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Health facility and workforce factors influencing utilization of reproductive health services in selected South Sudan public health facilities

Health facility and workforce factors influencing utilization of reproductive health services in selected South Sudan public health facilities 2

(Images: Supplied)

 

By DR. Emmanuel Timothy Thwol Onak (PhD)

 

Abstract

Background: Despite Africa's representation of only one-tenth of the global population and 20% of worldwide births, nearly half of all maternal deaths occur in this region. Reproductive health issues account for up to 18% of the global disease burden and 32% of the total burden for women of reproductive age (WHO Africa, 2020). Access to crucial reproductive health (RH) interventions, particularly family planning, remains restricted, characterized by low contraceptive use (13%) and a high total fertility rate (5.5 children per woman) in Sub-Saharan Africa (WHO, 2021).

Method: This study employed a mixed-method research design, which integrated both quantitative and qualitative research approaches to provide a comprehensive understanding of the topic, The mixed-method design enabled the research to capture the richness and depth of the phenomenon under investigation while also allowing for quantitative analysis to identify patterns, trends, and relationships within the data.

Results: The research findings illustrate key aspects of reproductive health service utilization among women in South Sudan. A significant percentage of women were aware of the nearest RH clinic; however, around 42.3% lacked awareness. Accessibility to RH services was notably limited, with over 45.8% of women living beyond a 2 km radius from the nearest RH clinic. The mean distance from households to the nearest RH centre was 2.2 km, indicating substantial distance barriers. The study revealed statistically significant relationships between health facility characteristics (such as RHS accessibility, hospital classification, revenue resources, NGO affiliation, and provision of modern contraceptives) and the use of reproductive health services. Additionally, interviews with key informants highlighted the importance of healthcare providers' higher education levels in enhancing specialized skills, critical thinking, and the delivery of comprehensive and individualized RH care, ultimately influencing RHS utilization positively. Conversely, findings indicated that overworked health workers receiving low wages negatively impacted the uptake and utilization of RHS in South Sudan's public health facilities, suggesting the pivotal role of fair compensation and manageable workloads in enhancing service utilization.

Conclusions: The study yielded significant insights into the factors influencing RHS uptake in South Sudan's public health facilities. It highlighted the impact of health facility characteristics, including awareness of services, proximity to facilities, and available contraceptives, on RHS utilization. Similarly, the health workforce's influence, encompassing staffing levels, qualifications, workload management, and fair compensation, emerged as crucial determinants affecting service utilization. To enhance RHS utilization, targeted measures such as community outreach to raise awareness, expanding health facilities in remote areas, and offering a diverse range of contraceptives were suggested. Limitations, including sampling biases and regional focus, need consideration, while future research should explore broader geographical areas, longitudinal trends, specific interventions' impacts, and technology's role in improving RHS access for remote populations. Qualitative studies involving stakeholders could offer deeper insights into barriers and facilitators to RHS utilization, guiding more effective policy interventions.

Introduction

The healthcare system comprises a network of production units aimed at enhancing the population's health status. Primary healthcare and its associated facilities serve as the gateway to advanced care levels (Murray & Frenk, 1999). Evaluating health system performance commonly involves analyzing care delivery components, which sheds light on the efficacy and efficiency of service provision (Olafsdottir et al., 2011). Measurement of health system functioning encompasses cost-effective analysis, technical efficiency, and allocative efficiency.

The World Health Organization (WHO) predicts a projected deficit of 12.9 million skilled healthcare workers by 2035, primarily concentrated in Africa and Southeast Asia due to low remuneration and insufficient incentives, potentially leading to a departure of 40% of health professionals within the next decade (Global Health Workforce Alliance and World Health Organization, 2013). This trend, exacerbated by internal and international health worker migrations, worsens regional disparities in healthcare staffing. The evolution of medical technology and the demand for advanced care underscore the need for a more proficient healthcare workforce. WHO emphasizes the pivotal role of health workers as the backbone of healthcare systems, responsible for care delivery, program management, and crisis response (Dieleman & Harnmeijer, 2006).

The utilization of health services significantly influences health outcomes, particularly in resource-limited rural regions, such as rural sub-Saharan Africa, where access to health services profoundly impacts health utilization patterns (Tanser et al., 2006). Enhancing health service accessibility is vital for improving quality of life, reducing health disparities, and better serving target populations, necessitating a comprehensive understanding and assessment of healthcare access and its spatial variations for effective resource allocation and program planning.

Despite Africa's representation of only one-tenth of the global population and 20% of worldwide births, nearly half of all maternal deaths occur in this region. Reproductive health issues account for up to 18% of the global disease burden and 32% of the total burden for women of reproductive age (WHO Africa, 2020). Access to crucial reproductive health (RH) interventions, particularly family planning, remains restricted, characterized by low contraceptive use (13%) and a high total fertility rate (5.5 children per woman) in Sub-Saharan Africa (WHO, 2021).

In the context of South Sudan, limitations in capacity and a challenging governance environment significantly impede the implementation of basic health services and governmental policies. Reports suggest persistent inadequacies in building government capacity (Larson et al., 2013). Moreover, economic and social challenges, encompassing health budget cuts, inflation, and food insecurity, further compound these difficulties (Integrity, 2018; IPC, 2018). The economic crisis has adversely affected programs, including reproductive health services, funded by external donors (Integrity, 2018). Consequently, the utilization and adoption of RH services in South Sudan are intricately linked to these multifaceted challenges, heightening the critical nature of this issue.

While global health outcomes have exhibited improvement over the past two decades, South Sudan has also experienced substantial progress, notably a reduction in maternal mortality, neonatal mortality, infant mortality, and under-five stunting (World Bank, 2018). Access to Reproductive Health Services (RHS), such as antenatal care and contraception, has shown significant improvement in Sub-Saharan Africa (United Nations, 2015). Nonetheless, access to healthcare, particularly RH services, remains a significant hurdle in South Sudan, largely due to ongoing conflicts and an unstable peace process (Pendle, 2014). The East African region, including nations like Uganda, Tanzania, and Kenya, continues to grapple with high maternal mortality rates compared to developed countries, emphasizing the urgent need for enhanced RH services (UNICEF, 2016). Low usage of modern contraceptives and unmet family planning needs affect a considerable proportion of married women in this region (United Nations, 2015).

South Sudan faces multifaceted challenges in its healthcare system, notably concerning reproductive health services. These challenges are compounded by capacity limitations, a challenging governance environment, ongoing conflicts, and external economic pressures, which have adversely affected the implementation and accessibility of basic health services, including reproductive health interventions. As a consequence, the uptake and utilization of RHS within the country are intricately tied to these complex healthcare, economic, and sociopolitical dynamics. The purpose of this study is to examine and assess the influence of health facility characteristics and the health workforce on the uptake and utilization of Reproductive Health Services (RHS) within selected public health facilities in South Sudan. Specifically, the research aims to scrutinize how varying health facility attributes and workforce dynamics impact the access, adoption, and utilization of essential reproductive health interventions among the population.

Understanding the nuanced relationship between health facility characteristics, the health workforce, and the utilization of RHS is imperative to address the persisting barriers and challenges faced by South Sudan's healthcare system. This study seeks to fill the existing research gap by offering an in-depth exploration of these determinants and their impact on reproductive health service accessibility and utilization. By identifying key influencers affecting the uptake of RHS, the study aims to provide evidence-based recommendations for policy formulation, resource allocation, and program planning to enhance reproductive health outcomes in South Sudan.

Methods

This study employed a mixed-method research design, which integrates both quantitative and qualitative research approaches to provide a comprehensive understanding of the topic, The mixed-method design enabled the research to capture the richness and depth of the phenomenon under investigation while also allowing for quantitative analysis to identify patterns, trends, and relationships within the data.

The quantitative data was collected from women of reproductive age visiting selected public health facilities during the study period. A structured questionnaire with only closed-ended questions was developed as the primary research instrument, focusing on the influence of health facility characteristics on the uptake and utilization of RHS. The qualitative data, on the other hand, was collected from the key informants who are knowledgeable about RHS. An interview guide with open-ended questions was used to establish the influence of the health workforce on the uptake and utilization of RHS.

The study's theoretical foundation primarily relies on two established theories: the Health Belief Model (HBM) and the Theory of Reasoned Action (TRA). These theories have been extensively employed in previous research to elucidate and forecast the utilization and adoption of reproductive health services.

The Health Belief Model (HBM) emphasizes individual subjective beliefs that shape decision-making processes. It incorporates elements such as perceived susceptibility, severity, benefits, barriers, and cues to action. In prior studies, these constructs were instrumental in constructing a predictive model for risky sexual practices among college students, effectively elucidating variations in risk behaviours and sexual partnerships. On the other hand, the Theory of Reasoned Action (TRA) provides a framework for examining attitudes toward behaviours, aiming to predict and comprehend individual actions. This theory operates under the assumption that individuals act rationally, considering available information and potential outcomes before making decisions. Key components of TRA include behaviour, intention, and personal attitude. In this context, intention stands as the primary influencer of behaviour, with stronger intentions indicating a higher probability of engaging in a specific behaviour.

The utilization of these theories within the context of this study aims to assess how health facility characteristics and the health workforce influence the uptake and utilization of Reproductive Health Services (RHS) in selected South Sudan public health facilities. By applying the principles of HBM and TRA, the study endeavours to elucidate the mechanisms and influences behind the utilization patterns of reproductive health services within the specified healthcare settings.

Study sites

The research was conducted within public health facilities situated in two specific states of South Sudan: Western Equatoria and Central Equatoria. In South Sudan, the majority of the population resides in rural areas, constituting roughly 83% of the total populace. Rural areas are characterized by a sparse population density of approximately 15 individuals per square kilometre. Challenges in healthcare service delivery arise from this low density, along with the presence of mobile pastoral communities and restricted access due to prolonged conflicts.

The data collection process encompassed all four tiers of the South Sudan health system, incorporating the Boma Health Teams at the community level, Primary Healthcare Units (PHCU), Primary Healthcare Centers (PHCC), and hospitals. These healthcare facilities are strategically distributed across the administrative subdivisions of the country, catering to both rural and urban regions (Ministry of Health, 2012; WHO South Sudan, 2020).

Sampling, recruitment of study participants and data collection

Sampling, recruitment of study participants, and data collection procedures were conducted within public health facilities situated in Western Equatoria and Central Equatoria. A multi-stage cluster random sampling method was employed for quantitative data collection, involving two distinct stages: the selection of health facilities and the subsequent identification of participants.

Initially, health facilities were selected within each state by creating a comprehensive list of public health facilities. From this list, specific facilities were chosen using a systematic random sampling method. A minimum of three public health facilities were randomly selected in each state. Subsequently, the selection of participants utilized a probability proportionate to size approach. Population lists, such as the 2018 census detailing women aged 15 to 49 in the selected states, were employed. The sampling interval was calculated by dividing the total population of the program area by the number of women in the specified age group visiting health facilities. A systematic random start number was used to identify the first client, followed by subsequent selections based on the sampling interval until the required number of participants was reached.

For key informants knowledgeable about Reproductive Health Services (RHS), a snowball sampling method was utilized. Prior notification of interviews was sent to key informants via letter, followed by confirmation through telephone communication. Appointments were scheduled for interviews and Focus Group Discussions (FGDs).

The responsibility for field data collection and management was assumed by the researcher. Prior to data collection, comprehensive training sessions were conducted for five research assistants (RAs). RAs were trained on the study's objectives, methodologies, and the administration of data collection tools. Training encompassed tool review, practical exercises, ethical considerations, data confidentiality protocols, and logistical aspects.

Written consent was obtained from participants before the interviews, ensuring the confidentiality of their information. Interviews commenced with an introduction by the interviewer, outlining their identity, organizational affiliation, and the study's objectives. Face-to-face interviews were conducted using the designated data collection tools.

Data analysis

The data derived from the questionnaires underwent a comprehensive data analysis process. Initially, all data were entered into a computer file using Microsoft Excel Spreadsheet. Subsequently, the data were exported to IBM Statistical Package for the Social Sciences (SPSS) version 23, where all sub-files were amalgamated into one master file for further analysis. The initial phase of data analysis was data preparation, which involved transforming raw data into a comprehensible and meaningful format. This process included data validation, editing, and coding.

Various statistical techniques were then employed to identify significant correlations between variables and assess the impact of one variable on another. Descriptive statistics, such as mean, median, mode, percentage, frequency, and range, were utilized to gain an overview of the data. Descriptive statistics are particularly valuable when the scope of the research is confined to the sample and does not necessitate generalization to a larger population. For example, when comparing the percentage of youth utilizing RHS in different states, descriptive statistics provide sufficient insights. Subsequently, cross-tabulations were utilized to delve deeper into the dataset. Cross-tabulations are a means to elucidate the relationship between two variables and are commonly employed to compare outcomes across demographic groups. They allow for the examination of results based on factors like age and the utilization of RHS.

To assess hypotheses, the researcher calculated measures of statistical significance, which ascertain whether findings are statistically meaningful or merely the result of chance. Statistical significance was indicated by the p-value statistic. Typically, a p-value of less than 0.05 is considered statistically significant, signifying a less than 5% probability that the results occurred by chance. Furthermore, the researcher applied various inferential analyses, including correlation, regression, and analysis of variance where relevant. Linear regression was employed, for instance, to predict the value of one variable based on another. This approach allowed the exploration of whether the utilization of RHS could be predicted based on factors like climate change or socio-cultural characteristics.

The researcher conducted preliminary content analysis of the qualitative data to identify any common patterns and trends arising from the narratives regarding: a) the influence of health facility characteristics on the uptake and utilization of RHS; and b) the influence of the health workforce on the uptake and utilization of RHS. This involved drawing connections between themes and discussing their implications.

Ethical considerations

Ethical considerations were paramount throughout the course of this study. Prior to the commencement of data collection, the researcher diligently sought ethical approval from the Division of Research, Monitoring and Evaluation within the Directorate of Planning and Coordination at the Ministry of Health, as well as the Research Ethics Committee (REC) of the Republic of South Sudan. Additional approvals were obtained from the Institutional Ethical Review Committee (IERC) of Mount Kenya University. In accordance with ethical standards, formal permissions were also secured from the respective sectoral and departmental heads, including the Ministry of Health and Local Governments within the Republic of South Sudan, to access public health facilities and other relevant offices.

The participants who willingly consented to take part in the study were assured of strict anonymity and confidentiality. These measures were implemented to safeguard their identities and instil confidence in the research process, thereby promoting the provision of accurate information. Furthermore, participants were granted the unequivocal right to exercise their free will, allowing them to decide whether they wished to participate in the research. The option of withdrawal from the study was extended to participants at any point, without the requirement to provide a reason. This opportunity was explicitly communicated to participants before the commencement of interviews and was also documented in writing.

In adhering to high ethical standards and principles for research, the study conformed to data collection, security, and protection requirements. Special consideration was also given to adaptations necessary to comply with COVID-19 control regulations. The risk level to both the research team and the communities was identified, and all personnel and participants were provided with essential protective equipment to mitigate risks effectively.

Results

Influence of Health Facility Characteristics on Uptake and Utilization of RHS in Selected South Sudan’s Public Health Facilities

Quantitative Analysis

Awareness of the Nearest Reproductive Health Clinic

The respondents asked whether they were aware of the nearest RH clinic in the region. Figure 1 shows that most of the women (57.8%) were aware of the nearest RH clinic with 42.3% of women reporting a lack of awareness of the nearest RH clinic.

Figure 1: Awareness of the nearest RH clinic

Source: Research Data (2023)

Distance to the Nearest RH Clinic

Most of the women (33.3%, 133) reported that public health facilities offering RHS were within 3 km from their households with 22.8% of women reporting that there were public health facilities offering RHS within 0.5 km (Figure 2). Women who lived within 2 km radius distance from the nearest RH service clinic and from their home less than 30 minutes walking distance were classified as having high geographical accessibility and low otherwise. Thus, over 45.8% of the women reported living outside 2 km radius distance from the nearest RH service clinic. The overall, mean distance to the nearest RHS centre from your household was 2.2 km.

Figure 2: Mean total PH facilities offering RHS within 0.5 to 5 km (range)

Source: Research Data (2023)

Health Facility Characteristics Associated with RH Services Utilization

Based on the provided research findings in Table 1, the relationship between health facility characteristics (RHS accessibility, hospital classification, revenue resources and NGO affiliation, and provision of modern contraceptives) and use of reproductive health services shows some statistically significant results. 

Relationship between the provision of intrauterine devices and uptake/utilization of reproductive health services: the p-value of 0.000 indicates a highly significant relationship between the provision of intrauterine devices and the uptake/utilization of reproductive health services. The odds ratio of 10.473 suggests that the provision of intrauterine devices is associated with a 10.473 times higher likelihood of uptake and utilization of reproductive health services compared to not providing intrauterine devices.

Relationship between provision of oral contraceptives and uptake/utilization of reproductive health service: the p-value of 0.000 indicates a highly significant relationship between the provision of oral contraceptives and the uptake/utilization of reproductive health services. The odds ratio of 33.060 suggests that the provision of oral contraceptives is associated with a 33.060 times higher likelihood of uptake and utilization of reproductive health services compared to not providing oral contraceptives. However, the wide range of the confidence interval (7.444 to 146.827) suggests some uncertainty in estimating the true odds ratio, but it still supports the notion that the odds of experiencing the outcome are significantly higher in the exposed group.

Table 1: Health facility characteristics associated with RH services utilization among women of reproductive age

Variables

User of RH services

n (%)

n = 290

Non-user of RH services

n (%)

n = 110

OR

(95% CI)

P Value

Hospital classification

       

Hospital (State, Teaching, and County)

101(34.8)

40 (36.4)

1

 

Primary Health Care Unit/Centre

189 (65.2)

70 (63.6)

1.178 (0.476-2.916)

0.723

RHS accessibility

       

Living within 2 km radius

160 (55.2)

57 (51.8)

1

 

Living outside 2 km radius

130 (44.8)

53 (48.2)

0.916 (0.429-1.956)

0.820

Additional revenue resources & NGO affiliation 

   

Yes

99 (34.1)

39 (35.5)

1

 

No

191 (65.9)

71 (64.5)

0.681 (0.271-1.709)

0.413

Provision of intrauterine devices

   

Yes

105 (36.2)

71 (64.5)

1

 

No 

185 (63.8)

39 (35.5)

10.473 (3.992-27.472)

0.000**

Provision of oral contraceptives

   

Yes 

203 (70.0)

108 (98.2)

1

 

No

87 (30.0)

2 (1.8)

33.060 (7.444 -146.827)

0.000**

Provision of condoms (male & female)

   

Yes

206 (71.0)

89 (80.9)

1

 

No

84 (29.0)

21 (19.1)

0.993 (.466-2.116)

0.986

Provision of injectables

       

Yes

125 (43.1)

65 (59.1)

1

 

No

165 (56.9)

45 (40.9)

0.213 (0.074-0.613)

0.004**

Provision of emergency contraceptive pills

   

Yes

258 (89.0)

78 (70.9)

1

 

No

32 (11.0)

32 (29.1)

0.453 (0.187-1.101)

0.080

Provision of spermicidal agents

   

Yes 

58 (20.0)

40 (36.4)

1

 

No 

232 (80.0)

70 (63.6)

3.171 (1.496-6.720)

0.003**

Source: Research Data (2023)

**. Correlation is significant at the 0.01 level

*. Correlation is significant at the 0.05 level

Relationship between provision of injectables and uptake/utilization of reproductive health service: the p-value of 0.004 suggests a statistically significant relationship between the provision of injectables and the uptake/utilization of reproductive health services, though with a slightly lower level of significance compared to the previous two relationships. The odds ratio of 0.213 indicates that the provision of injectables is associated with a 0.213 times lower likelihood of uptake and utilization of reproductive health services compared to not providing injectables.

Relationship between the provision of spermicidal agents and uptake/utilization of reproductive health services: the p-value of 0.003 suggests a statistically significant relationship between the provision of spermicidal agents and the uptake/utilization of reproductive health services. The odds ratio of 3.171 indicates that the provision of spermicidal agents is associated with a 3.171 times higher likelihood of uptake and utilization of reproductive health services compared to not providing spermicidal agents.

Influence of Health Workforce on Uptake and Utilization of RHS In Selected South Sudan’s Public Health Facilities

This section presented a qualitative analysis of workforce variables (level of education, cadre or academic qualification, workload, and salary) that are likely to influence the uptake and utilization of RHS in the selected public health services.

Table 2: Socio-demographic characteristics of the health workers in selected public health facilities

Variable 

Category

Frequency

State 

Central Equatoria

14

Western Equatoria

10

     

Cadre

Clinicians (Medical doctor/Public health officer)

5

 

Nurses

6

 

Midwives

4

 

Clinical Officers

4

 

Boma Health Workers (BHW)

5

     

Age (in Years)

18 – 34

8

35 – 49

11

 

50 – 60

6

     

Educational level

Only traditional/non-formal school

3

 

Completed secondary

2

 

Technical College

12

 

University

7

     

Place of residence

Urban

10

Rural

14

Source: Research Data (2023)

The health workforce refers to the professionals and staff involved in delivering healthcare services within public health facilities. This includes doctors, nurses, midwives, community health workers, and other healthcare providers who play a direct role in delivering reproductive health services to the population. The number of health workers that were selected and participated in the study was 24 health workers (see Table 2).

Adequate and Qualified Personnel Providing RH Services in Public Health Facilities

The research hypothesis in this study is that the presence of adequate and qualified personnel providing reproductive health services in South Sudan public health facilities significantly influences the uptake and utilization of these services. Several subthemes were established through conducting interviews with the key informants.

Adequate Staffing

The analysis reveals that the presence of an adequate number of healthcare providers in the public health facilities is crucial for meeting the demand for reproductive health services. Sufficient staffing levels ensure that individuals have timely access to services and reduce waiting times, leading to improved utilization. However, it was established that RH services in selected South Sudan's public health facilities is hindered by having few qualified staff and staff needing refresher training to improve reproductive health service delivery.

The analysis revealed that having a limited number of qualified staff, including doctors, nurses, and midwives, impacted the delivery of RH services. The lack of specialized skills and expertise result in suboptimal service provision and limited capacity to address the diverse needs of individuals seeking RHS in the selected public health facilities. In addition, with the shortage of qualified staff, it was evident that delays and bottlenecks in service delivery were a recurrent theme, leading to longer waiting times and decreased utilization of RHS. For instance, one of the key informants that was interviewed stated that:

“The limited availability of qualified personnel can hinder the ability to meet the demand for RHS, thereby affecting uptake and utilization.” (Nurse L.O., 2023)

It was also established that due to inadequate staffing levels, the quality of RH services provided was compromised. For instance, participants reported that the lack of qualified staff contributed to cases of errors during pregnancy tests, and reduced adherence to RHS guidelines such as building the capacity at all levels of MOH and partners in order to deliver quality comprehensive reproductive health services, which was found to negatively impact individuals' trust in and utilization of RH services.

Though it was established that personnel working in the selected health facilities had relevant academic qualifications, most of them needed refresher training. Participants argued that when it comes to RH service delivery, the field is continuously evolving, with new research, guidelines, and best practices emerging. Thus, it was important for staff including nurses and midwives, to undergo regular refresher training, since most of the staff knowledge and skills on RHS was considered outdated, it hindered their ability to provide up-to-date and evidence-based RH strategy such as the provision of modern contraceptives. From the interaction with key informants, it was evident that some of the personnel providing RH services in public health facilities had limited confidence and competence. One of the participants stated that: 

“Nurses and midwives who have not received refresher training lack confidence and competence in certain areas of RH service provision. This results in hesitation, suboptimal decision-making, and a decreased ability to address complex or specialized cases, leading to reduced uptake and utilization of RHS.” (Doctor P.O., 2023)

Refresher training ensures that all personnel are aligned with standardized protocols and practices in RH service delivery. Lack of refresher training can result in variations in care provided by different staff members, potentially leading to inconsistencies in service quality and patient experiences. Thus, the research findings suggest that the influence of adequate staffing on the uptake and utilization of RHS in South Sudan's public health facilities is constrained by having few qualified staff and staff needing refresher training. These factors can impact the quality, availability, and consistency of reproductive health services, ultimately affecting individuals' utilization of these services. 

For example, the analysis established that there was increased access to skilled birth attendants through the training and recruitment of midwives and training on life-saving skills including an authorization of mid-level cadres namely, nurses, clinical officers, and midwives to function as Clinical Associates (CAs) to provide essential obstetric care and selected life-saving obstetric and neonatal care (task shifting/sharing).

The analysis revealed that having qualified personnel, such as doctors, nurses, midwives, and skilled birth attendants, is essential. These professionals possess the necessary knowledge, skills, and training to provide comprehensive RHS, including family planning, HIV counselling and testing, prevention and management of STIs, and maternal and newborn care. In addition, healthcare providers with appropriate training and skills in RH can effectively address the specific needs and concerns of women seeking RHS. The participants mentioned that training programs and continuing education opportunities will enable health providers to stay updated on best practices and evidence-based approaches, ensuring the delivery of high-quality RH care.

Health Workforce Education Level

The analysis revealed that healthcare providers with higher education levels, such as advanced degrees in medicine, nursing, or midwifery, bring advanced knowledge and specialized skills to RHS provision. Advanced education equips them with a deeper understanding of RH concepts, research, and evidence-based practices, enabling them to deliver high-quality care. The experts that were interviewed posit that health professionals with higher education levels possess critical thinking abilities and analytical skills, enabling them to make informed decisions and provide comprehensive and individualized RH care. Individualized RH care was further found to contribute to improved utilization of RHS, as women visiting public health facilities felt confident in the expertise of the healthcare provider.

The study also found that having higher education levels empowered healthcare providers to take on leadership roles and engage in advocacy efforts to promote RHS. For instance, doctors and nurses who are well-trained were found to contribute to policy development, program implementation, and community education, which can positively impact the uptake and utilization of RHS. 

At the community level, trained mid-level cadres namely, nurses, clinical officers, and midwives. encouraged and supported community and home-based initiatives on life-saving skills. Emphasis was based on building the capacity of other community health workers/groups on health promotion (including referral for deliveries to the Primary health care centres (BHW, 2023).

It was also important to note that, the key informants believed that continuous professional development, including training, workshops, and conferences, helps healthcare providers stay abreast of advancements in RH. 

“By continuously updating their knowledge and skills, healthcare providers can provide up-to-date and evidence-based RH care, which can enhance the uptake and utilization of reproductive health services. In addition, professional development opportunities that are mainly offered by NGOs, allowed the healthcare providers to refine their skills and learn best practices for health service delivery including RHS (CO, 2023).”

The study proposes that by improving the health workforce education level and promoting continuous professional development, the influence of adequate staffing on the uptake and utilization of RHS in South Sudan's public health facilities can be strengthened. Investing in higher education levels and providing opportunities for continuous learning can enhance healthcare providers' knowledge, skills, confidence, and leadership abilities. Consequently, this can improve the quality of RHS, increase patient trust, and positively influence individuals' utilization of these services.

Workload and Salary

The research findings in this study evidenced the fact that the influence of workload and salary issues on the uptake and utilization of RHS in selected South Sudan public health facilities is negatively affected by health workers being overworked and receiving low wages.

Workload Issues

The analysis revealed that the health workers including nurses, clinical officers, and midwives are overburdened with excessive workload, and have limited time to spend with clients seeking RHS. For instance, one of the clinical officers who was interviewed complained that:

“Due to workload issues Clinical Associates (CAs) end up doing rushed consultations and reduced opportunities for thorough assessments and discussions about family planning, antenatal care, HIV testing and counselling or other RHS. As a result, most women visiting public health facilities felt that their concerns are not adequately addressed, leading to decreased utilization of RHS.” (KI-CO, 2023)

The study also established that overworked health workers struggle to provide individualized care due to time constraints. They had difficulty tailoring services to meet the specific needs and preferences of each woman visiting the clinic. This results in a standardized approach to care, which may not fully address the unique circumstances and concerns of women, potentially leading to decreased utilization of RHS. Therefore, MOH and other stakeholders should focus on expanding comprehensive RH coverage by developing a priority-oriented focus on RH service delivery and ensuring the best use of resources as well as addressing the unique circumstances and concerns of women of reproductive age.

The analysis also revealed that overworked health workers faced challenges in managing the demand for RHS, leading to longer waiting times for appointments and checkups. Women seeking timely care became discouraged or sought alternative options, especially in modern contraception, resulting in decreased utilization of RHS in public health facilities. It was also established that most of the health workers (doctors, nurses, clinical officers, and midwives) experienced excessive workloads that contributed to delays in service delivery, which were further perceived as inconvenient by the women who were seeking RHS. The perception of prolonged waiting times and service delays discouraged women from utilizing RHS across South Sudan.

Fatigue and burnout also emerged as common themes from the thematic analysis. It was evident from the analysis that most of the health workers felt that they were being overworked which led to fatigue and burnout. One of the doctors who was interviewed pointed that:

“As the only qualified hospital doctor in the health facility, I am extremely overworked, and this is likely to lead to reduced concentration, compromised decision-making, and increased likelihood of errors. This can also lead to suboptimal service delivery and reduced satisfaction among women who are seeking RHS in this health facility.” (KI-MD, 2023)

In addition to fatigue and burnout, it was established that overworking health workers will eventually lead to emotional exhaustion, which can further affect their ability to empathize and communicate effectively with clients who are seeking to use RHS in public health facilities. Indeed, emotional exhaustion can hinder the formation of trust and rapport with women of reproductive age seeking RH services.

The research findings suggest that the influence of workload issues on the uptake and utilization of RHS in South Sudan's public health facilities is negatively affected by health workers being overworked. By examining the challenges related to workload issues, the findings of this study can inform strategies to address these issues. For instance, increasing access to skilled health workers through training and recruitment of midwives and training on RH skills including an authorization of mid-level cadres namely, nurses, clinical officers, and midwives to function as CAs to provide essential RH services. Ultimately, addressing workload issues can enhance the uptake and utilization of RHS in South Sudan through workforce planning, task-shifting, sharing, and workload redistribution.

Salary Issues

The analysis established that the influence of salary issues on the uptake and utilization of RHS in selected South Sudan public health facilities is negatively affected by health workers being paid low wages and feeling that they are unfairly compensated for the amount of work done.  For instance, the key informant stated that: 

“Most of the health workers complained that they are receiving low wages that may lead to experiencing a lack of motivation and job satisfaction. The perception of being undervalued and under-compensated can negatively impact their dedication to providing high-quality RHS, further resulting in decreased motivation to go above and beyond, potentially affecting the utilization of RHS (MW, 2023).”

The analysis also revealed that being paid a low salary contributed to overall job dissatisfaction among the health workers in public health facilities, creating feelings of frustration, leading to reduced job engagement, as well as decreased enthusiasm for delivering RHS. 

“Low wages contributed to higher turnover rates among health workers in the public health facilities. Most of the health professionals are likely to seek better opportunities elsewhere or opt for alternative employment. The frequent turnover among trained and skilled health workers is likely to disrupt the continuity of care and decrease clients' trust and confidence in the RHS provided in the public health facilities.” (PHO, 2023)

The study established that some of the health workers who were working in the selected RH clinics believed that they were being paid low salaries, and a result created the perception that RHS are undervalued within the healthcare system. This perception can impact the community's trust and confidence in the quality of care provided, resulting in decreased utilization of reproductive health services. In addition, one of the participants stipulated that:

“Health workers who feel undervalued may be less inclined to invest their time and effort in enhancing their skills and knowledge, leading to stagnation in service delivery including RH services.” (MW, 2023)

According to the participants addressing salary issues and ensuring fair compensation for health workers can lead to increased motivation, job satisfaction, and retention rates. Adequate wages can also contribute to improved quality of care and increased trust from women who are seeking RHS in public health facilities. The findings of this study can guide policymakers and stakeholders in implementing interventions to improve the financial compensation of health workers, particularly those working in RH clinics, and address the salary disparities, thereby positively impacting the uptake and utilization of RHS in South Sudan public health facilities.

Discussion

Influence of Health Facility Characteristics on Uptake and Utilization of RHS in Selected South Sudan’s Public Health Facilities

The study found that 57.8% of the women were aware of the nearest RH clinic in the region, while 42.3% reported a lack of awareness. This indicates that there is a significant proportion of women who may not have knowledge about the availability of reproductive health services in their vicinity. Previous studies (Binu et al., 2018; and Helamo et al., 2017). also show a significant proportion of women lacking knowledge, for instance, lack of access to information about what RH services are available and where to seek service. They also found that young women who lacked knowledge of the type of RHS were not more likely to utilize the service than their counterparts. Lack of awareness can be a barrier to seeking and utilizing these services, as women may not know where to go or what services are offered. Increasing awareness through community outreach, education campaigns, and improved information dissemination can help address this issue.

The study examined the distance between women's households and the nearest RHS center. The findings showed that most women (33.3%) reported that public health facilities offering RHS were within 3 km from their households, while 22.8% reported that the facilities were within 0.5 km. However, over 45.8% of the women reported living outside the 2 km radius distance from the nearest RHS clinic. Study by Kane, Kok, et al. (2016) conducted in South Sudan also indicates that many women and girls live too far away to access emergency care or live on the other side of frontlines of conflict, making it too hazardous to travel to the facilities. In most cases RHS is not available in conflict-affected areas except in rare instances. This suggests that a significant number of women may face challenges accessing RHS due to long distances. Long travel distances can deter women from seeking care, particularly in rural areas with limited transportation options. To improve accessibility, efforts should be made to establish more health facilities or outreach services in underserved areas, particularly those far from existing clinics.

The study further investigated the relationship between the provision of specific RHS and the uptake of these services. The findings revealed that the provision of IUDs showed a highly significant relationship with the uptake and utilization of RHS. The odds ratio of 10.473 suggests that the provision of IUDs is associated with a 10.473 times higher likelihood of uptake and utilization of RHS compared to not providing IUDs. Studies across Africa show that IUD’s share of modern method mix is pitifully small, at less than 5%, in 63 countries and only5–9% in a further 32 countries as noted in a previous study (Cleland, Benova, and Daniele, 2017). This current finding highlights the importance of making IUDs available as a contraceptive option to promote RHS utilization.

The provision of oral contraceptives also demonstrated a highly significant relationship with the uptake and utilization of RHS. The odds ratio of 33.060 suggests that the provision of oral contraceptives is associated with a 33.060 times higher likelihood of uptake and utilization of RHS compared to not providing oral contraceptives. Previous studies (Cottingham, Germain, and Hunt, 2012: and World Health Organization, 2012) support this finding by stipulating that unmet need for contraception remains high in many settings, and is highest among the most vulnerable in society including those living in rural areas. This finding underscores the importance of ensuring access to oral contraceptives as an essential component of RHS. In addition, the provision of spermicidal agents also demonstrated a statistically significant relationship with the uptake and utilization of reproductive health services. These findings suggest that offering a range of contraceptive options, including spermicidal agents, can contribute to increased RHS utilization.

A previous study conducted by Kane et al. (2016) in South Sudan, established that the provision of family planning, including injectables, is largely unavailable in the majority of the States, largely due to the overall gaps in health infrastructure and services, and in part because the major healthcare provider does not provide contraception. The current study evidenced that the provision of injectables showed a statistically significant relationship with the uptake and utilization of reproductive health services. However, the odds ratio of 0.213 suggests that the provision of injectables is associated with a 0.213 times lower likelihood of uptake and utilization of RHS compared to not providing injectables. This finding suggests that factors such as availability, awareness, and preferences regarding contraceptive methods may influence the utilization of injectables.

These findings emphasize the importance of the availability and provision of a diverse range of RHS to meet the varied needs and preferences of women. It highlights the significance of including contraceptives like IUDs, oral contraceptives, injectables, and spermicidal agents as part of the service package in public health facilities. By expanding the range of available services and ensuring their accessibility, the uptake and utilization of RHS can be improved, leading to better RH outcomes for women in South Sudan.

Influence of Health Workforce on Uptake and Utilization of RHS In Selected South Sudan’s Public Health Facilities

The analysis revealed that the presence of an adequate number of healthcare providers in public health facilities is crucial for meeting the demand for reproductive health services and improving utilization. Sufficient staffing levels ensure timely access to services and reduce waiting times. However, the study found that the RH services in selected South Sudan's public health facilities were hindered by having few qualified staff and a need for refresher training. Previous studies support these findings by showing evidence of a direct and positive link between the number of health workers and population health outcomes (WHO, 2010). This limitation in the workforce resulted in suboptimal service provision and a limited capacity to address the diverse needs of women seeking RHS.

The analysis highlighted the importance of healthcare providers' qualifications and education levels in the delivery of reproductive health services. The study found that healthcare providers with higher education levels, such as advanced degrees in medicine, nursing, or midwifery, bring advanced knowledge and specialized skills to the provision of reproductive health services. Previous studies (Kane, Kok, et al., 2016) conducted in South Sudan support this finding, they established that pregnant women have extremely limited access to skilled health providers in public health facilities.  These providers are better equipped to meet the diverse needs of individuals seeking RHS and are empowered to take on leadership roles and engage in advocacy efforts to promote reproductive health.

The analysis revealed that healthcare providers, including nurses, clinical officers, and midwives, were overburdened with excessive workloads. This excessive workload resulted in limited time to spend with clients seeking RHS, which compromised the quality of care provided. Previous studies (Kane, Kok, et al., 2016: and Belaid et al., 2020) found that insecurity in some part of Central Equatoria and Western Equatoria State have led to a lack of staff and thus hindering women from accessing healthcare, including making antenatal visits.  In addition, overworked health workers faced challenges in managing the demand for RHS, leading to longer waiting times for appointments and checkups. These findings suggest that workload issues negatively impact the uptake and utilization of RHS in South Sudan's public health facilities.

The analysis found that health workers in selected public health facilities perceived low salaries and felt unfairly compensated for the amount of work they performed. The low salary levels contributed to overall job dissatisfaction among the health workforce, leading to reduced job engagement and decreased enthusiasm in delivering reproductive health services. Previous studies (WHO, 2010a) further revealed that the ability of a country to meet its health goals depends largely on motivation and financial compensation of the people responsible for organizing and delivering healthcare services. Thus, the perception of low salaries created the notion that reproductive health services are undervalued within the healthcare system. This finding suggests that salary issues negatively affect the uptake and utilization of RHS.

In conclusion, the findings highlight several workforce-related factors that influence the uptake and utilization of reproductive health services in South Sudan's public health facilities. These factors include having an adequate number of qualified staff, staff with higher education levels, manageable workloads, and fair compensation for healthcare providers. Addressing these workforce challenges is crucial to improving the delivery of reproductive health services and ensuring better access and utilization of these services by women of reproductive age in South Sudan. Policy measures should focus on recruiting and retaining qualified staff, providing opportunities for professional development and training, improving working conditions, and offering fair compensation to healthcare providers in order to strengthen the reproductive health workforce and enhance service delivery.

Conclusions

The study revealed significant insights into the factors influencing the uptake and utilization of RHS in South Sudan's public health facilities. The examination of health facility characteristics on RHS uptake indicated that awareness of available services, proximity to health facilities, and the provision of specific contraceptives significantly impacted utilization. Additionally, the influence of the health workforce on RHS utilization highlighted the importance of staffing levels, healthcare providers' qualifications, workload management, and fair compensation in facilitating or hindering service utilization.

The findings underscore the critical need for targeted interventions for RHS utilization in South Sudan. Increasing awareness through community outreach, educating women about available services, and enhancing information dissemination are crucial steps to address the lack of awareness among women regarding nearby RH clinics. Moreover, efforts to establish more health facilities or outreach services in remote areas could mitigate the challenges faced due to long travel distances, ensuring better accessibility to RHS. The study emphasizes the significance of including a diverse range of contraceptives such as IUDs, oral contraceptives, injectables, and spermicidal agents as part of the service package in public health facilities. This approach caters to varying preferences and needs, potentially enhancing RHS utilization. Furthermore, the study highlights the necessity of maintaining an adequate number of qualified healthcare providers, managing their workloads, and providing fair compensation to enhance service delivery and improve access to RHS.

The study faced certain limitations, including potential biases in participant selection due to the sampling method employed. The reliance on self-reported data might have introduced response biases, impacting the accuracy of the findings. Additionally, the study's scope focused on selected regions of South Sudan, limiting the generalizability of the results to the entire country. Furthermore, contextual factors such as ongoing conflicts or geopolitical situations might have influenced the availability and accessibility of reproductive health services.

Future research endeavours should aim to conduct comprehensive studies encompassing a broader geographical area within South Sudan, considering diverse socio-economic and cultural contexts. Longitudinal studies tracking changes in reproductive health service utilization over time could provide valuable insights into trends and variations. Exploring the impact of specific interventions, such as awareness campaigns or infrastructure improvements, on RHS utilization could guide targeted policy interventions. Furthermore, in-depth qualitative studies involving healthcare providers and community members could offer nuanced perspectives on barriers and facilitators to RHS utilization. Additionally, examining the role of technology, telemedicine, or mobile health interventions in improving access to reproductive health services among remote populations warrants exploration.

Acknowledgements:

This study was made possible through the support of my supervisors Dr. Alfred Owino Odongo and Dr. John Kariuki, and my colleagues within the Ministry of Health, particularly my fellow Public Health Officers and Surveillance Officers. Their support is acknowledged.

Funding Acknowledgements:

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Competing Interests:

Author(s) declares there were no competing interests.

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