2011 Baseline Survey for the Senegal Urban Health Initiative (ISSU) Service Delivery Site Survey: Final Report April 2012

Transcription

1 2011 Baseline Survey for the Senegal Urban Health Initiative (ISSU) Service Delivery Site Survey: Final Report April 2012 IntraHealth International 6340 Quadrangle Drive, Suite 200 Chapel Hill, NC USA

2 2011 Baseline Survey for the Senegal Urban Health Initiative (ISSU) Service Delivery Site Survey: Final Report March ISSU SDS Baseline Survey ii

3 TABLE OF CONTENTS List of Tables and Charts... v List of Abbreviations and Acronyms... viii Foreword... x Preface... xi Acknowledgments... xiii Chapter 1. Introduction The ISSU Project The MLE Project Population Policy Overview of the Health System Maternal and Child Health Chapter 2. Survey Methodology Organization of the Survey Sampling Base and Targets Assessment Questionnaires Pilot Survey Recruitment and Training of Field Staff Data Collection in the Field Data collection in pharmacies Data collection in health facilities Data Processing Ethical Aspects Chapter 3. Provision of Family Planning Services in Health Facilities Characteristics of Service Delivery Sites, Service Providers, and Female Clients Surveyed Service delivery sites Service providers Female clients Infrastructure, Equipment and Materials for Service Delivery Basic infrastructures and equipment Materials and equipment available for method provision Personnel Involved in the Provision of Services Staff numbers and composition FP Training Declared ability to provide FP methods Maternal, Neonatal and Child Health Services (MNCH) FP Services ISSU SDS Baseline Survey iii

4 Integration of FP Services Integration of FP counseling and the provision of FP methods into MNCH services Routine integration of FP counseling by MNCH service providers Product Ordering, Management and Storage Contraceptive Product Stock-Outs Consultation cost and Family Planning Methods Storage of Contraceptives in Health Facilities Service Providers Obstructing the Provision of FP Services Client Waiting Time and Satisfaction with the Services Received Access to Services and Choice of Health Facility by Female Clients Current Practices in Terms of Quality Assurance of the Services Advance Strategies including the Provision of FP Services IEC Material Chapter 4. Family Planning Services in Pharmacies Characteristics of the Pharmacies Characteristics of the People Responsible for Providing Services in Pharmacies Management of Contraceptive Supplies Range of Modern Contraceptive Methods Contraceptive Method Stock-Outs Stock-out frequency Procedures normally followed in case of emergency orders Storage of Contraceptive Products in Pharmacies Providers Obstructing the Provision of FP Services Social Franchises and Sale of FP Social Marketing Products Chapter 5. Conclusions and Recommendations Screening tool implementation to systematically identify client needs Procurement and monitoring systems for contraceptive products to reduce stockouts Public-private partnerships to increased FP use among the poor The role of pharmacies in delivering FP methods Alleviating barriers to access and use of FP methods ISSU SDS Baseline Survey iv

5 LIST OF TABLES AND CHARTS Table 1 Table 2 Table 3 Table 4 Table 5 Table 6 Table 7 Table 8 Table 9 Table 10 Table 11 Table 12 Table 13 Table 14 Table 15 Data Collection Evaluation among SDSs by Site, Type of Interview, and Interview Result Breakdown (%) of Health Facilities by Site, Type of Facility, Type of Administration in Charge of Management and Volume of Activities Breakdown (%) of Service Providers by Site, Type of Facility, Medical Service, Qualification, Gender and Age Breakdown (%) of Female Clients by Site Receiving Reproductive Health Services By Type of Service Received on the Day of the Interview, Age, Level of Education, Marital Status, Number of Living Children, Economic Level and Facility Percentage of Health Facilities Where Infrastructure and Equipment Are Available and Functional, By Site and Type of Facility Percentage of Health Facilities with the Adequate Equipment (Available and Functional) to Provide Certain FP Methods including Long-Term Methods, By Site Breakdown (%) of Facilities by Type of Permanent Staff Available Percentage of Service Providers Who Received Vocational Training and Continuing Education, by Subject and Type of Provider Percentage of Service Providers Who Are Currently Providing Clients with Modern Contraceptive Methods, By Type of Provider, Site, and Method Percentage of Health Facilities Providing Maternal and Child Health Services by Site, Type of Facility, and Type of Service Percentage of Health Facilities Offering Family Planning Services, Average Number of Days Open per Week, Average Number of Female Clients over the past Six Months, and Average Number of New* Female Clients over the past Six Months, By Site and Type of Facility Percentage of Health Facilities Providing Modern Family Planning Methods, By Type of Method, Site, and Type of Facility Percentage of Facilities Which Have Integrated the Range of FP Services (Information and Method) into Maternal and Child Health Services By Type of Facility and Site Percentage of Service Providers Who Have Routinely Integrated FP Information into Maternal and Child Health or Dermatological Services By Type of Service and Service Provider Qualification Source of Contraceptive Supply, Date of Last Routine Delivery, Average Wait Time between Order, Delivery, and Decision-Making Procedures About the Amount of Product to Be Ordered, By Method and Type of Facility 2011 ISSU SDS Baseline Survey v

6 Table 16 Table 17 Table 18 Table 19 Table 20 Table 21 Table 22 Table 23 Table 24 Table 25 Table 26 Table 27 Table 28 Table 29 Table 30 Table 31 Percentage of Facilities which Actually Have the Method in Stock, Percentage of Facilities Out of Stock in the Past 30 Days, Percentage of Facilities Out of Stock in the Past 12 Months, and Number of Facilities which Provide a Method, By Site, Contraceptive Method and Type of Facility Average Cost of Each Method to the Client and Percentage of Clients Who Pay for a Method, By Site and Method Percentage of Facilities Where Specific Storage Conditions Are Met, By Site and Type of Facility Percentage of Service Providers Who Place Certain Restrictions on Delivery of Contraceptive Methods, By Type of Service Provider, Type of Restriction and Method Breakdown (%) of Female Clients according to Average Wait Time, Percentage of Female Clients Satisfied with Services Received, By Type of Service Received and Facility Percentage of Female Clients Giving the Reasons for the Choice of Health Facility, By Type of Service Received during the Visit Breakdown (%) of Female Clients By Reason For Not Going to the Nearest Health Facility, and Socio-Economic Characteristics Percentage of Facilities Where Documents on Quality Assurance, Protocols and Standards Are Available, By Site and Type of Facility Percentage of Facilities with Local Awareness Programs and, among these Facilities, Percentage of Programs that Include FP/Birth Spacing, and Average Number of Areas Visited, By Site Percentage of Facilities Where IEC Materials on FP Are Available, By Type of Material, Site and Facility Breakdown (%) of Pharmacies by Specific Characteristics Breakdown (%) of Personnel Responsible for Providing Services in Pharmacies By Socio-Demographic Characteristics; Percentage of Personnel Whose Last Training Included FP Themes Percentage of Pharmacies According to the Type of Personnel Responsible for Managing Supplies, the Presence of a Stock Management System and Frequency of Stock Updates Breakdown (%) of Pharmacies By Delivery Time, for Each Method and Site Percentage of Pharmacies Providing Modern FP Methods, By Site and Method Percentage of Pharmacies with Stockouts in the Previous 12 Months, Average Number of Out-of-Stock Days During This Period Percentage of Pharmacies Out of Stock in the Previous 30 Days, Average Number of Stockout Days during this Period, by Site and Method 2011 ISSU SDS Baseline Survey vi

7 Table 32 Table 33 Table 34 Table 35 Breakdown (%) of Pharmacies by the Most Common Procedure Adopted When a Given FP Method is Out of Stock Breakdown (%) of Pharmacies by Product Preservation and Storage Conditions Percentage of Pharmacies with Restrictions on Certain FP Methods, by Type of Restriction and Site Breakdown (%) of Pharmacies by Affiliation to a Social Franchise Program for the Provision of FP Methods and by the Sale of FP Social Marketing Products, for Each Site 2011 ISSU SDS Baseline Survey vii

8 LIST OF ABBREVIATIONS AND ACRONYMS ANC ANSD APHRC ASBEF BMGF CAS CD CNERS CRDH CsPro DERF DHS DPP DS DSR DSRP EBMPPS FP GPHC HIV HN HP ICRW ISSU IUD Antenatal Consultation (Consultation prénatale) National Agency of Statistics and Demography African Population and Health Research Center Family Welfare Association (Association pour le Bien Etre Familial) Bill and Melinda Gates Foundation PNDS support and monitoring unit (Cellule d appui et de suivi du PNDS) Census District Senegal National Ethics Committee for Health Research (Comité National d Ethique et de Recherche en Santé du Senegal) Research Center for Human Development (Centre de Recherche pour le Développement Humain) Census and Survey Processing System Education, Research and Training Directorate (Direction des Etudes, de la Recherche et de la Formation) Demographic and Health Survey Declaration on Population Policy Health District (District Sanitaire) Division of Reproductive Health (Division de la Santé de la Reproduction) Poverty Reduction Strategy Document (Document de stratégie de réduction de la pauvreté) Baseline Survey among Households and Service Delivery points Family Planning General Population and Housing Census Human Immunodeficiency Virus Head Nurse Health Post International Center for Research on Women Senegal Urban Health Initiative Intra-uterine device 2011 ISSU SDS Baseline Survey viii

9 K4H LAM MICS MLE MNCH MSP MTEF NGO NHIS PDIS PNDS PO POCL PTA RH SDS SMO STI TFR UNC-CPC UR USAID Knowledge for Health Lactational Amenorrhea Method (LAM) Multiple Indicator Cluster Survey Measurement, Learning and Evaluation Maternal, Neonatal and Child Health Ministry of Public Health and Social Action (Ministère de la Santé et de l Action Sociale) Medium-Term Sector Expenditure Framework Non-Governmental Organization National Health Information System Integrated health development program (Programme de development Intégré de la Santé) National Health Development Plan (Plan National de Développement Sanitaire) Plan of Operation Local Government Operation Plan (Plan d'opération des collectivités locales) Annual Work Plan (Plan de Travail Annuel) Reproductive Health Service Delivery Site Senior Medical Officer Sexually transmitted infection Total fertility rate University of North Carolina - Carolina Population Center Unreported/unavailable United States Agency for International Development 2011 ISSU SDS Baseline Survey ix

10 FOREWORD The Urban Reproductive Health Initiative (URHI) was launched by the Bill and Melinda Gates Foundation as part of its global family planning/reproductive Health strategy (FP/RH). Its primary objective is to significantly improve the usage level of modern contraceptive methods in targeted urban areas of Kenya, Nigeria, Senegal and the State of Uttar Pradesh in India. The Measurement, Learning & Evaluation project (MLE), one of the components of this Initiative, is to evaluate the impact of the Initiative in each country, through data collection and analysis. The MLE project also aims at supporting the implementation and monitoring of the interventions. For these purposes, MLE has designed and implemented baseline surveys in each country. We are delighted to present the report on the baseline household survey for Senegal, which was established by the Research Center for Human Development (CRDH) with technical assistance from the MLE project - made up of the Carolina Population Center of the University of North Carolina in Chapel Hill (CPC-UNC) and the African Population and Health Research Center (APHRC) based in Nairobi - and the support of the Senegalese Urban Health Initiative (ISSU). This survey was conducted in the six (6) sites of the ISSU project, i.e. Dakar, Guédiawaye, Pikine, Mbao, Mbour and Kaolack. We wish to offer our sincere thanks to Dr. Bocar Mamadou Daff, Head of the Division of Reproductive Health of the Ministry of Health and Social Action, who played a decisive role in the success of the baseline survey. Our thanks also go to the MLE team, in particular Professor David Guilkey, Project Manager; Dr. Jean Christophe Fotso, Principal Investigator; Dr. Gwendolyn Morgan, Technical Coordinator; Mrs. Meghan Corroon, Technical Assistant; Dr. Estelle M. Sidze, Technical Assistant; and Mr. Cheikh Mbacké Faye, Local MLE Representative in Senegal. We are also grateful for the support of the personnel of the ISSU project, in particular Mr. Baka Tambouri Ndiaye, Monitoring-Evaluation and Research manager, and Mr. Djimadoum Koumtingué, Monitoring-Evaluation Assistant. We hope that this report, along with the Technical Memo on Senegal (which is currently being finalized and describes the trends and differenced between the major family planning and Reproductive Health indicators in Senegal's urban areas since 1993), can help the ISSU project and other programs adjust their intervention strategies with a view to improving the usage level of modern contraception in the targeted areas. Dr. Ilene Speizer Deputy Director, MLE Dr. Cheikh Seck Director, ISSU Salif Ndiaye Director, CRDH 2011 ISSU SDS Baseline Survey x

11 PREFACE With a view to achieving the Millennium Development Goals (MDGs), the Ministry of Health and Social Action, via the Division of Reproductive Health (DSR), implemented the roadmap for the reduction of maternal and neonatal mortality and morbidity to improve the health of the Senegalese population. The Senegal Urban Reproductive Health Initiative (ISSU) is a fiveyear project ( ) which supports the Ministry of Health and Social Action to revive family planning to reduce in the risk of maternal and child mortality in Senegal. The purpose of the ISSU project is to improve the quality of life of Senegal's most disadvantaged urban populations through increased access, quality and use of family planning services. It constitutes a testing ground to demonstrate that innovative approaches focused on the provision of quality services in public and private sectors, combined with demand and advocacy efforts, can act as catalysts to significantly increase the use of modern family planning methods by the poorest urban populations of French-speaking African countries. The ISSU project is implemented through an agreement between IntraHealth International and the Bill and Melinda Gates Foundation in six cities, in partnership with a consortium of partners. Prior to implementing its interventions, the ISSU project conducted a quantitative survey inspired by Demographic and Health Surveys (DHS) in six target cities to collect and analyze basic information which will provide greater insight into family planning issues and needs in urban areas. The survey includes two components: a household component and a service delivery site component. This report looks at the service delivery site component. The service delivery site survey examines themes of infrastructure, equipment and materials for the provision of services, range of family planning services, integration of family planning services, ordering, management and storage of family planning products and the availability of family planning services/methods in pharmacies. The report helps fill the information gap on major issues concerning reproductive health in urban areas. This survey ultimately helped collect a broad variety of up-to-date or new data necessary for good economic and social planning purposes. This report provides the Ministry of Health and Social Action with essential tools for monitoring and evaluating the National Health Development Plan (PNDS) for the period. Following this report, a national seminar designed to present and share survey results will be organized and all documentation will be available online to facilitate access by the Government and its development partners as well as the scientific community. I am convinced that they will all be able to make the most of this wealth of information to improve the planning of their activities. This survey was conducted by the Research Center for Human Development (CRDH), with technical assistance from Measurement, Learning and Evaluation (MLE). The professionalism with which the CRDH conducted this study confirms the pertinence of the Government's decision to rely on local expertise. I offer my congratulations to the CRDH and my sincere thanks to MLE for its valuable support. The implementation of this survey required considerable financial resources. My heartfelt thanks also goes to the Bill and Melinda Gates Foundation for providing these resources and to all institutional partners and all those who contributed to the success of this important 2011 ISSU SDS Baseline Survey xi

12 investigation. I also wish to convey my gratitude to the Senegalese people and government services for their availability during the collection of data in the field. Pr. Awa Marie Coll Seck Minister of Health and Social Action 2011 ISSU SDS Baseline Survey xii

13 ACKNOWLEDGMENTS The Service Delivery Site portion of the Senegal Urban Health Initiative (ISSU) Baseline Survey was implemented by the Research Center for Human Development (CRDH) with the technical assistance from Measurement Learning Evaluation (MLE). This survey mobilized considerable financial resources and required the availability and competence of several people. This is why I would like, on the occasion of the publication of this report, to express my sincere gratitude to the Government of Senegal whose various divisions were of great help in this research. I would also like to thank: The technical and administrative personnel of the Ministry of Health and Social Action, at central and peripheral levels, for their valuable contribution; Local Authorities for their considerable support in service delivery site sampling and enumeration as well as data collection; The researchers from the technical team (CRDH, MLE, ISSU) for their competence and availability; Field staff: interviewers, team leaders and supervisors. Their professionalism, dedication and resilience were crucial to the success of the survey. The IntraHealth office staff for their efficiency. Finally, I would like to thank the people of the localities surveyed as well as the administrative, local and tribal authorities for the warm welcome extended to field staff. Dr. El Hadj Babacar Gueye Country Representative IntraHealth International Senegal 2011 ISSU SDS Baseline Survey xiii

14 CHAPTER 1. INTRODUCTION The survey of service delivery sites (SDS) is one of the two components of the Baseline Survey conducted as part of the Senegal Urban Reproductive Health Initiative (ISSU), implemented in the urban areas of Dakar, Guédiawaye, Pikine, Mbao, Mbour and Kaolack. This SDS survey was carried out among all the health facilities which provide reproductive health services and private pharmacies in all six target sites. The main results of this survey are presented in this report which is divided into the following five chapters: Introduction; Survey methodology; Results for health facilities; FP services in pharmacies; and Conclusions and programming implications. The ISSU Project The Senegal Urban Reproductive Health Initiative (ISSU) is a project aimed at promoting family planning in Senegal's poor urban areas, the implementation of which is planned over 5 years (March 2010 March 2015). The Initiative is financed by the Bill and Melinda Gates Foundation as part of a large-scale reproductive health initiative in urban areas deployed in India, Kenya, Nigeria and Senegal. The purpose of the project is to improve the quality of life of the most disadvantaged urban populations in Senegal's largest cities, through increased access to, and use of, family planning services. It also intends to demonstrate that a solid approach focusing on supply, demand and the private sector helps increase the usage level of family planning methods by the poorest urban populations of French-speaking African countries. In Senegal, the project targets four major cities, i.e. Dakar, Pikine, Guédiawaye and Mbao, with the ambition of subsequently extending the process to the cities of Kaolack and Mbour. The ISSU project is implemented by a consortium led by IntraHealth International. Partners includefhi360, ENDA, Marie Stopes International (MSI), Action et Développement (ACDEV), the Islam and Population network (RIP), Senegal's National Association of State Midwives (ANSFES) and the National Association of Journalists in Population and Development (ANJPD). The project involves close collaboration with the Ministry of Health and Social Action via the DSR (Division of Reproductive Health). The MLE Project The Measurement, Learning & Evaluation (MLE) project is the "Evaluation" component of the Urban Reproductive Health Initiative implemented and financed by the Bill and Melinda Gates Foundation. The objective of the MLE Project is to promote an evidence-based decision-making process with a view to designing integrated family planning and reproductive health interventions as part of the Urban Reproductive Health Initiative. MLE is made up of a UNC-CPC-led consortium which includes APHRC, ICRW and K4H. The MLE project uses rigorous methods to assess the impact of the Initiative on the use of modern contraception by various population categories. To achieve these objectives, the MLE project strives to: Use a pertinent program framework to examine all stages of the process and evaluate the plausibility of the program's effects on the results; 2011 Baseline Survey for the Senegal Urban Health Initiative (ISSU) Service Delivery Point Survey 14

15 Use a longitudinal approach to ensure the best possible evidence with as little disruption as possible to the implementation of the ISSU project Develop surveying tools and methods enabling extrapolation across the project's intervention sites and countries Closely examine the intra-urban differences in the impact of the program via a comparison between the populations of the formal urban sector and those of the informal urban sector, and a comparison between the rich and the poor. This report presents the results of the SDS survey. Data was collected from 518 private pharmacies and 205 health facilities in all six intervention sites. These results, in addition to those of the household component, will be used to help implement the activities of the ISSU project and provide MLE with crucial information on family planning and reproductive health issues before the activities begin. Population Policy The population policy declaration adopted by the Government of Senegal in 1988 and reviewed in 2001, attests to the government's political desire to make population related issues a focal point of the economic and social development process. With its declaration on population policy, Senegal aims to improve the standard of living and quality of life and promote the welfare of all population categories, while ensuring gender equality and equity. Since the declaration on Population Policy was updated in 2001 to include reproductive health, Senegal has put in place health development plans, the latest covering the period from 2008 to 2015 (PNDS II, ). The population policy's strategy was to reduce maternal and child mortality, as well as fertility, and resulted in the legalization of family planning. This political desire became a reality in the form of a progressive increase in the State's operating budget allocated to health, from 8.3% in 1999 to 9.8% in 2004, and the development and construction of health infrastructures. Overview of the Health System The health policy is based on the constitution, which stipulates in article 17 that "the State and public authorities have a social duty to ensure the physical, moral and mental health of the family". The government of Senegal put in place a series of measures aimed at improving decentralization in the health sector, and in the interest of equity, to make basic social and health services accessible to the entire population, regardless of their economic and social conditions. This is why Senegal, following the Alma-Ata International Conference in 1978, instituted Primary Healthcare as a cornerstone of the Health Policy. However, basic healthcare was already somewhat organized as a result of the 1972 Administrative and Local Reform, Senegal's first step towards decentralization. The population's contribution to the public health effort is regulated under Decree of 17 January 1992, which defines the special obligations of Health Committees and establishes the statuses of these committees. Furthermore, the human dimension became an increasingly important part of the social policy due to the economic difficulties affecting the State's ability to help disadvantaged populations. Several reforms and initiatives in the health funding domain contributed to this, 2011 ISSU SDS Baseline Survey 15

16 with the reorganization of the Ministry for health and the creation of an environment conducive to health development. Senegal's health system is organized in accordance with the recommendations of the threelevel health development scenario proposed by the World Health Organization's African Region office since 1985, in a pyramid structure which includes: At the base, a peripheral level referred to as Health District 1 made up of health centers and health posts that supervise health huts and rural maternity hospitals. At the intermediate level, a strategic level referred to as medical region 2 which translates national policies into regional strategies. At the top, a central level which includes the Minister's office, national directorates and services who formulate health guidelines and policies. The provision of healthcare follows the design of the health pyramid. At the top, hospitals provide the highest level of services, health centers provide an intermediate level of care while health posts and huts are at the peripheral level. The public system is complemented by the private sector at all levels of the pyramid. However private and public services are parallel systems and there is limited links between the two. Over the past fourteen years, Senegal's health policy has been divided into two National Health development program (PNDS); the first was called the "Integrated health development program" (PDIS 1), was implemented from 1998 to A second PNDS was established for the period and places particular emphasis on universal access to quality care. Its objectives include improving the health of the population, the priority being a reduction in maternal and child mortality and the reduction of fertility. The implementation of this plan is managed via the Medium-Term Sector Expenditure Framework (MTEF), a three-year rolling operational planning program. This approach is characterized by the sharing of common objectives and pooling of resources, and provides a unique intervention framework for all health stakeholders,. Furthermore, the desire to respect the principles and rules of the program approach has led the Ministry of Health and its partners to set up a coordination system and adopt a planning cycle and a number of rules for the steering of this planning process. The National Health Information System (NHIS) is the instrument of choice for monitoring and evaluating the performance of the National Health Development Plan: it is responsible for establishing a directory of health statistics integrating data from all health facilities (public and private) based on the activity reports from health districts, hospitals and specialist health centers. Unfortunately, this system suffers from incomplete and unreliable data and delayed transmission. 1 The health district, which corresponds with the peripheral level, is regarded as an operational area which includes at least one health center and a network of health posts. Geographically, it can cover an entire department or part of a department. It is managed by a head physician. 2 The medical region, which corresponds with the regional level, is the structure responsible for coordinating the regional level. It is managed by a public health physician who is the primary coordinator of the management team made up of all department heads attached to the medical region. In each region, the regional reference is represented by a hospital or a level 2 public health institution (PHI) ISSU SDS Baseline Survey 16

17 Maternal and Child Health Over the past few decades, improving maternal and newborn health has been considered a priority by health authorities. The first objective of the 1988 Declaration on Population policy (DPP), reviewed in 2001, emphasizes the need to reduce morbidity and mortality, in particular of mothers and children, by reinforcing health programs, notably in terms of reproductive health. Although the Total Fertility Rate (TFR) decreased between 1978 and 2010 (from 7.2 to 5.0 children per woman) 3, fertility remains elevated. In a cultural context where the ideal family size remains high, fertility levels also vary considerably depending on the place of residence, the level of education and the standard of living. Even though family planning was introduced in Senegal at the Blue Cross Clinic (Dakar) in 1960, it was not until 1975 that the Senegalese Association for Family Welfare (ASBEF) inaugurated its first model clinic. Other projects and programs were launched within the Ministry for health: the Family Health project in 1981, the National FP Program in 1982 and the Family Welfare Project in The structure responsible for implementing the FP program has undergone significant changes. In 1997, the National Reproductive Health Department was established and later became the Division of Reproductive health in The objective of this division was to improve the health of the population in general and reduce maternal and child mortality by controlling fertility and preventing high-risk and unintended pregnancies. Thus, various projects and programs designed to improve the scope and quality of the services (by extending the range of methods, reinforcing the social marketing program, implementing a community-based service, building the providers' skills, involving the private sector, reinforcing the logistical management of contraceptive products, improving information management etc.) were implemented. However, it should be pointed out that, despite political desire, commitment and availability of development partners and implementation of different programs to improve maternal and newborn health, the results achieved have fallen well short of expectations. For example, the modern contraceptive prevalence rate among women in a common-law union remains low: it increased from 5% in 1993 (DHS-II), to 8% in 1997 (DHS-III), 10% in 2005 (DHS-IV), reaching 12% in 2010/2011. During the same period, the average number of children per woman dropped from 6.0 in 1993 to 5.0 in 2010/2011, i.e. less than one child in over two decades. 3 Multiple Indicator Demographic and Health Survey, , Preliminary Report, National Agency for Statistics and Demography, Dakar, Senegal, MEASURE DHS ICF Macro Calverton, Maryland, USA, June ISSU SDS Baseline Survey 17

18 CHAPTER 2. SURVEY METHODOLOGY The objective of the SDS survey is to establish a baseline on what reproductive health services are being provided in existing health facilities and private pharmacies in intervention areas. The data collected will also enable the ISSU project information to make informed changes to its current strategies that are increasing the demand for services, improving the quality services and promoting the development of FP services in the private sector. This chapter describes the technical approach and activities implemented for the completion of this survey. Organization of the Survey This survey was commissioned by IntraHealth International as part of the Senegal Urban Reproductive Health Initiative (ISSU) project and conducted by the Research Center for Human Development (CRDH) with technical assistance from the MLE (Measurement, Learning and Evaluation) project, and financed by the Bill & Melinda Gates Foundation. It was conducted in the intervention sites of the ISSU project, i.e. the urban areas of Dakar, Guédiawaye, Pikine, Mbao, Mbour and Kaolack. Sampling Base and Targets The data of the SDS target was collected among the following targets: Public and private health facilities providing RH services (including health center, health posts, health huts, private clinics and faith-based facilities) Service providers involved in RH service delivery in these facilities Female customers interviewed after receiving RH services in these facilities Private pharmacies. First, an exhaustive sampling base was set up and included the following elements: A list of operational health facilities providing RH services in survey sites including private clinics A list of existing private pharmacies. For each facility listed, a variety of information designed to facilitate their identification was provided, notably the address, site, district, district community, type of facility (private or public) etc. This sampling base established by the CRDH, with support from MLE, is the result of updating different sources (Dakar Medical Region, Mbour health District, Kaolack health District, National Health Information System and IntraHealth). This list was used as a basis for the execution of the survey. SDSs providing RH services identified in the field but were did not feature in the database, were also accounted for in the survey. Facilities were classified into two groups for the purposes of ISSU project interventions: those with a high volume of activities and those with a lower volume of activities. According to the ISSU project, a facility is referred to as having a high volume of activities if: It covers a significant population It is well used by the population 2011 ISSU SDS Baseline Survey 18

19 It provides a full range of modern contraceptive methods in accordance with the health pyramid. It employs trained and competent personnel for RH service delivery. The other facilities (which do not meet these criteria) were deemed to have a normal volume of activities. Each health facility s RH services (FP, Maternal and Child Health and STI/HIV) were audited, a questionnaire on RH services was completed, and as many as four RH service providers were interviewed. These service providers were selected randomly from a list of active, permanent facility personnel at the time interviewers visited each facility. In addition, at high-volume facilities, a maximum of 50 female clients aged 15 to 49 who had received RH services were interviewed. Assessment The assessment of the collection for the different targets is presented in table 1. Out of a total of 269 health facilities identified, 205 (i.e. 76%) were surveyed. The remaining 64 facilities were not surveyed for various reasons (refusal due to a strike, unavailability, closed or moved elsewhere, not eligible etc.). Fifty five of the 205 fully surveyed facilities were considered high volume (i.e. 27% of the facilities surveyed). Among the 205 health facilities surveyed, 648 service providers were identified to receive the service provider questionnaire. Six hundred thirty seven completed the questionnaire in its entirety, i.e. a 98% response rate. For female clients, 2,686 women out of 2,697 selected completed the survey, i.e. a 99.6% response rate. Finally, out of 576 pharmacies, 518 were audited, i.e. 90%. The remaining 58 pharmacies were not surveyed for a variety of reasons, including closure, refusal, or unavailability of personnel. Table 1. Data Collection Evaluation among SDSs by Site, Type of Interview, and Interview Result Site High-volume health facilities Interview completed Other result Lower-volume health facilities Interview completed Other result RH service providers Interview completed Other result Female clients leaving the health facilities Interview completed Other result Pharmacies Interview completed Other result Dakar Guédiawaye Pikine Mbao Mbour Kaolack Together Questionnaires Four baseline questionnaires, proposed by MLE and ISSU, were reviewed and adapted by the CRDH: a health facility audit questionnaire, a pharmacy audit questionnaire, a service provider 2011 ISSU SDS Baseline Survey 19

20 questionnaire and a questionnaire for female clients who receive RH services. Data collection materials were finalized in several workshops and technical meetings attended by ISSU, MLE and CRDH and draft versions of documents were used in the pilot survey. Similarly, an instruction manual on how to conduct the survey and complete the questionnaires was also developed by CRDH. The content of questionnaires presented in appendix is summarized below: Health facility audit questionnaire. Includes the following sections: i) general information on the facility; ii) FP and maternal and child health services; iii) service statistics; iv) IEC materials and activities; v) quality assurance and standard execution procedures; vi) physical facilities and equipment; vii) consumables; viii) logistical management of contraceptive products. Pharmacy audit questionnaire. Includes: i) general pharmacy information; ii) preservation and storage; iii) client advice and product sales. Questionnaire for female clients leaving health facilities. Includes the following sections: i) Purpose of visit; ii) current use of FP before visit; iii) if former user; iv) if first time user; v) potential integration user; vi) client satisfaction level; information on the health facility; vii) exposure to media; viii) personal characteristics of the client. Service provider questionnaire. Includes the following: i) working life and personal information; ii) information on FP services; iii) FP integration into other services; iv) standards and protocols. Pilot Survey The objective of the pilot survey was to verify the acceptability of collection tools and pertinence of the methodology. The pilot was conducted in the department of Rufisque (the only department of the Dakar region outside of the survey sites). Four midwives and two pharmacists were recruited and trained for five days for this operation. The collection started immediately after the end of the training phase and took four days. In total, five health facilities, 12 service providers, nine pharmacies and 25 female clients were surveyed. This activity helped assess work load, profile, and number of interviewers required for the main survey. With this information, a definitive decision was made to recruit health personnel (notably midwives) as interviewers to collect data for the main survey. Upon completion of the pilot survey, collection tools (questionnaires and manuals) were updated and these versions of the questionnaires and manual were used as didactic supports to train the interviewers. Recruitment and Training of Field Staff Taking into account the lessons learned from the pilot survey, 18 midwives, five pharmacists and two traditional interviewers were pre-selected and interviewed by the CRDH's technical team to undergo training in data collection. Selected interviewers were trained by CRDH's technical team and the MLE from August 16 to 24, 2011 on survey objectives, interview and collection techniques, and data collection tool content. There was also a post training assessment of the interviewers' ability to correctly administer the questionnaires. At the end of the course, five pharmacists, 16 midwives and two traditional interviewers were selected to collect information in service delivery sites ISSU SDS Baseline Survey 20

21 Data Collection in the Field Given the different types of SDSs to be surveyed (pharmacies, high-volume and lowervolume health facilities), interviewers were split into teams as follows: each of the five pharmacists worked independently (five teams); two teams made up of three interviewers each (two midwives and one traditional interviewer) were assigned to the high-volume health facilities; and six teams of two interviewers (midwives) were responsible for conducting surveys in health facilities with lower volumes of activities. Data collection in pharmacies Data was collected in pharmacies from August 26 to October 15, To monitor interviewer progress, pharmacist interviews were carried out district by district. All pharmacies identified in the sites were surveyed, whether or not they were featured on the initial list. New pharmacies were those not included on the initial list that were discovered during data collection. Data collection in health facilities Data was collected in health facilities from September 5 to November 20, All teams started data collection in the same district (North District of the Dakar). As with the pharmacy survey, data collection in health facilities was carried out district by district. During the entire process in the four Dakar sites (Dakar, Guédiawaye, Pikine and Mbao), district health facilities were distributed between all the teams. At the end of data collection in the Dakar sites, interviewers were assigned to the Mbour and Kaolack sites. Data Processing Data was entered and processed using CsPro (Census and Survey Processing System). The different data processing programs were developed by MLE. Once returned from the field, questionnaires were verified a second time before final validation. Subsequently, a team of two agents were in charge of coding before sending the questionnaires to be entered. All questionnaires were entered twice, in accordance with the IT program established. The data entry team included four operators and the CRDH's computer specialist who were assisted by an MLE consultant. The tables were produced by MLE using STATA software. Ethical Aspects The launch of the survey was subject to prior authorization by the Senegal National Ethical Committee for Health Research (CNERS). The interviewers recruited were given adequate training and guidelines so that they were suitably equipped to strictly comply with the ethical considerations to which they subscribed by signing a confidentiality agreement prior to their posting for the field work phase of the survey. Participation in the survey was strictly voluntary. Before beginning the interview, the interviewers clearly explained the purpose of the survey and that each participant was free to accept or refuse to participate in the survey. To ensure that the survey was conducted in accordance with ethical standards, a consent form was integrated into the individual questionnaires (service provider and client). Each person interviewed was asked to give their signed consent and it was prohibited to destroy or discard a questionnaire, even if it was not completed. Furthermore, all data collected was processed in a confidential manner and will not be disclosed for any reason. Access to the data processing department was regulated. Once the 2011 ISSU SDS Baseline Survey 21

22 data was processed, all completed questionnaires and other documents were archived and sent to MLE. During the analysis, all results were aggregated, which makes it impossible to associate a result with any particular individual ISSU SDS Baseline Survey 22

23 CHAPTER 3. PROVISION OF FAMILY PLANNING SERVICES IN HEALTH FACILITIES Family planning services in health facilities constitutes a key subject tackled by the survey. Several issues which refer to this subject are therefore tackled in this chapter. The results of the distribution of the health facilities surveyed by the type and services provided, the number and profiles of service providers, as well as their ability to provide certain services, are presented. The main characteristics of female clients are also explored. This chapter also deals with both the infrastructure and level of equipment to provide certain services, notably contraceptive methods. The effective level of maternal, neonatal and child health as well as family planning service delivery is assessed, as is the level of family planning integration into routine activities. Finally, access to and availability of contraceptive methods, their storage, cost to clients, and the perception of the quality of services by female clients are also analyzed. Characteristics of Service Delivery Sites, Service Providers, and Female Clients Surveyed Service delivery sites Table 2 below indicates the breakdown of health facilities surveyed by site, type of administration and volume of activities. As mentioned above, the vast majority of health facilities are located in Dakar (50%) and Kaolack (14%) while the proportion of facilities in other sites range from 8% to 10%. The vast majority of health facilities surveyed are also lower-volume facilities (73%). In terms of the type of facility, 54% are health posts, 16% private or NGO clinics, 11% health centers and 4% hospitals. Faith-based dispensaries represent 5% of the sample, while health huts, maternity hospitals, infirmaries and the Red Cross account for 11%. Most health facilities surveyed are administered by the government (75%); only 23% and 2% respectively belong to the private sector and NGOs. Table 2. Breakdown (%) of Health Facilities by Site, Type of Facility, Type of Administration in Charge of Management and Volume of Activities Characteristic Site Percentage of health facilities surveyed Dakar Guédiawaye Pikine Mbao Mbour Kaolack Total Number of health facilities surveyed Type of health facility Hospital Health center Health post Private clinic / NGO clinic Faith-based dispensary Other* ISSU SDS Baseline Survey 23

24 Characteristic Percentage of health facilities surveyed Total Number of health facilities surveyed Facility manager/administrator Government Private NGO Total Volume High volume Lower-volume Total * Other: health hut, maternity, infirmary, red cross etc. Service providers The vast majority of the 637 service providers surveyed (see table 3) were located in the Dakar (51%) while 13% were in Kaolack, 11% in Mbao, 10% in Guédiawaye, 9% in Pikine and 6% in Mbour. Nearly 82% of service providers were interviewed in public health facilities (31.9% in highvolume facilities and 49.8% in lower-volume facilities). Service providers surveyed in private health facilities (18.3%) were almost exclusively located in lower-volume facilities (17.8%). At the time of the survey, most service providers surveyed (76%) worked in three service areas: maternity (31.2%), general consultation (23.4%) and pediatrics/childcare (21.5%). Only 22% worked in antenatal care (ANC) (10.5%) and family planning (11.7%). Less than 3% were involved in other services such as surgery, dermatology, STI/HIV services etc.. Table 3. Breakdown (%) of Service Providers by Site, Type of Facility, Medical Service, Qualification, Gender and Age Characteristics Percentage of Service Providers Interviewed Site Dakar Guédiawaye Pikine Mbao Mbour Kaolack Total Type of health facility High Public Volume High Private Volume Lower Public Volume Lower Private Volume Total Service/Unit* General Consultation Maternity (childbirth, post-natal care etc.) Surgery Number of Service Providers Interviewed 2011 ISSU SDS Baseline Survey 24

25 Characteristics Percentage of Service Providers Interviewed Dermatology Pediatrics/Childcare FP service Antenatal care/anc STI/HIV department Other Missing values Total Qualification Physician** Nurse Midwife Nursing assistant CHW/Matron Welfare/Social workers Health promoter Other Total Gender Male Female Missing values Total Age (in years) < > Total * Service or unit where the service provider was working at the time of the survey ** The "Physicians" category includes general practitioners and specialist physicians Number of Service Providers Interviewed The service providers surveyed were essentially midwives (34.7%) and nurses (24.5%). Nursing assistants (18.1%), community health workers (CHWs) and matrons (15.7%) are also fairly well represented in the sample. Conversely, only 5% of service providers surveyed were physicians. Women make up the vast majority of this sample (83% compared with 17% of men). Most individuals surveyed are adults: 53.5% aged 30 to 49, 30.3% aged 20 to 29 and only 13.8% are under 20. Female clients Table 4 presents the breakdown of the 2,686 female clients surveyed according to the reason for their visits and socio-demographic characteristics. Notwithstanding differences from one site to another, female clients visit health facilities for four major reasons (more than 80%): antenatal consultation (27%), child vaccination (21%), curative services (20%), and family planning (18%). In the Dakar, the predominant reasons for visits are antenatal consultations (29.7%) and family planning (25.5%). Child vaccination was the purpose of the visit for 14% of clients; a similar percentage of women came to facilities for treatment. The other reasons for the visit (childbirth services, post-natal consultation, child development follow-up, STI/HIV/AIDS 2011 ISSU SDS Baseline Survey 25