1Management Sciences for Health Stronger health systems. Greater health impact. Health systems approach to integration of family planning: A critical look

1Management Sciences for Health

Stronger health systems. Greater health impact.

Health systems approach to integration of family planning: A critical look

Reconvening Bangkok : 2007 to 2010

Halida H. Akhter, Global Technical Lead FP/RH March 6-11, 2010, Bangkok, Thailand


HUMAN RESOURCES

MEDICINE AND TECHNOLOGIES

FINANCINGINFORMATION

LEADERSHIP AND GOVERNANCE

SERVICE DELIVERY

Six Building Blocks of Health Systems (WHO)


Stronger Health Systems save lives and improve health

Stronger health systems.1. Leadership,

management, & governance

2. Health service delivery

3. Human resources for health

4. Pharmaceutical management

5. Health care financing

6. Health information

Greater health impact.1. HIV & AIDS

2. Tuberculosis3. Communicable

diseases: malaria, avian & pandemic influenza

4. Maternal, newborn, child health

5. Family planning / reproductive health


Barriers are overcome using six health systems building blocks

AccessChoiceQuality

Barriers to FP and RH services

Fragmented services

Socio-cultural norms

Cost

Process

Physical

Inappropriate eligibility

criteria

Poor CPR

Provider bias

KnowledgeLocatio

n

Time

1.Leadership, management & governance

2. Health service delivery

3. Human resources for health

4.Pharmaceutical management

5. Health care financing

6. Health information

6 pillars of health systems


Six pillars of health systems

1. Leadership, management & governance Policy support reinforcing advocacy efforts with factual evidence leading to enabling policies, strategies, approaches and guidelines.

2. Health service deliverySustainable use of integrated FP/RH services—Fully Functional Districts with technical and operational support and referral system. Services through a mix of delivery points gets methods to potential users.

3. Human resources for healthHigh performing staff, task-shifting and improving performance cultivates a sustainable health care workforce.

.


4. Pharmaceutical management A strong logistics system, including procurement, sufficient equipment, drugs, supplies and infrastructure and, a plan for contraceptive security - ensure method availability

5. Health care financingSocial marketing, incentive based partnerships with private sector, CBO and NGO.

6. Health informationEvidence-based programming yields important information to guide program decision-making. Well designed MIS needs to be in place.

Six pillars of health systems


A strong health system helps integrate

services to offer greater health impact Integration means offering multiple health

care services at the same facility or through a community-based program to benefit clients, providers, programs

Integrated services are more efficient and ensure financial sustainability.

Combination of well selected interventions address a range of health needs, creates synergies, enhance impact.

They demand a strong political commitment and additional resources


Integration of FP and reproductive health: Bangladesh case

Bangladesh Family planning program created a success story 1965: Started as a vertical program Early ‘80s: MCH was integrated with Family

planning Post-ICPD: Reproductive Health was

integrated 1996: HPSS, Health and Population Sector

Strategy A five year (1998-2003) HPSP: A Sector-

Wide Approach ($3 bill budget) Moved from Project approach to Program

approach. HPSP: sector as a whole


Integrated sector-wide approach of HPSP

HPSP: world’s first example of Sector-Wide Approach (SWAP) donors pooled resources implementation and annual operations plan (AOP) to cover a range of integrated services (e.g., health, FP)

HPSP emphasized structural reform i.e. unification as indicator of program success as opposed to health outcome Unify two Directorates : Health and Family Planning (lower levels) Merged functions: BCC, logistics, and Information Systems Transition: domiciliary FP to static community clinics (CCs) Focus: Essential Services Package (ESP) Delivered from facilities close to the population affected


Essential Service Package: RH care content

Essential Service Package (ESP )elements:

1. Reproductive health care

2. Child health care

3. Communicable diseases control

4. Simple curative care

5. Behavior change communication(BCC)

HPSP Reproductive Health Care:

1. Safe motherhood

2. Family planning

3. Prevention and control of RTI/STD/AIDS

4. Maternal nutrition

5. Adolescent care

6. Neonatal care


HPSP’s Reproductive Health Strategy

HPSP’s reproductive health strategy matched well with the WHO recommendations, Identified 5 key areas of action1. strengthening health system capacity2. mobilizing political will3. creating supportive legislative and

regulatory frameworks4. improving information for setting priorities5. strengthening monitoring, evaluation, and

accountability.


The integration and merger of health and population sector components

Health and Family Planning MIS were merged

Former projects were grouped together under a small number of Line Directors

Financial authority was transferred from former Project Directors to Line Directors

Procurement of drugs, vaccines, and equipment centralized;

Training Procurement was centralized (not project-based)


Effects of merger reform

HPSP contained long list of reforms Policy reforms of the systems, changing

attitudes Operational definition of SWAP during

HPSP

Many elements of the reform faced opposition -

However, MOHW moved quickly to implement difficult structural changes--it unified health & family planning

services at lowest admin tiers Initiated ‘one stop’ community clinics

to provide Essential Service Package.


Impact of reform on nationwide program

Effects of these changes in the functioning of the health system included: Outreach services - disrupted by changes to

service delivery

Difficulties of restructuring health system

Some FP indicators became stagnant. Govt. lost a modest share of family

planning service provision, Transfer to Community Clinics needed more

time.


Impact of reform on community

Household visits for family planning by GOB fieldworkers started to decline leading to low client worker contacts.

Community clinics were yetto be fully functioning 43.0

35.2

21.218.2

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

45.0

50.0

1993-94 1996-97 1999-2000 2004

Field Worker Contact

Trends of Worker Client Contact


Effect on national FP indicators

“Stagnation" in fertility reduction:; TFR plateaued, although CPR went up, the use of clinical contraceptive declined

TFR

0

1

2

3

4

5

6

7

1971

-75

1984

-88

1986

-88

1989

-91

1993

-94

1996

-97

199-

00

2004

CPR among married women

Source: BDHS: 2004

0

10

20

30

40

50

60

1975

1983

1985

1989

1991

1993

-94

1996

-97

1999

-00

2004


Benefits from a comprehensive reproductive health strategy

In spite of the short dip in some FP indicators, the Bangladesh case exemplifies the benefits from a comprehensive reproductive health strategy

During HPSP (1998–2003), MMR declined from 440 to 322 deaths per 100,000 live births

ANC grew from 26% to 56% Use of EOC rose from 5% to 27% Contraceptive Prevalence Rate went up-- Because, as the household visits by GOB

workers reduced, the couples switched to private outlets, pharmacies, NGOs


Critical lessons learned

The critical issue related to integration of services or programs: Lack of ownership to the policy Lack of commitment and support from

domestic forces severely affects implementation

Integration will not bring desired impact unless ---• enough lead time is provided to strengthen health systems i.e. policy changes, creating strategies and guidelines for service delivery strengthening motivation and capacity of

appropriate human resources is instrumental to the success.


Lessons from Bangladesh experience

1. Political commitment is key to success of Integration

2. The people who design and implement health care policies and programs need to pay attention to both technical and political

feasibility. 3. Strong systems in place help backup minor

short falls

4. Improving governance is key to improving service delivery.

5. A major critical ingredient to use of public health services is leadership and governance strengths.


References

Jahan, R. 2003, "Restructuring the health system: Experiences of advocates for gender equity in Bangladesh", Reproductive health matters, vol. 11, no. 21, pp. 183-191.

Kamal, S.M. M., Akhter, S., Islam, A. "The Role of Proximate Determinants of Fertility Transition in Bangladesh”.

Osman, F.A. 2005, "Implementation Constrained by a Lack of Policy Ownership: Evidence from Bangladesh", The Asia Pacific Journal of Public Administration, vol. 27, no. 1, pp. 19-36.

Pearson, M. 1999, "Bangladesh - Health Briefing Paper", Department for International Development Health Systems Resource Centre.

Streatfield, P.K., Arifeen, S.E., Al-Sabir A. 2004, “Policy Implications of the 2004 BDHS.”

USAID 2009, "Health Systems Report to Congress", Sustaining Health Gains - Building Systems.

WHO 2007, "Everybody's Business: Strengthening Health Systems to Improve Health Outcomes; WHO's Framework for Action".


Stronger health systems. Greater health impact.

Saving lives and improving the health

of the world’s poorest and most vulnerable people

by closing the gap between knowledge and action in

public health.

Documents

1Management Sciences for Health Stronger health systems. Greater health impact. Health systems approach to integration of family planning: A critical look