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


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


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


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


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


Disentangling poverty and place of residence

for family planning strategic planning

Karen G. Fleischman Foreit MEASURE Evaluation PRH


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?


Who is poor?

Relative poverty

• Wealth quintiles, usually derived from household assets

Absolute poverty

• Defined against some standard of income and/or expenditures


0

5

10

15

20

25

30

% U

sing

Mod

ern

FP

Rural

Urban

Urban-rural differences are common


0

5

10

15

20

25

30

% U

sing

Mod

ern

FP

Bottom quintile

Top quintile

…as are differences by wealth quintile


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


0%

10%

20%

30%


% In

terv

iew

ed w

omen

Wealth Quintile

Urban Rural

…making it hard to interpret differences

Kenya 2003


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


Results

Highly variable residence-specific patterns


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


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


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


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


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


Limitations of assets-based quintiles

Track over-all trends in family planning outcomes

X Do not match individual consumption measures of poverty


0%

20%

40%

60%

80%

100%


% 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


0%

20%

40%

60%

80%

100%


% 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


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


Thank you – Merci – Gracias -

© 2

007

Felix

Mas

i, Co

urte

sy o

f Pho

tosh

are


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


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


Centro de Investigación, Educación, y Servicios – CIES, Bolivia


Full-capacity clinics Medium-sized clinics (no surgery ) Mobile Health Units


Defining vulnerability criteria

Poor

Under-served

Socially Excluded


Developing the client intercept questionnaire


Piloting the questionnaire

Training of staff

Sample selection

Data collection

Data analysis


No vulnerability criteria met

44%

1 Factor 35%

2 Factors 16%

3 Factors 5%

Vulnerable 56%

Percent of Clients Meeting Vulnerability Criteria


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


Challenges in Measurement

• Categories not mutually exclusive

• Differing definitions across countries, regions

• Sensitive measurement issues around SRH vulnerabilities (GBV, sexual minorities)


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


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


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


Thank you – Merci – Gracias -


Promouvoir l’accès à la planification familiale aux

populations urbaines défavorisées au Sénégal

Dr Cheikh Seck, MD, MPH ISSU Project Director Senegal


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


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


Vue d’un bidonville en plein centre ville de Dakar


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


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.


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


Besoins non satisfaits parmi les femmes de 15-49 ans en union

ISSU BHS 2011


Conférence avec des associations de femmes sur Islam et PF


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


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


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


Forum avec les prêcheurs des radios et TV sur Islam et PF


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.


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.


Dieredief


Increasing family planning resources for the poor in India

Suneeta Sharma Jayachandran AA

Futures Group International

http://usaid.gov/in/index.html


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


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


Analysis Action Advocacy and Dialogue


Focus States: Uttarakhand, Jharkhand

Uttarakhand

Jharkhand


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



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


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


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


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


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


Target resources and efforts for the poor

Prioritize districts

Implement demand side financing mechanism Voucher Scheme


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)


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


Thank you!

achieving equity in family planning: getting beyond the...

Documents