World Health Organization Department of Health Action in Crises
PRELIMINARY SUMMARY REPORT
RESPONSIVENESS OF HEALTH SERVICES TO WOMEN’S RH NEEDS IN THE SOUTHERN AFRICAN HIV/AIDS CRISES
SOUTHERN AFRICA MULTI-COUNTRY CASE STUDY December 2005
ACKNOWLEDGEMENTS
This publication is the result of the work of country experts from Lesotho, Malawi, Swaziland and Zambia who have worked with dedication to bring to light key challenges and constraints facing women in Southern Africa in accessing health care. WHO acknowledges the work of Dr Moteetee of Lesotho, Dr Zwane of Swaziland, Ms. Jane Namasasu of Zambia and Dr. Likwa Ndonyo Rosemary from Zambia. The Africa Regional Office of the World Health Organisation (AFRO) is gratefully acknowledged for the support and supervision received through the regional adviser for gender and women’s health, the WHO country representatives in Botswana, Lesotho, Malawi, Swaziland, Zambia and South Africa including the RIASCO office in Johannesburg. The project benefited from the discussion and contribution at the sub-regional consultation meeting held in Johannesburg, RIASCO office from 21 to 23 July 2005. Thanks to Milan and the team in RIASCO office. Further acknowledgement is for the support and supervision received from the WHO head quarters team in Geneva. The work at head quarters was coordinated and supervised by the DGR, Health Action in Crises unit in collaboration with the Gender and Women’s health department. The valuable inputs and comments of advisers and peer reviewers Dr. Valerie Manda, Sinsoke, Ms Lee Heywon, Ms. Kirselback Berit and Ms.Grace Ngabirano, are equally acknowledged. Finally, WHO is grateful for the funding made available by UNAIDS without which this project would not have been conducted.
2
CONCEPTS AND DEFINITIONS
Community based Distributor A Village Health Worker or/and Traditional Birth attendant. Mourning A period prescribed by the man's family post his death. During this period the bereaved wears special recognisable clothing that she has lost a spouse. The Period may also relate to the season of death; the usual period for cessation is beginning or during winter at the end, the woman then has to go to her parental family to be cleansed
Women The term "Women" in this study includes girls
Health Facility Any institution offering Healthcare e. g Hospital, Health care or Clinic Health System Organization and Management of Health Services
Health services Services that are performed by health care professionals or by others under direction, for the purpose of promoting, protecting, maintaining, or restoring health.
Human Resource for Health All persons (trained and untrained) involved in provision of Health Care Physical accessibility: Implying the availability of health facilities, goods and services must be within safe physical reach for all sections of the population, especially vulnerable or marginalized groups, such as ethic minorities and indigenous populations, women, children, adolescents, older persons, persons with disabilities and persons with HIV/AIDS. Accessibility also implies that medical services and underlying determinants of health, such as safe and portable water and adequate sanitation facilities, are within safe physical reach, including in rural areas. Accessibility further includes adequate access to buildings for persons with disabilities. Economic accessibility Health facilities, goods and services must be affordable for all. Payment for health care services as well as services related to the underlying determinants of health has to be based on the principle of equity, ensuring that these services, whether privately or public provided, are affordable for all, including socially disadvantaged groups. Equity demands that poorer house holds are not disproportionately burdened with health expenses as compared to richer households. Information accessibility: The right to seek, receive and impart information and ideas concerning health issues. However, it also emphasises the fact that accessibility to information
3 should not impair the right to have personal health data treated with confidentiality.1 Non-discrimination: Equity of access.
1 Ibid
4 LIST OF TABLES AND FIGURES Table 1: Study population Table 2: Distribution of Sample by Study Population in Zambia Table 3: Decision-Making of Household Budget Table 4: Mode of transport to nearest Health Centre Table 5: Distance to nearest Referral Hospital Table 6: Travel cost by residence Table 7: Availability of Emergency Services Table 8: Illustration on the distribution and type of Emergency Maternity Transport used Table 9: Waiting time for ambulance in Zambia Table 10: Transfer experience in Zambia Table 11: Cost of ambulance in Zambia Table 12: Solutions for the improvement of transport system in Zambia Table 13: Range of Service provided to Women in Swaziland and Lesotho Table 14: Cross tabulation of women by urban/rural abode and where they first seek emergency obstetric care in Lesotho Table 15: Frequency distribution of purpose of visit in Zambia Table 16: Purpose of visit by clinic sessions and residence in Zambia Table 17: Distribution of women by their knowledge /perception on service availability in Lesotho. Table 18: Proportion of women antenatal care services in Zambia Table 19: Provision of emergency Obstetric Service by residence in Zambia Table 20: Proportion of women Received delivery services in Zambia Table 21: Proportion of Integrated Management of Pregnancy and Child birth in Health facilities by residence in Zambia Table 22: Proportion of women who received post natal care services in Zambia Table 23: Proportion of women who received post natal care by residence in Zambia Table 24: Cross tabulation of women` s use of FP services by ecological zones in Lesotho Table 25: Population of women received family Planning Services in Lesotho and Zambia Table 26: Family planning services received by residence in Zambia Table 27: Proportion of women Received HIV/AIDS Services Table 28: STI/HIV/AIDS services in Zambia Table 29: Provision of VCT Services in Zambia Table 30: Support Care for women with Special Needs by Residence Table 31: Distribution of women by their experience of violence in Lesotho Table 32: Cross tabulation of women by perpetrator and type of violence in Lesotho Table 33: SGBV (Domestic violence) management by residence Table 34: HIV counselling and testing for Rape victims cases in Zambia Table 35: Proportion of women Received gynae and counselling services by Residence Table 36: Nutrition services Received by Residence in Zambia Table 37: Common Conditions Refer to other Health facilities by Residence in Zambia Table 38: Availability of Radio Communication Links by residence in Zambia Table 39: Availability of essential drugs for emergency obstetric care in health facilities in Lesotho Table 40: Availability of diagnostic facilities/services in Lesotho Table 41: The distribution of human resource in health facilities in Lesotho
5 Table 42: Proportion of health providers with in-service training in STD syndromic diagnosis and treatment by residence in Zambia Table 43: Proportion of health providers with In-service trained in VCT by residence Table 44: Proportion of health providers trained in VCT by residence in Zambia Table 45: Providers Listening to Clients concerns with satisfaction by residence in Zambia Table 46: Providers response to client` s questions by residence in Zambia Table 47: Suggested improvements in service delivery for Malawi Table 48: Satisfaction with health facility visit in Zambia Table 49: Proportion of female clients with adequate privacy by residence
Figure 1: Women` s contribution to the pre-payment health scheme Figure 2: Distance to clinic by residence in Zambia Figure 3: Duration to reach the clinic by status of the road in Zambia
6 ACRONYMS
ANC Antenatal Clinic ART Anti retroviral Therapy ARVs Anti retroviral BCC Behavioural Change Communication BP Blood Pressure CBD Community Based Distribution CHAM Christian Health Association of Malawi CHWs Community Health Workers CWIQ Core Welfare Indicator Questionnaire DHMBs District Health Management Boards DS Demographic Survey FIDA Federation of Women Lawyers FP Family Planning GNP Gross National Product HHs House Holds HIV/AIDS Human Immune Deficiency Virus/Acquired Immune Deficiency Syndrome HTC HIV Testing and Counselling IEC Information Education Communication IMP Integrated Management Pregnancy IMPC Integrated Management of Pregnancy and Child Birth MGDs Millennium Development goals MHO Ministry of Health MMR Mental Mortality Rate NAC National Aids Commission NGP National Gender Policy PLWHAs Persons Living with HIV/AIDS PMCT Prevention of Mother to Child Transmission PNC Post Natal Clinics RAP Rapid Assessment Procedure REM Rapid Evaluation Methodology RH Reproductive Health SGBV Sexual Gender Based Violence SPSS Statistical Package for Social Sciences STD Sexually Transmitted Diseases STIs Sexually Transmitted Infections SWAP Sector Wide Approach TBAs Traditional Birth Attendants TFR Total Fertility Rate UNAIDS United Nations AIDS Programme UNCT United Nations Action Team UNFPA United Nations Fund for Population Activities VCT Voluntary counselling and testing VCT Voluntary Counselling and Testing VHWs Village Health Workers WCBA Women of child-Bearing Age WHO World Health Organization WPF World Food Programme
7 TABLE OF CONTENTS ACKNOWLEDGEMENTS ...... 2 CONCEPTS AND DEFINITIONS 3 LIST OF TABLES AND FIGURES…………………………………………………………………………….. 4 TABLE OF CONTENTS ...... 7 EXECUTIVE SUMMARY...... 8 Chapter one ...... 13 1. BACKGROUND AND RATIONALE...... 15 1.1 Introduction...... 15 1.2 Problem statement…………………………………………………………………………………………….16 1.3 Objectives……………………………………………………………………………………………………..16 Chapter Two...... 2. STUDY APPROACH……………………………………………………………………………………17 2.1 Study setting...... 17 2.2 Variable identification and measurement...... 19 2.3 Study design and study population ...... 23 2.4 Sampling, sample size determination and distribution...... 263 2.5 Data collection ...... 27 2.6 Data analysis and presentation ...... 27 2.7 Study limitations ….…………………………………………………………………………………………27 Chapter 3 ...... 288 3. ANALYSES OF KEY CHALLENGES TO ACCESSING QUALITY, COMPREHENSIVE, HEALTH CARE...... 288 3.1 Financial challenges ...... 288 3.1.1 Affordability of health services...... 28 3.1.2 Penalties for failure to pay………………………………………………. …. ….……………………..29 3.1.3 User fees exemption ...………………………………………………………………………………....29 3.1.4 Women’s contribution to Pre-payment health scheme…………………………………………………30 3.2 Social-cultural challenges ...... 311 3.2.1 Decision making on resource allocation...... 311 3.2.2 Socio-Cultural norms...... 31 3.2.2.1 Puberty and adolescence ...... 33 3.2.2.2 Pregnancy and Child birth...... 33 3..2.2.3 Death of spouse...... 344 3.2.2.4 Effect of socio-cultural norms on the Status of women in society and access to health care...... 344 3.3 Physical access challenges...... 366 3.3.1. Distance...... 366 3.3.1.1 Mode of transport to nearest health centre ...... 36 3.3.1.2 Average distance to nearest health centre ...... 38 3.3.1.3 Average distance to nearest 1st referal hospital offering EMoC with surgical interventions………. 38 3.3.1.4 Travel costs ...... 39 3.3.1.5 Terrain...... 40 3.3.1.6 Access to transport services for emergency obstetric care…………………………………. 45 3.4 Organizational /institutional related challenges 3.4.1 Women` s protection against SGBV under the National Legal system...... 455 3.4.1.2 Access to legal representation ...... 465 3.4.2 National Health System factors…………………………………………………………………………..48 3.4.2.1 Health legislation, policy and planning...... 49 3.4.2.2 Health services operational barriers …………………………………………………………………..49 3.4.2.2.1 Availability and comprehensiveness of RH services…...……………………………………………..49 3.4.2.2.2 Challenges in accessing specific RH services and resources………………………………………...... 53 Chapter 4……………………………………………………………………………………………………83 4. Summary of key challenges and conclusions...... 83 Chapter five ...... 87 5. RECOMMENDATIONS……………………………………………………………………………………...87 6. Sources and references…………………………………………………………………………………………90 7. Annexes………………………………………………………………………………………………………...97
8 EXECUTIVE SUMMARY
Efforts to improve women’s health in crises and post crises recovery situations lead the WHO, to propose the establishment of the “women’s health initiative” that would eventually link to a potential inter-agency global programme. This multi country study project was designed to of examining the prospects for using a service responsiveness diagnosis as a base for building better capacities for responsive women’s health services, involving a broader analysis of women’s health care provision, through the development of an appropriate instrument to assess the quality and responsiveness of health services to meet women’s health needs in crisis settings. The problem being addressed is the neglect of health needs of women and girls in crises situations through inadequate attention and inappropriate response. The health of vulnerable population such as women and girls suffers most in crisis situations, and their specific needs do not receive due attention from humanitarian and other service providers. Whilst recognising the diversity of women’s health needs, the focus of this study has been on women’ s health care needs pertaining to reproductive health, including the need to access HIV/AIDS related services based on human rights approach.
The realization of women's rights to health requires the removal of barriers interfering with access to health services, education and information, including, in the area of sexual and reproductive health. It is also important to undertake preventive, promotive and remedial action to shield women from the impact of traditional cultural practices and norms that deny them full reproductive rights2. The general objective of the study project was therefore to establish an evidence base on challenges to women’s right to health, particularly sexual and reproductive health in crises settings, with a focus also on the health consequences of violent acts against women, and HIV/AIDS related services through multi- stake holder, rapid analysis. The specific objective was to conduct specific analysis on the responsiveness of health services to women` s health needs and generate appropriate recommendations in the target countries that can be used by the UNCTS and partners for follow up programmes to improve women’s access to health care. This has been accomplished through the undertaking of country-driven case studies, by means of a rapid assessment procedure (RAP) in Botswana, Lesotho, Malawi, Swaziland and Zambia, where a combination of multistage, stratified, random sampling method was applied with considerations of country specific demographic variations. The five selected countries are characterized by the crisis scenario termed as the “Triple threat" of poverty and food insecurity, weakened governance capacity, and HIV/AIDS prevalence rates which are the highest in the world. The project also intended to capitalise on other important developments in Southern Africa that provide a potential framework to carry forward the ideas generated, beyond the limited project time.
Despite Study limitations emanating from resource constraints in terms of short time frame and limited funding that have lead to the exclusion of special groups of women such as those in prison and migrants, the case studies have yielded bounteous country specific information
2 UN Human rights Website-treaty database- document C distribution general E/C.12/2000/4
9 pertaining to the hindrances women are facing in seeking reproductive health care. Health services were found not to be responsive to women` s health needs due to the existence of the following challenges and constraints: Cost of services There is a proportion of women for whom health care costs are a major constraint to accessing health care in all the four countries. The situation is aggravated by the women’s low economic status pertaining to lack of employment and limited capacity to make decisions in resource allocation. All four countries indicted that women were required to pay fees to access health services’ with the cost varying from one country to another. Equity demands that poorer house holds are not disproportionately burdened with health expenses as compared to richer households; however the study findings are that though user fee exemptions policies exist, there are bottlenecks in the mechanisms for putting them in operation. Women lack awareness on the criteria for exemption, and for those who do, lengthy procedures deter them from pursuing the user exemption avenues. Emergency obstetric services are not included in the exemption scheme and some women who have failed to pay have been denied access to such services. Additional health care costs are incurred due to unnecessary referrals and lack of ambulance services at health facility level forcing women to use public transport services leading to high transportation costs. Socio-Cultural challenges Women’s utilisation of health services is not only negatively influenced by their inability to make decisions to seek health care and resource allocation to cover health care costs. It is equally highly influenced by myths, taboos and misconceptions cantered on sexuality and reproductive issues as well as cultural practices related to adolescence and puberty, pregnancy and child birth, and widowhood and mourning periods. Some of the practices increase women’s vulnerability to HIV/AIDS too. Physical obstacles Long distance to health facilities is another challenge facing women in accessing care, especially in Zambia where almost 2.5 % of the women were reported to live further, beyond 10 kilometres, and Malawi where forty percent (40%) of the women reported as having to travel over a distance more than 4 kilo meters to reach a health facility. The long distance/ travel factor, combined with the fact that the majority of women walk to reach health (56.5% in Lesotho, 61.3% in Zambia and 52% in Malawi), that ambulance services are limited and that most community based health facilities do not offer basic RH services such as delivery services, indicates a great challenge for women seeking access to health care. Organizational factors within the health system and health related sectors Factors pertaining to the organization and management of healthy services compromise of the accessibility, quality and comprehensiveness of health services provided to women. The key organisational challenges highlighted by this study include: ¾ Lack of clearly defined policy guidelines and Strategic Plans for reproductive health services especially adolescent’s family planning services, and women’s access to safe abortion services. Statutory guidance on sterilisation and abortion are still grey areas in Swaziland. ¾ Inadequate institutional and community based structures for addressing sexual gender- based violence in the face of high HIV/AIDS prevalence also remains a great
10 challenge to women` s health. Health services lack guidelines, protocols and referrals paths linked to the judiciary system, while the customary law does not provide for adequate physical and legal protection from violence especially by husbands, the phenomena perpetuated by intimidating, patriarchal customary laws. Women, especially those in rural settings lack access to legal aid and civic education to empower them with the knowledge of their human rights, and assist them in making informed choices in the pursuit of legal remedies leading to impunity of perpetrators. ¾ Limited range of available services located close to house holds and families is was reported as another hurdle for women seeking health care services. Certain essential services, for instance delivery/maternity care and other RH services such as HIV/AIDS related services are not provided in the localities requiring women to cover long distances in search for care. PMTC, VCT and ARV services are skewed to urban areas. For example, not all community based health facilities attend to deliveries and, despite the high prevalence of HIV (30% in adults and 42% among pregnant women); HIV testing was still limited in Lesotho. Only 2 hospitals and one health centre of the facilities in the sample were offering HIV rapid testing. Furthermore, Access to diagnostic services pertaining to cervical and breast carcinoma w documented as limited. Findings from Lesotho bring to light the fact that because of late presentation, cancer of the cervix accounts for a high proportion of referrals to South Africa. While pap smears may be done throughout the country, the quality of slides is often below standard and laboratory capacity to read a high number of slides is limited. Only 33.3% of the health facilities surveyed in Lesotho provided pap smears diagnostic examination. Cancer of the breast accounts for a high proportion of admissions to the female ward yet screening and awareness are also low. For instance, no healthy facility was offering mammography services in Lesotho. ¾ Poor quality of existing women’s health services has been reported in relation to a variety of organisational hurdles ranging from lack of clear policy guidelines, resource constraints in the form of inadequate trained health staff to manage women health services; lack of logistic supplies including transport and communication facilities for emergency obstetric cases, essential drugs, medical equipment and supplies; to poor sanitary facilities. Such organizational hurdles have resulted in restricted facility operational hours, limited range of services available, causing unnecessary referrals of patients, and/or, discouraged women from utilising health services and forcing them to seek care elsewhere including resolving to self care. ¾ Existence of service utilisation gaps, due to the existence of a combination of economic, physical, socio-cultural and operational/organisational barriers brought to light in this by this study. For instance, literature from Swaziland indicate that a substantial proportion of women (44%) deliver at home, indicating poor service utilization. All the four the countries are known to have high mortality rate with Zambia in the lead, with an estimated 800 to 1,300 per 100,000 live births in remote areas. Some available services are still under utilised for instance, emergency obstetric and delivery care, post natal care, VCT and family planning service. ¾ Lack of Gender analysis and sexual violence surveillance data within the Health Management Information System is another major problem identified in terms of monitoring women` s health services for all the countries. For instance data on the prevalence of sexual violence was hard to retrieve both from police and health records.
11 ¾ Lack of the participation of women, especially rural women, in issues pertaining to service delivery or for addressing ills that affect women` s health despite the fact that women dominate most support and home based care groups and could be PLWH ¾ Critical shortage of staff, and appropriate skills to manage reproductive health problems including HIV/AIDS related services. Findings on the availability and quality of human resource for health indicate un filled vacant posts, high ratios of patients to staff and, lack of certain competencies required for the management of RH related conditions. ¾ Negative attitude of Health providers towards women is another dimension affecting women’s seeking care. Some women expressed negative views concerning the way health providers responded to them. Lack of respect, use of abusive language by some staff (rude and irritable), lack of privacy and confidentiality, health workers not performing standard operation procedures accurately in the management of delivery care and general care, and the practice of sending patients back are some of sentiments expressed by women. PLWAS additionally complained of the lack of effective counselling skills to encourage PLWAS response to ARV treatment and long waiting time. These factors were indicated as major obstacles to gain access to treatment among PLWAS in health facilities. The maintenance of confidentiality in dealing with cases of HIV/AIDS, and issues of sexuality was found not to be conducive in health facility environments. The desire to enhance privacy was highly emphasised by women.
Recommended cross country actions have been proposed in addition to country specific recommendations (highlighted in country case study reports) are as follows: 1. Policy Review to identify inequities and development of policy guidelines related to women’s health and rights to enhance access to health and social services for women. Such actions to include: ¾ Revision of health policies as well as interventions aimed at the prevention and treatment of diseases affecting women to put into consideration significant existing socio-cultural norms and practices. For instance, men who are the key decision makers at house hold level should be more involved in the planning and implementation of women’s health services such as family planning services. Social marketing programs for instance, Information, education and communication and BCC strategies to be equipped with locally relevant messages and materials tailored to overcome conflicting health risk messages contained in local socio-cultural norms and practices that deter service utilisation and diminish the impact of health education and promotion. ¾ Amendment of existing user fee exemptions policies to incorporate patients seeking emergency obstetric care, and HIV/AIDS related services such as VCT in the category of conditions exempted cases/conditions in order to increase coverage and health care accessibility and reduce health risks leading to high maternal mortality and morbidity. Where such arrangements exist, measures should be taken to reduce the level of bureaucracy. ¾ Redefinition of policies governing reproductive health and HIV/AIDS related service delivery to adolescents including family planning and Safe Abortion Services, and, development of operational guidelines to achieve more effective interventions and improve their accessibility and user friendliness.
12 ¾ Alteration of health delivery strategies to facilitate the provision of women’s Health services as close to the families as possible through decentralisation of primary health care services including maternity and HIV services to the community level, as a strategy for the reduction of constraints that curtail women’ access to health services, such as those associated with long distance to health facilities and travel costs. ¾ Establishment, implementation and monitoring by health authorities, of minimum RH service package and standards, as benchmarks in all health facilities to ensure the provision of comprehensive services and guarantee higher quality of health services provided to women by health authorities. ¾ Formulation of clear policies and strategies to address persisting sexual gender-based violence in the face of high HIV/AIDS prevalence. This should include context specific programming to capture various practices imbedded in cultures, setting up of monitoring and accountability mechanisms to enhance co-responsibilities amongst key stakeholders, the provision of guidelines and protocols, and the incorporation of clinical management of rape in the existing national reproductive health package and in the training curricula for front line health workers. 2. Institution of effective long range strategies for the development and management of human resource for health such as retention schemes high to reduce attrition, performance management including effective reward systems and training to improve motivation and client relations, and initiatives for supporting community based health care providers. Capacity building programs for community health workers including support groups, village health workers, and traditional birth attendants should be promoted. Traditional birth attendants still play an enormous role in maternity care especially in Malawi and Swaziland. The capacity of community Support Groups- for economic sustainability, support care for PLWAS and, orphans, widows and elderly persons by gender, and victim support for sexual gender and domestic violence should be improved. 3. Empowerment of women, through expanded civic education programs for men and women, on human rights, including their right to health (care), and freedom from violence should be promoted with intensive education and social mobilisation involving community leadership structures, addressing specific issues contravening cultural norms, beliefs and practices. Country programs including those aimed at improving women’s health should be deliberately designed to actively seek the involvement of men as the majority of decision makers at house hold level, as well as ensure women’s participation on issues relevant to their health. 4. Instituting systematic improvements in basic health infrastructure, equipment, medical supplies, transport, and referral facilities including instituting community based ambulance services, necessary for the delivery of quality minimum essential package of women’s reproductive health services. 5. Conduct further research in areas related to gender aspects of health policies, strategic planning, especially focussing on resource allocation and impact of funding initiatives, health reform programs on the health vulnerable groups like women and girls. 6. Establishment of mechanisms to monitor women’s health issues such as installing surveillance systems to capture and analyse gender and problem specific data. For instance, the inclusion of SGBV indicators in the routine reporting systems and, the setting up of a women’s advocacy desk within the ministry of health to monitor women` health.
13 Chapter one
BACKGROUND AND RATIONALE 1.1 Introduction This project was the initial phase of the proposed programme “women’s health initiative” focusing on the improvement of women’s health in crises within the action of WHO. This phase was designed to examine the prospects for using a service responsiveness diagnosis as a base for building better capacities for responsive women’s health services. This involved conducting a broader analysis of women’s health care provision through the development of an appropriate instrument to assess the quality and responsiveness of health services to meet women’s health needs in crisis settings. The project is intended to contribute to the development of a potential inter-agency global programme with the goal of preserving and promoting the health of women and girls in crises and post crises recovery situations. 1.2 Statement of the problem and justification 1.2 The problem addressed is that health of vulnerable population such as women and girls suffers most in crisis situations, and their specific needs do not receive due equitable attention from humanitarian and other service providers. For instance, 1. Most women in crisis settings, especially IDPs do not have equitable access to quality health care. Despite tremendous efforts made by the different organization, gaps still exist pertaining to women` s ability to access quality health care. Recent multi-country evaluation studies of reproductive health services provided to women refugees and internally displaced persons (IDPs) by the indicate that gaps in service delivery still exist (IAWG 2004). • Severe lack of access to reproductive health services especially by IDPs needing urgent attention. In Angola, no specific services were available for IDPs who had suffered sexual violence, which was not surprising given the lack of services for other aspects of reproductive health. Lack of access to reproductive health may lead to increased morbidity and mortality among women. Reproductive illness is actually a significant public health issue. In non crisis settings, it was estimated by the World Bank that 36% of disability-adjusted life years lost for women in developing countries in 1990 was caused by reproductive illness, especially maternity related causes (HPN Paper 2004). Fortunately, many of reproductive health conditions are preventable. • Gender based violence as the most recent, least familiar and most difficulty area has the lowest coverage. Where as, recent programming trends show that relief agencies are incorporating some reproductive health services into basic health programming, programmes for gender- based violence and HIV control tend to be seen more as special, stand alone interventions. Mental health services in relation to psychosocial needs of women especially those traumatised through sexual and gender based violence are not generally provided (HPN Paper 2004). • Most humanitarian agencies lack the qualitative or quantitative tools to assess or monitor gender based violence. Under reporting is also a problem.
14 • STIs and HIV/AIDS health services provided in conflict settings, are indicated as less comprehensive and needing greater strengthening, (IAWG 2004). Programs are reported to be focussed on the ABC approach (Abstain, Be faithful and use Condoms). Few refugees have access to additional interventions such as VCT, the prevention of maternal to child transmission of HIV through the targeted use of anti-retro viral therapy among HIV-positive women and their new-borns and anti retro viral therapy for HIV positive individuals (HPN Paper 2004). • Problematic referral health services due to location transport communication and personnel (IAWG 2004). • Lack of relevant technical skills among health providers and non incorporation of community health workers such as TBA in health service provision. Most of health services are reported to be provided by humanitarian worker, whom due to pressure of work are unable to transfer skills to build the capacity of local health providers. • Shortage of logistics and supplies which equally hamper the work of service provision (IAWG 2004). 2. Health services in crisis-affected settings are often unable to adequately respond to health needs of women affected by Crisis. Women have unique health needs related to their reproductive and nurturing role and responsibilities that require them uninterrupted access to health services. Unfortunately, at times, health care systems are not sympathetic to women` s health needs. These needs are usually not given top priority in emergency settings, especially in the acute phase. In emergency situations, humanitarian programmes tend to focus on life saving operations; hence reproductive care is often not deemed a priority as part of the minimum services provided (ICRC 2004). The current sexual and gender based violence to which women fall victims to, require prompt action and urgent establishment of mechanisms to prevent its occurrence and treatment of victims to minimize health complications that follow. Women victims of sexual violence endure a wide range of health consequences including obstructed labour, sterility, incontinence, vaginal fistula and STIs (ICRC 2004) for instance, HIV/AIDS. They also suffer from mental trauma and sociological implications of sexual violence such as unwanted pregnancies, stigmatization and rejection and isolation. 3. Poor access of women to reproductive health services and the poor quality of health services in crisis settings will negate efforts to meet targets set in the MDGs as more women are caught up in crisis settings. The millennium development goal 5, Improvement of maternal health, has a target of reducing by three quarters the maternal mortality ratio between 1990 and 2015, while goal 6, of combating HIV/AIDS has target of halving and begin to reverse the spread of HIV/AIDS by 2015. Women` s health is an integral part of the overall development. Improving women` s health contributes to development both directly through the economic And social contributions of the women, and indirectly, through their contribution to the health and welfare of their families. As more and more women are being caught in crises situations, the MDGs may not be shortly realised without designing specific strategies and interventions to improve the health of women in these crises. Reproductive health is part of the right to health according to the human rights, refugee, and humanitarian laws (ICRC 2004) and reproductive health services are part of the protection obligations of states and humanitarian agencies (HPN 2004).
15 WHO has for long played an active role in the promotion of women` s and human rights, including the advocacy and endorsement of the declaration of the promotion and protection of women` s health through the international law. This advocacy backed by the Global commission on women` s health which accords particular attention to violence against women and girls and maternal mortality and morbidity, has continued and is currently reflected in the millennium development goals (MDGs) (http://www.who.int).
There is need to develop and implement a comprehensive strategy for promoting women's right to health throughout their life span in order to eliminate discrimination against women. Such a strategy should include interventions aimed at the prevention and treatment of diseases affecting women, as well as policies to provide access to a full range of high quality and affordable health care, including sexual and reproductive health services. A major goal should be reducing women's health risks, particularly lowering rates of maternal mortality and protecting women from domestic violence. The realization of women's rights to health requires the removal of barriers interfering with access to health services, education and information, including, in the area of sexual and reproductive health. It is also important to undertake preventive, promotive and remedial action to shield women from the impact of traditional cultural practices and norms that deny them full reproductive rights3.
1.3 Objectives
General objective The general objective of the study project to establish an evidence base on challenges to women’s health in terms of the responsiveness (quality, completeness and accessibility) of health services to women’s health needs in crises, particularly reproductive health in crises settings, with a focus on HIV/AIDS services and the health consequences of violent acts against women, through multi- stake holder, rapid analysis
Specific objectives were to: • Conduct specific analyses on the quality, completeness and accessibility of women `s RH services • Make available a directory/database of resources at country level • Generate recommendations in the target countries that can be used by the UNCTS and partners for follow up programmes to improve women’s access to health care.
3 UN Human rights Website-treaty database- document C distribution general E/C.12/2000/4
16 Chapter Two STUDY APPROACH
2.1 The study setting The case studies were conducted in five countries in Southern Africa which face similar concerns, namely Botswana, Lesotho, Malawi, Swaziland and Zambia. It was decided to focus on Southern Africa because it was more feasible to achieve useful outputs with limited available funds in a relatively homogenous sub-region. The crisis there being characterised by the Scenario termed as the “Triple threat” of poverty and food insecurity, weakened governance capacity, and HIV/AIDS prevalence rates which are the highest in the world. The study project was intended to capitalise on other important developments in Southern Africa that provide a potential framework to carry forward the ideas generated, beyond the limited project time. The framework has been based on recommendations of the secretary general’s taskforce on women girls and HIV/AIDS in Southern Africa which are being advanced across the sub-region. Additional stimulus also being provided by the parallel follow-work from the missions of the secretary general’s special envoy on humanitarian needs in Southern Africa (Jim Morris) and the secretary general’s special envoy on HIV/AIDS in Africa (Stephen Lewis).
Country profiles Lesotho: Lesotho` s demographic profile of that of a developing country. The Gross National Product (GNP) per capita is estimated at US $1918. The Kingdom of Lesotho has an estimated population of 2.2 million with an estimated annual growth rate of 1.9%, The population below the poverty line is 43-58%. Adult literacy is estimated at about 58% for males and 63% for females. Life expectancy at birth reduced from the previous low level of 60 years in 1996 to even lower at 52.5 years in 2001 due to the impact of the Acquired Immune Deficiency Syndrome (AIDS). It is estimated that the life expectancy at birth by 2005 is 35 years. According to the 2001 Demographic Survey (DS) the urban population is 17% of the total. Children below 15 years comprise 36% of the total population while 58% are 15 to 64 years, and 6% 65 years and above. Based on the 1996 census Adolescents (10-19 years) comprised 21% and Women of Child- Bearing Age (WCBA) 24%, of the total population, with the contraceptive prevalence rate is estimated at 30.4%, 50% of which service is through the private sector. The Maternal Mortality Ratio (MMR) is reported to have increased from 282 in the 1990s to 419 per 100,000 LB in 2001. A number of risk factors have been identified, major ones being HIV/AIDS and unsupervised deliveries. The adult Human Immunodeficiency Virus (HIV) prevalence rate is estimated at 28.9% (sentinel surveillance report 2003); the third highest prevalence in the world. The sentinel surveillance report indicates a steady increase from 4% in 1993, 9.8% in 1998, to 31% in 2002. Women are particularly vulnerable representing 57% of all adult infections. The rate among mothers attending antenatal care was 28.9% in 2003. The facility reports also indicate a rate as high as 64% among the women that received HIV testing and Counselling (HTC) and women accounted for 55% of all AIDS admissions. UNAIDS estimates that there are
17 300,000 adults and 22,000 children living with HIV/AIDS. There were an estimated 29,000 AIDS related deaths in 2003 and the 3 x 5 plan of the MOHSW estimates there are 56,000 HIV infected individuals that require ART. Malawi: Malawi is a country with an agro-based economy.The agriculture sector accounts for over 38.6 % of the GDP, employing about 84.5% of the workforce, and accounting for 82.5% of foreign exchange earnings. The projected population of Malawi based on the housing Census is estimated at 12 million with an annual growth rate of 2.0 percent. It is estimated that 51% of the population in Malawi are women, of these 42.2% are said to be in the reproductive age group. Almost all Health Care Services in Malawi are provided by three main agencies. The Ministry of Health (MOH) provides about 60%, the Christian Health Association of Malawi (CHAM) provides 37% and the Ministry of Local Government provides 1%. There is a small proportion of health services limited to urban areas provided by private companies, private practitioners and commercial companies. Health Care Resources are inequitably and inadequately distributed as only 46% of the population has access to a formal health facility within a 5 km radius and 20% of the population lives within 25km of a hospital. Health indicators are reported to have remained poor with maternal mortality at 1120 per 100,000 live births, infant mortality rate at 104 per l000 and neonatal mortality at 42 per 1000, Fertility rate is very high at 6.3 children per woman. Malawi, like other countries in the Sub-Saharan Africa, has been seriously affected by HIV/AIDS. HIV prevalence among urban adults is estimated at 23% while that of rural adults is estimated at 12.4%. The national HIV adult sero-prevalence (15-19, 20-24 and 25-49) is estimated at 14.4% (Malawi National AIDS Commission, Annual HIV and AIDS Monitoring and Evaluation Report, 2003). Estimates also show that over 720,768 adults and children have since died of HIV/AIDS related diseases between 1985 and 2004. More than half of the new HIV infections are occurring in young people aged between 15-49 years with annual deaths from AIDS in 2004 being estimated at 60,823 (NAC Spectrum AIDS 2003) . It is estimated that by the year 2010, over one million people would have died from AIDS. Swaziland: Swaziland is a small country with a surface area of 17,000 square kilometres. According to the central statistics office (CSO), the population of Swaziland is estimated at 980,722 in 1997. Extrapolating from this data the latest population estimates are at approximately 1,100,000 in 2004 based on the growth rate. The country has both private and public health facilities distributed around the country. The country’s health care delivery system is divided into three main levels namely the clinic, which is the first level of contact and a primary health care unit, the health centres (HC) and the public health units (PHU), which is the second level of contact, and the hospital, which is the last level. About 80% of the total population resides within 8 km radius of a health facility. The health care programmes in Swaziland are coordinated at the central level by the Ministry of Health and Social Welfare (MOH&SW) and at regional level by the regional health management teams. Swaziland has also been extremely affected by the HIV/AIDS pandemic. The prevalence rate among antenatal clients, as measured by the sentinel surveillance, has rapidly risen from 3.9% in 1992 to 38.6% in 2002, placing it among the worst affected countries in the world. The rapid rise has been consistent among the four regions, and is noted in urban as well as in rural areas. The worst affected age category among women appears to be the 20-29 year old,
18 although the prevalence rate among teenage girls (15-19 years) was also extremely high (32.5%). Zambia: With a surface area of 753,614 square kilometres; Zambia`s population has varied characteristics. These include, high growth rates- a considerable momentum for future population increases, high and relatively stable fertility rates, increasing mortality rates, declining life expectancy, extreme youthfulness, substantial rural to urban migration, a high level of urbanization, low population densities and uneven spatial distribution. Its population increased from 3.5 millions in 1963 to 10.2 millions in 2000. Of these populations, females constitute 50.7 percent, while for males are 49.3 percent, demonstrating that there are more females than males. The rate of population growth rate has always been high and is currently estimated at 2.9 % per annum in the last 1990-00 inter-census population period. Fertility rates have been high, though the 1992-2002 official figures indicated significant incipient decline. There are great variations in total fertility rates (TFR) between geographical settings in Zambia. It is estimated higher in the rural with a TFR of 6.9 and 4.3 for the urban. The Contraceptive rate is still low in rural settings indicating 28 percent compared to 46 percent for urban. Economic growth in recent years has been slow and living standards have been falling for the past two decades. The real GDP growth rate was 1.9% in the 1998, but now it has risen to slightly over 2 percent due to successive efforts in curbing the economic burden in the recent years. Real earnings of employees in the formal sector have declined from the index of 72 in 1980 to below 20 in 2002. The formal sector employment declined from 26.6 percent of the labour force in 1975 to below 10 percent in recent years. Unemployment was officially estimated at 22 percent in 1991 has trebled in recent years Poverty is pervasive and increasing. Gender statistics show that female-headed households are poorer than male-headed households. Child poverty is significantly evident in Zambia. Studies show that child poverty takes in different forms: orphans, street kids, working children, and children heading households. Sixteen percent of children in Zambia are orphans. Child headed households and child labour are the indicative phenomena of children in distress. Zambia has a decentralized health policy to empower districts and sub-district levels in the delivery of health services. The health reforms initiated in 1992 have involved the establishment of Central Board of Health (CBOH) and the decentralization of management functions to the district and hospital boards. The Zambian health system was designed to operate in a pyramidal fashion. There was to be doctors at all hospitals. The doctors at district hospitals would be generalists, while those at (provincial) general hospitals would in addition have a limited range of experts in general surgery, obstetrics and gynaecology, medical physicians, and paediatrician. These form a base for the provincial referral centre. Central hospitals, which are also national referral centres, have higher level specialists are available. Past declines of mortality have been reversed. The overall adult mortality estimates based on a seven –year period preceding both the 1996 and the 2001-2002 surveys are 10.9 and 14.1 per 1,000 population, which implies an increase of 25 percent for both males and females. This analysis indicates that mortality in Zambia has increased sharply over the past decades. Infant mortality is currently 95 per 1,000 live births, while under-five mortality has slightly declined to 168 per 1000, compared with 197 per 1,000 in 1996. Maternal mortality is another major challenge showing sharp increases affecting mostly the rural population. It was estimated at 202 per100, 000 live births in 1992, but now it has gained a significant increase
19 to 729, when compared with 649 per 100,000 live births in 1996. It is further known to be as high as between 880 and 1,300 per 100,000 live births in some remote areas. Average mortality rates for reproductive age 15-49 years is 14.3 deaths per 1,000 and it is estimated higher among women than men- 14.8 deaths per 1000 versus 13.9 deaths per 1000, respectively. It implies that women are at a high risk of dying when compared with men in Zambia. The life expectancy at birth has radically declined in the last two decades from 52.5 years in 1980 to 51.7 years in the 2000 period for women.
2.2 Variables identification and measurement
The principles of the “rights based approach” and the concept paper (provided in annex3) guided the identification of variables and operational indicators and, a protocol for assessing the responsiveness (operationally defined in the context of this study as accessibility, quality and comprehensiveness) of health services to women` s health needs. This subsequently, directed the formulation of the prototype assessment tools with adjustments to accommodate country variations. (Please refer to the conceptual framework below and the concept paper, variables and operational indicators in annex 1 and 4). Based on the principle of equity, emphasised in the “rights based approach” the denial of the provision of equitable health services for women in situations of crises can be considered some form of gender discrimination. Women especially those living in resource constrained settings have to surmount numerous barriers prior to accessing health care. The major goal in eliminating discrimination against women is to reduce women’s health risks, particularly lowering rates of maternal mortality and protecting women from domestic violence (UN Human right - treaty data base). While recognising the diversity of women` s health needs, based on this goal, the study narrowed its focus to the assessment of the responsiveness (access to, quality and comprehensiveness) of health services4 to reproductive health needs of women as well as traditional cultural practices and norms that deny women full reproductive rights in the area of sexual and reproductive health including sexual and gender based violence and HIV/AIDS related services. Health services (refer to operational definition) have been assessed at national, institutional and community level. Therefore, the assessment tool was also designed to measure operational variables (described in details in annex 1) related to structural dimensions of: ¾ National health systems policy and development (factors of efficiency and effectiveness of policies and strategies) ¾ Health services (availability, receptiveness, comprehensiveness and quality) ¾ Social cultural institutions/community factors (awareness, affordability, sensitivity and openness of services, and social cultural dimensions and prevalence, of sexual and gender based (domestic) violence among women.
Measurement of accessibility Within the “rights based approach” accessibility implies that health facilities, goods and services have to be accessible to everyone without discrimination, within the jurisdiction of
4 www.merrea.org
20 the state party. Based on this principal, the study set out to assess the four overlapping dimensions of accessibility, non-discrimination, economic accessibility; physical accessibility and information accessibility in the health care system (Please refer to the section on operational definitions and indicators in annex 4 for further details). Measurement of quality and comprehensiveness As indicated below, quantitative and qualitative research methods were used in assessing quality (details are provided in individual country reports). 1. Quantitative Measures of Quality Quantitative measurement of quality for instance utilized the availability of a physician; level of (physical) access health facilities; and the state of facility infrastructure, effectiveness of staff supervision and the availability of needed drugs. Between issues of infrastructure, staff supervision and availability of needed drugs, the availability of needed drugs was taken to be a quality measure than the other two measures. The higher the proxy for assessing the quality of service, the more people were willing to pay a higher value for it. For instance, in Zambia, the long waiting time patients have to endure before being served has been a source of complaints from the community.
2. Qualitative Measures of Quality
These techniques have been used to assess the subjective and attitudinal factors, which have been associated with or underlie quantitative measures of quality to provide better explanation for aspects of quantitative measures. The focus group discussions (FGDs) have been a common technique for eliciting these measures of health service quality. The following factors have been used to assess quality: a) price and income factors; b) staff attitudes; c) availability of drugs; d) payment procedures (cash and in kind). These factors determine the customer’s choice of service sought. The decision trees on health seeking behaviour are factors of ability to pay, which is in some way related to the quality of services.
21 The conceptual frame work: Figure 1: Variables and relationship links to Responsiveness of Health Service for Women: Example for Zambia
National Health Social Institution Systems Development /Community Health Service Related and policy Dimensions Dimensions Dimensions
Effectiveness /equity of Availability of national Availability of Basic Economic variables: Socio-cultural services and protection: policies, guidelines, Equipment/supplies/human variables: resources/performance audit •Economic status: Living condition/ •Cultural protocols and eligibility: monitoring mechanisms: norms/beliefs Financial resource Occupation system allocation criteria Prevention and •Gainful •Social and management of empl.opportunity Regulatory sexual and gender frameworks for •Education Decentralization based violence women protection Hospital autonomy victims Basic essential RH •Cost/penalty and SWAP package affordability of health •Male services participation in Monitoring and RH services Diagnostic facilities •Decision-making on Evaluation: women’s Access to health resource allocation health services:HIMS exemption to cost •Perceptions of poverty sharing scheme (user Drugs/ stock record level fees) and food insecurity Statutory, customary and by laws enforcement: legal, physical and social protection Physical Access Barriers:
Quality and Accessibility to H/F: Distance Responsiveness of SkilledHealth manpower/ Services in- for service facilities/ Decision making on HIMS/guidelines/IECWomen Human resource development Advocacy: choice of service capacity for women’s health preference services: Existing national and
- RH local fora/ forum for - Gender focal points women and PLWA Waiting time for participation in health Coordination and Referral referral facility service system efficiency: delivery/monitoring Contracting out health bodies services/migration of H/Ws Referral service Availability/performance policies/ambulance Access to legal of community integrated services health and social presentation: sexual and Co-operate partnership in gender violence services: women’s health services Attitudes to h/ services delivery Provision of RH services (management of Civic education •Knowledge/Performance/attit pregnancy and child udes of providers/ waiting births, FP,HIV/AIDS: time/workload VCT, PMCT,ART, HBC,CBD,IEC) in com. •Infrastructure e.g. space,
privacy, sanitary system Access to sanitary facility, safe water •Gender inequity supply, Food relief Aid
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2.3 Study design and population
The study design involved the application of a participatory, country- driven, multi- country case studies using the rapid assessment procedure (RAP) and employing a triangulation method for both quantitative and qualitative data in Botswana, Lesotho, Malawi, Swaziland and Zambia. However, the researcher for Botswana did not complete her assignment and the report for Botswana was not compiled. The design involved the application of a cross sectional descriptive study to determine the factors associated with access to quality and comprehensive health services for women.
The study population comprised of four groups of persons. These were: a) Women (non user and users of health facilities, include those attending a health facility for a current episode of illnesses (preventive or curative). b) Health providers (health institutions and CHWs) c) Programme managers (i.e District Health Management Teams, Hospital directors, Central Board of Health Advisors/ Directors d) Key informants (i.e. stakeholders, decision-makers, village headmen, chiefs, ward councillors, traditional initiators and healers, representatives of District Health Management Boards (DHMBs), Hospital Management Board (HMBs), Health Centre advisory Committee and Neighbourhood Health Committees/village committee).
2. 4. Sampling, Sample size determination and distribution
A tabulation of the country case study population is presented below in Table 1. Table 1 depicts the study population in the four countries5.
Country Study population Number of Women (15- Key Health Health facilities/ study house holds 49 years) informants Providers sites Lesotho 550 573 39 Not 9 quantified Zambia 80 159 10 27 8 Swaziland Not sampled 500 ( in Not Not 5 (plus 14 study sites) focus groups) quantified quantified Malawi Not sampled 80 (exit 7 Not sampled Not sampled interviews & focus groups)
Sampling methods took into consideration multistage and stratification sampling methods for geographical residential settings, health facilities and communities by distance and ownership of health facilities.
5 Lesotho and Swaziland did not indicate the number of health workers interviewed
23 Based on the country case study approach used, considerations for country specific variations were made. Nevertheless critical variables such as rural/urban geographical locations, level of health care and age group for women were universally applied. Reference to specific country case studies should be made for details on the determination of the universe, sampling and sample size determination as these were based on country specific factors). For instance, In Lesotho the first stage comprised a random selection of three (3) of the ten (10) districts within which the enumeration areas were selected by ecological zone based on the probability proportional to population size, each enumeration area serving as the primary or first stage sampling unit, the assumption being that the respondents would be women aged 15 to 49 years, Sample size n= t^2pqdeff d^2 n= sample size t= standard normal deviate for 95% confidence limit =2 p= proportion of women that are 15-49 years (population of interest) =0.5 q= complement of p (1-p)= 0.5 deff =design effect =2 d = tolerated margin of error for the confidence limit of 95% (D= 0.05[(5%)]) The total population of women 15 to 49 years to be interviewed was therefore determined to be 661. Given the average households the number of house hold size of 5 and women aged 15 to 49 years comprise of 24% (BOS) of such house holds, the number of house holds to be visited was calculated to be 550(661/5x0.24). The average cluster size was determined to be 20 and therefore 28 clusters were required to cover the sample size of women. The second stage sampling units were selected through random systematic sampling, to a total of 20 house holds per each of the 28 clusters. Given that 25% of the population is urban the clusters were subdivided into 25% urban and 75% rural. Swaziland stratified its sample according to HIV prevalence rates (as indicated in the 8th sentinel survey) and urban vs. rural settings. Based on this criterion, two regions Hhohho (urban location with higher HIV/AIDS prevalence of 35%) and Lubombo (rural location with lower HIV/AIDS prevalence of 32.7%) were purposively selected. The formula adopted for the calculation of the sample assumed a normal distribution. The desired 95% confidence interval for this difference of 2.3% was set to be between 5% to 25% giving, a standard error of 5%. The sample size in each group was calculated using formula n= p1 (100-p1) + p2 (100-p2)/ e² 4475.7/25 = 179 women in each region. Over sampling was done to yield a total of 500 women. Second stage sampling was the systematic random selection of enumeration areas where study sites were finally picked. Exit interviews and focus group discussions were conducted form the health facilities and in communities.
24 Zambia In Zambia, the stratification was according to geographical residential settings, health facilities and communities by distance and ownership of health facilities (i.e. public sector, mission or private) to form basis for comparison purposes. Assessment of women’s health services was to be applied in three provinces representing urban and rural geographical settings, but due to limited timeframe, only two provinces were assessed. These are: Lusaka, and eastern provinces. The initial selected districts were: Lusaka, Central, and Southern Provinces. The areas were selected purposively in relation to current conditions of high prevalence of HIV/AIDS, high rates of maternal mortality and obstetric complications. Low fertility rates coupled with low contraceptive use (such as western province) and increase in gender violence incidence conditioned selection of these geographical settings (Ministry of Health 2004; CSO 2003 and 2004; LAZ 2004). The districts, which were to be assessed were as follows: a) Central province: Kabwe Urban and Mkushi rural district, b) Lusaka Province: Lusaka Urban and Luangwa rural district,c) Southern province: Mazabuka urban and Monze urban districts A sample size determination of 230 for each area to provide a total sample of 460 women for both areas, which has been calculated, based on the proportions of HIV prevalence rates for women in two geographical settings of urban (14%) and rural (6.4%) areas (ZDHS 2002:206). A precision of 95 % for power of 5% gives a confidence interval (CI) □5 to be 5% to 19%, with a standard error of 7.6. Using a comparison of two regions, where ‘□’ considers the percentage point of a normal distribution corresponding to the two sided significant level (i.e. in this case, the significant level is 5% for a normal distribution, representing ‘□’=1.96). ‘u’= 1.28 (i.e. for the power of 90 % was the probability of finding a significant result. ‘□’ was the proportion for comparison of two proportions to estimate a sample size for each group. Urban area of Zambia gave a proportion of HIV infection rate of 14 percent in women, while it was 6.4 percent in rural area. The sample size was thus calculated as: N = (u + )2 P1(100-P1)+ P2(100-P2) = (1.28+ 1.96)2 x 14 (100-14) + 6.4 (14-6.4)2 (P1-P2)2
= 10.5x1204 + 599.04 ------= 229.2 - to nearest sample of 230 in each group of geographical setting (7.6)2 The main sample therefore constitutes 460 women was evenly distributed between two different residential settings (i.e. 230 urban and 230 rural). It was estimated that in each district a total sample 115 would be achieved. Out of 460 women for both urban and rural areas, half of the sample was to be obtained in health facilities, while the other half is recruited from communities. Health facility sample was unevenly distributed due to unequal distribution of these facilities (i.e. 6 hospitals versus 8 health centres/clinic for frontline health care). The distribution to be 30 for referral hospitals to give a distribution of 5 clients per hospital, and 200 from health centres would provide 25 respondents recruited from each health centre/ clinic. However, a health facility sample was only 79 women, 27 health providers, and 8 record reviews to give a total of 114.
25 Community sample of women was evenly distributed. A total of 12 communities were stratified according to distance from the nearest health facility. Twenty women were selected from each community/village. Considering that there were variations in size of community population, it was estimated that and 10 households would form a rural village setting. Based on this assumption, it was estimated that a total number of 120 households (HHs) would be required to achieve a sample of 230 women. It gave a sample of 1-2 respondents to be recruited at a HH level for a sampled village with 10 HHs. There were only 80 women out of 230 recruited from 6 communities. The distribution of health institutions was organized according to ownership and type of facility. These were 1st referral hospital (4), 2nd referral hospital (1) 3rd referral hospital (1) and Health centres (8) to give total of 14 institutions. By ownership, there were GRZ (10), Private sector (2) and mission (2). However, the required sample was affected by the limited time for study, which means that data was only collected from two districts out of four districts. Table 3.4 shows the distribution of actual and estimated samples according to study population for urban and rural districts. Table 2: Example of Sample size distribution: Zambia
Study Population Required Sample Actual Sample Women 460 159 * Key Informants ( including Program managers) 36 36 Health providers 52 27 Record Review 16 8 Total 564 204
Malawi In Malawi, of the 710 sample size derived using Epi Info sampling software, only 80 were conveniently selected for exit interviews. The rational for this selection was the perceived resource constraints in terms of funding.
2.5 Data Collection and Analysis In addition to the literature review and the review of legislative and judiciary; health policy and strategy document used to collect data, six different data collection techniques were used in this multi-country study to collect primary data (These are provided for reference in annex 4). These are as follows: ¾ Structured interview schedule for women in the child bearing age (15-49 yrs) in communities and health providers in health facilities ¾ Structured interview schedule for exit interviews for women who had used health facility services ¾ Semi structured interviews for programme managers and key informants ¾ Record review ¾ Health facility Checks/observation
26 ¾ Focus group discussions for women in communities and health facilities However, inter country variations existed. For instance, health facility checks/observations were not conducted in Malawi and Swaziland.
Pilot study Prior to data collection, assessment tools were pre-tested within a small sub-sample in non- study areas and accordingly modified to be suitable for the respective population. The purpose of the pre-test was to ensure the practicability and face validity of the tool (details are provided in individual country case studies). Ethical considerations In view of the fact that the study involved collection of sensitive information, ethical considerations were taken by each individual researcher. Permission was obtained from relevant national scientific research regulating authorities, management of health institutions. Researchers obtained the consent of community leaders, house hold heads and individual respondents following adequate explanation on the study objectives, and assurance of confidentiality and anonymity prior to data collection. Trained research assistants were used in the data collection process.
2.6 Data analysis and presentation In general, data analysis employed the application of descriptive statistics and use of statistical tests, such as chi-square tests to determine associations between different variables. Data processing and analysis was facilitated by the use of locally available computer soft ware. For instance Zambia and Swaziland had computer assisted analysis using statistical package for social science (SPSS) 11.0 software was used, to process and analyze data including for some qualitative data which were categorized and quantified for analysis. A different computer program Epi Info 3.3 was used for by Malawi and Lesotho. (Details on this aspect can be accessed in individual country case studies).
2.7 Limitations The case study approach employed in this multi-country study was instituted following assumptions of funding limitations. Based on this approach multiple variables have been measured to effectively assess the key challenges women face in accessing health care, however, some variables were not measured by some countries (as already highlighted in the item 2.4 on data collection). This has therefore limits the scope for making inter-country comparisons in certain areas, for instance the quality of RH services. Furthermore, due to the reason of constrained resources especially limited time framework, the sample excluded special groups of women such as those in prison and migrants. However, focus groups of women living with HIV/AIDS were conducted. More time was also required to accommodate country procedural delays such as approval of the study by country research authorities. The wide range of study population and varied mixed research methods demanded more financial resources and time to achieve the study objectives.
27 Chapter 3 ANALYSES OF KEY CHALLENGES
3.1 Financial challenges
3.1.1 Affordability of health services and women’s economic status
1. Cost of user fees The finding from the study is that there is a proportion of women who are unable to afford health service user fees. All four countries indicted that women were required to pay fees to access health services’ with the cost varying from one country to another. The majority of women are not employed.
In Lesotho the main sources of health care for women were the health centre (55%) and (hospital 40 %) and all sites visited charged for health services. Among the women who had sought for emergency obstetric care at either the hospital (48.6%) or from the health centre (34%), 6.6% indicated they were not able to pay for the services. For general curative services, of the 543 women who had ever sought health care, the majority indicted they had paid less or equal to M20 (local currency) and 93% of those were able to pay. For the 19 who were unable to pay the medical fees, 73.7% indicated they had no money at the time. This can be associated to the fact that only 32.1 % of women were employed. The employment was mainly in the informal sector/income generating activities such as domestic work, dress making, sale of fruits and other commodities (including alcohol).
The women who lived in urban areas were more likely to be employed (34%) as compared to those living in rural areas (25.7%). Focus group discussions and key informants indicated that it is getting harder to access health services due to poverty contributed to retrenchment of mineworkers and poor agriculture production related to crop failure due to drought. Health care expenditure competes with other priorities such as education costs for children. The indication that women would even borrow money when in need of health care supports the fact that health care costs are a deterrent to utilisation of health services for women.
In Zambia It has been found that 65% of the women are able to afford low cost user fees for health services, but the ability to afford high cost services ranging from ZK 10, 000 to above ZK 20, 000 ( local currency) is limited to minimum distribution of 2.5% to 6.3%. Additional payments would also be required for investigations as indicated by 26.6% of respondents. The assessment of economic activities of women in Zambia depicts that the majority (61.3%) are engaged in small scale farming, business venture, or employed. Only 12.5% of the women were in regular employment indicating that the low participation of women in income generating activities, a phenomenon that contributes to women’s low economic status and subsequently there inability to purchase health services.
The situation in Swaziland is that there is a standardised user fee of E 10.00 (USD1.50) required for all health services including consultation and prescriptions.
28 This user fee applies to all and is required by all government health care facilities. For the women living in poverty such as the women studied, most (70.9 % ) of whom earn their living through odd jobs and small scale income generating activities such as beer brewing, hair dressing and sale of fruits and other commodities, it may be difficulty to raise the required (USD1.50). Women in Malawi reported (during exit interviews) that the health services they had received were free. However, key informants stated that women failed to go for services as they were sometimes unable to pay. 3.1.2 Penalties for failure to pay
Women can be denied access to services due to inability to pay user fees. During focus group discussions in Lesotho women indicated that most facilities would neither offer treatment nor services. Only one of the nine visited facilities would allow patients/clients to pay later. In Swaziland, Nurses who were interviewed at the facilities reported that patients/clients were required to pay even in emergency situations. However, only one out of 10 indicated possible denial of services without payment even in emergency situations. Over 60% of the women in households in Zambia were denied treatment due to failure of payment. It therefore follows that the perception of the majority (66.3%) of women from house holds on effects of user fees on the quality of health services is equally negative, indicating that it is a bad system.
3.1.3 User fee exemptions
Among those exempted from paying user fees in Zambia, the reasons for exemption include 11.3% due to medical conditions such as high blood pressure and chronic illnesses 2.5 (prepayment through employers, 1.3 medical insurance.
In Lesotho key informants were not aware of any user fee exemptions. Health workers were the only one with knowledge of the exemption criteria. The way for user fees exemption was by through declaring a person as being destitute or poor following an assessment made by the department of social welfare. However literature (MOHSW baseline study 2000) indicates 4% exemption for the user fees for the destitute, probably following assessment by social welfare officers. The same literature highlighted the fact that a high proportion of the destitute had not utilised the nearest health facilities because of cost. Deducing from this information and the ignorance portrayed by key informants concerning user fees exemption it can be concluded that those eligible for exemption are not aware of the services. It was also noted that exemptions are limited and follow a bureaucratic system that may intimate the deserving candidates. The user fees exemption services may not be accessible to women who are usually among the majority in terms of poverty. There is no indication on any exemptions for conditions or services unique to women such as emergency obstetric conditions even though safe motherhood emphasises the provision of essential obstetric care on a 24 hour basis.
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3.1.4 Women’s contribution to Pre-payment health scheme
The problem of women’s poor contribution to the pre-payment scheme has been highlighted in Zambia and it indicates further the inability of women to afford health care costs. The pre payment scheme for health services introduced as one of the health care financing mechanisms in the health reform programs exists in Zambia. The study findings (figure 1) suggest that there is very little contribution made by women in rural areas compared to that of those in the urban. A cross tabulation analysis demonstrates a distribution of 88.9% for the urban women and 10.5% for the rural. These differential statistics, which are highly significant, illustrate differences in socio-economic status of women. Rural women are more affected by poverty due to lack of employment opportunities, and social- cultural factors. Rural women are less economically empowered compared to those in the urban and this affects their access to health services. More than half of urban women were found to be in active employment (16.5) or business venture (35%), compared to rural women who were without gainful employment and with only 5% of them with business ventures.
Figure 1: women` s contribution to pre-payment health scheme
100
80
60
40
Payment of health sc 20
Yes
0 No Percent Urban Rural
Residence
30
3.2 Social-cultural challenges
The study has brought to light a mishmash of traditional artefacts, beliefs, and practices that negatively influence women’s health seeking behaviour and expose them to other health risks such as sexual and gender based violence and risks of contracting HIV/AIDS. The determination of this variable was done by reviewing related literature and conducting an inventory of social cultural norms by obtaining community/women’s reaction to the existence of, and reasons for, socio-cultural related behaviours that inhibit access to health care.
3.2.1 Decision making on resource allocation
The capability of women to influence decisions pertaining to house hold budget may directly affect their ability to afford health care and indirectly their ability to decide to seek health care. This variable was measure in the study by estimating the proportion of women with the ability to make decisions on resource allocation supported by data for focus group discussion.
For Lesotho the proportion on household resource allocation was both partners (31.8%), the woman herself (27.4%), the husband (12.2%), and relatives (28.1%), others (0.5%). The significant relatives were members of the family, predominantly biological mother mainly for single women. The capacity of women to decide significantly increased with their level of education: primary (23.3%), secondary (21.6%), high school (37%) and tertiary (44.4%). Pertaining to frequency of decision making, most decision making was a joint one by both husband and wife (30.4%), with the least being decision only made by husband. Women who are older and had been longer in marriage also made decisions more frequently.
Table 3: Decision-Making of Household Budget in Zambia
Decision maker Frequency Percent •Self 27 33.8 •Husband 20 25.0 •Jointly, but husband makes 20 25.0 final decision •Jointly, but self final 6 7.5 decisions 3 3.8 •All family members 3 3.8 •Other, self and husband 1 1.3 •Not sure Total 80 100.0 The findings from Zambia suggest that half (50%), of women’ s decisions are made by “husband” demonstrating that “husband” is an influential person in making decisions on financial resources in both rural and urban settings. Women who make own decision
31 amounted to (33.8%), while women who make joint decision but empowered to influence the verdict were few (7.5%).
The Zambian scenario is analogous to that of Swaziland where out of the 500 women interviewed only (14%) reported that, they were responsible for decision making in their households. For the majority (45%) decisions were made by husbands. Joint decision making was reported by 25%, with father in laws (5%), mother in laws (2%), and grandmothers (5%), being reported as being influential in decision making too. It can be concluded from these findings that the majority of women do not have authority to make decisions at household level.
This implies a great challenge for women’ access to health care in that women have to bargain with their husbands for permission to seek health care, where and when to seek health care, for resources required for them to access health care such as financial resources to cover user fees, travelling cost and over the choice of services. Delay in making decisions either in allocation of money to cover travel cost and/or user fees or authorisation to travel contributed to the delay in seeking health care.
It is reported that women in Swaziland have to obtain their husband’s consent prior to the prescription of family planning methods. Such practices are detrimental to the women’s attainment of human rights. Article 25.1 of the Universal declaration of Human rights affirms: “everyone has the right to a standard of living adequate for the health of himself and of his family, including food, clothing, social and medical care and necessary social services6. Irreversible complications/damage, at times leading to death (maternal mortality) or chronic conditions/ diseases such as is commonly the case in most emergency obstetric cases referred late, may occur when decisions are delayed.
3.2.2 Socio-Cultural norms
Social and cultural norms (taboos, customs and beliefs) indirectly affecting the access of women to health care have been reported as existing in this study, with country variations in terms of the magnitude and nature. Study findings from Zambia on the prevalence of socio-cultural hurdles signify that they do exist (16.2%) but not very common (almost 80%). The incidence is similarly reported in other countries but not according to magnitude. Lesotho cited a behavioural surveillance report by Sechaba consultants that pointed out to the existence of myths and misconceptions, including taboos, about sexual and reproductive health, influenced by gender dynamics that render women less likely to seek services, if perceived contrary to the norms. Such norms therefore indirectly deter women’s utilisation of health services and thereby denying them access to health care. Service utilisation may be sought after late or never at all, due to the influence of certain existing community based norms. Social and cultural norms highlighted in this study are mainly related to sexual and reproductive events for instance puberty, pregnancy, child birth and death (especially of the sexual partner). The discussion of study findings is predominantly centred on Social and cultural norms relating to these events.
6 UN Human rights Website-treaty database- document C distribution general E/C.12/2000/4
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3.2.2.1 Puberty, adolescence
Findings of cultural teachings that are contradictory to health information and education principals have been reported (Lesotho and Zambia). These mainly included dietary restrictions for girls (and pregnant women) such as abstaining from intake of eggs for fear of early sexual maturation and increased libido or for fear of intact membranes at delivery (amniotic membranes presenting first (Lesotho). The existence of such contradictions can render BCC and IEC efforts in health education futile.
Beliefs discouraging health service utilisation were unearthed during focus group discussion in Zambia and Malawi. Such beliefs (in Zambia) included dissuasion from the use family planning services as modern methods of contraception are perceived to cause congenital abnormalities like the delivery of a lame baby with a big head, women loose sexual feelings, and discharge water during sexual act, infertility and miscarriages. These beliefs, and the cultural expectation for women to have many children may provide explanations for women’s none compliance to modern family planning methods, high abortion rates (30% of women studied have had an abortion) and high fertility rates. The total fertility rate in Zambia range between 4.3 in rural settings and 6.9 lifetime births per woman while the growth rate was estimated at 2.9% per annum in the 1990-2000 inter census population period. Fertility rate is equally very high in Malawi, rated at 6.3 children per woman. Contraceptive prevalence rates (CPR) in all the four countries are correspondingly low. For instance, CPR for Lesotho is 30.4%. In Zambia, the CPR in rural settings is estimated at 28 percent and 46 percent for urban settings. Certain religious groups (Zion in Malawi) advice against utilisation of health services as their belief is that people should seek divine power other than visit a health facility.
Some norms (taboos, customs and beliefs) encourage high risk sexual behaviour that renders women and girls susceptible to sexually transmitted infections including HIV/AIDS. For instance Swaziland reported on of a survey of school aged girls in Manzini and Lubombo regions in which almost 30% believed that women engage in sexual relations with men for economic reasons and 13.9% believed that a girl could not refuse a proposal for sex made by a man. According to the 9th HIV/AIDS sentinel sero- surveillnce report, Manzini region had the highest prevalence (42.8%) while Lubombo had prevalence of 38.1%. In another study, cited by Swaziland, research findings indicated that teen age that having relations as young as 15. Consequences of early sex initiation include early pregnancy, early marriage, Sexual Transmitted Infections, high abortion rates and increased maternal mortality. The Lesotho behavioural survey report referred to earlier in the discussion above pointed out the use of risky sexual and reproductive health practices such as dry sex, genital mutilation, and sex across age barriers including sex with virgins as a cure for AIDS. It also revealed the fact that women in fulfilment of their service role to men also sometimes apply dangerous methods of sexual hygiene under the belief that it will increase sexual pleasure for the men. Additionally, sexual related cultural practices by men such as polygamy, multiple sex partners do also increase the risk of women to HIV/AIDS.
3.2.2.2 Pregnancy and Child birth
Further socio-cultural interferences to health seeking behaviour of women were reported in the area of antenatal care service utilisation. Women reported during focus group
33 discussions in Zambia that women are culturally cautioned against early antenatal booking. Such beliefs contradict the objective of ante natal care “the early detection and treatment and /or referral of conditions that complicate pregnancy and subsequently labour or puerperium” and therefore exposes women to undetected high risky pregnancies.
They also highlighted dangerous traditional practices surrounding labour, for example the oral consumption of traditional herbal medicinal preparations to accelerate labour usually prescribed by traditional birth attendants, the preference of untrained birth attendants over skilled attendants, and the dissuasion of pregnant women especially primi-gravida from hospital delivery. Unsupervised deliveries increase the risk to maternal mortality as deviations from normal process of labour are not detected early by untrained attendants. Respondents were aware of the dangers of such practices, as they narrated how herbal medicine taken during labour can cause excessive and continuous contraction of the uterus resulting in uterine rupture. Interviews with health providers on effects of traditional belief system on quality of care show that such practices do affect maternal care and health. Almost eighty one (81.5%) of health providers interviewed in Zambia stated that women who had traditional medicine administered have ended up with complications during delivery. Traditional practices reported in Lesotho, such as wearing of special attires as per clan norms, walking with bear feet and restrictions imposed on the women’s personal hygiene embarrass the women and could discourage them from going out to seek health care during such periods.
3.2.2.3 Death of spouse
The study has noted several myths and beliefs surrounding widowhood that can not only daunt health service utilisation but also increase the vulnerability of women and girls to contracting HIV/AIDS. Incest/child defilement, widow inheritance, sexual cleansing practices have been reported to exist but not very common. The findings from Zambia show that 22.5 percent of women respondents in households indicted the practice of sexual cleansing to be common practice. Seventy per cent stated that the practice was uncommon. In Lesotho a woman in mourning has several injunctions. She is decreed not pay visits to other house holds, travel after sunset, shout even in need, sit on a chair and should abstain from sex. These particular restrictions not only, emotionally traumatise the woman due to the isolation and stigmatisation, but, also limits access to health services, physically, as she cannot travel and economically as she cannot earn a living.
3.2.2.4 Effect of the Status, roles and responsibilities of women in society on access to health care
Socio-cultural norms to a great extent determine the status of women which in turn affect their access to resources and services. Focus group discussions (Swaziland) and interviews with key informants (Malawi), for instance, drew attention to the fact that women’s heavy domestic roles and responsibilities of child rearing and providing care for the sick and elderly reduce their time for productive activities and their ability to seek health care. The indication of the patriarchal dominance in decision making and resource allocation has been made by Swaziland, Lesotho and Zambia. According to the WILSA
34 report cited by Lesotho, men are culturally accepted to control decisions related not only to public life but also to sexual and reproductive decisions.
In Swaziland a combination of patriarchy and preference of the protection of group rights over those of individuals is said to create an environment conducive to the marginalisation of women and violation of their human rights. It is reported that married women in Swaziland remain legal minors despite the age. Under the marriage Act number 47/1964 women married under civil marriages “in community of property” remain legal minors because of the marital power of their husbands, which entitles men as the head of the family and the wife’s position as a perpetual minor.
Findings from Zambia correspondingly signify that customary law is principally based on a patriarchal system. It is reported that there are, under customary law, many cultural and traditional practices such as polygamy and women’s lack of land rights that systematically subject women to male domination even in matters of sexuality and reproductive rights.
In conclusion, this study has revealed the existence of, and described socio-cultural norms that indirectly inhibit the ability of women to accessing health care. This occurs by means of denying them the right information through misconceptions; denying them appropriate resources such as time and money, and right to seek care and protect themselves from known health hazards such as STIs including HIV/AIDS. Study findings concur with the findings cited by Lesotho7 previous studies which noted that sexual and reproductive beliefs and practices appear to be strongly influenced by the existing gender relations that are marked by a lot of inequality.
7 Kimane et al 1999, The behavioural survey report by Sechaba consultants for the ministry of Employment and labour
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3.3 Challenges to physical access According to Article 12.2 (a), the right to maternal, child and reproductive as indicated in the Human right “ the right to the highest attainable standard of health”, the provision for the reduction of the stillbirth rate and infant mortality and for the health development of the child may be understood as requiring measures to improve child and maternal health, sexual and reproductive health services, including access to family planning, pre- and post-natal care, emergency obstetric services and access to information, as well as to resources necessary to act on that information(1) For many women especially to those living in resource constrained environments access to services indicated in the declaration is still far fetched due to physical barriers they have to overcome. Health facilities are usually inappropriately located and not easy to reach due to several factors. This study set to determine existing physical barriers women face in accessing health care and assessed variables such as distance covered to seek care primary health services, including mode of transport, transport costs, terrain, community emergency mobilisation of transport for emergency obstetric care.
3.3.1 Distance The variable of distance was analysed by gathering the reactions and opinions of women through household interviews, interviews with health care providers, focus group discussions and key informants pertaining to distance to the nearest health centre; the nearest first referral hospital; and distance to a referral facility offering emergency (including surgical) obstetric services. The findings were as follows:
3.3.1.1 Mode of transport to the nearest primary health centre The findings on the most common mode of transport for women seeking health care in Malawi, Lesotho and Zambia were footing. The second common mode of transport was the use of public transport. The majority (56.5%) of women in Lesotho walk to the nearest health centre to seek care. 42.2% use public motor transport. A few 0.4% use horses and 0.9% use other means. In Zambia the majority (61.3) of women walk to the nearest health centre with little variations between those living in the urban settings (63.3%) and rural settings (55.0%). Almost (29%) use motor transport, with a few (10%) cycling. Similarly, findings in Malawi indicate emanating from exit interviews with women (patients/clients) indicate that 52% of them had walked to the health facility. Twenty four percent (24%) had travelled by public motor transport where 21.5% as used bicycles while 2.5 came by motorised cycle. On the other hand women in Swaziland mainly (80%) use motor transport with 5% of using private cars), with a few using other means like walking (5%). From these findings it can be concluded that women commonly walk to seek primary health care services8. Another common means of travel to health centre is by public motor transport. This implies that to achieve equitable accessibility of women to health services, services should be located within safe physical reach if possible within the reach of their localities to reduce on the burden of walking and cost of transport.
8 Caution should be taken in making comparisons due to small sample size.
36 Table 4: Mode of transport to the nearest primary health centre
Country By foot Motor transport By horse Bicycle Motorised cycle Other means Lesotho 56.5%) 42.2% 0.4% 0.9%
Malawi 52% 24% 21.5% 2.5%
Swaziland 5% 85% 5% Zambia 61.3 29% 10%
3.3.1.2 Average (mean) distance to the nearest health centre Even though the indicators were computed differently by countries, for instance, Lesotho and Swaziland calculating distance in terms of hours (time taken to reach the facility) whilst Zambia and Malawi used units of kilometres, the results highlight the fact that there is a large proportion of women who have travel distances of over four kilometres or take more than two hours to reach the nearest health facility. The situation was more critical in Zambia and, Malawi where more that 40% of women are affected, perhaps due to population dispersion over large land masses. The findings in Lesotho were that the majority of the respondents (73.8%) took less than an hour, (25.5%) took one to two hours, and 0.7% took three to four hours. For the minority (0.7%) who took three to four hours, the respondents (0.7% ) were located in the foothills, Sengu valley and (1.4% ) and the rural areas 0.3%. The Sengu valley lies within the mountains and both with the foothills area are predominantly rural. As for Swaziland, fourteen percent (14%) reported that the clinics were quite close to their residence, as they took less than one hour to travel. Fifty two percent (52%) reported that it took them about an hour and according to them the distance was acceptable. Nonetheless, for the remaining (34%) women, the location of the health facility (hospital and health centre) was reported to be difficult to reach as it took them two hours or more to reach. Forty percent (40%) of the women in Malawi were reported as needing to travel over a distance more than 4 kilometres to reach a health facility, with the majority 42.5% having to cover a distance of one to four (1-4) kilometres, only 17.5 % lived within a radius of less than one kilometre to the nearest health facility. The findings are close to those highlighted in literature. According to the literature (MOH, report) cited in the report, only 46% of the population in Malawi has access to a formal health facility within a 5 km radius and 20% of the population lives within 25km of a hospital. Almost 2.5 % of the women in Zambia were reported to live further, beyond 10 kilometres. This population consisted of women living in the rural areas. Fifty one percent (51%) live far (6-10 kilometres), while forty six percent (46%) live near (0-5 kilometres) to the health centre.
37
Figure 2: Distance to clinic by Residence in Zambia
60
50
40
30
20 Residence 10 Urban
0 Percent Rural Near-0-5kilometre ra Furthest-above 10 km Far-6-10kms radius
Distance to Clinic
3.3.1.3 Average (mean) distance to the nearest first referral hospital offering emergency obstetric care (including surgical interventions)
The estimation of women’s accessibility to first referral services indicate that for the same mode of transport in Lesotho, the health centre was less than an hour away for (60.3%), one to two hours for 38%, and three to four hours for 1.8%. In Zambia, interviews with health care providers show variation in distance in kilometres from a primary level of care (health centre) to a 1st referral hospital (refer to the findings in table 5). Among a sample of 27 health workers interviewed, 33.3 percent state health centre as situated less than 10 kilometres from the nearest 1st referral hospital, while others state as being situated between the range from 10 to 15 kilometres from the nearest referral hospital, with a proportion of 30 percent. Those with a distance range from 16 to 20 kilometres and above 20 shows a distribution of 11.1 percent and 7.4 percent, respectively. However, 22.2 percent of health providers were not sure of distant coverage from nearest referral hospital. Generally, the findings show that distant to 1st referral hospitals is long, and exceeds the standard range of 5 kilometre radius for accessing quality health services at health facilities. The probability of women dying during referrals or transfer cannot be underestimated in such situations. In order to demonstrate the reality of distance situation in relation to these statistics, it provides a distribution of 33.3 percent health centres or clinics being nearer to referral hospitals, while the bulk of other primary health facilities, above 48 percent, as situated furthest from the nearest referral hospitals. This exposes women at high risk of health consequences that are affected by long distance, mode of transport and cost of transport services in some referral conditions as it will shown in other findings.
Malawi and Swaziland had combined the health centre assessment with that of the hospital (both under distance to health facility).
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Table 5: Distance to nearest first referral hospital in Zambia
Distance to Nearest 1St Referral Hospital Frequency Percent < 10 Kilometres 9 33.3 10- 15 Kilometres 7 25.9 16- 20 Kilometres 3 11.1 Above 20 kilometres 2 7.4 Not sure 6 22.2 Total 27 100.0
3.3.1.4 Travel cost Zambia had further explored other indicators to physical barriers, travel cost involved when women travelled to their nearest health facilities and to the obstacles related to the terrain. Findings were that there is a difference in the affordability of cost travel between the residential settings (see table 6). However, most women indicate no cost involved when they travelled to their nearest health facilities in both different areas indicating 58.3 percent for the urban and 90 percent for the rural, even though the rural women are more affected than those in the urban. This may be related to the fact that the majority walked to seek care and the expended physical vigour and man hours are not costed. Among those who afforded to pay a cost of less than ZK 25,000 were more for the urban indicating 40 percent than for the rural with 10 percent. The cost of more than ZK 50,000 for transport was only evident in the urban with a minimum of 1, 7 percent, respectively. These findings show that cost of travel affects access to health services. The rural women are more affected than those in the urban due to differences in the socio-economic status between groups of women.
Table 6: Travel cost by Residence Cost of Travel Residence Total Urban Rural Nothing/no 58.3 90.0 53 cost Less than ZK 40.0 10.0 26 50,000 Above ZK 1.7 0.0 1 50,000 Total 100.0 100.0 80
2 X 6, 75, df 2, sig.Pvalue: 0.034
39 3.3.1.5 Terrain
With a view of exploring further physical barriers, as it relates to distance, terrain to cross was further assessed. The majority of women indicated not to be affected by the status of the road network. Among those who stated the road to be in good status are 83.3 percent urban, and 75.0 percent for the rural. Those who stated to be in poor condition are more in the rural with 25 percent than the urban indicating 16.7 percent. Even though there was not much statistical significant different in the road infrastructure (p value 0.408), the geographical terrain of the road seems to have effect on the rural women access to health services more than those in urban setting. Duration taken to reach a health facility also varied according to status of road, distance, cost, and mode of emergency transport. Figure 3: Duration to Reach the Clinic by Status of the road in Zambia
100
80
60
Duration taken to re 40
Less Than 2 Hours
20 2-4 Hours
not sure about time
taken Percent 0 Good Poor
Status of Road
Among those who took less than 2 hours to reach a health facility are more for those with good status of roads than those with poor condition of roads. Those who took 2-4 hours show a distribution of 58 percent for good roads and 45 percent for poor roads to reach a health facility. Among those with no idea about time could have been associated with lack of time conscious. Generally, the findings demonstrate that status of road can lengthen or shorten duration of time to reach a health facility and this affects service utilization by women especially those living in hard to reach settings.
3.3.1.6 Access to transport services for emergency obstetric care a. Availability of ambulance and/or any other community-organised transport services for emergencies Another indicator for physical accessibility explored in the study was the availability of ambulance services for emergency obstetric services. Overall, the findings were that women had little access to ambulance or organised transport services for obstetric emergences. Rural women appear to be more affected by the problem.
40 Lesotho reported that 98.9% of communities neither ambulance nor any other community- organised transport services for emergencies such as obstetric cases. Key informants were of the opinion that facilities for Emergency obstetric care were very limited. Focus group discussions further concurred with these findings indicating that even where health facilities transported a referred patient, the patient or family had to pay. A similar picture exists in Swaziland. Only 5% of the women in Swaziland cited using ambulances and only 3% of the ten health facilities studied had offered ambulance services. The other 80% with no ambulance services, patients were advised to use public transport to get to the nearest referral health facility. No data on this indicator was collected from Malawi. Additionally, the findings from Zambia equally demonstrated insufficient availability of ambulance services in communities and exemplified the problem with statistics. The percent distribution indicates 78.8 percent for those who stated “no availability” of ambulance services, compared with those who indicated “yes” for services being available in communities in both residential settings surveyed. When comparing further the distribution of responses between the urban and rural, table 4.11 shows variation in responses between these areas. Table 7: Availability of Emergency Services in Zambia
Availability of Emergency Transport facility Total Residence Urban Rural Yes 23.3 15.0 17 No 76.7 85.0 63 Total 100.0 100.0 80
The findings in table 7 show significant variations in responses between the urban and rural women. Adequate availability of emergency facilities, such as ambulance services is in the urban indicating 23.3 more than in the rural with only 15 percent. The percent distribution for insufficient availability of ambulance services is 76.7 percent for the urban and 85 percent for the rural. Even though, both areas have inadequate emergency facilities, the rural population is more at risk of dying due to expected delay to reach the nearest health facility than in the urban. For example, mode of transport for women is varied and range from on foot to ambulance service. Table 8: Illustration on the distribution and Type of Emergency Maternity Transport used in Zambia Type of Emergency Maternity Transport Frequency Percent On foot/ Walking 22 27.5 Bicycle 6 7.5 Vehicle 37 46.3 Ambulance 1 1.3 No emergency/delivered at home 14 17.5 Total 80 100.0
41
When considering the type of emergency maternity transport used in the current obstetric emergency for the last delivery, most women used any vehicle with 46.3 percent. Others walked showing 27.5, while some had used a bicycle (7.5percent) and only 1.3 percent had used an ambulance. The findings show that the emergency transport for women is either an ordinary vehicle or walking. For those who had no means of emergency means of transport had assisted delivery at home show 17.5 percent. It demonstrates that women are constrained with lack of obstetric emergency transport services in communities and affect their access to health facilities. These findings provide further explanation on high prevalence of assisted deliveries by family members in homes, coupled with increases of maternal deaths in communities. Lack of emergency transport facilities, such as ambulances, is observed to affect rural women‘s health much greater than in the urban. The need to recognize the potential use of ambulances in various communities can make a difference in women’s health status.
b. Waiting time for ambulance services Further exploration of physical barriers women face in accessing health care was done by probing on the average time taken for the ambulance to arrive at the health facility. Swaziland reported that when ambulance services were requested for by the health facility from a first referral hospital, it took approximately two hours to arrive at 40% of the health facilities and more than two hours for remaining health facilities. For Lesotho the estimation could not be indicated as such services were almost non existence. As reported above, 98.9% of communities in Lesotho had neither ambulance nor any other community-organised transport services for emergencies such as obstetric cases. The majority (81.3%) of women did not know time taken for ambulance to arrive since only 1.3 percent had used an ambulance. However, some of those who indicated waiting time show a distribution from 5 minutes to over 30 minutes.
Table 9: Waiting time for ambulance services in Zambia
Waiting time Frequency Percent Less than 10 minutes 3 3.8 10-30 minutes 6 7.5 More than 30minutes 6 7.5 Don’t know 65 81.3 Total 80 100.0 c. Attitude towards emergency transport systems Household interviews with women show some negative and positive responses towards emergency transport system used for referring women to the hospital or clinics. Table 10 shows that 37.5 percent of women were dissatisfied with the type of transport used stating unhappy or feeling awful, while others felt happy in the way of how they were transported to the hospital. However, some did not recall how they felt. Those in the category of “not
42 applicable” indicating 17.5 percent are those who delivered home and had no experience with any obstetric emergency. The findings show that women are faced with difficulties in accessing health services when faced with severe complications, especial maternal complications. Provision of ambulances is essential for women’s health services in communities. The main reasons stated for dissatisfied with transfer experience are associated with: • Long distance, awkward roads and no money (20 percent). • Difficult to walk, painful labour and seasonal variation, especially in the rain (16.3 percent); and • Taxi sitting space small and hard or uncomfortable (2.5 percent).
Table 10: Transfer experience in Zambia
Responses to Transfer Experience Frequency Percent Unhappy/awful 30 37.5 Happy 28 35.0 Don’t know 8 10.0 Not applicable 14 17.5 Total 80 100.0 The findings demonstrate a careful consideration for better transport facilities for women to be introduced in communities to enhance access of women to quality health services. Distance coupled with bad roads and poor economic status feature more as physical barriers than other reasons stated. d. Affordability of ambulance Cost Cost of ambulance services is found to affect women’s access to emergency transport facilities, particularly for the urban population. According to Lesotho findings obtained through focus group discussions, the costs to get to hospital through transfer by hospital ambulance ranged from M20.00 to M70.00. Women reported the cost as being expensive. Findings from Zambia exemplified below in Table 4.11, indicate variation in cost involved for paying emergency transport services. Table 11: Cost of Ambulance services in Zambia Cost of Ambulance Frequency Percent No cost involved 51 63.8 < ZK40,000.00 19 23.8 ZK40,000- 80,000.00 5 6.3 Above ZK80,000.00 2 2.5 Not sure 3 3.8 Total 80 100.0
43 These findings indicate that quite a high percent (63.8 percent) of women do not pay for ambulance service probably due to the fact that they walk to health facilities. Almost 32.6 percent are involved in payment of ambulance services. The distribution of cost shows a range from less than ZK 40,000 to over ZK80, 000 in some situations depending on the distance. A proportion of 3.8 percent is not sure of the cost. These findings demonstrate that cost of ambulance is high as most women are faced with poor economic situations. The fact that most women do not pay for ambulance services demonstrates inability to afford payment for services. Cost of ambulance seems as being affected by ownership status, particularly in urban settings. Ambulance services are provided mainly, through the government and private sectors, with little contributions from communities. The findings show a distribution of 17.5 % government and 18.8% for private sector. Private sector shows greater involvement in the provision of ambulance service than the Government. It is, therefore, expected in this situation to assume a high cost service from the private sector, when compared with those for the government. Cost of ambulance and ownership has great effect on women’s risk conditions resulting in severe consequences in communities. e. Suggested Solutions for Improvement of Transport System
The findings demonstrate that women are severely constrained with inadequate transport facilities that are coupled with long distance and cost to access health services. However, anxieties of women over transport system in their locality assisted in obtaining suggested solutions for improving transport for women. Table11 provides possible solutions for improving transport systems for women.
Table 12: Solutions for Improvement of Transport System in Zambia
Solutions for Transport Systems Frequency Percent Provide ambulances for Pregnant women in Labour/oxcart 36 45.0 Community to meet and mobilize transport services for women 1 1.3 Build clinics (health posts) near-by. 6 7.5 Road Maintenance 1 1.3 Ways to secure transport, such as transport scheme 3 3.8 No suggestions/no idea 33 41.3 Total 80 100.0
The findings in table 11 show that women advocate for more provision of ambulance service for pregnant women, especially those in labour, with 45 percent. Other possible solutions include building clinics, such as health posts within the domain of communities, introducing transport scheme in health facilities, especially in health centres, with a minimum proportion for community transport mobilization and road maintenance. Even though this variable was not assessed in other countries, the suggested solutions apply to other countries since women face similar obstacles in accessing transport services for emergency obstetric care.
44
3.4 Organizational/institutional related challenges
In addition to economic, socio-cultural and physical barriers, the study has exposed organizational barriers that equally diminish the access of women to health services. These relate to gaps in the national legal system, national health policies and strategies, and the health system (organization and management of health services). Within the health system barriers related to ineffective legislation, policies and planning; administrative and procedural impediments; technical and human inefficiencies; and logistic huddles such as inadequate supply of essential drugs, materials and equipment that have effect on the access of women to health services have been revealed.
3.4.1 Women` s protection against sexual and gender based violence under the National Legal system All the four countries have reported on the existence of a dual system of law, the customary/traditional and the statutory laws within the legal system. Advances made towards the achievement of gender equality through the ratification and integration into national laws of beneficial international instruments has been reported to be negated by customary laws which rationalises and legitimates gender inequalities9. The findings indicate that patriarchal values and ideologies contained in the customary law, (which is commonly known and widely applied), makes it insensitivity to the plight of women and perpetuates the existing gender inequalities which negatively influence the access of women to health to health services, and increase their risk to sexual and gender based violence (especially violence by intimate partner) and STIs including HIV/AIDS. For instance, it is reported that under customary law, women in Swaziland are regarded as minors passing from the control of their fathers or eldest family male to the custody of their husbands. Under the same law, the only property that a woman can own is cattle acquired upon marriage, or her earnings and other property acquired through her own work. Additionally, women are obliged to obtain their husband's permission or that of the male family member before doing things, including seeking health care for themselves or their children. This practice limits the woman's access to health care through lack of decision making authority or inability to afford health care services due to poverty. This finding may also explain why women's sexual and reproductive health is undermined, and also help explain the reason that in Sub-Saharan Africa, where HIV infection rates are highest in the world, condom use is lowest, at one percent (1%) among married couples. The prevalence of women's lack of empowerment is further cited in Zambia, where the customary matrimonial law tolerates a man having several sexual partners or wives, and his wife will not be granted divorce petition on these grounds. Hindrances for women’s attainment of human rights were also identified within the existing statutory law. Malawi and Zambia reported of the overt forms of gender discrimination such as the lack of full enforcement of the "Interstate Succession act" commonly known as the law of inheritance meant to protect widows from the ritual of property grabbing following the death of the spouse. The ritual of property grabbing decreases the economic status and therefore their inability to afford health care services, both for themselves and their children.
9 Towards improved leadership for women` s empowerment in Africa 1999
45 The insensitivity of the law to the plight of women equally perpetuates the silence or under reporting of sexual and gender based violence and subsequent impunity of perpetrators. A report from Lesotho indicates that the legal system is not user friendly for women. It shows that the higher the hierarchy, the more intimidating in terms of the language, procedure and male dominance.
3.4.1.2 Access to legal representation The study, furthermore explored the existence of physical and legal support by ascertaining the access to legal representation in matters pertaining to sexual and gender based violence available structure for female protection. The findings obtained through both literature review and, interviews with women from all the four countries indicated the existence of violence against women (refer to number 11 under item 3.2.2.2 ). Lesotho, Swaziland and Zambia reports depict the availability varied forms of physical protection and legal assistance. The Community Police system in Swaziland was cited as one method of providing physical and legal protection. The structure of community Police emerged as an extension of the law, which is supposed to work with Umphakatsi (chief`s residence) as well as the Royal Swaziland Police. Lesotho reported the existence of three types support in solving issues pertaining to women. These include the informal (family), semi -formal (chiefs, NGOs, Ombudsman), and the formal (courts hierarchy). It also highlighted the fact that a lot of the formal structures are based in towns and the capital, rendering them inaccessible to the majority of women. The same situation exists for Malawi and Zambia. The costs for accessing formal courts were reported as exorbitant and unaffordable for an ordinary woman. In Zambia, a legal aid department exists for women, but is reported as being ineffective and not decentralized too. Nevertheless, a number of institutions have also been established. Such include the actions taken by NGOs to promote women’s right and access to legal and social protection. These are taken in forms of sensitization of the police force and the legal fraternity. A number of institutions to assist female victims seeking legal redress have been established, mainly in urban areas, through Ministry of Community Development and Social Services, in partnership with the NGOs. The Women’s Legal Clinic established under the auspices of the Women’s Human Rights Committee of the Law Association of Zambia further provides free legal services to women who are not eligible to commercial legal fees. There is less access to these services to rural women. Lack of access to a supportive, fair, efficient, and effective justice system may discourage women from reporting incidences of sexual and gender based violence such as rape cases, both at health facilities and law enforcement facilities leaving women to suffer in silence without receiving appropriate care even for preventable conditions such as STIs.
3.4.2 National Health system organization and management
This study also explored to some extent factors within the health system and on going health related initiatives and policies that impact on the access of women to health care. The variables where assessed through the review of policy documents to determine gaps pertaining to access of care for women, and through personal interviews with key informants.
46 The organisation of the health system in all the four countries appear to be modelled based on the primary health care (PHC) approach as indicated in the Alma Ata declaration. The Ministries of Health (MOH) working at primary care level, secondary and tertiary care levels are mandated to provide health services. Delegation of certain roles and responsibilities to other ministries and other health actors such as the private and mission and voluntary non government health care institutions is common to all countries.
It has been gathered from this study that there exists within the countries several organisational development innovations in the quest to improve health care provision. Health sector reform programs exist at different phases in Lesotho, Zambia and Malawi. Nevertheless certain strategies, such as the cost sharing initiative meant to improve health care financing have been reported to negative impact on the health of poor populations especially women and girls whom, due to factors related to their reproductive and nurturing role are obliged to constantly seek health care.
3.4.2.1 Challenges associated with health legislation, policy, planning including resource allocation Lesotho reported that no special consideration is accorded to services targeting women. Financial resource allocation was based on the guidelines that indicate the line budget ceiling based on the history of allocations and expenditure, by the ministry of Finance. The budgeting by objective process and medium term expenditure framework (MTEF) introduced under the Health sector reform programme (HSRP) is only in its infancy. Human resource allocation is based on history and discretion of management of the MOHSW. The health sector review report 2005 in Lesotho indicates that the human resource allocation skewed to the urban setting, and persistent shortage of resources exist that negatively impact on the efficiency and effectiveness of services including women’s health services.
The National Health Strategic Plan (NHSP) 2001-2005 targets, though aimed at preventing further deterioration in terms of poverty in Zambia, still require an increase in the “pro-poor targeting” of the Plan. The Poverty Reduction Strategy Programme (PRSP) policy focussed on addressing the linkages between health and poverty, as well as the interaction between poverty trends and the health services is under implementation. Various studies show that poverty is increasing in Zambia and the lowest in the SADC region, with an estimation of 72.9 percent overall poverty in 1998. This is visible in health indicators, such under five mortality rates and the infant mortality for children of women with no education. The findings of this study concur with the findings from the above mentioned studies that imply the probability of more people as living in poverty. House hold interviews in Zambia revealed that 20% of the women have not been to school and only 12.5% are in formal employment and therefore can be concluded that they are the poor majority. Furthermore, lack of Clear Defined Policy Guidelines and Strategic Plans -for women’s access to health and social services in Zambia are found to be contributing to ineffectiveness of quality care among women. Despite the government having developed varied health and social service policies in the execution of health programmes and rights to such services, there is very little known in transformation of such policies into action and be accessible to women ‘s responsiveness. In summary, the gaps and weaknesses identified in this study during the desk analysis of national policies and plans include:
47 1. Obstacles created by the cost sharing healthcare financing schemes are linked to the limitation of access to health care. As pointed out earlier, the majority of women are not in formal employment and cannot afford to pay user fees (refer to item 3.1 on cost of user fees). The policies on user fees exemption appear to be vague, not adequately communicated, and difficult to implement in most countries. Zambia and Lesotho have reported on Policies that influence use of health services, such as cost sharing scheme/user fee policy, as not standardised to suit the needs of individuals accessing health services. In Lesotho and Zambia, user fee exemptions had few beneficiaries (refer to item 3.1.1). User fee payment varies in residential settings and between health facilities. It was further observed that health facilities lack guidelines that translate these policies into action at a facility level. For example, women’s responses to exemption from user fee payment vary from elderly women to children under five in some health facilities to pregnant women to chronically ill persons, and they seem to lack knowledge of how such persons are being supported. Such a finding reflects the knowledge gaps between health providers and clients. The lack of information on use fee exemption policies, coupled with lack of civic education that is aimed at empowering women to demand for their health rights impacts on women` s access to health. Women may not be aware of which services are exempted from payment.
2. The lack of the participation of women, especially rural women, in issues pertaining to service delivery or for addressing ills that affect women` s health despite the fact that women dominate most support health groups and could be PLWH (Lesotho). However, there are advances in gender main streaming such as development of deliberate policies to address women` s needs such as those contained in the National Aids policy, The national AIDS strategic plan, the strategic plan of the MOHSW, the gender policy, ART guidelines and the sexual offence Act 2003 in Lesotho. Other policies being drafted are the reproductive health Act, the Adolescent Health policy and the married Persons Equality Act.
In Zambia, Mainstreaming gender issues in development process is considered to present a way forward in addressing gender imbalances. The approach which began in the “Fourth National Development Plan1989-1993 facilitates linking women’s capabilities and contributions with macro-development issues, such as population, health, education, environment and agriculture, including others. The government has established a central level institutional framework, the Women in Development Division (WIDD) at Cabinet Office, which is the Office of the President. The division is mandated to ensure the integration of gender concerns in all development plans, programmes and strategies, co-ordination of gender activities, and the formulation of a national gender policy, which is now available for full execution. Women` s participation in health matters is equally limited in Malawi where only a few women for a exist such as Women Law society of Africa and the health and equity network.
3. The lack of reproductive health policy, lack of comprehensive and coherently integrated program to address women` s health issues exist in Swaziland and
48 Lesotho. The needs of women appear to be embarked upon by specific vertical programs addressed under certain policies which mainly depend much on the availability of donor funding. However, advancement in this area has been reported in Zambia where the Government decided to formulate the National Gender Policy (NGP) in 2000 to provide a holistic approach in ensuring that both women and men participate fully and equitable benefit from the development process. A new move is also under way to reduce maternal mortality and infant mortality through a “Road Map Approach (RMA)” for “accelerating the attainment of the Millennium Development Goals (MDGs) for maternal and newborn health in Zambia”. This approach is enhanced, through integrated management of pregnancy and childbirth to provide essential practice of pregnancy, childbirth, postpartum and Newborn Care.
4. The accessibility of safe abortion services is equally limited for women and girls in Swaziland due the difficulties in fulfilling the medico- legal requirements. The same situation applies to Zambia. Difficulties in accessing safe abortion services provided under the pregnancy termination act in Zambia due to the certain restrictions in the implementation of the related policies was reported. 5. The Zambia National Population Policy is reported to be the best piece of legislation, but it requires further review to integrate other population factors, such as safe abortion services, that are not clearly handled under the “Termination of Pregnancy Act 1972”. HIV/AIDS, rights of Adolescents to gain access to reproductive health services, including family planning services for in-school and out of school youths are some of the policy issues of concern. At the moment there are still controversies on who has the right to receive family planning services among female and male adolescents.
3.4.2.2 Health service operational factors
To obtain a full impression on the accessibility of women to health services, the study further surveyed a range essential health and social services and resources for women including sexual and reproductive health services in terms of availability and quality to a certain degree. At community level the measurement was conducted by determining, mode of provision- static or mobile services, proportion of women accessing services, sources of support, response and reasons for utilizing community health services. At facility level a combination of methods such as spot checks, exit interviews and interviews with care providers were used to determine the availability, quality and constraints to access.
3.4.2.2.1 Comprehensiveness of sexual and reproductive health services Main highlights in terms of challenges to accessing health care at health facility level are that:
1. Women in all the four countries face a great challenge of lack of access to a comprehensive package of reproductive health services. Not all health facilities offer a comprehensive basic essential package of RH health services. Certain essential services such as maternity/ delivery services are not offered in health facilities located close to families, even though the findings from the study show that a
49 range of sexual and reproductive health related services such as ANC, PNC,FP, VCT, maternity services, neonatal and under five children` s, services are offered.
2. Even in facilities where essential services for instance maternity/ delivery services such as are offered, they are not accessible all the time (24 hours).
Due to organizational barriers akin to logistic supplies including lack of water, electricity, equipment; inadequate human resource and lack of security, some essential services are not provided in certain facilities, some facilities in Swaziland and Lesotho for example, were unable to provide maternity services. Findings from Lesotho indicate that half (50%) of health facilities do not offer emergency obstetric care out side normal working hours. Key informants confirmed that health centres and filter clinics do not open out side normal working hours and women therefore resort to self management such as home delivery. Of the health facilities under study, only 40% in Swaziland and, 44.4% in Lesotho offered maternity care services. Similar observations were made concerning the provision of ART, PMCT, and VCT services. In addition to the increased risk to maternal mortality and morbidity resulting from women from resorting to self care, associated unwarranted referrals to higher level facilities, increase the hurdles in accessing health care (refer to earlier discussions in items 3.1, 3.2 and 3.4).
An illustration of this scenario is indicted in table 12, 13 and 14 as an example of services provided from the health facility in Swaziland, and Zambia.
Table: 12 Range of services provided to women in Swaziland and Lesotho
Type of service provided Percentage of facilities Frequency Swaziland Lesotho Family planning 100 77.8 Daily ANC 100 100 Daily PNC No data 88.9 Maternity care 40 44.4 Daily Neonatal care 40 No data Daily Treatment of STIs 100 No data Daily VCT 20 66.7 Daily PMTCT 40 No data Daily Curative 100 No data Daily Others 28.6
The implications are that women have to travel for long distance to seek maternity care services. Considering, earlier discussed, economic barriers regarding travel costs, physical barriers relating to distance, and socio cultural barriers such as the requirement for women to obtain the consent of their husbands to travel, such services may not be accessible to some women who may be forced to seek care elsewhere (as indicated by women in Lesotho in table 13).
50
Table 13: Cross tabulation of women by Urban/Rural abode and where they first seek Emergency Pregnancy Care in Lesotho.
Urban/rural First seek care (%) Health Hospital Traditional VHW TBA Other Total centre Healer Rural 41.2 42.3 1.8 1.5 1.8 11.3 100 Urban 25.8 55.8 0.8 1.7 1.2 14.6 100 Total 34.0 48.6 1.4 1.6 1.6 12.8 100
Chi-squared df Probability 16.0080 5 0.0068
Further depiction of the range of RH services received by women consulted through exit interviews is indicated in table 14 and 15 below.
Table 14: Frequency Distribution of Purpose of Visit in Zambia Purpose of Visit Frequency Percent Antenatal check up 46 58.2 Postnatal 8 10.1 Family planning 9 11.4 Voluntary counselling and testing 7 8.9 STD Treatment 1 1.3 FP & under five clinic 3 3.8 Gynae problem 4 5.1 Delivery 1 1.3 Total 79 100.0
The findings in table 14 show a distribution of varied clinic sessions in relation to purposes of visit. With a sample of 79 women respondents obtained for exit interviews, all women interviewed were in the reproductive age-group of 18-40 years. A mean age was 26.62 and median of 27 years. The sample was unevenly distributed between urban (59) and rural (20). Antenatal care features as the highest preferred visit, with 58.2 percent than other visits. Family planning shows a distribution of 11.4 percent as second preferred visit to be followed by postnatal service with a distribution of 10.1 percent. Acceptance to voluntary counselling and testing shows 8.9 percent of all women who attended health services in health facilities. Other services, gynaecology clinic attendance with 5.1 percent, combined visits of family planning and under- five clinics is 3.8 percent, with the least most services of 1.3 percent reflect STD treatment and those for delivery services.
51 Table 15: Purpose of Visit by clinic sessions and Residence in Zambia Purpose of visit Residence Total Urban Rural No % No % Antenatal Check up 36 61.0 10 50.0 46 Postnatal check up 3 5.1 5 25.0 8 Family planning 7 11.9 2 10.0 9 Voluntary counselling and Testing 7 11.9 0 0.0 7 STD Treatment 0 0.0 1 5.0 1 Family planning and under-five clinic 3 5.1 0 0.0 3 Gynaecological problem 3 5.1 1 5.0 4 Delivery 0 0.0 1 5.0 1 Total 59 100.0 20 100.0 79 2 X 15.497,df 8, Sig Pvalue= .050
The distribution of clinic visits further varies between residential settings. For antenatal clinic visit, it is higher in urban, with 61 percent than in the rural indicating 50 percent. Low percent in the rural could be attributed to other factors, such as long distance, cost of health services and some traditional values.
Even though, numbers are very small, postnatal attendance seems to be higher (25 percent) in the rural than in the urban with only 5.1 percent women who attended clinic visits. However, there are reasonable increases in family planning and voluntary counselling and testing (VCT) in the urban, with an equal distribution of 11.9 percent, compared with the rural, with 10 percent for family planning and zero for VCT. Similarly, combined services for family planning and clinic attendance and gynaecological problems are higher in the urban indicating an equal distribution of 5.1 percent than in the rural, with zero and only 5 percent respectively. There were no attendants for those who sought for assisted delivery in the urban, when compared with the rural, with 5 percent of all women who visited clinics in different health facilities sampled. The variation in attendance could have been attributed to the differences in the availability of required services, supplies and human resources of some specialized services, as in the case of urban setting. The findings show relative statistical significant differences in clinic service attendants between residential settings, with a p value .05, respectively.
3. In general, rural women are likely to have less access to a wide range of sexual and reproductive health services than their counterparts in the urban settings. For instance, in Zambia, provision of emergency obstetric services was lower by 2.3 % in Rural. A similar scenario exists in Swaziland where only a few rural located health facilities provide a full range of sexual and reproductive services. A significant example is the cross tabulation of women by urban /rural abode and where they first seek emergency obstetric care in Lesotho indicated in table 13 and table 17indicating similar findings in Zambia. Women in the urban areas utilised the hospitals more than those in the rural.
4. Even where services are available, certain services are still under utilised. Under utilisation of services such as emergency obstetric and delivery care, post natal care, family planning and VCT services exists.
52 In addition to economic, social- cultural and physical barriers, the rational for this could probably be to organisational barriers mentioned above such as the fact that these services are not widely provided as the situation is in Swaziland and rural Zambia, or women’s awareness of the availability of such services is lacking. The lack of service awareness is for instance, depicted in table 16 showing the distribution of women by their knowledge/perception on services availability in Lesotho, where women were least aware of service availability of family planning, counselling and maternity/delivery services.
Table 16: Showing distribution of women by their knowledge/perception on service availability in Lesotho.
Service Service available Number % yes Number % No Total Total % Yes No number ANC 519 91.9 46 8.1 565 100 Deliveries 381 67.4 184 32.6 565 100 PNC 515 91.2 50 8.8 565 100 FP 346 61.5 217 38.5 563 100 counselling 147 26.1 417 73.9 564 100 Curative 562 99.5 3 0.5 565 100
3.4.2.2.2 Challenges for the utilisation of specific RH services The review of health facility assessment for specific services offered show a range of reproductive health services and other related services that are available in the health facilities as indicated above. However, the findings indicate shortfalls pertaining to the comprehensiveness and quality of services provided. The attributes to these short falls which can either influence or affect health service utilization by women could be related to: •Cost of services. •Efficiency of services in relation to time and health facility capacity in the provision of adequate health services. •Skilful performance of health services by providers and •Attitudes of health providers towards clients’ response to health services. 1. Access to Antenatal care service All the countries findings signify higher ANC coverage. ANC in Lesotho, Swaziland and Malawi and Zambia are provided by all health facilities, being offered as part maternal and child health services offered at the out-patient department of hospitals, health centres, PHUs. Despite, this high coverage it has been reported in Swaziland, that women book late, in the second and third trimester for antenatal health care. Assessment findings in Zambia show an average of 50.6 percent who received antenatal care (ANC), which was higher than for other services received during the clinic visit. When comparing the findings between residential settings, there are variations in ANC received. Table 15 presents a summary of such differences.
53 Table 17: Proportion of Women Received Antenatal Care by Residence in Zambia
Antenatal care received Residence Total Urban Rural No % No. % Yes 31 52.5 9 45.0 40 No 28 47.5 11 55.0 39 Total 59 100.0 20 100.0 79 2 X= 23.598,df 1,sig P value= 0.000
The findings in table 17 show a highly significant difference in antenatal care received between the urban and rural. Among those who received adequate ANC was high in the urban, with 52.5 percent, while it has been 45 percent in the rural. By contrast, women who did not receive ANC in health facilities is higher, with 55 percent for the rural than the urban with 47.5 percent. The difference in the ANC received could be attributed to adequate facilities available for the provision of health services in health facilities, increased awareness, and affordability of the services in the urban area. In the rural, issues of cost of services, inadequate facilities in health centres and preference for choice of health providers could contribute to the low provision of adequate ANC required by women. The provision of ANC is therefore lower in the rural than in the urban.
2. Access to emergency Obstetric care services Rural women appear to have greater challenges in accessing emergency obstetric care at hospital level than their counterparts residing in urban areas. In Lesotho rural women (as indicated in table 13) sought hospital services less as compared to those in the urban. This may be related to the economic and physical barriers discussed earlier on, and organisational factors such as staff attitudes and resource constraints encountered by at health centre and hospital level including lack of ambulance services. Additionally, 17.4 % of women in Lesotho seek emergency obstetric care of other sources such as self care, traditional healers, village health workers, and traditional birth attendants other than health centres and hospitals. It is estimated that nearly half (46%) of mothers in Lesotho deliver at home. The provision of emergency obstetric /delivery service was determined by the availability of emergency obstetric kits in health facilities in Zambia. The following are the findings. Table 18: Provision of Emergency Obstetric Service by Residence in Zambia
Provision of Emergency obstetric kit Residence Total Urban Rural No. % No. % Yes 12 75.0 8 72.7 20 No 4 25.0 3 27.3 7 Total 16 100.0 11 100.0 27
54
The findings show a moderate response in the provision of emergency obstetric service for both areas, with 75 percent urban and 72.7 percent for the rural. The shortfalls in the limited responses for ‘no’ could be affected by the inadequate facilities, such as emergency obstetric kits that may be lacking in some health facilities. The lack of emergency obstetric kits and other related essential requisites, and lack of 24 hour provision of emergency obstetric /delivery service combined with other barriers such as distance, cost of health care and, lack of transport for emergency obstetric care may cause women to shun seeking care from health facilities.
3. Access to Maternity/ Delivery Services
Low utilisation of delivery services by women has been reported. For instance, In Swaziland nearly 44 % of mothers deliver at home and are in most cases assisted by Traditional Birth Attendants (TBAs). Maternal deaths are frequent in Swaziland. In 1995 overall Maternal Mortality rate was 229/100000 live births. The majority of maternal deaths are attributed to preventable or treatable conditions. Only 40% of the facilities surveyed in Swaziland provided delivery services. In Lesotho, only 44.4% of the facilities provide delivery services and delivery equipment was not available in almost 90% of the health facilities. The Maternal Mortality Ratio (MMR) in Lesotho is reported to have increased from 282 in the 1990s to 419 per 100,000 LB in 2001. A number of risk factors have been identified, major ones being HIV/AIDS and unsupervised deliveries. Assessment of delivery services in Zambia similarly indicated that delivery services were generally lowly utilized in health facilities despite of the adoption of Integrated Management of Pregnancy and Child Birth (IMP) in Health Facilities.
Table 19 for example, indicates the percentage of women who had benefited from maternity/delivery services in Zambia. On the overall, only 3.8 percent had received delivery services from health facilities visited. Within the residential settings, it shows a distribution of 1.7 percent for the urban and 10 percent rural, demonstrating that health facility delivery is quite low.
Table 19: Proportion of Women Received Delivery Service in Zambia
Delivery service received Frequency Percent Yes 3 3.8 No 76 96.2 Total 79 100.0
Low utilisation of maternity services predisposes to high risk of maternal mortality and morbidity due to the risk of being attended by unskilled birth health personnel, delivery in unhygienic conditions, lack of referral services and many other factors. All the four countries are known to have high mortality rates, with Zambia in the lead with an estimation of 800 to 1,300 per 100,000 live births in remote areas (as indicated in chapter one).
55 4. Integrated Management of Pregnancy and Child Birth (IMP) Most of the health facilities in Zambia provide integrated management of pregnancy and child birth (IMP), with 87.5 percent in the urban and 100 percent for the rural. The findings show similarities in the provision of IMP to women. Table 20: Proportion of Integrated Management of Pregnancy and Child Birth in Health Facilities by Residence in Zambia Provision of Residence Total IMP Urban Rural No % No. % Yes 14 87.5 11 100.0 25 No 2 12.5 0 0.0 2 Total 16 100.0 11 100.0 27
5. Access to Postnatal care
Low utilisation of postnatal services has been reported. Only 34% of the women received such services in Lesotho, eventhough the study that almost ninety percent (88.9%) of health facilities were providing post natal care services. Findings in Zambia from exit interview show an average of 8.9 percent of all women to have received postnatal care. Table 21: Proportion of Women Received Post natal Care Service in Zambia
Postnatal care received Frequency Percent Yes 7 8.9 No 72 91.1 Total 79 100.0
There is very low percent of women who received postnatal care in various health facilities in all areas studies. However there is also variation in the provision of postnatal care according to residence (see table 22). Table 22: Proportion of Women Received Postnatal Care Received by Residence in Zambia
Postnatal care received Residence Total Urban Rural No. % No. % Yes 4 6.8 3 15.0 7 No 55 93.2 17 85.0 72 Total 59 100.0 20 100.0 79 2 X 25.180,df1,sig. P value 0.000
56 The findings further show a significant difference in the postnatal care (PNC) for those who actually received in health facilities between the urban and the rural. The distribution indicates 6.8 percent in the urban and 15 percent for the rural. The difference could be linked to great variation in the sample, which is unevenly distributed between residential areas. However, by contrast, those who did not receive PNC is higher in the urban, with 93.2, than in the rural, with 85 percent. Even if the findings show a difference in PNC received, generally, it is low.
6. Access to Family Planning Services
Under utilization of family planning services has been reported by all the countries in the study For instance in Lesotho, more than half (58.5%) of the women in Lesotho were not using a modern family planning method. The findings were almost similar to the Lesotho population data sheet stating the contraceptive prevalence rate of 41%; the demographic Survey` s recorded of 40.6%. The MOH selected indicators estimate CPR at 27.6%. Given the high prevalence of HIV/AIDS, and the findings of low utilisation of condoms (29.8%), there is a signal that the dual protection accorded by condom use is not appreciated or women have no authority to use them. Women are particularly vulnerable to HIV/AIDS representing 57% of adult infections in Lesotho. The rate among women attending ANC was 28.9% in 2003. The study findings on FP service utilisation are indicated below in table 23. The Sengu valley lies within the mountains. Both the Sengu valley and the foothills area are predominantly rural.
Table 23: Cross tabulation of women’s use of FP by ecological zone in Lesotho Ecological Zones Use of FP (%) No TOTAL
Foothills 29.6 70.4 100.0
Lowland 51.5 48.5 100.0
Mountain 28.6 71.4 100.0
Senqu valley 42.4 57.6 100.0
TOTAL 41.5 58.5 100.0
Chi-squared df Probability 22.3697 3 0.0001
In spite of progress made in Swaziland towards fertility reduction, the study findings imply that there remains a substantial unmet need for family planning. Reproductive health services such as family planning are not readily available to women and girls especially adolescents. Teenage girls who are not physically mature are at greater risk of obstructed labour and complication other complication during delivery increasing the threat of maternal mortality and morbidity.
57 The high incidence of illegal abortion is a growing concern in Swaziland. Induced abortion is a particularly significant problem among teenage girls. Faced with the prospect of an unwanted pregnancy, many teenage girls resort to abortion to avoid expulsion from school. Unmarried teenage women are more likely to have unwanted pregnancies because of the barriers they face in obtaining contraceptives. For example, it is reported that health workers often require proof of the husband’s authorization before dispersing contraceptives, even though this is not a legal requirement. It is has been reported that men are not equally involved in family planning though they play a crucial role in terms of decision making at household level (as discussed in item 3.2).
Literature in Swaziland indicates a total fertility rate of 4.7 children per woman and a population growth rate of 2.9 per cent for 1995-2000. Age-specific fertility rate (per 1,000 women aged 15-19, 1995-2000 was 90. It is reported that the Government recognizes that the current levels of population growth and fertility are too high and its goal is to reduce the level of fertility in order to improve family well-being and maternal and child health. Contraceptives are provided at all government health-care centres. The national family planning programme, which was launched in 1973, provides family planning services at all its service delivery centres and mobile units. The family planning programme has achieved a certain measure of success. By 1988 more than 80 per cent of women knew at least one effective contraceptive method, and 17 per cent of all women reported use of a modern contraceptive method, up from about 5 per cent in 198510.
The findings from Zambia equally demonstrate even a lower utilisation of FP services. Only 6.3 percent of the women consulted through exit interviews reported having sought for family planning services during the clinic visits in all the health facilities. Records obtained from literature review confirm that contraceptive prevalence rate is still low in rural settings indicating 28%, compared with 46% for the urban. The current use of a modern family planning method in Zambia is estimated at 22.6% for married Table 24 below shows summary of findings.
Table 24: Proportion of women Received Family Planning Services in Lesotho and Zambia
Family planning service Frequency (in percentage) received Zambia Lesotho Yes 6.3 41.5 No 93.7 58.5
The findings show a very low utilization of family planning services by women who visited health facilities in different residential settings.
10 http://un.org/esa/..
58 Table 25: Family Planning Service Received by Residence in Zambia
Family planning service Residence Total Urban Rural No. % No. % Yes 5 8.5 0 0.0 5 No 54 91.5 20 100.0 74 Total 59 100.0 20 100.0 79 2 X 23,584, df 1, sig. P value 0.000
The findings show a highly significant difference in the utilization of family planning services between the urban and the rural. In the rural, 100 percent women who visited health facilities did not receive family planning, but received other services. In the urban, only 8.5 percent utilized family planning services during the clinic visit. It shows the availability of family planning services in health facilities for the urban more than in the rural, where such services are inaccessible. However, family planning services in health facilities are generally low. These preliminary findings suggest further the need to expand more family planning services to rural areas and most remote parts of the country. The community based distribution approach may benefit many women.
Advice and Counselling Service for Family Planning The findings from Zambia show that the majority of health providers advise and conduct counselling services for family planning in health facilities, with 100 percent service provision in the rural higher than in the urban, indicating 81.3 percent, with limited figure of 18.8 percent not providing family planning counselling service. This variation could be attributed to inadequate manpower and other factors, such as IEC materials and perceptions of family planning. Generally, services are provided in health facilities.
7. Access to HIV/AIDS Services (VCT/ ARV s including PMCT and PEP)
Women especially those residing in rural settings still face challenges in seeking HIV/AIDS related services in all the countries. For instance, despite the high prevalence of HIV (30% in adults and 42% among pregnant women), the study findings indicate that HIV testing was still limited in Lesotho. Only 2 hospitals and one health centre of the facilities in the sample were offering HIV rapid testing, and HIV testing for rape victims was only offered at two hospitals. The MOHSW review report for the year 2005 indicates that all hospitals have the capacity to perform basic tests with 3 of the 17 hospitals being able to provide CD4 counts. According to the report of the department of AIDS and STI as well Laboratory services in Lesotho, there are thirty eight (38) out of a hundred and fifty eight (158) health centres that provide VCT services. ART has only been introduced in seven hospitals and no drug stock outs have been documented. Preventive ARV services were also reported to be limited. Lesotho highlighted the fact that the utilisation of Post Exposure prophylaxis services was dependant on the knowledge of the person consulted and the availability of ARV’ s at such a facility (currently limited to 9 (3x5) and 1 BMS sites.
59 Above all, in addition to the constraints related to the availability of services, the issue of the individual woman capacity to pay is another determining factor for service utilisation. This extends to ART services too. Nevertheless, purposeful strategies and interventions to promote women’s access are reflected in the National AIDS policy, National AIDS strategic plan, the gender Policy, the HIV testing and counselling (HTC) guidelines, and ART guidelines in Lesotho.
A higher coverage of HIV/AIDS related services among antenatal and intra-natal care beneficiaries has been reported by Swaziland and Zambia. Women discharged from maternity wards were more informed on HIV/AIDS services than those who have not been. Table 26: Proportion of Women Received HIV/AIDS Services (PMCT/VCT/ARVs)
HIV/AIDS services Frequency Percent received Yes 13 16.5 No 66 83.5 Total 79 100.0
The findings from Zambia show an average of 16.5 percent for women who received PMCT, VCT or ARV supply. The majority were those who attended ANC services. However, there is still a high proportion for those who are not receiving HIV/AIDS services in health facilities. Differences in the utilization rates between residential areas are also evident.
Table 27: STI/HIV/AIDS Services (PMCT/VCT/ARVs) Received by Residence in Zambia
HIV/AIDS services Residence Total received Urban Rural No. % No. % Yes 10 16.9 3 15.0 No 49 83.1 17 85.0 Total 59 100.0 20 100.0 2 X 22.869,df 1, sig.Pvalue 0.000
There is a significant difference in the utilization of HIV/AIDS services in health services between the residential areas. The findings show a higher proportion of 16.9 percent in the urban than in the rural, with 15 percent to give a low proportion in the rural more than in the urban. The difference is mainly attributed to the availability of adequate HIV/AIDS services in health facilities that are more in the urban than in the rural. Another reason for the low utilisation of services in rural settings could be the low HIV/AIDs prevalence in rural locations. The prevalence has been reported to be twice as high in urban areas (23%) than in rural areas (11%).
60 8. Access to VCT for HIV Status VCT services are still inaccessible by some women. In Swaziland the study findings signify that almost 26% of the women were not talked to about testing of HIV infection indicating lack of awareness. The findings from Zambia show similar gaps between residential settings in the provision of VCT to clients to determine their HIV status. Table 28 provides a summary of findings.
Table 28: Provision of VCT Service by health facility in Zambia
Provision of VCT Residence Total Urban Rural No. % No. % Yes 13 81.3 11 100.0 24 No 3 18. 7 0 0.0 3 Total 16 100.0 11 100.0 27
The majority of health facilities provide VCT for HIV status, with 100 percent in the rural higher than in the urban, with 81.3 percent. The limited number observed in the urban could be attributed to some facilities not providing such services due to inadequate trained staff in VCT procedures. 9. Sexually Transmitted Diseases (STD) services Universal screening for all antenatal service attendants and for suspect cases is conducted in Zambia. Screening for Treatment- shows a distribution of 3.4 percent urban, and zero percent for the rural. The findings may indicate availability of STD treatment and incidences of STD cases among women in urban health facilities. However STDs cases seemed to be low in rural health facilities at the time of the visit.
10. Support and Care for Women with Special Needs (PLWHAs and adolescents) Service delivery gaps exist concerning the provision of reproductive health services for female adolescents and youths (as discussed in item 3.4.2.2.7). The services are reported not to be user friendly for Lesotho, where, although ADRH corners had been opened in almost all hospitals, they were perceived more as antenatal clinics for the youth and therefore are not accessible to non-pregnant youths. 13% of the female youths are reported to get pregnant and expelled from school in Lesotho. A baseline study in Lesotho reported indicated teenagers (13-19 years) formed 14% of all hospital admissions and 27% of premature deliveries, while they formed 23% of all ANC first visitors. The gaps in the provision of reproductive health services to adolescents have been similarly identified in Swaziland where the lack of a comprehensive RH program to enhance the reproductive health of adolescents is seen to be lacking. Current services are also reported to not to be user friendly including the unfavourable attitudes of health providers. Adolescents and youth contribute to high fertility rate in Swaziland. This is evidenced by the high incidence of teenage antenatal attendance and high ratio of institutional deliveries among teenagers (27%).
61 Another challenge indicated by Zambia, lies with the fact that, access to adolescent services is affected by demand for cost of services. The problem of facilities that are mal designed and not conducive to meet the needs of adolescents was also highlighted. Furthermore, the review of the national policies in Zambia, has brought to light existing gaps the fact that the elements of safe abortion and adolescent's health rights to a comprehensive reproductive health service are not clearly defined to reflect their reality on individuals. HIV/AIDS, rights of Adolescents to gain access to reproductive health services, including family planning services for in-school and out of school youths are some of the policy issues of concern. At the moment there are still controversies on who has the right to receive family planning services among female and male adolescents in Zambia. Support for women with special needs especially those living with HIV/AIDS (PLWHAs) at community level in Lesotho was indicated to emanate from Support groups who mainly provided home based care for the chronically ill. Support groups were regarded very helpful by the PLWHAs as in addition to nursing care, they also provided counselling and referral services; food supplies and protective materials such as gloves. PLWHAs found support groups to be more empathetic as compared to Village health workers (VHW) and health facility workers. PLWAS also felt discriminated against at health facilities. For instance, they were required to bring in a contact when seeking treatment for STIs. According to the training manual, VHW are required to offer health promotion and preventive services including those relating to nutrition, water and sanitation and reproductive health such as community based distribution of contraceptives. Perhaps due to the burden of the HI/AIDS epidemic their services are reported to be biased towards the provision of home based care. Further support is provided by women's organisations such as burial societies, church groups and home economics groups who have extended their activities to incorporate the organisation of emergency transport and home based care. Negative attitudes of health providers are further reflected in the perceptions of HIV/AIDS management in Zambia. Health providers at facility level, especially nurses, have affected women’s response to HIV/AIDS care in health facilities. The findings from focus group discussions show use of abuse language-with no respect- by health providers to people living with AIDS (PLWAS) and lack of confidentiality. Other factors have included, health providers taking time to see patients to prolong waiting time, erratic distribution of food and lack of effective counselling skills to encourage PLWAS response to ARV treatment. These factors were indicated as major obstacles to gain access to treatment among PLWAS in health facilities. It is therefore quite evident that the behaviour of health providers, as reflected in their attitudes, has a significant importance in determining the extent to which women’s access to health services in the different communities. The findings from Zambia depicted below show the availability of support and care for women with special needs especially PLWAS and adolescents by health providers in the different residential settings. The distribution indicates high response rate of 81.8 percent in the rural, while it is 62.5 percent in the urban. Among those not providing support care for women with special needs is higher in the urban, with 37.5 percent, than in the rural indicating 18.2 percent. These variations, even though there is no significant difference between areas, could result in high prevalence of women with special needs in the rural more than in the urban
62 Table 29: Support Care for Women with Special Needs by residence in Zambia
Support Care to Women Residence Total Urban Rural No. % No. % Yes 10 62.5 9 81.8 19 No 6 37.5 2 18.2 8 Total 16 100.0 11 100.0 27
Negative attitudes of health providers are further reflected in the perceptions of HIV/AIDS management. Health providers at facility level, especially nurses, have affected women’s response to HIV/AIDS care in health facilities. The findings from focus group discussions show use of abuse language-with no respect- by health providers to people living with AIDS (PLWAS) and lack of confidentiality. Other factors have included, health providers taking time to see patients to prolong waiting time, erratic distribution of food and lack of effective counselling skills to encourage PLWAS response to ARV treatment. These factors were indicated as major obstacles to gain access to treatment among PLWAS in health facilities. It is therefore quite evident that the behaviour of health providers, as reflected in their attitudes, has a significant importance in determining the extent to which women’s access to health services in the different communities.
11 Access to Sexual and gender based Violence Victim Management services including domestic violence support services
Country variations exist pertaining to SGBV service provision specifically clinical management of rape. The findings give an impression of the provision of un coordinated and non- comprehensive services in all the four countries. In Lesotho, there is a signal from the study findings, that health facilities do not offer counselling nor adequate services for SGBV including PEP. Equally lacking was the availability of protocols or clear guidelines for the prevention and management of SGBV even though there was evidence of the prevalence of violence among women (15.5%), the majority of whom have been violated by husbands (84%).
Table 30: Distribution of Women by their Experience of Violence in Lesotho
Ever been a victim of any form of violence Frequency Percent Yes 88 15.5% No 481 84.5% Total 569 100.0%
The 1998 women` s health Survey, the study on violence and, in search of justice in Lesotho “Where do women go?” also indicate that husbands and partners are often the perpetrators. As for the type of violence, it highlights the plight of female domestic workers who are children, often subjected to emotional bullying physical abuse, and sexual violence. Findings according to this study are tabulated below in table 31.
63
Table 31: cross tabulation of Women by Perpetrator and Type of Violence in Lesotho
Perpetrator Type of violence Physical Psychological/ Sexual Total Verbal Number % Number % Number % Number % Husband 21 84 2 8.0 2 8 25 100 Brother 2 50 2 50 0 0 4 100 Relation 2 25 5 62.5 1 12.5 8 100 Other 12 26.7 14 31.1 18 40 45 100 Total 37 45.1 23 28 21 25.6 82 100 Chi-squared df Probability 29.3651 9 0.0006
Health facilities had a record of SGBV victims ranging from 1 to 300. The issue of underreporting could be considered. Literature alludes to the fact that women do not want to report their husbands since the statutory system is not conciliatory and they would not want to be separated from their children. Women still have to negotiate with their perpetrators (husbands) for resources (financial and time) necessary to access health care. Customary practices and values also condition women to be subservient even in cases where behaving otherwise would be to their health benefit or that of their spouses. Furthermore, women stayed stigmatised following reports. The above mentioned study, further reported that, community members were also reluctant to report, or intervenes where they knew abuse occurred. The practice in health facilities in Lesotho was that women are required to obtain the consent of the husband before certain procedures could be under taken. However, SGBV services were provided in the form of IEC on subject related topics such as PEP and emergency contraceptives. Besides, there is on- going social mobilization at community level by the department of gender pertaining to women and politics, education through the education transformation resource centre (ETRC), the activities of the federation of women lawyers (FIDA) as well as women and law in southern Africa Research trust (WILSA). On the other hand, there was evidence in Zambia of health providers managing sexual gender and domestic violence in the urban and rural areas. The findings form Zambia point out that 57.5 percent of women indicated that rape/beating and other forms of domestic harassment being were common. Consequences of such SGV victims have resulted in high prevalence of unwanted pregnancy, divorces and STIs/HIV, which indicate 30 percent. Among those who were ‘ever sexually abused’ show 33.8 percent. Girl child defilement indicates 47.5 percent, while sexual cleansing practice for widows is 22.5 percent as common practices. Similar to the scenario in Lesotho, the majority of women who are abused in Zambia are also reported to remain silence and unreported cases due to socio-cultural factors, such as lack of civic education, cultural influence and fear of being divorced, if married. Most women interviewed at household level are aware of some forms of legal protection. Over 57 percent indicated availability of social system or legal support for protecting women against sexual and domestic gender violence in urban and rural areas. The influence of cultural practices coupled with lack of knowledge of human rights protection on women expose them more to the risk of sexual and domestic violence that result in severe consequences.
64 Table 32: Sexual gender and Domestic Violence Management by residence in Zambia
SGBV services Residence Total Urban Rural No. % No. % Provide care 4 25.0 1 9.1 5 Referred case 12 75.0 10 90.9 22 Total 16 100.0 11 100.0 27
The findings in table 32 show some variation in the provision clinical care for SGBV victims between urban and rural. Very few SGBV victim cases are managed by health providers in their health facilities due to, most likely, none availability of other providers authorized to provide a legal support. The distribution show 25 percent in the urban and only 9.1 percent for the rural who provide actual care in health facilities. More cases are referred to other health facilities for management. The findings also show a distribution of 75 percent in the urban and 90.9 percent for the rural. There is limited care provided to SGBV victims by health providers at designated health facilities. The lack of policies, guidelines, protocols for the prevention and management of sexual and gender based violence was also observed in Zambia. Concerning the provision of VCT to post rape victims, the findings tabulated below (table 339 show adequate provision of VCT for rape victim cases in Zambia, with 87.5 percent for the urban and 81.8 in the rural. There are limited numbers for those not providing the services in urban and rural (12.5 versus 18.2 percent). The 1998 women` s health Survey, the study on violence and, in search of justice in Lesotho “Where do women go?” also indicate that husbands and partners are often the perpetrators. As for the type of violence, it highlights the plight of female domestic workers who are children, often subjected to emotional bullying physical abuse, and sexual violence.
Table 33: HIV Counselling and Testing for Rape Victim Cases in Zambia
VCT for Rape Victim Residence Total Cases Urban Rural No. % No. % Yes 14 87.5 9 81.8 23 No 2 12.5 2 18.2 4 Total 16 100.0 11 100.0 27
12. Access to gynaecological related service i. Safe abortion care There is currently limited access for women to adequate, quality abortion care services. The baseline study on the magnitude of Abortion conducted by MOHSW/WHO in Lesotho found similar gaps as those described in this study pertaining to the provision of safe abortion
65 services. Its findings were that while abortion was high (consisting of 16% of female admissions and female impatient mortality), such affected individuals had limited access to adequate, quality and humane post abortion care services and appropriate enhanced technology. Findings from this study indicate that safe abortion services are not commonly offered as they have not been mentioned in the range of services available to women, and were not utilised by women as expressed in exit interviews. There is no statutory law in Swaziland governing the performance of safe abortions. Instead, abortion is a matter of common law, which is patterned after Roman-Dutch common law. Under this law, which was also in effect in South Africa prior to the enactment of its Abortion and Sterilization Act (1975), abortion is prohibited except in cases of necessity. There is some disagreement, however, as to what constitutes a case of necessity. The majority position of commentators is that a case of necessity exists only when an abortion is performed to save the life of the pregnant woman. However, it is possible that a case of necessity need not be so serious and that an abortion could be performed in cases of serious threat to both physical and mental health, foetal defect and rape. There is no case law on this issue in Swaziland. Because there is no statutory law on abortion in Swaziland, there are no legal provisions dealing with the professional qualifications required to perform an abortion, the place where the procedure must be performed or the period during pregnancy when an abortion can be performed. Abortions are reportedly usually performed by a registered physician in a government hospital or other approved institution and may be performed within 20 weeks of pregnancy. Swazi physicians generally seek permission from the Ministry of Health prior to performing an abortion. Although this permission is not a legal requirement, it is a precaution that physicians have chosen to take in order to protect them selves and to prove their good faith. In practice, the person performing the abortion must usually be satisfied that the woman’s physical or mental health is endangered by the birth and must act in good faith for therapeutic purposes only. There are no data concerning the number of legally induced abortions, but it is believed that the numbers are small. However, the high incidence of illegal abortion is a growing concern in Swaziland. In Zambia, the elements of safe abortion and adolescent health rights to a comprehensive reproductive health service are not clearly defined to reflect their reality on individuals. These need further re-visiting for operational definitions and responsiveness. For example, the operation definition of safe abortion is not clearly understood within the health service environment. What exit is the management of incomplete septic abortion as service offered in clinical areas, which distorts the meaning of safe abortion as defined in the legal frame-work. The pregnancy termination act 1972 in Zambia is reported to have several practical implementation limitations which has consequences that are associated to high maternal mortality. Abortion was allowed for health and socio-economic reasons from 1972. However, the law is marked by restrictive conditions: that the operations should be performed in hospitals; consent should be given by the one seeking abortion; and that three doctors must authorize and clearly state the grounds on which termination is permitted. Due to various factors such as the inability to access three doctors to authorise abortion, women are unsuccessful in fulfilling these conditions resort to seeking illegal avenues of obtaining such services. A time analysis series of abortions shows that 1983, the Ministry of Health reported a total of only 1164 cases of legally induced abortion. There were in the same report, 14,840 and 16,977 cases of “unspecified abortions” in 1982 and 1983, respectively. Using data from Zambia Demographic and Health Survey 1992, a study by Rogo and others estimate that there are 115,000 abortions per year in Zambia, 46,000 of these are induced.
66 Adolescents and the youth form the majority of women seeking abortion services. This could be linked to mainly organisational barriers such as the location of adolescent services described earlier, in addition to economic, socio cultural barriers that they face in seeking FP services. A study by Likwa cited in the Zambian report, described the characteristics of women presenting for abortions at University Teaching Hospital (UTH), Lusaka where 64 percent of the cases were in the 15-24 year age-group. Young girls often resort to abortions for fear of shaming parents and families or curtailment of further education opportunities. Trained health workers, mainly doctors, are reported to induce up to 25 percent abortions in their private surgeries before referring to UTH (or government hospital) for evacuation. Traditional herbs and roots apparently are, also, widely used in communities to procure abortions. The interpretation of this scenario is that choice on where to procure an abortion is guided by knowledge of who provides services; knowledge of where services are provided; advice from peers or friends; and affordability and acceptability. The accessibility of safe abortion services is equally limited for women and girl in Swaziland too. The study findings point out to the fact that though abortion services are available to any women when it is legally necessary, lengthy procedures required by the Ministry of Health and Social welfare render it impossible for some women to access safe abortion services legally within the medically sanctioned period. A much neglected category of women who suffer due to the lack of safe abortion services are adolescents and women with gross physical or mental disability. These women are also the most vulnerable to sexual abuse. Safe abortion services are not available to them even when the consenting parents or guardians are willing for the necessary procedure to be performed. ii. Cancer screening services Access to diagnostic services pertaining to cervical and breast carcinoma is documented as limited in Lesotho and Zambia. Findings from Lesotho bring to light the fact that because of late presentation, cancer of the cervix accounts for a high proportion of referrals to South Africa. While pap smears may be done throughout the country, the quality of slides is often below standard and laboratory capacity to read a high number of slides is limited. Only 33.3% of the health facilities surveyed in Lesotho provided pap smears diagnostic examination. Cancer of the breast accounts for a high proportion of admissions to the female ward but screening and awareness are also low. For instance, no healthy facility was offering mammography services. Findings from Zambia on the utilisation of gynaecological services such as cervical and breast cancer screening services including the creation of awareness, portrays a similar deficiency.
67 Table 34: Proportion of Women Received Gynaecological and Counselling Services by Residence in Zambia
Other services received Residence Total Urban Rural No. % No % Gynae service Yes 3 5.1 1 5.0 4 received No 56 94.9 11 55.0 67 Counselling service received for suicide 0 0.0 8 40.0 8 Attempt Total 59 100.0 20 100.0 79 2 X 27.072, sig . Pvalue 0.000 There is a significant difference in the other services given during clinic visit between residential areas. Relative high proportion of women who received gynaecological services is in the urban, with 5.1 percent, compared with those in the rural. However, a higher figure of women who received counselling services for attempted suicide is in the rural, with 40 percent than in the urban. 13. Access to information for behaviour change- information, education and communication The study findings show the inadequacy of health information and education services and materials. Where such were available, for instance in Lesotho, materials were not locally relevant and are sometimes presented in a language that may not be understood by the majority of users. Data obtained from the facility checks and exit interviews, signify that available IEC materials covered subjects ANC (6), safe deliveries (1), Family planning (2), Immunisation (6), PMTCT (2), PNC (2), SGBV (1), VCT/HTC (1), Materials had been obtained from various sources including from South Africa in English language. Despite the problem of lack of IEC materials, health facilities were making an effort to provide health education in Lesotho. All but one (1), of the nine (9), facilities surveyed had conducted IEC activities over the past three months. The topics included ANC (100%), Family planning and emergency contraception (77.8%), safe deliveries (33.3%), ART (22.2%), post exposure prophylaxis (PEP) (22.2%), Prevention of mother to child transmission (PMTCT) (44.4%), post natal care (PNC) (66.7%), sexuality (62.5%), and SGBV (33.3%). Efforts for disseminating information to women at national level are done through the commemoration of international days. The findings from Swaziland denote that women are more likely to receive information when they are in contact with the health service. For instance the availability of HIV/AIDS counselling and IEC services was communicated to only 42.1% of the women who had been discharged form the maternity wards. More than 50% of the women had not been informed of available HIV/AIDS services. Zambia reported a very low turn over on the educational materials that were given to clients. The assessment findings show a distribution of 5.1 percent for urban and 5 percent in the rural for those supplied with some educational materials to take home. It demonstrates that educational materials for female clients are lacking in all health facilities visited.
68 Among those who participated in health education group talks further show 27.1 percent for the urban and 10 percent in the rural. Health education discussion/talks are not conducted in the health facilities. This could be attributed to lack of educational material supply on health issues, inadequate manpower to manage all health activities and lack of interest by health providers. However, other means of EIC such as radio and television education services were available, but unfortunately not easily accessible for rural women. 14. Access to food and nutrition Services Study finding in Lesotho illustrate that there is a proportion of women depending food aid for survival. This signals the impact of the southern Africa “triple threat” scenario on the population. Five point one percent (5.1%) of interviewees relied on food Aid, while 1.8% depended on handouts. Sixty point one percent (64.1%) however, relied on purchasing food for the house holds, while 28.6% relied on farming. Dependency on food Aid while comparatively low, were significantly much higher in the mountains (5%) and 2.1%), and Sengu (12.1% and 2.9%), compared to the lowlands (2.1% and 1.3% respectively); these were not options in the foothills. Reliance on food Aid and handouts were also more in the rural (7% and 1.3%), than the urban areas (3% and 2.2%). Focus groups also indicated increased food shortage consequent to the continued drought leading to reduced agricultural output. Women leaving with HIV/AIDs complained of the discriminatory nature of the food aid through the use of screening indicators such as perceived place of residence and perceived economic status. With the high level of unemployment among women (estimated at 57% in the 2001 demographic survey) the purchasing power of households will probably reduce, negatively affecting the quality of their diet. The World bank CWIQ core indicators and tables also indicate that more women than men are unemployed with up to 38.37% of households finding difficult to access food. In Swaziland the WFP and a national consortium of NGO formed a partnership in 1994 to distribute food aid to the most affected. Swaziland was also incorporated as a beneficiary of WFP regional Emergency Operational plan in 2002. However, About 44.6% of women in this study reported that they are unaware of the food distribution program signalling that access to food AID is limited for women. The findings in Zambia signify that nutrition services in terms of food supplements were received only affected those living with HIV/AIDS condition. The data show a distribution of 1.7 percent for urban and 20 percent rural, with an average of 6.3 percent of all women who received nutrition supplement services in health facilities (details are provided in table 35). Table 35: Nutrition Services Received by Residence in Zambia Nutrition services Residence Total received Urban Rural No. % No. % Yes 1 1.7 4 20.0 5 No 58 98.3 16 80.0 74 Total 59 100.0 20 100.0 79 2 X 33.562, df 1, sig.Pvalue 0.000
69 The findings show a highly significant difference in the provision of nutrition services between residential settings. The difference is attributed to poor economic status among the rural population, compared with those in the urban with adequate economic status.
15. Access to referral Services Provision of referral system was determined by availability of radio communication links, ambulance facility at station, distance and common conditions that are referred. The study findings confirm the existence of referral services in health facilities. All health facilities in Lesotho reported having referred patients to a higher level of care. The reasons for referral included lack of (11.1%) and need for higher level/further management. The criteria followed were based on the workers’ skills. Key informants reported that women could also self refer. Referral from lower levels of care was also undertaken as deemed fit by the person consulted. Major problems concerning the referral services in Lesotho, were lack of feed back from higher level facilities, that in all cases transport costs had to be borne by the women, the lack of guidelines or protocols for referrals, and the break down of the communication systems. Transport was indicated as often expensive and patients/clients sometimes opted not to go. Key informants at the national leve, reported that the referral system was not effective because the individual is usually not assisted with transportation, from the community level up to the central referral hospital. Even where transport was offered they have to pay for this transport. In Zambia, the Ministry of Health 2004 report highlighted the lack radio communication equipment and ambulances to take referred cases to the next level of care especially in the rural health facilities, with clients therefore, compelled to mobilize their own transport and financial resources for travelling. As such, feedback for continuum of care is rarely provided to the original site of referral. Evidence on the cases ever referred to other health facilities show a distribution of 87.5 percent for the urban, which is higher than for the rural, with 63.5 percent. Among those who did not refer cases is high in the rural, with 36.4 percent, compared with those in the urban indicating 12.5 percent. The variation could be attributed to the availability of adequate referral facilities, which are more obtainable in the urban than in the rural. Common Conditions Referred to Other Health Facilities The assessment findings show quite significant differences in the common conditions that are referred to other health facilities for high level interventions. Table 36: Common Conditions Referred to Other Health Facilities by Residence in Zambia. Common conditions Residence Total Urban Rural No. % No. % Pre-Eclampsia toxaemia 1 6.3 0 0.0 1 Fetal distress/malpresentation 3 18.7 2 18.2 5 Obstructed labour/prev.c/s/ 10 62.5 1 9.1 11 Induced abortion Cancer of Cervix 2 12.5 8 72.7 10 Total 16 100.0 11 100.0 27
70 The findings show variation in the common conditions that are referred to other facilities between residential settings. Obstructed labour and abortions are the highest common conditions referred in the urban, with 62.5 percent than in the rural indicating only 9.1 percent. By contrast, cancer of cervix is the highest common condition that is referred to other facilities in the rural, with 72.7 percent, which is more than in the urban, with 12.5 percent. However, the differentiated conditions between residences are cancer of cervix, being common in the rural, obstructed labour, abortions and pre-eclampsia toxaemia, which are common in the urban. There are similarities in the occurrence of fetal distress and mal- presentation indicating 18.7 percent in the urban and 18.2 percent in the rural. Variation in condition suggests association with quality health care, unsafe abortion practices and cultural practice, as in the case of rural population.
16. Access to communication mechanism Access to communication mechanisms is another great challenge facing women in accessing quality health care. Communication mechanisms are limited especially rural women. Even though telephone communication may be used as an option for urban areas, a large proportion of rural areas, often with inadequate infrastructure, may only be reached through two way VHF radio communication systems ( please refer to item 3.2.2.2 for details). Lesotho reported that 77.7% of the health facilities surveyed were equipped with one of a two-way radio system (2), telephone (2), or cell phone (2), which used to facilitate referrals through consultations and seeking assistance where essential. At national level, the report was that the two-way radio communication system which had been the norm, linking hospitals to health centres, and facilitated referrals, had to a large extend broken down and needed replacement. The national infrastructure plan included the procurement and replacement of the radio system in the all facilities. However, the progress report indicates that only 40% of the facilities have functioning two way radio communication systems. For Zambia, Radio communication was found to be more available in the urban, with 75 percent responses than for the rural indicating 45.5 percent. More than half of respondents in the rural lacked radio communication links in their health facilities, compared with those in the urban indicating 25 percent. Poor radio communication system evident in some health facilities has a bearing on women’s access to quality health services in health facilities. Effective radio communication system, are life saving , especially in rural settings where there are limited communication options. Table 37: Availability of Radio Communication Links by Residence in Zambia
Availability of radio communication Residence Total links Urban Rural No. % No. % Yes 12 75.0 5 45.5 17 No 4 25.0 6 54.5 10 Total 16 100.0 11 100.0 27
71 17. Access to essential life saving drugs and supplies The study findings were that there was significant proportion of health facilities without emergency life saving drugs for emergency obstetric care. The problem of shortage of essential drugs, though not quantified has been highlighted by other countries as a contributing factor to the poor quality of services and unnecessary referrals. Table 38 below depicts the availability of essential drugs for emergency obstetric care in health facilities surveyed in Lesotho. Almost 40% of the facilities did not have intravenous fluids, and almost half (55.6%) of the facilities had no local anaesthesia. Table 38: availability of essential drugs for emergency obstetric care in health facilities, Lesotho
Drug Proportion of Remarks Facilities (%) Adrenaline 77.8 Analgesics 44.4 Ergometrine, syntometrine 77.8 I.V. Fluids 66.7 Local Anesthesia 55.6 Magnesium Sulphate 22.2 2 Hospitals only
18. Access to diagnostic facilities and services The findings indicate limited access to diagnostic services more especially, those services that are exclusive for women. Similar remarks have been made in other countries. For instance none of the facilities in Lesotho offered mammography services. Pap smear examination was only available in 33.3% of the facilities surveyed. Additionally, despite the high prevalence of HIV/AIDS (30% adults, 42% ANC sentinel surveillance) in Lesotho, HIV testing was limited to 33.3% of health facilities.
Table 39: availability of Diagnostic Facility/Service in Lesotho
Diagnostic Facility/Service Proportion (number) with Remarks Facility Urinalysis 77.8 (7) Full Blood Count 11.1(1) Hospital Pap smear 33.3 (3) 2 Hospitals and 1 HC HIV Testing Rapid 33.3 (3) 2 Hospitals and 1 HC HIV Test Rape Victims 22.2 (2) Hospitals only X-Ray 22.2 (2) Hospitals only Mammography 0 ** Health centers indicated transport blood and other specimen to hospitals for most tests.
19. Availability of Basic equipment and infrastructure The shortage of basic equipment and, supplies compromise the capacity of facilities to offer services such as emergency obstetric care. The quality of care is forfeited and unnecessary referrals are made increasing the cost of health care for women. In this study key informants,
72 facility checks, health workers and women themselves did confirm to the shortage of equipment and supplies and to some extend the existence of dilapidated health infrastructure. In Lesotho, the national level key informants indicated that a lot of equipment in the facilities was not functional due to lack of maintenance and lack of replacement resulting from the inadequacy of funds. The MOHSW review report supports this assertion of lack of equipment and its poor maintenance. Facility checks in Lesotho found shortages of delivery equipment and supplies. For instance Oxygen that is crucial for resuscitation of babies and mothers was only available at hospital level. The sanitary status of a recognisable proportion of health facilities was found to be unsatisfactory with inadequate infection control, even in the delivery rooms. Such a situation may deter service utilisation. Findings from exit interviews in Lesotho, show that only two facilities were considered as having good sanitary amenities. Facility checks found bathrooms and toilets to be in good sanitary condition only in 38% of the health facilities. Major complaints on the poor sanitary facilities were specially made by PLWHAs during focus group discussions who reported that even where sanitary amenities were available, they were usually locked up and inaccessible to patients. In Malawi, women complained of the locking of bathrooms meant to be used by patients. Women reported as quoted "We use maize fields as a bathroom, and men passing by sometimes watch us taking a bath".
20. Availability of information for monitoring women’s health services
Lack of Gender-Disaggregated Data within the Health Management Information System is another major problem identified during the review of national records. Zambia in addition, reported on the lack of relevant gender indicators to show what progress has been made in making the health system gender sensitive.
21. Access to skilled health care attendants Regarding the availability and technical capacity of human resources for health, all the four countries in the study reported the inadequacy of human resource as a critical problem affecting the provision of health care. Human resources for health are the men and women who make health care happen. They include health care professionals, technicians and other paraprofessional personnel, auxiliary health workers, community health workers, practitioners of traditional medicine. Co temporally, the use of community members in the provision of health care has increased. According to the focus groups in Lesotho, the services at community level were provided by village health workers, TBAs, support groups and clinic staff. Of the women interviewed, their primary source of care included village health workers (1.3%) and 0.9% traditional healers, indicating the vital role community based health providers still play. It is important to note that services of TBAs were rarely mentioned in Lesotho. The health sector review report in Lesotho indicates the skewed human resource allocation, with the lower doctor/patient and, nurse/patient ratios in the rural hospitals. It also highlighted the inadequacy of skill by health workers. (Table 39 depicts the study findings on the distribution of human resource in health facilities). Other countries have equally echoed the shortage of staff in health facilities. An assessment conducted in Malawi on the quality of obstetric care in 2003 found that only one midwife was
73 available to provide care for 24 hours at a health facility with an establishment of three workers. Findings from the study in Swaziland, equally point to the critical shortage of human resource, mainly knowledge workers such as doctors and nurses in health facilities. Though not quantified, the skewed distribution of skilled health care providers towards urban settings, and the inadequate capacity in terms of clinical skills, of the remaining health workers, to manage women‘s services especially obstetrical care and abortion emergencies has been highlighted by key informants. The latter, is also documented by ministry of health (MOH) in the Rapid Evaluation Methodology (REM) study which was conducted by the ministry of health and Social Welfare in 1994. Nurses/midwives are reported to be the major providers of women’s health services at community level through health clinics and mobile services. Unlike for Lesotho, the findings from Swaziland point toward the role played by rural health motivators (RHM) and TBAs in the provision of health services at community level. It is estimated that nearly 44% of women deliver at home and are assisted by TBAs. Rural Health Motivators’ duties include condom distribution, making referrals and health education on breast feeding, environmental sanitation, and general prevention of diseases. Table 40: The distribution of human resource in health facilities in Lesotho
Health Number per Number per Health Centre Worker Hospital Cadre #1 #2 #1 #2 GOL #3 CHAL #4 #5 #6 #7 GOL CHAL CHAL LRC LRC Medical Doctor 3 3 1 1 Dentist 1 1 Nurse Clinician 2 0 1 1 1 1 Public Health 2 2 Nurse Registered Nurse 19 21 2 1 1 Nursing Assistant 15 28 1 1 1 2 2 2 1 Counselor 4 5 1 2 1 Pharmacist 0 0 Pharmacy 4 4 1 2 Technician Laboratory 3 Technician Health Inspector 1 1 Health Assistant 1 2
The table signifies that nurse clinicians, nursing assistants and to a less extend registered nurses and councillors are the majority health care providers available at nearly every level of care. It can be concluded that the nursing staff are the main providers of women’s health services in Lesotho. Access to the doctor was only possible at hospital level. Inadequate trained health staff to manage women health services, such as provision of adequate obstetric and gynaecological services is also evident in all the health facilities visited in Zambia. According to the Ministry of Health 2004 report, the number of doctors and midwives working in public health sector has declined over the years and has affected quality care of women and children in the country. It is estimated that there is only one doctor per approximately 14,000 people. Lack of trained medical personnel has increased during the past decades. There has been serious drain of trained medical personnel. The situation is worse as regards nurses, especially midwives, resulting in some wards being closed down in large institutions. The major attributes to this rapid decline of medical professionals is reported to be related to poor conditions of service in public health sector and, the brain drain of medical staff by other
74 countries. Other factors are the voluntary separation scheme implemented in 1978, and loss of skilled professionals due to HIV/AIDS epidemic (Ministry of Health and ILO 2004). Lastly, is the recent phenomenon of freezing recruitment in the public sector as part of the HIPC conditions, which means that even graduates and retired health providers are not eligible for recruitment in health sector. In addition to the inadequate number of personnel, Lack of appropriate skills within the current stock of health workers has also been pointed out. The Zambian Ministry of Health in 2004 indicted that medical doctors lack adequate skills to conduct caesarean section, even when they available at health facility cites, which are equipped with Obstetric emergency facilities. In addition, nurses who lack midwifery training and life saving skills to manage obstetric emergencies skills are the majority of frontline workers. There are a maximum of four midwives in established health centres, so called mini hospitals in an urban setting of Lusaka, while only ten midwives were available in a teaching hospital- a 3rd referral hospital. The poor staffing pattern and lack of appropriate skills in the urban setting has resulted in closure of some maternity wards at the University Teaching hospital (noted at the time of hospital assessment) has affected referral of cases who are seeking further management care at a tertiary level and also for emergency treatment. Poor staffing situation has further affected the rural health facilities. Health centres lack specialized professionals, such as midwives for frontline primary level of care. In all rural health centres assessed, health services for women are provided by nurses and clinical officers, and assisted by auxiliary or domestic staff in critical situations. The staffing pattern varies from one to two trained staff per health facility. Staff shows adequately equipped in a district hospital (as 1st referral hospital) more than in health centres. Poor staffing pattern at health centres has resulted in cumulative of cases seeking health care either at the district hospital or resorting to community care approaches. The findings support the evidence of increased deliveries and postnatal care services being offered in communities or homes more than in clinical facilities. Assessment of health providers’ reproductive health competencies To further explore the parameter of access to skilled attendants, the researcher in Zambia assessed the Knowledge, Skill and attitudes for Performance of sexual and reproductive health related services. The results as tabulated in table 40 show, a wide knowledge on base in certain RH areas and wide attendance of in-service training in reproductive health and child health services, STD case management, HIV/AIDS management and family planning. Nevertheless, gaps in knowledge are observed in some specialized services, such as psycho- social counselling, VCT, PMCT, family planning, management and Syndromic diagnosis and treatment of STDS, with 63 percent of all respondents interviewed. Gender Concept shows a wide knowledge gap of 88.9 percent, compared with other subjects stated as having little knowledge. Only 11.1 percent of all health providers have been trained in gender mainstreaming. The majority of health providers interviewed were qualified professionals, with a distribution of one medical doctor, 4 nurses, and 22 nurse/ midwives who are unevenly distributed in health facilities surveyed. Service record range from 3 to 20 years implying, that the majority of health providers are highly experienced in their field of practice. In addition to exit interviews, data on determining the level of knowledge and skill performance of health providers were extracted by using interview questionnaire, which administered by a sample of 27 health providers. Among health provider, 23 were females and 4 males, which did not seem to affect provision of health services to women in health facilities.
75 Table 40 provides a summary of differentiated knowledge gap in prevention of mother to child HIV transmission (PMCT) management
1. Knowledge of PMCT Management Table 41: Proportion of Health Providers with in-service Training in PMCT Management by residence.
PMCT In-service Training Residence Total Urban Rural No % No. % Not Received In-service Training 6 37.5 7 63.6 13
Training received 10 62.5 4 36.4 14
Total 16 100.0 11 100.0 27
The findings show a significant difference in knowledge gap in PMCT management between residential settings. It indicates 63.6 percent rural, compared with the 37.5 urban for those who did not received in-service training. Among those who received in-service training are higher in the urban, with 62.5 percent than in the rural with only 36.4 percent. There is a high knowledge gap in PMCT management in the rural more than in the urban, and the findings are statistically significant in these differentiated areas. Such knowledge gap can affect the quality of health services and service utilization by women.
2. Knowledge of STD Syndromic Diagnosis and Treatment and VCT Table 42: Proportion of Health Providers with In-service Training in STD Syndromic Diagnosis and Treatment by Residence
STD-In service Training Residence Total Urban Rural No. % No. % Not Received In-service Training 10 62.5 7 63.6 17 In-service Training Received 6 37.5 4 36.4 10 Total 16 100.0 11 100.0 27
The study in Zambia found that there is inadequate knowledge in STD management for both residential areas, with 62.5 for the urban and 63.6 percent in the rural. Very few have been trained, 37.5 percent urban and 36.4 percent for the rural. The findings show no significant difference in the extent of STD training among health providers between the urban and the rural. Lack of knowledge affect quality health care provision and, deter service utilization impacting on the access to health care.
76 Similarly, the assessment of knowledge in voluntary counselling and HIV testing by providers’ participation in training vary between different residential settings.
Table 43: Proportion of Health Providers Trained in Voluntary Counselling and Testing (VCT) by Residence
Trained in VCT Residence Total Urban Rural No % No. % Not Trained in VCT 5 31.3 6 54.5 11 Trained in VCT 11 68.7 5 45.5 16 Total 16 100.0 11 100.0 27
The findings in table 42 show more than half (54.5 percent) of health providers interviewed are not trained in voluntary counselling and HIV testing in the rural, compared with those in the urban, indicating 31.3percent. Most of them who are trained are in the urban. The findings show lack of knowledge among the rural health providers, compared with those in the urban having opportunities for training services. It demonstrates that the rural population is constrained with limited opportunities for training in some essential components of health care services, such as voluntary counselling and HIV testing skills that are lacking. Given the current situations of HIV/AIDS epidemic in the country, it is, therefore, important to ensure expanded training opportunities for all health providers in clinical services areas, especially in the rural, in order to increase knowledge and skill performance that may influence use of health services.
3. Provider’s explanation before examination Providers’ explanation before examination was not adequately maintained in the rural. The distribution show 54.5 percent urban and 20 percent in the rural for ‘yes’ responses to providers’ explanation before examination, while it is 40.7 percent urban and 80 percent rural for ‘no’ responses out of a total 79 female clients who visited health facilities. The general assessment of clinical examinations given to clients show that quality of care is not provided adequately and varies in performance. Several factors are identified, which include, a) providers attitudes, b) in adequate clinic space to provide privacy for female clients and c) lack of communication skills to effect client-provider interaction abilities for clinical care management of female clients. Response to provider’ handling of clients shows some dissatisfaction with clinical care given. It has affected mainly the urban health facilities.
4. Client - Provider interaction In Zambia client-provider interaction was assessed according to the extent to which health providers listen to clients concerns in satisfaction with the health services received and response to client’s questions. Client-provider interaction is an important tool of communication skill to ensure adequate care and influence use of health of health services.
77
Table 44: Provider Listening to Clients Concerns with Satisfaction by Residence
Provider Listening to Client’s Residence Total Concerns with satisfaction Urban Rural No. % No. % Yes 19 32.2 5 25.0 24 No 39 66.1 13 65.0 52 Not sure 1 1.7 2 10.0 3 Total 59 100.0 20 100.0 79
The findings in table 4.2.15 show no attention given by providers listening to clients concerns during clinical care, with high responses of 66.1 percent in the urban and 65 percent for rural. Among those with adequate attention by listening to clients’ concerns were few, with 32.2 percent for the urban higher than in the rural indicating 25 percent, respectively. Those not sure show 1.7 percent for the urban and 10 percent in the rural. Judging from these statistics, it demonstrates that very little attention is given to clients seeking health care in health facilities for both urban and rural settings, and reflects on providers’ attitudes towards clients. However, there is no significance difference in responses between differentiated residential settings. Responsiveness to adequate quality health services was further reflected in providers’ response to clients’ questions in any situations during the visit.
Table 45: Provider’s Response to Client’s Questions by Residence
Provider’s response to Residence Total Client’ s Urban Questions No. % No. % Yes 28 47.5 3 15.0 31 No 26 44.0 15 75.0 41 Not sure 5 8.5 2 10.0 7 Total 59 20 79 100.0 100.0 2 X 6.803, sig. Pvalue 0.033 The findings in table 44 show some positive responses to clients’ questions reflected to be high in the urban, with 47.5 percent, compared with those in the rural indicating 15 percent. Among those with mixed feelings of not being sure indicate 8.5 percent for the urban and 10 percent in the rural. Inability to effective communications with clients to respond to their needs seems to affect those in the rural, when compared with those in the urban. The findings show some significant differences in providers’ responses to the clients’ needs for
78 clarification in relation to questions asked between residences. Given these differential statistics, there is attention to clients’ response to their questions by health providers, indicating some support care provided to urban women more than in the rural, with limited support care to clients during clinic visits. Generally, the observations show that communication among health providers during clinical care is inadequate and barrier to adequate provision of quality health care needed by clients in health facilities. Client-provider interaction determines the extent to which women respond and access to quality health services in clinical care environment. It can affect women’s access to health services. It is important to recognize that communication is an important tool for enhancing service utilization and need to be strengthened in health facilities.
5. Breast examination Women were asked further to relate clinic experience with tasks performed by health providers on whether they were generally examined including breast examination. Very little performance is done to ensure breast examinations conducted among client who visited the clinics. The findings show a distribution of 10.2 percent for the urban, less than for the rural with 25 percent. It shows some concern over breast examination conducted in rural health facilities, unlike in the in the urban.
22. Women` s satisfaction with the quality of health services It was found during the study that there is a general satisfaction by women with the type of services being provided to them. However, issues pertaining to quality still hamper women` s access to health care. When women in Lesotho were asked to classify services at their health facilities in terms of quality, 65.4% thought they were good, 21% indicated they are satisfactory, 11.1% as poor and 2.5% graded them as bad. The results of 13.6 5 (for poor and bad) are almost similar to the those indicated in the 2005 MOHSW sector review report in Lesotho which indicted that 18% of the clients were dissatisfied with the services due to problems in obtaining prescribed drugs, lack of testing reagents, break down of x-ray machines, or because they were beyond the set quota for the day or the negative attitude of health workers. Still in Lesotho, exit interviews indicated the average (mean) waiting time for consultation as 1-8 hours for 50 % of the women and 2 hours for the other half. The negative attitude of health workers was considered as deterrent factor to women` s utilization of health services. All the four countries have reported that long waiting time in health facilities was considered to be a problem for women seeking health services. In Malawi of the 80 interviews, about 68% indicated satisfaction, 24% indicated dissatisfaction while 8.8% were neutral. Women in Malawi suggested improvements in service provision as summarized in table 45.
79 Table45: suggested improvements in service delivery for Malawi
Suggested improvements Frequency Percentage More medicines 22 27.5 More staff 10 12.5 Politeness/friendlier 12 15 Shorter waiting time 15 18.75 Provide free services 0 0 Reduce charges 0 0 Services to be provided on daily 0 0 basis None 21 26.3
Pertaining to the satisfaction with women `s Health Service Visit in Zambia women were asked to state whether they were satisfied with the services offered during the clinic visit. All the respondents, with 100 percent were satisfied with health services provided during their visit to health facilities in the rural, where as in the urban 91.5 percent were satisfied with clinic visit. A minimum percent (8.5 percent) were not satisfied with clinic visit, and affect the urban population. Table 46: Satisfaction with Health Facility Visit in Zambia
Satisfied with clinic Residence Total visit Urban Rural No % No % Satisfied 54 91.5 20 100.0 74 Dissatisfied 5 8.5 0 0.0 5 Total 59 100.0 20 100.0 79
The reasons stated for not being satisfied with the health service visit were related to: •Seeing different doctors every time during the visit seems to affect women’ attitudes towards health service provision.
•Long waiting time. Clients echoed that they are kept for a long time. Long waiting time in health facilities was considered to be a problem for women seeking health services.
•Poor quality health care related to poor performance of health providers in health centres was a problem. Views expressed included, ‘ the nurse did not take the fetal heart beat,’ ‘nurses not paying attention to patients, rude and irritable’ show negligence of some health providers in performing their professional standards of quality of health care, coupled with their negative
80 attitudes towards clients. Clients’ responsiveness to quality health services is likely to be affected. Other explanations stated by some community women during focus group discussions to emphasize on the poor performance and negative attitudes of health providers in health facilities include:
Case 1: ‘I have never seen nurses take a temperature when you complain of fever. They will just give malaria tablets (Fansidar), some times they will tell you that we don’t have thermometers and when you confront them they will tell you to go home.’
Case 2: ‘Services at the labour ward are not good. If you fail short of some requirement, e.g. cord clamps that women are required to bring when going to delivery, you will be told to go back’
Case 3: ‘The attitude of the nurses in the labour ward is very bad. One day, I took a neighbour who became sick while we were attending a funeral, but the way nurses handled us was not good. The nurses told us to go back because we didn’t have the baby layette. I tried to plead with them to allow her to deliver and would bring the things later, but they refused. The woman delivered on the way. I had to break the bottle to cut the cord.’
Case 4: ‘When elderly women go to deliver in labour ward, the nurses shout at them and tell them muleke khubara mwakota (meaning, stop bearing children you are old).’
The above four cases demonstrate that clients are able to evaluate the poor performances and attitudes of health providers that may result in serious health consequences as stated in cases 1,2,and 3. With these explanations, it is possible that many women who have faced such challenges would have resulted in maternal and neonatal deaths due to negligence of health providers. Explanations in cases 1 and 2 show further evidence on shortage of adequate supplies or emergency equipment to manage health services effectively that are experienced by health providers. However, their attitudes and lack of effective communication seem to affect clients accessing health services in health centres or hospitals. The findings, therefore, suggest improvement on quality performance and change in behaviour for health providers. Policy guidelines on maternity requirement for health facilities, given an example of baby layette (see case 3), need to be reviewed to provide flexibility for those who are not able to afford or not provided at the right time.
Access to a private and confidential environment The findings indicate a general satisfaction with confidentiality. Nonetheless, the provision of privacy still remains a challenge. For instance in Lesotho, assessment of these variables through spot checks, indicated that 77.8% of the facilities ensured confidentiality and privacy; 22.2% were satisfactory in terms of confidentiality only, and 11.1% qualified as satisfactory for both confidentiality and privacy.
81 In Zambia, Privacy seems to be maintained in all facilities visited. However, there is a difference observed between residential settings. The findings show adequate privacy to be well maintained by the health providers in the rural health facilities indicating 100 percent higher responses than the urban with 74.6 percent, which gives 25.4 percent with no privacy being maintained. These observations show some significant differences in the extent of adequate privacy between residential settings, with a pvalue 0.012 (see table 4.2.17).
Table 39: Proportion of female clients with adequate privacy by residence
Adequate Privacy Residence Total Urban Rural No % No % Yes 44 74.5 20 100.0 64 No 15 25.4 0 0.0 15 Total 59 100.0 20 100.0 79
The reasons for no privacy reflected in the urban relate to: •There was another client (s) in the room, with 20.3 percent. •Open place for scale and blood pressure (BP) check-up, with 5.1 percent The findings show that presence of another person and open place for examination can affect access to health care provision in health facilities.
82 Chapter 4 4.Summary of key challenges and Conclusions on the responsiveness of health services This study has attempted to assess to a certain extend all the four dimensions of accessibility and brought to light many factors that hinder women’s access to essential services required to meet women’s health needs. Women, especially those living in rural settings have been found t o be surmounting numerous barriers prior to accessing health care. Such barriers are usually in the form of financial hindrances where payment is mandatory prior to service delivery, as is usually recommended in health systems under going reformation a common phenomenon in Southern African countries; social cultural factors that negatively affect their health seeking behaviour and dis-empower them by lowering their social and economic status in society. Other barriers relate to physical hurdles and organisational deficiencies pertaining to the organisation of health systems including health policies, administrative structural processes, technical and human.
Economic barriers (affordability) There is a proportion of women in each country for whom health care costs are a major constraint to accessing health care in all the four countries. The situation appears to be worse for rural women and, is aggravated by increased health care costs due to limited range of basic women’s health services offered locally, compelling women to travel further longer distances in search for care; the women’s poor economic status resulting from lack of employment opportunities as an outcome of the low regard for women in the society and illiteracy; and limited capacity to make decisions at both at household and community level over resource allocation. All four countries indicted that women were required to pay fees to access health services’ with the cost varying from one country to another. Equity demands that poorer house holds are not disproportionately burdened with health expenses as compared to richer households, however the study findings are that, although user fee exemptions policies exist, there are bottlenecks in the mechanisms for putting them in operation. Women lack awareness on the criteria for exemption, and for those who do, lengthy procedures deters them from pursuing the user exemption avenues. Emergency obstetric services are not included in the exemption scheme and women who have failed to pay have been denied access to such services.
Socio-Cultural Barriers Women’s utilisation of health services is not only negatively influenced by their inability to make decisions to seek health care and resource allocation to cover health care costs. It is equally highly influenced by myths, taboos and misconceptions centred on sexuality and reproductive issues as well as cultural practices related to adolescence and puberty, pregnancy and child birth, and widowhood and mourning periods. Some of the practices increase women’s vulnerability to HIV/AIDS too and certain cultural teachings contradict health education messages and BCC strategies.
83
Physical Barriers Long distance to health facilities especially for Malawi and Zambia where almost 2.5 % of the women reported to live further, beyond 10 kilometres, and Malawi where forty percent (40%) of the women reported as having to travel over a distance more than 4 kilo meters to reach a health facility). The status of the road network is reported as poor in most rural areas, being characterised by difficult terrain conditions of hilly places, with seasonal variations where flood becomes a barrier during rainy season. Public transportation is more limited and at a higher cost in rural areas, compared with those in urban settings. The factors of difficult to cross terrain, long distance, very limited ambulance and general transport services, coalesced with the fact that most community based health facilities do not offer delivery services, and that majority of women walk to reach health (56.5% in Lesotho, 61.3% in Zambia and 52% in Malawi) present a great challenge for women seeking access to health care.
Organisational barriers
Organisational barriers compromise the range of services available, and the quality of health services provided to women and contributes to maternal mortality and morbidity. The key organisational barriers and challenges within the health system and related sectors highlighted by this study include:
1. Lack of clearly defined policy guidelines and Strategic Plans for reproductive health services such as adolescent’s family planning services, women’s access to safe abortion services. The identified lack of clear policies and strategies to address persisting sexual gender-based violence in the face of high HIV/AIDS prevalence is a great challenge for women. Health services lack guidelines and protocols, while the law does not provide adequate protection from violence especially by husbands, the phenomena perpetuated by intimidating, patriarchal customary laws. Women, especially those in rural settings lack access to legal aid and civic education. 2. Poor Quality of health Care- affecting access to health services by women in all countries. The poor quality of health care is characterised by several factors such as:
(1) organisational hurdles ranging from lack of clear policy guidelines, resource constraints in the from of inadequate trained health staff to manage women health services; lack of logistic supplies including transport and communication facilities for emergency obstetric cases, essential drugs, medical equipment and supplies; to infrastructure limitations including lack of electricity supply, clean and safe water supplies, and absence of delivery rooms in most rural facilities, compelling health workers to conduct deliveries in outpatients screening room and reducing privacy. Such organisational hurdles have resulted in restricted facility operational hours, limited range of services available, unnecessary referrals of patients and/or, have discouraged women from utilising health services.
84 (2) Limited range of available services including existing difficulties for women seeking HIV/AIDS related services. VCT and ARV services are skewed to urban areas. For example, despite the high prevalence of HIV (30% in adults and 42% among pregnant women), HIV testing was still limited in Lesotho. Only 2 hospitals and one health centre of the facilities in the sample were offering HIV rapid testing. Furthermore, Access to diagnostic services pertaining to cervical and breast carcinoma is documented as limited. Findings from Lesotho bring to light the fact that because of late presentation, cancer of the cervix accounts for a high proportion of referrals to South Africa. While pap smears may be done throughout the country, the quality of slides is often below standard and laboratory capacity to read a high number of slides is limited. Only 33.3% of the health facilities surveyed in Lesotho provided pap smears diagnostic examination. Cancer of the breast accounts for a high proportion of admissions to the female ward but screening and awareness are also low. For instance, no healthy facility was offering mammography services. (3) Existence of service utilisation gaps, due to the existence of a combination of economic, physical, socio-cultural and operational/organisational barriers brought to light in this by this study. Some available services are still under utilised for instance, emergency obstetric and delivery care, post natal care, family planning and VCT services. For example, the study found that in Swaziland a substantial proportion of women (44%) deliver at home increasing the probability of maternal deaths and morbidity. The provision of reproductive health services for female adolescents and youths is still limited and not user friendly. Under utilization of family planning services was reported in the study. For instance, more than half (58.5%) of the women in Lesotho were not using a modern family planning method. (4) Negative attitude of Health providers towards management of health services for clients is another dimension affecting women’s access to quality health services. Some women felt that health providers have negative attitudes towards care of women. Use of abusive language by some staff (rude and irritable), not performing accurate prescribed tasks required in the management of delivery care and general care and sending patients back are some of sentiments expressed by women during focus group discussions, household and exit interviews. Attitude of midwives towards delivery care in labour wards was indicated to be very bad in urban health facilities more than in the rural. (5) Lack of privacy in the management of clients is another factor affecting women access to health services in facilities. Women dislike presence of other health personnel when being examined. Further more, maintaining confidentiality in dealing with cases of HIV/AIDS, and, sexuality issues are found not being conducive in a health facility environment. The desire to enhance privacy was highly emphasised by women. (6) Lack of Gender-Disaggregated Data within the Health Management Information System is another major problem identified in the review. Relevant gender indicators to show what progress has been made in making the health system gender sensitive are lacking. (7) Lack of the participation of women, especially rural women, in issues pertaining to service delivery or for addressing ills that affect women` s
85 health despite the fact that women dominate most support groups and could be PLWH In conclusion, the findings of this multi-country study show similarities to the gaps in service delivery highlighted by literature even though the study was conducted in a different kind of crises situation indicating the need for re-examining current strategies. The contribution of this multi-country study is that it provides added empirical data for use by principal stakeholders such as governments, UN agencies, bi-laterals and NGOs the prospect to facilitate the re-evaluation of existing policies, strategies, competences and institutional arrangements for addressing reproductive health needs of women in low income crises settings.
86 Chapter 5
RECOMMENDATIONS
1. Policy Review to identify inequities and facilitate the development of Policy Guidelines related to women’s health and rights to enhance access to health and social services for women. Such actions to include: ¾ Revision of health policies as well as interventions aimed at the prevention and treatment of diseases affecting women to put into consideration significant existing socio-cultural norms and practices. For instance, men who are the main decision makers at house hold level should be more involved in the planning and implementation of women’s health services such as family planning services. Information, education and communication and BCC strategies to be equipped with locally relevant messages and materials tailored to overcome conflicting health risk messages contained in local socio-cultural norms and practices that deter service utilisation and diminish the impact of health education and promotion. ¾ amendment of existing user fee exemptions policies to incorporate patients seeking emergency obstetric care, and HIV/AIDS related services such as VCT in the category of conditions exempted cases/conditions in order to increase coverage and health care accessibility and reduce health risks leading to high maternal mortality and morbidity. Where such arrangements exist, measures should be taken to reduce the level of bureaucracy. ¾ Redefinition of policies governing reproductive health service delivery and HIV/AIDS related services, especially those for adolescents, including family planning and Safe Abortion Services, and development of operational guidelines to achieve more effective interventions and make them more accessible and user friendly. Women and girls suffer or die from complications performed under health hazardous conditions to terminate pregnancies they did not want. The desired fertility in the region is considerable lower than actual fertility, which remains high at 5-7 children per woman in most countries11 ¾ Modification of health policies as well as interventions aimed at the prevention and treatment of diseases affecting women to take into consideration significant existing socio-cultural norms and practices. For instance, men who are the main decision makers at house hold level should be more involved in the planning and implementation of women’s health services such as family planning services. Social marketing programs for instance, Information, education and communication and BCC strategies to be equipped with locally relevant messages and materials tailored to overcome conflicting health risk messages contained in local socio-cultural norms and practices that deter service utilisation and diminish the impact of health education and promotion. ¾ Alteration of health delivery strategies to facilitate the provision of women’s Health services as close to the families as possible through
11 Repositioning family planning in Sub Saharan Africa, July 29, 2005
87 decentralisation, in order to minimise constraints that curtail women’ access to health services, such as those associated with physical distance, travel costs, high attrition of human resource. Initiatives supporting community based health service delivery schemes like community based distribution of family planning supplies and capacity building of community health workers including support groups, village health workers, and traditional birth attendants should be promoted. Traditional birth attendants still play an enormous role in maternity care especially in Malawi and Swaziland. The capacity of community Support Groups- for economic sustainability, support care for PLWAS and, orphans, widows and elderly persons by gender, and victim support for sexual gender and domestic violence should be improved. ¾ Establishment and implementation of a minimum essential women’ s health service package embracing management of rape, and HIVAIDS related services, and a minimum service standards including sanitary amenities by Health policy, planning and implementing authorities, as benchmarks in all health facilities to guarantee higher coverage and quality of health services provided to women. The Integrated Management of Pregnancy and Child Birth in Health initiative can be replicated to other countries where it is not in current practice with lessons learnt from Zambia. ¾ Establishment of clear policies, strategies, guidelines and protocols to address persisting sexual gender-based violence in the face of high HIV/AIDS prevalence alongside the provision of health services guidelines and protocols as well as instituting surveillance systems to capture community based data on the magnitude, characteristics, and consequences of SGBV including the estimation of annual disability life years (DALYs).
2. Empowerment of women and shifting fundamental perceptions, through expanded civic education programs for men and women, on human rights, including their right to health (care), and freedom from violence should be promoted with intensive education and social mobilisation involving community leadership and structures, addressing specific issues contravening cultural norms, beliefs and practices. Country programs including those aimed at improving women’s health should be deliberately designed to actively seek and involve as well as ensure women’s participation on issues relevant to their health. Best practices on community based approaches such as community involvement in health care provision, through neighbourhood health committees to oversee health activities initiated in Zambia and actions taken by NGOs to promote women’s rights and access to legal and social protection for instance through victim support groups and legal clinics should be replicated in places where there are non- existence including reinforcing peri-urban and rural services.
3. Building the capacity of the human resource for health to increase the quantity and quality of the current stock to improve the quality of care provided to women. Human capacity development should involve the creation of management systems to enable governments and health care organisations to effectively respond to human resource crises12.Such efforts should include addressing policy and financial requirements, improving human resource management, instituting recruitment processes,
12 http://.msh.org
88 development of effective retention schemes to reduce the urban biased skewed distribution, and establishing of in service training programs to improve attitudes, skills and knowledge base of health providers in the management of women’s health services such as PMCT, VCT, STIs and SGBV and gender main streaming where knowledge gaps exist. Such efforts should be mainly targeted to Nurses/midwives who have been reported in this study to be the major providers of women’s health services at community level through health clinics and mobile services, and community health workers and volunteers such as rural health motivators, support groups, village health workers, and traditional birth attendants who play an equally vital role at community level.
4. Instituting systematic improvements to develop institutional capacity pertaining to basic infrastructure, equipment, transport and referral facilities and medical supplies necessary for the delivery of quality minimum essential package of women’s health services.
5. Conduct further research in grey areas related to gender aspects of Health policies of policy especially in resource allocation, and impact of funding initiatives, health reform programs and initiatives on the health vulnerable groups like women and girls.
6. Establishment of mechanisms to monitor women’s health issues such as women’s advocacy desk and for a within the ministry of health.
89 Chapter 6 SOURCES AND REFFERENCES
1. Kimane et al (1999), the behavioural survey report by Sechaba consultants for the ministry of employment and labour, Lesotho. 2. Reproductive Health Services for Refugees and Internally Displaced Persons, Report of an Inter-agency working group on RH, Global Evaluation 2004, p2 3. Therese McGinn, Sara Casey, Susan Purdin and Mendy Marsh, HPN Network Paper, Reproductive health for conflict-affected people: policies, research and programmes, no. 45, April 2004, p5 4. Reproductive Health Response in Conflict (RHRC) Consortium Conference, Reproductive Health: From Disaster to Development, Proceedings, October 7-8, 2003, Brussels, Belgium 5. Sara Longwe and Roy Clarke, (1999) African Leadership Forum, Towards improved leadership for women` s empowerment in Africa 6. UNAIDS, WHO (2004) Guidance on ethics and equitable access to HIV treatment and care, 7. http://un.org/esa 8. UN Human rights Website- treaty database- document C distribution general E/C:12/2000/4 9. UNAIDS (2003) Handbook on access to HIV/AIDS- related treatment A collection of information, tools and resources for NGOs, CBOs, and PLWHA groups. Geneva Switzerland. 10. WHO (1997) care of the mother and baby at the health centre: practical guide 11. WHO, (2004) HIV/AIDS care and treatment, guide for implementation, Geneva Switzerland. 12. WHO, (2005) Southern Africa multi-country case study reports Lesotho, Malawi, Swaziland and Zambia, Geneva Switzerland.
90 ANNEXES Annex 1: Measuring the responsiveness of women` s health services. Conceptual Framework: Variables identification and relationship links to Women’s Quality Health Care Access Variables that were measured related to the concept paper, with only a slight adjustment to suit the local condition of Zambian women population. This considered some variations in the identification of variable measurements between countries of study. These are as follows: 1. National Health Systems and Policy Development Measurement The variables for measurement have been classified as follows: Effects of decentralization, hospital autonomy and, SWAP- determines the impact assessment of decentralization, hospital autonomy and the Sector Wide Approach of Planning (SWAP) on quality of health services for women. The measures for this variable are determined by estimations of morbidity and mortality rates for women’s health status and utilization rate of health services by women with different conditions. Other measures are proportionate of activity based resources utilization in relation to strategic plans at national, district and community level, including the functioning of community structures, such as neighbourhood health committees (NHCs) to oversee the delivery of women health services at community level and type of support. Proportionate of case-management quality control in relation to standards for a hospital set-up and recovery rate, including safety of environment and adequate equipment, supplies and specialized professionals to manage acute and chronic conditions were estimated. Measures of level of governance (i.e. extent of decision-making and decision making space) in relation to Hospital Management Board (HMB) authority to oversee recruitment, dismissal and procurement of equipment/supplies for the management of hospitals are examined to determine effects on quality of health services for women. Others include, management in- puts and out-puts for hospital autonomy facilities and decentralized health services. Level of hospital autonomy policy is estimated by proportion of hospitals with autonomy of quality health services in relation to total hospitals for public sector. Human resource development capacity – is another major factor affecting women’s access to quality health services. The assessment of human resource capacity for women’ s quality of health services were measured through estimation of staffing level by cadre at different level of health care facility for public sector, Mission and private. This included estimation of staff ratio per population of women in reproductive ages. 2. Health Service and Related Measurements (Policies, Strategies and Resources) Health services and related measurements were classified as: Status of health facility infrastructure for women, which include accessibility to surgical facilities: gynaecological and obstetric conditions (i.e. caesarean section, minor and gynaecological procedures/barriers for health service delivery. Referral system: policies and services. Availability of health facility basic infrastructure, logistics and environment Accessibility to diagnostic facilities and services: i.e. rapid HIV testing, mammography, pap smear, pelvic examination, laboratory and radiography tests. Knowledge and quality performance of health providers
91 Perceptions of socio-cultural norms and practices inhibiting health service utilization and quality performance of health provider. Adequacy of Health facility human resources Sexual and gender based violence: Psycho-social counselling and support service availability and adequacy Existence of health information management system (HIMS) for monitoring and evaluation of women’s health status. Measures for the above variables with emphasis on some of the factors affecting maternal health service utilization especially Infrastructure and logistics limitations. Infrastructure and logistics - measurement is estimated by proportion of health facilities providing quality of health services for women in relation to total facilities for public sector, private and mission. Other measures included, adequate space, proportionate of equipment, supplies and drug stock level. 3. Community Level Measurements Community level measurement are presented and discussed under the following variable main themes: I. Economic Variables: The economic variables for measurement include: o Affordability of health service cost (i.e. user fees scheme contribution in the Zambian context). o Penalties of non-payment o Effect of user-fees scheme on health financing o Economic status of women o Gainful employment opportunities o Decision- making on resource allocation, and o Community partnership in health: empowering women •Affordability of user fees scheme contribution- is a major factor not much documented and affects women’s access to quality health services. The variable is measured by estimating the proportion of women with income inability in relation to those contributing to cost-sharing scheme. Other indicators are: estimation of amount of fee-payment in relation to type of service or visit, type of family members benefiting from the scheme, Amount of cost of drugs (if known), travelling cost and reaction /response to cost-sharing scheme. •Penalties of non-payment- are measured by proportion of women exposed to failure of not contributing to cost-sharing by those accessing health services, types of penalties and reaction of women to non-payment. •Effect of user fees scheme on health facility financing- is to determine cost-sharing scheme contributions in improving quality of health services for women in health facilities (i.e. estimating the impact on health financing). The variable is measured by estimating proportion of user fees contribution to total health facility budget on women’s health, user fees utilization rate by type of activity for health facility improvement, and response to user fees utilization in health facilities. This indicator seeks possible solutions for improving use of cost-sharing scheme in health facilities.
92 •Economic status- measures proportion of women in gainful employment or engaged in income-generating activities for economic sustainability. Other measures included status of living condition/occupation by type and level of income support per month. •Gainful employment opportunities for women in communities- This variable determines existing job opportunities for women by type and sources of providers. The variable is measured by estimating the proportion of employment opportunities for women by type in relation to gender and determining community and women reaction and reasons for availability of such opportunities. •Decision-making on resource allocation-The variable is measured by estimating proportion of women with ability to make decision on resource allocation, type of person responsible for decision-making in a household and reasons for/and reaction to such a decision. •Community partnership in health: empowering women- is recognized as a great challenge for improving women’s health. Effective collaborative mechanisms for empowering women’s groups through generation of micro-credit schemes have a self-multiplying effect on women’s income status to gain access to health and education of their family members. This variable is measured by estimating the proportion of women exposed to micro-credit scheme in relation to use of quality services and affordability of cost-sharing scheme, type of income generating activities and sources of support, and their reaction to this approach. II. Social Cultural Variables •Cultural norms- that encompassing taboos and belief system and customs affecting reproductive behaviour in relation to adolescence and sexuality, pregnancy, childbearing and child spacing, and widowhood and sexual practices have been documented e.g. in Zambia (UNFPA 2002; Likwa Ndonyo 2003). Measured through response or reaction to effects of traditional practices on women’s health status is also estimated. •Decision-making and hierarchy systems of gender roles- are other factors influenced by the cultural values of societies. Women with low education status and residing in rural areas, for example, are less likely to be attended by skilled health care providers, but would opt for untrained birth attendants. The assessment examines further social cultural norms (taboos, customs and beliefs) by estimation of women seeking traditional health care services in relation to specified conditions, types of cultural norms and reasons for practice. Response or reaction to effects of traditional practices on women’s health status is also estimated. •Community social/legal systems- for women’s protection against sexual and gender based violence and harmful traditional practices, such sexual cleansing and child defilement are measured by estimating proportion and types of community legal systems for women’s protection. Other measures include reaction and reasons for such legal systems against gender sexual and gender violence, including sexual cleansing and girl-child defilement practices. III. Physical Access Barriers The barriers to accessing reproductive health in particular, delivery and emergency obstetric care services for most women. However, gaps in their measurement still exist and require a further exploration to provide a better understanding of effects on women’s health status. •Distance to seek quality health services- is a major barrier for timely arrival at health facilities. Major obstacles faced by women are associated with difficulties for accessing financial support or permission from their partners and other family members who have major roles in controlling reproductive health and rights of childbearing women in communities. Delay in decision or rather decision-making on choice of health services is another attribute
93 that affects women’s access to quality health services or resisting women to see health care, as permission has to be granted from higher authorities. Alongside with this attribute are cost of travelling, time spent to reach a nearest health facility and terrain condition of geographical setting. The study assessed this factor through women’s and key informants’ reaction to distance, mode of transport and estimation of cost of travelling, to provide estimation of mean travelling time to nearest health centre, first referral hospital and referral health facility offering emergency obstetric and surgical services. •Community emergency mobilization system- is another measurement that determines the existing emergency facilities for handling obstetric conditions in communities. The variable was measured by estimating availability of ambulance services in communities and sources of support (i.e. through government, private sector, NGOs or community initiatives), proportion of women exposed to such facilities for the current conditions. Cost of ambulance services and community/women’s reaction to facilities are explored to determine the reasons and possible solutions to handling of community emergency mobilization system for the welfare of children and health status of women. •Waiting time- is measured by time taken for the ambulance to arrive and reaction to duration of time, which will be explored by reasons to satisfaction or dissatisfaction of ambulance service at community level. •Community health and social services for women- examine a category range of varied health and social services, which are provided at community level. Health services provided to women include: Integrated management of pregnancy and childbirth (IMPC) encompasses pregnancy, childbirth, postpartum and newborn care, including family planning such as community based distribution (CBD) of family planning commodities (contraceptives and condoms), Information, education and communication Mental health to include psycho- social counselling and VCT Home based care (HBC) for women living with HIV/AIDS (WLWHAS) Adolescent health (such as peer education on AIDS education, STIs, family planning and maternal health IV. Social Services: Management of sexual and gender based violence Support services/include Insurance schemes for vulnerable groups i.e. girls and PLWA. The range of health and social services were measured by determining mode of provision- static or mobile services, proportion of women accessing community services, sources of support, response and reasons for utilizing community health services (table 1: 6). •Family planning accessibility – was measured by estimating prevalence rate in relation to proportion of women accessing modern family planning services by type of contraceptive brand offered at health facilities and at community level (through static, mobile or CBD). Response/reaction to family planning services has been estimated by determining the proportion and reasons for satisfaction and dissatisfaction of services and solutions to improvement of quality of family planning services (Table 1:6). •Availability and quality performance of skilled health care attendants
94 Measuring availability and quality performance of health care providers has been determined by estimation of proportion of women accessing community services by type of service, and their perceptions of quality. This variable was measured by estimating reasons for satisfaction and none satisfaction of services provided by CHWs. Other measures included estimating the proportionate of CHWs actively involved in community health services by type of activity.
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Annex 2: Reporting format that was provided to the researchers to provide guidance.
WORLD HEALTH ORGANISATION
Reporting format for consultants reporting back on country studies on the quality and responsiveness of health services to meet the needs of women in crisis settings
Introduction
The envisaged participatory, country-driven methodology assessment focusing on the following countries Botswana, Lesotho, Swaziland, Malawi and Zambia is expected to yield the following out puts:
a) Specific analysis, directory/databases of resources and recommendations in the target countries that can be used by United Nations country teams (UNCT s), and partners for follow-up programs to improve women's access to health care. b) A prototype health-for-women access assessment tool. c) Contracted consultants are required to conduct necessary literature reviews including an assessment of prevalent national policies, legislation, and health and social services' plans. Each will carry out consultations with service policy makers and providers, actual or potential service beneficiaries, and other stakeholders.
Possible sources of data include: • Secondary data include National DHS, WHS and other reports from government ministries, organizations and institutions whose work contribute to women` s health. • Primary data can be collected through interviews with key informants such as policy makers, health care managers, frontline health workers; interviews and focus group discussions (with community health care providers, women (as health care beneficiaries) and women's groups, including women living with HIV/AIDS); Observation/ facility checks and record reviews at health (primary, secondary and tertiary) facility levels.
REPORT STRUCTURE
The final report should be constructed as follows:
i Acknowledgements ii Table of content iii List of tables and figures iv Acronyms v Concepts and definitions vi Executive summary
Chapter 1. Introduction
1.1 Background (Country socio-economic and demographic profiles including sex-disaggregated data relating to mental health, reproductive morbidity including STI, HIVAIDS, SGBV ) 1.2 Objectives of the study (information is provided in the project concept note available at the WHO country office) 1.3 Structure of the report
Chapter 2. Literature review Presentation of results from the literature review including the review of national policies, legislation, and health and social services ` plans.
Chapter 3. Methodology
3.1 Sampling 3.1.1 Probability sampling techniques for selecting measurement units in the collection of quantitative and non probability techniques for collecting qualitative data from service providers, actual or potential service beneficiaries and key informants.
96 3.1.2 Stratification The methodology should indicate a multi-stage random sampling method incorporating different characteristics including where possible, urban, peri-urban and rural settings, geographic, cultural and administrative regions, all health care providers (private, public, NGOs and volunteers). Where this is not possible, stratification of residential settings as urban and rural for easy accessibility can be done including communities according to distance in addition to health facility characteristics determined by some scale of measurement. 3.1.3 Sample size determination (Formula, sampling error, significant level, coverage or details of sample. 3.2 Description of data collection methods 3.3 Data processing and analysis indicating the statistical software used (preferably SPSS where available) and content analysis techniques for qualitative data. 3 .4 Limitations of the studies e.g. on sampling, data collection e. t .c.
Chapter 4. Data presentation
Key findings on constraints and challenges to women` s access to health and basic services
COMMUNITY LEVEL
4.1. Economic factors and impact of health care financing
4.1 .1 Affordability of health services by women in comparison to their income in line with cost sharing or fee paying schemes (user fee contributions ) Proportion of those whose income disables them from affording user fee payments obtained through personal interviews. Penalties for non- payment Focus group discussions Women’s access to resources (time, finance, transport) 4.1.3 Perception women of the magnitude of poverty and food insecurity and on factors contributing? Focus group discussions
4.1.4 Women’s occupations and level of education. Personal interviews. 4.1.5 Opportunities available to women for gainful employment? Focus group discussions and personal interviews.
4.1.6 Women` s capacity to decide on resource allocation? Focus group discussions and personal interviews.
4.2 Socio-cultural factors
4.2.1 Socio-cultural norms (taboos, customs, beliefs) that discourage or inhibit health service utilization such as those relating to the roles of women, mobility and women` s share of family income? Focus group discussions
4.2.1 Available social/legal systems for protection of women against sexual and gender based violence? Focus group discussions and personal interviews.
4.3 Physical access barriers (community focus group discussions)
4.3.1 Average (mean) distance to nearest health centre
4.3.2 Average (mean) distance to nearest First referral hospital 4.3 .3 Average (mean) distance to a referral health facility offering emergency (including surgical) obstetric services
4.3.4 Availability of ambulance services for emergency obstetric cases?
4.3.5 Affordability of ambulance services (where there cost- sharing schemes exist)?
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4.3.6 Average (mean) waiting time for ambulance services?
4.3.7 Availability of systems or community mechanisms for the provision of transport for emergency cases (including emergency obstetric cases) to the nearest health facility?
4.3.8 Range and quality of health/ social services (mobile or static) available to women and girls at community level (such as RH, VCT, ART, IEC and mental health, community home based care and management of SGBV ? Focus group discussions and facility visits
4.3.9 Proportion of women who have accessed such services to family planning services (personal interviews)
4.3.10 Availability of trained community health workers or volunteers including trained traditional (skilled) birth attendants at community level? Ratio to population of women in the child bearing age.
4.3.11 Access to sanitary facilities? Proportion
4.3.12 Access to safe water supply? Proportion
4.3 13 Access to food Aid (where applicable)?
NATIONAL LEVEL
4.4 Factors related to national health system and policies Interviews with health care managers, frontline service providers at peripheral level and women as care beneficiaries and other relevant stakeholders.
4.4.1 Impact of financial resource allocation criteria on the quality and availability of services for women? Effect of decentralization and hospital autonomy on the quality women` s health services? (where applicable) 4.4.2 Effect of SWAP on the quality women’s health services?
4.4.3 How the issues of contracting out health services affect the quality and availability of services relating to women` s health? (where applicable) 4.4.4 Effect of Policies on eligibility for health services e.g. ART on women` s access to health services.
4.4.5 Effect of Policies on eligibility for exemption to user fees payment on women` s access to health services on women` s access to health services
4.4.6 Fora (forum) for participation (or voice) of women concerning issues pertaining to service delivery including women living with HIV/AIDS 4.4.7 Availability of national fora (forum), deliberate policies and/or monitoring bodies to address ills that affect women` s health? 4.4.8 Effectiveness of statutory, customary and by-laws enforcement of (e.g. by the police, judicial systems) meant to offer legal, physical and social protection to women and girls? Community focus group discussions and interviews with women` s pressure groups or NGOs, key informants from the legislative, judiciary bodies
4.4.9 Availability of civic education on women` s (human) rights related to Sexual and gender based violence and gender related inequalities? Community focus group discussions and interviews with women` s pressure groups or NGOs
4.4.10 Access to legal representation in matters related to Sexual and gender based violence? Community focus group discussions and interviews with women` s pressure groups or NGOs, key informants from the executive, legislative, judiciary bodies.
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4.4.11 Availability of national policies, guidelines and protocols for the prevention, and management of Sexual and gender based violence victim? Interviews with key informants, record review, and spot checks
4.4.12 Availability of Health Information Management Systems (HIMS) that capture (sex- disaggregated) data for the comprehensive monitoring and evaluation of the status of women` s health services including SGBV (data in addition to maternal morbidity and mortality records). Record review, and physical checks.
FACILITY LEVEL
4.5 Factors relating to service delivery level (policies, strategies, and resources)
4.5.1 Existing referral service policies that prevent women from accessing health services such as the requirements of women to obtain referral letters from primary care providers to seek the 1st or 2nd referral level; and matters relating to eligibility for referral? Interviews with health care managers, frontline service providers at peripheral level and women as care beneficiaries and other relevant stakeholders .
4.5.2 Barriers in accessing health services pertaining to opening and closing time? Determine average (mean) waiting time (for consultation, medication, hospital beds , referral services including emergency obstetrics case management and transportation). Focus group discussions and exit interviews
4.5.3 Health facility basic infrastructure, logistics and environment embracing concerns associated with: a. Availability of Privacy and confidentiality? b. Availability of life saving drugs? Record stock-outs including those for ART (e.g. proportion of HIV positive women on ART whose treatment has been interrupted due to drugs being out of stock)? Record review. c. Availability of basic equipment in addition to basic essential RH package? Physical facility spot check d. Availability of sanitary facilities? Interviews with health care managers, frontline service providers and other relevant stakeholders at peripheral level, Focus group discussions and exit interviews with women as care beneficiaries e. Availability of communication mechanisms such as radio for referral and emergence assistance?
4.5.4 Availability of, and access issues related to diagnostic facilities and services including HIV Testing ( as well as rapid HIV testing for rape victims), mammography, pap smear, pelvic examination, laboratory test such as total blood count e. t. c. (data collection same as above)
4.5.5 Availability of IEC services such as HIV/AIDS knowledge ( prevention and treatment- ART, family planning including emergency contraceptive regime, STI, PEP, body knowledge e. t. c. (data collection same as above)
4.5.6 Scope and quality of health services (Reproductive health, VCT, ART, mental and social services including child services (estimates of coverage) and safe blood transfusion (assess to blood within 24 hrs) offered to women at facility level and/or community level. Interviews with health care managers, frontline service providers and other relevant stakeholders at peripheral level Records review and physical facility spot check.
99 4.5.7 Response of health care providers to Socio-cultural norms (taboos, customs, beliefs) that discourage or inhibit health service utilization? Interviews with health care managers, frontline service providers and other relevant stakeholders at peripheral level
4.5.8 Availability of psycho-social counselling, mechanisms for confidential complaints and other support services for victims of gender based violence. (Data collection same as above)
4.5.9 Availability of policies, guidelines and protocols for the prevention, and management of Sexual and gender based violence victim? Records review and physical facility spot check.
4.5.10 Availability of human resources ( skilled health workers and specialists such as doctors, midwives, gynecologists, obstetricians, psycho- social counsellors, social worker e. t .c Estimates of ratios of specific health cadres e.g. midwives to population of women in the child bearing age, (Records review) and/ or median waiting time required to see a gynecologist). Interviews with health care managers, frontline service providers and other relevant stakeholders at peripheral level Focus group discussions and exit interviews with women as care beneficiaries
4.5.11 Inhibition of access due to ills pertaining to health workers` Attitudes (including sex, cultural biases; and general insensitivity to the plea of women) Focus group discussions and exit interviews with women as care beneficiaries
4.5.12 Availability of Health Information Management Systems (HIMS) that capture data for monitoring and evaluation of the status of women` s health services in totality including GBV (sex-disaggregated data in addition to maternal morbidity and mortality records). Records review and physical facility spot check.
Chapter 5 . Organizations providing health and basic social services to women
Chapter 6. Recommended components of a health assessment instrument that would be considered locally relevant and useful (incorporating feed back from country level post-assessment meeting)
Chapter 7. Recommendations for action to increase women’s access to health and related basic social services, in the specific National context. Chapter 8. References
Chapter 9. Appendices 9.1 Questionnaires 9.2 Tables and figures 9.3 Other relevant materials
100 Version 2/30 October 2004
Annex 3: Project administration To establish an evidence base on challenges to women’s health, a participatory, country- driven, multi- country study was conducted in Botswana, Lesotho, Malawi, Swaziland and Zambia. The selection of the countries was done following consultations with the Africa regional office. Following project communication and the establishment of communication channels at regional and country level, the selection of a national expert (consultant) was conducted in each country through the WHO acting on behalf of the UN country team and the national government. The selection was made based on the terms of references drawn by WHO, HQ and the Africa regional office (AFRO), RH/ women’s health directorate. Consultants were contracted for a period of 20 days which was later extended on behalf of WHO based on the Agreed performance of Work (APW) (Refer for terms of reference in annex ii for details).
Technical support was granted to consultants from all the three levels of WHO (country, regional and HQ) through out the planning and implementation phases of the multi-country study. A participatory approach was followed in establishing consensus in the development of study design, methodology, assessment instruments, measuring indicators, reporting format, and, in the synthesis and outlining of the final country reports.
Supervision of the work of the consultants was steered by Women’s health adviser in each country under the delegation of the WHO country representative with support from WHO regional office and Head quarters.
101 Annex 4: PROJECT CONCEPT NOTE: ASSESSING HEALTH ACCESS FOR WOMEN IN THE SOUTHERN AFRICAN CRISIS
Preamble
As a follow up to the ongoing work on gender and health (gender based health risks) undertaken at country level and regional level within Africa, a broader analysis of women` s access to health care in crisis is now being developed. This note describes some preliminary work with the hope that colleagues in AFRO as well as HQ will support the work at country level.
Context
1.In early 2004, UNAIDS provided US$ 50,000 to WHO for the purpose of developing an appropriate instrument to assess the quality and responsiveness of health services to meet women’s needs in crisis settings. This is seen as a preliminary component of a potential interagency global programme with the goal of preserving and promoting the health of women and girls in crisis and post crisis recovery situations.
2.The problem addressed is that the health and well-being of women and girls (and children) suffers most in disasters and conflicts, and their additional needs do not receive due attention from humanitarian and other service providers. These special needs derive from the vulnerability of women and girls to sexual and gender based violence, reproductive morbidity, sexually transmitted infection including HIV, mental distress, and gender-related inequalities that impact on the health and nutrition of women. Apart from the evident need to address women’s' rights to protection and services to which they are entitled, women’s' ill-health has severe adverse consequences for families and communities, as women are often the principal carers or/and providers in many crisis settings.
Background to project
3.This project was initiated in August 2004 but had to be re-designed in October when the initially recruited consultant expert withdrew for personal reasons, without having completed any of the outputs of the consultancy.
4.In reformulating the project, it has been decided to focus on Southern Africa because it is more feasible to achieve useful outputs with limited available funds in a relatively homogenous sub-region. The crisis there is characterised by the so-called "triple threat" of poverty and food insecurity, weakened governance capacity, and HIV/AIDS prevalence rates which are the highest in the world. This project intends to capitalise on other important developments in Southern Africa that provide a potential framework to carry forward the ideas generated, beyond the limited project timeframe. This framework is provided by the recommendations of the Secretary General's Task Force on Women, Girls, and HIV/AIDS in Southern Africa which are being advanced across the sub-region. Additional stimulus is provided by the parallel follow-up work from the missions of the Secretary General’s Special Envoy on Humanitarian Needs in Southern Africa (Jim Morris) and the Secretary General’s Special Envoy on HIV/AIDS in Africa. (Stephen Lewis).
Project Approach
5.A participatory, country-driven methodology is envisaged. It is suggested that the project will focus on the following countries, which face similar concerns: Botswana, Lesotho, Swaziland, Malawi and Zambia.
6.In each country a member of the womens health consortium (eg. country offices of WHO, UNAIDS, or UNFPA or other interested agencies in the UN Country Team) would be requested to identify a national expert to conduct a study (estimated time requirement 20 days) on the status of womens' health and their access to health services. Consultants will be expected to conduct necessary literature reviews including an assessment of prevalent national policies, legislation, and health and social services' plans. They will carry out consultations with service policy makers and providers, actual or potential service beneficiaries, and other stakeholders. A draft format for reporting will be provided to each consultant that will, inter alia, require feedback on: a) local organisations providing health and basic social services to women b) key constraints and challenges to women’s access to health and basic services c) recommended components of a health assessment instrument that would be considered locally relevant and useful d) concrete recommendations for action to increase women’s access to health and related basic social services, in the specific national context.
7. The national reports will be synthesised into a sub-regional report. Subsequently, a sub-regional meeting (including the 5 participating countries and others in the sub-region if resources permit) will be convened jointly by WHO and UNAIDS to review the experience and distil key conclusions and draft a prototype womens health services assessment instrument.
8. In summary, the main outputs will be a) specific analyses, directory/databases of resources, and recommendations in the target countries that can be used by UNCTs and partners for follow-up programmes to improve women’s access to health care. b) A prototype health-for-women access assessment tool. c) Insights for the design or evolution of the potential interagency global programme on women’s health in crisis situations.
102
Table 1: Variables and Operational Indicators Variables Operational Indicators ζDependent Variable (s): •Quality of health services •Effectiveness in relationship to staff performance and outcome measured by disability –adjusted life expectancy (DALE) or proportion of those dying to recovery-as health attainment level •Efficiency in provision of health services in relation to average level of satisfaction, with timing of services for attendance/ average and proportion of resource allocation to achieve output. •Provider/client ratio •Availability of equipment /supplies/space • Level of Responsiveness to health services •Types of responses in respect to: dignity, autonomy, confidentiality, prompt attention (timing), quality of basic amenities, access to social support net- works during care and choice of care provider •Response distribution in relation to reasons to various reactions Independent Variables: a) National Health systems and policy Develop. •Efficiency of Health Financing •Proportion of government financial resource allocation and expenditure on health systems development i.e. for decentralization of health services and hospital autonomy of delivery care •Proportion of government financial resource allocation on women’s health service activities in relation to total health budget in public service and NGOs •Criteria for financial resource allocation •Adequacy of financial resource allocation to women’s health services •Reaction to Government health financing on women’s health •Mortality and morbidity rates of women’s health status •Effect of decentralization, hospital autonomy and SWAP on •Utilization rate and level of satisfaction for women accessing health services quality health services for Women in decentralized and hospital autonomy facilities •Level of governance, finance, management inputs and out-puts for hospital autonomy facilities and decentralized health systems •Proportion of activity based resource utilization in relation to strategic plans at national and district, and community level/NHCs
•Reaction to Decentralization and Sector Wide Approach to Planning (SWAP)
(and the basket funding approach) by number of participating partners, type of
commitment and resource allocation contributions by activity-based approach.
•Total number of established professionals in health institutions in relation to
total national requirement •Human Resource Development Capacity •Proportions of professionals by type providing reproductive health
services/FP in relation to total health professionals in the country
•Proportion of health professional trained in reproductive health and child health, and gender mainstreaming •Proportion of health professionals by type migrated to other countries •Reaction to health professional drain •Presence and total number of gender focal points established at national/central level •Proportion of services contracted and level of satisfaction •Proportion use of national health information for women in HIMS •Proportion of health facilities integrating women’s health services in relation •Contracting out Health Services to total health facilities in the country (inventory of health facilities •Availability of national HIMS for monitoring and •Performance audit format indicators by type of intervention, and reporting evaluation of women’s health status system of health information from the health services & community/flow and feed-back information/Type of aggregated data available about women’s health status/ proportion of research & used.
WHAS /Zambia/2005
Classification of Variables(cont.) Operational indicators Independent Variables: •Partnership in Women’s health services •Type of collaborative strategies for women’s health services •Reaction/reasons for co-operate partnership in women’s health services
•Presence and type of policies, guidelines/protocols for prevention and •Availability of national health policies management of sexual and gender based violence victims •Reaction to type of policies available for women’s health •Presence of policy eligibility for women’s access to health by exemption to user fees •Proportion of category of specific women by age exempted from user-fee payment
•Proportion of stakeholders/institutions with knowledge on statutory and • Effectiveness and Perceptions of Laws enforcement on customary laws enforcement in relation to legal, social and physical women and girls
103 protection to women and girls •Proportion of cases convicted and reports •Collaborative links between statutory and customary laws enforcement •Type of legislative laws for protecting women and girls health status •Reaction to varied laws enforcement
•Presence and type (s) of forum/for a for women’s participation in health service delivery to include women living with HIV/AIDS at local level •Presence and type of national forum/for a/deliberate policies/or monitoring •Advocacy bodies addressing women’s health problems •Presence of civic education on women’s human rights relating to sexual and gender violence
•Proportion of women’s access to legal representation in aspects of sexual
and gender based violence
•Proportion of health facilities offering women’s health services by type in
relation to total health facilities at different levels. b) Service Delivery System: Policies, Strategies and Resources: • Proportion of availability and adequacy of health facilities (infrastructure- space, equipment, supplies, emergency management facilities and drug stock •Status of quality health services/ access barriers of Health level, clean and safe water, sanitary facilities, and electricity) services • Proportionate and Type of health services • Average timing of health services by type •Mean waiting time- consultation, medication, Hospital bed, etc. • Proportionate level of satisfaction with health services •Responses on experiences of illness episodes/preventive care at nearest hospital and health centre/clinic •Average and proportion of types of access barriers/problems of health service care •Proportion and types health services owned by government, private and mission •Reaction/response to ownership by level of satisfaction
•Ownership of Health Services
WHAS /Zambia/2005 Annex Classification of Variables (cont.) Indicators •Referral System: Policies and Services •Proportion of health facilities equipped with radio communication equipment and ambulances for referred cases •Presence of referral services by type and policy guidelines from primary care to 1st , 2rd and 3rd referral level •Reaction to eligibility for referral services •Availability of health facility basic infrastructure, logistics and •Presence of privacy and confidentiality (space, screen, etc) environment •Presence of basic life saving drugs •Proportion of women on treatment interrupted due drugs out of stock (i.e. Iron supplement, ART, Contraceptives, etc) •Presence of basic essential equipment and essential RH Package •Presence of radio communication and emergency facilities
•Proportion of health facilities with basic essential equipment, essential RH
package, radio communication and emergency equipment in relation to total
facilities •Access to Diagnostic Facilities and Services: •Presence of laboratory tests and x-ray facilities (rapid HIV testing, Mammography, pap smear, pelvic •Proportion of women tested for HIV to include rape cases examination, laboratory and radiography tests) •Proportion of women exposed to breast examination, pap smear and pelvic examination •Proportion of women exposed to other diagnostic tests with different conditions (e.g. .FBC, C4 count, parasitology) •Health Promotion Facility Availability: IEC services •Proportion of h/f with access to IEC services •Mode of provision •Type of IEC materials available at health facilities • Average sessions conducted for HIV/AIDS/STI awareness, ART, family planning including emergency contraceptive regime, ANC, delivery care, postpartum ,adolescent health/abortion, nutrition, child health care and risk taking behaviour per day or monthly
104 •Availability and types of reproductive health service interventions for •Knowledge and quality performance of health services: women in health facilities at different level of care Reproductive health, VCT, ART, mental health (Psychological •Proportionate of trained and skilled staff in managing integrated management), social and child services reproductive health services to total staff available at a health facility to gynaecologists, obstetricians, midwives •Provider/client ratio, and workload •Number of qualified/skilled health providers for women’s health services at facility level •Correct responses ( scale rated: high, average, low) for managing RH, VCT,ART, mental health, social and child services •Standard procedures of managing integrated management of pregnancy and childbirth including PMCT, ART treatment, psycho-social counseling, family planning and child health services •Application of procedures in relation to standard procedures
•Availability of guidelines and protocols for essential practice
•Proportion of skilled providers trained in specialized fields HIV/AIDS,
psycho-social counseling, family planning •Perceptions of socio-cultural norms: taboos, customs and •Positive and negative responses to socio-cultural norms of communities beliefs inhibiting health service utilization affecting service utilization by women
•Reasons for such belief system •Availability of psycho-social counselling and support services •Types of beliefs/taboos for each intervention on women’s health for victims of gender based violence •Number of psycho-social counselors available at the institution •Type of support service for victims of gender based violence •Reaction/response to support service care Sexual and gender based violence: •Availability of policies, guidelines and protocols for prevention and management of sexual and Gender based violence victims. •Proportion of women exposed to sexual and gender violence Response to sexual and gender violence
WHAS /Zambia/2005 Annex Classification of variables Indicators •Health facility human resource availability •Number of skilled worker by type (i.e. doctors, midwives, gynaecologists, obstetrician, psycho-social counselors and social workers) per health facility •Specific health cadre ratio to women population •Consultant waiting time •Reaction to current staffing pattern in a facility by health providers and women
•Positive and negative responses to health provider’s working relations •Attitudes towards quality performance of Health providers •Reasons for responses to performance of health providers •Reaction to solutions/actions to health provider’s attitudes to women’s health care •Reasons for adequacy and dissatisfaction with quality of health care provided to women/clients.
•Availability of case records for maternal morbidity and mortality
•Gender disaggregated data •Health Information Management System (HIMS) for •Types of data management formats monitoring and evaluation of women’s health status •Availability of health information officer c) Community Level: •Proportion of women with income disability in relation to those contributing to cost-sharing scheme i. Economic variables: •Amount of fee-payment per service •Affordability of health service Cost (user-fee scheme •Amount of cost of drugs contribution and transport cost) •Reaction/response to cost-sharing scheme •Amount of transport cost •Reasons for non-payment •Type of penalty •Proportion of user fees contribution to total health facility budget •Penalties of non-payment •User fee exemption rate in relation to policy guideline by characteristics of women population and sources of cost recovery revenues/User fee •Effect of user fees scheme on health facility financing: policy utilization rate by type of activity for health facility Improvement and user fees revenues •Reaction/response to user fees utilization in health facilities
•Proportion of women in gainful employment/income generating activity
•Type of living condition/occupation status
•Level of income per month •Economic status •Availability of employment opportunities by type and gender •Response to such gainful opportunities •Proportion of women with ability to make decisions on resource allocation •Type of person responsible for decision-making in a household
105 •Gainful employment opportunities •Reasons for/ and reaction to such decision Proportion of women with •Decision-making on resource allocation •Incidence of poverty in female headed households to males by characteristics (non poor, moderately poor and extremely poor)/ •Type of community initiatives for empowering women’s economic support by sources of support •Poverty level •proportion of women exposed to micro-credit scheme in relation to quality health access •Community partnership in health: empowering women •Types of socio-cultural norms affecting use of health services •Reasons for practice/Reaction /response to effects of traditional practices on women’s health status ii. Socio-cultural variables: •Existence (i.e. proportion) and type of community legal systems for •Socio-cultural norms/belief system (taboos, customs, beliefs) women’s protection/Reasons /Types of penalties for offenders affecting health service utilization for women
•Community social/legal systems for women’s protection against sexual and gender based violence WHAS /Zambia/2005
Annex Classification of Variables Indicators iii. Physical Access barriers: •Distance •Mean traveling time/kilometer to nearest health facility •Mean travelling time/kilometer to nearest first referral hospital •Mean travelling time/kilometer to a referral health facility offering emergency obstetric services •Terrain conditions/geographical condition (poor road net-work, hilly or seasonal variations) • Average cost of traveling to nearest health facility •Mode of transport (i.e. walking, cycling, motor bike, donkey, vehicle) •Reaction to travelling time
•Community Emergency mobilization system •Proportion/ average of community ambulance services for obstetric cases and sources of support
•Proportion of women exposed to community ambulance services
• Average cost of ambulance services
•Reaction to community emergency obstetric ambulance services
•Decision- making •Type of persons deciding for choice of health care •Reasons for such decisions •Reaction/response to such decisions •Waiting time •Average time taken for ambulance services •Response/reaction to waiting time •Community health and social services • Proportion of provision of static and mobile community health and social services to women and girls •Type of community health and social services (i.e. integrated management of pregnancy and childbirth (IMPC),VCT,ART,IEC, mental health, home based care (HBC) for PLWHAS, elderly women and widows, management of SGBV and CBD of family planning services ). •Proportion of women access to community health and social services in current condition in relation to type of service. •Response/reaction to community health services •Family planning accessibility •Utilization rate of community health information and performance audit of health services /functioning of community health committees •Presence of community based distribution system for family planning services •Availability of Trained Community Health •Type of family planning services offered workers/volunteers •Proportion of women accessing family planning services •Ratio of CHWs/volunteer to women population in child bearing •Proportion of CHWs actively providing community health services •Response/reaction to CHWs performance in integrated health services for •Accessibility to sanitary facilities, safe water supply and women food aid •Proportion of women households with safe sanitary facilities by type •Proportion of women with access to safe water supply •Type of water sources
•Proportion of women by characteristics with access to food aid
•Sources of supply
•Reasons for supply •Reaction to food relieve •proportion of women in sample with varied demographic characteristics •Demographic characteristics of women in sample:
106 Marital status, education, religion, age, fertility, residence estimation
107
Household Interview Schedule Questionnaire:
Questionnaire Number………………………………………
Respondent’ Identification Official use
Code Residence : 1. Urban ( ) 2. Rural ( )
Province :1. Central ( ) 2. Lusaka ( ) 3. Southern ( )
District : 1. Mazabuka Urban ( ) 2. Luangwa Rural ( ) 3. Monze Urban ( ) 4. Mkushi Rural ( ) Community / Village:……………………………………………. Head of Household and relationship (specify)…………………………… Age:………………………….. Marital status :1. single ( ) 2. married ( ) 3. divorced ( ) 4. widow ( ) 5. separated ( ) ( tick (3) where applicable) Occupation:------(state type of gainful job) Parity: 1.Number of living children………. 2.Number of children Died……… 3. Number of Abortions/miscarriage… Religion: 1. No religion ( ) 2. Catholics ( ) 3 UCZ ( ) 4. New Apostolic Church ( ) 5. SDA ( ) 6.Anglican ( ) 7.Other, specify………….( )
Name of Interviewer------
Date of Interviews------Day month year Interviewer’s Identification
108
The questions I would like to ask you are mainly concerned with how you have been getting some treatment whenever you
became sick, what conditions you ever suffered, how services were provided and problems that prevented you from getting
proper care at the your clinic or hospital.
But before I do that, I would like to ask you few questions about your self. Please be free to answer the questions. Your name
will not appear on this paper. It is intended to improve the health of women in the country, and specifically in your area.
A. Background Information
When were you born? ………………………… Q1.
Day Month Year
Are you in married relationship, or single, separated, divorced, or widowed? Q2.
1. Single………………………………… ( )
2. Married……………………………. ( )
3. Separated………………………….. ( )
4. Divorced………………………….. ( )
5. Widowed……………………….. ( )
Have ever been to school?………………….1. Yes ( ) 2. No ( )
If yes, what is your level of education?
Q3. 1. Primary……………………………. ( )
Q4. 2. Secondary……………………….. ( )
3. College………………………… ( )
4. University…………………. ( )
(Tick ( 9) where applicable)
What do you do for you living?
1. Not working in a gainful employment……………. ( )
2. Employed…………………………………………. ( )
3. Just a housewife………………………………….. ( )
4. Business venture………………………………. ( )
109 Q5. 5. Farming/Plouphing…………………………… ( )
6. Other, specify……………………………….. ( )
If married or living with your partner, what does your partner/husband do to support your self and family (if any)?
1.Unemployed …………………….. ( )
2. Employed……………………….. ( )
3. Business venture………………… ( )
4. Farming/Plouphing……………….. ( )
5.Other, specify…………………….. ( ) Q6.
B. Physical Access Barrier and Referral systems
Now, I would like to ask you few questions about how you and your family get to your nearest clinic to receive health care.
Where do you go to get regular treatment each time you fell sick or needed care?
1. Hospital…………………………………. ( )
2. Health centre/clinic……………………. ( )
3. Community Health post………………. ( )
4. Community based distributor………… ( )
5. Mobile service……………………. ( )
6. Other, specify……. ( )
(Please tick ( 9) where applicable )
Who Owns this hospital/clinic or community service, which you stated?
Q7. 1. Government……………………………… ( )
2. Private………………………………….. ( )
3. Mission ………………………………… ( )
4. Other, specify…………………………. ( )
If your nearest clinic is the hospital or health centre, how far is it from your home?
1. Near ……………………………. ( )
2. Far…………………………… ( )
3. Furthest……………………… ( )
110
(Please specify distance in hours, days or kilometers ( if known))
Q8.
How do you travel to reach your nearest clinic during the last time of your visit?
1. On foot/walking……………………………. ( )
2. Scotch-cat/donkey……………………….. ( )
3. Cycling…………………………………. ( )
4. Motor bike…………………………….. ( )
Q9. 5. Vehicle/minibus……………………… ( )
6. Other, specify……………………….. ( )
What is the status of roads from the village/ community to the health centre/hospital?
1. Good………………………………………….( )
2. Poor (hilly, flooded during rain season,etc)….( )
How much money do you spent for travelling to reach your nearest clinic?
1. Nothing/.no cost involved…………………………….. ( )
2. Less than K50,000 ( specify exact figure)……………. ( )
Q10. 3. K50,000-100,000……………………………………… ( )
4. >K100,000………………………………………… ( )
What are your views on how your clinic is situated or placed?
Specify reasons ……………………………………………………………………………
………………………………………………………………………………………………
……………………………………………………………………………………………….
Are there usually means of transporting very ill patients to the nearest health centre/ clinic or hospital, such as ambulance
services or any in this community/ village?
Q11. 1.Yes ( ) 2. No (Î go to Q 25 ) ( ) 3 not sure ( )
If yes, How long do you wait for it to come?
1 Less than 10 minutes….. ( )
Q12.
111 2. 10-30 minutes……………(. )
4. more than 30 minutes… ( )
5. Don’t know……………( )
Q13. In case of pregnancy problems or if you have ever experienced labour pains, which required immediate transfer to the clinic
or hospital, how long did you take you to reach the clinic or hospital?
(Qs16-22, applies to women ever conceived)
1. Less than two hours……………………..( )
2. 2-4 hours……………………………….. ( ) Q14. 3. >4hours to even days…………………….( )
If there were more delays than expected, why did it happen?
Specify reasons…………………………………………………………………………
Q15. …………………………………………………………………………………………..
How were you transported to the clinic or hospital?
1. On foot………………………………………..( )
2. By bicycle…………………………………….( )
3. Vehicle, specify type………………………… ( )
4. Ambulance……………………………………. ( )
5. Other, specify…………………………………. ( )
Who escorted you to the hospital/clinic? Q16.
1. No one…………………………………………( )
2. My mother…………………………………… ( )
3. Husband……………………………………… ( )
4. Husband and family member, specify relationship ( for a family member)….( )
5. Other, specify…………………………………………………………………( )
How did you feel about your experience of being transferred in such a manner?
1. Awful /very bad/not happy………………….. ( )
112 Q17. 2. Happy…………………………………………( )
3. I don’t know…………………………………. ( )
If you were not happy, Why?
Specify reasons……………………………………………….. Q18.
……………………………………………………………….
Probe: What do you suggest should have been done to improve the way how you were transferred to the
clinic/hospital?…………………………………………………………………..
………………………………………………………………………………….
How much is/was the cost of ambulance services/ emergency transport services can be/ paid ?
Q19. 1. No cost involved ……… ( ) 4. More than K 80,000……. ( )
2. Less than K 40,000 …….( ) 5. Not sure ………………….( )
3. K40,000- 80,000 ……. ( )
( Please tick (9) where applicable)
Who owns the ambulance services facility
1. Government……………….( )
2. Private……………………..( )
3. Mission……………………( ) Q20. 4. Community members…… ( )
5. Don’t Know………………( )
What is your feeling about the ambulance service being provided in your community?
……………………………………………………………………………………………
………………………………………………………………………………………….. Q21.
…………………………………………………………………………………………..
Who decides for you when you want to go to the clinic or rather do you have to seek permission from any family members
before going to the clinic, or you just go on your own?
1. my self………………..( )
113
2. My husband…………..( )
3. Mother………………( )
4. father………………. ( ) Q22. 5. grandmother……… ( )
6. Other, specify………( )
(Please tick (9 ) once where applicable)
Q23.
Do you have any trained CHWs or Volunteers including trained traditional birth attendants available in your area?
1. Yes ( ) 2. No ( ) 3. Not sure ( )
If yes, how many?
Number available by gender
Men Females Q24.
a). Community Health Workers (trained)……………..
b). Skilled Traditional Birth Attendants (TBAs)……….
c). Other Trained Volunteers, specify type of skill………. Q25.
What do they do to assist women who are sick?
a. CHWs b. TBAs c. Other Volunteers
1. Distribute condoms and family planning pills…. .( ) ( ) ( )
2. Provide treatment to women for any illness………. ( ) ( ) ( )
4. Refer those who are very sick to hospital……… ( ) ( ) ( )
5. Provide health care to pregnant women……… … .( ) ( ) ( )
114
6. Assist in delivery of women in labour …………… ( ) ( ) ( )
7. Nothing……………………………………………. ( ) ( ) ( )
8. Other activities, specify……………………… …. ( ) ( ) ( )
(Please Tick (9 ) more than once where applicable)
Are you satisfied with these services provided to women in your community?
Q26. 1. Yes ( ) 2. No ( Î go to Q 25 ( )
If yes, what are your reasons?………………………………………………
………………………………………………………………………………
Q27. If no, Why?………………………………………………………………….
……………………………………………………………………………….
………………………………………………………………………………
Now, I would like to ask you further on other facilities, such as sanitary measures, safe water and distribution of food relief
aid.
Where do you go for the call of nature?
1. Help my self in the push………………………( )
2. Toilet attached to our house………………….. ( ) Q28. 3. Use pit latrine near our house………………… ( )
4. Communal toilet……………………………… ( )
How do you dispose rubbish around your house where you live?
1. Dispose them in the dust bin……………………………….( )
2. Dispose them in the bush/any where…………………… ( )
3. Use a pit ……………………………………………….. ( )
4. Heap them in one place and the council collects them……..( )
5. Other arrangements, specify…………………………………( )
(please tick (9 ) where applicable)
115 How far and where to go to collect household water, including drinking water?
1. From the river/well far away …………………….( )
2. From the well nearby or down the river………….( ) Q29. 3. Use bore hole in the village…………………….. ( )
4. Piped water provided by council………………. ( )
Is water safe for use? Q30.
1. Yes ( ) 2. No ( Î go to Q36) ( ) 3. Not Sure ( )
If yes, what makes you think so? Q31.
1. We are provided with medicine (chlorine) which we put in our drinking water
2. Piped water is safe because they put medicine……………( )
3. People come to inspect our water………………………. ( )
4. I am not sure …………………………………………… ( )
If no, why?
------Q32.
…………………………………………………………………….
……………………………………………………………………..
Are you being supplied with any food relief?
1 yes ( ) 2. No (Îgo to Q40) ( )
If yes, Who supplies you with food for your family? Q33.
1. Government…………………( )
2. NGO, specify……………….( )
3. Church/Mission…………….( )
4. Community Members………( )
5. Other, specify……………….( )
Are you satisfied with the help given to you?
1 Satisfied ( ) 2. Not satisfied ( )
116 Q34. If not satisfied, Why?
…………………………………………………………………………………
………………………………………………………………………………….
…………………………………………………………………………………….
What health services are provided for women in your community?
Q35 1. Pregnant care for women………………………………………………..( )
2. Delivery care………………………………………………………….. ( )
3. Care for women and babies who have delivered (postnatal care) …… ( )
4. Family planning………………………………………………………. ( )
5. Health education/AIDS education…………………………………… ( )
6. Home-based care of women living with AIDS…………………….. ( )
7. Counseling services for women and girls with SGBV………………. ( )
8. Other, specify………………………………………………………. ( )
( Please tick (9 ) more than once where applicable).
How are these health services provided in communities? Q36
1. Using a health post…………………………………………………( )
2. Mobile services…………………………………………………….( )
3. Community based distribution……………………………………. ( )
4. Home based care…………………………………………………. ( ) Q37 5. Drama (in-school and out of school)/ peer group approach…… ( )
6. Other, specify…………………………………………………. ( )
What social services are provided to women in this community? Q38
1. Support Care of elderly women and orphans…………………….( )
2. Distribution of food relief to women in need……………………..( )
3. Education/Illiteracy classes to women………………………….. ( )
4. Income generating activities ( specify type)…….. ……………. ( )
5. Victim support group for Sexual and Gender based violence for women and girls ( )
6. Other, specify………………………………………………………………………( )
117 Q39 (Please tick (9) more than once where applicable)
What do you think about the health and social services that are assisting women in communities?
Q40 a) health services:………………………………………………………………………………
………………………………………………………………………………………………….
……………………………………………………………………………………………………
b)social services:…………………………………………………………………………………
Q41 ……………………………………………………………………………………………………
C. Affordability of Health Services and Economic Situation
I would like to ask you once more again on how your self and family members manage to get proper health care support each time you visited your clinic or hospital
Do you pay for a health scheme at your nearest health centre or clinic?
1. Yes ( ) 2. No (Îgo to Q49) ( )
If yes, how much do you pay?
1. Less than K10,000, specify exact amount…………….. ( )
2. K10,000- 20,000, specify exact amount………………. ( )
3. >K20,000, specify exact amount……………………… ( )
Q42
For what purpose do you pay this health scheme?
1. Consultation only……………………………………….. ( )
2. Consultation, drugs and examination…………………….. ( )
3. Consultation and examination only………………………. ( )
4. Other uses, specify…………………………………………. ( )
What happens if you don’t pay the scheme?
1. They chase you from the clinic/ no treatment………………….( )
2. You pay at a higher cost……………………………………….( )
118 Q43 3. Nothing happens………………………………………………. ( )
4. Other, specify…………………………………………………..( )
If no, who pays for you?
1. Government regulation…………………………………… ( )
2. Social welfare service……………………………………. ( )
3. My medical insurance scheme…………………………… ( )
4. My employers…………………………………………… ( )
5. Other, specify………………………………………………… ( )
Do you know people who may be eligible to be exempted from paying a health scheme?
1. Pregnant women……………………………………………….. ( )
2. Women in labour…………………………………………….. ( ) Q44 3. Breastfeeding mothers……………………………………….. ( )
4. Young children, specify age………………………………… ( )
5. Elderly women, specify age……………………. ……………. ( )
6. Other, specify………………………………………………….. ( )
(Please tick (9 ) more than once where applicable ).
How do you feel about the introduction of user fees or health scheme provided at the clinics or hospitals?
…………………………………………………………………………………………………
………………………………………………………………………………………………..
………………………………………………………………………………………………..
What do you do for your living?
Q45. 1. Working, specify type of gainful job ………………………… ( )
2. Farming/ plouphing in fields …………………………………( )
3. Business venture, specify type of business……………………( ) Q46 4. Brewing beer ………………………………………………….( )
5. No job/just housewife………………………………………. ( )
6. Other, specify…………………………………………….. ( )
Do you have places offering jobs to women in your area?
119 1 yes ( ) 2. No (Îgo to Q50) ( ) 3. Not sure ( )
Q47 If yes, which ones?
Specify:………………………………………………………………..
…………………………………………………………………………
…………………………………………………………………………
Who makes decisions on how money should be spend in your home?
Q48. 1. My self make decision……………………………………………….( )
2. My husband………………………………………………………… ( )
3. It is a joint decision , but my husband makes a final decision………( )
4. It is a joint decision, but I make a final decision……………………. ( )
5. It is a joint decision with my family (to include children)…………. ( )
6. Other, specify……………………………………………………….. ( )
Tick (9 ) where applicable
Q49. How do you feel about this arrangement of decision making?
Comment………………………………………………………………………………..
……………………………………………………………………………….
……………………………………………………………………………..
Do you have existing structures that support women to improve on their financial situation in communities?
1. Yes ( ) 2. No ( ) 3. Not sure ( )
Q50.
If yes, which ones?
Specify
a) :……………………………………………………………
b)…………………………………………………………….
120 c)…………………………………………………………….
d)…………………………………………………………...
Q51. D. Socio-Cultural Practice
Quite often women may be affected by our cultural beliefs, which we practice in our villages, and these may stop us from
going to hospitals or clinics to receive proper care. I would like to ask few question about such beliefs that may be existing in
your community/ village.
Do you have cultural beliefs, customs or taboos that may prevent women from using hospital or health centre services/clinic
for women, such as those for maternal care services, family planning and others, which you may be familiar with? Q52
1. Yes ( ) 2. No ( ) 3. Not Sure ( )
If yes, which ones are these?
Specify:
a)…………………………………………………………………….
b)…………………………………………………………………….
c)……………………………………………………………………..
d)………………………………………………………………………….. Q53.
How do feel about the traditional practices on women?
State reasons…………………………………………………………………………………………. Q54.
……………………………………………………………………………………………………….
………………………………………………………………………………………………………
Are sexual cleansing, defilement and rape common or uncommon practices among women and children in your community
and other surrounding communities?
Q55. 1. Common practice 2. Uncommon
a) sexual cleansing …………. ( ) ( )
b) Child defilement……….. ( ) ( )
121 C ) Rape ……………….. ( ) ( )
If some of them are practiced, why?
Specify reasons:…………………………………………………………………….
Q56. ………………………………………………………………………………………
……………………………………………………………………………………….
E. Sexual and Gender Violence
Finally, are aspects of sexual abuse and other kinds of domestic violence that affect children and women in their homes. I
would like to ask you further if such experiences are also common in your village where you live or in other nearby villages. Q57.
Is rape or experiences of fighting/beatings or other forms of harassment to women and girls common in your area?
1. Yes ( ) 2. No ( ) 3. Not Sure ( )
If yes, what are some of the consequences experienced by the victims that are observed in your area? Q58.
1. Unwanted pregnancies……………………………… ( )
2. Abortions…………………………………………. ( )
3. Divorces…………………………………………. ( )
4. STIs including HIV/AIDS ………………………. ( )
5. Other, specify…………………………………….. ( )
How are aspects of sexual and gender violence victims handled in your community/villages?
Explain (state type of penalties for offenders)
:………………………………………………………………………………….
……………………………………………………………………………………………
Q59. …………………………………………………………………………………………….
What social systems or legal aspects exist that protect women from sexual abuse and gender violence in your communities?
122 Q60. Specify:------
……………………………………………………………………………………..
Have you ever been sexually abused/ raped or exposed to some kind of domestic violence before in your life time?
1 Yes ( ) 2. No ( ) 3. Can’t remember ( )
Q61.
If yes, what was it?
1. Sexually abused by my own father, relative, stranger or partner………..( )
2. Beatings by parents/husband/boy friend/relations……………………… ( ) Q62. 3. Abusive language by parents/husband/relations ………………………. ( )
4. Other, specify…………………………………………………………. ( )
Have you currently experienced sexual abused, beaten or offended in any form by your husband/ boy friend or parents and
relatives in your home?
1.Yes ( ) 2. No ( )
How do you feel about such cases that occur in your communities?
……………………………………………………………………………….
Q63. ……………………………………………………………………………….
What are your views on how sexual and gender violence can be prevented among women in your community/villages?
………………………………………………………………………………………
………………………………………………………………………………………..
Any comments from the questions I asked you.
……………………………………………………………………………..
123 Q64. ……………………………………………………………………………
…………………………………………………………………………….
Q65.
Thank you for your time
Q66.
Q67.
Q68.
Q69.
124
Q70.
Q71.
Q72.
Q73.
WHAS/Zambia/2005
Annex II
125 Zambia Study Questionnaire Number…………………………………………………..
Exit Interview for Maternal and Family Planning Clients
INTRUCTIONS TO INTERVIEWER: Interviews must be conducted to women clients who have attended clinical care on Antenatal, post postnatal and family planning, VCT, ARV Treatment, STDs.
Health facility Visited (state name): Type of health facility:
------1. = Central Hospital Circle number Health facility Code: 2. = Provincial Hospital for response
District (State name: 3. = District referral Hospital
------4. = Rural Health centre
District Code: 5. = Urban Health centre
Community/town (name): 6. = Maternity
------7. = Health Centre
Community/town (Code): 8 = VCT centre
Client Identification number: 9 = Other, specify
Type of Sector:
Client’s Location/ward: 1. = Government
Client’s Age: 2. = Mission Circle number for response
Date of Visit: Day……Month…..Year… 3. = Private
4 = Other, specify………..
Locality:
1. Urban 2. Rural
------
Purpose of Visit: WHAS/Zambia/2005 1=ANC Check up Name of Observer/interviewer:------2= PNC Check up
3= Family planning New/revisit Signature of Team Leader:……………………….. 4= VCT 5= STD treatment 126 6=Other, specify………………..
Exit Interviews For All Women Clients
------
( Read Greeting: )
Hello. We would like to improve the services provided by the facility and would be interested to find out about your experience today. I would like to ask you some questions about the visit you have just had with the health facility staff and would be very grateful if you could spend some time answering these questions. All the information you give will be kept strictly confidential. Your participation is voluntary and you are obliged to answer any questions you want. Do I have your permission to continue?
1 = Yes ( ) 2.= No (Thank the client and go to the next interview) ( )
Q1. Overall, would you say you were satisfied with your visit to the facility today, or were you dissatisfied with your visit today?
1= Satisfied (go to Q3.)
2= Dissatisfied
3= Other, specify……………… ( go to Q3)
------
Q2. Why were you not satisfied with your visit today?
……………………………………………………………………..
…………………………………………………………………….
……………………………………………………………………
Q3. In addition to your visit, which you stated, did you receive any other health services from the service provider?
1= Yes
2= No ( to Q 5
Q4. Now I would like to ask you about all the other services you received today. Did you receive any of the following services?
127 1= Antenatal care
2= Maternal care/delivery services
3= Postnatal care
4= HIV/AIDS management, such as VCT or ARV treatment/drugs
5= other STD Treatment
6= Treatment of Incomplete abortion
7= Nutrition services
8=Other, specify……..
(Read them all and circle all that apply)
Q5. Do you feel that you received the information and services that you wanted today?
1= Yes
2= No
3= Partially
4= Don’t Know
Q6. Do you feel that your visit consultation with the clinical staff was too short, too long, or about the right amount of time?
1= too short
2= Too long
3=About right
4= Don’t know
Q7. During this visit, did you have any concerns about family planning or other health issues that you wanted to discuss with the provider?
1= Yes
2= No (go to Q9)
Q8. If yes, did the provider listen to your concerns to your satisfaction?
128 1= Yes
2= No
Q9. During this visit, did you have any questions you wanted to ask?
1= Yes
2=No (go to 12)
Q10. If yes, did the provider let you ask the questions?
1= Yes
2= No (go to Q12)
Q11. If yes, did the provider respond to your questions to your satisfaction?
1=Yes
2= No
Q12. During this visit, did the provider conduct any clinical examinations, such as general or pelvic examination or breast examinations? a) General /body examination: 1= Yes 2=No b) Pelvic Examination/cervical or Paps Smear 1= Yes 2= No c) Breast examination 1=Yes 2= No –Go to Q15 d) Other, specify………………………..
Q13. If yes, did the provider explain the examinations before they were performed
1=Yes
2=No
Q14. Did the provider explain the results of the health/ clinical examinations, including blood investigations?
1=Yes
2=No
Q15. In your opinion, did you have enough privacy during your consultation with the service provider?
1=Yes
129 2=No
Q16. If no, why?
…………………………………………………………..
……………………………………………………….
Q17. Were you happy with the way the service providers handled you during your consultation?
1= Yes
2=No
Q18. If no, what happened?
………………………………………….
………………………………………..
………………………………………
Q19. During this visit were you given or did you take any brochure or educational materials to bring home?
1=Yes
2=No (go to 21)
3= Don’t know (go to 21)
Q20. If yes, what is the subject (s) of that material?
(Do not read list, but probe by asking, ‘Any other subjects?’ Circle that apply)
1=MCH
2=family planning
3= STDs
4= HIV/AIDS to include VCT or ARVs
5= Other, specify
6= Don’t know
130 Q21. Did you attend a group talk(s) at the facility today?
1= Yes
2=No (go to 23)
3=Don’t Know (go to 23)
Q22. If yes, what topics were covered in this group talk (s)?
( Do not read list, but probe by asking,’ Any other subjects?’ Circle all that apply).
1= Antenatal care
2= Maternity care/Delivery services
3=Postnatal Care
4= HIV/AIDS management(PMCT/VCT/ ARVs and Home Based care)
5= Other STD management
6= Child immunization and ORT
7= Malaria in pregnancy
8= Treatment of incomplete abortion
9= Nutrition services
10= Family planning
11= Breastfeeding
12=Other, specify………
98= Don’t know
Q23. Did any service provider tell you when to come back for another visit?
1=Yes
131 2=No
3=Don’t know
Q24. Are the hours this facility is open convenient to you?
1= Yes (go to 26)
2=No
Q25. If no, what time would be most convenient to you?
(circle one)
1= Earlier in morning
2= Over lunch hour
3=Afternoon
4=Evening/night
5=Weakends/holidays
6=Other, specify……………………..
Q26. Have you ever been turned away from this facility during official working hours?
1=Yes
2=No
3=No previous experience with facility
4=Don’t know
Q27. About how long did you have to wait between the time you first arrived at this facility and the time you began receiving the services that you came for ?
1= Minutes, specify ------
2= Hours, specify…………..
8= Don’t Know
132 Q28. Do you feel that the wait between the time you first arrived at this facility and the time you began receiving the services you cam for was reasonable or too long?
1= Reasonable
2=Too long
8= Don’t know
Q29. How long did it take you to come here today?
1=couple of minutes, specify……………..
2= Couple of hours, specify…………….
Q30. What was the main means of transport that you used to get here?
(circle one)
1= Walked
2= Scotch Cart
3= Minibus
4= Bicycle
5= Private car/taxi
6=Other, specify
Q31. As far as you know, what types of services other ante-natal care are usually provided at this facility?
(Do not read, but probe by asking, ’Any other services?’ Circle all that applies)
1= Postnatal care
2= Maternity care/delivery care
3=HIV/AIDS Counseling /IEC
4= HIV/AIDS testing
5= Other STDs diagnosis and treatment
133 6=Child immunization and growth monitoring
7=Consultation for infertility
8= Oral rehydration therapy services
9= Treatment of incomplete abortion/abortion services
10=Family planning
11=Nutrition services
12=Other, specify…………………………..
Q32. Apart from this facility, is there any other place near your home where you can go for the same visit?
1=Yes
2=No
3=Don’t know
Q33. If yes, what type of facility is it?
(Circle one. If more than one facility, choose closest to home)
1= CBD
2=Health post
3=Health cetre
4= Hospital
5=Other, specify……………
8= Don’t know
Q34.What would you say is the main reason you did not go there for your health service?
(Do not read list. Probe for the main reason and circle one)
1= Inconvenient opening times
2= Takes too long to get there
134 3= Poor quality of services
4=Fewer services available
5= Want to be anonymous
6= have other reasons to come here, specify………………………..
7=More expensive there
8=Prefer provider here
9= Other, specify…………………….
Q35. Now I would like to ask you about the cost of travel and services that you have received from this clinic. How much did you pay for your consultation?
1= less than K10,000
2= K10,000- 30,000
3= above K30,000
4= free consultation
Q36.How much did you pay for medicines?
1=less than K10,000
2= K10,000-30,000
3= K30,000-60,000
4=above K 60,000
5= non
Q37. How much did you pay for consumables?
1= Less than 20,000
2= K20,000-40,000
135 3= Above K40,000
4=Non
Q38. How much did you pay for registration card/membership?
1= less than K5,000
2= K5-10,000
3=above K10,000
4= Not sure
Q39.How much did you pay for your travel?
1= Less than K 20,000
2=K20,000-40,000
3= above K40,000
4.Don’t know
Q40. How much did you pay for any other services, such x-ray or laboratory investigations (if any)?
1=Less than K30,000
2= K30,000-60,000
3= above K60,000
4= Free
Q41. Overall, do you feel that the local cost of obtaining services is much too expensive, a little too expensive, or acceptable to you?
1= Much too expensive
2=A little expensive
3= acceptable
4= Don’t know
Q42. Any other comment from the questions I asked you?
136 …………………………………………………………………
………………………………………………………………..
…………………………………………………..
Thank you for participating in the interviews for today.
137
WHAS/Zambia/2005
Annex III
Zambia Study Questionnaire Number…………………………
Health Facility Assessment Questionnaire: Facilities Available and Services Provided at Service Delivery Point
INSTRUCTIONS TO DATA COLLECTOR: This assessment should be completed by observing the facilities that are available and through discussions with the person in charge of Reproductive Health services on the day of the visit. In all cases you should verify that the items exist by actually observing them yourself. If you are not able to observe them, then code accordingly. Remember that the objective is to identify the equipment and facilities, including emergency referral equipment facilities that are currently exist and not to evaluate the performance of the staff or clinic. For each item, circle the response or describe, as appropriate.
Health Facility (indicate name): Type of health facility:
------1=Referral Hospital
Health Facility Code: 2= District Hospital Circle number that ------3= Private hospital applies
District (indicate name): 4= Health centre
------5=Health Post
District Code: 6= Maternity centre
Village/township (indicate name): 7=VCT centre
------8= Other, specify………………….
Village/township Code: Type of sector:
Date of Visit: 1= Government
Day------Month------Year------2=mission Circle number that 3= Private applies
138 4=Other, specify------
Locality: 1= Urban 2= Rural
Name of Observer:/interviewer:------
Signature of team leader:…………………………….. WHAS/Zambia/2005
Health Facility Assessment Questionnaire
A. Accessibility
What is the catchment population and area for this health facility? Q1.
(Check with person in charge of the facility)
1= Area…………………………….. Square kilometre
2= Population………………………..
3=Population density……………… Square kilometre
4= Nature of terrain: flat/mountanous/flooded /jungle with thick forest………………………
What is the average distance from which most female clients come?
1= Northern side:------minutes/ hours Q2.
2= Southern side:……………………….minutes/Hours
3= Eastern side:…………………………minutes/hours
4= Western side:------minutes/hours
What is the official opening time for this health facility?
am/pm Q3.
What is the official closing time for this health facility?
am/pm
139 Q3. How many days per week are reproductive health services offered at this health facility?
1= ANC: ------Days per week
Q4. 2= Maternity/delivery services:------Days per week
3= Postnatal care :------Days per week
4= Family planning:------Days per week
5= HIV/AIDS VCT (psycho-counseling services)……. Days per week
6= HIV testing service:………………………………… Days per week
7= Pre and post abortion services……………………… Days per week
8= STDs management……………………………… Days per week
9= Adolescent health services………………………Days per week
10= Sexual and gender violence management………. Days per week
11= Other, specify…………………………………… Days per week
Is there a sign announcing that reproductive health services are available?
1= Outside building
Q5. 2= Inside building
3= Both inside and outside building
4= No sign visible
(circle that applies)
Is ( read 1-18) usually available to clients at this reproductive health service unit or elsewhere in the health facility?
A. Tick if available at RH unit B. Tick if available elsewhere in facility
------
Q6. 1=Family planning
140 ------
2= Ante-natal care
------
3= Maternity care/delivery services
------
4= Post-natal care
------
5= HIV/AIDS counseling/VCT
------
6= HIV/AIDS testing
------
7= Health education/IEC
A.Availability in RH B. Elsewhere in facility
8= STD Counseling/IEC
------
9= STD diagnosis
------
10=STD treatment
------
11=consultation for infertility
------
12=Treatment of incomplete (septic) abortions
141 ------
14= Nutrition services
------
15= ART management/treatment
------
16= Sexual and gender violence victim management
------
17= Adolescent health services
------
18= Other curative services
WHAS/Zambia/2005
Health Facility Assessment Questionnaire
B. Accessibility
What is the catchment population and area for this health facility? Q1.
(Check with person in charge of the facility)
1= Area…………………………….. Square kilometre
2= Population………………………..
3=Population density……………… Square kilometre
4= Nature of terrain: flat/mountanous/flooded /jungle with thick forest………………………
What is the average distance from which most female clients come?
142 Q2. 1= Northern side:------minutes/ hours
2= Southern side:……………………….minutes/Hours
3= Eastern side:…………………………minutes/hours
4= Western side:------minutes/hours
What is the official opening time for this health facility?
Q3. am/pm
What is the official closing time for this health facility?
Q3. am/pm
How many days per week are reproductive health services offered at this health facility?
Q4. 1= ANC: ------Days per week
2= Maternity/delivery services:------Days per week
3= Postnatal care :------Days per week
4= Family planning:------Days per week
5= HIV/AIDS VCT (psycho-counseling services)……. Days per week
6= HIV testing service:………………………………… Days per week
7= Pre and post abortion services……………………… Days per week
8= STDs management……………………………… Days per week
9= Adolescent health services………………………Days per week
10= Sexual and gender violence management………. Days per week
11= Other, specify…………………………………… Days per week
Is there a sign announcing that reproductive health services are available?
Q5. 1= Outside building
143 2= Inside building
3= Both inside and outside building
4= No sign visible
(circle that applies)
Is ( read 1-18) usually available to clients at this reproductive health service unit or elsewhere in the health facility?
B. Tick if available at RH unit B. Tick if available elsewhere in facility
Q6. ------
1=Family planning
------
2= Ante-natal care
------
3= Maternity care/delivery services
------
4= Post-natal care
------
5= HIV/AIDS counseling/VCT
------
6= HIV/AIDS testing
------
7= Health education/IEC
A.Availability in RH B. Elsewhere in facility
8= STD Counseling/IEC
144 ------
9= STD diagnosis
------
10=STD treatment
------
11=consultation for infertility
------
12=Treatment of incomplete (septic) abortions
------
14= Nutrition services
------
15= ART management/treatment
------
16= Sexual and gender violence victim management
------
17= Adolescent health services
------
18= Other curative services
145
B. Infrastructure
Q7. Does the reproductive health unit have the following: Tick if Present
1= Piped running water
2= electricity
3=Fuctioning toilets/latrines available for clients
4= Sufficient space for Maternity services/delivery
5= sufficient space for HIV/AIDS/FP psycho-social counseling services/IEC
Q8. What is the bed capacity of this facility
1= number of beds------
2= number cots------
C. Staffing Pattern
Q9. How many (read 1- 6)are assigned to work full time at this RH/MCH/FP section or unit?
1= Medical doctor, specify if general or gynaecologist /obstetrician------Number
2=Nurse, specify if registered or enrolled nurse…………………………………………Number
3=Nurse midwife: registered midwife/enrolled midwife………………………………… Number
4= Clinical officer:…………………………………………………………………………Number
5= Nurse assistant…………………………………………………………………………Number
146 6=Other,specify……………………………………………………………………………Number
Q10. How many (read 1-6) are today at RH/ MCH/FP section?
1= Medical doctor, specify if general/gynacologist /obstetrician……………………… Number
2= Nurse, specify if Registered/enrolled nurse…………………………………………. Number
3= Nurse midwife: registered midwife/enrolled midwife…………………………….. Number
4= Clinical officer………………………………………………………………………. Number
5= Nurse assistant………………………………………………………………………. Number
6= Other, specify……………………………………………………………………….. Number
Q11. How many ( 1- 12) are assigned to work at this facility?
1= Medical doctor……………………………………………… Number
2= Nurse: Enrolled/Registered………………………………. Number
3= Nurse midwife: Enrolled/Registered…………………… Number
4= Clinical Officer………………………………………… Number
5= Laboratory technician…………………………………. Number
6= Radiology technician…………………………………. Number
7= Radiologist……………………………………………. Number
8= Pharmacist……………………………………………… Number
9= Pharmacy technician…………………………………… Number
9= Psycho-social counselor……………………………….. Number
10= Health education officer……………………………… Number
11= Nutritionist………………………………………….. Number
12= Other, specify……………………………………… Number
147 D. Health education: IEC materials and Activities
Q12. Which IEC materials on the following are available in the RH or MCH/FP unit?
Tick if Flip chart Tick if brochure/pamphlet Tick if Posters
Available Available Availble
1= Family planning
2= Ante-natal /postnatal care
3= Delivery services
4= HIV/AIDs incl. VCT/ART/HBC
5=Other STDs
6= Under five care/welfare
7= Nutrition
8= Other, specify………………………………………..
Was the health talk (group lecture or discussion with clients) held today? Q13.
1= Yes
2= No
3= Don’t know
(circle that applies)
If yes, which topics did the health talk include? Q14.
Tick if topic included
1= family planning…………………………………………..
2= Antenatal care/postnatal…………………………………
148 3= Maternity care/delivery services………………………..
4= HIV/AIDS management…………………………………
5= STD management………………………………………
6=Adolescent health………………………………………
7= Sexual and gender based violence victim management…
8= Child immunization/growth monitoring………………..
9= ORT…………………………………………………..
10= pre and post abortion services………………………
11=Nutrition services………………………………….
12= Breast feeding……………………………………..
13=Other, specify………………………………………
E. Medical Examination Facilities
Are the following conditions present in the examination area?
Q15. 1= auditory privacy………………………( ) Tick if available
2= Visual privacy…………………………( ) “ “
3= Cleanliness13 ………………………………( ) “ “
4= Adequate light14………………………………( ) “ “
5= Adequate water15
F. Emergency Services
13 Floors swept and mopped at the start of the day, no dust on widow sills and tables 14 Functioning electric light or sufficient natural light 15 A sufficient quantity of clean water for washing hands and equipment
149 Are there emergency services for ambulant clients? Tick if available
Q16. 1=Radio communication system for referral and emergency assistance………….( )
2=Ambulance service………………………………………………………………( )
3= Safe blood transfusion bank……………………………………………………..( )
4= Other, specify……………………………………………………………………. ( )
G. Equipment supply
Can we check if the following types of equipment are available in the RH/ MCH/FP unit or in the stockroom for MCH/FP
services? Tick if available
Q17. 1= Sterilizing equipment in MCH/FP unit……………………………………………………( )
2= Sterilizing equipment outside MCH/FP unit (shared)…………………………………….( )
3= Angle poise/gynaecology lamps/torch……………………………………………………( )
4= Blood pressure machines………………………………………………………………….( )
5= Adult weighing scale……………………………………………………………………….( )
6= child weighing scales………………………………………………………………………..( )
7=Scissors………………………………………………………………………………………( )
8= Antiseptic lotions……………………………………………………………………………( )
9=Stethoscopes…………………………………………………………………………………( )
10=Refrigerator for EPI………………………………………………………………………..( )
11=Examination couch…………………………………………………………………………( )
12=Thermometer/syringes/needles …………………………………………………………….( )
13=Microscope ………………………………………………………………………………( )
150 14=Sponge holding forceps/uterine forceps/spatula…………………………………………… ( )
15= Tenacula………………………………………………………………………….( )
16=Non disposable and disposable gloves……………………………………………( )
Does the health facility (incl.MCH/FP) usually provide the following services or counseling? (Read 1-8)
Q18. Tick if provided
1= Female sterilization……………………………………………………………………………..( )
2= Scientific Natural family planning counseling………………………………………………….( )
3= Exclusive breast feeding counseling…………………………………………………………….( )
4= Psycho-social counseling/VCT/ART……………………………………………………………( )
5= Emergency contraception………………………………………………………………………..( )
6= Sexual and gender violence management services: policy guidelines and protocols………….. ( )
7= Youth friendly services/Adolescent health services………………………………………………( )
8= infertility management services……………………………………………………………………( )
H. Screening and Diagnostic Facilities
Is there any laboratory testing facility for STDs, HIV, or pregnancy offered at this service delivery point?
Q19. 1= Yes
2=No
If yes, is there a test for (read 1-10) available at this RH/MCH/FP unit or at this health facility, or are clients specimens, or the
clients themselves sent elsewhere? Q20
Tick if test is available at H/F Tick if sent elsewhere
151 ------
1= Syphilis……………………………………….( )…………………………….. ( )
2= Gonorrhea……………………………………( )…………………………….. ( )
3=Chlamydia……………………………………( )………………………………..( )
4= HIV………………………………………….( )……………………………….( )
5=Cervical Cancer (pap smear)…………………( )………………………………( )
6=Pregnancy…………………………………………….( )………………………..( )
7=Anemia……………………………………………….( )………………………..( )
8= Malaria……………………………………………….( )………………………..( )
I. Immunization Services
Does this health facility usually provide the following immunization services? Q21. Tick if provided Tick if out of stock in last 6 months
------
1=BCG ……………………………………………… ( )………………………( )
2= Polio………………………………………………. ( )……………………….( )
3=Measles……………………………………………. ( )………………………. ( )
4=Hepatitis B……………………………………….. ( )……………………….. ( )
5=Tetanus for ANC for clients……………………… ( )……………………….. ( )
6= DPT……………………………………………… ( ) ……………………… ( )
J. Drug and Supplies Stock Level
152 Q22. Is there a written inventory and adequacy for the following commodities and supplies?
Tick yes if written Inventory available Tick Yes for adequacy of drugs and No if not
adequate.
------
1=Contraceptives incl. Condoms…………..( )……………………………..( )
2=STD Treatment Drugs………………….. ( )…………………………….( )
3=Vaccines…………………………………( )……………………………..( )
4=ART…………………………………….( )…………………………….( )
Q23. 5=Other Medicines……………………….( )…………………………….( )
Do you order drugs from the Medical stores Limited or from the District Office?
1= Medical Stores Limited………………( )
2= District Office ……………………. ( )
Q24.
Q25. When did you last order drugs?------
Have you received your order?
Q26. 1=yes 2= No
Do you generally receive your order with no delay?1/2/3/ months delay?
1= no delay……………………………….( )
2= one month delay……………………. ( )
3= two months delay………………….. ( )
4= Three months delay………………. ( )
Q27. 5= above 3months delay……………… ( )
If no, do you receive a prepared drug kit?
153 Q28. 1=yes 2=No
Q29. If yes, how often?------
How long does it usually last? ------weeks/months
K. Record Keeping and Reporting
Q30. How are the clients’ records cards maintained at this facility?
1= Kept in clinic……………………………( )
2= Kept by clients………………………. ( )
3= No cards……………………………… ( )
4= Other, specify……………………….. ( )
Q31. In what condition is the record-card system?
1= Well ordered…………………………………….. ( )
2= Partially ordered, still usable……………………. ( )
3= Disordered, not usable………………………….. ( )
Q32. Is there a common daily register for all the Reproductive and child health
1= Yes for all services………………………………..( )
2= Yes for some of the services……………………..( )
3= Separate for each of the services………………… ( )
Q33. 4= No daily activity register for any of the services….( )
Are service statistics reports for the following services sent to a supervisor or high unit?
Tick if reports sent
1= MCH
2= Family planning
154 3= STD/HIV/AIDS
Q34. L. Planning and Management
Do you have job description for your technical staff?
1=yes 2= No
Q35. (If yes, ask to see)
Are areas of responsibility clearly defined within the health team?
!=yes 2=No
Q36. (if yes, verify)
Do you hold meetings to discuss schedules and problems?
Q37. 1= Yes 2= No
Q38. If yes, when was the last one? ______period
Do you develop schedules of planned activities?
1=yes 2=No
Q39. (If yes, ask to see the one for the present period , e.g strategic plan)
Do you involve community members when planning health facility activities?
Q40. 1=yes 2= No
Are all staff receiving their salaries regularly?
1=Yes 2= No
Q41. a) . Finance
What is the total budget for your facility per year?
Q42. ------(amount per years)
Do you have a budget breakdown by line items?
Q43.
155 1=yes 2=No
Q44.
If not, can you enumerate the recurrent financial inputs at your facility?
1=Yes 2=No
If yes, list according to the following items listed:
1= Staff overtime allowances over the last three months------Amount
2= Travel allowances paid out over the last three months…………………….Amount
3= Amount spent annually on drugs………………………………………….. Amount
Q45. 4= Transport (actual vehicle or motor bike running cost………………………Amount
5=Maintenance and repair……………………………………………………….Amount
Q46. 6= Other annual expenditure (specify)………………………………………… Amount
Do you have any discretionary funds?
Q47. 1= Yes 2= No 3= Don’t know
If yes, where do they come from?
Q48. Specify------
What do you use them for?
Q49. Specify------
Do you charge any fees for services or drugs?
1=Yes 2= No
Q50. If yes, what services do you charge for, all or some?
Specify------
Q51. …………………………………………………………………………………..
Do you have policy guidelines on how to use fees paid for services?
156 1=Yes 2=No
If yes, what do they indicate?
Specify------
Q52.
b). HMIS/Records
Are records available that provide information on the status of women’s health services on the following aspects?
Yes No
Number of outpatient visits ……………………………………………….. ------
Outpatient diagnosis------
First and follow-up visit------
Family planning------
Antenatal /delivery/postnatal services………………………………………. ------
HIV/ADS services (VCT/HBC/ART/PMCT------
STD services------
Sexual and Gender based violence activities------
Q53. Tetanus Toxoid immunizations to Pregnant women------
Outreach activities ( i.e .Home visiting, CBD,HBC, IEC)------
Q54. Are monthly returns made to the district/next higher administrative centre?
1= Yes ------2= No ------
Q55.
157 Q56. Are copies of the returns made?
1= Yes ------2= No ------
Q57. Is there any evidence that any use is being made of the records in the facility, such as for training, supervisory, progress review
purposes? Yes------No ------
Do you have inpatient facilities for women?
1= Yes 2= No Q58.
If yes, how many beds do you have for women and men in total for this facility? (check record and observe)
1= Women------Number of beds
2= Men……………………. Number of beds Q59.
What was the bed utilization rate (BUR) for women over the past two months?
(Calculate BUR by number of patient days over the past two months divide by number of beds multiply by population times Q60 100 ).
Q61. Are records on referral kept?
1=Yes 2= No
If yes, how many women were referred to a higher centre in the past two months?
Women referred ------Number
Where were they referred to?
Specify------
c). Service Statistics
Q61. How many clients received the following services in the past 12 months?
(If no data is available, enter 999. Indicate number of months in a year of continuous records i.e. January- December 2004)
New clients Repeat clients Number of months of continuous records-January-
158 December 2004
1= Family Planning
2=Antenatal services
3= Maternity/delivery services
4= Postnatal services
5= Safe abortion services
6= HIV/AIDS services
7=STD services
8= Sexual and Gender violence
9=Child health services
10= Other, specify------
d). Support Systems :Supervision
How many times in the last three months has a supervisor come to this Reproductive health unit/MCH/FP for supervisory Q62. purposes?
Specify number of times------
Q63.
When visiting this facility, what does the supervisor do?
Tick if mentioned
1= Observe delivery of different services
2= Observe only service he/she is responsible for
159 3= Inquire about service problems
4= Examine the records
5= Make suggestions for improvements
6= Offer praise for good work
Q64. 7= Other, specify………………………
Do you have any of the policy guidelines or protocols for the following services, or other health services policies?
Tick if policy guidelines/protocols present
1= Sexual and gender based violence
2= referral systems
3= ART
4= Health scheme
5=Integrated management of pregnancy and child
birth: A guide for essential practice
6=Reproductive health policy
7= Termination of Pregnancy Act,1972
8= National health services Act,1995
9=Child Policy
10=Population policy
11=Other, specify………………………
Thank you for your assistance.
WHAS/Zambia/2005
160
Annex IV
Zambia Study Questionnaire Number ……………………………………………
Interview for Frontline Health Service Providers For Reproductive Health Services at Health Facility
INTRUCTIONS TO INTERVIEWER: All health facility staff who are responsible for providing reproductive health services to women (i.e. family planning, maternal health, HIV/AIDS /STDs, infertility and Sexual and Gender violence management) should be interviewed individually and in private at the end of the working day. It should be made clear that you are seeking their assistance in finding out ways of improving the functioning and quality of the services offered by facilities in general. For each item, please circle the response or describe as appropriate.
Health Facility Visited (indicate Name): Type of health facility:
------1= referral hospital
Health facility code: 2= District hospital Circle that applies District (name): 3=Primary Hospital
------4= Health centre
District Code : 5= Maternity Centre
Village/Township (name): 6= Health Post
------7= VCT centre
Village/Township Code: 8= Other, specify
Staff Identification Number: Type of sector:
1= Government Circle that applies Date of Visit: 2= Mission
Day ------Month ------Year ------3= Private
4= Other,specify
Name of interviewer………………….
Sign. of team leader………… 161 Locality: 1= Urban 2= Rural
Designation:
1=Doctor 2=Nurse 3.= Nurse/midwife 4=C/officer 5=CHW
6=Other,spcify………
WHAS/Zambia/2005
Read Greeting:
We are carrying out a survey of health facilities that provide reproductive health services to find ways of improving services. We would be
interested to know about your experiences so far with providing reproductive health services for women specifically, and include sexual and
gender violence. Could I ask you some questions about this? Please be assured that this discussion is strictly confidential and that your name
is not being recorded. May I continue?
A. Experience and Training in FP/MCH/HIV/AIDS/STD services and Sexual and Gender based Violence Victim
management
I would like to ask you about services you provide to clients at this facility. Do you yourself provide (Read 1-18) to clients at this Q1. facility?
Tick (3) if yes
1 .Family planning to include emergency FP ………………………………………..( )
2 .Antenatal care……………………………………………………………………….( )
3 .Maternity care/delivery services…………………………………………………….( )
4 .Postnatal care………………………………………………………………………..( )
5.. HIV/AIDS Counselling/IEC…………………………………………………………( )
6 .HIV/AIDS Testing…………………………………………………………………..( )
162 7 .PMCT and ART management………………………………………………………( )
8 .Other STD counselling/IEC…………………………………………………………( )
9 .Other STD treatment and management …………………………………………….( )
10. Child Immunization and growth monitoring………………………………………( )
11 .Consultation for Infertility…………………………………………………………( )
12..Integrated management of pregnancy and child birth……………………………..( )
13 .Treatment of incomplete (septic abortion)/abortion services……………………..( )
14 .Nutrition services…………………………………………………………………( )
15 .Health education…………………………………………………………………( )
16 .Curative services……………………………………………………………….. ( )
17 .sexual and gender based violence management………………………………. ( )
18 .Other, specify………………………………………………………………… ( )
Q2. How long have you been working here at this facility?
Tick (3) where applicable
1=Less than 1year…………………………………………………………..( )
2= 1-2 years…………………………………………………………………( )
3=3-4 years………………………………………………………………….( )
4= 5years and above……………………………………………………….. ( )
Q3. How many years ago did you finish your basic training?
1= Basic training, specify ------year ago………………………..( ) (go to Q4)
2= No basic training……………………………………………………….( )
3= Don’t know ……………………………………………………………( )
163 Q4. Did your basic training cover the following areas (Read 1-12)?
Tick (3) if yes
1=Antenatal care………………………………………………………… ( )
2= Maternity care/delivery services………………………………………. ( )
3=Postnatal care…………………………………………………………… ( )
4=Family planning………………………………………………………… ( )
5=HIV/AIDS concepts and management…………………………………. ( )
6=Abortion services/Treatment of incomplete abortions…………………. ( )
7=STDs screening and treatment…………………………………………. ( )
8= Gender mainstreaming and violence management…………………… ( )
9= Health education……………………………………………………… ( )
10=Infertility management……………………………………………… ( )
11= Child immunization and growth monitoring………………………. ( )
12= Nutrition services…………………………………………………. ( )
13=Other, specify………………………… ………………………….. ( )
Q5. Have you ever had refresher training in the following areas (read 1-11)
Tick (3) if yes
1= family planning…………………………………………………..( )
164 2= Integrated management of pregnancy and child birth………….. ( )
3=Child immunization and growth monitoring……………………. ( )
4= HIV/AIDS psycho-social counseling……………………………( )
5=Abortion services…………………………………………………( )
6= Gender aspects………………………………………………….. ( )
7= Infertility management………………………………………… ( )
8= STD screening and treatment………………………………….. ( )
9=Nutrition services……………………………………………… ( )
10=Health education……………………………………………… ( )
11=Other , specify………………………………………………… ( )
Q6. Have you attended any training courses specifically on family planning clinical skills, family planning programme, Obstetrical
procedures or HIV/STD counseling and treatment?
Tick (3) where applicable
1= Yes…………………………………………………………… ( )
2= No…………………………………………………………… .( )
8= Don’t know………………………………………………… ( )
What topics/subjects were included in that training and how long ago? Q7.
Tick (3) where applicable period in months/years ago
1= General clinical skills in FP……………( )……………………………………… .Month/Years
2= FP counseling………………………….( )……………………………………….Months/years
3=IUD insertion/removal…………………(. )……………………………………… . Months/Years
165
4= Norplant insertion/removal……………( )……………………………….Months/years
5= ML/LA(surgical procedure)…………..( )…………………………………Months/years
6= Vasectomy (surgical procedure)………( )…………………………………Months/years
7= Caesarean section (surgical procedure)..( )…………………………………Months/years
8=Episiotomy (surgical procedure)……….( )…………………………………Months/years
9= Partogram monitoring procedure………( )……………………………….. Months/years
10=Exclusive breastfeeding (LAM)……….( )………………………………..Months/Years
11= Natural family planning………………( )………………………………..Months/years
12=manegement/supervision……………..( )…………………………………Months/years
13= Record keeping / drug stock keeping…( )………………………………….Months/year
14= STD risk assessment/screening/counseling( )……………………………….Months/years
15= Laboratory diagnosis…………………..( )…………………………………Months/years
16=Syndromic approach to diagnosis and treatment( )……………………………Months/years
17= HIV/AID counseling and testing (VCT)…( )…………………………………Months/years
18=HIVPMCT management……………….. ( )………………………………….Months/years
19=Other, specify……………………………( )………………………………….Months/years
B. Knowledge and Quality of Health Services
Q8. In the last 3 months, have you your self actually provided or referred clients for (read 1-20)
Tick (9)if yes
Actually provided care Referred clients
166 ------
1= Combined pill supply………………………………. ( )……………………….. ( )
2= Progestin-only pill………………………………….. ( )……………………….. ( )
3= IUD insertion……………………………………… ( )………………………… ( )
4= Injectable…………………………………………… ( )……………………….. ( )
5= Norplant…………………………………………… ( )………………………… ( )
6= Condom supply…………………………………….( )………………………… ( )
7= Diaphragm …………………………………………( )………………………… ( )
8= Female sterilization(ML/LA)…………………….. ( )………………………… ( )
9= Natural family planning…………………………. ( )………………………. ( )
10= Exclusive breastfeeding………………………… ( )………………………. ( )
11= Emergency family planning supply……………. ( )……………………….. ( )
12=VCT…………………………………………….. ( )………………………… ( )
13= ART supply to PLWA…………………………. ( )……………………….. ( )
14=Labour and delivery complications ……………. ( )……………………….. ( )
15= Pregnancy complications……………………… ( )……………………….. ( )
16= STD syndromic treatment and screening ……… ( )……………………….. ( )
17= Sexual and gender violence victim management….. ( )………………………. ( )
18=Other, specify……………………………………… ( )……………………….. ( )
Q9. If a pill client comes for a check- up/re-supply and she appears to be at high risk of infection with an STD or HIV/AIDS, what
advice would you give?
Tick(9) for Response
1= Continue to use the pill alone………………………………( )
167 2= Continue to use a pill, but use a condom also………………( )
3= Switch from the pill to the condom……………………….. ( )
4=Stop using any type of contraception………………………. ( )
5=Other, specify……………………………………………… ( )
8=Don’t know………………………………………………… ( )
Q10. If you think that a client has an STD, what do you do for her?
Tick if mentioned
1= Request for laboratory tests……………………………………. ( )
2= Diagnose………………………………………………………. ( )
3= Treat………………………………………………………….. ( )
4= Refer for diagnosis …………………………………………. ( )
5= Refer for treatment…………………………………………… ( )
6= Provide counseling…………………………………………… ( )
7=Refer for counseling…………………………………………. ( )
8= Issue a contact or partner slip……………………………….. ( )
9=Other, specify……………………………….. ……………… ( )
168 Q11. If you think that a client has HIV/AIDS, what do you do for her?
Tick if mentioned
1= Request or refer for HIV test…………………………………….. ( )
2=Provide condoms………………………………………………….. ( )
3= Provide or refer for treatment of complications…………………. ( )
4= Provide counseling……………………………………………… ( )
5= Refer/request for counseling …………………………………… ( )
6= Issue contact or partner slip……………………………………. ( )
7=Other, specify…………………………………………………… ( )
Q12. Do you request a RPR syphilis test or other STIs for antenatal clients you see at this health facility?
1= Yes ( ) 2= No ( )
How comfortable are you discussing sexual behaviour related to STD/HIV with clients? Would you say you are very
uncomfortable, somewhat uncomfortable, comfortable or very comfortable? Q13.
1= Very uncomfortable
2= Somewhat uncomfortable
3= Comfortable
4= Very comfortable
As far as you know, do women come to this facility for advice of termination of pregnancy?
1= Yes ( ) 2= No ( ) 8=Don’t know Q14.
As far as you know, do women come to this facility for medical treatment as a consequence of an incomplete/induced
abortion, other pregnancy complications, labour and delivery complications, or women requiring special needs as a
consequence of living with violence, or just for check-up? Q15.
1= Yes 2= No 8=Don’t know
1= Incomplete/induced abortion……………( ) ………… ( )…………( )
169 2= Pregnancy complications…………………( )………….( )………… ( )
3= Labour and delivery complications……… ( )………… ( )………… ( )
4= Women living with violence……………. ( )…………. ( )……….. ( )
5=Just check-up………………………….. ( )………… ( )……….. ( )
6=Other, specify………………………….. ( )………… ( )…………( )
What obstetrical emergency facilities for referral service are available at this health facility?
Q16. Tick if mentioned
1= Radio communication link……………………………… ( )
2= Ambulance………………………………………………. ( )
3= Emergency obstetric/delivery Kit……………………….. ( )
4= Other, specify,. ………………………………………. ( )
Do you provide integrated management of pregnancy and childbirth at this facility?
Q17. != Yes ( ) 2= No ( ) 8=Don’t know ( )
If yes, what is involved in this integrated management of care and childbirth care?
Q18. Tick if mentioned
1=Care of pregnancy, childbirth, postpartum and newborn……………….( )
2= Prevention of mother and child HIV transmission……………………. ( )
3= Voluntary Counseling and testing for HIV status……………………..( )
4=Advice,and counseling for family planning……………………………( )
5= Support care for women with special needs …………………………..( )
(HIV/AIDS, living with violence, and adolescents)
6=Coordination with other health care providers and community
groups………………………………………………………………..( )
170 7= Links with TBAs and traditional healers…………………………..( )
8=Community involvement in quality of services through
needs assessment, health education discussions and community support
in action plan development………………………………………………..( )
9=Don’t know ……………………………………………………………( )
Q19 Are services provided on a daily basis at this facility?
1=Yes ( ) Go to Q 20 2=No ( )
Q20. If no, which services are not provided on daily basis?
1……………………………………………
2…………………………………………..
3………………………………………….
4…………………………………………
Q21. Are there other services you would want to be provided at this health facility?
1=Yes 2=No ( )
Q22. If yes, specify:
1……………………………………………………
2…………………………………………………..
3…………………………………………………
4…………………………………………………
Can you give reasons why these desired services are not provided to women? Q23.
1……………………………………………………..
2…………………………………………………….
171 3……………………………………………………
4……………………………………………………
Q24. C. Diagnostic Facilities
Are women accessible to the following diagnostic facilities or services for clinical examination?
1=HIV testing to include rapid HIV testing for rape victims………………( )
2= Mammography………………………………………………………….( )
3= pap smear……………………………………………………………….( )
4=pelvic examination……………………………………………………… ( )
5= Laboratory tests for FBC and other tests……………………………….( )
Q25. 6=Other, specify……………………………………………………………( )
Do you have adequate space and light for examination?
1=Yes ( ) 2=No ( )
Q26. D. Essential Drugs Supply
Is the supply of essential drugs adequate or not adequate?
1=Adequate supply ……………………………( )
Q27. 2= Not adequate supply…………………………( )
Is the supply of essential drugs regular or irregular?
1= Regular supply
Q28.. 2=Irregular supply
If not regular, what are the reasons?
1……………………………………………………………….
2………………………………………………………………..
3…………………………………………………………………
172 Q29. 4…………………………………………………………………
E. Effect of User Fees Payment
Q30. Do clients/patients pay for health services at this health facility?
1=Yes ( ) 2=No ( )
If yes, what has been the effect of paying for services on patient/client attendance at this health facility?
1= No effect on attendance
2=Reduced attendance
3=Attendance reduced for a while and then stabilized
4=Improved quality of services by improvement in recovery of patient attendance
5= Increased attendance
Q31. 6=Other,specify
G. Referral Services
Q32. Do you refer patients to other health institutions?
1=Yes ( ) 2=No ( )
Q33. If yes, how far apart from this facility?
Specify distance------kilometres/miles
What are the common conditions for which you refer patients?
1……………………………………………………………..
2…………………………………………………………….
Q34. 3……………………………………………………………
4…………………………………………………………..
Do you get feedback on your referred patients?
1=Never………………………………………..( )
173 2=Sometimes………………………………….( )
Q35. 3=All the time…………………………………( )
4=Other, specify………………………………( )
Q36. Do you get patients referred to you from other health institutions?
1=Yes ( ) 2=No ( )
Do you have existing referral service policies that may prevent women from accessing health services, such as the
requirement of obtaining referral letters from primary care providers to seek first or second referral level of care? Q37.
1=Yes ( ) 2=No ( )
If yes, is there any effect on women’s access to quality health service provision?
Specify:
1…………………………………………………
2………………………………………………… Q38.
3………………………………………………..
Do you provide out- reach activities? Or does this health facility carry out some health activities in the community?
1= Yes 2=No ( )
If yes, which activities (see records at the end of the interview)
1………………………………………………………
2……………………………………………………..
3……………………………………………………
4…………………………………………………….
H. Management and supervision
Q39. Do you have a running vehicle attached to this health facility?
174 1=Yes ( ) 2=No ( )
Q40. If yes, is it accessible to all patients?
1=Yes ( ) 2=No ( )
Q41. If no, why?
Specify reasons:
1……………………………………………………….
2……………………………………………………….
3……………………………………………………….
4……………………………………………………….
Q42. Do you think the type of services provided to women at this facility could be improved?
1= Yes ( ) 2=No ( )
If yes, what improvements would you want to see?
1………………………………………………………….
2………………………………………………………….
3…………………………………………………………
Q43. 4…………………………………………………………
How often dose your professional supervisor visit you from district of provincial office?
1=no visit at all………………..( )
2= once in three months……… ( )
3=once a month……………….( )
Q44. 4= Other, specify………………( )
If visited, are you satisfied with supervision provided?
Q45. 1=Yes ( ) 2=No ( )
175 If never visited, how has this affected you?
1…………………………………………….
Q46. 2……………………………………………
Are you satisfied with the management of this facility?
Q47. 1=Yes ( ) 2=No ( )
If no, why?
Specify reasons:
1…………………………………………………..
2………………………………………………….
3…………………………………………………
Q48.
H. Perception of Socio-Cultural Practices
Has cultural norms or beliefs, or customs of women who access services at this facility affected your quality of care?
Q49. 1=Yes ( ) 2=No ( )
If yes, how have they affected your quality of care for women?
………………………………………………………………………………….
Q50. ………………………………………………………………………………….
…………………………………………………………………………………
Do you think these traditional beliefs and practices have discouraged women from using health services at this facility?
Q51 1=Yes ( ) 2= No ( ) 3= Not sure ( )
In what ways would you like to reduce traditional practices among women?
1…………………………………………………………………….
2……………………………………………………………………
176 3…………………………………………………………………..
4………………………………………………………………….
I Socio-demographic Characteristics
Q52. To end this interview, I would like to ask you a few questions about your self. How old are you?
------Years old
Q53. What is your current marital status?
1= Married
2=Living together
3=Single (never married )
4= Divorced/separated
5=Widowed
Q54. How many living children of your own do you have?
………………..Number of children
Q55. What is your religion?
1= Catholic…………………( )
2=Protestant………………. ( )
3=African Spiritual………..( )
4= none……………….. ( )
5=Other,specify……………( )
Q56.
Gender: 1= Female
Q57. 2= Male
Anything you would like to add on the interviews about quality of health services for women at your facility?
177
Thank you for your participation.
WHAS/Zambia/2005
Annex V
Zambia Study Questionnaire Number…………………………………….
Semi-Structured Interview Questionnaire for Programme Managers and Key Informants:
Health Systems Development Support for Women
Instruction to Data Collector: Interviews must be conducted to relevant programme managers/directors and key informants (incl. policy makers) who are involved in providing support to women and health issues. The objective is to determine the extent of support and effects of health systems development efforts at national, provincial, district and community level on provision of quality health services for women.
Seek permission from relevant stakeholders and managers before discussions. Circle or describe responses as appropriate.
Organization/Agency (Name): Type of Organization/Agency:
------Code: 1= MOH/CBOH16
17 Province (name) ------Code: 2= MOE Circle that applies District (name)------Code: 3= MOCD18
Community/Township…………………Code: 4= Ministry of Youth and Sports
Respondent’s Identification Number: 5= Ministry of Justice
Designation: 6= Cabinet Office: Gender Desk
1= National health Advisor/Planner 7= National AIDS Council
2= Programme Officer/manager 8= UN Agencies
3= Provincial Health Advisor Circle that 9= NGOs,specify…………………… applies
4=District Health Advisor 10=Provincial Health Office
16 Ministry of health and Central Board of Health 17 Ministry of Education 18 Ministry of Community Development charged with social services for women’s support, e.g. exemption of fees for specific population.
178 5=UN Representative 11= District Health Office
6= Community support agents (TBA/CHW. etc) 12=Hospital Management Board
7=Other, specify………………………………. 13= Other, specify…………………….
Date of Interviews: Day…… Month….. Year….. Locality: 1= Urban 2= Rural
Interviewer’s Name…………………………. Gender: 1= Female 2= Male
A. Impact of Financial Resource Allocation on Quality Health Service for Women
Q1. What criteria are used for financial resource allocation to avail and make provision of quality health services for women in health institutions? a)…………………………………………………………………………………………………………………………. b)…………………………………………………………………………………………………………………………. c)………………………………………………………………………………………………………………………. d)…………………………………………………………………………………………………………………………..
Q2. In what way (s) does your organization/agency contribute to the provision of adequate health services for women in this country?
………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………
Q3. What is your annual budget contribution to women’s health services ?
……………………………………………………………………………………………………………………….
………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………
Q4.What specific activities do you funds to support health services for women?
……………………………………………………………………………………………………………………
………………………………………………………………………………………………………………….
179 ……………………………………………………………………………………………………
Q5. What is the impact of financial resource allocation on quality of health services/reproductive health services for women in health facilities?
……………………………………………………………………………………………………….
……………………………………………………………………………………………………….
……………………………………………………………………………………………………..
Q6. Any suggestions on how funds should be disbursed to improve the quality of health services for women in your area or at national level?
B. Effect of Decentralization and Hospital Autonomy
Now, I would like to get some views about the effect of decentralization of health services at district level and the hospital autonomy on quality of health services for women.
Q7. In your own assessment, what do you think are the negative and positive effects of Decentralization of health services at district level in relation to those affecting women’s health services? a) Negative effects of decentralization:
………………………………………………………………………………………………
………………………………………………………………………………………………
………………………………………………………………………………………………. b) Positive effects of Decentralization:
………………………………………………………………………………………………
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180 Q8. If there are negative effects of decentralization, what possible solutions would you suggest to improve the quality of health services for women in your area or at country level?
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Q9 Are you aware of autonomous hospitals in this country? Or rather is your hospital autonomous organization? If so, how has is affected the adequate provision of quality health services for women in your institution?
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Q10. In what way (s) has autonomous hospital policy in Zambia in relation to decision making space affected institutional governance, finance and revenue, managing inputs and specification of outputs as it relates to quality care provision for women? a) Governance:………………………………………………………………………………………………
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………………………………………………………………………………………………………………. b) Finance and Revenue:…………………………………………………………………………………..
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……………………………………………………………………………………………………………. d) Specification of outputs (e.g. cost-sharing fees and cost recovery for those within hospital basic package and those outside):…………………………………………………………………………….
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Q11. If so, what suggestions would you like to give to improve quality of services for women seeking care in autonomous hospitals?
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Q12. How has the issue of Sector Wide Approach to Planning (SWAP) and Basket funding approach of district health services affected quality health services for women at service delivery points?
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Q13.What types of services are contracted out to other organizations/agencies? a)………………………………………………………………………………………………… b)…………………………………………………………………………………………………. c)…………………………………………………………………………………………….. d)……………………………………………………………………………………………….
Q14. How has the aspect of contracting out services affects the quality and availability of services for women’s health?
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Effect of Policies on Quality health services
Q15. Would you know types of policies that regulate the provision of health services to women?
Tick if mentioned
182 a) User fees policy [ ] b) Reproductive health policy [ ] c) Gender policy [ ] d) Drug policy [ ] e) Population policy [ ] f) Termination of Pregnancy Act [ ] g) Other, specify………………… [ ]
Q16. How has any of the above stated policies improved access to quality health services among women?
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Q17. Is there any effect of policies on eligibility for ART service, or emergency contraception or exemption to user fees payment on women’s access to health services?
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Q18.Is there any local or national forum/fora for women’s advocacy on issues pertaining to service delivery including women living with
HIV/AIDS? If yes, give example of such themes and when are they usually convened to create awareness on women?
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Q20. How effective are statutory, customary and by-laws enforcement by the police and judicial systems in legal, physical and social protection to women and girls?
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Q21. Is there a civic education on women’s rights related to sexual, gender violence and inequalities? If yes, how has empowered women’s sexual right, reduction in gender violence and inequalities?
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Is there anything that you would like to add?
Thank you for your participation
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