Universal Access to Reproductive Health: Strengthening Institutional Capacity Why? What? And How? Presented at International Workshop on Capacity-Building in Programme Management on Population and Development, Beijing, China, November 7-9, 2006 By Jay Satia International Council on Management of Population Programmes (ICOMP)
World leaders at the World Summit in September 2005 committed themselves to achieving universal access to reproductive health by 2015, as set out at the ICPD, integrating this goal in strategies to attain the internationally agreed development goals, including those contained in the Millennium Declaration, aimed at reducing maternal mortality, improving maternal health, reducing child mortality, promoting gender equality, combating HIV/AIDS and eradicating poverty.
Framework for Institutional Capacity Development Why? Gap in access How? What? • Policies • Service delivery • Systems • Organizational • Capacities • Governance
Framework for Institutional Capacity Development Why? Gap in access
How well are we doing on universal access to RH?
How well are we doing on universal access to RH? Percent of Deliveries Attended by Skilled Attendants % d eliveries atten d ed b y skilled atten d an ts 100 90 80 70 58.7% 60 50 40 30 20 10 0 Asia Latin America Middle East/North Sub-Saharan Central Asia Caucasus Africa Africa Republics Source: Ross et al., 2005
How well are we doing on universal access to RH? Percent of Unmet Need for Contraception for All Women 25 20 % of unmet need 15 13.0% 10 5 0 Asia (ex. China) Sub-Saharan Latin America Middle East/North Central Asia Africa Africa Source: Ross et al., 2005
How well are we doing on universal access to RH? Percent of Women Ages 15-24 with Comprehensive Knowledge of HIV/AIDS 45 40 38 37 40 34 35 30 25 percent 25 18 20 15 15 7 10 5 1 0 i a a a a a m a t a i i n i i d y r a i s n a n a e H e n o N a e h g e b n w m G i K o m t N e t r d s A a i V o n C B I Source: Ashford et al., 2006
How well are we doing on universal access to RH? Prevalence of Physical Violence by an Itimate Partner according to Severity of Violence, among Ever-partnered Women 70 60 12 moderate physical violence 50 13 percent severe physical violence 40 23 22 17 30 22 21 14 16 11 16 49 12 20 36 10 15 26 25 24 10 20 20 19 19 18 17 9 16 13 8 4 0 Serbia & Montenegro city Ethiopia province Tanzania province Bangladesh province Thailand province Namibia city Thailand city Peru province Peru city Samoa Bangladesh city Tanzania city Japan city Brazil province Brazil city Source: WHO, 2006
WHY THE GAP? If the countries of the Asia-Pacific region are to achieve the Millennium Development Goals (MDGs) they will need to invest sufficient resources. Just as important, … well functioning INSTITUTIONS can help to accelerate this progress towards the MDGs – especially those that are crucial for delivering health, education and other vital services to the poor. UN ESCAP, September 2005
WHY THE GAP? … The Commission for Africa, the Millennium Review and the G8 Gleneagles meeting reached a clear conclusion: capacity development is one of the most critical issues for both donors and partner countries. Richard Manning Chair, OECD Development Assistance committee (2005)
Successful countries pay attention to institutional capacity development Malaysia has achieved the health MDGs and attributes some of this success to its strong health system and institutional capacities. Malaysia MDG Report 2005
Successful countries pay attention to institutional capacity development Thailand, having achieved the health MDGs, would like to go beyond them. It seeks to address some of the institutional issues for this purpose: • training for health personnel, • proactive involvement of families and their communities, • improving monitoring capacities, and • more targeted programmes to vulnerable groups for HIV infections. Thailand MDG Report 2004
In contrast…. The MDG Reports of many countries focus on programmatic initiatives but do not adequately address institutional issues of how these initiatives will be effectively implemented
MAIN IDEA Institutional capacity development matters
Framework for Institutional Capacity Development What? • Service delivery • Organizational • Governance
What institutional capacity should be strengthened?
Institutional capacity development 1. Strengthen service delivery to provide universal access to needed health interventions 2. Institute appropriate institutional arrangements to address special needs for population and RH issues 3. Improve governance
We have the health interventions. However, health service are failing poor people.
Strengthen service delivery: Reaching the poor Percent of Demand Satisfied by Wealth Quintile 80 70.7 70.5 68 70 62.1 and satisfied 60 50 49.7 48 Q1: poorest 50 Q5: richest 38.1 37.9 40 of dem 30 23.7 20 % 10 0 Africa Latin Asia North Global America Africa/West Average Source: Ross et al., 2005 Asia
Strengthen service delivery: Reaching the poor Percent of deliveries attended by doctor, nurse or trained midwife 100 Brazil 80 60 Indonesia % 40 India 20 0 e d t t h s s l n t d e e r o u d r h o c o i c M e o F i R S P Quintiles Source: Bulletin of WHO 2003:81:616-623
Strengthen service delivery: Reaching the poor • Targeting the poor: geographic, household, individual (Progressively narrower targeting) • Community-based or outreach services • Subsidizing poor, removing user fess • Voice and choice
Strengthen service delivery: Reaching the poor The framework of accountability relationships Policymakers Poor people Providers WDR 2004, World Bank
Strengthen service delivery: Reaching the poor Governments themselves, and in partnership with civil society and private sector, must take the lead if the reproductive health status of the poor is to significantly improve.
Strengthen service delivery: Improving quality of care 1. Quality assurance 2. Situation analysis approach 3. Quality improvement approach 4. Total quality management
Strengthen service delivery: Improving quality of care Key measures taken No. of countries Increased staff and training 77 Introduction of quality standards 45 Improvement of management and logistics 36 Affordable reproductive health services 21 Provision of youth-friendly services 9 Total number of countries reporting 143 UNFPA State of World Population Report 2005
Strengthen service delivery: Improving quality of care Availability of Multiple Contraceptive Methods % of countries reaching 50% of 100 90 80 70 population 60 50 40 30 20 10 0 At least one long-term At least one short-term At least one long-term and method method at least one short-term method
Strengthen service delivery: Strengthening health systems 1. Decentralized service delivery management 2. Strengthening local initiatives (Grants, participatory planning, implementation skills) 3. Human resources 4. Health sector reform (decentralization, user fees, sector-wide financing (SWaPs), formulating essential service packages)
Strengthen service delivery: Strengthening health systems Health sector reforms are failing reproductive health. A rethink is needed Local level commitment to reproductive health Towards Emphasize quality of care Gender awareness Greater community participation Reorientation of service delivery to local needs
MAIN IDEA Improve the coverage and quality of services by opening them up to fresh options, attitudes and ideas. More of the same will not do
Appropriate institutional arrangements for special population and reproductive health issues • adolescent/youth reproductive health, • closer collaboration between HIV/AIDS and reproductive health, • migration and • ageing are lacking.
Appropriate institutional arrangements Holistic youth policies and multi-sectoral coordination
Appropriate institutional arrangements Linked response between Reproductive health and HIV/AIDS
Appropriate institutional arrangements Reinvent population agencies
Quality of governance affects all sectors. What should population/ reproductive health agencies do?
Gender is key… Relation of Percent of Deliveries Attended by Skilled Attendants to GDI score 0.9 0.8 0.7 0.6 GDI score 0.5 0.4 0.3 0.2 0.1 0 0 20 40 60 80 100 120 % of deliveries attended by skilled attendants
Education helps… Relation of Percent of Deliveries Attended by Skilled Attendants to Female Literacy Rate 120 100 ale literacy rate 80 60 40 fem 20 0 0 20 40 60 80 100 120 % of deliveries attended by skilled attendants
Role of public, private and civil society sectors Private sector Incentives for good performance and capacity to hold providers accountable Civil society sector Middle way between state and private sector
MAIN IDEA Need to increase social capital
Framework for Institutional Capacity Development How? • Policies • Systems • Capacities
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