Document

Report
Module 5
Session 3
Demand and Accountability
February 27, 2014
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Contents of the session
Purpose &
Objective
Presentation
of Concepts
15 minutes
Examples of
Demand
20 minutes
Group
work
20 minutes
Feedback
20 minutes
2
Relevance of
demand to
DCST
members
Purpose & Objective
3
Purpose
The purpose of this session is for DCST members to
consider and reflect on the patient perspective regarding
access and uptake of health care services targeted to
maternal and child health.
Overall Objective of the Session
Consider demand side issues in MCH and
how this relates to the supply side work of
DCSTs
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Presentation of Concepts
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What is supply?
The supply slide of MCH concerns the
health systems perspective on how to
overcome barriers within the health system.
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7 Elements of Supply
Provision - Supply Side
7 system elements
Governance (administration)
Human Resources (staffing – nurses,
doctors etc.)
Information
Utilisation – access and uptake
Quality and coverage
Community Engagement
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What is Demand?
The demand side of MCH pays attention to the
community and patient perspective on MCH and
the barriers that they face.
Barriers to demand – core message
Patient behaviour in the use, access and
uptake of MCH services informs demand
side barriers
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Three Dimensions of Patient Behaviour
Use & Access - Demand Side
3 Dimensions of Patient Behaviour
Patient Behaviour

Knowledge (about health services
they need & the facility providing it)

Belief and Attitudes (about the
appropriate response)

Action ( actions/activities taken)
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Demand Side Barriers – Types and
Examples
Type
Example
Socio – cultural - social norms
and conventions - beliefs and
practices
 Practice of “hiding” a pregnancy
 Use of traditional healers and
herbs
Context - conditions e.g.. poverty
and levels of education, location
 Poor road and limited transport
options
 Lack of household income to
cover the costs of accessing
services
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Demand Side Barriers – Key Features
Level of Operations

Individual

Family

Local leadership / representative

Community / community institutions

Society as large
Illustration
 Limited confidence and self advocacy
 Tendency for families to “punish”
pregnant teenagers/ young mothers

Traditional healers not well integrated
into health system – poor referral
system

Preference for using traditional healers
in combination with clinic care

Practice that men do not accompany
women to clinics
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Challenge - Reduce / Remove Demand
Side Barriers
Key message:
To improve MCH outcomes, demand for
service must increase. Actions must be taken to
identify and overcome demand side barriers.
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Barriers to demand
Related to the health system
Related to the context outside the
health system
Lack of / poor ambulance service
Lack of knowledge on what they should access
Shortage of staff
Socio- cultural norms – e.g.. hiding
pregnancies, use of traditional medicines
Poor staff attitudes and treatment
Preference for using traditional healers in
combination with clinic care
Lack of confidentiality
Stigmatization of AIDS
Long queue and waiting times
lack of familiarity with appointment system
Absence of maternity homes
Difficulty in getting access e.g. transport
Clinic hours
Teenagers and workers not able to go during
normal hours
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Some Actions to Increase Demand:
• Ensuring that poor women and their families understand the
importance of accessing healthcare services and learn how to take
responsibility for their health
• Overcoming cultural barriers to the use of MCH services
• Offering services tailored to special groups
• Improving the approach & frequency of communicating the
importance of accessing MCH services and linking to behaviour
• Working with healthcare workers to help them to understand steps
they can take to create an enabling environment for patients to
access MCH services
Examples of Demand
“what if and just because statements”
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Statement # 1
Different strategies can make sure that family
planning methods are readily available but will
young people come and get it and furthermore
use it consistently? What might stop them?
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Different strategies can make sure that family
planning methods are readily available but will
young people come and get it and furthermore
use it consistently? What might stop them?
• Stigma around having sex means young people find it hard to
discuss contraception at a facility
• Power dynamic makes it hard for girls to negotiate condom use,
• Myths around the impact of contraception on the women and baby
• Use contraception with regular partners but not others
• Power dynamic between the HCW and the teenager
• Young people don’t like waiting in queues
• Fear of being tested for HIV/AIDS
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Statement # 2
If you provide EANC, post natal services and
advice on nutrition or breastfeeding to women, what
might be some reasons why they don’t use them?
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If you provide EANC, post natal services and
advice on nutrition or breastfeeding to women,
what might be some reasons why they don’t
use them?
•
•
•
•
•
•
Cultural norm of hiding a pregnancy
Belief and practice that only go to clinic if you do not feel well
Fear of being shamed or scolded (teens)
Prefer to discuss breastfeeding with other mothers – so if HCW is not a
mother….
Partial to taking advice on nutrition within the family not at a clinic
Poverty and can’t afford the transport
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Statement # 3
Making HIV counseling and testing a routine part
of the ante-natal care screening process done by
health workers is a clever way to target women age
15-24 . But why might this strategy not always
work?
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Statement # 3
Making HIV counseling and testing a routine part
the ante natal care screening process done by
health workers is a clever way to target women
age 15-24 . But why might not always work?
•
•
•
•
Young women resist testing for fear of testing positive and lack of
confidentiality
Fear of judgment by the community
Dislike isolating HIV patients in the clinic so they “stand out” – drawback of
the fast tracking service
What do they do? - “avoid” routine checks
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Statement # 4
Even when ToP is legal, free and available in
public hospitals what could stop people from using
this service?
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Even when ToP is legal, free and available in
public hospitals what could stop people from using
this service?
• Social norms on abortion are entrenched
and carry a heavy stigma
• Young women don’t know about it
• Fear of being shamed and “preached” at
• Long queues and abrasive treatment can
drive girls to “the back street” and “Dr. Love”
• Get herbs from traditional healer to terminate
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Statement # 5
If the queues get shorter and levels of
respect, privacy and confidentiality
increase why might patients still not be
satisfied with MCH services?
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If the queues get shorter and levels of
respect, privacy and confidentiality increase
why might patients still not be satisfied with
MCH services?
• Appointment system is not liked – not clear why?
• To be taken seriously, young women believe they must be treated
“roughly”
• Hard to get confidentiality in a small waiting room… risk of people
waiting for ARVs to have status disclosed publically
• Fear from young people that nurses will share their effort to get
family planning with others – family / community members
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Statement # 6
Just because a new facility – such as a maternity
waiting home is built, would women automatically
use it? What could get in the way of this?
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Just because you build a new facility – such as a
maternity waiting home, would women
automatically use it? What could get in the way
of this?
•
•
•
If food is not provided (new DoH policy) then women are discouraged from
using it
Negative attitude of HCWs/preference for particular HCWs
People shop around
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Group work and plenary feedback
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 Exercise 1
TASK:
On a flip chart list the barriers to service delivery that you are aware of from the
demand side (community and user perspective).
Now, prioritise which ones you would focus on first given your position on the DCST.
Then think about what steps you would take to address the barrier and the
stakeholders you would engage.
Capture this information in the template provided.
Present group work to a plenary using a flip chart.
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Template
Barrier to
demand
Step / action to
address the
barrier
Stakeholders to
engage with
Priority
Intervention
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Relevance of Demand to DCST members
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Why is it important to take demand into
account?
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How do you see demand issues fitting into
your work?
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What do you need from us?
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To effectively implement and
operationalize supply side improvements,
barriers to demand have to be reduced.
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Thank You
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Contacts
•
•
•
Ellen Hagerman – Demand and Accountability Advisor/Project Manager,
[email protected]; t: 072 981 0668
Mario Classen - CSO Capacity Building Advisor,
[email protected] t: 071 1515 142
Shuaib Kauchali – Deputy Lead: Technical, [email protected]
•
Marie-Therese Mukayiranga – Grants Manager.
[email protected]
•
Dr Gugu Ngubane – Team Leader [email protected]
•
Caroline Mbi-njifor - Deputy Lead: Operations and Finance [email protected]
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