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A case of Gulu and Luwero districts

Issue Brief on

Citizens’ Satisfaction with

Family Planning Services

Forum for Women in Democracy

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CITIZEN’S REPORT CARD ON FAMILY PLANNING SERVICES IN UGANDA is published by Forum for Women and Democracy (FOWODE) with support from the Results for Development (R4D)

© 2012

Forum for Women in Democracy (FOWODE)P.O. Box 7176, KampalaTel: +256-41-286063E-mail: fowode@fowode.orgWeb www.fowode.org

All rights reserved. No part of this publication may be reproduced, or reprinted in any form by any means without the prior permission of the copyright holder. Nevertheless, FOWODE and Results for Development (R4D) encourage its use and will be happy if excerpts are copied and used. When doing so, however please acknowledge FOWODE.

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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).

1 Rationale of the studyOne way of improving reproductive health care in Uganda is to ensure that family planning1 services are accessible and affordable. The Ministry of Health (MoH) has put in place maternal

mortality reforms which include improving family planning services. In line with these efforts, the use of modern methods of family planning has consistently increased over the past decade, growing from 14 per cent of married women in 2001 to 26 per cent in 2011 (UBOS, 2012).2 However, contraceptive prevalence rates3 are still very sparse. 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 planning4 stands at 34.3 per cent (UBOS, 2012). 43 per cent of family planning users in Uganda discontinued using the method within 12 months

1 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 2011

3 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)

Unmet need of family planning in Uganda stands at 34.3 per cent (UBOS, 2012){

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of starting its use.5 Although women want to reduce the number of children that they have, only one fifth of married women (23 percent) practice birth control due to many factors including: misconceptions about family planning; lack of information; limited access; costs; limited decision-making power on reproductive choices; and, opposition from male partners (NCG, 2012).6

As part of the efforts to address the above-mentioned challenges, the Government of Uganda, with support of donors, has made efforts to increase funding for procurement and distribution of Family Planning supplies. However, a recent study by FOWODE using the Public Expenditure Tracking Study (PETS) methodology7 showed that the utilization of Family Planning services in the five districts8 covered was very low.

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 Uganda

8 Kabale, Gulu, Luwero, Kibaale, and Kibuku districts

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.

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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.

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{ {Only 23% of married women practise birth control

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Key

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1. Access and Utilization

a) Utilization of government health facility for family planning services

Of the 690 households surveyed, 57percent, (63percent of females and 38 percent of males) reported to have visited the government health facility during the last one year for Family Planning services. Gulu reported the highest at 58 percent, compared to Luwero which had 56 percent of respondents. Fear of side side effects (such as constant bleeding, loss of weight, loss of sexual desire) and the need to have many children after the LRA insurgency (in Gulu), were noted as the main reasons for not using family planning and discontinuation. This is also consistent with the recent UDHS (2011), which showed that 43 per cent of family planning users in Uganda discontinue use of a method within 12 months 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)

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b) Type of family planning service soughtHalf (50 percent) of the combined respondents who visited the health facility sought for injectable contraceptives, followed by contraceptive implant at 20 percent, male condoms 11 percent, oral contraceptives10 percent and intrauterine device (IUD) at 6percent. Across all the age groups, injectable contraceptive are the most commonly

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preferred family planning service whereas the 51 percent of the unmarried preferred condoms 52 percent of married preferred injectable contraceptives. The choice of the family planning methods, especially by women, is influenced by the inability to be detected by the husband (for those who oppose family planning), thus most prefer injectables. Although 67 percent of males sought condoms there were other men that indicated preference for other methods such as injectables. Most people shun family planning mainly due to lack the knowledge and misconceptions about it.

c) Involvement of partners/SpousesA small percent (20 percent) of the respondents went with their partners/ spouses to the health facility for family planning services. The smallest percent was reported in Luwero (12 percent), while Gulu reported 30 percent. Only 26 percent of women in Gulu and 12 percent of women in Luwero went with the partners. Majority reported their spouses were busy or never around. 30 percent of women stated they did not go with their husbands, because they did not want them to use family planning. Thus, many women secretly use contraceptive methods. In an effort to hide contraceptive use, clients sometimes administer contraceptives in a manner that could lead to failure (Mugisha and Reynolds, 2012).

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)

“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-county

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d) Visit to other facilities for family planning services

Men tend to use other health facilities (such as private clinics, NGOs or traditional birth attendants) besides the government health facility, for family planning services compared to women. The survey shows that 56 percent of men compared to 39 percent of women had visited another health facility for family planning services. The main reasons for use of other health facilities rather than the government health facility include: closeness to where they live; no longer hours of waiting and, provision of better quality services. 20 percent used ‘self’ (bought family planning commodities from a pharmacy or drug shops), people noted that they sometimes used traditional methods of family planning.

e) Information about availability of family planning commodities

There is minimal information on availability of family planning commodities. The majority (75 percent) of the respondents did not know when the government health facility received family planning commodities. Only 31 percent of the respondents in Gulu and 18 percent in Luwero reported to have had information. By gender, men were less aware (25 percent) compared to women (20percent). For those who had information when the government health facility received family planning commodities, 40 percent got to know when they visited the facility, 23 percent through radios/TVs, and 14 percent through village notice boards and 14 percent from other village members. Thus, provision of information on family planning needs to be enhanced especially through the use of mass media such as radios and TVs.

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2. Quality and Reliability

a) Availability of serviceThe CRC revealed that Family planning services are always available. Majority (90 percent) of the respondents who visited the health facility got the service they wanted and almost all (99 percent) of the respondents who visited the government health facility for family planning services found a health worker available at the facility.

Time spent before being attended to by the health worker is critical in effective delivery of services. The survey revealed that that three-quarters (75 percent) of the respondents waited for less than one hour, 16 percent waited between 1-2 hours and 9 percent more than 3 hours. The survey further reveals that that 84 percent of the respondents received all the information about family planning service being offered from the health worker.

b) Outreach servicesOutreach activities are critical in increasing access and utilization of family planning services. However, only 11percent of the respondents reported that the health facility carried out outreach services on family planning in their villages. Gulu reported a dismal 7 percent,

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 services

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whereas Luwero reported 15 percent. Only 9 percent of women and 17percent of men reported that the health facility carried out outreach services on family planning in their villages. People noted that no outreach was done by health workers, but by some Village Health Teams (VHTs); however, they were poorly facilitated. Most outreaches were conducted by Non- Governmental Organizations such as Marie Stopes.

c) Changes in the delivery of family planning services

51 percent of the respondents reported having experienced improvement in the government health facility’s delivery of family planning services in the previous one year. However, 31 percent reported no change, 16 percent did not know, whereas 3 percent reported deterioration. By gender, 53 percent of the male respondents reported improvement, 37 percent reported no change, 7 percent did not know, whereas 4 percent reported deterioration. On the other hand, 50percent of the female respondents reported improvement, 30 percent no change, 18 percent did not know, whereas 3 percent reported deterioration

d) Recommendation to seek assistance from government health center

According to the survey data, 88 percent of the respondents reported that they would recommend someone else to the government health facility for family planning services. In Gulu 84 percent would recommend, whereas 93 percent in Luwero would recommend someone. By gender, 98 percent of females and 85 percent of males would recommend someone else to the government health facility.

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3. Problem and Grievance RedressRespondents who had problems/ issues during the visit to the health facility for family planning were few; only 21 percent reported to have had a problems. The major problems were lack of family planning commodities, impolite staff, absence of health workers and health workers asking them to pay or bribe. Despite having problems, only 8 percent of the respondents made a complaint. Ignorance, apathy and fear were the major reasons for not making complaints; whereby 39 percent did not know where to complain, 35 percent did not think anything would be done, and 13percent were afraid of making a complaint.

4. Corruption / BribesCorruption did not seem to be a big issue experienced by respondents while accessing family planning services at a government health facility. Only 7 percent of the respondents reported to have paid some money. 68% of reported to have paid for injectables and majority (90 percent) paid to a nurse while (81percent) paid to a midwife and (19percent) paid to a clinical officer.

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).

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5. SatisfactionRespondents were asked about their satisfaction using eight different indicators9. 81 percent of the respondents said they were satisfied, 17 percent were dissatisfied and 2 percent were neither satisfied nor dissatisfied. The five common reasons for dissatisfaction reported by respondents included: inadequate supplies of family planning supplies (20 percent), poor attitudes of health workers (18 percent), long waiting time (10 percent), inadequate information (8 percent), and health facility being too far (8 percent).

During Focus Group Discussions, some people said that they were not happy with the family planning services provided. They noted that Health workers did not provide adequate information about family planning; had no capacity to provide certain services like implants; could not address side effects; did not provide due diligence on the appropriate method. Some of the community concerns are genuine given the fact that some health workers lack knowledge of the latest medical eligibility criteria and practice recommendations. This lack of training and skills limited which methods they offered and limited when clients could receive methods. Many health facilities did not provide implants and intrauterine devices because they lacked trained providers who 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.

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This Citizens’ Report Card was conducted in two districts of Gulu and Luwero to measure citizens’ satisfaction with the family planning service. The report card has provided valuable feedback to improve family planning services and provides important information to guide policy makers and other key stakeholder to consider when addressing the key challenges:

6. RecommendationsIn line with the above findings, the following recommendations are made to various stakeholders to address the key challenges in effective delivery of 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,trainandfacilitatevillagehealthteams to implement family planning outreach activities.

• Promotetheuseofalternativefamilyplanningmethods with fewer side effects such as rhythm/moon beads.

• Undertakemoresensitizationonfamilyplanning through drama, theatre, etc to change people’s attitudes and behaviour.

• Recruitmorehealthworkersespeciallythosethat handle family planning issues.

• Integrateoutreachforfamilyplanningwithother campaigns such as Prevention of Mother to Child Transmission (PMCT), HIV/AIDs programmes, immunization and home hygiene etc.

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• Increasefundingforfamilyplanningeducationand advocacy.

National Medical Stores• Increaseprocurementandsupplyoffamily

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• Increaseoncommunitysensitizationand

outreach activities in a bid to popularize family planning methods at community level.

• Partnerwithrelevantpartnerssuchasvillagehealth teams, community development workers and Community Based Organizations to mobilize people to effectively participate in family planning programmes.

• Carryoutproperinvestigation/testingbeforeprovision of any family planning method in a bid to reduce side-effects

• Sensitisepeopleonthesideeffectsoffamilyplanning and how they can manage them.

• Improveonprovisionofinformationonavailability of free family planning services at

government health facilities.

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{ {Undertake more sensitization on family planning through drama, theatre, etc to change people’s attitudes and behaviour.

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Civil Society Organizations• Shouldlobbygovernmentforincreased

funding for family planning services.• Undertakecommunitysensitizationonthe

importance of family planning through the use of the mass media and community dialogues.

• Deliberatelytargetmenintheirfamilyplanning campaigns through the use of Information, Education and Communication materials and mass media

• Develophealthinformationpackagesaboutthe rights of men and their responsibilities in family planning.

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Forum for Women in Democracy (FOWODE)

P O BOX 7176, Kampala • Tel: + (256) 041 4 286063

Email: fowode@utlonline.co.ug • Email: fowode@fowode.org Web: www.fowode.org

Our VisionA just and fair society where women and men equally participate in and benefit from decision making processes.

Our MissionTo promote gender equality in all areas of decision making through advocacy, training and research and publication.