State Level Consolidated Report of Uttar Pradesh

Transcription

1 State Level Consolidated Report of Uttar Pradesh Findings of Community Monitoring for Improving Informed Choice and Quality of Care in Family Planning Centre for Health and Social Justice, New Delhi

2 Content Page number 1 Family Planning in India 3 2 The Process 3 3 Methodology Adopted 4 4 Major Findings -District Wise 7 5 District Level Dialogues and Sharing 8 6 State Level Score Card 11 7 District wise Findings of Community Monitoring Process 12 8 Conclusion 18 9 Annexure of Media Coverage of District Level Dialogue 20 Content List of Acronyms ANM Auxiliary Nurse Midwife ASHA Accredited Social Health Activist AWW Anganwadi Worker CHSJ Centre for Health and Social Justice CHC Community Health Centre CBM Community Based Monitoring CMO Chief Medical Officer CSO Civil Society Organisation FGD Focus Group Discussion GOI Government of India IUD Intra Uterine Device MOIC Medical Officer in-charge NRHM National Rural Health Mission PRI Panchayati Raj Institution PHC Primary Health Centre OCP Oral Contraceptive Pills 2 P a g e

3 1. Family Planning in India Family planning within the context of health is one of the flagship programmes of the Government of India (GoI). India started its national family planning programme in 1951 which has a long and chequered history. There was an obsessive fear of explosive population growth which led to the introduction of coercive components like targets, incentives and penalties for the community as well as the health worker. However, the programme was often reduced to provision of female sterilisation. In rapidly conducted sterilisation camps the quality of surgical procedures was poor. After signing on to the Program of Action of the International Conference on Population and Development (PoA- ICPD, 1994), the GoI made many changes in the way the family planning programme was designed and implemented. Method specific targets were abandoned; standard operating procedures and quality assurance mechanisms were introduced. Today the GoI has shifted its programme focus from female sterilisation to an approach focusing more on birth spacing and temporary methods. However, India is a large country and the manner in which programmes are delivered on the ground can be very different from the policy intentions. There is need to understand whether couples especially women can access high quality family planning services according to their needs and choice which is the true intention of the family planning programme. 2. The Process Community based monitoring (CBM) methodology has been developed within the auspices of the National Rural Health Mission to understand the communities experience of service delivery. It is also seen as an integral component of community participation as well as of accountability mechanisms, and is aimed at improving the quality of services demanded by the community and delivered by the health system. CBM methodology has been used in this initiative since it increases participation of the community and civil society organisations (CSOs). In an effort to strengthen people s access to quality family planning services and build understanding on quality of care in family planning, five CSOs undertook community based monitoring on family planning services in selected villages in five districts of Uttar Pradesh, Azamgarh, Chandauli, Chitrakoot, Mirzapur and Shrawasti. The CBM exercise included discussions with women where the experience of women who are intended as well as actual beneficiaries of the family planning programme was understood. Interviews were conducted with a selected group of ASHAs in each district and the Medical Officer and ANM of one Block in each district were also interviewed. The district level public dialogues based on the findings of CBM has been undertaken in five districts of Uttar Pradesh during last two months focussing on informed choice and quality of care in family planning. In district level Jansamvad, score cards with findings and experiences of family planning users were shared with community, health service providers, Panchayati Raj Institution (PRI) members and media. Objectives: The main objectives of the study are: To monitor compliance of quality standards in family planning services. To advocate for improvement of quality and fulfillment of reproductive rights. 3 P a g e

4 3. Methodology Adopted In each of the five districts of Uttar Pradesh, one village each from five panchayats in one block in the district were selected for the study. The entire survey in five districts was done by women selected from the community in the villages. These women were given orientation on the objectives and provided trainings on data collection. Table 1 enumerates district wise block and village names. Table 1: District wise block and village name District Block Panchayat Village Azamgarh Atraulia Madanbatti Madanbatti Madhoipadhti Madhoipadhti Mundera Mundera Banspur Banspur Chattarpur Khas Chattarpur Khas Chitrakoot Pahadi Babupar Babupar Raghubanshi Pur Raghuvanshipur Tora Shikria Pahadi Khas Pahadi Khas Buda Buda Mirzapur Rajgarh Dakhan Indira Nagar Sarso Sarso Nunati Kodpari Lusa Lusa Bichla tola Jangalamhaal Domri Shrawasti Jamunaha Achrora Shahpur Laxmanpur Mahrumurtiha Murtiha Phholbariya Sahpur Khanbapur Badla Bejanapur Bejanapur Hardantnagar Girant Kebaranpurwa District Selection Criteria The selection of the five districts was done on the basis of concentration of socially excluded and marginalised communities. These five districts Azamgarh, Chitrakoot, Chandauli, Mirzapur, and Shrawasti have a concentration of socially excluded and marginalised communities. These districts have a considerable presence of Scheduled Caste/Schedule Tribe, extremely backward communities and forest dwellers. There is a low level of awareness and uptake of modern methods in these districts. There is a good presence of the Uttar Pradesh Health Watch Forum partners who are already taking forward the health rights agenda in the state. The list of organisations that participated in collecting data for the study is given in Table 2. Further the dalit and the backward communities, use long acting contraceptives more. But this option is still not part of the national programme, leading to questions around equity in access to contraceptives for minority communities. 4 P a g e

5 Table 2: List of organisations: S. No. District Name Organisation Name 1 Azamgarh Gramin Punar Nirman Sansthan (GPS) 2 Chandauli Gramya Sansthan 3 Chitrakoot Ibteda Sewa Sansthan (ISS) 4 Mirzapur Sikhar Prashikshan Sansthan (SPS) 5 Shrawasti Developmental Association for Human Advancement (DEHAT) Selection criteria of villages and study population Table 3: Selection criteria of study population USERS COMMUNITY PROVIDERs FACILITY 50 interviews with women in each district who have used either Intrauterine device (IUD), oral contraceptive pill (OCP) or sterilisation, injectables as a method of family planning in last two to three years Two focus group discussions (FGDs) with women in 5 villages in one district. The inclusion criteria comprised of following: o Pregnant women o Newly married o Women who have children of one to two years o Women who used the family planning methods within a year o Age group for selection is 19 to 45 years of age Interview with Medical Officer of Primary Health Centre (PHC) Interviews with ASHAs of all 5 selected villages Observation of one PHC using a checklist Interviews and FGDs: Two FGDs (12-15 women per focus group discussion) (total 10 FGDs per district) One interview with ASHA in each village (five ASHAs per district) 10 interviews (with users) in every village (50 interviews per district) One facility survey (PHC) in one district One interview with Medical Officer in Charge (MOIC) in one district Case stories (no number is defined) In each districts, two FGDs were held in each of the five selected villages along with interviews with the ASHAs of each village and Medical Officer. A PHC was observed in five blocks of five districts as a facility observation. A total of 50 FGDs conducted across the five selected villages. Score Card Preparation After gathering the information through the FGDs, interviews with family planning users, interviews with ASHAs and MOIC, and facility observation, scores were given to each of the conducted inquiry, and a community scorecard was processed. Data triangulation was done by identifying and clubbing the responses from various tools under the themes/issues that were identified from the reference guidelines, documents and manuals consulted for developing the tools. Under each theme, questions and sub questions were developed and each question had an indicative response: Yes or No. In case of a negative response, the score given was zero and in case of a positive response, the scoring 5 P a g e

6 was one. Cumulative scoring was calculated for each of the themes and later percentage was calculated and colour coding was developed in order to obtain final results in the form of a traffic light. Reverse scoring was done in case of questions related to coercion. Thus, percentages were calculated for each of the indicators, 100 percent being the most desirable condition. For the purpose of translating the results into traffic lights, below 50 percent (poor) was put under red colour, results from percent (average) under yellow colour and results above 80 percent (good) were green coloured. The issues considered for preparing these report cards are enumerated in Table 4 and 5. Table 4: Issues for community report card Theme Client identification Counseling Information and choice Quality of services Follow up and management Coercion/incentives Source of Information 10 Focus Group Discussions, 50 user interviews 10 Focus Group Discussions, 50 user interviews 10 Focus Group Discussions, 50 user interviews 10 Focus Group Discussions, 50 user interviews 10 Focus Group Discussions, 50 user interviews 10 Focus Group Discussions, 50 user interviews Table 5: Issues for facility/provider report card Theme Source of Information Knowledge of methods MO Interview, Facility Checklist, ASHA Interviews Counseling and IEC MO Interview, Facility Checklist, ASHA Interviews Basket of options MO Interview, Facility Checklist, ASHA Interviews Facility preparedness MO Interview, Facility Checklist, ASHA Interviews Quality of clinical services MO Interview, Facility Checklist, ASHA Interviews Follow up and management MO Interview, Facility Checklist, ASHA Interviews Target/ Incentives MO Interview, Facility Checklist, ASHA Interviews 4. Findings Family Planning Users Interviewed (District wise) Table 6 and Figure 1 show the number of family planning users that were interviewed. Community meetings and focus group discussions were conducted in each of the five villages and interviews with the women contraceptive users (married women who have used or IUD, or contraceptive pill or sterilisation as a method of family planning) from were identified during the FGDs and also from the records maintained by ASHAs. Interviews were conducted with women users and women who are expected to be visited by service providers for family planning counselling and services in the district. Women Participating in Focus Group Discussion in Azamgarh District 6 P a g e

7 Table 6: Family planning users that were interviewed Districts Sterilisation IUD Oral Contraceptive Injectables Total Pills (Mala D) Azamgarh Citrakoot Chandauli Mirzapur Shrawasti Total users Major Findings -District Lack of Counseling and Information Sharing Across the five districts, sterilisation users reported that they were neither counseled about the side effects/ health problems that could occur due to sterilisation, nor were they informed about the family planning insurance scheme in case any health problem occurred after the operation. All of them related that they had not been counseled about any other method of family planning. Very few women reported that the consent forms of sterilisation operation were read out to them and they were Women Participating in a Focus Group Discussion in Chitrakoot made to understand what was written in them. The providers lack proper skills of counselling and also lack in skills of carrying out physical and pelvic examinations before insertion of IUD and sterilisation. In all the districts, family planning service providers never identify the newly married couples and also fail to understand the need of the newlyweds for spacing methods. They focus solely on women who already have two or more children. ASHAs never provide any detailed information on spacing methods except seterilisation. Information and Basket of Choice Across the five districts, the providers only gave emphasis on female sterilisations and other methods were not given as a choice to the community. ASHAs only share information related to sterilisation operation and they themselves were not aware about other family planning methods. Across the five districts, Unused Equipments lying in a PHC in Shrawasti many sterilisation users reported that that the consent form was not read out to them and no assistance was provided to understand what was written in the consent form. 7 P a g e

8 Follow-up Mechanism The follow-up mechanism after selection of a family planning method was reportedly very poor in all the districts. The women said that ASHAs did not pay visits after the selection of any family planning methods. ASHAs hardly came if the family planning users felt any discomfort after using any of the methods. Challenges and Gaps at Facility Level From the facility survey, it was found that the Primary Health Centres/ Community Health Centres were not well equipped to provide family planning services and no family planning counsellors were available in the PHCs across the five districts of Uttar Pradesh. There was lack of regular supply of family planning services to the facility. In all the five districts, it was found that there were no family planning counsellors at health service facilities. Lack of training on family planning among service providers was a major challenge in all the districts. District Level Jansamvad in Mirzapur 5. District Level Dialogues and Sharing During interview and district level public dialogues across five districts, the service providers accepted that there was lack of counselling from the providers side. The service providers also accepted that they only emphasised female sterilisations in order to meet the targets set by the State Government and that other spacing/family planning methods were not given as a choice to the community. The MOIC of Atraulia block CHC in Azamgarh district stated in the interview that they provided reward Participants in District Level Public Dialogue of Rs each to all the women who come for sterilisation operation after two children. ASHA and ANM reported that administration often failed to provide them with sufficient medical supplies and material to meet the family planning needs of the population they were catering to. In Shrawasti district, the National Rural Health Mission (NRHM) District Programme Manager said that he personally talked about family planning methods in the villages. He added that, the people were willing to have more than two children. The community did not want to listen when we provide information on different family planning methods he added. He also said that the government needs to appoint advisors/ counsellors for one to one counselling on family planning services. In District level sharing in Azamgarh district, the Upper Level Chief Medical Officer said that the couples should used spacing methods to avoid pregnancy at least for three years between first child and second child. He also added that Couple should delay their first child after marriage at least for three years. Women can use IUD as a spacing method In district level Jansamvad in Chitrakoot, the MOIC said This report has revealed some important findings that most often escape our notice. It is a serious situation that women are not taking oral 8 P a g e

9 contraceptives (Mala-D). I will now ensure that a family planning counselor is employed in the hospital to disseminate all this information. If women are facing problems in adopting family planning methods they can discuss their concerns with ASHA/ ANM in the village or else communicate the same to me. I will try my best to extend any help needed. In Mirzapur, the Deputy CMO said to address the issues and problems of family planning, it is necessary to create awareness. ASHA only works as a community link worker and is not trained to remove stitches after any surgery. ANM is responsible for that. We cannot drive a car without a driver. To make the community aware about the basket of family planning choices is essential and important and without creating awareness people will never use family planning methods. I can assure that my department will help in accessing the right kind of information on family planning methods. Many ASHAs stated that they did not distribute spacing methods in their village. From the interviews with users and FGD with community, it came out that ASHAs only tried to lay emphasis on female sterilisations. No other methods were given as a choice to the community. The highest number of family planning users had used sterilisation as a family planning method. ASHAs were never provided any demonstration kit of different family planning methods to demonstrate among community members. There was no Information Communication Board on family planning services in the PHC. Across the districts, regular supply of family planning services to the facility was found to be lacking. Across all the districts, women reported that ASHAs do not give information on family planning to the newly wed couples and they only provide information to those women who have more than two children. Health service providers accepted that the health system had been facing a dire lack of health staff and they had to provide different types of services by engaging limited number of staff. Though the wall painting is about spacing methods but the hidden agenda is reinforcing the Two Child Norm The below Table 7 and 8 show the state level score card and district wise findings of the community based monitoring to improve informed choice and quality of care of family planning: The score card is reinforcing community enquiry and service provider s enquiry findings. The findings from provider and facility observations clearly show that there is a strong gap in service delivery of family planning. 9 P a g e

10 The community enquiry and providers and facility enquiry process describe a similar kind of trend. The community data also shows there is little work done by providers to identify potential family planning users. 10 P a g e

11 Table 7: State level score card of Uttar Pradesh Indicators Districts Colours AZAMGAR H CHANDAU LI CHITRAKO OT MIRZAPUR SHRAWASTI RED YELLOW GREEN COMMUNITY ENQUIRY Client identification 13.8% 24.7% 8.3% 10% 7.2% Counseling 42.5% 12.2% 19.8% 14.6% 26.8% Information and Choice 74.6% 40.2% 37.2% 64.5% 57.46% Quality of Clinical 65.2% 36.6% 47.8% 69.6% 67.4% services Follow-Up Management 44.3% 6.9% 45% 7% 26.3% Element of Coercion 70.4% 50.7% 80.8% 10.4% 94.4% PROVIDERS AND FACILITY ENQUIRY Knowledge of Method 77.7% 45.7% 71.1% 59.7% 60.49% Counseling and IEC 77.3% 36% 68.8% 66.6% 74.6% Basket of Choice 70% 60% 60% 10% 100% Targets and Coercion 41.4% 70.3% 73.1% 20.4% 61% Facility Preparedness 66.6% 100% 83.3% 33.3% 100% Quality of Clinical 62.5% 40.3% 72.7% 73.5% 76.4% Services Follow-Up Management 72.7% 11.5% 72.7% 71.4% 91.6% Red <50% of cumulative score Poor Yellow 50-80% of cumulative score Average >80% of cumulative score Good 11 P a g e

12 Table 8: District-wise findings of the community monitoring process INDICA TORS AZAMGARH MIRZAPUR CHANDAULI CHITRAKOOT SHRAWASTI Counseli ng and Informati on Sharing None of the five IUD users were told about the problem side effects of IUD. Client identification has scored poor in Azamgarh, only 13.8%. Poor level of counseling is also reported. Poor level of counseling of users by family planning service providers. Counseling and client identification scored very poor in Mirzapur (14.6% in counseling and 10% in client identification). The community said that the ASHAs mostly provide information on sterilisation. One woman in Mirzapur told that ASHA did not pay a visit to her after the sterilisation operation to remove the stitches Women reported that ASHAs do not come to their villages regularly and ASHAs do not provide any information on family planning and contraceptive methods. There is a poor level of counseling of users by the family planning service providers. 19 out of 25 family planning users reported that they had been counseled for only one contraceptive method i.e. female sterilisation and two women respondents reported having been counseled for IUD use. Out of 25 family planning users, none of the women were told about the benefits of family Out of 29 family planning users, only nine were told about more than one family planning methods by ASHAs. Out of 22 sterilisation users, only 5 were informed and counseled about other family planning methods. None of the sterilisation users were counseled about the side effects/health problems that could occur after sterilisation operation. Out of 49 family planning users, only fifteen women were told about more than one family planning methods by ASHAs. Out of 18 sterilisation users, only 4 were counseled on other family planning methods. 12 P a g e

13 INDICA TORS AZAMGARH MIRZAPUR CHANDAULI CHITRAKOOT SHRAWASTI planning methods Informati on and Choice Husbands and ASHAs played major roles in motivating the women to use family planning methods. Out of 19 sterilization users only 3 reported that the consent form was read out to them. ASHAs only share information related to sterilisation and they try to influence women to go for sterilisation operation. None of the sterilisation users reported that the consent form was read out to them and that they were helped to understand what was written there. None of the users reported that the consent form was read out to her and that she was helped to understand what was written there ASHAs only share information related to sterilisation operation and they themselves were not aware about other family planning methods. Out of 22 sterilisation users, only 2 of the users reported that the consent form was read out to them Husbands play a major role in motivating the women to use family planning methods. The providers only tried to give emphasis on female sterilisations and other methods were not given as a choice to the community. ASHAs only share information related to sterilisation operation and they themselves were not aware about other family planning methods. Followup managem ent ASHAs do not pay regular visits after the selection of any family planning methods by the women. There is a very low follow-up mechanism from provider s side. ASHAs do not pay regular visits. ASHAs do not come if the family planning users feel any discomfort after using ASHAs do not come if the family planning users feel any discomfort after using any method. None of 18 sterilisation users were given the sterilisation 13 P a g e

14 INDICA TORS AZAMGARH MIRZAPUR CHANDAULI CHITRAKOOT SHRAWASTI ASHAs do not come if the family planning users feel any discomfort after using any method. None of the OCP users were told what they should do if they forget to have tablets by ASHAs None of seven IUD users were asked about any feeling of discomfort after the IUD insertion ASHAs do not come if the family planning users feel any discomfort. Family planning users were not informed about the family planning insurance scheme and about compensation in case any health problem occurs after sterilisation operation. None of the sterilisation users were given sterilisation certificates. any method. None of the family planning users were given the sterilisation certificate till the date of interview None of the IUD users had received any prescription or written slip describing the date of insertion and duration of the insertion. None of the sterilisation users reported that they had been informed about the family planning insurance scheme. None of them were given the sterilisation certificate. None of the OCP users were told what they should do if they forget to have tablets by ASHAs. certificate till the date of interview. None of the 27 OCP users were told what they should do if they forget to have tablets by ASHAs. Element of Coercion The service providers accepted that there is coercion for family planning The providers only tried to give emphasis on female sterilisations and other methods were not given as a choice to the community. The health service providers accepted that there were targets set for sterilisation operation and The providers only tried to give emphasis on female sterilisation. The health service providers accepted that there were targets for sterilisation operation. ASHAs accepted that they pressurised the women for sterilisation operation by repeated visits to the women s house. They also reported that they were scolded by ANM for Two, out of five ASHAs told that they pressurised the women for streilisation operation by repeated visits the women s house Medical Officer in- Charge accepted that they were given targets and they were also rewarded if they could fulfil the target. They had an annual target One sterilisation user said that she was forced to go for sterilisation by ASHA and another woman accepted that ASHA visited repeatedly to her house for sterilisation. Medical Officer in-charge accepted that they were given targets and they were also rewarded if they could fulfill the target. All the ASHAs were given targets to bring in sterilisation Medical Officer in- Charge accepted that they were given targets and they were also rewarded if they could fulfill the target. They had an annual target of 450 sterilisation cases. In one day the MOIC operates in sterilisation operation. 14 P a g e

15 INDICA TORS AZAMGARH MIRZAPUR CHANDAULI CHITRAKOOT SHRAWASTI Basket of Choice they promote female sterilisation. Medical Officer in-charge reported that they were given targets and they distribute the targets among health service providers to fulfil the targets. The MOIC stated in the interview, they provided reward of Rs each to all the women who come for sterilisation operation after two children. ASHAs also accepted they were forced to bring sterilisation cases by senior officials. Family planning service providers do not provide information on other family planning methods except on sterilisation. not bringing any case for sterilisation. Medical Officer in-charge accepted that they had an annual target of 1020 sterilisation cases. Most of the ASHA do not distribute contraceptive methods in the village. ASHAs were not heard many of the contraceptive methods themselves. of 431 sterilisation cases. In one day the MOIC operates in sterilisation operation. He also shared that, in year, there were total 870 women were sterilized in his hospital. There were 229 women were operated in one day. All the five ASHAs reported that they were given targets to bring in sterilisation cases. They were scolded by ANM for not bringing in case for sterilisation. None of the family planning users were counseled about other methods of family planning other than female sterilisation. cases. Two out of five ASHAs stated that they did not distribute spacing methods ASHAs only tried to give emphasis on female sterilisations. No other methods were given as a choice to the All the five ASHAs reported that they were given targets to bring in sterilisation cases. Very less number of sterilisation users was told about other methods of family planning. 15 P a g e

16 INDICA TORS AZAMGARH MIRZAPUR CHANDAULI CHITRAKOOT SHRAWASTI community. The highest number of family planning users had used sterilisation as a family planning method. Challeng es and Gaps at facility level There was no lady doctor and no Non-Scalpel Vasectomy (NSV) specialist was available in the PHC. There was no Information Communication board on family planning services in the PHC. There was no sign board on family planning methods in the PHC. There was a lack of staff to provide family planning services. There was separate room for the women to take rest after an operation. There was no proper storage system for contraceptive methods in the hospital. It was found that there was no family planning counselor in the PHC. There was no Non-Scalpel Vasectomy (NSV) specialist available in the Health Centre. MOIC accepted that lack of special surgeon on family planning operation is a huge problem. MOIC reported that many a times he had to send back women who come for sterilisation operation. No communication and information on family planning services in the PHC and no family planning councillor was available in the PHC. None of the family planning methods were available in the MOIC accepted that there is a lack of supply of basic facilities like gloves, etc. Lack of service providers on family planning methods is a huge problem. The MOIC also accepted that the hospital had to manage huge crowd in the out patients department during day time. MOIC accepted that none availability of family planning counselor was a biggest problem There was no lady doctor and no Non-Scalpel Vasectomy (NSV) specialist was available in the PHC. There was no Information Communication board on family planning services in the PHC. There was no regular supply of family planning services to the facility. MOIC accepted that lack of finance and training on family planning methods is a huge problem. The MOIC also accepted that there has been an issue of carelessness from health service provider s side.s 16 P a g e

17 INDICA TORS AZAMGARH MIRZAPUR CHANDAULI CHITRAKOOT SHRAWASTI Challeng es and Gaps at Providers Level There is no grievance redressal mechanism in the PHC. ASHAs were not provided any demonstration kit of different family planning methods to demonstrate among community members. MOIC accepted that he did not provide any special information related to female sterilisation to the women who come for sterilisation operation. PHC. ASHAs accepted that they did not provide any advice to the community on family planning. ASHAs were not given any demonstration kit on family planning. Only one ASHA was given training on family planning. ASHAs were never provided any demonstration kit of different family planning methods to demonstrate among community members. All the ASHAs were not given any training on family planning. Only three ASHAs said that they were ever provided any demonstration kit of different family planning methods to demonstrate among community members.. Only two ASHAs were ever provided any demonstration kit of different family planning methods to demonstrate among community members.. 17 P a g e

18 6. Conclusion Basically, family planning services are a matter of self choice and should be put into use through proper motivation and counseling and not as a matter of compulsion as there is dearth of staff and lack of family planning services. The health authorities admitted that there was a need for good Information Education and Communication (IEC) services related to family planning. In district level Jansamvad, service providers accepted that they should be trained on family planning counseling and how to provide proper information to the users. District wise data says that a very few ASHAs were trained on family planning. Proper counselling with informed choice and strong follow-up mechanism should be an integral part of family planning services. Though these criteria are mentioned in family planning guidelines but there is no evidence that these are followed in field level implementation. 18 P a g e

19 ANNEXURE 19 P a g e

20 Media Coverage on District Level Public Dialogues 20 P a g e