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USAID-DFID NGO Health Service Delivery Project
Surjer Hashi Network Clients’ Satisfaction Assessment Report
Pathfinder International
ARMM Kamal, Community Mobilization Advisor
October 2017
English
Contract AID-388-C-13-00002
Contracting Officer’s Representative: Brenda Doe
This publication was produced for review by the United States Agency for International Development. It was
prepared by Pathfinder International.
USAID-UKAID NHSDP SH Network Clients’ Satisfaction Assessment Report 2017, DEVCARE LTD
USAID-UKAID NGOs Health Service Delivery Project (NHSDP)
Surjer Hashi Network Clients’ Satisfaction
Assessment Report
September 2017
DEVCARE LIMITED Kalpona Sundor: A-2, 13/14 Babor Road (Block-B), Mohammadpur, Dhaka 1207, Bangladesh
Tel. +(8802) 58151983 (land), +8801712519562 (cell), Email: [email protected]
1
Study Team
Mr Bayezid Dawla
Team Leader
Ms Fatema Mahmuda
Gender & Research Expert
Mr Narayan K Bhowmick
Sociologist & Field Research Coordinator
Ms Shameem Akter Jahan
Data Analyst
2
Acknowledgement
On behalf of DEVCARE LIMITED, I would like to express our sincere gratitude to Dr Halida
Hanum Akhter, Chief of Party, USAID-DFID NGO Health Service Delivery Project (NHSDP), for kindly
awarding the assignment titled “Surjer Hasi Network Client Satisfaction Assessment”.
We are particularly grateful to Mr Bruce Rasmussen, Deputy Chief of Party; Dr. Najmus Sahar
Sadiq, Director—Health Management System; Mr ARMM Kamal, Advisor & Team Leader; and Ms
Nahid Farjana, Sr. Human Resource, Admin & Procurement Manager; for the professional input
and support we received from them during the assessment. Special thanks are due to Dr Bram
Brooks, Senior Research and Metrics Advisor, Pathfinder International, for his valuable and critical
feedback on the findings we shared with the NHSDP.
We must thank the field research assistants (FRAs) who have taken the pains of visiting the static
and satellite clinics and interviewing the clients living in different parts of the country even amid the
extremely bad weather that paralysed most of the urban and rural life. I do appreciate that my
colleague Mr Md. Selim Reza has travelled tirelessly across the country to provide supervision
support for the enumerators.
We are thankful that Ms Fatema Mahmuda (Gender and Research Expert), Mr Narayan Kumer
Bhowmick (Field Research Coordinator & Sociologist), and Ms Shameem Akter Jahan (Data Analyst)
kindly teamed up with me at DEVCARE for this study. We gratefully acknowledge their sincere
efforts that enabled the study to be completed on time.
We are very grateful to the clients who kindly made time for our enumerators to collect the data
from them. We are equally grateful that the NGO project directors and managers, clinic managers
and other staff have cooperated with us in the field.
We hope the study would bring desired benefits to all stakeholders.
Bayezid Dawla
Chairman, DEVCARE
& Team Leader
3
Contents
1.0 Introduction ............................................................................................................... 8
1.1 Background .................................................................................................................... 8
1.2 Main Objective ............................................................................................................... 9
1.3 Scope of Work ............................................................................................................... 9
2.0 Methodology ................................................................................................................ 10
2.1 Desk Review ................................................................................................................. 10
2.2 Sampling Strategy ......................................................................................................... 10
2.2.1 Sampling Area and Population ............................................................................ 10
2.2.2 Sampling Framework ............................................................................................ 10
2.2.3 Sampling Approach/Procedure ............................................................................ 12
2.3 Data Collection ............................................................................................................ 12
2.3.1 Translating and Piloting the Data-collecting Tool ............................................... 12
2.3.2 Recruiting and Training the Data Collectors ....................................................... 13
2.3.3 Structured Interview ............................................................................................. 13
2.3.4 Quality Control and Monitoring .......................................................................... 13
2.4 Data Management ........................................................................................................ 14
2.4.1 Data Processing and Analysis ............................................................................... 14
3.0 Findings ........................................................................................................................ 15
3.1 Services Received by Clients during their Last Visits ................................................. 15
3.2 Amount of Time Clients Waited to See Health Providers .................................... 16
3.3 Interpersonal Behavior of Medical Staff ..................................................................... 16
3.4 Clients’ Privacy Status .................................................................................................. 17
3.5 Asking Questions and Getting Responses .................................................................. 17
3.5.1 Opportunity for Clients to Ask Questions .......................................................... 17
3.5.2 Clients Allowed to Ask Questions ....................................................................... 18
3.5.2 Clients’ Satisfaction about Health Providers’ Responses to Questions .............. 18
3.6 Understanding Solutions to Health Problems ............................................................ 19
3.7 Health Providers’ Treatment of Clients ...................................................................... 19
3.8 Length of Service Time ............................................................................................... 20
4
3.9 Confidentiality of Clients’ Information ....................................................................... 20
3.10 Overall Satisfactions of Clients about Services of SH Clinics .................................. 21
3.10.1 Overall Satisfaction by Age ................................................................................. 21
3.10.2 Overall Satisfaction by Residence ...................................................................... 22
3.10.3 Overall Satisfaction by Poverty ........................................................................... 23
3.10.4 Overall Satisfaction by District ........................................................................... 23
3.10.5 Overall Satisfaction by Type of Clinic ............................................................... 25
3.10.6 Overall Satisfaction of Clients by NGOs ........................................................... 25
3.10.7 Overall Satisfaction by Health Services Received ............................................. 27
3.11 Clients’ Comments and Reflections .......................................................................... 27
3.12 General (Community) Observation .......................................................................... 28
4.0 Analysis ........................................................................................................................ 28
5.0 Conclusion ................................................................................................................... 30
5.1 Conclusion ................................................................................................................... 30
5.2 Recommendations ....................................................................................................... 31
6.0 Annex ........................................................................................................................... 32
5
Glossary of Terms and Abbreviations
BAMANEH An NGO
Bangla Bengali
BCC-CM Behavior Change Communication and Community Mobilization
DEVCARE LTD A private research firm based in Dhaka, Bangladesh
DfID Department for International Development
ESP Essential Service Package
IR Intermediate Results
NGO Non-Governmental Organization
Pathfinder International An international NGO
Pourasava Municipality
SH Surjer Hashi (Smiling Sun), a network of 25 NGOs
SPSS Statistical Package for the Social Sciences
SHCSG Surjer Hashi Community Support Group
Swanirvar An NGO
UKAID United Kingdom Agency for International Development
Upazila Administrative sub-district in Bangladesh
USAID United States Agency for International Development
6
Executive Summary
The NGOs Health Service Delivery Project (NHSDP) supports the delivery of an essential service
package (ESP) of primary healthcare through a nationwide network called “Surjer Hashi (SH)” also
known as “Smiling Sun.” The network consists of 25 Non-Governmental Organizations (NGOs)
operating 391 static clinics with over 10,000 associated satellite clinics and serving approximately
22.2 million poor and underserved people (15% of the population) in 64 districts of the
Bangladesh.
Pathfinder International is implementing the project through a contract awarded by USAID and
UKAID/DfID. One important milestone of the project is to ensure increased satisfaction of at least
90% clients with NGO clinic services. Through its informal mechanisms such as Client Exit
Interview and Community-based Assessment, the project has found 99% clients satisfied.
However, the mechanisms being not methodologically sound to defend the stated rate of
satisfaction, Pathfinder undertakes an independent assessment of clients’ satisfaction carried out
by DEVCARE LTD. The objective of the assessment is to assess the satisfaction of clients with the
services received at the Surjer Hashi (SH) clinics.
The methodology adopted to conduct the assessment includes a quantitative survey led by a
preset questionnaire and administered among 700 female clients from 50 clinics—25 in rural areas
and 25 in urban areas—in 32 out of 64 districts in Bangladesh. The sample units, clinics, sites and
districts have been selected by the NHSDP using the random sampling strategy. DEVCARE has
translated the questionnaire from English into Bengali, piloted it in two different sites, modified
the tool, and administered it with prior approval from the NHSDP. The data have been collected
over a period of four weeks by three teams of experienced, trained and skilled female
enumerators under constant supervision and monitoring support from the study team and the
firm. The data have been edited and analyzed by a professional Data Analyst using Excel/SPSS
format and developing a data-entry software.
The study has found that the clients have received a variety of services from the SH clinics. The
services they have received most include family, ante-natal care, child immunization and “other”.
The majority clients have been found satisfied about length of time to see the health providers for
the services. The health providers welcomed most of them politely, and almost none of them felt
ignored. Of the respondents 76.1% have enjoyed “enough privacy” with the medical staff while
17% experienced a lack of privacy. The majority (71%) wanted to ask the health providers
questions while 29% showed a lack of interest in asking questions. Among those willing to ask
questions, 70% have said that the health providers let them ask questions, and 68% of the
respondents who asked questions have found the responses satisfactory. The majority (96.4%)
have said that the responses they received from the health providers were easy to understand. As
found, the health providers have treated 97.1% respondents with respect. Regarding the time
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spent with the health providers, for 75.4% clients the time was “about right” and for 14.9% it was
“too short”. Among the respondents, 40.7% believe that the information they have shared with
the health providers would remain confidential while 41% “don’t know” that it would will remain
confidential. However, 76.6% of them have said they are satisfied, 20.1% have said they are
moderately satisfied and 3.3% have said they are dissatisfied.
The analyses of services received from the clinics, health providers’ treatment of clients, time
waited to see health providers, institutional flexibility and opportunity for clients to ask questions,
health providers’ responses to queries, confidentiality of information and overall feeling of
satisfaction about the services indicate that the quality of service delivery and performances by
most of the SH clinics is satisfactory from the clients’ perspective. This finding, however, differs
from the data generated through the informal mechanisms orchestrated by the project.
The study remains limited to the assessment of the randomly selected sample clients who have
visited the clinics within the last seven days of the survey, and therefore, it is recommended that a
further study be undertaken to generate a wide and comprehensive status of satisfaction from the
clients’ perspective.
Taking the findings into consideration, the study recommends below a set of measures for
consideration of the NHSDP:
To increase the number of doctors;
To reduce the services fees;
To ensure privacy of clients at satellite clinics;
To make pathological test facilities to all clinics;
To reduce operational theater (OT) charge rates;
To reduce the waiting time; and
To assure the clients of the confidentiality of their personal information.
8
1.0 Introduction This section introduces the study titled “Surjer Hashi (Smiling Sun) Network Clients’ Satisfaction
Assessment” conducted for Pathfinder International by DEVCARE LIMITED to “assess client’s
satisfaction among Surjer Hashi Clinic beneficiaries” in 64 districts of Bangladesh. Pathfinder
International implements a NGO Health Service Delivery Project (NHSDP) in Bangladesh through a
contract awarded by USAID and DfID/UKAID. Devcare, a partner-led firm based in Dhaka, carried
out the assignment during the July—September 2017 period under an agreement between the
Project and the firm.
1.1 Background
The NGO Health Service Delivery Project (HNSDP) supports the delivery of an essential service
package (ESP) of primary healthcare through a nationwide network called “Surjer Hashi (SH)” also
known as “Smiling Sun.” The network consists of 25 Non-Governmental Organizations (NGOs)
operating 391 static clinics with over 10,000 associated satellite clinics and serving approximately
22.2 million poor and underserved people (15% of the population) in 64 districts of the country.
The static clinics are of three different categories—Vital Clinic, Emoc-B Clinic and Emoc-C clinic,
each with a number of satellite clinics delivering healthcare at the community level.
The ESP covers reproductive health, child health, behavior change communication, communicable
disease control, and limited curative care. The network provides the women with access to
information and healthcare facilities with a focus on the unique sexual and reproductive health
needs of adolescents.
To deliver the above-stated quality services, the project builds the capacity of the local
organizations and supports the delivery of primary health care through the SH network. The
network is built on previous experiences and current successes in NGO service delivery and
incorporates new approaches to promote optimal health behaviors and community participation as
well as to enhance local ownership of service delivery through community mobilization and
participation and institutional strengthening.
The NHSDP has three Intermediate Results (IRs) of which IR 2 is dedicated to increasing health
seeking behavior of the community people through Behavior Change Communication and
Community Mobilization (BCC-CM). Each IR builds on a number of sub-IRs with a number of
milestones. Under Sub-IR 2.2 (Communities are actively engaged in promotion of healthy behaviors
and care seeking practices), one of the important milestones is 2.2.1 that sates, “At least 90%
targeted communities report increased satisfaction with NGO Clinic services”. To assess the clients’
satisfaction which is one of the important milestones of the program as found in the review of
9
relevant documents, the NHSDP has devised and operationalized the following informal
mechanisms of satisfaction assessment through clinic managers, leaders of SH community support
groups (SHCSGs) and project staff.
Client Exit Interview: The clinic managers conduct exit interviews with ten clients using a
checklist to assess the client’s satisfaction once a month at the clinic level. The clients are
selected on a random basis. The results of the interviews reflect that 99% clients are
satisfied with SH clinic services.
Community-based Assessment: The NHSDP has introduced a community-based system
under its community mobilization components to assess its clients’ satisfaction through
Surjer Hashi Community Support Group (SHCSG) formed in each static and satellite clinic by
the people of the catchment area. Currently, there are 10,756 SHCSGs functioning with
75% meeting on a regular basis. The groups have systematically included client satisfaction
as a standing agenda item for discussion in their monthly meetings. The participation of the
group members in the meetings has improved due to renewed emphasis on and support to
the SHCSGs through training of group leaders. The group leaders collect clients’ opinions
about their satisfactions from the members participating in the meetings and share the
opinions with clinic staff in the quarterly meetings of the group leaders held in the static
clinics.
Nonetheless, a discussion with the BCC-CM team at the NHSDP reveals that the BCC-CM team
members attending a number of SHCSG meetings have found anecdotally that the clients, especially
the women and the girls, are generally satisfied with SH clinic services. The team members have
shared their findings/opinions with clinic staff for taking measures. The project, however, observes
that the mechanisms followed and practised so far do not appear methodologically sound and
justifiable to defend the stated rate of satisfaction. In this backdrop, Pathfinder resorts to an
independent assessment of clients’ satisfaction to review its approach and improve the quality of its
clinical services for the clients (the poorest of the poor, the poor and the able-to-pay clients).
1.2 Main Objective
The main objective of this assessment is to assess the satisfaction of clients with the services received at the Surjer Hashi (SH) clinics.
1.3 Scope of Work
As per the instructions of the RFQ, DEVCARE undertakes the following tasks:
To review the related project documents/guidelines;
To develop a detailed plan for conducting this assessment and get approval from NHSDP, including for the randomized selection of 25 urban and 25 rural clinics as further detailed below;
10
To translate the survey instrument (RFQ Annex A) into Bengali and conduct pilot test with at least 10 Surjer Hashi clients to ensure client comprehension of questions; (NHSDP must review and approve translated survey before piloting, as well as giving final approval for any revisions after piloting.)
To recruit and train field assessors, and conduct the client satisfaction survey;
To compile and manage data using an Excel database;
To prepare a draft report of the assessment and submit to NHSDP for feedback and suggestion; and
To prepare a final report describing the purpose and methodology; and presenting and discussing the findings—especially the clients reporting overall satisfaction, disaggregated by: residence, sex, age, poverty level, region, clinic type, NGO, and service.
2.0 Methodology To conduct the assessment, DEVCARE has adopted the quantitative method combining a structured
interview led by a structured questionnaire as preset by the RFQ. The research design is presented
below.
2.1 Desk Review
The study team has undertaken an extensive desk review of the NHSDP documents, such as the
project proposal, progress reports, monitoring reports, publications, and/or any documents
available from the NHSDP.
2.2 Sampling Strategy
2.2.1 Sampling Area and Population
The NHSDP is serving both the rural and urban women through its 391 static clinics—Vital Clinics
and Ultra Clinics—in all the 64 districts of the country, and reaching out to the clients though 10,000
satellite clinics. However, the sampling area covers 50 static clinics in 32 districts, which is 50% of
the total area as per the random sampling procedure recommended by the HNSDP.
2.2.2 Sampling Framework
Sample size: As per the RFQ, the formula for determining sample size is:
Z = confidence level (99%; Z = 2.576) E = desired margin of error (±5%; E =0.05) P = population proportion (value that will generate the largest sample size; P = 0.5)
11
To estimate the proportion of clients who are satisfied with health services from the NHSDP
clinics, while ensuring a 99% confidence level within 5% of the true proportion, a minimum of 664
clients are required for this assessment. For the purpose of this assessment, the number is
rounded up to 700 as shown in the table that follows.
No. of
Districts
No. of
Sites
No. of
NGOs
No. of Clinics % of Clinic Types No. of
Respondents
Urban Rural Vital EMOC-B EMOC-C
32 50 25 25 25 56% 8% 36% 700
The survey has been administered at all the 50 clinic sites for a four-week period during July -
August 2017.
Characteristics of Survey Respondents
All selected respondents are female. The total client population includes all unduplicated clients (n
= 700) from 50 clinics based at city corporation, purasava and upazila levels in 32 districts. As per
terms of reference, 50% respondents have been drawn from urban area and 50% from rural area
of the selected districts.
Figure-1 as below shows the respondents disaggregated by age. Age distributions are not similar
among the client population as the lowest proportion of survey participants’ age group is 54 to 64
years (1.3%) and the highest 42.6% client age group is 14 to 24 years.
Figure-1: Distribution of Respondents by Age
0.05.0
10.015.020.025.030.035.040.045.0
14 to 24 yrs
25 to 34 yrs
35 to 44 yrs
45 to 54 yrs
55 to 64 yrs
64+ yrs
42.639.9
11.3
2.6 1.7 2.0
Age distribution of the respondents
12
Figure-2 as below illustrates the poverty levels of the clients. Given the poverty levels, 10.3% are
ultra-poor, 48.4% poor, and 41.3% are not poor.
Figure-2: Distribution of Respondents by Poverty
2.2.3 Sampling Approach/Procedure
Following the RFQ instructions, DEVCARE has used a two-stage random sampling approach. At the first stage, approximately 10% static clinics have been randomly selected from each NGO, followed by a random selection of clients who received services within the last 7 days. In order to disaggregate results by residence, at the second stage, clinic selection has been stratified based on urban and rural sites resulting in randomized selection of 25 rural and 25 urban clinics, with 14 clients randomly selected from each clinic for a total of 700. The clients have been selected from among those who received services at the clinics within the last 7 days. They have been identified from the clinic registers and the randomized selection done in collaboration with the NHSDP.
2.3 Data Collection
The following techniques and tools have been used in collecting data from the field:
2.3.1 Translating and Piloting the Data-collecting Tool
The survey has been conducted using the structured questionnaire offered by the RFQ. The questionnaire has been translated into Bangla (Bengali) and submitted to the NHSDP for its review. With feedback from the NHSDP, the instrument has been piloted on 8 July 2017 in two different SH clinics in Dhaka district – Keraniganj (rural) SH Clinic run by BAMANEH and Adabor (urban) Clinic run by Swanirvar. The piloting was administered in two different study sites by the core team of consultants in two teams, each of two members. The consultants visited the respective SH clinics and randomly selected from books of “Customer Record Sheet” 20 female clients having cell phone numbers who received health services from their centre within the past seven (7) days. The firm has prepared a report and submitted it to the NHSDP for its further modification and improvement. (See the report in annex.) With approval from Pathfinder, the improved version of the questionnaire has been administered in the field for data collection by the enumerators recruited and trained by the firm.
0.0
10.0
20.0
30.0
40.0
50.0
Ultra Poor Poor Not Poor
10.3
48.441.3
Poverty level % of respondents
13
2.3.2 Recruiting and Training the Data Collectors
Considering the geographical coverage of the large sampling area across the country, the firm has recruited eight female enumerators having five-ten years of field research and data collection experience.
A two-day training course on the proposed study methodology has been organized for the data collectors to learn and acquire the hands-on interviewing norms, techniques and skills from classroom sessions and field practices. To maintain the data quality standard, the course has also trained the enumerators on how to deal with difficult situations and respondents in different contexts, communities and cultural backgrounds.
2.3.3 Structured Interview
The data collectors have conducted a total of 700 face-to-face structured interviews with 14 clients from each of the 50 clinics, using a preset questionnaire in Bangla. Data collection has been carried on by three teams, each of two female enumerators, under the constant coordination, guidance and supervision of an experienced Field Research Coordinator. Considering the length of data collection experience and skills, one of the two data collectors in a team has been entrusted with an additional responsibility of team supervision to strengthen the line of accountability between the field and the headquarters. The fieldwork kick-started in the third week of July 2017 with a massive drive undertaken by the three teams—Team A, Team B & Team C— in three different locations and collected data under strong supervision of the core members of the study team. The teams have visited the selected clinics in the morning and randomly chosen from the client record sheets at least 25 respondents ensuring representation of the varying services received by the clients. The enumerators have telephoned the respondents requesting interviews and prior consent, and made them physical visits at their residence at the mutually agreed time of convenience. While collecting the data from the respondents the enumerators and supervisors have interacted with local people and informally gathered a set of data which appears to be valuable for study as well as the project to consider for future actions. However, to ensure the proper implementation of the plan, the Field Research Coordinator has maintained constant communication with the sampled clinic contacts via the HNSDP management and facilitated interactions between the contacts and the enumerators to ensure smooth operation of the data collection process.
2.3.4 Quality Control and Monitoring
2.3.4.1 Supervision and Monitoring of Field Work
The quality of data to be collected has been maintained through the constant monitoring and physical supervision of the field research coordinator (sociologist), a senior social development professional having similar field research management skills and experience with support from the Team leader and the Gender Expert. The data collection has been supported with physical supervision by additional skilled staff deployed by the firm. The supervisors have randomly checked few questionnaires filled out by the enumerators, and this process has been accomplished efficiently under the constant supervision and technical guidance of the core team. Both the Team Leader and the Gender Expert have also visited a few data collection sites, supervised the field during data collection, and guided the teams to ensure quality work. The Gender Expert has visited fields with a particular attention to examining the gender sensitivity of
14
the project performances and screening the gender-based violence issues and factors being addressed by the project.
2.3.4.2 Quality Control: Data Quality and Reliability
To ensure the increase in data quality and reliability, DEVCARE has undertaken the following quality control measures at different stages of the study:
a. Showing Respect to Cultural Sensitivity: As the respondents (beneficiaries) are women, female interviewers have been recruited to show respect to the cultural sensitivity and help collect the improved and authentic data from the beneficiaries.
b. Eliminating Fear and Building Trust: Before the interviews, the enumerators have properly introduced themselves, described the objective of the interviews, and assured the anonymity of the respondents to eliminate their fear and doubt as well as build confidence and trust.
c. Interviewing in an Ecological Environment: Collecting the list from the clinic registers, the data collectors have visited the respondents, identified them, and checked their availability for interviews. With prior consent from them, they have interviewed the beneficiaries in places of their choices secure from noise and interruptions.
d. Field Editing: After completion of each day’s activity, the field investigators have checked the filled-in or completed questionnaires in the evening of that very day. The supervisors
have checked few filled-out questionnaires on a random basis and ensured the data gathered so
far are correct.
e. Office Editing: After completion of fieldwork phase, the data collectors have returned the filled-in questionnaires to the office for editing. The Gender Expert and the Data Analyst have checked each questionnaire carefully and made the responses or data meaningful and specific to eliminate problems during data entry.
2.4 Data Management
2.4.1 Data Processing and Analysis
The data of individual interviews have been transferred into the electronic format using Access database, which has been transferred later into Excel/SPSS (18.1 version) format to provide the main frame for data analysis.
A smart and conditional data-entry software has been developed using a combination of Access and Visual basic to filter quality and consistency during data entry. Coding and de-coding has been done to handle the data in the electronic form. A thorough consistency check will be done using logical sequence method before taking simple tables, data ranges, frequency distributions and descriptive tables. The basic tables work as guide to develop a data analysis framework. Data editing includes the checking of range, structure and a selected set of checks for internal consistency. The data analyst has developed the data entry screen for entering data into computer.
15
The following steps have been taken for processing and analysis of the data:
STEP 1-System Design: In this step, the analyst has prepared a suitable system design based on the survey questionnaire for computerization of the field data.
STEP 2-Editing and Coding: Each questionnaire has been assigned a serial number and sent for coding. Data editors have reviewed the questionnaire for completeness and accuracy.
STEP 3 -Development of Data Entry Program: While registration, coding and translation continue, data-entry programs have been developed, tested and finalized by the analyst for computerization of data.
STEP 4-Data Entry into Computer Files: Double data entry operation have been started by data-entry operators. Before that, the data screen has been installed into computer.
STEP 5-Validation Checks and Data Cleaning: The two data sets (first entry and second entry) have been matched and inconsistencies removed in phases with internal consistency checks. Tables have been generated using the key variables for quality control of the data set.
STEP 6- Data analysis and reporting: The Data Analyst has prepared a data analysis framework which forms the basis for data presentation and reporting. Tables and matrixes framework have been used for data presentation. Statistical tests/theories have been used wherever applicable, and as such the reporting structure and its scope have been developed through a rigorous experiential process by bringing inputs from study team members.
3.0 Findings
3.1 Services Received by Clients during their Last Visits
The first question relates to the services the respondents have received within the last seven days
from the clinics. In response to the question, the respondents provide a list of services as
illustrated by Figure-3 as below:
Figure-3: % of Respondents Receiving Services from SH Clinics
0.05.0
10.015.020.025.030.0
28
.3
28
.7
2.1 5.9
1.1 5
.4
14
.0
2.3
0.0
24
.0
0.3
22
.0
Health services received by respondents
16
Figure-3 illustrates a variety of services the clients have received from the SH clinics. The services
include family planning (28.3%), antenatal care (28.7%), delivery services (2.1), postnatal care
(5.9%), post-abortion care (1.1%), growth monitoring (5.4%), child immunization (14%), STI
management (2.3%), HIV/AIDS management (0%), curative services (24%), VCT (0.3%) and other
(22%).
3.2 Amount of Time Clients Waited to See Health Providers
The respondents have been asked how long they waited to see the health providers. In response,
14.7% respondents have said they waited “too long”, 48.0% have said their time was “about
right”, and 37% have said it was “too short”. The following figure (Figure-4) shows the picture of
the time the clients waited to see the health providers:
Figure-4: Time waited to see health providers
3.3 Interpersonal Behavior of Medical Staff
Figure-5: Welcoming Clients Politely
Too short37%
Too long15%
About right48%
The amount of time waited to see the
health providers
97%
3%0%
Welcoming clients politely
Yes No Don't Know
17
Figure-5 illustrates the response categories. Asked whether medical staff welcomed them politely,
96.6% of respondents have replied and in the positive while only 3% have replied in the negative.
3.4 Clients’ Privacy Status
The following illustrates the clients’ experience of privacy during the last session while they have
visited the health providers. Of the respondents asked if they have had enough privacy with the
health providers, 76.1% have reported that they have enjoyed “enough privacy”, 17% have said
they have not experienced privacy during the service time while only 7% have replied that they are
not sure they have had “enough privacy” with the medical staff.
Figure-6: Clients Having Privacy with Health Providers
3.5 Asking Questions and Getting Responses
3.5.1 Opportunity for Clients to Ask Questions
Figure-7 demonstrates responses to a question asking if the clients wanted to ask the health
providers any questions. We have found that 71% respondents wanted to ask questions during
the last visit while 29% have said that they did not want to.
Figure-7: Clients’ Interest in Asking Questions
Yes76%
No17%
Not sure7%
Privacy status of the clients
Yes71%
No29%
Patients' interest in asking questions
18
3.5.2 Clients Allowed to Ask Questions
Figure-8 shows that 70% of the clients who wanted to ask questions have said that the health
providers let them ask questions while the responses of 30% clients have not been found
applicable because they did not want at all to ask questions.
Figure-8: Clients Let to Ask Questions
3.5.2 Clients’ Satisfaction about Health Providers’ Responses to Questions
Figure-9 shows that 68% of respondents who asked questions have said that they found the
responses satisfactory while none has reported dissatisfaction about the responses. However,
30% responses have not been found applicable as they did not want at all to ask questions.
Figure-9: Health Providers Response to Clients’ Queries
Yes70%No
0%
Not applicable
30%
Health providers let patients ask questions
Yes68%
No2%
Not applicable30%
Health providers' response satisfying patients
19
3.6 Understanding Solutions to Health Problems
Figure-10: Understanding Health Providers’ Responses
The respondents have been asked if the health providers were easy to understand while they
explained things to them. The majority (96.4%) have said that the responses they received from
the health providers were easy to understand while a very minor percentage of respondents
(3.3%) have opined that they (health providers) were difficult to understand. The responses
indicating that they were not sure are very insignificant (0.3%).
3.7 Health Providers’ Treatment of Clients
Figure-11 reveals that the health providers have treated 97.1% respondents with respect. Of the
rest, 2.7% have reported that they have been treated with a difference while 0.1% have noted
that they have been treated with disrespect.
Figure-11: Health providers’ Treatments of Patients
0.0
20.0
40.0
60.0
80.0
100.0
Easy to understand
Difficult to understand
No opinion/ Not sure
96.4
3.3 .3
Clients' level of understanding health providers' responses
0.0
20.0
40.0
60.0
80.0
100.0
Respectfully With indifference
Disrespectfully
97.1
2.7 .1
Health providers' treatment of patients
20
3.8 Length of Service Time
Regarding the length of time the clients have spent with the health providers, Figure-12
illustrates that 75.4% clients have reported the length of time was “about right”. However, for
14.9% the time was “too short” and for 3.1% it was “too long” while 6.6% have said they ‘don't
know’.
Figure-12: Length of Time Clients Spent with Service Providers
3.9 Confidentiality of Clients’ Information
As we have asked if they think the medical staff would keep their information confidential,
40.7% have said “yes”, 1% have said “no” while 41% have said they “don’t know” if the
information they have shared with the staff would remain confidential. Figure-13 below
demonstrates the clients’ responses regarding the confidentiality of their information.
Figure-13: Clients’ Trust on Health Providers in Relation to Information
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
Too short Too long About right Don't Know
14.9
3.1
75.4
6.6
Length of time patients spent with health providers
Yes58%
No1%
Don't Know41%
Patients' Trust on health providers in relation to confidentiality of information
21
3.10 Overall Satisfactions of Clients about Services of SH Clinics
While the respondents have been asked if they are satisfied with the services they received in
their last visit in clinics for general health services, 76.6% of them have said they are satisfied,
20.1% have said they are moderately satisfied and 3.3% have said they are dissatisfied. Figure-14
represents the three different levels of satisfaction the respondents have expressed during the
survey.
Figure-14: Satisfaction about Services Received
The following sub-sections report the overall level of satisfaction disaggregated by residence, age,
poverty level, region, clinic type, NGO, and health services.
3.10.1 Overall Satisfaction by Age
Figure-15: Clients’ Overall Satisfaction by Age
0.0
20.0
40.0
60.0
80.0
Satisfied Moderately satisfied
Dissatisfied
76.6
20.1
3.3
Clients’ level of satisfaction about services received
0.0
20.0
40.0
60.0
80.0
100.0
14 to 24 yrs
25 to 34 yrs
35 to 44 yrs
45 to 54 yrs
55 to 64 yrs
65+ yrs Total
32.3 31.18.6 1.4 1.3 1.9
76.69.4 6.9
2.31.0 0.4 0.1
20.1
0.9 1.9
0.40.1 0.0 0.0
3.3
Overall Clients' Satisfaction by Age
Satisfied Moderately satisfied Dissatisfied
22
As Figure-15 exhibits, of the 14-24 age group 75.8% clients are satisfied with the services provided
by the SH clinics, 22.1% moderately satisfied, and 2% dissatisfied; of the 25-34 age group 78.1%
are satisfied, 17.2% moderately satisfied, and 4.7% dissatisfied; of the 35-44 age group 75.9% are
satisfied, 20.3% moderately satisfied, and 3.8% dissatisfied; of the 45-54 age group 55.6% are
satisfied, 38.9% moderately satisfied, and 5.6% dissatisfied; of the 55-64 age group 75% are
satisfied, and 25% moderately satisfied; and of the 65+ age group, 92.9% are satisfied, and 7.1%
moderately satisfied.
3.10.2 Overall Satisfaction by Residence
Figure-16 shows the overall satisfaction level of clients in the last visit disaggregated by residence.
Of 76.6% clients satisfied with the services delivered by the SH clinics across the country, 38.4%
are from the rural areas and 38.1 from the urban areas. Of 20.1% clients moderately satisfied
with the services delivered across the country, 9.3% are from the rural areas and 9.3% from the
urban areas. Of 3.3% clients dissatisfied with the services, 1.0% are from the rural areas and 2.3%
from the urban areas.
Figure-16: Clients’ Overall Satisfaction by Residence
38.4 38.1
76.610.9 9.3
20.1
1.0 2.3
3.3
0.0
20.0
40.0
60.0
80.0
100.0
120.0
Rural Urban Total
Overall Clients' Satisfaction by Residence
Satisfied Moderately satisfied Dissatisfied
23
3.10.3 Overall Satisfaction by Poverty
Figure-17 illustrates the overall satisfaction of clients disaggregated by poverty level. Among the
clients who received health services from the SH clinics 10.3% are ultra-poor, 48.4% poor, and
Figure- 17: Clients’ Overall Satisfaction by Poverty
3.10.4 Overall Satisfaction by District
Figure-18 represents the overall satisfaction level of clients disaggregated by selected districts.
Figure- 18 Clients’ Overall Satisfaction by District
As shown in the graph above, of the total clients having received health services from the SH
clinics 92.9% have reported satisfaction and 7.1% moderate satisfaction in Bagerhat district;
85.7% have reported satisfaction, 7.1% moderate satisfaction and 7.1% dissatisfaction in Barisal
0.0
20.0
40.0
60.0
80.0
100.0
Ultra Poor Poor Not Poor Total
8.6
37.0 31.0
76.6
1.4
9.79.0
20.1
0.3
1.71.3
3.3
Overall Clients' Satisfaction by Poverty
Satisfied Moderately satisfied Dissatisfied
0.0
20.0
40.0
60.0
80.0
100.0
Gai
ban
dh
a
Ran
gpu
r
Bra
hm
anb
aria
Co
x`s
Baz
ar
Bo
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Din
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Nar
ayan
gan
j
Dh
aka
Ch
itta
gon
g
Jess
ore
Mag
ura
Mo
ula
vib
azar
Sylh
et
Kis
ho
rega
nj
Laks
hm
ipu
r
Bar
isal
Fari
dp
ur
Kh
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a
Nar
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Nat
ore
No
akh
ali
Raj
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i
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ur
Bag
erh
at
Co
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a
Go
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Jam
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Jhen
aid
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Ku
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am
Mym
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Ku
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Sher
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District wise clients are satisfied
24
district; 64.3% have reported satisfaction and 35.7% moderate satisfaction in Bogra district;
57.1% have reported satisfaction and 42.9% moderate satisfaction in Brahmanbaria district; 69.0%
have reported satisfaction, 27.4% moderate satisfaction and 3.6% dissatisfaction in Chittagong
district; 92.9% have reported satisfaction and 7.1% moderate satisfaction in Comilla district;
57.1% have reported satisfaction, 35.7% moderate satisfaction and 7.1% dissatisfaction in Cox`s
Bazar district; 66.7% have reported satisfaction, 23.8% moderate satisfaction and 9.5%
dissatisfaction in Dhaka district; 64.3% have reported satisfaction and 35.7% moderate
satisfaction in Dinajpur district; 85.7% have reported satisfaction, 7.1% moderate satisfaction and
7.1% dissatisfaction in Faridpur district; 32.1% have reported satisfaction and 67.9% moderate
satisfaction in Gaibandha district; 92.9% have reported satisfaction and 7.1% dissatisfaction in
Gopalganj district; 92.9% have reported satisfaction and 7.1% moderate satisfaction in Jamalpur
district; 71.4% have reported satisfaction, 21.4% moderate satisfaction and 7.1% dissatisfaction in
Jessore district; 92.9% have reported satisfaction and 7.1% moderate satisfaction in Jhenaida
district; 85.7% have reported satisfaction, 7.1% moderate satisfaction and 7.1% dissatisfaction in
Khulna district; 76.2% have reported satisfaction and 23.8% moderate satisfaction in Kishoreganj
district; 92.9% have reported satisfaction and 7.1% moderate satisfaction in Kurigram district;
100% have expressed satisfaction in Kushtia district; 78.6% have reported satisfaction, 14.3%
moderate satisfaction and 7.1% dissatisfaction in Lakshmipur district; 71.4% have reported
satisfaction, 21.4% moderate satisfaction and 7.1% dissatisfaction in Magura district; 89.3% have
reported satisfaction, 3.6% moderate satisfaction and 7.1% dissatisfaction in Meherpur district;
71.4% have reported satisfaction, 25.0% moderate satisfaction and 3.6% dissatisfaction in
Moulavibazar district; 92.9% have reported satisfaction and 7.1% moderate satisfaction in
Mymensingh district; 64.3% have reported satisfaction, 28.6% moderate satisfaction and 7.1%
dissatisfaction in Narayanganj district; 85.7% have reported satisfaction and 14.3% moderate
satisfaction in Natore and Narsingdi districts; 85.7% have reported satisfaction 7.2% moderate
satisfaction and 7.1% dissatisfaction in Noakhali district; 85.7% have reported satisfaction and
14.3% moderate satisfaction in Rajshahi district; 50% have reported satisfaction and 50%
moderate satisfaction in Rangpur district; 100 % clients have reported satisfaction in Sherpur
district; and 71.4% have reported satisfaction, 26.2% moderate satisfaction and 2.4%
dissatisfaction in Sylhet district.
25
3.10.5 Overall Satisfaction by Type of Clinic
Figure-19 exhibits the overall satisfaction of clients disaggregated by type of clinic.
Figure-19: Clients’ Overall Satisfaction by Clinic
As shown above, of the clients having received services from the vital clinics 44% are satisfied,
10.6% moderately satisfied and 1.4% dissatisfied; of the clients having received services from the
EMOC-B clinics 5.7% are satisfied, 2.1% moderately satisfied and 0.1% dissatisfied; and of the
clients having received services from the EMOC-C clinics 26.9% are satisfied, 7.4% moderately
satisfied and 1.7% dissatisfied.
3.10.6 Overall Satisfaction of Clients by NGOs
The above graph shows the varying levels of satisfaction expressed by the respondents from SH
clinics run by 25 different NGOs across the country. Among those served by the Bamaneh
Figure-20: Clients’ Overall Satisfaction by Services Received by Clients
0.0
20.0
40.0
60.0
80.0
100.0
Vital Clinic Emoc-B Clinic Emoc-C Clinic Total
44.0
5.726.9
76.610.6
2.1
7.4
20.1
1.4
0.1
1.7
3.3
Overall Clients' Satisfaction by Clinic
Satisfied Moderately satisfied Dissatisfied
0.020.040.060.080.0
100.0
VP
KA
Bam
aneh
CR
C
PSK
S
SSK
S
VFW
A
Swan
irva
r
JDF
NIS
HK
RIT
I
PR
OSH
AN
TI
SOP
IRET JT
S
Kan
chan PK
S
CW
FD
SUP
PS
PST
C
IMA
GE
SUS
Tilo
ttam
a
FDSR
Ban
dh
an
UP
GM
S
PSF
Sham
anti
k
Clients are satified by NGOs providing services
26
SH clinics 95.2% are satisfied and 4.8% moderately satisfied. Among those served by the
Bandhan SH clinics 57.1% are satisfied and 42.9% moderately satisfied. Among those served by
the CRC SH clinics 92.9% are satisfied and 7.1% moderately satisfied. Among those served by
the CWFD SH clinics 75% are satisfied, 24.4% moderately satisfied and 3.6% dissatisfied.
Among those served by the FDSR SH clinics 60.7% are satisfied, 32.1% moderately satisfied and
7.1% dissatisfied. Among those served by the IMAGE SH clinics 67.9% are satisfied, 28.6%
moderately satisfied and 3.6% dissatisfied. Among those served by the JDF SH clinics 85.7% are
satisfied, 7.1% moderately satisfied and 7.1% dissatisfied. Among those served by the JTS SH
clinics 78.6% are satisfied, 19% moderately satisfied and 2.4% dissatisfied. Among those
served by the Kanchan SH clinics 78.6% are satisfied and 21.4% moderately satisfied. Among
those served by the NISHKRITI SH clinics 85.7% are satisfied, 7.1% moderately satisfied and
7.1% dissatisfied. Among those served by the PKS SH clinics 78.6% are satisfied, 11.9%
moderately satisfied and 9.5% dissatisfied. Among those served by the PROSHANTI SH clinics
85.7% are satisfied, 7.1% moderately satisfied and 7.1% dissatisfied. Among those served by
the PSF SH clinics 45.2% are satisfied, 52.4% moderately satisfied and 2.4% dissatisfied. Among
those served by the PSKS SH clinics 89.3% are satisfied, 3.6% moderately satisfied and 7.1%
dissatisfied. Among those served by the PSTC SH clinics 69% are satisfied, 26.2% moderately
satisfied and 4.8% dissatisfied. Among those served by the SHIMANTIK SH clinics 35.7% are
satisfied and 64.3% moderately satisfied. Among those served by the SOPRIET SH clinics 85.7%
are satisfied, 10.7% moderately satisfied and 3.6% dissatisfied. Among those served by the
SSKS SH clinics 89.3% are satisfied, 7.1% moderately satisfied and 3.6% dissatisfied. Among
those served by the SUPPS SH clinics 71.4% are satisfied, 25% moderately satisfied and 3.6%
dissatisfied. Among those served by the SUS SH clinics 64.3% are satisfied and 35.7%
moderately satisfied. Among those served by the Swanirvar SH clinics 87.1% are satisfied,
11.4% moderately satisfied and 1.4% dissatisfied. Among those served by the Tilottama SH
clinics 64.3% are satisfied and 35.7% moderately satisfied. Among those served by the UPGMS
SH clinics 50% are satisfied and 50% moderately satisfied. Among those served by the VFWA
SH clinics 89.3% are satisfied, 3.6% moderately satisfied and 7.1% dissatisfied. Among those
served by the VPKA SH clinics 100% clients have reported satisfaction.
27
3.10.7 Overall Satisfaction by Health Services Received Figure-21: Clients’ Overall Satisfaction by Services Received
The clients have received from the SH clinics a variety of services including family planning,
antenatal care, delivery services, postnatal care, post-abortion care, growth monitoring, child
immunization, STI management, HIV/AIDS management, curative services, VCT and other. Among
those (28.3%) who have received family planning services 21.9% are satisfied, 6% moderately
satisfied and 0.4% dissatisfied. Among those (28.7%) who have received antenatal care 22% are
satisfied, 5.9% moderately satisfied and 0.9% dissatisfied. Among those (2.1%) who have received
delivery services 1.9% are satisfied and 0.3% moderately satisfied. Among those (5.9%) who have
received postnatal care 4.7% are satisfied, 0.9% moderately satisfied and 0.3% dissatisfied. Among
those (1.1%) who have received post-abortion care 1.0% is satisfied and 0.1% moderately
satisfied. Among those (5.4%) who have received growth monitoring services 4.6% are satisfied,
0.4% moderately satisfied and 0.4% dissatisfied. Among those (14%) who have received child
immunization 10.1% are satisfied, 2.9% moderately satisfied and 1.0% dissatisfied. Those (2.3%)
who have received STI management services are all satisfied. No client has reported receiving
HIV/AIDS management service from any clinics surveyed so far. Among those (24%) who have
received curative services 18% are satisfied, 5.4% moderately satisfied and 0.6% dissatisfied. A
very insignificant percentage (0.3%) of clients has received VCT services, and they are all satisfied.
Among those (22%) who have received other services 18.6% are satisfied, 2.7% moderately
satisfied and 0.7% dissatisfied.
3.11 Clients’ Comments and Reflections
Finally, we asked respondents to name the best thing about their visit, and to name one thing that
could be done to make their next visits better. Many respondents are very positive about the
staff, providers, ease of accessing services and getting the information they needed. However, the
0.0
5.0
10.0
15.0
20.0
25.0
30.02
1.9
22
.0
1.9 4
.7
1.0
4.6
10
.1
2.3
0.0
18
.0
0.3
18
.6
6.0
5.9
0.3 0.9
0.1 0.4 2
.9
0.0
0.0
5.4
0.0 2
.7
28
.3
28
.7
2.1
5.9
1.1
5.4
14
.0
2.3
0.0
24
.0
0.3
22
.0
Health services wise satisfaction level of clients
Satisfied Moderately satisfied Dissatisfied Total
28
majority clients have mentioned specific need for increasing the number of doctors, reducing the
services fee, decreasing the waiting time, and making pathological services available to all clinics.
Below is a selection of comments:
“Be clear about appointment times and how long it will take to wait.”
“I am always satisfied with help that is available at this clinic. I don’t know what could make
it better.”
“It would be nice to be quicker but I understand why it takes as long as it does, and I really
didn’t wait that long.”
3.12 General (Community) Observation
The informal interactions at the community level reveal that the SH clinics are very popular and
well known among different sections of people who even do visit the clinics for services. The local
elites, husbands, relatives and neighbors of the clients have appreciated the services delivered by
the clinics, which appears to be an important milestone of progress made so far in creating a
positive image of the SH brand in terms of acceptance, recognition and ownership as a result of
constant community mobilization mechanisms orchestrated by the project.
4.0 Analysis This section provides an analysis of the findings presented in the previous section. The findings
represent a survey of 700 sample clients among approximately 22.2 million people for an overall
participation rate of 15.0%. The clients have received a variety of health services such as family
planning, antenatal care, delivery services, postnatal care, post-abortion care, growth monitoring,
child immunization, STI management, curative services, VCT and other from the SH clinics.
Participation rates are slightly higher for Antenatal Care services (28.7%) than Family Planning
(28.3%) and at rural clinics (72.3%) than urban clinics (68.6%) while only 0.3% clients received VCT
service. Data reveals that the majority clients have visited the clinics mostly for family planning,
ante-natal care and child immunization services indicating their priority health service needs and
options. No visits for HIV/AIDS management services have been reported.
To see the health providers for the stated services, the time the majority clients have waited is
“about right” (48%) and “too short” (37%) indicating their satisfaction while the remaining 15%
who have waited “too long” indicate a lack of satisfaction.
In most cases, the health providers have welcomed the clients gently and politely, which indicates
professional care the staff has shown to yield a positive feeling of security, comfort and
satisfaction among the clients.
The majority clients have found ample opportunities of asking questions about their health
problems, and almost all of them have easily understood the health providers’ responses to their
queries, indicating their satisfaction due to the flexibility of the facilities and the adequacy of
services delivered so far.
29
The health providers have treated most of their clients with grace and respect indicating the
latter’s satisfaction, which is much higher than the feeling of disgrace and indifference
experienced by a very few.
Most respondents are satisfied that the health providers have spent “about right” with them,
which contrasts a feeling of dissatisfaction about the service time being “too short” suggesting
that they have expected a little more time with the health providers.
The majority clients (58%) hold that the information they have entrusted with the health providers
will not be disclosed indicating a good level of trust the facilities have created among the clients.
However, a feeling of doubt seems to loom large among quite a good number of clients (41%) as
they are not sure their information will remain confidential.
Nevertheless, the majority have reported overall satisfaction about the services. The distribution
of clients by age reveals that satisfaction sweeps most clients almost equally except those of the
45-54 age-group, and stimulates special interest in noting satisfaction among the clients of 64+
age-group.
The distribution of clients by residence or location demonstrates almost equal levels of
satisfaction among the rural and urban clients, indicating a sort of equity the facilities have
ensured via their services.
The distribution of clients by poverty exhibits that the highest levels of satisfaction represent the
“poor”(37%) and the “non-poor” (31%) clients, which appears to be increasing benefits for them
as well as narrowing down the opportunities to the ultra-poor found at the lowest level (only
8.6%) of the satisfied category of clients.
The majority districts represent very high levels of satisfaction. Among them the district
representing 100% satisfaction of clients is Sherpur while the district scoring the lowest
satisfaction for SH services is Gaibandha (32.1%).
The distribution of clients by clinic type in relation to satisfaction reveals that the majority clients
who have received services from the Vital clinics have expressed satisfaction followed by those
receiving services from the Emoc-C ones. The minority are the recipients of services from the
Emoc-B clinics.
The clients from 11 NGOs out of 25 delivering the SH health services demonstrate the high level of
satisfaction (80—100) compared to 13 showing mid-level satisfaction (40—79). The NGO having
scored the highest level of satisfaction is the VPKA (100%) while the NGO found at the lowest is
Shimantik (35.7% satisfied and 64.3% moderately satisfied).
The distribution of clients by services shows that satisfaction is the highest among the clients for
family planning, ante-natal care, child immunization and curative services indicating their high
popularity and demand compared to the common services such as postnatal care, post-abortion
30
care, growth monitoring, STI management that have scored lower levels of attention and
satisfaction. The satisfaction for HIV/AIDS accounts for none found with this service.
Given the indicators of treatment, time waited, flexibility and opportunity to ask questions,
responses to queries, confidentiality of information and overall feeling of satisfaction about the
services, it seems that the performances of most SH clinics demonstrate are satisfactory from the
clients’ perspective which, however, differs from the data generated through the informal
mechanisms orchestrated by the project.
5.0 Conclusion This section concludes the report outlining the contents of the each section and recommends a set
of measures for consideration of the NHSDP.
5.1 Conclusion
The first section of the report introduces the study conducted by DEVCARE LTD to “assess client’s
satisfaction among Surjer Hashi Clinic beneficiaries” being supported by NGOs Health Service
Delivery Project (NHSDP) implemented in 64 districts by Pathfinder International through a
contract awarded by USAID and UKAID/DfID. The project has set one important milestone to
ensure increased satisfaction of at least 90% clients with NGO clinic services and found 99% clients
satisfied through its informal mechanisms such as Client Exit Interview and Community-based
Assessment. The NHSDP observes, however, that the mechanisms in practice are not
methodologically sound to defend the stated rate of satisfaction, and therefore, resorts to an
independent assessment of clients’ satisfaction by DEVCARE. The objective of the assessment is to
assess the satisfaction of clients with the services received at the Surjer Hashi (SH) clinics.
The second section of the report describes the methodology adopted to assess the satisfaction of
the clients that have received services within the last seven days of the survey. The methodology
includes a quantitative survey led by a preset questionnaire and administered among 700 female
clients from 50 clinics—25 in rural areas and 25 in urban areas—in 32 out of 64 districts in
Bangladesh. The sample units, clinics, sites and districts have been selected by the NHSDP using
the random sampling strategy. DEVCARE has translated the questionnaire from English into
Bengali, piloted it in two different sites, modified the tool, and administered it with prior approval
from the NHSDP. The data have been collected over a period of four weeks by three teams of
experienced, trained and skilled female enumerators under constant supervision and monitoring
support from the study team and the firm. The data have been edited and analyzed by a
professional Data Analyst using Excel/SPSS format and developing a data-entry software.
The third section presents an account of the study findings. The clients have received a variety of
services from the SH clinics. The services they have received most include family, ante-natal care,
child immunization and “other”. To see the health providers for the services, 14.7% respondents
waited “too long”, 48.0% waited a time which is “about right”, and 37% waited a time which is
31
“too short”. The health providers welcomed 96.6% clients while only 3% felt neglected. Of the
respondents 76.1% have enjoyed “enough privacy” with the medical staff, 17% experienced lack of
privacy and 7% are not sure of the experience. The study has found that 71% respondents wanted
to ask questions while 29% showed a lack of interest in asking questions. Among the clients willing
to ask questions, 70% have said that the health providers let them ask questions, and 68% of the
respondents who asked questions have found the responses satisfactory. The majority (96.4%)
have said that the responses they received from the health providers were easy to understand.
Data reveals that the health providers have treated 97.1% respondents with respect. Regarding
the time spent with the health providers, for 75.4% clients the time was “about right” and for
14.9% it was “too short”. Among the respondents, 40.7% believe that the information they have
shared with the health providers would remain confidential while 41% “don’t know” that it would
not be disclosed. However, 76.6% of them have said they are satisfied, 20.1% have said they are
moderately satisfied and 3.3% have said they are dissatisfied.
The fourth section provides an analysis of the findings. The analyses of services received from the
clinics, health providers’ treatment of clients, time waited to see health providers, institutional
flexibility and opportunity for clients to ask questions, health providers’ responses to queries,
confidentiality of information and overall feeling of satisfaction about the services indicate that
the quality of service delivery and performances that most SH clinics demonstrate is satisfactory
from the clients’ perspective. This, however, differs from the data generated through the informal
mechanisms orchestrated by the project.
The study remains limited to the assessment of the randomly selected sample clients who have
visited the clinics within the last seven days of the survey, meaning that it does not represent the
opinions of others who have not visited the facilities during the time. However, to generate a wide
and comprehensive status of satisfaction from the clients’ perspective, further study is
recommended.
5.2 Recommendations
Taking the data into consideration, the study recommends below a set of measures for
consideration of the NHSDP:
To increase the number of doctors;
To reduce the services fees;
To ensure privacy of clients at satellite clinics;
To make pathological test facilities to all clinics;
To reduce operational theater (OT) charge rates;
To reduce the waiting time; and
To assure the clients of the confidentiality of their personal information.
32
6.0 Annex
Action Plan with Timeline The assignment is carried out in 12 (twelve) weeks from July to September 2017 as shown in the following matrix:
Sl Activities WEEKS (JUL-SEP)
1 2 3 4 5 6 7 8 9 10 11 12
1 Signing of agreement
2 Inception Meeting: Finalization of Methodology
3 Submission of Inception Report
4 Desk review of project documents
5 Translation, piloting & finalization of tool
6 Recruitment and training of data collectors
7 Data collection
8 Data entry
9 Data analysis
10 Report writing
11 Submission of draft report
12 Revision, finalization & submission of report
Plan for Piloting the Tool
Date Steps or Activities Note
08 Jul 2017 Piloting at two nearby sites around--one in Dhaka city and the other in a rural area;
Support from HNSDP
09 Jul 2017 Preparing a report on the results of the piloting
10 Jul 2017 Sending the report to NHSDP
11 July 2017 Feedback on the results, modifications if needed, and finalisation of the tool
12 July 2017 Preparatory work for orientation of the fieldforce
13—14 Jul 2017
Fieldforce orientation on Data Collection Method
Venue: Devcare
15 Jul 2017 Data collection starts as planned
33
Report on Results of the Piloting of NHSDP Client Satisfaction Survey Draft
Questionnaire
1. Introduction
This report presents the results of piloting of the draft Bengali questionnaire. Piloting is the
administration of the data collection instrument with a small set of respondents from the
population for the full scale survey. If problems occur in the pre-test, it is likely that similar
problems will arise in the full-scale administration. The objective of the pre-testing questionnaire
is to get at the thinking behind the answers so that the researcher can accurately assess whether
the questionnaire is being filled out properly, whether the questions are actually understood by
respondents, and whether the questions ask what the researcher thinks they are asking. Pre-
testing also helps assess whether respondents are able and willing to provide the needed
information.
DEVCARE LIMITED, the firm commissioned by the USAID-DFID NGOs Health Service Delivery
Project (NHSDP) to conduct the Surjer Hasi (SH) Network Clients’ Satisfaction Assessment in 50
clinics operating in 32 districts of Bangladesh, administered the piloting of the draft Bangla
questionnaire, translated from English, in two areas (urban and rural) of Dhaka district selected in
consultation with the HNSDP management. This questionnaire will be used to interview clients
who received health services from the Surjer Hashi Clinics in rural and urban areas of Bangladesh.
2. Piloting of Questionnaire
Pre-testing allows the researchers to test solutions to problems with the questionnaire. In this
assessment, the questionnaire translated into Bengali was piloted on 8 July 2017 in two different
SH clinics in Dhaka district – Keraniganj (rural) SH Clinic run by BAMANEH and Adabor (urban) Clinic
run by Swanirvar. The piloting was administered in two different study sites by the core team of
consultants who formed two teams, each of two members. The consultants visited the respective
SH clinics and randomly selected from books of “Customer Record Sheet” 20 female clients having
cell phone numbers who received health services from their centre within the past seven (7) days.
The teams contacted the clients through cell phone and finally interviewed 10 female clients in
each area.
3. Key Findings
The main findings of the piloting exercise are as follows:
3.1 Identifying and Locating the Sample Clients
The two teams randomly selected the sample units from the books of the “Customer Record
Sheet” containing information of the clients that have received services from the clinics over the
34
last seven days. It was, however, difficult for us to identify and locate the majority clients who did
not leave any other information than their mobile telephone numbers which, however, did not
work in few cases. Under these circumstances, the cooperation of the clinic staff will be
unavoidable.
3.2 Greetings
While reading the “greetings” out to the clients, the majority respondents were found cooperative
with the interviews; however, few looked a little worried and were reluctant to proceed as they
wanted to know what the data would be used for.
3.3 Introductory Part of the Questionnaire 3.3.1 Sex: The sex of the client is not categorized. However, it would be helpful for the data
collectors if rooms, such as “Male/Female/Other” are created for them. 3.3.2 Poverty Level: It was hard for the teams to define the “poverty level of the client” as the
majority respondents were not sure about the socioeconomic classes/poverty groups they belong to. However, it may be useful to clearly define the ‘Client poverty level’ and create options in place of open ended text, i.e. space for writing text. Otherwise it will be difficult to analyse the socio-economic condition of the respondents.
3.3.3 Location: The majority respondents were not able to give names of the facilities, such as satellite clinics, providing the services. The common response we received from them was “Surjer Hasi”. The administrative information categorised as district, upazila, union, city corporation/municipality, and ward, may be reorganzied/reverted to ease the pace of interviews.
3.4 Questions
Q. 4: During your last visit with the health provider, did you have any questions you wanted to ask? When we asked this question we found both “Yes”/”No” responses. The ‘Yes’ response was
quite fine for us to continue to the questions 5 & 6 but the “No” response stopped us from
continuing to the next two questions as they appeared invalid. However, it may be useful to
include an instruction such as “If the answer is NO, skip questions 5 & 6.
Q 5: Did the health provider let you ask the questions? In response to this question, few clients said, “There was no need to ask any questions.” We
would like to suggest incorporating a third response option as “No need to ask questions”.
Q. 10: Do you feel that the health provider will keep your information confidential?
We found both Yes and No responses. However, few respondents have said, they are not sure
that the information they provided will not be disclosed to anyone. To record this response,
we suggest including the third option, i.e. ‘Don’t know’.
Q. 11: Overall, are you satisfied with the services you received in your last visit?
35
While we were recording the responses from the clients, we found few responses indicating
that they were neither satisfied nor dissatisfied, suggesting the need for including one more
option, ie “moderately satisfied” and rephrasing the options as “Satisfied”, “Moderately
satisfied” and “Not satisfied”.
Q. 12: What were the health services that you received in your last visit (select all that apply)? All of us have felt that the last question should come first to allow the respondents to recall
the services they have received the last time they visited the service providers and prepare
them to respond to the questions that follow.
Q. 13: This does not exist in this questionnaire. However, before closing the interviews, it may
be worthwhile to ask a last question like
Would you like to say anything else? or
Would you like to leave any suggestions for improvement of the services?
36
Survey Questionnaire (Modified) in Bengali
GbGBPGmwW cÖK‡í (m~‡h©i nvwm) †mevMÖnxZv‡`i mš‘wó Rwi‡ci cÖkœcÎ
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37
GbGBPGmwW cÖK‡í (m~‡h©i nvwm) †mevMÖnxZv‡`i mš‘wó Rwi‡ci cÖkœcÎ (2017)
cÖkœcÎ b¤i:
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38
µg. cÖkœ DËi
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39
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Surjer Hashi Network Client Satisfaction Assessment: Data Collection Plan
Date Team A Team B Team C
Dist Upazila Cat. NGO Clinic Dist Upazila Cat. NGO Clinic Dist Upazila Cat. NGO Clinic
15.07.17 Dhaka Mirpur Urban Swanirvar Ahmed Nagar
Dhaka Dhaka Cantt.
Urban CWFD Manikdi Dhaka Badda Urban PSTC Aftab Nagar
16.07.17 Narayan-ganj
Kutubpur Urban JTS Kutubpur Narsingdi Belabo Rural PSTC Belabo Kishoreganj Bhairab Urban PSTC Bhairab
17.07.17 Mymensingh
Sadar Urban CWFD Mymensingh
Maulavi-bazar
Sreemongol
Urban SUPPS Sreemongol
B. Baria Nasir Nagar
Rural Bandhan
Nasir Nagar
18.07.17 Kishoreganj
Hossain-pur
Rural Swanirvar Hossainpur Maulavi-bazar
Sreemongol
Rural SUPPS Satgaon
Sylhet Sadar Urban SSKS Sylhet
19.07.17 Kishoreganj
Tarail Rural Swanirvar Tarail Sylhet Balaganj Rural SSKS Sadipur Sylhet Kanaighat
Rural SHIMANTIK
Kanaighat
20.07.17 Travel Travel Travel
21.07.17 WEEKEND/TRAVEL
22.07.17 Bagerhat Sadar Urban CRC Bagerhat Comilla Chandina Rural BAMANEH
Chandina
Rajshahi Mohanpur
Rural JTS Mohanpur
23.07.17 Khulna Sadar Urban PKS Labanchara Comilla Sadar Urban Swanirvar Sangraish
Natore Singra Rural JTS Singra
24.07.17 Khulna Botiarghata
Rural CRC Botiaghata Comilla Laksham Urban
Urban SOPRIET Laksham
Bogra Sadar Urban Tilottama
Bogra
25.07.17 Khulna Sadar Urban PKS South Cent. Road
Travel Gaibandha Gobindaganj
Rural PSF Gobindaganj
26.07.17 Jessore Sadar Urban PKS Jessore Noakhali Begumganj Urban PROSHANTI
Chowmuhani
Gaibandha Sadullapur
Rural PSF Sadullapur
27.07.17 Meherpur Sadar Urban PSKS Meherpur Lakshmipur Ramgati Rural SOPRIET Ramgati
Rangpur Kownia Urban UPGMS Haragach
28.07.17 WEEKEND/TRAVEL
29.07.17 Meherpur Gangni Rural PSKS Gangni Bhola Lalmohan Rural Swanirvar Lalmohan
Dinajpur Sadar Kanchan
Urban Newtown
30.07.17 TRAVEL TRAVEL TRAVEL
31.07.17 Kushtia Kumarkhali
Rural VPKA Kumarkhali Faridpur Sadar Urban VFWA Sadar TRAVEL
01.08.17 Jhinaidah Shailkupa
Rural BAMANEH Shailkupa Gopalganj Kashiani Rural VFWA Kashiani
Chittagong Double Moorin
Urban Niskriti Rangipara
01.08.17 Magura Sreepur Rural PSF Sreepur TRAVEL Chittagong Boalkhali
Rural IMAGE Boalkhali
02.08.17 TRAVEL Chittagong Bayejid Urban IMAGE Jalalabad
TRAVEL
03.08.17 Sherpur Sadar Urban BAMANEH Sherpur Chittagong Lohagara Rural FDSR Lohagara
Chittagong Sandwip
Rural SUS Sandwip
04.07.17 WEEKEND/TRAVEL
05..08.17 Jamalpur Dewanganj
Rural Swanirvar Dewanganj Cox’s Bazar Chakaria Urban FDSR Chakaria
Chittagong Sitakunda
Urban SUS Sitakunda
06.08.17 Kurigram Rajibpur Rural Kanchan Rajibpur TRAVEL BACK TRAVEL BACK
07.08.17 TRAVEL BACK
