], Website: www.heps.or.ug
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