Achieving Equity in Family Planning: Getting Beyond the...
Transcript of Achieving Equity in Family Planning: Getting Beyond the...
Achieving Equity in Family Planning Achieving Equity in Family Planning
Achieving Equity in Family Planning: Getting Beyond the Rhetoric
Session 1.2.11
Karen Foreit1, Janine Barden-O'Fallon2, Jessica Dietrich3, Cheikh Seck4, Suneeta Sharma1
1Futures Group, USA 2University of North Carolina, USA 3International Planned Parenthood Federation WHR, USA 4Initiative Senegalaise de Sante Urbaine, Senegal
Achieving Equity in Family Planning
Why equity?
Neglected topic in family planning
Inequities in access to services violate principles of human rights
May prevent countries from reaching health and development goals
Achieving Equity in Family Planning
What is an equity approach?
Addresses differences in access to and use of quality family planning services that are: o Unwanted and avoidable
o Unfair and unjust
Focuses on sub-groups, not the general population
Targets the most disadvantaged
Achieving Equity in Family Planning
Strategic options: Focus on the poorest of
the rural poor
Different situations require different approaches
0%
10%
20%
30%
40%
50%
60%
Poorest Least poor
% M
oder
n M
etho
d U
se
Urban Rural
Kenya 2008
Achieving Equity in Family Planning
Strategic options: Improve family planning
nation-wide Give special attention to
rural areas May be too soon for a
poverty focus
Different situations require different approaches
0%
10%
20%
30%
40%
50%
60%
Poorest Least poor
% M
oder
n M
etho
d U
se
Urban Rural
DR Congo 2007
Achieving Equity in Family Planning
Our panel: research to practice
Disentangling poverty and place of residence
Increasing coverage of vulnerable populations in Bolivia
Designing interventions for urban poor in Senegal
Increasing public resources for health in poorest states of India
Achieving Equity in Family Planning Achieving Equity in Family Planning
Disentangling poverty and place of residence
for family planning strategic planning
Karen G. Fleischman Foreit MEASURE Evaluation PRH
Achieving Equity in Family Planning
Equity begins and ends with measurement
Who shows the disparities?
How big are the disparities?
How do we know that our interventions are reaching the people with the disparities?
How do we know if we have made an impact?
Achieving Equity in Family Planning
Who is poor?
Relative poverty
• Wealth quintiles, usually derived from household assets
Absolute poverty
• Defined against some standard of income and/or expenditures
Achieving Equity in Family Planning
0
5
10
15
20
25
30
% U
sing
Mod
ern
FP
Rural
Urban
Urban-rural differences are common
Achieving Equity in Family Planning
0
5
10
15
20
25
30
% U
sing
Mod
ern
FP
Bottom quintile
Top quintile
…as are differences by wealth quintile
Achieving Equity in Family Planning
0%
10%
20%
30%
Bottom 2nd 3rd 4th Top
% In
terv
iew
ed w
omen
Wealth Quintile
Urban Rural
But residence and wealth go together
Kenya 2003
Achieving Equity in Family Planning
0%
10%
20%
30%
Bottom 2nd 3rd 4th Top
% In
terv
iew
ed w
omen
Wealth Quintile
Urban Rural
…making it hard to interpret differences
Kenya 2003
Achieving Equity in Family Planning
Methods
Secondary analysis DHS standard recode files
Separate urban and rural strata
Rank by wealth score within strata
Create residence-specific wealth quintiles
Analyze outcome indicators by residence-specific quintiles
Achieving Equity in Family Planning
Results
Highly variable residence-specific patterns
Achieving Equity in Family Planning
Wealth and Residence: Ghana 2008
0%
10%
20%
30%
Q1 Q2 Q3 Q4 Q5
% U
sing
a M
oder
n M
etho
d
Urban
Rural
0%
10%
20%
30%
Q1 Q2 Q3 Q4 Q5
% U
sing
a M
oder
n M
etho
d
National
Achieving Equity in Family Planning
Wealth and Residence: Senegal 2005
0%
10%
20%
30%
Q1 Q2 Q3 Q4 Q5
% U
sing
a M
oder
n M
etho
d
Urban
Rural
0%
10%
20%
30%
Q1 Q2 Q3 Q4 Q5
% U
sing
a M
oder
n M
etho
d
National
Achieving Equity in Family Planning
Wealth and Residence: Zambia 2007
0%
10%
20%
30%
40%
50%
60%
Q1 Q2 Q3 Q4 Q5
% U
sing
a M
oder
n M
etho
d
Urban
Rural
0%
10%
20%
30%
40%
50%
60%
Q1 Q2 Q3 Q4 Q5
% U
sing
a M
oder
n M
etho
d
National
Achieving Equity in Family Planning
Wealth and Residence: Kenya 2003
0%
10%
20%
30%
40%
50%
60%
Q1 Q2 Q3 Q4 Q5
% U
sing
a M
oder
n M
etho
d Urban
Rural
0%
10%
20%
30%
40%
50%
60%
Q1 Q2 Q3 Q4 Q5
% U
sing
a M
oder
n M
etho
d
National
Achieving Equity in Family Planning
Wealth and Residence: Kenya 2008
0%
10%
20%
30%
40%
50%
60%
Q1 Q2 Q3 Q4 Q5
% U
sing
a M
oder
n M
etho
d Urban
Rural
0%
10%
20%
30%
40%
50%
60%
Q1 Q2 Q3 Q4 Q5
% U
sing
a M
oder
n M
etho
d
National
Achieving Equity in Family Planning
Limitations of assets-based quintiles
Track over-all trends in family planning outcomes
X Do not match individual consumption measures of poverty
Achieving Equity in Family Planning
0%
20%
40%
60%
80%
100%
Bottom 2nd 3rd 4th Top
% M
atch
w/
cons
umpt
ion
Assets-based Quintile
>1 quintile +/- 1 quintile Exact match
Match-up between consumption and assets measures of poverty
Ecuador 2004 RHS
Achieving Equity in Family Planning
0%
20%
40%
60%
80%
100%
Bottom 2nd 3rd 4th Top
% M
atch
w/
cons
umpt
ion
Assets-based Quintile
>1 quintile +/- 1 quintile Exact match
Match-up between consumption and assets measures of poverty
Ethiopia 2005 DHS 2004/5 HIES
Achieving Equity in Family Planning
Conclusions
Disaggregate place of residence and relative poverty to identify pockets of greatest disparities and to assess impact
Use consumption-based measures of poverty to monitor uptake of program interventions by the poor
Achieving Equity in Family Planning
Thank you – Merci – Gracias -
© 2
007
Felix
Mas
i, Co
urte
sy o
f Pho
tosh
are
Achieving Equity in Family Planning Achieving Equity in Family Planning
Enhancing utilization of reproductive health services by
vulnerable groups in Bolivia Jose Osvaldo Sejas
Centro de Investigación, Educación, y Servicios – CIES Salud Sexual y Reproductiva, Bolivia
Shelly Makleff and Jessica Dietrich International Planned Parenthood Federation/Western Hemisphere Region
Heidi Gagnebe Marriott International Planned Parenthood Federation
Achieving Equity in Family Planning
Background
Latin America is behind in addressing MDG 5 IPPF/WHR Member Associations provide
essential sexual and reproductive health services Serving poor, marginalized, socially-excluded
and under-served populations is key to our mission Reporting on the percentage of clients who
are vulnerable has been challenging
Achieving Equity in Family Planning
Centro de Investigación, Educación, y Servicios – CIES, Bolivia
Achieving Equity in Family Planning
Full-capacity clinics Medium-sized clinics (no surgery ) Mobile Health Units
Achieving Equity in Family Planning
Defining vulnerability criteria
Poor
Under-served
Socially Excluded
Achieving Equity in Family Planning
Developing the client intercept questionnaire
Achieving Equity in Family Planning
Piloting the questionnaire
Training of staff
Sample selection
Data collection
Data analysis
Achieving Equity in Family Planning
No vulnerability criteria met
44%
1 Factor 35%
2 Factors 16%
3 Factors 5%
Vulnerable 56%
Percent of Clients Meeting Vulnerability Criteria
Achieving Equity in Family Planning
Behind the averages, variability
0%
10%
20%
30%
40%
50%
60%
El Alto Potosí Santa Cruz Sucre
Perc
ent V
ulne
rabl
e
Poor Excluded Under-served
Achieving Equity in Family Planning
Challenges in Measurement
• Categories not mutually exclusive
• Differing definitions across countries, regions
• Sensitive measurement issues around SRH vulnerabilities (GBV, sexual minorities)
Achieving Equity in Family Planning
Using the data: CIES and beyond
• Concrete data against which to develop strategies to increase uptake of reproductive health care services – Set vulnerability targets for each facility
– Develop strategies to meet targets
– Measure, report and utilize data annually
• Advocate internally and externally – Strengthen institutional mission
– Promote accountability to government and donors
– Demonstrate social sustainability
Achieving Equity in Family Planning
Scaling up across the Federation
Latin America
o Core group of affiliates to lead regional initiative
o Share experience through South-South training
Africa
o Pilot in Uganda
Achieving Equity in Family Planning
Disseminating the methodology
Standardized training manual
o Examples of instruments
o Using data for strategic planning
o Illustrative country results
Posting on websites
o IPPF
o MEASURE Evaluation
Achieving Equity in Family Planning
Thank you – Merci – Gracias -
Achieving Equity in Family Planning Achieving Equity in Family Planning
Promouvoir l’accès à la planification familiale aux
populations urbaines défavorisées au Sénégal
Dr Cheikh Seck, MD, MPH ISSU Project Director Senegal
Achieving Equity in Family Planning
Problématique
Accroissement de la population urbaine au Sénégal – 42% urbaine actuellement, 53% prévu d’ici 2030
Proportion de pauvres – 43% de ménages, 32% des individus
Mauvais état de santé – Mortalité maternelle: 401 pour 100.000
– Mortalité infantile : 47 pour 1000
– Indice de fécondité: 5.3 par femme
Achieving Equity in Family Planning
Initiative Sénégalaise de Santé Urbaine (ISSU)
Financé par Bill & Melinda Gates Foundation Consortium de partenaires locaux et
internationaux Augmenter le taux de prévalence contraceptive
dans les zones urbaines défavorisées ciblées Contribue au repositionnement de la PF au
Sénégal Sites: 4 villes d’intervention et 2 villes de contrôle
Achieving Equity in Family Planning
Vue d’un bidonville en plein centre ville de Dakar
Achieving Equity in Family Planning
Méthodologies de recherche
1. Enquête quantitative de base
2. Cartographie de l’offre et des acteurs de services, et de la vulnérabilité des populations
3. Revue des données secondaires
4. Etat des lieux de la gestion de la chaine d’approvisionnement en contraceptif
5. Plan Stratégique du Secteur Privé au Sénégal
6. Evaluation de la Chaine d’Approvisionnement des Produits PF
Achieving Equity in Family Planning
Résultats de la recherche
Inaccessibilité financière et géographique de certaines populations aux structures de santé
Barrières socioculturelles ‒ absence de ciblage des hommes,
‒ faible capacité de négociation sur les problèmes de sante de la reproduction.
Achieving Equity in Family Planning
Résultats de la recherche (suite)
Au Niveau Institutionnel : Ressources Financières faibles de la part
de l’Etat
Au niveau opérationnel : Rupture fréquente des méthodes PF dans les
points de prestation de service Faiblesse de la distribution à base communautaire Autres
Achieving Equity in Family Planning
Besoins non satisfaits parmi les femmes de 15-49 ans en union
ISSU BHS 2011
Achieving Equity in Family Planning
Conférence avec des associations de femmes sur Islam et PF
Achieving Equity in Family Planning
Interventions pour l’offre de services
Intégration de la PF dans les services de santé maternelle-infantile à l’aide de l’outil d’Identification Systématique des Besoins du Client
Stratégies d’offre de service de proximité – consultations foraines, stratégies mobiles offre de service
PF à domicile, offre initiale de pilule
Développement de partenariat secteur public-privé, franchise sociale
Amélioration de la qualité des services de PF
Achieving Equity in Family Planning
Interventions pour la création de la demande
Communication de proximité avec les religieux communautaires
Ciblage des hommes – Partenariat avec les organisations à base communautaires
à travers un réseau de relais communautaires
Utilisation de médiateurs formés comme facilitateurs au sein des réseaux sociaux
Communication de masse
Achieving Equity in Family Planning
Interventions pour le plaidoyer
Dialogue et renforcement des capacités des leaders religieux pour l’implication dans la promotion de la planification familiale
Mise en place de cadre de concertation pour l’amélioration de l’environnement de la PF et des ressources allouées −Comités de pilotage municipaux
−Observatoire au niveau national
Achieving Equity in Family Planning
Forum avec les prêcheurs des radios et TV sur Islam et PF
Achieving Equity in Family Planning
Au terme du projet …
Les populations, y compris les femmes en âge de procréer, vivant dans les zones urbaines défavorisées auront l’accès de manière continue à des services PF de qualité.
Un kit de ressources d’interventions efficaces est disponible au Sénégal et en Afrique francophone pour accroitre l’utilisation des méthodes modernes de PF.
Achieving Equity in Family Planning
Conclusion
Mise en œuvre des approches basées sur des évidences pour améliorer l’état de santé des populations dans les villes ciblées par la promotion de la PF;
Synergie entre les partenaires et les autres acteurs reste un défi pour permanent;
Suivi régulier et permettront de définir d’ici la fin du projet des modèles à répliquer au Sénégal et en Afrique francophone.
Achieving Equity in Family Planning
Dieredief
Achieving Equity in Family Planning Achieving Equity in Family Planning
Increasing family planning resources for the poor in India
Suneeta Sharma Jayachandran AA
Futures Group International
Achieving Equity in Family Planning
How to Achieve Equity
Engage and empower the poor
Quantify levels of inequality in healthcare use and health status
Understand barriers to access
Integrate equity goals, approaches, and indicators in policies, plans, and agendas
Target resources and efforts to the poor
Yield public-private partnerships for equity
Achieving Equity in Family Planning
Equity Framework
Quantify the level of
inequalities
Understand barriers to
equitable access
Integrate equity goals,
approaches, and indicators into policies, plans,
and development
agendas
Target resources and efforts to
reach the poor
Yield public-private
partnerships for equity
Engage and empower the poor
Analysis Action Advocacy and Dialogue
Achieving Equity in Family Planning
Focus States: Uttarakhand, Jharkhand
Uttarakhand
Jharkhand
Achieving Equity in Family Planning
How many are poor?
0%
10%
20%
30%
40%
50%
Jharkhand Uttarakhand
Livi
ng b
elow
pov
erty
line
Rural
Urban
All India
Source: National Sample Survey Organisation, Ministry of Statistics and Planning Implementation, 2007
Achieving Equity in Family Planning
Engage and empower the poor
Focus group discussions: gather and understand
evidence on operational and implementation aspects of services
understand the barriers in accessing FP services
provide inputs on strategies to reduce the barriers
Achieving Equity in Family Planning
Quantify levels of inequality
0%
10%
20%
30%
40%
Lowest Second Middle Fourth Highest
Unm
et n
eed
for
Fam
ily P
lann
ing
Wealth Quintile
Limiting Spacing
Source::District Level Household and Facility Survey (DLHS- 3), 2007-08: International Institute for Population Sciences, Mumbai
Jharkhand
Achieving Equity in Family Planning
Quantify levels of inequality
0%
10%
20%
30%
40%
Lowest Second Middle Fourth Highest
Unm
et n
eed
for
Fam
ily P
lann
ing
Wealth Quintile
Limiting Spacing
Source::District Level Household and Facility Survey (DLHS- 3), 2007-08: International Institute for Population Sciences, Mumbai
Uttarakhand
Achieving Equity in Family Planning
Understand barriers to FP services
Poverty Illiteracy and lack of livelihood opportunities Socio-cultural and religious norms Inadequate health facilities and human
resources Difficult access due to hilly terrain and dense
forests
Achieving Equity in Family Planning
Integrate equity into policies, plans, and agendas
Policy
Market
Poverty Financing
Barriers
Multi-sectoral Planning meetings
Demographic Projection modeling
Framework Analysis, Advocacy and Dialogue
Action
Achieving Equity in Family Planning
Target resources and efforts for the poor
Prioritize districts
Implement demand side financing mechanism Voucher Scheme
Achieving Equity in Family Planning
Yield Public-Private Partnerships for equity
Mobile units Jharkhand – 108 MMUs Uttarakhand - 33 MHVs
Other partnerships Scale up voucher scheme (Uttarakhand 2010 Health and Population Policy)
Achieving Equity in Family Planning
Interventions to reach poor and other marginalized populations
Prioritize and roll out in 10 poorest districts Map urban slums and poverty pockets Mobile clinics Train front line workers and engage tribal
women Public-Private Partnership for urban slums Increase public expenditure on health
Achieving Equity in Family Planning
Thank you!