Baseline Study for the Maternal and Newborn Health Performance Based Financing Project in Lesotho January 2017 World Bank Group 1818 H Street N.W. Washington, DC 20433 1 Acknowledgements This report was produced and written by a task team consisting of Jeanette Walldorf (consultant), Damien de Walque (DECHD), Gil Shapira (DECHD) and Kanako Yamashita-Allen (TTL, GHN01). The authors would like to thank Omer Zang Sidjou (GHN01) for comments on earlier drafts and to acknowledge the support received from Ministry of Health. The local firm Leads Services implemented all tasks related to data collection, under supervision of the impact evaluation team. The financial contributions of the Health Results Innovation Trust Fund (HRITF) are gratefully acknowledged. This version: April 2017 2 Table of contents 1. Survey Methodology ............................................................................................................................. 6 1.1. Household survey.......................................................................................................................... 9 1.2. Facility-based survey ................................................................................................................... 10 2. Descriptive Statistics - Household Survey ........................................................................................... 12 2.1. Background Characteristics of the Samples................................................................................ 12 2.2. Maternal Health .......................................................................................................................... 20 2.3. Child health ................................................................................................................................. 31 2.4. Fertility Preferences & Family Planning ...................................................................................... 34 2.5. Adolescent Fertility Preferences ................................................................................................. 38 3. Descriptive Statistics - Facility Survey ................................................................................................. 42 3.1. Quality indicators ........................................................................................................................ 42 3.2. General information.................................................................................................................... 45 3.3. Services ....................................................................................................................................... 49 3.4. Administration and Management............................................................................................... 54 3.5. Hygiene and patient safety ......................................................................................................... 56 3.6. Drugs, contraceptives and supplies ............................................................................................ 59 3.7. Equipment ................................................................................................................................... 62 3.8. Health Providers.......................................................................................................................... 64 3.9. Exit Interviews ............................................................................................................................. 70 Appendix ..................................................................................................................................................... 76 Figures Figure 1-1: Administrative Districts of Lesotho ............................................................................................ 8 Figure 2-1: Result of Recent Pregnancy ...................................................................................................... 13 Figure 2-2: Main source of drinking water ................................................................................................. 16 Figure 2-3: Type of toilet facility ................................................................................................................. 17 Figure 2-4: Durable goods ........................................................................................................................... 18 Figure 2-5: Antenatal Care Visits................................................................................................................. 22 Figure 2-6: Content of Care......................................................................................................................... 23 Figure 2-7: Why didn’t you deliver in a formal health facility? .................................................................. 27 Figure 2-8: Postnatal Care Visit ................................................................................................................... 29 Figure 2-9: Why didn’t you have a postnatal care visit? ............................................................................. 30 3 Figure 2-10: Current use of Contraception ................................................................................................. 36 Figure 2-11: Knowledge of effective methods of contraception ................................................................ 41 Figure 3-1: The Health Center refer the following to other facilities ......................................................... 46 Figure 3-2: Services Offered ........................................................................................................................ 49 Figure 3-3: Immunization by vaccine .......................................................................................................... 51 Figure 3-4: Laboratory tests ........................................................................................................................ 54 Figure 3-5: Representatives in Health Center Executive Committees ........................................................ 56 Figure 3-6: Patient Safety – Consultation Room ......................................................................................... 57 Figure 3-7: Patient Safety – Procedure used for Sterilizing before Reuse .................................................. 58 Figure 3-8: Vaccine Storage ........................................................................................................................ 59 Figure 3-9: Out of Stock – General drugs .................................................................................................... 60 Figure 3-10: Out of stock - Vaccines ........................................................................................................... 61 Figure 3-11: Out of Stock – Family Planning Methods................................................................................ 61 Figure 3-12: General Equipment ................................................................................................................. 62 Figure 3-13: Equipment - Delivery .............................................................................................................. 63 Figure 3-14: Equipment – Delivery (Intensive Care) ................................................................................... 63 Figure 3-15: Equipment – Newborn Care ................................................................................................... 64 Figure 3-16: Case Scenario #1 ..................................................................................................................... 68 Figure 3-17 Case Scenario #2 ...................................................................................................................... 69 Figure 3-18: Case Scenario #3 ..................................................................................................................... 69 Figure 3-19: Case Scenario #4 ..................................................................................................................... 70 Figure 3-20: Content of Care - ANC............................................................................................................. 71 Figure 3-21: Content of Care – Awareness of danger signs ........................................................................ 72 Figure 3-22: Family Planning ....................................................................................................................... 73 Figure 3-23: Content of care – growth monitoring’ .................................................................................... 74 Figure A-0-1: Main material used for (a) Walls and (b) Rooftop ................................................................ 79 Figure A-0-2: Main material used for Floor ................................................................................................ 79 Figure A-0-3: Distribution of number of ANC visits .................................................................................... 81 Figure A-0-4: Distribution of months pregnant at first ANC visit................................................................ 82 Tables Table 2.1.1: Household Composition .......................................................................................................... 12 Table 2.1.2: Characteristics of Women with a Recent Pregnancy .............................................................. 13 Table 2.1.3: Characteristics of Child Sample ............................................................................................... 14 Table 2.1.4: Characteristics of Adolescent Girls ......................................................................................... 15 Table 2.1.5: Type of Dwelling. ..................................................................................................................... 15 Table 2.1.6: Household Water Source ........................................................................................................ 15 Table 2.1.7: Household Sanitation .............................................................................................................. 16 Table 2.1.8: Household Source of Energy ................................................................................................... 17 Table 2.1.9 : Wealth Quintiles..................................................................................................................... 19 Table 2.1.10: Health Expenditure ............................................................................................................... 19 Table 2.2.1: Antenatal Care ........................................................................................................................ 21 4 Table 2.2.2: HIV testing, protection against tetanus, and iron supplementation ...................................... 24 Table 2.2.3: Deliveries ................................................................................................................................. 26 Table 2.2.4: Postnatal Care ......................................................................................................................... 28 Table 2.3.1: Growth monitoring ................................................................................................................. 31 Table 2.3.2: Bukana..................................................................................................................................... 32 Table 2.3.3: Vaccination Coverage.............................................................................................................. 33 Table 2.4.1: Fertility preferences ................................................................................................................ 35 Table 2.4.2: Contraceptives ........................................................................................................................ 36 Table 2.4.3: Contraceptives (sample of women not currently using)......................................................... 37 Table 2.5.1: Reproductive Decisions ........................................................................................................... 38 Table 2.5.2: Fertility preferences ................................................................................................................ 39 Table 2.5.3: Family Planning (adolescents) ................................................................................................. 40 Table 3.1.1: General Services ...................................................................................................................... 43 Table 3.1.2: Primary Care Services .............................................................................................................. 44 Table 3.1.3: Community Services ................................................................................................................ 44 Table 3.2.1: General information ................................................................................................................ 45 Table 3.3.1: Available Services – Child Health ............................................................................................ 51 Table 3.3.2: Available Services - Contraceptives......................................................................................... 52 Table 3.3.3: Available Services – Maternal Health...................................................................................... 53 Table 3.4.1: Administration and management ........................................................................................... 56 Table 3.5.1: Water source and toilet facilities ............................................................................................ 57 Table 3.6.1: Drug Storage............................................................................................................................ 59 Table 3.7.1: Equipment and diagnostic kits - Antenatal Care ..................................................................... 63 Table 3.9.1: Time and satisfaction .............................................................................................................. 75 Table A.1: Catchment population ............................................................................................................... 78 Table A.2: Housing Characteristics across Wealth Quintiles ...................................................................... 81 Acronyms Ministry of health MOH Adults equivalent AE Antenatal care ANC Christian Health Association of Lesotho CHAL Enumeration area EA Health management information system HMIS Integrated Management of Childhood Illness IMCI Lesotho demographic and health survey LDHS Maternal and child health MCH Maternal and Newborn Care MNH Performance based financing PBF Postnatal care PNC Principal component analysis PCA 5 Executive Summary This report presents results from baseline survey for the Maternal and Newborn Health Performance-Based Financing Project in Lesotho. Data has been collected in the districts of Mafeteng, Mohale’s Hoek, Mokhotlong and Thaba-Tseka through household surveys and facility assessments of health centers. The objective of the survey was to measure outcomes prior to the implementation of the PBF intervention. Almost all health centers managed by the Ministry of Health (MOH) and the Christian Health Association of Lesotho (CHAL) in the four districts were included in the sample. In the catchment area of each health center, a sample of households was selected. Households were eligible to be included in the sample if they had a female member who was either recently pregnant or was an adolescent. The fieldwork was implemented by a local firm, Leads Services, from March to June 2015. The final sample included 53 health centers and 2120 households. Key Findings  Almost all women receive at least some antenatal care during pregnancies. However, about a quarter of women have less than the recommended number of four visits and only 36 percent initiated the care during the first trimester of their pregnancy as recommended by international and local guidelines.  Seventeen percent of women received antenatal care in hospitals rather than at the health centers providing primary health care.  The content of antenatal care is overall good according to the women’s reporting of the components of their antenatal consultations, including being offered HIV testing and iron supplementation. The rate of women receiving two or more tetanus injections is 76 percent and can be improved.  Seventy-seven percent of women reported delivering in a formal health facility. The main reasons cited by women for not delivering in a health facility were the long distance to facilities and lack of time to reach the facilities.  Seventy-seven percent of women reported receiving postnatal care by a skilled health provider but only 39 percent reported to receive the care within the first two days after delivery.  Only 44 percent of children under-5 were measured in the six months before the survey to determine their nutritional status.  Thirty-five percent of households reported having had a health-related financial shock in the 12 months preceding the survey. In Mokhotlong district, 49 percent of the household reported such shocks while Mafeteng the rate was 28 percent. Many of these households had to sell possessions or borrow from others in order to cover the healthcare costs that exceeded what the households could afford with their usual income. In  Almost all health centers offer the services targeted by the PBF program. However, about 18 percent of health centers reported to not provide delivery services. All health centers also report operating around the clock.  Structural quality is overall good. For example, almost all facilities have access to an improved source of water, all have safety boxes and high share of facilities have functioning toilet facilities and telecommunication abilities. 6  There is room for improvement practices of disposal of medical waste and sterilization of medical equipment. As well, 17 percent of MOH centers did not have soap and water available in all consultation rooms.  It is not uncommon for health centers to run out of supplies of very basic drugs and vaccines. For example, 21 percent of MOH centers and 25 percent of CHAL centers reported running out of paracetamol in the 30 days prior to the survey.  Responses of health providers to questions using clinical vignettes as well as exit interviews of patients suggest a big variation in actions taken by providers when treating common cases and potential lack of understanding or knowledge of treatment protocols by some providers. 7 1. Survey Methodology This report presents results from the baseline survey for the Maternal and Newborn Health Performance Based Financing Project in Lesotho. The baseline survey covers four districts: Mafeteng, Mohale’s Hoek, Mokhotlong and Thaba-Tseka. The PBF is implemented in health centers managed by the Ministry of Health (MOH) and Christian Health Association of Lesotho (CHAL). Table A.1 in the appendix shows the 2006 census population in terms of households for each of the catchment areas for health centers in the four districts. Lesotho is a small, mountainous kingdom, surrounded by the Republic of South Africa. The country is divided into 10 administrative districts and further divided into four ecological zones: Lowlands, Foothills, Mountains, and Senqu River Valley (Ministry of Health [Lesotho] and ICF International, 2016). This report occasionally uses a crude measure of the ecological zones and refer to the district of Thaba-Tseka and Mokhotlong as highland districts (Mokhotlong is entirely mountainous, whereas Thaba-Tseka is mostly mountainous except for the part of Senqu River Valley), and Mafeteng and Mohale’s Hoek as lowland districts (Mafeteng has lowlands and foothills whereas Mohale’s Hoek covers all four ecological zones). Figure 1-1: Administrative Districts of Lesotho Provided by MOH, Lesotho The baseline data consists of two main sources of data: 1) a household survey and 2) a facility- based survey. The HRITF survey instruments was used as a starting point and tailored to the Lesotho context. A local firm, Leads Services, was contracted to implement the baseline survey for the study, for both households and health centers. Leads Services was responsible for all aspects of the baseline survey implementation under the supervision and guidance of the research team. 8 The national Health Institutional Review Board authorized to conduct the survey on February 13th, 2015. 1.1. Household survey The household sampling follows a two-stage strategy. Enumeration areas (EAs) were initially defined by the 2006 census but in case the enumeration area covered two different catchment areas, the EA was split into smaller units defined by the catchment areas. First, EAs within the catchment area of each health center were ranked for listing by random drawing. In each of the villages in the EA ranked first, a dedicated listing team did a household listing, collecting information on the presence of women who were pregnant in the preceding two years and of adolescent females. The listing team did a complete listing whether eligible or not. In cases in which the EA had less than 80 households or if less than 18 eligible households for any of the two samples were listed, the next ranked EA was added. Listing was always done at the EA level, i.e. all households in the EA were listed unless a village was not found by the listing team. Second, up to 50 households were then randomly selected by the research team for survey. The selection of households was according to the following two criteria: (a) 25 households with at least one birth or pregnancy, regardless of the outcome of the pregnancy, in the two years preceding the survey; (b) 25 households with at least one adolescent girl. In cases with less than 25 eligible households listed, all eligible households were selected for the survey. The selection of the ‘recent pregnancy’ and of the ‘adolescent’ sample was done separately. However, in some cases, the same household was randomly selected for both samples. The overall selection probability of a household is the product of the selection probabilities of the two stages. # ℎℎ ℎ ℎ # ℎℎ = × # ℎℎ ℎ # ℎℎ The research team calculated the sample weights as the inverse of the selection probability. The survey instrument was administered to women in the sampled households. The main themes covered in the household survey include:  Socio-economic characteristics of the household  Health behaviors for MNH services  Health seeking behaviors, barriers to use and health service use  Household health expenditures  Fertility  Maternal health (recent pregnant sample)  Anthropometric of children less than five (recent pregnant sample)  Reproductive decisions  General experience with Health Center (adolescent sample)  General perceptions of health service quality  Interactions with VHWs Household survey team organization 9 Four field teams were trained to do the household survey and the survey was pre-tested before the implementation. Each team consisted of one supervisor and five interviewers. The interviewers reported directly to their supervisor, while the supervisors reported directly to the manager. Given the potentially sensitive topics related to reproductive health covered in the survey, all interviewers and supervisors were women. Final household sample The final household sample includes 2120 households. From these the research team was able to link 1252 female questionnaires and 972 adolescent questionnaires. Deleted from the raw sample were 41 female questionnaires and 9 adolescent questionnaires that could not be matched to a household roster. 1.2. Facility-based survey The facility survey was conducted in all MOH and CHAL health centers in the four districts, except for three randomly excluded health centers and one health center that was not accessible for the survey team. The facility-based survey includes multiple components; a facility assessment, health provider interviews, and patient exit interviews. Facility assessment module The facility assessment module collects data on key aspects of facility functioning and structural aspects of quality of care. The respondent for this module was the individual in charge of the health facility at the time when the survey team visited the health center. The main themes covered by the facility assessment include:  Facility staffing, including the staffing complement of the facility, staff on duty at the time of the survey team’s visit and staff present at the time of the survey team’s visit  Facility infrastructure and equipment  Availability of drugs, consumables and supplies at the health center  Supervision  Record keeping and reporting to the Health Management Information System (HMIS)  Facility management Health worker interview module A sample of up to three health providers with maternal and newborn health service delivery responsibilities at health facilities were interviewed as part of this module. The main themes covered include:  Role and responsibilities of the interviewed health worker  Staff satisfaction and motivation  Technical knowledge on Maternal and Newborn Health. This was assessed through the use of vignettes. Eligible health workers include doctors, nurses, midwifes, and any other health worker providing maternal and newborn care. However, no doctors were available for interview in the health centers. In facilities with less than three health workers on the staff roster, all eligible health workers were interviewed. Patient exit interviews 10 A sample of two caregivers of children less than five visiting the facility for curative care with (preferably) a new complaint were interviewed to record the patient’s experience and assess the patient’s perception of quality of care and satisfaction at all health centers. In addition to this, exit interviews were conducted with two (preferably) first time ANC clients. Health Facility survey team organization One field team was trained to conduct the facility survey and the survey was pre-tested before the implementation. The team consisted of two supervisors and two interviewers. The interviewers reported directly to their supervisor, while the supervisors reported directly to the manager. Final facility sample The final sample includes 53 health centers, 107 health provider interviews, 106 exit interviews with women who visited the health center for ANC, and 105 exit interviews with caregivers of children less than five who visited the health center at the day of the survey. 11 2. Descriptive Statistics - Household Survey 2.1. Background Characteristics of the Samples This section provides background information on the socio-demographic characteristics of the households and on the dwelling characteristics. Demographic Characteristics of Households Table 2.1.1 shows household composition. Households in the sample are composed, on average, by 5.9 members, about half of which are adults (older than 17 years). The households have on average 0.9 children under five. Households in Mokhotlong district are the largest with an average of 6.3 members and those in Mafeteng are smallest with an average of 5.7 members. An average of 1.7 household members are reported to be employed. Table 2.1.1: Household Composition HH HH head Children Children Adults AE1 Employed Sample members (% male) <5 5-17 > 17 HH size members District Thaba-Tseka 6.1 73.8 0.9 2.2 2.9 3.1 1.7 623 Mokhotlong 6.3 76.4 1.0 2.3 2.5 3.2 1.8 334 Mafeteng 5.7 58.2 0.8 2.0 2.8 3.0 1.6 625 Mohale’s 6.0 60.0 0.8 2.0 2.9 3.1 1.9 538 Hoek Total 5.9 64.3 0.9 2.1 2.8 3.0 1.7 2,120 Table 2.1.1: Household Composition The table includes households selected for both samples. 1) Adults equivalent (AE) is calculated using the following weights; 1 for the first adult, 0.5 for each subsequent household member age 14+, and 0.3 for all children less than 14 years of age Table 2.1.2 presents background characteristics of the sample of women aged 15-49 selected for a recent pregnancy. The sample used for the analysis of fertility preferences and family planning is a subsample of these women who are not currently pregnant and report to have a sexual partner (observations=894). The sample used for the analysis of maternal health outcomes is a subsample of these women with a live birth since January 2013 who are not currently pregnant (observations=1078). Note, in cases with more pregnancies since January 2013, the most recent live birth pregnancy is used. Table 2.1.2: Characteristics of Women aged 15-49 interviewed for a Recent Pregnancy Thaba-Tseka Mokhotlong Mafeteng Mohale’s All Miss. Hoek Obs. Age (mean) 27.2 28.2 26.0 26.1 26.6 0 Marital status Never married 9.4 7.1 20.3 27.0 17.8 16 Married 83.5 86.3 69.2 66.0 73.8 Divorced 2.4 3.4 6.0 4.9 4.7 Widowed 2.8 3.2 4.3 1.3 3.1 Other 1.9 0.0 0.3 0.7 0.6 12 Relationship to head of household Head 3.6 4.6 9.5 4.7 6.5 17 Spouse 61.8 74.8 32.4 36.0 45.5 Son/Daughter 12.5 11.0 24.7 28.9 21.4 Son/Daughter in-law 14.7 7.0 20.3 13.3 15.3 Grandchild 4.8 1.3 6.9 10.8 6.6 Other 2.6 1.4 6.1 6.3 4.8 Educational level Primary or less 62.8 65.7 43.3 44.2 50.6 19 Secondary 27.8 28.7 40.6 39.6 36.2 High school or more 9.4 5.6 16.1 16.3 13.2 Literate 94.5 90.4 96.7 96.8 95.2 31 Employment status Subsistence agriculture 26.0 24.7 7.3 13.9 15.0 29 Employed (other) 22.3 23.9 27.1 31.4 26.8 Looking for work 39.5 30.0 45.6 41.3 40.8 Unemployed, but not 3.5 18.1 11.5 12.3 11.6 looking for a job Other 8.6 3.3 8.5 1.2 5.7 Sample size 372 186 380 314 1252 Table 2.1.2: Characteristics of Women with a Recent Pregnancy Figure 2-1: Result of Recent Pregnancy The sample for this figure includes all women aged 15-49 interviewed for a recent pregnancy (1252) except 86 with missing information about the result of the pregnancy. 13 Table 2.1.3 shows the sample used for the child health section. This sample includes children of women in table 2.1.2. The survey team were supposed to interview all children less than five of the women selected for a recent pregnancy. However, this was not properly implemented in the beginning of the survey and part of the survey only includes information about the youngest of the children. The child sample is therefore restricted to the youngest child aged 0-35m. Table 2.1.3: Characteristics of most Recent Child less than 36 months of Women with a Recent Pregnancy Thaba-Tseka Mokhotlong Mafeteng Mohale’s All Miss. Hoek Obs. Gender (% male) 51.5 43.9 54.3 53.9 51.8 21 Age 0-11m 27.2 31.6 26.7 34.4 29.7 0 12-23m 59.9 47.6 51.6 40.8 49.3 24-35m 12.9 20.8 21.7 24.8 21.0 Relationship to head of household Son/Daughter 68.2 80.1 44.8 42.7 54.5 12 Grandchild 29.2 17.5 50.4 49.2 40.6 Other 2.6 2.4 4.8 8.1 4.9 Sample size 296 166 308 259 1,029 Table 2.1.3: Characteristics of Child Sample Table 2.1.4 shows the sample of adolescent girls. This sample is used for the section on adolescent fertility preferences. Table 2.1.4: Characteristics of Adolescent Girls Thaba- Mokhotlo Mafeteng Mohale’s All Miss. Tseka ng Hoek Obs. Age (mean) 14.8 14.9 14.9 15.0 14.9 5 Marital status Never married 99.4 100.0 99.2 98.8 99.2 42 Relationship to head of household Son/Daughter (incl. in-law) 66.9 74.9 58.6 56.6 61.0 Grandchild 21.4 18.7 32.1 33.4 29.6 Other 11.6 6.4 9.3 9.9 9.5 Educational level Primary or less 73.8 63.6 44.3 50.0 52.0 3 Secondary 24.7 31.9 49.0 45.2 42.8 High school or more 1.5 4.5 6.7 4.8 5.2 Literate 97.9 99.3 99.3 98.6 98.9 36 Employment status Employed 1.1 3.4 3.0 3.1 2.8 Looking for work 5.5 2.3 3.2 2.8 3.3 Unemployed, but not 91.5 92.8 93.5 93.0 93.0 looking for a job1 Other 2.0 1.5 0.3 1.1 0.8 14 Sample size 224 123 335 290 972 Table 2.1.4: Characteristics of Adolescent Girls 1) Not looking for a job includes being a student Housing Characteristics In Mafeteng and Mohale’s Hoek, households tend to reside in modern houses. However, in Mohale’s Hoek 22 percent of the households live in the traditional Rondavel. In Thaba-Tseka and Mokhotlong, the traditional Rondavels are the most common type of dwelling. Differences in material used for housing across districts in Lesotho are also observed (see figure A-1 and figure A-2 in the appendix). Table 2.1.5: Type of Dwelling Type of dwelling1 Number Number Sample Traditional Improved Rondavel Modern of rooms of rooms Size hut traditional house (per AE) hut District Thaba-Tseka 19.6 6.8 46.3 24.6 2.1 0.7 623 Mokhotlong 35.4 4.8 47.8 11.0 1.7 0.6 334 Mafeteng 2.9 1.8 7.6 73.8 2.7 1.0 625 Mohale’s 8.7 4.3 21.7 62.2 2.3 0.8 538 Hoek Total 12.7 3.7 24.3 52.1 2.3 0.8 2,120 Table 2.1.5: Type of Dwelling. 1) Excluded are answers labeled as ‘other’ Table 2.1.6 shows that overall 87.5 percent of households in the covered districts have access to improved source of water. However, 25 percent have an improved source of water more than 10 minutes away. Figure 2-2 shows that the most common source is a public tap or standpipe. Access to improved source of water within 10 minutes distance is more common in Mafeteng and Mohale’s Hoek. Treatment of drinking water is most commonly used in Thaba-Tseka with 15.8 percent boiling the water and an additional 3.7 percent straining the water before drinking it. Table 2.1.6: Household water source Access to improved Treatment of drinking water2 Sample source of water1 Size Within 10 More than 10 Boil Strain No treatment min distance min distance District Thaba-Tseka 58.9 22.8 15.8 3.7 78.9 623 Mokhotlong 55.0 32.9 6.6 0.5 86.8 334 Mafeteng 64.4 24.5 8.5 1.6 88.8 625 Mohale’s Hoek 67.1 21.6 3.9 1.0 94.8 538 Total 62.5 25.0 8.2 1.6 88.3 2,120 Table 2.1.6: Household Water Source 1) Improved water source includes piped into dwelling, piped into yard/plot, public tap / standpipe, tube well / borehole, protected well or spring, and bottled water. 2) Excluded categories are chlorine, filter and other 15 Figure 2-2: Main source of drinking water Table 2.1.7: Household Sanitation Access to improved Deal with rubbish2 Sample sanitation facilities1 Size Not shared Shared Thrown into Burn Thrown onto a pit street / public area District Thaba-Tseka 69.6 23.6 2.5 14.1 83.0 623 Mokhotlong 66.7 33.1 0.5 5.8 93.8 334 Mafeteng 71.7 12.4 4.5 21.6 73.1 625 Mohale’s Hoek 67.9 23.1 3.2 13.4 82.6 538 Total 69.7 19.9 3.2 15.6 80.6 2,120 Table 2.1.7: Household Sanitation 1) Improved sanitation includes flush to piped sewer or septic, ventilated pit, pit latrine with slab, and composting toilet. 2) Excluded categories are refuse collected and refuse buried Table 2.1.7 shows that 69.7 percent has access to improved non-shared sanitation with an additional 19.9 percent with access to improved shared sanitation1. Rubbish is mainly dealt with by throwing it onto the street or a public area. 1 The rate of improved sanitation is found to be much higher than reported in (Ministry of Health [Lesotho] and ICF International, 2016) 16 Figure 2-3: Type of toilet facility As seen in Table 2.1.8, the most common source of energy (for cooking and heating) is wood or charcoal with around three-in-four of households using it. Table 2.1.8: Household Source of Energy Energy used for cooking Energy used for heating Sample Size Kerosene/ Wood, Animal dung, Kerosene/ Wood, Animal dung, paraffin, gas, charcoal agricultural paraffin, gas, charcoal agricultural electricity, waste, shrubs/ electricity, waste, shrubs/ diesel straws diesel straws District Thaba-Tseka 8.6 85.6 5.7 7.8 78.0 14.2 623 Mokhotlong 6.4 84.9 8.7 2.9 79.2 17.9 334 Mafeteng 22.0 65.9 12.1 17.1 67.4 15.2 625 Mohale’s 15.7 74.5 9.8 7.5 78.8 13.3 538 Hoek Total 15.6 74.5 9.9 10.8 74.0 15.1 2,120 Table 2.1.8: Household Source of Energy 17 Figure 2-4: Durable goods Figure 2-4 shows possessions of durable goods. Mafeteng and Mohale’s Hoek (labeled as lowlands) are better off in terms of durable goods than Thaba-Tseka and Mokhotlong (labeled as highlands). For example, 82 percent of households in Mafeteng and Mohale’s Hoek own a bed, this is only 65 percent of households in Thaba-Tseka and Mokhotlong districts. The pattern seems consistent across all durable goods. Wealth Index This section has pointed out some clear differences between households in the four districts covered. These differences are likely to represent differences in wealth across the districts. For the purpose of the remaining analysis, a wealth index is created using principal component analysis (PCA). Included in the PCA are dummy variables for the following indicators:  Type of dwelling  Number of rooms per adult equivalent  Main material used for walls, rooftop, and floor  Access to improved source of water: Within 10 minutes or more than 10 minutes away  Access to improved sanitation facilities: Shared or non-shared  Source of energy: For cooking and heating  Procession of durable goods Table 2.1.9 : Wealth 1st 2nd 3rd 4th 5th All Quintiles District Thaba-Tseka 24.2 23.1 10.4 13.2 9.6 16.1 18 Mokhotlong 31.3 22.1 18.3 10.1 5.5 17.5 Mafeteng 25.8 32.0 45.3 50.7 56.6 42.1 Mohale’s Hoek 18.7 22.8 25.9 26.0 28.4 24.4 Sample Size 480 448 415 418 359 2,120 Table 2.1.9 : Wealth Quintiles Table 2.1.9 shows how, using the wealth quintiles, Mafeteng turns out as the wealthiest of the four districts while Thaba-Tseka and Mokhotlong are the poorest districts in the sample. The wealth quintiles are not directly comparable to the quintiles calculated for the LDHS2014 as it is sample specific. However, it is reassuring that it shows a consistent pattern with LDHS2014, where the majority of the population in Mokhotlong and Thaba-Tseka is in the lowest quintile and Mafeteng has the third highest percentages of its population in the highest quintile (after Maseru and Berea; two districts not covered in the baseline survey). Table A-2 in the appendix shows how housing characteristics are distributed by wealth quintiles. Health Expenditure 34.9 percent of the households in the sample reported experiencing a health related financial shock. This is defined as having a health expenditure that was higher than what the household could afford with its usual income in the past 12 months. Of the households that experienced such a shock, 27.6 percent reported having to sell possessions to cover the cost, 38.8 percent reported having to borrow money, and 6.6 percent reported receiving assistance (gifts). Table 2.1.10 : Health (A) (B) Expenditure Had a health Sample Had to sell Had to Received Sample related financial Size any borrow gift Size shock possessions District Thaba-Tseka 37.9 620 38.9 42.0 5.0 206 Mokhotlong 49.1 332 40.0 38.1 3.3 139 Mafeteng 27.5 624 15.6 38.4 9.4 165 Mohale’s Hoek 37.2 534 23.2 37.6 7.2 161 Wealth Quintiles 1st 37.4 479 25.4 36.4 4.8 146 2nd 39.9 447 28.8 43.6 7.8 162 3rd 36.8 412 30.1 40.2 6.1 147 4th 34.8 415 27.1 38.0 6.0 130 5th 27.6 357 26.0 34.2 8.4 86 Total 34.9 2,110 27.6 38.8 6.6 671 Table 2.1.10: Health Expenditure The reference period is 12 months. The table is divided in two; the first part (A) uses the full household sample, and the second part (B) uses the conditional sample of households that had a health related financial shock in past 12 months. 19 2.2. Maternal Health The maternal health section uses the sample of households with a member who was pregnant in the two years preceding the survey. The following analysis is restricted to pregnancies resulting in a live birth (after January 2013). Antenatal Care Antenatal care (ANC) by a skilled attendant is important to monitor the status of a pregnancy, to prevent or treat complications associated with the pregnancy, and to provide appropriate information and advice for a healthy pregnancy (Provision of effective antenatal care, 2006). All pregnant women should have at least four ANC visits throughout the pregnancy. The first one within the first trimester of the pregnancy and the last one in the last trimester (Pregnancy, childbirth, postpartum and newborn care: a guide for essential practice, 2003). Almost all women, 97.8 percent, attended at least one ANC visit. Only 36 percent initiated their antenatal care within the first three months of their pregnancy. On average, women were 4.2 months pregnant at their first visit. About 73 percent of the women had at least four consultations with the average number of consultations being 4.6. Seventy-seven percent reported having their last consultation in the last month of their pregnancy. Figure A-3 in the appendix shows that the modal number of ANC visits is the recommended four visits. Figure A-4 in the appendix shows that 21.1 percent had their first visit in the fourth months of pregnancy, i.e. one months after the recommended standards. Table 2.2.1: (A) (B) Number of (C) Timing Sample Antenatal visits Size Care at first visit Last visit in Number of last month Months at At least 4 pregnant Received First visit in first 3 last visit Months months visits visits ANC District Thaba- 99.4 4.8 81.3 4.2 35.1 8.7 84.7 333 Tseka Mokhotlong 97.8 4.5 68.4 4.0 43.0 8.6 66.4 170 Mafeteng 96.4 4.6 71.9 4.3 33.4 8.6 81.5 314 Mohale’s 99.2 4.7 72.1 4.4 35.4 8.7 72.9 261 Hoek Age <20 98.7 4.7 68.4 4.4 36.0 8.6 71.2 136 20-24 98.5 4.5 69.4 4.3 33.0 8.7 79.3 351 25-29 97.2 4.8 77.8 4.1 37.0 8.6 77.2 265 30-34 98.8 4.7 76.7 4.2 35.3 8.5 73.5 171 35+ 95.3 4.5 72.0 4.1 42.6 8.8 80.4 155 Educational level 20 Primary or 97.6 4.7 73.2 4.2 39.8 8.7 73.8 558 less Secondary 98.6 4.6 71.5 4.3 32.2 8.7 79.1 370 High school or 100.0 4.5 72.2 4.4 31.0 8.4 82.3 133 more Birth order 1 99.3 4.6 71.4 4.3 31.9 8.7 79.2 402 2 96.6 4.7 72.7 4.3 33.5 8.6 77.1 271 3+ 97.0 4.6 73.5 4.1 41.7 8.6 75.0 369 Wealth quintile 1st 97.2 4.7 65.8 4.4 35.7 8.7 76.9 261 2 nd 97.8 4.6 77.5 3.9 45.9 8.6 71.9 229 3rd 100.0 4.5 69.5 4.5 31.3 8.7 81.4 187 4th 95.0 4.7 76.7 4.2 35.4 8.7 77.6 220 5th 99.2 4.6 75.0 4.3 31.0 8.5 77.7 181 All 97.8 4.6 72.8 4.2 36.0 8.6 77.0 1,078 Table 2.2.1: Antenatal Care This table is divided in three parts; the first part (A) uses the full sample of women, part (B) and (C) are conditional on at least one ANC visit. The sample size column refers to the full sample of women. We have less than one percent missing information for the ANC variables. The ANC coverage level corresponds well to the national level reported in LDHS2014 (Ministry of Health, Lesotho and ICF International, 2016). LDHS2014 defines skilled ANC visits to include doctors and nurse/midwifes and report a coverage of at least one skilled visit to be 95 percent. In the baseline survey sample, 36 percent had their first visit during the first trimester compared to the national level of 41 percent and 77 percent had four or more visits compared to the national level of 74 percent. Figure 2-5 shows that ANC were provided either by a medical doctor (6.6 percent), a nurse or midwife (88.4 percent) or a nurse assistant (2.8 percent). 61.5 percent had their visit at a MOH health center and 14.6 percent at a CHAL health center. 16.9 percent went to a hospital for ANC visit. 21 Figure 2-5: Antenatal Care Visits The content of ANC is also very important in assessing the quality of services. Figure 2-6 shows that the majority of important tasks were done in more than 90 percent of the cases. The most pronounced exception is asking for blood type, however almost all women were asked to give a blood sample. In Mokhotlong, less than 65 percent of the women received advice on diet and on what to do in a case of emergency. Overall, Thaba-Tseka, Mafeteng and Mohale’s Hoek score around 90 percent on a content of care index (mean average across tasks); on average, a little less than 11 out of the 12 selected tasks were done during at least one ANC visit. In Mokhotlong, the level is less than 10 out of 12 tasks. 22 Figure 2-6: Content of Care (*) The calculated level of at least one ANC visit has been adjusted for missing observations. Table 2.2.2 shows that almost 98 percent of the sample were offered counseling and testing for HIV. This increases to more than 99 percent if we conditioning on women who had at least one ANC visit with a health provider. 99.3 percent of the tested women also received the result (data not shown). Tetanus toxoid injections are given during pregnancy to prevent neonatal tetanus. The level of women that received at least one injection is above 90 percent and conditional on an ANC visit, it is 93.9 percent. However, only 76 percent received two shots during the pregnancy. This level could partly be explained by coverage from previous pregnancies. The national rate reported in the LDHS 2014 is 74 percent. 2 Table 2.2.2: HIV, tetanus Thaba- Mokhotlong Mafeteng Mohale’s All and iron Tseka Hoek HIV testing and counseling Unconditional 98.6 95.2 97.3 99.5 97.6 Conditional on ANC visit 99.1 96.9 100.0 99.6 99.2 Tetanus injections 2 LDHS2014 defines protection against neonatal tetanus as either (1) two injections during the pregnancy, (2) two or more injections and the last one within 3 years of the birth, (3) three or more injections and the last one within 5 years of the birth, (4) four or more injections and the last one within 10 years of birth, or (5) five or more injections at any time prior to the birth 23 Unconditional 96.3 92.8 89.9 91.6 91.9 Conditional on ANC visit 96.8 94.5 93.3 92.3 93.9 At least 2 injections 74.4 72.4 78.0 76.5 76.0 Iron supplementation Mother-baby-pack 96.0 89.8 91.3 93.6 92.3 Other source 0.9 3.9 1.9 2.3 2.2 Either source 96.9 93.5 93.1 95.8 94.4 For at least 90 days 71.7 73.1 80.4 74.5 76.3 Sample Size 333 170 314 261 1,078 Table 2.2.2: HIV testing, protection against tetanus, and iron supplementation Pregnant women in Lesotho are supposed to receive a mother-baby-pack that among other things contains iron syrup or tablets. 92.3 percent of our sample received the mother-baby-pack and an additional 2.2 percent received iron from another source. In total, 94.4 percent of the pregnant women received iron supplement during their pregnancy. However, less than 80 percent reported taking it for 90 days or more. Delivery Table 2.2.3 shows that 77 percent of deliveries are attended by a skilled health provider, and 77 percent of deliveries are at a formal health facility. This is similar to the national level of 77 percent in LDHS 2014. A skilled health provider is defined as either a medical doctor or a nurse/midwife. An additional 2.7 percent of deliveries are attended by a nurse assistant, and 4.3 percent by a village health worker or a traditional healer. The remaining 16 percent were attended by family, friends or no one. 45 percent delivered at a hospital and 28 percent at either a MOH or CHAL health center. Variations were observed across districts, with 64 percent of women in Thaba-Tseka delivering at a health center compared to the overall level of 28 percent. Family, friends or no one are assisting in 22 percent of deliveries in Mokhotlong. Some variation were also observed across age with the younger age group more likely to deliver in a formal health facility. The most pronounced variation is observed across educational level, birth order and wealth quintile. Hospital delivery is highly correlated with being in the wealthier quintiles and the difference between the poorest and wealthiest quintile is 23 percentage points for deliveries in a formal health center. The difference for primary level of education versus high school or more is 20 percentage points, and 23 percentage points for first time pregnancies vs. third or higher rank pregnancies. 24 Table 2.2.3: Who assisted with the delivery? Where did you deliver? Sample Delivered at formal skilled provider Deliveries Size Delivered by a health facility Medical Nurse or Nurse Village Family, Government Health Other Provider’s doctor midwife assistant health friends Hospital Center health home or worker or none (MOH or facility own home or assisting CHAL) tradition al healer District Thaba-Tseka 12.6 65.8 6.4 3.3 11.6 78.4 13.5 63.6 5.3 17.2 80.4 333 Mokhotlong 8.4 63.9 1.0 5.1 21.6 72.3 49.8 20.6 1.9 26.6 71.2 170 Mafeteng 17.3 62.0 1.3 4.2 15.2 79.3 54.9 19.0 4.2 19.3 76.9 314 Mohale’s 15.6 60.2 3.9 4.6 15.7 75.8 49.0 25.2 3.8 21.2 77.2 261 Hoek Age <20 15.6 63.0 4.1 5.4 12.0 78.6 48.1 31.2 1.2 18.8 80.5 136 20-24 17.6 65.0 1.9 3.0 12.4 82.5 50.2 27.9 4.4 16.5 82.3 351 25-29 11.8 60.3 3.2 6.1 18.4 72.1 42.4 28.6 3.3 24.1 73.1 265 30-34 13.7 61.6 3.1 4.2 17.6 75.2 46.2 23.4 6.8 20.7 71.7 171 35+ 11.0 61.3 1.9 4.0 21.7 72.4 38.5 30.1 1.9 27.5 70.3 155 Educational level Primary or 10.0 58.8 2.9 6.1 22.1 68.8 34.9 30.6 2.8 29.1 67.1 558 less Secondary 16.1 68.3 3.2 3.1 9.0 84.5 57.9 26.7 2.6 12.5 86.9 370 High school 29.7 62.3 0.4 1.4 6.2 92.0 59.3 20.0 12.3 7.4 87.5 133 or more Birth Order 1 17.5 70.0 3.3 2.1 7.0 87.5 57.2 28.2 3.7 10.1 88.7 402 2 12.7 62.2 2.2 4.7 18.0 75.0 46.2 26.8 2.5 23.2 74.5 271 3+ 12.9 54.9 2.0 5.9 24.3 67.8 35.1 28.5 4.0 30.0 65.9 369 Wealth Quintile 25 1st 6.0 57.7 0.4 8.0 27.8 63.8 27.6 31.5 2.2 37.3 60.1 261 2 nd 9.8 61.1 2.9 5.5 20.7 70.9 35.7 33.8 1.8 26.3 71.3 229 3rd 12.3 72.4 6.4 2.6 6.3 84.7 59.2 27.7 2.7 10.4 88.5 187 4th 20.7 61.7 2.4 1.9 13.0 82.5 53.5 25.6 2.3 14.7 81.4 220 5th 24.2 60.6 1.6 3.2 10.2 84.8 55.8 20.6 10.5 13.1 83.3 181 All 14.4 62.6 2.7 4.3 16.0 76.9 45.8 28.0 3.8 20.8 76.5 1,078 Table 2.2.3: Deliveries 26 Around one-in-five of the women did not deliver in a formal health facility. To address factors that potentially prevent women from institutional deliveries, the household survey asks those women why they did not deliver in a formal health facility. . Figure 2-7 shows the difference in institutional deliveries by the height of the bars. Within the bars, the level for selected explanations are indicated. Figure 2-7: Why didn’t you deliver in a formal health facility? In Mokhotlong, with the highest percentage of women who did not deliver in a formal health facility, more than half of the women explained that it was too late in pregnancy. In addition, 27 percent report that it was too far and 22 percent that it was too expensive. Overall, around 20 percent of the women find it too expensive to deliver in a formal health facility. Postnatal Care Postnatal checkups provide an opportunity to assess and treat delivery complications and to counsel mothers on how to care for themselves and their babies. Most maternal and infant deaths occur in the first month after birth: almost half of postnatal maternal deaths occur within the first 24 hours and 66% occur during the first week. WHO recommends postnatal care in the first 24 hours after births as well as a total of four visits in the first six weeks after birth (Postnatal Care for Mothers and Newborns: Highlights from the World Health Organization 2013 Guidelines , 2015). Overall, 78 percent of the women receive at least one postnatal check. The level is 77 percent if restricted to PNC by a skilled health provider defined as either a medical doctor (9.1 percent), a nurse or midwife (65.5 percent) or a nurse assistant (2.4 percent). Conditional on receiving at least one PNC check by a skilled health 27 provider, the average number of checks is a little less than two. Only 39 percent receive a check within the crucial first two days of delivery, conditional on at least one visit. This is much lower than the national level reported in LDHS2014 (with an unconditional level of 61 percent). The level is 91.4 when looking within 7 days. 7 days is also the modal observation (data not shown). Table 2.2.4: (A) (B) Postnatal Care Received Received Number Days after First visit First visit PNC skilled of visits delivery within 2 within a PNC days of week of delivery delivery District Thaba-Tseka 84.7 83.7 1.9 7.5 33.3 89.1 Mokhotlong 60.1 59.3 1.9 7.9 37.0 77.1 Mafeteng 87.0 86.2 1.8 4.6 45.8 96.9 Mohale’s Hoek 71.5 70.2 2.0 6.4 29.6 93.8 Age <20 82.4 81.6 1.7 5.7 37.5 90.7 20-24 75.5 75.1 1.9 5.1 40.0 95.5 25-29 80.1 79.0 2.0 7.5 35.6 86.6 30-34 80.2 78.8 1.8 4.8 41.9 93.4 35+ 72.9 71.4 1.8 6.9 38.7 92.0 Education level Primary or less 70.4 69.2 1.8 6.7 38.0 87.1 Secondary 84.6 83.9 1.9 5.6 38.3 95.8 High school or 88.4 87.7 1.9 4.2 42.4 96.8 more Birth order 1 83.0 82.7 1.9 5.26 39.5 94.4 2 75.8 75.0 1.8 5.05 45.1 95.2 3+ 73.8 72.3 1.9 7.41 34.8 86.3 Wealth quintile 1st 63.4 61.7 1.8 7.24 37.3 84.8 2nd 69.7 68.8 1.8 5.61 42.4 92.8 3rd 82.5 82.4 1.9 6.00 39.0 92.1 4th 85.4 84.2 1.7 5.79 41.0 95.4 5th 90.2 89.6 2.0 5.34 34.7 93.2 All 77.8 76.9 1.9 5.94 38.8 91.9 Table 2.2.4: Postnatal Care For PNC indicators, we observe much variation across wealth quintiles with 28 percentage point difference between the poorest and wealthiest quintile for at least one skilled PNC check. The same indicator shows a 19 percentage point difference between women with primary or less education versus high school or more, and 10 percentage point difference between first time birth and three or more births. 28 Figure 2-8: Postnatal Care Visit Figure 2-9 shows explanations given by women who did not have a postnatal care visit. The cost of the service is given as an explanation in less than 3 percent of the cases (data not shown). The common answers given are: it was too far, the women were too busy, or thought that the check was not needed. This indicates that to increase coverage, more information about the importance of a PNC check is needed in order to have the women prioritizing spending time on a visit. 29 Figure 2-9: Why didn’t you have a postnatal care visit? 30 2.3. Child health Information on growth monitoring and vaccination coverage was collected in the household survey for children under age five of women with a recent pregnancy. The subsample of children aged 7-35 months is used for growth monitoring and children aged 12-35 months is used for vaccination coverage. If a woman has more than one child in the age range, the youngest is included in the sample used to calculate the statistics. Growth Monitoring Malnutrition is an underlying cause of childhood diseases and early identification and proper management is therefore highly important. Less than half (43.5 percent) of the children aged 7-35 months were measured in the past 6 months before the survey. Among these children, around half only had their weight measured. The majority of the children were measured at a health center. However, in Mohale’s Hoek 48 percent were measure by a village health worker. According to the mothers’ recall, the result of the growth measurement were in 94 percent of the cases green (child is well nourished), in 5 percent of the cases yellow (the child is at risk for acute malnutrition), and 1 percent of the measured children were categorized as red (indicates severe acute malnutrition). Table 2.3.1: Methodb Facilityb Sample Measureda Growth Sizea monitoring Health Center (MOH Other health facility Height and weight Provider’s home Village Health Government Weight only Height only or CHAL) Hospital Worker MUAC District Thaba-Tseka 54.6 1.7 35.2 56.4 6.7 2.0 55.3 11.3 24.8 5.3 278 Mokhotlong 29.1 0.0 39.0 50.0 11.0 18.2 40.1 7.1 22.3 4.3 160 Mafeteng 43.6 2.0 54.1 41.8 2.1 14.2 38.4 4.7 28.5 14.2 295 Mohale’s 47.4 3.0 53.5 42.4 1.1 7.9 31.1 2.3 48.2 6.7 246 Hoek Total 43.5 2.0 48.6 45.7 3.8 10.7 39.8 5.6 32.4 9.3 979 Table 2.3.1: Growth monitoring a) The sample includes children aged 7-35 months. b) The sample is conditioned on being measured. Vaccination Coverage The vaccination schedule up to the age of one in Lesotho is comprised of: 1) BCG given at birth or at first contact 2) Polio 0 given from birth to two weeks of age 3) Polio and Pentavalent given at six weeks (dose 1), ten weeks (dose 2), and fourteen weeks (dose 3) (interval between doses is 30 completed days) 4) Measles given when a child has completed 9 months of age 31 Since late 2008, pentavalent has been given to infants in Lesotho. This vaccine is DPT combined with other antigens that protect against hepatitis B and Haemophilus influenza type b. However, in many cases it was observed that the Bukana mentions DPT instead of Pentavalent. This was not communicated well enough to the survey team and the data reports a level of pentavalent coverage that do not represent the true level in Lesotho. For the purpose of this report, the pentavalent level is not shown but is referred to as the level of polio I, II, and III. According to the vaccination schedule, the polio vaccines and pentavalent are to be given at the same visit to the health center. The assumption is that the level of pentavalent coverage is similar to the level of polio coverage. This assumes that the pentavalent vaccine is not more likely to be out of stock at the health centers than the polio vaccine. Table 2.3.2 shows that almost all children have a Bukana. However, in 20.3 percent of the cases the Bukana was not available at the time of interview. Table 2.3.2: Bukana Thaba- Mokhotlong Mafeteng Mohale’s All Sample Tseka Hoek size Yes (seen) 73.3 77.9 78.5 80.7 78.1 525 Yes (not seen) 26.5 17.1 20.2 18.8 20.3 140 No 0.2 5.0 1.3 0.6 1.6 8 Sample Size 205 106 199 163 673 Table 2.3.2: Bukana Table 2.3.3 shows the vaccination coverage. A child is considered to have received all basic vaccinations, if the child received a BCG (against tuberculosis), at least three doses of polio vaccine (assumed three doses of pentavalent), and one measles vaccine. Table 2.3.3: Vaccinations Coverage BCG Polio 3+ polio Measles All None Sample basic Size District Thaba-Tseka Bukana 70.6 72.5 70.5 57.4 55.1 0.2 207 Recall 26.4 27.3 14.4 26.2 14.4 0.4 Total 97.0 99.8 84.9 83.6 69.5 0.6 Mokhotlong Bukana 75.1 75.1 68.4 60.0 57.1 0.0 109 Recall 19.8 20.3 6.0 20.3 5.3 3.3 Total 94.9 95.4 74.4 80.3 62.4 3.3 Mafeteng Bukana 79.1 79.6 75.7 72.4 70.6 0.5 193 Recall 13.9 14.4 8.4 13.5 8.3 5.5 Total 93.0 94.0 84.1 85.9 78.9 6.0 Mohale’s Hoek Bukana 81.4 81.4 76.9 74.5 72.1 0.4 159 Recall 17.6 17.7 11.6 17.1 11.3 0.5 Total 99.0 99.1 88.5 91.6 83.4 0.9 Age 12-23 Bukana 77.8 78.5 73.9 67.8 65.3 0.5 492 Recall 18.3 18.7 8.6 17.8 8.3 2.0 32 Total 96.1 97.2 82.5 85.6 73.6 2.5 24-35 Bukana 77.0 77.0 73.4 68.9 67.3 0.0 176 Recall 16.9 17.4 12.1 17.2 11.9 5.6 Total 93.9 94.4 85.5 86.1 79.2 5.6 Total Bukana 77.6 78.1 73.8 68.2 65.9 0.3 668 Recall 17.9 18.3 9.7 17.6 9.4 3.1 Total 95.5 96.4 83.5 85.8 75.3 3.4 Table 2.3.3: Vaccination Coverage The vaccination coverage for children age 12-23month is 5.6 percentages points higher than the national level reported in LDHS2014. Vaccination coverages are similar to LDHS2014 for Thaba-Tseka and Mafeteng and higher for Mokhotlong and Mohale’s Hoek. Vaccination coverage reported in LDHDS2014 for Mohale’s Hoek is 65 percent, compared to 84 in this sample (data not shown). 33 2.4. Fertility Preferences & Family Planning Information on fertility preferences allows for an understanding of the desire for children and — in combination with data on contraceptive use— the demand for family planning methods. Due to the selection of the sample, unmet demand is not estimated in this report. . The nationally representative level for unmet need for family planning among currently married women is estimated in LDHS2014 to 18.4 percent. The total demand for family planning is estimated in LDHS2014 to 78.6 percent. This section will provide information about fertility preferences and contraceptives used for the sample of women with a recent pregnancy. The sample is restricted to include women who report to have a sexual partner and are not currently pregnant. It is likely that this will exclude some women with a husband living and working outside the country. In general, it is important to keep in mind that these women are selected for maternal health purposes and the sample is not representative of all women aged 15-49. For this reason, a direct comparison to LDHS2014 is not possible. The report finds a higher level of approval and use of contraceptives compared to LDHS2014. Table 2.4.1: Fertility If you could choose for yourself, how long would you wait Sample preferences from now until the birth of your next child? Size Would not Less than More than No more Have not wait two years two years children decided District Thaba-Tseka 0.8 4.4 69.4 15.1 10.3 276 Mokhotlong 0.4 4.4 74.6 13.5 7.1 134 Mafeteng 0.1 2.0 64.1 20.2 13.6 274 Mohale’s Hoek 2.5 1.6 67.9 23.5 4.6 210 Age Group 15-19 3.3 3.4 72.4 6.9 14.0 88 20-24 0.3 3.4 74.9 8.0 13.4 298 25-29 0.9 0.8 72.7 17.0 8.6 230 30-34 0.0 4.2 61.8 25.8 8.2 147 35-39 0.5 0.7 53.4 43.3 2.1 85 40+ 2.9 6.8 34.0 54.4 2.0 46 Number of living children 0 1.7 1.7 73.9 6.4 16.2 34 1-2 0.9 3.0 72.8 10.8 12.5 580 3-4 0.5 1.4 61.0 33.4 3.7 202 5+ 0.6 4.8 45.6 46.2 2.7 78 Time since last pregnancy <1 year 0.4 0.7 65.9 22.0 11.0 118 1-2 years 0.9 2.3 69.7 14.4 12.6 355 2-3 years 0.6 3.8 64.5 24.8 6.4 292 >3 years 2.8 0.0 66.0 19.0 12.1 66 Educational level Primary or less 1.1 4.7 64.8 22.3 7.0 474 34 Secondary 0.6 1.0 71.5 15.4 11.4 302 High school or 0.4 0.0 70.1 12.0 17.5 105 more Wealth quintile 1st 0.3 3.7 68.3 19.5 8.2 219 2 nd 0.3 4.5 64.1 20.8 10.3 181 3rd 2.4 1.2 68.9 15.9 11.7 161 4th 1.1 4.3 65.8 23.7 5.1 180 5th 0.2 0.1 71.7 14.6 13.3 153 Total 0.8 2.8 67.8 18.9 9.7 894 Table 2.4.1: Fertility preferences 3.6 percent of the sample wants another child soon (within less than two years) – this compares to 14.9 percent in LDHS2014. 67.8 percent of women want to wait more than 2 years compared to 25 percent in LDHS2014. In the sample, less than 20 percent do not want any more children whereas the level in LDHS2014 is 56 percent. It is likely that the younger IE sample explains much of the difference to the national level in LDHS2014. Table 2.4.2: Contraceptives Approve of Currently using Currently using Sample contraceptives any FP method modern FP Size District Thaba-Tseka 93.3 73.2 70.5 276 Mokhotlong 97.5 85.8 84.8 134 Mafeteng 98.1 81.0 80.8 274 Mohale’s Hoek 96.5 77.6 77.6 210 Age Group 15-19 94.4 75.9 75.9 88 20-24 95.5 76.8 75.9 298 25-29 98.2 83.3 82.1 230 30-34 98.2 81.3 80.5 147 35-39 99.6 85.1 85.1 85 40+ 92.5 73.5 73.5 46 Educational Level Primary or less 96.0 77.2 76.2 474 Secondary 96.6 80.6 80.4 302 High school or more 100.0 86.4 85.9 105 Wealth Quintile 1st 95.2 75.8 75.8 219 2 nd 96.5 81.6 80.4 181 3rd 95.6 75.4 74.1 161 4th 98.1 81.4 80.2 180 5th 98.7 84.9 84.9 153 Fertility Preferences Would wait less than 2 years 84.2 80.5 78.4 37 35 Would wait more than 2 years 97.2 78.7 78.1 591 Would not have more children 97.7 81.7 81.7 173 Total 96.8 79.8 79.1 894 Table 2.4.2: Contraceptives Figure 2-10 shows the current use of contraception by method. Injectables are the most commonly used method of contraception. Figure 2-10: Current use of Contraception Table 2.4.3 shows that among women who are currently not using any contraceptive methods, 4.4 percent report that they do not themselves approve of contraceptives, and 13.8 reports that their partner or other family members do not approve. Forty-four percent report that they did use contraceptive previously and 14.4 percent that they are about to start using contraceptives. 36 Table 2.4.3: Ever Why are you currently not using any method to delay or avoid getting pregnant? 1 Sample Contraceptives (sample of used? Size women not currently Would like to Does not Partner or Not available Scared of No No need2 About to get pregnant approve family does side-effects knowledge of start using) not approve any method District Thaba-Tseka 42.8 1.1 8.3 24.7 1.7 5.4 2.7 34.9 13.9 79 Mokhotlong 44.5 0.0 5.4 9.2 21.1 15.9 2.6 36.5 0.0 23 Mafeteng 43.9 4.8 1.2 11.1 17.5 9.3 2.7 26.0 22.6 54 Mohale’s Hoek 44.9 1.2 5.3 10.2 3.4 5.5 0.0 50.4 9.9 41 Age Group 15-19 13.7 0.0 0.0 5.7 24.5 0.0 3.4 44.0 12.6 20 20-24 43.4 0.8 4.6 12.3 17.2 7.7 1.5 33.4 16.9 62 25-29 38.0 8.3 3.3 17.9 3.5 8.1 0.0 30.9 20.8 52 30-34 62.9 0.0 1.1 20.0 3.1 13.1 0.9 44.3 5.2 28 35+ 60.1 2.2 15.1 10.4 0.0 12.8 7.0 31.0 8.8 35 Education Primary or less 46.4 3.2 5.8 17.0 8.4 6.1 1.7 36.5 11.5 120 Secondary or more 40.0 1.4 2.8 9.2 14.0 11.4 2.4 34.8 18.3 74 Wealth Quintile 1st 44.4 1.2 7.6 16.1 5.9 9.8 0.6 36.4 13.8 63 2nd 42.8 1.4 5.8 17.7 12.1 4.2 4.3 38.6 13.0 36 3rd 40.3 0.0 0.0 13.3 26.7 6.4 0.0 38.5 15.2 37 4th 45.1 11.0 1.8 9.7 4.9 9.5 0.0 30.9 13.8 35 5th 49.3 0.0 6.8 10.1 0.0 12.4 6.6 31.9 16.3 26 Total 44.0 2.4 4.4 13.8 10.7 8.3 2.0 35.7 14.4 197 Table 2.4.3: Contraceptives (sample of women not currently using) 1) Excluded category is labeled as other. 2) ‘No need’ includes reasons as lactational amenorrhea, hysterectomy, menopausal, infecund and lives apart. 37 2.5. Adolescent Fertility Preferences There is an interest in reproductive health of adolescents, both from a health and social perspective. Although adolescents aged 10-19 years account for 11 percent of all births worldwide, they account for 23 percent of the overall burden of disease (disability- adjusted life years) due to pregnancy and childbirth (http://www.who.int /maternal_child_adolescent/topics/maternal/adolescent_pregnancy/en/). Fourteen percent of all unsafe abortions in low- and middle-income countries are among women aged 15–19 years, and adolescents are more seriously affected by complications than are older women. For example, stillbirths and death in the first week of life are 50 percent higher among babies born to mothers younger than 20 years than among babies born to mothers 20–29 years old. In addition, girls who become pregnant often leave school with potentially long-term implications for them as individuals, their families and communities. (http://www.who.int /maternal_child_adolescent/topics/maternal/adolescent_pregnancy/en/). The sample of adolescents provides an opportunity to address their reproductive decisions and fertility preferences. Table 2.5.1: What age is a good Ideal According to you, in a couple, Sample Reproductive age to have the first number how should the number of Size decisions child? of children be decided?1 children Woman Man at age 50 Woman Man Both District Thaba-Tseka 20.2 22.7 3.2 23.8 36.4 39.8 224 Mokhotlong 22.3 25.0 3.2 31.5 39.6 28.9 123 Mafeteng 21.1 23.3 2.9 31.9 31.4 36.6 335 Mohale’s Hoek 21.6 23.6 2.7 39.1 34.6 26.3 290 Age Group <15 21.1 23.5 3.0 32.6 36.6 30.7 376 15 21.4 23.3 2.8 32.1 32.7 35.2 288 >15 21.2 23.5 2.9 33.2 31.1 35.7 303 Education Level Primary or less 21.2 23.4 3.0 33.4 37.7 28.9 545 Secondary 21.4 23.5 2.8 32.8 29.6 37.6 383 High school or 20.5 23.2 3.1 24.4 28.1 47.5 41 more Wealth Quantiles 1st 20.7 23.1 3.2 29.6 44.6 25.7 182 2nd 21.0 23.3 2.9 32.8 31.9 35.3 201 3rd 21.7 23.9 2.9 28.6 33.4 38.0 197 4th 21.2 23.3 2.8 41.3 32.4 26.2 207 5th 21.3 23.4 2.8 29.1 30.2 40.7 185 Total 21.2 23.4 2.9 32.6 33.8 33.6 972 Table 2.5.1: Reproductive Decisions 1) This variable contains 3 percent missing values Note that 2.9 preferred number of children at age 50 is lower than the estimated total fertility rate in LDHS2014 of 3.3. 38 Table 2.5.2 shows that 56.3 percent of the adolescents would wait more than two years before the birth of their first child (38.8 percent have not decided). 98.3 percent say that it would be a big problem to be pregnant now (data not shown). Table 2.5.2: If you could choose for yourself, how long would you wait from Sample Fertility now until the birth of your first child?1 Size preferences Would not Less than two More than Does not Have not wait years two years want children decided District Thaba-Tseka 1.0 7.9 52.3 0.5 37.5 197 Mokhotlong 4.9 5.2 59.8 1.6 28.6 55 Mafeteng 0.2 1.4 57.3 1.0 40.1 189 Mohale’s 0.7 2.8 56.8 0.0 39.6 134 Hoek Age Group <15 0.5 2.4 61.7 0.3 35.1 232 15 0.4 2.9 52.5 0.0 44.1 160 >15 1.3 4.6 52.6 2.0 38.9 180 Education Level Primary or 1.2 4.1 53.8 0.2 40.5 321 less Secondary 0.4 2.7 58.5 1.2 37.0 227 High school or 0.0 0.0 59.0 1.8 39.3 25 more Wealth Quantiles 1st 1.4 6.0 59.8 0.0 32.3 123 2 nd 1.2 2.9 52.5 0.6 42.9 109 3rd 0.0 6.9 46.0 0.6 46.1 106 4th 0.5 0.8 58.5 0.0 40.2 122 5th 0.9 1.6 62.0 2.1 33.4 115 Total 0.8 3.2 56.3 0.8 38.8 575 Table 2.5.2: Fertility preferences 1) This variable includes 35 percent missing values. This is due to a misunderstood skip pattern in the questionnaire. Table 2.5.3 shows if the adolescents have received information about family planning methods by selected categories. 53 percent of the sample does not mention to have talked to either a health worker, LPPA, a village health worker, friends or family, or a teacher about family planning methods. 87 percent of the sample report to approve of family planning methods. Table 2.5.3: Have any of the following ever talked to you about Approves Sample Family family planning methods? of FP Size planning Health LPPA Village Friends or Teacher1 methods worker health family worker District 39 Thaba-Tseka 6.2 2.8 2.8 8.2 0.5 88.6 224 Mokhotlong 6.6 5.0 6.2 14.2 0.0 87.9 123 Mafeteng 8.9 6.3 8.1 22.0 16.3 88.3 335 Mohale’s 8.2 4.8 3.5 14.9 8.1 84.4 290 Hoek Age Group <15 5.6 3.0 2.4 13.9 9.1 87.6 376 15 8.9 7.7 7.0 19.1 5.0 86.8 288 >15 10.7 6.0 9.5 20.0 17.3 87.1 303 Educational Level Primary or 6.1 3.6 5.2 15.3 4.5 86.4 545 less Secondary 9.0 6.4 5.7 17.7 16.1 88.4 383 High school 20.7 13.0 14.8 35.3 21.7 85.5 41 or more Wealth Quantiles 1st 5.3 2.9 2.8 7.4 2.7 84.8 182 2nd 6.6 3.8 2.7 15.4 10.6 87.7 201 3rd 6.1 2.1 7.8 15.8 11.3 86.8 197 4th 7.5 5.7 8.6 18.8 7.0 85.9 207 5th 13.5 10.3 6.5 25.4 17.0 90.2 185 Total 8.1 5.3 5.9 17.3 10.4 87.2 972 Table 2.5.3: Family Planning (adolescents) 1) In the questionnaire it is not specifically asked whether a teacher provided the information. The adolescent has to explicitly mention this in order to have the information recorded. The adolescent questionnaire included a section on knowledge assessment. One of the questions was ‘Which are effective methods of contraception?’ Figure 2-11 shows the answers provided by the adolescents. The questionnaire only allows for a yes or no answer and it is therefore possible that missing observations could be interpreted as don’t know. The height of the bar in figure 2-11 shows the level of answers for each option. Conditional on an answer provided, the orange bar indicates the level who answered yes. 40 Figure 2-11: Knowledge of effective methods of contraception Overall, 85 percent of adolescents recognize oral contraceptives, injections, and condoms as effective methods of contraceptives. The level is lower for IUD (68 percent). Twenty-three percent report breastfeeding to be effective and 30 percent says that withdrawal is an effective method of contraceptive. 41 3. Descriptive Statistics - Facility Survey This chapter starts with an overview section that follows the structure of the health center quarterly quality checklist used in the context of the Performance-Based Financing pilot. This section is followed by a more in-depth analysis of the baseline data from the 53 surveyed health centers; this includes data from the health provider interviews. The last section looks into patient reports from the exit interview. 3.1. Quality indicators The following indicators are chosen based on the quarterly quality checklist for health centers (from November 2015) and adapted to the baseline survey questionnaire. Part A: General Services Part A: General Services By type By district All MOH CHAL TT MOK MAF MH Staff is correctly managed Staff meeting is 83.3 86.4 80.0 75.0 93.8 84.6 84.6 conducted monthly All staff have written 38.7 45.5 43.8 0.0 43.8 61.5 41.5 job descriptions Staff performance has 46.4 38.1 46.7 62.5 31.3 40.0 42.9 been assessed internally in past year Health center has access 96.8 100.0 100.0 100.0 100.0 92.3 98.1 to improved water source Health center has access 93.5 100.0 100.0 87.5 93.8 100.0 96.2 to official phone line Consultation room Equipped with a safety 100.0 100.0 100.0 100.0 100.0 100.0 100.0 box Posted procedures of 41.9 31.8 56.3 87.5 18.8 7.7 37.7 decontamination Water source and soap 83.9 100.0 87.5 100.0 93.8 84.6 90.6 The health center did 90.3 95.5 75.0 100.0 100.0 100.0 92.5 not ran out of disinfectants (in past 30 days) Patient Safety Medical waste is 67.7 59.1 75.0 75.0 56.3 53.8 64.2 disposed according to standards1 Sterilization is done 86.7 90.9 81.3 87.5 93.8 91.7 88.5 according to standards2 Posted procedures 3.3 4.5 0.0 0.0 6.3 7.7 3.8 Patients have access to 86.7 95.5 93.3 100.0 100.0 69.2 90.4 functioning toilet facility Sample Size 31 22 16 8 16 13 53 42 Table 3.1.1: General Services 1) Burned and outsourced are accepted as appropriate standards. 2) Dry-heat sterilization, autoclaving, steam sterilization, chemical method and outsources are accepted as appropriate standards. Part B: Primary Care Services Part B: Primary Care By type By district All Services MOH CHAL TT MOK MAF MH Patient amenities There is a reception and 100.0 100.0 100.0 100.0 100.0 100.0 100.0 a waiting room There is a room with 100.0 86.4 100.0 100.0 81.3 100.0 94.2 privacy for patients There is a room for 36.7 31.8 46.7 37.5 43.8 7.7 34.6 minor surgery Service availability ANC 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Delivery 90.0 71.4 78.6 75.0 93.8 76.9 82.4 PNC 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Family planning 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Immunization 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Growth monitoring & 100.0 100.0 100.0 100.0 100.0 100.0 100.0 nutritional advice Tuberculosis, STI & HIV 100.0 100.0 100.0 100.0 100.0 100.0 100.0 Laboratory services 100.0 85.7 86.7 100.0 93.8 100.0 94.1 Equipment is available and functional1 General equipment 85.5 86.8 82.5 92.5 86.3 86.2 86.0 ANC 99.4 100.0 100.0 100.0 100.0 98.5 99.6 Delivery 80.0 83.0 75.2 98.2 75.9 84.5 81.2 Delivery (intensive care) 53.4 51.9 48.5 65.9 55.1 46.5 52.8 PNC and Newborn care 78.6 76.2 70.0 78.1 79.7 84.1 77.6 Stock of drugs and contraceptives are adequate2 General drugs 81.5 80.4 74.3 92.1 76.2 88.3 81.0 Vaccines 82.0 86.5 60.9 78.5 96.9 93.9 83.9 Contraceptives 78.2 79.5 77.5 85.0 83.6 71.5 78.6 National guidelines are available IMCI 93.3 81.8 86.7 87.5 100.0 76.9 88.5 Graphs for growth 100.0 90.9 100.0 100.0 100.0 84.6 96.2 monitoring Vaccination 96.7 86.4 86.7 100.0 93.8 92.3 92.3 Family planning 93.3 68.2 100.0 100.0 68.8 69.2 82.7 ANC 96.7 95.5 93.3 100.0 100.0 92.3 96.2 Delivery 96.7 90.9 93.3 87.5 100.0 92.3 94.2 PNC 83.3 72.7 93.3 75.0 75.0 69.2 78.8 43 Newborn care 76.7 77.3 100.0 75.0 62.5 69.2 76.9 National health 10.0 18.2 0.0 0.0 31.3 15.4 13.5 strategy Immunization processes are in order Vaccines are stored 100.0 95.5 100.0 100.0 93.8 100.0 98.1 appropriately in fridge Temperature in 93.3 86.4 86.7 87.5 93.8 92.3 90.4 vaccination fridge is within standard range Sample Size 31 22 16 8 16 13 53 Table 3.1.2: Primary Care Services 1) The indicators are defined as the average availability of functional equipment across the selected items shown in figure 3-12, 3-13, 3-14, 3-15, and table 3.7.1, respectively. 2) Stock of drugs and contraceptives are defined as adequate if the items have not been out of stock in the past 30 days. The indicators are defined as the average across items shown in figure 3-9, 3-10, and 3-11. Part C: Community Services Part C: Community By type By district All Services MOH CHAL TT MOK MAF MH Health center has an 80.6 80.0 60.0 71.4 93.8 92.3 80.4 estimate of the size of the catchment area Village Health Workers At least one visit a 36.7 52.4 42.9 12.5 50.0 53.8 43.1 month Specially assigned 80.6 68.2 81.3 75.0 50.0 100.0 75.5 village health supervisor There is a Health Center 96.8 86.4 100.0 87.5 87.5 92.3 92.5 Executive Committee Representative of VHC 93.3 100.0 100.0 85.7 92.9 100.0 95.9 Representative of 96.7 100.0 100.0 85.7 100.0 100.0 98.0 community A least one meeting a 64.3 40.0 61.5 50.0 25.0 83.3 55.8 month Written records of 96.7 77.8 100.0 85.7 76.9 91.7 89.6 meetings Sample Size 31 22 16 8 16 13 53 Table 3.1.3: Community Services 44 3.2. General information 66 percent of MOH health centers have had a major investment in infrastructure in either 2013 or 2014. Overall health facilities in Lesotho provide services round-the-clock with the only exception of one health center in Mafeteng. At some point in the seven days preceding the survey, 17 percent of the health centers had experienced disconnection from the water system, 28 percent had an electric power outage and 37 percent had a lack of telephone services. Most of the health centers in Thaba-Tseka and Mohale’s Hoek have a functioning computer whereas it is only one in four of the health centers in Mokhotlong and one in three of the health centers in Mafeteng. Table 3.2.1: General By District Missing information obs Thaba-Tseka Mokhotlong Mafeteng Mohale’s Hoek Last major investment in 61.5 83.3 69.2 63.6 10 infrastructure (2013/14) 24 hours services 100.0 100.0 93.8 100.0 0 Any time in last 7 days 12.5 12.5 31.3 8.3 1 with no water Electric power outage in 56.3 25.0 6.3 23.1 0 the last 7 days No telephone services in 56.3 14.3 20.0 46.2 2 past 7 days Access to a functioning 86.7 25.0 33.3 100.0 2 computer Access to functioning 37.5 12.5 43.8 46.2 0 transportation Sample Size 16 8 16 13 General information By Type Missing obs MOH CHAL All Last major investment in 65.5 71.4 67.4 10 infrastructure (2013/14) 24 hours services 100.0 96.0 98.1 0 Any time in last 7 days 10.0 27.3 17.3 1 with no water Electric power outage in 29.0 27.3 28.3 0 the last 7 days No telephone services in 41.4 31.8 37.3 2 past 7 days Access to a functioning 60.0 71.4 64.7 2 computer Access to functioning 35.5 40.9 37.7 0 transportation Sample Size 31 22 53 Table 3.2.1: General information 45 All health centers report referring patients to other facilities. Figure 3-1 shows some selected services that are referred. Only 38 percent of the health centers have access to functioning transportation that can be used to transport patients to a referral facility. Figure 3-1: The Health Center refer the following to other facilities Most of the health centers report to have a reception and waiting room, room with privacy for patients, and heating during the winter. Only around one-in-three of the health centers report to have a room for minor surgery. 46 Figure 3-2: Patient amenities Figure 3.3 shows the level of health centers that report to have information for patients publicly posted. 47 Figure 3-3: Patient Information 48 3.3. Services Figure 3-2: Services Offered Overall, the facilities are likely to offer all main MCH services except for delivery services (see figure 3-2). In CHAL facilities in the districts of Thaba-Tseka and Mokhotlong (highlands districts) only 43 percent of the facilities provide delivery services. In the districts of Mohale’s Hoek and Mafeteng (lowlands districts) the level is around 85 percent for both MOH and CHAL facilities. We now turn to tables that describe in more detail what is included in the different services provided. These tables are divided according to the following MCH services: child health including immunization, family planning, and maternal health including ANC, PNC, and deliveries. Included is also a section on laboratory services. Data on service availability are collected in two separate main sections in the facility assessment. The main part of the following tables are oral reports from the head of facility (or most informed staff) in combination with utilization coverage from the HMIS system. The interviewer asked the head of facility if the service is offered (in-facility or as outreach) and then verified the number of patients per service from the HMIS. This section provides information on a more detailed level. For example, for delivery it is not asked in general if delivery services are provided, it is asked specifically if the health center offers a) Spontaneous vaginal delivery, b) Assisted delivery, c) Home delivery, d) C-section. In addition, we have oral reports from the facility head from a general section about services. This section asks questions in general terms about services. For example, are delivery services offered in the health center? Figure 3-2 reports the level based on this general information 49 whereas the following is mainly based on the detailed information from HMIS - whenever data is from the general section it will be marked with a * and when inconsistencies are found this will be mentioned in the text. Child Health All health centers offer in-facility growth monitoring and nutritional advice. The outreach availability varies across districts and type of facility: 100 percent outreach availability in Mohale’s Hoek and only 43 percent of facilities in Mokhotlong – and 83 percent versus 75 percent for MOH facilities and CHAL facilities. All facilities also report in-facility immunization services and around 70 percent report immunization outreach activities. Again, Mokhotlong has the lowest outreach activity with less than 20 percent of MOH facilities and none of CHAL reporting immunization done outside the facilities. However, 63 percent of facilities in Mokhotlong have outreach work plans. Service availability does not vary noticeable by vaccine (see figure 3-3). 98 percent of all health centers provide a Bukana with an immunization schedule. Table 3.3.1: Available By District Missing Services – Child Health obs Thaba-Tseka Mokhotlong Mafeteng Mohale’s Hoek Growth monitoring & nutritional advice In-facility availability 100.0 100.0 100.0 100.0 4 Outreach availability 92.9 42.9 66.7 100.0 4 Days per week 4.5 5.0 2.9 3.2 5 Immunization In-facility availability 100.0 100.0 100.0 100.0 5 Outreach availability 83.3 12.5 66.7 100.0 5 Days per week 3.0 3.3 1.1 2.0 6 Outreach work plan* 73.3 62.5 6.3 30.8 1 Bukana* 100.0 87.5 100.0 100.0 1 Sample Size 16 8 16 13 Available Services – By Type Missing Child Health obs MOH CHAL All Growth monitoring & nutritional advice In-facility availability 100.0 100.0 100.0 4 Outreach availability 82.8 75.0 79.6 4 Days per week 4.0 3.3 3.7 5 Immunization In-facility availability 100.0 100.0 100.0 5 Outreach availability 71.4 70.0 70.8 5 Days per week 2.2 2.0 2.1 6 Outreach work plan* 53.3 22.7 40.4 1 Bukana* 96.7 100.0 98.1 1 50 Sample Size 31 22 53 Table 3.3.1: Available Services – Child Health Figure 3-3: Immunization by vaccine Family Planning The level of family planning services is only conducted for the MOH health centers. All MOH health centers report offering family planning services; in particular, all health centers provide contraceptive pills, injections and male condoms as an in-facility services. The outreach availability for these methods is around 80 percent, with Mokhotlong showing the lowest level of activity. The availability for implant insertion is a little lower, with in-facility availability around 90 percent and 50 percent as an outreach service. IUD is provided in a little less than 60 percent of the health centers, and sterilization is a very uncommon service. Table 3.3.2: Available MOH Health Centers Missing Services - Thaba- Mokhotlong Mafeteng Mohale’s All obs Contraceptives Tseka Hoek In-facility Contraceptive pill 100.0 100.0 100.0 100.0 100 2 Injection 100.0 100.0 100.0 100.0 100 3 Implant insertion 90.0 100.0 50.0 100.0 89.3 3 Male condoms 100.0 100.0 100.0 100.0 100 3 IUD 50.0 20.0 50.0 88.9 57.1 3 Female sterilization 0.0 0.0 0.0 11.1 3.6 3 Male sterilization 0.0 0.0 0.0 0.0 0.0 3 Outreach Contraceptive pill 90.0 40.0 80.0 100.0 82.8 2 Injection 88.9 40.0 80.0 100.0 81.5 4 Implant insertion 55.6 0.0 50.0 75.0 50.0 5 Male condoms 80.0 40.0 80.0 100.0 78.6 3 Days per week 51 Sample Size 10 6 6 9 31 Table 3.3.2: Available Services - Contraceptives Maternal Health All health centers report providing antenatal care services in the general section. The following table shows service availability divided by in-facility and outreach. In Mohale’s Hoek only 83.3 percent of the health centers report ANC as an in-facility service, however the outreach level is reported to be 91 percent. Ninety-two percent of the health centers prescribe iron and folate routinely (78 percent is verified by records) and all health centers provide a Bukana with a section on pregnancy. All MOH health centers offer spontaneous vaginal delivery services while the level for CHAL health centers is 86 percent. Only one of the health centers reports having the capacity to manage emergency caesarian sections and none of the facilities offer home delivery services. Note that the general level in figure 3-2 for deliveries is lower. I.e. when asked if the health center offers delivery services some health centers answers no, although they do have spontaneous vaginal deliveries at the facility. All health centers report to offer postpartum services. However, as for ANC some facilities in Mohale’s Hoek report to offer this exclusively as an outreach service. Table 3.3.3: Available By District Missing Services – Maternal Thaba- Mokhotlong Mafeteng Mohale’s Health Tseka Hoek Antenatal Care In-facility availability 100.0 100.0 100.0 83.3 4 Outreach availability 86.7 33.3 64.3 90.9 7 Days per week 4.3 2.3 3.1 2.9 9 Iron and folate* 92.9 87.5 93.8 92.3 2 (verified by records) (64.3) (62.5) (93.8) (84.6) Bukana* 100.0 100.0 100.0 100.0 2 Postnatal Care In-facility availability 100.0 100.0 100.0 91.7 3 Outreach availability 66.7 14.3 69.2 80.0 7 Days per week 4.9 4.7 4.4 3.8 10 Delivery Spontaneous vaginal 100.0 85.7 93.8 91.7 2 delivery Assisted delivery 12.5 0.0 0.0 0.0 4 Home delivery 0.0 0.0 0.0 0.0 7 C-section 6.3 0.0 0.0 0.0 4 Sample Size 16 8 16 13 Available Services – By Type Missing Maternal Health MOH CHAL All Antenatal Care In-facility availability 96.6 95.0 95.9 4 Outreach availability 77.8 68.4 73.9 7 52 Days per week 3.5 3.1 3.3 9 Iron and folate* 96.7 85.7 92.1 2 (verified by records) (80.0) (76.2) (78.4) Bukana* 100.0 100.0 100.0 2 Postnatal Care In-facility availability 100.0 95.2 98.0 3 Outreach availability 63.0 61.1 62.2 7 Days per week 4.9 4.0 4.6 10 Delivery Spontaneous vaginal 100.0 85.7 94.1 2 delivery Assisted delivery 3.3 5.3 4.1 4 Home delivery 0.0 0.0 0.0 7 C-section 0.0 5.3 2.0 4 Sample Size 31 22 53 Table 3.3.3: Available Services – Maternal Health Laboratory All MOH health centers report providing laboratory services as well as 86 percent of the CHAL health centers. The following figure shows for the facilities with laboratory services, the percentages of facilities that are able to do a specific test today or in the past 3 months. The number in the figure refers to the following tests: 1: White cell and red cell counts 2: Hemoglobin estimation 3: Blood type and cross match 4: Tuberculosis 5: Gram stains 6: HIV testing 7: CD4 count 8: Hepatitis B testing 9: Hepatitis C testing 10: Syphilis testing 11: Urine protein and glucose test 12: Pregnancy test 13: Blood sugar test 14: Stool tests for parasites 15: Stool tests for occult blood 16: Liver functioning testing 53 Figure 3-4: Laboratory tests 3.4. Administration and Management Table 3.4.1 shows some selected indicators for the administration and management in the health centers. 77 percent of the health centers have a facility work plan for the current financial year. Of these facilities, 80 percent identifies ANC as a priority for the fiscal year, 85 identifies deliveries as a priority, 72 percent identifies PNC, 54 percent identifies family planning, 77 percent identifies integrated management of child illness, and 82 percent identifies immunization as a priority. On average the health centers had 5 staff meetings in the past 3 months and in 42 percent of the health centers, all staff members have a written job description. 72 percent of the health centers had their overall performance assessed externally in the past year, while staff performance has been assessed externally in 46 percent of the health centers. Table 3.4.1: By district Missing Administration and Thaba- Mokhotlong Mafeteng Mohale’s management Tseka Hoek Facility work plan (verified) 75.0 62.5 81.2 84.6 0 (37.5) (37.5) (68.8) (61.5) Priority health-related activities (conditional sample) 54 ANC 91.7 75.0 75.0 72.7 2 Delivery 100.0 75.0 75.0 81.8 2 PNC 83.3 75.0 50.0 81.8 2 Family planning 58.3 75.0 41.7 54.5 2 IMCI 91.7 75.0 75.0 63.6 2 Immunization 91.7 75.0 83.3 72.7 2 Number of facility staff 6.2 4.8 4.3 4.5 1 meetings in past 3 months All staff have written job 43.8 0.0 43.8 61.5 0 descriptions Supervisions in past 3 months by: Hospital representative 62.5 62.5 6.3 38.5 0 DHMT representative 40.0 100.0 80.0 76.9 2 Performance of facility 80.0 85.7 60.0 69.2 3 assessed externally (in past year) Staff performance assessment (in past year) Internally 46.7 62.5 31.3 40.0 4 Externally 56.3 37.5 46.7 38.5 1 Sample Size 16 8 16 13 Administration and By type Missing management MOH CHAL All Facility work plan (verified) 77.4 (51.6) 77.3 (54.5) 77.4 (52.8) 0 Priority health-related activities (conditional sample) ANC 79.2 80.0 79.5 2 Delivery 83.3 86.7 84.6 2 PNC 70.8 73.3 71.8 2 Family planning 66.7 33.3 53.8 2 IMCI 75.0 80.0 76.9 2 Immunization 79.2 86.7 82.1 2 Number of facility staff 5.3 4.6 5.0 1 meetings in past 3 months All staff have written job 38.7 45.5 41.5 0 descriptions Supervisions in past 3 months by: Hospital representative 45.2 31.8 39.6 0 DHMT representative 74.2 65.0 70.6 2 Performance of facility 80.0 60.0 72.0 3 assessed externally (in past year) 55 Staff performance assessment (in past year) Internally 46.4 38.1 42.9 4 Externally 56.7 31.8 46.2 1 Sample Size 31 22 53 Table 3.4.1: Administration and management 97 percent of MOH health centers and 86 percent of CHAL health centers have executive committees. Figure 3-5 shows the composition of these committees. Most committees have a Village Health Worker representative and a community leader representative. Rarely is there a representative from the ministry of health, from CHAL or the district health management team. Figure 3-5: Representatives in Health Center Executive Committees 3.5. Hygiene and patient safety Table 3.5.1 shows that almost all facilities surveyed has access to improved water source at the health center. Only one health center reports using a village tap. Overall, 17 percent of the health centers report that there was a time in the preceding seven days with no water availability. Table 3.5.1 further shows access to functioning toilets, separated by gender. 90 percent of the health centers have functioning toilets. Table 3.5.1: Water By Type By District All source and toilet MOH CHAL TT MOK MAF MH facilities Access to improved 96.8 100.0 100.0 100.0 100.0 92.3 98.1 water source (piped into facility/plot) 56 Any time with no available 10.0 27.3 12.5 12.5 31.3 8.3 17.3 water (in past 7 days) Access to functioning 86.7 95.5 93.3 100.0 100.0 69.2 90.4 toilet facility (separated for male and female) Sample Size 30 22 15 8 16 13 52 Table 3.5.1: Water source and toilet facilities All health centers report having consultation rooms. The following figure shows the percentages for [1] having a safety box or closed container for disposal of used sharps, [2] having posted procedures for decontamination, and [3] having a basin with a water source and soap. Figure 3-6: Patient Safety – Consultation Room Four health centers in the sample ran out of disinfectants in the past 30 days and had no disinfectants for 30 out of these 30 days. The following figure shows what kind of sterilization methods are used by the health centers. Boiling is not recommended for sterilization. 57 Figure 3-7: Patient Safety – Procedure used for Sterilizing before Reuse 58 3.6. Drugs, contraceptives and supplies The following table shows how drugs are stored at the health centers. All MOH health centers and 82 percent of CHAL health centers store drugs in separate rooms. However, only one in four of the health centers uses an area that looks clean and dry with protection from sunlight. More than 90 percent of the facilities have maintained stock registers. Table 3.6.1: Drug storage By Type Missing MOH CHAL All Separate room only used for drugs with 100.0 81.8 92.2 2 doors and windows that can be locked Area looks clean and dry and windows 25.0 27.3 26.0 3 can be covered to keep sunlight out Drugs kept on an elevated platform 100.0 100.0 100.0 2 Stock register maintained 96.3 90.9 93.9 4 Sample Size 31 22 53 Table 3.6.1: Drug Storage Figure 3-8 shows the storage method that the health centers report to have. Figure 3-8: Vaccine Storage Ninety-seven percent of health centers logged the temperature twice a day for the past week and 92 percent of the observation were in the range of 2-8 degrees Celsius. 59 The following figures show the availability of (1) selected general drugs, (2) selected vaccines and (3) selected family planning methods. The height of the bar indicates the level of non- missing observations. The percentages within the bars indicate the level of health centers that have been out of stock in the past 30 days for the selected item. Figure 3-9: Out of Stock – General drugs 60 Figure 3-10: Out of stock - Vaccines Figure 3-11: Out of Stock – Family Planning Methods 61 3.7. Equipment This section shows the level of available and functioning equipment for 1) selected general equipment, 2) selected equipment for ANC, 3) selected equipment for delivery, 4) selected equipment for delivery (intensive care), 5) selected equipment for PNC and newborn care. Figure 3-12: General Equipment Table 3.7.1: Equipment and MOH CHAL All Missing diagnostic kits - Antenatal Care Equipment: Examination table/bed 100.0 100.0 100.0 0 Fetoscope 100.0 100.0 100.0 0 Blood pressure instrument 100.0 100.0 100.0 0 Tape measure 100.0 100.0 100.0 0 Adult weighing scale 96.8 100.0 98.1 0 Diagnostic kits: Out of stock in past 30 days HIV testing kit 39.3 36.4 38.0 3 Pregnancy testing kit 26.9 22.7 25.0 5 Rapid plasma reagin (RPR) test 54.5 55.0 54.8 11 Urine protein & glucose testing kit 36.0 23.8 30.4 7 Sample Size 31 22 53 62 Table 3.7.1: Equipment and diagnostic kits - Antenatal Care Figure 3-13: Equipment - Delivery Figure 3-14: Equipment – Delivery (Intensive Care) 63 Figure 3-15: Equipment – Newborn Care 3.8. Health Providers On average, the health centers report having 7.3 authorized positions and 6.5 filled positions. The following figure shows the level by health provider category. Few health centers report having more filled positions than authorized positions for some categories. 64 Figure 3-16: Authorized and Filled Position For each health center, the baseline survey included up to three health provider interviews. Forty-seven percent of these interviews are with a trained nurse or midwife and the remaining 53 percent with a nurse assistant. Based on information from the health provider interviews, the following figure shows the percentages of health providers who have provided (1) curative consultation for children, 2) family planning consultation, 3) ANC, 4) PNC and 5) deliveries in the past 3 months. 65 Figure 3-17: Selected Activities in past 3 months The following figure shows for selected subjects, the most recent time the health provider received in-service training. This training only includes training received after undergoing professional education. The selected subjects are the following; 1) IMCI, 2) Family planning, 3) ANC, 4) Deliveries, 5) Newborn care, 6) PNC, 7) Nutrition and growth monitoring, 8) Immunization. 66 Figure 3-18: Health Provider Training Staff knowledge: For the purpose of the health provider knowledge assessment, this report presents four case scenarios; the first three cases assess the health providers’ knowledge related to IMCI guidelines in high HIV prevalence settings and case 4 is an ANC scenario. The case scenarios do not ask for the specific diagnosis but for actions and recommendations that the health provider would take in these cases. In the first scenario the health provider is informed that a 25 months old child with diarrhea and fever has not eaten/drunk since yesterday and has two of the danger signs; she is lethargic and a skin pinch goes back very slowly. The health provider is explicitly told that it is a low malaria area and there is no cholera. In Thaba-Tseka and Mokhotlong, around half of the health providers mention urgent referral to hospital. The level is lower in the districts of Mafeteng and Mohale’s Hoek (around 30 percent). Seventy percent of CHAL health providers in the lowlands districts and 81 percent of MOH health providers would start IV treatment. This level is lower in the highlands district. In the Lowlands CHAL health centers, 87 percent of the health providers would initiate oral rehydration salts (ORS) at the facility, followed by 66 percent in Lowlands MOH facilities, 53 percent in Highlands MOH facilities, and 37 percent in highlands CHAL facilities. A little more than 70 percent of health providers in the lowlands prescribe ORS for home treatment, the level in highlands is less than 50 percent. 67 Figure 3-16: Case Scenario #1 The level of health providers that would inject one dose of an injectable antibiotic varies from around 20 percent in CHAL health centers in Thaba-Tseka and Mokhotlong to around 50 percent in MOH health centers in the same districts. . Less than 30 percent of health providers in Thaba-Tseka and Mokhotlong mention to treat to prevent low blood sugar whereas around 70 percent of the health providers in Mafeteng and Mohale’s Hoek do that. Health providers who mention that they would recommend continuing breastfeeding is also higher in Mafeteng and Mohale’s Hoek compared to Thaba-Tseka and Mokhotlong. The second case presented is of a 29 months old with fever and ear discharge. There is no other symptom or malaria in the area. Assessment of the child confirms the fever and reveals a stiff neck and an area of tenderness behind the right ear. More than 90 percent of health providers in MOH and around 85 percent of health providers in CHAL prescribe or administer antibiotic. Overall, 44 percent would refer urgently to a hospital. 68 Figure 3-17 Case Scenario #2 In the third case, the health provider are informed that a 13 months old child has been coughing for 5 days (no stridor or wheezing) and had fever since last night. The assessment confirm 38.80C and shows fast breathing and chest in-drawing. Figure 3-18: Case Scenario #3 69 The ANC case scenario is a 30-week pregnant woman who has attended the antenatal clinic three times. All findings were within normal limits until her last antenatal visit in the prior week. At that visit, it was found that her blood pressure was 130/90 mm Hg., her urine was negative for protein. The fetal heart sounds were normal, the fetus was active and uterine size was consistent with duration of the pregnancy. She has come to the clinic, as requested, for follow-up. The following figure shows the danger signs mentioned by the health provider that requires the woman to go immediately to the hospital or health center. The majority of the health providers recognize vaginal bleeding, severe headache, blurred vision, lightheadness, dizziness, and blackouts as a danger sign. In Mafeteng and Mohale’s Hoek convulsions is also mentioned as a danger sign by 75 percent of health providers in MOH health centers and 67 percent of CHAL health centers. Convulsion is only mentioned by around 40 percent of the health providers in Thaba-Tseka and Mokhotlong, which is fewer than providers mentioning abdominal pain or to feel ill as a danger sign. Figure 3-19: Case Scenario #4 3.9. Exit Interviews For each health center, the baseline survey included two exit interviews with women who went for ANC and two exit interviews with caregivers of children less than 5 who visited the health center at the day of interview. Half of the ANC sample is a first time visit while 1 out of 3 children is a first time visit for that particular illness. In 91 percent of the child sample, the mother took the child to the health center. All interviewed women and caregivers report to have their or their children’s Bukana with them to the health center (98 percent is confirmed by the interviewer). 70 ANC: The Tetanus Toxoid (TT) vaccine is given during the pregnancy to prevent the risk of tetanus for mother and baby. According to the Bukana, 50 percent of the women has a record of one tetanus injection and 47.1 percent has a record of two or more injections. This leaves 2.9 percent with no record, with the highest level of no injection in Mokhotlong (5.9 percent) and the lowest level in Mafeteng where all women have at least one record of an injection. When the women are asked about TT injections, 7.6 percent report that they never had an injections and 34 percent report that the health provider did not ask about TT injections. Only 34 percent of the Bukana mention the women’s blood group. The following figure shows some indicators for content of care for ANC as reported by the women in the exit interview. Most women report to have their weight and height measured and to have their blood pressure measured. Few women were asked about their blood type, however most women gave a blood sample. Figure 3-20: Content of Care - ANC The exit interview also asks the women if the health provider talked with them about danger signs for the pregnancy. 30 percent of the women report that a health provider did not inform about danger sign, neither at this visit nor at previous visits. The exit interview also asks the women to mention the danger signs that they know of. The following figure shows the level of awareness of danger signs in pregnancies. Vaginal bleeding is the most commonly cited danger sign with 64 percent of the women mentioning it. 71 Figure 3-21: Content of Care – Awareness of danger signs Overall, 57 percent of the women discussed family planning methods with the health provider during their ANC visit. The following figure shows the family planning methods discussed where the numbers refer to; [1] Sterilization (male or female), [2] Injectables, [3] Implants, [4] Contraceptives pill, [5] Condoms (male or female), [6] other modern method, and [7] any traditional method. 72 Figure 3-22: Family Planning Child Care: The following figure shows some indicators for content of care for the child sample as reported by the caregiver in the exit interview. 72 percent of the children were weighed whereas only 41 percent had their height measured. 70 percent of the children either had their weight or height compared against a growth chart. 73 Figure 3-23: Content of care – growth monitoring’ The exit interviews includes 24 children aged 12-23months. According to the Bukana, they all received the BCG vaccine, Polio 0, and 3 doses of pentavalent. Time and satisfaction: The most time consuming aspect of visiting the health center is the transportation. On average, the patients that participated in the exit interview spent one hour and 40 minutes on transportation. The worst situation is in Mokhotlong where the patients spent more than 2 hours on average to get to the health facility. 88.6 percent walked to the health center and 6.6 percent took a public bus. On average, the waiting time at the health center was one hour and 20 minutes. The longest waiting time is in Mafeteng where patients waited on average two hours for their consultation. Despite the long waiting time in Mafeteng, the consultation time was on average less than 10 minutes. In Mohale’s Hoek that has the shortest waiting time (one hour) the consultation took the longest (17 minutes). On average, patients spent more than half an hour longer to get to a MOH health center compared to CHAL, and the waiting time was also around 10 min longer. Average consultation time is 13 minutes for both types of facilities. In the interview, the patients/caregivers were asked if they thought the waiting time was too long. Forty percent agreed with this statement (data not shown). 74 Table 3.9.1 By type By district All MOH CHAL Thaba- Mokhotl Mafeten Mohale’s Tseka ong g Hoek Time Transportation time 114 78 109 160 58 86 100 Waiting time 86 77 67 103 122 66 83 Consultation time 13 13 12 10 9 17 13 Important reasons to choose this health center Location close to home 84.7 97.6 89.1 73.3 96.8 92.3 90.0 Trust in providers / high 26.6 27.1 10.9 26.7 41.3 28.8 26.8 quality of care Availability of drugs 5.6 5.9 1.6 3.3 11.1 5.8 5.7 Other 6.5 2.4 4.7 13.3 0.0 5.8 4.8 Sample Size 64 31 64 52 211 Table 3.9.1: Time and satisfaction Despite the long transportation time, 90 percent of the patients / caregivers mention location close to home as one of the two most important reason for choosing the health center. This is by far the most common reason provided. A little more than one out of four mentioned trust in providers or high quality of care. The third most common reason is availability of drugs. However, this is only mentioned by 6 percent of the interviewed. 75 Appendix Table A.1: Catchment population District Catchment area MOH/CHAL Catchment Estimated HHs w. Estimated HHs w. Population (HHs)1 recent birth2 an adolescent3 Thaba-Tseka Auray HC CHAL HC 820 132 102 Bobete HC MOH HC 3313 900 695 Ha Lephoi HC CHAL HC 1130 197 131 Ha Mokoto HC MOH HC 1112 215 74 Ha Popa CHAL HC 661 141 149 Katse HC MOH HC 328 78 53 Khohlo-Ntso HC MOH HC 928 78 49 Linakeng HC MOH HC 979 204 87 Manamaneng HC MOH HC 1179 191 247 Methalaneng HC MOH HC 1530 353 176 Mohlanapeng HC CHAL HC 1495 316 173 Montmartre HC CHAL HC 1662 496 248 Sehong-Hong MOH HC 1158 269 181 Semenayane MOH HC 1571 321 304 St Theresa HC CHAL HC 1696 484 142 Thaba-Tseka HC MOH HC 1459 267 222 All 21,021 4642 3033 Mokhotlong Libibing HC MOH HC 1740 427 333 Linakaneng HC MOH HC 1077 375 351 76 Malefiloane HC MOH HC 2470 582 456 Mapholaneng HC CHAL HC 4434 1338 1029 Moeketsane HC MOH HC 1133 217 190 Molikaliko HC MOH HC 3010 1060 721 St James HC CHAL HC 1498 786 504 St Martin HC CHAL HC 1014 206 192 Tlhanyaku HC MOH HC 2787 876 617 All 19,163 5867 4393 Mafeteng Emmaus HC CHAL HC 3141 906 509 Kole HC CHAL HC 2645 684 476 Leco-op HC MOH HC 6152 1483 989 Litsoeneng HC MOH HC 4832 1232 900 Malea-Lea HC MOH HC 685 174 98 Masemouse HC CHAL HC 1088 422 218 Matelile HC CHAL HC 2813 414 301 Motsekuoa HC CHAL HC 2514 735 580 Mount Olivet HC CHAL HC 1515 585 210 Mount Tabor HC CHAL HC 1394 449 272 Ribaneng CHAL HC 1217 416 223 Samaria HC CHAL HC 4513 2310 1075 Sekameng HC MOH HC 1869 578 372 St Andrew HC CHAL HC 960 323 333 Thaba Tsoeu HC MOH HC 1874 457 571 Thabana-Morena MOH HC 2073 777 379 Tsakholo HC HC MOH HC 3851 1180 870 All 43,136 13125 8376 Mohale’s Hoek Bethel HC CHAL HC 507 152 65 Holy Cross HC CHAL HC 2873 613 473 77 Kuebunyane HC MOH HC 2017 431 327 Liphiring HC MOH HC 689 139 67 Lithipeng HC MOH HC 2863 404 439 Mofumahali Oa MOH HC 3287 430 635 Mohalinyane Rosari HC HC MOH HC 1253 485 260 Mootsinyane HC MOH HC 1199 179 217 Morifi HC MOH HC 2356 424 224 Mpharane HC MOH HC 4087 719 474 Nkau HC MOH HC 3166 881 441 Nohana HC MOH HC 5243 921 1121 Phamong HC MOH HC 1282 210 234 Ha Tsepo HC CHAL HC 3444 964 827 All 34,266 6952 5804 Total 117,586 30,586 21,606 Table A.1: Catchment population 1) Catchment population calculated from 2006 population census. 2) Estimated number of households with recent birth is calculated as number of households times the estimated share of households with recent birth (information from listing). 3) Estimated number of households with an adolescent is calculated as number of households times the estimated share of households with an adolescent (information from listing). 78 Figure A-0-1: Main material used for (a) Walls and (b) Rooftop Figure A-0-2: Main material used for Floor 79 Table A.2: Housing 1st 2nd 3rd 4th 5th characteristics across Wealth Quintiles Type of dwelling Traditional hut 27.0 15.1 12.5 7.1 1.6 Improved traditional hut 4.7 4.5 4.0 3.9 1.5 Rondavel 41.5 40.3 21.5 11.9 6.0 Modern house 21.2 34.5 52.9 68.1 84.5 Water source Non-improved and more than 10 9.6 6.5 6.2 8.9 6.2 min away Non-improved and within 10 min 8.2 6.1 4.4 2.8 1.8 Improved and more than 10 min 24.8 23.9 28.7 23.6 20.3 away Imporved and within 10 min 57.3 63.4 60.8 64.8 71.7 Sanitation Non-improved and shared 0.6 2.5 2.7 2.0 4.3 Non-improved and not shared 1.0 2.4 3.2 5.8 5.3 Improved and shared 8.5 9.6 11.7 11.5 15.8 Improved and not shared 89.8 85.4 82.4 80.7 74.5 Material (floor) Bricks or blocks 0.9 1.3 2.2 1.2 2.8 Tiles / slates 0.0 0.5 1.8 6.1 23.7 Earth / mud 93.6 84.7 65.7 41.4 14.5 Concrete 4.7 12.7 27.9 44.8 53.8 Material (roof) Corrugated iron 26.8 42.5 63.4 75.9 73.7 Tiles / slates 0.5 0.6 2.0 2.9 16.0 Thatch / grass 71.0 54.3 31.9 19.4 6.2 Material (walls) Bricks or blocks 78.7 88.3 89.6 91.3 94.9 Wood 4.6 3.5 2.4 0.7 0.3 Earth / mud 13.2 6.4 6.6 3.9 1.5 Energy (cooking) Kerosene/ paraffin, gas, electricity, 0.6 2.6 12.9 23.8 37.9 diesel Wood, charcoal 94.1 90.1 74.5 65.0 48.8 Animal dung, agricultural waste, 5.3 7.3 12.5 11.2 13.3 shrubs/ straws Energy (lighting) Kerosene/ paraffin, gas, electricity, 0.4 0.9 6.9 15.4 30.3 diesel Wood, charcoal 89.2 87.9 77.1 65.5 50.3 Animal dung, agricultural waste, 10.5 11.2 16.0 19.2 18.3 shrubs/ straws Selected durable goods Television 0.2 0.3 2.4 15.0 68.0 Electric stove 0.0 0.5 1.5 5.5 16.6 80 Bed 21.6 74.7 87.7 97.5 99.1 Refrigerator / freezer 0.0 0.0 0.3 1.9 34.1 Mobile 45.9 65.0 79.1 89.6 96.4 Truck or car 0.0 0.0 0.8 1.2 19.1 Trailer 0.2 0.6 0.8 8.3 27.8 Sample Size 480 448 415 418 359 Table A.2: Housing Characteristics across Wealth Quintiles Figure A-0-3: Distribution of number of ANC visits 81 Figure A-0-4: Distribution of months pregnant at first ANC visit 82