Overcoming Barriers to Effective Anemia Interventions during Antenatal Services in Uganda

41 Pages·2004·0.21 MB·English

Overcoming Barriers to Effective
Anemia Interventions during
Antenatal Services in Uganda
This is a publication of the Regional Centre for Quality of Health Care (RCQHC)
and the MOST project. It was made possible through support provided by the
Office of Health, Infectious Diseases and Nutrition, of the Bureau for Global
Health, U.S. Agency for International Development (USAID). The International
Science and Technology Institute, Inc. (ISTI) manages the MOST project under
the terms of Cooperative Agreement No. HRN-A-00-98-0047-00. MOST partners
are the Academy for Educational Development (AED), Helen Keller International
(HKI), the International Food Policy Research Institute (IFPRI), and Johns Hopkins
University (JHU). Resource institutions are CARE, the International Executive
Service Corps (IESC), Population Services International (PSI), the Program for
Appropriate Technology in Health (PATH), and Save the Children.
The RCQHC is a regional quality of health care capacity development institution
that is largely supported by the Regional Economic Development Service Office/
East and Southern Africa (REDSO/ESA) in Nairobi, and the Makerere University in
Kampala.
The opinions expressed herein are those of the author(s) and do not necessarily
reflect the views of USAID, of MOST, or of the RCQHC.
December 2002
For copies of this report, please contact:
RCQHC
c/o IPH Makerere,
P. O. Box 7072
Kampala, Uganda
Tel: [phone], 530321
Fax: [phone]
E-mail: [email protected]
Download the file from
www.RCQHC.org or
www.MOSTproject.org.
Overcoming Barriers
to Effective Maternal Anemia Interventions
during Antenatal Services in Uganda
D e c e m b e r 2 0 0 2
Robert K. N. Mwadime
Nutrition and Child Survival Advisor, AED/Regional Centre for Quality of Health Care, Kampala, Uganda
Philip W. J. Harvey
Nutritionist, MOST, The USAID Micronutrient Program, Arlington, Virginia, and the Johns Hopkins
Bloomberg School of Public Health, Baltimore, Maryland, USA
Sarah Naikoba
Child Health Advisor, Regional Centre for Quality of Health Care, Kampala, Uganda
Louise Sserujongi
Nutritionist, Child Health Development Project, Makerere, and MOST Coordinator in Uganda
Hanifa Bachou
Medical Officer Mwanamungimu Nutrition Centre, Mulago Hospital, Kampala, Uganda
Loyce Arinaitwe
Coordinator of the Anemia Project, Regional Centre for Quality of Health Care, Kampala, Uganda
Wamuyu G. Maina
Consultant and Lecturer, Kyambogo University, Kampala, Uganda
Acknowledgements
The research described in this publication was strongly supported by the Reproductive and Child
Health Divisions of the Ministry of Health in Uganda. Specifically, we would like to acknowledge
the technical and moral support provided by Drs. Florence Ebanyat and Anthony. K. Mbonye
from the Reproductive Health Division and Dr. A.L. Abongomera and Ms. Usula Wangwe from
the Child Health Division. We also acknowledge the technical inputs that Dr. Alice Mutungi, the
RCQHC Reproductive Health Advisor, provided.
A number of districts and people contributed to the development of this publication. We
appreciate the technical input and support provided by Dr. Sara Byakiika of Jinja Hospital and
the district directors of health services from Apac, Kumi, Mukono, and Ssembabule districts.
Specifically, we would like to thank Dr. Felix Ocom, District Director of Health Services in Kumi,
for the facilitation he provided in the operations of district activities. We would also like to thank
the district staff that participated and contributed in the data collection at various stages of the
research. Finally, we appreciate the technical and administrative support that the RCQHC staff
provided.
Table of Contents and Acronyms
Table of Contents
Acronyms ii
Executive Summary iii
Introduction 1
Background 1
Effectiveness of National Anemia Programs 1
Anemia in Uganda 2
Study Objectives 3
Methodology 4
The Study Districts 4
Assessment Framework 6
Setting a Stakeholder Advisory Group 7
Defining the Desired Performance 7
Measuring the Actual Performance 7
Identifying Performance Gaps and Determining the Root Causes 9
Selecting Performance Improvement Interventions 10
Results 11
Characteristics of Study Facilities and Health Workers Interviewed 11
Characteristics of Respondents in the Exit Interviews 11
Accessibility To and Use of ANC Services 12
Iron and Folic Acid Supplementation 18
Other Critical Actions to Control Anemia in Pregnancy 22
Discussion and Conclusions 25
Recommendations 27
Systems Level (District and MOH) 27
ANC Health Provider Level 28
Community Level (client/pregnant woman) 29
Literature Reviewed 30
Appendix: Factors influencing women’s supplementation behavior 30
Overcoming Barriers to Effective Anemia Interventions during Antenatal Services in Uganda i
Table of Contents and Acronyms
Acronyms
AIDS Acquired immunological deficiency syndrome
ANC Antenatal care
ARV Anti-retrovirals
DDHS District Director of Health Services
DHT District health team
DISH II Delivery of Improved Services Project
FAO Food and Agricultural Organization
FGD Focus group discussion
HIV Human immune deficiency virus
HMIS Health management information System
HSD Health sub-district
IDA Iron deficiency anemia
IEC Information, education and communication
IMCI Integrated management of childhood illness
ITNs Insecticide-treated bed nets
MOH Ministry of Health
MTCT Mother-to-child-transmission of HIV
NGO Non-governmental organization
PMTCT Prevention of mother-to-child-transmission of HIV
QOC-CPI Quality of Care-Client Provider Interaction Study
RCQHC Regional Centre for Quality of Health Care
REDSO USAID Regional Economic Development Support Office
for East and Southern Africa
TB Tuberculosis
TBA Traditional birth attendant
TIPs Trials of improved practices
UDHS Uganda Demographic and Health Survey
UGAN Uganda Action for Nutrition
UNICEF United Nations Children’s Fund
USAID United States Agency for International Development
WHO World Health Organization
VCT Voluntary counseling and testing
ii MOST The USAID Micronutrient Program
Executive Summary
Executive Summary
A
nemia is a widespread problem in Uganda, adversely affecting four out of every ten
pregnant women. The main strategies of controlling anemia in pregnancy are provided
during facility-based antenatal care (ANC). Previously, iron/folate supplementation was
often seen as the primary approach to anemia control. Over the last few years, however, it has
been recognized increasingly that anemia will be controlled more effectively by addressing its
major causes, such as malaria and intestinal worms as well as iron deficiency. Furthermore, the
effectiveness of a) intermittent preventive treatment (IPT) and insecticide-treated bed nets (ITNs)
in controlling malaria and b) using antihelminthics in treating hookworm infections have been
firmly established.
The Regional Centre for Quality of Health Care (RCQHC), the Ministry of Health (MOH),
and MOST, the USAID Micronutrient Project, collaborated in assessing specific local barriers to
integrating the implementation of these three interventions as part of a revised ANC approach to
anemia. This formative assessment used the performance improvement framework to determine
the district health system’s capacity to implement an integrated approach to anemia and other
constraints that limit the effectiveness of anemia control during pregnancy. The first step was
defining the desired performance—actions needed to control anemia through ANC contacts—
then actual performance was assessed.
The fieldwork to assess actual performance was undertaken in four districts with eight health
facilities that were selected to represent both government and non-governmental organization
(NGO) services. Qualitative and quantitative data collection methods were used; these included
focus group discussions (FGDs) with district health teams (DHTs), in-depth interviews with
managers of the health facilities and the officers in charge of ANC services, and interviews
with clients immediately after receiving ANC service. Inventory checklists were used to assess
supplies in the facilities. All interview guides and checklists were developed from instruments
used previously in Uganda. Enumerators and supervisors from each study district were recruited
from the health services from each district and given five days of training. After pre-testing the
instruments in a district not involved in the study, the enumerators worked in pairs and spent a
full day in each facility.
The fieldwork results were validated through meetings held with district health teams and
national experts. Together with experts and stakeholders at the district and national levels, the
root causes of the barriers to effective anemia programs were identified and solutions to them
recommended.
The results were summarized at the health system, health provider, and client levels.
At the health system level
(cid:1) The number of days each week that the facilities provided ANC services varied between
districts and also within districts, depending on the facility level concerned. In over 40%
of the facilities, ANC services were provided only one or two days a week, in many cases
limiting client access to services.
Overcoming Barriers to Effective Anemia Interventions during Antenatal Services in Uganda iii
Executive Summary
(cid:1) Most facilities had “enough” ferrous (cid:1) Group health talks were often given as a
sulfate/folic acid (IFA) only 50% of the component of ANC clinics, but overall,
time over the previous three months. about one-third of women reported not
Because of this inconsistent supply, having understood most of what was
providers tended to “save” supplies by discussed.
not providing it to all pregnant women
(cid:1) Despite the above findings, most clients
and/or dispensing tablets for less than
reported that the ANC services they
the required number of days.
received were adequate in quality.
(cid:1) Although almost all health units reported Almost 80% complained of long waiting
that they were providing the ANC times, but said that they did not mind
package recommended in the National this as long as they received the services
Reproductive Health Guidelines, only 9% and the “medicines” they expected.
of the ANC providers interviewed were
aware of the existence of the guidelines. At the client level
(cid:1) ANC providers considered the number of (cid:1) On average, there were four ANC visits
supervisory visits to be inadequate. per pregnancy, but very few women
attended ANC in their first trimester.
At the ANC provider level (cid:1) 60% of the women in the exit interviews
had attended an ANC clinic previously
(cid:1) The implementation of the guidelines
for their current pregnancy and been
was inconsistent both between and
given IFA. Of these, two-thirds reported
within districts, e.g., the dose of
having finished all the tablets given
iron supplements provided solely for
them. It was a little surprising that few
prevention varied from one to three
clients expressed any concern about
tablets per day.
taking iron supplements.
(cid:1) Although most health facilities reported (cid:1) Receiving an ANC card was the primary
routinely controlling malaria and
reason for going to the clinic for most
hookworm, these services were not often
women. This card was required if
observed in this study. 48% of the clients
women wanted to access emergency
reported receiving antimalarials on the
services during the pregnancy or delivery.
current or the previous ANC visit, and a
Delivering in the health facilities was not
similar percentage reported being asked
seen as desirable in some communities.
about malaria symptoms. Almost two-
41% of women reported attending
thirds of the facilities reported conducting
a clinic after experiencing a specific
routine de-worming, but of the women
problem rather then for “preventive”
interviewed in their third trimester, only
reasons.
14% had ANC cards recording such
The root causes of barriers to the effectiveness
treatment.
of anemia services provided through ANC
(cid:1) Counseling provided to ANC clients was
programs concur with what was reported
of uneven quality. While most were
previously. The barriers include: inadequate
told of the iron dosage to take, fewer
logistics, late and infrequent use of antenatal
than 10% were warned of potential side
services, and a lack of awareness among
effects or how to deal with them. Half
pregnant women of the benefits of using ANC
the women were not told of the benefits
services and of reducing their anemia. The
of malaria control during pregnancy.
causes are associated with factors operating at
iv MOST The USAID Micronutrient Program
Executive Summary
the health systems, health worker, and client The findings emphasize that urgent actions
levels. Some other findings may have been must be taken to improve logistics and health
less commonly reported. For example, there worker performance (“pull effect”), and to
were huge differences in the dosages of iron create demand among pregnant women for the
provided to women to prevent anemia, and ANC services (“push effect”). In the absence
the side effects from taking iron were rarely of such actions, community-based alternatives
reported as a major reason for not complying to existing facility-based ANC services should
with the daily regimen. be developed as a means of controlling anemia
among pregnant women in Uganda.
Overcoming Barriers to Effective Anemia Interventions during Antenatal Services in Uganda v
This report describes the process and results of a study
undertaken to identify barriers to implementation of
effective interventions aimed at addressing anemia
in pregnancy. The study was conducted in four
districts in Uganda in 2001-2002. The study findings
will be used to develop strategies for improving
the implementation of effective interventions for
addressing anemia in pregnancy at the district level.