A case study of Kasangati Health Centre IV

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2 The community score card for family planning services was produced by the Civil Society Budget Advocacy Group (CSBAG) with support from Action Aid International Uganda. The contents of this publication are the responsibility of CSBAG and n0t of our development partners Civil Society Budget Advocacy Group (CSBAG) P.O. Box 660, Ntinda Plot 15 Vubya Close, Ntinda Nakawa Rd Fixed Line: , Mob: Web CSBAG/Facebook.com All rights reserved. No part of this publication may be reproduced, or reprinted in any form by any means without the prior permission of the copyright holder. CSBAG encourages its use and will be happy if excerpts are copied and used. When doing so, however please acknowledge CSBAG.

3 Table of Contents List of Tables... 1 Acronyms...2 Acknowledgements... 3 Executive Summary INTRODUCTION STUDY OBJECTIVES METHODOLOGY Phases undertaken Sampling Criteria Community Score Card Process Observations CONCLUSION, POLICY RECOMMENDATIONS, AND ADVOCACY ACTIONS Conclusion Policy Recommendations Advocacy Actions References...32 List of Tables Table 1: Kasangati Health Centre Iv Family Planning Service Entitlements Table 2: Input Tracking Matrix Kasangati Hc Iv...18 Table 3: Community Score Card-Men Kasangati Parish Table 4: Community Score Card - Women Kasangati Parish Table 5: Community Score Card-Men Gayaza Parish...22 Table 6: Community Score Card-Women Gayaza Parish...23 Table 7: Self Assessment Score Card Kasangati Hc Iv Table 8: Interface Meeting Separate And Consensus Scores Kasangati Hc Iv...25 Table 9: Interface Meeting Action Plan Matrix Kasangati Hc Iv A Community Score Card for Family Planning Services 1

4 List of Acronyms A case study of Kasangati Health Centre IV AIDS AMREF CAO CRC CSBAG CSC DHD DHO FGD HC HIV IUDs LCs MoH NMS OPD UDHS UNICEF VHTs Acquired Immune Deficiency Syndrome African Medical Research Foundation Chief Administrative Officer Community Report Card Civil Society Budget Advocacy Group Community Score Card District Health Department District Health Officer Focus Group Discussions Health Centres Human Immune Virus Intra Uterine Devices Local Council Chairpersons Ministry of Health National Medical Stores Out-Patient Department Uganda Demographic Health Survey United Nations Children s Fund Village Health Teams 2 A Community Score Card for Family Planning Services

5 Acknowledgent In conducting the Community Score Card (CSC) in Wakiso district, we received support and guidance from various people. We are grateful to the Chief Administrative Officer and the District Health Officer of Wakiso District first for welcoming us; for granting permission to visit the sampled areas and providing an introduction letter to the in- charge of Kasangati Health Centre IV. We are also grateful to Officers in the Medical Records Department in the Health Section of Wakiso District who provided us with reliable information on the entitlements of the indicators we had for the study and that contributed immensely to the data that was required before we proceeded to the field. We express sincere and profound thanks to Dr. Bbaale Edward the lead consultant and to the data collection team we say thank you and we are truly indebted to you as this work would not have been completed without your dedicated efforts. This dedicated team included: Ms. Harriet Birungi- moderator and Mr. Allan Ndaula-VHT member of Kasangati Health Centre IV. Special thanks also go the independent reviewers whose input greatly enriched the quality of this report these included Frank Twinamasiko and Mr. Abbot Ntwali This report was produced under the guidance of Mr. Julius Mukunda Mugisha, the Coordinator of CSBAG, whose technical input at the different stages complemented greatly enriched this report. Lastly, we are grateful to the Local Councils (LCs), area councilors, women, men and health workers in the community from the various villages for effective mobilization, participation in the discussions and providing additional information that supported our field work. A Community Score Card for Family Planning Services 3

6 Executive Summary A case study of Kasangati Health Centre IV Only 30% of married women in Uganda are using some method of contraception. It is noteworthy that Uganda has the world s second fastest growing population after Niger. The contraceptive unmet need stands at 34.3%, the highest in Africa. More than half (56%) of all pregnancies that occur in Uganda are unintended and occur due to low contraceptive use. The major aim of this study was to assess how the community rated the provision of family planning services in the government owned health centre of Kasangati in Wakiso district. Using the Community Score Card process, we sought to examine the availability, reliability, affordability and quality of family planning services. In addition we sought to ascertain the permeability of information concerning family planning services (quality, quantity and type) to the grass root communities. We utilized a globally recognized online facility (random.org) to obtain random numbers for the Parishes, villages and the health centres used in the study. Using a complete listing of all health centres in Wakiso district, we randomly selected Kasangati Health Centre IV to conduct the Community Score Card. For the catchment area of Kasangati Health Centre IV, we randomly selected two Parishes, that is Kasangati Parish and Gayaza Parish. For each Parish, we randomly selected two villages; Gayaza Parish: Gayaza and Kabanyolo, Kasangati Parish: Seeta and Kito. To obtain a homogeneous sample of respondents that participated in our Focus Group Discussions (FGDs), we used purposive sampling where, with the help of Village Health Teams (VHTs) and Local Council Chairpersons (LCCs), we identified only those individuals that had used family planning services from Kasangati Health Centre IV. 10 women and 10 men from each of the four (4) villages enrolled to participate in our Focus Group Discussions. We employed FGDs as a standard qualitative methodology of enlisting peoples opinions and submissions concerning family planning service provision. The FGDs were conducted on a maximum of 10 people per group independent of the other. The groups included those of men only, women only, service providers only and an interface meeting that comprised of a maximum 5 4 A Community Score Card for Family Planning Services

7 men, 5 women, 5 service providers and any number of opinion leaders such as political, religious, and cultural leaders. Each of these groups was expected to examine indicators concerning the provision of family planning services and award a score of its performance ranging from A score of zero (0) was awarded to the worst performing indicator, five (5) to an average performance and ten (10) to an excellent performance of a particular indicator. The performance indicators were agreed upon in particular FGDs but generally they included: attended to by a medical personnel; staff working hours; availability of family planning commodities; availability of physical infrastructure (particularly private consultation rooms, waiting rooms, and dispensing rooms); and availability of information/outreach concerning family planning services. It was noted that the women were very much concerned about the fact that there is no private room for private consultations. A big knowledge gap between men and women regarding family planning services at the health facility was noted. Both men and women were also concerned that the health facility has no signage indicating its location and there are also no directions within the facility to direct patients to the services available. The health workers were mainly concerned about the heavy work load, given the disproportionate number of patients assigned to the few staff. In addition there is no specific personnel dedicated to handling family planning services only. All Maternal Child Health (MCH) services are integrated and family planning services are only offered between 8:00am to 3:00pm. Overall, the highly scored indicator was the Attended to by medical personnel with an average of 9 out of 10. This is attributed to the fact that both men and women appreciated the availability of the service providers at the facility. During its hours of operation 8.00am to 3.00pm, a qualified medical staff offers family planning services and addresses patient concerns. The least scored indicator was the Availability of physical infrastructure with an average of 3.8 out of 10. The reason was mainly because the facility had no private room for family planning services. There is no waiting room. Patients have to wait on the A Community Score Card for Family Planning Services 5

8 veranda. The consultation room available is multipurpose and not exclusively private for family planning services. It is used as a consultation room, staff room, sleeping room for staff on duty and a dispensing room. Policy Recommendations Construct staff houses to curb on late coming and early exit of health workers on a daily basis. Construct independent family planning units with private consultation rooms, waiting rooms, and dispensing rooms. Inspect and monitor health centres regularly, but most especially towards the weekend when more absenteeism is common. Provide transport and other logistics for service providers and VHTs to be able to carry out outreach services. Train staff on all the family planning services offered at the centre. Avail family planning posters at the centre. Consider posters translated into the local languages. Recruit and train VHTs so as to subsidize on the limited number of staff. Government budget allocations should be displayed for the public to view and provide input. Provide adequate family planning commodities to overcome the problem of stock outs. Family planning education for men should be provided to encourage their participation in accessing services. Government should ensure that the entitlements designated for the health centre match actual needs. Raise staff ceiling (entitlement) to address work overload. Provide machine for administering Intrauterine Devices (IUDs),a long-term family planning method. 6 A Community Score Card for Family Planning Services

9 Advocacy Actions i. Government should continue to provide services regardless of external support from development partners. ii. iii. iv. Include family planning commodities on the National Medical Store(NMS) forms Update reporting system i.e. data collection tools to identify gaps at the health centre level. Provide IUD insertion equipment specific for family planning and not the current multi-purpose one. v. Erect signage to direct patients around the health facility. vi. vii. Improve infrastructure to accommodate private rooms for family planning services. Institutionalize family health days currently facilitated by UNICEF on Fridays, Saturdays and Sundays. viii. Provide family planning information and education materials such as posters in local languages both at the community and the health centre. ix. Increase working hours from 8am 3pm to 8am-6pm. x. Increase competent family planning providers at centre. xi. xii. Improve customer service at the health centre Employ more VHTs preferably men to promote family planning. A Community Score Card for Family Planning Services 7

10 1.0 Introduction A case study of Kasangati Health Centre IV The role of an efficient and effective public service system in assuring a good quality of life for the citizens of a country cannot be underestimated. It is no surprise then that Governments the world over strive to achieve favorable policies for effective service provision. According to the Health Sector Strategic Plan (HSSP III) of 2010/ /15, The 1995 Constitution and the 1997 Local Government Act mandates the District Local Government to plan, budget and implement health policies and health sector plans. The Local Governments have the responsibility for the delivery of health services, recruitment, deployment, development and management of human resource (HR) for district health services, development and passing of health related by-laws and monitoring of overall health sector performance. A reliable tool for evaluating the effectiveness and efficiency of service delivery through a feedback mechanism is the Community Score Card (CSC). The CSC is a social accountability tool used to bring about improved governance through the promotion of participation, transparency, accountability and informed decision-making. The CSC enables maximum participation of the local community, by bringing together the service users ( the demand side ) and service providers ( the supply side ) to jointly analyze service delivery and create a shared way to address challenges. Used at the community level, the CSC aims to empower communities to evaluate service provision, demand social accountability for improved responsiveness to customer-needs and quality service. In return, it offers the opportunity for government and service providers to explain decisions, constraints and challenges faced in service provision. By facilitating this two-way, participatory dialogue, accountability to citizens and service provision can be strengthened. The CSC has three different functions: 1) Community Empowerment: Promote discussion and dialogue between service user and service provider. 2) Joint Decision Making: Create opportunities for information sharing, defining mutual objectives, and critical assessment 8 A Community Score Card for Family Planning Services

11 of service quality, effectiveness and efficiency. 3) Monitoring and Evaluation for Quality Improvement: Score and monitor service delivery, encourage service providers to measure and improve their performance. The CSC was used to evaluate the delivery of family planning services in Wakiso district. According to the UDHS (2011), family planning refers to a conscious effort by an individual or a couple to limit or space the number of children they want to have through the use of contraceptive methods. The UDHS classifies contraceptive methods into modern and traditional methods. Modern methods include female sterilization, male sterilization, pills, IUDs, injectables, implants, male condoms, diaphragms, Lactational Amenorrhea Method (LAM). Several traditional methods exist including rhythm (periodic abstinence), and withdrawal techniques. According to the UDHS, 2011, three in ten currently married women use some method of contraception. The majority (26%) use modern methods. Use of modern contraceptive methods has increased substantially over the past fifteen years from 8 percent in 1995, to 18 percent in 2006 and to 26 percent in The most commonly used modern method is injectables (14%). Four percent of women use traditional methods. The most commonly used traditional method is withdrawal (2.1%). For rural-urban differentials there is a wide gap in the use of any methods between urban and rural areas (39% versus 23%). Distribution by sub region shows that they have the lowest percentages. The use of contraception increases with increasing levels of education. Forty-four percent of currently married women with a secondary or higher education are using contraceptive methods compared with 18 percent of those with no formal education. In general, women do not begin to use contraception until they have had at least one child. Only about one-third of married women with three or more children use contraception methods (UDHS, 2011). percentage of women currently in a stable union or relationship using contraceptive methods is highest in Kampala (48%) while West Nile (15%) and Karamoja (8%) sub regions A Community Score Card for Family Planning Services 9

12 2.0 Study Objectives A case study of Kasangati Health Centre IV The objectives of the study were to ascertain; i. Whether community members access and actually utilize family planning services, ii. iii. iv. The quality of family planning services offered, The reliability of family planning services, Whether information on family planning services is available (quality, quantity and type of family planning). CSC was used to evaluate Family Planning Services in Wakiso 10 A Community Score Card for Family Planning Services

13 3.0 Methodology We used the Community Score Card (CSC) a qualitative monitoring tool utilized globally for lower level monitoring, performance and evaluation of services (World Bank 2004). The CSC approach enabled us assess the availability, affordability, reliability, utilization and quality of family planning services. The assessment was conducted in six (6) interrelated phases. 3.1 PHASES UNDERTAKEN Phase 1: Building capacity of implementers Training of moderators, scribes and videographers to teach them how to use the Community Scorecard. Phase 2: Meeting with the District Officials The lead consultant held meetings with the District Chief Administrative Officer (CAO), and the District Health Officers (DHOs) to introduce the study, request permission to visit Kasangati Health Centre IV and obtain the family planning services entitlements of the health centre. The meeting enabled us to provide clarification on the project, build rapport with the district leaders and access key information (input tracking) required during field implementation. Phase 3: Field Visits 1. The lead consultant visited Kasangati Health Centre IV to schedule appointments for the focus group discussions with the community and the service providers, and also collected information on the actuals of the family planning services provided at the centres. 2. For the community Focus Group Discussions (FGDs), appointments were made with the Chairman Local Council 1, VHTs and the officers In- charge at the health centres. A Community Score Card for Family Planning Services 11

14 3. Prior to setting up the appointments, an orientation was conducted for the two categories of discussion groups. They were taken through the process of the CSC and the different roles and responsibilities of each group which equipped them to participate effectively throughout the project. Phase 4: Community Score Cards As agreed during the FGDs, men and women scored the family planning service separately. The two groups focused on performance indicators to provide their assessments, recommendations and justifications. The process measured the actual quality of services the community receives from service providers during an identified period. Phase 5: Self Evaluation Scorecard Service providers evaluated themselves against the developed performance indicators and scores included reasons for current status of family planning services and recommendations on how to improve service delivery. Phase 6: Interface Meeting A joint meeting of the service users and providers at Gayaza and Kasangati Parishes was organized. Results of each category of respondents were displayed and presented by their respective group representative. Members were then required to come up with a consensus score and develop a joint action plan including time lines and persons responsible. The interface included the health workers, service users (both men and women), and opinion leaders including community and religious Leaders). 3.2 SAMPLING CRITERIA A Simple Random Sampling (SRS) technique was used to select the health centre and communities for the CSC. We obtained a complete list of all the health centres in Wakiso district and assigned 12 A Community Score Card for Family Planning Services

15 them numbers in an excel sheet. The online facility RANDOM.ORG was used to obtain 1 random number of a health centre (Kasangati Health Centre IV) to be used for the assessment. RANDOM.ORG offers true random numbers free of charge. The randomness comes from atmospheric noise, which for many purposes is better than the pseudo-random number algorithms typically used in computer programs. Popular services used on RANDOM.ORG include lotteries, drawings, and sweepstakes, to drive games, gambling sites, scientific applications, art and music. The service has existed since 1998, built and operated by Mads Haahr of the School of Computer Science and Statistics at Trinity College, Dublin in Ireland. For the catchment area of each health centre, we obtained a complete list of the Parishes served by Kasangati Health Centre IV and we assigned them numbers in an excel sheet. We then used random.org to randomly select two Parishes; Kasangati and Gayaza Parishes that we considered for the CSC process. For each Parish, we used random.org to randomly selected two villages; Gayaza Parish: Gayaza and Kabanyolo, Kasangati Parish: Seeta and Kito. To obtain a homogeneous sample of respondents that participated in our FGDs, we used purposive sampling where, with the help of VHTs and Local Council chairpersons, we identified only those individuals that had used family planning services from Kasangati Health Centre IV. We enrolled 10 women and 10 men from each of the four (4) villages to participate in the (FGDs). Step 1: Preparation of the data collection teams Identified moderators, scribes and photographers for training on the Community Score Card Process. 3.3 COMMUNITY SCORE CARD PROCESS Step 2: Developed the Input Matrix The input tracking matrix was developed along the following general indictors of family planning service delivery and were measured at a scale of 0-10, Zero (0) as the worst performing indicator, five (5) average and ten (10) as the best performing indicator. A Community Score Card for Family Planning Services 13

16 I. Human Resource a) Were you attended to by qualified medical personnel when you visited Kasangati Health Centre for family planning? b) Staff capacity; is the number of health workers adequate to cater for the demand for family planning services? c) Behaviour of health worker towards patients; are they remorseful? II. III. IV. Budget a) Entitlement How much does government inject into family planning? b) Do they receive this money? c) Do they display how much was received and how much was used? Information availability/outreach services a) Are there displays at the facility level? b) Are there outreach campaigns for family planning (onsite and offsite visits)? c) Family Planning Education and information/ communication Do you receive information on the side effects of the methods used and how to overcome them? Physical Infrastructure a) Buildings; Are they temporary or permanent? b) Are there private consultation rooms, waiting rooms, and dispensing rooms available? c) Number of beds d) Surrounding environment e) Public facilities f) Toilet facilities 14 A Community Score Card for Family Planning Services

17 g) Water facilities h) Disposal facilities i) Directions e.g. to doctor s room, treatment room j) Disability sensitive facility e.g. access to the bed, accessing clinic V. Availability of commodities e.g. condoms, pills, injectables, IUDs a) How satisfactory? b) Costs involved c) Corruption tendencies (do they make payments in kind or monetary form) Step 3: Collected data on entitlements from the District Health Office of Wakiso District. Table.1 shows family planning service entitlements from government to Kasangati Health Centre IV. S.NO INPUT INDICATOR ENTITLEMENT Staffing 1 Senior Medical Officer 1 Medical Officer 1 Senior Nursing Officer 1 Public Dental Officer 1 Dispenser 1 Nursing Officer-Nursing 1 Nursing Officer Midwifery 1 Nursing Officer-Public Health 1 Nursing Officer- Psychiatry 1 Thalamic Clinical Officer 2 Health Inspectors 1 Anaesthetic Officer 2 Anaesthetic Assistant 1 Medical Entomology Officer 1 Laboratory Technician 2 Clinical Officers 3 Enrolled Nurse 1 Enrolled Nurse- Psychiatry 3 Midwives 1 Laboratory Assistant 1 Health Assistant 1 Stores Assistant 1 Accounts Assistant 1 Cold chain Assistant 1 Office typist 5 Nursing Assistants 1 Driver 3 Guards 3 Porters A Community Score Card for Family Planning Services 15

18 Budget Allocation Information Availability/Outreach Physical Infrastructure Requests for family planning commodities come from National Medical Stores Health centres do not receive cash from Government for family planning but rather commodities Information [nonspecific] is availed to the health centres in form of flip charts and brochures in both English and the local language and are pinned at the health centres In every community, Village Health Teams have been trained to sensitize the community on family planning services. 1 Operating Theatre 1 Inpatient ward for Men 1Inpatient ward for Children 1 Inpatient ward for Women 1 HIV/AIDS Clinic 1 Laboratory 1 Incinerator 1 Placenta pit 1 Maternity Labour ward 1 Antenatal Ward 1 Postnatal ward 1 OPD Availability of Commodities Working Hours 24 hours Pills- Emergency Contraceptive, Progestin Oral Pill ; Combined Oral Contraceptives Injectables Implants [sometimes not available] IUDs Condoms Moon Beads Vasectomy and Tubaligation Counselling Commodities are of good quality, they never exceed expiry date All services and Oral Contraceptives are given free of charge Step 4: Collected actual data Step 5: Set an appointment with the In-charge of the Health Centre Made an appointment with the Health Centre In-charge Step 6: Mobilized community through VHTs Made appointments with Village Chairpersons of Local Council (I) of the Parishes that were visited Step 7: Decided on venue for CSC Step 8: Community evaluation process 16 A Community Score Card for Family Planning Services

19 Conducted the Community Score Card with the community: Women and Men were separated under their respective Parishes. The community was expected to provide information and score the performance of family planning services at their health centre. They also provided a justification for the score given and recommendations for improvement. Step 9: Service Providers self-evaluation process Conducted a self-assessment Scored Card with the service providers: Service providers evaluated their delivery of family planning services. Step 10: The interface meeting Conducted the Community Scored Card with the service providers and community with both men and women in Kasangati and Gayaza Parishes. The three categories were expected to assess the delivery of service as well as discuss action points and make recommendations highlighting the timing and the person/officer responsible to take action. At Kasangati Health Centre IV, the CSC exercise was conducted with groups composing of 11 men, 10 women for the community score card of Kasangati Parish; 9 men, 10 women for the community score card of Gayaza Parish; 8 health workers for the self-assessment score card and 22 (14 females and 8 males) for the interface score card amongst which were two VHTs and a Local Council (I) chairman. Overview In general, all participants contributed equally to the discussions in their respective groups. It was noted that the women were very much concerned about the fact that there is no room designated for private consultations. It was also observed that there is a big knowledge gap between men and women regarding family planning services provided at the health facility. Both men and women were also concerned that the health facility has no signage both outside and on the grounds. A Community Score Card for Family Planning Services 17

20 A female health worker in charge of the maternity section decried the limited family planning knowledge among health workers. She argued that the majority cannot advise family planning patients appropriately on how to use the commodities and or manage the expected side effects. Additionally there are also no directions within the facility to help patients locate service points. The health workers were mainly concerned about their heavy work load. The number of staff are disproportionate to the number of patients and there are no specialized personnel dedicated to providing family planning services. All Maternal Child Health (MCH) services are integrated and family planning services are only offered between 8:00am to 3:00pm. The details of the CSC exercise at Kasangati Health Centre are shown in Table 2. A review of the input tracking matrix, indicates the entitlements of a Health Centre IV are not in effect at Kasangati Health Centre IV. There are several gaps. Table 2: Input tracking matrix Kasangati HC IV S.NO INPUT INDICATOR ENTITLEMENT ACTUAL REMARKS/ OBSERVATIONS 1. Staffing 1 Senior Medical Officer 1 Medical Officer 1 Senior Nursing Officer 1 Public Dental Officer 1 Dispenser 1 Nursing Officer-Nursing 1 Nursing Officer Midwifery 1 Nursing Officer-Public Health 1 Nursing Officer- Psychiatry 1 Thalamic Clinical Officer 2 Health Inspectors 1 Anaesthetic Officer 2 Anaesthetic Assistants 1 Medical Entomology Officer 1 Laboratory Technician 2 Clinical Officers 3 Enrolled Nurses 1 Enrolled Nurse- Psychiatry 3 Midwives 1 Laboratory assistant 1 Health assistant 1 Stores assistant 1 Accounts Assistant 1 Cold chain Assistant 1 Office typist 5 Nursing Assistants 1 Driver 3 Guards 3 Porters 1 Senior Medical Officer 1 Medical Officer 1 Senior Nursing Officer 1 Public Dental Officer 1 Dispenser 3 Nursing Officer-Nursing 1 Nursing Officer Midwifery 1 Nursing Officer- Psychiatry 1 Thalamic Clinical Officer 1 Health Inspector 1 Anaesthetic Officer 1 Anaesthetic Assistant 1 Medical Entomology Officer 1 Laboratory Technician 4 Clinical Officers 4 Enrolled Nurses 1 Enrolled Nurse- Psychiatry 4 Midwives 1 Laboratory assistant 1 Health assistant 1 Stores assistant 1 Accounts Assistant 1 Cold chain assistant 1 Office typist 3 Nursing Assistants 1 Driver 1 Guard 1 Porter Few staff in relation to number of patients Maternal and child services are integrated therefore no independent Family Planning Unit. 2. Budget Allocation Do you request for commodities from National Medical Stores(NMS). Budget not known: Family Planning commodities are delivered in by NMS. The revised order form from NMS for these family planning commodities currently has a component of pricing. 18 A Community Score Card for Family Planning Services

21 3. Information Availability/Outreach Information [non specific] is availed to the Health Centres in form of flip charts and brochures in both English and the local language should be pinned at the health Centres In every community, Village Health Teams have been trained to sensitize communities on family planning No Health Centre Signage at the road side No Directions and Poster Displays at the Facility There is general health talk and one on ones No offsite visits because of limited resources Out reaches mainly carried out by Marie Stopes 4. Physical Infrastructure 1 Operating Theatre 1 Inpatient ward for Men 1Inpatient ward for Children 1 Inpatient ward to Women 1 HIV/AIDS Clinic 1 Laboratory 1 Incinerator 1 Placenta pit 1 Maternity Labour ward 1 Antenatal Ward 1 Postnatal ward Out Patient Department(OPD) There are over 4 permanent structures at the health centre including 1 Maternity wing also used for family planning 1 Administration block 1 In patient block 1 Antiretroviral (ART Clinic 1 OPD 1 store room for medicines There is no specific waiting room. Facilities available include Water facilities, Toilet facilities, 1 Placenta pit 1 Laboratory 1 Maternity Labour ward 1 Antenatal Ward The maternity block was not initially planned as a maternity ward The consultation room is multipurpose and not exclusively private for family planning services The client waiting area is on the veranda, with a provision for sitting The toilet available is not functional Water supply is on and off No Incinerator 5. Availability of Commodities Pills- Emergency Contraceptive, Progestin Oral Pill ; Combined Oral Contraceptives Injectables Implants [sometimes not available] IUDS Condoms Moon Beads Vasectomy and Tuba ligation Counseling Commodities of good quality, they never exceed expiry date All services and Oral Contraceptives are given free of charge Type of Commodity Oral Pills Mycrogynon Injectables Depo Provela Implants (only for 3 years) Condoms IUDs - Quantity 200 cycles per request 200 viles 200mg. - Only Mycrogynon is supplied at the Centre for Oral pills Requisitions for commodities are made whenever there is need. It is not done periodically. Majority of the women at the centre prefer Implanon and have rejected IUDs. It is for this reason that IUDs are not supplied because they are never requested for. And for those who prefer them, they cannot be administered because the centre has no machine for inserting them. All services and contraceptives are Free. However when there is a stock out of syringes for administering the Injectaplan, clients are asked to buy their own syringes NMS doesn t supply the centre with Condoms. Most of the condoms at the centre are supplied by Marie Stopes 6. Working Hours 24 hours 24 hours Family Planning Services offered from 8.00 am 3.00pm and not on weekends. Even as I speak now, there are no condoms in the store. If it were not for private partners like Marie Stopes, we would have a very big problem, said a health worker. According to the In-charge of the centre most of the commodities at this centre are supplied by Marie Stopes and there are regular stock outs. A Community Score Card for Family Planning Services 19

22 Table 3: Community score card-men Kasangati Parish S.NO INDICATOR SCORES (0-10) REASON FOR SCORE RECOMMENDATION 1 Attended to by the Medical Personnel when you go for family planning services 10 Always available 2 Staff working hours 05 Very few workers. Patients wait for longer hours. At times the facility is open very early but there are no medical workers to assist the patients. Recruit more staff The in-charge should make sure a staff on duty is always there on time 3 Availability of Physical Infrastructure 0 4 Availability of Commodities 0 5 Availability of Information/Outreach 02 No Private consultation Rooms No waiting rooms, patients wait from the veranda. Dependent on supplies from Marie Stopes. The health Centre experiences several stock outs. Dispensing of commodities ends at 3pm. Refer patients to pharmacies to buy family planning commodities. No posters in villages. Language barrier. No signage at the facility. No directions to the maternity wing and to the family planning section. Public Sensitization absent. Family Planning Education absent. Construct an independent Family Planning Unit with private consultation rooms, waiting rooms and dispensing rooms Avail VHTs with family planning commodities for ease of accessibility by the community. Government should ensure a smooth flow of family planning commodities in order to avoid stock outs. Motivate and empower VHTs to be able to deliver family planning information to the communities. Produce posters in local language and disseminate them up to the grassroots level I sent my wife at this facility for family planning services at 8am and she came back home in the evening. My wife kept coming to this facility for two months for implants and did not get because they were out of stock. My wife moved many times in search of an injectable at this facility, she finally got it but at the same time she got pregnant. The men in Kasangati Parish were satisfied with being attended to by medical personnel whenever they visited the facility for family planning services. This performance indicator received a maximum score of 10 points. However, they were concerned that they have to wait for longer hours to be attended to given that there are few staff available to serve all the patients. Additionally the men pointed out that there is no private room for family planning counseling. Therefore, the performance indicator of infrastructure in terms of private consultation rooms received the worst score at zero. They were also concerned about the issue of commodities running out at the facility and therefore being asked to go and purchase at the pharmacies thus scoring it zero as the centre experiences regular stock outs. Availability of information/outreaches was scored amongst the least because the facility hardly has any posters or directions to the different service units within the facility. There is also no signage at the road side to indicate the existence of the health facility. The 20 A Community Score Card for Family Planning Services

23 men were also concerned about the facility not carrying out any outreach activities. Most of it is done by Marie Stopes, said one man. Let the VHTs be motivated through facilitation(resources) to carry out the outreach activities, he added. Table 4: Community score card women Kasangati Parish Women that receive family planning information from us are only those that come for antenatal care because we don t conduct outreach family planning health centre staff S.NO PERFORMANCE INDICATOR SCORE REASON FOR SCORE RECOMMENDATION Availability of commodities 08 Whereas family planning commodities are available, at times the Women are requested to buy injections for administering Injectaplan. More injections should be provided because clients cannot afford the Injections Availability of Physical Infrastructure Availability of Information/ outreach 05 Staff working hours 05 Attended to by the Medical Personnel when you go for family planning services No Private consultation rooms No waiting rooms patients wait on the veranda 10 Information is provided 07 Staff are over worked Report late and patients come early but there no staff to tend to them The Service providers are available but impolite. They have no compassion. Independent family planning unit furnished with private facilities, waiting rooms and dispensing rooms. Recruit more staff Strict rules about time keeping Build staff quarters so that health workers on duty can stay around longer Improve on their behavior Pay staff more for motivation Provide specific family planning service specialists The women in Kasangati Parish scored Availability of Physical Infrastructure and Staff working hours the least with an average score of 5 points during the assessments. It was noted with concern that the facility has no private consultation rooms for family planning. The one available offers no opportunity for privacy at all as it is also used as a staff room and other activities. The facility also has no waiting rooms thus patients are forced to wait on the verandas. About Staff working hours, the women suggested staff quarters be built at the facility to reduce on staff coming late to work. We come early to the facility but find no health worker to attend to us, said A woman coming for antenatal care waits in the same queue with one that has come for family planning services, this has made service delivery very unsatisfactory Focus group member A Community Score Card for Family Planning Services 21

24 Table 5: Community scorecard-men Gayaza Parish one female patient at the centre. The women are availed with all the necessary information they require about family planning services whenever they come to the facility thus scoring the indicator the highest with a maximum score of 10 points. Concerns about the impoliteness of the over worked service providers were highlighted. Suggestions to improve this included improving staff remuneration to boost their morale. Some service providers don t have a passion for their worker and profession. They become impolite once they are overstretched with work, said one woman attending the health centre. The women are happy with the commodities availed, however they are disheartened at the shortfalls in supply which forces them to buy medical supplies like syringes and injections for those opting for injectables. S.NO 1. INDICATOR Attended to by the Medical Personnel when you go for family planning services Staff working hours 07 Availability of Physical Infrastructure SCORES (0-10) REASON FOR SCORE 10 Always available 04 Availability of Commodities 08 Staff retire from work early Health workers are few and overstretched. The Private Room available is used as a multipurpose room. It serves as a staff Office, sleeping room for staff on night duty, and counseling room The health Centre experiences several stock outs RECOMMENDATION Conduct surprise supervision Recruit more staff Provide fringe benefits like evening tea to motivate staff to keep around Construct an independent Family Planning Unit with private consultation rooms Increase quantities of commodities supplied at the centre Availability of Information/ Outreach 06 No signage indicating that Kasangati HC IV facility In addition there no signage indicating that family Planning services are available No family planning outreaches Provide appropriate signage Motivate VHTs to avail villagers with information in the communities 22 A Community Score Card for Family Planning Services

25 The least scored indicator amongst the men of Gayaza Parish was that of Availability of Infrastructure. They indicated that the facility has no privacy for family planning services. The room currently used is a multipurpose room. It is used as a staff room and a resting room for staff that work over night (i.e. night duty) and is also a counseling room. Sometimes this room is used by staff as a baby nursery as some of them bring their babies and rest them there, said one male participant. The men in this Parish also had complaints about staff leaving work very early. Similar to the other participants, the men of Gayaza Parish were very concerned by the rate at which supplies at the facility run out. They argued that if it was not for Marie Stopes, the patients would go for a while without family planning services. Government should be mindful of the population served by Kasangati Health Centre IV and therefore provide enough supplies. What will happen if Marie Stopes stops subsidizing Government supplies? asked one man. The men here were also concerned about the facility having no signage and directions. One day I sent my wife to come to the facility for an injection and that day she reported twice at 2 and 3pm but never found them there. However, when she returned the following morning at 8.00am she found them there, reported one of the men. Table 6: Community score card-women Gayaza Parish S.NO INDICATOR SCORES (0-10) REASON FOR SCORE RECOMMENDATION 1. Attended to by Medical Personnel when you go for family planning services 08 Staff are over worked and therefore at times impolite Recruit more staff 2. Staff working hours 05 Staff work up to 3pm for family planning and do not work on weekends Increase the time of working Motivate staff to stay around for longer hours 3. Availability of Physical Infrastructure 05 Only one private room and is shared with Staff as a changing room, team room and resting room Construct an independent Family Planning Unit 4. Availability of Commodities 07 The health Centre experiences several stock outs Patients are asked at times to buy their own injections and gloves Provide commodities in time to avoid stock outs 5. Availability of Information/ Outreach 04 Only Marie Stopes posters that announce their visits are provided No signages/directions at the facility No Family Planning Signage Avail posters in local languages A Community Score Card for Family Planning Services 23

26 It is worth noting that the women in both Kasangati and Gayaza Parish argue that the staff are impolite because they are over worked. The women in Gayaza Parish suggested recruiting more staff to reduce on the overload imposed on the ones available. The women rated staff working hours with one of the lowest scores because staff leave early on weekdays and do not work on weekends. The women rated Information availability the least because the only posters they always see around are those of Marie Stopes announcing their visits. Additionally, posters are not in local languages and hence are not easily understood by the community. Table 7: Self-assessment score card Kasangati Health Centre IV S.NO PERFORMANCE INDICATOR SCORE REASON FOR SCORE RECOMMENDATION Availability of commodities 08 Stock outs of microgynon No long term methods IUDs available but machines for insertion missing Condoms missing and those that are supplied are of poor quality (small ones) There should be a continuous supply of commodities like Implanon Avail machines for inserting the IUDs. Availability of Physical Infrastructure 05 Waiting on verandas Privacy provided with a curtain Improve Infrastructure Availability of Information/ outreach 05 No Posters Limited Knowledge by Health Workers No outreach facilities for family planning Avail posters in local languages Refresher courses for health workers so that they can be equipped to handle family planning cases Staff working hours 08 There is a time limit for family Planning Services between 8am 3pm Revise the Staffing Structure for Maternal Child Health (MCH) services Attended to by the Medical Personnel when you go for family planning services 10 Service Providers are always available The service providers at the facility scored their availability the highest because they are always accessible. The In-charge of the maternity wing argued that there is immense need for mentorship and training of more staff on family planning services because the majority of the staff are not sufficiently knowledgeable. 24 A Community Score Card for Family Planning Services

27 Similar to the concerns of the community members, the service providers also noted that the facility has no posters on Family Planning services. They also concurred with the community members that the facility has no private room and that there is need for infrastructure at the facility to be improved. The service providers also pointed out that despite the IUD service being offered at the facility, it is important to secure an insertion machine specifically for IUDs. The one available is used by multiple departments. The Maternity Wing In-charge argued our staff cannot appropriately counsel family planning patients, leave alone the administration of same family planning methods like IUDs and Implants. Table 8: Interface meeting separate and consensus scores Kasangati Health Centre IV S.NO PERFORMANCE INDICATOR Availability of commodities Availability of Physical Infrastructure Availability of Information /Outreach SCORE BY COMMUNITY (MEN)-GAYAZA PARISH SCORE BY COMMUNITY (WOMEN)- GAYAZA PARISH SCORE BY COMMUNITY (MEN)- KASANGATI PARISH SCORE BY COMMUNITY (WOMEN)- KASANGATI PARISH SCORE BY SERVICE PROVIDER CONSENSUS SCORE Staff working hours Attended to by the Medical Personnel when you go for family planning services During the assessments, it was noted with concern that there is a knowledge gap on family planning services amongst the men. Majority are conversant with Condoms only. According to the Incharge, We avail information to the women that visit the facility. There is no facilitation for community outreach, therefore making it impossible to carry them out. We are also challenged when a service is administered by Marie Stopes and in a way it affects the patient, they come running to us because Marie Stopes comes occasionally. We request that Marie Stopes also trains some of our staff on the services they offer so that there is continuity on A Community Score Card for Family Planning Services 25

28 The insertion machine is used in the theatre for other purposes and is currently also used for family planning. When I receive a family planning patient, I have to go hunting for whoever is using the insertion machine. This leads to loss of time on my side and also for the patient, said the In-charge of the Maternity Wing. Actually most of the IUDs eventually expire because we do not offer the service due to not having the insertion machine available whenever needed. In-charge of the Maternity wing, Kasangati HC IV provision of a particular service, she added. Staff argued that they decided to time table family planning services from 8am -3pm because the facility has no independent family planning unit rather all maternal and child health services are integrated therefore the need to balance between the services they are required to offer. Table 9: Interface meeting action plan matrix Kasangati Health Centre IV S.NO INDICATOR ACTION PLAN WHO TAKES ACTION AND WHEN Availability of commodities Availability of Physical Infrastructure Availability of Information/ Outreach Staff working hours Attended to by the Medical Personnel when you go for family planning services Government should continue to provide services despite the assistance from Partners Include family Planning commodities on the National medical Store forms Improve on the reporting system i.e. data collection tools to identify gaps Provide IUD insertion equipment specific for family planning and not the current multi-purpose one. Provide an independent unit for Maternal Child Health Services Erect signages to direct patients Improve infrastructure to accommodate private rooms for family planning services Introduce family health days i.e. Fridays, Saturdays and Sundays. This is currently done by UNICEF Provide Family Planning Posters in local languages Provide posters in the community and at the health centre Increase the family planning service hours from 8am 3pm to 8am-6pm Revise staffing in family planning services Improve handling of patients by service providers Employ more VHTs preferably men Government to take action Immediately Health Workers and In charge Government and/or NGOs should help to provide extra insertion machines Government Government Government and In charge Government-Immediately 26 A Community Score Card for Family Planning Services

29 The service providers requested to have more VHTs employed and trained to boost their services especially in the communities given that their time is constrained because of the large numbers of patients at the centre. Due to previous experiences, they preferred men to women who had proved more willing and committed to working long hours. Multipurpose room where patients are counseled. It also doubles as a ward and baby nursery as well as a meeting room. A Community Score Card for Family Planning Services 27

30 4.0 Observations A case study of Kasangati Health Centre IV The service providers generally take their time to explain to us about the different commodities available and it is upon us to make a decision. They never force us to take on anything out of our will, woman participant, Kasangati Parish. Overall, participants contributed equally to the discussions in the respective groups where the study was undertaken. They all demonstrated keen interest in the subject matter discussed. It was observed that in both groups from Kasangati and Gayaza Parish, the women were generally satisfied with the family planning services provided at the centre. The service providers were concerned that Kasangati Health Centre is always left out in most services given to Wakiso district because they consider it to be under Makerere University which is not the case. 28 A Community Score Card for Family Planning Services

31 5.0 Conclusion, Policy Recommendations, and Advocacy Actions The In Charge, Sister Sarah Ssenkungu stated that staff need more training on family planning services and that cervical cancer screening should be incorporated with family planning services. 5.1 Conclusion This study undertook a community score card process for family planning services in Wakiso district. The community score card collects information from respondents basing on Focus Group Discussions (FGDs) at the community level, service provider level and consequently from an interface meeting between the community and service providers. The FGDs were conducted on a maximum of 10 people per group independent of the other. The groups included those of men only, women only, service providers only and an interface meeting that comprised of a maximum of 6 men, 6 women, 5 service providers, 2 VHTs and one opinion leader. As agreed upon in the different FGDs, we employed various performance indicators: availability of family planning commodities; availability of family planning information/outreach;, attended to by a medical personnel during the family planning visit; availability of private consultation rooms, waiting rooms and dispensing room; and staff working time. We evaluated these performance indicators on a scale ranging from 0-10, with 0 being the worst performance and 10 being the excellent performance. It was found out that family planning service delivery has strengths and weaknesses. Public policy and stakeholder advocacy campaigns need to applause the strengths and design measures of overcoming the weaknesses. The following constraints, which were observed, need to be overcome in order to improve the service delivery system: Absence of signage and lack of display materials on family planning services; Lack of financial support to conduct family planning A Community Score Card for Family Planning Services 29

32 outreaches and absence of community sensitization on family planning; It was also noted that some family planning commodities are sold to the community yet they are meant to be free of charge, e.g. injections for the injectaplan; Short service hours were reported, with service providers indicating that since family planning is integrated into Maternal and Child health, they are limited staff with multiple duties and a disproportionate staff: patient ratio; The problem of impolite health workers was reported in Kasangati Health Centre IV. Community members argued that health workers are both overwhelmed and apathetic towards their work which makes them easily irritable; Lack of transparency in government budget allocation was also an issue of concern at the centre; The entitlements for health centre IV do not match the actuals on the ground; Men were less informed about family planning services. 5.2 Policy Recommendations Construct staff houses to curb late coming and early departure of health workers before their shift end. Construct independent family planning units with private consultation rooms, waiting rooms, and dispensing rooms. Provide transport and other logistics for service providers and VHTs for effective community outreach services. Train staff on all the family planning services offered by the centre. Provide Family Planning Posters at the Centre including local language materials Recruit and train VHTs so to complement the work of the already overstretched staff. Government budget allocations should be displayed for the public to view and suggest inputs. Inspect and monitor Health Centres regularly, but most especially towards the weekend to ensure effective service. Provide adequate family planning commodities to 30 A Community Score Card for Family Planning Services

33 overcome the problem of stock outs Offer specialized family planning education for men to promote male involvement Government should make sure that the entitlements match actuals at the health centre. Raise staff ceiling (entitlement) to address work overload Provide appropriate machine to be used in administering the IUD 5.3 Advocacy Actions 1. Government should continue to provide services despite the assistance from Partners 2. Include family planning commodities on the National medical Store forms 3. Improve reporting system by providing effective data collection tools to identify gaps at the health centre level. 4. Request and follow up on provision of IUD insertion equipment specific for family planning and not the current multi-purpose one. 5. Erect signages to direct patients to appropriate service units. 6. Improve infrastructure to accommodate private rooms for family planning services. 7. Introduce family health days for example Fridays, Saturdays and Sundays to increase opportunities for family planning services. This is currently done by UNICEF. 8. Provide family planning posters in Local languages 9. Provide family planning posters in the community and at the health Centre 10. Increase working hours from 8am 3pm to 8am-6pm. 11. Revise staffing in family planning services 12. Improve customer service for patients at the health centre 13. Employ more VHTs preferably men to support the health centre function in the community A Community Score Card for Family Planning Services 31

34 6.0 References A case study of Kasangati Health Centre IV Deepti Bhatnagar, Ankita Dewan, Magüi Moreno Torres and Parameeta Kanungo Citizen Report Cards on Public Services:Bangalore, India. Paul, Samuel Holding the State to Account: Citizen Monitoring in Action. First Edition. Bangalore: Books for Change. Making Voice Work: The Report Card on Bangalore s Public Services. Public Affairs Centre, Bangalore, India. URL: html/dec/publications/workpapers/wps1900series/wps1921/wps1921.pdf Transparency International. The Corruption Fighters Tool Kit: Civil Society Experiences and Emerging Strategies Report Cards as an Aid to Public Accountability in India. URL: World Bank Case Study Bangalore, India: Participatory Approaches in Budgeting and Public Expenditure Management. Social Development Notes, Environmentally and Socially Sustainable Development Network, March, No. 70. URL: pdf Civic Engagement in Public Expenditure Management, Case Studies Bangalore: Report Card on Public Services. URL: Empowerment and Poverty Reduction: A Sourcebook. Tools & Practices 16. URL: tool16.pdf Filipino Report Card on Pro-Poor Services, Chapter VIII. Institutionalization of the Report Card. URL: participation/web/webfiles/philipreport.htm Web Links Health Sector Strategic Plan III 2010/ /15 URL: go.ug/docs/hssp_iii_2010.pdf Home Page of the Public Affairs Centre, Bangalore. URL: Resources Tools and Practices /Citizen Report Cards URL, Inweb18.worldbank.org/ESSD/sdvext.nsf/68ByDocName/Empowerment URL: advocacy/debt/guide/pdf World Bank (May 30,2001) Filipino Report Card on Pro-Poor Services, Report No PH, Environment and Social Development Sector Unit, East Asia and Pacific Region. 32 A Community Score Card for Family Planning Services