Showing posts from category maternal health.
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Family Planning and Results-Based Financing Initiatives
›“Family planning means healthier moms and kids – and it’s good for development too,” said Lindsay Morgan, a senior health analyst at Broad Branch Associates, a healthcare advocacy group. But any number of hurdles can keep women from accessing family planning services. Morgan spoke at a May 21 discussion about results-based financing (RBF) programs, which aim to address hurdles on both the supply and demand sides of the equation in developing countries by incentivizing the provision of a variety of quality services while removing barriers to access for women in need of those services.
Removing Barriers to Providing and Using Family Planning Services
Incentives in RBF programs can come in a variety of forms – like subsidies or fees paid to clinics or vouchers sold to women, said Morgan. In Burundi, for example, under a pilot program rolled out across three provinces in 2006, health facilities receive payments for each patient that uses a modern method of contraception. In 2009, the government and international partners began scaling up the program to a nationwide level. In addition to expanding the program’s geographic reach, the scale-up incorporated new payment criteria to better incentivize quality of care (as opposed to just quantity) and longer-lasting methods of contraception.
Since the RBF pilot began, maternal and child health indicators have improved. The number of children being fully immunized is up, as is contraceptive prevalence, said Morgan. Additionally, those immediate results can lead to a slew of additional benefits down the line. For instance, improving modern contraceptive prevalence is one of the most cost-effective interventions available for reducing maternal death, she said.
In nearby Kenya, the health ministry leads a voucher system across four districts and two Nairobi slums to help some of the country’s poorest women afford maternal healthcare, family planning, and gender-based violence services.
The program is “written into large policy documents [and] strategic pieces,” including Vision 2030, a long-term government-wide strategy document “unveiled in 2008 as a way to reach middle-income country status by 2030,” said Ben Bellows, a reproductive health associate at Population Council Kenya. The government’s emphasis on the voucher program as more than just a health initiative is an acknowledgment of the downstream impact that improved maternal and reproductive health can have on the country’s development, he said.
“An Equity Gap in Family Planning”
However, the fact that the voucher program is needed at all is evidence of “an equity gap in family planning,” Bellows said. Access to family planning services can be significantly skewed depending on a woman’s income level, he said, pointing to a recent article in The Lancet assessing health inequalities in 12 different maternal and child health services across 54 priority Millennium Development Goal countries.
The equity gap reflects “an interesting problem with development,” said Bellows: Though low-income countries are converging with higher income countries, in terms of economic growth rates and income levels “the benefits of growth aren’t being evenly distributed.” The Africa Progress Panel’s annual report, released last month, echoes that point, he said.
“Governments are failing to convert the rising tide of wealth into opportunities for their most marginalized citizens,” the report concludes, and “unequal access to health, education, water and sanitation is reinforcing wider inequalities.”
Kenya’s voucher system is designed to help shrink that gap. Among the poorest of the poor – those benefitting from the system – inequalities are dropping, even if on a broader scale, inequity still exists between poor and wealthy Kenyans. “We’re seeing lower inequalities of service in areas exposed to the voucher,” said Bellows.
“RBF supports progress on a path towards universal health coverage,” said Beverly Johnston, the senior policy advisor at USAID’s Office of Population and Reproductive Health. And within the context of family planning “the whole idea is to level the playing field” so that all contraceptive methods are equally readily available to the women seeking them.
“A Catalyst for Change” in Family Planning
In addition to addressing equal access concerns, RBF programs can serve as “a catalyst for change…to stimulate quality of care and quality of family planning counseling in particular,” said Johnston.
A commonly cited hurdle to better family planning access is social norms that support large family sizes or otherwise limit a woman’s ability to space or limit her pregnancies. Given community health workers’ unique roles within their communities – “often on the front lines…where many of these social taboos and barriers exist,” as Morgan described – simply strengthening their training, and in turn improving the quality of care that women receive, can help counter norms that might otherwise prohibit access to family planning.
As more women receive higher quality care, norms dissipate even further, said Morgan. “There is evidence that [quality of care] is strongly associated with a woman’s decision to choose a method to use, to continue to use it, and to recommend it to others.”
“Rights Are Tantamount”
One trap RBF programs need to be aware of is over-incentivizing expansion of coverage to the detriment of quality or individual women’s concerns about what makes sense for them, said Johnston.
“Rights are tantamount,” she said. In order to ensure that rights are upheld, programs must reflect and be sensitive to local histories and local needs – particularly given the fact that some countries have had “a history of coercive programs and policies.”
Ultimately, “we really look at RBF as just one tool,” said Johnston. “RBF is not for every place and every context,” and neither is family planning’s place in RBF programming.
As one tool of many, RBF programs are gaining prominence as a way to meet MDGs related to maternal and child health. Bellows sees RBF’s importance lasting long past that 2015 deadline, though.
“The high inequity that we witness across many low-income countries, and the ability of targeted mechanisms [like Kenya’s voucher program] to address that, suggest that this may be a kind of generalized solution,” he said. “Obviously it will be context specific in the way in which it is rolled out, but the strategy of incentivizing clients and providers suggests that there’s some sort of globalized solution that could be considered for this widespread challenge.”
Event Resources
Photo Credit: Sean Peoples/Wilson Center. -
Carl Haub, Behind the Numbers
Republic of Congo Demographic and Health Survey Shows High Maternal Health, But No Fertility Decline
›June 5, 2012 // By Wilson Center StaffThe original version of this article, by Carl Haub, appeared on the Population Reference Bureau’s Behind the Numbers blog.
The Congo (Brazzaville) 2011-2012 Demographic and Health Survey (DHS) is the second DHS taken in the country and the preliminary report has just been released. The survey interviewed 10,819 women ages 15-49 and 5,145 men ages 15-59 from September 2011 to February 2012. A major finding of the survey was that fertility has not declined in the country since the previous DHS in 2005. The total fertility rate (TFR) report in the recent DHS for the three year period before the survey was 5.1 children per woman, 4.5 in urban areas, and 6.5 in rural areas. This appears to represent an increase in the TFR since 2005 but the survey report cautions that there is likely to have been some understatement of the actual level of childbearing in the 2005 survey, particularly among women ages 25-29.
Rural women accounted for two-thirds of those interviewed in the most recent survey. The rather high TFR is reflected in the desire for large families. Among women with five living children, only 37.3 percent said they did not wish to have additional children. An additional 9.8 percent of that group said they were incapable of conceiving, however.
In the survey, 44.7 percent of currently married or in-union women said that they were using some form of family planning and 20 percent were using a modern method. The most common type of modern method was the male condom at 12.3 percent, a rather unusual pattern of contraceptive use in Africa. That was followed by the pill at 2.9 percent and injectables at 2.8 percent. This continues the often-observed preference in sub-Saharan Africa for methods to space births, not necessarily to limit them. The use of modern contraception was 24.6 percent in urban areas and 11.7 percent in rural areas. Modern contraception rose since the 2005 DHS when it was reported at 12.7 percent and the condom was also the most frequently used method at that time. The prevalence of HIV was reported in the 2009 AIDS Indicator Survey at 4.1 percent for women ages 15-49 and 2.1 percent of men of the same age group.
Continue reading on Behind the Numbers.
Sources: MEASURE DHS.
Image Credit: Carl Haub/Population Reference Bureau. -
USAID’s New Global Health Framework and Delivering Equity in Health Interventions
›USAID’s new Global Health Strategic Framework, Better Health for Development, lays out the agency’s major health priorities for the next five years. “Core global health priorities” include reducing maternal mortality, ensuring child survival and nutrition, fostering an “AIDS free generation,” and fighting infectious diseases. Family planning and reproductive health is listed as a key area for bilateral engagement. In particular, the strategy hopes to continue to “graduate” countries from the agency’s family planning program, which since the 1980s has transitioned 21 countries into local ownership of family planning support. The strategy also takes stock of the shifting global health environment, noting the rise of the “BRICS” countries as new donors and the need to strengthen public health systems in developing countries. “Already, private payments account for 50-80 percent of total health spending in Africa and Asia, leading to system inefficiencies, inequitable access, and health costs that prove catastrophic to individuals and families,” the report reads. In order to achieve its priorities within this context, the document sets out a number of strategies, including a focus on program sustainability, the empowerment of women, and integrated approaches to development. Health, it says, “cannot be isolated from other development challenges.”Speaking of health interventions, a team of researchers led by Aluisio Barros of the Federal University of Pelotas, Brazil, recently compared coverage data from more than 50 countries against an index of household wealth to estimate the most and least equitable interventions. The study, “Equity in Maternal, Newborn, and Child Health Interventions in Countdown to 2015: A Retrospective Review of Survey Data From 54 Countries,” published in The Lancet, found that “interventions with similar levels of overall coverage often have very different degrees of inequality.” According to the data, “the most inequitable indicator was skilled birth attendant, followed by four or more antenatal care visits, whereas the most equitable was early initiation of breastfeeding.” For example, though the average for attendance by a skilled birth attendant was 53.6 percent across the entire sample, the wealthiest fifth had an 84.4 percent coverage rate and the poorest stood at 32.3 percent. “Interventions that are usually delivered in fixed health facilities…tend to be the most inequitably distributed,” write the authors, with geographical access, financial barriers, and discrimination appearing as likely obstacles for the poor. The authors conclude that, although “concern about inequalities in maternal and child health in poor countries was conspicuously absent from the global agenda in the past,” the availability of new, intervention-specific data provides a means of targeting equity issues in health delivery more successfully. -
“Afghanistan, Against the Odds: A Demographic Surprise” Launches ECSP Report 14
›A few months ago, Elizabeth Leahy Madsen broke down Afghanistan’s first-ever nationally representative survey of demographic and health issues in a two-part series here on the blog. Now, we’ve published her analysis in a rich new policy brief format. It is the first issue of Environmental Change and Security Program Report 14, the latest volume of ECSP’s flagship publication.
In “Afghanistan, Against the Odds,” Madsen examines the surprising results of this fall’s demographic survey and how the country’s statistics compare to neighboring Pakistan.
“Just as Afghanistan and Pakistan’s political circumstances have become more entwined,” writes Madsen, “their demographic paths are more closely parallel than we might have expected. For Afghanistan, given its myriad socioeconomic, political, cultural, and geographic challenges, this is good news. But for Pakistan, where efforts to meet family planning needs have fallen short of capacity, it is not.”
The publication of this brief marks the re-launch of ECSP Report as an online-only volume, with individual issues scheduled to be released throughout the year. Forthcoming ECSP Report 14 briefs will address the demographic roots of the Arab Spring; the links between population dynamics and environmental resources like water, biodiversity, and food; and the potential impact of climate change mitigation efforts on conflict.
Published since 1996 in hard copy and online, the new ECSP Report will now be available on the Wilson Center website, New Security Beat, and Issuu. You can read the previous 13 volumes of the ECSP Report on the Wilson Center website.
Download ECSP Report 14: “Afghanistan, Against the Odds” from the Wilson Center. -
Adenike Esiet: Building Support for Improving Adolescent Sexual and Reproductive Health in Nigeria
›“In Nigeria, young people under the age of 25 are driving the HIV epidemic…and that’s been the opening place for people to begin to say, ‘let’s address the issues of young people’s sexual and reproductive health,’” said Adenike Esiet, executive director of Action Health Incorporated in Lagos, during an interview with ECSP.
On any number of health indicators, girls suffer disproportionately. “For every one boy in the age bracket of 10 to 24 who is HIV positive, there are three girls who are HIV positive,” Esiet said. “Over 60 percent of cases of complications from unsafe abortion reported in Nigerian hospitals are amongst adolescent girls. In fact in literature, 10-15 years ago, this was described as ‘a schoolgirl’s problem’…and it’s still an ongoing problem.” She added: “And for girls too, the issue of sexual violence is huge. It goes largely unreported but it’s occurring at epidemic levels.”
Esiet spoke on an adolescent health panel during the April 25 “Nigeria Beyond the Headlines” event at the Wilson Center. Progress is slow on these issues, in large part because “there’s a whole lot of silence about acknowledging young people’s sexuality,” she said.
Adults “want to believe [adolescents] shouldn’t be sexually active.” But turning a blind eye to adolescent sexuality can mean that efforts “to provide access to education or services is hugely resisted by practitioners who should be doing this.”
Action Health works to fill the gap that emerges. “Our work covers advocacy, community outreach, and service provision for young people,” said Esiet.
“Our primary entry road in to work with young people is creating access to sexuality education and youth friendly services. And in the course of trying to do that, we have to do a whole lot of advocacy with government and also with ministries or education and ministries of health and youth development.”
The group has worked with government officials and agencies to establish a nationwide HIV education curriculum and paired with local healthcare providers to increase access to “youth-friendly” sexual and reproductive health services. Funding shortages and insufficient resources have hampered the curriculum’s success, though, and the pervasive attitude against youth sexuality has limited the reach of services, she said. Ultimately, “there are a whole range of issues that truly need to be addressed” for outreach efforts to be successful.
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Nigeria Beyond the Headlines: Demography and Health [Part One]
›“Nigeria is a country of marginalized people. Every group you talk to, from the Ijaws to the Hausas, will tell you they are marginalized,” said Peter Lewis, director of the African Studies Program at the Johns Hopkins University School of Advanced International Studies. Lewis spoke at an April 25 conference on Nigeria, co-hosted by ECSP and the Wilson Center’s Africa Program, assessing the country’s opportunities for development given its demographic, governance, natural resource, health, and security challenges. [Video Below]
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Learning From Success: Ministers of Health Discuss Accelerating Progress in Maternal Survival
›“The gains we have made [in reducing maternal mortality rates] are remarkable; however, gains are fragile and donor resources are declining. Substantial investments must be maintained to safeguard these hard-wins,” said Afghan Minister of Health Suraya Dail at the Wilson Center on April 23. [Video Below]
As part of the Wilson Center’s Global Health Initiative, the Advancing Dialogue to Improve Maternal Health series partnered with the U.S. Agency for International Development to co-host Minister Dail, along with Honorable Dr. Mam Bunheng, Minister of Health, Cambodia; Honorable Dr. Bautista Rojas Gómez, Minister of Health, Dominican Republic; and Dr. Fidele Ngabo, Director of Maternal and Child Health, Ministry of Health, Rwanda.
These ministers spoke about the lessons learned in countries where there has been tremendous progress under challenging circumstances.
In the Dominican Republic, Bautista Rojas Gomez said the first challenge was to address the “Dominican paradox,” where maternal mortality rates were high despite the fact that 97 percent of women received prenatal care and delivered in hospitals. The government created a zero tolerance policy that included a comprehensive surveillance system, mandatory maternal death audits, and community oversight of services, which assured better quality services.
Similar political commitment improved indicators in Cambodia, where maternal mortality rates dropped from 472 to 206 per year from 2005 to 2010. “It takes a village…and the prime minister has inspired the country to act,” said Mam Bunheng. Through increased access to contraception the number of children per woman went from seven to three and commitment to family planning, education, technology, infrastructure, and community have been the key drivers of success.
“In Rwanda, the big challenge we are having is education,” said Fidele Ngabo. “Many of the maternal health indicators depend on education.” When women and girls are educated they are twice as likely to utilize modern contraception. The efforts of Rwanda’s government have been instrumental in facilitating positive change, he said, particularly the efforts of First Lady Jeannette Kagame, who he called a “champion” for women and girl’s health.
As witnessed throughout the Advancing Dialogue to Improve Maternal Health series – and reiterated by the ministers of health – the interventions to improve maternal mortality rates exist, what’s left is to generate the needed political willpower.
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Photo Credit: David Hawxhurst/Wilson Center. -
Carl Haub, Behind the Numbers
Bangladesh 2011 Demographic and Health Survey Shows Continued Fertility Decline, Improved Health Indicators
›May 7, 2012 // By Wilson Center StaffThe original version of this article, by Carl Haub, appeared on the Population Reference Bureau’s Behind the Numbers blog.
The Bangladesh 2011 Demographic and Health Survey is the ninth demographic survey taken in the country since 1975. Except for a few very small countries and city-states, Bangladesh is the world’s most densely populated country with about 1,100 people per sq. kilometer. The country’s area is about the same as the U.S. state of Arkansas and a bit more than Greece but is home to over 150 million people.
The preliminary 2011 report has just been released and it shows that fertility has continued its decline to a low level. The total fertility rate (TFR) for the three-year period before the survey was 2.3 – 2.0 in urban areas and 2.5 in rural areas. The survey interviewed 17,842 ever-married women ages 12 to 49 and 3,997 ever-married men ages 15 to 54 from July to December 2011. Rural women accounted for two-thirds of those interviewed. From 1975 to 1994, the TFR in Bangladesh was in continuous decline. But the next three surveys showed a tendency for TFR decline to “stall” at a medium level (see graph). Desired family size has greatly decreased. In the survey, 76.2 percent of women with two living children said that they did not wish to have any more children, an additional 5.3 percent had been sterilized, and 1.3 percent said they were incapable of conceiving.
In the survey, 61.2 percent of currently married women said that they were using some form of family planning, a level comparable to developed countries. The use of modern methods was quite high at 52.1 percent. Unlike neighboring India, where female sterilization predominates, the contraceptive pill is the most widely used modern method at 27.2 percent, followed by injectables (11.2 percent), and the male condom (5.5 percent). Contraceptive use has risen steadily in surveys, up from 7.7 percent in 1975. Family planning use has risen despite the fact that fewer women report a visit from a family planning worker, either government or private. Overall, only 15.5 percent reported contact with a home visitor, which has been an important part of the country’s family planning program. The report notes that this may be due to workers deciding to provide services from community clinics for three days a week.
Continue reading on Behind the Numbers.
Sources: MEASURE DHS.
Imaged Credit: Carl Haub/Behind the Numbers.
