Bangladesh: Offering Reproductive Health Services
for Men Improves Clinic Utilization
OR Summary no. 47

Background

In 2000 the Bangladesh Directorate of Family Planning collaborated with the National Institute of Population Research and Training (NIPORT) and FRONTIERS to test the feasibility, acceptability, and impact of adding reproductive health services for men at rural Health and Family Welfare Centers (HFWCs). Traditionally, HFWCs have focused on women’s reproductive health and have not addressed men’s needs, including protection from and treatment for reproductive tract infections (RTIs) and sexually transmitted infections (STIs).

Photo credit: FRONTIERS Bangladesh

The two-year study took place at eight HFWCs and results were compared with four additional HFWCs that served as control sites. In the experimental areas, 127 service providers and field workers received training on reproductive health, including the diagnosis and management of RTIs and STIs and men’s reproductive health. For RTI or STI clients, providers gave counseling, supplied medications or prescriptions, and encouraged clients to bring their partners for treatment and counseling. To promote community awareness of services for men, the project distributed posters, leaflets, and brochures in the intervention areas, and  organized over 400 group discussions for men aged 15 and over and community and religious leaders. Researchers assessed the intervention’s impact through supply inventories, clinic registers, focus group discussions, interviews with providers, and exit interviews with clients.

Findings

• The integration of men’s services at HFWCs was acceptable to both male (100%) and female clients (91%) in the experimental areas. There was no need to alter clinic schedules to accommodate men.

• Virtually all providers knew about the transmission and prevention of HIV/AIDS and were aware of syphilis and gonorrhea. Following the intervention, however, knowledge of other STIs, such as chlamydia and herpes, increased significantly in the intervention clinics. Providers’ knowledge of the signs and symptoms of STIs and RTIs in men was also significantly higher in the experimental areas.
   
• Overall use of clinical services increased significantly in the experimental areas relative to the control areas. The monthly average of male clients per clinic nearly tripled at the experimental clinics: from pre-intervention levels of 131 to 345 in the second six months after the intervention. Women’s use of any service increased from an average of 425 per clinic per month to 693 in the second six months post-intervention at the experimental clinics.
   
• At experimental sites, men’s visits for RTI or STI services increased from an average of less than one per month at baseline to more than five per month after the intervention. Women’s use of these services increased even more markedly at the experimental clinics, from an average of less than one per month to 13 per month by the second six months post-intervention (see Figure). The control clinics received no RTI or STI clients during this period.

• Medicines for treatment were often unavailable and supplies were insufficient to cover increased use of services. Clients received prescriptions to purchase medicines at pharmacies, but it was not possible to assess their use of the medicine. It was also not possible to assess how clients managed their partner’s symptoms.
   
• Men’s treatment-seeking behavior needs to be improved. While over half of male clients interviewed at experimental and control clinics said that they had experienced symptoms of RTIs or STIs, only 20–30 percent sought treatment from a qualified provider. This points to a need to address social stigma associated with STIs and increase efforts to improve partner management.

Utilization

• The Ministry of Health and Family Welfare has asked NIPORT to expand RTI and STI services for men to 100–150 additional HFWCs. If this expansion results in significant improvements in service delivery and clinic utilization, the Ministry plans to integrate the services nationwide to all 3,700 HFWCs.

Policy Implications

• The targeted outreach strategy, particularly the group discussions, was instrumental in increasing both men’s and women’s use of RTI, STI, and general health services. Programs should consider targeted community outreach as an integral part of strategies to attain sustainability. Evaluations should include documentation of the elements in the outreach efforts to enable other programs to replicate successful strategies.
   
• Strategies to scale up the intervention should address the frequent problem of drug stock outs and the implications of increased demand. Managers should ensure a reliable supply of medicines as well as contraceptive supplies, and should particularly document changes in demand for and use of condoms.
   
• There is a clear need to address the continuing stigma associated with STIs and RTIs and its relationship to service utilization. Scale-up efforts should also include a strategy for ensuring, and documenting, management of partners when RTIs or STIs are detected.

 August 2004