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 What? Service delivery Organizational Governance How? Policies Systems Capacities
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 % deliveries attended by skilled attendants 100 90 80 70 60 50 40 30 20 10 0 Asia Latin America Middle East/North Africa Sub-Saharan Africa Central Asia Republics Caucasus 58.7% Source:Rossetal.,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 10 5 13.0% 0 Asia (ex. China) Source: Ross et al., 2005 Sub-Saharan Africa Latin America Middle East/North Africa Central Asia
How well are we doing on universal access to RH? Percent of Women Ages 15-24 with Comprehensive Knowledge of HIV/AIDS percent 45 40 35 30 25 20 15 10 5 0 Bostwana 40 38 Ghana Source: Ashford et al., 2006 Kenya 34 18 Nigeria 15 Haiti Armenia 7 Indonesia 1 37 Cambodia 25 Viet Nam
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 50 40 30 20 10 0 12 49 13 36 23 22 26 25 22 19 17 24 21 16 14 19 18 20 16 11 17 moderate physical violence severe physical violence percent 20 12 10 16 13 15 8 9 4 Peru province Ethiopia province Peru city Tanzania province Bangladesh province Samoa Bangladesh city Thailand province Brazil province Tanzania city Namibia city Brazil city Thailand city Serbia & Montenegro city Japan 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 % of demand satisfied 80 70 60 50 40 30 20 10 23.7 48 38.1 68 70.7 70.5 50 49.7 37.9 62.1 Q1: poorest Q5: richest 0 Africa Source: Ross et al., 2005 Latin America Asia North Africa/West Asia Global Average
Strengthen service delivery: Reaching the poor Percent of deliveries attended by doctor, nurse or trained midwife % 100 80 60 40 20 0 Brazil Indonesia India Richest Fourth Middle Second Poorest 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 population 100 90 80 70 60 50 40 30 20 10 0 At least one long-term method At least one short-term method At least one long-term and 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 Towards Local level commitment to reproductive health 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 GDI score 0.6 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 female literacy rate 80 60 40 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
Way Forward: Leadership for Action
Poverty is not just a lack of opportunities and resources, but also in great part a lack of capability. Amartya Sen Nobel Prize Winning Economist
Institutional capacity development is neglected It is not glamorous
Institutional capacity development is neglected Requires detailed work
Institutional capacity development is not only training
Institutional capacity development requires 1. Building policy consensus 2. Systems capacity for implementing best practices 3. Strengthening individual and organizational capacities
Institutional capacity development : Change is resisted Requires political commitment Set an ambitious tone Encourage a culture of resultsbased management Create a consensus for change Garner support from broad coalition of interest groups
Framework for Institutional Capacity Development Why? Gap in access What? Service delivery Organizational Governance How? Policies Systems Capacities
Thank you 谢谢 Xie Xie