MD. ZAKIUL ALAMDPSDU

UNIVERSITY OF DHAKA

Program Strategies for Reducing Inequities in Reproductive Health

Services

OBJECTIVES OF THIS PRESENTATION (ON THE BASIS OF ARTICLE)

To address what is inequity in the perspective of RH

To address the descriptors (Indicators) of inequity in RH

To address the program strategies for reducing inequities in RH

And finally to address ethical issues related to program strategies of RH

INTRODUCTION: INEQUITY AND INEQUITY

Inequality:

Inequality is just unequal distribution in health, wealth, income, status etc.

Inequity:

Inequity is injustice, unfair etc.

For example,

Income difference between “educated and uneducated” but difference in “male and female”.

INEQUITY IN RH

Inequity justice framework analyzes how the ability of any woman to determine her own reproductive outcomes is linked directly to the conditions in her community—

that is, to conditions that are not just a matter of individual choice and access rather integrated.

Reproductive justice addresses the reality of inequality— specifically, the inequality of opportunities that control reproductive outcomes (Ross 2005).

INEQUITY INDICATORS (DESCRIPTORS):

Inequity is often expressed as the difference in an outcome variable by categories of descriptors such as

1. age (young–old),

2. sex (female–male),

3. wealth (lowest–highest quintile),

4. ethnicity (indigenous–nonindigenous),

5. and location of residence (urban–rural) etc.

For example, In 2005 women from poor countries had a maternal mortality rate of about 650 deaths per

100,000 live births, compared with 9 deaths for women from wealthier countries (WHO 2007).

In 2005 that a 15yearold female would die from a complication related to pregnancy or childbirth during her lifetime was one in seven in Niger (the country with the highest rate), compared with a lifetime risk of one death in 48,000 live births for a girl of the same age in Ireland.

INEQUALITY INDICATORS (DESCRIPTORS) CONTD.

• Some descriptors are based upon • self identifiers, such as ethnicity or sexual identity,

• whereas others are based upon observable measures of wealth, such as housing type.

• Some are not amenable to change, such as age, whereas others may be difficult to change at a group level, such as rural residence.

• Indeed, many of the indicators of more vulnerable groups may be highly correlated.

• For example, indigenous women are more likely to be poor and to live in rural areas.

PROGRAM STRATEGIES FOR REDUCING INEQUITIES

Efforts to reduce inequity can be undertaken within program operations through actions at three different phases:

1. 1st phase: through better understanding at the development stage,

2. 2nd Phase: through better program design,

3. 3rd Phase: through post program evaluation of the distribution of benefits.

It is just the process of Behavior Change Communication (BCC) for

DEVELOPMENT PHASE: PRE-INTERVENTION STAGE

1. Selection of target area on the basis of severity

E.g. CPR increase in Sylhet area.

2. Selection of target population:

Specify the target population on the basis of a) age e.g. (15-49) for women

b) sex

c) and wealth (income)

PRE-INTERVENTION STAGE CONTD

3. Objectives and goals of the interventions: a) What are the principal outcomes that we want to

achieve?

b) and what parts of the health system must be engaged with to have the greatest effect on program coverage, potential impact, and financial sustainability?

4. Timing: Selection of appropriate timing

5. Preliminary analysis: Conducting preliminary analyses to better target the intervention often leads to greater impact and better use of limited resources.

2. REDUCING INEQUITY USING INTERVENTION DESIGN: INTERVENTION PHASE

The second approach to reducing inequity is to incorporate reduction of inequity into

1. program design

2. and public policy.

Development economists offer a range of strategies for this approach, including

1. the provision of universal health insurance coverage,

2. increased public spending on health care (on the assumption that the poor will benefit disproportionately),

3. and better targeting of programs and services to populations in need.

REDUCING INEQUITY IN ACCESS TO FAMILY PLANNING

• Access to family planning can vary greatly as a result of diverse strategies for achieving coverage— e.g. clinic versus community efforts.

For Example, Since 1984, little difference has been observed in the contraceptive prevalence rate in Bangladesh according to wealth quintile, compared with Kenya.

But why?

• Bangladesh emphasize on universal coverage of family planning services through community outreach efforts, especially for the poor,

• whereas in Kenya the commitment to expanding family planning through community based distribution (CBD) programs. When Kenya failed to maintain its CBD program.

REDUCING THE INCIDENCE OF EARLY MARRIAGE AND ITS HEALTH

CONSEQUENCES FOR YOUNG WOMEN

• Early marriage is highly correlated with a series of undesirable, often devastating health outcomes.

For example, ranging from the risk of early pregnancy to obstetric fistula due to obstructed labor.

• Erulkar and her colleagues (2006) are examining means of addressing the vulnerability of young Ethiopian girls aged 10–14 by delaying marriage and seeking alternative transitions to adulthood through

a) education,

b) livelihoods training,

c) and community involvement activities.

INCREASING SKILLED ATTENDANCE AT CHILDBIRTH AMONG THE POOR

The provision of skilled childbirth attendants where prenatal care is poor and maternal mortality rates are high is one of the most inequitable of health services.

• This inequity exists because of the costs associated with addressing delivery complications in public and private hospitals in many developing countries.

• How it can be reduced? 1. Addressing the affordability of these services through the use of coupons or vouchers given to the poorest women expands their reach.

2. A financing mechanism such as vouchers for women who meet poverty standards is an effective way to increase the use of hospital services rapidly.

INCREASING SKILLED ATTENDANCE AT CHILDBIRTH AMONG THE POOR

• Incentive programs such as the JSY (Janani Suraksha Yojana) safemotherhood intervention in India, efforts in Rwanda supported by the World Bank, and programs supported by KfW (the German development bank) in Bangladesh, Kenya, and Uganda are working to determine how to make these services accessible to those who need them most.

• Experience to date in several countries suggests that the use of vouchers increases women’s demand for hospital childbirth services.

3. ADDRESSING INEQUITIES BY IMPROVING EVALUATION OF

DISTRIBUTIVE BENEFITS AND COSTS: EVALUATION PHASE

• The third approach focuses on the necessity of assessing whether the benefits planned reached those who are most vulnerable within the target areas.

• For policies to be effective in the long run, determining the effects of early investments is important in order to ensure that the funds set aside were used effectively and that those groups who were to receive the benefits of the interventions were exposed to them.

• The best intentions built into a program’s design do not always have the anticipated effects. Weiner and his collaborators employed rapid assessments and analysis creatively to examine who makes use of youth centers in countries around the world (Weiner 2007).

M&E QUESTIONS

• Monitoring questions• What is being done?

• By whom?

• Target population?

• When?

• How much?

• How often?

• Additional outputs?

• Resources used? (Staff, funds, materials, etc.)

THE ETHICS OF INEQUITY AND INACTION

• Any discussion of the issue of inequity should take…..1. Ethics,

2. Accountability,

3. and the role of reproductive justice into consideration.

• The ICPD Program of Action calls for all societies and individuals to have access to the benefits of scientific innovation (UNFPA 1994).

• Expanding the stream of these benefits to all requires that the principle of reproductive justice be applied to research and service models to ensure the inclusion of those individuals who are commonly left out.

• Policymakers and program planners must take into account the disproportionate burden of diseases among certain segments of the population that can be ameliorated through public investments in health.

THE ETHICS OF INEQUITY AND INACTION CONTD.

• we must ask: How do families, communities, and social norms support or inhibit the provision of these benefits to those who are most vulnerable and most in need of the interventions?

• Accountability is a major part of good governance.

• By employing reproductive justice frameworks, programs can achieve greater marginal impacts, improve their efficiency, and attain a better grasp on monitoring the distributive benefits and costs of interventions.

• The result of focusing on inequity is that societies achieve better devel-opment outcomes by making smart investments in reproductive health.

CONCLUSION

• One practical way of approaching the process of reducing or eliminating inequity is to use the techniques of market segmentation.

• The focus of our investments, then, should be on the social norms and program operations that affect these outcomes.

THANK YOU EVERYONE FOR YOUR PATIENCES.

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