ASSESSING QUALITY OF CARE AND RESPONSIVENESS OF HEALTH SERVICES FOR WOMEN IN CRISES SETTINGS. SWAZILAND CASE STUDY Dr I. T. ZWANE, CONSULTANT FOR WHO JUNE 2005 1 Acknowledgements As author and principal investigator, I would like to express my acknowledgements to the invaluable support I and the research team received from the Ministry of Health & Social Welfare and World Health Organization. I would like to extend my sincere gratitude to research team members who worked with me at various stages of this project. These are Dr Isabella S Ziyane, Ms Eunice M Mabuza, both from the Faculty of Health Sciences of the University of Swaziland, and Ms Dudu Mbuli Ministry of Health & Social Welfare for their assistance in formulating the research instruments. The WHO local office is also acknowledged for the support provided. Ms Dudu Dlamini WHO focal person for this study is recognized immensely for her support. The success of this study is an outcome of the commitment and tire-less efforts of the above- mentioned officers. The participation and contribution of the World Health Organization (WHO) during the preparations for the study is highly appreciated as well as the Tinkhundla, chiefdoms and service providers that were part of the study. 2 ACRONYMS AIDS Acquired Immune Deficiency Syndrome ANC Antenatal Clinics ASRH Adolescent Sexual Reproductive Health CSO Central Statistics Office ESRA Economic and Social Reform Agenda FLAS Family Life Association of Swaziland FP Family Planning HEU Health Education Unit HIS Health Information System HIV Human Immune Deficiency Virus ICPD International Conference on Population and Development IEC Information, Education Communication IMR Infant Mortality Rate MCH Maternal and Child Health MI Male Involvement MOE Ministry of Education MOHA Ministry of Home Affairs MOHSW Ministry of Health and Social Welfare MTCT Mother to Child Transmission NDS National Development Strategy NGO Non-Governmental Organization PAC Post Abortion Care REM Rapid Evaluation Method RHM Rural Health Motivator RHMT Rural Health Management Team RHU Reproductive Health Unit SB Stillbirth SHAPE School Health AIDS Programme in Education SNAP Swaziland National AIDS Programme SINAN Swaziland Infant Nutrition Action Network SDP Service Delivery Point SMI Safe Motherhood Initiative STD Sexually Transmitted Disease STI Sexually Transmitted Infection TBAs Traditional Birth Attendants UNAIDS United Nations AIDS Programme UNDP United Nations Development Programme UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund WHO World Health Organization WILSA Women in Law in Southern Africa 3 EXECUTIVE SUMMARY BACKGROUND INFORMATION The kingdom of Swaziland is located in Southern Africa and covers a surface area of 17,000 square kilometres. Swaziland shares borders with Mozambique in the east and the Republic of South Africa in the south, north and west. It is further divided into four administrative regions namely; Hhohho, Manzini, Lubombo and Shiselweni. Each region has an Administrator who is a political appointee and reports to the Deputy Prime Minister. The country is further subdiveided into fuifty five (55) administrative centres (Tinkhundla), under which there are about two hundred chieftancies. The Chiefs have control and authority of the country’s land. The legal system comprises a misture of Roman-Dutch Law and the English Common Law and the unwritten Swazi Law and Custom With a common language, culture and tradition, Swazialnd is one of the few ethnically homogenous countries in Africa. HIB/AIDS SITUATION IN SWAZILAND Swaziland has 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, although the prevalence rate among teenage girls (15-19 years) was also extremely high (32.5%). Sero-prevalence data among men is scarce. A survey conducted among a high-risk population, namely sugar estate workers, in 2002 showed a similar high-prevalence rate of 37.5%. No population-based HIV sero-prevalence survey has ever been conducted in Swaziland. The Demographic and Health Survey (DHS) planned to be conducted in 2005, will include a biological component allowing a more accurate estimation of the population prevalence rates. HEALTH CARE SYSYTEM IN SWAZILAND Health care at community level is ensured by the services provided by rural health motivators (RHM’s) whose duties include giving health talks, condom distribution, referrals, and advising communities on issues such as environmental sanitation, breastfeeding and general prevention of diseases. In addition to the formal health care services, traditional medicine is practiced through traditional healers/herbalists, etc. 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 4 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. Antenatal care is offered at clinics as part of the services offered at the out-patient department and at health centres, PHUs and hospitals as part of the services offered at the maternal and child health department. More than 90% of pregnant women are reported to make contact with the ANC services at least once during pregnancy (Swaziland Community Health Survey, 2002). 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. PURPOSE AND OBJECTIVES The following were set out to: 1 identify local organizations providing health and social services to women 2 Determine key constraints/ challenges to women’s access to health and basic services 3 Recommend components of a health assessment tool that would be considered locally relevant and useful 4 Formulate concrete recommendations for action to increase women’s access to health and related social services for women in Swaziland METHODOLOGY The target population for this study was all women of child bearing age (15-49 years) living in Swaziland with the exception of those who were in special institutions such as prisons, mental health institutions, schools and universities. A multistage sampling approach was used in this study as follows: Two of the four regions of Swaziland were selected using HIV prevalence in both urban and rural geographic settings. Enumeration areas were selected using the 1997 Census Enumeration sites. From the EAs households were selected using the circular systematic sampling method. Within households systematic random sampling was carried out to identify eligible women. Where there was only one eligible woman in a household, that person would be interviewed. Sample size determination Sample size was determined using the HIV/AIDS prevalence rates in the two selected study regions. These are Hhohho and Lubombo. These regions represent both urban and rural geographic settings of Swaziland. Lubombo region is typically rural. Sample size determination was calculated based on the national rural and urban HIV prevalence as indicated in the 8th Sentinel Survey (2002). The prevalence for the rural areas was reported to be 32.7% and 35% for urban settings. The formula adopted for the calculation of the sample assumed a normal distribution. The desired 95% confidence 5 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 2 N = p1 (100-p1) + p2 (100-p2)/ e 4475.7/25 = 179 women in each region. Oversampling was done to yield a total of 500 women. TRAINING OF FIELD WORKERS After the team was formed field workers had a two-day training on the study survey. Tools used for data collection were pretested at Ludzeludze Inkhundla which was not included in the study sample. Interviews were conducted with women, family planning clients (exit interviews), maternity women (exit interviews), focus group discussions with women, and Heath care providers (nurses). Only one team collected data from the two regions. DATA HANDLING AND ANALYSIS Colour coding was done to distinguish data from each of the two regions that were studied. After each interview data was checked for accuracy and completeness. All questionnaires were kept in a safe cabinet to ensure that privacy and anonymity of participants was maintained. Data was analyzed using a computer software package, SPSS for descriptive statistics. Data from focus group discussions was analyzed using content analysis LIMITATIONS OF THE STUDY The exclusion of women aged below 15years and those above 49 is a limiting factor because needs identified in this sample cannot be generalized to apply to all women in Swaziland. Additional limitations arise from the fact that the time allocated to the study was very limited. This was coupled by inadequate funding for the study. Consideration of time and funding should form the basis for quality studies. KEY FINDINGS OBJECTIVE 1 To identify local organizations providing health and basic social services to women Several organizations in Swaziland provide health and social services in Swaziland. These organizations include the following: Family Life Association of Swaziland (FLAS), Swaziland Action Group Against Abuse (SWAGAA), Women and Law (WLSA), Ministry of Health & Social Welfare, Social Welfare programme. Findings from analysis of these organizations indicate that services for women are diverse but uncoordinated. Women in rural areas do not know where to go for protection. This was as a result of lack of publicity of these organizations as most of them are located in urban 6 areas.