'The question should not be why do women not accept the service that we offer, but why do we not offer a service that women will accept?' Contents Acknowledgements The authors This work was carried out as part of a research project on maternal health in India sponsored by the Wellcome Trust. The authors would like to thank the following people for their help and comments on various drafts of the text; Choices, a knowledge programme on reproductive health in developing countries funded by the Department for International Development based at Southampton University, has also supported the production and distribution of this monograph. Views expressed in this publication are, however, solely the responsibility of the authors. Louise Hulton is a researcher and occasional lecturer in the Department of Social Statistics at the University of Southampton, currently working on health-seeking behaviour among the urban poor of Mumbai. She has previously worked on AIDS research in sub-Saharan Africa and maternal health care in rural India. She is also the secretary of AIMS (Association for Improvements in Maternity Services), UK. Her work on quality in maternal health care is dedicated to the birth of her daughter Ella. Zoë Matthews is a researcher and lecturer in Demography in the Department in Social Statistics at the University of Southampton. She has research interests in reproductive and child health in developing countries, with particular emphasis on maternal health in South Asia. Hospitals NHS Trust. He has research interests in interdisciplinary work on women's reproductive health including pelvic pain, contraception and maternity services and also in laboratory studies of human ovarian vascular biology.

A framework for the evaluation of quality care in maternity services.

Understanding safe sex: gender narratives of HIV and pregnancy prevention by rural South African school-going youth

Malaria is one of the leading causes of mortality and morbidity in Nigeria. It is not known how user fees introduced under the Bamako Initiative (BI) system affect healthcare seeking among different socio-economic groups in Nigeria for diagnosis and treatment of malaria. Reliable information is needed to initiate new policy thrusts to protect the poor from the adverse effect of user fees. Structured questionnaires were used to collect information from 1594 female household primary care givers or household head on their socio-economic and demographic status and use of malaria diagnosis and treatment services. Principal components analysis was used to create a socio-economic status index which was decomposed into quartiles and chi-square for trends was used to calculate for any statistical difference. The study showed that self diagnosis was the commonest form of diagnosis by the respondents. This was followed by diagnosis through laboratory tests, community health workers, family members and traditional healers. The initial choice of care for malaria was a visit to the patent medicine dealers for most respondents. This was followed by visit to the government hospitals, the BI health centres, traditional medicine healers, private clinics, community health workers and does nothing at home. Furthermore, the private health facilities were the initial choice of treatment for the majority with a decline among those choosing them as a second source of care and an increase in the utilization of public health facilities as a second choice of care. Self diagnosis was practiced more by the poorer households while the least poor used the patent medicine dealers and community health workers less often for diagnosis of malaria. The least poor groups had a higher probability of seeking treatment at the BI health centres (creating equity problem in BI), hospitals, and private clinics and in using laboratory procedures. The least poor also used the patent medicine dealers and community health workers less often for the treatment of malaria. The richer households complained more about poor staff attitude and lack of drugs as their reasons for not attending the BI health centres. The factors that encourage people to use services in BI health centres were availability of good services, proximity of the centres to the homes and polite health workers. Factors deterring people from using BI centres should be eliminated. The use of laboratory services for the diagnosis of malaria by the poor should be encouraged through appropriate information, education and communication which at the long run will be more cost effective and cost saving for them while devising means of reducing the equity gap created. This could be done by granting a properly worked out and implemented fee exemptions to the poor or completely abolishing user fees for the diagnosis and treatment of malaria in BI health centres.

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Socio-economic differences and health seeking behaviour for the diagnosis and treatment of malaria: a case study of four local government areas operating the Bamako initiative programme in south-east Nigeria

Grouping existing providers under a franchised brand, supported by training, advertising and supplies, is a potentially important way of improving access to and assuring quality of some types of clinical medical services. While franchising has great potential to increase service delivery points and method acceptability, a number of challenges are inherent to the delivery model: controlling the quality of services provided by independent practitioners is difficult, positioning branded services to compete on either price or quality requires trade-offs between social goals and provider satisfaction, and understanding the motivations of clients may lead to organizational choices which do not maximize quality or minimize costs. This paper describes the structure and operation of existing franchises and presents a model of social franchise activities that will afford a context for analyzing choices in the design and implementation of health-related social franchises in developing countries.

Franchising of health services in low-income countries.

The Kenya government in collaboration with other stakeholders involved in the provision of family planning services have put in place various strategies and policies to increase uptake of family planning services. These are aimed at increasing contraceptive prevalence rate (CPR), reduction in both total fertility rate (TFR) and unmet need for family planning services. Despite the various strategies and policies, total fertility rate still remains high at 4.6 percent, while CPR and unmet need for family planning are estimated at 46 percent and 24 percent, respectively. The purpose of the study was to examine the utilization level of family planning services and to analyze the determinants of demand for family planning services among women in City slums in Kenya. To realize this objective, a survey design was adopted. The target population constituted women in city slums in Kenya, who were identified through multistage random sampling. Primary data was collected from the women using a structured interview schedule. A fact sheet was used to summarize the data collected before it was cleaned, coded and edited for completeness and accuracy. The study revealed low usage of contraceptives compared to the national level. Use of the services varied in terms of demographic and socioeconomic factors of the woman and also the woman’s perception in terms of the facility/provider factors such quality, friendliness of staff and promotion. Various factors accounted for the low use of family planning services. These included partner’s approval, quality of the services, friendliness of the staff administering the services and the woman’s knowledge about family planning services. Other factors included the woman’s income level, proximity to the provider and the religious background of the woman. To increase the use of family planning services among women in slums, activities of community based distributors should be revived and enhanced, promotion of family planning education and activities at the household level should be accorded priority. Formation of lobby groups to enhance cultural change, awareness creation and counselling and integrating family planning services with HIV/AIDS are recommended.

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Contraceptive Use among Women of Reproductive Age in Kenya’s City Slums

This article offers a conceptual scheme that clarifies the confusion and overlap existing among the definitions of "access" "quality of care" and "medical barriers" as these terms apply to family planning (FP) programs. After an introduction the article explains that these concepts are characteristics of the supply environment and apply to any type of service delivery point. The article also bases its framework on a distinction between what happens "inside" and "outside" of the service delivery point. The article then defines the terms and discusses related issues and concerns. The next sections explore the linkages among the terms and set forth the following research priorities: 1) developing methods of "scoring" various elements of quality 2) improving methods of measuring clients perspectives of access and quality 3) verifying the population-based effects of variations among the components of the concepts and 4) validating the presumed linkages among these concepts. Finally the article enumerates the policy implications of its attempt to clarify these concepts as follows: 1) access involves more than simply geographic availability of services points 2) access and quality must be enhanced concurrently 3) quality promotion should employ a humanitarian and a demographic rationale 4) expansion of FP services to include reproductive health services will require careful consideration of medical barriers as well as monitoring of levels of quality of care and 5) that it is important to have a balanced approach.

http://www.jstor.org/stable/pdfplus/2133525.pdf

Marcia A. Angle

Papers

Access quality of care and medical barriers in family planning programs.