Module 5 Session 3 Demand and Accountability February 27, 2014 1.

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Module 5Session 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

Relevance of demand to

DCST members

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Purpose & Objective

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 Side7 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 Illustration Individual Family

Limited confidence and self advocacy Tendency for families to “punish”

pregnant teenagers/ young mothers

Local leadership / representative Community / community institutions Society as large

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

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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

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

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Examples of Demand

“what if and just because statements”

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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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.

Exercise 1

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TemplateBarrier 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?

To effectively implement and operationalize supply side improvements, barriers to demand have to be reduced.

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Thank You

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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