What clients say about private sector reproductive health services
Findings from an exit interview service among clients attending services provided by Marie Stopes Sierra Leone in 2013.
Addressing issues related to quality of reproductive health care is vital to encourage individuals to use health services and to maintain and increase coverage if progress is to be made in improving maternal survival.
This research briefing shares findings from a survey among clients exiting health services provided by Marie Stopes Sierra Leone. It offers recommendations to translate the findings into action to improve quality of care.
Marie Stopes Sierra Leone is one of the leading organisations in sexual and reproductive health (SRH) in Sierra Leone providing, for example, almost 50% of all family planning services across the country.
Marie Stopes has seen significant increases in update of family planning through its services, contributing to the doubling in uptake of modern family planning methods between 2008 and 2013 [i], [ii]. Marie Stopes services are delivered through ten static sites with 13 outreach teams who together, cover more than 2,000 harder to reach sites across the country. In addition, Marie Stopes have 25 social franchises under the ‘Blue Star’ brand.
Despite increases in the uptake of reproductive health services, health outcomes remain poor; the maternal mortality ratio notably, remains high at 1,100 per 100,000 live births [iii].
The need to ensure quality of care is key to ensuring sustained and high uptake of services.
One of the ways in which Marie Stopes does this is to ensure the experiences and ideas of their clients feed into the design of their services through exit interviews with clients.
The objective of the quantitative 2013 client exit survey [iv] presented here was to identify whether target groups are being reached and to understand how service design and delivery can better meeting the needs of clients and potential clients.
Clients were sampled from all static sites and social franchises and from 38 of the outreach site over three consecutive days in November 2013.
Ethics approval was granted from the Ministry of Health and Sanitation in Sierra Leone. A total of 436 clients took part in the survey which took place in November 2013.
A standardised questionnaire used across Marie Stopes International asked clients about their demographic profile, socio-demographic data, details of what services our clients were received on the day of the survey, their satisfaction with different aspects of the services, and information on marketing strategies.
Few men attend services: The vast majority of clients (one out of 10) were female.
Marie Stopes is successfully targeting youths and those with lower education levels: More than six out of 10 clients were 19 years or younger and the median age of clients was 23. Close to half of all clients had no formal education or have not completed primary education. In total, 44% had no or only some primary education and unsurprisingly, the proportion was higher among clients of outreach centres (46%) compared to static sites (24%) and social franchises (28%). Many clients were students at the time of the study.
Reaching the under-served
Outreach services enable greater accessibility to those living in rural locations. On average, clients accessing outreach spent less time (seven minutes) travelling to access MSSL services than those accessing static clinics (30 minutes). and social franchises (10 minutes).
Those living in poverty are accessing Maire Stopes services, especially those living in more rural areas: across all sites, more than four out of every 10 of clients live on under $25 USD a day. This proportion is higher among clients at outreach sites (45%) than those in static sites and social franchises (29 and 26% respectively) which are based in more urban settings.
Marie Stopes is providing affordable and accessible services, and greater choice: overall, three out of every 10 clients would have had further to travel for services if it was not for MSSL and almost 15% said that alternative services were more costly. In total, one of ten clients said that they would not be able to access any method or get their family planning method of choice were it not for MSSL.
Choice of family planning method
Of all services offered by Marie Stopes, the vast majority of clients attended for family planning services. Of these, the most popular commodities accessed were injections and implants. Across all service types, injectable contraceptives were the most popular with over a third of all clients choosing this method (36%), followed by a quarter of clients choosing implants (24%) and a fifth choosing oral contraception (18%).
Twice as many clients at static centres chose injectables (59%) compared to clients at outreach and social franchises (29% and 26% respectively).
Implants were selected amongst as many clients at outreach and social franchises as chose injectables, whereas only around a tenth (13%) of static centre clients chose implants.
Client satisfaction and quality of care
Satisfying clients: Almost nine out of 10 clients at Marie Stopes services were people who had continued using a method of family planning provided previously by Marie Stopes and more than nine out of 10 received their method of choice; this suggests that clients are happy with the service they receive as they return to Marie Stopes subsequently.
Supporting this,almost all (over 99%) of respondents would recommend Marie Stopes services to a friend; almost all would return for another service and nine out of every ten clients reported that their experience met or exceeded their expectations.
Static sites score more highly than outreach and franchises for components of quality: Overall, 83% clients were satisfied or very satisfied with their overall experience. More clients who used static and outreach facilities reported higher levels of satisfaction (66% and 86% respectively). However, less than half (46%) of social franchise clients - where Marie Stopes have less direct control over quality - stated this level of satisfaction. Specifically;
- Cleanliness, Privacy and advice and information were ranked the highest components of quality at static sites.
- Lower cost of services is preferred: Outreach services are subsidised and this is reflected in the more pronounced satisfaction among outreach clients where eight out of every 10 clients (80%) expressed satisfaction compared to almost half (46%) of clients at static clinics and a third (36%) of clients at social franchises.
- Waiting time was the most common complain at static centres and social franchises, privacy was the most common complaint at outreach.
Clarity on follow up information: Almost all clients reported receiving clear instructions as to where to go if they had any problems at all sites (93%, 97% and 98% among clients at static sites, social franchise and outreach clients respectively).
The power of radio: according to the exit interview data, the most common types of media used by clients were radio supporting the continued use of radio as a marketing medium, followed by television. Very few had access to the internet and few (four per cent or less) had read newspapers or magazines. [*]
Potential for mobile phone technology: 63% of all clients reported owning a mobile phone, in high proportions among clients from all service types (46% among users of outreach, 76% of static clinic and 80% of social franchise users).
The power of interpersonal communication: more than four of every ten clients at all service delivery types reported receiving information from someone who had used a Marie Stopes service before. This supports the assertion from another Marie Stopes study that found that peers are a favoured source of information on reproductive health matters [v].
Translating evidence to action
Based on the findings from this study, the following actions have been identified:
- To ensure sustained targeting of adolescents and young people, expand behaviour change communication activities to schools; strengthen collaboration with School Health Services in supporting strong sexual health and reproductive health rights.
- Ensure services are accessible to men; review communication strategies to address male clients and promote couple counselling for family planning advice and information.
- Review client flow patterns, human resource profiles and attendance data to assess if efficiencies can be made to reduce waiting times; explore potential to maximse waiting time to strengthen interventions or to reduce waiting time (e.g. developing software to enable access to information or facilitate decision-making).
- Resources should focus radio as a medium for marketing and information. As digital and mobile media use increases across the country, future surveys should dissaggregate TV, radio and internet.
[*] Note: Information on TV, radio and internet was not collected separately; however, a separate question determined that in the 2 week prior to the survey, radio was by far the most common source of media used among 77% of all clients, compared to only ≤2% who used the internet among clients at each service delivery type, and 19% who used TV (lower among outreach and social franchise clients compared to static clinic clients – 8%, 13% and 42%, respectively ).
[i] Statistics Sierra Leone, Measure DHS, and ICF Macro. (2014). Demographic and Health Survey 2013: Preliminary Report. Freetown and Rockville: SSL, MEASURE DHS, and ICF Macro.
[ii] Evidence for Action. (2014). MamaYe Facts and Figures on the Sierra Leone Demographic and Health Survey 2013. London: Evidence for Action.
[iii] World Health Organization, UNICEF, UNFPA, the World Bank and the United Nations Population Division.(2014). Trends in Maternal Mortality: 1990 – 2013. Estimates by WHO, UNICEF, UNFPA, the World Bank and the United Nations Population Division
[iv] Marie Stopes Sierra Leone (2013) MSSL 2013 Client Exit Interview Report. Freetown: Marie Stopes Sierra Leone.
[v] Nam, S.L., Juana, S., Missah, T., Brown, E. & Grellier, R. (2013). Qualitative Research to Improve Health Services to Prevent and Manage Unwanted Pregnancies. Kabala, Koinadugu District, Sierra Leone. Results from a PEER Study, February 2013. London: Options and Marie Stopes Sierra Leone.Evidence for Action (2014) Research briefing: What clients say about private sector reproductive health services. London: Evidence for Action.