Bolivia
Access to and Use of Reproductive Health Services in El Alto
Rural-to-urban migration has challenged sexual and reproductive health services in the Bolivian highlands. El Alto, a large urban center adjacent to the capital city of La Paz, has an annual population growth rate of 9 percent. Contraceptive use is low (30 percent), and the use of modern methods is even lower (only 10 percent), leading to a large proportion of unwanted pregnancies and a significant number of unsafe abortions. To improve access to and increase the use of reproductive health services among the migrant population, Programas para la Mujer (PROMUJER), a nongovernmental organization based in La Paz, sought to identify barriers to services and to assess the quality of the existing services.
Research Findings
This study was conducted in 1994 in the Altiplano region, in the city of El Alto, and in five rural provinces. Research included 18 focus group discussions with local women and men, plus 110 in-depth interviews in rural areas and El Alto. In addition, a situation analysis of sexual and reproductive health services was conducted at 93 pharmacies and health facilities. Health center directors, pharmacists, service providers, clients and nonusers of services were interviewed. Researchers examined three elements of quality of care in the provision of family planning: 1) interpersonal relations between providers and clients; 2) the availability of methods; and 3) the acceptability of services. Among their findings:
- The majority of providers at public and private facilities believed that client treatment was good (83 and 98 percent respectively), and the majority of clients at public and private facilities (57 and 75 percent) said the care they received was excellent or good. However, half of the non-clients characterized treatment as average, 22 percent as bad, and only 12 percent as good. Also, researchers found that those who wore traditional dress, such as the pollera, were more likely to report that they were not treated well.
- When asked whether providers give explanations prior to physical examinations, approximately three-fourths of clients answered "yes." However, not all women were satisfied with the information they received. One woman stated, "They give you an exam, and then they never tell you what ails you. Many times you ask, 'What is it that I have?' They say, 'Why do you want to know?' That's the answer you get."
- Fifteen of the 36 health center directors reported that they did not have any contraceptive methods available, and none of the public facilities reported having all five program methods available (pills, IUDs, injectables, condoms, and spermicides). Three of 19 public facilities did not provide modern methods because of their religious affiliations. Sterilization was available only in the two government hospitals. Spousal consent was required of all women requesting reversible methods, which was believed to pose a significant barrier to women interested in the IUD. However, researchers found that among the 26 women who obtained spousal consent, the majority (23) chose sterilization; one used an intrauterine device while two used other methods. Therefore, providers do not make burdensome requests of women seeking reversible contraception.
- Eight of the 36 health centers did not offer counseling services to individuals who came to the clinics alone. Only five of 17 public sector facilities reported offering counseling to adolescents. One-third of users thought their providers were professionals who explained things well, in easy-to-understand language. One woman said, "I prefer to go [to the health clinic], even though it is far away, because they treat me kindly. They talk to me; they explain things - everything. And when I don't understand or don't know, he [the doctor] explains to me. I am thankful to this doctor because even though it is far, other people do not treat me as he does. Even though I have to pay, that's okay."
- Providers and clients had different perceptions of waiting and consultation times: providers said waiting times were shorter and consultation times were longer than clients did.
- Five public facilities did not have running water, and two did not have electricity. Only seven facilities had more than three exam rooms for counseling and services. One client commented, "I am afraid to talk to the doctor sometimes because there isn't an appropriate place to do so, to talk about our problems, or the illnesses that are bothering us."
Recommendations
Service providers should interact with and counsel all clients in a timely, confidential, and cordial manner regardless of the ethnicity, gender, age, or social class of their clients. Local officials should more effectively publicize the different reproductive health services available. Health professionals should monitor and supervise services to assure that services are in fact being provided and identify at what level barriers exist. Health programs should seek economic support from governmental and non-governmental agencies to improve clinic facilities and medical equipment; all facilities should have running water and electricity.
Study Details
The researchers responsible for this study on quality of care were Carmen Velasco, Claudia de la Quintana, Gretzel Jové, Luz Angela Torres and Patricia Bailey. Technical assistance was supported by the Women's Studies Project at Family Health International, through a Cooperative Agreement funded by the U.S. Agency for International Development. The field work and book publication were supported by the United Nations Population Fund (UNFPA).
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