Forum for Women in Democracy in 2012, commissioned a study in Gulu and Luwero districts to measure citizens’ satisfaction with Family Planning (FP) services using a Citizens’ Report Card (CRC).

1. Issue Brief on
Citizens’ Satisfaction
with
Family Planning Services
A case of Gulu and
Luwero districts
Forum for Women in Democracy i

2. ii

3. CITIZEN’S REPORT CARD ON FAMILY PLANNING SERVICES
IN UGANDA is published by Forum for Women and Democracy
(FOWODE) with support from the Results for Development (R4D)
© 2012
Forum for Women in Democracy (FOWODE)
P.O. Box 7176, Kampala
Tel: +256-41-286063
E-mail: fowode@fowode.org
Web www.fowode.org
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. Nevertheless, FOWODE and Results
for Development (R4D) encourage its use and will be happy if
excerpts are copied and used. When doing so, however please
acknowledge FOWODE.
1

4. 2
Background

5. Forum for Women in Democracy in
2012, commissioned a study in Gulu
and Luwero districts to measure
citizens’ satisfaction with Family
Planning (FP) services using a
Citizens’ Report Card (CRC).
1 Rationale of the study
One way of improving reproductive health care in
Uganda is to ensure that family planning1 services
are accessible and affordable. The Ministry
of Health (MoH) has put in place maternal
{
Unmet need of family planning in
Uganda stands at 34.3 per cent
(UBOS, 2012)
mortality reforms which include improving family
planning services. In line with these efforts, the
use of modern methods of family planning has
consistently increased over the past decade,
growing from 14 per cent of married women in
2001 to 26 per cent in 2011 (UBOS, 2012).2
However, contraceptive prevalence rates3 are
still very sparse. Access and usage of modern
family planning methods remains a challenge in
Uganda. According to the recent Demographic
and Health Survey (DHS), unmet need for family
planning4 stands at 34.3 per cent (UBOS, 2012).
43 per cent of family planning users in Uganda
discontinued using the method within 12 months
1 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.
2 UBOS (2012), Uganda Demographic and Health Survey
2011
3 Percent of currently married women aged 15-49 using
any method of contraception.
4 Women who have a desire to limit their births but who are
not using family planning (UBOS; UDHS, 2011)
3

6. of starting its use.5 Although women want to
reduce the number of children that they have,
only one fifth of married women (23 percent)
practice birth control due to many factors
including: misconceptions about family planning;
lack of information; limited access; costs; limited
decision-making power on reproductive choices;
and, opposition from male partners (NCG,
2012).6
Access and usage of modern family
planning methods remains a challenge
in Uganda. According to the recent
{
Demographic and Health Survey (DHS),
unmet need for family planning stands
at 34.3 per cent (UBOS, 2012). Forty-
three per cent of family planning users in
Uganda discontinued using the method
within 12 months of starting its use.
As part of the efforts to address the above-
mentioned challenges, the Government of
Uganda, with support of donors, has made
efforts to increase funding for procurement and
distribution of Family Planning supplies. However,
a recent study by FOWODE using the Public
Expenditure Tracking Study (PETS) methodology7
showed that the utilization of Family Planning
services in the five districts8 covered was very
low.
5 ibid
6 NCG (2012), A Gender Analysis of PMTCT and related
RH programs in Uganda
7 FOWODE (2012), Public Expenditure Tracking Survey
of Funds/Commodities for Family Planning Services in
Uganda
8 Kabale, Gulu, Luwero, Kibaale, and Kibuku districts
4

7. The findings of the CRC study will:
§ Help public health providers to facilitate
open and proactive discussions on their
performances;
§ Empower citizen groups to play a watch-dog
role to monitor public health service delivery;
§ Enable the central government, especially
the ministry of health, to streamline and
prioritize budget allocations towards family
planning and monitor implementation;
§ Increase citizen awareness on family
planning.
Only 23% of
{ married women
practise birth control {
5

8. 6
Key Findings

9. 1. Access and Utilization
a) Utilization of government health
facility for family planning services
Of the 690 households surveyed, 57percent,
(63percent of females and 38 percent of males)
reported to have visited the government health
facility during the last one year for Family
Planning services. Gulu reported the highest at
58 percent, compared to Luwero which had 56
percent of respondents. Fear of side side effects
(such as constant bleeding, loss of weight, loss
of sexual desire) and the need to have many
children after the LRA insurgency (in Gulu),
were noted as the main reasons for not using
family planning and discontinuation. This is also
consistent with the recent UDHS (2011), which
showed that 43 per cent of family planning users
in Uganda discontinue use of a method within 12
months of starting its use.
Responses on family planning
“…people were using FAMILY PLANNING
but reduced due to many side- effects.”
“… family planning is not good, it causes
{
cancer, and loss of sexual desire” (FGD in
Wabusana S/C)
“… we lost so many people during the LRA
war; we need to produce more now…” (FGD
in Palaro S/C)
“… we marry these women to produce, why
family planning?” – (FGD in Awach S/C)
b) Type of family planning service sought
Half (50 percent) of the combined respondents
who visited the health facility sought for injectable
contraceptives, followed by contraceptive implant
at 20 percent, male condoms 11 percent, oral
contraceptives10 percent and intrauterine device
(IUD) at 6percent. Across all the age groups,
injectable contraceptive are the most commonly
7

10. preferred family planning service whereas the
51 percent of the unmarried preferred condoms
52 percent of married preferred injectable
contraceptives. The choice of the family planning
methods, especially by women, is influenced
by the inability to be detected by the husband
(for those who oppose family planning), thus
most prefer injectables. Although 67 percent of
males sought condoms there were other men
that indicated preference for other methods
such as injectables. Most people shun family
planning mainly due to lack the knowledge and
misconceptions about it.
“You have to use family planning in
secrecy since some of our husbands
{
don’t like it; in case they (husbands)
they get to know, you have to endure the
repercussions.” “…I have to go when they
he is not aware; otherwise, if I tell him, he
will refuse me…”FGD in Palaro sub-county
c) Involvement of partners/Spouses
A small percent (20 percent) of the respondents
went with their partners/ spouses to the health
facility for family planning services. The smallest
percent was reported in Luwero (12 percent),
while Gulu reported 30 percent. Only 26 percent
of women in Gulu and 12 percent of women in
Luwero went with the partners. Majority reported
their spouses were busy or never around. 30
percent of women stated they did not go with
their husbands, because they did not want them
to use family planning. Thus, many women
secretly use contraceptive methods. In an effort
to hide contraceptive use, clients sometimes
administer contraceptives in a manner that could
lead to failure (Mugisha and Reynolds, 2012).
8

11. d) Visit to other facilities for family
planning services
Men tend to use other health facilities (such
as private clinics, NGOs or traditional birth
attendants) besides the government health
facility, for family planning services compared
to women. The survey shows that 56 percent
of men compared to 39 percent of women had
visited another health facility for family planning
services. The main reasons for use of other health
facilities rather than the government health
facility include: closeness to where they live; no
longer hours of waiting and, provision of better
quality services. 20 percent used ‘self’ (bought
family planning commodities from a pharmacy or
drug shops), people noted that they sometimes
used traditional methods of family planning.
e) Information about availability of family
planning commodities
There is minimal information on availability
of family planning commodities. The majority
(75 percent) of the respondents did not know
when the government health facility received
family planning commodities. Only 31 percent
of the respondents in Gulu and 18 percent
in Luwero reported to have had information.
By gender, men were less aware (25 percent)
compared to women (20percent). For those who
had information when the government health
facility received family planning commodities,
40 percent got to know when they visited the
facility, 23 percent through radios/TVs, and
14 percent through village notice boards and
14 percent from other village members. Thus,
provision of information on family planning needs
to be enhanced especially through the use of
mass media such as radios and TVs.
9

12. 2. Quality and Reliability
a) Availability of service
The CRC revealed that Family planning services
are always available. Majority (90 percent) of
the respondents who visited the health facility
got the service they wanted and almost all (99
percent) of the respondents who visited the
government health facility for family planning
services found a health worker available at the
facility.
Factors affecting choice of a healthy
{
facility for family planning
Distance, quality of service, waiting time
and availability of health workers are
key in choice of health facility for family
planning services
Time spent before being attended to by the
health worker is critical in effective delivery of
services. The survey revealed that that three-
quarters (75 percent) of the respondents
waited for less than one hour, 16 percent waited
between 1-2 hours and 9 percent more than
3 hours. The survey further reveals that that
84 percent of the respondents received all the
information about family planning service being
offered from the health worker.
b) Outreach services
Outreach activities are critical in increasing
access and utilization of family planning services.
However, only 11percent of the respondents
reported that the health facility carried out
outreach services on family planning in their
villages. Gulu reported a dismal 7 percent,
10

13. whereas Luwero reported 15 percent. Only
9 percent of women and 17percent of men
reported that the health facility carried out
outreach services on family planning in their
villages. People noted that no outreach was
done by health workers, but by some Village
Health Teams (VHTs); however, they were poorly
facilitated. Most outreaches were conducted by
Non- Governmental Organizations such as Marie
Stopes.
c) Changes in the delivery of family
planning services
51 percent of the respondents reported having
experienced improvement in the government
health facility’s delivery of family planning
services in the previous one year. However, 31
percent reported no change, 16 percent did not
know, whereas 3 percent reported deterioration.
By gender, 53 percent of the male respondents
reported improvement, 37 percent reported
no change, 7 percent did not know, whereas 4
percent reported deterioration. On the other
hand, 50percent of the female respondents
reported improvement, 30 percent no change,
18 percent did not know, whereas 3 percent
reported deterioration
d) Recommendation to seek assistance
from government health center
According to the survey data, 88 percent of
the respondents reported that they would
recommend someone else to the government
health facility for family planning services. In
Gulu 84 percent would recommend, whereas 93
percent in Luwero would recommend someone.
By gender, 98 percent of females and 85 percent
of males would recommend someone else to the
government health facility.
11

14. 3. Problem and Grievance Redress
Respondents who had problems/ issues during
the visit to the health facility for family planning
were few; only 21 percent reported to have had a
problems. The major problems were lack of family
planning commodities, impolite staff, absence of
health workers and health workers asking them
to pay or bribe. Despite having problems, only
8 percent of the respondents made a complaint.
Ignorance, apathy and fear were the major
reasons for not making complaints; whereby 39
percent did not know where to complain, 35
percent did not think anything would be done,
and 13percent were afraid of making a complaint.
Additional costs of family planning
“it’s free to get an implant here, but when
{
you get a complication like over bleeding,
the nurses here can’t help you, they refer
you to Gulu hospital, and there you need
to pay, that becomes too expensive for us”
(FGDs in Awach and Bobi S/Cs).
4. Corruption / Bribes
Corruption did not seem to be a big issue
experienced by respondents while accessing
family planning services at a government health
facility. Only 7 percent of the respondents
reported to have paid some money. 68%
of reported to have paid for injectables and
majority (90 percent) paid to a nurse while
(81percent) paid to a midwife and (19percent)
paid to a clinical officer.
12

15. 5. Satisfaction
Respondents were asked about their satisfaction
using eight different indicators9. 81 percent
of the respondents said they were satisfied,
17 percent were dissatisfied and 2 percent
were neither satisfied nor dissatisfied. The five
common reasons for dissatisfaction reported
by respondents included: inadequate supplies
of family planning supplies (20 percent), poor
attitudes of health workers (18 percent),
long waiting time (10 percent), inadequate
information (8 percent), and health facility being
too far (8 percent).
During Focus Group Discussions, some people
said that they were not happy with the family
planning services provided. They noted that
Health workers did not provide adequate
information about family planning; had no
capacity to provide certain services like implants;
could not address side effects; did not provide
due diligence on the appropriate method. Some
of the community concerns are genuine given the
fact that some health workers lack knowledge of
the latest medical eligibility criteria and practice
recommendations. This lack of training and skills
limited which methods they offered and limited
when clients could receive methods. Many health
facilities did not provide implants and intrauterine
devices because they lacked trained providers
who could insert them (Mugisha and Reynolds,
2012).
9 The satisfaction indicators included: provision of information
about FP; distance to the government health facility;
availability of FP commodities; availability of heath workers;
level of privacy; waiting time; hygiene / cleanliness of
health facility; and behavior of health workers.
13

16. 14
14
Conclusions and Recommendation

17. 15
15

18. This Citizens’ Report Card was conducted
in two districts of Gulu and Luwero to
measure citizens’ satisfaction with the
family planning service. The report
card has provided valuable feedback to
improve family planning services and
provides important information to guide
policy makers and other key stakeholder
to consider when addressing the key
challenges:
6. Recommendations
In line with the above findings, the following
recommendations are made to various stakeholders
to address the key challenges in effective delivery
of family planning services.
Ministry of Health
• Devise strategies for targeting men to support
family planning through use of mass media,
community dialogue, scaling up integrated
outreach services and use of fellow men as peer
mobilizers.
• Establish, train and facilitate village health
teams to implement family planning outreach
activities.
• Promote the use of alternative family planning
methods with fewer side effects such as
rhythm/moon beads.
• Undertake more sensitization on family
planning through drama, theatre, etc to change
people’s attitudes and behaviour.
• Recruit more health workers especially those
that handle family planning issues.
• Integrate outreach for family planning with
other campaigns such as Prevention of Mother
to Child Transmission (PMCT), HIV/AIDs
programmes, immunization and home hygiene
etc.
16
16

19. • Increase funding for family planning education
and advocacy.
National Medical Stores
• Increase procurement and supply of family
planning commodities used by men, especially
condoms and surgical kits for vasectomy and
those used by women with fewer side effects
such as moon beads and surgical kits for
sterilization.
Health Facilities
• Increase on community sensitization and
outreach activities in a bid to popularize
family planning methods at community level.
• Partner with relevant partners such as village
health teams, community development
workers and Community Based Organizations
to mobilize people to effectively participate in
family planning programmes.
• Carry out proper investigation /testing before
provision of any family planning method in a
bid to reduce side-effects
• Sensitise people on the side effects of family
planning and how they can manage them.
• Improve on provision of information on
availability of free family planning services at
government health facilities.
Undertake more
sensitization on family
{ planning through
drama, theatre, etc
to change people’s
{
attitudes and behaviour.
17
17

20. Civil Society Organizations
• Should lobby government for increased
funding for family planning services.
• Undertake community sensitization on the
importance of family planning through the use
of the mass media and community dialogues.
• Deliberately target men in their family
planning campaigns through the use of
Information, Education and Communication
materials and mass media
• Develop health information packages about
the rights of men and their responsibilities in
family planning.
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22. Our Vision
A just and fair society where women and
men equally participate in and benefit
from decision making processes.
Our Mission
To promote gender equality in all areas of
decision making through advocacy, training
and research and publication.
Forum for Women in Democracy (FOWODE)
P O BOX 7176, Kampala • Tel: + (256) 041 4 286063
Email: fowode@utlonline.co.ug • Email: fowode@fowode.org
Web: www.fowode.org
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