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Citizen Report Card issue brief on family planning in uganda


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Forum for Women in Democracy in 2012, commissioned a study in Gulu and Luwero districts to measure citizens’ satisfaction with Family Planning (FP) services using a Citizens’ Report Card (CRC).

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Citizen Report Card issue brief on family planning in uganda

  1. 1. Issue Brief on Citizens’ Satisfaction withFamily Planning Services A case of Gulu and Luwero districtsForum for Women in Democracy i
  2. 2. ii
  3. 3. CITIZEN’S REPORT CARD ON FAMILY PLANNING SERVICESIN UGANDA is published by Forum for Women and Democracy(FOWODE) with support from the Results for Development (R4D)© 2012Forum for Women in Democracy (FOWODE)P.O. Box 7176, KampalaTel: +256-41-286063E-mail: fowode@fowode.orgWeb www.fowode.orgAll rights reserved. No part of this publication may be reproduced,or reprinted in any form by any means without the prior permissionof the copyright holder. Nevertheless, FOWODE and Resultsfor Development (R4D) encourage its use and will be happy ifexcerpts are copied and used. When doing so, however pleaseacknowledge FOWODE. 1
  4. 4. 2 Background
  5. 5. Forum for Women in Democracy in2012, commissioned a study in Guluand Luwero districts to measurecitizens’ satisfaction with FamilyPlanning (FP) services using aCitizens’ Report Card (CRC).1 Rationale of the studyOne way of improving reproductive health care inUganda is to ensure that family planning1 servicesare accessible and affordable. The Ministryof Health (MoH) has put in place maternal { Unmet need of family planning in Uganda stands at 34.3 per cent (UBOS, 2012)mortality reforms which include improving familyplanning services. In line with these efforts, theuse of modern methods of family planning hasconsistently increased over the past decade,growing from 14 per cent of married women in2001 to 26 per cent in 2011 (UBOS, 2012).2However, contraceptive prevalence rates3 arestill very sparse. Access and usage of modernfamily planning methods remains a challenge inUganda. According to the recent Demographicand Health Survey (DHS), unmet need for familyplanning4 stands at 34.3 per cent (UBOS, 2012).43 per cent of family planning users in Ugandadiscontinued using the method within 12 months1 Family planning refers to a conscious effort by an individual or a couple to limit or space the number of children they want to have through the use of contraceptive methods.2 UBOS (2012), Uganda Demographic and Health Survey 20113 Percent of currently married women aged 15-49 using any method of contraception.4 Women who have a desire to limit their births but who are not using family planning (UBOS; UDHS, 2011) 3
  6. 6. of starting its use.5 Although women want toreduce the number of children that they have,only one fifth of married women (23 percent)practice birth control due to many factorsincluding: misconceptions about family planning;lack of information; limited access; costs; limiteddecision-making power on reproductive choices;and, opposition from male partners (NCG,2012).6 Access and usage of modern family planning methods remains a challenge in Uganda. According to the recent { Demographic and Health Survey (DHS), unmet need for family planning stands at 34.3 per cent (UBOS, 2012). Forty- three per cent of family planning users in Uganda discontinued using the method within 12 months of starting its use.As part of the efforts to address the above-mentioned challenges, the Government ofUganda, with support of donors, has madeefforts to increase funding for procurement anddistribution of Family Planning supplies. However,a recent study by FOWODE using the PublicExpenditure Tracking Study (PETS) methodology7showed that the utilization of Family Planningservices in the five districts8 covered was verylow.5 ibid6 NCG (2012), A Gender Analysis of PMTCT and related RH programs in Uganda7 FOWODE (2012), Public Expenditure Tracking Survey of Funds/Commodities for Family Planning Services in Uganda8 Kabale, Gulu, Luwero, Kibaale, and Kibuku districts4
  7. 7. The findings of the CRC study will:§ Help public health providers to facilitate open and proactive discussions on their performances;§ Empower citizen groups to play a watch-dog role to monitor public health service delivery;§ Enable the central government, especially the ministry of health, to streamline and prioritize budget allocations towards family planning and monitor implementation;§ Increase citizen awareness on family planning. Only 23% of { married women practise birth control { 5
  8. 8. 6 Key Findings
  9. 9. 1. Access and Utilizationa) Utilization of government health facility for family planning servicesOf the 690 households surveyed, 57percent,(63percent of females and 38 percent of males)reported to have visited the government healthfacility during the last one year for FamilyPlanning services. Gulu reported the highest at58 percent, compared to Luwero which had 56percent of respondents. Fear of side side effects(such as constant bleeding, loss of weight, lossof sexual desire) and the need to have manychildren after the LRA insurgency (in Gulu),were noted as the main reasons for not usingfamily planning and discontinuation. This is alsoconsistent with the recent UDHS (2011), whichshowed that 43 per cent of family planning usersin Uganda discontinue use of a method within 12months of starting its use. Responses on family planning “…people were using FAMILY PLANNING but reduced due to many side- effects.” “… family planning is not good, it causes { cancer, and loss of sexual desire” (FGD in Wabusana S/C) “… we lost so many people during the LRA war; we need to produce more now…” (FGD in Palaro S/C) “… we marry these women to produce, why family planning?” – (FGD in Awach S/C)b) Type of family planning service soughtHalf (50 percent) of the combined respondentswho visited the health facility sought for injectablecontraceptives, followed by contraceptive implantat 20 percent, male condoms 11 percent, oralcontraceptives10 percent and intrauterine device(IUD) at 6percent. Across all the age groups,injectable contraceptive are the most commonly 7
  10. 10. preferred family planning service whereas the51 percent of the unmarried preferred condoms52 percent of married preferred injectablecontraceptives. The choice of the family planningmethods, especially by women, is influencedby the inability to be detected by the husband(for those who oppose family planning), thusmost prefer injectables. Although 67 percent ofmales sought condoms there were other menthat indicated preference for other methodssuch as injectables. Most people shun familyplanning mainly due to lack the knowledge andmisconceptions about it. “You have to use family planning in secrecy since some of our husbands { don’t like it; in case they (husbands) they get to know, you have to endure the repercussions.” “…I have to go when they he is not aware; otherwise, if I tell him, he will refuse me…”FGD in Palaro sub-countyc) Involvement of partners/SpousesA small percent (20 percent) of the respondentswent with their partners/ spouses to the healthfacility for family planning services. The smallestpercent was reported in Luwero (12 percent),while Gulu reported 30 percent. Only 26 percentof women in Gulu and 12 percent of women inLuwero went with the partners. Majority reportedtheir spouses were busy or never around. 30percent of women stated they did not go withtheir husbands, because they did not want themto use family planning. Thus, many womensecretly use contraceptive methods. In an effortto hide contraceptive use, clients sometimesadminister contraceptives in a manner that couldlead to failure (Mugisha and Reynolds, 2012).8
  11. 11. d) Visit to other facilities for family planning servicesMen tend to use other health facilities (suchas private clinics, NGOs or traditional birthattendants) besides the government healthfacility, for family planning services comparedto women. The survey shows that 56 percentof men compared to 39 percent of women hadvisited another health facility for family planningservices. The main reasons for use of other healthfacilities rather than the government healthfacility include: closeness to where they live; nolonger hours of waiting and, provision of betterquality services. 20 percent used ‘self’ (boughtfamily planning commodities from a pharmacy ordrug shops), people noted that they sometimesused traditional methods of family planning.e) Information about availability of family planning commoditiesThere is minimal information on availabilityof family planning commodities. The majority(75 percent) of the respondents did not knowwhen the government health facility receivedfamily planning commodities. Only 31 percentof the respondents in Gulu and 18 percentin Luwero reported to have had information.By gender, men were less aware (25 percent)compared to women (20percent). For those whohad information when the government healthfacility received family planning commodities,40 percent got to know when they visited thefacility, 23 percent through radios/TVs, and14 percent through village notice boards and14 percent from other village members. Thus,provision of information on family planning needsto be enhanced especially through the use ofmass media such as radios and TVs. 9
  12. 12. 2. Quality and Reliabilitya) Availability of serviceThe CRC revealed that Family planning servicesare always available. Majority (90 percent) ofthe respondents who visited the health facilitygot the service they wanted and almost all (99percent) of the respondents who visited thegovernment health facility for family planningservices found a health worker available at thefacility. Factors affecting choice of a healthy { facility for family planning Distance, quality of service, waiting time and availability of health workers are key in choice of health facility for family planning servicesTime spent before being attended to by thehealth worker is critical in effective delivery ofservices. The survey revealed that that three-quarters (75 percent) of the respondentswaited for less than one hour, 16 percent waitedbetween 1-2 hours and 9 percent more than3 hours. The survey further reveals that that84 percent of the respondents received all theinformation about family planning service beingoffered from the health worker.b) Outreach servicesOutreach activities are critical in increasingaccess and utilization of family planning services.However, only 11percent of the respondentsreported that the health facility carried outoutreach services on family planning in theirvillages. Gulu reported a dismal 7 percent,10
  13. 13. whereas Luwero reported 15 percent. Only9 percent of women and 17percent of menreported that the health facility carried outoutreach services on family planning in theirvillages. People noted that no outreach wasdone by health workers, but by some VillageHealth Teams (VHTs); however, they were poorlyfacilitated. Most outreaches were conducted byNon- Governmental Organizations such as MarieStopes.c) Changes in the delivery of family planning services51 percent of the respondents reported havingexperienced improvement in the governmenthealth facility’s delivery of family planningservices in the previous one year. However, 31percent reported no change, 16 percent did notknow, whereas 3 percent reported deterioration.By gender, 53 percent of the male respondentsreported improvement, 37 percent reportedno change, 7 percent did not know, whereas 4percent reported deterioration. On the otherhand, 50percent of the female respondentsreported improvement, 30 percent no change,18 percent did not know, whereas 3 percentreported deteriorationd) Recommendation to seek assistance from government health centerAccording to the survey data, 88 percent ofthe respondents reported that they wouldrecommend someone else to the governmenthealth facility for family planning services. InGulu 84 percent would recommend, whereas 93percent in Luwero would recommend someone.By gender, 98 percent of females and 85 percentof males would recommend someone else to thegovernment health facility. 11
  14. 14. 3. Problem and Grievance RedressRespondents who had problems/ issues duringthe visit to the health facility for family planningwere few; only 21 percent reported to have had aproblems. The major problems were lack of familyplanning commodities, impolite staff, absence ofhealth workers and health workers asking themto pay or bribe. Despite having problems, only8 percent of the respondents made a complaint.Ignorance, apathy and fear were the majorreasons for not making complaints; whereby 39percent did not know where to complain, 35percent did not think anything would be done,and 13percent were afraid of making a complaint. Additional costs of family planning “it’s free to get an implant here, but when { you get a complication like over bleeding, the nurses here can’t help you, they refer you to Gulu hospital, and there you need to pay, that becomes too expensive for us” (FGDs in Awach and Bobi S/Cs).4. Corruption / BribesCorruption did not seem to be a big issueexperienced by respondents while accessingfamily planning services at a government healthfacility. Only 7 percent of the respondentsreported to have paid some money. 68%of reported to have paid for injectables andmajority (90 percent) paid to a nurse while(81percent) paid to a midwife and (19percent)paid to a clinical officer.12
  15. 15. 5. SatisfactionRespondents were asked about their satisfactionusing eight different indicators9. 81 percentof the respondents said they were satisfied,17 percent were dissatisfied and 2 percentwere neither satisfied nor dissatisfied. The fivecommon reasons for dissatisfaction reportedby respondents included: inadequate suppliesof family planning supplies (20 percent), poorattitudes of health workers (18 percent),long waiting time (10 percent), inadequateinformation (8 percent), and health facility beingtoo far (8 percent).During Focus Group Discussions, some peoplesaid that they were not happy with the familyplanning services provided. They noted thatHealth workers did not provide adequateinformation about family planning; had nocapacity to provide certain services like implants;could not address side effects; did not providedue diligence on the appropriate method. Someof the community concerns are genuine given thefact that some health workers lack knowledge ofthe latest medical eligibility criteria and practicerecommendations. This lack of training and skillslimited which methods they offered and limitedwhen clients could receive methods. Many healthfacilities did not provide implants and intrauterinedevices because they lacked trained providerswho could insert them (Mugisha and Reynolds,2012). 9 The satisfaction indicators included: provision of information about FP; distance to the government health facility; availability of FP commodities; availability of heath workers; level of privacy; waiting time; hygiene / cleanliness of health facility; and behavior of health workers. 13
  16. 16. 1414 Conclusions and Recommendation
  17. 17. 1515
  18. 18. This Citizens’ Report Card was conductedin two districts of Gulu and Luwero tomeasure citizens’ satisfaction with thefamily planning service. The reportcard has provided valuable feedback toimprove family planning services andprovides important information to guidepolicy makers and other key stakeholderto consider when addressing the keychallenges:6. RecommendationsIn line with the above findings, the followingrecommendations are made to various stakeholdersto address the key challenges in effective deliveryof family planning services.Ministry of Health• Devise strategies for targeting men to support family planning through use of mass media, community dialogue, scaling up integrated outreach services and use of fellow men as peer mobilizers.• Establish, train and facilitate village health teams to implement family planning outreach activities.• Promote the use of alternative family planning methods with fewer side effects such as rhythm/moon beads.• Undertake more sensitization on family planning through drama, theatre, etc to change people’s attitudes and behaviour.• Recruit more health workers especially those that handle family planning issues.• Integrate outreach for family planning with other campaigns such as Prevention of Mother to Child Transmission (PMCT), HIV/AIDs programmes, immunization and home hygiene etc.1616
  19. 19. • Increase funding for family planning education and advocacy.National Medical Stores• Increase procurement and supply of family planning commodities used by men, especially condoms and surgical kits for vasectomy and those used by women with fewer side effects such as moon beads and surgical kits for sterilization.Health Facilities• Increase on community sensitization and outreach activities in a bid to popularize family planning methods at community level.• Partner with relevant partners such as village health teams, community development workers and Community Based Organizations to mobilize people to effectively participate in family planning programmes.• Carry out proper investigation /testing before provision of any family planning method in a bid to reduce side-effects• Sensitise people on the side effects of family planning and how they can manage them.• Improve on provision of information on availability of free family planning services at government health facilities. Undertake more sensitization on family { planning through drama, theatre, etc to change people’s { attitudes and behaviour. 17 17
  20. 20. Civil Society Organizations• Should lobby government for increased funding for family planning services.• Undertake community sensitization on the importance of family planning through the use of the mass media and community dialogues.• Deliberately target men in their family planning campaigns through the use of Information, Education and Communication materials and mass media• Develop health information packages about the rights of men and their responsibilities in family planning.1818
  21. 21. Our Vision A just and fair society where women and men equally participate in and benefit from decision making processes. Our Mission To promote gender equality in all areas of decision making through advocacy, training and research and publication. Forum for Women in Democracy (FOWODE) P O BOX 7176, Kampala • Tel: + (256) 041 4 286063Email: • Email: Web: 20