Table 4

Client and community leader perspectives on improvements and challenges amid SSDI-PBI

Perceptions of facilitiesCommunity leader and client quotes
Facility looks nicer (curtains, cleanliness)Women feel more comfortable and welcome in facility spaces.
"The place is just clean. Cleaner than before… Yes, we are very happy with the changes because we have now things happening which were not happening like our hospital is now well taken care of—for instance the painting it has been a long time since they had last painted the walls.” - FGD mothers, facility 17
Facility has improved infrastructure (clean toilets, in-house labs, dedicated maternity wings)Women have greater confidence that the facility is prepared to provide care, and they enjoy privacy while giving birth.
“Just look at those new toilets. So clean!” - FGD mothers, facility 7
More community outreach/engagement by providers with community directly and with health advisory committees, and via antenatal care outreach clinicsCommunity leaders appreciate having a better-defined role in promoting access to care in their communities;
Women welcome information that helps them seek care in a timely and effective fashion.
"In the past community would not have ownership and were thinking that the facility is for government and there were not caring for it. After civic education, community is now aware that the facility belongs to them. When the chiefs or politicians ask them (community members) to do something like moulding bricks they do because they own the facility” - FGD leaders, facility 2
"… many things have been implemented. In the communities, there are committees that are working with chiefs … indeed there are women who are working in communities to enhance women to start antenatal care when they are pregnant” - FGD leaders, facility 9
"… outreach clinicians came to me after my child was born and educated me on antenatal care and its advantages… They encouraged us to go for regular check-ups … so that we prevent complications … so that we save our lives and the lives of our children.” - FGD mothers, facility 10
PBI facilities seem to have more drugs (especially paracetamol)"…The drug consignments are coming in good intervals, so it’s like here at facility 11 we are not running out of drug stocks for long.” – FGD leaders, facility 11
Impression of enhanced desire to seek services (ANC, HIV, maternal health programs generally)"Through this PBI programme more children are being vaccinated to reach the target, and there is more outreach being done compared in the past, and women are encouraged to be delivering at the facility, so we also did something on this that when a pregnant woman visits ANC, she receives a basin and those who have delivered at the facility receive a piece of cloth (chitenje). So this is all done because of the PBI programme, which is making us work so hard in order to win more money at our facility! As the result the population of families coming to this facility has greatly increased most especially pregnant women compared with the past.” - FGD leaders, facility 12
"PBI has taught us a lot. Our families are now going to the health facility together as a family for HIV testing and also encouraged to avoid maternal death.” - FGD leaders, facility 13
More equipment and materials (blood pressure machines, motorcycles, uniforms, computers, bed nets, lawnmowers)"Of course … we like these changes… Yes, when you deliver at the postnatal ward, now there are mattresses, so at least we are sleeping on mattresses.” - FGD mothers, facility 11
"This year has brought good things like water. We are happy about it because… we don’t have to go to the river to wash. We can wash here.” - FGD mothers, facility 17
Distribution of items (mosquito nets) to pregnant mothers"In just this past year, they've really been telling us about mosquitoes, giving us nets after we deliver our babies (women nod heads in agreement, smiling)” - FGD mothers, facility 13
More reliable operating hours"In the past years, the health providers would only attend to those clients who would come in the morning hours only, all those who came after lunch would be sent back and told to come the following morning but now these years, even a client who comes after lunch, they are attended to.” - FGD leaders, facility 5
"…even the way the services are being provided at the facility, the services are now being provided in good time, even if there may be a huge number of clients, but they are being attended to in time.” - FGD leaders, facility 10
Providers ‘forced’ to be nicer to clients"These days, it's like they want to help us very well unlike before where people used to complain a lot, and providers would take their time in attending to us…They are now listening to us and when they have the medicines they give them faithfully… This is very, very welcome for us.” - FGD mothers, facility 8
“We are very happy because the providers treat us well now.” - FGD mothers, facility 15
“It's since 2015… (the nurses) have been receiving us so nicely, explaining things so nicely, welcoming us with openness” - FGD mothers, facility 1
Challenges unchanged
Chronic drug and supply shortages—pregnancy test kits not available during early ANC, iron tablets often out of stock, essential items not available in-house during delivery"So when we are going to deliver our babies, we still even now we need to carry our own razor blades, candle, plastic papers, threads. We are always told not to forget these things.” - FGD mothers, facility 8
"…there are no drugs – when you are sick and you go for treatment you are told that there are no drugs. When our children are sick of malaria and we go to seek for medical attention we are being told that they are no drugs for malaria and we are stranded when we are told like that and they give us a prescription so that we go and buy from a private hospital, and we are saying that if we came to this hospital it means that we cannot afford the private hospital!” - FGD mothers, facility 4
Challenges in geographical access not overcome"…because the big hospital is the (District 3) district hospital, which is far from here … sometimes a pregnant woman may start bleeding and call the ambulance …(but) it’s not here, it’s … somewhere else.” - FGD community leaders, facility 13
Challenges created or exacerbated
Men being encouraged to accompany women for services; to be attentive to women's health issues/messages"The problem is… men are not interested. They are not interested in family planning they want women bearing children now and again… Men are not accepting to come with their wives… to have their wives on family planning.” - FGD mothers, facility 1
“Why can't the doctor talk to our men directly? Teach our men directly.” - FGD mothers, facility 8
Inadequate staffing, overworked/ tired/ stressed providersWomen sympathise with some staff who have problems delivering quality care under greater pressure, but are reticent to return to facilities/ providers who resort to disrespectful care when under such stress
"As you understand that each person has time to rest so this is also causing the health worker to be harsh when attending patients because of tiredness. For instance, being the only health worker at the facility is a problem … same person work the whole day without resting but during night is also called to attend to a patient. Sometimes the health worker tell us not to call him for assistance because he is tired wants to sleep” - FGD Leaders, facility 16
“Sometimes, they just have no more patience. And then they just, they shout at us.” - FGD mothers, facility 13
"We deliver (in the facility) because if we deliver at home we are charged a fine. We are scared to pay the fine. But when we delivery here, we are ignored and we suffer.” - FGD mothers, facility 11
"Most of the times the nurses do not respond to our call immediately and we are not closely monitored and assisted but we know that during this time its when we need the nurse most because anything can happen even complications may arise. Most of the times we received insults for only asking for their help so we are very concerned because of the treatment we are receiving at District 2 District Hospital especially in maternity has resulted in some mothers and babies dying.” - FGD mothers, facility 4
"…this baby (points to 1-month-old), I delivered at the hospital but instead of them welcoming me they were busy with their phones and when I tried to call the nurses they were just shouting at me … we are begging then to have mercy on us. " - FGD mothers, facility 4
Overcrowding in facilities and inadequate facilities (especially labour wards)Women shared beds with other maternity clients after delivery. Clients screened for HIV did not have a private space for consultations. Waiting times were longer.
"The biggest problem is the labour ward. It is still small, and we heard that the maternity section will be extended but up to now nothing has been done, and the problems of space are still there. There are some women are delivering on the floor.” - FGD mothers, facility 8
“Women are delivering their babies on the floor.” - FGD mothers, facility 11
"… health workers are not enough…we usually wait for long hours before receiving care. Normally we wait from morning up to afternoon hours without assisted. This is because there is only one person who attends out patients.” - FGD Leaders, facility 7
  • ANC, antenatal care; FGD, focus group discussion; PBI, performance based incentives; SSDI-PBI, Support for Service Delivery Integration - Performance-Based Incentives.