RAISE Initiative, Columbia University Global Evaluation Steering Committee Workshop

Reproductive Health Services in South Sudan, DRC and Burkina Faso:

Preliminary Results from the Service Availability and In-Depth

Studies

RAISE Initiative, Columbia UniversityGlobal Evaluation Steering Committee WorkshopFebruary 12, 2014

2

Presentation Outline1. Study methods2. Preliminary results

• South Sudan• DRC• Burkina Faso

3. Summary

3

Study Objectives1. To assess the availability, quality and utilization of RH

services2. To propose how to adapt service delivery and IEC

programs according to barriers and perceptions3. To highlight differences between policies and practice,

evidence-based decisions vs beliefs/myths/perceptions-based decisions.

4. To propose how to improve quality and utilization of services

5. To systematically assess the availability and use of facility-based RH services

4

In depth - Methods

• Background desk review• Interviews with key informants• Focus group discussions with men, women and

young people• Detailed facility assessments (small sample)• Assessment of provider knowledge and attitudes

5

Service availability - Methods

• Facility assessment (shorter than in-depth)• All (or sub-sample of) facilities providing RH

6

Data collectionS. Sudan DRC Burkina Faso

Dates July-Aug. 2013 Oct. 2013 Nov. 2013

Location Maban County Masisi HZ Sahel Region

Population 91,754 385,134 45,000

No. Facilities - Service availability 15 11 28

No. Facilities - In-Depth 3 8 6

No. Provider surveys 18 0 (?) 11

No. FGDs 9 12 9

No. Key informant interviews 22 20 15

7

PRELIMINARY RESULTS: SOUTH SUDAN

8

National Policies and Financing

• RH integrated into government health policy• No functional public health sector financial

management system• Services are free, in theory• Critical shortage of trained health providers• Low access to and utilization of RH services

9

Coordination and Emergency Preparedness• National RH Forum meets monthly, open to all

active agencies in sector• RH integrated in health and protection clusters,

but considered low priority– GBV is an active sub-cluster of the protection cluster

• Maban County:– UNFPA coordinates MISP and provides (insufficient)

RH kits– RH working group launched in May 2013

10

Facilities assessed, n=15

• PHCUs: Dispensaries, short acting FP methods• PHCCs: BEmOC, delivery, all short and long acting FP

methods

Govt.-Supported

INGO-supported & camp-based

Local FBO-supported

Total

PHCUs 0 9 0 9PHCCs 1 4 1 6Total 1 13 1 15

11

Family Planning

OCP Injectable Implant IUD TL Vasectomy Condoms EC0

2

4

6

8

10

12

14

16

75

0 0 0 0

10

4

South Sudan: Provision of Family Planning in the last 3 months, Self Reported (n=15 health facilities)

12

Abortion

PAC with MVA PAC with Misoprostol

FP to PAC Clients

Induced Abortion0

2

4

6

8

10

12

14

16

35

3

0

South Sudan: Provision of Abortion services in the last 3 months, Self Reported (n=15 health facilities)

13

EmOC

0

2

4

6

8

10

12

14

16

5

32

43 3

10 0

South Sudan: Provision of EmOC services in the last 3 months, Self Reported (n=15 health facilities)

14

HIV & STIs

Syndromic Diag-nosis & Treament

STIs

VCT ART ARVs in Maternity0

2

4

6

8

10

12

14

16

12

0 0 0

South Sudan: Provision of HIV/STI services in the last 3 months, Self Reported (n=15 Health Facilities)

15

Care for Survivors of Sexual Assault:

PEP EC Antibiotics for STIs0

2

4

6

8

10

12

14

16

24

6

South Sudan: Availability of commodities for Care for Sexual Assault Survivors (n= 15 health facilities)

16

Key Beneficiary Perceptions of RH Issues• Women aware of benefits of birth spacing• Men think stopping a woman from having children is bad for

women and the community• FP for unmarried women is unacceptable; husband consent

required• In rare cases, a women can have her baby “removed” with herbs• General belief that delivering at health facility important• All knew HIV/AIDS – but have misconceptions about

transmission• Domestic violence common, but rape (outside marriage)

considered rare– Rape sometimes used as strategy to force a woman to marry

17

Key Beneficiary Perceptions of RH Services

• No FP information or services available in camps

• Women like delivering at camp health facilities – high quality, free and later receive food assistance

• No treatment exists for HIV/AIDS• Don’t know of any GBV services

18

PRELIMINARY RESULTS: DEMOCRATIC REPUBLIC OF CONGO

19

National Policies and Financing

• RH services part of national health policy and minimum service package at health centers

• Practical availability of RH services depends on support by INGOs

• 4% of national budget goes to health - fee for service in place for all services (unless supported by NGO)

20

Coordination and Emergency Preparedness• RH Working Group

– Meets monthly & coordinates with Health Cluster– Trained NGO staff in MISP implementation

• Agencies have separate EP plans, usually include RH– UNHCR provides hygiene & PEP kits– WHO includes MISP supplies in pre-positioned kits

21

Facilities assessed, n=19

• Health Centers: ANC, post-natal care, BEmOC, delivery, All short and long acting FP methods, testing and treatment of chronic diseases (including HIV)

• Hospital: Referral, surgery, CEmOC, all short-acting long-acting and permanent FP methods

Govt.-Supported

(only)

INGO-supported*

Total

Health Centers 3 15 18Hospital 0 1 1Total 3 16 19

*1 or more RH service

22

Family Planning

OCP Injectable Implant IUD Condoms EC0%

10%20%30%40%50%60%70%80%90%

100%

61% 61%50%

39% 44%33%28% 22%

11%22%

ND

47%

DRC: Provision of Family Planning services and availability of essential resources (n=18 health centers)

Provided last 3 months (self-reported) Essential supplies and trained staff

23

Abortion

PAC with MVA PAC with Misoprostol

FP to PAC Clients

Induced Abortion0%

10%20%30%40%50%60%70%80%90%

100%

35%

6%

44%

0%

29%

6% ND 0%

DRC: Provision of Abortion services and availability of essential resources (n=18 health centers)

Provided last 3 months (self reported) Essential supplies and trained staff

24

Basic EmOC

0%10%20%30%40%50%60%70%80%90%

100%

44%

17%22%

33% 35%

0%

22%

ND

82%

29%

ND

29%

ND12%

DRC: Provision of Basic EmOC services and availability of commodities (n=18 health centers)

Provided last 3 months (self reported) At least 1 unit available

25

HIV & STIs

Diagnosis & Treament STIs

VCT ART ARVs for PMTCT (mothers only)

0%10%20%30%40%50%60%70%80%90%

100% 89%

18%6% 6%

DRC: Provision of HIV/STI services in the last 3 months, Self Reported (n=18 health centers)

26

Care for Survivors of Sexual Assault

PEP EC Antibiotics for STIs0%

10%20%30%40%50%60%70%80%90%

100%

67% 61%

78%

47% 47%

ND

DRC: Provision of Care for Sexual Assault Survivors and availability of commodities (n= 18 health centers)


27

Key Beneficiary Perceptions of RH Issues

• Aware of some modern methods, but FP associated with “prostitution” and should be kept secret

• Children outside marriage common, but present many social challenges

• Catholic influence is strong• Aware of importance of facility deliveries, but actual

behavior influenced by many factors, decision-makers• Some unmarried women have never heard of HIV• Physical and sexual violence considered common

28


• FP services not considered available for adolescents• Access to FP difficult due to misconceptions and lack of

information (by community and providers)• ANC services available and of high quality• Concerns about availability of staff, comfort and distance

for facility delivery• Induced abortion considered unavailable, but believe

demand exists for unmarried women• HIV services not believed to be widely available• Services for survivors of sexual assault not available in

IDP camps but are in HCs and hospitals

29

PRELIMINARY RESULTS: BURKINA FASO

30

National Policies, Financing and Emergency Coordination• RH integrated in national health policy, services for

refugees expected to align• Refugees receive free care, but host population typically

pays a small portion of cost of care• In practice, access difficult in Sahel Province but

refugees have better access than host population• Emergency preparedness and response plan developed

in 2012• Weekly national coordination meetings held with relevant

actors

31

Facilities assessed, n=28Govt.-

SupportedINGO-

SupportedFBO-

SupportedTotal

Hospitals 3* - - 3

Refugee Camp Facilities - 4 - 4

Health Centers 20 - 1 21

Total 23 4 1 28

• Hospitals: Referrals, CEmOC, all FP methods, HIV services, care for sexual assault survivors

• Health centers and refugee camp facilities: Delivery, short and long-acting FP methods, HIV services, care for sexual assault survivors

*2 hospitals receive NGO support for FP

32

Family Planning

OCP Injectable Implant IUD Condoms EC0%

10%20%30%40%50%60%70%80%90%

100% 96% 96% 93%

29% 33% 36%46%

56%43%

18%

ND

39%

Burkina Faso: Provision of Family Planning services and availability of essential resources (n=28 health facilities)

Provided last 3 months (self-reported) Essential supplies and trained staff

33

Abortion

PAC with MVA PAC with Misoprostol FP to PAC Clients Induced Abortion0%

10%20%30%40%50%60%70%80%90%

100%

29%

11%0%

29%

ND ND 0%

Burkina Faso: Provision of Abortion services and availability of essential resources (n=28 health facilities)

Provided last 3 months (self reported) Essential supplies and trained staff

34

Basic EmOC

0%10%20%30%40%50%60%70%80%90%

100% 96%

50%

24%

75%

29%

7%

61%

ND

100%

29%

ND

29%

ND

57%

Burkina Faso: Provision of Basic EmOC services and availability of commodities (n=28 Health Facilities)


35

HIV & STIs

Syndromic Diag-nosis & Treament

STIs

VCT ART ARVs for PMTCT (mothers and

newborns)

0%10%20%30%40%50%60%70%80%90%

100%100% 93%

25%

89%

Burkina Faso: Provision of HIV/STI services in the last 3 months, Self Reported (n=28 health facilities)

36

Care for Survivors of Sexual Assault:

PEP EC Antibiotics for STIs0%

10%20%30%40%50%60%70%80%90%

100%

32%

50% 54%

11%

36%

ND

Burkina Faso: Provision of Care for Sexual Assault Survivors and availability of commodities

(n=28 health facilities)


37

Key Beneficiary Perceptions of RH Issues

• Believe ANC visits and facility deliveries important for maternal & child health

• Unmarried women most lacking in knowledge of RH issues, services

• All had heard of HIV/AIDS• Most knew of other STIs, but some hold misconceptions• Domestic and physical violence common, sexual

violence occurs but considered less common– Women collecting firewood and visiting latrines at night

considered high risk

38


• Refugees have better access to RH services than host population

• Most aware of free FP services at camp facilities, but have concerns about confidentiality

• Camp ANC and delivery services high quality – better than “back home”

• Most aware of HIV testing services, some thought treatment available at the hospital

• Aware of reporting system for sexual violence, little discussion of services

39

OVERALL SUMMARY

40

Summary results• FP: Some methods available at most facilities

– Long-acting methods available in some facilities– Permanent methods unavailable

• PAC is very limited• Comprehensive abortion care non-existent• EmOC: Few facilities offer all BEmOC signal

functions• GBV: Care for survivors of sexual assault available

in about half of facilities

41

Summary results (continued)• HIV/STIs services are sporadic

– Syndromic diagnosis and treatment of STIs mostly available

– VCT, PMTCT and ART largely unavailable• RH often included in govt. health policies• RH working group active in 2 of 3 countries

Documents

RAISE Initiative, Columbia University Global Evaluation Steering Committee Workshop