This study looked at what barriers to accessing SRH services exist at both the supply- and demand side in the public, private and PNFP sectors and what ought to be done to improve the situation, from the perspective of HCWs. It found that some significant differences existed in perspectives of HCWs across the different sectors, even though in general many barriers were cross-cutting. One of the most commonly raised barriers to accessing SRH services was patient lack of knowledge. Issues with supply of commodities and frequent stockouts were often raised in the public sector. Patient costs were a significant barrier in the private and PNFP sectors, and religious and cultural beliefs were commonly mentioned in the PNFP sector. HCWs in all sectors mentioned delay in delivery of supplies as main reason for stockouts, with affordability of commodities being a significant problem in the private and PNFP sectors. Further, HCWs believed that clients were often reluctant to access SRH services, caused by fear of stigmatisation, their lack of knowledge, myths and superstitions, religious beliefs, and fear of side effects. Main recommendations to improve access were similar across the sectors and in line with the raised barriers.
Patient lack of knowledge about SRH and SRH services, raised as a main challenge by HCWs across the sectors, is an often-raised barrier to accessing SRH services [24,25,26,27]. Related to this, HCWs believed that clients’ reluctance to access SRH services was caused for a large part by their lack of knowledge, as well as myths or superstitions, and fear of side effects. Again, this has been well-documented elsewhere, and has been perceived by both HCWs and clients themselves as barriers [14, 25, 27,28,29]. Thus, more should be done to improve clients’ knowledge about SRH services and commodities, including on offered services, on how to properly use certain commodities (e.g. condoms), and on true side effects of commodities (e.g. the birth control pill). This because many misunderstandings persist, including that contraceptives cause infertility [14, 28, 29]. However, research has shown that only tackling client knowledge may only have a limited effect on health-seeking behaviour [24, 25]. A multi-pronged approach is thus needed, tackling the other factors which also influence access to SRH services.
For instance, religious and cultural beliefs were also seen as one of the key challenges to accessing SRH services. Especially in the PNFP sector, which in these countries constitutes for the most part faith-based facilities, it seemed to negatively impact access. HCWs in this sector who indicated they were at times unable to provide clients with SRH services gave as most common reasons that the service was not culturally or religiously acceptable and that the health facility did not offer family planning services. These arguments were both much less relevant across the other sectors.
Research has shown that adolescents saw unsupportive attitudes from HCWs as a major barrier to access to SRH services. In contrast, the HCWs themselves did not think their attitudes interfered with the use of services among adolescents [26]. In other studies, however, HCWs did recognise that HCWs’ negative attitudes impacted access [19, 30]. Previous research has shown that some HCWs might be reluctant to provide family planning services because they believe the use of any type of contraceptive is inappropriate, especially to adolescents or unmarried women and girls [14, 18, 19]. Our study found that HCWs who work at PNFP sector facilities acknowledge that religious beliefs form a barrier to access to SRH services. Many Catholic health facilities in the four countries also do not provide contraceptives, with the exception of condoms, which forms a significant issue for those dependent on these facilities for their healthcare services [31, 32]. HCWs, especially those in PNFP sector facilities, are an important group to target for continuous education. Improvements in their knowledge and attitudes will improve access to services [33]. Secondly, engaging them in campaigns with civil society and communities to fulfil a more activist role can be a powerful tool to improve access [34].
Next to knowledge and attitudinal barriers, this study also highlighted the high costs of care to patients in the private and PNFP sectors. This finding is not surprising, as out-of-pocket health expenditure in the countries ranges from 10% of all health expenditure in Zambia, to 38% of all health expenditure in Uganda [35]. In sub-Saharan Africa, many countries are focusing on attaining universal health coverage (UHC). They often establish public-private partnerships (PPPs), through which the government collaborates with the private sector to provide health services [36]. As part of these PPPs, countries are implementing prepayment health financing schemes such as social insurance or national health insurance (NHI). Members of such schemes pay a fee which allows them to access care at private facilities for ‘free’, with private facilities reimbursed for the care provided [37]. However, rollout of NHI schemes differs across the four countries. About 15% and 30% of Kenya’s and Tanzania’s population is covered by such a scheme, while in Zambia, as of October 2021, only 191 of 1956 registered health facilities had been accredited. Uganda has no NHI in existence yet [8, 38,39,40,41].
PPPs and NHI can be useful tools to reduce costs for clients and improve access to medicines when it is functioning well and has a high population coverage [42,43,44].However, at the moment many bottlenecks exist in the two study countries where NHI has been implemented for a longer time that limit its potential. Premiums paid by the insured are unaffordable to parts of the population, stockouts or lack of commodities at facilities force clients to buy out-of-pocket at non-accredited facilities, shortages of HCWs affect quality of services, a pro-urban distribution of health facilities results in clients needing to travel long distances to accredited facilities in rural areas, and delays in provider reimbursement by the NHI scheme result in co-payments by clients, denial or limiting of services, and long waiting times [39, 40, 45, 46]. To fulfil its potential, governments ought to focus on tackling these bottlenecks.
Logistical problems were also raised by the HCWs as causing significant challenges. These included issues with supply to the facility as well as stockouts, which were said to be caused by delays in deliveries, incorrect orders and deliveries, and problems with the stock at the medical stores. Problems with stockouts have also been identified previously in the four countries [14, 18, 20, 47]. Strengthening the supply chain systems should be one of the main priorities of the countries’ governments. Stockouts can be prevented, or at least minimised, with a well-functioning logistic management information system, staff trained in supply chain management, and sufficient budget allocations to commodity procurement [48].
It is important to note that not only barriers at the provider or supply chain level influence commodity availability and stockouts; they are also influenced by global forces. For instance, sufficient budget allocations to commodity procurement are dependent on the health budget available. These budgets are still dependent on donor funding, making them vulnerable to the whims of donors, and challenging sustainable programme implementation [49,50,51,52]. This is especially the case as over the past years, the countries have seen a decrease in this type of funding [49,50,51,52]. In Kenya, for example, donor funding made up 33% of the health budget in financial year 2017/18, which decreased to 16% in financial year 2019/20 [53]. Even though the government has increased their own spending on the health budget, it has been inadequate to offset the decrease in donor aid [53]. Further, the global gag rule re-instated and expanded during President Trump’s presidency had far-reaching consequences on access to SRH services far beyond abortion care. In Uganda, for instance, organisations that had lost funding due to the global gag rule were forced to scale down or close down community sensitisation programmes on family planning, outreach services focusing on long-term contraceptives, and health facility collaborations on family planning with community health workers [54]. Another organisation had to shut one of their health facilities due to the lost funding [54]. Last, preferences of international development organisations and donors also impact the availability of commodities. The female condom, for example, invented in 1984, has for decades been met with scepticism and neglect by international development organisations and donors. They referenced a lack of user demand and high prices, resulting in lack of rollout at the national level and subsequent low availability [55]. To offset the impact of global forces and decrease the dependency on donor aid, and ensure sustainable and improved access to SRH services, the governments ought to increasingly and continuously invest in their health systems.
