DHS ANALYTICAL 

STUDIES 55

Quality of Care 

in Family Planning Services

at Health Facilities in Senegal

September 2015

This publication was produced for review by the United States Agency for International Development. It was prepared by 

Shireen Assaf, Wenjuan Wang, and Lindsay Mallick of ICF International.

DHS Analytical Studies No. 55 

Quality of Care in Family Planning Services 

at Health Facilities in Senegal 

Shireen Assaf 

Wenjuan Wang 

Lindsay Mallick 

ICF International 

Rockville, Maryland, USA 

September 2015 

Corresponding author: Shireen Assaf, International Health and Development, ICF International, 530 

Gaither Road, Suite 500, Rockville, MD 20850, USA; phone: 301-407-6500; fax: 301-407-6501; 

email: Shireen.Assaf@icfi.com 
Acknowledgment: The authors are grateful for the comments provided from Francis Ogojo Okello, Jose 

Miguel Guzman, and Paul Ametepi on an earlier version of the report. The authors would also like to 

thank Bryant Robey for editing the report and Natalie La Roche for formatting it. 

Editor: Bryant Robey 

Document Production: Natalie La Roche 

This study was carried out with support provided by the United States Agency for International 

Development (USAID) through The DHS Program (#AID-OAA-C-13-00095). The views expressed are 

those of the authors and do not necessarily reflect the views of USAID or the United States Government. 

The DHS Program assists countries worldwide in the collection and use of data to monitor and evaluate 

population, health, and nutrition programs. For additional information about The DHS Program, 

contact The DHS Program, ICF International, 530 Gaither Road, Suite 500, Rockville, MD 20850, 

USA; phone: 301-407-6500; fax: 301-407-6501; email: reports@dhsprogram.com; Internet: www. 

dhsprogram.com. 

Recommended citation: 

Assaf, Shireen, Wenjuan Wang, and Lindsay Mallick. 2015. Quality of Care in Family Planning Services 

at Health Facilities in Senegal. DHS Analytical Studies No. 55. Rockville, Maryland, USA: ICF 

International. 
iii 

Contents 

Tables ........................................................................................................................................................ v 

Figures ........................................................................................................................................................ v 

Preface ...................................................................................................................................................... vii 

Abstract ....................................................................................................................................................... ix 

Executive Summary ..................................................................................................................................... xi 

1. Introduction and Rationale .................................................................................................................... 1 

1.1. Literature Review ...................................................................................................................... 1 

2. Data and Methods ................................................................................................................................. 5 

2.1. Senegal Continuous SPA Surveys ............................................................................................ 5 

2.2. Methods ..................................................................................................................................... 6 

3. Results ................................................................................................................................................. 10 

3.1. Health Facilities ...................................................................................................................... 10 

3.2. Quality of Care in General Structure ...................................................................................... 12 

3.3. Quality of Care in Family Planning Structure ......................................................................... 18 

3.4. Health Huts ............................................................................................................................. 21 

3.5. Quality of Care in Family Planning Process ........................................................................... 23 

3.6. Quality of Care in Family Planning Outcomes ....................................................................... 30 

4. Discussion ........................................................................................................................................... 35 

4.1. General Structure .................................................................................................................... 35 

4.2. Family Planning Structure ...................................................................................................... 36 

4.3. Process .................................................................................................................................... 37 

4.4. Outcome .................................................................................................................................. 38 

4.5. Limitations .............................................................................................................................. 39 

5. Conclusions ......................................................................................................................................... 40 

References ................................................................................................................................................... 41 

Appendix A ................................................................................................................................................. 45 

Appendix B ................................................................................................................................................. 47 

Appendix C ................................................................................................................................................. 49 

Appendix D ................................................................................................................................................. 51 

v 

Tables 

Table 1. Selection of estimated population and health indicators for Senegal from five DHS surveys 

from 1992 to 2014 .......................................................................................................................... 2 

Table 2. Description of facility characteristics ........................................................................................... 12 

Table 3. Services offered by facility type for round 1 and round 2 ............................................................ 13 

Table 4. Percentage of facilities that have electricity, improved water source, and adequate sanitation 

by facility characteristics .............................................................................................................. 14 

Table 5. Percentage of facilities that have communication equipment, private room, emergency 

transport, and computer and Internet access by facility characteristics........................................ 16 

Table 6. Levels of readiness of equipment, diagnostic tests, and medicines by facility background 

characteristics (N=364), round 1 .................................................................................................. 17 

Table 7. Levels of readiness of equipment, diagnostic tests, and medicines by facility background 

characteristics (N=363), round 2 .................................................................................................. 18 

Table 8. Association of the availability of progestin-only injectables and combined oral pills 

by facility characteristics among facilities that provide family planning services ....................... 20 

Table 9. Results of adjusted logistic regressions of availability of progestin-only injectables and 

combined oral pills among facilities that offer family planning services for both rounds ........... 20 

Table 10. Percentage of health huts that have the following: infrastructure, equipment, and other 

commodities ................................................................................................................................ 22 

Table 11. Description of client, provider, and facility background characteristics after selecting 

for clients using a contraceptive method. ................................................................................... 24 

Table 12. Family planning counseling and clinical examination by client, provider, and facility 

characteristics ............................................................................................................................. 26 

Table 13. Adjusted logistic regression of family planning process dependent variables, round 1 ............. 29 

Table 14. Association of overall client satisfaction with family planning services and client knowledge 

of family planning method’s protection from STIs by client’s and provider’s background 

characteristics, round 1 ............................................................................................................... 31 

Table 15. Adjusted logistic regression of clients very satisfied with family planning services and 

client’s correct knowledge of method’s protection from STIs, round 1 ..................................... 33 

Figures 

Figure 1. Facilities with family planning commodities and at least one staff member trained 

in family planning ....................................................................................................................... 19

Figure 2. Description of outcome-dependent variables, all users ............................................................... 30

vii 

Preface 

The Demographic and Health Surveys (DHS) Program is one of the principal sources of international data 

on fertility, family planning, maternal and child health, nutrition, mortality, environmental health, 

HIV/AIDS, malaria, and provision of health services. 

One of the objectives of The DHS Program is to analyze DHS data and provide findings that will be 

useful to policymakers and program managers in low- and middle-income countries. DHS Analytical 

Studies serve this objective by providing in-depth research on a wide range of topics, typically including 

several countries, and applying multivariate statistical tools and models. These reports are also intended to 

illustrate research methods and applications of DHS data that may build the capacity of other researchers. 

The topics in the DHS Analytical Studies series are selected by The DHS Program in consultation with 

the U.S. Agency for International Development. 

It is hoped that the DHS Analytical Studies will be useful to researchers, policymakers, and survey 

specialists, particularly those engaged in work in low- and middle-income countries. 

Sunita Kishor 

Director, The DHS Program

ix 

Abstract 

Analysis of quality of care in family planning services in Senegal was conducted using data from two 

rounds of the Senegal Service Provision Assessment (SPA) surveys of 2012-2013 and 2014. The 

measures of quality of care were divided into structure (infrastructure of the facility and availability of 

commodities), process (provider’s performance), and outcomes (client’s overall satisfaction with services 

and knowledge of their method’s protection from sexually transmitted infections [STIs]). 

Findings revealed that most facilities have the basic infrastructure required (adequate sanitation, improved 

water, and private examination room). However, some facilities lack electricity, communication 

equipment, emergency transport, and computer and Internet. Some facilities perform better than others in 

availability of equipment and diagnostic tests, and some regions outperform others. The presence of 

several family planning commodities has improved significantly, and the presence of injectables and pills, 

the two most used methods, remains high, although they are much more likely to be available in public 

than private facilities. 

The percentage of providers who offered various forms of counseling was relatively low. New clients 

were significantly more likely to receive counseling and a high-quality pelvic examination compared with 

returning clients. Although overall client satisfaction was relatively high (84 percent), only 58 percent of 

clients had correct knowledge of whether their method protects them from STIs. Counseling had a 

negative effect on overall client satisfaction and no effect on client’s correct knowledge concerning 

protection from STIs, indicating a lack of effectiveness of counseling methods. Notably, clients who saw 

a provider trained in family planning in the last two years significantly increased their odds of having 

correct knowledge of their method’s protection from STIs. 

KEYWORDS: Quality of care, health facilities, SPA, SARA, counseling, family planning, client 

satisfaction, knowledge of method protection from STIs, Senegal 

xi 

Executive Summary 

Introduction 

Senegal has shown increases in contraceptive use over the years, but modern contraceptive prevalence 

remains relatively low, at an estimated 20% of women in 2014, while total unmet need for family 

planning is higher, at an estimated 25%. One factor that could increase contraceptive prevalence and 

decrease the level of unmet need is improving quality of care in family planning services. Studies have 

supported the link between high quality of care and increased uptake and continuation of family planning 

use. The present analysis examines the quality of care in health facilities in Senegal, with a focus on 

family planning services. It assesses the structure, process, and outcome of the delivery of family 

planning services, as well as the facility, provider, and client characteristics that may be associated with 

quality of care. 

Methods 

Measures of quality of care in Senegal’s health facilities were divided into three areas using the 

Donabedian framework (Donabedian 1988): structure (includes basic infrastructure, equipment, 

commodities); process (includes counseling and examinations by the provider); and outcome (measured 

by client overall satisfaction and correct knowledge on whether their method protects from sexually 

transmitted infections [STIs], including HIV/AIDS). The data used in the analysis are from the first two 

rounds (2012-2013 and 2014) of the Senegal Continuous Service Provision and Assessment (SPA) 

survey. 

For the analysis of structure, indicators were selected using the WHO Service Availability and Readiness 

Assessment (SARA) indicator guideline. This guideline describes the equipment, diagnostic tests, and 

medicines that a facility should provide for quality services (both in general and service specific). In 

addition, a list of the basic requirements for providing family planning services was provided. The 

required services include family planning commodities (mainly contraceptive methods but also a device 

to take blood pressure), family planning guidelines, and at least one staff member trained in family 

planning. For the analysis of process, the counseling that was provided to family planning clients was 

examined, including counseling on how to use the chosen method, possible side effects, when to return to 

the facility, and the method’s protection from STIs. In addition, the quality of pelvic examinations was 

assessed. The analysis of outcome used two measures: client’s satisfaction with family planning services 

received and client’s knowledge of whether their chosen method protected them from STIs. 

Results 

General Structure 

The great majority of facilities appear to have an improved water source, adequate sanitation, and a 

private room for examination and/or consultations. However, electricity, communication equipment, 

emergency transport, and especially computer and Internet access were less available. In round 2, public 

and rural facilities had a significantly higher percentage of facilities with a high equipment score. All 

facility characteristics except managing authority in round 1 were significantly associated with the 

diagnostic test index. In both rounds, the categories of hospitals and health centers, private facilities, and 

urban facilities had higher diagnostic test scores compared with health huts, public facilities, and rural 

facilities. 
xii 

Family Planning Structure 

In round 2, contraceptive pills, progestin-only injectables, and male condoms were available in at least 80 

percent of facilities. Other modern contraceptive methods were found in fewer facilities, although 

availability significantly increased from round 1 to round 2. The availability of combined injectables 

declined substantially between the two rounds. In both rounds, over 90 percent of the facilities had a 

blood pressure machine and had at least one staff member trained in family planning. However, only twothirds of facilities in round 1 and three-fourths of facilities in round 2 had family planning guidelines. 

In round 1, public facilities had 13 times higher odds of having injectables and 30 times higher odds of 

having combined oral pills compared with private facilities; in round 2, the odds were 18 times higher for 

injectables and 47 times higher for pills. For combined oral pills, both rounds showed significantly higher 

odds of having pills in health posts compared with hospitals. Urban versus rural location was not a 

significant covariate for availability of either method. 

Process 

The analysis showed that the level of counseling was inadequate. Only 18 percent of providers counseled 

their clients on all three items examined—how to use their method, possible side effects, and when to 

return. Just 9 percent of providers counseled on whether their client’s method protects from STIs. 

Counseling was more likely to be provided to new than returning clients. Few provider characteristics 

studied were significant predictors of counseling, although providers with a monthly or daily salary had 

almost nine times higher odds of providing counseling on STIs compared with providers with no salary. 

Also, providers with the most supervision had almost three times higher odds of providing high-quality 

pelvic examinations compared with providers with no supervision. 

Outcome 

About 8 in every 10 clients reported being very satisfied with family planning services, but fewer had 

correct knowledge of whether their method offered protection from STIs. Clients with a lower level of 

education, clients who did not have to wait to see a provider, and clients who left the facility with a family 

planning method had significantly higher odds of being very satisfied compared to their respective 

reference categories. Few provider characteristics were significant predictors of client satisfaction. 

However, providers with less education had higher odds of client satisfaction compared with providers 

with the most education. 

Counseling on side effects and when to return to the facility showed a significant negative effect for client 

satisfaction: clients who did not receive such counseling were more likely to be very satisfied with 

services than clients who received counseling—perhaps a sign that client counseling was ineffective. 

Clients who saw a nurse or nurse’s assistant had almost twice the odds of having correct knowledge of 

their method’s protection from STIs compared with clients who saw a midwife or other provider. Clients 

who saw a provider with family planning training in the past 24 months had 1.7 times higher odds of 

having correct knowledge about protection from STIs compared with clients who saw a provider with no 

recent training. Whether or not the client received counseling from a provider on their method’s 

protection from STIs was not a significant predictor of having correct knowledge. 
xiii 

Conclusions 

The results indicate that improvements are required in some areas of structure, level and effectiveness of 

counseling and medical examinations, and outcome of client’s knowledge of their method’s protection 

from STIs. The availability of several modern contraceptive commodities in health facilities increased 

significantly between the two SPA rounds, but the availability of some basic infrastructure components 

did not improve significantly. The percentage of providers offering family planning counseling to their 

clients was relatively low, and the effectiveness of the different forms of counseling was not seen in the 

outcomes of client overall satisfaction and client knowledge of their method’s protection from STIs. The 

results of the analysis identify the providers, facilities, and regions where interventions are likely to 

improve quality of care for clients of health care facilities in Senegal. 

1 

1. Introduction and Rationale 

Providing high quality of care, whether preventive or curative, improves the overall health and wellbeing 

of a population. Improving general health care services, including family planning services, can increase 

contraceptive use and reduce fertility rates (Creel, Sass, and Yinger 2002). Basic infrastructure is required 

to have a functioning facility. A number of studies have found that high quality of care in family planning 

is associated with an increased uptake and continuation of family planning use (Arends-Kuenning and 

Kessy 2007; Blanc, Curtis, and Croft 2002; Jain 1989; Koenig, Hossain, and Whittaker 1997; Magnani et 

al. 1999; Mariko 2003; Mensch, Arends-Kuenning, and Jain 1996; Sanogo et al. 2003). Exploring the 

covariates associated with quality of care in family planning services can help identify areas that require 

further attention and improvement. 

This analysis was conducted on the Senegal Service Provision Assessment (SPA) surveys of 2012-2013 

and 2014, using data obtained mainly from inventory, observation, and exit interviews conducted in a 

sample of formal health care facilities in Senegal. The analysis examined quality of care in health 

facilities’ structure, health providers’ processes, and clients’ outcomes, using the Donabedian framework 

for measuring quality of care (Donabedian 1988). The literature review presented here begins with 

background on Senegal and the Senegalese health system and is followed by a brief review of quality of 

care and how it can be assessed. 

1.1. Literature Review 

1.1.1. Setting 

Located in West Africa, Senegal has an estimated population of 13.5 million, as of 2013, and a land area 

of 196,722 square kilometers, with 700 kilometers of coastline (Agence Nationale de la Statistique et de 

la Démographie (ANSD) [Senegal] and ICF International 2015). There are 14 administrative regions: 

Dakar, Ziguinchor, Diourbel, Saint-Louis, Tambacounda, Kaolack, Thiès, Louga, Fatick, Kolda, Matam, 

Kaffrine, Kédougou, and Sédhiou. Dakar is the capital, and other major cities include Pikine, 

Guédiawaue, and Mbao. The country is highly urbanized, with 23 percent of the population living in 

Dakar, which constitutes only 0.3 percent of the country’s land area (Agence Nationale de la Statistique et 

de la Démographie (ANSD) [Senegal] and ICF International 2015). 

Senegal’s population has a high percentage of youth, with over 50 percent under age 20 (Table 1). This is 

due to a high fertility rate, which has only decreased slightly, from a total fertility rate (TFR) of 6.0 in 

1992 to 5.0 in 2014 (Table 1). Contributing to high fertility are early marriage and low levels of 

contraceptive use, although both indicators have improved over time. Modern contraceptive prevalence 

increased from 5 percent in 1992 to 20 percent in 2014. Senegal has made fertility reduction one of its 

priority areas in the National Health Development Program (PNDS) for 2009-2018 (Ministère de la Santé 

et de la Prévention 2009). The challenges that Senegal faces in increasing levels of contraceptive use 

include clients’ concerns about side effects, cost of contraception, poor quality of family planning 

services, and supply stockouts (Cleland et al. 2006; Sedgh et al. 2007; Sidze et al. 2014). In addition, 

myths, misperceptions, and lack of knowledge still exist about family planning methods and reproductive 

health (IntraHealth International (a) 2012; Katz and Nare 2002). 

Other priority areas of the Senegal National Health Development Program are improving access to goodquality health care and reducing maternal and child mortality. Infant mortality rates in Senegal have 

almost halved, from 68 deaths per 1,000 births in 1992-1993 to 33 in 2014, still relatively high. The 

maternal mortality ratio was estimated at 392 maternal deaths per 100,000 births by the 2010-2011 

Multiple Indicator Cluster survey (Agence Nationale de la Statistique et de la Démographie [Senegal] and 
2 

ICF International 2012). This translates into a Senegalese woman having a risk of approximately 1 in 43 

of dying due to a maternal cause in her childbearing years (Agence Nationale de la Statistique et de la 

Démographie [Senegal] and ICF International 2012). Indicators related to reducing mortality rates, such 

as making more than four antenatal care visits, delivering in a health facility, and obtaining the 

recommended childhood vaccinations, have improved since 1992 (see Table 1). 

Table 1. Selection of estimated population and health indicators for Senegal from six DHS surveys 

from 1992 to 2014 

 1992-1993 1997 2005 2010-2011 2012-2013 2014 

Population 

% population age 0-14 48.1 47.6 44.6 44.8 44.2 44.8 

% population age 15-19 10.2 10.5 11.1 9.8 10.6 9.9 

% population over age 6 with secondary 

or higher education (male) 11.1 - 14.7 19.5 19.4 20.8 

% population over age 6 with secondary 

or higher education (female) 5.4 - 8.9 13.5 14.1 15.8 

Fertility and family planning 

TFR (3 years preceding survey) 6.0 5.7 5.3 5.0 5.3 5.0 

Current use of modern contraceptive 

method (women in union) 4.8 8.1 10.3 12.1 16.1 20.0 

Total unmet need 28.8 35.0 32.0 30.1 29.3 25.1 

Median age at first marriage (among 

women age 25-49) 16.2 17.4 18.3 19.3 19.3 19.8 

Maternal care 

Antenatal care visits 4+ (births in 5 years 

preceding survey) 13.3 16.6 39.8 50.0 46.5 48.1 

Health facility place of delivery (births in 

5 years preceding survey) 46.9 48.0 61.8 72.8 71.3 76.9 

Child health and child mortality 

Total vaccination 49.1 - 58.7 62.8 70.2 73.7 

Stunted 29.11 - 19.6 26.5 18.7 18.7 

Underweight 17.81 - 8.5 10.1 15.7 12.6 

Wasted 9.21 - 14.2 17.7 8.8 5.9 

Infant mortality rate (5 years preceding 

survey) 68.0 68.0 61.0 47.0 43.0 33.0 

Source: DHS data, DHS final reports, and STATcompiler 

1These estimates are only for children of interviewed mothers. In the remaining years, all children in the household were 

measured for height and weight to obtain these estimates. The 1997 Senegal DHS did not include height and weight 

measurements of children. 

1.1.2. Senegalese Health System 

The health care system in Senegal is organized in a pyramid design, with hospitals representing the top of 

the pyramid followed by health centers and finally health posts and huts at the lower level (IntraHealth 

International (b) 2012). Each health post can have a number of health huts that it supervises. As of 2014, 

Senegal had 86 hospitals, 242 health centers, 1,250 health posts, and 1,506 health huts (Agence Nationale 

de la Statistique et de la Démographie (ANSD) [Senegal] and ICF International (b) 2015). In addition to 

the public health sector, private for-profit and nonprofit entities, as well as the Senegal armed forces, 

provide health care at each level of the pyramid (Tine et al. 2014). In 2009 the government began to enact 
3 

a “National Health Plan” (Plan National de Développement Sanitaire et Social du Sénégal [PNDS] 

2009-2018), which describes a strategy for improving the health of the population (IntraHealth 

International (b) 2012; Ministère de la Santé et de la Prévention 2009). The plan places emphasis on 

improving maternal and child health through decreased total fertility. It seeks to guide Senegal toward a 

higher quality of health services through strengthening human resources and management, improving 

infrastructure, and increasing availability of commodities (IntraHealth International (b) 2012; Ministère 

de la Santé et de la Prévention 2009). 

1.1.3. Quality of Care 

Numerous studies have attempted to describe and assess quality of health care (Aldana, Piechulek, and 

Al-Sabir 2001; Basinski et al. 1992; Bruce 1990; Caper 1988; Choudhry, Fletcher, and Soumerai 2005; 

Donabedian 1988; Mosadeghrad 2012; Shaikh et al. 2008); however, there does not appear to be a 

consensus in the literature on how to define or measure quality of care (Basinski et al. 1992). The 

definition and measurement of quality of care also depend on the stakeholders’ priorities, whether from 

the perspective of clients, health professionals, or providers, researchers, program managers, or 

policymakers (Conry et al. 2012; Creel, Sass, and Yinger 2002). 

One of the widely used and referenced frameworks used to measure quality of care in health care is that 

of Donabedian (Donabedian 1988), who classified quality of care in three dimensions: structure, process, 

and outcome. Structure is mainly concerned with the physical attributes of a health facility, its 

infrastructure, inventory, and equipment, as well as the number of qualified personnel. Process refers to 

health care delivery, both technical and interpersonal, while outcome examines the effect of care on the 

patient and includes client’s satisfaction with health care services received (Donabedian 1988). 

Other authors have looked at other dimensions of quality of care, but most can be included within 

structure, process, or outcome. For example Caper (Caper 1988) stated that efficacy, appropriateness, and 

caring should be used to asses qualify of care. The appropriateness and caring aspects could be considered 

part of the process component, as they cover how care was delivered by the health professional, from both 

technical and interpersonal perspectives. Caper referred to the outcome component as ‘efficacy’ and 

defined it as whether the diagnostic or therapeutic procedure accomplished its goal (i.e., was the outcome 

successful?). The suggested measurements for this component were mortality rates or severity of illness, 

and client satisfaction with services (Caper 1988). 

Many other articles discuss process as important to the assessment of quality of care, referring to it 

variously as professional competence, the technical component, effectiveness, the personal relationship, a 

generic quality, or an intangible attribute, among other terms (Basinski et al. 1992; Joss and Kogan 1995; 

Mosadeghrad 2012; Parasuraman, Zeithaml, and Berry 1985; Zyzanski, Hulka, and Cassel 1974). 

Concerning measurement of outcome, (Basinski et al. 1992) discussed how a cause-effect measurement 

of the medical outcome can be affected by many complex patient variables, such as coexisting medical 

conditions and psychological and socioeconomic factors, which can make this measurement difficult. 

“Excellent outcomes may be expected but cannot be assured, even with exemplary delivery of care” 

(Basinski et al. 1992, p2155). An alternative is using patient satisfaction as a measure of outcome. 

However, Donabedian warned that asking patients about their satisfaction with specific attributes of care 

as well as the interpersonal relationship with their provider may result in misreporting due to the patient’s 

reluctance to alienate their medical providers (Donabedian 1988). Another outcome measure can also be 

the knowledge gained by the client following a specific service (Bruce 1990; Donabedian 1988). This 

may also reflect the interaction with the provider and whether the provider was effective in transferring 

certain vital information regarding the service in question (Bruce 1990), for instance the use of a family 

planning method or knowledge of protection from sexually transmitted infections (STIs). 
4 

Structure is the most straightforward component of quality of care to assess and measure. This component 

can be seen as service availability and the readiness of the health facility as defined by the World Health 

Organization (WHO) Service Availability and Readiness Assessment (SARA) indicators (O’Neill et al. 

2013). The SARA indicator guidelines also provide a set of indicators that are service specific (antenatal 

care, family planning, child curative services, etc.) to determine whether a health facility has met the 

minimum criteria for provision of the specific service in question (O’Neill et al. 2013). These indicators 

mainly involve assessing the availability of trained staff, relevant up-to-date guidelines, functioning 

equipment, diagnostic capacities, and essential medicines and commodities. 

1.1.4. Quality of Care in Family Planning 

The quality of family planning services is an important determinant of the uptake and continuation of 

contraceptive methods. Studies in various settings have reported a significant positive relationship 

between quality of family planning services and use of contraceptives (Arends-Kuenning and Kessy 

2007; Blanc, Curtis, and Croft 2002; Jain 1989; Koenig, Hossain, and Whittaker 1997; Magnani et al. 

1999; Mariko 2003; Mensch, Arends-Kuenning, and Jain 1996). A panel study in Senegal found that 

women who received good quality family planning services in health facilities were 1.3 times more likely 

to be using a contraceptive method compared with women who received poor quality of care (Sanogo et 

al. 2003). 

Analyzing data from DHS and SPA surveys in Tanzania, (Arends-Kuenning and Kessy 2007) found that 

information given to clients and the provider’s technical competence were significant predictors of 

modern contraceptive use. A longitudinal study in the Philippines found strong evidence of increased 

contraceptive use with improved quality of family planning services (RamaRao et al. 2003). The authors 

found that the probability of modern contraceptive use was 55 percent for clients who received lowquality care, 62 percent for medium-quality care, and 67 percent for high-quality care. An analysis of 

DHS data from 15 countries found that, within a year of starting use of a method, between 7 and 27 

percent of women discontinued the method for reasons related to the quality of the service environment 

(Blanc et al. 2002). 

Given the importance of quality of care, it is essential to use reliable methods to measure it. Two 

frameworks have been widely used to guide the research on quality of family planning services. One is 

Avedis Donabedian’s structure-process-outcome framework, discussed previously (Donabedian 1988). 

The other is Judith Bruce’s quality framework (Bruce 1990). The framework consists of six elements: 

choice of methods, information given to clients, technical competence of providers, provider-client 

interpersonal relations, mechanisms for encouraging continuity and follow up, and appropriate 

constellation of services. 

In Donabedian’s framework, family planning structure refers to the basic infrastructure and management 

system for family planning service delivery, including physical infrastructure (access to electricity, 

improved water source, adequate sanitation facilities, etc.); availability of contraceptive commodities, 

materials, and equipment essential for providing physical examination; and counseling services, as well as 

supportive management practices, such as regular supervision and in-service training for providers (Agha 

and Do 2009; Donabedian 1988; Ndhlovu 1995). Process refers to how the family planning services are 

delivered and whether the provider adheres to the standards of care. The provider’s technical competency 

and the provider-client interpersonal relationship are often examined in assessing process (Agha and Do 

2009; Hutchinson, Do, and Agha 2011). The outcome aspect in family planning can be measured by the 

acceptance of contraception and whether the reasons for continuation or discontinuation are related to the 

quality of services (RamaRao et al. 2003). With increased focus on client-centered health services, client 

satisfaction is also an important outcome indicator of quality of care. In addition to assessing individual 

dimensions of the quality of care, studies commonly have examined correlations among the dimensions, 
5 

especially how structure and process are associated with outcome measures. The general finding from 

these studies is that process attributes are more predictive of outcome indicators than structural attributes 

(Hutchinson 2011, Wang et al. 2013, Agha and Do). 

Bruce’s framework focuses on the process of service provision and highlights the client’s perspectives 

and experiences (Strobino, Koenig, and Grason 2000). Bruce linked the six elements of quality to three 

types of outcomes: client knowledge, satisfaction, and contraceptive use behavior (Bruce 1990). Based 

upon this framework, the EVALUATION Project working group developed a list of quality indicators 

measuring each dimension (Bertrand, Magnani, and Rutenberg 1994). While many of the indicators can 

be obtained by either interviewing clients or observing the provider-client interactions, Bessinger and 

Bertrand suggested a combination of observations and client exit interviews to better assess quality of 

care in family planning facilities (Bessinger and Bertrand 2001). 

2. Data and Methods

2.1. Senegal Continuous SPA Survey 

Service Provision Assessment surveys provide detailed information on how a country delivers services, 

and are conducted by taking a national sample of formal health care facilities in the country. The Senegal 

Continuous Survey project contains a SPA component and a DHS component and is designed to have five 

annual rounds of data collection, with the last round in 2017. The Senegal SPA survey produces 

indicators that are representative at the national level, by facility type, managing authority, and the 14 

regions of the country. Each round covers a representative sample of health facilities, including 50 

percent of hospitals and health centers and 20 percent of health posts and a sample of their associated 

health huts (Agence Nationale de la Statistique et de la Démographie [Senegal] and ICF International 

2014). Health facilities selected in the first round were not selected in the second round, creating a 

dependent sampling structure between the two rounds. The first two rounds comprise a census for 

hospitals and health centers but not for health posts or health huts. A census for all facility types would 

only be achieved after combining all five phases of the Continuous SPA. 

The analysis uses data from the first two rounds of the Senegal Continuous SPA, round 1 in 2012-2013 

and round 2 in 2014. The description of the sample of health facilities for rounds 1 and 2, excluding the 

health huts, is found in Table 2 in the Results Section. 

The selection of health huts is different from other types of facilities. Among all health huts associated 

with a sampled health post, one health hut is randomly selected. Not every health post sampled supervises 

a health hut. In 2012-2013, 74 health huts were examined, while in 2014 this number increased to 89. The 

sampling methodology used to select the health huts does not allow analysis with the other health facility 

types, since the probability of selection for health huts depends on that of the health posts. Therefore, 

health huts were excluded from the overall sample and, when applicable, were analyzed separately. 

In both rounds of the Senegal Continuous SPA used in the analysis, a health facility inventory was 

conducted that includes information about the infrastructure, equipment, commodities, and medicines that 

are necessary for providing priority services. When applicable, the inventory questions include observing 

the presence of the item and whether it is functioning (for equipment), or still valid (for medicines and 

commodities). Separate and reduced inventory and health worker questionnaires were used for health 

huts. 

The other types of data collected in the SPA include the observation checklist and client exit interviews, 

as well as interviews with health providers. Health workers were selected and interviewed with a 

questionnaire that covers information about the workers, including their qualifications, training, and the 
6 

type of services they provide. The observation checklist has both technical aspects, such as adherence to 

international protocols, and nontechnical aspects, such as the level of counseling provided. At the end of 

the observation, the clients were interviewed to assess their level of satisfaction with the services and the 

health facility in general. In addition, the client’s knowledge of the services and counseling offered was 

examined. 

The two rounds of the Senegal Continuous SPA survey differ in the type of observations and exit 

interviews conducted. In the 2012-2013 SPA, the observation and exit interviews were conducted for 

family planning and child curative services, while in the 2014 SPA the observation and exit interviews 

were conducted for antenatal care and child curative services. Therefore, while comparisons can be made 

between the two rounds from data obtained from the inventory and health provider questionnaires, 

comparisons cannot be made from data from the family planning observation checklist and exit 

interviews. Health huts did not have observation checklists or exit interviews. 

To select a sample for observation of family planning services, family planning clients were 

systematically selected if there were clients waiting to be seen. Otherwise, clients were selected for 

observation as they arrived. A general rule is to observe the consultations for a maximum of three 

providers of family planning services. For each selected provider, a maximum of five consultations were 

observed on the day of the assessment. All family planning clients whose consultations were observed 

were eligible for the exit interview. In addition, a sample of health workers was selected for conducting 

the health provider interviews, which elicit information on the provider’s background characteristics. In 

facilities with eight or fewer providers, all providers were eligible for interview. In facilities with more 

than 8 providers, between 8 and 15 providers were selected for interviewing, in a systematic sample. 

Providers whose consultations were observed and providers who were respondents for the entire 

inventory questionnaire or parts of it were automatically selected for the health worker interview. 

2.2. Methods 

2.2.1. Construction of Variables 

Following the Donabedian framework (Donabedian 1988), three types of dependent variables were 

constructed to represent the three components of quality of care: structure, process, and outcome. 

Structure was measured with facility inventory data. Dependent variables were constructed for general 

structure and more specific dependent variables for family planning structure. The process and outcome 

dependent variables only focused on measuring family planning quality of care; the data required to 

construct these variables came from observations and client exit interviews for family planning. Therefore 

these variables were only available for the 2012-2013 SPA, since the 2014 SPA did not have observation 

and exit interviews for family planning. For each component of quality of care, the appropriate 

independent variables were used to describe associations and/or perform regressions in order to identify 

the determinants of quality of care. 

2.2.1.1. General Structure Variables 

The WHO Service Availability and Readiness Assessment (SARA) was used as a guide to construct the 

structure quality of care indices (World Health Organization (WHO) 2013), which represent the structure 

dependent variables. This reference provided a list of indicators, both general and service specific, 

required to provide the necessary quality of care. These include indicators on the infrastructure, 

equipment, diagnostic tests, commodities, and medicines of health facilities. 

Appendix A summarizes the infrastructure indicators and covers the availability of the basic infrastructure 

required for a functioning health facility—access to electricity, improved water source, adequate 
7 

sanitation facilities, communication equipment, private room, computer and Internet access, and an 

emergency transport vehicle. These indicators were examined separately for each survey round. 

To examine the availability and readiness of the facilities in terms of equipment, diagnostic tests, and 

medicines, a number of indicators were required, as Appendix B shows. Principal component analysis 

(PCA), a data reduction method, was used to create a composite index for each of these areas. PCA based 

on DHS data is routinely used to construct the wealth index. This method has been criticized because the 

PCA technique, designed for use with continuous normally distributed data, is being applied to binary or 

categorical data (Howe, Hargreaves, and Huttly 2008; Sharker et al. 2014). However, alternative methods 

that may be more appropriate for categorical data, such as multiple correspondence analysis, are more 

complex and do not provide much improvement (Howe, Hargreaves, and Huttly 2008). Therefore, PCA 

was seen as an appropriate method to create service readiness indices in a manner analogous to the 

construction of the wealth index. To improve the results produced from PCA and to reduce 

misclassification, Sharker et al. (2014) recommend removing negative loadings. In addition, they 

recommend that any PCA that produces a first component explaining less than 30 percent of the total 

variation be interpreted with caution. These recommendations were considered in the construction and 

interpretation of the composite indices. To perform the PCA, each indicator was coded as a binary 

variable for having the item/service or not. The first PCA was then performed, and any indicators that 

produced negative loadings or loadings below 0.1 were removed. Then PCA was conducted again. The 

first component of the second analysis, which explains the highest percent of the variance in the data, was 

then used to produce a composite score or index. The composite index was then divided into terciles to 

represent low, medium, and high quality of care for the respective area. 

Appendix B summarizes the indicators used for constructing the composite indices for equipment, 

diagnostic tests, and medicines. For the diagnostic test and medicine indices, no indicators showed any 

negative loadings or loadings below 0.1. For the equipment index, however, the indicators for sharps and 

waste disposal produced negative loadings in both rounds and were therefore removed from the PCA. The 

resulting first component from the analysis of equipment and diagnostic test explained more than 30 

percent of the variance in both rounds. The PCA for medicines in the first round did not produce any 

negative loadings or loadings below 0.1; however, in the second round the medicine Simvastatin had a 

negative loading, and the medicines Amitriptyline and Amlodipine both had loadings below 0.1. In order 

to have comparable results, these three medicines were dropped from the PCA in both rounds. These 

medicines were not present in high percentages in the facilities. The resulting PCA for medicines was less 

than 30 percent in both rounds, and, therefore, the interpretation and analysis of this index should be 

interpreted with caution. As Appendix B shows, Cronbach’s alpha for each of the indices was above 0.7 

and thus shows general agreement in the grouping of the indicators. 

2.2.1.2. Family Planning Structure Variables 

To assess the readiness of health facilities for providing family planning services, the analysis used a 

number of indicators from the WHO SARA guide for family planning services. These indicators include 

availability of various types of modern contraceptive methods, a family planning guideline, a functioning 

blood pressure machine, and at least one staff member in the facility with family planning training. For 

the availability of modern contraceptive methods, only methods that were found to be valid and not 

expired were considered as having the method available in the facility. Figure 1 summarizes these 

indicators for both rounds among facilities that offer family planning services. The health provider data 

were used to construct the training variable. In round 1, the question on training asked the providers if 

they had family planning training in the past two years, while in round 2 the question was for family 

planning training in the past three years. This difference is minor but should be taken into consideration 

when interpreting the results from Figure 1 and Table 10. 
8 

Only the variables for availability of progestin-only injectables and combined oral pills were selected for 

further analysis of family planning structure among facilities that provided family planning services. 

Progestin-only injection was found to be the method most used by the clients, and combined oral pills 

was second in popularity (see Results, Table 11). These were also the top two modern methods according 

to the most recent Senegal DHS household survey (Agence Nationale de la Statistique et de la 

Démographie (ANSD) [Senegal] and ICF International 2015). 

2.2.1.3. Covariates for structure 

The covariates used to study quality of care for structure (both general structure and family planning 

structure) are found in Table 2. These variables were chosen to identify the characteristics of the health 

facility most associated with improved quality of care. For the managing authority variable, the private 

category includes health facilities managed by NGOs or religious-based organizations. The region 

variable was constructed as follows: North (regions of Louga, Matam, and Saint Louis); Dakar; Thiès; 

Central (regions of Diourbel, Fatick, Kaffrine, and Kaokack); East (regions of Kédougou and 

Tambacounda); and South (regions of Kolda, Sédhiou, and Ziguinchor). 

2.2.1.4. Process Variables 

Data for the analysis of the process component of quality of care came from direct observations of family 

planning consultations and physical examinations. The process assessment focused on the quality of 

counseling and the appropriateness of procedures during the pelvic examination. There was only one male 

in the observation sample; therefore, the analysis was restricted to female clients who were provided or 

prescribed a method during the observed visit. The quality of counseling was measured with four binary 

indicators on the content of information exchanged between the provider and the client during the 

counseling session: whether the provider counseled on how to use the method; whether the provider 

discussed side effects of the method; whether the provider gave advice on when to return for follow-up 

services; and whether the provider counseled about method protection from STIs. These indicators were 

defined specifically for the method provided or prescribed to the client (see Appendix C). To assess the 

overall quality of counseling, a binary variable was also created for all methods used, based on whether 

the client was counseled on all three aspects about the method: how to use it, side effects, and when to 

return to the facility. 

To measure the quality of pelvic examinations, the number of appropriate procedures performed by the 

provider was first calculated based on a checklist of the procedures that should be performed before, 

during, and after a pelvic examination (see Appendix D). A binary quality indicator was then constructed 

using the median number of procedures as the cutoff point. A client was considered to have received a 

high quality of pelvic examination if the number of procedures she received was at or higher than the 

median level; otherwise she was considered to have received a low quality of pelvic examination. This 

indicator was only available for women who received a pelvic examination during the visit. 

2.2.1.5. Outcome Variables 

Two dependent variables were used to study the outcome component of quality of care in family 

planning. The first variable used a question in the family planning client exit interview that asks clients 

about their overall satisfaction with the services provided. The categories for response were: (1) very 

satisfied, (2) more or less satisfied, and (3) not satisfied. To create a binary dependent variable, the 

response “more or less satisfied” was combined with “not satisfied.” The second outcome dependent 

variable, also a binary variable, examines the knowledge of the client after receiving services, and is 

derived from a question asked during the family planning exit interview. The question asks the client if 

their method protects them from STIs, including HIV/AIDS. The method the client was using was 

determined from the observation of the family planning consultation, during which the method or 
9 

methods provided or prescribed to the client were recorded. Clients who answered yes and who were not 

using condoms (only two observations) were coded as having incorrect knowledge, those who answered 

no were coded as having correct knowledge (unless they were using condoms), and those who answered 

that they did not know were removed from the analysis. The analysis of the satisfaction outcome was 

restricted to users of pills, injectables, IUDs, and implants (all users except for 10 cases), and the analysis 

of the knowledge outcome was restricted to all users. This was because two variables on counseling 

required in the satisfaction outcome analysis were only available for users of pills, injectables, IUDs, and 

implants. All the outcome analyses on quality of care were restricted to female clients. 

2.2.1.6. Covariates for Process and Outcome 

Table 11 shows all of the independent variables used for the analysis of process and outcome. The 

independent variables are divided into three groups: the background characteristics of the client, the 

provider, and the facilities. The managing authority variable (private or public) used to describe facilities 

was not included in the analysis of process or outcome, since only 17 observations and exit interviews 

were in private health facilities, after selecting users of a modern contraception method. The appropriate 

independent variables were selected for each process and outcome dependent variable. The provider’s 

characteristics were drawn from the health provider interview. The client’s characteristics were taken 

mainly from the client exit interviews, except for client status (new or returning client), family planning 

method used, and whether the client left the clinic with a method, which were drawn from the observation 

of the family planning consultation. 

For client’s age, 52 clients who responded that they do not know their age were placed with the oldest 

group, age 40-58, on the assumption that the oldest were least likely to know their age. Similarly, 21 

clients who responded that they did not know how long they waited to see a provider were placed with the 

largest waiting category of two hours or more, on the assumption that clients who had to wait very long 

might not remember exactly how long they waited. As for the provider characteristics, only eight 

specialists and general physicians (four if we select for current users of a modern method) were observed, 

and these were placed within the nurse or nurse assistant category. One important characteristic was 

personal supervision that the provider received during the six months before the survey. It refers to 

technical support or supervision from a facility-based supervisor or from a visiting supervisor in various 

forms, including review of records or reports, observation of work, feedback on work performance, and 

discussion of problems encountered by the provider. A three-category variable was constructed to 

measure personal supervision: received none, received one to five supervisory items, and received all six 

listed supervisory items. 

For process analysis, the independent variables included the client’s background characteristics (age, 

education, new or returning, and contraceptive method used), the provider’s background characteristics 

(provider category, years of education, training received, supervision, having a job description, and salary 

type), and the facility characteristics (health facility type, locality, region, and the equipment composite 

index created from the PCA). Years of education received was used as a proxy for the number of years of 

experience (Choudhry, Fletcher, and Soumerai 2005). In addition, the variable salary type was included as 

a measure that might influence the provider’s motivation, which in turn could affect their performance 

(Rowe et al. 2005). The facility characteristics, and specifically the equipment composite index, represent 

the structure component, which was discussed by Basinski et al. and Donabedian (Basinski et al. 1992; 

Donabedian 1988) as possible predictors of the process component of quality of care. While the presence 

of equipment in a facility may not necessarily have a direct effect on the process or the provider’s level of 

care, it may serve as a proxy for the overall environment and readiness of the facility, and is included as a 

predictor of the process quality of care for this purpose. The diagnostic tests composite index could not be 

included, as it was highly correlated with facility type, while the medicine composite index was not 

recommended for use in further analysis because it explained less than 30 percent of the variance. 
10 

Outcome analysis of client’s overall satisfaction included the client variables of fee paid for service, 

waiting time, and whether the client left with a family planning method (Agha and Do 2009; Aldana, 

Piechulek, and Al-Sabir 2001; Hutchinson, Do, and Agha 2011). In addition, the process dependent 

variables were included as covariates. These included variables based on providing counseling on how to 

use the method, the side effects of the method, and when to return if side effects appeared. Counseling on 

side effects and counseling on when to return were highly correlated with each other and therefore were 

not included in the same regression model. These variables were only asked of user of pills, injectables, 

IUDs, and implants and not all users (difference of only 10 cases). The facility characteristics and the 

equipment composite index were also added as covariates in the outcome analysis. 

Finally, for the outcome analysis of knowledge of the method’s protection from STIs, a variable 

representing whether the provider provided counseling on this issue was included as a covariate. The 

covariates used for the outcome satisfaction analysis, such as fee paid for service, waiting time, whether 

the client left with a method, other counseling process variables, and the structure composite indices were 

not included, as these do not have a direct pathway to this outcome. 

2.2.2. Analyses 

For the structure analyses, comparisons between the two survey rounds were conducted when possible. 

This involved testing whether the differences in the proportions of services offered, basic infrastructure, 

and family planning structure indicators were significant. A separate but similar analysis was conducted 

for health huts. Due to the dependent sampling structure between the two survey rounds, a conservative 1 

percent significance level was used for testing the differences between the rounds. This is due to the 

underestimation of the standard errors of the estimates. The standard test assumes independence, whereas 

the two samples were actually dependent. Therefore, to be conservative, a lower level of significance was 

used. Only p-values below 0.01 were considered significant. 

The analysis takes into consideration the sampling weights and the stratified sampling design, with 

stratification by facility type and the 14 regions of Senegal. This consideration does not allow the usual 

Chi-square tests for associations, and F-tests were used instead. For the analysis of structure, the unit of 

analysis was the health facility, and therefore the facility weight was used. However, for the process and 

outcome components of quality of care, the unit of analysis was the client, and therefore the client’s 

weight was used. 

All regressions performed in family planning structure, process, and outcome analyses involved binary 

dependent variables, and therefore logistic regressions were used for fitting models. For the logistic 

regressions, pseudo-R2

 values are reported, which take into consideration the weights but not the stratified 

sampling design. All analyses were performed using the Stata statistical software version 13.0 

(StataCorp. 2013). 

3. Results 

3.1. Health Facilities 

The maps on the following page show the distribution of the sample of health facilities for each round of 

the SPA. The maps also show the main roads and other geographical information, such as main rivers and 

asphalted roads, to demonstrate the accessibility of these facilities. The facilities shown in the map are the 

hospital (hôpital), health center (centre de santé), health post (poste de santé), and health hut (case de 

santé) facilities visited in each SPA round. 
11 

 
12 

Table 2 provides a descriptive summary of the facilities surveyed in round 1 and round 2. Specifically, 

Table 2 outlines the facility type, managing authority, urban/rural location, and regional breakdown of the 

facilities. Most of the facilities in the sample were at the health post level (87 to 88 percent for both 

rounds) and were publically managed (83 percent in round 1 and 81 percent in round 2). There were 

slightly more facilities in rural than urban regions, 56 percent rural in round 1 and 62 percent in round 2. 

The Central region had the most facilities (23 percent for both rounds), and the East region had the fewest 

(9 percent for both rounds). 

Table 2. Description of facility characteristics

 Round 1 

(N=364) 

Round 2 

(N=363) 

 % Weighted 

N 

Unweighted 

N % Weighted 

N 

Unweighted 

N 

Health facility type 

Hospital 4.7 17 35 4.1 15 35 

Health center 8.2 30 64 8.1 29 62 

Health post 87.1 317 265 87.9 319 266 

Managing authority 

Private 17.0 62 59 18.8 68 70 

Public 83.0 302 305 81.2 295 293 

Locality 

Urban 44.1 161 168 37.6 136 158 

Rural 55.9 203 196 62.4 227 205 

Region 

North 18.7 68 63 18.9 69 62 

Dakar 19.6 71 71 19.0 69 72 

Thiès 13.2 48 41 13.3 48 43 

Central 23.3 85 83 23.4 85 83 

East 9.0 33 41 9.2 33 41 

South 16.1 59 65 16.2 59 62 

3.2. Quality of Care in General Structure 

3.2.1. Basic Infrastructure 

Tables 3 through 5 present changes in service provision and the general structure of the facilities between 

the two rounds. Table 3 compares the differences between the two rounds in types of services provided 

(family planning services, antenatal care (ANC) services, child vaccination services, and child curative 

services) by facility type (hospital, health center, health post, and health hut). Even though all facility 

types demonstrated some increase in types of service provided from round 1 to round 2, these increases 

were small and not significant at the 1 percent level. At the health hut level, facilities that provided family 

planning services increased by 22.9 percentage points and child vaccination services increased by 11.6 

percentage points, but these increases were not significant. As mentioned previously, health huts were 

analyzed separately due to the nature of their selection in the sample. 
Table 3. Services offered by facility type for round 1 and round 2 

Family planning Services ANC services Child vaccination services Child curative services 

Round 1 Round 2 diff Round 1 Round 2 diff Round 1 Round 2 diff Round 1 Round 2 diff % [C.I.] % [C.I.] % [C.I.] % [C.I.] % [C.I.] % [C.I.] % [C.I.] % [C.I.]

Hospital 

68.0 72.6 

4.6 

75.9 79.1 

3.2 

33.5 28.1 

-5.4 

81.9 83.5 

1.6 [50.7,81.5] [54.3,85.5] [59.1,87.3] [60.6,90.3] [19.9,50.6] [14.9,46.6] [65.0,91.7] [64.7,93.3]

Health center 

77.9 83.8 

5.9 

79.5 83.7 

4.2 

74.8 73.2 

-1.6 

93.7 98.7 

5.0 [65.7,86.6] [70.6,91.7] [67.7,87.7] [70.5,91.7] [62.8,83.8] [59.5,83.6] [84.4,97.6] [90.9,99.8]

Health post 

86.6 88.1 

1.5 

90.6 92.0 

1.4 

87.0 87.1 

0.1 

95.1 96.7 

1.6 [81.5,90.4] [83.5,91.5] [86.1,93.8] [87.8,94.8] [81.9,90.8] [82.5,90.6] [91.5,97.2] [93.6,98.3]

Total 

85.0 87.1 

2.1 

89.0 90.8 

1.8 

83.4 83.6 

0.2 

94.3 96.3 

2.0 [80.6,88.6] [83.0,90.3] [85.1,92.0] [87.1,93.5] [79.0,87.1] [79.5,87] [91.2,96.4] [93.6,97.9]

Health hut 

43.2 66.1 

22.9 

28.7 31.4 

2.7 

45.5 57.1 

11.6 

96.6 96.5 

-0.1 [31.1,56.0] [54.0,76.4] [19.6,40.0] [20.1,45.5] [32.8,58.7] [46.2,67.4] [86.5,99.2] [89.6,98.9]

Note: Health huts analyzed separately. Estimates reported as % [95% C.I.] for each round.Differences are round 2 − round 1 and are tested at 1% level; all differences were found to be non-significant.

13 
14 

Tables 4 and 5 depict the general structural indicators and the changes between rounds 1 and 2, stratified 

by facility type, managing authority, locality, and region. The structural items in Table 4 consist of 

electricity, improved water source, and adequate sanitation. Overall, most facilities (over 97 percent in 

both rounds) had access to adequate sanitation and almost 90 percent in both rounds had access to an 

improved water source. However, only about 60 percent of the facilities had electricity, with large 

variations by health facility type and region. For instance, and as expected, the percentage of hospitals 

with electricity was over 90 percent in both rounds, while almost half of the health post facilities lacked 

regular electricity. The percentage of facilities with electricity decreased slightly overall, but there were 

large decreases in private facilities (-15 percentage points) as well as in the Dakar region (-17 percentage 

points); these decreases were not significant. Since, overall, the percentage of facilities with access to 

improved water and adequate sanitation was high, there was little room for improvement. There was a 

large increase in the percentage of facilities with access to an improved water source in the East region 

(an increase of approximately 20 percentage points), although this was not significant. 

Table 4. Percentage of facilities with electricity, improved water source, and adequate sanitation, by 

facility characteristics. 

 Electricity Improved water source Adequate sanitation 

 Round 1 Round 2 diff Round 1 Round 2 diff Round 1 Round 2 diff % [C.I.] % [C.I.] % [C.I.] % [C.I.] % [C.I.] % [C.I.]

Health facility type 

Hospital 91.8 98.4 6.6 98.6 100.0 1.4 100.0 100.0 0.0 [76.4,97.5] [89.7,99.8] [91.0,99.8] 

Health center 76.9 68.2 -8.7 93.5 100.0 6.5 98.4 100.0 1.6 [64.8,85.7] [54.0,79.7] [84.3,97.5] [89.6,99.8] 

Health post 54.8 53.7 -1.1 87.8 91.6 3.8 97.5 98.2 0.7 [48.7,60.8] [47.8,59.5] [83.5,91.1] [88.0,94.2] [94.8,98.8] [95.5,99.3] 

Managing authority 

Private 66.2 51.0 -15.2 94.8 98.6 3.8 100.0 100.0 0.0 [51.6,78.2] [38.5,63.4] [86.4,98.1] [90.8,99.8]

Public 56.8 58.0 1.2 87.5 91.2 3.7 97.3 98.0 0.7 [50.8,62.6] [51.9,63.9] [83.2,90.9] [87.3,94.0] [94.4,98.7] [95.1,99.2] 

Locality 

Urban 56.9 59.4 2.5 98.2 99.2 1.0 98.8 98.2 -0.6 [48.6,64.8] [50.5,67.7] [93.1,99.6] [94.5,99.9] [94.4,99.8] [92.9,99.5]

Rural 59.5 55.1 -4.4 81.3 88.7 7.4 96.9 98.5 1.6 [52.1,66.6] [48.1,61.9] [75.3,86.1] [83.7,92.3] [93.1,98.6] [95.1,99.6] 

Region 

North 43.5 40.8 -2.7 92.6 92.7 0.1 100.0 100.0 0.0 [31.2,56.7] [28.7,54.1] [81.4,97.3] [82.3,97.2]

Dakar 76.3 59.2 -17.1 96.0 100.0 4.0 98.0 98.1 0.1 [63.1,85.9] [46.2,71.1] [85.0,99.0] [86.6,99.7] [87.2,99.7] 

Thiès 58.6 67.3 8.7 94.3 100.0 5.7 97.1 100.0 2.9 [41.9,73.5] [50.6,80.6] [79.5,98.6] [81.8,99.6] 

Central 40.2 42.0 1.8 94.5 97.7 3.2 99.2 100.0 0.8 [29.5,52.0] [31.7,53.0] [85.6,98.0] [90.6,99.5] [94.5,99.9] 

East 69.1 76.9 7.8 61.7 81.6 19.9 93.1 90.9 -2.2 [50.0,83.3] [58.2,88.9] [43.9,76.8] [63.3,91.9] [77.2,98.2] [72.9,97.3] 

South 73.8 73.3 -0.5 78.0 76.8 -1.2 95.7 97.5 1.8 [60.2,84.0] [60.1,83.3] [66.3,86.5] [63.5,86.3] [85.9,98.8] [83.9,99.7] 

Total 58.4 56.7 -1.7 88.8 92.6 3.8 97.7 98.4 0.7 [52.9,63.6] [51.3,61.9] [85.0,91.7] [89.4,94.9] [95.4,98.9] [96.0,99.4]

Notes: See Appendix A for description of basic infrastructure variables. Estimates reported as % [95% C.I.] for each round. 

Differences are round 2 − round 1 and are tested at 1% level, all differences were found to be non-significant.
15 

Table 5 describes the presence of communication equipment, private room, emergency transportation, and 

computer and Internet access in the facilities for each round. Overall, almost all facilities had a private 

room, and this was true for all facility types and for both rounds. However, the presence of 

communication equipment, emergency transport, and especially computer and Internet access was 

lacking, particularly in health posts. Only 58 percent of facilities in round 1 and 50 percent in round 2 had 

communication equipment, with large and significant decreases between the two rounds in rural areas (-

14 percentage points) and in the East region (-61 percentage points). There were also large discrepancies 

by facility characteristics. For instance, the South and North regions had lower proportions of facilities 

with communication equipment compared with the Dakar region. Approximately two-thirds of the 

facilities in both rounds had emergency transport. A large and significant decrease between the two 

rounds in the percentage of facilities with emergency transport was found in the South region (-25 

percentage points). There was an increase of 22 percentage points in the Dakar region, although this 

increase was not significant. The percentage of facilities with access to computer and Internet was 

relatively low in both rounds (only 26 percent in round 1 and 33 percent in round 2). There were very 

large variations by all facility background characteristics. Hospitals had the highest proportion of facilities 

with computer and Internet access, reaching 87 to 94 percent in both rounds compared with 19 to 27 

percent for health posts. Some significant increases were found between the two rounds; the percentage of 

urban facilities with computer and Internet access increased by 19 percentage points, and in the Dakar 

region by a significant 26 percentage points. 
Table 5. Percentage of facilities that have communication equipment, private room, emergency transport, and computer 

and Internet access by facility characteristics 

Communication equipment Private room Emergency transport Computer and internet 

Round 1 Round 2 diff Round 1 Round 2 diff Round 1 Round 2 diff Round 1 Round 2 diff % [C.I.] % [C.I.] % [C.I.] % [C.I.] % [C.I.] % [C.I.] % [C.I.] % [C.I.] 

Health facility type 

Hospital 

93.4 98.4 5.0 100.0 100.0 0.0 87.6 92.1 4.5 86.7 93.5 6.8 [77.0,98.4] [89.7,99.8] [69.6,95.6] [75.9,97.7] [67.9,95.2] [77.4,98.4] 

Health center 

86.0 79.9 -6.1 98.4 98.4 0.0 86.9 88.4 1.5 68.5 72.3 3.8 [75.8,92.4] [67.3,88.4] [89.3,99.8] [89.3,99.8] [75.8,93.3] [74.7,95.2] [55.3,79.2] [57.9,83.2] 

Health post 

53.4 45.4 -8.0 99.5 98.3 -1.2 62.0 62.5 0.5 18.9 27.1 8.2 [48.0,58.7] [40.1,50.9] [96.5,99.9] [95.5,99.3] [56.5,67.2] [56.3,68.3] [14.3,24.4] [22.2,32.6] 

Managing authority 

Private 

81.5 74.6 -6.9 96.6 100.0 3.4 60.5 60.5 0.0 60.8 66.2 5.4 [68.8,89.8] [62.0,84.1] [85.2,99.3] [46.0,73.3] [47.2,72.4] [46.0,73.8] [53.6,76.9] 

Public 

53.2 44.7 -8.5 100.0 98.0 -2.0 66.2 67.0 0.8 19.1 25.8 6.7 [47.7,58.5] [39.3,50.4] [95.1,99.2] [60.8,71.2] [60.8,72.7] [15.2,23.6] [21.2,31.1] 

Locality 

Urban 

72.4 79.9 7.5 99.7 98.8 -0.9 52.7 61.3 8.6 39.1 58.1 19.0** [64.4,79.2] [71.6,86.2] [97.9,100.0] [94.8,99.7] [45.2,60.1] [52.2,69.6] [31.6,47.2] [49.1,66.5] 

Rural 

46.6 32.6 -14.0** 99.2 98.1 -1.1 75.1 68.5 -6.6 15.9 18.6 2.7 [40.0,53.2] [26.5,39.3] [94.6,99.9] [94.3,99.4] [68.3,80.8] [61.4,74.9] [11.3,21.8] [13.7,24.8] 

Region 

North 

42.9 23.0 -19.9 100.0 100.0 0.0 74.5 72.4 -2.1 20.0 34.3 14.3 [30.3,56.4] [14.0,35.4] [61.1,84.4] [59.5,82.4] [11.8,31.7] [23.4,47.2] 

Dakar 

80.3 87.2 6.9 99.3 99.3 0.0 33.1 55.2 22.1 42.3 68.1 25.8** [67.4,89.0] [75.0,93.9] [95.3,99.9] [95.3,99.9] [23.8,43.9] [42.5,67.3] [31.0,54.6] [54.7,79.1] 

Thiès 81.9 75.9 -6.0 96.7 100.0 3.3 54.5 60.4 5.9 32.0 39.6 7.6 [65.7,91.5] [59.3,87.2] [79.3,99.5] [38.2,69.9] [44.0,74.6] [19.8,47.4] [25.8,55.2] 

Central 48.7 45.2 -3.5 100.0 100.0 0.0 78.3 74.2 -4.1 16.2 22.1 5.9 [38.8,58.6] [34.1,56.8] [67.1,86.5] [62.5,83.3] [10.1,24.9] [14.5,32.2] East 

91.8 30.9 -60.9*** 100.0 92.3 -7.7 58.1 66.5 8.4 25.2 13.1 -12.1 [72.2,98.0] [18.1,47.5] [73.4,98.1] [40.2,74.1] [47.2,81.5] [13.5,42.0] [5.9,26.7] 

South 

23.2 36.7 

13.5 100.0 

95.0 

-5.0

87.4 62.4 

-25.0** 

23.6 14.5 

-9.1 [14.4,35.1] [25.8,49.3] [82.1,98.7] [76.9,93.6] [48.3,74.6] [14.2,36.6] [7.4,26.2] 

Total 

58.0 50.4 

-7.6 

99.4 98.4 

-1.0

65.2 65.8 

0.6 

26.1 33.4 

7.3 [53.1,62.7] [45.5,55.2] [97.3,99.9] [96.0,99.3] [60.3,69.8] [60.3,70.9] [21.9,30.9] [28.9,38.3] 

Notes: See Appendix A for description of basic infrastructure variables. Estimates reported as % [95% C.I.] for each round. Differences are round 2 − round 1 and are tested at 1% level, **p <0.01, *** p<0.001 

16 
17 

3.2.2. General Structure Composite Indices 

A composite index was created using PCA to describe the level of availability and readiness of the 

facilities in terms of equipment, diagnostic tests, and medicines (see Appendix B). Each index was then 

divided into terciles to represent low, medium, and high levels of availability and readiness in equipment, 

diagnostic tests, and medicines for each round. Table 6 for round 1 and Table 7 for round 2 describe the 

associations between these index levels and facility characteristics. For the equipment index in round 1, 

only region was significantly associated with the equipment index, with Thiès and Central regions having 

the highest percentage of facilities with a high score for the equipment index. The North and Dakar 

regions had the highest percentage of facilities with a low score (62 percent and 48 percent respectively). 

In round 2, managing authority, locality, and region were significantly associated with the equipment 

index. Within these variables, the facilities that were public, rural, and located in Thiès or South regions 

had the highest percentages, with a high score on the equipment index. As in round 1, the North and 

Dakar regions had the highest percentage of facilities with a low score (45 percent and 49 percent 

respectively). In both rounds, facility type was not significantly associated with the equipment index. 

Table 6. Levels of readiness of equipment, diagnostic tests, and medicines by facility background 

characteristics (N=364), round 1 

 Equipment Diagnostic tests Medicines 

 Low 

(%) 

Medium 

(%) 

High 

(%) p-value Low 

(%) 

Medium 

(%) 

High 

(%) p-value Low 

(%) 

Medium 

(%) 

High 

(%) p-value

Health facility type 0.070 <0.001 <0.001 

Hospital 33.3 19.8 47.0 23.3 7.8 68.9 49.2 12.2 38.7

Health center 47.1 23.9 29.0 11.8 9.4 78.8 28.7 26.8 44.6

Health post 32.8 34.7 32.5 49.9 24.3 25.7 33.0 42.3 24.7

Managing authority 0.502 0.731 <0.001 

Private 33.9 27.0 39.1 47.2 18.1 34.7 56.6 14.1 29.3 

Public 34.0 34.3 31.6 45.2 23.2 31.6 28.6 44.8 26.6 

Locality 0.064 0.001 <0.001 

Urban 41.0 29.0 30.0 52.2 13.0 34.8 47.2 35.2 17.6

Rural 28.5 36.3 35.2 40.3 29.7 30.0 22.5 43.1 34.5

Region <0.001 <0.001 <0.001 

North 62.0 30.0 7.9 28.2 28.6 43.2 20.4 49.7 29.9 

Dakar 48.4 28.3 23.3 66.5 5.6 27.9 71.5 21.5 7.0 

Thiès 25.7 28.1 46.2 80.2 4.8 15.0 23.2 35.2 41.6 

Central 17.3 25.1 57.7 27.1 48.1 24.8 28.5 48.7 22.8 

East 23.4 61.0 15.6 48.1 23.3 28.6 32.8 35.6 31.6 

South 20.9 42.5 36.5 37.0 12.0 51.0 17.9 42.5 39.5 

For the diagnostic test index, all the variables except managing authority in round 1 were significantly 

associated with the index for the availability of diagnostic tests. In both rounds, hospitals, health centers, 

and urban areas had the highest percentage of facilities with a high score in the diagnostic test index. 

Managing authority was not significant in round 1; however, in round 2 this variable was significantly 

associated with the diagnostic test index, with private facilities having the highest score. For the region 

variable, in round 1 the highest scores were found for the North and South regions, while in round 2 the 

Dakar region had the highest score. In round 1, 80 percent of the facilities in the Thiès region had a low 

score for diagnostic tests; this improved substantially, decreasing to 26 percent of facilities with a low 

score in round 2. 
18 

While all variables in both rounds were significantly associated with the medicines index, these results 

may not be reliable since the first component from the PCA for medicines was below 30 percent. 

Therefore, no further interpretation of the results will be discussed for this index. 

Table 7. Levels of readiness of equipment, diagnostic tests, and medicines by facility background 

characteristics (N=363), round 2 

 Equipment Diagnostic tests Medicines 

 Low 

(%) 

Medium 

(%) 

High 

(%) p-value Low 

(%) 

Medium 

(%) 

High 

(%) p-value Low 

(%) 

Medium 

(%) 

High 

(%) p-value

Health facility type 0.129 <0.001 0.025 

Hospital 39.1 41.2 19.7 29.8 4.7 65.5 55.0 6.1 38.9

Health center 47.9 32.7 19.5 19.5 26.5 53.9 38.1 20.6 41.3

Health post 32.4 38.4 29.1 37.3 57.0 5.7 36.9 31.1 32.0

Managing authority 0.039 <0.001 0.001 

Private 44.9 39.2 15.9 52.3 25.3 22.4 51.4 9.8 38.8

Public 31.4 37.8 30.8 31.6 58.7 9.6 34.6 33.7 31.7

Locality <0.001 <0.001 <0.001 

Urban 45.2 38.1 16.7 38.2 38.3 23.5 57.9 17.6 24.5

Rural 27.2 38.1 34.7 33.9 61.0 5.1 25.6 36.2 38.3

Region 0.002 0.012 <0.001 

North 45.4 39.3 15.3 33.8 57.8 8.5 36.1 35.5 28.4

Dakar 48.9 37.5 13.6 40.3 34.6 25.1 65.8 16.1 18.2

Thiès 24.8 35.9 39.3 26.3 59.4 14.3 33.7 28.4 38.0

Central 33.5 33.8 32.8 34.6 59.3 6.1 20.8 29.5 49.7

East 20.1 49.6 30.2 38.3 51.1 10.5 18.8 44.5 36.8

South 19.0 38.9 42.1 39.2 52.4 8.4 45.3 28.8 25.9 

3.3. Quality of Care in Family Planning Structure 

Figure 1 describes the readiness and availability of the facilities for providing family planning services. 

The availability of family planning methods was highest for combined oral pills, progestin pills, 

progestin-only injectables, and male condoms (over 80 percent in round 2). Other family planning 

methods were not as available. The availability of male condoms, female condoms, IUDs, implants, 

emergency pills, and natural methods (cycle beads) increased significantly in round 2, by almost 20 

percentage points for implants and more for these other methods, except male condoms, which increased 

in availability by 9 percentage points. The availability of the combined injectable method decreased 

significantly, from 43 percent of facilities in round 1 to 7 percent in round 2. In both rounds, a high 

percentage of facilities had at least one trained health provider—95 percent in round 1 and 92 percent in 

round 2. For round 1, the question asked about training in the last two years, while in round 2 the question 

asked about training in the last three years. The percentage of facilities with a blood pressure machine was 

also high (above 96 percent in both rounds). Only 67 percent of the facilities in round 1 and 75 percent in 

round 2 had a guideline manual on family planning. Although the percentage increased between the two 

rounds, the increase was not significant. 
19 

Figure 1. Facilities with family planning commodities and at least one staff member trained in family 

planning 

42.5

27.8

42.7

47.2

48.1

67.0

57.6

73.8

77.9

85.4

83.0

95.3

97.8

7.3

55.3

67.8

70.4

73.4

75.1

77.0

83.1

84.5

86.0

88.3

91.8

96.3

0 10 20 30 40 50 60 70 80 90 100

Combined injectable ***

Emergency pills ***

Female condom ***

IUD ***

Natural method (cycle beads) ***

Guidelines on family planning

Implant ***

Male condom **

Progestin pill

Progestin-only injectable

Oral pill

Family planning training

Blood pressure machine

Round 2 Round 1

Note: Differences are round 2 − round 1 and are tested at 1% level, **p <0.01, ***p<0.001 

Progestin-only injectables were the most used method for women visiting the facilities in round 1 

(60 percent), and pills were the second most used method (25 percent) (see Table 11); this information 

was not available for round 2, since there were no observation or exit interviews for family planning in 

round 2. Injectables were also the most used modern method in the DHS household survey conducted in 

the same year as round 1 of the SPA (6 percent among women in union), although the DHS did not 

differentiate between progestin-only and combined injectables (Agence Nationale de la Statistique et de la 

Démographie [Senegal] and ICF International (a) 2013). Pills were reported as the second most used 

method in the DHS survey (5 percent), but the survey did not differentiate between combined pills and 

progestin-only pills (Agence Nationale de la Statistique et de la Démographie [Senegal] and ICF 

International (a) 2013). 

Further analysis was conducted to study the facilities providing progestin-only injectables and combined 

oral pills among facilities that offered family planning services, as Tables 8 and 9 show, in order to assess 

the family planning structure of the facilities in terms of availability of the two most used contraceptive 

methods in Senegal. Table 8 shows that all facility background variables were significantly associated 

with the availability of progestin-only injectables, with the highest percentages found in health centers 

and health posts, public facilities, rural areas, and the North and South regions, for both rounds. However, 

in the adjusted logistic regression, shown in Table 9, only public facilities were found to have 

significantly higher odds of having progestin-only injectables available compared with private facilities, 

in both rounds (OR 12.7 in round 1 and 17.6 in round 2, p<0.001 in both rounds). For round 1, health 

centers had significantly higher odds of having injectables available compared with hospitals. Facility 

type was not a significant predictor of availability of injectables in round 2. In round 2 the variables of 
20 

facility type and locality were highly correlated, which may affect the estimates. This was not the case in 

round 1. 

Table 8. Association of the availability of progestin-only injectables and combined oral pills by 

facility characteristics among facilities that provide family planning services 

 Injectables 

Round 1 

Injectables 

Round 2 

Combined oral pill 

Round 1 

Combined oral pill 

Round 2 

 % p-value % p-value % p-value % p-value 

Health facility type <0.001 0.012 <0.001 <0.001 

Hospital 41.2 63.6 34.4 59.1 

Health center 92.2 84.0 81.6 87.7 

Health post 86.8 87.0 85.2 89.4 

Managing authority <0.001 <0.001 <0.001 <0.001 

Private 28.7 41.2 20.1 38.9 

Public 90.4 92.2 88.5 95.2 

Locality 0.005 0.003 0.063 0.004 

Urban 77.6 76.9 77.5 79.9 

Rural 90.3 90.6 86.4 92.5 

Region <0.001 0.033 0.007 0.105 

North 95.6 89.7 91.6 93.8 

Dakar 65.7 70.6 70.3 76.2 

Thiès 81.5 86.3 79.8 89.8 

Central 83.4 88.5 84.4 91.8 

East 92.1 86.2 67.6 91.0 

South 96.6 94.7 94.2 86.2 

Table 9. Results of adjusted logistic regressions of availability of progestin-only injectables and 

combined oral pills among facilities that offer family planning services for both rounds 

 Injectables 

Round 1 

Injectables 

Round 2 

Combined oral pill 

Round 1 

Combined oral pill 

Round 2 

 OR C.I. OR C.I. OR C.I. OR C.I. 

Health facility type (ref.=hospital) 

Health center 6.8* 1.2 - 39.7 0.9 0.3 - 3.3 3.4 0.9 - 13.4 1.4 0.3 - 5.7 

Health post 3.6 1.0 - 13.8 1.7 0.5 - 5.5 6.2** 1.8 - 20.6 3.9* 1.2 - 12.9 

Managing authority (ref.=private) 

Public 12.7*** 3.9 - 40.8 17.6*** 6.2 - 50.2 29.9*** 8.7 - 102.2 46.7*** 14.8 - 147.6

Locality (ref.=urban) 

Rural 0.7 0.3 - 2.2 0.7 0.2 - 2.1 0.7 0.3 - 1.7 0.4 0.1 - 1.6 

Region (ref.=North) 

Dakar 0.1* 0.0 - 0.8 0.6 0.2 - 2.8 0.5 0.1 - 2.3 0.6 0.1 - 4.0 

Thiès 0.3 0.1 - 1.6 0.9 0.2 - 4.5 0.6 0.2 - 2.2 0.8 0.1 - 6.2 

Central 0.3 0.1 - 1.4 1.0 0.3 - 3.7 0.8 0.2 - 2.6 1.0 0.2 - 5.2 

East 0.6 0.1 - 4.9 0.7 0.1 - 4.6 0.2* 0.1 - 0.7 0.7 0.1 - 9.1 

South 1.6 0.2 - 13.1 2.7 0.5 - 14.5 2.0 0.4 - 10.5 0.4 0.1 - 2.9 

Pseudo R2 0.25 0.22 0.25 0.32 

* p<0.05, ** p<0.01, *** p<0.001 
21 

As Table 8 shows, managing authority and health facility type were significantly associated with the 

availability of the combined oral pill in both rounds. Region was only significantly associated with this 

dependent variable in round 1 and locality was only significant in round 2. After adjusting for the other 

variables, only managing authority and the health post category of the facility type variable remained 

significant in both rounds (Table 9). Public facilities had almost 30 times greater odds of having the 

combined oral pill available compared with private facilities in round 1, and the odds were 47 times 

greater in round 2 (p<0.001 in both rounds). In round 1, Dakar region had lower odds of having progestinonly injectables compared with the North region, and the East region was also marginally significant with 

lower odds of having the combined oral pill available compared with the North region. 

For both dependent variables in the adjusted model, the width of the odds ratio confidence intervals for 

public facilities is very large, due to the small percentage of private facilities in the sample, and especially 

private facilities that offer family planning services. In fact, only 25 private facilities in round 1 and 39 

facilities in round 2 offered family planning services (the number was the same whether weighted or 

unweighted). 

3.4. Health Huts 

Health huts are the lowest level of health facility in Senegal. They are also the most accessible and 

numerous type of health facility. Health huts report to their respective health posts. Table 10 shows the 

infrastructure, equipment, and commodities available at the health huts surveyed, as well as the 

differences in these items from round 1 to round 2. As with the other facility types discussed in Table 4, a 

high percentage of health huts had a private room (over 90 percent in both rounds). Availability of 

adequate sanitation facilities was also relatively high (approximately 70 percent in both rounds), while 

access to electricity, improved water, communication equipment, and emergency transport was lacking. 

Almost half of the health huts surveyed in both rounds had no access to improved water, and more than 

half (almost 60 percent) had no emergency transport. A very low percentage of health huts had electricity 

or communication equipment in both rounds. This percentage increased in round 2 but not significantly. 

For basic equipment, more than half of the health huts in round 1 had disinfectant, running water with 

soap or alcohol rub, gloves, and a sharps container. In round 2, these items were found in approximately 

70 percent or more of health huts. In both rounds, however, only about 40 percent of health huts had a 

waste receptacle. There were no significant increases in the equipment items between the two rounds 

when comparisons could be made. No data were available for the remaining equipment listed in Table 10 

for round 1, but for round 2 only 40 percent of health huts had an adult scale and 45 percent had a 

stethoscope. 

For basic family planning commodities, the presence of combined oral and progestin-only pills was 

relatively low in round 1, but increased significantly in round 2, when 44 percent of health huts had 

combined oral pills available and 39 percent had progestin-only pills. The availability of male condoms 

increased to 46 percent of health huts in round 2, but the increase was not significant. Estimates were not 

reported for injectables as they had very low counts. Female condoms also had low counts in round 1, 

while 24 percent of health huts had female condoms in round 2. In round 1, approximately 81 percent of 

health huts had at least one staff member trained in family planning, declining to 67 percent in round 2 

although the decrease was not significant. As with the other facility types shown Figure 1, only a minority 

of health huts had a family planning guideline available (31 percent in round 1 and 42 percent in round 2). 

The increase between the two rounds was not significant. 
22 

Table 10. Percentage of health huts that have the following: infrastructure, 

equipment, and other commodities 

 

Round 1 Round 2

N=74 N= 89 

% [C.I.] % [C.I.] diff 

Basic infrastructure 

Electricity 14.1 26.1 12.0 [7.8,24.2] [16.8,38.2] 

Improved water 47.6 50.8 3.2 [33.2,62.5] [38.6,63.0] 

Adequate sanitation facilities 70.5 69.5 -1.0 [54.1,82.9] [56.6,79.9] 

Communication equipment 17.8 25.9 8.1 [9.5,31.0] [16.2,38.8] 

Private room 92.8 95.6 2.8 [79.1,97.8] [88.3,98.4] 

Emergency transport 43.3 44.0 0.7 [30.8,56.7] [32.3,56.5] 

Basic equipment 

Adult scale no obs 39.9 - [28.9,52.0] 

Child scale no obs 65.8 - [53.0,76.7] 

Thermometer no obs 78.5 - [66.1,87.2] 

Stethoscope no obs 44.7 - [33.6,56.3] 

Disinfectant 67.8 85.3 17.5 [52.6,80.0] [75.0,91.8] 

Running water with soap or alcohol rub 56.2 70.1 13.9 [42.2,69.2] [57.1,80.5] 

Gloves 64.0 76.6 12.6 [48.7,76.9] [63.7,86.0] 

Sharps container (safety box) 64.7 67.6 2.9 [49.5,77.4] [54.5,78.4] 

Waste receptacle (pedal bin) with lid and plastic 

bin liner 

39.3 39.6 0.3 [26.5,53.9] [27.8,52.8] 

Basic family planning commodities 

Combined oral pills (21.1) 43.7 22.6** 

[13.2,32.0] [32.0,56.3] 

Progestin-only pills (13.3) 39.3 26.0** 

[6.0,27.0] [28.2,51.6] 

Combined injectable ^ ^ 

Progestin-only injectable ^ ^ 

Male condom (23.5) 46.0 22.4 

[15.1,34.7] [34.3,58.1] 

Female condom ^ 23.5 

[15.1,34.7] 

At least one staff member trained in family 

planning 

80.9 66.8 -14.1 

[69.5,88.8] [54.3,77.3] 

Guidelines on family planning 

31.4 42.1 10.7 

[21.5,43.4] [30.6,54.6] 

Note: See Appendix A for description of basic infrastructure variables. 

( ) Indicated counts are lower than 20, ^ indicates counts were lower than 10. 

Differences are round 2 − round 1 and are tested at 1% level, **p <0.01 
23 

3.5. Quality of Care in Family Planning Process 

3.5.1. Description of Study Population 

The analysis of the process and outcome components of quality of care used data mainly from the 

observation and exit interviews (in addition to data from the health provider interview for obtaining 

information on provider characteristics). As described in the methods section, the clients of providers 

whose consultations were observed were selected for an exit interview, so that the analysis could match 

each client to her provider. Table 11 describes the independent variables used in the process and outcome 

analysis for users of modern family planning methods (90 percent of clients interviewed were either 

prescribed or provided with a modern method). Most of these clients were age 25-39 (58 percent), had no 

education (49 percent), were returning clients (69 percent), and were mainly using progestin-only 

injections for family planning (60 percent). Almost half paid between 500 and 999 CFAs1

 for their family 

planning visit (47 percent), and approximately 30 percent waited less than half hour to see a provider, 

while 13 percent did not wait at all. Almost all the clients left the facility with a family planning method 

(94 percent). 

One-third of family planning providers (32 percent) were nurses or nurse assistants, while two-thirds 

(68 percent) were midwives or other providers. (Only 41 of the 592 providers in this group were classified 

as other.) Correspondingly, 82 percent of the providers were female since it is unusual for men to be 

midwives. In fact, since provider category and provider sex were very highly correlated, the two factors 

were not included together in regression analyses. Most providers had 13-16 years of education (58 

percent). Just over half (55 percent) had not received any family planning training in the past two years. 

Half (50 percent) received all six items of supervision, and 58 percent had a job description. The majority 

of the providers received a monthly or daily salary (64 percent), while 10 percent received no pay. 

As for the facility characteristics, hospitals and health centers were combined in the analysis due to the 

small number of observations and exit interviews conducted in hospitals. The majority of these interviews 

were conducted in health posts (81 percent), and in urban areas (52 percent), and 28 percent were in 

Dakar. 

 

1

 1 USD ~ 500 CFA in the period of 2012-2013 
24 

Table 11. Description of client, provider, and facility background characteristics after selecting for 

clients using a contraceptive method 

Variable Category % Weighted N 

Client characteristics 

Client’s age 

14-24 26.6 232

25-39 57.6 502

40-58 and don’t know 15.8 138

Client’s education 

No education 49.3 430

Primary and post-primary 30.3 264

Secondary or more 20.4 178

Fee paid for service1

0-9 7.7 67

10-499 14.4 125

500-999 46.6 407

1,000 or more 31.3 273

Waiting time 

No wait 12.8 111

Less than half hour 29.4 257

Half hour to one hour 19.8 173

One hour to 2 hours 18.4 161

2 hours or more 19.6 171

Client status New client 30.7 268

Returning client 69.3 605

Contraceptive method used 

Pills 24.8 216

Progestin-only injection 60.3 526

IUD or implants2 14.9 130

Client left with a method Yes 94.0 820

No 6.0 52

Provider characteristics 

Provider category Nurse or nurse assistant3 32.2 281

Midwife and other 67.8 592

Provider sex Male 18.2 159

Female 81.8 713

Provider years of education 

6-12 6.5 56

13-16 58.2 507

17+ 35.4 309

Provider training in family planning in the past 

24 months 

Yes 45.1 393

No 54.9 479

Provider number of items supervised 

None 20.7 181

1-5 28.8 251

6 50.4 440

Provider has a job description Yes 57.8 504

No 42.2 368

Provider salary type 

Monthly or daily salary 63.7 556

No regular salary but other compensation 26.0 227

None 10.2 89

Health facility characteristics 

Health facility type Hospital/health center 19.0 166

Health post 81.0 706

Locality Urban 52.1 454

Rural 47.9 418

Region 

Northern 18.0 157

Dakar 27.6 241

Thiès 14.4 126

Central 19.4 169

East 4.4 38

South 16.2 142

General structure equipment composite index 

Low 40.5 353

Medium 27.0 235

High 32.6 284

Notes: 1 Currency in CFA, 1 USD ~ 580 CFA 2

 Includes 10 respondents who used other methods, which were male condoms, LAM, and counseling on periodic abstinence 3

 Includes 4 unweighted doctors and specialists for users 
25 

3.5.2. Family Planning Process 

Table 12 shows the quality of counseling and pelvic examination by selected characteristics of clients, 

providers, and facilities. Overall, the quality of counseling was poor. Just 18 percent of clients were 

counseled on all three important aspects of their method: how to use the method, possible side effects, and 

when to return to the facility. Among 872 observed female clients who were provided or prescribed a 

method, fewer than two-thirds (63 percent) received information on how to use the method, such as 

dosage and frequency of use, duration of effectiveness, and correct use of natural family planning 

methods such as the standard days method and lactational amenorrhea (LAM). Among women using 

pills, injectables, IUDs, or implants, fewer than one-third (29 percent) were counseled on their method’s 

side effects; 37 percent were told when to return for follow-up. Counseling related to method protection 

from STIs was even less common. Only 9 percent of the observed consultations involved a discussion on 

whether the method protects against STIs, including HIV. With regard to the clinical examination, only 

32 percent of providers performed 8 or more of the 16 listed procedures that should be conducted before, 

during, and after the procedure. 
Table 12. Family planning counseling and clinical examination by client, provider, and facility characteristics 

Family planning counseling Clinical examination 

Counseling on 

how to use 

method, side 

effects, and 

when to return1

How to use 

method2 Side effects1 When to return1

Method 

protects from 

STI2

Performed a 

high quality of 

pelvic 

examination3

 Variable Category % p-value % p-value % p-value % p-value % p-value % p-valueClient’s age 

0.170 0.115 0.176 0.005 0.074 0.413 

14-24 22.5 69.1 33.4 47.8 13.1 28.7 25-39 15.9 59.8 25.7 33.6 8.1 31.6 40-58 or don’t know 17.1 62.1 31.6 31.9 4.5 38.3 

Client’s education 

0.046 0.092 0.245 0.111 0.288 <0.001 

No education 13.9 58.4 25.8 32.7 6.8 20.7 Primary & post primary 22.2 66.5 29.9 40.5 10.8 41.2 Secondary or more 21.0 67.0 33.6 42.4 11 42.9 

Client status 

<0.001 <0.001 <0.001 <0.001 <0.001 0.002 

New client 38.1 89.2 53.9 60.8 18.1 43.3 Returning client 8.9 50.8 18.0 27.0 4.8 25.0 

Contraceptive method 

used 

0.013 <0.001 0.001 <0.001 0.547 <0.001 

Pills 15.6 77.0 22.2 26.8 7.1 32.2 Progestin-only injection 16.0 54.8 27.6 37.4 9.0 21.6 IUD or implants4 29.0 70.3 45.2 54.5 11.4 60.7 

Provider category 

0.586 0.186 0.592 0.707 0.063 0.889 

Nurse or nurse assistant 16.4 58.1 26.9 38.4 13.1 31.0 Midwife and other 18.5 64.7 29.5 36.5 6.8 32.4 

Provider sex 

0.955 0.158 0.789 0.257 0.039 0.813 

Male 18.1 56.3 27.4 42.7 16.1 29.8 Female 17.8 64.0 29.0 35.9 7.2 32.3 

Provider years of 

education 

0.972 0.513 0.401 0.770 0.267 0.657 

6-12 18.4 52.9 37.7 31.8 2.3 15.6 13-16 18.2 64.0 29.8 36.7 10.3 31.9 17+ 17.3 62.0 25.3 38.8 7.7 33.4 

Provider training in family 

planning in the past 24 months 

0.644 0.789 0.740 0.394 0.862 0.119 

No 17.1 61.9 28.0 35.3 9.1 37.2 Yes 18.8 63.2 29.5 39.3 8.6 26.6 

(Continued...) 

26 
Table 12 − Continued 

Family planning counseling Clinical examination

Counseling on 

how to use 

method, side 

effects, and 

when to return1

How to use 

method2 Side effects1 When to return1

Method 

protects from 

STI2

Performed a 

high quality of 

pelvic 

examination3

 Variable Category % p-value % p-value % p-value % p-value % p-value % p-valueProvider number of items 

supervised 

0.646 0.127 0.277 0.125 0.105 0.064

None 20.4 65.4 34.3 38.2 7.0 21.31-5 15.5 55.9 23.9 43.4 5.3 27.56 18.2 65.3 29.1 33.2 11.7 39.4

Provider has a job 

description 

0.814 0.478 0.803 0.618 0.550 0.9

No 17.3 60.7 28.0 38.4 7.8 32.6Yes 18.2 64.0 29.2 36.2 9.6 31.7

Provider salary type 

0.346 0.340 0.740 0.532 0.003 0.513

Monthly or daily salary 19.3 64.5 29.8 38.6 11.7 21.7No regular salary but 

other compensation 17.1 61.5 27.1 35.1 4.8 34.4

None 10.7 53.8 25.7 32.8 1.4 28.2 

Health facility type 

0.138 0.583 0.077 0.120 0.169 0.019

Hospital/health center 13.9 64.4 22.7 31.5 5.9 45.3Health post 18.8 62.2 30.1 38.5 9.6 28.1

Locality 

0.295 <0.001 0.225 0.524 0.263 0.001

Urban 19.7 70.1 31.3 35.8 7.1 42.2Rural 15.8 54.4 25.8 38.6 10.7 17.9

Region 

0.545 <0.001 0.179 0.010 0.339 <0.001

Northern 11.7 49.1 19.6 29.2 4 9.8Dakar 17.2 77.0 30.5 28.0 8.6 54.7Thiès 24.3 64.0 40.1 39.0 8.9 23.8Central 17.5 44.6 26.8 49.4 8 21.6East 24.0 43.1 34.6 26.9 7.3 28.2South 18.8 78.6 25.7 48.0 16 29.3

General structure 

equipment composite index 

0.127 0.373 0.093 0.005 0.842 0.74

Low 13.3 64.7 23.1 28.5 7.8 30.5Medium 21.8 64.9 34.7 41.6 10 28.9High 20.2 58.1 30.7 44.2 8.4 35.4 

Total 17.9 62.6 28.7 37.1 8.9 32.1 1 Only applies to users of pill, injectable, IUD, and implant 2 Applies to all users, only ten respondents reported using methods other than pill, injectable, IUD, or implant. 3 Applies to clients who conducted a pelvic exam 4 Includes 10 respondents who used other methods, which were male condoms, LAM, and counseling on periodic abstinence. 

27 
28 

Table 12 also indicates variations in the quality of counseling and pelvic examination associated with 

selected characteristics of client, provider, and facility. New clients were significantly more likely to 

receive counseling on all aspects of their method compared with returning clients. For example, 89 

percent of new clients compared with 51 percent of returning clients received advice on how to use their 

method, and 54 percent of new clients compared with 18 percent of returning clients were told about side 

effects. Similarly, a higher percentage of new clients than returning clients received high quality of pelvic 

examination, at 43 percent and 25 percent, respectively. Quality of counseling was also associated with 

the specific method received by the client. Users of pills or injectables were less likely to be counseled on 

side effects and follow-up services than those who were provided or prescribed implants or IUDs. Users 

of injectables were also less likely to be advised on how to use the method compared with users of all 

other methods. Users of implants or IUDs were also more likely to receive a better quality of pelvic 

examination. 

Quality of counseling and pelvic examination were also associated with some characteristics of the 

facility, including facility type, urban or rural location, and region. The provider’s characteristics were 

less important. Only provider’s salary type and sex showed significant associations with counseling on 

method protection from STIs. 

Table 13 presents the results of the adjusted logistic models for the three process outcomes. After 

controlling for other variables, being a new client was still significantly associated with receiving better 

quality of counseling and pelvic examination. The odds of receiving high-quality counseling for new 

clients was more than five times the odds for returning clients (p<0.001 for both counseling measures). 

For pelvic examination, new clients had over twice the odds compared with returning clients (95% CI: 

1.3-4.6). Provider’s salary type also remained significant; providers who received a monthly or daily 

salary had nine times higher odds (p<0.05) of providing counseling on method protection from STIs 

compared with providers without a salary. In the adjusted models, personal supervision received by the 

provider was an important determinant of performing a good-quality pelvic examination, but it was not 

important in the unadjusted analysis, shown in Table 12. Providers who received all six listed supervisory 

items in the last six months had 3.3 times the odds (p<0.01) of performing a high quality of pelvic 

examination compared with those who did not receive any personal supervision. Clients observed in 

health posts were less likely (OR 0.3, p<0.05) to receive a high quality of pelvic examination than those 

in a hospital or health center, and rural facilities had four times higher odds (p<0.01) of providing 

counseling on method protection from STIs compared with urban facilities. The facility equipment 

structure index was not associated with any of the process outcomes. 
29 

Table 13. Adjusted logistic regression of family planning process dependent variables, round 1 

 Counseled on how 

to use, side 

effects, and when 

to return1

Counseled on 

method protection 

from STI2

High quality of 

pelvic 

examination3

Variable Category OR C.I. OR C.I. OR C.I.

Clients age 

(ref.=14-24) 

25-39 0.7 0.4 - 1.3 0.7 0.4 - 1.4 0.9 0.5 - 1.5 

40-58 & don’t know 1.1 0.6 - 2.1 0.4* 0.1 - 0.9 1.7 0.7 - 3.9 

Client’s education 

(ref.=secondary or more) 

No education 0.5 0.3 - 1.1 0.5 0.2 - 1.3 0.4* 0.2 - 0.8 

Primary & post primary 1.0 0.5 - 1.8 1.1 0.4 - 2.7 1.0 0.5 - 1.8 

Client status 

(ref.=returning client) New client 6.1*** 3.7 - 10.2 5.3*** 2.8 - 10.2 2.4** 1.3 - 4.6 

Contraceptive method used 

(ref.=IUD or implants) 

Pills 0.6 0.3 - 1.4 1.2 0.4 - 3.4 0.3** 0.1 - 0.7

Progestin-only 

injection 0.7 0.4 - 1.4 1.8 0.8 - 4.3 0.2*** 0.1 - 0.4 

Provider category 

(ref.=midwife and other) 

Nurse or nurse 

assistant 0.8 0.4 - 1.4 1.4 0.6 - 3.3 1.0 0.4 - 2.8 

Provider years of education 

(ref.=17+) 

6-12 1.6 0.4 - 7.1 0.3 0.1 - 2.0 0.3 0.0 - 2.1 

13-16 1.2 0.7 - 2.2 1.2 0.6 - 2.7 0.7 0.3 - 1.7 

Provider training in family 

planning in the past 24 months 

(ref.=no) 

Yes 1.5 0.8 - 2.7 0.8 0.4 - 1.9 0.5 0.2 - 1.0 

Provider number of items 

supervised 

(ref.=none) 

1-5 0.6 0.3 - 1.4 0.8 0.3 - 2.6 2.0 0.7 - 5.8 

6 0.7 0.4 - 1.6 1.4 0.6 - 3.6 3.3** 1.5 - 7.7 

Provider has a job description 

(ref.=no) Yes 0.9 0.4 - 1.8 1.4 0.6 - 2.9 0.7 0.3 - 1.6 

Provider salary type 

(ref.=none) 

Monthly or daily salary 1.9 0.5 - 6.4 9.0* 1.4 - 58.0 2.1 0.5 - 8.5 

No regular salary but 

other compensation 1.7 0.5 - 5.5 3.9 0.6 - 24.5 2.6 0.6 - 11.5

Health facility type 

(ref.=hospital/health center) Health post 1.6 0.9 - 2.9 1.0 0.4 - 2.4 0.3* 0.1 - 0.8 

Locality 

(ref.=urban) Rural 0.8 0.4 - 1.6 4.0** 1.4 - 11.6 0.6 0.2 - 1.6 

Region 

(ref.=Northern) 

Dakar 1.0 0.2 - 4.0 2.1 0.5 - 8.4 4.6* 1.3 - 16.5

Thiès 1.9 0.6 - 6.1 2.0 0.4 - 9.1 2.0 0.4 - 10.2

Central 0.9 0.3 - 3.1 1.1 0.2 - 5.4 2.8 0.6 - 13.5

East 1.6 0.3 - 7.1 1.0 0.1 - 9.0 6.0 0.9 - 40.8

South 0.8 0.2 - 2.8 1.8 0.5 - 7.2 1.9 0.4 - 9.5 

General structure equipment 

composite index 

(ref.=low) 

Medium 1.8 0.7 - 4.7 0.5 0.2 - 1.3 1.6 0.6 - 4.3 

High 1.9 0.8 - 4.5 0.5 0.2 - 1.3 1.0 0.4 - 2.5 

Pseudo R2 0.17 0.19 0.26 

1Only applies to users of pill, injectable, IUD, and implant

2Applies to all users, only ten respondents reported using methods other than pill, injectable, IUD, or implant. 

3Applies to clients who conducted a pelvic exam

* p<0.05, ** p<0.01, *** p<0.001
30 

3.6. Quality of Care in Family Planning Outcomes 

Figure 2 shows the two dependent variables used to assess the outcomes of quality of care in family 

planning service delivery. The first outcome variable, overall satisfaction with family planning services, 

indicates that 84 percent of users of pills, injectables, IUDs, or implants were very satisfied with the 

services they received. For the second outcome dependent variable, only 58 percent of the clients had 

correct knowledge on whether their method protects from STIs (clients using all methods). 

Approximately 16 percent of clients did not know whether the method they were using protects from STIs 

(results not shown). Further analysis of the respondents in the “do not know” category does not clearly 

indicate whether to group them with the respondents who answered either “yes” or “no,” as we cannot 

know for certain how they would have answered if probed further. Therefore, for this dependent variable, 

clients who responded that they did not know were removed from the analysis. Consequently the 

denominator for this variable differs from that of the satisfaction outcome. 

Figure 2. Description of outcome dependent variables, all users 

3.6.1. Overall Satisfaction with Family Planning Services 

Table 14 summarizes the associations of both outcome variables with several covariates representing 

client, provider, and facility characteristics. The counseling variables produced from the process analysis 

(taken from the observation data) were also included as part of the provider variables in the outcome 

analysis. Waiting time, whether the client left with a method, provider years of education, provider 

number of items supervised, having a job description, salary type, region, and the general structure 

equipment composite index all had significant associations with overall client satisfaction. Clients who 

did not have to wait to see a provider and clients who left with a method were more satisfied with family 

planning services compared with the remaining categories for each variable. Clients who were seen by a 

provider who had 13-16 years of education had higher overall satisfaction compared with providers with 

6-12 years or 17 or more years of education. In addition, clients seen by a provider who had the maximum 

number of supervisory items, had a job description, and had a monthly or daily salary were more satisfied. 

The greatest difference in satisfaction appears to be by region, as only 59 percent of clients in the 

Northern region were satisfied with services compared with 97 percent in the South. Finally, clients who 

visited facilities with a high general structure equipment composite index were more satisfied than clients 

who visited facilities categorized as medium or low. 

83.7

57.7

Very satisfied (N=872) Correct knowledge (N=716)
31 

Table 14. Association of overall client satisfaction with family planning services and client knowledge of 

family planning method’s protection from STIs by client’s and provider’s background characteristics, 

round 1 

 

All users that are 

very satisfied 

N=872 

Correct knowledge of 

all users 

N=716 

 Variable Category (%) p-value (%) p-value 

Client’s age

0.312 0.181

14-24 82.1 51.5 

25-39 83.1 60.3 

40-58 & don’t know 88.5 59.3 

Client’s education

0.202 0.169

No education 84.7 54.5 

Primary & post primary 85.3 57.6 

Secondary or more 78.9 64.6 

Fee paid for service

0.707 

0-9 81.2 

10-499 81.7 

500-999 83.3 

1000 or more 85.8 

Waiting time 

<0.001 

No wait 96.5 

Less than half hour 77.0 

Half hour to one hour 81.1 

One hour to 2 hours 88.4 

2 hours or more 83.6 

Client status 

0.859 0.222

New client 84.1 53.9 

Returning client 83.5 59.5 

Contraceptive method used

0.090 0.469

Pills 78.4 57.6 

Progestin-only injection 85.3 56.3 

IUD or implants2 86.1 63.9 

Client left with method 

<0.001 

Yes 85.1 

No 62.3 

Provider category 

0.883 0.002

Nurse or nurse assistant 84.0 66.6 

Midwife and other 83.6 53.4 

Provider sex

0.114 0.300

Male 79.5 61.8 

Female 84.6 56.7 

Provider years of education

0.007 0.700

6-12 83.0 61.7 

13-16 87.1 58.6 

17+ 78.2 55.7 

Provider training in family planning in the past 

24 months

0.278 0.019

Yes 85.3 63.2 

No 82.4 53.6 

(Continued...) 

 
32 

Table 14 − Continued

 

All users that are 

very satisfied 

N=872 

Correct knowledge of 

all users 

N=716 

 Variable Category (%) p-value (%) p-value 

Provider number of items supervised

<0.001 0.004

None 73.5 52.3 

1-5 82.8 49.4 

6 88.4 64.3 

Provider has a job description

<0.001 0.236

Yes 88.6 59.8 

No 76.9 54.9 

Provider salary type

<0.001 0.003

Monthly or daily salary 91.6 63.0 

No regular salary but other 

compensation 70.7 49.9 

None 67.6 46.2 

Counseled on how to use method

0.495 0.137

Yes 84.4 60.1 

No 82.5 53.8 

Counseled on side effects of method1

0.068 0.993

Yes 79.5 57.4 

No 85.3 57.5 

Counseled on when to return1

0.249 0.983

Yes 81.6 57.4 

No 84.9 57.5 

Counseled on whether method protects from 

STI

 0.165

Yes 66.8 

No 56.7 

Health facility type 

0.084 0.756

Hospital/health center 79.8 58.8 

Health post 84.6 57.5 

Locality

0.316 0.922

Urban 85.0 57.5 

Rural 82.3 57.9 

Region

<0.001 <0.001

Northern 58.9 44.9 

Dakar 87.9 64.6 

Thiès 75.0 53.4 

Central 94.5 46.7 

East 91.5 61.0 

South 96.7 78.1 

General structure equipment composite index

0.020 

Low 79.3 

Medium 85.3 

High 87.8 

1 Only applies to users of pill, injectable, IUD, and implant 

2 This includes 10 respondents who use other methods, which were male condoms, LAM, and counseling on periodic 

abstinence.

As Table 15 shows, some of the variables that had significant associations with overall satisfaction in 

Table 14 lost their significance in the adjusted logistic regression models. Only client’s waiting time, 

provider’s years of education, and region remained significant. In addition, client’s education and 
33 

counseling on side effects, in Model I, and counseling on when to return, in Model II, became significant 

in the adjusted regression model. 

The results of the logistic model summarized in Table 15 indicate that clients with no education or with 

primary and post-primary education had almost twice the odds of being very satisfied compared with 

clients with secondary or more education, in both Model I and Model II (p<0.05 for all). Clients who did 

not have to wait at all to see a provider had 5.4 times the odds of being very satisfied (p<0.05) compared 

with those who waited two hours or more in Model I, and 5.7 times the odds (p<0.05) in Model II. Clients 

who left with a family planning method had approximately four times the odds of being very satisfied 

(p<0.01) compared with those who did not leave with a method, in both models. The confidence intervals 

for this variable are very wide due to the small number of clients who did not leave with a method (only 6 

percent, as shown in Table 10). The results also indicate that clients who were seen by providers having 

6-12 years of education or 13-16 years of education had almost three to four times significantly higher 

odds of being very satisfied compared with clients who saw providers with the highest level of education 

(17 years or more). No pattern was observed in the odds ratios for provider’s education—that is, the odds 

of a client being very satisfied did not increase with increasing years of the provider’s education. An 

interesting finding was the effect of counseling on side effects (Model I) and when to return for follow-up 

(Model II). Both counseling variables indicated that clients who did not receive any counseling had higher 

odds of being satisfied compared with clients who received counseling; (OR = 2.6, p<0.01 in Model I and 

OR = 2.0, p-value<0.05 in Model II). Finally, the highest odds ratios for being very satisfied were for the 

region categories, with clients from the South region of Senegal having 12.3 times the odds of being 

satisfied compared with Northern Senegal, in Model I (p<0.001), and 13.9 times in Model II (pvalue<0.001). Clients in Central Senegal had over 10 times the odds of being very satisfied compared 

with those in the North region (OR = 10.7, p<0.001, Model I and OR = 11.5, p<0.001, Model II). 

Table 15. Adjusted logistic regression of clients very satisfied with family planning services and client’s 

correct knowledge of method’s protection from STIs, round 1 

Variable Category 

Very satisfied 

Model I1

Very satisfied 

Model II1

Correct 

knowledge2

OR C.I. OR C.I. OR C.I. 

Clients age 

(ref.=14-24) 

25-39 0.9 0.5 - 1.6 0.9 0.6 - 1.6 1.4 0.9 - 2.2

40-58 & don’t know 1.9 0.8 - 4.4 1.8 0.7 - 4.3 1.3 0.7 - 2.3

Client’s education 

(ref.=secondary or more) 

No education 2.1* 1.2 - 3.9 2.1* 1.2 - 3.8 0.7 0.4 - 1.2

Primary & post primary 2.0* 1.0 - 3.7 2.0* 1.1 - 3.7 0.9 0.5 - 1.5

Fee paid for service 

(ref.=1000 or more) 

0-9 1.3 0.6 - 3.0 1.4 0.6 - 3.1 

10-499 0.9 0.4 - 2.0 1.0 0.4 - 2.2 

500-999 0.9 0.5 - 1.6 1.0 0.6 - 1.8 

Waiting time 

(ref.=2 hours or more) 

No wait 5.4* 1.2 - 24.0 5.7* 1.3 - 25.2 

Less than half hour 0.8 0.4 - 1.4 0.8 0.4 - 1.4 

Half hour to one hour 1.0 0.5 - 2.1 1.1 0.5 - 2.2 

One hour to 2 hours 1.2 0.5 - 3.0 1.2 0.5 - 2.8 

Client status 

(ref.=returning client) New client 1.2 0.6 - 2.4 1.1 0.6 - 2.2 0.7 0.5 - 1.1

Contraceptive method used 

(ref.=IUD or implants) 

Pills 1.1 0.5 - 2.7 1.1 0.5 - 2.6 1.1 0.6 - 2.0

Progestin-only injection 1.4 0.7 - 2.9 1.4 0.6 - 3.0 0.9 0.5 - 1.6

Client left with method 

(ref.=no) 

Yes 3.9** 1.5 - 10.4 3.7** 1.4 - 10.0 

(Continued...) 

 
34 

Table 15 − Continued

Variable Category 

Very Satisfied 

Model I1

Very Satisfied 

Model II1

Correct 

Knowledge2

OR C.I. OR C.I. OR C.I. 

Provider category 

(ref.=midwife and other) 

Nurse or nurse 

assistant 1.0 0.6 - 1.9 1.1 0.6 - 1.9 2.1** 1.3 - 3.2

Provider years of education 

(ref.=17+) 

6-12 3.6* 1.2 - 10.3 2.9* 1.0 - 8.3 1.7 0.8 - 3.7

13-16 3.8*** 2.2 - 6.6 3.4*** 1.9 - 6.1 1.1 0.8 - 1.7

Provider training in family planning in 

the past 24 months 

(ref.=no) 

Yes 

1.5 0.9 - 2.6 1.5 0.9 - 2.5 1.7** 1.2 - 2.5

Provider number of items supervised 

(ref.=none) 

1-5 1.0 0.6 - 2.0 1.2 0.7 - 2.3 0.7 0.4 - 1.2

6 0.9 0.5 - 1.6 0.9 0.5 - 1.7 1.1 0.7 - 1.9

Provider has a job description 

(ref.=no) Yes 

1.1 0.6 - 1.9 1.1 0.6 - 1.9 1.0 0.6 - 1.5

Provider salary type 

(ref.=none) 

Monthly or daily salary 2.0 0.9 - 4.5 2.0 0.9 - 4.6 1.3 0.7 - 2.5

No regular salary but 

other compensation 0.9 0.4 - 1.8 0.9 0.4 - 1.8 1.3 0.7 - 2.5

Counseled on how to use method 

(ref.=no) Yes 

1.3 0.8 - 2.2 1.3 0.8 - 2.2 

Counseled on side effects of method1

(ref.=yes) No 

2.6** 1.5 - 4.6 

Counseled on when to return1

(ref.=yes) No 2.0* 1.2 - 3.5 

Counseled on whether method 

protects from STI 

(ref.=no) 

Yes 

 1.2 0.6 - 2.3

Health facility type 

(ref.=hospital/health center) Health post 1.5 0.8 - 2.8 1.4 0.8 - 2.6 0.7 0.5 - 1.1

Locality 

(ref.=urban) Rural 0.9 0.5 - 1.7 1.0 0.5 - 1.8 1.3 0.8 - 2.0

Region 

(ref.=Northern) 

Dakar 5.3*** 2.1 - 12.9 4.8*** 1.9 - 11.9 3.0** 1.4 - 6.3

Thiès 2.8* 1.2 - 6.6 2.5* 1.1 - 5.9 1.9 1.0 - 3.7

Central 10.7*** 3.6 - 32.3 11.5*** 3.7 - 36.3 1.3 0.6 - 2.6

East 5.2* 1.4 - 19.0 4.6* 1.3 - 16.6 2.0 0.8 - 4.9

South 12.3*** 3.4 - 45.4 13.9*** 3.7 - 52.5 4.2*** 1.9 - 9.2

General structure equipment 

composite index 

(ref.=low) 

Medium 0.9 0.5 - 1.7 0.9 0.5 - 1.5 

High 1.0 0.5 - 2.0 1.0 0.5 - 1.9 

Pseudo-R2 0.25 0.25 0.09 

Note: For client satisfaction outcome, Model I includes the variable for counseled on side effects, and 

Model II includes the variable on counseled on when to return. 1 Users of pill, injectable, IUD, and implant. 2 All users. 

* p<0.05, ** p<0.01, *** p<0.001 

3.6.2. Knowledge of Method’s Protection from STIs 

As Table 14 shows, it was mainly the provider’s characteristics that had a significant association with the 

client’s knowledge of whether their method protects from STIs. No background characteristics of clients 

were significantly associated with their knowledge. A significantly higher percentage of clients with 
35 

correct knowledge were found among clients who saw providers categorized as nurse or nurse assistant, 

or clients who saw providers receiving family planning training in the past two years. Provider’s number 

of supervised items received and provider’s salary type were also significantly associated with client’s 

knowledge; however, these two variables lost significance in the adjusted logistic regression, as Table 15 

shows. Region was also found to be significantly associated with client’s knowledge; in the South 78 

percent of clients had correct knowledge compared with 45 percent in Northern Senegal (p<0.001). An 

interesting finding was the lack of significance in the association between a provider’s counseling on the 

method’s protection from STIs and the client’s knowledge of the topic. 

Table 15 summarizes the estimates of logistic regression for clients having correct knowledge of their 

method’s protection from STIs. Only three independent variables remained significant in the adjusted 

logistic regression model: provider category, provider family planning training, and region. Clients who 

saw a nurse or nurse’s assistant had twice the odds of having correct knowledge compared with clients 

who saw a midwife or other provider (OR = 2.1, p<0.01). Similarly, clients who saw a provider who 

received family planning training in the last two years had higher odds of having correct knowledge 

compared with clients who saw a provider with no recent training (OR = 1.7, p<0.01). For region, only 

the South and Dakar had significant odds ratios in the logistic regression model for correct knowledge. 

Clients in the South had 4.2 times the odds of having correct knowledge compared with clients in the 

North (p<0.001), while clients in Dakar had three times the odds of having correct knowledge compared 

with Northern Senegal (p<0.01). 

4. Discussion 

The purpose of this report was to assess the quality of care in family planning services in Senegal in order 

to identify areas for intervention. Improvements in the quality of care in family planning services can 

contribute to the increased use and continuation of contraceptive methods. Data from the first two rounds 

of the Senegal Continuous SPA were the basis of the analysis. The analysis was organized around three 

components of quality of care: structure, process, and outcome. This discussion will highlight some of 

the variations across facilities and providers in the quality of care in family planning service delivery. 

4.1. General Structure 

Family planning services were most commonly available at the health post level, the third of four tiers of 

the health system in Senegal, and least available in health huts, the lowest tier, although the proportion of 

health huts offering family planning services increased between the two rounds of the Senegal Continuous 

SPA. Almost all health facilities—excluding health huts—had access to an improved source of water, 

adequate sanitation, and a private room. When comparing hospitals, health centers, and health posts, in 

terms of infrastructure, health posts were at a disadvantage in electricity, communication equipment, 

emergency transport, and computer and Internet access. Health posts were also at a disadvantage in terms 

of the availability of essential medicines and diagnostic tests. In both rounds, they had the lowest 

percentage of facilities with a high score for the composite indices constructed for medicines and 

diagnostic tests using several indicators as identified by the WHO Service Availability and Readiness 

Assessment (SARA) indicator guideline. Improvements in basic infrastructure as well as readiness and 

availability of equipment, diagnostic tests, and medicines are needed for these facilities to be able to 

provide good quality health care (O’Neill et al. 2013). Since health posts appear to be the main facility for 

providing family planning services, improvements in the infrastructure of health posts can help improve 

the quality of care provided. 

Health huts, which are supervised by a health post and are mainly found in remote locations, were found 

to have poor infrastructure. Of particular concern is the lack of communication equipment and emergency 
36 

transport for a large proportion of the health huts in both rounds of the SPA, leaving women vulnerable in 

emergency situations. Moreover, the proportion of health facilities with communication equipment in 

rural areas, where most health huts are found, significantly decreased between the two rounds. 

There were large differences between regions in availability of basic infrastructure, equipment, diagnostic 

tests, and medicines. The North region had the fewest facilities with electricity and communication 

equipment in round 2. The South and East regions also had a low proportion of facilities with 

communication equipment (only about a third of the facilities), and for the East region this decreased 

significantly, by 61 percentage points, between the two rounds. In both rounds, the North and Dakar had 

the highest percentages of facilities with a low score on the equipment composite index. For the 

diagnostic test index the highest percentages of facilities with a low score were in Dakar and Thiès in 

round 1, and Dakar, South, and East in round 2. The medicine index had a first component of variance 

explained below 30 percent, so caution is required in interpreting the results; however, Dakar had the 

highest percentage of facilities with a low score on the medicine index in both rounds. The findings of the 

low scores for Dakar region seem unexpected as this is a very urban region. In the analysis of the 

availability of progestin-only injectables in the health facilities, the Dakar region was also found to have 

significantly fewer injectables available compared with the North region in round 1. However, the 

analysis of the process and outcome components have shown that Dakar outperforms the Northern region. 

This indicates that the structure component is not necessarily linked to the process and outcome 

components in the quality of care. 

Some of the suggested improvements highlighted in this analysis are at the national level in terms of 

infrastructure (for instance, electricity and communication) and therefore may take time to achieve. Other 

improvements can be achieved directly at the facility level in terms of improvements in the availability of 

commodities, which include emergency transport, equipment, diagnostic tests, and medicines. 

4.2. Family Planning Structure 

Many improvements in the availability of family planning methods were seen between the rounds, 

especially in availability of family planning methods that are less commonly used (i.e., male condoms, 

female condoms, IUDs, implants, emergency pills, and cycle beads). A significant increase was also 

found for health huts in their availability of combined oral and progestin-only pills. This increase is 

important, as having more choices of methods available at health facilities can be an approach to raise 

levels of contraceptive use (Ross and Stover 2013). However, without further research we cannot know 

whether more options will in fact lead to higher contraceptive prevalence in Senegal. These 

improvements in the availability of family planning methods can be attributed to successful interventions, 

such as the informed push distribution of contraceptives aimed at reducing stockouts of modern 

contraceptive methods, especially pills, injectables, IUDs, and implants (Daff et al. 2014). This 

intervention began in some regions of Dakar and Saint-Louis in June 2012 and is expected to be 

implemented nationwide by July 2015. 

While the availability and clients’ use of progestin-only injectables is high, the combined injectable 

method is less popular. In addition, the availability of this method decreased significantly, by 35 

percentage points, between the two rounds. This result is disconcerting since the combined injectable, 

which contains progestin and estrogen hormones, is medically preferable to its progestin-only counterpart 

due to less disruption in the menstrual cycle and faster return to fertility compared with progestin-only 

injectables (Gallo et al. 2008). Further study is required to understand why the combined injectable is not 

used in the health facilities. The significant decrease should be examined in the upcoming rounds of the 

Senegal Continuous SPA. 
37 

Public health facilities had much higher odds of having progestin-only injectables and combined oral pills 

available compared with private facilities. These findings are consistent with a study that examined 

services in Ghana, Tanzania, and Kenya (Hutchinson, Do, and Agha 2011), which found that more 

methods were available at all levels of public facilities than in private facilities. Availability of progestinonly injectables and combined oral pills did not differ significantly by region (except for the East for pills 

in round 1) or locality in the adjusted models, in both rounds. Although the confidence intervals are wide, 

more research may be required to understand why private facilities appear to be less prepared in these two 

family planning structure indicators. In addition, hospitals seem to be less prepared in terms of the 

availability of these methods. In both rounds, health posts were more likely than hospitals to have pills. In 

round 1, health centers were more likely than hospitals to have injectables. 

4.3. Process 

With few exceptions, the results have shown little variation in counseling or the high quality of pelvic 

examinations provided, by characteristics of the client, provider, or facility. The proportion of clients who 

received counseling was relatively low. Providers appeared to concentrate counseling on how to use the 

method (63%) and less on side effects (29%) or when to return (37%). In addition, only 9% of the clients 

received counseling on their method’s protection from STIs; only a third of the clients received highquality pelvic examinations. None of the providers’ characteristics were significantly associated with the 

different forms of counseling or high quality of pelvic examinations, with the exception of provider sex 

and provider salary type, which were found to be significantly associated with counseling on STIs. In the 

adjusted models, counseling on STIs was significantly more likely from providers who had a regular 

monthly salary than from those with no salary. This difference may indicate that providers with no salary 

are less motivated or less inclined to provide counseling. (Rowe et al. 2005) mentioned that the 

administrative environment of health workers, including salary, could influence their performance. 

Another important provider factor associated with the quality of services is personal supervision received 

by the provider (Thatte and Choi 2014). Supervision, especially with resulting feedback, can directly link 

to quality of care. After a formative supervision intervention in health facilities in four districts of 

Senegal, significant improvement was observed in a range of service areas across all districts (Suh, 

Moreira, and Ly 2007). In the present analysis, in the adjusted models, supervision did not have an effect 

on whether the provider gave counseling, but providers who received all six supervisory items were over 

three times as likely to provide high-quality pelvic examinations. Only a few of the other covariates 

representing the client and facility characteristics were significantly associated with provider counseling 

or pelvic examination. In the adjusted models, new clients were more likely to receive counseling or a 

high-quality pelvic exam compared with returning clients. Perhaps providers assumed that returning 

clients had already been counseled about their method in previous visits and thus did not need further 

counseling at each visit. However, counseling may be required more than once to ensure that clients 

understand fully how to use their family planning method, are aware of the side effects, and know 

whether their method protects from STIs. Only 9 percent of the providers were observed to provide 

counseling on whether the client’s method protects from STIs, and 42 percent of clients had incorrect 

knowledge of whether their family planning method protects from STIs. Many women believe incorrectly 

that their method protects them from STIs. 

In the adjusted models for counseling, the only facility characteristic found to be significant was locality. 

Rural facilities had four times the odds of providing counseling on method’s protection on STIs compared 

to urban facilities. In the adjusted models for high quality of pelvic examinations, health facility type and 

region had one significant category. Health posts were found to be significantly less likely to provide a 

high quality of pelvic examination. This is most likely due to the absence of the equipment and specialists 

available for providing pelvic exams in health posts. Similarly, the Dakar region, which has more 

hospitals and health centers than the other regions, was significantly more likely to provide pelvic 

examinations of high quality, compared with the other regions. The structure equipment index, which was 
38 

used as a proxy for the facility’s overall structure, was not significantly associated with the processdependent variables in the unadjusted and adjusted analysis. In addition, virtually no significant 

relationships were found between the basic infrastructure indicators in Appendix A and the processdependent variables (results not shown). The link between structure and process has been reported as 

being weak by Donabedian (Donabedian 1988); Basinski et al. indicated that this relationship depends on 

which structure and process components are compared (Basinski et al. 1992). This potentially explains 

how the region of Dakar, housing the capitol of Senegal, could score low on the equipment index yet still 

provide a higher quality of pelvic examinations. Because providing the various forms of counseling and 

high quality of pelvic examinations does not differ greatly by the client, provider, or facility 

characteristics, with some exceptions, it appears that the promotion of adequate counseling and a high 

level of pelvic examination is required in all the health facilities of Senegal. 

4.4. Outcome 

The final component of quality of care is the outcome. This was measured by the client’s satisfaction with 

the family planning service they received and by their knowledge of their method’s protection from STIs. 

As the outcome analysis showed, most clients (84 percent) reported being very satisfied with the family 

planning services they received, but satisfaction is negatively associated with some aspects of counseling. 

The process indicators of whether the client received counseling on side effects and when to return 

actually significantly decreased the odds of being satisfied. Counseling on how to use the method was not 

significantly related to satisfaction, perhaps implying that the provider/client interaction during 

counseling was unsatisfactory. Clients who were seen by providers with less than 17 years of education 

were more satisfied than those who were seen by providers with 17 or more years of education. As other 

studies have found (Agha and Do 2009; Aldana, Piechulek, and Al-Sabir 2001; Hutchinson, Do, and 

Agha 2011), waiting time was a significant predictor of client satisfaction. Clients who did not have to 

wait had higher odds of being satisfied than those who waited two hours or more. However, the other 

categories of waiting time were not significant. Having no education, primary education, or post-primary 

education also increased the odds of being very satisfied compared with having secondary or higher 

education. The same result has been found in Kenya (Agha and Do 2009), but in another study involving 

three sub-Saharan countries this was not always found to be true (Hutchinson, Do, and Agha 2011). The 

structure equipment index was not a significant predictor of client satisfaction. There were large and 

significant variations across regions. The North region had the lowest level of client satisfaction, and the 

South and Central regions had the highest. The South region, followed by Dakar, also had significantly 

higher odds of clients with correct knowledge of whether their method protects from STIs. It may be 

worth examining further the health facilities in the South region to understand why they produce higher 

levels of client satisfaction than other regions. 

After adjusting for all the covariates in the model, the only significant predictors of client’s correct 

knowledge on whether their method protects from STIs were provider’s category, provider’s training, and 

region. Clients who saw a nurse or nurse assistant had twice the odds of having correct knowledge 

compared with those who saw a midwife or other provider. Provider training on family planning almost 

doubled the odds of clients having correct knowledge. Although most facilities had at least one staff 

member trained in family planning (Figure 1), only 45 percent of providers who prescribed or provided a 

modern family planning method had receiving family planning training in the past two years (Table 11). 

The differences in family planning training by provider category were not significant (results not shown). 

These findings imply that training providers in family planning could improve the client’s knowledge of 

their method’s protection from STIs. While correct knowledge could be gained elsewhere and not only 

from a family planning provider, providing more training for midwives and other types of providers, as 

well as providing more facilities with family planning guidelines, may be effective interventions to 

improve client knowledge of STI protection. 
39 

As in the analysis of client satisfaction, counseling was not found to improve outcomes. Clients who 

received counseling on whether their method protects from STIs were not more likely to have correct 

knowledge. In a study in Zambia, the odds of correct knowledge were higher among clients who were 

counseled in their method’s protection from STIs (Chikamata et al. 2002). That study also found a much 

higher proportion of clients who had correct knowledge compared with Senegal—75 percent—among 

users of a method other than condoms (Chikamata et al. 2002). The apparent lack of impact of the 

counseling on STIs in Senegal suggests that this type of counseling offered in the health facilities is of 

poor quality. This result is similar to the absence of a significant impact of counseling on how to use a 

method and a negative impact of counseling on side effects, and when to return, on client satisfaction with 

family planning services. Further analysis on the effectiveness and quality of the counseling provided in 

family planning services may be required to understand why counseling is not improving outcomes. The 

apparent lack of effective counseling could be a result of the manner in which the counseling was 

provided, including the provider/client interpersonal relationship, which is an important aspect of 

providing quality of care in family planning (Bruce 1990), as well as in maternal health care (Srivastava 

et al. 2015). Effective counseling can improve outcomes; a study on client-centered versus physiciancentered consultations found that clients who received a client-centered consultation significantly 

increased their likelihood of satisfaction with services and method continuation at seven months (AbdelTawab and Roter 2002). 

In the 2015 Senegal SPA, observation and exit interviews will be available for family planning, and future 

analysis can provide comparisons between the 2012-2013 and 2015 rounds of the Senegal Continuous 

SPA surveys. This type of analysis may provide insight as to whether improvements have been made in 

the process and outcome measures of quality of care in family planning services and whether counseling 

is able to improve outcomes. 

4.5. Limitations 

The complexity of defining quality of care, as well as selecting and constructing the indicators, is one of 

the limitations of the study. There is also the question of whether providers who know they are being 

observed are providing better or more counseling than normal. That is, they may perform differently 

under observation, a phenomenon known as the Hawthorne Effect (Mayo 2003; McCambridge, Witton, 

and Elbourne 2014). Even though the overall percentage of providers offering different types of 

counseling is relatively low, the percentage could be even lower when the providers are not being 

observed. 

There are limitations to the outcome measures as well. Client satisfaction may be over-reported due to the 

client perhaps not wanting to speak against their providers (Donabedian 1988); satisfaction is also 

subjective. Knowledge of whether a family planning method protects from STIs could be gained from 

other sources and may not be attributed to the providers or facility characteristics. It can be difficult to 

find appropriate and objective outcome measures of quality of care, since health outcomes do not depend 

solely on the quality of care. Another limitation, when comparisons were made between the two rounds in 

the structure analysis, is the short time period between the two surveys. Despite the short time period, 

differences were detected, and these indicated that many facilities had increased their availability of 

family planning commodities. Fewer changes were detected between the rounds in terms of the basic 

infrastructure of facilities. This was expected, as infrastructure requires more time for change compared 

with increasing the availability of family planning commodities or equipment. 
40 

5. Conclusions 

The analysis of the first two rounds of the Senegal Continuous SPA indicate that improvements may be 

required in the structure, process, and outcome of the quality of care in family planning services. Some of 

the basic infrastructure components that are essential for providing quality of care in health services are 

lacking. Significantly more methods of family planning became available between the two rounds, 

especially methods that are less commonly used, such as emergency pills and condoms, suggesting that 

the mix of available methods may be improving. However, the availability of the combined injectable 

method decreased significantly between the two rounds. For the two most used methods—progestin-only 

injectables and combined oral pills—public facilities were more likely to have these methods available in 

their facilities compared with private facilities. 

Improvements may be required in the level and effectiveness of counseling and examinations provided by 

health workers. The percentage of providers who gave the necessary family planning counseling to their 

clients as well as a high quality of pelvic examination was relatively low. New clients were more likely to 

receive counseling and high-quality pelvic examinations compared with returning clients. Few other 

characteristics of clients, providers, and facilities were significant predictors of receiving counseling and a 

high quality of pelvic examination. The effectiveness of the counseling provided in facilities with family 

planning services was also not seen in the analysis of the outcomes of overall satisfaction and the client’s 

knowledge of their method’s protection from STIs. Clients who were counseled on side effects and when 

to return were less likely to be satisfied, and whether clients received counseling on their method’s 

protection from STIs was not a significant predictor of having correct knowledge. This may indicate that 

not only is more counseling required in the health facilities in Senegal, but also more training may be 

required on how to provide more effective and client-centered family planning counseling. For the 

outcome of correct client knowledge of their method’s protection from STIs, which was relatively low at 

58 percent, clients who saw a provider with family planning training were almost twice as likely to have 

correct knowledge compared with clients who saw a provider with no training, indicating that more 

training in the methods of family planning may be another desirable type of intervention. 

One of the main findings is the apparent weak link between the structure of the facility (measure by the 

equipment index) and the process and outcome components. For example, the Dakar region had poor 

scores for equipment, diagnostic tests, and medicine, and was less likely to have progestin-only 

injectables available, when compared to the Northern region, but Dakar significantly outperformed the 

Northern region in terms of high quality of pelvic examinations, client satisfaction, and client’s 

knowledge of their method’s protection from STIs. Improvements in structure may not be required to 

achieve improvements in process and outcome, and it may be more effective to focus interventions on 

provider training in family planning and counseling methods in order to improve outcomes. However, this 

conclusion is probably related to the type of structure components being examined; some structural 

components are essential for a functioning and well-performing facility that offers family planning 

services of high quality. Further analyses of the remaining rounds of the Senegal SPA will explore these 

findings, but the initial results provided in this report have identified some of the factors related to 

providers and facilities where interventions could improve the quality of care in family planning. 
41 

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45 

Appendix A 

Description of basic infrastructure variables 

Variable Definition 

Electricity Facility is connected to national grid that is always available during service hours, or has 

other sources of electricity such as a generator or solar system. 

Improved water source Access to water source from piped, public tap, standpipe, tubewell/borehole, protected dug 

well, protected spring, or rain water. 

Adequate sanitation facilities Toilet/latrine uses flush or pour flush to piped sewer system, septic tank, pit latrine, or other 

place; or ventilated improved pit latrine, pit latrine with slab, or composting toilet. 

Communication equipment Facility has an observed and functioning landline or an observed and functioning facilityowned cellphone. There were no observations for variables for short-wave radio. 

Private room Facility has a private examination room or other room with auditory and visual privacy. 

Computer and Internet Facility has an observed and functioning computer and access to Internet for at least two 

hours on the days that client services are offered. 

Emergency transport Facility has an observed functional ambulance that has fuel, or has access to an ambulance 

or other vehicle for emergency transport in another facility. 

47 

Appendix B 

Variables used to construct the structure PCA of equipment, diagnostic tests, and medicines 

Equipment Diagnostic tests Medicines 

Adult scale Hemoglobin Amoxicillin adult 

Child scale Blood glucose Amoxicillin child 

Thermometer Malaria Ampicillin powder 

Stethoscope Urine dipstick protein Beclometasone inhaler 

BP machine (digital or manual with 

stethoscope) Urine dipstick glucose Ceftriazone injection 

Light source Urine pregnancy Glivenclamide 

Sharps container (safety box) HIV Insulin injection 

Waste receptacle (pedal bin) with lid 

and plastic bin liner Syphillis Metformin 

Disinfectant Omeprazole 

Syringes ORS 

Running water with soap or alcohol rub Paracetamol 

Gloves Salbutamol 

Guidelines for standard precautions Zinc 

Round 1 Round 2 Round 1 Round 2 Round 1 Round 2 

31.4% (0.750)1 34.2% (0.723) 58.6% (0.898) 42.7% (0.806) 26.0% (0.747) 23.1% (0.702) 

Note: All variables were coded as binary variables, having item versus not having the item. Variables with negative 

loadings or loadings below 0.1 were removed. 

1 % explained by first component in PCA (Alpha) 

49 

Appendix C 

Family planning process variables 

Variables used for constructing indicators on quality of counseling

Method* How to use1 Side effects2 When to return2 Protection from STIs1

Pills or injectables When to take Initial side effects that 

may occur (such as 

nausea, weight gain, 

and breast 

tenderness) 

Return to clinic if side 

effect appears 

Method does not 

protect against STIs, 

including HIV 

What to do if forget 

Condoms Each can be only used 

once 

 Dual protection 

IUD Good for up to 

5-12 years 

Common side effects 

that may occur 

Return to clinic 3-6 

weeks post-insertion 

or after first menses 

Method does not 

protect against STIs, 

including HIV 

Users should regularly 

check strings after 

each menstruation 

Return to clinic if side 

effects continue 

Implants Good for 3-5 years Initial side effects that 

may occur (such as 

nausea, weight gain, 

breast tenderness) 

Return to clinic if side 

effects continue 

Method does not 

protect against STIs, 

including HIV 

Periodic abstinence or 

SDM 

How to identify a 

woman’s fertile period

 Method does not 

protect against STIs, 

including HIV 

No intercourse during 

woman’s fertile period 

without alternative 

method (condom) 

 

LAM Must be exclusively (or 

near-exclusively) 

breastfeeding 

 Method does not 

protect against STIs, 

including HIV 

Not effective after 

menstruation begins 

again 

 

 Infant must be less 

than age 6 months 

 

Note: Only methods provided or prescribed to observe clients were included. 

1 Apply to users of all methods reported.

2 Apply to only users of pills, injectables, IUDs, and implants.

51 

Appendix D 

Variables used for constructing the quality of pelvic examination indicator 

Before Procedure 

1 Ensured that client had visual privacy 

2 Ensured that client had auditory privacy 

3 Explained procedure to client before starting 

4 Prepared all instruments before starting procedure 

5 Washed hands with soap and water or disinfected hands before starting procedure 

6 Put on latex gloves before starting procedure 

During Procedure 

7 Used sterilized or high-level disinfected (HLD) instruments 

8 Asked the client to take slow deep breaths and to relax muscles 

9 Inspected the external genitalia 

10 Explained speculum procedure to client (if speculum used) 

11 Inspected the cervix and vaginal mucosa (using speculum and light) 

12 Performed a bimanual examination 

After Procedure 

13 Removed gloves 

14 Washed or disinfected hands after removing gloves 

15 Wiped contaminated surfaces with disinfectant 

16 Placed reusable instruments in chlorine-based disinfecting solution immediately after the procedure