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From page 146... ... 146 REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES 146 6 Program Design and Implementation This chapter addresses issues of design and delivery of health andrelated services to improve reproductive health. We start by reviewing data showing the great variation in existing capacity and utilization of reproductive health services. Read the entire page →
From page 147... ... PROGRAM DESIGN AND IMPLEMENTATION 147 lated maternal and child health (MCH) and family planning services at different levels of facility. Read the entire page →
From page 148... ... 148 REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES TABLE 6-1 Maternal and Child Health and Family Planning Service Availability to Sample Clusters of Eight Selected Countries with DHS Data: in percent Maternal and Child Country Numbera Facilityb and Year (and type) type Prenatal Delivery Bolivia 624 Hospital 54.3 54.6 1989 Health center 72.4 50.3 Clinic 30.1 38.0 Colombia 181 Hospital 1986 Health center Clinic Philippines 744 Hospitald 93.3 92.6 1993 Other facility 96.9 65.6 Thailand 192 Hospital 1988 (rural) Read the entire page →
From page 149... ... PROGRAM DESIGN AND IMPLEMENTATION 149 Health Services Offered Immun- Rehy- Family Postnatal ization dration Growth Other Planning 54.6 46.2 52.1 49.4 54.8 67.8 68.3 58.0 70.2 58.8 37.5 10.1 24.2 23.6 28.5 74.6 76.8c 76.8 59.1 59.1 86.2 37.0 44.8 30.4 93.0 90.6 90.0 93.5 97.3 94.2 93.2 95.3c 95.3 69.3 69.3 69.3 58.3 72.4 79.2 90.6 13.3e 34.2e 39.2 77.5 82.5 88.3 92.5 66.7 37.5 41.7 45.8 90.8 2.5 7.5 17.5 49.2 72.0 67.3 79.3 76.6 43.1 40.7 48.3 53.0 45.8 52.0 50.8 45.8 53.6 0.0 54.2 55.2 54.9 82.1 0.3 80.9 79.3 39.4 35.2 32.1 20.6 26.1f 37.6 30.3 41.2 36.9 23.6 30.3 21.8 31.5 29.1 27.3 16.9 18.8 20.0 eFor all Egyptian facilities, availability of services based on reported number of clients for service type in past month. fNutrition demonstration. Read the entire page →
From page 150... ... 150 REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES data do not necessarily reflect the full availability of contraceptive supplies, which are often distributed through private stores and pharmacies and providers. Still, the concurrent availability of family planning and MCH care suggests that efforts to ensure availability of treatment for reproductive tract infections (RTIs) Read the entire page →
From page 151... ... PROGRAM DESIGN AND IMPLEMENTATION 151 Morocco 3.3 320 62 45 40 42 45 Pakistan 5.4 340 91 26 19 9 70 Philippines 4.1 280 34 83 53 25 25 Sri Lanka 2.7 140 25 97 87 41 25 Thailand 2.2 200 35 77 66 64 20 Tunisia 4.2 170 50 58 69 40 40 Turkey 2.7 180 53 62 76 35 50 Yemen 7.7 1400 83 26 16 6 70 Bolivia 4.8 650 75 53 47 18 55 Brazil 3.4 220 76 74 -- 57 45 Northeast Brazil 3.7 -- 75 64 70 54 -- Colombia 3.0 100 28 83 85 59 25 Dominican Republic 3.3 110 43 97 92 52 35 Ecuador 4.2 150 58 70 61 36 45 El Salvador 4.2 300 71 -- 86 45 35 Guatemala 5.1 200 51 53 35 27 45 Mexico 4.0 110 47 71 70 45 40 Haiti 4.8 1000 74 68 46 13 95 Paraguay 4.7 160 34 84 66 35 40 Peru 3.5 280 55 64 53 33 35 Trinidad and Tobago 3.1 90 26 98 98 44 -- NOTES: TFR = total fertility rate; MMR = maternal mortality ratio; IMR = infant mortality rate; ANC = antenatal care; DEL = proportion of births delivered by medically trained attendant; CPRM = modern contraceptive prevalence; PMR = perinatal mortality rate. SOURCE: Data from Demographic and Health Surveys and World Health Organization and UNICEF (1996) Read the entire page →
From page 152... ... 152 REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES services, particularly for RTI/STD treatment and prevention, is only superficially known, largely due to difficulties of measurement and incomplete reporting of service statistics. As the limitations of these DHS SAM and household data indicate, national assessments are needed of the distribution, accessibility, quality, and acceptability of existing services for reproductive health concerns. Read the entire page →
From page 153... ... PROGRAM DESIGN AND IMPLEMENTATION 153 organizations would tend to be production organizations" which adopt a "clear result orientation and a sharp focus on measurable disease control activities." Measurable results provide program management with an unambiguous means of gauging performance. Access to trend information on performance indicators provides decision makers with a standard basis by which to determine the adequacy and efficiency of their efforts. Read the entire page →
From page 154... ... 154 REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES Adequate Resources Health initiatives have foundered because insufficient resources were allocated. Some, like the primary health care movement and safe motherhood, seem to have stalled for lack of organizational and financial resources. Read the entire page →
From page 155... ... PROGRAM DESIGN AND IMPLEMENTATION 155 Table 6-3 shows a possible allocation among community-based activities and levels of facility in the health system of the major health-sector interventions discussed in the preceding chapters. For this table (and for the cost models described in Appendix C) Read the entire page →
From page 156... ... 156 REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES T A B L E 6 -3 I llu st ra ti ve D iv is io n of R ep ro d u ct iv e H ea lt h In te rv en ti on s A m on g L ev el s of t he H ea lt h C ar e Sy st em H ea lt h I n te rv en ti on C om m u n it y L ev el H ea lt h P os t H ea lt h C en te r D is tr ic t H os p it al P re ve n ti on o f V io le n ce , IE C b ab ou t vi ol en ce , T re at m en t of v ic ti m s, T re at m en t of v ic ti m s, T re at m en t fo r se ve re P ro m ot io n o f H ea lt h y so u rc es o f su p p or t re fe rr al t o so u rc es o f re fe rr al t o so u rc es o f ca se s Se xu al it ya IE C a bo u t h ea lt h e ff ec ts le ga l an d c om m u n it y co m m u n it y su p p or t of f em al e su p p or t ci rc u m ci si on (w h er e n ee d ed ) Read the entire page →
From page 157... ... PROGRAM DESIGN AND IMPLEMENTATION 157 M at er n it y an d N ew bo rn C ar e B re as tf ee d in g P re n at al v is it s/ n u tr it io n M an u al p ro ce d u re s C om p le te e ss en ti al c ar e p ro m ot io n a n d an d h ea lt h e d u ca ti on O xy to ci n f or h em or rh ag e of o bs te tr ic su p p or t M al ar ia p ro p h yl ax is A n ti bi ot ic s fo r se p si s co m p li ca ti on s , Ir on a n d f ol at e L ab or m an ag em en t vi a Se d at iv es f or p ac ka ge i n cl u d in su p p le m en ta ti on p ar to gr ap h ; r ef er ra l p re gn an cy -i n d u ce d ca es ar ea n s ec ti on , T et an u s to xo id an d t ra n sp or t fo r h yp er te n si on bl oo d t ra n sf u si on s im m u n iz at io n co m p li ca ti on s T re at m en t of IE C f or w ar n in g si gn al s P ro p h yl ax is f or in co m p le te of c om p li ca ti on s; go n oc oc ca l ey e ab or ti on se p si s; w h er e to in fe ct io n M an ag em en t of s h oc k se ek c ar e Fi rs t ai d f or n ew bo rn s IE C f or n ew bo rn c ar e (r es u sc it at io n , (d ry in g/ w ar m in g; h yp ot h er m ia ) Read the entire page →
From page 158... ... 158 REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES tional compatibility among service clusters, availing themselves of possible arrangements for linkage, coordination, or integration. Their decisions can be guided by establishing targeted levels of effectiveness in terms of outreach and coverage and by defining measurable outcomes and developing protocols to guide activities of staff by type of facility. Read the entire page →
From page 159... ... PROGRAM DESIGN AND IMPLEMENTATION 159 Ce nt ra l C oo rd in at io n N at io na l L ev el Pr ov in ci al L ev el D is tri ct L ev el M al ar ia Fa m ily Pl an ni ng G en er al H ea lth Se rv ice s Ce nt ra l I nt eg ra tio n Pr ov in ci al In te gr at io n In te gr at ed D ist ric t H ea lth S ys te m In te gr at ed P er ip he ra l S er vic es In te gr at ed S er vic es Fa m ily Pl an ni ng M al ar ia (a) Read the entire page →
From page 160... ... 160 REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES level of administration but have its services delivered by the same field personnel who are responsible for other general health services. These two forms of service organization have been variously called the "hour glass" shape (b) Read the entire page →
From page 161... ... PROGRAM DESIGN AND IMPLEMENTATION 161 level of care in family planning or prenatal care. But implementation of that essential care is likely to require efforts to stimulate community awareness of complications and of where to seek treatment; all first-line health care providers, for both women and men, could usefully have this educational role added to their duties. Read the entire page →
From page 162... ... 162 REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES receiving RTI and family planning services, from those receiving other services and variation in service "cultures": the risks of RTIs and of unintended pregnancies both involve sexual contact and both are higher for younger than for older individuals. Important gender differences exist in that women bear the physiologic responsibility of pregnancy, are more susceptible to sexually-transmitted infection by men than the reverse, and are less symptomatic than men. Read the entire page →
From page 163... ... PROGRAM DESIGN AND IMPLEMENTATION 163 ally increases embarrassment for those seen to be using the services. Young people may have fewer opportunities or socially acceptable reasons for trips to specialized health facilities or pharmacies, and so would have to be reached in fixed or mobile clinics located in or near schools or workplaces. Read the entire page →
From page 164... ... 164 REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES Among their disadvantages, decentralized services do not exploit economies of scale, and they require greater management capabilities. Evidence of the overall effectiveness of decentralization schemes is mixed (Heaver, 1995) Read the entire page →
From page 165... ... PROGRAM DESIGN AND IMPLEMENTATION 165 conferred by high levels of political commitment and by specific demandgeneration activities. As Cleland and Wilson (1987) Read the entire page →
From page 166... ... 166 REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES as a concomitant to the "supply-side" interventions, not as a precondition for them. IMPLEMENTING REFORM OF HEALTH SERVICES How then should program designers and managers proceed to select among possible interventions to improve reproductive health? Read the entire page →
From page 167... ... PROGRAM DESIGN AND IMPLEMENTATION 167 recommend that governments of developing countries adopt a nationallevel process to specify objectives and timetables, specifying the strategies to achieve them and the agencies and communities that are expected to help achieve them. Table 6-4 gives an example of what the outcome of the process could be. Read the entire page →
From page 168... ... 168 REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES T A B L E 6 -4 I llu st ra ti ve N at io na lL ev el O bj ec ti ve s fo r R ep ro d u ct iv e H ea lt h G oa lSp ec if ic O bj ec ti ve s St ra te gi es t o A ch ie ve O bj ec ti ve s C ri ti ca l P ar tn er sh ip s (1 ) Read the entire page →
From page 169... ... PROGRAM DESIGN AND IMPLEMENTATION 169 D ec re as e p er ce n ta ge s ex u al ly H ea lt h p ro m ot io n v ia m as s m ed ia ; h ea lt h R el ig io u s an d l ay c om m u n it y le ad er s; ac ti ve p er so n s w h o h av e h ad > 1 se x ed u ca ti on i n s ch oo ls ( w it h c om p on en t m in is tr y of e d u ca ti on , t ea ch er s; m as s p ar tn er i n l as t 12 m on th s by to b u il d s ex u al n eg ot ia ti on s ki ll s) Read the entire page →
From page 170... ... 170 REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES Su bg oa l: I m p ro ve d c ou n se li n g In cr ea se t h e p er ce n ta ge o f cl ie n ts D ev el op m en t an d d is se m in at io n o f gu id el in es B eh av io r in te rv en ti on e xp er ts a n d m ed ic al se ek in g fa m il y p la n n in g, S T D , on r is k as se ss m en t an d c ou n se li n g fo r an d f am il y p la n n in g co m m u n it ie s p os tp ar tu m o r p ri m ar y h ea lt h c ar e bo th p re gn an cy a n d i n fe ct io n t ai lo re d t o se rv ic es w h o al so r ec ei ve S T D r is k lo ca l so ci oc u lt u ra l co n te xt as se ss m en t an d c on tr ac ep ti ve m et h od co u n se li n g fo r p re ve n ti on o f bo th in fe ct io n a n d p re gn an cy b y [p ro p or ti on ] Read the entire page →
From page 171... ... PROGRAM DESIGN AND IMPLEMENTATION 171 Su bg oa l: I n fe ct io n C on tr ol In cr ea se p er ce n ta ge o f p ro vi d er s D ev el op m en t an d d is se m in at io n o f in fe ct io n M ed ic al a n d f am il y p la n n in g co m m u n it ie s of d el iv er y, I U D i n se rt io n s, a n d a bo rt io n co n tr ol g u id el in es ; a ss u re a d eq u at e se rv ic es w h o ca n d oc u m en t ad h er en ce t o su p p li es a n d e qu ip m en t in fe ct io n c on tr ol g u id el in es b y [p ro p or ti on ] Read the entire page →
From page 172... ... 172 REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES T A B L E 6 -4 C on ti nu ed G oa lSp ec if ic O bj ec ti ve s St ra te gi es t o A ch ie ve O bj ec ti ve s C ri ti ca l P ar tn er sh ip s (4 ) Read the entire page →
From page 173... ... PROGRAM DESIGN AND IMPLEMENTATION 173 sample table will not prove to be the agreed reproductive health strategy for every country. In this spirit, we have avoided giving real target dates; these must be determined during the national-level process. Read the entire page →
From page 174... ... 174 REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES In 1995 the GISR issued a 5-year plan that incorporated several key aspects of the ICPD agenda -- the Reproductive Health and Family Planning Program (Grupo Interinstitucional de Salud Reproductiva, 1995) Read the entire page →
From page 175... ... PROGRAM DESIGN AND IMPLEMENTATION 175 Strengthening Services for Reproductive and Maternal Health in Uganda5 With external assistance, the government of Uganda has begun an effort to strengthen health programs associated with childbirth and sexual behavior in selected districts. Through this new initiative, it expects to increase use of health services and adoption of behaviors to reduce unwanted pregnancies, HIV infection, and maternal and child mortality. Read the entire page →
From page 176... ... 176 REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES • maternal nutrition counseling, and tetanus vaccination; • intrapartum care, including safe deliveries, responses to common obstetric emergencies (along with complications of illegal abortions) , and appropriate referral systems; • care of the neonate; • postnatal care, including the promotion of exclusive breastfeeding, optimal weaning practices, and full childhood immunization; • syndromic STD diagnosis and treatment, based on laboratory validation of management algorithms; • HIV testing and counseling, with integration of family planning and STD services; and • family planning, STD treatment, and counseling for HIV-positive individuals. Read the entire page →
From page 177... ... PROGRAM DESIGN AND IMPLEMENTATION 177 adopt behaviors to improve reproductive/maternal health. Service utilization is to be promoted directly by providing accurate information about services and outlet location. Read the entire page →

From page 146...

... 146 REPRODUCTIVE HEALTH IN DEVELOPING COUNTRIES 146 6 Program Design and Implementation This chapter addresses issues of design and delivery of health andrelated services to improve reproductive health. We start by reviewing data showing the great variation in existing capacity and utilization of reproductive health services.