A PROJECT TO INDUCE WOMEN TO SEEK PROFESSIONAL HEALTH SERVICES AND BOOSTING WELFARE OF HEALTH WORKERS

Title of the Project:

Inducing Women to Seek Professional Health Services and Boosting Welfare of Health Workers

Project Summary:

The project is to use a package of inducements to get as many women as possible to access professional medical services at Kajjansi Health Center III (Wakiso District of Uganda), to boost their health and at the same time provide incentives as a motivation of the health center staff so that they can deliver to the patients.  The project outcomes to include:  1) Empowering women who visit the health facility through free training and issue of free hand – outs on health matters and income generating activities; 2) Using incentives and financial bailout given women problems; 3) Boosting the welfare of the medical staff service providers.  Activities under Output 1: i) Giving financial assistance to needy women whose treatment requirements are beyond the medicine resources of the health center or professionalism attached to it; ii) Giving free hand – outs/reading material on how to avoid/treat a selected health problems as well as how to manage some income generating activities; iii) Packaging localized training for women at the health center.  Activities under Output 2:  i) Free assorted hand – outs in form of basics for newly born children to needy mothers immediately after delivery;   ii) Help with financial resources or procurement of medicines for needy women whose treatment requirements may be beyond the facilities resources for free medicine or medicine stock at the time; iii) Offer some backing to needy women ready to undertaking income generating activities after attending training sessions as shall be provided.  Activities under Output 3: To open up a garden on a hired piece of land where food for the health center staff will be grown and provided at highly subsidized meals during working time and food that can be bought by the medical staff at highly subsidized prices; ii) Operate a canteen where staff can get goods at reasonable prices and credit facility.  Project Outputs: The project will induce many more women to get professional medical services hence better their health; ii) A number of women to benefit from knowledge availed through hand – outs given and hence get to implement what is there to boost better health and income; iii) Financial assistance to enable those who would not afford referral treatment to get treated; iv) Free hand – outs to women who will have delivered will boost welfare of newly born children and lessen the burden to parents; v) More income to women who previously had no income or had very little after benefiting from the training; vi) having a garden to boost feeding/welfare of medical staff; vii) Better service delivery by medical staff due to incentives including a canteen when credit may be accessed.

GOGOP Context Situation Analysis APPLICATION TO THE HEALTH POLICY ACTION FUND

Health Care demand relative to the income of a household using the 2002 National Census Data forUganda shows that women in the poorest receive disproportionately less treatment compared to men.  Increasing incomes generally raises the demand for health care.

The Causes of Gender inequality in Uganda

1. Unequal access to control of resources: The lack of control of resources, and the associated lack of decision making power, is by far the most important, and most complex of the issues raised by Uganda Participatory Poverty Assessment Process (UPPAP).  From UPPAP’s findings, the issue of lack of control by women concerns economic matters and choices related to earning or disposing of income or assets.  It is also concerned with “when and how often to have children.”
2. The economic dependence of women – their lack of control over productive resources and assets is at the root of the problems women face.  At the household level, women’s limited decision making is associated with their insecurity of access to productive resources, especially land, and to their being predominantly engaged in the unpaid care economy.  While women perform most of the agricultural work, they do not make decisions of what enterprises to get involved in or how the benefits accruing from them are distributed.  This leaves women in unfavourable bargaining positions as well as poor fall back positions in cases of marriage break – ups.
3. Differences in decision making power within the household is one of the factors contributing to poor health outcomes in Uganda, including the high levels of maternal and child mortality.  The combination of heavy work load, resource dependency, and limited decision making may also help to explain why 44% of pregnant women delay their first visit to a health facility to the last trimester of their pregnancy.
4. Maternal mortality ratio is 506 per 100,000 live births
5. 51% of the women get less than shs 40,000 per month.
6. High fertility coupled with poverty, illiteracy, and low status of women are key obstacles to safe motherhood.  Maternal mortality is one of the most important causes of loss of healthy life years in Uganda, and places surviving children at great risk, as the death of the mother has been found in a variety of setting to be an important predictor of school drop out and child mortality.  The majority of maternal deaths occur outside the hospitals (health units), indicating that delay in seeking care and delay in reaching care are critical.  Of the deaths that occur in the hospital, many of the women arrived at hospital moribund.  In one study, 86.1% of maternal deaths in 74 facilities occurred within an hour of arrival.  It is also suggested, strongly, that women lack the resources and decision making power over when and how to seek care, and that their ‘overburden’ is a contributing factor in delaying efforts to seek care.
7. Although both men and women believed that large families led to poverty, women reported not being able to use family planning because of a negative attitude by their husbands.  Payment of bride price, domestic violence and illiteracy were all perceived to be important factors in perpetuating unequal gender relations.

Use of antenatal services and delivery care in Entebbe, Uganda: a community survey

Background

This study was conducted to facilitate the understanding of the changing use of maternity care services in a semi-urban community in Entebbe Uganda and to examine the range of antenatal and delivery services received in health care facilities and at home.

Methods

A retrospective community survey was conducted among women using structured questionnaires to describe the use of antenatal services and delivery care.

Results

In total 413 women reported on their most recent pregnancy. Antenatal care attendance was high with 96% attending once, and 69% the recommended four times. Blood pressure monitoring (95%) and Tetanus vaccination (91%) were the services most frequently reported and HIV testing (47%), Haematinics (58%) and presumptive treatment for malaria (66%) least frequently. Hospital clinics significantly outperformed public clinics in the quality of antenatal service.  Although 63% delivered their newborn at a local hospital, 11% still delivered at home with no skilled assistance and just under half of these women reported financial/transportation difficulties as the primary reason. Less educated, poorer mothers were more likely to have unskilled/no assistance. Simple newborn care practices were commonly neglected. Only 35% of newborns were breastfed within the first hour and delayed wrapping of newborn infants occurred after 27% of deliveries.

Conclusion

Although antenatal services were well utilised, the quality of services varied. Women were able and willing to travel to a facility providing a good service. Access to essential skilled birth attendants remains difficult especially for less educated, poorer women, commonly mediated by financial and transport difficulties and several simple post delivery practices were commonly neglected. These factors need to be addressed to ensure that high quality care reaches the most vulnerable women and infants.

Attendance for antenatal care represents a unique opportunity to improve the health of women and their infants. It is imperative that we optimise this opportunity by offering a full range of health promoting services that may include voluntary counselling and testing for HIV (VCT), screening and treatment for syphilis, prevention and presumptive treatment of malaria in pregnancy (IPTp) and health education. At delivery, the importance of skilled attendance has long been recognised. However, distance to health facilities, inadequate transportation and the need for immediate and specialised services have hampered women's ability to access these services. Attention to clean and hygienic delivery practices and the provision of essential care for the newborn, such as thermal protection and early and exclusive breast-feeding, are important for the health of all infants whether born at home or in a health care facility. Community and primary care level interventions targeting the reduction of maternal and neonatal mortality have been found to be highly cost effective, although in many communities these services are still lacking. In Uganda, the national Maternal Mortality Ratio is estimated to be 505 per 100,000 live births.  Source: This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 

DESCRIPTION OF OTHER WORK HAPPENING AROUND THE ISSUES IN (CONTEXT/SITUATION ANALYSIS)

A Research was undertaken taking into consideration 50 dispensaries currently called Health CenterIII’s.

Location:  50 dispensaries (Health Center III) and roughly 5,000 households in 9 districts

Timeline: 2004

Themes: Governance; Health Policy Goals: 

Uganda, like many newly independent countries in Africa, had a functioning healthcare system in the early 1960s, but saw a collapse of government services as the country underwent political upheavals.  Rural dispensaries are the lowest tier of the Ugandan health system and they provide preventive outpatient care, maternity and laboratory services. A number of actors are responsible for supervision and control of the dispensaries including the Health Unit Management Committee, who monitor the day-to-day running of the facility, but have no authority to sanction workers. The Health Sub-district, one level above, is supposed to monitor funds, drugs and service delivery, but this monitoring is infrequent. Only the Chief Administrative Officer of the District and the District Service Commission have the authority to suspend or dismiss staff. Usually staffed by one medical worker, two nurses and three aides, dispensaries provide no incentives for their workers to increase their efforts. Community members are generally unaware of how many children are dying in their community, and don’t know what level of quality to expect in their health services.

Details of the Intervention: 

Researchers conducted a randomized evaluation at 50 dispensaries from nine districts in Uganda to see if community monitoring would improve health worker performance and the impact this might have on health utilization and outcomes. Baseline data was collected from all providers’ records and 5,000 individuals across communities, quantifying utilization, facility performance and health outcomes. 

 

In the randomly selected treatment villages, local NGOs facilitated three sets of meetings. In the first, community members, both the disadvantaged and the elite, discussed the status of their health services and means of identifying steps the providers should take to improve health service provision. Second, a provider staff meeting was held to contrast the information on service provision as reported by the provider with the findings from the household survey. The third, an interface meeting, allowed community members and health workers to discuss patient rights and provider responsibilities. The outcome was a shared action plan, or a contract, outlining the community’s and the service provider’s agreement on what needs to be done, how, when and by whom. These three sets of meetings were aimed to kick-starting the process of community monitoring. Finally, staff and interface meetings were held 6 months later to review progress and suggest improvements. More than 150 participants attended a typical village meeting

Results and Policy Lessons: 

Impact on Quality Care: A year after the first round of meetings, health facilities in treatment villages were 32% more likely to have suggestion boxes and 16% more likely to have numbered waiting cards, relative to the comparison facilities. There was a 12 minute reduction in wait time, a 13 percentage point reduction in absenteeism, and the overall facility cleanliness improved.

Impact on Health Outcomes: In the intervention group, utilization of general outpatient services was higher (20%), more people came for child birth deliveries (58%) and more patients sought prenatal care (19%). More people sought family planning services (22%) and immunizations increased for all age groups, especially newborns. Households also began switching from self treatment and traditional healers to dispensaries in response to the intervention. Relative to the comparison group, intervention communities saw an increase in infant weight and a 33% reduction in the mortality of children under 5 years old. Variation in treatment intensity across districts shows a significant relationship between the degree of community monitoring and health utilization and outcomes.

Scale-Up: The overall effect of this intervention was significantly positive, bringing great hope to the possibility of community led and sustained monitoring efforts. However, before scaling up, future research should examine long term effects, experiment with alternative tools, and study to what extent the results can be generalized to other social sectors.

GOGOP DETAILED PROJECT DESCRIPTION

The project which is to be implemented at Kajjansi Health Center III (Ssisa sub-county, Wakiso district of Uganda) after signing a Memorandum of understanding with the relevant Health Center authorities; in a nutshell is to act as a magnet in that it will use incentives to the majority poverty stricken women and have them follow up medical services they were not previously accessing mainly because of lack of empowerment (finances) and the gender imbalance all of which are related to poverty and in some instances ignorance of benefits as more often than not they opt for alternatives like using services of traditional practitioners who have no reliable scientific diagnostic equipment and training, which ends up putting many women’s lives in danger to the extent that a number die while delivering babies, while others develop complications that would have been avoided if they had opted for professional medical services.  The alternatives to professional medical services are to blame for child mortality as treatable/immunizable diseases end up being given opportunity to claim the lives of children less than 5 years.  The project is to offer opportunity in form of free hand outs in local language (Luganda) which will boost women’s understanding of causes of common health problems that can be avoided and how to go about treatment in case of infection.  Equally, there will be hand outs on income generating activities which needy women can choose from so that they get out of the inherent problem of having no income which prevents many from seeking professional medical services. 

The women on calling at Kajjansi Health Center III, will get their bio-data feed into a laptop computer by a volunteer; such that the indicators to which they give response can be used to determine whether they are needy or not.  There shall be scheduled training in skills that will help women’s income generation.  As an incentive, needy women shall be helped with a few basics for newly born babies delivered at the Health center; these among others to include soap; bed sheets; basin; simple clothes to mention a few.  It is also true that some patients may have to be facilitated with cash when it is found that they have to be referred to a higher level health facility when the equipment/professionalism at the health center is not sufficient to help diagnose their problems or when the medicine prescribed may not be in stock and has to be bought from elsewhere, yet may not be capable of meeting the cost in either case.  Women without any finances who will have attended income generating courses will be assisted with some little funding to afford them start some economic activity on conviction that they have what it takes at least to start the said activity.

Lack of morale on the part of the medical staff is a problem which leads to low morale in dealing with patients; late coming to work and leaving early as well as absenteeism will be approached when a garden is opened out of which we shall be able to provide highly subsidized lunch as well as avail them with food at greatly discounted prices.  A canteen facility shall equally be opened where they will not only get goods at lower prices but shall be able to get goods on credit.