BETTER REPRODUCTIVE HEALTH FOR POOR WOMEN IN SOUTH ASIA Report of the South Asia Region Analytical and Advisory Activity MAY 2007 Authors Meera Chatterjee Ruth Levine Shreelata Rao-Seshadri Nirmala Murthy Team Meera Chattejee (Team Leader) Ruth Levine (Adviser) Bina Valaydon (Bangladesh) Farial Mahmud (Bangladesh) Tirtha Rana (Nepal) Shahnaz Kazi (Pakistan) Kumari Navaratne (Sri Lanka) G. Srihari (Program Assistant) ResearchAnalysts Pranita Achyut P.N. Rajna Ruhi Saith Anabela Abreu: Sector Manager, SASHD Julian Schweitzer: Sector Director, SASHD Praful Patel: Vice President, South Asia Region Consultants Bangladesh International Center for Diarrheal Disease Research, Bangladesh Data International, Bangladesh India IndicusAnalytics,New Delhi Foundation for Research in Health Systems,Bangalore Nepal New Era, Kathmandu Maureen Dar Iang, Kathmandu Pakistan Population Council, Pakistan Sri Lanka Medistat, Colombo Institute for Participation in Development, Colombo Institute of Policy Studies,Sri Lanka Thisstudyand report were financedby a grant from the Bank-NetherlandsPartnership Program (BNPP) BETTER REPRODUCTIVE HEALTH FOR POOR WOMEN I N SOUTH ASIA CONTENTS ACRONYMSAND ABBREVIATIONS .................................................................................. V Chapter 1 Reproductive Health in South Asia: Poor and Unequal . ...1 WHY FOCUS ON REPRODUCTIVE HEALTH I N SOUTH ASIA? ........................ ........................................................................3 2 HOW THIS REVIEW WAS DONE THE SOUTH ASIAN CONTEXT ......................................................................... 5 ADOLESCENT REPRODUCTIVE HEALTH ..................... .................................... 7 SEXUALLY-ACTIVE ADULTS .......................... ............................................... 11 THE MATERNAL STAGE .................................................................................... 16 OLDER WOMEN'S HEALTH .................................................................................22 IMPROVING REPRODUCTIVE OUTCOMES .......................................................22 Chapter 2 Reproductive Health Services: Inadequate and Unused 25 . . 2.1 UNDERSTANDING USE OF HEALTH CARE ....................... .............................26 2.2 USE OF REPRODUCTIVE HEALTH SERVICES .....................................................27 2.3 REPRODUCTIVE HEALTH SERVICE SYSTEMS ................... ..............................34 2.4 INCREASING USE OF SERVICES ..................................................................... 41 Chapter 3 . Planning and Practicing Better Reproductive Health 45 3.1 DECENTRALIZATION TO BRIDGE INEQUALITIES ........................................ . 46 3.2 DECENTRALIZED ACTION PLANNING ............................................................. 47 3.3 PROMISING GLOBAL PRACTICES ..................................................................... 50 3.4 MOVING FORWARD I N SOUTH ASIA ............................................................... 62 Chapter 4 . Financing Reproductive Health for Poor Women ...........65 4.1 THE POLICY CONTEXT ...................... ..........................................................66 4.2 RESOURCE MOBILIZATION FOR REPRODUCTIVE HEALTH ..............................66 4.3 RESOURCEALLOCATIONS WITHIN REPRODUCTIVE HEALTH ..........................70 4.4 IMPROVING REPRODUCTIVE HEALTH FINANCING .................. ....................74 Chapter 5 . Improving Poor Women's Reproductive Health .............83 5.1 WHAT NEEDSTO BE DONE AND HOW .............................................................. 84 5.2 REFORMSTHAT COUNT FOR REPRODUCTIVE HEALTH ............... ................. 93 5.3 OTHERS MATTERSARISING .............................................................................99 DEFINITIONS................................................................................................................101 ..................................................................................................... BACKGROUND REPORTS 105 REFERENCES.....................................................................................................................107 POVERTYAND REPRODUCTIVE HEALTH STUDY METHODOLOGY TABLES ON REPRODUCTIVE HEALTH STATUS THE ESSENTIAL PACKAGE OF REPRODUCTIVE HEALTH SERVICES TABLES ON USE OF REPRODUCTIVE HEALTH SERVICES PUBLIC HEALTH SYSTEMS I N SOUTH ASIA EXAMPLES OF PROMISING PRACTICES FOR SOUTH ASIA TABLES ON REPRODUCTIVE HEALTH EXPENDITURES POLICIES RELATEDTO REPRODUCTIVE HEALTH KEY ACTIONS TO IMPROVE REPRODUCTIVE HEALTH HEALTH SECTOR REFORMS RELATEDTO REPRODUCTIVE HEALTH Acronyms and Abbreviations ADB Asian Development Bank AIDS Acquired Immuno-deficiency Syndrome AM0 Assistant Medical Officer ANC Antenatal Care ANM Auxiliary Nurse Midwife ARI Acute Respiratory Infection ASFR Age-specific Fertility Rate ASHA Accredited Social Health Activist AYUSH Ayurveda, Yoga, Unani, Siddha and Homeopathy (Indian medical systems) BBS Bangladesh Bureau of Statistics BCC Behavior Change Communication BD Bangladesh BDHS Bangladesh Demographic Health Survey BEmOC Basic Emergency Obstetric Care BHU Basic Health Unit BINP Bangladesh Integrated Nutrition Program BMI Body Mass Index BMMS Bangladesh Maternal Health Services and Maternal Mortality Survey BNNP Bangladesh National Nutrition Program BSPAS Bangladesh Service Provision Assessment Survey CAC Comprehensive Abortion Care CBFPT Clinic-based Family Planning Project CDP Community Drug Program CEmOC Comprehensive Emergency Obstetric Care CHC Community Health Center CIET Canadian Institute of Education and Training CMH Commission on Macro-economics and Health CMR Child Mortality Rate CNA Community Needs Assessment CPR Contraceptive Prevalence Rate (earlier Couple Protection Rate) CREHPA Center for Research on Environment, Health and Population Activities CSSM Child Survival and Safe Motherhood CSW Commercial Sex Worker D&C Dilatation and Curettage DAP Decentralized Action Planning DCPP Disease Control Priorities Project DCS Department of Census and Statistics (Bangladesh) DGFP Directorate General of Family Planning DGHS Directorate General of Health Services DHAP District Health Action Planning DHM District Health Mission DHS Directorate of Health Services DHS Demographic and Health Survey DHS Department of Health Services ED0 Executive District Officer EmOC Emergency Obstetric Care EOC Essential Obstetric Care EPI Expanded Program of Immunization ESP Essential Services Package FP Family Planning FCHV Female Community Health Volunteer FFPAM Federation of Family Planning Associations of Malaysia FGD Focus Group Discussion FHB Family Health Bureau FHD Family Health Division FP Family Planning FPAN Family Planning Association of Nepal FPASL Family Planning Association of Sri Lanka FPI Family Planning Inspector FPW Family Planning Worker FRU First Referral Unit FWA Family Welfare Assistant FWC Family Welfare Center FWV Family Welfare Visitor GDP Gross Domestic Product GOB Government of Bangladesh GO1 Government of India GON Government of Nepal GOP Government of Pakistan GOSL Government of Sri Lanka GOTN Government of Tamil Nadu GTZ Gesellschaft fur Technische Zusammenarbeit (German Agency for Technical Cooperation) HA Health Assistant HIV Human Immuno-deficiency Virus HLSP Health and Life Sciences Program HPSP Health and Population Sector Program ICDS Integrated Child Development Services' Program ICPD International Conference on Population and Development IDU Injecting Drug User IEC Information, Education and Communication IFA Iron Folic Acid IIPS International Institute of Population Sciences (India) IMR Infant Mortality Rate IN India IPS Institute of Policy Studies (Sri Lanka) IUCD Intra-Uterine Contraceptive Device IUD Intra-Uterine Device LBW Low Birth Weight LHV Lady Health Visitor LHW Lady Health Worker LHWP Lady Health Worker Program LLP Local Level Planning MAM Median Age at Marriage MAQ Measuring Access and Quality MCH Maternal and Child Health MDG Millennium Development Goal MICS Multiple Indicator Cluster Survey MMR Maternal Mortality Ratio M0 Medical Officer MOH Ministry of Health MOHFW Ministry of Health and Family Welfare MOHP Ministry of Health and Population MOPW Ministry of Population Welfare MPA Maternal and Perinatal Audit MPHW Multi-Purpose Health Worker MR Menstrual Regulation MSM Men who have Sex with Men MSU Mobile Service Unit MTP Medical Termination of Pregnancy MVA Manual Vacuum Aspiration NACO National AIDS Control Organization (India) NACP National AIDS Control Program (India) NAFCI National Adolescent-Friendly Clinic Initiative NFHS National Family Health Survey (India) NGO Non-Governmental Organization NHA National Health Accounts NIPORT National Institute of Population Research and Training (Bangladesh) NIPS National Institute of Population Studies (Pakistan) NNMR Neonatal Mortality Rate NP Nepal NPS National Planning Secretariat (Nepal) NRHM National Rural Health Mission (India) NSACP National Sexually-Transmitted Diseases and AIDS Control Program (SriLanka) NSS National Sample Survey (India) NSV Non-Scalpel Vasectomy OC Oral Contraceptives OPD Out Patient Department 0R Odds Ratio PAC Post Abortion Care PC Population Council PDHS Provincial Director of Health Services PFLEU Population and Family Life Education Unit PHC Primary Health Center PHI Public Health Inspector PHM Public Health Midwife PHNS Public Health Nursing Sister PID Pelvic Inflammatory Disease PIDE Pakistan Institute of Development Economics (Pakistan) PIHS Pakistan Integrated Household Survey PK Pakistan PMCT Prenatal Mother-to-Child Transmission PNC Postnatal Care POA Programme of Action (of the ICPD) PPP Public-Private Partnership PRHFPS Pakistan Reproductive Health and Family Planning Survey PRSP Poverty Reduction Strategy Paper PRI Panchayati Raj Institution (Local Government Institution) PSI Population Services International RCH Reproductive and Child Health RD Rural Dispensary RGD Register General's Department RGI Registrar General of India RHC Rural Health Center RHL Reproductive Health Library (WHO, Geneva) RMO Registered Medical Officer RTI Reproductive Tract Infection SACMO Sub-Assistant Community Medical Officer SC Scheduled Caste SHC Sub-Health Center SL Sri Lanka SMI Safe Motherhood Initiative SMP Social Marketing Pakistan ST Scheduled Tribe ST1 Sexually-Transmitted Infection SW Sex Worker TB Tuberculosis TBA Traditional Birth Attendant TFR Total Fertility Rate THC Thana Health Complex TISS Tata Institute of Social Sciences (India) TNMSC Tamil Nadu Medical Services Corporation (India) TQM Total Quality Management TT Tetanus Toxoid U5MR Under-5 Mortality Rate UHC Upazilla Health Complex UHFWC Urban Health and Family Welfare Center UNDP United Nation's Development Programme UNFPA United Nation's Population Fund UNICEF United Nation's Children's Fund vii USAID United States Agency for International Development VaRG Valley Research Group (Nepal) VDC Village Development Council/Committee VHW Village Health Worker WB World Bank WHO World Health Organization WWC Well-Woman Clinic Executive Summary WHY REPRODUCTIVE HEALTH I N SOUTH ASIA REQUIRES ATTENTION 1. Over 12 years have passed since the International Conference on Population and Development (ICPD) formulated a reproductive health agenda for the world, and about eight years remain for the Millennium Development Goals (MDGs) to be achieved. Whether poor countries will be able to improve health outcomes among women and children through comprehensive, good-quality services that are responsive to the needs of the poor is now an urgent question. South Asia has not yet focused adequate public sector attention on the interventions, quality improvements and financing arrangements needed to ensure that the women of the region - particularly the poorest - are able to achieve the good reproductive health outcomes in these global agendas. However, many countries in the region have embarked on health sector reforms. Both the opportunity of these reforms and the challenges they pose need to be met to improve the reproductive health of poor women in South Asia. 2. Among the region's 500 million poor, women are particularly disadvantaged. Its sex ratios reflect the discrimination against females from before birth to the age of 35 years. Contributing to the "missing women" are deaths that occur in pregnancy. Anemia, a condition that is relatively simply prevented or treated, is widespread among women and adolescent girls in the region. The region also has very high rates of under-nutrition, beginning with a high proportion of infants born with low birth weight because of chronic or acute under- nourishment or infections among their mothers. In South Asia about one-third of all infants are born under the acceptable weight, and the region accounts for half of all low birth weight babies in the world. Over ten percent of infants die due to this and other preventable causes. 3. Many women, from adolescents to those in their prime, are bearing unwanted children because of poor access to contraception. Many undergo abortion at great risk to their lives or health: at least four million unsafe abortions take place in South Asia, causing 10-20 percent of the region's maternal deaths. Fertility is high in the region as a whole but varies widely across and within countries. An adolescent population of 73 million girls provides momentum for continued high population growth. At the same time higher life expectancy is increasing the number of elderly. Hence South Asia's health systems are being stretched to deal simultaneously with the diseases commonly associated with poverty and a young and growing population and the chronic conditions related to old-age and affluence. These are among the many reasons why the reproductive health of the region is important and a challenge. 4. In this context the overall purpose of this review is to bring attention to the opportunities that five countries in the region - Bangladesh, India, Nepal, Pakistan and Sri Lanka - have to strengthen and expand interventions to improve the reproductive health of poor women. The report's specific objectives are: to provide an accurate picture of the current status of women's reproductive health, describe the use of reproductive health services and barriers to use, and identify the improvements required to increase their effectiveness and improve health outcomes; ' to identify individual and household characteristics that affect reproductive health status and use of services so that the most important of these can be used to assist women and households with the greatest need for care to achieve better health; to develop a simple and effective approach to decentralized health planning that can be used widely in each of the five countries to improve reproductive health service delivery and outcomes locally, and identify a body of best practices in reproductive health that can provide models and lessons for improvements in South Asia; and to strengthen the case for investing in poor women's reproductive health by demonstrating the links between poverty, inequality and reproductive health. '.Chapter 1 presents the conceptual framework and approach of the study and Annex 2 describes the methodology and indicators used in the analyses. ix REPRODUCTIVE HEALTH OUTCOMES ARE POOR AND UNEQUAL 5. A comparison of the reproductive health goals in the MDGs and current levels shows that four of the five countries (excluding Sri Lanka) face enormous challenges. Maternal mortality is two to five times higher than the targets set for 2015. Under-five mortality is 1.6 to 2.6 times higher. This is due in part to the low ages at marriage and childbearing of South Asian girls. The median ages at marriage in Bangladesh, India and Nepal are still below the legal age in these countries and, for example, in India almost twice as many of the poorest rural girls aged 15-19 years are married compared with the richest. I n urban areas this ratio is six. Adolescents in all five countries have very high fertility rates. Overall fertility is high everywhere except Sri Lanka and a handful of Indian states; and that of the poorest is almost twice that of the richest in Nepal, and still about a third higher in Sri Lanka. 6. Underlying the high child mortality of the region are high rates of under-nutrition (especially anemia) among mothers beginning in childhood. Anemia and under-nourishment are 25 percent higher among the poorest rural adolescent girls compared with the richest, and in urban areas this increases to 50 percent. Child malnutrition is appallingly high on average, and two to three times higher among the poorest quintile of children than among the richest in India, Nepal and Sri Lanka. The poor:rich ratios in infant mortality in Pakistan and child mortality in Bangladesh, India and Nepal - all between four and five - are particularly distressing. Female child mortality remains 25 to 50 percent higher than male child mortality in the last three countries. All told, the data leave little doubt that adolescents and poor women have been highly neglected by the health services in South Asia and must be the focus of attention henceforth if reproductive health goals are to be achieved. LOW USE OF SERVICES I S A SIGNIFICANT REASON 7. Sri Lanka and the Indian states of Kerala and Tamil Nadu show that better and more equitable reproductive health outcomes can be achieved in the region. Using Sri Lanka as a yardstick to assess health services, we find that coverage with family planning in the other countries falls short by 25 to 60 percent. Contraceptive use among the poorest quintile of women ranges from about 25 percent of that among the richest quintile in Pakistan to 40-50 percent in Nepal and rural India, to 75 percent in Bangladesh and urban India. Overall 'unmet need' for family planning is highest in Nepal and Pakistan (24-28 percent) but substantial even in Sri Lanka (11 percent). Among the poorest women it ranges from 23 percent higher than among the richest in Pakistan to 87 percent higher in Bangladesh, pointing to service delivery and utilization failures rather than only to 'lack of awareness' or 'desire for more children'. 8. Although the use of antenatal care (ANC) is higher than that of contraception in four of the five countries (excluding Bangladesh), the poorest quintiles of women in four countries (excluding Sri Lanka) have half to one-third as much coverage as the richest. There is virtually no difference in the coverage of poor and rich women in Sri Lanka. Elsewhere there are substantial differences even in the simplest intervention, tetanus immunization of mothers. I n Pakistan the poorest women have one-sixth the coverage of the richest, in Nepal and rural India the ratio is about half, and in Bangladesh and urban India it is about four- fifths. In all countries the number of ANC visits, their contents and quality need serious attention to contribute to better reproductive health. 9. Institutional delivery, an effective intervention to reduce maternal mortality, is under 25 percent in Nepal, Bangladesh and Pakistan; in Sri Lanka it is near universal. The rich:poor ratios for this service are striking: almost 18 in Nepal, 13 in Bangladesh; 6 in Pakistan, and 5 in rural India. Despite supportive policies and guidelines, postnatal care is highly neglected. Coverage and equity in child immunization are most disappointing given over 20 years of emphasis on "universal immunization" in the region. Compared to Sri Lanka's 94 percent, coverage in Bangladesh and Nepal is 65 percent, Pakistan 53, and India only 43 percent. Inequality is high in all countries: the poorest in Bangladesh have 72 percent the coverage of the richest; in Pakistan this is 63 percent, in urban India, 55, and in rural India 37 percent. 10. The distortions in health service coverage suggest not only that services need to be targeted to the poor but that concerted attention is needed to both the supply- and demand- side factors that cause inequalities in access, use and outcomes of reproductive health care. The determinants of outcomes and use point to the importance of other sectors in bringing about improvements. Girls' education and women's empowerment deserve special attention, and have been improved successfully in some parts of South Asia, but many gaps persist in the formulation and implementation of social policies in the region. Policies to promote the value of girls, increase the age of marriage, reduce son preference (e.g., social security), reduce gender-based violence, and increase women's autonomy are important to reduce South Asia's glaring gender inequalities and improve the reproductive health of poor women. HEALTH SERVICES NEED GREAT IMPROVEMENT 11. Indeed, low service utilization levels can be explained by prevailing demand- and supply-side barriers. Information about services is poor and awareness even of the need for certain services (such as ANC) is inadequate. Demand for services such as family planning and skilled birth attendance is low in part because of social prescriptions (e.g., to have a child soon after marriage) or proscriptions against use. Cultural norms and social attitudes prevent women from seeking health care even for problems they recognize (such as reproductive tract infections) or cause them to approach the wrong providers (such as 'quack' abortionists). Some crucial supply-side constraints to the use of public reproductive health services are: the unavailability of appropriate health facilities within distances that are physically, socially and economically acceptable for women and children; a lack of staff, particularly of female doctors and trained paramedical workers, on account of vacancies as well as absenteeism; inadequate amenities, equipment and medicines at health centers and for outreach; overcrowding and a lack of privacy at health facilities; low technical and/or managerial competence among providers and managers; inadequate provision of information and counseling; and improper behaviors among staff. 12. Superimposed on the household constraints faced by women, the structures and processes of public health services are particularly daunting for the poor, who consequently remain less covered by health care than they need or want to be. All these problems must be addressed either directly, e.g., by increasing public information, supplies, staff and facilities, or indirectly, e.g., by providing incentives to clients to use services ("demand-side financing"), to public providers to improve their behavior, quality and accountability, and/or to private practitioners to serve more poor women at a cost they can afford. 13. The ICPD Programme of Action was accepted by all the five countries. Despite this, several key aspects of the "paradigm shift" have not yet been implemented. These include instituting a "client-centered women-friendly approach" to services; integrating the essential package of reproductive health services; focusing on adolescents and sexuality; and advancing reproductive rights. There is also limited evidence of key policy and implementation changes needed to achieve country and global goals such as pro-poor actions, preventive health activities, or measures to reduce cost burdens on the poor. THE COSTS OF CARE ARE DAUNTING 14. Besides the limitations imposed by poor awareness of need and low familial permission to use health services, affordability of care is a serious constraint faced by poor women. This affects the use of private as well as public services, which have both direct (often informal) and opportunity costs. Health crises such as hospitalization are known to be major causes of indebtedness and can result in poor people falling deeper into poverty. Private reproductive health expenditure (as a share of GDP) is two to three times higher than public expenditure in Bangladesh and the Indian state of Rajasthan, while in Sri Lanka it is half.2 In Bangladesh more than half of private spending is on infant care, while in Sri Lanka other outpatient reproductive services account for most private spending. High out-of-pocket expenditure on reproductive health has grave consequences for equity and financial protection against the costs of illness. It is a strong explanation for low care among the poorest and their dreadful outcomes. Despite their greater disease burden, the poorest quintile of women accounts for 10 percent of reproductive health spending while the richest accounts for 60 percent. 15. In South Asia, reproductive health expenditures account for a mere 0.2 to 0.4percent of GDP. In Bangladesh and Nepal this spending has been largely on family planning and infant care (mostly immunization), while spending on childbirth and other reproductive health services is relatively small. By contrast, in Sri Lanka childbirth and other reproductive services for women, particularly in-patient services, make up the largest share of public spending on reproductive health. Over time all the five countries have increased their reproductive health expenditures. In Bangladesh and Nepal family planning services have received most of the increases, while in Sri Lanka the proportion of total expenditure on family planning has decreased while that on pregnancylchildbirth services and other inpatient obstetric/ gynecological care has increased. Donor contributions account for about 3 percent of reproductive health spending in Sri Lanka (primarily to family planning) but 65 percent of reproductive health spending in Nepal. Donor contributions to childbirth services appear to be insignificant across countries, which is disappointing given the importance attached to safe motherhood and the MDGs in South Asia and global commitment to achieving them. 16. Not only do South Asian governments have to increase the supply of services to the poor, but they must do so ensuring that poor women do not remain vulnerable to high formal or informal costs, direct and indirect. Resource allocations within reproductive health must redress the imbalance of services/spending, and donor contributions should be increased especially for the most needed, under-funded and costly services. WHAT NEEDS TO BE DONE AND HOW 17. Improving reproductive health in South Asia will not be easy as a number of actions are required. Many are closely related, presenting dilemmas about what should be done first; some lie outside the health sector or call for other sectors to collaborate. Nevertheless, several measures can be taken by the health sector and would produce good results if implemented well. The most important to improve poor women's health are given below. 18. First, in all five countries (including some areas and services in Sri Lanka) mechanisms to increase the supply of reproductive health services to poor women must be strengthened. This should start with those services, such as birth spacing and safe abortion, for which there is considerable 'unmet demand' among poor women. The chief approaches are to target poor geographic areas for special planning and resource allocations (at the national, state/province/etc. and decentralized levels), and the poorest villages and households for attention through local outreach mechanisms (e.g., fieldworkers, camps, mobile services, etc.) and demand-side financing (discussed further below). 19. Reproductive health services must also target adolescents (married and unmarried) as they are central to the achievement of reproductive health goals. They require information as well as services which can be provided through frontline health workers if these are given a clear mandate and training in the social and counseling skills required to access this difficult group. These interpersonal efforts must be bolstered by behavior change communication (BCC) programs through mass media, schools and community institutions. Many innovative approaches have been developed and could be supported through public grants. '. Our analysis of Indian states covered only Rajasthan,Andhra Pradesh and Kamataka. The ratio of private: public health expenditure is similar in these three states, and close to the all-India average. But the ratio varies considerably across Indian states, e.g., from 2.7 to 9 among the large states. xii 20. Second, a corollary of targeting is to enhance demand among the poor for services that are poorly understood and under-utilized, notably ANC and safe delivery. For this BCC efforts should be made relevant to poor women, and demand-side financing used to reduce cost barriers, particularly for the use of indoor services and purchase of medicines. Supply- side improvements that address the problems listed above would also enhance demand. 21. Third, all countries need to deliver the Essential Package of Reproductive Health Services in an integrated manner.3 The services that should be provided through single- window primary health facilities and workers are: maternal and child health care, nutritional prophylaxis, family planning, safe abortion, diagnosis and treatment of RTIs/STIs, all relevant counseling, and referral to emergency/surgicaI/specialized care at secondary facilities. To start with it is advisable to integrate separate departments of family planning, health, and nutrition, and develop unified policy and program guidelines. I n the field, providing clear guidelines, tools and training would help workers implement a client-centered approach efficiently, and managers should encourage and monitor performance on the basis of a continuum of care (a.k.a. "integrated targets"). Creating and disseminating the know-how for this should be a central function while implementation and management are decentralized. Integration will improve demand for and use of services. 22. Some neglected aspects of the essential package require special a t t e n t i ~ n . ~ Throughout South Asia, the availability of safe abortion services must be increased through both the public and private sectors. The public systems could increase medical abortion and vacuum aspiration facilities, and public financing could help increase the availability of private services. Providing capital grants and/or per-service subsidies (especially for poor women) through contracts, and social franchising of clinics are some promising approaches in South Asia. Simultaneously, governments must take their regulatory role in this area seriously, cracking down on unqualified providers to eliminate abortion-related mortality and morbidity. 23. Counseling to improve mother and child nutrition, anemia prophylaxis and care of the under-nourished are currently inadequate everywhere and must be enhanced by training health staff better to preventlmanage under-nutrition. They should start by focusing on poor women who are at greatest risk of bearing low birth weight infants. The health systems must take responsibility for this care because it is central to maternal and infant survival. 24. While ANC and skilled delivery receive attention and efforts to increase the availability of essential obstetric facilities continue, postnatal care needs more emphasis. Improvements in timing and quality could help to reduce maternal and neonatal mortality and morbidity. Women who deliver at home should be visited within 24 hours of delivery by a qualified female paramedic, and transport vouchers or funds provided to those who need medical attention. 25. Fourth, progress in poor women's reproductive health will depend greatly on improving the quantum and quality of outreach care by frontline women workers: they need to be readily available (i.e., in larger numbers, more efficiently deployed), more highly skilled, adequately equipped, and supplied with medicines. The critical role they play in ensuring South Asia's health must be fully recognized and rewarded as their status is reflected in their behavior toward clients. Women providers must be the focus of the 'health system fix'. REFORMS FOR REPRODUCTIVE HEALTH 26. The recommendations above: to increase the supply of reproductive health services to poor women and adolescents by specifically targeting the poorest areas and households; to enhance demand among the poor for key services using BCC and demand-side financing; to integrate reproductive health services through a client-centered approach and strengthen weak services using specific relevant approaches; and to improve the reach, quality and status '.The Essential Package is described in Annex 4. . RTVSTl services are also important and neglected, but emphasized less here because it is already on the radar screen of South Asia's health systems. ... Xlll of women providers by better training, deployment and support are the 'frontline' improve- ments required for better reproductive health among poor women in South Asia. To bring them about three significant reforms are required in the health sectors of the five countries. 27. First, particularly to improve the supply and quality of services to the poor, outcome- based planning and monitoring must be introduced/expanded. Planning actions and allocating resources should be decentralized at least to the district level in all countries, requiring higher levels to commit to flexibility in decision-making. Decentralized action planning (DAP) identifies what needs to be done and can be done locally, and measures results in repeated cycles using local data. It can improve the effectiveness of available resources by ensuring their application to priority problems and by helping service providers and managers do what works in local experience or promising examples. DAP can enhance the technical and practical knowledge of those involved as information is shared during the planning efforts. Besides improving the supply of services, it can motivate efforts to create demand and integrate services. In addition to health staff and managers, DAP can involve local government members, private providers, clients and others to ensure that public resources are used efficiently and mobilize other local resources. Good results would help attract additional public or private, local or 'transferred' resources. Decentralized and participatory planning could be the cornerstone of increased ownership and accountability in South Asia's health systems. 28. Second, the recommendations above call for robust human resource development in the five countries including attention to strategic 'womanpower' planning and to developing staff skills, motivation and performance. Some specific measures are: increasing the numbers of qualified female staff (especially doctors and paramedics) at the frontline; the important strategies to achieve this include additional recruitment, contracting in, improved allowances and support, and performance-based incentives; enhancing organization and management of integrated reproductive health service delivery through technical and managerial training and by making implementation and monitoring guidelines and good practice information available everywhere; improving attitudes and behaviors toward poor women through sensitization programs and accountability measures; and increasing accountability for health outcomes among providers and managers using performance incentives in addition to decentralized planning. 29. Third, in addition to better spending through decentralized planning and monitoring, more public finance must flow to the reproductive health sub-sector. This is necessary to ensure that pressing needs for staff, equipment, medicines, etc. in the public system are met, and that the availability of services to the poor is increased by reducing the costs to them of using private services. From an equity perspective, general revenue financing is desirable as it is a progressive source of health care financing and when combined with low user fees and universal coverage it provides high levels of financial protection against catastrophic ill-health. Promising demand-side financing options include voucher schemes to assist poor women to have institutional deliveries in the private sector, reimbursement of transport and other out- of-pocket expenses when they use public facilities, and conditional cash transfers (e.g., after completion of three ANC visits). Private resources for poor women's reproductive health can be enhanced through public-private partnerships, including social marketinglfranchising schemes, contracting out, grants or subsidies (e.g., for safe delivery or abortion facilities), and support in cash or kind to services (e.g., for adolescents in schools or communities). 30. These improvements fit squarely with the overall agenda for health sector reform in the region which includes greater responsibility to sub-national and local authorities for the delivery of essential services, improved efficiency in health spending, and the development of financing mechanisms to reduce the burden on the poor of out-of-pocket spending. As health reforms are strengthened, special attention must be paid to reproductive health. By examining outcomes, use of services and determinants, and planning and financing of reproductive health, this report seeks to contribute to constructive action to improve the health of the region's most vulnerable citizens, women in poverty. xiv Chapter 1 Reproductive Health in South Asia: Poor and Unequal Every year about 185,000 South Asian women die from causes related to pregnancy (WHO, 2004). Millions more are afflicted by illness or disability as a result of childbearing. Many suffer from anemia and under-nutrition which increase their risk of ill-health and affect the starting life chances of their infants. About 11 million infants are born low birth weight every year, 2.4 million die due to this and other preventable causes, and a high proportion of survivors suffers from malnourishment. Many women at risk of maternal death are bearing unwanted children, in part because of high child loss. A fair number are adolescents under pressure to 'prove' their fertility within a short period of marriage. Almost one-third of South Asia's 73 million 15-19 year-old girls are married. Not yet fully grown and with limited education and poor life skills, they have little knowledge or choice in the matter of childbearing. Many adult women too conceive against their wishes because they lack the appropriate knowledge, means or autonomy. Some do what their teenage counterparts find more difficult: undergo abortion. An estimated eight million abortions occur annually in South Asia, half of them unsafe. Their sequelae (such as hemorrhage or infection) are among the leading causes of maternal death. Botched abortion can also lead to infertility, a difficult condition for South Asian women because the region's culture still places a premium on childbearing. Maternal deaths, disability and excess childbearing have profound impacts on children's well-being and can impoverish families. All women who are sexually active run the risk of contracting reproductive tract or sexually- transmitted infections (RTIs/STIs) including HIV/AIDS. South Asia was a major contributor to the 340 million new cases of STIs that occurred worldwide in 1999 (WHO, 2001). Currently at least 6 million people in the region are infected with HIV. Other reproductive tract problems such as uterine prolapse, breast and cervical cancer are increasing as South Asian women live longer. AS they attain menopause, changes in their hormonal and social status result in physical and psychological stresses that require attention to ensure health and a better quality o f life. I n most of South Asia poor women fare substantially worse than rich women on almost all reproductive health indicators. Thus efforts to improve reproductive health must be targeted to them i f regional and equity goals are to be met. The importance of adolescence to establishing good reproductive health and behaviors and low starting point of adolescent girls in South Asia (inadequate awareness of sex and reproduction, poor communication with parents and other adults who could provide information, lack of access to formal structures such as schools, pressure to marry and bear children, and pervasive gender discrimination) require targeting of reproductive health efforts to both married and unmarried adolescents to meet their special needs (and large numbers). The continuum of need over the reproductive life cycle calls for care to be provided in an integrated manner using a person- centered approach. The importance of women's education and empowerment in influencing reproductive health outcomes puts a responsibility on program designers and implementers to overcome the handicaps of illiteracy and lack of autonomy, and shows that efforts in these areas could contribute to improving reproductive health. 1.1 WHY FOCUS ON REPRODUCTIVE HEALTH I N SOUTH ASIA? 1.1 Among the world's regions, South Asia has the largest number of poor - an estimated 500 million (World Bank, 2005).' This mass of poverty cannot be reduced substantially without serious, systematic and effective attention to the region's reproductive health. Why? Poor reproductive health increases the risk of individual and family impoverishment through health crises, maternal and child deaths, and excess fertility; and poverty in turn engenders serious reproductive health problems, setting up a vicious cycle. Reproductive ill-health contributes significantly to the morbidity, mortality and fertility burdens that undermine economic growth, especially in low-income countries. Box 1.1 Reproductive Health and Rights 1.2 Several recent trends make an assessment of reproductive health in South Asia invaluable at this juncture. First, as over 12 years have passed since the International Conference on Population and Development (ICPD) at Cairo, it is time to review South Asia's progress in implementing the reproductive health agenda. How well have the five countries that are the focus of this report - Bangladesh, India, Nepal, Pakistan and Sri Lanka - implemented the recommendations of the ICPD Programme of Action (POA)? An examination of current reproductive health status in the countries and of their services will reveal both their achievements and the obstacles they face. 1.3 Second, while they do not cover reproductive health fully, the Millennium Development Goals (MDGs) drawn up by the international community in 2000 include some specific new reproductive health targets. The region is important for the achievement of the poverty and health goals because of its large population (about 22 percent of the world's total), high maternal and child mortality rates, and widespread communicable diseases. Although all the five countries have progressed since 1990, improvements have been variable across countries and indicators (Figure 1.1).~ Only a few years remain to 2015 and unless efforts are '.See Annex 1 Table Al.l for details. '. While the ICPD set a direction for reproductive health, the MDGs provide specific targets. Between 1990 and 2015 it is expected that under-five mortality rates would be brought down by two-thirds, and maternal mortality ratios would be reduced by three- quarters. The spread of HIVIAIDS is to be stopped and reversed. Progress in achieving the goals is to be monitored on the basis of the proportion of deliveries attended by trained health personnel, contraceptive prevalence, and H N prevalence among adults (15-49 years). The specific data are given in Annex 1 Table A1.2. accelerated both local and global goals will not be reached. Fortunately, there is substantial evidence that reproductive health can be improved, and the governments of South Asia and international donors are committed to doing so. Figure 1.1 Current Reproductive Health Levelsand Goals for the Five Countries of South Asia MaternalMortality Ratio Under-5 Mortality Rate (Deaths per 100,000) (Deaths per 1,000) I I I ( Bangbdesh India Mpai RWltan liLanka Bangbdesh hdii NpaI Rkhtan Sri Lanka I I I I Note: The graphs above are based on modeled estimates provided in WHO (2004) which facilitate comparisons across the five countries. The 2006 N e ~ aDHS has ~rovidednew estimates of the MMRs for N e ~ ain l l 1995 (539) and 2000 (470) and a revised goal for 2015 (213) based on'the estimated 1988 (rather than 1990) level (GON-MOHP, 2007). It also ;eports aU S M R O65 ~ in 2006. 1.4 A third trend that predates the other two has increased in importance more recently in South Asia. Health sector reforms began hesitantly in some parts of the Subcontinent in the 1990s and are now picking up momentum. A review within their context will show how reproductive health care could be improved over the next ten years to meet South Asia's challenges. 1.2 HOW THIS REVIEW WAS DONE 1.5 The purpose of this review is to assist its five 'focus' countries to strengthen and expand interventions to improve the reproductive health of their poor women. It does so by: a providing a picture of the current status of women's reproductive health in each country and demonstrating the links between poverty, inequality and women's health; describing the use and quality of reproductive health services and barriers to use and supply, and identifying the improvements required; identifying the household and individual characteristics that affect reproductive health status and use of services so that the most important of these can be used to target women and households with the greatest need for reproductive health care; a presenting a simple and effective method for decentralized action planning that can be used widely in the region to improve reproductive health services and outcomes; . identifying some promising practices that provide models and lessons for improvement of reproductive health in South Asia; and a discussing reproductive health spending and financing options in order to strengthen the case for investing in poor women's reproductive health. 1.2.1 Our Analytical Framework 1.6 Reproductive health outcomes are the result of individual, household and community factors, health system factors, and other governmental and macro-economic factors (Figure 1.2). Health sector policies and regulatory mechanisms along with the financing they cause influence service provision in both the public and private spheres. Household use of health services depends on the resulting availability, price and quality of services, and on household resources and community characteristics. Household resources (obtained and consumed) are influenced by macro-economic and other sectoral policies, and the supply of goods such as food, water, transport, employment and so on. Individual factors come into play not only in affecting use of health services but, importantly, in producing desired health outcomes. The methodology and indicators used in the study are given in Annex 2. Figure 1.2 A Conceptual Framework: Factors Influencing Reproductive Health Outcomes 0 a Areas of Areas e x a r n m Background v a r w Outside the scope of study Source: Adapted from Claeson et al. (2001) 1.7 Improved reproductive health can be brought about by a favorable interaction of these factors: policies, services, household resources, community institutions, and individual charac- teristics. These factors and their interactions are examined in this study, while others (for example, policies and services in sectors such as water supply or transport) are acknowledged to be important but are outside its scope.3 The focus on health services is based on the hypothesis that they have an important proximal role in improving reproductive health, and on the pragmatic consideration that the health sector is not meeting its potential to improve reproductive health in any of the countries under study, thus offering opportunities for action. 1.2.2 A Life-Cycle Approach to Reproductive Health 1.8 Reproductive health problems and solutions vary at different stages of the life cycle. As reproductive concerns begin earnestly in adolescence, this stage is considered first.4 How ready, physically and psychologically, are South Asian adolescents for sex and reproduction? What do they know of these matters? What about their sexual behavior or practice of contraception? I n South Asia, adolescent marriage and childbearing are widespread. What delays marriage, sex or pregnancy? Do adolescents have access to services? Do they use them? These are some issues discussed for this life-cycle group. 1.9 Most reproductive matters that arise in adolescence continue into maturity. What are the reproductive strategies and outcomes of sexually-active adults? Analysis of the reproductive health of adult women, including their wanted and unwanted fertility, practice of family planning, 'unmet need' for contraception, abortion, and reproductive morbidity (RTIs, STIs and HIVIAIDS) provides a fuller picture of sexual and reproductive health in South Asia. 1.10 Every year about 15 percent of South Asian women of reproductive age become pregnant and about 12 percent have a live birth. During this 'maternal stage' of the life cycle, the focus is on women's nutritional status, use of antenatal care, delivery practices, postnatal and infant care, and outcomes for mothers and children. The last stage of the reproductive life cycle concerns the winding-down of reproductive capability. Health problems related to menopause, conditions such as uterine prolapse and diseases such as breast and cervical cancers are important during this period. 1.2.3 How This Report I s Organized 1.11 This report discusses the conceptual framework from right to left! I n the rest of Chapter 1below it presents reproductive health outcomes and their associated individual and household characteristics. It then examines the use and provision of health services, and constraints to these (Chapter 2). These two chapters focus on 'what" needs to be done to improve reproductive health, while the remaining chapters turn to the "how" of doing so. Chapter 3 describes how improvements can be made in health services through decentralized action planning and use of promising practices from around the world, and Chapter 4 discusses how financing can be increased and improved. The final chapter (5) positions the improvement of reproductive health care within health sector reform in South Asia. 1.3 THE SOUTH ASIAN CONTEXT 1.12 South Asian societies and demography have several special features that are critical to reproductive health outcomes. They include: a large population with sizeable cohorts of reproductive-age women and young people; continued high population growth, albeit with significant variations across the Subcontinent; high poverty and widespread inequality in all but a few areas; 'masculine' sex ratios in most parts that speak of the low status of women, which is also borne out by low female literacy, employment and empowerment; and wide regional variations in almost every parameter. 1.13 The five countries had a total estimated population of 1,362 million in 2001 - over '. Where the data permit, the impact of other sectors (e.g., education) on reproductive health outcomes, use of services, etc. is pointed out. In addition, experiences in other sectors that have succeeded in improving reproductive health are discussed, especially in the section on 'promising practices'. 4. Although women's reproductive health is in fact determined earlier (as nutrition and health in childhood have a bearing on physical growth), this issue is discussed in the maternal and child stage. one-fifth the world's total (Table 1.2). Together they account for 98 percent of South Asia's popu~ation.~Women of reproductive age (15-49 years) account for 23-27 percent of the country populations, while adolescents constitute one-fifth. People over 60 account for 10 percent of Sri Lanka's population and are expected to reach 25 percent by 2030. I n India 8 percent and in the other three countries 5-6 percent of the population is above this age. 1.14 One of the most unusual features of South Asia's population is the masculine sex ratio.6 I n the region, Sri Lanka and Nepal have female-favorable sex ratios, suggesting a better status of women.' India's ratio hides considerable geographic and social variations. I n general, the North and West of the country have a greater bias against females than the South and East. Variations at the state level - from 861 to 1,058 - are related more to culture and social practices than to economic levels.' The sex ratios of Pakistan and Bangladesh are similar to those of the adjoining areas of India. All told there are about 50 million "missing" women in South Asia. Except in Sri Lanka, female mortality is considerably higher than that of males up to the age of 30 or 35 years, especially in the first five years of life. The male- female gaps in life expectancy in Nepal: six months lower for women, and Sri Lanka: 5.7 years higher for women, illustrate the need and potential to improve women's health in South Asia. Table 1.2 Demographic Indicators for the Five South Asian Countries, various years. Bangladesh: NIPORT et al., 2003; GOB-BBS, 2001; India: IIPS and ORC Macro, 2000; GOI-RGI, 2001; &I-RGI,-2004; GOI- MOF, 2001; Nepal: GON-MOH et al., 2002; GON-MOF, 2003; GON-CBS, 2003; Pakistan: NIPS, 2001; GOP-FBS, 2003; GOP- PCO, 2001; GOP-MOF, 2003; SriLanka: GOSL-DCS, 2002a; GOSL-DCS, 2002b; GOSL-FHB, 2001; GOSL-DHS, 2001. Note: New data are available for Nepal from the 2006 DHS. They show a CBR of 28.4 and IMR of 51. The Poverty Head Count Ratio was 31 percent. 1.15 An important indicator of poverty and women's status, female literacy is dismally low in the region. Almost two-thirds of Nepalese and Pakistani women are unable to read and write. I n Sri Lanka, on the other hand, more than 80 percent of women are literate. Poverty is both widespread and deep - between one-quarter and two-fifths of people in each country The remaining 2 percent live in Afghanistan, Bhutan and the Maldives. 6.While the sex ratio in most parts of the world is expressed as the number of males per 1000 females, India and other parts of South Asia report the number of females per 1000 males. '.Nepal's sex ratio may reflect some under-counting of males in the 2001 Census due to the on-going ethnic conflict and considerable male out-migration in recent decades, as life expectancy, mortality rates and other indicators are still unfavorable to women. '.The states of Kerala and Goa have feminine sex ratios and are much like Sri Lanka in terms of their spatial, social and cultural characteristics. They are also the most advanced areas of India in terms of health and demographic transitions. spend below a dollar-a-day. Inequality illustrated by the small share in national consumption of the poorest quintiles of the populations of each country (around 8 percent). All the countries have experienced moderate growth in GDP in the recent past except Nepal which has the lowest per capita GDP. I n Pakistan and India, which have seen moderate levels of economic growth over the past decade, economic inequalities are believed to have widened. These issues have a bearing on health service development and financing and, critically, on the access of the poor to health care. 1.16 Comparing the five countries requires attention to their vast differences in size: India's population is about seven times those of Bangladesh and Pakistan, which in turn are seven times larger than Nepal and Sri ~ a n k a !Comparisons are worthwhile because of the shared ~ cultures, economic conditions and histories of the countries, including similarities in the development of their health policies and services, and the potential for learning - even from differences. Among these differences are variations in how health policies are made, financed and implemented sub-nationally.1° 1.17 There are also important differences within each country which are concealed by its national averages. Although all five countries have advanced significantly in reproductive health over the past several decades, progress has been spatially and socially uneven. Socio- economic differentials in reproductive health are a key focus of this report. Spatial differences are clearly also critical - and are the reason for the reports key recommendation - that decentralized action planning is the way to improve reproductive health. The other recommendations also need to be fine-tuned to different sub-units. Both intra-national and cross-national learning are important and made interesting by the spatial variations across the Subcontinent. For example, India borders on all the other countries and its contiguous areas "behave" like the neighboring country (e.g., Kerala and Tamil Nadu like Sri Lanka; Bihar and parts of Uttar Pradesh like Nepal; Indian Punjab like Pakistan Punjab; and so on). There is much to exchange between neighbors. 1.4 ADOLESCENT REPRODUCTIVE HEALTH 1.18 Almost one-quarter of the world's adolescents and youth, about 420 million, live in the five countries of South Asia. Approximately two of every ten people in the region are aged between 10 and 19 years, and another one is between 20 and 24 years (Annex 3 Table A3.1). In the absence of dramatic changes in fertility, mortality or migration, ten-year cohorts of adolescents or youth will continue to constitute over a fifth of the population of the region at least up to 2021. Their numbers - large and growing due to past high fertility - underlie the population momentum that the region will experience in the first half of the 21Stcentury. To address both fertility and mortality challenges it is essential to address the reproductive health needs of adolescents. To do so for such large numbers will place increasing pressures on health services henceforth. 1.19 In South Asia, many girls are subordinated and subjected to discrimination within their families and communities - a process that begins in childhood. This is manifest in their poorer health and nutritional status compared with boys, lack of education and information, heavy domestic work burdens and constrained mobility - all of which have a bearing on their reproductive health at this stage as well as later in the life cycle. The practices of seclusion and purdah, which limit girls spatially and in social interactions, usually begin during puberty and have a serious impact on schooling. While educational attainments are high in Sri Lanka, and rising in the other four countries, gender gaps in schooling indicators are commonly about 20 percent. For example, in India 86.7 percent of boys in the 15-19 year age-group are literate compared to 62.4 percent of girls. 9. Several states of India and provinces of Pakistan are larger than Nepal and Sri Lanka as a whole. There are significant geographic differences within countries on many reproductive health indicators but space limitations constrain analyses of these in this report. 10. For example, states in India and provinces in Pakistan have important roles in decision-making and financing of health care, while the sub-national units of Sri Lanka, Nepal and Bangladesh have lower levels of 'autonomy'. 1.20 The low economic value of women due to their involvement predominantly in traditional work and unpaid domestic labor, and the practice of dowry that prevails in South Asia, fuels a vicious cycle of low investment in girls, early marriage and childbearing, and low access to resources and power. The subordinate position of women also exposes them to violence, including sexual abuse and violence within and outside the family. As in most matters concerning sex and reproduction, secrecy shrouds the issue of gender-based violence, so that its actual extent is largely unknown. 1.4.1 Reproductive Knowledgeand Sexual Behavior 1.21 In addition to the physical development that adolescents experience, they undergo emotional and psychological changes related to the development of sexuality and sexual behavior. As a consequence they are exposed to a wide range of sexual and reproductive health risks. Both sexes are vulnerable, but in South Asia girls face greater risks than boys. 1.22 Although there is a paucity of information in the region on sexual debut and behavior (whether marital or premarital) on account of the conservative attitudes that prevail (even among the young themselves), the vast majority of girls in South Asia begin sexual activity during adolescence, often within the context of marriage. Only a small proportion reports premarital sex, e.g., below 10 percent in India compared to about one-quarter to one-third of boys (Jejeebhoy, 2000).11 Sexual encounters are most often unplanned and unsafe. Young men and women in low-income urban areas appear particularly vulnerable to sexual coercion, including physical force. While young girls tend to report a casual encounter or a steady partner, young men have multiple casual partners and almost always fail to use a condom. 1.23 There is increasing openness about sex and reproduction among the youth of South Asia thanks largely to the spread of television and other media in the past two decades. In Pakistan almost 60 percent of adolescents had some awareness of reproductive health, including information about puberty, childbirth and pregnancy-related problems (NIPS, 2002). However, they also had many misconceptions, for example, about the fertile period during the menstrual cycle and about causes of infection. Underlying these was a lack of communication with parents and other responsible adults, e.g., only one-third of mothers had discussed puberty with their daughters. Reproductive health is not discussed in most families, and sex education is hardly provided in schools. The majority of adolescents felt that there was great need for reproductive health education, and that the most appropriate age for this was between 14 and 17 years, when most children should be (but in South Asia are not) in school. 1.24 The inadequacy of information about sexual and reproductive health is exacerbated by a lack of services for adolescents, particularly the unmarried. Girls are particularly disadvantaged because their access to formal institutions such as schools and health facilities is constrained. As a result, they frequently experience reproductive health problems, including unplanned pregnancies and HIV/AIDS. Even adolescents whose sexual and reproductive health needs are different and 'legitimized' by marriage have inadequate access to services as their youth limits their autonomy to make decisions and move around freely. 1.25 Adolescents are, of course, a heterogeneous group, but while their situations vary markedly across and within the five countries, their needs are poorly served almost everywhere. Girls require emotional support and assurance that menstruation is normal and healthy, along with information that sex thereafter can lead to pregnancy or infections. They need information about sex, sexuality, and reproduction. Mothers are important communicators of these subjects, but are themselves in need of empowerment to carry out this role. Involving men in reproductive health must begin in adolescence when socialization determines sexual behaviors, gender ideologies, and social and familial roles. Schools, health services and other institutions need to provide information to young people in culturally- appropriate and effective ways to improve sexual behaviors and gender relations. ' I . Higher rates are reported in Sri Lanka and Nepal. 1.4.2 Reproductive Infections 1.26 A lack of knowledge about sexually-transmitted infections (STIs) and low use of condoms expose young men and women to reproductive tract infections (RTIs), STIs and HIV/AIDS. For example, in Nepal, about 22 percent of sexually-active young men said they were suffering from a STI, and a further 23 percent were not sure if they had an infection or not (UNICEF/UNAIDS, 2001). Among sexually-active girls, 13 percent had suffered from an ST1 at least once, and a further 16 percent were not sure. While inadequate knowledge of RTIsISTIs may lead to over-reporting of symptoms in studies and surveys, even when women know they have a problem, they do not seek health care. For example, in Tamil Nadu, India, while 49 percent of young married women in a few communities experienced symptoms, and clinical and laboratory examinations diagnosed an ST1 in 18 percent, only 9 percent sought care because of 'shyness' and expectations that the condition would simply go away (Joseph et al., 2003). Awareness of STIs does not lead to care even in Sri Lanka where services are relatively accessible. Only five to six percent of people attending STD clinics in Sri Lanka are adolescents, a low proportion as many needy adolescents fear being 'found out' by their parents and do not seek care (Goonewardene, 2002). 1.27 Knowledge of HIVIAIDS appears to be relatively better. About 95 percent of adolescents in Nepal are aware of HIV/AIDS, and know its modes of transmission (VaRG, 1999). In India, 60 percent of urban and 54 percent of rural 15-19 year-old boys could identify two ways to prevent HIV infection (NACO and UNICEF, 2002). However, only 30 percent of urban and 22 percent of rural boys had correct information on how HIV is transmitted, and the proportion of girls with this knowledge was much lower. Awareness that STIs increase the risk of HIV infection was limited to 21 percent of young men and 18 percent of young women. There is evidence from India that young women (15-24 year-olds) have a higher rate of HIV infection (0.96 percent) than young men (0.46 percent) and adults in general (0.8 percent) (UNICEF/UNAIDS/WHO, 2002). Both a feminization and declining age of HIV infection appear to be occurring. 1.4.3 Early Marriage and Childbearing 1.28 Marriage is almost universal throughout South Asia and early marriage continues to be the norm, especially among girls, leading to early sexual activity and exposure to pregnancy and infections, with their attendant consequences. Over the past 25 years, there has been only a marginal increase in the age at marriage in Nepal and Bangladesh, and in India the median age has increased only from 15.8 to 18.0 years. At present in these countries, one- third to one-half of adolescent girls are married. Most women in the 25-49 year age-group were married by the age of 16, two years below the legal age (Annex 3 Table A3.2). The median ages at marriage are higher in Pakistan (18 years) and Sri Lanka (23 years). Despite a recent increase in Pakistan, however, adolescent marriages are still prevalent among girls, particularly in rural areas, and are strongly associated inversely with education (Population Council, 2003). Among 20-24 year-old women, 68 percent of the illiterate were married by the age of 20 compared to 13 percent of those with ten or more years of education. 1.29 In India there is considerable variation across states, communities, castes and economic strata in the age at marriage. On average, urban women marry almost two years later than rural women. Within urban or rural areas, women from the richest quintile marry two to three years later than those from the poorest quintile. Women belonging to the Scheduled Castes or Scheduled Tribes (SCIST) have the lowest mean age at marriage among social groups whether rural or urban (15.98 years and 17.04 years, respectively) (IIPS and ORC Macro, 2000). To increase the age at marriage, awareness generation, school enrolment and retention, and employment generation efforts must be directed specifically to these groups. Countries such as the Republic of Korea, Taiwan and Thailand have demonstrated the impacts of girls' schooling and employment on delaying age at marriage, and in the region these have been seen in Sri Lanka and more recently in Bangladesh (Malhotra and Tsui, 1996; Amin and Gilda, 1998; Amin et al., 1998; Arends-Kuenning and Amin, 2000). 1.30 Sri Lanka's high age at marriage is very positive from the point of view of adolescent growth, education, and maternal and child health outcomes. However, the unmarried who are sexually active are highly vulnerable to the health and social risks of STIs, including HIV/AIDS, unwanted pregnancy and unsafe abortion. These problems need to be addressed among adolescents in Sri Lanka, as elsewhere. 1.31 Early marriage is virtually synonymous with early childbearing in the South Asian context. In Bangladesh, India and Nepal, half to two-thirds of married women have either had a child already or are pregnant by the age of 19. Too early these births account for one-fifth of all in India. Even in lower fertility states such as Andhra Pradesh and Karnataka, a high proportion of all births occurs early (25 and 15 percent, respectively). I n high fertility states such as Bihar and Rajasthan, the proportion is about 9 percent (Sharma, 2003). This information suggests that early childbearing persists during fertility decline while births among older women and higher order births are reduced due in large part to the lack of emphasis on delaying and spacing in favor of terminal contraception in India. So, even in low-fertility areas, greater attention is needed to adolescents to reduce their exposure to pregnancy and its sequelae. Births among adolescents can be reduced by delaying marriage or pregnancy through increased awareness and promotion of spacing contraceptives. 1.32 Adolescent fertility rates among in Bangladesh (134), India (107) and Nepal (110) were more than four times that of Sri Lanka (27) (in 1995-2000; GOSL-DCS, 2002b). However, the majority of adolescent pregnancies in Sri Lanka are unwanted (more in urban than rural areas) as pregnancy out of wedlock remains culturally unacceptable. Hence, a large number of adolescent pregnancies result in unsafe abortions and post-abortion complications (Soysa, 2000; UNICEF, 2001a). A meta-analysis of 27 urban hospital-based studies found that girls under 20 accounted for approximately 69 percent of women with abortion-related complications (Attapattu, 2000). As discussed, the young are severely constrained in their access to services, whether for contraception, abortion or pregnancy care (Chapter 2). Their multiple handicaps need to be addressed through integrated services aimed squarely at them. 1.4.4 Nutritional Status of Adolescents 1.33 Adolescent girls are at high risk of simultaneous nutritional deficiency of iron, vitamins and energy which adversely affects their reproductive health and outcomes. Over half of all 15-19 year-old mothers in India, and one-third even in Sri Lanka, are anemic (IIPS and ORC Macro, 2000; USAID/OMNI, 2000). Anemia is almost as prevalent among adolescents as among all reproductive women, suggesting that it sets in early in reproductive life, as iron intakes fail to keep pace with increased requirements after menarche (Table 1.3). 1.34 In Nepal, about one-fourth of adolescent women are underweight (BMIc18.5 kg/m2), and in India the proportion is even higher (42 percent). There are also important differences between the richest and poorest quintiles (Table 1.3). About one-fifth of girls also suffer from vitamin A deficiency. Iodine deficiency also occurs in this age-group - in some of Sri Lanka's south-central districts over 20 percent of girls suffer from goiter. Table 1.3 Nutritional Status of 15-19 year-old Mothers, India, 1998-99, percent 1.35 Bearing children in poor nutritional condition further depletes women's bodies, with far-reaching consequences for women and children's health. Maternal anemia and under- nutrition are associated with a high incidence of fetal wastage, have a negative impact on the growth and development of the fetus (increasing the proportion of infants born underweight), and reduce infant survival. The second Indian National Family Health Survey (NFHS-2) established that neonatal mortality was three times higher among adolescent mothers (63) than among 20-29 year-old mothers (21) (IIPS and ORC Macro, 2000). 1.36 A cohort of young women will have a larger number of pregnancies (than more mature, healthy women) to produce children that survive. Frequent pregnancies erode women's health and increase their risk of maternal death. A rural community-based study in India found that adolescents had twice the maternal mortality ratio of women (25-39 year- old). Additional negative consequences for mothers include permanent damage to the reproductive tract which can render them infertile or cause chronic ill-health. Teenage pregnancies also carry a higher risk of cervical cancer later in life (Goonewardene, 2002). 1.37 I n addition to youth, poverty is an important determinant of adolescent reproductive health - poor young women have gender, age and socio-economic status against them. They have the least access to household health goods and services of all age-and-sex groups, and circumscribed mobility and interactions with formal structures such as health services. These result in poor nutrition and growth, low levels of education and poor reproductive health awareness, behaviors and outcomes. They are inducted early into 'maternal behaviors' as they are often the main care-givers to younger siblings, and they marry and bear children early themselves. The sex, infections, pregnancies, child births and deaths they experience often leave lasting physical and psychological effects. Prevention is better than cure. 1.5 SEXUALLY-ACTIVE ADULTS 1.38 Fertility and RTIs/STIs (including HIV/AIDs) also take a heavy toll on the health of sexually-active reproductive-age women in South Asia as discussed below. 1.5.1 Fertility 1.39 Fertility is high in South Asia where women's 'value' continues to be associated with childbearing. Among the five countries fertility in 2000/2001 was highest in Pakistan (Total Fertility Rate=4.1) and Nepal (4.1; by 2006 this had declined to 3.1) followed by Bangladesh (3.2) and India (2.8), and lowest in Sri Lanka (1.9) (Annex 3 Table A3.3). However, fertility is declining in many areas as desired fertility is significantly lower than the prevailing TFRs (except in Sri Lanka). For example, in Bangladesh, desired family size is 2.2 while total fertility is 3.3. India, Nepal and Pakistan experienced fairly significant declines in fertility during the 1990s, Sri Lanka a somewhat smaller decline at its already low level, and Bangladesh a very slight decline. A few states of India such as Kerala, Goa and Tamil Nadu have already achieved replacement level fertility or are close to attaining it. However, five states that account for nearly 40 percent of the country's population (Bihar, Uttar Pradesh, Madhya Pradesh, Rajasthan and Orissa) will contribute well over 50 percent of its population increase during the next decade. 1.40 Figure 1.3 shows the age-specific fertility rates of the five countries at the end of the 1990s. During that decade fertility declined among all age-groups in all the countries. In Bangladesh, it fell most among women over 30 years of age, while in Pakistan an impressive decline occurred among 15-24 year-olds due to increased schooling among girls and changes in social awareness and norms. I n India, by contrast, fertility declined more dramatically among women over 20 than among 15-19 year-olds. The ASFRs reported by the 2006 DHS in Nepal show substantial declines in fertility among women over 25-29 years during the five year period from 2001 to 2006. Nepal's 'new' curve lies between those of Bagladesh and India in the figure. The fertility of women over 40 years of age is significantly higher in Pakistan than in the other countries. 1.41 Most of the socio-economic differentials in fertility in the five countries are 'expected' - with a few surprises (Annex 3 Table A3.4). Education and economic status have negative influences on the total fertility rate (Figure 1.4).12 In Bangladesh, Pakistan and Sri Lanka, the TFR of women with secondary schooling or more is about one-third lower than that of illiterate women, and the difference between these two groups is more significant in Nepal (56 percent). However, even the richest and most educated groups in Bangladesh and Pakistan have fertility well above replacement level. In four countries (barring Sri Lanka), rural women have TFRs one to two points higher than urban women. In Sri Lanka, only the estate sector has not been able to achieve replacement fertility level (TFR 2.4). These differences show the importance of targeting family planning services geographically and socio-economically. Figure 1.3 Age-Specific Fertility Rates, Five Countries in South Asia Sources: Bangladesh: NIPORT, 2001; India: IlPS and ORC Macro, 2000; Nepal: GON-MOH et al., 2002; Pakistan: NIPS, 2001; Sri Lanka: GOSL-DCS, 2002a. 1.42 In several parts of the Subcontinent, notably India and Nepal, the strong preference for sons over daughters has an impact on fertility.13 In their effort to bear sons, many couples continue to have children even after achieving their desired family size. I f son preference were eliminated India's fertility would decline by 8 percent (Mutharayappa et. al., 1997). Figure 1.4 Total Fertility Rate and Maternal Educationand EconomicStatust4 1 I 1 Maternal Education EconomicQuintile I 1 Bangladesh hd'i p a Pakistan SriMe Bangladesh hdii Nepal Pakistan Sri Lanka a None a Upto 5years 6-9years 10+years b r e s t Second m Third Fourth Rchest IZ.The TFR in India varies among Scheduled Castes (3.2), Scheduled Tribes (3.1) and those not belonging to these groups (2.7), and by religion: Christians (2.4), Hindus (2.8)and Muslims (3.6). However, these differences encompass variations within these groups in education and economic status. 13.See also the sections on the Contraceptive Prevalence Rate and unmet need. 14. For India, the economic categories in the TFR analysis are low, medium, and high income-groups, not quintiles 1.5.2 RTIs, STIs and HIV/AIDS 1.43 Given socio-cultural sensitivities in South Asia, RTIs, STIs and HIVIAIDS are most likely under-reported. Treatment of these infections has been neglected almost everywhere, so service statistics also are inadequate. Only a few small-scale studies provide information on the prevalence of these infections in the five countries. 1.44 I n a rural thana of Bangladesh, 56 percent of married women were suffering from an RTI and 13 percent had confirmed STIs (Hussain et al., 1996). Among women seeking care for abnormal vaginal discharge, there was a 30 percent prevalence of endogenous infections (Hawkes et al., 1999). Among young married women in 13 South Indian villages, 53 percent had at least one symptom suggestive of an RTI (Joseph et al., 2003). However, in four states 13 percent of men (aged 20-54 years) and 30 percent of currently-married women (aged 15- 44 years) suffered from a symptom of an RTI or ST1 in the three months preceding the survey (IIPS, 2002). The prevalence of RTIs is higher in rural areas and among illiterate women (IIPS and ORC Macro, 2000). I n general these infections affect one-third to one-half of women and their prevalence is about one-third higher among poorer women than better-off ones.'' Box 1.2 The Importance of Being Fertile 1.45 The Prevalence of HIV-AIDS. Over the past decade or so, there has been an increase in the collection of data on HIVIAIDS. However, it is likely that the infection is still under-estimated given the difficulties of measurement, under-reporting, and limited surveillance systems in the region. The serious nature of HIVIAIDS and the heterogeneity of 15.Studies on RTVSTI prevalence in Nepal, Sri Lanka and Pakistan are limited. Ministry of Health figures in Nepal suggest that the ST1 prevalence rate is approximately4.7 percent (GON-MOH, 2003). In Sri Lanka in 2002 there were about as many men as women with STIs registered at governmentclinics,but it was estimated that only 10-15 percentof ST1 cases presented at these clinics. the epidemic call for more active assessment of its incidence and prevalence throughout the region. 1.46 The National AIDS Control Organization (NACO) in India measures the prevalence of AIDS at about 659 sites across the country. The official estimate of HIV infections in India was around 5.2 million in 2004. Overall prevalence is low at 0.91 percent. However, seven states - Maharashtra, Karnataka, Goa, Andhra Pradesh, Manipur, Mizoram and Nagaland - have high prevalence: over 1percent among women seeking antenatal care (NACO, 2005).16 Prevalence in these states is five times higher than in the rest of India. About 50 districts with 10 percent of India's population have 50 percent of all HIV infections. This concentration points to the potential efficiency of a geographically-targeted response. 1.47 In the region, the prevalence of HIV in the adult population is lowest in Pakistan and Sri Lanka (0.06 percent) followed by Bangladesh (0.3 percent) and Nepal (0.5 percent) (UNAIDS, 2004). Overall, South Asia has a prevalence of 0.4 percent, and in most parts the epidemic remains concentrated among vulnerable groups. In Bangladesh, although syphilis rates were high among HRGs in 2002 (e.g., 40 percent among brothel-based female sex workers (FSWs), 11percent among injecting drug users (IDUs)), HIV rates were less than one percent except among IDUs (4.0 percent). Male circumcision in Bangladesh and Pakistan is among the reasons for low prevalence of HIVIAIDS. Injecting drug use is thought to ignite transmission in these two countries and in the Northeast region of India, while in the rest of India transmission is largely fueled by sex work (Wilson, 2005). Intensive focus on IDUs and FSWs in these areas could contain further transmission significantly. 1.48 I n Nepal FSWs and IDUs are responsible for a significant proportion of HIV transmission (UNICEF, 2002). The prevalence rate among IDUs rose dramatically in the 1990s to about 50 percent, and is currently 67 percent in the Kathmandu Valley. The majority of IDUs are in their early 20s and have risky sexual behavior (CREHPA and FHI, 2003; New Era, 2003; CREHPA and FHI, 2002). Sex workers in Kathmandu are estimated to have a prevalence rate of 15.7 percent. The prevalence of STIs and HIV is higher among FSWs who have returned from India (about 40 percent) and especially among those returning from Mumbai (71 percent) (GON-MOH, 2003). About 40 percent of Nepal's epidemic is linked to such migration (Wilson, 2005). Risky behavior and its consequences are also high among truckers and other migrants (CREHPA and FHI, 2002; GON-MOH, 2003; UNICEF, 2002). 1.49 Over the past ten years, HIV prevalence has climbed to 8 percent among high-risk groups in Sri Lanka (NSACP, 2002). In Colombo district two-thirds to four-fifths of those in four high-risk groups (FSWs, their clients, men who have sex with men (MSM) and female migrant workers) were under 35 years, and nearly half of MSM were 15-24 year-olds, indicating the high vulnerability of youth (Saravanapavananthan, 2002). Consistent condom use was only 38 percent among FSWs and 19 percent among clients. 1.50 Separate data are not available on the poor, but 60 percent of HIV infections in India are in rural areas. I n both rural and urban areas, many people among the high-risk groups are poor. The inability of poor and powerless women and youth to negotiate the use of protective measures during sex makes them exceedingly vulnerable. 1.51 Knowledge and Awareness of RTIs, STIs and HIV/AIDS. Systematic information on people's knowledge of RTIs, STIs or HIVIAIDS is not available for the five countries, but such studies as exist suggest that awareness is much lower among women than men. In India and Nepal in 2000, only half of women surveyed were aware of HIVIAIDS compared to two-thirds of men. Knowledge of RTIsISTIs was even lower (NACO and UNICEF, 2002; GON-MOH et al., 2002). Two-fifths of Nepali women and two-thirds of men believed that AIDS could be avoided. In Pakistan, 42 percent of ever-married women had heard of HIVIAIDS, while in Sri Lanka 79 to 93 percent had (NIPS, 2001; GOSL-DCS, 2002a). 16.Tamil Nadu was earlier a high prevalence state but this has reduced, e.g., among ANC cases from 1.13 percent in 2001 to 0.75 percent in 2003. Among MSM, prevalence was 4 percent in 2000 and 0 in 2003. The state has also focussed on STIs and has reduced these from over 16percent in 2000 to 9 percent in 2003 (NACO, 2005). 14 Although awareness had increased in Nepal by 2006 (to 73 percent among women and 89 percent among men), the gender gap persists, and levels of awareness vary with education. Awareness is severely limited among poor and illiterate women. I n Pakistan, for example, only about one-fourth of women with no education were aware of AIDS compared to 98 percent of college-educated women. In Nepal and India there is great variation in awareness across geographic areas. 1.52 Among high-risk groups, knowledge is below 10 percent in Bangladesh. Knowledge of correct preventive methods was found to be 55 percent among women and 75 among men high in Nepal in 2006. However, even though awareness may be high, adequate precautions are often not taken (New Era, 2003; VaRG, 2001; CREHPA and FHI, 2002). The lack of awareness of symptoms and modes of transmission of RTIs/STIs among clients and, in some instances, health care providers, and the low availability of female providers hinder use of services. I n India, among women who had experienced one or more symptoms suggestive of an RTI or STI, over 50 percent considered the problem 'normal' and sought treatment only when they were not able to carry out their usual household chores. In Pakistan women either did not seek care from male doctors or were too embarrassed to discuss their problems with the latter (Khan et al., 2000). Symptoms of infection are often perceived to be due to eating 'hot foods', and home remedies are believed to cure the problem. In Nepal, Village Health Workers were unsure if condoms were to be used only when men had sex with FSWs or with other women as well (Bhattarai, 2000). They also thought that HIVIAIDS could be transmitted through mosquitoes and that infected persons should live in isolated camps. 1.53 This information points to the need for effective communication and behavioral change. Providing condoms widely could be an effective preventive strategy, and some successful efforts are discussed in Chapter 3. There is also a need to strengthen services for the treatment of RTIsISTIs. The topics in this section also point to the need to involve men in women's reproductive health (especially in decisions about contraception and health care) as well as to address men's reproductive issues, including their sexual health (sexual dysfunctions, infections, infertility and cancers), practice of contraception (including vasectomy), responsibility in conjugal and other sexual relations, and roles in family care. Men's sexual behaviors are more risky than women's (e.g., they have more partners and visit FSWs) and increase women's health risks. Their dominant role in reproductive health decisions means that communication and services need to be directed to them. For example, treating STIs in men could reduce the risk of infection and subsequent complications (HIV/AIDS, cervical cancer, infertility) among their women partners. Men can reduce unwanted pregnancies by practicing contraception or supporting its use by their partners. Indeed, the integrated approach to reproductive health focuses on couples. 1.54 Clearly, individual, household and community factors have a strong influence on women's fertility and most likely on their susceptibility to reproductive infections, although data on these are severely limited. The association of poverty and fertility is well-established, and poverty exacerbates infections (including HIVIAIDS) through low awareness, lack of women's empowerment to seek care or negotiate safe sex, lack of access to services, and so on. The use of unqualified practitioners may be a poor woman's only resort, and may further worsen the situation, as in the tragic case of unsafe abortion. 1.6 THEMATERNALSTAGE 1.55 The third stage of the reproductive life cycle encompasses pregnancy and birth and mother and child health during and after these events. Only a few indicators of mothers' nutritional status and maternal and infant mortality are used here to describe the situation of South Asian women. Information on maternal morbidity comes largely from service statistics or hospital-based studies, and is therefore unrepresentative of the population at large. 1.6.1 Women's Nutritional Status 1.56 Poor nutrition is a widespread problem among the women of South Asia, particularly during pregnancy and lactation. It begins in early childhood when girls may be underfed relative to their needs and compared with boys, and is manifest clearly in inadequate growth and development during adolescence. Early childbearing (discussed above) stops adolescent growth and adds to nutritional demands. Mothers who receive inadequate nutrition give birth to underweight infants, among whom are girls who will remain small in stature and pelvic size. This vicious cycle is particularly devastating for poor women who have limited access to food throughout their lives. 1.57 Underweight Women. The proportion of women who are underweight varies from one in three in India and Bangladesh to one in four in Nepal and Sri Lanka, and is related clearly to poverty and its correlates." For example, among Indian women who are illiterate or have not completed primary school, 40 percent are underweight, while among those who have secondary or higher education, about 20 percent are underweight (Annex 3 Table A3.5 and Figure 1.5). The proportion underweight in the poorest quintile was two (in Bangladesh) to three times higher (in Sri Lanka) than in the richest quintile. In urban India, this proportion was five times higher. However, even among the richest fairly high percentages of women are under-nourished: from around 13 percent in Nepal and Sri Lanka to 23 percent in India. 1.58 Our multivariate analyses show that in Bangladesh, India and Sri Lanka, in addition to poverty and illiteracy, high parity and age increase the risk of being underweight (Annex 3 Table A3.6). While even primary education is associated with better nutrition in India, only higher levels of education make a difference in Bangladesh and Sri Lanka. Controlling other variables, SC/ST women in India are more likely to be underweight than other groups. Figure 1.5 Undernutrition (Percent of Motherswith BMI < 18.5 kg/m2) Maternal Education EconomicQuintile I I I I hdi Nepal Bangladesh hdia Fhrral hdi Urban - - Nepal Sri sri rn None Up to 5 years m 6-9 years rn 10+years rn Fuorest rn Second m Third rn Fourth 1.59 The far-reaching impact of poor nutrition is simply illustrated: in Bangladesh, short stature among mothers increased the odds of a child death almost two-fold (Baqui et al., 1994). This goes beyond correlation to causation as the stunting and small pelvic size brought about by poor nutrition during childhood and adolescence increase the obstetric risks to both mother and child during delivery. 1.60 Anemia. Diets that do not provide enough iron, vitamin Biz or other vitamins and minerals may result in iron-deficiency anemia.'* Anemia during pregnancy exacerbates problems such as infection and hemorrhage and is associated with increased fetal loss, perinatal death, and a several-fold increase in the risk of a mother dying in childbirth; severe anemia even more so. 1.61 The prevalence of anemia among 15-49 year-old women is highest in Nepal (67.7 percent) but the majority of women in Sri Lanka (58.0 percent), India (51.8 percent) and Pakistan (49.7 percent) also are anemic. I n India, 55 percent of women who are illiterate are 17.'Underweight'is definedby the Body Mass Index (BMI), a person's weight in kilograms divided by height in meters squared. A BMI of less than 18.5 kg/m2indicatesunderweight or under-nutrition. The BMI data discussed here are for married non-pregnant women aged 15-49 years. la.A woman is anemic if her hemoglobin level is less than 11.9grams per decilitre in the non-pregnantstate or 10.9gmldl during pregnancy. In the DHS, only ever-mamed women aged 15-49 years are assessed. Anemia here refers only to iron-deficiency anemia. anemic but the problem is still widespread among those who have secondary and higher education (38 percent). Although socio-economic differences (e.g., rural/urban, economic quintile and social group) are apparent in India and elsewhere, levels of anemia are so high even among the best-off that a summary conclusion is that most South Asian women require prevention or treatment of this problem.lg Taking iron and folic acid supplements during pregnancy is a medically-proven intervention to reduce anemia and its negative outcomes. 1.6.2 Maternal Mortality 1.62 Maternal mortality is an important indicator of the status of women in a society - a maternal death often represents the endpoint of a life of gender discrimination and deprivation 'inside' the household, and failure of the 'outside' (e.g., health system) to provide timely and effective care. Chronic conditions such as under-nutrition, anemia, diabetes and hypertension make women more susceptible to maternal death, but even healthy women can succumb to an unexpected complication during pregnancy or childbirth. Only use of good health care can make maternal death a rarity, as it has in the developed world. Indeed, a striking feature of maternal health in the world today is the vast difference in maternal mortality in developed and developing countries, the latter still alarmingly high. In 2000, 13 developing countries accounted for 70 percent of maternal deaths world-wide, and South Asia for one-third. The country with the single largest number of deaths was India, where an estimated 136,000 women died (Annex 3 Table A3.7). 1.63 Among our five focus countries the maternal mortality ratio (MMR) was highest in India (540), Nepal (539), and Pakistan (500), and 25-30 percent lower in Bangladesh (380). Sri Lanka clearly shows what can be achieved in the region - its MMR is 92. Box 3.3 in Chapter 3 describes in detail how Sri Lanka has achieved this. I n brief, two sets of factors are believed to have reduced maternal mortality in Sri Lanka after 1940. The first includes general interventions made between 1930 and 1950, such as malaria control, deworming, improvements in sanitation, and the spread of infrastructure such as roads, hospitals and schools. These assisted the MMR to decline from around 2,000 to about 500. The second set, which caused the decline to below 100, consisted of specific obstetric interventions that were practiced widely after 1950. Modern obstetric techniques and antibiotics were extended to the majority of the population. Well-trained public health midwives provided antenatal care at both the domiciliary and institutional levels, ensured skilled attendance at delivery, and encouraged institutional deliveries. The establishment of more sophisticated obstetric services and of a national blood transfusion service throughout the country have contributed to further reductions in maternal mortality most recently (Gunathilake, 2000). 1.64 There are important geographic differentials in all the countries (NIPORT et al., 2003; GOI-RGI, 2000; WHO, 2004) as well as serious concerns that maternal mortality has not been declining sufficiently in recent years (e.g., Fikree, 2000). A number of individual and household factors put women at high risk of death during pregnancy and delivery. These include age (too young or too old), high parity, poor nutritional status, low access to health services, low social status, illiteracy and poverty. As with other indicators of reproductive health, maternal mortality is higher in rural areas, among the economically worse-off, and those with little or no ed~cation.~'Women who have received no antenatal care appear to be at greater risk of death (a cause or correlate), and those with unmet need for contraception are at higher risk than they would be if they could avoid pregnancy. However, the lower MMR in Bangladesh compared with India, Nepal and Pakistan gives pause as coverage with antenatal and postnatal care and skilled attendance at delivery are lowest in Bangladesh among the five countries (see Chapter 2). This suggests that factors within the household that directly affect women's health and nutrition play an important role in reducing maternal mortality. Most likely these include actions that reduce the "three delays" in obtaining obstetric care (discussed in section 1.8.4). 19 . For example, over 56 percent of SCIST women, over 47 percent of other Hindu and Muslim women, and about 45 percent of women among Christians and other religious groups in India were anemic. . The data on maternal mortality do not permit multivariate analysis to determine the specific influence of different factors. 20 17 1.65 Data on the causes of the most intractable maternal deaths in Sri Lanka, where rigorous audits are carried out, are instructive. During 1995-2001, direct obstetric causes accounted for two-thirds to three-quarters of deaths, and among these ante- and post-partum hemorrhage and pregnancy-induced hypertension (eclampsia) accounted for about half (GOSL-FHB, 2001). Among indirect causes, which accounted for about 30 percent of deaths, cardio-vascular diseases, pneumonia (including tuberculosis pneumonia) and bronchial asthma were the most important. In the other countries, in addition to these puerperal sepsis (13 percent in Pakistan) and post-abortion complications (11 percent in Pakistan and 20 percent in India) are still significant causes of death (NIPORT et al., 2003; Bhutta et al., 2003; Anandalakshmy and Buckshee, 1997) which should be addressed vigorously. 1.6.3 Child Survival 1.66 Good reproductive health outcomes include the health of very young children. Beginning in the intra-uterine period, a child's development and survival are a function of her mother's nutrition and health and access to care. Child survival in turn influences women's health and subsequent fertility. Some key indicators of the health of the mother-child dyad are birth weight, breastfeeding, child growth, and early child mortality. 1.67 Birth Weight. More than 20 million infants are born low birth weight (LBW) annually across the world - over 95 percent of them in developing countries and about 55 percent in South Asia (UNICEF and WHO, 2004). LBW is one of the most serious public health challenges as it has multiple underlying causes and several associated risks including substantially increased child mortality. In India, nearly 50 percent of neonatal deaths are of LBW babies. Survivors grow poorly and risk death later in infancy or childhood due to inadequate feeding, susceptibility to infections or impaired neurological development. 1.68 Despite existing policies, weighing infants at birth is not common practice in South Asia. However, direct and indirect estimates indicate that one-fourth to one-third of newborn are underweight, except in Sri Lanka where this proportion is 17 percent (Annex 3 Table A3.8). Analysis of data from India and Sri Lanka showed that maternal education, nutritional status and the length of the previous birth interval were influential factors. For example, in Sri Lanka 27 percent of the neonates of illiterate mothers were LBW compared with 11percent of those born to mothers with A-level education or more. LBW is not readily reduced by wealth or education, a finding that is consistent with the wide prevalence of poor maternal nutrition. 1.69 Breasffeeding. Breastfeeding practices have an important effect on infant health and survival. Malnutrition is directly or indirectly responsible for 60 percent of the deaths that occur among children under five years of age in developing countries, and two-thirds of these deaths occur in first year of life, many associated with inappropriate feeding practices (WHO, 2003). Fortunately, breastfeeding is practiced widely in South Asia - over 95 percent of infants in the national surveys of all five countries were brea~tfed.~'However, despite this beneficial situation, a number of unhealthy practices exist that jeopardize infant health, growth or survival. These include late initiation of breastfeeding, discarding of colostrum, lack of exclusive breastfeeding, and introduction of weaning foods too early or too late. I n Bangladesh, for example, only 16 percent of children below two had been exclusively breastfed up to four months of age (NIPORT, 2001). I n Sri Lanka, a lower proportion of infants was exclusively breastfed during the first month of life than in the second to fourth months because of the use of traditional preparations believed to be good for the child or to be necessary because mother's milk is considered inadequate (Jayathilake and Fernando, 2002). 1.70 In Bangladesh, maternal education had a positive influence on breastfeeding: mothers who had completed primary school were 1.6-1.8 times more likely to breastfeed their infants exclusively for six months than those who had not received any formal education. Similarly, children born to the richest quintile of mothers had a three-fold greater chance of being exclusively breastfed for the first six months than children of the poorest mothers. I n addition 'I. The country-specific rates were: India - 96 percent of children under 3 years (NFHS2 1998-99); Nepal - 98 percent of 'babies' (NDHS 2001); Pakistan - 96 percent of 'last babies' (PRHFPS 2000-01); Sri Lanka -98 percent of 0-4 year-olds (DHS, 2000). 18 to a lack of awareness, these situations may be due to poorer mothers having to leave their infants behind while they go to work. 1.71 Young Children Malnutrition. South Asia is characterized by high protein-energy malnutrition among children under five. Almost half the children assessed in Bangladesh, India and Nepal, and around one-third in Pakistan and Sri Lanka were underweight (Table 1.4). The high levels of underweight and stunting and relatively lower levels of wasting signify chronic under-nutrition in Nepal. The 6-23 month period is critical in establishing children's nutritional status (Annex 3 Table A3.9). The fast growth and high nutritional needs of their children create the opportunity for growth retardation, underscoring the importance of timely and adequate complementary feeding and the need to protect them from infections. Table 1.4 Nutritional Status of Children in Five Countries of South Asia, various years, percent. Bangladesh India Nepal Pakistan Sri Lanka 1999-2000 1998-99 2001 2001-02 2000 Age-qroup Under 5 Under 3 Under 5 Under 5 Under 5 Underweight 47.7 47.0 48.3 37.4 29.0 Stunted 44.7 45.5 50.5 40.0 13.5 Wasted 10.3 15.5 9.6 14.9 14.0 Sources:Bangladesh: NIPORT, 2001; India: IIPS and ORC Macro, 2000; Nepal: GON-MOH et al., 2002; Pakistan: PIDE, 2002; Sri Lanka: GOSL-DCS, 2002a. 1.72 As expected, children of poor illiterate women living in rural areas (and the estate sector in Sri Lanka) are more likely to be underweight. I n Bangladesh, India and Nepal, over 50 percent of the children of illiterate women were underweight compared to about 20 percent of those of women with secondary education or more. The proportion of children in the poorest quintile who are underweight is clearly much higher than of children in the other quintiles. Even among the richest quintile of children, however, about a quarter are underweight in India and Nepal. This indicates that even in better-off households some child feeding and care practices are sufficiently detrimental to produce under-nutrition. Mothers' nutritional status (assessed by a BMIc18.5kg/m2) also has a bearing on the nutritional status of children. These findings are consistent with those discussed earlier on mothers' nutritional status and low birth weight among infants.22 1.73 Three-fourths of young children in India and Nepal are anemic and one-third in Pakistan (IIPS and ORC Macro, 2000; GON-MOH et al., 2002; PIDE, 2002). By 2006 Nepal appears to have reduced anemia to 48.4 percent among children and 36.2 percent among women (GON-MOPH, 2007). Anemia does not differ significantly by the sex of children but appears to decline with children's age. It is higher among rural than urban children. Overall, the situation warrants strenuous efforts to improve the iron status of mothers during pregnancy and of infants. The persistence of the impact of poor nutrition across socio- economic groups underscores the need for attention to it in women's reproductive health. 1.74 Neonatal and Infant Mortality. Neonatal and infant deaths are of central concern in reproductive health.23 They reflect the level of development of a population (including the status of women) and of health services. The wide gap between developed and developing countries in infant mortality demonstrates that the majority of these deaths are preventable - most with relatively simple interventions such as immunization of mothers during pregnancy to prevent neonatal tetanus, aseptic delivery, maternal nutrition and infection control and care of the newborn. As infectious diseases that affect infants (such as diarrheas) are brought under control, post-neonatal deaths decline and deaths in the neonatal period which have non- infectious causes loom larger. These require more specialized health intervention~including emergency obstetric care. 22 The nutrition gap between SCIST children and others grows over time. About 26 percent of SCIST infants are low birth weight compared to 22 percent of others, while the extent of under-nutrition among children under 3 years is 56 percent among STs, 52 percent among SCs and 43 percent among others. . The neonatal period is the first month of life, and infancy the first year. 'Post-neonatal' refers to the period between one month 23 and one year of life. Table 1.5 Infant and Neonatal Mortality Rates in the Five Countries, Various Years. FBS, 2003; ~ r~anka.GOSL-DCS, Zb02a. Note: In Nepal the IMR was 5 1 and N ~ 34 I ~ I2006 (GON-MOPH, 2007). : R 1.75 Despite sustained declines, infant and child mortality remain high in four of the five South Asian countries (excluding Sri Lanka). Due to its large population, India alone accounts for one-fifth of all under-five deaths. The highest levels of neonatal and infant mortality are in Bangladesh and Pakistan among the five countries, with India and Nepal following closely (Table 1.5). Sri Lanka's mortality rates are about one-fifth those in the other countries, showing what can be achieved in the Subcontinent. The residual situation is instructive. The major causes of neonatal deaths are related to pre-term birth and low birth weight, infections, birth asphyxia and other respiratory conditions of the newborn (GOSL-RGD, 1998a, b, c; GOSL-DHS, 2001). Deaths within the first week of life account for one-third of neonatal deaths. Neonatal sepsis, congenital malformation and birth trauma are among the identified causes of these early neonatal deaths. Some infections such as neonatal tetanus and sepsis that contribute substantially to neonatal deaths in the rest of South Asia would be most amenable to health service interventions. Figure 1.6 Neonatal Mortality and Maternal Education 1 Maternal Education 1 Bangbdesh hdia Nepal Sri Lanka I m hbne I&to5 years m6-9 years 10+years ! 1.76 Like other reproductive health indicators, infant and neonatal mortality decline with increases in maternal education (Annex 3 Tables A3.10 and A3.11 and Figures 1.6 and 1.7). In Bangladesh, Nepal and India, the mortality rate exceeds 50 among neonates of women who are illiterate, but is 36, 24 and 9, respectively, among those born to women who are educated to secondary or higher levels. The IMR even of the richest quintiles in Nepal, Bangladesh and India is higher than the overall IMR of Sri Lanka. This suggests that better access to health goods and services among the well-off in these countries is 'bested' in Sri Lanka by other conditions that reduce infant mortality, such as environmental sanitation and hygiene. 1.77 Disparities between rural and urban areas in neonatal and infant mortality are also large - more so than the disparities in most other reproductive health indicators. I n India, religion and SCIST status have effects on neonatal, infant and child mortality.24 Gender discrimination removes the initial biological survival advantage of females, resulting in excess female mortality over the age of one, especially in India and Nepal (Annex 3 Table A3.12). Demographic factors such as birth order, maternal age and birth interval also affect mortality rates significantly in South Asia. I n India, newborn of women who had even one ANC visit had a lower likelihood of death. However, institutional delivery had a negative relationship with neonatal survival because women who seek care from institutions often do so only when they are in critical condition. 24.Neonatal mortality was around 53 among SCISTs and 41 among others; infant mortality: 83 among SCISTs and 62 among others; and child mortality: 42 among SCISTs and 22 among others. Figure 1.7 Infant Mortality by Maternal Educationand Economic Status 1 i Maternal Education Economic Quintile . 1 I Nepal Pakktan Sri Lanka Bangladesh hdia Nepal Pakistan Sri Lanka None Upto 5 years m 6-9 years 10+ years Poorest w Second m Third w Fourth 8 Richest 1.78 The links between maternal health and early child mortality are profound, and point to the need for maternal care during pregnancy, including improved nutrition, iron-folate supplementation, tetanus toxoid immunization, and treatment of maternal infections such as STIs and malaria. Proper care during labor and delivery is also important to manage obstetric complications, reduce maternal and neonatal sepsis, and resuscitate newborn. In the postnatal period, the umbilical cord, breastfeeding, hypothermia, low birth weight, and infections require attention. Antenatal care, skilled attendance at delivery, and ensuring the attention of a trained provider within the first few days of birth (when most maternal and neonatal deaths occur) are the appropriate service provision strategies. In poor settings, local midwives or community health workers can be trained to provide basic care and link needy households to higher level services, greatly improving maternal and infant survival. 1.79 There is scope for involving men also to improve maternal and child health and survival. Increasing their knowledge of maternal and child nutrition, of the needs of pregnancy (including the importance of ANC and of identifying pregnancy and post-partum complications) and of family planning can improve household practices during this life-cycle stage. Men can play important roles in deciding that women will deliver in institutions, seeking trained assistance in time, providing transportation and funds, and sharing in the care of children. 1.80 The need to address the most proximate causes of maternal and infant deaths (anemia, infections, pregnancy-related problems, septic deliveries, infant feeding and illnesses) arises from the magnitude of deaths still occurring in South Asia and the urgency to reduce them. Underlying factors such as poverty and illiteracy and other individual household factors have a profound influence on maternal and child nutrition and survival. Community factors such as unhealthy environments, inadequate institutions and infrastructural constraints need to be addressed to consolidate individual gains and widen impacts. 1.7 OLDER WOMEN'S HEALTH 1.81 The focus of reproductive health in South Asia to date has been on women who are capable of bearing children -- those beyond this stage have been neglected although many of their concerns are within the reproductive health agenda. Women over 45 years comprise 7 to 9 percent of the populations of Bangladesh, India, Nepal and Pakistan, and 13 percent in Sri Lanka. With increases in life expectancy, these proportions will rise, and governments will need to take serious steps to ensure that services are available to address their health needs. 1.82 Unfortunately, information on menopause and on the reproductive morbidities of older women are deficient, so only a few threads are drawn together here. The main problems are the morbidities associated with menopause and reproductive tract cancers. Cancers of the breast and uterine cervix account for the majority of malignancies among older women. For example, in Bangladesh, although the incidence and prevalence of cervical cancer in the population at large are unknown, this was the most common cancer among women in a hospital (Akhter, 1998).25 I n Sri Lanka, the five leading sites of cancer in females include the breast (22.5 percent), cervix (15.2 percent), and ovaries (8.4 percent).26 India alone bears a quarter of the world's burden of cervical cancer which accounts for at least 20 percent of all cancers among Indian women. Among important risk factors for cervical cancer (which follows persistent genital infection with human papilloma virus) are some that are common among South Asian women: early onset of sexual activity, multiple sexual partners and a history of STIs. Most reproductive cancers are curable if diagnosed early but screening (which should begin when women are in their 30s or 40s) is largely unavailable to poor rural women.27 1.83 Another problem with a high incidence (e.g., in Nepal) is uterine prolapse. This is associated with multiple pregnancies, unskilled birth attendance and heavy physical work, and hence most likely among poor women in South Asia. Although some other health problems of older women such as cardiovascular disease and osteoporosis are not reproductive in nature they are linked to post-menopausal changes and can result in disability, reduction or loss of mobility, disfigurement, lower self-esteem, increased dependence and a lower quality of life. 1.8 IMPROVING REPRODUCTIVE OUTCOMES 1.84 This chapter focused on reproductive health outcomes and the community, household and individual influences, as shown in the conceptual framework (Figure 1.2). Several factors are amenable to health sector intervention to improve outcomes, particularly those related with knowledge of reproductive health, behavior and the availability and use of household resources and services. Impacts can be enhanced by improving community characteristics that support the use of health care such as facilities for adolescents or women's groups. Other important factors, such as education and economic status are crucial to achieving and sustaining reproductive health improvements and require interventions in other sectors. 1.8.1 Focusing on the Poor 1.85 Poor women in South Asia clearly have a disproportionate burden of reproductive ill- health. Hence, socio-economic and geographic targeting of health services to poor households and the poorest areas is essential if the bulk of health needs are to be addressed and reproductive health goals met. The social context of most poor women in the Subcontinent calls for services to be provided 'at the doorstep' by well-qualified providers (especially in areas where topography or socio-political problems are further impediments to women reaching health centers). The public health systems in all five countries need to be socialized into serving the poor and excluded. As discussed in Chapter 2 health providers must improve and be held accountable for their behavior towards poor and female patients - particularly those from stigmatized communities such as Scheduled Castes or FSWs. 1.86 A focus on the poor is also needed to address the related problem of malnutrition. Although prevalent among rich and poor mothers and children, its impact on the poor is greater. Health services need to integrate nutrition counseling and monitoring, and care of the under-nourished squarely into their efforts. Attention to nutrition should start with mothers who are at the greatest risk of bearing low birth weight infants, and include the care and survival of young children. This is currently done poorly in all five countries and improvements are essential if the MDGs for health, poverty and hunger are to be met. 1.8.2 Actively Seeking Adolescents 1.87 Adolescents are the most neglected biological target-group in all five countries, and the most important to improve reproductive health outcomes. South Asia's health systems ". The study covered 10,095 cancer patients in Dhaka. 26.Since 1990a Cancer Registry has been maintained by the National Cancer Control Programme in Sri Lanka. The registry receives data from the central Cancer Institute, as well as from Cancer Units attached to two urban hospitals. It is estimated that these data cover about 80-90 percent of the annual incidence of cancers in the country. 27.The pre-cancerous stage of cervical cancer, when screening is critical, often occurs within the reproductive period. need to cater to their reproductive health needs in a concerted way. Several interventions constitute a well-designed adolescent reproductive health program, including: IECIBCC, covering sex and sexuality, reproductive health and contraception, and including sensitization to engender positive attitudes and behaviors;*' sensitization of parents, teachers and service providers to adolescent health issues; youth-friendly services for contraception and diagnosis and management of RTIsISTIs; iron-folate supplementation, treatment of hookworm, and education about nutrition to prevent and manage anemia; recognizing and addressing gender issues to enhance safe and consensual sex, childbearing and rearing; and enforcement of the legal minimum age of marriage. 1.88 Most of these services are needed for adults as well and so are not 'add-ons' to health services but need to be focused on adolescents. Programs in other sectors that target young women are also important. Increasing girls' education, skills and job opportunities would help to raise their age at marriage. There is need to enhance the status of women through programs that increase their economic productivity and control over resources, including micro-credit and employment-generation schemes, equal inheritance laws and their enforcement. 1.8.3 Meeting the Needsof Sexually-ActiveAdults 1.89 Among sexually-active adults the most critical reproductive health issues are unwanted fertility and widespread prevalence of RTIsISTIs including HIVIAIDS. Even among adolescents, a high proportion of births is unwanted. There is need to expand family planning through community-based mechanisms, targeting couples to delay and space pregnancies as well as to stop child-bearing when they achieve their desired family size. Social marketing is a promising approach to providing contraceptives and social franchising has worked for clinic based services. A recent series of articles on sexual and reproductive health in The Lancet discuss effective strategies to increase family planning (Cleland et al., 2006), safe abortion (Grimes et al., 2006), and control STIs (Low et al., 2006). 1.90 Disseminating accurate information through a variety of channels could help to enhance awareness of RTIs/STIs/HIV/AIDS. Promote the use of condoms, and increase treatment of RTIsISTIs. Targeting high-risk groups is essential but the time has come to extend these interventions to a wider public. Male condoms offer the best protection against STIs and HIV, and female condoms, diaphragms and cervical caps also provide barrier protection against infections. Despite its limitations, the syndromic approach provides an option to manage RTIsISTIs in poor settings without laboratory facilities, and updating the skills of workers in this method could help. Providing voluntary HIV testing and counseling is also necessary. Most importantly, these services need to be integrated with other reproductive health activities so that women - especially the poor - can be served effectively and the efficiency of health services increased. 1.8.4 Integrating Services 1.91 The majority of maternal deaths can be prevented using available knowledge and technology, as demonstrated in Sri Lanka. The Lancet has recently described strategies for reducing maternal mortality (Campbell et al., 2006) and what it would take to implement the most important globally (Koblinsky et al., 2006; Borghi et al., 2006). Similarly, evidence- based cost-effective interventions to address neonatal mortality and child mortality have also been elucidated (Darmstadt et al., 2005; Krippenberg et al., 2005; Jones et al., 2003; Bryce et al., 2003; Victora et al., 2003; Bellagio Study Group, 2003.) Specific interventions such as assured skilled attendance at delivery and emergency obstetric care including blood transfusion services need to be increased substantially in South Asia. Many mothers could be saved by reducing the "three delays" in identifying danger signs and deciding to seek care, 28.'IECIBCC' is Information, Education and CommunicationIBehavior Change Communication. reaching an appropriate facility and receiving care at the facility (Thaddeus and Maine, 1994).~' Family and community awareness and access to transport are critical to reduce the first two delays. Where trained health professionals are scarce, community-based efforts such as training village women to provide clean delivery and advise mothers when to go to a health facility could substantially reduce mortality. In Nepal, a recently introduced maternity incentive scheme in the Support to Safer Motherhood program has increased assisted childbirth, with two-thirds of the women who used the scheme delivering at institutions. 1.92 The post-natal period is another critical time for action. I f trained female workers were to visit women within a day or two of their deliveries, to detect and treat hemorrhage and make an additional visit within the first week, much post-natal morbidity and mortality could be prevented. Arrangements for emergency transport should be extended to these mothers and newborn. In Sri Lanka where infant mortality is low, focusing attention on two neonatal conditions, birth asphyxia and low birth weight, could further reduce deaths. 1.93 Some proven and cost-effective interventions for child survival are: management of hypothermia, exclusive breastfeeding, adequate and appropriate complementary feeding, immunization, and management of pneumonia, diarrhea, malaria and malnutrition. These interventions could prevent more than half of all under-five deaths. As many children suffer from more than one illness at a time, Integrated Management of Neonatal and Childhood Illness provides better outcomes. Given the importance to child health of six months of exclusive breastfeeding, Baby-Friendly Hospitals and counseling which have shown positive results, for example, in Bangladesh, could encouraging this. Current constraints in the public health systems of Bangladesh, India, Nepal and Pakistan to providing these services to poor women could be eased by enabling them to use private facilities, but it is also necessary to address constraints to demand by increasing awareness and reducing out-of-pocket costs. Other interventions such as family planning, maternal nutrition, women's education and employment also contribute significantly to child survival. The impact of birth spacing on newborn, infant, child and maternal health has been described by Norton (2005), Conde- Agudelo et al. (2006) and several others. 1.8.5 Help for Older Women 1.94 Depending on the resources available, appropriate services for older women include counseling on menopause, diet, exercise and other elements of a healthy lifestyle to prevent cardiovascular disease and osteoporosis; treatment of reproductive tract and urinary infections, uterine prolapse, fistulas and other gynecological disorders; screening and treatment for cervical and breast cancer; and medical management of women at high risk for fractures and cardiovascular disease. Well Women Clinics introduced in Sri Lanka in 1996 to screen for cervical and breast cancers, test for diabetes and hypertension, and treat common health problems among women over 35 years provide a model in the region. ~- - ~ 29.Delays in deciding to seek care are due to a lack of understanding of complications, acceptance of maternal death, the low status of women, and socio-cultural barriers to seeking health care. Delays in reaching care are caused by physical barriers andlor poor availability (or unaffordability) of transport. Delays in receiving care at institutions may be due to shortages of personnel, supplies or equipment, poor training or attitudes of personnel (especially toward the poor), and the family's inability to pay for services. Chapter 2 ReproductiveHealthSetvices: Inadequateand Unused Despite available knowledge and technology to ensure effective reproductive health services, their provision and use in South Asia remain far short of need. Contraceptive use ranges from 32 percent of eligible couples in Pakistan to 70 percent in Sri Lanka. It is low among poor illiterate women in rural areas. While this is partially because their desired fertility is high, even their expressed needs are not met. Married adolescents are another group with high unmet need. Well-off educated women in urban areas are better served but still not fully so. Terminal methods predominate in Nepal and India and temporary methods in Pakistanand Bangladesh. Immediate attention is required to women's unmet need for contraception and promotion of spacing methods, including condoms that protect against pregnancy as well as Sl7s and HIV/AIDS. The best strategies would be to increase contraceptive distribution through public and private channels using social marketing and private-public partnerships, and to actively increase male involvement in family planningand responsible sexual behavior. Given high unmet need, it is not surprising that the region has a high incidence of abortion - an estimated eight million every year. Adverse social attitudes (among providers as well) and low access to safe and confidential services force women to approach unqualified practitioners in at least half of all cases. There is need to increase the availability and quality of safe abortion services through the public and private sectors, and simultaneously to crack down on 'quack' abortionists and unhygienic facilities. I n Sri Lanka legalization of abortion would help poor women. A related concern, particularly in India, is sex-selective abortion, which is increasingdespite the existence of punitive legislation because this is hardly enforced. The utilization of maternal health services shows great variation: high in Sri Lanka and lowest in Nepal and Bangladesh. I n four countries (excluding Sri Lanka) large proportions of women do not receive even one antenatal check-up despite the presence of outreach staff for the purpose and the private health sector. While Sri Lankan women have almost universal skilled birth attendance, less than one-eighth do in Bangladeshand one-sixth in Nepal. Poor uneducated young rural mothers, trapped in repeated pregnancies are most in need of maternal and child health services. Ensuring that women who deliver at home are visited by a qualified provider within 48 hours could help reduce maternal and neonatal mortality, but such postnatal care is hardly provided. Skilled birth attendance and antenatal and postnatal care 'in the village' must be improved while efforts to increase the availability of essential obstetric facilities continue. Transport vouchers or funds could be provided to all women for institutional deliveries. and to those womenand newborn who need medicalattention after a home-based birth. There are several supply- and demand-side constraints to the use of reproductive health services. Awareness of the need for care and of its availability is low. Cultural norms and social stigma prevent women from seeking services even for problems they recognize, such as RTIs/STIs, or result in their approaching the wrong providers. These hurdles must be addressed through enhanced behavior change communication(BCC) for reproductive health. BCC should also focus on improving nutrition, hygiene and health practices in the home. Besides knowledge, the costs of care are an important demand-side constraint for poor households. Hence, demand-side financing for the poor could achieve much-needed increases in service utilization. Supply needs to catch up with demand for some services (such as family planning), and addressing supply-side problems would enhance demand for others. Both physical access and quality of care raise serious concerns. Access to first-level care remains limited in many 'under-developed'areas where public and private facilities are often both in short supply. At existing public facilities, quality issues that constrain reproductive health service provision and utilization include: inadequatestaff, particularly women providers; inadequate supplies, equipment and basic amenities; bad behavior of service providers; overcrowding and a lack of privacy; inadequate or inappropriate information; poor technical competence; lack of follow-up; and demands for informal payments. Inadequate monitoring and supportive supervisionadd to these problems. Targeting poor areas and poor people, strengthening primary facilities and outreach services, improving provider behavior and skills, and integrating services (to improve efficiencies for clients as well as the health system) are some critical improvements needed in reproductive health care in South Asia. To achieve better outcomes the essential package of reproductive health services - importantly including maternal and young child nutrition - must be delivered with 'quality'. Outreach services must be improved by ensuring proper deployment of frontline female health workers who are skilledand fully equipped. The longer term strategic plan should be to provide more highly skilled care at the frontline. Enhancingthe status of women providersthemselves is a critical element o f reform, relatedclosely to improvingprovider behavior towards women and the poor. 2.1 UNDERSTANDING USE OF HEALTH CARE 2.1 Most reproductive health problems are amenable to prevention or cure through health service interventions. But what determines whether women actually use reproductive health services? This chapter addresses this question, focusing on the key services needed at the four stages of the reproductive life cycle, and on how these must be improved in order to achieve reproductive health goals. 2.2 In addition to need to prevent or cure a reproductive health condition, other factors determine the use of health services by women (Chatterjee, 1990). In South Asia, need is qualified greatly by knowledge and perceptions - for example, women are unaware of the benefits of antenatal care so their perceived need for ANC is low; or they consider the symptoms of RTIs to be normal and so do not feel the need for treatment. A lack of permission further limits use of services. This encompasses the set of socio-cultural factors that determines whether a woman can seek health care outside her home, from male providers, and so on, including women's conditioning to "suffer in silence", their status and autonomy, and family decision-making processes. Ability comprises the economic factors that decide whether - or which - health services are used. Women's ability to obtain health care depends on its direct costs as well as transaction and opportunity costs, and the extent to which families agree to invest in their health. As Figure 2.1 shows, the use of services occurs when need, unconstrained by these 'demand-side' factors, coincides with the availability (i.e., supply) of services. Availability is a function of access and appropriateness. Figure 2.1 Factors Determining Use of Health Services Perceived Need 2.3 An effective health system provides the range and quantity of services required to address the health needs of the population being served. To ensure that services are used and not wasted by disuse or misuse, it would also address the societal constraints inherent in perceived need, permission and ability. To begin with, perceptions and knowledge of the need for care and the benefits, e.g., of preventive services must be addressed through information and communication. I n the reproductive health arena in South Asia, this is particularly germane to ANC, skilled attendance at delivery, nutrition and most aspects of child health. Educating communities about the risks of maternal death would increase perceived need for institutional delivery. To enhance permission, strategies such as informing and involving men, employing female health workers where women are not permitted to consult male providers, outreach, and developing channels to reach adolescents are needed. Efforts to increase ability include emergency transport vouchers and funds, insurance schemes, and user incentives which reduce the direct costs of services. Indirect costs can also be reduced by improving access, reducing waiting time, using regimens that reduce the required frequency of visits, and more effective treatment.' Ultimately, an efficient health system is one that fosters health-seeking behaviors that are commensurate with need and supplies the services required, i.e., where all the circles in the diagram are completely congruent. 2.2 USE OF REPRODUCTIVE HEALTH SERVICES 2.4 Interventions to improve reproductive health have been examined closely across the world and this has led to formulation of an essential package of services (Annex 4). The key elements of this package are family planning, safe abortion, treatment of RTIsISTIs, antenatal, natal and postnatal services, child health care, and the treatment of post- menopausal problems. This section examines the actual use in South Asia of the services for which data are a~ailable.~ To achieve reproductive health goals this package must be delivered to the majority of those in need. 2.2.1 Family Planning 2.5 Fertility rates in the five countries (Chapter 1) are mirrored in levels of contraceptive use (Table 2.1).3 Sri Lanka has a high overall level of use, Bangladesh and India moderate levels, and Nepal and Pakistan low levels. Between 2001 and 2006 Nepal increased contraceptive use to 48 percent (44.2 percent with modern methods and 19.9 percent with temporary methods). Table 2.1 Use of Contraceptives in Five Countries, various years, percent. al., 2002; ~akistan:NIPS, 2003; Sri Lanka: GOSL-DCS, 2002a. 2.6 Use of Different Contraceptive Methods. The five countries have three distinct patterns of contraceptive use. Terminal methods predominate in India and Nepal, temporary methods in Bangladesh and Pakistan, and there is an equal distribution in Sri Lanka. In India women who chose sterilization already have four children on average (Pathak et al., 1998), more than their desired number, but they delay acceptance because terminal methods are irreversible. In effect, poor availability of temporary methods results in excess fertility and '. Actions to improve permission and ability can also be taken outside the health sector. For example, schools could educate youth and provide services, and women's programs can facilitate micro-credit or micro-insurance for health care. On account of data limitations, RTVSTI services and the care of older women are not discussed in this chapter. 3. Current use of contraception is defined as the percentage of currently married women aged 15 to 49 years who are currently using any modem method of family planning (oral pills, IUDs, condoms, female sterilization, male sterilization, injectables, implants or others). unmet need. Although women who use spacing methods generally have lower parity, discontinuation of contraception among them is an important concern. I n Bangladesh temporary methods are discontinued by almost 50 percent of women in the first year of use. This demonstrates the need to manage perceptions as well as side effects among women (NIPORT, 2001). 2.7 The public sector is the major source of contraceptives in both India and Bangladesh, particularly for the poorest women. In India the private sector contributes to condom and pill use and in Nepal, mainly to condom use. Condoms are used as contraceptives by only three to five percent of couples in the region. Injectables and implants are hardly used in India and Pakistan. In sum, all countries need to expand the choice of contraceptives available, especially temporary methods in India, Nepal and Pakistan, terminal methods in Pakistan and Bangladesh, and male methods everywhere! 2.8 Determinants of Contraceptive Use. Contraceptive use depends on awareness of different methods, access to them, perceptions of their side effects, and desired fertility. Knowledge about contraception is generally high in all five countries. Almost all 15-49 year- old women interviewed in the latest DHS in each country knew of at least one method. However, they knew little about the options available, their correct use, side effects, or sources of different contraceptives. Although 'lack of knowledge' was a reason for not using contraception among 5 percent of women in Nepal, fear of side-effects was reported by 25 percent. Service providers also have misconceptions. Health staff in Nepal, for example, thought that women needed at least one child to be permitted to use condoms and two children to use IUDs (VaRG, 2003). In India low awareness of the ease and benefits of vasectomy, and misconceptions (e.g., that it leads to impotence) are responsible for current low use of this method. A more gender-sensitive and equitable program would promote male methods as well. 2.9 Use of different methods is influenced strongly by social norms. The key obstacles to contraceptive use in Pakistan Punjab are perceptions that it is culturally or religiously unacceptable, and wives' beliefs that their husbands are opposed to it (Casterline et al., 2001). However, recent research is positive about male support to contraception. For example, in Bangladesh almost all men are able to name modern contraceptives and, more importantly, almost all agree with their wives on the desired number of children. Figure 2.2 Met and Unmet Need for Contraception in Four Countries, Poorest and Richest Quintiles 60 percenl 50 I Poor Rich Poor Rich Poor Rich Poor Rich Poor Rich Bangladesh India Rural - India - Urban Nepal Pakistan I BMet BUnrnet I Sources: Bangladesh: NIPORT, 2001; India: IIPS and ORC Macro, 2000; Nepal: GON-MOH et al., 2002; Pakistan: NIPS, 2001; Sri Lanka: GOSL-DCS, 2002a. 2.10 Contraceptive use increases with education and economic status (Annex 5 Table A5.1). The gap between rich and poor is particularly striking in Pakistan: use is four times higher in the richest quintile compared to the poorest (Figure 2.2). The situation in Sri Lanka is the reverse: women in the poorest quintile have higher use (80.3 percent) than those in the richest (69.5 percent), and use of modern methods is lower and traditional methods higher among the richest women compared to the poorest. As there is no evidence of higher family size or higher desired fertility among the better-off, these differences suggest they are more able to control their fertility through means other than contraception - for example, by 'saying 'no' to sex". Abortion, which is more easily accessible to the better-off, may also play a role in establishing smaller family sizes. Further investigation is needed to unravel this conundrum. 2.11 Contraception is higher in urban than rural areas in all countries; in Sri Lanka, use is lowest in the estate sector. Among different age-groups, while use is lowest among 15-19 year-olds, the variation across countries in this age-group is revealing: it ranges from a low five percent in India to 50 percent in Sri Lanka. Other important social differences occur in India: use is higher among Hindus (44 percent) and Christians (45 percent) than among Scheduled Castes (40 percent), Scheduled Tribes (35 percent) and Muslims (30 percent). 2.12 The effects of various socio-economic and demographic variables in determining contraceptive use are similar in four of the five countries, excluding Sri Lanka (Annex 5 Table ~ 5 . 2 ) .Maternal education, economic status and urban residence have independent positive ~ influences on use. I n Bangladesh the impact of education is significant only among those with secondary or higher education when compared with illiterate women (Odds Ratio, OR=1.44). The difference in the likelihood of use between the richest and poorest quintiles is lowest in Bangladesh (OR=0.65 for the poorest compared with the richest) and highest in Nepal (OR=0.31). Women's age and son preference also play important roles. 2.13 The desire to end childbearing among women in all five countries is influenced greatly by education and economic status, particularly in ~ n d i aIlliterate and poor women are more . ~ likely to have a desire for more children. Despite this, the poorest still have the highest unmet need, indicating that even the low demand of illiterate and poor women living in rural areas is not met. Ubiquitously, low use among adolescents and young women arises from their poor knowledge of reproduction (e.g., low perceived risk of pregnancy), lack of information about contraception, and/or inability to express their desire to delay conception and to interact with service providers. Among older women, unmet need is related more closely to the methods available, their perceptions of the quality of services or of the side effects of contraception, and/or inadequate access to providers. For example, much unmet need in India is due to the inadequacy of spacing methods in the government family planning program and wrong beliefs about those methods that are sparingly available (such as IUDs and oral pills). Social barriers to contraception (e.g., low spousal, familial or societal acceptance) are also important determinants of use. In Sri Lanka unmet need (8 percent) is concentrated among women in plantations, factories, displaced populations, urban slums and underserved rural areas and, along with contraceptive failure, underlies much abortion as emergency contraceptives are not readily available. 2.14 Thus family planning programs need to take a two-pronged approach - immediately addressing unmet need and increasing demand by addressing both demand- and supply-side constraints which are discussed below in the section on quality of health services. The most effective actions would be to: expand contraceptive supply through providers (public and private) who have good counseling skills and make home visits so that they can meet husbands and wives together to discuss family planning and better reproductive health. 2.15 Unwanted Pregnancies and Abortion Services. One outcome of 'unmet need' is unwanted births - nearly one-fifth of births in the region are unwanted or mistimed. At the 4.The variables are: mother's education, husband's education, economic status, woman's employment, place of residence, autonomy, exposure to mass media, maternal age, number and sex of children, socio-religious group, and desire for more children. '.The 2006 DHS in Nepal reports a 'U-shaped' impact of education on contraceptive use. Use is high among women with little or no education as many are sterilized. individual and family levels, eliminating unwanted births could enhance the well-being of women and children, and at the societal level it could reduce mortality, fertility and population growth substantially. A drastic consequence of unwanted pregnancies is abortion. The legal environment and attitudes of service providers determine how women end unwanted pregnancies and how safe the procedures will be, but have little effect on the incidence of abortion (Rahman et al., 1998, Cook et al., 1999). Abortion laws vary across the five South Asian countries. Nepal's law, enacted in 2002, allows any woman to terminate her pregnancy up to 12 weeks, up to 18 weeks if the pregnancy resulted from rape or incest, and at any time if recommended by a qualified medical practitioner. India legalized abortion in 1971 through its Medical Termination of Pregnancy (MTP) Act. Under this abortion can be performed if a pregnancy carries the risk of grave physical harm to a woman or endangers her mental health, and when conception results from contraceptive failure or rape, or is likely to result in a physically or mentally abnormal child. Bangladesh allows menstrual regulation up to eight weeks of pregnancy, and abortion by qualified physicians in hospitals only, if approved by two physicians and necessary to save a woman's life. Sri Lankan law is the most restrictive as abortion is prohibited except when needed to save a woman's life, while in Pakistan preserving physical and mental health are also valid reasons. Sri Lanka's law results in an important difference between poor and non-poor women although almost all other reproductive health services are equitable. Women from higher-income households are able to obtain abortions at private clinics or government hospitals while lower-income women resort more to backdoor abortion and suffer its negative consequences. Legalization of abortion in Sri Lanka would help both poor women and adolescents as discussed in Chapter 1. 2.16 Cultural norms and attitudes play a strong role in decisions about abortion. In all five countries, abortion is not socially acceptable among unmarried women and to some extent among married women also. Thus, the primary criterion that women use to choose an abortion provider is confidentiality, which is usually lacking at public facilities. I n Bangladesh menstrual regulation is conducted on an out-patient basis free of cost at Family Welfare Centers by trained Family Welfare Volunteers. There may be large numbers of clients waiting at a center and women are unable to get the privacy they want. Consequently, they prefer to use private services if they can afford them or, if not, to try home remedies or approach unqualified practitioners. The moral stance of health providers may also obstruct abortion services. A study in India found that many qualified service providers felt that unmarried women and sex workers had no right to abortion (Bandewar, 2003). As a result, they devised punitive measures for these women, such as exorbitant charges, ill-treatment or ignoring complaints. The result was that many clients resorted to unqualified providers whom they believed were more sympathetic. Hence, both provider attitudes and the organization of health facilities need to be improved for better abortion services. 2.17 Although illegal (under the Pre-Natal Diagnostic Technologies (PNDT) Act of 1994), the practice of selectively aborting female fetuses is on the increase in India because of continued strong son preference in the face of declining 'desired family size' and increased availability of sex-determination techniques. This issue needs to be addressed by increasing awareness, enforcing the PNDT Act, providing social security, and increasing measures to improve the status of girls and women. To reduce abortion-related morbidity and mortality there is need to increase safe abortion services, emergency care for complications, post-abortion counseling, and non-physician care (Ganatra and Johnston, 2003). A client-centered approach to promoting contraception would reduce the need for abortion services. 2.2.2 Antenatal Care 2.18 There is substantial variation among and within the five South Asian countries in coverage of pregnant women with even one antenatal care (ANC) visit. This ranges from 83 percent in Sri Lanka to 37 percent in Bangladesh (Annex 5 Table A5.3). I n Pakistan and Nepal half of all pregnant women are reached, while in India two-thirds receive a check-up. The majority of women are registered in the second or third trimester. The value of one or two visits is questionable especially as the quality of care also requires vast improvement - for example, blood pressure is often not measured in India and Nepal. In all countries, coverage with tetanus toxoid (TT) is higher than that with antenatal check-ups, but again there is wide inter- and intra-country variation. Sri Lanka has a high level of coverage (96 percent) followed by Bangladesh (81 percent), India (75 percent), Nepal (55 percent in 2001 and 72 percent in 2006), and Pakistan (51 percent). Opportunities to provide antenatal check-ups at the time of l 7 immunization are clearly missed. While health workers have a strong mandate and supplies to carry out tetanus immunizations, they apparently lack the skills, time, equipment, incentive and/or household 'permission' to perform antenatal check-ups. 2.19 Despite the high prevalence of anemia in South Asia and uniform policy to treat this, only one-fourth to half of pregnant women in four countries (excluding Sri Lanka) received iron folic acid (IFA) supplements. Inadequate knowledge among health workers of "nutrition" - even of this simple micro-nutrient supplementation action - is a major contributory factor. For example, in three districts of Nepal only 13 to 44 percent of Maternal and Child Health Workers knew the appropriate dose of IFA. Another issue is inadequate knowledge among pregnant women and their families of the importance of IFA and consequent resistance to (or "non-compliance" with) supplementation. Nepal is making significant strides in improving this service: in 2006 60 percent of pregnant women reported receiving IFA supplements. Figure 2.3 Antenatal Care in South Asia, Poorest and Richest Quintiles 100 80 E 60 g 40 20 0 BD IN-R IN-U NP PK SL II Poorest IRichest Computed using data from the following sources: Bangladesh: NIPORT, 2001; India: IIPS and ORC Macro, 2000; NepI: GON-MOH eta].,2002; Pakistan: NIPS, 2001; Sri Lanka: GOSL-DCS, 2002a. 2.20 Antenatal care among illiterate women is half to one-fourth that of women with secondary or higher education in four countries (except Sri Lanka) (Annex 5 Table A5.3). Even in Sri Lanka, only two-thirds of illiterate women received ANC compared with three- fourths or more of literate women. In Bangladesh, rural India, Nepal and Pakistan only the richest economic quintiles have coverage levels comparable to Sri Lanka's overall level (Figure 2.3). I n urban India, coverage among the richest quintile is universal, and the gap between rich and poor is somewhat lower. Only one out of three or four women from the poorest quintiles were checked in Bangladesh, Nepal and Pakistan compared with over three out of four among the richest quintiles. I n Sri Lanka less than half of pregnant women in the estate sector receive antenatal check-ups. There are wide differences in ANC coverage among religious groups in India, with 84 percent of Christians obtaining ANC services compared with less than 65 percent among Hindus and Muslims (Annex 5 Table A5.4). Among Scheduled Tribe women, 43 percent had not received even one antenatal check-up. 2.21 Low coverage with ANC can be attributed partially to the prevailing belief that pregnancy and childbirth are natural processes that do not require medical attention. During a focus group discussion in Bangladesh a participant declared: "Why should I go for antenatal care? I didn't have any problem during the births of my last two children, so I don't think it is necessary to go." Such lack of belief in preventive care affects other aspects of reproductive health, and a wide range of misconceptions also exists. For example, many South Asian women believe that if a pregnant woman eats too much, the fetus will be too large, painful to deliver, or crushed in the birth canal. Consequently, pregnant women 'eat down' to keep a fetus small, a practice that contributes to low birth weight. There is some evidence of change in India and Bangladesh (ICRW, 2006), particularly where fertility is declining, suggesting greater awareness and a higher value placed on bearing healthy children. Nevertheless, such beliefs and practices need to be addressed more actively to tackle the serious problem of under-nutrition among pregnant women and children. 2.22 Maternal education, economic status and husband's education play strong positive and independent roles in determining the use of ANC (Annex 5 Table A5.5). The exception is Sri Lanka where none of these factors play a role because services reach all women. Young maternal age is a strongly negative factor. Adolescent girls are thus doubly disadvantaged: not only do they face higher biological risks but they also have lower chances of receiving ANC. Clearly both coverage and quality of ANC, including counseling which is almost absent, need vast improvement, especially in rural areas where the majority of poor and illiterate women live. Socio-economic targeting is needed to deliver services to these needy groups. 2.2.3 Care during Delivery 2.23 In general, about 85 percent of births are expected to be normal and 15 percent complicated (WHO, 1996). While the first group may not need obstetric intervention (and hence could occur at home), the latter require assistance at adequately-equipped facilities. However, all women are at risk of complications and it is not possible to predict into which group they would fall. Untreated or improperly treated complications of pregnancy or delivery can lead to maternal or perinatal death. Hence, the current recommendation is to ensure skilled attendance at delivery whether at home or at a health facility and a well-functioning referral system. Skilled attendants include doctors, nurses and midwives trained to conduct normal deliveries and to diagnose and manage or refer obstetric complications. 2.24 Differences in reproductive health care among the countries of the region are widest in care during delivery. Almost all births in Sri Lanka occur in an institution and the use of government facilities is widespread (93 percent). However, a lower proportion of women in the estate sector (87 percent) deliver in institutions. Institutional delivery in Nepal and Bangladesh is abysmally low at less than 15 percent; in Pakistan it is 28 percent and in India, 34 percent. Institutional deliveries are more common than antenatal check-ups in Sri Lanka, while it is the reverse in the other four countries. Rich-poor and education gaps are highest for institutional delivery among all reproductive health services. In Bangladesh and Nepal three to four percent of illiterate women deliver in an institution compared to half to two-thirds of those with secondary or higher education. I n India and Pakistan about 15 percent of illiterate women deliver in an institution. The situation is similar among the poorest women. In Bangladesh, rural India, Nepal and Pakistan, even among the richest quintile of women, half or less deliver in institutions (Figure 2.4). Figure 2.4 Institutional Delivery in South Asia among Women in the Poorest and Richest Economic Quintiles BD IN-R IN-U NP PK SL 7 1 Computed using data from the following sources: Bangladesh: NIPORT, 2001; India: IIPS and ORC Macro, 2000; Nepal: GON-MOH et al., 2002; Pakistan: NIPS, 2001; Sri Lanka: GOSL-DCS, 2002a. 2.25 In Sri Lanka most socio-economic and demographic variables (except birth order) have no influence on institutional delivery as this is near universal, while in the other countries education and economic status have independent effects (Annex 5 Table A5.5). As in the case of some health outcomes and knowledge (e.g., of AIDS and contraception, discussed in Chapter I), caste affects care during delivery, possibly because beliefs about purity and pollution surround childbirth closely. Indeed the 'distance' between health providers and women clients may be exacerbated by 'untouchablility' at this time. 2.26 The role of antenatal care in influencing institutional delivery is strong. In Bangladesh and India the odds of women who had more than three antenatal check-ups delivering in an institution were 15 and 9, respectively, over those who had none. I n Nepal even one ANC visit led to odds of 4.6. The chances of an institutional delivery were lower in the youngest age- group than among older women (odds between 0.3 in Bangladesh and 0.6 in India). 2.27 Many women fear going to hospitals to deliver, believing that they would not have a normal delivery there. As a poor woman in Bangladesh put it: "For money, they (doctors) are ready with knives for surgery." I n Bangladesh more than maternal education and antenatal care, identification of potential delivery complications was the most significant factor determining use of modern health facilities for childbirth (Paul and Rumsey, 2002). Very few home-based births are conducted by skilled attendants: under 5 percent in Bangladesh and 10 percent in India. The determinants of skilled attendance are broadly similar to those of institutional delivery. Power dynamics within households determine the use of health facilities as well as of skilled providers. Most often South Asian women get low priority in household resource allocations, and decisions about contact with outsiders are made by husbands or mothers-in-law. Such dependence and deprivation can have serious repercussions. At a large public hospital in Karachi, Pakistan, about a third of obstetric cases were dead on arrival. Delays were often due to husbands' absences from home and the women's lack of autonomy to approach health providers or facilities on their own (Jafarey and Korejo, 1995). Inadequately skilled service providers can aggravate the situation. An evaluation of the Lady Health Worker program in Pakistan found that nearly 40 percent of LHWs failed to recognize the need to refer cases of pre-eclampsia; and in three districts of Nepal, less than one-fourth of VHWs recognized convulsions as dangerous (Oxford Policy Management, 2002; Bhattarai, 2000). Improving the reach and quality of skilled birth attendance are clearly of critical importance for South Asian women. 2.2.4 Postnatal Care 2.28 The postnatal period is critical for both mothers and infants - the majority of maternal deaths occur at this time, e.g., two-thirds of all in Bangladesh (NIPORT et al., 2003). About four of every ten infant deaths occur in the first week of life. Most of these deaths could be prevented by timely medical attention, but few women obtain care during this period. In India for example, although 65 percent of women received some antenatal care and 53 percent received intra-natal care, only 30 percent received any attention post-partum (Mathai, 1999). 2.29 There are different norms in the five South Asian countries for postnatal care. In Nepal the Ministry of Health recommends that all women receive a postnatal visit within two days of delivery, while in Sri Lanka the policy is to ensure at least two visits to women who had institutional deliveries and three within ten days to those who delivered at home. India recommends three visits during the first six weeks, the first of which should be within a week of delivery. Thus, comparisons of postnatal coverage across the five countries must be made cautiously. More importantly, appropriate standards need to be adopted and implemented, keeping in mind that most women in South Asia deliver at home. 2.30 As in the case of other maternal services, postnatal care is highest in Sri Lanka (75.5 percent of women are visited), low in India (36 percent) and Pakistan (23 percent), and lowest in Nepal (17 percent) and Bangladesh (11 percent). Coverage is two to three times higher among those with secondary or higher education compared to illiterate women in Bangladesh, India and Pakistan. However, even among well-educated women, levels of postnatal care are substantially lower than those of skilled birth attendance and institutional delivery. For example, in Bangladesh only 28 percent of women with higher secondary education and above received postnatal care compared with 66 percent who delivered in institutions and 77 percent who had skilled assistance. These gaps show that even follow-up of women who have been in contact with the health system is poor. In four countries (excluding Sri Lanka), while postnatal coverage of women in the richest economic quintiles was very low, it was two to three times higher than that of the poorest quintiles of women. Antenatal care has a strong positive impact on PNC (Annex 5 Table A5.6). A continuum of care from ANC to delivery to PNC would help prevent much maternal and child morbidity and mortality but coordination is often lacking and the poor quality of individual services reduces effectiveness. Exit interviews following antenatal, delivery or postnatal visits to secondary and tertiary hospitals in Multan, Pakistan, revealed that counseling for iron supplementation, breastfeeding, family planning and child immunization was uncommon (Fikree et al., 2003). Good protocols, training and support of health workers are needed to improve these services (including check-ups, referral and nutrition) and 'integrated targets' could help to improve reach and effectiveness. 2.2.5 Immunization of Children 2.31 In South Asia childhood immunization is provided through Reproductive or Maternal and Child Health programs - hence its consideration here. Child immunization coverage is an indication of continued contact between mothers and health services, and is less affected by the taboos that keep post-partum women away from service providers. In the region, Sri Lanka has the highest child immunization coverage (94 percent) followed by Pakistan (77 percent), Nepal (66 percent in 2001, which had increased to 83 percent in 2006) and Bangladesh (65 percent). Despite continuous and strong emphasis on this service in India, only half of all children are fully immunized (UNICEF, 2004). Data on dropouts indicate a lack of tracking mechanisms and follow-up - for example in Bangladesh, although 95 percent of infants received the first vaccination (BCG), only 70 percent obtained three doses each of DPT and OPV and only 65 percent received one dose against measles. 2.32 Immunization coverage of children increases substantially with maternal education and economic status. Although levels among the richest quintiles in Nepal and Pakistan are similar to those in Sri Lanka (around 90 percent), in India even in the richest urban quintile coverage is 76 percent. One reason for India's current low coverage is the decline of routine immunization activities in favor of episodic approaches such as the Pulse Polio program. On the demand side there continues to be resistance among families who are not adequately reached by information efforts. Substantial differences are seen between children of women who are illiterate and those who have had at least some primary schooling (e.g., in India coverage in these two groups is 28 percent and 47 percent, respectively, and in Nepal it was 57 and 83 percent in 2001, and 74 and 88 percent in 2006). Although immunization increases further with more education, differences are not as large. In Sri Lanka over 80 percent of children of illiterate women are immunized. 2.33 Other factors constant, maternal age, birth order and religion influence immunization. In Pakistan a strong positive influence is seen when mothers are educated to secondary level or above (OR=6 compared to illiterate women). In India there is no significant difference in child immunization among children of the richest rural and urban quintiles, although the former had lower chances of using health services compared to the latter. ANC visits also influenced child immunization coverage. Surprisingly, children belonging to Scheduled Castes in India were more likely to be immunized than those of other caste or religious groups. 2.34 In Sri Lanka immunization is provided largely through government health services. Similarly in Nepal, most children are immunized at public health facilities or outreach clinics. In India also, the public sector is the major source of immunization, accounting for 36 percent while overall coverage is 43 percent. NGOs provide 16 percent coverage in urban areas and 3 percent in rural areas, and other private providers for less than one percent in each area. 2.3 REPRODUCTIVE HEALTH SERVICE SYSTEMS 2.35 Having examined the use of health care, and some constraints related to 'permission' and 'ability' that limit demand, we turn to 'availability' (Figure 2.1). This section first briefly describes the government health systems that provide reproductive health services in the five countries, and then discusses private services. Both the public and private sectors are extensive in all five countries. Their relative use varies as discussed here as well as in Chapter 4 on the basis of reproductive health expenditures. This section also describes the 'system constraints' faced by poor women who want reproductive health care. 2.3.1 The Public Sector 2.36 The broad nature of reproductive health services calls for a look, first, at the structures that make policy decisions, plans and intra-sectoral financial allocations in the five countries. I n Nepal, India and Sri Lanka health and family planning services are under one Ministry at the national level.6 Even so, different departments are involved in reproductive health and coordination between them tends to be weak. For example in India, both the Health and Family Welfare departments have roles in reproductive health as well as a department in charge of women and child nutrition in a separate ministry. I n Bangladesh family planning is under the Director General of Family Planning (DGFP) and health services under the Director General of Health Services (DGHS). I n Pakistan a decision was taken in 2003 to integrate the Ministry of Population Welfare (responsible for Family Planning) and the Ministry of Health (responsible for Maternal and Child Health). Integration of the outreach workers of the two programs was accomplished successfully but moving beyond to the facility level and above remains a challenge. Thus, functional as well as managerial integration, accompanied by a rationalization of structures at the national and sub-national (state/province/etc.) levels, is an important reform to improve reproductive health services. 2.37 In all countries, reproductive health care is provided largely through primary and secondary facilities (Table 2.2; Annex 6 provides a fuller description including the current status of the systems). While the service structures are broadly similar, worker- and facility- population norms and skill levels differ. Two differences are immediately apparent between Sri Lanka and the other countries which may partly explain the former's better performance. At the primary level in Sri Lanka, a well-functioning preventive health network gets most reproductive health services actively out to women, rationalizing their use of curative facilities, while in the other countries primary preventive outreach activities are limited so that health centers receive a mix of preventive and curative demands. Second, the technical expertise available at each service level in Sri Lanka is generally higher, and the quality of similar cadres of service providers may be better than elsewhere. For example, the PHM in Sri Lanka is better trained, skilled and focussed on reproductive health care than her counterparts in the other countries. She also has clear responsibility for counseling and for serving pregnant adolescents (even if unmarried), which is not the case elsewhere. A thorough review of job descriptions, needed and actual skills, training and performance of these workers would help to identify bottlenecks in their ability to meet the reproductive health needs of their assigned populations. Table 2.2 Norms for the Public Reproductive Health Service Systems in the Five Countries 6.These arc the Ministry of Health and Population (MOHP) in Nepal, the Ministry of Health and Family Welfare in India, and the Ministry of Health Care and Nutrition in Sri Lanka. In Nepal, the Population Division of the MOHP is responsible for other aspects of population policy and activities other than service delivery. key reproductive health staff to show the expertise available at each level.*** The focus is on the rural health system and facilities included are illustrative. Health Posts and Family Welfare Centers provide services in urban areas. 36 2.38 Utilization of the Public Sector. Despite extensive governmental health systems in all five countries, coverage and quality are of grave concern. Each country has set meaningful norms in terms of worker:population and facility:population ratios, but in many areas these ratios have not been achieved. This is especially true in "backward" areas where infrastructure is generally poor, and results in a vicious cycle of ill-health and under- development. Sparse, distant and poorly connected facilities constrain use and reduce outreach. I n Sri Lanka this concern is strong in the North and East where the ethnic conflict has led to non-functioning facilities, and in the estate sector where the normal pattern of health facilities was not established earlier. I n the other countries, the problem is more widespread, though variable. Even Indian states that have better health such as Kerala and Tamil Nadu have areas that remain under-served. Further, the use of population norms has resulted in the public systems 'running to stay in place' as populations continue to grow, and uneven demand on facilities. I n most cases, staffing is inadequate or imbalanced. Reproductive health services suffer particularly from vacancies in female paramedical positions, nurses and women doctors. The neediest populations often have the poorest worker:population ratios. Existing staff are allocated larger areas; overstretched and faced with geographic and/or social obstacles they provide poor coverage and quality. Absenteeism is high at primary and secondary health facilities, affecting both ambulatory and in-patient services. 2.39 Both clients and providers perceive the inadequacy of staff to be a key problem in service delivery. I n Pakistan providers mentioned that at outlets of the Population Welfare Department the lack of trained staff results in a concentration on family planning services although the mandate is to deliver maternal and child health care. I n India PHCs often do not conduct deliveries because of the absence of female doctors or indoor staff (Murthy and Barua, 1998; Tata Institute of Social Sciences, 2003; Kavitha and Audinarayana, 1997; Rana and Johnson, 2003). Both vacancies and absenteeism are caused by unwillingness among trained professionals to work in rural areas with poor infrastructure, inadequate 'compensation', and limited opportunities for professional growth. Female doctors and paramedics are reluctant to live in isolated places with inadequate security. The conflicts in Nepal and Sri Lanka have severely depleted staff in the affected areas. 2.40 I n addition to staffing-up, greater attention is needed to provider skills, motivation and efficiency. Technical knowledge needs to be improved at all levels. Even simple procedures may be poorly performed. A study of hygiene in Nepal observed that hands were not washed routinely before and after treating patients (Friedman, 1996). Workers are poorly motivated as (in addition to their heavy workloads, poor skills and inadequate supplies) supervision tends to be punitive rather than supportive or capacity-enhancing, and there are few incentives. Many doctors and nurses engage in dual practice (whether permitted or not), often referring patients from public facilities to their private clinics and cutting corners in their public efforts. Among the most important needs of public reproductive health care (which is highly dependent on motivated workers to reach out, especially to poor women) are strategies and plans to improve worker performance. 2.41 Basic amenities and maintenance are often poor at health facilities. Inadequate water and toilets deter clients and hamper service delivery. For example, an assessment of 40 facilities in Pakistan found that only 13 percent of Basic Health Units and 62 percent of Rural Health Centers had 'good' basic infrastructure (Aziz, 1998). Problems are often found in the availability/functioning of equipment, from the simple to the sophisticated. As a Senior Staff Nurse at an Upazilla Health Center (UHC) in Bangladesh said: "We have only one labor table and one set of instruments. Sometimes we have to conduct labor on the floor or on a trolley." The lack of one item can render an entire system dysfunctional: another UHC in Bangladesh had blood grouping and storage facilities but the absence of a blood-bank nearby led to patients who needed blood transfusions being referred to a higher-level facility. Failure to supply medicines is a major cause of client dissatisfaction. A doctor at a primary health facility in Pakistan summed up the situation: "Why would others come when we have very little to offer those who do come?" (Khan et al., 2000). 2.42 Referral and follow-up also need to be strengthened. For example in Nepal, clinic staff seldom provided referrals to clients with medical problems, and they often did not even mention that a client should seek medical advice (New Era, 2004). Almost everywhere, visits to secondary or tertiary hospitals are direct, without prior consultation at primary facilities. Providers in Pakistan highlighted the need for greater coordination between community-based workers and health facilities so that the fieldworkers could refer clients properly. None of the countries has a well-established system of fixing dates or reminding patients to pay follow-up visits for antenatal or postnatal care, family planning, and so on. 2.43 Lack of privacy and rude or insensitive behavior among public service providers are among the important reasons why women prefer to approach private practitioners. In India women complained that government doctors dismissed their complaints about the side effects of contraceptives or post-abortion complications (Murthy et al., 2002). Consequently, they either did not seek treatment (30 percent) or sought it from private providers (50 percent) who were often unqualified. I n general, patients preferred private facilities as they found staff more attentive to their needs, especially in cases of emergency. Providers at public facilities give a number of explanations for these behaviors, ranging from high patient loads to clients' "ignorance" - particularly among the poor or uneducated. Serious social biases are evident - clients belonging to lower castes in India and Nepal often feel discriminated against. A participant in a focus group discussion in Pakistan said: "We are poor and so the female doctor at the hospital does not even talk to us properly. She is very rude and considers us to be worse than animals. On the other hand, her behavior is impeccable when she talks to well- dressed women" (Pakistan Poverty Assessment, 2003). In Sri Lanka, where the use of public health facilities is very high (85 percent of inpatient care is provided by the government), the majority of respondents were satisfied with way they were treated. 2.44 In sum, there is clearly still a need in all countries to invest in the physical facilities of government health centers, including equipment, supplies and maintenance. The deployment and performance of staff are crucial areas for improvement. Accountability among providers must be increased - they must be held responsible for coverage, quality, continuity of care, and health outcomes. The vicious cycle between inadequate facilities, skills and poor performance must be broken. This could be done through efforts to identify and solve problems locally - for example, through decentralized action planning, which is the subject of Chapter 3. Regular monitoring and evaluation are the corollaries of good planning and problem solving. In Sri Lanka several mechanisms are used to monitor quality and credited with achieving results: a routine management information system, district reviews, special reviews (e.g., for Well Women Clinics) and maternal death audits (which are considered "best practice"). While these measures need to be implemented more vigorously in Sri Lanka, they also provide examples for other countries. 2.3.2 Private Services 2.45 Private reproductive health services in South Asia are provided by both the commercial and not-for-profit sectors. Commercial providers include individual medical practitioners clinics, dispensaries, nursing homes and hospitals following allopathic ('Western"), homeopathic or indigenous systems of medicine. There are also registered pharmacies, laboratories and formally-trained paramedics. An informal sector includes "less-than-fully - qualified" practitioners, faith healers and traditional midwives (dais). In the five countries, the formal private sector is concentrated largely in urban areas and spread thinly in rural areas, while the informal sector is predominantly, though not solely, rural. For example in Pakistan, rural areas with almost 70 percent of the country's population have 30 percent of the country's private health facilities. This pattern is repeated in Bangladesh, India and Nepal. Incomplete data indicate that in these countries there may be three to four times as many formally-qualified practitioners in the private sector compared with the public, and up to twice again as many "less-than-qualified" providers. I n Sri Lanka there appears to be a more even distribution between the public and private sectors, the ratio of trained to untrained practitioners is higher, and there is a better spatial distribution of trained providers. 2.46 The private sector provides care to the majority in all countries except Sri Lanka. I n Pakistan for example, it serves 60 to 70 percent of the population (Haq, 2001). Even poor people use private care to a greater extent than public services. Ease of access importantly determines use of private facilities but women seeking reproductive health care also feel that they receive better quality services and they appreciate the greater confidentiality, "better behavior" and flexible payment arrangements of private providers. I n India the private sector bears 60 percent of the case load of maternal and child services (Kavitha and Audinarayana, 1997; IIPS and ORC Macro, 2000). I n Bangladesh the proportion of households using government health services for treatment was estimated as 10 percent, while 60 percent of clients consulted unqualified practitioners (CIET, 2003). I n reproductive health the poor qualifications of private practitioners are clearly evident in the high proportion of abortions that are botched. Using spending is a yardstick to compare the use of private and public services, one-half (in Sri Lanka) to over three-quarters (in the other countries) of health care is provided by the private sector (see Chapter 4). 2.47 Non-Governmental Organizations. There is also a wide range of non-profit organizations in the reproductive health sector in South Asia. I n Bangladesh non- governmental organizations (NGOs) provide as much as 40 percent of all reproductive health care, in contrast with the other four countries where their coverage is limited to a few percent. They provide both curative and preventive care, the latter including contraceptive services and health education, especially for family planning, STIs (including HIV/AIDS) and safe motherhood. I n curative care, their main focus is maternal and child health. While some NGOs are localized, others have extensive networks across their country of operation. For example in Pakistan, the Family Planning Association of Pakistan, Marie Stopes Society and Aga Khan Health Services, and in Bangladesh, BRAC and the Marie Stopes Society have a wide presence. The Family Planning Association of Sri Lanka and Population Services Lanka Limited have a large network of associated sub-national organizations. The Family Planning Association of Nepal is involved in the full range of reproductive health services, having gradually shifted its focus from family planning to comprehensive sexual and reproductive health. I n Sri Lanka in recent years NGOs have increased their care (and legal assistance) to victims of gender violence. On balance, however, the non-profit sector in South Asia leans toward preventive and promotive health, providing less curative and clinical services. 2.48 I n India the NGO sector covers an estimated 4 percent of the population and is diverse in capacity and performance. An evaluation of a USAID-supported program that involved 131 small and large NGOs providing primary health care in remote villages in 13 states found, on the whole, that the NGOs performed rather poorly, particularly in ensuring community participation and the sustainability of their efforts (Ved, 1997). Generally, however, NGOs in the health sector are believed to be pro-poor, client-friendly and more "rational" in their use of medicine than the public sector, thereby achieving greater efficiencies and reputations for more sensitive and better managed care. These attributes and their willingness to work in backward or remote areas make them useful partners to meet reproductive health goals. 2.3.3 Public/Private Shares of Reproductive Health Services 2.49 Few data are available for the five countries (particularly Nepal and Pakistan) on the private and public shares of reproductive health care, and comparability is a moot issue. I n general, and in some contrast with "general" health care, public sources tend to outstrip private services for immunization, family planning and antenatal care. On the other hand, private sources (particularly if traditional providers are included) surpass public providers for treatment of RTIs/STIs, abortion and "home deliveries". There are some exceptions to these generalizations. For example, greater availability of medical abortion in the public system in Bangladesh is encouraging a shift to it, while community-based distribution and social marketing are increasing private provision of birth spacing. As institutional deliveries in India increase, a greater share is being provided by the private sector, and the private market share of condom distribution has increased not only because of higher over-the-counter sales but also because of social marketing (some of which is through public-private partnerships). I n Sri Lanka provision of reproductive health care is overwhelmingly public. 2.50 I n addition to differences by type of service, use of public/private providers varies by socio-economic status. I n Kerala, the Indian state which has amongst the most favorable reproductive health indicators in the Subcontinent and good services in both the private and public sectors, there are wide variations by service and economic quintile (Table 2.3). The poorest people obtain greater shares of all three services from the public sector, while the reverse is true for the richest and middle quintiles (Mahal et al., 2001). In other states which do not have as well-developed services nor as favorable heath indicators, the proportion of hospitalization at public facilities among the poorest is roughly the same (57 percent in Kerala and 55 percent in UP); but among the richest, 29 percent of hospitalizations in Kerala and 39 percent in UP were at public facilities. Furthermore, while the richest quintile in Kerala has about 1.5 times the hospitalization rate as the poorest, in Uttar Pradesh this ratio is 5. I n Orissa, another poor performing state, the private sector accounts for less than 15 percent of hospitalizations among the richest quintile, and only 8 percent of those among the poorest quintile. During the 1990s in India the private sector share of both out-patient and hospitalization services grew considerably in both urban and rural areas and among the poor. Table 2.3 Private and Public Share of Health Services in Kerala, 1995-96. Source: Adapted from Mahal et al. (2001) 2.51 I n Bangladesh 36 percent of institutional deliveries took place in private (including NGO) facilities, and the rest at government health facilities (NIPORT et al., 2003). Of 62 percent of pregnant women who sought care for a life-threatening condition, almost as many went to an unqualified private doctor as to a qualified doctor (private or public) (Table 2.4). Among 42 percent who sought treatment for non-life-threatening conditions again almost equal shares went to unqualified and qualified doctors. Among those who sought treatment for life-threatening conditions outside the home, almost equal shares approached government facilities and private/NGO facilities. However, for non-life-threatening conditions a far larger share used private facilities. The poorest quintile used more unqualified doctors than the richest, and fewer qualified doctors overall for both types of conditions. When facilities are compared, however, the poorest use government facilities proportionately more than private facilities for life-threatening conditions than for less severe ones. A study in Gujarat is germane to these data. It suggests that women's education, income and family structure were important predictors of the use of private/governrnent/NGO/traditional services, and that women were more sensitive to the social and indirect costs of services (travel time, transport costs) than to direct costs (Vissandjee et al., 1997). Table 2.4 Public and Private Shares of Consultations by Pregnant Women in Bangladesh, 2001.' Y&i$di&$rj 24.8 27.6 21.9 22.7 15.2 17.8 17.2 33.9 &d$hpsy 53.5 ui*A l i 1 *, 16.3 30.1 38.3 45.0 10.6 27.0 51.3 Alg-i* 42 ,-; 27.5 25.3 23.6 25.9 19.0 16.9 20.8 35.9 Note: a. Columns 2 and 3.4 and 5,6 and 7, and 8 and 9 can be compared. Those who d ~ not seek assistance or who approached d paramedics or TBAs are excluded from columns 2 and 3, and 6 and 7; and those who sought treatment at home are excluded in columns 4 and 5, and 8 and 9. Source:NIPORT et al., 2003. 2.3.4 Public-Private Partnerships 2.52 There have been many and various types of public-private partnerships (PPP) in the reproductive health sector in South Asia. In a unique example from Sri Lanka, the services of doctors (especially specialists) from the government sector are provided to the private sector through 'channelling centers." Doctors officially provide services during their free time and charge consultation fees. This arrangement helps the private sector to cater to the demands of those who are well-off and able to afford paid services. Further, there is co-operation in emergency care. Government specialists who are Visiting Consultants in the private sector have the option to refer patients in emergencies to the government hospital where better facilities exist.' These arrangements exemplifying public to private human resource flows in Sri Lanka and contrast with PPPs in the other four countries that involve contracting in of private providers or contracting out of services because of manpower or infrastructure deficits in the public systems. 2.53 In Bangladesh the Government's Health and Population Sector Program (HPSP) includes an initiative to support NGOs to deliver MCH and FP services to poor and under- served communities. Essential health care services have been implemented through this PPP model in two upazillas. While successful, it is unclear how this will be scaled up to the national level (i.e., to about 460 upazillas). In India's Child Survival and Safe Motherhood Program and its successor, the Reproductive and Child Health Program, a large number of NGOs have received support for service delivery, and many involved in health communications and training. Although useful to extend coverage, the reach of these efforts has been short of expectations and the adoption of innovative or improved practices by the public sector, a desired by-product of the PPPs, has been slow. 2.54 In Pakistan the Ministry of Population Welfare has Reproductive Health Centers located within larger public and private health facilities to provide a range of family planning services. A bold initiative in the mid-1980s was the social marketing of condoms through private channels to expand information and services to a larger clientele. This PPP has been quite successful (see Chapter 3). Another type of partnership involves public facilities being run by private agencies such as the Punjab Rural Support Program. If current examples work well, the government aims to turn over other poorly functioning health centers to private managers. A similar strategy has been successful in some states of India (e.g., Maharashtra and Gujarat), but there have been few 'takers'. Not only are there a limited number of suitable applicants, but many consider the government's terms and conditions too rigid. 2.55 A number of other PPPs have also been tried in India in addition to social marketing and franchising of family planning services and contracting out of government health facilities. Private service providers from anesthetists to laundries and security-guards have been contracted in. NGOs have been involved extensively in community mobilization, IEC, HIVIAIDS counseling and care, training and advocacy in reproductive health. In the RCH program the services of private gynecologists and anesthetists are engaged for CHCs with operation theaters to perform Caesarean sections. However, implementation is scanty due to a lack of interest among private practitioners (who fear losing their practice) as well as government staff (who do not want the additional workload). 2.56 I n sum, the government ministries responsible for reproductive health in all the five countries have sufficient experience of the potential and pitfalls of PPPs to develop a more systematic approach to these to meet the desired objectives. The objectives encompass: providing more and better services, reaching more poor women, developing innovative strategies, and improving public system performance. The pitfalls include private entities feeling that they are treated shoddily by the government personnel with whom they interact, that they are inadequately remunerated, and/or that they do not have the flexibility they need to provide better care, and government officials believing the opposite! Such problems need to be addressed when developing PPPs in the future. '.In contrast, in Bangladesh and some Indian states, private practice by government staff is permitted after working hours but there are no formal arrangements, while in Nepal, Pakistan and other Indian states, such dual practice is not permitted. 2.4 INCREASING USE OF SERVICES 2.57 Despite extensive services, public and private, in all countries of South Asia, the access of poor women to reproductive health care remains limited. I n Sri Lanka reproductive health care coverage is high and quite equitable. Using its achievements as a yardstick, we find that even family planning coverage in the other four countries falls short by 25 to 60 percent. Despite long-standing family planning programs in all countries, even low demand from the poor is not met. Given high unmet need for contraception, the significant use of abortion is not surprising. A substantial proportion of poor women do not receive any care during pregnancy. Although anemia (an easily preventable and treatable condition) is widely prevalent and has serious consequences, only one-fourth to one-half of women receive iron supplements. Differences in reproductive health services among and within the four countries are most evident in care during delivery. Rich women are five to ten times more likely to deliver in an institution than poor women. Post-natal care falls far short of its potential to avert maternal and neonatal deaths. Immunization (except tetanus toxoid in Pakistan) is the most equitable service, followed by contraception. 2.58 Both demand- and supply-side constraints are responsible for low use of services. The supply of services is limited by the unavailability of facilities, staff or medicines 'at the right place and time'. Supply-side problems that inhibit demand include: perceived low efficacy of treatment (read: inadequate technical skills), poor state of facilities (managerial standards), bad behavior of staff and culturally-unacceptable care. Demand-side constraints include: low knowledge of the need for and availability of services; cultural barriers to women approaching appropriate service providers on their own; and the formal and informal costs of care (even at public facilities, and including indirect costs such as transportation or wages foregone). 2.59 Health sector reforms must focus on increasing the supply of services to poor women, and on enhancing demand and quality so that services are used and improve health. On the supply side, there is a need to ensure fully-functional facilities and increase their numbers in under-served areas, as well as to improve outreach by service providers. Both these needs could be partially met through greater participation of private providers under various forms of public-private partnerships. In addition to improving availability, targeting the poor and integrating reproductive health services would achieve greater efficiencies for providers and users, and improving management and skills would enhance quality. Interventions that would enhance demand include: more information, incentives to use services in time, and financing mechanisms that reduce the burden on poor households. 2.60 The most important functional improvements are: ensuring the availability of doctors (especially women) and nurses at health facilities; adequate drugs and supplies; better amenities (especially water and toilets); better behavior of staff toward poor and female patients; and reduced waiting times. As physical distance is a significant constraint, this must be addressed by better location of facilities and/or outreach mechanisms including field workers and mobile service teams. Outreach workers can also help to increase demand, for which their counseling and communication skills and technical knowledge must be improved. Their mandate to serve adolescents and poor women must be strengthened and their demand- creation efforts must be reinforced through other public education means - mass media, campaigns, school and youth programs, and so on. Integrating the essential package of reproductive health services (Annex 4), including RTIISTI care, safe abortion and nutrition, at the frontline would increase access, improve quality and optimize the use of available resources. To achieve this, it would help to integrate the departments of family planning, health and nutrition where these are still separate. 2.61 Most of these improvements (with the possible exception of increased numbers of facilities and staff) can be brought about with available resources thorough better planning and management (including logistics). Better management of workers and incentives are necessary to improve delivery. The availability of services could be increased by developing functional synergies between the public and private sectors through PPPs. For example, the public sector could contract out services that are currently in short supply, such as safe abortion, and contract in others, such as anesthetists for FRUs. The success of social marketing in contraceptive delivery could be extended to other services. 2.62 Quality assessment and improvement must encompass health facilities (buildings, amenities, equipment and supplies), human resources, and service delivery processes (e.g., provider behavior, information provision, and privacy), and take into account individual/household knowledge, behavior and satisfaction. Human resource development is perhaps the most critical ingredient to improve the quality of reproductive health care in the five countries. It includes ensuring that staff are available (i.e., positions adequate and filled), working (not absent), up-to-date in knowledge and skills, and able to interact and communicate sensitively and effectively with clients. Quality also entails specification of what is to be done and how, standard-setting and commensurate monitoring. Some strategies to improve the quality of specific services are discussed below. 2.63 Contraception. Expanding the menu of contraceptives (especially to include spacing methods where these are currently limited, as in India), providing informed choice, strengthening follow-up, managing side-effects, and actively promoting male methods and involvement are needed in all countries. A broad method mix would increase overall use and continuation, and reduce failure rates, abortion and coercive sterilization. The difficulties of providing services to adolescents and secluded women and the burden of RTIs/STIs/HIV/AIDS call for condoms and "dual protection" to be promoted actively. Given the aggressive nature of family planning programs in the past, it is particularly challenging to provide contraception in a 'user-friendly' manner and address women's specific needs. Sound programs require strong technical and counseling skills and social and gender sensitivity among providers. Ensuring home visits to advise husbands and wives together to discuss their family planning objectives and preferences would be an effective strategy to address unmet need and increase demand. Family planning education through mass media, based on accurate social and cultural understanding (especially of the problems faced by poor young women), could create an enabling environment for services. Public education is also important to dispel misconceptions (such as those that surround injectables in India). 2.64 Abortion. The large number of abortions, complications and deaths reflect a serious failure of reproductive health policies in the region. Ready access to safe and confidential abortion is a critical need everywhere. Sri Lanka and Pakistan need to liberalize their abortion laws, and all five countries need to enforce safety laws, regulate clinics and penalize providers of unsafe abortions. Qualified providers can be encouraged to use the safest methods such as manual or electrical vacuum aspiration. Mifepristone (recently legalized in India) is a safe and effective option if providers are adequately informed. Importantly in South Asia, where women's decisions about abortion are often taken jointly with their husbands, mothers-in-law or other family members, IEC and counseling programs should include these people to ensure 'safe' abortion decisions, post-abortion care and contraception. PAC is essential to reduce mortality due to unsafe abortion. It includes emergency treatment of complications, family planning counseling and services to prevent repeat abortions, and links to other reproductive health services, such as diagnosis and treatment of RTIs. The experience in Bangladesh of providing menstrual regulation through trained providers such as nurses and midwives could be extended through appropriate training to providing PAC. 2.65 Skilled Birth Attendance. Given the positive association between antenatal care and use of skilled birth attendance, expanding ANC could increase women's chances of safe delivery and survival. This is particularly important given the socio-cultural and physical barriers to institutional delivery in South Asia. Demand-side financing mechanisms, such vouchers for pregnant women to use safe delivery facilities in the public or private sectors, and/or reimbursing transportation and other costs, could reduce economic constraints. Although traditional birth attendants (TBAs) are not classified as skilled, they could be given incentives to refer pregnant women to qualified birth attendants or facilities. Safe motherhood demonstration projects in Ghana and elsewhere have shown that a brief course in obstetric life-saving skills given to staff at primary and secondary health facilities can be effective in detecting life-threatening obstetric conditions (Osei et al., 2005). Improving maternal health through ANC and safe delivery will also enhance neonatal and infant survival, as Sri Lanka's experience shows clearly. 2.66 Postnatal Care. Strengthening outreach to ensure that every mother who has delivered at home receives a check-up and care within 24 hours of delivery could help to reduce maternal and neonatal deaths. Financial support (vouchers or refunds) to use medical facilities in case of complications would be helpful at this time. As many home-based births are conducted by TBAs, they must be trained to refer women with postpartum complications. Counseling women and informing the public at large about danger signs would also be helpful. 2.67 In the context of South Asia's tenacious patriarchy, addressing gender issues is essential to improve both supply and demand for reproductive health care. Unfortunately, gender equality is still poorly understood and practiced by the health sector in most areas of the Subcontinent, but some bias can be reduced through better design of facilities and programs (e.g., by ensuring privacy, involving men in maternal care, nutrition, RTIISTI treatment, etc.), availability of services (e.g., male contraceptive methods), and provider status and behavior (e.g., proper remuneration and support of women workers, sensitive treatment of women clients). Indeed, male involvement in reproductive health is a promising area of action to promote demand for and utilization of services by women. Chapter 3 Planning and Practicing Better Reproductive Health Although the five South Asian countries studied have had programs in place for several decades to address aspects of reproductive health, their outcomes have not been commensurate with expectations for a variety of reasons. Many socio-cultural, political, institutional and technical factors have caused the inequalities in service utilization and reproductive health status discussed in the previous chapters. The inequalities can be attributed also to normative planningand supply-driven implementationof health programs, without adequateattention to local needs, conditions or demand. I n all five countries the most backward areas and worst affected people require urgent attention if disparities are to be reduced and the MDGs achieved. This can be done through decentralized planning, with appropriate resource allocations to correct inadequacies. The chapter recommends a practical and simple method to plan actions to address local needs and inequalities and use available resources optimally. The method involves managers, providers, clients, local government representatives, and other important stakeholders. The planning can be done at the district level or below. Actions are developed on the basis of local analysis of needs and promising approaches, and a cyclical process of planning, implementation and monitoring builds the capacities of the health services and communities to improve health care. Good use of resources and demonstrated ability to get results could help decentralized units get the additional resources they need. Decentralized Action Planning can be used to increase the supply of services to poor women by targeting geographic areas, villages and households for attention, including outreach. It can also enhance demand where needed by targeting BCC and demand-side financing; identify supply-side improvements that would address local constraints; and ensure that programs for sensitive groups such as adolescents or tribal people are appropriately delivered. It can foster the integration of services, strengthening those in the essential package that are weak locally, providing the necessary tools and training to implement a client-centered approach, and measuring performance accordingly. To energize preparation of effective action plans for reproductive health in South Asia, the chapter identifies and presents some 'promising practices' These focus on 'how' more and better reproductive health services can be delivered. They include demand- and supply-side efforts and address access, quality of care and program management. Some focus on creating enabling environments to improve women's health. The practices were selected after a thorough search for field-tested efforts that have had measurable impacts. To bring a fillip to local praxis, particular attention was paid to practices that are innovative and represent 'out-of-the-box' thinking, and could be implemented, scaled-up and sustained in South Asia. 3.1 DECENTRALIZATION TO BRIDGE INEQUALITIES 3.1 Decentralized health planning has been and is being carried out in various ways in each of the five countries. In 1994 Bangladesh devolved the planning and financial management of family planning services to the sub-district level. It allowed local governments to allocate locally-generated funds to implement the program. In 1998 the Local Initiative Program started 'bottom-up' input planning to promote community-based action and ensure more equitable, pro-poor allocations of health resources. However, the approach is considered complex and time-consuming as it involves formulation of logistic and procurement plans among other things (Cooper-Stephens, 2001). 3.2 In India, decentralized planning began in the mid-'60s with block-level planning for Community Development, and has continued in the form of sectoral plans and multi-sectoral district and state plans which have established the bases for programs, activities and resource allocations. Districtlstate health plans have been funded largely on the basis of 'past actual expenditure plus' per capita or per facility, and have not been prepared in a participatory manner. In 1993 the adoption of the 73rd and 74th Constitutional Amendments provided for elected local governments to manage some aspects of health services, providing a new framework for planning and implementation. The introduction of a Community Needs Assessment (CNA) approach in the Family Welfare program in 1998 was intended to produce quality improvements from the sub-center level upward, but 'top-down' introduction of formats and poor preparation stymied its success (Policy Project, 2000). This experience resulted in recognition of the importance of decentralized service delivery and integration of reproductive health services, and various approaches to decentralized planning are being tested in different programs or parts of the country. 3.3 In Pakistan, devolution was introduced through a Presidential Ordinance in 2001, and the roles of district and provincial governments in planning, personnel management and procurement are still evolving. Nepal's Local Self Government Act of 1999 devolved management of health care from the central and regional directorates to lower levels. The first major step of transferring the property, equipment and staff of all Health Posts and Sub- Health Posts to Village Development committees is unfolding slowly. Beginning in 2004, Pro- Poor District Health Investment Plans are being prepared as part of the Second Long-Term Health Plan (1997-2017), which is expected to accelerate the decentralization process. I n Sri Lanka, health administration was decentralized in 1987 with the passage of the 1 3 ~ ~ Amendment to the Constitution and planning is decentralized. The Central Government, however, retains responsibility for formulating and administering the National Health Policy. 3.4 In essence, although decentralized planning is recognized in all five countries as a way to address local variations in health needs, the appropriate methods for such planning are still evolving. Current approaches fall mainly into three categories: (i) need-based planning, (ii) resource-based planning and (iii) norm-based planning. Need-based planning involves assessing local health needs using data on the disease burden, demographic information, and people's responses to questions about health care. The approaches in the GOI's RCH Program and Sri Lanka's District Health Planning initiative are examples of need-based planning. Eliciting people's health needs is important but not fully reliable because respondents usually describe their needs on the basis of recent efforts to obtain curative care, and they rarely perceive a need for preventive care which encompasses many reproductive health services. 3.5 Resource-based planning accepts general health objectives as a given and focuses on allocating uncommitted resources to activities that are under-Funded or flagging. It serves to improve the utilization of resources but usually does not address major gaps or inequalities. Norm-based planning assumes certain input and activity norms and estimates the resources required. Its weakness lies in the poor fit between norms and local situations, particularly in the most backward areas. India's family planning program was an example of norm-based planning that went wrong - considerable resources were allocated over a long period of time to implement activities based on norms, but poor outcomes and inequalities were not addressed adequately. Bangladesh's Local Level Planning is another example. 3.2 DECENTRALIZED ACTION PLANNING 3.6 Although decentralizing health services is national policy in all five countries, and large units such as provinces and states enjoy some autonomy, below this level 'decentralization' is largely restricted to the devolution of certain tasks. Generally, district health organizations plan and finance activities within norms, targets and budget envelops specified by higher-level authorities, manage and supervise the delivery of services, oversee in-service training and coordinate with other government departments. They have little choice between priorities or even activities, and can usually modify resource allocations only on the margin. Existing approaches to planning focus largely on inputs and on the allocation of resources to specific activities. Local action plans are prepared rarely and usually do not address inequalities. 3.7 Our review of the quality of reproductive health care in the five South Asian countries identified many weaknesses in program implementation. All the countries are interested in accelerating effective implementation through local-level planning in keeping with their decentralization policies. As capacities in the field are limited, they need a simple and practical approach that can be implemented with available knowledge and skills. Consequently, during this study, local managers and researchers developed a decentralized action planning (DAP) method, keeping local limitations in mind and aiming to build capacities over time. The participatory nature of the method harnesses local human resources and can lead to the garnering of other local resources also. 3.8 On account of size and the availability of a range of human and material resources, the district was deemed the most appropriate unit for planning in all countries. The DAP method was developed simultaneously in 12 districts in South Asia: four in India (two in Karnataka and two in Rajasthan) and two each in Bangladesh, Nepal, Pakistan and Sri Lanka. The method combines concepts from Total Quality Management and the Problem-Solving Approach to address three key questions: (i) How well is the district doing in terms of coverage and equity in reproductive health service delivery? (ii) Which essential services are under-utilized, especially by the poor, and why? (iii) How can the utilization of these services and their quality be improved? The planning initiates a cyclical process including implementation and monitoring, as shown in Figure 3.1, and described briefly below. Fig. 3.1 Decentralized Action Planning and Implementation: A Cyclical Process Implement and Prioritize and select monitor Action Plans a few services for and services to the action planning 3.2.1 Assessing the Local Situation 3.9 I n order to assess the gaps between actual and expected levels of reproductive health service coverage and equity in the district, information was compiled on the district's demographic profile, health infrastructure, staff, reproductive health indices, government- sponsored reproductive health schemes, and private and NGO resources. Information on privateING0 providers included the types of services they provide and their areas of operation. All the information was presented simply in the local language in consultative workshops at the district level (which were also conducted primarily in the local language). Information on Good Practices in reproductive health (some of which are discussed in section 3.4) was also made available to those involved in the planning effort. 3.2.2 Participatory Action Planning 3.10 Workshops were organized in each district to develop Action Plans. The district teams typically consisted of 20-25 persons, about equal numbers from each of three key stakeholder groups: health program administrators (District Health Officers and those dealing with family planning, reproductive health, health education, and mother and child nutrition), service providers (doctors, nurses, supervisors and workers), and private sector, NGO, local government and community representatives. Members of the planning teams were selected using two criteria: (i) they had a role in the delivery of reproductive health services, and (ii) they were capable of analyzing program constraints and suggesting solutions. 3.11 Each workshop consisted of five sessions, following the first five steps in the process in Figure 3.1. I n the first session, the information on the district was discussed and validated. Team members provided additional or alternative information. Next, reproductive health services were broadly categorized into three groups - Maternal and Neonatal Health, Reproductive Health of Sexually-Active Adults, and Adolescent Health - and participants discussed service provision in their district. They identified one service in each of the three categories that required priority attention using 'inadequacy' and 'inequality' indicators: InadequacyRatio = Performanceof Best District in the State/Province/Reaion Performance of the District Inequality Ratio = Coverase amons the Non-~oor Coverage among the Poor 3.12 This exercise attracted a lot of discussion. For example, a District Health Officer in India was in favor of giving priority to Safe Delivery because it was the most inequitable service. Service providers, however, felt that attention to Full Antenatal Care would ensure Safe Delivery. After a lengthy discussion, the team selected Full ANC and Safe Delivery for action planning. Similar discussions occurred in other districts. I n Pakistan, in the absence of district level data, the teams used a method developed by the Ministry of Health and the Multi- Donor Support Unit to calculate inadequacy and inequality. They scored services on the: Magnitude of the problem addressed by the service, Severity of consequences if the problem were unattended, Availability of feasible interventions, Cost-effectiveness of the intervention, and Public and political demand for the service. 3.13 I n the third session, participants were divided into the three stakeholder groups to discuss why the services they had selected were under-utilized, inadequate and inequitable in their district. Both demand- and supply-side constraints were identified. For example, in Mysore district of Karnataka, India, participants identified a lack of awareness, cost and poor quality as the reasons for low RTIISTI treatment. Using ranking or voting techniques, one or two of the most important problems that are amenable to action for each of the services were selected to be addressed in the action plans. This exercise showed that different problems were perceived to affect the utilization of the same service in different districts. For example, the prime obstacle identified for under-utilization of maternal care in Karnataka was cost, while in Rajasthan (India) it was poor access and in Nepal it was lack of awareness. 3.14 For each problem selected, the planning team identified actions to improve utilization and equity and identified some potential opportunities for and constraints to implementation. I n the next session, the team worked on converting their ideas into action plans using a logical framework. Each Action Plan contains the actions, opportunities and constraints identified. The plans were completed by assigning responsibilities, goals and time-frames, and discussed to check whether any aspects had been ignored or unrealistic assumptions made, to ensure final practical Action Plans. Finally, the members of each stakeholder group assessed the Action Plan on the basis of several criteria: innovation, potential effectiveness, practicality, sustainability, effective resource utilization, and community participation. This final step gave all a sense of the challenges that lay ahead and the impetus to make their 'own" plan work. 3.15 The decentralized Action Plans had several important features including meaningful roles for communities in their implementation, and re-deployment of existing human resources for more effective service delivery. The activities proposed were practical and within the district's control, features which were particularly encouraging to those involved. The participants also realized that over time they could tackle other problems because planning and implementation would be repeated in cycles, and they could take on more difficult issues as they gained in experience and confidence. Although it was not possible to do so in this first round of planning, participatory local-level planning has the potential to identify and utilize a range of local public and private resources (e.g., service providers, facilities, donations in cash or kind) and develop meaningful local partnerships. 3.2.3. Key Lessonsfrom the Pilots 3.16 The pilots in the five countries suggest that the following are important to support a decentralized planning process: Concise and clear information on the district's reproductive health status, service utilization, health resources and policy mandate; A manageable number of participants with different backgrounds who can make positive contributions; A skilled facilitator who appreciates community participation, understands the local health system and management practices, knows national reproductive health programs and strategies, and has critical thinking faculties; A set of locally-appropriate 'promising practices', including information on their implementation process; Community views on how to make plans more pro-poor; Methods to assess the services for which data are not available; Proper monitoring and supervision of implementation, with inclusion of communities in monitoring, in order to improve the next cycle of planning; An efficient Management Information System and use of the data for decision making; Functional inter-sectoral planning and management teams in the districts. 3.17 The DAP process brings about change through understanding (the situation), agreeing (on goals), adapting (practices), improving skills, expanding efforts, and empowering providers and clients. It is similar to the SEED-SCALE model (Ide-Taylor and Taylor, 2002) as it involves "Self-Evaluation for Effective Decision-making (SEED) and is a "System for the Community (of practitioners) to Adapt, Learn and Expand" (SCALE) as it begins with health providers and those most closely related. The health system catalyses change within itself first and then in its community of clients. Several of the principles of the SEED-SCALE model are integral to DAP. It builds on the existing capacities and strengths of those involved in health care, and can increase confidence with each round. It focuses on available resources and assets and plans actions to address needs based on what is possible. Decisions are made and actions planned on the basis of objective local data (evidence). The health managers and providers may need guidance to interpret and use the data which can be obtained from outside experts. Local expertise can also be used to introduce appropriate up-to-date ideas and build capacity, and help to gather better data for the next round of planning, helping the process develop from simple to sophisticated. However, DAP uses fewer resources from outside than working directly with communities, which would require a lot of facilitation. Such resources cannot always be obtained where they are needed or because of the expense involved. Scaling up using NGOs or private professionals would simply take too long given the scale of South Asian countries. I n effect DAP eliminates intermediaries except as facilitators and as decided by the local planninglimplementation teams. 3.3 PROMISING GLOBAL PRACTICES 3.18 As discussed in Chapter 2, operational and contextual factors play vital roles in determining the outcomes of reproductive health services (beyond the technical effectiveness of interventions). It is usually not possible to optimize these factors within short periods or all at the same time. Hence local program managers need to identify and adopt approaches that are most likely to succeed in their specific contexts. The DAP process includes brainstorming about 'what may work' which can be facilitated by examples of 'what has worked'. Many efforts within and outside South Asia have succeeded in enhancing reproductive health in resource-constrained settings.' This section discusses some field-tested practices that could be adapted and/or adopted more widely in the region to address the key problems with reproductive health outcomes and service delivery identified in the previous chapters. To facilitate their use in decentralized action planning, they are grouped into approaches that address demand, access and quality of reproductive health care. While some practices focus on one stage of the reproductive life-cycle, others can be applied to any stage or to reproductive health more generally, as shown in Annex 7 Table A7.1. 3.19 Operational approaches cannot be tested as rigorously as can technical interventions through, say, randomized controlled trials.* However, they can be - and many have been - evaluated for effectiveness. Others may be untested but show promise because they have worked in several settings or are simple enough to be adapted readily to different situations. 'Best' or 'promising' practices range from specific tools or techniques to "packages of interventions" or programs. Clearly the more complex the intervention, the more likely it is to require adaptation to local contexts and the more challenging it would be to make it succeed. 3.20 The discussion of promising practices here and their use in decentralized action planning is not intended to suggest (top-down) that they be replicated or scaled up, but to illustrate the potential of using good practices to enrich DAP and improve implementation. It is difficult to take local successes to regional or national scale as contextual factors are highly variable and administrative units very large. Even districts are geographically varied, covering several hundreds of villages, and 1.5 to 3 million people from many different communities (with different needs, beliefs, behaviors, practices, etc.). Thus "scaling up" can at best be done through gradual changes effected by local teams exposed to ideas that they can adopt or adapt to their own data and contexts. Local NGOs may partner with government (and enter into formal PPPs) to introduce their innovations into the public system as a logical follow-up of their participation in DAP efforts where they share their experience, expertise and insights. The prime purpose of discussing promising practices here is to share some useful ideas that could be infused into the public systems through DAP to improve their effectiveness. '. There have been several reviews of global best practices in reproductive health, notably those by Gelband et al. (2003),Lule et al. (2003)and Nanda et al. (2005)which focus on matemal health. While the first two summarize the impact of various interventions, Nanda et al. also provide two-page summaries of 39 promising approaches. The selected practices cover most technical areas of matemal health and range from needs assessment to monitoring; the enabling environment to community-based approaches, communication and capacity building; and several aspects of health sector reform including accreditation, financing and partnerships. '. Many clinical practices in reproductive health have been scientifically tested and systematically reviewed. The Cochrane Review Collection contains several relevant reviews of the evidence for clinical interventions in all areas of reproductive health. The WHO Program to Map Best Reproductive Health Practices covers evidence-based obstetric interventions. The Better Births Initiative, a related effort, seeks to promote proven beneficial practices related to matemal health. Advance Africa, a project sponsored by USAID, documents reproductive health interventions and program models that have had measurable impact. The database developed as a result includes information on lessons leamed and the program context to help program managers elsewhere apply the practices. The Implementing Best Practices Consortium Initiative assists reproductive health program implementers to enhance their program's effectiveness in a variety of ways. For example, the Consortium assisted Jordan to decide on a single reproductive health training cumculum for counseling, and program for health care providers to avoid duplication (Shears, 2003). The MAQ Exchange is another effort to share the wealth of new information, data and lessons on improving access and quality. 3.3.1 Enhancing Demand for Services 3.21 Generally, health service interventions have focused on improving aspects of supply to enhance the availability and quality of services. These have been supported by efforts to implement "information, education and communication" (IEC) or "behavior change communication" (BCC) activities to increase awareness either to reduce the need for medical care by improving lifestyles and preventive health actions or generate demand for and appropriate use of services. 'Two-way communication' encompassing efforts to solicit users' perspectives on service delivery have been undertaken in order to design solutions that are more acceptable to clients. However, as discussed in previous chapters, knowledge about health or illness care and awareness of services continue to be quite low in South Asia, particularly among poor women and adolescents, and much more needs to be done to improve these. It is important to focus on them in decentralized action planning because of the very localized nature of health beliefs and practices, socio-economic determinants of health and, of course, health service availability. 3.22 Critical questions concerning adolescents include how and where to reach them, in addition to what information and contraceptive and RTI/STI services to provide. Successful approaches include providing information on gender roles and responsibilities, sexuality, safe sexual behavior and reproductive health, and focus on ensuring contraceptive services and counseling, particularly about pregnancy and abortion. These cover the main needs of adolescents in South Asia that were discussed in Chapters 1 and 2. Particularly promising initiatives use peer educators ('animators") or motivators to reach out to adolescents in schools, community organizations, homes or clinics, or a variety of media to deliver simple, appropriate and accurate health messages and promote utilization of services. Some establish special youth centers, use 'edutainment' approaches, and/or broaden content to include social skills ('lifeskills"). Involving adolescents themselves in planning strategies, designing activities and materials, and allowing them to voice to their concerns have been key aspects of these programs. The commitment of staff is an important ingredient in their success. 3.23 While societal changes that enhance the status of women - including increased education - raise demand for services sustainably, as they have in Sri Lanka, Kerala and Tamil Nadu, a number of shorter-term approaches have been used to enhance demand among poor women. IECIBCC strategies are used widely and appear to have variable chances of success as they depend heavily not only on content and mode of delivery but on the local social, economic and political situations of poor women. As in the case of adolescents, creative efforts such as the "3W Safe Motherhood Game in Senegal" build on local context, generating interest among clients and providers (Spadacini, 2001). In this example, women's awareness of maternal and child health risks is heightened through association with local cultural images, beliefs and proverbs. Evaluation showed increased knowledge of risk factors among the women who participated, and an increase in the number of women who completed three antenatal visits. The interest created in the communities is believed to be spreading the message of safe motherhood even further. Also widely practiced are participatory approaches to delivering or managing services which are similarly sensitive to context - unless poor women are targeted specifically, they are often 'crowded out' by the better-off, and unless they perceive the activities in which they are involved as having high returns to their scarce resources of time and energy they are ineffective or unsustainable. Many initiatives have used community-based women's groups to raise awareness of reproductive health needs and rights, mobilize women's participation and enhance use of services. 3.24 Involving men in reproductive health programs has also shown the potential to achieve better outcomes for women and reproductive health (Anon, 2003~).Successful efforts in India include PRIME I1and Shramik Bharti's Community Partnerships for Safe Motherhood in Uttar Pradesh and Pati Sampark in Gujarat (India). The latter program engaged men in monitoring their wives clinic attendance and consumption of nutritional supplements during pregnancy. Evaluation found that women whose husbands participated in the program attended clinics six to seven times compared with two or three times among others, and men's awareness of family planning was also increased. Another NGO in Gujarat, Sewa Rural, organizes health workers' visits according to men's schedules so that husbands can be involved in discussions and actions for Safe Motherhood. This has led to a 40 percent increase in men seeking out health workers to register their wives early for antenatal care, one-third of men accompanying their wives to hospital, and a significant increase in the number of fathers bringing their infants for immunization. In Pakistan Punjab, a project set up demonstration sites for men's reproductive health services, with each site developing its own strategies to promote services. At one, community religious leaders became very involved; at another, rickshaw drivers were trained to answer basic questions about the clinic and men's services. Vasectomies increased four fold as a result of these innovations (EngenderHealth, 2003). Such location-specific action makes programs work on the ground and calls for health managers to be flexible in allowing and financing different approaches rather than prescribing the 'how' of implementation from above and afar.3 3.25 In addition to improving awareness, protecting the poor from the adverse financial consequences of illness can increase demand for services. Karnataka's Yeshasvini Scheme is among programs that have devised mechanisms to assist the poor to meet the costs of health care (Box 3.1). Health insurance for the poor will be discussed further in Chapter 4. Box 3.1 Insuring Poor Health: A Community-based Scheme in India 3.3.2 Increasing Access to Services 3.26 Successful efforts to increase access to services may, once again, focus on supply or demand-led interventions. As noted in Chapter 2, supply-side improvements encompass the establishment of health centers in previously underserved areas; improvements in facilities, equipment, drug supplies, etc.; extension, outreach, camp or mobile services; better management and training of workers; community-based mechanisms such as 'lay health workers' and health groups; and several others. These improvements can be brought about through top-down policies, financing and instructions, or through decentralized action planning that concentrates on improving the use of available resources and can help secure additional resources either locally or from higher authorities. Given the large needs and current '. Reproductive Health Outlook (htM:llu,ww.rho.org) has many other examples of successful or promising practices related to enhancing demand for reproductive health care among adolescents or families. limitations in public sector service delivery, it is necessary to mobilize all available resources to enlarge the pie of services available and achieve better health outcomes in poor settings. 3.27 Involving community members in the DAP process can give participants a better understanding of health needs and build commitment and support for health care in the community. Establishing facilities beyond public hospitals and clinics, such as birthing homes and maternity waiting centers, to improve geographic access to EOC especially for women living in remote areas has worked to reduce maternal mortality. For example, in Malaysia low- risk birth centers with four to six beds are attached to health clinics. They are staffed by doctors, nurses and midwives from the respective clinics. High-risk women are also allowed to deliver at these centers if they do not want to go to a hospital, but are sent to the nearest hospital by ambulance in case of emergencies. Through this strategy both demand and access to good obstetric care have increased and outcomes have improved (Anon, 2003a). Efforts to improve home-based life-saving skills have been undertaken in India and elsewhere. They improve the ability of pregnant women and family members to recognize danger signs and increase birth preparedness. They have also helped to increase postpartum and post- abortion family planning; develop referral systems with emergency transportation and funds; and establish sustainable networks of community volunteers who manage the entire process and solve problems at the local level (PRIME, 2003) Organizing camps on well-publicized dates and sites has also helped to increase service delivery. 3.28 Other interventions that have successfully addressed some key barriers and increased access to quality reproductive health services include those that: encourage communities to take responsibility for their reproductive health needs; make use of private formal and non- formal service providers to increase available options; and increase efficient use of available resources. These also demonstrate that communities and households can take more responsibility in improving their own health when the formal system fails. In a project in Ethiopia that aimed to overcome social and geographic barriers to family planning in rural areas, extension agents lived in villages for six months and worked intensively with the communities to organize them and develop community-based service systems (e.g., to distribute pills and condoms). After three months, the villagers selected and trained local volunteers who then gradually took over the duties of the extension agents including counseling, group education and distribution of contraceptives. This allowed the outside agents to move on to other villages, making efficient use of scarce human resources (Rubardt, (2002) cited in Anon, 2003b). In India, the SEARCH Foundation in a tribal area of Maharashtra trains village health workers and TBAs to diagnose childhood pneumonia and treat it with antibiotics under the supervision of a medical team. This has helped to reduce the case fatality rate and consequently lowered infant and child mortality. The Indian Council of Medical Research is carrying out a multi-center study to assess the feasibility of scaling up this approach through the government health system (Bang et al., 1999). I n Sri Lanka, for the past ten years trained ANMs have identified children with risk signs for ARI and sent them for medical care. The ARI Control program has already expanded nationwide. 3.29 There is considerable scope for expanding public-private collaboration, including using public funds to purchase health services for the poor from NGOs and other private providers (through a variety of financing mechanisms such as "contracting out" or voucher schemes that will be discussed in Chapter 4). Other strategies to involve the private sector include social marketing and social franchising. At least two excellent examples are available in South Asia itself - the Pakistan Green Star Program and Janani in India (Box 3.2). Assessments point to many positive outcomes of this approach, such as better targeting of services, easier access to new products and procedures, service quality improvements, and utilization of spare capacity or efficiency improvements in the private sector. The public sector can also collaborate with the private sector in training, communications, organization of emergency transport and so on to improve access to, demand for and/or quality of services. 3.3.3 Improving Quality o f Care 3.30 I n South Asia, where there is a paucity of safety nets for the poor, the free services provided at public health facilities are virtually the only 'health insurance' currently available to them. However, the credibility and quality of these services need to be enhanced substantially, as discussed in Chapter 2. Although this is a difficult task in resource-poor environments, some programs in developing countries have been able to demonstrate marked quality improvements with simple enhancements. For example, in Tanzania a package of improvements led to a several-fold increase in RTI treatment and family planning, greater patient satisfaction, and increased community participation within two years (Atherton et al., 1999). The package included capacity-building (continuing education, training in service quality concepts, strengthened management systems, and enhanced community links), improving infrastructure, regular provision of supplies and drugs, quality monitoring (through regular management meetings and quality assurance techniques), service integration, community participation, and additional service provision through the private sector. Box 3.2 Promising Approachesto Increase Access to Reproductive Health Services 3.31 Several countries such as Malaysia and South Africa have developed total quality management programs, instituted accreditation to establish national standards, or carry out external assessments to ensure quality. At the Castle Street Women's Hospital in Sri Lanka "work teams" use participatory decision-making processes to identify and analyze problems and devise strategies to overcome deficiencies in the system. A monitoring system was set up and monthly meetings of sectional heads are conducted to review progress and sort out cross-cutting issues. The obstetricians and gynecologists in the system play an advisory role to these groups (Withanachchi et al., 2004). I n Egypt, clinical standards and protocols, training courses, a three-tiered supervision system, and a clinic certification plan were introduced to "push" quality into every level of the service delivery system. At the same time, public media campaigns were designed to "pull" quality into health facilities by raising community expectations of the quality of family planning services and prompting clients to demand good quality care (Anon, 2003b). Maternal death audits have also been effective in improving the quality of maternal care in Sri Lanka. It is mandatory for all relevant functionaries to promptly notify a maternal death, and this is investigated. I n addition, District Maternal Death Reviews are carried out every three months to identify managerial and technical problems that may have led to a maternal death, and measures are taken to correct them. The findings are also used to review relevant policies and devise strategies to prevent such deaths in the future (UNICEF, 2004). 3.32 Most critical to enhance quality in reproductive health care in the public health sectors of the five countries are human resource development and improvement activities. There are many examples that indicate that initiatives in skilled-based training and incentives have been successful in improving the availability and competence of service providers. The importance of having well-skilled frontline workers is demonstrated by the following experience. I n Andhra Pradesh (India) an experiment set up private midwifery practice by trained ANMs in poor remote villages. Women's associations were involved in appointing the ANMs and deciding on the payment for their services. One village appointed a local married woman who was trained to provide basic health care, while the other village appointed a qualified ANM. The qualified ANM was more effective in providing services as she could treat women's illnesses and conduct deliveries. Within a year, she was earning more than she would have earned working at a private nursing home. The basic-trained worker, on the other hand, was not effective as she did not conduct deliveries and could not treat minor ailments. 3.33 Elsewhere, twinning arrangements between providers and training agencies have been effective in increasing women's confidence in and utilization of services. Integration of services has also strengthened service delivery through efficient utilization of available human and other resources, including in the Pakistan Lady Health Worker Program in which this single cadre of community-based workers provides home-based reproductive health services. The program has had a significant impact on the delivery of services and helped to achieve PRSP goals for immunization and contraception. For doctors, the government of Andhra Pradesh established a Tribal Medical Service which provides incentives such as priority in admission to post-graduate medical courses to those who work in tribal areas for three years after receiving their basic medical degree (Andhra Pradesh Vaidya Vidhana Parishad, 1998). This approach contrasts with that of Karnataka and Orissa, where all medical graduates are compulsorily posted to rural areas for 2-3 years. I n some states, to fill vacancies and reduce absenteeism, doctors are consulted on their preference for posting. 3.34 Finally, using a combination of strategies could produce lasting results. For example, in Bangladesh, a 'multi-angle approach" has been adopted to improve the quality of family planning services (Landovitz (1997) cited in Anon, 2003b). Under this project, health officials are oriented in local planning using COPE (Client-Oriented Provider-Efficient services) exercises. They identify factors hindering service quality and develop and implement action plans, which are reviewed monthly. At the same time, service providers are given technical, counseling and supervisory skills to make them more responsive to clients' needs and rights. 3.3.4 Creating an Enabling Environment 3.35 The concepts of the ICPD POA have been incorporated into the policies of all five countries. However, despite this, several key aspects of reproductive health such as a 'client- centered women-friendly approach," delivering an integrated essential package of services, a focus on adolescents and sexuality, and reproductive rights have hardly been implemented. There is little evidence also of broader strategies needed to achieve reproductive health goals, such as pro-poor actions, rights-based approaches, preventive health activities, and reductions in the financial burdens on the poor. Specific activities to implement these approaches are needed to provide an enabling environment for reproductive health care. 3.36 The reproductive health policies in place are most likely to succeed if they are supported by a wide range of stakeholders - from policymakers to service providers, women's advocacy groups to grassroots organizers and client representatives. Bolivia provides an example of robust political and social commitment to improving the quality of maternal and child health care. The Ministry of Health has been implementing the Making Pregnancy Safer Initiative with WHO support, focusing on increasing comprehensive obstetric care and capacity at the first referral level. This has been supported by the adoption of national standards of care, revitalization of the epidemiological surveillance system, and development of a uniform death certificate especially for maternal deaths. The initiative plans to continue to focus on improving the quality of care and to ensure that services are culturally sensitive (Anon, 2003a). This set of reinforcing actions was possible due to a high level of political support to health reforms in Bolivia. 3.37 Many developing countries including Sri Lanka have established a strong enabling environment through health sector reforms, women's education and employment, political and human rights, and have successfully improved reproductive health (Box 3.3). I n India, Tamil Nadu has made rapid progress in strengthening its health system, getting good results in terms of service utilization and mortality and fertility reductions (Box 3.4). Box 3.3 Sri Lanka's Historical Efforts to Improve Maternal Health Sri Lanka started maternal and child health services through doctors, nurses and midwives at the turn of the 20m century when birth and death registration were also made compulsory. In 1927 a Medical Ordinance required all midwives to be registered. The government focused on reorganizing midwifery services and introduceda scheme to train midwives in order to modernize birthing practices in rural areas. Although suitable candidates were initially in short supply (they were required to be 'respectable', which conflicted with the low status of midwives), the scheme gradually succeeded, and the number of midwives trained and employed by government increased almost three-fold between 1931 and 1938. Infant and maternal care services were developed alongside. In 1920 a scheme was formulated for the provision of financial and other assistance to expectant mothers from poorer groups. It focused on two stages of children's lives- antenatal and infancy. The state took responsibilityfor the health of mothers by ensuring that every woman had the services of a qualified midwife during childbirth. Maternity centers and antenatal clinics staffed with qualified medical practitioners and midwives were set up. After the 1960s, the expansion of family planningservices also helped to reduce births and deaths. Sri Lanka is among the few developing countries that have successfully reduced maternal mortality to levels comparable to those of developed countries - its maternal mortality ratio was 23 per 100,000 live births in 2000. In the 1930s, the MMR was estimated to be over 2,000 per 100,000 live births; by the 1950s it had declined to below 500. Successful efforts to combat malaria and the introduction of modern medical practices for infant gnd maternal care, including midwifery services, deserve much of the credit for this achievement. A functioning referral system for obstetric care has been largely responsible for recent reductions, and strong civil registration and maternal death audit systems have provided the information necessary to assess and accelerate progress in maternal health. In addition, public access to education expanded rapidly during the first half of the 20thcentury, resulting in a remarkable increase in female literacy from 8.5 percent In 1901to 44 percent in 1946 and 71 percent in 1971. Increasedgender equality and effective public investmentsin improving living standards also contributed. To improve service delivery, the government introduced Health Units in 1926 focused on expanding free services in rural areas, an important step in the improvement of health in the country. Attention was given to preventive and promotive activitles at the community level, and especially to control of the major communicablediseases. Each unit had a Medical Officer and a team of field workers who were responsible for serving the population in the area and provided services at the domiciliary level and at health centers. Public health midwives provided care to pregnant women within populations of 3,000 to 4,000. These units remain the main providers of reproductive health services today. Until 1940, skilled attendants assisted only about 30 percent of births. By 1950, after the implementation of policies to introduce and expand the cadre of public health midwives, this percentage doubled and, currently, skilled practitioners attend 97 percent of births, the majority within institutions. While field services were being expanded, institutional facilities from General Hospitals at the higher levels to Rural Hospitals at the lowest - were - also improved. Municipalities set up Maternity Homes where trained midwives attended to deliveries. The higher level facilities had specialist services and served as referral centers. Geographical access to these was facilitated by good road networks, and economic access was enabled by free services for all. A well-functioning referral system for pregnancy-relatedand other health problems was also established early. The number of health facilities was expanded rapidly from 112 government hospitals in 1930 (about 182 beds per 100,000 people) to 247 hospitals in 1948 (close to 250 beds per 100,000). Between 1948 and 1950 the national ambulance fleet was increased from 12 to 67 ambulances. These improvements continued through the second half of the century. A program to reach women on tea estates is another example ~f a targeted effort to ensure good quality services to all. In Sri Lanka now, maternity care including surgery and blood transfusion is available free to any woman in the country. A strong civil registration system in Sri Lanka provided valuable information to plan and monitor progress in maternal health. The government used death inquiries to identify problems in the delivery of care. Since 1970, all maternal deaths have been required to be notified to the local Medical Officer (MCH) within 72 hours. A Medical Officer of Health then visits the hospital and home and files a detailed report. A full inquiry and a meeting at the institution where the death occurred are completed with two weeks. There are also regional reviews to discuss all deaths and plan remedial measures, and finally a national review at Family PlanningAssociation of Sri Lanka spearheadedefforts to make barrier methods available through clinics and to train doctors in family planning. Family welfare activities were carried out along with antenatal and postnatalcare, contraceptives were distributed free, and mass media were used for education purposes. In addition to birth spacing and family limitation services, sub-fertility services were also provided. From the 1960son, family planning serviceswere integrated with MCH programs and widened to lncludeoral contraceptives, condoms, and IUCDs. Male and female sterilization were introduced in the 1970s. Family planningservices providedby the government are complemented by the efforts of four major NGOs, hnd some provisionby the private sector. A social marketing program provides OCs and condoms through 8000 outlets in the country. Counseling and choice are hallmarksof the program and currently injedables are the most popular modern method, followed by oral pills, IUCDs, condoms and sterilization. Incentives are paidto medical teams and clients for sterilization. Education has also contributed to the increase in contraceptiveprevalenceand in a rise In the age at marriage both of which have helped Sri lanka to reduce fertility to replacement level by 2001, and contributed to the declines in maternal and infant mortality. Sri Lanka achieved its health improvementswith relatively low spending. Analysis of public health expendituresshows that total government spending on health care was a modest 1.8 percent of GDP, wlth maternal health accounting for 0.23 percent. This has been decreasing - duringthe 1990s, government expenditurefell to about 1.5 percent of GDP, and after 1999 it fell further to about 1.2 percent. Sri Lanka spent about 4-5 percent of total government expenditureon health during the periodfrom 1996-2001. About 50 percentof total expenditureon health in the country is public, and an equal amount is private expenditure so that total health expenditure (including out-of-pocket and insurance payments) has been about 3.0-3.5 percent of GDP since 1990. Some of the private out-of-pocket expenses are incurredon use of public facilities (e.g., for transport, prescribeddrugs, and patient attendants). The remainder is largely fees for out-patient services provided by the private sector - private practitioners contribute about 50 percent of 'first-contact' curative care, including RH services. Government doctors are allowed to practice privately outside working hours. Private hospitals with beds are largely in urban areas -about 70 percent in Colombo alone. Only 6 percent of deliveries take place in private hospitals. The private sector provides some sophisticated services (such as in vitro fertilization) which are not available in the public sector. Box 3.4 Health Sector Reforms in Tamil Nadu, India, and Bangladesh 3.38 Collaborations with and efforts within other sectors are important to achieving reproductive health goals. An example of a strategic collaboration with another sector (in this case Women's Development or Education) is provided by efforts to increase health workers' awareness of gender differentials and violence against women that in turn helps to increase their sensitivity to female clients. I n South Africa, a four-day training module on gender violence was introduced into the training curriculum of primary care nurses. It focused initially on exploring the nurses' own attitudes, beliefs and personal histories of violence. Popular sayings and wedding songs were deconstructed to help them understand gender stereotypes and conditioning. Finally it focused on their responsibilities as health professionals. They brainstormed about implementing their role in addressing domestic violence, and the practical skills involved in doing so. This program is expected to counter the widely-prevalent gender violence in rural areas of the country (Kim and Motsei, 2002). 3.39 More broadly, programs to improve girls' education, empowerment and nutritional status can have profound impacts on their health. Box 3.5 discusses Bangladesh's fertility decline and the importance of health services and other factors, such as the program to enhance girls' secondary schooling. There are many examples in South Asia of integrated health, nutrition and 'women and child development programs' (read: pre-school education and women's awareness and income-generation), such as India's Integrated Child Development Services (ICDS) Program, and the Bangladesh National Nutrition Program (BNNP). Examples of other types of multi-sectoral efforts are community nutrition programs in several countries that improve women's reproductive health directly or indirectly. A program in Senegal is similar to the ICDS and BNNP, and like the latter is also a partnership program involving private administration and public financing, but it includes water supply provision (Ndure et al., 1999). A program in Swaziland focuses on vegetable gardening, helping to improve the nutrition and health status of HIV-affected households by increasing their vitamin consumption, food security and incomes (Shumba, 2003). Box 3.5 Bangladesh's Fertility Decline and the Role of Education 3.4 MOVING FORWARD I N SOUTH ASIA 3.40 In adopting promising practices, clearly every unit of planning should think about its specific needs and the potential of making the promising practice work locally. Interventions that are appropriate, for example, in Sri Lanka may not be appropriate for most of the rest of the region, and even within countries there would be significant variations. Each area would need to select approaches that would work within their social, managerial and resource environments and set realistic goals for their achievement. Thus, 'promising practices' are best implemented within the decentralized planning framework described earlier. To illustrate how appropriate practices can be identified so that materials providing details about them can be prepared and used in DAP efforts, Table A7.1 in Annex 7 provides a suggestive list of practices that address some of the priority issues identified in South Asian countries. Many of these innovations have already been piloted and tested in South Asia - the list focuses on interventions that would be of benefit if replicated and scaled up. Many other practices are known and details can be obtained through the sources mentioned earlier. 3.41 Chapters 1 and 2 discussed the five south Asian countries, recognizing the geographical and social variations within each. While the overall recommendations of how reproductive health must be improved in the five countries were mentioned briefly in those chapters and are developed further in Chapter 5, this chapter focused on how reproductive health care can be improved "where the rubber hits the road", i.e., where planning and implementation take place. DAP is not intended to start a debate on the merits of "bottom- UP" vs. "top-down" planning - in essence, both are necessary in large and complex countries. The DAP process can help to sort out what is done which way, and how they interact. 3.42 Using the DAP method, every unit of health planning can take heed of its differences from the average or the norm, and direct its resources and efforts to better its own situation. Decentralized action planning is a significant step toward evidence-based decision-making and policy which are much-needed in South Asian countries. It is a process within the health system (with some help from outside partners such as NGOs or private professionals) which: Uses available data and evidence of what works; Adapts and expands these experiences in appropriate and manageable ways; Checks what works locally through monitoring and evaluation; and Improves data collection and quality, focusing on what is needed and useful to plan and make improvements. 3.43 The DAP framework facilitates appropriate use of 'promising practices', 'lessons learned' or 'best practices' (following the Advance Africa taxonomy) as it can both 'do with learning' (i.e., be evidence-based) and 'learn by doing' as conscientious use of DAP entails a cycle of planning, doing (action) and M&E (learning). I n this way DAP can help to make better use of resources, and obtain additional resources on the basis of local or higher-level decisions facilitated by evidence of success emanating from below. 3.44 The DAP approach suggests strongly that change must come from those involved - in this case primarily the providers and managers of health services - through a better understanding of what they are trying to achieve, for whom, and how; and through their empowerment by participation in decision-making, resource allocation, and capacity development. Such change is fundamental to improving poor women's access to quality reproductive health care. More and better reproductive health care - "scaling up" - will require intensive and extensive collaboration between program decision-makers, implementers, communities and professional experts, and DAP actively promotes such collaboration. Indeed, DAP involves a horizontal reaching-out at every level at which it is practiced, causing the health system to work with communities as well as professional resources. A key feature of DAP is the sharing of power by decision-makers. Senior officials guide and facilitate (rather than control) staff and others by showing their willingness to adjust policies, rules and resources to achieve agreed (shared) and reachable goals. 3.45 The five countries in which the DAP method was piloted are at various stages of decentralizing health management and implementation. They either need or are in the process of developing decentralized planning methods to produce need-based health plans. Sri Lanka has already made the DAP method described above an integral part of its District Health Plan initiative under the Health Sector Development Program and in India it has been used in the states of Maharashtra and Orissa. Health sector reforms offer the opportunity to institutionalize DAP to improve implementation with the involvement of all stakeholder groups and to build capacity among district health managers and decision-makers for better planning, resource allocation, management and results. 3.46 Recently, India has begun a widespread process of decentralized action planning under the Reproductive and Child Health Program and National Rural Health Mission (Box 3.6). It aims to improve equity in access to health services through this local level planning and resource allocation process, which is also focused on the key reproductive health goals of reduced maternal and child mortality. Thus, it will be on the watch-list of all those concerned with improving poor women's reproductive health in South Asia. Box 3.6 India's Rural Health Mission and Reproductive and Child Health Program In April 2005 India launched a National Rural Health Mission (NRHM) to provide health care more effectively to rural people throughout the country, especially in 18 (of 35) states with poor public health indicators and inadequate health infrastructure. The NRHM aims to improving access to, utilization and quality of healthservices and also emphasizesthe equity and gender dimensionsof healthcare. The main objectives of the program are to reduce child and maternal mortality, prevent and control communicable and non-communicable dibeases, and stabilize the population, achieving gender and demographic "balance". The second phaQeof the Reproductive and Child Health Program was launchedat the same time and subsumed into thq NRHM. It focuses on reducing the IMR, under-five mortality rate, MMR and TFR, with national,state an/Jdistrict plans directedat achievinglocalgoals inthese areas. SfrengMenlng Me ~ealllh/Structure. The NHRM aims to 'undertake architectural correction" of the health system to improve qublic health management and service delivery. The vertical health and family welfare programs will be ifltegrated. "Comprehensive" primary health care is to be provided. Women health activists called ASHAs are expected to "organizethe demand side" and promote use of healthcare. There is also a focus on strengtheningSub-centers by increasingthe number of ANMs, skill development, quality standards, communitysupport and an "untiedfund" to support localactions. PHCswill be similarly improved, and 30-50 beddedCHCs broughtupto IndianPublicHealthStandardsto provide better curative care. NRHM is placing long overdue emphasis on human resource improvements including locally residentworkers, contractualpositions, multi-skilling,career developmentandtransparent policies. Promoting Institutional Dellvery. An important intervention under NRHM is the Janani Suraska Yojana to promote institutionaldelivery and reduce maternal and neonatal mortality. Women who complete three antenatal visits, two tetanus toxoid injections,and deliver in an institutionreceivecash paymentsfor these. ASHAs who accompanywomen to institutionsfor deliveries also receivecash incentives. "Funds, functions and functionaries" are to be transferredto local government (Panchayati Raj) institutions (PRls), and facility-based health management committees (Rogi Kalyan Samitis) are expected to play a greater role. Capacity enhancements are planned for PRls to control and manage public health services. These mechanisms are expectedto addressthe problemsof inter-districtand inter-statedisparities. Attention to Deteminants of Health. District planning and managementare expected to foster greater attention to the determinants of health and coordination across government departments concerned with nutrition, drinking water, sanitation, and efforts to improve the status of women. The program aims to universalize access to public food, nutrition, sanitation, immunization and health services. The program also aims to activateadolescent girls' andwomen's groups Health Spending. The NRHMaims to increasepublic spending on healthfrom India's current0.9 percent of GDP to 2-3 percent, including communityfinancing and risk pooling. Healthcare is expected to become more affordable to the poor. The non-profit health sector is to be promoted especially in underserved areas. Allocations of RCHINRHMfunds to the states are done on the basis of populationwith additional weightage given to more needy states. States have the option of allocating equal shares to districts, or providingthem funds on the basis of sociodemographiccriteriato improveequity, or on the basisof need. Accountability. The goals of NRHM are "time bound" and its processes transparent. Data collectionwill be strengthened and data used for planning as well as for progress monitoring against standards and goals. The programis expectedto reportpubliclyon its progress. 3.47 As action planning is not a one-time activity, the DAP method needs to be institutionalized and used on a continuous basis to improve the performance of the health system, simultaneously augmenting resources to bring about better outcomes for poor women. Identifying relevant and feasible actions is critical to decentralized action planning. The DAP process is at once a strategy for communication, diffusion, dissemination and promotion of innovation. Local people know the social, political and economic context best to decide what innovations may work. The pool of promising practices relevant to South Asia provides a basis for this but needs to be strengthened continuously, side by side with the dissemination of the means of introducing them into the public system, decentralized action planning. The several existing initiatives could help this process, but it is important for South Asia to develop a database of promising practices based on its own experiences and relevant efforts from around the world. This would be a useful and exciting beginning to a regional effort to improve the reproductive health of poor women. Chapter 4 Financing Reproductive Health for Poor Women South Asia faces significant challenges in organizing its health institutions and financing to ensure sufficient resources, improve access to and equity in health care, and protect people - especially the poor - against health shocks. Significant improvements in reproductive health outcomes in South Asia will be realized only with larger and more effective investments in health services, oriented to benefit poor households currently facing the greatest constraints to service use. This chapter presents new analyses of the level and allocation of financing of reproductive health care in the five South Asian countries, and highlights several "points to watch" as decision- makers assess various financing options. Four findings stand out: Across the countries of the region, per capita spendingon reproductive health services delivered through the public sector is not correlated with health outcomes. This suggests that in at least some countries there is significant room to increase the efficiency of spending with respect to outcomes. I n most countries a large financing burden falls on households. I n the absence of effective risk-pooling mechanisms, the poor are disproportionately affected. As financial barriers limit the use of preventive services and/or lead to delays in seeking medicalattention, this contributes to poor health outcomes. The priorities of donors and governments are poorly aligned, hindering implementation. Both need to focus squarely on supporting the essential package of reproductive health services. I n particular, while donors have focused on support to family planningservices, the greatest share of the financing burden on householdshas been in the area of maternal services. This is an important area in which greater spending is required to achieve improved outcomes - donors need to increase their investments and national governmentsneed to increase their investments even more. Creative approaches to using general revenues that are spent on reproductive health, such as demand- side financing, and greater contributions of the private sector to the health of poor women, possibly through partnerships, could help to improve outcomes. Important data limitations affect our ability to make definitive statements about financing patterns. Comprehensive National Health Accounts and breakdowns, including private spending, were available only for Bangladesh, Sri Lanka and the Indian state of Rajasthan, thus limiting the analysis of private and total spending. Estimates of public financing were compiled for all countries, but a detailed comparisonof Pakistanwith the other countries was not possible because of accounting inconsistencies. The chapter is structured as follows. The policy context is described briefly. The next three sections deal with resource mobilization, resource allocations, and purchasing/paying for reproductive health care. The last section deals with financing options and emphasizes the issues that need to be considered in selecting among them to increase the supply of reproductive health services and improveoutcomes in South Asia. 4.1 THE POLICY CONTEXT 4.1 I n South Asian countries, the public health sector provides free or highly-subsidized health care funded from general revenues (supplemented to varying degrees by grants from bilateral donors and/or loans from international financial institutions). Whether funding is from national or sub-national sources varies by country. 4.2 I n all countries, private out-of-pocket financing plays an important role. User fees are levied on services at many public facilities (except in Sri Lanka), typically with exemptions for low-income patients. However, in several countries, informal payments are the norm, even for the poorest patients. Social insurance mechanisms have not been of major importance (notwithstanding the scheme which covers formal sector workers in India). Thus, private spending occurs primarily as out-of-pocket expenditure, which is least desirable from an equity perspective. 4.3 In all five countries, a variety of changes are underway in health sector financing and organization to support expansions in quantity and quality improvements in health care. I n Nepal, for example, government policy has focused on three areas: privatization, use of community schemes particularly with respect to essential drugs, and income generation at public facilities (Agarwal, 1998). In India, financing reforms at the state level have included the introduction of user fees, setting up 'autonomous bodies' to manage public hospitals, various types of public-private contracts and health insurance schemes. 4.4 Although the region has re-conceptualized reproductive health care after the ICPD, institutional constraints have impeded implementation. Among these, a particularly important constraint to reproductive health improvement is the continued separation of organizational structures for MCH-Family Planning, general health services and nutrition. This 'trifurcation' not only causes a separation of service delivery sites and affects integration of services but also results in inefficient allocations of scarce public sector resources and, most likely, increased out-of-pocket spending as well. To date, only limited attention has been devoted to addressing demand-side barriers to improve utilization of key reproductive health services. 4.5 Within these contexts, Sri Lanka's long standing policies for maternal and child health are noteworthy. The country has put a strong emphasis on motivating women to obtain institutional care for delivery as well as for treatment of infections at the same facilities. Investing simultaneously in its preventive network, it achieved efficiencies by ensuring that PHMs covered all the relevant target groups in their areas, including adolescents and, as the country's age structure changed, older women who could seek care at Well Women Clinics that have been established over the past 12 years. Sri Lanka's investments in health have been proportionately greater than in the other countries and egalitarian, protecting the poor from the costs of inpatient services and keeping levels of private spending relatively lower, especially for reproductive health. 4.2 RESOURCE MOBILIZATION FOR REPRODUCTIVE HEALTH 4.6 A picture of resources currently mobilized for reproductive health is provided by public and private spending on these services. New estimates of expenditures on reproductive health care were developed for this study.' The reproductive health services covered include maternal health (ANC, PNC and dietary supplementation), childbirth (delivery, care of pregnancy complications, and abortion), infant care (immunization, micronutrients, growth monitoring and health care), family planning (including goods and services, counseling and IEC), prevention and control of RTIs/STIs including HIV/AIDS, and other personal reproductive health services for women (all obstetric and gynecological service^).^ In the case of integrated '.The estimates are full costs (as measured by expenditures) including both the recurrent and capital costs of providing services, but do not represent full economic costs of service delivery. 2.Reproductive health expenditures do not include child nutritional supplementation other than micronutrients. Among child health expenditures beyond infancy, some such as immunization are included but others - such as general illness consultations - may not be services, the estimates include the relevant shares of program overheads, supporting infrastructure and other non-service delivery expenditures. 4.7 Differences in the data available for each country result in some variations in the methods used to analyze public (including donor) and private expenditures on reproductive health. Details of the methods used for each country and assumptions made are presented in Annex 2 Section 2.5. For example, Bangladesh and Sri Lanka have National Health Accounts (NHA) enabling direct computations; for the Indian states of Andhra Pradesh and Rajasthan, it was necessary to use a combination of NHA-based methods and private expenditure data from the National Sample Survey. I n Nepal, data on private expenditure were not available, while in Pakistan, government data were incomplete. The details of the household surveys that provide out-of-pocket expenditure data also vary across countries. While public expenditures could be analyzed by service components in five locations (excluding Pakistan) private spending could be disaggregated only in Bangladesh, Sri Lanka and Rajasthan. Hence, comparisons between the countries/states are made cautiously, mindful of these variations. 4.2.1 Total Spending 4.8 Estimates of total (public and private) expenditures on reproductive health are only presented for Bangladesh, Sri Lanka and the Indian state of Rajasthan. As a percentage of GDP they vary considerably between Sri Lanka (0.3 percent) and Rajasthan (1.3 percent), mainly due to differences in private pen ding.^ As a share of total health spending, reproductive health spending varies in a similar way: from 10 percent in Sri Lanka to 21 percent in Rajasthan. 4.2.2 Public Expenditure 4.9 Public sector health expenditures as a share of GDP are high in Sri Lanka and Rajasthan, but relatively small shares are allocated to reproductive health (Table 4.1). Despite its low expenditure, however, Sri Lanka provides near universal access which supports high utilization of reproductive health care. Another Indian state, Andhra Pradesh, has lower overall health expenditure as a share of GDP, but spends a much larger share on reproductive health. Bangladesh and Nepal also allocate over a quarter of public sector health resources to reproductive health services. Table 4.1 Public Sector Expenditures on Health and Reproductive Health in South Asia '.The private spending for Rajasthan could be overestimated, as the estimates are based solely on household survey data and have not been reconciled with provider-side data as in Bangladesh and Sri Lanka. 4.2.3 Private Spending 4.10 Household resources spent on both health and reproductive health as a share of national or state income are significantly larger in Bangladesh (2.6 and 0.4 percent) and Rajasthan (4.2 and 1percent) than in Sri Lanka (1.6 and 0.1 percent) (Table 4.2). Although public and private health expenditures as shares of GDP are roughly the same in Sri Lanka, private reproductive health expenditure is half that of public, reflecting the greater degree of support provided by the state for reproductive health - an outcome of its policy emphasis on maternal and child care that began early in the 20th century. I n Rajasthan, private reproductive health expenditure is more than three times public expenditure. Indeed, in most parts of the region, the levels of out-of-pocket spending on essential health care (relative to public investments) are cause for concern, particularly given the barrier that this can create in the health-seeking behavior of poor households. Table 4.2 Private Expenditureson Health and ReproductiveHealth in South Asia 4.2.4 Public-Private Financing Mix 4.11 Overall resource mobilization for reproductive health as a share of national resources is inversely related to the level of public financing. For example, the lowest level of reproductive health spending is in Sri Lanka which has the highest proportion of public funds, and the highest overall spending is in Rajasthan with the largest private funding mix. Since households pay for both private spending (directly out-of-pocket) and public spending (indirectly through taxes), the financing strategy that would be least burdensome for households is likely to be that which involves the most extensive risk pooling. 4.2.5 Inter-Country Comparisonsof Public Expenditures Per Capita 4.12 When standardized, the levels of public sector reproductive health expenditure per capita vary somewhat among the five co~ntries.~Expenditure in Andhra Pradesh (US$ 2.5) is greater than in Sri Lanka (US$ 2) and the other countries (around US$ 1.5). However, these variations could not account for the differences between countries in service delivery levels and reproductive health outcomes. Instead they suggest that efficient use of financial resources can achieve better outcomes. Sri Lanka has better reproductive health than the other countries not because it spends more but because it uses a similar level of finance more efficiently and equitably. 4.13 The standardized private expenditures reinforce the conclusion made above and in the preceding section. The burden on households with reproductive age women in Sri Lanka (US$ 0.6) is substantially lower than that in the other countries (US$ 2.7). It appears that Sri Lanka's stronger public sector effort, including higher efficiency, considerably reduces out-of- pocket contributions by households for reproductive health. Pakistan could not be included in this comparative analysis in the absence of rigorous accounting estimates 68 4.2.6 Donor Assistance 4.14 Donor support to reproductive health varies greatly across the region from 3 percent of public reproductive health expenditure in Sri Lanka to around 30 percent in Bangladesh and Rajasthan and 65 percent in ~epal.' In India as a whole, a large proportion of public expenditure on reproductive health is funded by international agencies. For instance, in 2001- 02, two-thirds of the estimated US$ 228 million of Family Welfare spending by the Central Government was met from external funds (GOI-MOHFW, 2002). 4.15 I n Pakistan donor support to the Population Welfare program has declined over time and over the past decade the program has relied largely on government funding. Donors, however, continue to finance the two major social marketing agencies which distribute more than two-thirds of all condoms and one-third of oral pills in the country. Foreign assistance as a proportion of public health sector allocations has varied between 4 and 16 percent during the period from 1998-99 to 2004-05 (Heartfile, 2006). 4.2.7 Who Benefits from Public Reproductive Health Spending? 4.16 Severe data inadequacies introduce difficulties in estimating reproductive health expenditures at sub-national levels. In Bangladesh, India and Sri Lanka household surveys have the necessary data, but the sample sizes of those reporting reproductive health expenditures at the provincial or district levels are too small to permit any meaningful analyses. Therefore, only quintile analyses of the national samples were attempted. The distribution of use of services is an acceptable proxy to assess how well public resources are targeted at poor users. The data indicate that the richest quintile of women obtain a disproportionate share of institutional deliveries at government health services in most South Asian countries (Figure 4.1). Figure 4.1 Distribution of Deliveries in the Public Sector, Poorest and Richest EconomicQuintiles, Various Years, percent 60% 50% 40% 30% 20% Xl% 0% . 6 D IN-R IH-11 NP SL PUOIPIt RbleTt The exceptions are urban India, where the distribution is progressive as richer women have more private sector alternatives, and Sri Lanka where institutional deliveries are near- universal. The distributions of other reproductive health services presented in Chapter 2 demonstrate a similar pattern, with few exceptions. These data suggest that public resources need to be targeted more efficiently at the poor and/or that governments need to achieve universal coverage with essential health services. 4.2.8 What Resources are Needed for Reproductive Health? 4.17 The ICPD POA contained estimates of the resources required to provide basic reproductive health services, covering family planning, ANC, delivery, PNC and abortion services, STIs, IEC, treatment of infertility and some capacity building. However, resources These estimatesare based on an analysisof donorproject data for Nepal and Sri Lanka,national health accountsfor Bangladesh and reproductive health accounts for Rajasthan. Comparable estimates could not be produced for A.P. and Pakistan because similar data were unavailable. required for emergency obstetric care, child survival programs, broader ST1 programs including HIVIAIDS and strengthening primary health care delivery systems were not included. Subsequently, the UN Millennium Project estimated the resources required to achieve the health MDGs (among others) at the country level, and the WHO (2005) worked out the requirements to achieve universal coverage with maternal and newborn care. Most recently, Vlassoff and Bernstein (2006) have been able to rework and update the ICPD costs, including health system overheads as well as improvement costs, EmOC, HIVIAIDS prevention, data collection needs, and other relevant investments. The estimates for one of the focus countries, Bangladesh, show that US $3.6 will be required per capita by 2015, over double the estimate for 2005 (US $1.6). The figures for Cambodia and Ghana were similar - so that an extrapolation to the rest of South Asia would not be unreasonab~e.~ 4.18 I f reproductive health services in Bangladesh called for a total of $229 million in 2005 and US $610 million in 2015, at least these amounts would be needed in Pakistan, and seven times as much in India. Clearly, expenditure in all these countries is far short of what it would take to deliver adequate reproductive health care to serve the MDG goals. Another estimate points out that over the next 20 years increases in population and changes in the age structure alone in South Asia will result in an increased need of 45 percent in total health spending or 2-3 percent annually (Gottret and Schieber, 2006). The South Asian governments must take the major responsibility for meeting the costs of providing services at least to the poor. It is noteworthy that the country that provides the best reproductive health care in the sub-continent, Sri Lanka, also has the lowest proportion of its health budget provided by donors (3 percent). Nevertheless, increases in donor assistance would be helpful to achieve the increased spending required. This in turn would increase the proportion of the total reproductive health budgets of the five countries contributed by donors, which is currently quite low in four of the five countries (except Bangladesh). While total donor funding to health globally is estimated to have doubled between 2002 and 2005, much of the increase constituted assistance to HIVIAIDS programs, including treatment and care costs, and South Asia received a relatively low share. 4.3 RESOURCE ALLOCATIONS WITHIN REPRODUCTIVE HEALTH 4.19 In concert with mobilizing additional resources for reproductive health care, governments and donors need to pay attention to how these resources are distributed in order to achieve greater equity and better health outcomes. This section discusses the current scenario and points to improvements that must be made. 4.3.1 Total Resource Allocations to Reproductive Health Components 4.20 The distribution of total reproductive health resources by different service components is similar in Bangladesh, Rajasthan and Sri Lanka (Table 4.3). Maternal health and childbirth services account for 26 to 33 percent of total spending, and family planning for 7 to 18 percent. One striking difference among the three countries is the relative share of resources spent on routine gynecological outpatient and inpatient services. It is less than 3 percent in Bangladesh compared with 35 percent in Sri Lanka and 43 percent in Rajasthan. 6.While there are many studies on the costs of different reproductive health services in developing countries, they measure different activities and use different units (e.g., visits, pregnant women, couples, etc.), the costs of individual services range widely, and few have worked out the cost of a total package, correcting for the common infrastructure used in the delivery of different services. While several studies are useful to estimate the costs of individual services, even in the aggregate they would not serve well to work out the cost of the essential package of RH services for other countries. Information on the costs of individual or 'packaged' RH services is woefully inadequate for South Asian countries - and there is considerable deviation from the cost estimated by Vlassoff and Bernstein (2006). For example, an effort to cost "Essential Health Care Services" in Nepal reported the 2003 cost per woman of 2 ANC visits as USS2.53 and the cost of a Mother-Baby package as USS7.57. Even the latter figure does not include, for example, the full cost of family planning or ST1services (Alban and Sakya, 2004). Considerably work needs to be done in this area. cost-effectiveness analyses focus on deaths averted or DALYs saved, and thus also do not serve reproductive health services well enough as the benefits, for example, of family planning are not fully captured by these measures. Many studies on the cost-effectiveness of RH interventions are ably summarized in the DCPP chapters on Adolescent Programs, Contraception, STIs, HNIAIDS, Maternal and Perinatal Conditions, Quality of Care (for child health), Gender (for "women's conditions") and Overview chapter (World Bank, 2006). Table 4.3 Total Expenditure on Re productive Health by Components, percent 4.3.2 Allocations of Government Resources 4.21 Public reproductive health resources in Andhra Pradesh, Bangladesh and Nepal are allocated largely to family planning and infant care (Table 4.4). Maternal health receives moderately large shares in Bangladesh and A.P. Resources to other reproductive health services are relatively small or insignificant in these countrieslstate. 4.22 I n Sri Lanka, on the other hand, childbirth and other reproductive health services for women, particularly inpatient services, obtain the largest shares of public resources for reproductive health, thus providing a form of public insurance for inpatient care which could otherwise impose a large financial burden on households. This pattern in Sri Lanka emerged from the very early emphasis on institutional care in the context of addressing maternal and child health needs in the island country. The Indian state of Rajasthan also allocates about 20 percent of reproductive health resources on other services for women (including treatment of RTIs and abortion services which are not captured separately by this analysis). Table 4.4 Allocation of Public Sector Resourcesto Reproductive Health Components, percent 4.23 Trends in Resource Mobilization for Reproductive Health Services. Reproductive health received increasing shares of public health resources during the periods studied in Bangladesh, Andhra Pradesh and Nepal, with significant variations in different components.' I n real terms resources increased most in maternal health (45 percent), infant health (30 percent) and family planning (45 percent) in Bangladesh, while in Nepal an increase occurred in family planning. In A.P. spending on childbirthlpregnancy and FP increased by over 40 percent, infant care by 50 percent and maternal health by 62 percent. 4.24 I n Pakistan the trends in population welfare expenditures were rather erratic due to the program's heavy dependence on donor funding (see below). There was a sharp increase in MOH expenditure on AIDS control during 1994-1998 and on the LHW Program which was launched in 1994. Since the late 1990's the population program has relied increasingly on government financing. In Sri Lanka the ratio of public and private reproductive health expenditures to total public and private health expenditures changed very little during 1990- 1997. In real terms, government spending on childbirth and general obgyn services increased by more than 60 percent in this period, while family planning expenditures declined by 20 percent. NGO expenditures on family planning increased sharply in the same period. 4.25 Donor Support to Various Services. A functional analysis of donor expenditures indicates that an overwhelming proportion of resources to reproductive health goes to family planning in Nepal and Sri Lanka (Annex 8 Table A8.1). In Bangladesh, however, infant care expenditures receive the largest share of donor reproductive health resources (37 percent) and maternal health and family planning account for 28 percent each. The pattern of donor assistance to Bangladesh stayed roughly the same during 1999-2001. 4.26 In Nepal, 80 to 90 percent of donor support was to family planning during the period from 1995 to 1999. In a country whose maternal mortality ratio is among the highest in the world, less than 20 percent of donor reproductive health assistance was on maternal health and childbirth services. The GON's improved fiscal position after 1994 and medium-term expenditure framework have enabled it to increase financing of essential health services, with priority to reproductive health care, and the proportions of government funding to family planning and 'safe motherhood' services have increased gradually. I n Sri Lanka, the share of donor resources to infant care has fallen from about 50 percent to 10-20 percent in recent years, while the share on family planning (which may include some MCH care) has increased significantly. This is incongruous given that the country has had below replacement level fertility since 1993. The low proportions of donor contributions to maternal, childbirth and infant services are surprising, given the importance of safe motherhood to the Millennium Development Goals and donor commitments to achieving these. 4.27 Continued donor emphasis on family planning harks back to historical concerns about population growth in South Asia and demonstrates insufficient agility after ICPD. Sri Lanka's early success in controlling fertility and other positive social indicators kept levels of donor assistance to the health sector low in that country. Support to the other countries has increased over time and expanded from family planning to some MCH activities such as immunization, vitamin A supplementation and child nutrition, but despite recent efforts at sector-wide approaches and budget support, many donors continue to prefer picking up the tabs for specific "vertical programs", components or c~mmodities.~It is difficult to pick '.Expenditures on reproductive health were estimated for the following years: Bangladesh: 1999-00 - 2001-00; India-Andhra Pradesh: 1996-97 2000-01;India-Rajasthan: 1998-99; Nepal: 1995-96 - 1999-00; Pakistan: 1993-94 - 1998-99; Sri Lanka: actuals for 1990- - 1997 and estimates for 1998-1999. The ratios used to estimate reproductive health expenditures from data on total health expenditures were the same across the years for each country. The estimation ratios were generally calculated using household data and other information that were not available on an annual basis. No trend analysis was possible for Rajasthan. '. Indeed, while the vertical programs (e.g.,malaria, TB, EPI, HIVIAIDS) emerged originally from the desire of technical agencies to deliver interventions efficiently to the field level, they have persisted due to separate sources of funding and technical assistance, resulting in waste and inefficiency. Governments, donors (and international partnerships) and technical agencies have been concerned to ensure priority to and mobilize/protect budgets for particular programs, bypass weak systems by having separate delivery 'shutes', and achieve "quick results". As a result, and because resources have been insufficient even in the aggregate, they have been spread thin, systems have remained fragmented and weak, and human resources underdeveloped and uncoordinated - both horizontally and vertically. (In some cases, there may be more than one cadre carrying out similar tasks - for example, MCH and FP workers in Bangladesh.) The need to integrate reproductive health services is discussed in Chapter 2. Their funding must also be rationalized. "reproductive health services" because of the broad ways in which these are organized (e.g., institutional deliveries are supported by overall hospital resources, diagnosis and treatment of RTIs/STIs are done by general health services) other than at the field level. As discussed in Chapter 2, reproductive health services need to be integrated even further, so clearly their financing must also be rationalized. 4.28 Unit Costs of Public Services. In South Asia, the unit cost for institutional delivery at public facilities ranged from over US$100 in Bangladesh and A.P. to less than US$40 in Sri Lanka, Rajasthan and Nepal. The low unit cost in Sri Lanka reflects the high utilization of public facilities for childbirth (which was discussed in Chapter 2), while the very low unit cost in Nepal (US$12) reflects low spending. Similarly, very low unit costs for family planning in Sri Lanka can be attributed to high utilization, while high unit costs in A.P. reflect the low use of the services relative to the high level of spending on family planning in the state. Overall, the picture that emerges is that Sri Lanka achieves good reproductive health outcomes with relatively low per capita and per service spending. 4.3.3 Allocations of Private Resources within Reproductive Health Care 4.29 Allocations of private resources to different reproductive health services vary across the five countries (Table 4.5). Other reproductive health services for women take up a substantial share of total private resources in Sri Lanka and Rajasthan. Around one-third of private spending in Sri Lanka is on outpatient services, which are generally low cost and are provided at reasonable quality. I n Bangladesh, more than half of private resources are spent on infant care. Table 4.5 PrivateAllocations to Reproductive Health Components, percent 4.30 Private financing of each reproductive health component increases with an increase in overall private expenditure (Fig. 4.2). I n Sri Lanka, public funding is the predominant source for all components (80 to 90 percent), except routine outpatient obstetric and gynecological services (40 percent), demonstrating a progressive use of public and private resources. A high degree of public financing of maternity (around 55 percent) and inpatient services (80 percent) is seen also in Bangladesh, indicating that public spending responds to some extent to market failure. However, no such pattern is seen in Rajasthan. 4.3 1 Average Private Costs of Reproductive Health. Average private costs per couple for modern contraceptives are very high in Bangladesh (0.72 percent of per capita GDP) compared with Sri Lanka (0.05 percent of per capita GDP) and can be attributed almost entirely to NGO spending. 4.32 Survey-based estimates of out-of-pocket payments for reproductive health have been derived for Pakistan and A.P. The 1995-96 round of India's National Sample Survey (NSS) provides data on payments for childbirth which indicate the variation in out-of-pocket expenditure between rural and urban settings. I n Andhra Pradesh, institutional deliveries were expensive, more so in rural areas (9 percent of per capita GDP) than urban (7 percent), while home deliveries were cheaper in rural areas (1.2 percent) than in urban ones (2.1 percent) (Annex 8 Table A8.2). I n Pakistan, a visit to a private practitioner for immunization costs four times more than a visit to a government facility (0.4 and 0.11 percent of GDP, respectively) (Annex 8 Table A8.3). Figure 4.2 Public-Private Compositionof Financingof Reproductive Health Components, Bangladesh, Rajasthan and Sri Lanka, Various Years, percent 4.33 Analysis of data on household consumption and health expenditure in Bangladesh indicates that the richest quintile of households accounts for a larger share of household spending on reproductive health care (61 percent) than of household spending on health care in general (34 percent) (Annex 8 Table A8.4). An important issue is the financial burden imposed on households by reproductive health spending. Analysis of household data for Andhra Pradesh and India indicates that (with the exception of urban areas in A.P.) the financial burden of facility-based deliveries is somewhat progressively distributed in India, with richer households more likely to incur higher payments as a share of total household consumption (Annex 8 Tables A8.5 and A8.6). The fact that richer women make use of private hospital services for childbirth may account for much of this difference. However, this distribution of spending also reflects the low overall use of institutional facilities by poor women. 4.4 IMPROVING REPRODUCTIVE HEALTH FINANCING 4.4.1 What Issues Need to be Addressed through Financing? 4.34 As discussed in Chapters 1and 2, reproductive health outcomes and services in South Asia are inadequate in the aggregate and particularly for poor women, affected by both supply- and demand-side barriers. To increase the supply of services several interventions are required including: filling in the gaps between 'norms" for government health facilities and staff and "actuals" on the ground; expanding outreach; and increasing the availability of acceptable quality private services to poor women. Addressing demand-side barriers mainly entails: improving information about reproductive health and its care; improving the quality of services provided, and improving affordability. 4.35 Indeed, low affordability is a serious constraint to poor women's access to reproductive health care even when it comes to public services which have both direct (often informal) and opportunity costs. As discussed above, private expenditure on reproductive health is two to three times higher than public expenditure in countries other than Sri Lanka. Dependence on household resources to finance a large share of reproductive health services in most of South Asia has grave consequences for equity and outcomes. Inappropriate financing (i.e., mostly out-of-pocket payments) leaves women (particularly those from poor households) more vulnerable to inattention to their health, and health crises, especially those requiring hospitalization, are a major cause of indebtedness, often resulting in poor people falling deeper into poverty. Thus, improvements in reproductive health financing must involve greater pooling of risks and resources across the whole population and reduction of the financial burden on individual poor households. 4.36 There is clearly a need to increase public expenditure on reproductive health, to improve the efficiency of available resources (including targeting to the poor), and to enhance accountability at health facilities. The large differences between Sri Lanka and the other countries in service delivery levels and reproductive health outcomes with modestly higher overall spending show that it is not only the amount of spending that is important but how efficiently resources are used to produce services and outcomes, i.e., both financial and technical efficiency matter. While general revenue financing is currently the most viable option to increase the size of the reproductive health 'pie' for the poor in South Asia, efforts to enhance efficiency can include many supply-side improvements (such as filling in the gaps in norms, outreach, etc.) and demand-side financing can be introduced or expanded, as is being done in Bangladesh. 4.37 Given the large share of private services, efforts must also be made to increase the supply to poor women, including improvements in access/affordability and quality. Quality improvements can be brought about in part through regulation (e.g., of unsafe abortion) and in part through incentives that encourage providers to deliver good quality services to poor women at low cost. The latter can be effected through a variety of public-private partnerships including contracting out and reimbursement schemes. 4.38 The significant differences in spending by reproductive health components among the countries of the region suggest the need to revisit resource allocations. While Sri Lanka allocates a substantial proportion of its public resources to cost-intensive services such as pregnancy, childbirth and inpatient obstetric care, the other countries spend more than half their public resources on family planning. Sri Lanka's financing strategy clearly manages to protect poor women from both physical and financial shocks, while the investments in family planning in the other countries have not improved reproductive health more broadly. Wide variation in donor financing of reproductive health in the different countries are accompanied by insignificant contributions to childbirth services in all countries. This issue needs to be addressed in view of the importance of safe motherhood in the Millennium Development Goals, and of South Asia in achieving the global MDGs. 4.39 Significantly greater resources are required to meet the MDGs for health, especially in India, Nepal and Bangladesh, but the absorptive capacities of the government health systems are a key issue. Larger resources for enhanced service delivery will require more and better human resources, greatly improved management, and better governance. For this reason and because such a large proportion of health spending is private, there is no option but to call into service a variety of financing strategies including more and better spending in the public system, greater contributions by private health providers, and better management of client demand and purchasing. The next section discusses how these strategies could be implemented. 4.4.2 Financing Options 4.40 Improving reproductive health in South Asia requires both the mobilization of more resources and better spending through more efficient organization and allocation of resources, including paymentlpurchasing systems. Whether financing interventions are optimal and effective depends on how they address demand- and supply-side constraints, and improve the use and quality of reproductive health services. Different financing options address demand and supply issues differently as discussed below. All countries will need to use a mix of financing options. The optimal choice for each country (or sub-national unit, where these are at different reproductive health service and achievement levels) would be based on its particular situation in terms of public resource availability, private sector capacity and willingness, and client demand and ability to 'negotiate' the health system. Optionsfor Resource Mobilization. 4.41 General revenue financing has two attractive features from an equity perspective. First, it has proven to be a progressive source of health care financing in both developed and developing countries (Van Doorslaer et al., 1993; Institute of Policy Studies, 2004). Second, when combined with universal coverage and low or no user fees, it provides high levels of financial protection against catastrophic ill-health. In South Asia, Sri Lanka has shown the way to achieving these goals. The scale of the other countries' reproductive health problems, the need to keep prices low while substantially increasing the supply of services, and the challenges of increasing demand for and utilization of services among the poor call for greatly increased general revenue financing of reproductive health care in South Asia. Additional public and private efforts are needed to cover the poor, improve quality and performance, and provide adequate choice to clients. Among promising approaches in the region are on-going efforts to provide matching grants to autonomous bodies managing (and partly self-financing) public hospitals in India, grants to local governments in India and Pakistan, and contracting private (usually non-profit) organizations to manage public facilities, provide childbirth or abortion services, or distribute contraceptives in several countries. 4.42 Unfortunately, the provision of public resources for health care in South Asia has been subject to political pressures. I n most countries, health and reproductive health have been accorded low priority compared to sectors such as defense, infrastructure, power, water, education and so on. However, direct spending on health is needed to reduce maternal and child mortality and fertility, all of which have implications for resource needs in other sectors. The determinants of reproductive health point especially to the importance of girls' education, women's social and economic empowerment, and nutrition to achieving good outcomes. With the exception of Sri Lanka and Kerala in India, South Asian countries have underinvested in these historically. While efforts are being made more broadly now in the areas of girls' education and women's empowerment, there are still 'miles to go" for the majority of South Asian women. Reaching the MDGs will require investments in health as well as sectors such as food, water supply, sanitation, education, and transport which could improve the efficiency of health spending and further improve health outcomes. 4.43 Most official development assistance to the health sector in South Asia either goes through government health budgets or, if off-budget, supports identifiable public efforts. Bilateral and multilateral institutions need to increase their support, ensuring that funds are additional and absorbable, and that they foster much-needed integration and rationalization of reproductive health services. I n addition to maternal and neonatal care, other reproductive health services such as RTI/STI treatment are under-emphasized by donors relative to family planning and, increasingly in South Asia, HIV/AIDS. Private financiers (once confined to supporting non-governmental efforts albeit significantly in, say, Bangladesh) are increasingly pooling their funds to support public efforts (e.g., national HIV/AIDS control programs). 4.44 Productivity Improvements. Improving allocative and technical efficiency is an important mechanism to finance increased coverage and access to services (Hensher, 2001). Information gathered in this study indicates large variations in cost levels and technical efficiency in the delivery of similar reproductive health services in the public sector. Although Sri Lanka now enjoys social and economic indicators that set it apart from most of the rest of South Asia, its high levels of technical efficiency and low unit costs were the result of public policy and decades of cost-reducing productivity gains (rather than of high levels of education as widely believed) (Pathmanathan et al., 2003). Low unit cost levels in Sri Lanka contribute to its high levels of reproductive health access, and are not the consequence of it. Although not enough is known about the determinants of productivity improvement to make very specific recommendations, achieving universal access to reproductive services is unlikely to be attained in the rest of South Asia without some contribution from cost-reducing productivity gains. Among the improvements that could be achieved (as discussed in Chapter 2) are: increasing the productivity of individual workers by providing motivation/incentives and reducing absenteeism; improving outputs from investments by supplying 'missing ingredients' such as essential staff at health centers, medicines where staff are available, etc.; and increasing the effectiveness of outreach efforts by ensuring better instructions, training, and reducing 'overload' with extraneous tasks. I n addition, some of the broader mechanisms discussed such as targeting and integrating services would also enhance productivity. 4.45 Private financing. In South Asia, the disproportionately large share of reproductive health services financed by households has consequences not only for equity and financial protection against the costs of illness as discussed above, but also for 'protection' through contraception, assisted delivery, identification of pregnancy risks through ANC, timely diagnosis and prevention of infections, and so on. Households may not purchase reproductive health services - many of which are 'preventive' or 'promotive' - because they perceive them to be low needlbenefit-high cost; or they may purchase 'more affordable' poorer quality services. Private financing is desirable for low-cost items for which there are no significant market failures and which would be delivered regardless of public financing. One example is the provision of routine outpatient reproductive health care services. The empirical findings of this study indicate that these services are more likely to be privately financed than other types of services. In this situation, public financing is not necessarily best targeted at funding ambulatory services for all at the expense of reduced delivery of inpatient services (Filmer, et al., 2002). It is better to use household resources to finance a large proportion of those services, leaving the public sector to finance more expensive and unaffordable in-patient care. However, this should be determined by the extent to which market failures are present in the supply of different types of services and distributional concerns. For example, the lack of information about appropriate health care is a critical form of market failure in reproductive health. This relates to the lack of awareness of signs/symptoms and clinical quality, and inability to identify appropriate providers. Private financing in such a setting carries the risk of women increasingly seeking poor quality care from unqualified providers or not seeking care at all. For many of the poorest households, even outpatient services are unaffordable with private financing. The optimal resource allocation pattern is therefore to ensure that all or most households are publicly financed for inpatient services, and that outpatient services are funded primarily for the benefit of poorer households. This type of funding pattern is seen in Sri Lanka. 4.46 There is scope for greater engagement of private sector providers - both commercial and non-profit - in financing provision of reproductive health services for poor women. Governments could encourage private providers to deliver a proportion of their services free or at low cost to the poor through incentive or award programs, contracts (discussed below) or even regulation. For example, in India, land is made available for private hospital construction at subsidized rates provided 25 percent of beds are used to treat poor patients. While results have been mixed (due in part to poor monitoring) such strategies can enlarge the pie of private services for the poor. 4.47 Options for Resource Allocation. Resource allocations affect access, cost, quality, satisfaction and outcomes. Other than the risk pooling achieved through national health systems, insurance efforts could optimize resource allocations - but these face some difficulties in the South Asian context. 4.48 The national health systems in South Asia have networks of facilities and providers, largely funded from general revenues. As they cover entire populations the 'risk pool' is broad. However, as discussed above, there is a need to increase the efficiency and equity of public spending on reproductive health. The national health systems need to operate more efficiently, reach out to the poor and target resources to them, and actually achieve universal coverage. The wide range of problems that are encountered in health care (health problems as well as difficulties in service delivery) calls for better allocation and rationalization of resources in tandem with productivity improvements. This includes allocations by services - in this case to reproductive health and within reproductive health to the package of services that are essential to achieve the MDGs. Low priority expenditures could make room for more necessary ones, especially interventions that have the greatest marginal impact of the poor. 4.49 Resource allocations must also be improved by level (e.g., to in-patient rural health facilities because the transaction costs to the rural poor of using local health centers are lower than those of using more distant urban facilities) and by 'input'. Many examples of the last were discussed in Chapter 2. For example, imbalances in staff, equipment, drugs and supplies may need to be rectified through appropriate budget allocations. Insufficiencies in staff of certain types may require contracting in (e.g., anesthetists and ob-gyn specialists in India) to provide the necessary range of services (in our example, EmOC) and use available resources (such as operation theaters) more efficiently. Allocative and technical efficiency provide value for money and hence improve financing of health care. 4.50 I n addition to addressing the inadequacy and allocation of resources, and improving the efficiency of national health systems, South Asian governments also need to improve accountability. Poor experience with internal staff or management may call for services (such as cleaning, conservancy, watch or transport) to be contracted out; low motivation of staff may call for incentives (promise or performance-based) to be provided; and so on. Such detailed allocation decisions are best made at the local level through decentralized action planning within an administrative framework that supports the principle of subsidiarity, as discussed in Chapter 3. 4.51 Although we have not attempted a functional classification of reproductive health expenditures in this chapter, it is important to note that all five countries need to invest in increasing human resource capacity, especially of skilled professionals. Indeed, valuable investments in human resources in the health sector are being lost from South Asia through the emigration of doctors, nurses and technicians to other countries. Information and innovative strategies are needed to stem this flow or compensate for it, particularly in view of the allied flow from rural to urban areas. 4.52 Turning to private spending, South Asia's high out-of-pocket expenditure could be channeled to public or private pooling arrangements to increase financial protection through public sector health systems or various forms of insurance including social health insurance, community health insurance, or private/voluntary health insurance. However, private health insurance is less likely to produce more and more equitable health care in most South Asian contexts. 4.53 Social health insurance has been developed successfully for mothers and children in Bolivia. The government allocates 20 percent of national revenues to municipalities on a per capita basis, and they in turn reimburse facilities for services provided. The scheme led to increased use of services by adolescents and poor women, and service improvements (e.g., availability of medicines). As services were provided free, some users shifted from private to public services, and providers were dissatisfied because their remuneration was not enhanced as a result of increases in workload and clients. 4.54 There is little experience in South Asia with social health insurance - it accounts for only 8 percent of public spending on health (or less than 2 percent of total spending) (Gottret and Schieber, 2006). It would be a challenge to introduce at a national level in at least four of the five countries because of low incomes, predominance of informal sector employment, large rural populations, inadequate administrative capacities, governance issues, poor quality of peripheral health services, etc. These constraints may produce negative consequences for equity in delivering and financing reproductive health care. It could be argued that social insurance could alleviate the need for public financing of services for middle-income groups, thus releasing resources for the poor. However, international experience indicates that political economy factors result in two-tier systems in which it is difficult to divert resources from richer groups to health services for the poor. 4.55 Community insurance involves risk pooling at the community level, albeit to a limited extent. It faces the problems of raising sufficient resources from the limited incomes and small populations on which they draw, limited management skills, and dominance of providers over prices and quality. A promising scheme that was begun in 2001 in a few districts of Indonesia was extended country-wide in 2005. The JPK-Gakin Scheme is administered by local governments, which has facilitated responsiveness to local conditions, such as the problems of remote areas and seasonal or geographic vulnerability to epidemics Although a review suggests that many improvements are needed in the scheme, it appears to have successfully increased health care coverage among the poor and deserves to be on a watch-list (Arifianto et al., 2005). In South Asia it is unlikely to work alone, but attention to several aspects could enhance its usefulness as a complementary means of financing reproductive health care. First, most schemes in South Asia currently do not cover the more expensive in-patient reproductive services including childbirth. Coverage would need to extend beyond the narrow range of services to insure households against the financial consequences of illness. Second, community insurance schemes rarely enroll the richest groups in the population, nor are they able to enroll the poorest groups, as underlined by BRAC and Grameen Bank in Bangladesh (Rannan-Eliya and Hannan, 1997).' This needs to be addressed to exploit the progressive nature of this mode of financing. Finally, approaches to scaling up and sustaining community insurance schemes need to be developed in order to ensure lasting reproductive health benefits in South Asia. 4.56 Options for Purchasing/Payment Systems. Although the five national health systems provide services through staff who are salaried public employees, the bulk of purchasing in reproductive health care (except in Sri Lanka) is by individuals from private service providers. The goals of more and more equitable reproductive health care can also be furthered through purchasing mechanisms. I n the public sector, for example, governments can get better value for the money they spend through a variety of purchasing mechanisms, including decentralized planning and management which were discussed in Chapter 3, and contracting in or out for services and efficiency-based provider payments or incentives, discussed above. Other promising approaches for reproductive health care in South Asia include demand-side financing and social marketing. 4.57 Demand-side financing. The main advantages of demand-side financing are the potential to target benefits, provide a choice of providers, increase utilization of services and compliance with service or treatment regimens, and improve quality through competition (within a fixed price limit). Subsidizing specific health services for the poor, such as institutional delivery, abortion or contraception, could enhance demand and use, and increase the quantity of services flowing to them. Competitive voucher schemes are considered to be better than those in which there is a single provider, but non-competitive schemes can fulfill the purposes of targeting, providing an incentive to change a health behavior, or referral. Several countries have implemented successful schemes. A Safe Motherhood scheme in Indonesia distributed a booklet of coupons for MCH and FP services to poor women, who could redeem them through contracted midwives (who otherwise charged for their services). In addition to reaching poor women, the scheme increased utilization of these services, and increased the services of the providers (Gorter et al., 2003). A scheme in Nicaragua provided vouchers to high-risk groups for ST1 treatment and reported a fall in the prevalence of infections as well as a lower treatment cost per patient. Bangladesh has initiated a health voucher scheme to increase demand for maternal and neonatal services and insure poor women against the costs of a normal delivery by a skilled provider or of emergency obstetric services. The vouchers enable pregnant women to purchase antenatal, delivery and postnatal services from a qualified private provider of their choice. Providers are reimbursed from a special fund. 4.58 Public monies can also be used for direct cash payments ("conditional cash transfers" or "incentives") to poor households that achieve certain goals, such as "three ANC visits" or "delivering in an institution". This would protect the poor, allow process monitoring, and improve health outcomes. The PROGRESA program in Mexico gives families below the poverty line a subsidy of about 25 percent of their annual income if they utilize a full package of 9.Private/voluntary health insurance imposes financial barriers to access because of the low affordability of premia, and so is not considered here as our concern is primarily with poor women. mother and young child health and nutrition services. In addition to increased utilization of services, improvements were reported in health (Gertler, 2000). India has instituted reimbursement of transport and attendant costs for the use of public sector EmOC facilities. Although this has had variable success it could be improved and expanded, and increased in scope to cover other out-of-pocket expenses for reproductive health care. 4.59 Social marketing is an intervention that has effectively mobilized household resources in the reproductive health sector and simultaneously improved delivery. It involves selling government- or donor-subsidized products through commercial channels, NGOs or public retail outlets. The main advantages are that the products which are partially subsidized become more accessible to adolescents, poor and high-risk populations, and create demand. However, social marketing is not without drawbacks. Amongst the poorest households, where there are competing demands for scarce resources, having to pay, for example, for contraceptives may deter use even when prices are subsidized. Nevertheless, social marketing has been found to be a viable method for delivering contraceptive supplies in South Asia and is to be recommended, provided that publicly-funded zero-priced supplies are still available to the poorest. 4.60 Social franchising of reproductive health services can involve the private health sector in reproductive health goals, taking advantage of its contacts with the poor and improving quality and accountability. Clients benefit through improved access to information, facilities, services and discounts, and private providers gain as a result of bulk purchases, branding, incentives, mass marketing and referrals. The public sector benefits from the organization of private providers and bulk handling, and relative ease with which quality standards can be maintained and the possibility of performance-based contracts. The Greenstar experience in Pakistan and Janani in India provide useful financing and service delivery models to expand commodity and service distribution. Janani provides products, testing, and clinical abortion, delivery and contraceptive services through conventional shops, special centers for non-clinical services, or clinics. The Greenstar network operating through private clinics, doctors, paramedics and chemists provides 21 reproductive and related health products and services, at roughly half the cost of Pakistan's overall family planning program. 4.61 User fees are a means of generating additional revenues at health facilities and function as an incentive to facilities to improve service availability and quality. The actual amounts collected may be less important than how the funds are used to improve the quality of care. Financial barriers faced by the poor may be reduced if the fees collected are managed well and produce better quality public services, reducing waiting time or the need to use more costly private care. In addition, paying user fees can cause clients to express their demands (or 'vote with their feet') and consequently increase provider accountability. User fees are usually combined with policies to exempt the very poor. However, evidence from Nepal and Bangladesh suggests that such exemptions need to be made more effective as exempt individuals often end up paying similar amounts in unofficial fees (Borghi et al. 2004; Ensor, 2003). Alternatively, the exempt may receive an inferior quality of service or - where quality is good - non-exempt individuals may crowd out the poor. Thus, decisions to introduce user charges must weigh the availability of public and private services, their quality, governance of the health institutions, and South Asia's strongly class- and/or caste-based societies. Transparency mechanisms and reliable information on willingness to pay for different services are needed to ensure that user fees support reproductive health services effectively particularly where insufficient demand is a critical problem. 4.4.3 Choosing among Options 4.62 Improvements in reproductive health financing must be developed in the context of broader reforms in the health sector. Depending on starting conditions and underlying values and preferences, the different countries may arrive at distinct "solutions" to their major health financing challenges. In assessing their financing options, several factors should be considered to ensure that adequate priority is given to improving reproductive health outcomes for the poor. All the five national governments need to take responsibility for financing health care strongly and subscribe to the urgency of improving reproductive health to reduce maternal and infant mortality, allow families to control their fertility, reduce RTIs/STIs/HIV/AIDS in the population are large, and enhance well-being among women and adolescents and their contributions to national development. The urgency leads to the conclusion that a broad mix of solutions, achieving wide coverage, needs to be adopted. Reliance on out-of-pocket payments contributes to demand-side barriers, and efforts should be made to introduce and/or strengthen collective funding of reproductive (and particularly maternal) health services for the poor. On-going monitoring of out-of-pocket payments and the benefit incidence of public spending on reproductive health should accompany financing reforms. Potential exists for demand-side financing to be used to encourage very poor households to seek appropriate reproductive health services. Various approaches are being introduced in South Asian countries, and should be considered for scale-up especially in areas where significant demand-side barriers are identified. Even at current low levels of spending, there is room for greater efficiencies in the use of funds. Greater efficiency could be achieved by increasing the productivity of workers, integrating services, and promoting higher utilization, for example, through improved quality and outreach services. Some of these approaches may require increased spending, but would produce proportionately greater impacts if properly implemented. It is clear that current levels of investment would not achieve the MDG or ICPD goals so both donors and national governments need to increase their investments many fold. While South Asia's people and governments need to fully 'own" the efforts to improve reproductive health, donors could work more actively with them to identify how adequate resources could be mobilized from national and international sources and how these could best be programmed to achieve the necessary outcomes. 4.4.4 A Multi-sectoral Approach? 4.63 Reaching the MDGs requires growth and a multi-sectoral effort. The determinants of reproductive health point to the importance of girls' education, women's social and economic empowerment, and nutrition to achieving good outcomes. With the exception of Sri Lanka and Kerala in India, South Asian countries have underinvested in these. Broader efforts are being made in the areas of girls' education and women's empowerment more recently, but for the vast majority of South Asian women, there are still "miles to go." While direct spending on health positively affects maternal and child mortality more than other public investments such as sanitation, education, infrastructure, allocations to health in South Asia have shown themselves to be highly subject to political vicissitudes. I n most countries health is considered a low priority compared to defense, infrastructure, power, water and even education. While arguing for higher health spending it would be well to encourage simultaneous investments in other sectors to improve food availability/distribution, water supply, sanitation, education, and transport infrastructure as these can help to enhance the efficiency of health spending and further improve health outcomes. Chapter 5 Improving Poor Women's Reproductive Health To improve poor women's reproductive health, South Asian health systems have to implement number of related improvements: Enhance inclusion. They need to bring two important groups - poor women and adolescents - squarely into the fold of reproductive health services through geographic and household targeting and clearly directed outreach. Social and gender sensitivity among providers, managers and policy-makers is essential to achieve this inclusion, as well as the supply and demand improvements noted below. Improve supply. They must enhance the supply of services for all stages of the reproductive life cycle, for which integrating the essential package and providing a client-centered continuum of care are good approaches. Four services have been particularly neglected and require additional attention in this context: safe abortion, nutrition counseling and care, RTI/STI diagnosis and treatment, and postnatal care. Improving the availability and quality of frontline female health workers through recruitment/contracting in, training, field support and performance-based incentives would help to fulfill many needs, while contracting out (e.g., abortion services) and other client/provider payments could increase the availability of care for poor women. Increase demand They need to increase demand for several services that are provided by the health system, such as ANC, IFA, institutional deliveries and family planning (although supply may be a constraint in some areas). I n addition to 'behavior change communication', demand-side financing could help to achieve this. Reform the health sector for reproductive health. As reforms take place in the health sector, the delivery and financing of reproductive health services merit special attention. Reforms are especially necessary in three areas to support the above approaches to improving reproductive health. Decentralized planning and resource allocations, human resource developments, and financing improvements are important to implement targeting, integration of services, a client- focus, demand-creation, and effective outreach. 5.1 WHAT NEEDS TO BE DONE AND HOW 5.1 A 'results framework' showing what is to be done to achieve reproductive health goals for poor women in South Asia and how it can be done is presented in Table 5.1. The "what" actions cover the essential package of reproductive services and are listed in order of their priority and feasibility overall (based on the evidence presented in earlier chapters). Detailed prioritization, particularly for decisions about resource allocation, must be worked out at the local level. Decentralized action planning is a key "how" strategy to prioritize and get the necessary improvements in service delivery and financing as described in Chapter 3. While disadvantaged districts can be targeted through selection at national/provincial/state/etc. levels, poor areas, groups and households within districts would be targeted (to improve demand for and coverage of services) through DAPs at district level and below. The DAP method is in fact focused on redressing these inequalities. Higher authorities should mandate and facilitate DAPs, provide additional resources as needed and deserved on the basis of plans and performance, and examine and act on policy implications. For example, if additional staff requirements cannot be met locally there may be need for changes in HR policies, training, etc. Another example: in addition to inter-personal creation of demand which can be brought about through training and incentives to workers within the DAP framework, pre-service training may need to develop communication skills, and sensitive and creative information provided through mass means. Indeed, complementarity between decentralized planning and higher-level actions must evolve through the implementation of DAP. All the five countries have policies in place that would enable the higher level actions (Annex 9). 5.2 Decentralized planning facilitates choices between supply-side improvements and demand creation, including demand-side financing, and encourages combinations of these suited to local circumstances. Supply improvements may include human resource development, performance incentives, management improvements, and public-private partnerships that can be effected at the local level. These can be fine-tuned appropriately - for example, decisions can be made about which services require incentives or performance rewards, what needs to be supervised and monitored more carefully, and so on. As described in Chapter 3, DAP emphasizes better use of available resources, and need- and evidence- based requests for additional resources. By exploring what private resources are available locally, DAP teams can also plan for better public-private complementarities and partnerships to improve the overall 'pie' of services for the poor. Table 5.1 Results Framework to Improve ReproductiveHealth I n South Asia 1. Increaseaccess to and use of skilled - Increase availability of frontline female workers through birth attendance, including referral in recruitment or contracts with private individuals or agencies case of need - Strengthen skills and social and gender sensitivities through technical, managerialand communicationtraining of frontline workers; and provision of guidelines (incl. referral instructions) and adequate supplies - Provide incentives to providers for better coverage and performance rewards - Provide information through mass means and interpersonal communication skills to create awareness of need, and demand for SBA; and demand-sidefinancing to reduce constraints 2. Increase access to and use of EmOC - Motivate community-basedemergency transport by financing groups; or reimburse individualcosts - Fully establish EmOC facilities within reasonable reach. Districtsto determine needs and locationsof facilities on the basis of local conditions including availability in private sector. Where latter are available enter into purchase agreements 3. Increase access to and use of PNC - Mandate timely home visits of workers and ensure skills to including managementof PPH, detect problems among women who have delivered at home treatment of infections and depression, - Finance community transport or individualcosts to EmOC as adolescents and unmarried women) 1.Increase access to and use of workers and strengthen their technical and counselling skills contraception to delay first, space through training through public-private partnerships 2. Increase access to information on sexuality, sex, sexual health, - Expand Behavior Change Communication programs through responsible sexual behavior, mass media, and interpersonal communications through better delaying marriage, reproduction, training of frontline workers; both can be contracted out abstinence, contraception, abortion, RTIs/STIs, hygiene, nutrition and - Increase Life Skills Development Programs (to develop gender roles, es~eciallvfor talents, self-esteem, negotiation and economic skills, etc.) through other sectors and private organizations (e.g., CBOs, NGOs), especially to reach groups such as adolescents and to vulnerable groups visits/clinic work The sections below further describe how these recommendations can be implemented. Sections 5.1.2-5.2.3 can also be related to the discussion of promising practices in Chapter 3. 5.1.1 Achieving a Better Understanding of the 'Poor Woman as Client' 5.3 Reproductive health problems are clearly concentrated among the poor who also receive insufficient care. For poor women in South Asia, the key problem with regard to reproductive health services is inadequate access. Thus, to improve reproductive health there is a need to ensure coverage of the socio-economically disadvantaged by targeting the supply of public services to areas and groups (and within these, to households) that have the greatest reproductive health needs, and to create demand among these groups for necessary services. Both targeting and demand creation strategies can be effected through creative financing mechanisms which will be discussed later. Socio-economic targeting of services must be overlaid on the biological targeting that is integral to reproductive care and calls for a reordering of priorities, modifications in the organization of services, improvements in processes as well as facilities, and innovations to create effective demand. 5.4 Understanding Client's Needs. A focus on the poor calls, firstly, for an understanding of client needs - not only of the services they require, but also of how they expect services to be provided, and how their constraints to using services can be overcome. Two mechanisms can be adopted fairly quickly to improve this understanding. First, information can be collected from those who visit health facilities through independent exit interviews and used almost immediately to make improvements through decentralized action planning. Client satisfaction surveys can be carried out at the community level (e.g., by DAP teams) to give poor women a voice and identify problems. The evidence points to patients' needs being quite straightforward: better timings, availability of staff and medicines, better behavior, and so on. Many are easily addressed with little or no additional resources. Second, information must be collected at the community level through collaborations between local government bodies or citizens' groups (e.g., Village Health Committees) and health providers, and used to plan better outreach, clinic-based services, incentive mechanisms, and monitoring. 5.5 Serving the Poor. Beyond understanding poor clients' needs, it is necessary to act on them. The public health systems in all five countries need to be actively oriented to serving the poor. There is need for clear pro-poor policies, programs, approaches and incentives in all countries. Several examples of pro-poor activities do exist such as free maternity beds for poor women, special camps, and outreach mechanisms providing free medicines. A novel scheme is the "one-day mataram", an effort in Karnataka (India) to rope in private sector ob- gyn specialists to provide free care on one day of the month. However, these are hardly enough to produce a significant impact on the maternal mortality ratio or infant mortality rate. A range of mechanisms including targeting of supply, subsidies and incentives (to both clients and providers) are needed to ensure that larger numbers of poor women are reached and a much larger proportion of services (both public and private) flow to the poor. 5.6 The social context of most poor women in the subcontinent calls for services to be provided through outreach by well-qualified providers (see below). The Public Health Midwives of Sri Lanka are perhaps the best example of this, but all the five countries currently have one or more cadres of female paramedics with frontline responsibilities for reproductive health. Management of these workers has proved to be one of the most difficult tasks, and needs to be improved throughout South Asia. In addition to ensuring that there are sufficient numbers 'on the job", the workers must be provided the necessary supplies, up-to-date knowledge and skills - including technical, communication and simple managerial skills, and support to carry out difficult social and technical tasks. 5.7 Geographical targeting is also of great importance throughout South Asia (including Sri Lanka) because of the current wide micro-regional variations in service availability and outcomes. Every level of the health systems should consciously plan to allocate resources preferentially to the most neglected areas in their charge and monitor their achievements. For example in India, the significant differences in reproductive health outcomes in different states and districts call for the RCH program to target the worst ones; and even within districts, decentralized planning must focus attention on the worst blocks and villages, towns and urban slums. This approach could be taken down to the village and household level through outreach workers to achieve full socio-economic targeting. 5.8 Gender-sensitive services. Gender issues are among the core constraints to better reproductive health on both the supply and demand sides. On the supply side, provider behavior towards women, the design of facilities and programs, the availability of services (their type, timings, location, and integration) and the status of women service providers (especially frontline workers most of whom are women) are significant issues that need to be addressed. All health providers need to be held accountable for their behavior towards poor and female patients, particularly those from stigmatized communities. Regarding demand, poor women throughout South Asia report that ill-behaved staff deter them from using health facilities. As reproductive health concerns the most important commodity traded between men and women (sex) and women's primal role in society (reproduction), efforts to promote women's care at the household level in the patriarchal cultures of South Asia need to take cognizance of the imbalance of power in decision-making and control over resources and employ strategies that can help poor women overcome their weak position. Some examples are: involving men in family planning, providing pregnant women vouchers to deliver in institutions, and promoting gender-sensitive behavior in adolescents. 5.9 Women's Reproductive Rights. The concept of women's reproductive rights has hardly entered the lexicon of the health services in South Asia (leave alone their "mindset"). To begin the process, they need first to be translated into a charter of health service rights and responsibilities toward clients (similar to that evolved in ~angladesh).' Then, working from the inside out, the reproductive rights of women should be the subject of considerable public education. A further step would be additional legislation to ensure a rights-based approach. 5.1.2 Increasing Information and Demand 5.10 Many community, household and individual factors that determine health and use of health services could be influenced by information. A key role for the public sector during health reform is to provide information to improve personal and household practices and encourage appropriate use of services. Creating demand for good quality preventive and curative services, and publicizing client rights and responsibilities are critical for improved reproductive health. This has several dimensions to it: Widening and deepening communication with women and families, especially among the poor and disadvantaged, through mass media and inter-personal communication. Information (and services) can be provided through 'local action', for example, adolescent reproductive health can be addressed in schools and in out-of-school/youth programs. a Providing information on the availability of services (e.g., on service timings, what the worker can/should provide, location of referral facilities, etc.) to facilitate their use by poor women as well as to hold workers accountable for delivering services where and when these are expected. IEC/BCC and community involvement mechanisms must be seen as central to improving service and not as 'add-ons' or afterthoughts. A two-way flow. It is as important for the health system (and allied institutions) to understand the needs and wants of clients to create demand for services, as it is for them to give information about right health practices and options. '. During the Health and Population Sector Program in Bangladesh, the MOHFW developed a Clients' Charter of Rights. It was prepared by a National Stakeholder Committee (NSC) to facilitate the incorporation of community voices into health programs, establish their right to transparency, and build a foundation for program accountability. The charter includes rights to a choice of provider, accessibility, privacy, etc. A large number of copies of this Charter were disseminated by the MOHFW to all Divisions in the country with instructions to distribute them to the Upazilla Health Complex level, and then to Community Clinics. Although several problems were experienced the approach can be adopted and improved upon by other countries. Health information is also needed by public and private providers, administrators and policymakers. For example, the contents of the essential package of reproductive health services and their benefits are little understood. Table 5.2 illustrates how many of the improvements that are required in the supply of services need to be supported by the provision of information and demand creation. Table 5.2 Examples of Supply-Side Improvements in ReproductiveHealth Care that Need Information/Demand Creation. . ,Supph( of Reproduc#va HealthServices Service Provision/Technical Issues Providing an integrated packageof ANC, Delivery I care, PNC, Child Survival, Family Planning Policy-makers (politicians at all levels including (including men and adolescents), local bodies, bureaucrats, opinion leaders) RTI/STI/HIV/AIDS care, Abortion and PAC, care Health service managers and providers of older women's problems and general health Communlties in general care Poor people Improving nutrition in the household Women Adolescents Institutional Other influencers, e.g., teachers Improving the skills/competenciesof providers Ensuring the availability of the right mix of What to cover (not an exhaustive list) medical, paramedical and support staff Knowledgeabout reproduction and the (especially women doctors, nurses, outreach importance of proper growth and sexual workers) development Establishmentand equipment of basic health Importanceof delaying marriageand facilities childbearing Enhancing the availability of medicines and Preventing, identifying and proper treatment of supplies reproductivehealth problems Improving outreach Use of services for different concerns, esp. Improving the knowledge/skills/practices of institutional delivery, treatment of RTIs/STIs, traditional providers; ensuring quality standards, abortion, family planning accreditation of providers and institutions Enhancing gender equality (from childhood Financing mechanismsfor the poor through, e.g., through adulthood) public-private partnerships Consumer rights in the public and priv sectors Policy Ensuring that "no targets" also means that FP Indirect services are not pushed in isolation Social policies beyond health Decentralizingdecision-making about program 5.1 Girls education contents, activities and use of resources 5.2 Women's employment Legislatingfor quality (in both the private and 5.3 Old-age security public sectors), accreditation 5.4 Poverty reduction Clients' charter of rights at public facilities and in private services 5.11 Successful supply efforts to reduce constraints to demand have included regular service camps, integrated services at the village level, gender sensitization of health staff, and social marketing that reaches the poor with services. Initiatives that have successfully overcome socio-cultural obstacles to better reproductive health include: comprehensive counseling for family planning involving men; improved technical and interpersonal communication skills among staff and strengthened management for better quality ST1 services; and cooperative networks of public and private doctors, to name a few. Community mobilization efforts can help to raise awareness of reproductive health, involve both women and men to change household health-seeking behavior, and promote women's status and empowerment. Community-based interest groups such as self-help groups or local government bodies can be sensitized and involved in these efforts. 5.1.3 Expanding Services to Cover the Reproductive Life Cycle 5.12 Adolescents. Better overall reproductive health requires attention to all stages of the life cycle. Annex 10 summarizes the key interventions needed to improve reproductive health at different stages. By far the most neglected biological target group in all five countries, and the most important in terms of long-term reproductive health outcomes, is adolescents. The health system must take greater responsibility for adolescent knowledge of body processes, sex and safety, reproduction, nutrition, and preparation for marriage and childbirth. As adolescent needs are relatively new to the health sector, meeting them calls for considerable shifts in attitude and organization. Several interventions have been identified as parts of well- designed adolescent reproductive health programs, including: (i) Behavior Change Communication, which provides access to accurate information on sexuality, reproduction, abstinence, contraception, abortion, STIs, and gender roles; (ii) adolescent-focused reproductive health services, specifically for contraception, prevention and treatment of STIs (including HIVIAIDS), and abortion; and (iii) life-skills development (through cross-sectoral cooperation) to enhance self-development and economic opportunities. In Bangladesh, in addition to the cash and food incentives offered to encourage girls' schooling, programs such as the mass Total Literacy Movement run by the government, and non-formal education by many NGOs have contributed to raising awareness and literacy among adolescents. 5.13 Sexually-active adults. For adults, the prevention and management of RTIs/STIs, and safe abortion are key services that are widely deficient. RTI/STI diagnosis and treatment. These tend to be separated from other reproductive services and provided if and when women approach curative health facilities (or, more recently, HIV 'Integrated Counseling and Testing Centers'). Active identification of problems by outreach workers and simple treatment or referral by them, and 'single window' reproductive services at health centers would greatly benefit women as well as improve the chances of healthy pregnancy, safe birth and family planning acceptance. Abortion services. Both availability and quality in the public system need to be improved. These facilities or referral units must also provide post-abortion care including contraceptive advice and services. Emergency contraceptives that are now available could be helpful in preventing some abortions if used - and users managed - properly. Increasing safe abortion clinics by supporting franchises in the private sector or providing other subsidies are promising approaches. At the same time, unsafe abortion facilities/providers must be eliminated through stringent enforcement of available laws. Family Planning. Despite decades of effort, contraceptive services remain woefully inadequate. Many things need to be done: provision of information; increasing the choice of methods; training providers in counseling and technical aspects; regular supply of contraceptives; follow-up and management of side-effects; involvement of men in decision-making, contraceptive use, and women and child health care. Promising approaches include subsidized supply through private social marketing and other means and providing workers with incentives to retain satisfied users. 5.14 Maternal Health. Many service improvements are required for mothers: 5.11 Prevention and treatment of anemia beginning in adolescence and before pregnancy. While providing adequate supplies at the local level it is also necessary to addressing the demand side, possibly through extensive education campaigns aimed at families. Only a more-supportive family and community environment will encourage women to comply with prophylaxis during pregnancy. Social marketing is another potentially successful method. 5.12 The quality of antenatal care. It is necessary to identify risk factors clearly, counsel women, detect and manage complications early, and encourage women to have a safe delivery. Information on risk factors and danger signs needs to spread in communities and among providers. Some efforts to train and provide incentives to traditional birth attendants (who attend many births in South Asia) to perform these tasks have worked. 5.13 Access to skilled birth attendance. It is critical for poor women to have access to skilled birth attendance irrespective of the place of delivery. Investment in birthing skills, accessible facilities and incentives to frontline workers to attend deliveries or help women use available facilities are justified by the number of women's lives and very large number of neonates who could be saved. These must be supported by emergency transport to well- equipped obstetric facilities: in most of the five countries progress in developing emergency obstetric services has been far too slow and needs to be accelerated. Poor women must also be encouraged to use private facilities through targeted financing mechanisms such as vouchers or provider incentives. Motivating families and women to deliver in institutions would entail a sizeable effort as current beliefs in most of South Asia do not support this. 5.14 Improving postnatal care. As long as the majority of South Asian women deliver at home and progress toward institutional births is slow, increasing postnatal visits is necessary to partially fill the breach. The standard for a post-partum visit by a trained provider should be a first visit within 24 hours. Appropriate incentives, training and supplies should be provided to workers, and transport arrangements (including funds and vouchers) made available to move mothers and neonates who are experiencing difficulties to hospitals. Widespread information campaigns are needed on the problems that precede and follow childbirth and how these should be attended. Increased postnatal care also offers the opportunity to improve exclusive breastfeeding and other aspects of child care. 5.15 Older women. Strategies are needed to encourage them to approach health providers for reproductive and other health problems to ensure that life-threatening and debilitating conditions are diagnosed and treated. Treatment of menopausal problems and screening for breast and cervical cancers are relatively simple efforts that can be implemented where female nurses and doctors are available. 5.1.4 Integrating Services 5.16 A major challenge in South Asia, where the poor have multiple health needs, women are socially and economically restricted from using services, and the direct and indirect costs to the poor of health care are high, is to optimize their visits to health providers and facilities. This can be achieved in part by integrating the essential package of services (Annex 4), and in part by improving quality (which is discussed below), even while extending reach. The services in the package must be made available using the principle of subsidiarity, beginning at the community level and moving upwards, including the necessary linkages. Table 5.3 lists the key actions that can be taken by providers at different levels and service delivery points. The providers of services should be responsible for reporting to the closest level in charge of management and financing. Implicitly, where health workers are involved, they must be trained and instructed to refer clients upward for services not provided at their level. Table 5.3 Reproductive Health Services from the Bottom Up Maintaining personal hygiene Practicing safe sex, using contraceptives Women's Group including men's involvement Traditional Provider Peer counseling for prevention of RTIs/STIs/ Community Health HIV/AIDS (including men) Preventing anemia Preparing for birth (planning delivery) Identifying risk indicators and signs Skilled birth attendance Referral Arranging referral transport Postnatal visit Initiating breastfeeding early, exclusive breastfeedina, and timely supplementation Information on sexuality, reproduction, l 1 I I I I I -risk cases and refer to I cancer and manual t-abortion care dical workers 5.17 Previous experience in South Asia shows that it is possible to combine maternal and child health services well with family planning as the same workers can deliver both at the frontline.* However, the diagnosis and management of RTIsISTIs (including HIVIAIDS), safe abortion, nutrition counseling and care, and prevention and treatment of common diseases such as tuberculosis and malaria are generally provided separately and need to be integrated better in all five countries. Depending on the state of health services the essential package of reproductive health services can be integrated in the following stages, with each stage including all the activities of the prevlous (Table 5.4). This strategy for integration is most suited to South Asia as it prioritizes maternal and child health and adolescent reproductive health needs. However, it brings older women services in later and does not deal specifically with men's needs. Integration will require coordinated planning at both micro and macro levels, flexible management, and motivated staff. While it may require additional resources in the short run (e.g., for training), it would be expected to improve efficiencies and effect cost- savings in the long run. It will achieve efficiencies for providers as well as clients. It could be deemed successful when monitoring and evaluation show that all reproductive health actions possible at a given level can be obtained through a 'single window" (worker or facility) and the needs of poor clients are met at the lowest possible opportunity cost to them. Table 5.4 How Reproductive Health Services Can be Integrated ANC incl. nutritional supplements and comiunication train';ng of fFontline workers counseling, management of illness and Disseminate complete and appropriate guidelines premature labor (incl. referral instructions) Intra-natal care (skilled birth attendance Rationalize deployment and management of staff, and EmOC) mobile facilities, camps, etc. at the local level '.An exception of some consequence in South Asia is the delivery of services to the opposite sex-generally male workers (except doctors, in some areas) cannot serve women clients, nor can female workers provide services to men. Thus enhancing men's involvement in women's reproductive care may require additional communication and outreach strategies, and integration of men's services almost certainly would, and may need further operations research. Postnatal care Ensure adequate supplies (incl. menu of IMNCI contraceptives); promote social marketing Organize community-based emergency transport Family planning, including IECIBCC, and fully establish EmOC facilities counseling, choice of methods and follow- Expand availability through private providers up. Starting with newly-weds and FP to through purchase agreements or reimbursement 'delay the first' would be a good approach. mechanisms Involve other sectors and private organizations Anemia preventionltreatment and FP (e.g., CBOs, NGOs) in reaching groups such as services should also proactively address adolescents and to promote and assist in keeping non-pregnant and unmarried adolescents. girls in schools; secondary school stipend proqrams are worthwhile3 2 Safe abortion and post-abortion care Expand abortion methods, train public providers and increase public abortion facilities and ICTCs RTI/STI diagnosis and treatment Disseminate protocols, ensure supplies, etc. (including HIVIAIDS), all including Provide information publicly on safe abortion and adolescents RTI/STI/HIV/AIDS - involve CBOs, NGOs where available, esp, to reach adolescents Expand social franchising of abortion, ST1 clinics and ICTCs (or other PPPs to enhance availability) 3 Adolescent services covering all IECIBCC Extend mass education for adolescents and needs, peer counseling and life-skills families on SRH topics 5.1.5 Improving Quality 5.18 Perceived "good quality" attracts clients and can achieve efficiency and better outcomes. With increasing wealth and technology in South Asia, the quality gap between (some) private and public health care is widening, and the prices of private services of acceptable quality are rising out of reach of the poor, increasing their risks of financial crises or leaving them to the mercy of poor private services and the public sector. In this scenario, the public health sectors need to improve the quality of services as well as target them increasingly to the poor, ensuring better allocative efficiency. Organization, planning and financing mechanisms are needed to achieve this balancing act. 5.19 To begin with, all five countries need to put into effect adaptations (to their own situations and to different services) of the Bruce (1990) framework for assessing quality from a client's perspective. Good quality includes: an appropriate constellation of services, availability of a choice of methods, provision of information, good interpersonal relations, technically competent providers, and follow-up and continuity mechanisms. Ensuring these can result in individual gains and overall better health outcomes. A South Asian example of the application of such a framework is described in Box 5.1. '.While integrating health, family planning and nutrition services is necessary to improve reproductive health, other sectors such as education, women's development, and water supply and sanitation could work through collaborations and implement programs in parallel. Box 5.1 Initiatives Implemented in Sri Lanka to Improve the Quality of Care 5.20 Perhaps most critical to enhancing the quality of reproductive health care in the public sectors of the five countries are human resource improvements. These include ensuring that staff are available, working (not absent), up-to-date in knowledge, skilled and well-behaved. While the first of these requires attention to pre-service training and hiring, which may have significant financial implications, the others entail less costly managerial improvements and training. Each country or sizeable administrative unit (state/province/etc.) will need to review its personnel requirements and identify 'macro' strategies to meet these including, importantly, staff needs (such as transport or travel allowances) to carry out their jobs, incentives for good performance, and options to contract in staff (or contract out services). The section below discusses these further. 5.2 REFORMSTHAT COUNT FOR REPRODUCTIVE HEALTH 5.21 Bangladesh, India, Nepal, Pakistan and Sri Lanka have all embarked on health sector reforms (see Annex l l ) , which enables them to examine the impediments to implementing the policies to which they are committed, and identify and implement the changes that are needed. Because of its role in improving the welfare of the poor and in building the foundations for health and productivity of future generations, reproductive health merits special attention in the design and implementation of the reform agenda.4 In South Asia, health sector reforms need to result in increased availability of health services, because they are dreadfully short of need; improved access of the poor to them to enhance equity; better responsiveness to client needs to improve utilization; better quality care to improve impact and efficiency, because needs are immense and resources relatively scarce; and 4.There are several persuasive reports on reproductive health and health sector reforms including Ravindran and de Pinho (2005), WHO (2005), Standing (2002), Hardee and Smith (2000), and Krasovec and Shaw (2000). more and better financing, accompanied by increased accountability. This section suggests and briefly discusses the chief reforms that constitute the 'how' of improving reproductive health: institutional and human resource development, public-private cooperation, decentralization of planning, resource allocation and management, improved financing, and monitoring and evaluation. 5.2.1 Reforming Institutions and Human Resources 5.22 The institutions and staff managing and delivering health care must be developed by: integrating health, family planning and nutrition departments to increase the commitment of policymakers, managers and providers to all aspects of reproductive health, particularly, integrated reproductive health services; developing clear policy and program guidelines for integrated services; training to enhance technical and managerial capacities to deliver services, and to plan, organize and manage change; increasing flexibility in decision-making and resource allocation and improving information within the health system; redressing shortages (due to norms, vacancies and/or absenteeism) in particular cadres, especially frontline female staff, through human resource strategies as mentioned above; strengthening supply chains to ensure availability of adequate drugs, medical supplies and equipment so that workers can provide effective services; fostering attitudinal and behavioral change among providers towards poor female clients through training, incentives and disincentives (as discussed in section 5.1.1); replacing input and output targets with a focus on outcomes, using a broad set of reproductive health indicators, and supplanting normative planning with decentralized outcome-oriented action planning and resource allocation as discussed below; and increasing accountability among service providers and managers for health outcomes, following responsibility for planning and monitoring, and using data for decision-making. 5.23 The government health systems in all five countries need to be strengthened from the bottom up - i.e., much more emphasis needs to be given to basic services that reach out to peripheries: remote areas, villages and urban slums. This means investing in frontline workers and mechanisms that provide services "at the doorstep", with relevant changes such as ensuring that workers' timings fit local women's work and domestic patterns. Providing incentives to workers to deliver services and clients to use them could drive better outreach care - for example, full antenatal care, completion of infant immunization schedules, acceptance and continuation of spacing methods of contraception. 5.24 Improving institutional and providers' capacities should include accreditation, competency-based training, and management accountability. Most of the countries would benefit from long-term strategic manpower planning for health, undertaken with clarity on the skills required in the public and private health sectors (such as community health and public health management) and realistic expectations of the professionals trained. 5.2.2 Public-Private Synergies 5.25 A significant proportion of reproductive health services is provided by the private sectors in all countries. Given client preferences for private providers, both formal and informal, efforts to expand reproductive health services for poor women could increase their involvement. Public financing of private provision (e.g., of safe abortion services), contracting out of services (e.g., diagnosis and treatment of RTIs/STIs), or contracting in of private providers (such as anesthetists for FRUs) are possible options to increase the availability, accessibility and utilization of services for poor women. Many private providers could be trained to deliver essential services. For example, an innovative strategy that is spreading in India is a public-private partnership with traditional practitioners to extend family planning and antenatal services and encourage institutional delivery. As discussed in Chapter 3, public- private partnerships for social marketing have been quite successful in the region and could be increased. The private sector could also be encouraged to extend its reach, for example, to adolescents in schools, or range of services (e.g., to provide integrated reproductive health care). Table 5.5 shows the types of partnerships that could be developed between different private sector providers and the public health sector. Loevinsohn (2006) has discussed how public-private partnerships can be developed and managed. Table 5.5 PossibleInteractions between the Public and Private Health Sectors me partnerships: R.egulation (shut I - down unsafe provide services facilities) provide inputs,. . e.g., training to health staff Wide range of partnerships: Some partnerships: Regulation (shut Contracting out of public sector facilities Contracts to down unsafe Contracts to provide services - provide services in facilities) purchaser/provider splits, voucher the community schemes, insurance Social marketing Contracts to carry out accreditation1 of ORS, supervision of facilities, continuing contraceptives, education for doctors delivery kits, etc. Contracting in of services, e.g., Contracts for specialists traininglcontinuing Contracts for technical services -e.g., education for pathology, biochemistry government staff Train and enqaqe rnRequlate and I $1 I rnContracts to carry out accreditation1 I ~nbas~ctasks, - I control ~lleqall I supervision of facilities, continuing e.g., contraceptive unsafe acthies education for doctors, etc. depot holders, bv enforcinq - I I health and hygiene education. Trainlaws for sim~le I I identifying clients tasks, e.g., for farnib ContraCeDtive incentives for institutional delivery 5.25 I n addition to quantities of services, the government can influence the quality of care in the private sector (for example, reducing unsafe abortion) through its stewardship roles: policy-making, regulation, accreditation, information provision, monitoring, and so on. Health sector reforms can streamline and strengthen these roles. There is also scope for a flow of benefits from the private to the public sector. As discussed in Chapter 3, private participants in decentralized planning can facilitate the adoption of good or innovative approaches and assist their replication/scaling-up through the public system, they can be involved in training government staff, and so on. 5.2.3 Decentralization 5.26 Each of the five countries has its own form and path of decentralization, and intra- country variations also are substantial in terms of the responsibilities and capabilities of different levels to plan, finance, manage and monitor health services. There is need everywhere to clarify which roles and responsibilities in the health sector can be executed effectively by local elected governments at each level, from provincial and district down to village/ward, and which require technical or bureaucratic management. The participatory planning approach described in Chapter 3 harnesses the knowledge and skills of local governments, technocrats, providers and clients to better meet the needs of clients and improve health management and resource allocations. It could be used to evolve appropriate roles and relationships among various stakeholders. Over time, it can help to mobilize additional public resources from above and/or private resources. 5.27 Considerable capacity building is needed for decentralized planning to be effective, but an advantage of the method described is that capacity can be 'built by doing' in repeated six- monthly cycles. Stakeholders can think through and prioritize local needs and goals, identify technical and managerial options to meet these needs, own and manage implementation of the plans they have forged, and evaluate them. The district level is currently the most critical level to strengthen and empower to make decisions to improve health care in all countries. As districts with the worst health situations are also likely to have the weakest capacity, there will be a need to support their planning efforts with appropriate skills and knowledge, and ensure adequate resources are available to make a difference. Opportunities for districts to exchange experiences, methods and examples would help to expand use of the tool and improve it over time. Higher-level authorities can provide incentives for good planning and performance, ranging from simple recognition awards to substantial increases in financial allocations. 5.28 While decentralization implies a policy of flexibility, in a technical sector such as health there is need for uniform standards for professional services, competencies, etc. Thus, higher authorities (national/state/provincial/ etc.) have an important role to play in developing, setting and monitoring standards. Each country needs to review the extent to which these are already available and fill in the gaps. Figure 5.1 shows how actions at the different levels in the conceptual framework fit together for better reproductive health. 5.29 The decentralized action planning (DAP) technique is a simple and practical approach to 'evidence-based planning' which can facilitate supply improvements as well as demand creation. Reproductive health needs are identified using available (limited) data initially, but as capacity grows, information can be obtained through strengthened health management information systems as well as broader and more systematic community needs assessments. A community-based MIS could be built over time so that communities can monitor progress and influence the planning and implementation process more purposefully. 5.2.4 Financing: Outlays for Outcomes 5.30 In 1994 the World Bank estimated that a package of reproductive health services including family planning, antenatal and delivery care, prevention and treatment of STIs, and health education (quite short of the essential package) would cost about $6.75 per capita in low income countries. Most of the governments (central and sub-national) in South Asia are spending under ten percent of this; Sri Lanka's public expenditure is about 30 percent of this. Recent calculations of the actual costs of care are substantially higher than the 1994 estimates (Singh et al., 2004)~suggesting that all five countries need to spend much more on reproductive health. 5.31 As discussed in Chapter 4, household resources finance a disproportionately large share of reproductive health services in most of South Asia, with grave consequences for equity and health outcomes. Health crises such as hospitalization are major causes of indebtedness, resulting in poor people falling deeper into poverty. Improvements in reproductive health financing must clearly reduce the financial burden on individual households, particularly poor households, and involve greater pooling of risks and resources across appropriate populations. From an equity perspective, general revenue financing has proven to be a progressive means of financing health care. When combined with little or no 5 .For example,a first visit to obtain oral contraceptives was estimated to cost $8.00 and a normal delivery, $28. user fees and universal coverage, general revenue financing provides high levels of financial protection against catastrophic expenditures associated with ill-health. 5.32 An optimal resource allocation pattern would ensure that all or most households are publicly financed for inpatient services and that outpatient services are funded primarily for the benefit of poorer households. However, public subsidies in South Asia generally go to the better-off. I n India, for example, services received by the poorest quintile of the population accounted for 10 percent of total public expenditure, while the richest quintile accounted for over 30 percent (Mahal et al., 2001). Targeting services could help to redress such inequalities to the extent that socio-political factors permit! 5.33 Low demand for certain important reproductive health services and the large size (and heterogeneity) of the private health sectors in the five countries, however, call for additional innovative efforts at health financing for the poor, such as demand-side financing and purchasing arrangements. For example, a voucher scheme could assist poor women to have institutional deliveries in the private sector with reimbursements made to accredited facilities. Alternatively contractual agreements with such facilities could be used to purchase a specified number of deliveries for poor women. Community funds or patient refunds for transportation to EmOC facilities could be improved and expanded as well as diversified to cover other out- of-pocket expenses for reproductive health care. Other promising financing approaches in the region include provider payments and incentives, social franchising (e.g., the Green Star and Janani programs), and contracting out through PPPs. Figure 5.1 Actions at Different Levels Influence Reproductive Health Outcomes 5.2.5 Monitoring and Measuring 5.34 Reproductive health services must be measured more effectively. Table 5.6 lists process and outcome indicators that could be used to assess reproductive health. Obtaining data by quintile or other socio-economic disaggregation would be useful to focus planning and programs on improving equity, and separate data on adolescents (especially their knowledge, nutrition, contraception and abortion) is necessary to address their needs. Strategies to collect data should include community needs assessments, sample studies and client satisfaction surveys that provide independent information, in addition to data from health management information systems. To improve care there needs to be a two-way flow of information based on these measures. Data that come up must go down: there is little point in collecting community-based information or service statistics if these are not used by health managers, providers and communities to make decisions on how to improve coverage, equity and quality. DAP is the appropriate mechanism for this as amply described. 5.35 Much of the analysis in this report has been based on cross-sectional surveys which do not establish causality nor reveal the time it takes for effects to occur. This limits the inferences that can be made, calling for a stronger evidence base for future analyses. Impact evaluations and operations research are needed to assess the effectiveness of significant interventions and strategies, and regional capacity for these needs to be strengthened. Table 5.6 Processand Outcome Indicators for Reproductive Health Activities Adolescent Unmet need pressure apparatus Ensure counselling (on diet, attendance or danger signs, birth planning, institutional births institutional delivery, etc.) Proportion of poor Strengthen supportive women who delivered at an institution (Public or providing abortion Number of safe abortions pography) and two d three visits in first in first week (or ten by a trained service receive multiple workers and mothers Coverage of areal 5.3 OTHER MATTERS ARISING 5.3.1 Actions beyond the Health Sector 5.36 It is critical to involve other sectors such as education, nutrition and rural development in improving women's reproductive health. Besides the impact of the three R's, the psychosocial effects of schooling on women (e.g., increased assertiveness) help them to make better decisions in sexual and reproductive matters. Increased schooling has both direct and indirect effects on the age at marriage and consequently on childbearing and women's health. The on-going efforts in South Asia to expand girls' education are already showing some positive impacts on reproductive health. One area that remains neglected, however, is sex education, which schools could usefully provide at the right age to girls and boys. To counter nutritional deficiency, nutrition education, school meals and supplements, targeted programs for out-of-school adolescents, and women's employment are some effective interventions. 5.37 Women's empowerment efforts are important in South Asia. The combination of reproductive health services and social policies could greatly increase gender equity and improve women's health. These policies include: promoting the value of girls; enforcing the minimum age at marriage through compulsory education and other means; reducing son preference, e.g., through social security; reducing gender-based violence; enhancing sexual and reproductive rights; increasing women's autonomy, for example through information or inheritance laws; and improving their economic status through employment opportunities. 5.3.2 Learning across Borders and the Role of the Bank 5.38 The five countries covered in this study have strong cultural similarities and shared histories. In addition, some of their problems are inter-related. For example, intra-regional migrations of workers and women in the sex trade (e.g., between Nepal and India) are causing the spread of HIV across borders. The five countries together have a rich body of experience, both good and bad, which could be explored jointly. This 'cross-border learning' could include effective interventions ('regional best practices'), human resource development, financing, and monitoring and evaluation. Providing a forum for such exchange could be a role for the World Bank - and this report is a beginning. 5.39 A multi-stakeholder and regional policy dialogue could help to establish further areas for country collaborations, and the comparative advantages and responsibilities of different development partners. I n addition to inter-country and inter-agency exchange, the Bank has an important role in assisting further development of the reproductive health sector in South Asia. Key areas (in addition to on-going activities) that require investment are: training and other aspects of human resource development; decentralization of technical knowledge (a top- down process); information and education programs through personnel, media and technology; developing and scaling-up innovations; and services, services, services... The Bank's comparative advantage lies in positioning and promoting these improvements within health sector and overall economic reform frameworks. 5.3.3 Study and Information Gaps 5.40 Due largely to space limitations, this study has not dealt with two important topics related to poor women's reproductive health in South Asia: gender-based violence and men's reproductive health. Violence against women in the home, on the streets and on account of politics is intimately related to their reproductive health and to women's health in general. However, it is a broad and increasingly deep topic whose complex manifestations, severity, underlying causes and legal ramifications call for concerted attention. Men's reproductive health is also a specialized topic deserving consideration in the future. 5.41 Many gaps remain in our knowledge of poor women's reproductive health, such as sexual practices and behaviors underlying reproductive decision-making, or 'positive deviance' in reproductive health outcomes. More operations research in South Asian health systems would help to identify how changes in service provision and use could be accelerated further. Definitions Abortion: Termination of pregnancy from whatever cause before the fetus is capable of extra- uterine life or before 28 weeks of gestation. Spontaneous abortion refers to those terminated pregnancies that occur without deliberate measures even if an external cause such as trauma, accident or disease is involved. Induced abortion refers to termination of pregnancy through a deliberate intervention intended to end the pregnancy (Royston et al., 1989). Adolescence: The term "adolescence" has been defined as including those aged 10-19 years, and "youth" as those between 15 and 24. "Young people" is a term that covers both age groups, i.e., those between the ages of 10 and 24 years. True adolescence is the period of physical, psychological and social maturing from childhood to adulthood, and may fall within either age range (WHO, 1989). Adult literacy rate: The percent of persons (male, female or both sexes) aged 15 years and over who can read and write a short simple statement on their everyday life with understanding. Age-specific fertility rate: The number of births occurring to women of a specified age group during a specified period (usually of one year) per 1000 women in the same age group. Anemia prevalence: The proportion of women aged 15-49 years whose hemoglobin levels are below 12.0 gms/dl if they are not pregnant, or below 11.0 gms/dl if pregnant. Annual population growth rate: The average rate of change of population size for a given country, territory or geographic area, during a year. It expresses the ratio between the annual increase in population size and the total population in that year (multiplied by 100). Antenatal visit: A health check up provided to a pregnant woman any time during pregnancy for reasons related to the pregnancy. Basic emergency obstetric care facility: A facility with functioning basic emergency obstetric care, including parenteral antibiotics, oxytocics, and sedatives for eclampsia and the manual removal of placenta and retained products; usually measured per 500,000 population. Birth weight: The weight of the newborn obtained at birth, preferably within the first hour of life before significant postnatal weight loss occurs (WHO, 2006). Body mass index (BMI): Weight in kilograms divided by height in meters squared. Women with BMIs c 18.5 kg/m2 are considered underweight (Last, 1995). Child Mortality rate (per 1000 live births): The number of deaths of children in the age group 1-4 years per 1000 live births in a year. Children Stunted (percent): Percent of children whose height measurement is more than two standard deviations below the median reference standard for their age (established by the U.S. National Center for Health Statistics). Children wasted (percent): Percent of children whose weight is more than two standard deviations below the median reference standard for their weight as established by the U.S. National Center for Health Statistics. Children moderately underweight (percent): Percent of children whose weight measurement is more than two standard deviation below the median reference standard for their age as established by the U.S. National Center for Health Statistics. Children severely underweight (percent): Percent of children whose weight measurement is more than three standard deviations below the median reference standard for their age as established by the U.S. National Center for Health Statistics. Comprehensive emergency obstetric care facility: A facility with functioning compre- hensive emergency obstetric care, including basic emergency obstetric care facilities plus surgery, anesthesia and blood transfusion facilities; usually measured per 500,000 population. Contraceptive prevalencerate (percent): Number of currently married women aged 15-49 years using any method of contraception, modern or otherwise, per 100 women of that age. Crude birth rate: Annual number of live births per 1000 mid-year population (U.N., 2003). Currently married (couples, women or men): All those in consensual unions or married, including those not currently living together but not divorced. Dependency ratio: The ratio of persons aged under 15 years and over 65 years to those in aged 15-64 years. This ratio is usually referred to as the total dependency ratio, while the first component of the numerator alone (children under age 15) gives the child or young dependency ratio, and the second component (those aged 65 and over), the old-age or old dependency ratio (U.N., 2002). Disability-adjusted life year (DALY): This measure expresses the years of life lost to premature death and lived with a disability of specified severity and duration. One DALY is one lost year of healthy life. The total DALYs of a population in a given year indicate that population's disease burden for the year (Murray and Lopez, 1996). DPT3: A complete course of three doses of vaccination against diphtheria, pertussis (whooping cough) and tetanus. Full immunization coverage: Percent of infants (or children 12-23 months) who have been fully immunized with one dose of BCG, three doses of DPT, three doses of oral polio and one dose of measles vaccine (and hepatitis B vaccine as applicable) according to the national immunization schedule. The denominator used to calculate the percentage is the number of infants surviving to age one (WHO, 1993). Fertility rate of women in the 15-19 year age-group: The number of live births in a given year to women aged 15-19 years per 1000 women in the same age group. GDP spent on health (percent): Public expenditure on health in a given year divided by GDP for the same year, expressed in current prices multiplied by 100. Gross domestic product (GDP): The total output of goods and services for final use produced by an economy by both residents and non-residents, regardless of the allocation to domestic and foreign claims. It does not include deductions for depreciation of physical capital or depletion and degradation of natural resources (UNDP, 1999). Human development index (HDI): A composite of three indicators which reflect important dimensions of human development: longevity and health as measured by life expectancy at birth; educational attainment as measured by a combination of adult literacy (two-thirds weight) and combined primary, secondary and tertiary school enrolment ratios (one-third weight); and standard of living as measured by real GDP per capita (in purchasing power parity US dollars) (UNDP, 2005). Infant mortality rate (per 1000 live births): The total number of infants who die before reaching one year of age in a given year divided by the total number of live births in the same year multiplied by 1000 (U.N., 2003). Infertility: Primary infertility is the failure to conceive despite coitus in the absence of contraception, and secondary infertility is the failure to conceive despite coitus following a previous pregnancy (in the absence of contraception, breastfeeding or postpartum amenorrhoea) (WHO, 2006). Assessment is usually over a two-year period. Life expectancy at birth: Average number of years that a newborn could expect to live if he or she were to pass through life exposed to the sex- and age-specific death rates prevailing at the time of his or her birth, for a specific year in a given country, territory, or geographic area. Low birth weight: A weight of less than 2500 grams at birth (WHO, 2006). Maternal death: Death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accident or incidental causes. A late maternal death is the death of a woman from direct or indirect obstetric causes more than 42 days but less than one year after termination of the pregnancy (WHO, 2006). Maternal morbidity: Morbidity in a woman who has been pregnant (regardless of the site and duration of the pregnancy) from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes. The term is used interchangeably with obstetric morbidity (WHO, 1994). Maternal mortality ratio: The number of maternal deaths occurring over a year per 100,000 live births in that year. It may also be expressed per 1000 or 10,000 live births (WHO, 2006). Menstrual regulation: Any chemical or mechanical process used to induce menstruation (that has been delayed by 14 days or more) within six weeks of the due date of onset. The most common method is by mini-vacuum aspiration, which is safe and can be performed as an out-patient procedure without anesthesia. The current medical method of choice is a combination of 200 mg mifepristone and 400 mcg misoprostol. Midwife: A person who has been regularly admitted to a midwifery education program that is duly recognized in the country in which it is located, and has successfully completed the prescribed course of studies and acquired the requisite qualifications to be registered and/or legally licensed to practice midwifery (International Confederation of Midwives). Menopause: The time of a woman's life when her reproductive capacity ceases - the ovaries stop functioning, their production of steroid and peptide hormones falls, and a variety of physiological changes take place in the body. Some of these result from cessation of ovarian function and related menopausal events while others may be a function of aging (WHO, 1996). Neonatal mortality rate: The number of deaths in infants under 28 days of age in a given year per 1000 live births in that year (Last, 1995). Nurse: A person who has completed a program of basic nursing education and is qualified and registered or authorized by the country to provide responsible and competent services for the promotion of health, prevention of illness, care and rehabilitation of the sick. OPV3: A complete course of three doses of oral poliomyelitis vaccine. Per capita expenditure on health: Public expenditure on health in a given year in current value of US dollars, divided by the mid-year population. Perinatal mortality rate: Number of deaths of fetuses (of at least 22 weeks of gestation) and early neonatal deaths (within 7 days of birth) per 1000 live births (WHO, 2006). Population below the national poverty line (percent): Percentage of the population living below the national poverty line in a given country, territory, or geographic area, at a specific period in time, usually a year. The operational definition for a national poverty line varies from country to country and represents the amount of income required by each household to meet the basic needs of all its members. Poverty estimates are based on data from an actual household budget, income or expenditure survey and on the concept of an "absolute" poverty line expressed in monetary terms, i.e., the income or expenditure below which a minimum nutritionally-adequate diet plus essential non-food requirements are not affordable. Population below the international poverty line (percent): The percentage of the population in a given country, territory, or geographic area living below the international poverty line at a specific period in time, usually a year. For low-income countries the international poverty line is drawn at a "dollar a day" i.e., a daily per capita consumption of less than US$1.00 at constant 1985 prices (equivalent to $1.08 a day at 1993 prices) adjusted to local currency using purchasing power parities (World Bank, 1993). Population density: The number of persons in the total population divided by the total surface area of a country or territory in square kilometers (U.N., 2003). Prevalence: The number of events (e.g., instances of a given disease or other condition) in a given population at a designated time. When used without qualification, the term usually refers to the situation at a specified point in time (point prevalence). The prevalence rate (ratio) is the total number of all individuals who have an attribute or disease at a particular time (or during a particular period) divided by the population at risk of having the attribute or disease at this point in time or midway through the period (Last, 1995). Proportion of births attended by skilled health personnel: The percentage of births attended by a skilled birth attendant (see below). Reproductive tract infections/Sexually-transmitted infections (RTI/STIs): Reproductive tract infections include both those that are sexually-transmitted and those that are not. Non-sexually transmitted infections may be endogenous infections caused by the abnormal growth of organisms that are normally present in the vagina, such as bacterial vaginosis or vulvovaginal candidiasis, or exogenous infections caused by unsafe obstetric and gynaecological practices (traditional and modern) and poor genital hygiene. Sexually- transmitted infections (STIs) include chlamydia, trichomoniasis that can cause chronic and frequently painful vaginal infections, gonorrhoea, syphilis and genital warts. Sex ratio: Normally, the number of males in a population for every 100 females (U.N., 2003). In India and this report, the number of females per 1000 males in a population. Singulate mean age at (first) marriage: The mean age in years at first marriage of those ever-married in the 15-50 year age-group. It is computed from the proportions never-married in the each five-year age group within the broad age-group 15-50, and therefore measures the average age at first marriage over the historical period covered by the age group 15-50, rather than the average age of those currently marrying for the first time (U.N., 2004). Skilled birth attendant: A health professional such as a midwife, doctor or nurse who has been trained and is competent in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate postnatal period, to identify complications, and to provide necessary emergency management and/or referral to a higher level of health care. Total fertility rate: The total number of children a woman would have by the end of her reproductive period if she experienced the currently prevailing age-specific fertility rates throughout her childbearing life. Under-five mortality rate: The annual number of deaths of children under five years of age per 1000 live births (U.N., 2003). Background Reports Reviews of Health Status Indicus Analytics (2004) Reproductive and Child Health of the Poor in India, New Delhi. International Center for Diarrheal Disease Research, Bangladesh - Center for Health and Population Research (2004) Women's Reproductive Health Status and Poverty in Bangladesh, Dhaka. Medistat Medical Research Consultancy (2004) Status of Women's Reproductive Health in Sri Lanka, Colombo. New ERA (2004) Women's Reproductive Health Status and Poverty in Nepal, Katmandu. Population Council (2004) The Reproductive Health Status of Women and Its Relationship with Poverty in Pakistan, Islamabad. (Authors: Z.A. Sathar, A. 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Part I1 ANNEXES Page Poverty and Reproductive Health Study Methodology Tables on Reproductive Health status The Essential Package of Reproductive Health Services Tables on Use of Reproductive Health Services Public Health Systems in South Asia Examples of Promising Practices for South Asia Tables on Reproductive Health Expenditures Policies related to Reproductive Health Key Actions to Improve Reproductive Health Health Sector Reforms related to Reproductive Health (Last page Annex 1 POVERTY AND REPRODUCTIVE HEALTH Table A l . l Poverty in the Five Countries of South Asia, Various Years* Nepal, thewpercentof population living below $1 a day was 31.0in 2004 (NLSS,2004)but other data are not available for this year Sources:World Bank (2004);UNDP (2005);GON-MOHP(2005). Table A1.2 Reproductive Health Levelsand Millennium Development Goals, Five Countries Annex 2 STUDY METHODOLOGY This annex contains details on: (a) the data used to analyse reproductive health status and service use in Chapters 1 and 2; (b) the methodology of the quintile and multivariate analyses; (c) the approach to primary data collection for the analysis of constraints to the use of health services; (d) the methodology used to determine costs and financing in Chapter 4. 2.1 Survey Data The reproductive health indicators used in the study are given in Box 2A. Box A2.A Reproductive Health Indicators used in the Study Data from the following sources were used to analyze reproductive health status and use of health services. Bangladesh Bangladesh Demographic and Health Survey 1999-2000 (sample size of over 10,000). Bangladesh Maternal Mortality and Morbidity Survey, 2001. India National Family Health Surveys, 1992-93 and 1998-99 (sample size of almost 90,000 ever-married women in the reproductive age group of 13-49 years). Reproductive and Child Health Rapid Household Survey, 1998-99, for district level analysis. 5oth (1993-94) and 5sth (1999-2000) rounds of the National Sample Survey covering over 100,000 households in 10,000 sampling units (villages and urban blocks). Sample Registration Survey, 2002. Annex 2 Nepal Nepal Demographic and Health Survey, 2006 (Preliminary report). Nepal Living Standards Survey, 2004. Nepal Demographic and Health Survey, 2001. Nepal Family Health Survey, 1996. a Micro-nutrition Status Survey, 1998. Pakistan a Pakistan Social and Living Standards Measurement Survey, 2004-05 a Status of Women, Reproductive Health and Family Planning Survey, 2003 a Pakistan Reproductive Health and Family Planning Survey, 2000-01. a National Nutrition Survey, 2002. Pakistan Fertility and Family Planning Survey, 1996-97. Adolescent and Youth Survey, 2001-2002. a Study of Unwanted Pregnancies and Post-abortion Care, 2002. Sri Lanka a Demographic and Health Surveys in 1993 and 2000. a Annual Health Bulletins published by the Ministry of Health. a Reports of the Household Income and Expenditure Surveys, 1980-81, 1990-91, 1995- 96 and 2000. 2.1.1 Data Limitations The demographic surveys focus on ever-married women in the reproductive age group of 13 or 15 to 49 years, thus excluding early adolescents aged 10-13/14 years and adults 50 years and above. The sample sizes of these large-scale surveys are inadequate to disentangle the impact of socio-economic or health service factors on low frequency events such as maternal deaths. Further, there have been no attempts to track women over time to study behavioural or other changes at different stages of the reproductive life cycle. The orientation of large sample surveys is generally such that subjective and qualitative responses are rarely available. In the case of reproductive health, issues such as comfort levels with health care providers, self-confidence in interacting with the outside world, atmosphere within the household, and support from spouse are important determinants of service utilization, but we are unable to study these on a large scale. Recent advances in psychometrics and survey techniques may enable such surveys in the future. In the absence of national data on certain subjects, data that are specific to smaller areas or population groups have been included in the review and analyses. Due to a lack of uniformity these data serve, at best, to illustrate phenomena. It is difficult to make comparisons and draw unerring inferences. 2.2 Quintile Analysis Respondents' economic status was measured using an asset index as described by Gwatkin et al. (2000). The items included in calculating the index were: source of water supply, electricity, presence of radio, television, refrigerator, bicycle, motorcycle, car, van, tractor or any other vehicle, type of flooring, latrine and other characteristics related to wealth status that are available in the demographic surveys. Each of these assets was assigned a weight and scores generated through principal component analysis. The scores were then standardized against a standard normal distribution with a mean of zero and a standard deviation of one using the formula given below: 3 Value of asset variable - Unweighted mean of asset variable x Raw asset factor score Unweighted standard deviation of asset variable Annex 2 The section within brackets indicates the standardized value of the asset status based on the presence or absence of a particular asset (1 or 0)in the whole sample. The scores were then added up by household and individuals ranked according to the total score of the household in which they live. The sample was then divided into quintiles (five groups of equal numbers of individuals). I n India, the asset index was developed separately for rural and urban areas. 2.3 Multivariate Analyses As most dependent variables are dichotomous, logistic regression was used to carry out the multivariate analyses. The net effect of each category of an independent variable on the dependent variables, with respect to the reference category, is represented by an odds ratio. The odds ratio for the reference category is 1. An odds ratio of greater than 1therefore indicates a higher chance of occurrence of the dependent variable for that category, with respect to the reference category, when other independent variables are controlled. The dependent and independent variables included in the multivariate analyses are as follows: Some of the dependent variables were also used as independent variables where relevant, e.g., the number of antenatal visits was used as an independent variable in the analysis on intra-natal care. 2.4 Primary Data Collection for the Assessment of Quality of Care Primary research was carried out in selected sub-national units within each country. Criteria for the selection of sub-national units were as follows: India: Rajasthan and Karnataka were selected because they represent different regions of the country (North and South) and different levels of social and economic development and reproductive health, based on a reproductive health index.' Karnataka fares better than Rajasthan in these respects. I n each state, two districts were selected based again on the districts' reproductive health indices. These were: Raichur (low) and Mysore (high) in Karnataka, and Udaipur (low) and Jhunjhunu (high) in Rajasthan. From each district, two blocks were selected randomly. Two Primary Health Centers (PHC) were selected in each block, and two Sub-centers in each PHC area. Interviews, focus group discussions, and assessments of health facilities were carried out in these selected areas. '. The reproductive health indices of all states were calculated on the basis of five indicators: percent female literacy, percent of pregnant women who received complete antenatal care; percent of deliveries conducted by health professionals; percent of children fully immunized; and percent of couples using modem contraceptive methods. 4 Annex 2 Bangladesh: Using data for six indicators of reproductive health, two average-performing districts, were selected from the 64 districts in the countt-yS2In each district one upazila was chosen as the field site: Ishwardi upazila in Pabna district and Ullapara upazila in Sirajganj. Nepal: Three districts were selected purposively: Darchula in the Far-Western Development Region and Bardia and Pyuthan in the Mid-Western Region. Bardiya and Pyuthan are among the districts in Nepal with a high percentage of people living below the poverty line and a low human development index. Pakistan: Punjab province was selected on the basis of its population size and number of districts. A disadvantaged district was selected on the basis of socio-demographic (including total population, rural and urban proportions, ethnicity, education and electricity) and health data (crude birth rate, maternal mortality ratio, number and type of health facilities). Multan was the district selected. Sri Lanka: The two districts selected in Sri Lanka, Anuradhapura and Vavuniya, are situated in provinces that are predominantly rural and relatively under-developed. These districts have a lower availability of services, and have been facing the challenges of poverty and pressures due to the North East conflict - directly in the case of Vavuniya and indirectly in the case of Anuradhapura (some areas of the district border the conflict areas). 2.4.1 Data Collection Techniques Data was collected in the selected sub-national units in the five countries from clients and health providers, and by direct observation of health facilities. Clients. Several tools were used to obtain the perspectives of clients: (1) Survey Questionnaire: In the study area in Sri Lanka, a survey was administered to households selected by using a multi-stage sampling process. The focus was on individuals in those households that had used reproductive health care in 12 months prior to the survey. I n order to identify event-based households, 5,382 households were checked and 1,002 of these were administered the questionnaire. (2) Focus Group Discussions (FGD): This method was used in Bangladesh, India, Nepal and Sri Lanka. In Sri Lanka the groups were comprised of younger mothers, older women, female adolescents, and men. One FGD was conducted per group in each of four locations. It was divided into five sessions to discuss participants' concepts of reproductive health, household decision-making processes regarding care and other issues. In Bangladesh the FGDs were carried out with poor womena3 In Nepal, 12 FGDs were conducted, four in each study district. The four focus groups were: unmarried adolescent girls, married women, elderly women, and married males. In India, adolescent boys and girls were a specific focus group. (3) Interviews and informal discussions: In Bangladesh, male family members of poor women who participated in the FGDs were interviewed. In Nepal, the team had informal discussions with unmarried adolescent males. I n India, 834 interviews were carried out with 436 poor and 398 non-poor women who had had a recent reproductive event such as a birth, infant death, reproductive illness, or abortion. Health Providers and Key Informants. The information was obtained from providers at different levels of the health system, from policy-makers and administrators to community-level workers. Private practitioners and representatives of non-governmental organizations were also included. The views of some opinion leaders and 'responsible' '. The six indicators were: total fertility rate, contraceptive prevalence rate for women aged 13-49years, pregnancies with at least one antenatal visit, deliveries with assistance from a medically-trained person, mothers who received antenatal care, and infant mortality rate. '. The criteria used for the selection of 'poor' women were as follows: member of a household that resides in the village, has less than 50 decimals of land, and whose head of household works as a day labourer for 100days out of 365 days. The women were aged from 15-45years, mamed with at least one child (or pregnant), and used the local health services. Annex 2 members of the communities (e.g., journalists, educationists, social workers) were also obtained. The following methods were used. (i) Consultation Workshops were carried out in Sri Lanka and Nepal. I n Nepal, one workshop was conducted in each district with participants ranging in number from 21-36. Participants included government health providers and representatives from local NGOs. Some key informants (e.g., a college principal, women's group representatives, social workers) were also present. I n Sri Lanka, different categories of service providers from government, representing different levels of the district health system, private practitioners and NGO representatives participated in the two district-level workshops (which had 28 and 47 participants). (2) Focus Group Discussions. Nine FGDs were conducted in India with health providers from the public and private sectors, and five were conducted in Pakistan. (3) Interviews. These were conducted in all five countries. They were with government health personnel in administrative, managerial and policy-related positions, as well as field workers, medical officers, nurses, and personnel from private clinics. I n Bangladesh, traditional healers, untrained TBAs and 'quacks' were included among those interviewed. I n Nepal, other responsible members of the community were also interviewed. NGO representatives were interviewed in Bangladesh, Nepal and Pakistan. Facility Assessments. Assessments of health facilities were carried out by the study teams in Bangladesh, India, Pakistan and Sri Lanka. I n India, a list was prepared of all facilities where women seek reproductive health care, including public and private hospitals and clinics as well as clinics of unqualified rural medical practitioners. Of these, 75 health institutions - 40 government and 35 private run by qualified practitioners (20 percent of all facilities) were selected for the facility survey and interviews with providers. I n Bangladesh, the medical doctor in the team observed health facilities. To assess the quality of reproductive health care in the facilities, a facility assessment form was filled out through discussions with doctors, nurses and managers. I n Sri Lanka, two large public institutions, namely the Provincial Hospital in Anuradhapura and the General Hospital in Vavuniya, were assessed along with three other facilities in each district. The institutions were visited and information was obtained through interviews, examination of records and direct observation. I n Pakistan, a rapid qualitative assessment was conducted in Multan city and its adjoining tehsil by visiting 11 health facilities, seven clinics and two private sector hospitals. 2.5 Assessment of Costs and Financing The methodology used to assess the costs and financing of reproductive services in the five countries was as follows: 2.5.1 Analysis by Source of Financing Given differences in the availability of data, there were variations in the methods used to analyze the public, private and donor spending on reproductive health in the five countries. The methods are described below. Bangladesh and Sri Lanka possess National Health Accounts (NHA) that are updated on a regular basis and used to track the relative importance of different fund channeling mechanisms in the health sector. Andhra Pradesh, India. Two types of analyses were undertaken to estimate expenditures on reproductive health in the state. The first was an analysis of public expenditures using a method derived from the NHA, and the second was an analysis of health expenditures using the National Sample Survey (NSS). Budgetary accounts with details of the programs and projects within each heading and sub-heading of the Medical and Health Department of the state government are used. Annex 2 For the estimation of private expenditure, the 52ndround (1995-96) of the NSS which has detailed information on health utilization and expenditures for a range of symptoms reported to have occurred during the previous month (for outpatient care) and previous year (for inpatient care) was used. Expenditures on childbirth were reported separately. The two reproductive health-related items in the list of symptoms on which the survey collected information were 'pregnancy and childbirth related complications" and "sexually-transmitted diseases". The sample size for A.P. was too small to derive any meaningful estimates of expenditure on either of these. Mean expenditures on childbirth were, however, estimated. Distributional analysis of expenditures was done by sorting households into household consumption-based quintiles. This analysis was also carried out for India as a whole. Rajasthan, India. Results for Rajasthan that are used in this study are derived from an earlier effort to produce reproductive health accounts for the state by Sharma et al. (2000). The study used a National Health Accounts framework to track government, donor and household resource flows for overall health and reproductive health. Since donor expenditures were not reported separately, it was assumed that 12 percent of public expenditures were from external resources and donor funding was estimated on that basis.4 The division of total expenditures between the Government of Rajasthan, Government of India and donors was based on an earlier analysis of family welfare and reproductive and child health program budgets. Government expenditures on different reproductive health components were estimated by weighting utilization rates of each reproductive health service by relevant unit costs. Utilization data were obtained from household surveys. As actual unit costs were not available for all reproductive health activities, expert opinions were sought. For the estimation of private expenditure, household expenditures on reproductive health care services were derived from household survey by Hotchkiss et al. (2000). Nepal. The estimation of public expenditure involved creating a set of limited health accounts for the public sector to produce a detailed functional classification of all health expenditures. Reproductive health spending was then derived from the functional classification of expenditures, either directly or using secondary estimation methods. The analysis was done separately for the regular budget, central development budget and the district development budget. Estimates derived from a recently completed public facility survey (Nepal Public Facility Survey) were used to disaggregate hospital spending between inpatient and outpatient care. I n the absence of data, it was not possible to derive reliable estimates of private spending for Nepal. Pakistan. National Health Accounts do not exist for Pakistan. Data from government and donor documents and household surveys (PIHS, 1998-99 and 2001-2002) were therefore used for the analysis. It was not possible, however, to produce a full set of reproductive health expenditure estimates compared to those produced for other countries/states in the region. The functional classification of available budgetary data does not allow a breakdown of public spending on reproductive health. Government health expenditure data used were extracted from a range of government and donor documents and donor agencies for the years 1993-94 to 1998-99 (using limited breakdowns). Further, in the absence of reliable NHA- based private expenditure estimates, two rounds of the Pakistan Integrated Household Survey were analyzed. The health expenditure module of the survey does not collect information on the types of illness conditions for which expenditures were incurred. Only estimates of spending on immunization (on the last visit) and family planning were obtained. Donor contributions to governments are included in the budgetary data that were used to estimate public expenditures on reproductive health. I n order to assess the use of external resources for reproductive health activities, a functional analysis of donor support to governments was carried out for Bangladesh, Nepal and Sri Lanka. 2.5.2 Analysis by Level of Provision 4.This assumption was based on estimates by the Netherlands Interdisciplinary Demographic Institute, 1999. 7 Annex 2 This analysis was carried out for India and Pakistan using household survey-based estimates of out-of-pocket spending on childbirth and family planning by type of provider. Such information is not available for the other three countries. 2.5.3 Standardization of Results The levels of public and total expenditures on reproductive health services in each country cannot be directly compared as the estimates are for different years and in different currencies. Besides, the income levels in each country differ, as also the relative need for services. To provide some comparison, expenditure levels in each country were standardized. Standardization involved converting expenditures into US dollars at constant 2000 prices, and adjusting these with respect to per capita income level and to factors relevant to each item of service. The standardization was carried out using Sri Lanka as the reference country. A higher level of expenditure in a particular country indicates that controlling for its income level and relevant indicator of need, it spends more resources than Sri Lanka. 2.5.4 Analysis to Assess the Distribution of Spending A distributional analysis of the utilization of reproductive health services using Demographic and Health Surveys was undertaken to indicate the distribution of public subsidies. An asset index, a composite measure of asset wealth, was constructed for each country in order to rank households by socio-economic status. A second type of analysis done was payment incidence analysis, which looks at the distribution of out-of-pocket payments for reproductive health across socio-economic groups. It requires detailed household level data on reproductive health expenditures, which were only available for Bangladesh (HDS, 1999) and India (NSS, 1995196). The annual household expenditure was estimated and used as a proxy for living standards. Household estimates of aggregate consumption were adjusted to reflect household size and composition (age and sex) by dividing total household expenditures by an equivalence scale defined as: where Ah is the number of adults in a household, h and Kh the number of children (0-14 years olds). Households were then ranked on the basis of this measure of living standards and grouped into quintiles. Mean values for the out-of-pocket expenditures for each quintile were then estimated. Annex 3 TABLES ON REPRODUCTIVE HEALTH STATUS Table A3.1 Adolescent (10-19 years) and Youth (15-24 years) Populations in the Five South Asian Countries, 2000. Age Bangladesh India Nepal Pakistan Sri Five Group Lanka Countries 10-14 Females (in million) 9.08 52.91 1.47 9.07 0.85 73.38 years Total (in million) 18.39 109.41 3.04 18.74 1.73 151.31 Percent of Total 14.09 10.91 12.30 12.80 8.97 11.43 Population 15-19 Females (in million) 8.26 48.76 1.33 7.58 0.94 66.87 years Total (in million) 17.06 101.78 2.74 15.68 1.92 139.17 Percent of Total 13.08 10.15 11.10 10.71 9.95 10.51 Population 20-24 Females (in million) 6.06 43.20 1.14 6.22 0.87 57.49 years Total (in million) 12.29 92.64 2.36 12.91 1.75 129.94 Percent of Total 9.42 9.2 9.5 8.81 9.09 9.44 population source: Population Reference Bureau, 2000. Table A3.2 Early Marriage and Childbearing in Five Countries of South Asia, Various Years. I Bangladesh I India I Nepal I Pakistan l ~ rLanka i 1 1999-00 11998-99 1 2001 1 2001 1 2000 I Note: a: These figures are for all women. b. See Table A3.3 for rates from the 2006 Nepal DHS. Sources: Bangladesh: NIPORT, 2001; India: IIPS and ORC Macro, 2000; Nepal: GON-MOH et al., 2002; GON-MOHP, 2007; Pakistan: NIPS, 2001; Sri Lanka: GOSL-DCS, 2002a. Table A3.3 Changes in Fertility in Five Countries of South Asia during the 1990s. Sources: Bangladesh: Mitra et al., 1994;NIPORT, 2001; India: IIPS, 1995; IIPS and ORC Macro, 2000; Nepal: Pradhan et al., 1997; GON-MOH et al., 2002; GON-MOHP, 2007; Pakistan: NIPS and IRD/Macro International, 1992; NIPS, 2001; Sri Lanka: GOSL- DCS, 1994; GOSL-DCS, 2002a. Annex 3 Table A3.4 Total Fertility Rates of Women with Different Levels of Education, EconomicStatus and Place of Residence. Notes: a: 1-7 years of schooling; b: 1-4 years; c: 5-9 years; d: 8-9 years; e: 6-10 years; f: 11+ years; g: The higher value is for GCE O- level and the lower for A-level; h: Data for 'Low', 'Medium' and 'High' standard of living (not quintiles); i: The lower value is for 'Major Urban' and the higher for 'Other Urban'; j: The higher value is for 'Other Urban' and lower for 'Colombo Metro'. Sources: Computed using data from Bangladesh: NIPORT et al., 2003; India: IIPS and ORC Macro, 2000; Nepal: GON-MOH et al., 2002; Pakistan: NIPS, 2001; Sri Lanka: GOSL-DCS, 2002a. Table A3.5 Under-Nutrition among Mothers in Four Countries, Various years (Percent with 6~1<18.5kg/rn'). 30-34 30.7 29.9 35-39 29.0 40-44 26.1 45-49 N 5055 77613 Notes: a: 1-4 years of schooling; b: 5-9 years; c: 12+ years; d: Age categories for India are 15-19,20-29,30-39 and 40-49 years; e: 35+ years of age. Sources: Computed using data from Bangladesh: NIPORT, 2001; India: IIPS and ORC Macro, 2000; Nepal: GON-MOH et al., 2002; Sri Lanka: GOSL-DCS, 2002a. Annex 3 Table A3.6 Socio-Economic and Demographic Determinantsof Under-Nutrition among Mothers (BMI <18.5 kg/m2). Explanatory variables Banqladesh India Sri Lanka Maternal Education Illiterate 1.000 1.000 1.000 Primary 0.033 (1.034) -0.067a(0.934)* -0.267 (0.766) -0.185b(0.830)*** High School/Secondary -0.130 (0.878) -0.321 (0.725)*** -0.552 (0.576)* Secondary and Higher -1.225 (0.294)*** -0.395'(0.673)*** -0.309 (0.734) * -0.685 (0.504)* EconomicStatus Rural I Urban Poorest Quintile 1.043 1.726 1 1.574 0.462 1 (2.837)*** ] (5.620)*** 1 (4.827)*** 1 (1.587)* Second Quintile 1 1.057 1 1.694 1 1.147 1 0.445 (2.879)*** (5.441)*** (3.148)*** (1.561)* Third Quintile 0.931 1.656 0.771 0.185 (2.536)*** (5.241)*** (2.162)*** (1.204) Fourth Quintile 0.544 1.518 0.479 0.215 (1.723)*** (4.562)*** (1.616)*** (1.240) Richest Quintile 1.000 1.037 1.OOO 1.OOO (2.819)*** 1 Age of the Mother 15-19 -0.263 (0.769) 0.290 (1.336)*** -0.178'(0.837) 20-29 -0.421 (0.656)* 0.415 (1.515)*** -0.483 (0.617) 30-39 -0.351 (0.704)* 0.091 (1.095)*** -0.604 (0.546) 40-49 1.000 1.000 1.000 Constant -0.882 (0.414)*** -1.862 -1.961 (0.141) Chi Square 411.090 7008.68 126.269 Df 29 27 34 (N ( 4344 ( 76150 1 2847 Notes: ***: p 1.001, **:p 1.01, *:p 5.05. The figures in brackets denote Odds Ratios. a: This data is for those who have not completed primary education; b: This data is for those who have completed primary education; c: Data is for higher secondary and above; d: This figure is for 0 level; e: This data is for A level and higher; f: Maternal age categories for Sri Lanka are 15-25,26-35, 36- 45 and 45+. Sources: Computed using data from Bangladesh: NIPORT, 2001; India: IIPS and ORC Macro, 2000; Nepal: GON-MOH et al., 2002; Pakistan: NIPS, 2001;Sri Lanka: GOSL-DCS, 2002a. Table A3.7 Estimated Number of Maternal Deaths, Maternal Mortality Ratios and Lifetime Risk of Maternal Death in the Five Countries, 2000. 1 Estimated Number of I Maternal Lifetime Risk of Maternal Deaths Mortality Ratio Maternal Death Banqladesh 16,000 380 1:59 India 136,000 540 1:48 Nepal 6,000 539 1:24 Pakistan 26,000 500 1:31 Sri Lanka 300 92 1:430 South Asia (5 countries) 184,000 560 1:43 Developing Countries 527,000 440 1:61 Industrialized Countries 1,300 13 1:4000 World 529,000 400 1:74 Source: WHO, 2004. The MMR estimate for Nepal for 2000 has been revised as suggested in the 2006 DHS report. Annex 3 Table A3.8 Socio-Economic Characteristics of Infants Weighing less than 2.5 kg at Birth India (1998-99) and Sri Lanka (2000), percent. Maternal Education Illiterate Literate Primary Secondary Higher Secondary below and above Primary India (N=9685) 30.17 24.20 23.52 18.49 16.98 Sri Lanka (N=337) 27.4 19.0 17.7 11.5-13.8 Economic Quintile Poorest Second Third Fourth Richest India-Rural 27.11 28.02 28.26 23.88 19.95 India-Urban 24.91 23.55 20.05 22.08 16.50 - - snka 1 19.4 1 21.2 1 16.2 114.6 1 11.3 Residence Rural I Urban 1 Other IColombo I Estate Urban Metro India 23.94 21.06 Sri Lanka 11.6 11.6 14.9 20.8 Sources: Computed using data from India: IIPS and ORC Macro, 2000; Sri Lanka: GOSL-DCS, 2002a. Table A3.9 Socio-Economic and Demographic Differentials in Children's Nutritional Status in Four Countries, percent. Annex 3 Sex of the child Male 45.8 45.3 46.1 Female 49.6 48.9 50.5 N 27359 6410 Note: a: 1-4 years of schooling; b: 5-9 years; c: 12+ years; d: The higher value is for GCE 0 - level and lower for A-level; e: The higher figure is for 'Other Urban' and lower for 'Colombo Metro'; f: The age m o u ~ for India are: c6..6-11.. 12-23. 24-36 months:," s e: %e age &oups for Sri Lanka are 3-5, 6-11, 12-23, 24-36 months;' h: In 1ndiaand 'Sri Lanka, children under 3 years; Nepal, children under five years. Sources: Computed using data from Bangladesh: NIPORT, 2001; India: IIPS and ORC Macro, 2000; Nepal: GON-MOH et al., 2002; Sri Lanka: GOSL-DCS, 2002a. Table A3.10 Socio-Economic and Demographic Differentials in Neonatal Mortality, Various Years. Banqladesh India Nepal Sri Lanka 2001 1998-99 2001 2000 Total 47.2 43.4 38.8 8.3 Maternal Education None 52.5 55.3 51.6 15.9 Up to 5 years 47.8 40.5 a 41.2 21.3 6-9 years 46.4 33.7 * 31.3 14.6 10+ years 36.4 24.3 8.8' 6.3-9.0 Economic Quintile Poorest 56.5 55.8h 49.3 Second 52.1 59.9 Third 48.1 47.0 49.3 Fourth 39.7 43.6 Richest 32.5 30.9 29.8 Note: Overall rates are based on events over five years preceding the survey while rates for different socio-economic indicators are based on events for ten years preceding the survey. a: 1-7 years of schooling; b: 1-4 years; c: 5-9 years; d: 8-9 years; e: 6-10 years; f: 11+ years; g: The higher value is for GCE 0-level and lower for A-level; h: The data for India are for 'Low', 'Medium' and 'High' standard of living (not quintiles); i: The higher value is for a birth order of 2, and lower for 3;j: The lower value is for a birth order of 4 and higher for 5; k: This figure is for a birth order of 6 and above; 1: The higher value is for a birth interval of 2 years and the lower value for 3 years; m: The age categories in Sri Lanka are <20 years, 20-29,30-34, and 35+ years. Sources: Computed using data from Bangladesh: NIPORT et al., 2003; India: IIPS and ORC Macro, 2000; Nepal: GON-MOH et al., 2002; Sri Lanka: GOSL-DCS, 2002a. Annex 3 Table A3.11 Socio-Economic and Demographic Differentials in Infant Mortality, Various Years. 1 Bangladesh I India 1 Nepal I Pakistan I Sri Lanka 2001 1 1998-99 1 2001 1 2000-01 1 2000 Fourth 58.6 73.7 78 16.7 Richest 45.3 42.7 46.5 29 14.6 Residence Rural 72.9 79.7 79.3 103 Urban 64.6 49.2 50.1 29.0-56.0 Birth Order 1 60.9 74.9 88.8 19.8 2-3 41.3 65.7-61.7 71.6 17.0 4-6 41.0 73.1-76.2 69.4 24.0 7 + 47.0 101.1 94.1 Previous Birth Interval < 2 years 71.9 109.5 124.4 85 34.5 2-3 years 34.8 58.1 45.2-67.8 69 9.3 4 years and above 34.5 38.5 38.9 86 13.4 Sex of the Child Notes: a: Total mortality rates are for the five years preceding the survey; b: Mortality rates for different socio-economic categories are for the ten years preceding the survey; c: 1-7 years of schooling; d: 1-4 years; e: 5-9 years; f: 8-9 years; g: 6-10 years; h: 1I+ years; i: This figure is for GCE 0-level; j: The data for India are for 'Low', 'Medium' and 'High' standard of living (not quintiles); k: Birth order categories are 1,2,3,4, 5 and 6+, the first value is for the lower birth order and the second for the higher birth order; 1: The age categories for Pakistan are <21 years, 21-34 years and 35-49 years; m: In Sri Lanka the age categories are <20 years, 20-29 years, 30- 34 years and >35 years. Sources: Computed using data from Bangladesh: NIPORT et al., 2003; India: IIPS and ORC Macro, 2000; Nepal: GON-MOH et al., 2002; Pakistan: NIPS, 2001; Sri Lanka: GOSL-DCS, 2002a. Table A3.12 Sex Differentials in Components of Under-Five Mortality in South Asia Female 67.3 71.1 75.2 67 Child Mortality Rate Male 22.5 24.9 27.8 Female 28.7 36.7 40.2 Sources: Computed using data from Bangladesh: NIPORT et al., 2003; India: IIPS and ORC Macro, 2000; Nepal: GON-MOH et al., 2002; Pakistan: NIPS, 2001. Annex 4 THE ESSENTIAL PACKAGE OF REPRODUCTIVE HEALTH SERVICES Annex 4 Annex 5 TABLES ON USE OF REPRODUCTIVE HEALTH SERVICES Table A5.1 Socio-Economic and Demographic Differentials in Contraceptive Use, percent Notes: a: This figure includes both modem and traditional contraception methods. b: This figure is for 1-4years of schooling; c: 5-9 years; d: 12+ e: 6-10 years; f: 11+ years; g: This is coverage ievel among GCE 0 level; h: In ~akista",data is for 'LO;', 'Medium', 'Upper' standard of living and not by quintile; i: This data is for 35+; j: The age groups for India are 15-19,20-29,30-39 & 40-49. Sources:Computed using data from Bangladesh: NIPORT, 2001; India: IIPS and ORC Macro, 2000; Nepal: GON-MOH et al.,2002; Pakistan: NIPS, 2001; Sri Lanka: GOSL-DCS, 2002a. Table A5.2 Socio-Economic Determinants of Contraceptive Demand and Use Contraceptive Use Unmet Need Desire for No More Children Maternal There is a strong positive There is an inverse Compared to illiterate Education relationship in countries relationship in Bangladesh women, educated other than Sri Lanka (BD), Nepal (NP) and Pakistan mothers have higher (SL). I n SL, maternal (PK). I n BD, unmet need is desire for no more education has no direct lower among women with children in all five role in contraceptive use. secondary education than countries except BD. I n illiterate women. In SL, there BD, women with is no relationship. secondary education have lower desire for no more children compared to illiterates and other categories are not significantly different. Economic There is a positive There is an inverse I n IN and NP, economic Quintile relationship in all relationship in IN, NP and PK. status has a positive countries except SL. The The odds ratio is 4 for the influence. I n the other gap in contraceptive use poorest rural quintile in IN three countries, it is between the richest and compared to the richest largely independent. poorest quintile is wider quintile. I n the other in NP and India (IN) countries, the odds ratio is 1.8 compared to BD. for the poorest quintile. I n BD and SL, it has no influence. Husband's Has a positive role in NP Has an inverse relationship in Positive influence in BD Education and PK only. PK and to some extent in NP, and NP, negative in IN but is positive in IN. and no influence in PK and SL. Residence The likelihood of use is The likelihood of having unmet Significantly lower in rural higher among urban need is higher in rural and compared to major urban women in NP, and major other urban women compared women in PK have desire urban women in PK, but to major urban women in PK. for no more children. I n independent in SL. I n other countries, it has no SL, compared to Colombo influence. Metro, women in rural, other urban and estate have lower desire. Woman's Has a positive influence Has a negative influence on I n BD, chances are higher Autonomy in countries other than unmet need in IN and SL. The among those who are PK. In PK, autonomy is odds ratio among those allowed to go out alone not analyzed. without autonomy is 8.22 compared to those not compared to those with allowed. Not significant in autonomy. other countries. Woman's The odds ratios for In NP, the chance of having Positive influence in ED Employment contraceptive use among 'unmet need' is lower among and NP; independent in women working is working women. I n SL and PK, PK and SL. agriculture and in non- unmet need is independent of agriculture sectors are women's working status. 1.7 and 2.4, respectively, compared to non-working women in NP. However, use is independent in PK. I n BD, the odds ratio is 1.3 for those who worked compared to non- workers. Exposure to Analysed in IN, PK and I n SL and IN, mass media No influence in IN, PK and Mass Media SL and has positive exposure has negative SL and not analysed in influence on influence on unmet need. I n other two countries. contraceptive use. Odds SL, the odds ratio among non- ratio for use is between exposed is 3.7 compared to 1.3 in PK to 2.4 in SL exposed. among those who are exposed compared to those who are not. Annex 5 Contraceptive Use Unmet Need Desire for No More Children Maternal Age Has an 'inverse U' shaped Has an inverse relationship in A positive relationship is relationship in IN, BD and countries other than SL. The observed in four countries PK. I n SL, the likelihood odds ratio of unmet need (barring SL). of use is higher among 15-19 years olds is 7-8 compared to the 15-19 in BD and IN compared to year age group. women over 40 years. In SL, it has not influence. Number and I n IN and NP, the I n IN, unmet need is likely to I n BD, IN and NP, women Sex likelihood of using be higher among those with with two or more sons Composition contraception is higher no child or one son or two have a higher desire for of Living among those with two or daughters. I n NP, it is lower no more children. I n PK, Children more sons, with or among those without children parity has a positive without a daughter. I n or only one child. relationship. I n SL, BD, the chance of using women with one son and contraceptives is lower one daughter have the among those with no son highest desire for no or no daughter. I n SL, it more children. has not direct influence, while in PK, it is not analysed. Socio- There is a lower chance I n IN, the chances of unmet I n IN, the desire for no Religious of use among Muslims need are higher among more children is highest Group and Christians compared Muslims, Christians and among non-SC/ST to Hindus in IN. Among Schedule Castes and Tribes. It Hindus. In SL, it has no various castes the has no influence in SL. influence. chances are lowest among Schedule Castes in IN. I n SL, use is independent of religion and ethnic groups. I I I I I Note: Based on multi-variate analysis of DHS data. Sources mentioned earlier. Table A5.3 Socio-Economic and Demographic Differentials in Use of Antenatal Care, percent Bangladesh India Nepal Pakistan Sri Lanka 1999-00 1998-99 2001 2000-01 2000 Total 37.0 65.7 49.1 48.8 83.4 Maternal Education None 23.4 49.1 39.2 37.7 66.7 Up to 5 years 35.2 77.2 a 64.5 66.4 74.3 6-9 years 61.7 83.2 84.0 86.1 87.0 1O+ 94.8 96.5 94.8 95.8 79-86' N 5179 33016 4746 5844 2432 Economic Status Rural Urban I Table A5.4 Social Differentials in Use of Maternal Health Services, India, 1998-99, percent At least one At least one Institutional At least one post antenatal visit TT vaccine delivery natal check-up I Reliaion I I I I I ~ i n d ; ~ 65.2 74.9 33.1 29.1-38.2 Muslim 63.4 73.6 31.6 31.9 Christian 84.2 84.8 54.5 58.2 N 32990 33026 32814 32882 Caste Scheduled Caste 61.4 73.5 27.0 32.2 Scheduled Tribe 56.3 60.2 17.1 23.3 Other 46.3 78.1 38.4 39.6 N 32753 33026 32579 32646 Source:IlPS and ORC Macro, 2000. Coverage for PNC among Hindu is assessed separately for Hindu-SCIST and Hindu-Forward Annex 5 Table A5.5 Socio-Economic Determinants of Antenatal and Natal Care Delivery Institutional Conducted by Antenatal Visit TT Immunization Delivery Skilled Birth Attendant Maternal Has a positive Has a positive A positive relationship A positive Education relationship in relationship in in all the countries relationship in all countries other countries other than except SL. In NP and countries. I n NP, BD than SL SL BD, the odds ratio is and SL, the odds higher among ratio are higher secondary and higher among secondary educated women and higher educated compared to illiterate women compared to women, while in the illiterate women, other countries, an while in the other increase is seen from countries, the the primary level. increase starts with primary education. Economic Has positive Has a positive Has a positive Has a positive Quintiles influence in influence. In BD and relationship in relationship in countries other NP, the poorest one countries other than countries except SL. than SL. In SL, or two quintiles SL. The odds ratio is The odds ratio is where the have lower chances around 0.5 for the around 0.5 for the likelihood of ANC of being immunized fourth quintile fourth quintile is higher for the compared to the compared to the compared to the fourth richest richest quintiles. It richest. richest. quintile compared has no influence in to the richest SL. quintile. Husband's Has a positive A positive Has a positive The chances of a Education relation in BD, NP association in influence in IN, NP and skilled attendant are and PK. I n IN, countries other than PK only. The odds higher among those higher education BD and SL, but only ratio is 5 for higher with higher has a negative for higher education secondary and more secondary or above influence, and it is levels in NP and PK educated women in IN, NP and PK. No independent in compared to illiterate significant influence SL. women. in BD and SL. Woman's No significant Has a positive Has a negative In SL, the chances Working influence. influence in PK, but influence in PK, and no are lower among Status is negative in SL. No influence in BD and those who have influence in BD and SL. ever worked. In BD not analyzed in IN and PK, there is no and NP. influence. Residence I n SL, compared I n PK chances are In NP and PK, chances Higher odds for to Colombo Metro, lower in rural and are lower in rural urban women in BD. the chances of other urban areas areas compared to In PK, rural and ANC are higher in compared to major urban and major other urban women other urban and urban and in rural urban respectively. It have lower chances rural areas but NP they are higher is not analysed in BD than women from lower in Estates. compared to urban and not significant in major urban areas. In PK, they are areas. No influence SL. Compared to lower in Other in BD and SL. Colombo Metro, urban compared chances are lower in to major urban rural and estate of areas. In NP, it SL. has no influence. BD not analyzed. Annex 5 Women's A positive Has positive I n IN, there is a Has no influence in Autonomy association was influence in BD and positive influence, BD, but has positive found in BD, IN IN. It has no while there is no relation in IN and and PK; no influence in SL and influence in BD, PK SL. influence in SL; not analyzed in NP and SL. NP not analyzed. and PK. Number of Not analyzed Has a positive Has a positive ANC visit influence in BD, IN relationship with and NP. Not analyzed ANC visits in BD, IN in PK and not and NP. Has no significant in SL. The relationship in SL. odds ratio is 9 in IN Not analyzed in PK. and 15.6 in BD for 3+ANC visits compared to no visit. Maternal Not strongly Chances are higher There are Lower odds No influence in BD, Age related. In IN, PK among 15-19 year of having an NP and SL. In IN and SL, the old than women institutional delivery and PK, women in chances of ANC above 40 years in among 15-19 year- the age group 15-19 were lower among BD and lower in PK olds in countries other years have 15-19 year-olds compared to 20-29 than SL. In SL significantly lower compared to older year-olds. l 7 maternal age has no chances compared women. There vaccination is influence. to older women. was no influence independent in the I in BD and NP. I other countries. Number of I Has a neaative I Has a neaative I Birth order has an Chances decrease Living influence-in BD, influence-in IN and inverse relationship with an increase in Children/ IN and PK, and an PK but is, with institutional birth order in IN. In Parity inverse U-shape independent in NP delivery in IN. In SL BD, PK and SL, influence in SL. and SL. compared to 4+ birth there is a negative In NP, it has no orders, the chances influence. No influence. are higher among significant influence lower birth orders. I n was observed in NP. PK, parity has a negative influence. I n BD, the odds ratio is lower for women with three or more living children compared to those with no living children. Preceding No influence. In PK, a birth interval I n PK, a birth Birth ANC increase with of over 48 months has interval of over 36 Interval an increase in the a higher odds ratio. I n months has a higher birth interval in NP and SL, it has no odds ratio compared SL. There is no influence. to 8-12 months. I n influence in IN NP and SL, there is and NP, and it no influence. was not analyzed Socio- SC women in IN I n IN, Scheduled Scheduled Tribes Religious of ANC were have lower odds of Castes have lower have lower odds Group higher among receiving lTthan odds than higher even compared to Sinhalese. There others. I n SL, castes and other Scheduled Castes in were no Moors and others backward castes. No IN. differences in IN. have lower odds influence in SL. compared to the Sinhalese. Note: Based on multi-variate analysis of DI idata for each country. Sources mentioned earlier. Annex 5 Table A5.6 Socio-Economic Determinants of Postnatal and Child Health Care Postnatal Care Child Immunization Maternal Education Has a positive relationship in IN. I n BD, A positive relationship in countries the odds ratio is significantly higher for other than SL. secondary and higher education. I n NP and PK, it has a negative influence. It has no influence in SL EconomicQuintile In IN, the chances of PNC are higher A positive relationship in countries among the third and fourth rural other than SL. In NP and PK, the odds quintiles compared to the richest urban ratio for the poorest quintile is 0.3 quintile. There is a positive influence in compared to the richest quintile, while NP, and in PK the odds ratio is higher in BD, it is 0.57. for all quintiles compared to the richest. Husband's Analyzed in BD, NP and PK and no Has a positive influence in NP and PK, Education significant Influence found. but is independent in BD and SL. Women's Analyzed in BD, SL and PK and no Chances of children being immunized Employment influence found. are higher among working women in BD. Has no influence in PK and SL. Residence I n PK, chances are lower in rural and Not analyzed other urban areas compared to Major urban areas. No influence in Nepal and Sri Lanka. Women's Has a positive influence in BD and IN. The odds ratio is 1.4 for women who Autonomy In Bangladesh, chances are higher for can go out with their children or those who are allowed to go out with husbands compared to those who their children and husband compared to cannot in BD. I n IN, autonomy has a those who are not allowed to go out at positive influence on child all. immunization. ANC Visit Has a positive influence in BD, IN and Has a positive influence in India. The SL. Not analyzed in the other two odds ratio for 4+ visits is 4.3 countries. compared to no visit. Maternal Age No significant influence. With reference to 15-19 year-olds, 20- 24 year-olds have higher odds of getting their child immunized. In BD, the odds ratio is lower for those between 15-39 years compared to those above 39 years. I n PK, chances are lower among 40-49 year-olds compared to 20-29 year olds. I n SL, children of adolescent women have higher chance of immunization compared to 40-49 years. Birth order/ Chances are lower for birth orders 1-3 Has a negative relationship with birth Parity / Number of compared to 4+ in SL. I n IN, the odds order in BD, SL and IN, but is LivingChildren ratio is lower for women with living independent in the other two children compared to those without any, countries. while in Pakistan, the odds ratio is higher for high parity women compared to those with parity 1. Preceding Birth Chances are lower for longer birth Analyzed in India and found to have no Interval intervals compared to those with influence. intervals < 2 years in SL. No influence in Nepal, and not analyzed in the other countries. Socio-religious In India, compared to Hindu Scheduled Compared to Scheduled Castes, the Groups Castes, chances are lower among odds ratios are lower among Scheduled Tribes. It has no influence in Scheduled Tribes, Muslims and SL. Christians in IN. Similarly, in SL, compared to Buddhist, odds of getting immunized is lower among other groups. Annex 6 PUBLIC HEALTH SYSTEMS I N SOUTH ASIA Most reproductive health services can be delivered at the primary level of health care but strong back-up is required from secondary facilities for some diagnostic tests, surgical interventions, treatment of complications and so on. For poor South Asian women, the two levels must be linked by good referral and mechanisms that facilitate appropriate use of each level, including information to clients, patient records, transport especially for emergencies, follow-up of clients, supportive supervision of frontline workers, and financial support. Primary Care The primary level is that at which the first contact is expected to occur between health providers and individuals, families and communities. It is the level at which 'essential" health care is provided. Primary services can be delivered by field or outreach paramedical workers, or at health facilities by paramedics, more highly trained staff such as nurses, and doctors. Some hybrid approaches have been developed to provide clinical skills in an outreach mode - for example, family planning "camps" for male/female sterilization and mobile vans for diagnosis and treatment or serious medical problems. Fieldworkers. Fieldworkers are the 'frontline' of the health system. They visit villages and homes and play the key role of establishing contact between individuals and the health system. Their functions are usually quite basic but range across a spectrum of health needs. I n Sri Lanka, for example, Public Health Midwives (PHMs) are the main fieldworkers in the preventive health network, providing domiciliary maternal and child health (MCH) and family planning (FP) services in well-defined areas of 2000 to 4000 people. The PHM initiates reproductive health care by registering eligible families (those with members in the reproductive age group and with children under five) within her area. She provides FP services including counselling and contraceptives (pills and condoms) to couples, and regularly follows up her clients. Through systematic home visits, she ensures care of pregnant women, infants and pre-school children in her area. She also provides reproductive health information and advice to adolescents when necessary, and educates women on the importance of early screening for reproductive organ malignancies, motivating them to attend "Well Woman Clinics" in the Ministry of Health area. The PHM's activities are guided by a system of record- keeping which enables her to plan and monitor her routine work. She is supervised by a Public Health Nursing Sister or Supervising Public Health Midwife. I n the other four countries, fieldworkers focus on the provision of basic health care, MCH and FP services (although, for example in India, they may also be asked to carry out other frontline tasks such as those entailed by disease control programs). The Sri Lankan focus on adolescent health or reproductive health of older women is largely absent although some initiatives have begun on these. I n Bangladesh, Health Assistants (HA) and Family Welfare Assistants (FWA) are 'mobile' health and FP service providers under the DGHS and DGFP, respectively. They provide basic domiciliary care, visiting every household in their area every four to eight weeks. I n Pakistan, Lady Health Workers (LHW) offer similar basic health and FP services in their own homes as well as through household visits. The LHW's primary responsibilities are antenatal and postnatal care. They do not conduct deliveries but liaise with local birth attendants. The LHW program has had a significant impact on the delivery of MCH services, and the Government of Pakistan is committed to strengthening it. Pakistan also has Male Family Planning Workers who provide counselling, health education and contraceptive services specifically to men. I n India, the Auxiliary Nurse Midwife (ANM) (also known as the Female Multi-Purpose Worker, MPW-F) is the main provider of RCH services. (A dwindling cadre of Male MPWs exist, but these workers have been largely involved in disease control programs.) Under the recently-launched National Rural Health Mission "Accredited Social Health Activists" (ASHAs) are being engaged and trained to act as an "interface" between communities and the government health system. They are volunteers, selected by and accountable to local village governments (gram panchayats). Their main responsibilities are to increase awareness of and promote immunization, other health programs, and construction and use of household toilets, and to support contact with the health system, escorting women clients to health centers for RCH care (Government of India, 2005). Annex 6 In addition to the formal fieldworkers mentioned above, dais or traditional birth attendants (TBAs) continue to assist home deliveries in Bangladesh, India, Nepal and Pakistan. Efforts have been made to 'modernize'their delivery skills and to formalize their role as health providers by training and supplying them with delivery kits. In India, for example, dai-training was carried out over several decades with the aim of ensuring at least one skilled birth attendant in every village. However, commitment to the program varied over time, and it is currently at low ebb. In Bangladesh an evaluation of the TBA training program that had been initiated in the 1970s found little impact on maternal mortality in the country. More recently, a competency-based six-month program, the Skilled Birth Attendant Training Pilot, was started to train FWAs, HASand NGO workers in basic midwifery. I f scaled up, this effort would increase the supply of certified providers of domiciliary maternal and neonatal services, safe home deliveries and newborn care. I n Nepal, dais work alongside Female Community Health Volunteers (FCHVs) to distribute condoms and oral contraceptive pills. Outreach Clinics. Outreach clinics - usually the responsibility of the nearest health facility - provide services on specific days in villages which have no health center. I n Sri Lanka, for example, MCH-FP clinics are conducted fortnightly in every village. Another approach is the provision of a specific service at a health facility on a periodic basis. For example, the Well Woman Clinics (WWCs) in Sri Lanka carry out screening for reproductive organ malignancies and certain other conditions every two to four weeks. Women over 35 years of age are checked by trained Medical Officers (MOs) for conditions such as hypertension, diabetes, breast malignancies and cervical cancer. The WWC program is a best practice in the region, but similar specific attention to the health needs of older women is still not part of outreach or clinic-based efforts in the other four countries. In Nepal, outreach clinics are run by field staff from Sub-Health Posts and Health Posts on fixed days of each month. They provide minor first aid treatment and basic health care, and "basic" FP and MCH services such as condom and oral pill distribution and provision of iron tablets to pregnant women. They also offer education on topics such as breastfeeding, nutrition, and prevention of communicable diseases. Under the 1998-2003 Health and Population Sector Programme (HPSP) in Bangladesh, Community Clinics were started at the village level, "owned" by local communities. These clinics are intended to be one-stop centers providing integrated health care services: HASand FWAs are expected to deliver an Essential Service Package comprising interventions for reproductive and child health, communicable disease control, curative care, and behavior change communication. In India, Anganwadi Centers established under the Integrated Child Development Services' Scheme (ICDS) are a village locus for the provision of basic maternal and child health care by ANMs or MPWFs who visit periodically (e.g., once a month). The focus has been on immunization, identification of pregnant women, supplementary nutrition, and child health check-ups. Pakistan has adopted a different approach to outreach care in addition to the efforts of LHWs. Mobile Service Units reach out to remote areas where no family planning or health facilities exist. Each unit is expected to organize ten to 12 camps per month and provide basic curative health care and family planning services. Similar mobile units exist in some states of India, primarily to reach into isolated tribal, forest or hilly areas. Primary Health Facilities. Facilities for primary care vary from those that provide only basic ambulatory care including some MCH and FP services, to others with beds for patients with common illnesses or for normal deliveries, to some with emergency obstetric care (EmOC) faci~ities.~In Sri Lanka primary health facilities are of two broad types. In the first category are Central Dispensaries, Maternity Homes and Rural Hospitals, managed by non-MBBS Registered or Assistant Medical Officers (RMOsjAMOs) and without nurses on the staff. While Central Dispensaries offer only ambulatory care for minor ailments and some basic family health clinics, the Maternity Homes and Rural Hospitals provide some essential in-patient care. The RMOs/AMOs are given basic training for three years and intern in obstetric units. - ~ 6. Basic EmOC includes the ability to administer parenteral antibiotics, oxytocics, and anticonvulsants; perform manual removal of the placenta or removal or retained products; and perform assisted vaginal deliveries. Comprehensive EmOC includes, in addition to the Basic EmOC activities, the ability to perform Caesarean sections and blood transfusions. Annex 6 Facilities for uncomplicated deliveries are available at these institutions and backed-up by referral and ambulance services. I n the second category are Peripheral Units and District Hospitals which are managed by medical graduates, provide nursing care, and have a wider range of services for in-patients in addition to maternity facilities and, in some cases, paediatric care.7 These facilities are also expected to provide Basic EmOC but, in practice, cases requiring assisted vaginal delivery or removal of retained products (which are part of Basic EmOC) are transferred by ambulance to a higher-level institution within a half to two hours reach. The availability of Basic EmOC facilities in Sri Lanka is 0.9 facilities per 500,000 people - about one-fourth that advocated by U.N. process indicators. (There are 1.25 Comprehensive EmOC institutions per 500,000.) About 24 percent of institutional deliveries in Sri Lanka take place at primary care institutions and 70 percent at secondary or tertiary facilities. I n India, according to the second National Family Health Survey (1998-99), only 16 percent of institutional deliveries are conducted at public facilities although intra-natal care is provided at 34 percent of PHCs, 84 percent of CHCs and 9 1 percent of District Hospitals. I n Nepal, Sub-Health Posts provide basic health care, MCH and FP services. The MCH workers are trained and conduct normal home deliveries. Health Posts provide basic health care, comprehensive MCH care, and additional FP services such as IUD insertion if trained ANMs are available there. The Health Posts also run a Community Drug Program (CDP) in which drugs provided by the Ministry of Health and Population are sold at reduced prices or provided free to eligible poor patients. Above these Posts are Primary Health Care (PHC) Centers which have doctors to provide a higher level of medical care. I n 2005-06, comprehensive abortion care (CAC) facilities were expanded to 69 districts in the public or private sector and utilization of CAC services has increased steadily. Basic and comprehensive EmOC services were established at 67 sites in 47 districts and 36 sites in 32 districts, respectively. A newly- introduced maternity incentive scheme is expected to contribute to increases in the utilization of EmOC services, but formal monitoring of the use of funds and the scheme's effectiveness has yet to be undertaken. The National Policy on Skilled Birth Attendants was finalized and approved by MOHP in 2005-06, and the Safe Motherhood and Neonatal Health Long-term Plan (2006-2017) was formulated. Human resource policies for skilled birth attendants - their production, capacity building, accreditation, deployment and retention - will be crucial to reduce maternal and neonatal mortality. Maternal and Neonatal Tetanus Elimination was confirmed at the end of 2005, and school TT immunizations started. Nationwide programs for vitamin A and deworming continue. The Community-based Integrated Management of Childhood Illnesses (CB-IMCI) program has substantially increased the number of Acute Respiratory Illness cases treated. I n Bangladesh, Union Health and Family Welfare Centers (UHFWCs) provide basic health care, FP and MCH services. Efforts are underway to make Basic EmOC available at all UHFWCs. The Upazilla or Thana Health Complexes (UHC or THC) are the bedrock of primary health care and the first referral units. This level has three specialists (in Medicine, Surgery, and Obstetrics and Gynaecology) and another Medical Officer in charge of MCH care, and it is proposed to make Comprehensive EmOC available at this level. I n Pakistan, at the primary level, Family Welfare Centers, managed by female family planning workers provide FP counselling and services (for non-surgical contraceptives). MCH centers managed by Lady Health Visitors provide basic health care, antenatal care, normal delivery, postnatal care and FP services. Basic Health Units (BHUs) above these provide services to the same areas as MCH centers, are better staffed and equipped,. The BHUs are linked to larger Rural Health Centers (RHCs) with in-patient facilities. I n India, Sub-Health Centers (SHCs) are the most peripheral facilities, providing basic MCH care, including immunization and family planning, to populations of 5,000 in rural areas (or 3,000 in tribal and hilly areas). There are proposals to improve SHCs to carry out IUD insertions and simple laboratory investigations. Primary Health Centers (PHCs), one per 30,000 people, have a few beds for in-patient care and normal deliveries and offer basic health and MCH-FP services. They supervise sub-center workers and have some facilities for '. District hospitals in the other four countries are classified under Secondary Health Care. 26 Annex 6 training of field staff. Attempts are being made in the on-going Reproductive and Child Health Programme to enable 24-hour services for deliveries at PHCs and at the next level, Community Health Centers (CHCs) (one per 'block' of 120,000 people in the plains and 80,000 in hilly area^).^ PHCs are being upgraded to provide paediatric care and perform selected surgical procedures (such as medical termination of pregnancy, and male and female sterilization). CHCs have specialists in Medicine, Surgery, Paediatrics, and Obstetrics and Gynaecology. As they are referral units for cases from SHCs and PHCs but also points of first contact they function as primary as well as secondary health facilities. I n order to promote preventive health care, a new non-medical post of Community Health Officer has been established at each CHC. Secondary and Tertiary Facilities Secondary health facilities provide obstetric, paediatric and other specialist care and Comprehensive EmOC including Caesarean section and blood transfusion. I n Pakistan the Talukaflehsil Headquarter Hospitals offer this specialized care and 40 to 60 beds. They are the first referral unit (FRU) for complicated cases from the peripheral facilities, providing Comprehensive EmOC. A wider range of specialists is available at larger District Headquarter Hospitals. I n India secondary care is provided at CHCs, Taluka/Tehsil/Rural Hospitals, District and Sub-divisional Hospitals which provide specialty care and receive referrals from the lower levels of the health ~ y s t e m . Under the earlier Child Survival and Safe Motherhood (CSSM) ~ Programme, FRUs were set up at CHCs or sub-district hospitals. However, most planned FRUs have not become fully operational due to a lack of skilled medical manpower (especially anesthetists and gynecologists), inadequate infrastructure (such as operation theaters and labor rooms), or a lack of blood-banking facilities. These shortcomings are to be addressed under the RCH program and Comprehensive EmOC services at CHCs strengthened to provide round-the-clock services for obstetric emergencies and newborn care. A number of innovative schemes have been implemented to address the shortages of specialists. For example, some CHCs contract private anesthetists to assist in emergency operations, while elsewhere MBBS doctors are being trained to administer anesthesia for this purpose. I n all five countries, tertiary institutions provide specialized medical care that involves advanced or complex procedures or treatment performed by highly-qualified medical practitioners. I n reproductive health they would, for example, perform intricate cancer surgery or carry out in vitro fertilization. These institutions are usually located in large cities and may have regional or national standing. Those in the government sector are often linked to teaching institutions and hence used as a base for training doctors, nurses and a range of technical staff. . Thereare about 6,000blocks in India. '. A districthasapopulationof 1.5 to 3 million. Annex 6 Table A6.1 Health Facility and Worker Normsand Actual Position in the Five Countries of South Asia Trained Birth Attendants Community Cllnlcs Ward level, 1per 6,000-7,000 people Health Assistants (DGHS) Ward level, 1per 6,000-7,000 people Family Welfare Assistants (DGFP) Ward level, 1per 6,000-7,000 people Unlon HFW Centers (Baslc EmOC) Based on adm~n~strat~vesub- 250 posts of union- (wlth 3 pararned~calstaff, Sub- division, regardless of level Medlcal Assistant Community Medlcal Officer, populat~onsize Officer (Famlly Family Welfare V~s~tor,and Welfare) created; Pharmac~st) Medlcal Officer post for each of 1275 upgraded HFWCs Upazilla Health Complexes (FRU with Based on administrative sub- 397 UHC Comp. EmOC, 31-50 beds of which 6 division, regardless of for MCH-FP; 9 doctors (incl. specialists population size in medicine, obgyn, Surgeon); 2 MedicalAssistants, Pharmacist, Radiographer, EPItechnician, Staff nurses; HFP staff under separate line of command: Upazila FP Officer, MO- MCH, Assistant FP Officer, Senior FW Visitor, 2 Family Welfare Visitors) District Referral Hospitals (50 to 250- Based on administrative sub- 64 55 Maternal and Remaining 9 MCWCsare "almost beds) division, regardless of Child Welfare readynto provide EmOC and other population size Centres (MCWCs) services. under DGFP are staffed and equipped to provide Comp. - (ASHA) 250,000 is planned between 2005- 2009 in 18 states. Annex 6 Auxiliary Nurse MidwifeIMPWF 1per 5000 (3000 in 169,262 133,194 MOHFW reports a shortfall in Sept tribal/hill/forest areas) 2005 of 19,311 sanctioned posts for ANMs IMPWFs, and a further 6640 (4.7%) vacancy in posts.a Male Multi-PurposeWorkers 1per 5000 (3000 in 146,026 61,907 MOHFW reports a shortfall in Sept. triballhilllforest areas) 2005 of 64,211 MPWMs and a further vacancy of 19678 (24%) of sanctioned Sub-Health Centers 1per 5000 (3000 in 158,792 based on 146,026 (Sept MOHFW reports a shortfall of 19,269 tribal/hill/forest areas) 2001 rural and 2005) SHCs in Sept. 2005. Of existing sub- tribal populations centers, 5769 (4.8%) were without ANMs, 44766 (39.2%) without MPWMs, and 2522 (2.8%) without both workers. In addition, populations will have increased by at least 10 percent between 2001 and 2006. The states of Bihar, Haryana, Madhya Pradesh, Maharashtra, Orissa, Punjab, U.P. and West Bengal are particularly short of ANMs. Primary Health Centers (staffed with 1per 30,000 (20,000 in 26,022 based on 23,236 MOHFW reports a shortfall of 4337 at least one doctor, one LHV and one tribal/hill/forest areas) 2001 rural and THF (Sept 2005) PHCs in Sept. 2005, and a vacancy Male Health Assistant) populations rate of 17.4% in sanctioned posts for PHC doctor^.^ Of PHCs, 1130 (6.5%) had no doctor, 3478 (15%) had no lady doctor, 6822 (39%) had no Lab Technician, and 2343 (13.7%) had no Pharmacist. In addition, populations will have increased by at least 10 percent between 2001 and 2006. Fourteenstates have serious shortages of PHCs. Nurse Midwives 1per PHC and 7 per CHC 46,658 MOHFW reports a shortfall of 13,352 in Sept. 2005, and a further vacancy of 5280 in sanctioned posts at PHCs and CHCs. LHVIHealth Assistant (Female) 1per PHC 23,236 MOHFW reports a shortfall in Sept 2005 of 4,214 and a further 2602 (13.1%) vacancy of sanctioned posts at PHCs. a Health Assistant (Male) 1per PHC 23,236 MOHFW reports a shortfall in Sept. 2005 of 5,290 and a further vacancy of 6880 (25.4%) of sanctioned posts at PHCs.a Community Health Centers (FRUs, 1per 120,000 (80,000 in 6,491 3,346 MOHFW reports a shortfall of 3206 ComprehensiveEmOC) tribal, hilly, forested areas) (Sept 2005) CHCs, and 6110 specialist posts at Specialists in Medicine, Pediatrics, CHCs in Sept 2005. Further, about Obg~n,Surgery 52% of Surgeon posts, 44% of Obgyn Non-medical Community Heath specialists, 57% of Physicians and 56% Officer of Pediatrician posts, amounting to about 50% of posts overall - were ~ a c a n t .In addition, populations will ~ have increased by at least 10 percent between 2001 and 2006. 24 states have serious shortages of CHCs. First Referral Units (with Comp. 1926 (Sept. 2005) 89 at Btock PHCs, 992 at CHCs, 311 at EmOC) at Block PHCs, CHCs, Sub- Sub-district and 24 at District district and District Hospitals) hospital^.^ Many FRUs are not functioning due to an absence of doctors (e.g., anesthetists, f infrastructure Trained Birth Attendants 15,603 (2001-02) Sub-Health Posts with Female MCH 1in each Village Development 3190 (2001-02) 1MCH Worker for 7500.' Only 29% of Workers (MCHWs) Committee (VDC) area the poor can reach a health facility within half and hour. Village Health Workers 4015 1VHW per 6000' ParamedicIHealthAssistant 5295 1Paramedic/HealthAssistant per 4500' Nurse/ANM and Auxiliary Health 6216 1nurse/40001 Workers (AHWs) Health Posts 711 (2001-02) PHC Centers (Basic EmOC) with 1in each electoral 205 180 (2001-02) 1doctor per 18,500 people Doctors constituency 1259 Doctors Ladv Health Worker 1~ e1000 households r 110,000 to cater to 100,000 30% of the urban (2007) and 90% of the rural population LHW Supervisor 1per 30 LHWs 3071 (2005) Male PopulationCommunity Workers Target: 70002 81g3 Annex 6 MCH Centers 907 Family Welfare Centers Target: 23002 16883 FP Workers Female Male Mobilizers/Village-based FP Target: 22802 Workers Mobile Service Units Tehsil level; provides services Target: 17S2 1313 to about 30,000people Reproductive Health Service 'A" Target: 14S2 106~ Centers (provide contraceptive surgical services) Dispensaries 4582 Basic Health Units 5334 (2005) Rural Health Centers 556 (2005) Taluk/Tehsil HQ Hospitals (40-60 906 (All hospitals) beds; FRU, Comprehensive EmOC) . . 4000 people Public Health Nursing Sister 1.4 per 100,000pop in 2001 Supervising PHM Well Women Clinics Maternity Homes/ Rural Hospitals 44.8doctors and 84.4nurses per 100,000pop in 2001 Peripheral UnitsIDistrict Hospitals (Basic EmOC) Comprehensive EmOC Notes: 1.National average - conceals regional differences, especially the situation in remote areas; 2.These are cumulative targets up to 2002-03and 3.are existing in 2001-02(data from http://www.mopw.gov.pk/planning.html). Sources:a. GOI,2006. Annex 7 EXAMPLES OF PROMISING PRACTICES FOR SOUTH ASIA Table A7.1 Promising Practice Examples to Address Some Areas for Action Annex 7 Annex 7 The boxes below provide very brief descriptions of the practices listed above. Box A7.1 Promising Practices to Improve Demand for Reproductive Health Services Annex 7 Box A7.2. PromisingPracticesto ImproveAccess to Health Care Box A7.3 PromisingPracticesto Improve the Quality of Care Annex 7 Box A7.4 Cross-Sectoral Efforts Annex 7 TABLES ON REPRODUCTIVE HEALTH EXPENDITURES Table A8.1 Donor Expenditureson Reproductive Health by Component, South Asia, percent Bangladesh Nepal Sri Lanka (2000/2001 [1999/2000] 119971 Maternal health 28 11 5 Childbirth and pregnancy 5 0 Infant care 37 0 15 Family planninq 28 92 62 Prevention and control of STDs 1 c 1 8 Other inpatient reproductive health expenditures 1 0 0 Other outpatient reproductive health expenditures 1 0 0 General RH 0 3 5 Note: 'General Reproductive Health' consists of donor projects that involve two or more reproductive health activities, which could not be classified into one of the other reproductive health categories. Table A8.2 Average Expenditures per Child Born by Location of Birth in the Last 365 Days, Andhra Pradesh, India, 1995-96 Rural Urban Hospital/ Hospital/ PHC/ PHC/ Home M:FA:)ol Other Total Home Maternity Other Total Nursing Nursing home home Cost per childbirth 6 44 11 16 10 34 7 27 (constant 2000 US$) Cost per childbirth (share of per capita GDP, 1.2 9.1 2.2 3.3 2.1 7.1 1.4 5.6 percent) Source: Computed from NSS 1995196. Table A8.3 Mean Out-Of-Pocket Cost per Immunisation by Type of Provider, Pakistan, 1998-99 'On' Health Mother Private hospital, unit, NGO/ Lady Vaccina- Child Practi- Dispen- Rural Health Health tion Other Health tioner/ sary/ Health Worker Worker Teams Center Provider Doctor Center - - Cost per visit (US$, 0.49 0.22 0.18 0.01 0.00 0.03 1.79 0.81 n n n : Cost per visit (share of per capita GDP, 0.11 0.05 0.04 0.00 0.00 0.01 0.40 0.18 percent) Notes: Calculated from households that reported expenditures for the last immunisation visit; includes transport costs. Source: Computed from PIHS 199811999. Annex 7 Table A8.4 Incidence of Household Consumption and Household Expenditures on Health and Reproductive Health, Bangladesh 1999/2000 Source:Computed from HDS, 199912000. Table A8.5 Household Expenditures on Childbirth during the Past One Year as a Share of Annual Household Consumption, Andhra Pradesh, India, 1995-96, percent Rural HH Urban HH Source: Computed from NSS 1995196by Indicus. Table A8.6 Household Expenditures on Childbirth during the Past One Year as a Share of Annual Household Consumption, India, 1995-96, percent Rural HH Urban HH Hospital/ Hospital/ Expenditure PHs/ PHs/ based quintile Maternity Home Other Average Home Other Average home/ I I I Nursing I I I I I Source: Computed from NSS 1995196. Annex 9 POLICIES RELATEDTO REPRODUCTIVE HEALTH prioritized four services: FP, Policy 2000 refers to (1998) refers to a RH package (1991) Reproductive Health MCH, abortion related and basic rather than package which is includes FP, maternal policy is committed to RTIs/STIs. comprehensive package comprehensive (includes and infant health care, provide comprehensive of RCH services i.e. FP, MCH, abortion, adolescent health, reproductive healthcare Health and Population Sector MCH and management STDsIRTIs, sub- fertility, elderly women, and suggests the Strategy (HPSS) developed of RTIs and STIs. adolescent RH and the RTIsISTIs, abortion following as areas to be Essential Services Package problems of elderly and health related addressed a) anaemia which includes: a) basic RH Suggests delivery women). issues of men. b) sub fertility c) care (i.e. safe motherhood, through Anganwadi unwanted pregnancy d) malnutrition, neonatal care, centers, self-help group The Health Sector Strategy induced abortion e) FP, adolescent health, meetings which would (HSS) focuses in an RTIs f) STDs g) RTIsISTDs and infertility); b) include village-level Essential Health Services HIVIAIDS h) child health care, including registration of births, Package on five priority reproductive system immunization; c) control of deaths, marriages and elements: safe malignancies (breast, some basic communicable pregnancies. motherhood, FP, child pelvic and prostrate diseases; d) limited curative health, control of cancers). care (that is, basic first aid, communicable diseases pain relief and so on); and e) and strengthening of Itdoes not mention behavior change outpatient care. MCH care, which is largely well developed communication. ESP to be 10th five year plan focuses delivered through static in the country. on MCH. community clinics rather than earlier domiciliary approach. Health and family planning workers merged to deliver package. level policy but the HPSP and NPP of adolescent health and development (2000) guiding principle: independent goal in the HNPSP recognize adolescents needs, especially in strategy (2000). IEC to identify and RH needs Population and RH as an under-served priority rural areas where there programs to increase of people at all stages policy. group. is a high prevalence of health information; including adolescents. Broad-based strategies adolescent marriages Adolescent health program in and pregnancies. Amendment passed in Specific measures for proposed to address the HPSP mainly concerned 2002 making abortion implementation of RH drug abuse, sexual with increasinq awareness of legal. policy for adolescents not harassment, child the reproductLe process, elaborated. prostitution, Policy endorsed so that pregnancies and rise of STD, safe sex etc.; and the adolescents can be HIVIAIDS. treatment of anemia and provided FP services Annex 9 gynecological problems. irrespective of marital status (earlier provided only if married). Abortion Amendment passed in 2002 Fairly liberal MTP Act Illegal, except to save the Illegal, except to save Illegal, except to save that allows abortion under (1971). Allows mother's life. the mother's life, or if it the mother's life, certain condition, including on termination, up to a is considered as although the practice is request up to 12 weeks or gestation period of 20 'necessary treatment'. common under the longer if rape or incest is weeks, under any rubric of Menstrual involved (abortion was illegal condition construing a Regulation. prior to this amendment) grave risk to the physical or mental condition of the mother. The Act has been further amended to increase the number of centers which can conduct abortions. formed in 1995. ~at'onalRH Policy and STD control (1995) discusses prevention and HIV predates ICPD. A promotes HIVIAIDS service delivery to high National Taskforce was National Policy on HIVIAIDS RCH program proposes prevention, including safe risks groups. set up in 1989. and STD- related issues "Camp and Campaign" sex, but ignores the formulated in 1997 is mode. National Health Policy Multi- sector National gender dimension. concerned with public health (2001) discusses a AIDS Committee set up National Aids Control aspects (surveillance, HIVIAIDS is only loosely program for HIVIAIDS as in 1991and included in Organization (NACO) counseling and testing) and integrated with the RH a vertical program that is the National Health oversees the identifies vulnerable groups. package in the National not integrated with RH. Council agenda headed management and RH strategy. by the Prime Minister. prevention of HIVIAIDS Strategies transmission of HIVIAIDS strategy 2003: Framework (2001- 2006) Included in the HIVIAIDS identifies high risk groups; developed. Population and focuses on prevention; Reproductive Health multi- sector approach policy as an area of involving society, NGOs concern in the RH and donors. services package. vulnerable groups, e'specially Policy is primarily of'the Long- Term Health Policy talks of the need Reproductive Health women and children. concerned with eauitv . . Plan. Focus is on ~ o o r . . . to address urban bias in Policy proposes the between rural and under- privileged, health. provision of good family The HNPSP targets poor in urban areas, different marginalized, women and planning services to examininq: the financing The National Population Annex 9 services; channeling health socio- economic children. Policy talks of serving the urban slums, services; ensuring groups, and between under- served and plantations, internally The HSS focus is on the participation and states. To address vulnerable groups in the displaced population, poor and those in remote representation in local- level equity, a major portion context of HIVIAIDS. factory laborers and areas. Direct public planning; and monitoring of public expenditure is migrants. finance is proposed for trends in inequality. to be allocated to Other policies focus on improving PHCs. primary health care in these areas. Private health education in The National Population sector regulation is urban areas in view of Policy identifies under- proposed to ensure that changed life styles. served groups: urban the poor get more value slums, tribal for their out-of-pocket communities, hill expenditure areas. Direct areas, displaced and public finance is proposed migrant communities. for primary health care in These are to be served these areas. Private by mobile clinics. sector regulation is proposed to ensure that the poor get more value for their out- of- pocket expenditure. , - * a,,y - * I ) r - z ~ $; - XhtegrdtlonAofSewIces- 7.=" * L B#a, 1 ? d Integration of local level Integratton of vertical Initiated in 1991. Further The National Health Integration i f Family Health and Family Welfare programs proposed by integration of disease Policy (2001) continues Planning with existing workers in the HPSS. the Nattonal Population control programs proposed to promote disease- MCH was done in 1965. Policy (2000). under the HSS. speciftc vertical programs. At the delivery level, the National Population Pollcy (2002) has proposed a merger of Lady Health Visitors with Family Planntng workers. level in 1983. administrative level in passed in 1999, in which Health Policy (2001) and No particular emphasis 1993, but only local authorities are to be in Interim Population HPSS suggests major in post-ICPD policies. gradually getting made fully responsible for Sector Perspective Plan reorganization and operational in the the delivery of public (2002). restructuring of service Health sector. services (including Health) delivery organs at the Still at a preliminary by 2007. thanafupazilla levels, in order The National Population stage in the Health to be decentralized Policy (2000) proposes sector. strengthening Panchayati Raj Institutions and forming a sub- committee to take Annex 9 responsibility for health. Limited decentralization approach adopted in the RCH program. Public-Private Partnerships The HPSS proposes a balance The National Health The National Reproductive The National Health Long-standing between the public and and Population Policies Health Strategy promotes Policy proposes that involvement of NGOs in private sector in financing of both encourage the NGO and private sector provincial governments family planning. delivery and health services. involvement of NGOs, collaboration with the should develop policies Successful public- private sector and civil public sector. favorable for the public- The Essential Services private partnership society to complement private partnerships. Package operates through the One of the guiding already exists through the government's public sector, but other principles of the Long- The National Population channeling centers. health efforts. services (especially hospital- Term Health Plan is the Policy provides incentives The Population and based ones) involve NGOs and A network of accredited involvement of the private for the private sector to Reproductive Health the private sector on a public, private and sector. work in rural areas. Policy proposes the co- contractual basis. NGO centers is The HSS elaborates on the The Interim Population operation of NGOs and proposed with payment role envisaged for Perspective Plan involves civil society in the through a system of interactions between the NGOs, civil society and counseling of youth, coupons. oublic and Drivate sectors. the private sector in care of the elderly, and NGOs are seen in both family planning. provision of family policies as being planning information. particularly important The National Health in the provision of care Policy talks of the to the under- served regulation of the private (hill areas, displaced, sector and its co- migrant population and ordination with the tribal communities). public sector. recovery for public sector private insurance and that the poor get best value community involvement the need for alternative services. social health insurance for their out- of- pocket and financing. mechanisms of funding, schemes to allow the expenditure. This includes especially in the areas Health insurance coverage is use of private care, social and community of health promotion and also promoted. and the institution of insurance mechanisms with prevention. user charges in an intermediary institution secondary and tertiary as an "informed purchaser"; public health services. and cost- sharing schemes Annex 9 schemes to serve as incentives for family planning. Inter-Sectoai Coordination A major component of the The National Population National HIVIAIDS National Health Policy Emphasis in health- HNPSP involves inter-sector Policy provides for strategy focuses on multi- (2001) recognizes the related policies on co- coordination to provide inter- sector sectoral involvement need for a multi- sectoral ordination especially nutrition coordination between (especially with the approach and especially with the education municipal departments education sector). mentions the areas of sector; dealing with water, nutrition and education. sanitation, industry and National Reproductive A parallel preventative pollution, housing, Health Policy: proposes health structure exists transport, women and strengthening links with with inter-sectoral child development, education, women and linkages. education and development, legal or nutrition. justice system and the develo~mentof a national The National Population IEC &ategy. Policy recommends The HSS aims to ensure setting up a co- ordination cell in the access to clean water, Planning Commission sanitation and school for coordination education. between Ministries. National Rural Health Mission is concerned with the preparation of district health plans, including aspects related to drinking water, sanitation, hygiene and nutrition. The National Strategy for The National Population The National Policy on One of the ten key areas The Penal Code (1995) Maternal Health (2001) Policy (2000) places a Family Planning (1997) of The National ~ e a l t h makes martial rape, focuses on essential services strong emphasis on focuses on reduction of Policy (2001) is the sexual and verbal for maternal health. It aims to women's fertilitv. ~romotionof aender harassment a criminal change the perception of the empowerment. It is kquity in the health offence. The National Safe community to safe concerned with broader sector. The National Population motherhood, violence and objectives than family Motherhood Policy (1998) takes a broad view of safe I n the Draft National and Reproductive discrimination. planning, like education, delaying motherhood. It suggests Reproductive Health Health Policy (1998) The National Population Policy girls' marriages, IMR, the provision of free Policy (2000) there is a addresses gender- (2002) addresses the MMR and meeting the education and completion clear shift from targets to based violence, elimination of gender needs for basic RH of primary education for empowerment of women, intimidation and disparities in education, health girls. It proposes a literary using a rights- based harassment of women. Annex 9 It also discusses the and nutrition. The principal services. program for perspective. increased participation objectives are to ensure empowerment. The Policy proposes The National Policy for of women in decision gender equity; creating strategies to increase The National Reproductive the Empowerment of making and public life; income generation female participation in Health Strategy (1998) Women (2002) and proposes the opportunities; and ensuring a paid employment; and recognizesthe role of announced by the initiation of measures to more active male the active involvement women in population Ministry of Women's ensure equal access for involvement. of men in family stabilization. Development, includes women to the labor planning and other access to good quality market. The policy also A Ministry of Women and aspects of safe healthcare services for promotes the equal Social Welfare and a motherhood and the poor as one of its participation by males National Commission for childcare. objectives. in all areas of family Women have been and household The National Health established. The Interim Population responsibilities. Policy (2002) Sector PerspectivePlan A legal amendment in recognizes the catalytic 2012 (2002) calls for 2002 allows women to role of empowered male involvement, but in inherit parental property. women in improving the context of achieving the overall health Programsfor food family planning goals. standards in the supplementation, community. I t commits scholarships, sensitizing of the central government parents to the need for to giving the highest education, and an action- priority to funding plan to stop trafficking of programs related to women and children women's health proposed. Annex 10 KEY ACTIONS TO IMPROVE REPRODUCTIVE HEALTH - - Address adolescent boys' behavior as well Development of self-esteem and ability to handle sexual advances, access to contraception Improve status of education on laws, nutritional needs and adolescence and hygiene education (Education and Lack of information Health departments on/observance of Hygiene education Fear of sexual abuse or consensual activity Annex 10 couple programs education in schools and communities aPoor knowledge of associated risks client (counselling and fostering CBOs to aLack of access to collaborate with family planning information and NGOs/CBOs/SHGs in information and aLack of access to safe Provide information about other women abortion and safe services, services within reach, and planning services close to fostering CBOs to aInaccessible family planning services Discontinuation of contraception due to other women contraindications for different contraceptives Manage side-effects Strengthen post-partum Provide information about post-abortion care programs, women's Poor personal hygiene groups, etc. could aEnsure regular supply of Lack of ability to condoms; promote social include health negotiate safe sex marketing of condoms information in through private entities IEC/BCC activities, Lack of access to and NGOs/CBOs/SHGs and distribute health services for Annex 10 Lack of ability to Ensure regular supply of negotiate safe sex condoms; promote social marketing of condoms Increased risk due to through private entities untreated RTIsISTIs and NGOs/CBOs/SHGs multiple partners or women through Lack of access to Expend menu of family planning contraception options services (including distribute condoms Distribute condoms, oral spouse counseling) and other simple pills, other simple method methods through High desired family through private entities private entities and and NGOs/CBOs/SHGs NGOs/CBOs/SHGs Even where legal, Where legal, provide access to and quality abortion and post confidentiality of safe abortion care facilities; services is inadequate PPPs could help expand Cultural norms abortion providers* NOor low use of Provide quality family programs/groups to disseminate Provide access to skilled information on birth attendants Low access to skilled Encourage institutional attendance and birth attendant or institutional Delay in getting to skilled attendant or women for institutional Public education about labor and danger signs Annex 10 complicated cases information on ANC Failure to recognize Improve access to appropriate facilities Local government bodies to assist in Few facilities providing basic/comprehensive emergency obstetric programslgroups to disseminate information on reproductive tract cancers and on and treatment Annex 11 HEALTH SECTOR REFORMS RELATED TO REPRODUCTIVE HEALTH BANGLADESH Past and On-going Reforms Involved stakeholders including clients (poor women, men and young people) and providers in the health sector reform process that began in 1998. Government invited stakeholders to help to prepare the Health and Population Sector Program (HPSP). MOHFW has piloted demand-side subsidies, i.e., a voucher scheme for antenatal care and safe delivery, as a way to reach the poor. MOHFW established a Management Accounting Unit, revised delegation of financial powers, initiated staff training, formed a Budget Committee to improve financial management. Despite commendable progress, overall public financial management systems remain highly regulation-bound, input- and process-oriented rather than results- or outcome-focused. Proposed Reforms Shifting resource allocations to poorer districts (or districts with poor health outcomes) through a revision of norms for per capita allocations to districts, weighted by a poverty- related index of health needs; these allocations are to be used to provide incentives for practitioners to attend to the needs of the poor, and for efforts at demand-side financing. Diversification of service provision through public-private partnerships. The pattern of service provision will be adjusted over time by increasing the use of contracts and commissions for NGOs to provide primary and secondary care in areas where they have a comparative advantage and for private providers to offer secondary and tertiary services for poor people where they can do so cost-effectively at high quality. Creating links with other ministries and programs that have a direct impact on the health status of the poor. Improving the quality and scope of Health, Nutrition and Population services through regulation, quality control measures such as registration and accreditation of practitioners. ~estructuringservice provision through free provision of emergency services to those in need, and expanding HNP services in urban areas for provision of coordinated primary, secondary and tertiary care. Options will be explored to mobilize more resources through social insurance, community financing schemes, religious taxation, charitable contributions through corporate social responsibility, service fees and private insurance. Wherever appropriate, these will be scaled up. Improving service efficiencies by enhancing workforce motivation and productivity and by the use of service providers according to their comparative advantage Improving sector management to focus on improving institutional and personal skills in planning and monitoring in close liaison with the Financial Management and Audit Unit; budget management through a Medium-Term Expenditure Framework; management of pooled and non-pooled aid funds; information management to identify priority interventions to improve efficiency, equity and effectiveness. Decentralization and local-level planning will be piloted in six districts as a first step in a decentralization process. For promoting 'voice', community and stakeholder participation, MOHFW and civil society will together facilitate the establishment of a Health Service Users' Forum at local and national levels to strengthen a rights-based approach in service delivery. Annex 11 NEPAL On-Going Reforms Decentralization: The government sector program will support capacity-building for decentralized management of health services. It aims to hand over responsibility and authority over health posts and sub-health posts throughout the country. Large district/zonal hospitals will be made autonomous. Government health officials will be oriented to support local bodies. Districts will have authority to purchase drugs and equipment. Local bodies will acquire new skills in personnel management to modify compensation in order to attract staff to underserved areas. Sector management: Government will review the roles and functions of different sectors including its own to remove gaps and overlaps, clarify responsibilities and improve accountability. A management training program will be implemented to develop vision, strategy, budget and implementation management. Sustainable health financing: A Sector-Wide Approach will be adopted to provide greater transparency in resource allocation. A financial allocation formula adjusted for poverty, morbidity patterns, population size and density will be developed for allocations to districts. A review of national experience with user fees, community insurance and the community drug program will be finalized to design a path for scaling-up. Development partners have agreed to pool their contribution to finance the health sector program. Monitoring and Evaluation: Household and facility surveys will disaggregate results by socio-economic status and gender to address differences in service utilization and health outcomes among socially-excluded groups. PAKISTAN Ongoing and Proposed Reforms Increased investment in the social sectors is a central element of the government's agenda, reflected in the Pakistan Poverty Reduction Strategy (PRSP) Iand 11. Overall health expenditures have grown significantly over the past decade in nominal and real terms. PRSP I1aims to double the share of public health spending as part of GDE from the current level of 0.5 percent. A National Maternal and Child Health Strategic Framework (NMCH) was developed for 2005- 2015. I n the firs five years, the strategy is to be implemented through an NMCH Program. Program priorities include: introduction of a cadre of community-based skilled birth attendants, basic and comprehensive EmONC services, nutrition interventions (including breast-feeding, appropriate and timely complementary feeding) and other child and neonatal health interventions. The program places strong emphasis on creating demand through advocacy, community mobilization and health education, and on piloting incentives for mothers to deliver at health facilities. It also envisages improving services through management and program innovations, strengthening and upgrading training schools, and strong monitoring and evaluation. Expansion of the Lady Health Workers' Program: The numbers of LHWs has risen from 70,000 in 2004 to 100,000 currently. The additional 30,000 LHWs were deployed to relatively underserved areas, indicating a greater poverty focus in the program. Some innovations have been introduced, including a direct role for LHWs in immunization. Further program and management reforms will be informed by an external evaluation planned later in 2007. Population Policy 2002: The overall vision of the policy is to achieve population stabilization by 2020. The key priorities include: a multi-sectoral approach and coordination across all levels of government; public private partnerships; advocacy campaigns with policy-makers and Annex 11 opinion leaders, and effective use of the media; expansion of social marketing in urban and semi-urban areas, and in rural areas by associating registered medical practitioners, hakims, homeopaths, chemists and community-based organizations; promoting male involvement through a cadre of male workers recruited in the rural areas to engage in regular dialogue with male community members and to sensitize elders and parents to the benefits of small families. Key reforms include: decentralization of administrative, financial and program powers to the province and further to the district level; provision of family planning services in the primary health structure. These reforms are in various stages of implementation. Public-private partnerships and a strong focus on monitoring and evaluation are key aspects of reform that cut across most programs. An extensive effort to contract out primary health services to NGOs has been initiated following the success of a pilot in one district of Punjab which showed significant improvements in service utilization and client satisfaction. Other models are also being tested including contracting in technical assistance to build district capacity. The HIV-AIDS program relies entirely on NGOs to deliver services to high risk populations. Strengthening monitoring and evaluation is central to the MNCH Strategy, the Population Policy, the Lady Health Workers Program and the HIV-AIDS Program. Past Reforms The following reforms are mainly national initiatives. There has been a gradual shift in the organization structure and delivery of health care services. Some of the important policy shifts envisaged in the VIII, IX and X Five-Year Plans and implemented were: Introduction of user charges for diagnostic and curative services for those above the poverty line, while these remained free or were highly subsidized for the poor. Increased involvement of voluntary, private organizations and self-help groups in the provision of health care, and inter-sectoral coordination in the implementation of health programs. Enabling Panchayati Raj Institutions (PRI) to plan and monitor health programs at the local level to bring greater responsiveness to the health needs of people and greater accountability, and to utilize local and community resources for health care. Making the national family planning program target-free in 1996. This meant that centrally-determined targets were no longer the driving force behind the program. Instead, community needs were to determine program priorities. In 1998, the family planning program was "included" in the reproductive and child health program (RCH). lo On-going and Proposed Reforms Contractual appointments of staff for maternal health, e.g., Public Health NursesIStaff Nurses at PHCsICHCs that have adequate infrastructure for deliveries. To enhance NGO involvement in RCH, a "Mother NGO (MNGO) scheme" was introduced. Under this, the Department of Family Welfare identifies and sanctions grants to select MNGOs, which in turn issue grants to smaller "field NGOs" (FNGOs). The functions of MNGOs include: identification and selection of FNGOs; capacity building; providing technical support; networking with State and District health services, PRIs and other NGOs; and monitoring the performance of FNGOs. The FNGOs are required to provide RCH services based on community needs, to orient PRI members to RCH, etc. To achieve actual decentralization and increase state ownership, the Government of India offers technical assistance to strengthen capacity to prepare realistic and specific 'O. In addition to reforms initiated at the national level, several states have initiated health sector reforms (and some have obtained external assistance to increase their resources). Some of the broad areas that they have addressed are: decentralization, public-private partnerships, contracting of health services, and health care financing. Annex 11 state plans. Flexibility to incorporate community needs is an important aspect of the RCH I1 program. To overcome the fragmented approach (different activities and initiatives), various partners' activities/projects will be converged. There will be lateral infusion of personnel to improve management capacity at National, State and District levels, with functional responsibilities and clear roles. To improve the utilization of services and quality of care, the steps proposed are: to hire contractual staff, include quality standards in the core minimum package, outsource service delivery and demand-generation through behaviour change communication. To bring about a more comprehensive sector approach, Public- Private-Partnerships will begin with service delivery and will gradually expand to include preventive/promotive health. a Infrastructure will be strengthened and operationalized through focused investment in the delivery of the essential package, including more integrated management of the safe motherhood and child survival strategies. The RCH I1 Program will have performance-based financing. Financial management systems will be built into the program management structure and professionals will be appointed to speed-up the flow of funds. To improve equity, RCH I1 will explore innovative ways of 'demand-side financing', particularly assessing the feasibility of introducing RCH services into existing health insurance and community-financing schemes. Improved drug procurement and supply systems (such as that established in Tamil Nadu) will be set-up in non-EAG (Empowered Action Group) states." SRI LANKA Past Reforms Responsibility for health services was devolved to eight Provincial Councils in 1987 (following the Thirteenth Amendment). A further decentralization process took place in 1992 when the administration of health services was further devolved to the Divisions. However, budget responsibility was not devolved. A system of National Health Accounts was established to report and monitor health expenditure data for the country. Government released the first estimates in 2001. The National Health Policy recognizes community participation as an important component of the health development process. About 15,000 young volunteer health workers assist in PHC activities. Ongoing and Proposed Reforms Although Sri Lanka has achieved success in maternal and child health, the interventions and internal organization still reflect the needs of a population at the early stage of the epidemiological transition. Therefore, to better address the present needs of the population, the managerial and technical capacity of the Family Health Bureau will be strengthened. The objectives, strategies and guidelines of the existing maternal and child health program will be revised in collaboration with professional medical associations, and delivery of preventive health services will be strengthened. Annual Health Forums will be constituted to encourage participation of different stakeholders in the policy-making process, including the private sector, civil society, development partners and clients. To become entitled to a larger allocation, districts will need to be accredited as Program Management Centers based on availability of planning and accounting teams and other financial criteria. An environmentally-sustainable health waste management system will be developed and implemented. ". The EAG states are the ten mostbackward states in the counhy. 52 Annex 11 Hospital management including the information system will be modernized and countrywide service delivery networks that provide responsive services to clients within and across provinces will be developed. The preparation of the Health Sector Strategy is an initial step to clarifying budgeting for the health sector in Sri Lanka. The process of strengthening a "results orientation" for the public expenditure and budget framework of the central Ministry of Health (MOH) will be piloted in the Ministry of Health of one Provincial Council. To strengthen knowledge-based decision-making, a Monitoring and Evaluation cell will be developed within the Management Development and Planning Unit of the MOH by strengthening the capacity of the Health Information Directorate.