6

Program Design and Implementation

This chapter addresses issues of design and delivery of health and related services to improve reproductive health. We start by reviewing data showing the great variation in existing capacity and utilization of reproductive health services. Next we discuss organizational issues for reproductive health programs. Finally, we discuss an illustrative, generalized strategic plan for measures to improve reproductive health and describe steps that are being taken in two countries.

No one program design or service configuration can be formulated to promote reproductive health in all settings. Instead, given the limited empirical research available, we review and discuss the features of effective interventions. The chapter emphasizes the organizational setting for effective reproductive health initiatives, including the selection of prevention and treatment approaches, the advantages and disadvantages of service integration, and management by governmental and nongovernmental institutions. The experiences of past and ongoing large-scale health initiatives, in such areas as family planning, primary health care, child immunization, infectious disease control, and environmental sanitation, offer lessons in how to define and develop reproductive health programs. There is no technological or programmatical "magic bullet" for reproductive health care.

EXISTING SERVICE CAPACITY AND UTILIZATION

Almost all countries have some infrastructure in place to deliver related



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Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions 6 Program Design and Implementation This chapter addresses issues of design and delivery of health and related services to improve reproductive health. We start by reviewing data showing the great variation in existing capacity and utilization of reproductive health services. Next we discuss organizational issues for reproductive health programs. Finally, we discuss an illustrative, generalized strategic plan for measures to improve reproductive health and describe steps that are being taken in two countries. No one program design or service configuration can be formulated to promote reproductive health in all settings. Instead, given the limited empirical research available, we review and discuss the features of effective interventions. The chapter emphasizes the organizational setting for effective reproductive health initiatives, including the selection of prevention and treatment approaches, the advantages and disadvantages of service integration, and management by governmental and nongovernmental institutions. The experiences of past and ongoing large-scale health initiatives, in such areas as family planning, primary health care, child immunization, infectious disease control, and environmental sanitation, offer lessons in how to define and develop reproductive health programs. There is no technological or programmatical "magic bullet" for reproductive health care. EXISTING SERVICE CAPACITY AND UTILIZATION Almost all countries have some infrastructure in place to deliver related

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Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions maternal and child health (MCH) and family planning services at different levels of facility. Some have services for the prevention, diagnosis, and treatment of sexually transmitted diseases (STDs), though these are typically weak and poorly coordinated with other health services. Most countries also have health education or communication programs, though again the quality and funding is often low, and these efforts are poorly coordinated with other prevention and treatment services. Hence, organizing delivery for reproductive health services does not typically start from a zero base; rather, it requires strengthening coordination, linkage, or integration and diversifying existing services, as well as adding new ones. Table 6-1 presents information on existing MCH and family planning service capacity obtained through the Demographic and Health Surveys (DHS) service availability module (SAM) administered either through direct facility visits or to key informants in sample clusters (communities). 1 In the eight countries, services are reasonably accessible to most clusters, at a facility within 30 kilometers. Coverage of basic services ranges varies widely across countries: for example, residents in 93 percent of the sampled clusters in Thailand have access to immunization services at a hospital, compared with only 35.2 percent of the Nigerian DHS clusters. In approximately one-half of the 624 clusters in Bolivia, residents have access to a constellation of six types of MCH services, as well as contraception, from a nearby hospital.2 These aggregate data only show availability of services at the community level, of course; they do not show the great variation in quality of services (Fisher et al., 1994) or in barriers to access that may exist. The availability of contraceptive services is highly associated with the availability of MCH services. This pattern reflects the common practice of integration of contraceptive with MCH services in health facilities. These 1   The DHS SAM (Wilkinson, Njogu, and Abderrahim, 1993), as well as the situation analysis tool used in several regional operations research programs (Fisher et al., 1994), obtains information about services at the nearest facility of four to five main types, located within a specified radius of the sampled cluster. Although not a probability sample of facilities, the information from the DHS SAM is presently the most standardized and systematic available for a cross-national comparison of MCH and family planning services. Often the SAM is restricted to rural areas. The DHS SAM has not yet included data on STD diagnosis and treatment services. Some include information on information, education, and communication activities and other community-based services carried out in sample clusters. To monitor and evaluate the effectiveness of reproductive health programs, the content of existing facility-level surveys would need to be modified. 2   These data are not weighted or linked to the individuals interviewed; thus, one cannot generalize about the areas or population covered by the clusters.

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Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions 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 and Year Numbera (and type) Facilityb 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) Health center         Clinic         Pharmacy               Egypt 120 Hospital 29.2e 33.3e 1989 (rural) Government center 88.3 85.8     Government family planning clinic 43.3 40.0     Private family planning clinic 10.0 1.7           Kenya 508 Hospital 71.6 71.5 1993   Health center 78.5 60.0     Dispensary 40.2 5.5           Tanzania 319 Hospital 50.2 50.8 1991 (mainland) Health center 54.9 46.7     Dispensary 81.2 73.0           Nigeria 165 Hospital 39.4 39.4 1990 (rural) Health center 33.3 27.9     Clinicg 37.6 36.9 a See text and footnote 1 for explanation of community (cluster) samples. b Nearest facility of each type within 30 kms. of cluster; in Bolivia, family planning services at nearest facility where available. c Any service. d Nearest hospital or nearest other health facility if nearest was not a hospital.

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Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions Health Services Offered           Postnatal Immunization Rehydration Growth Other Family 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 e For all Egyptian facilities, availability of services based on reported number of clients for service type in past month. f Nutrition demonstration. g Health clinic, maternity center, or maternity home.

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Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions 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), along with targeted information, education, and communication services, can be built on an existing service capacity. Table 6-2 shows recent estimates of total fertility rates, infant mortality rates and perinatal mortality ratios, maternal mortality ratios, and service utilization for countries and subnational regions where there have been DHS surveys. Along with wide variation of mortality rates, there is wide variation in estimates of service utilization. Prenatal care coverage TABLE 6-2 Selected Reproductive Health Outcomes and Service Utilization for 51 Demographic and Health Surveys Country TFR MMR IMR ANC DEL CPRM PMR Botswana 4.9 250 37 92 77 32 25 Burkina 6.9 930 94 59 42 4 80 Burundi 6.9 1300 75 79 19 1 60 Cameroon 5.8 550 65 79 64 4 75 Central African Republic 5.1 700 97 67 46 3 80 Eritrea 6.1 — — 49 21 4 — Ghana 5.5 740 66 86 44 10 90 Ivory Coast 5.7 810 89 83 45 4 55 Kenya 5.4 650 62 95 45 27 45 Liberia 6.7 560 144 83 58 6 130 Madagascar 6.1 490 93 78 57 5 65 Malawi 6.7 560 134 90 55 7 70 Mali 7.1 1200 108 31 18 1 100 Ondo Nigeria 5.9 — 56 80 59 4 — Namibia 5.4 — 57 87 68 26 60 Niger 7.4 1200 123 30 15 2 100 Nigeria 6.0 1000 87 57 31 4 90 Rwanda 6.2 1300 85 94 26 13 65 Senegal 6.0 1200 68 74 47 5 80 Sudan 4.7 660 70 70 69 6 55 Tanzania 6.3 600 92 92 53 13 65 Togo 6.4 420 81 82 46 3 90 Uganda 6.8 1200 — 91 38 8 70 Zambia 6.5 940 107 92 51 9 70 Zimbabwe 4.3 570 53 93 69 42 40 Bangladesh 3.4 850 87 26 10 36 85 Egypt 3.6 170 — 39 46 46 45 Indonesia 2.9 650 57 82 37 52 45 Jordan 5.6 150 34 80 87 27 30 Kazakstan 2.5 60 — 92 99 46 30

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Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions Country TFR MMR IMR ANC DEL CPRM PMR 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). is notably high, but these estimates do not gauge the quality or adequacy of that care (see Chapter 5). Some countries, such as Trinidad and Tobago, the Dominican Republic, and Kazakstan, have already achieved very high rates of attended deliveries, while rates are far lower in countries such as Mali, Niger and Pakistan.3 Utilization of reproductive health 3   Unfortunately, reliable direct estimates of maternal mortality ratios are available for only a small, unrepresentative sample of the countries shown in Table 6-2. The estimates reported here were imputed, or were adjusted, using models with fertility rates and proportions of births attended by trained personnel as independent variables (World Health Organization and UNICEF, 1996). Likewise, perinatal mortality ratios are imputed for many of these countries as proportions of total infant mortality, using variables highly correlated with those shown in Table 6-2. Because of this lack of independence of measurement or estimation, we cannot use these aggregate data to show how the service utilization models affect the demographic outcomes; nevertheless, the data suffice to illustrate the range among countries.

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Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions 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. Countries vary by mortality and morbidity conditions as well as levels of economic well-being. LESSONS LEARNED FROM LARGE-SCALE HEALTH PROGRAMS Reviews of effective organizational models for health programs often cast their conclusions in terms of lessons learned from what are considered ''best practices." Reviews of health program development in developing countries over several decades (e.g., Simmons and Lapham, 1987; Mosley, 1988; Bulatao, 1993; Liese, 1995) suggest that at least two factors can influence successful performance: a focused commitment to achieving program objectives and access to adequate resources. (Public-private partnership in service provision, a third important condition, is discussed in the next chapter.) Focused Objectives Commitment to promote and support a new health initiative can be demonstrated in different ways, such as vesting the health initiative under the authority of strong, capable and senior leadership; formulating or reformulating national policy; undertaking highly visible strategic planning, including the adoption of clear, explicit goals and objectives; or implementing an active and comprehensive agenda to achieve those program goals and objectives. The governments of Malaysia, Indonesia, Kenya, and Egypt, for example, elevated the visibility of their support for family planning services by placing them under the supervision of national coordinating boards or councils. In Egypt, India, and Indonesia, these programs eventually acquired ministry status. In Thailand, China, Brazil, and Uganda, HIV / AIDS, schistosomiasis, tuberculosis, malaria, and other communicable diseases have received specialized status in central ministries of health. Such commitment to program visibility, strategic management and institution building will be required for reproductive health programs to achieve their goals. As much as political or managerial commitment can influence health program performance, the ability to monitor results appears to be equally important. As Liese (1995:352) comments, "Successful disease control

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Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions 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. Other large-scale health programs focused on disease control—STDs/HIV, malaria, and tuberculosis, for example—have benefitted from registry data on new and recurring infection cases to calculate incidence and fatality rates. Child immunization programs have diligently monitored levels of immunization through rapid assessment and national health surveys (UNICEF, 1995). Family planning programs similarly monitor the contraceptive prevalence rate and method mix to assess the extent of contraceptive practice, while MCH programs have emphasized infant and child mortality rates, antenatal and delivery care coverage, and children's nutritional status as the key indicators of their performance. Reproductive health programs will likewise benefit if their achievement can be defined and measured. Given the diversity of programs, a single comprehensive indicator is unlikely to prove useful. Reproductive health programs may target outcomes, such as reduction in STD/HIV prevalence, increased contraceptive practice, universal prenatal care and child immunization, increased levels of obstetrical complications managed by medical staff, and elimination of maternal mortality. An emphasis on measurable program achievements does have some risks. The pressure on workers to achieve simple targets could lead to coercion of clients and distortion of fundamental objectives. For example, family planning workers given method-specific targets, or targets for numbers of acceptors of all methods, may not have direct incentives to ascertain client needs and inform them about all options. They may even have perverse incentives for fraud or aggressive promotion of contraceptives. Effective reproductive health programming will require a reorientation of existing MCH, family planning, and STD services toward the health needs of women, newborns, and men in terms of service quality standards. An example is India's experience with replacing contraceptive acceptors targets for its family welfare program (see Townsend and Khan, 1996). The program evaluation literature suggests that managerial focus on achieving measurable results will tend to strengthen the chances of effective program implementation. An initial challenge to reproductive health programs is for them to determine which synergistic, measurable results can be feasibly pursued.

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Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions 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. Obstetric care has been an underemphasized component of MCH programs. International assistance has traditionally given priority to contraceptive services, MCH (primarily for antenatal care and traditional birth attendant training), and nutrition, with less than 1 percent going toward obstetric care (Nowak, 1995). In order to build the institutional and administrative capacity to implement an effective reproductive health program, new or re-invigorated health initiatives must be sufficiently supported in terms of personnel, financing, materials and equipment, medical supplies, and information. Costa Rica, for example, increased its public expenditure on health care coverage from 4.5 percent in 1972 to 7.5 percent in 1981 and 8.0 percent in 1991 (World Bank, 1985, 1993). Between 1970 and 1980 Costa Rica enjoyed a 71 percent decline in infant mortality from 68 to 20 deaths per 1,000 births (Rosero-Bixby, 1986). As Chapter 7 shows, a package of reproductive health services can be provided at a per capita cost that is within the reach of many governments. 4 ORGANIZATIONAL ISSUES FOR REPRODUCTIVE HEALTH PROGRAMS Three organizational issues cut across the types of reproductive health services we have discussed in preceding chapters: the scope or breadth of services, service intergration, and the need to inform potential clients and create demand for unfamiliar services. Breadth of Services Several international organizations have recently proposed combinations of services for reproductive health programs, either generic programs or for particular countries (e.g., World Health Organization, 1994; Measham and Heaver, 1996). A prominent example is the Mother-Baby Package, a package of reproductive health services (described in Chapter 7 and Appendix C). The breadth and scope of the services to be delivered presents a formidable challenge in design, execution, administration, and evaluation. 4   Rosero-Bixby (1986) notes that Costa Rica's ability to allocate significant resources to health programs was in part aided by its constitutional renunciation of a military.

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Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions 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), we assume that there are three levels of health care facility, although in several countries, particularly for urban populations, a two-tier system is used. Each of the major categories of reproductive health intervention involves tasks for each of the levels of the system; the higher level facilities need to be able to perform the functions of lower-level facilities as well, since in practice very few hospitals exclusively treat serious cases referred from health centers. Several interventions and treatments listed are known to be effective in addressing a number of key sexual and reproductive morbidities. Some of these services are needed continuously over an adult's reproductive lifetime, while others are necessary only during various stages of reproduction, such as after conception, during and after pregnancy, or for the newborn. For example, postconception services may include pregnancy testing and counseling and induced abortion, as well as postabortion services for family planning and STD prevention. Postabortion care is important for the treatment of complications and prevention of additional unwanted pregnancies. Coordination could also require training staff, especially at the field level, in multiple technical areas to provide high-quality, competent and comprehensive reproductive health care to clients. In some cases, this may best be accomplished by using MCH/family planning workers to emphasize specific tasks known to be effective, while deleting other less effective ones. The interventions shown in Table 6-3 will require coordination and linkage across levels and within the relevant service clusters. Those addressing fertility through postconception services should be coordinated with those addressing pregnancy health. For example, the latter might involve three clusters of services: (1) prenatal care, such as nutrition counseling and supplements, screening for syphilis and other STDs, treatment of these infections, maternal tetanus immunization, fetal monitoring for intrauterine growth, and delivery planning; (2) delivery care, particularly, referral for complications, attended delivery by trained personnel especially for complications, appropriate instrument delivery, and immediate newborn care, including prophylaxis for neonatal ophthalmia; and (3) postpartum care, such as lactation and nutrition counseling, infection control, and family planning. The simultaneous delivery of different clusters of services at different levels of the health care system imposes major demands on clinical and nonclinical training, acquisition and distribution of essential drugs, contraceptives, nutrition supplements and equipment, worker supervision, and client record-keeping. Program planners must achieve an operational

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Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions TABLE 6-3 Illustrative Division of Reproductive Health Interventions Among Levels of the Health Care System Health Intervention Community Level Health Post Health Center District Hospital Prevention of Violence, Promotion of Healthy Sexualitya IECb about violence, sources of support; IEC about health effects of female circumcision (where needed) Treatment of victims, referral to sources of legal and community support Treatment of victims, referral to sources of community support Treatment for severe cases Prevention and Management of RTIs/STDs IEC messages on symptoms; Promotion of safe sex, partner reduction; Condom distribution Syphilis testing and treatment for pregnant women; Partner notification and referral; Syndromic management (vaginal discharge, lower abdominal pain, genital ulcers, etc.); Infection control Syndromic management (vaginal discharge, lower abdominal pain, genital ulcers, etc.); Infection control Laboratory diagnosis and treatment of RTIs; Infection control Prevention and Management of Unintended Pregnancies IEC for contraceptive methods; Community-based distribution; social marketing of condoms, oral pills Counseling/screening for contraception; Counseling and referral for menstrual regulation or abortion; Provision of injectable contraceptives, IUD insertions; Counseling and treatment of contraceptive side effects Menstrual regulation/MVA abortion; Performing surgical contraception on set days; Post-abortion counseling and contraception; Counseling and treatment of contraceptive side effects Surgical contraception; Abortions through 20 weeks, where indicated; Post-abortion counseling and contraception

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Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions recommend that governments of developing countries adopt a national-level 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. The first column lists the positive goals of reproductive health that were used as the vision for this report. The second column lists specific objectives, which can be either instrumental, intermediate steps toward these goals, or measurable changes in indicators of reproductive health in the population at large. These objectives should have some target date attached. The third column lists examples of strategies designed to achieve the objectives, and the fourth lists "critical partnerships," agencies and segments of the population needed to put the strategies into action. This last column highlights the importance of intersectoral involvement for the success of an expanded concept of reproductive health. The partnerships need to be specified, since most of the strategies would be unworkable as "top-down" or single-agency missions. Each of the strategies listed here would also have implications for applied research and training needs. The advantage in linking goals, objectives, and strategies this way is partly that it helps synthesize what could otherwise be a long, incoherent list of isolated actions. It also helps avoid the problem, called suboptimization by economists, whereby agencies focus on objectives too narrowly defined, or stated only in terms of their own outputs, to the detriment of the larger social goals they were meant to serve. The process of tailoring and completing such a table to make it relevant to local conditions itself could be valuable by stimulating new collaboration and data-based decision making. Leadership and political commitment would be required, but a purely top-down process would be unlikely to achieve much, since most countries already have a sufficient stock of policy pronouncements, plan documents, similar materials. Any such table would need to be revised periodically. There is hope that technical advances—diagnostic tests for STDs, microbicides, new contraceptives—will radically change the "menu" of cost-effective interventions in ways we cannot now foresee. If the reproductive health movement gains strength in a country, the list of relevant actors would also change, to include new nongovernmental organizations, community groups, and professional associations, new agencies or interagency task forces, and the like. A table like this would be put to good use if the first column changed not at all, the second column changed only very slowly as old objectives are achieved or new ones set, and the other columns are updated continually. Table 6-4 is illustrative; the panel anticipates that the entries in this

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Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions TABLE 6-4 Illustrative National-Level Objectives for Reproductive Health Goal-Specific Objectives Strategies to Achieve Objectives Critical Partnerships (1) Reproductive Health Goal: Every sex act free of coercion, and based on informed and responsible choice Eliminate commercial sex involving children, by [year] Enforcement of existing laws and penalties for sexual exploitation of children Police and judicial system, Newspaper editors and reporters, parent groups, religious leaders, nongovernmental organizations working for children Reduce incidence of female genital mutilation by [proportion], by [year] Information campaign about health consequences of female genital mutilation Public- and private-sector health care providers, religious leaders, social-science and communication researchers Reduce percentage of women beaten by husband or partner by [proportion], by [year] Enforcement of laws; promotion of awareness of violence; better detection and treatment referrals in health and family planning clinics Police and judicial system, religious and other community leaders, health care providers, teachers Provide sexuality education appropriate to grade level in all schools, by [year] Develop and adopt appropriate curricula and other materials; train teachers and principals Parent associations, private-school associations, curriculum researchers and evaluators, religious leaders (2) Reproductive Health Goal: Every sex act free of infection Subgoal: Reduction of the number of sex partners Increase average age of coital debut to 17 years, by [year] Health promotion via mass media; health education in schools (with component to to build sexual negotiation skills); community-based peer intervention programs; legal sanctions against marriage at younger ages; legal sanctions against adults engaging in sex with minors Religious and lay community leaders; mass media (TV, radio, print media); community-based organizations ministry of education, teachers; behavioral interventions experts; judicial system; medical and family planning communities

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Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions Decrease percentage sexually active persons who have had >1 sex partner in last 12 months by [proportion], by [year] Health promotion via mass media; health education in schools (with component to build sexual negotiation skills); targeted community-based intervention programs Religious and lay community leaders; ministry of education, teachers; mass media (TV, radio, print media); community-based organizations; behavioral interventions experts; medical and family planning communities Subgoal: Increased condom use Increase percentage consistent and correct condom use among sexually active persons <30 years old who have had >1 sex partner in last 12 months by [proportion], by [year] Condom social marketing; targeted, community-based intervention programs; health education in schools (with component on condom use); assure adequate condom supplies at all clinical and community distribution points Religious and lay community leaders; mass media (TV, radio, print media); community-based organizations; ministry of education, teachers; behavioral interventions experts; agency that sets import tariffs; pharmaceutical companies; medical and family planning communities Subgoal: Improved health education Increase percentage of population >12 years old who can correctly describe 2 ways to prevent STDs/RTIs by [proportion], by [year] Health promotion via mass media; health education in schools (with skills building component); targeted, community-based intervention programs Religious and lay community leaders; mass media (TV, radio, print media); community-based organizations; ministry of education, teachers; behavioral interventions experts; medical and family planning communities

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Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions Goal-Specific Objectives Strategies to Achieve Objectives Critical Partnerships Subgoal: Improved counseling Increase the percentage of clients seeking family planning, STD, postpartum or primary health care services who also receive STD risk assessment and contraceptive method counseling for prevention of both infection and pregnancy by [proportion], by [year] Development and dissemination of guidelines on risk assessment and counseling for both pregnancy and infection tailored to local sociocultural context Behavior intervention experts and medical and family planning communities Subgoal: Improved STD/RTI management Increase the percentage of family planning, prenatal, and primary health care clients who are appropriately tested and treated for STDs and other RTIs by [proportion], by [year] Development and dissemination of STD/RTI detection and treatment guidelines at a minimum: abdominal, pelvic, and genital exams; syndromic management of STDs in symptomatic men and women using WHO algorithms; prenatal syphilis screening. Whiff (KOH) test; pH and microscopy of vaginal secretions strongly recommended for women with signs or symptoms of abnormal discharge. Tests for chlamydia and gonorrhea should be included if feasible.; Development and dissemination of guidelines for notification of sex partners of patients diagnosed with STDs.; Assure adequate laboratory and anti-microbial supplies in all clinics Medical and family planning communities, agency that sets tariffs, pharmaceutical companies, pharmacists, public and private laboratories, and behavioral interventions experts

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Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions Subgoal: Infection Control Increase percentage of providers of delivery, IUD insertions, and abortion services who can document adherence to infection control guidelines by [proportion], by [year] Development and dissemination of infection control guidelines; assure adequate supplies and equipment Medical and family planning communities (3) Reproductive Health Goal: Every pregnancy and birth intended All couples have access to more than one method of effective contraception, by [year] Train providers in clinical methods; strengthen logistical system for resupply methods Public and private health care providers, family planning nongovernmental, pharmacists Young adults know about contraceptive options, where to obtain supplies/services and information about effective use, health effects, by [year] School health curricula; mass media (information, education, and communication efforts; public service announcements); health care/family planning provider training (initial refresher); packages for emergency contraception, train providers Family planning nongovernmental organizations, health care providers, social marketing agencies/mass media, teachers/principals/school administration, pharmacists All sexually active women have access to safe legal abortion in first trimester, by [year] Legalization of abortions; health care provider training and quality assurance Legislators; health administrators, quality assurance managers; health care providers Contraceptive supplies and services, and safe abortion and post-abortion care, affordable to the poor, by [year] Implement and monitor sliding-fee scales, outreach services in poor communities Legislators/taxpayers, health sector planners, hospital/clinic administrators, family planning program administrators

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Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions Goal-Specific Objectives Strategies to Achieve Objectives Critical Partnerships (4) Reproductive Health Goal: Every pregnancy/birth safe Increase percentage of women with complications attended by trained medical staff by [proportion], by [year] Increase knowledge of warning signals, where to go in emergencies; increase availability of reliable transport to essential care for obstetric complications facilities; increase number of hospitals/clinics trained/ equipped to provide essential care for obstetric complications; institute targeted subsidies, reduce unauthorized fees Community leaders, teachers; first level health care providers; family planning workers Increase percentage of women with complications correctly managed by [proportion], by [year] Quality assurance/provider training (competency-based); eliminate financial incentives for inappropriate obstetric interventions Hospital/clinic administration Decrease clinic/hospital care fatality rate for women and newborns by [proportion], by [year] Quality assurance/provider training (competency-based); develop protocols Hospital/clinic administrators, medical education and licensing authority, health care providers Reduce prevalence of anemia among women aged 15-49 by [proportion], by [year] Distribution of iron/folate supplements in adequate amounts to all pregnant women; information, education, and communication campaign about iron-rich foods Health educators, mass communications, first-level prenatal care providers

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Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions 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. The rationales for our choice of objectives and strategies is given in the chapters above; the table provides an overview to help in translating concepts to implementation steps. This is certainly not meant to be a comprehensive design for the health sector, nor an exhaustive list of current programs that promote one or another goal of reproductive health. However, it may be useful as a checklist or point of departure to ensure that a comprehensive reproductive health strategy is being built. We have argued that the process of externalizing and reforming existing services and creating new ones to meet reproductive health needs will vary among countries. This process has already begun in many countries, of course. In the rest of this section we discuss examples of government efforts to implement a reproductive health agenda in Mexico and Uganda. The Mexican case highlights how organizational issues have been addressed to raise the visibility of reproductive health; the Ugandan case highlights steps taken to strengthen existing services in a very poor country. Implementing a Reproductive Health Program in Mexico Since 1974 the Mexican government has been strongly committed to achieving fertility reduction through a national family planning program (Riquer Fernandez, 1995). Currently, the public sector provides the majority (71%) of contraceptive users with their family planning methods (Pathfinder International, 1995). At the ICPD, Mexico endorsed the Programme of Action without reservations (unlike several other Latin American countries, which expressed reservations about some controversial sections dealing with reproductive rights and health) (United Nations, 1994). After the ICPD, two formerly separate divisions of the Ministry of Health—maternal and child health and family planning—were merged into a new General Directorate of Reproductive Health. In addition, an intersectoral body that sets family planning priorities and monitors programs changed its title from the Interinstitutional Group on Family Planning to the Interinstitutional Group on Reproductive Health (GISR). The GISR includes all national institutions that provide health services, as well as the National Population Council, the Education Ministry, the family welfare program, and six nongovernmental organizations that are active in the women's health and rights movement—the Information Group on Reproductive Choice and the Safe Motherhood Committee. The GISR is the most recent incarnation of a coordinating body on family planning that dates back to 1976 (Martínez Manatou, 1994).

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Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions 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). The program defines reproductive health as ''the capacity of individuals and couples to enjoy a satisfactory, healthy and safe sexual and reproductive life, with the absolute freedom to decide in a responsible and informed manner on the number and spacing of their children." This definition comprehends a broad range of services: family planning; perinatal health; adolescent reproductive health; women's health; early detection and treatment of infertility and reproductive cancers; and prevention, detection and treatment of STDs, including HIV/AIDS. The document emphasizes improving quality of services, instituting a gender perspective in service delivery, ensuring reproductive rights, providing a wide range of method choices, and attending to previously ignored populations (adolescents, men, and indigenous peoples). Several steps have been taken toward implementing an ambitious agenda. At least one of the major public health care providers, the Mexican Institute of Social Security (IMSS), has a structure that favors service integration. Most of its services for the insured population are provided by family physicians in primary care clinics called family health units. Therefore, family planning is integrated with other health services and has been for many years through the predominant role of the family physician. With the new policy framework, attempts are being made to integrate less traditional services, such as cervical cancer prevention and treatment and STD screening, into the family physicians' services. The other major provider of public health services in Mexico is the Ministry of Health, which serves the population not insured through social security. Various new programs have recently been introduced or gained renewed attention in the ministry, including maternal mortality committees in hospitals, postabortion care, and modules for adolescents. There are several barriers to full implementation of this reproductive health and rights program. The government has expanded the range of family planning method choice somewhat; however, there is still a strong emphasis on physician-controlled, long-term methods. Clients who are using condoms, for example, are not counted as contraceptive users by most health institutions. This attitude toward barrier methods can be problematic in a country where HIV is a growing problem for women in stable unions—the traditional target groups served by family planning programs. The prevalence of STDs among the general population is unknown and, in general, STD programs have been neglected in Mexico. Nonetheless, the Mexican government has taken important steps to promote integration and expansion of reproductive health services in a context of serious economic constraints.

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Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions 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. Under Uganda's newly decentralized government structure, the principal responsibility for the provision of primary health care rests with district administrations, although the central Ministry of Health retains policy making, quality control, technical support, and monitoring and evaluation functions and responsibility for all public hospitals. Most districts are ill-equipped to cope with prevailing reproductive health problems. The public health sector is characterized by low salaries, skills, and motivation of staff and insufficiencies in facilities, equipment, supplies, supervision, training and other support systems. Projected government, donor, and household expenditures on health for 1996-1997 are about $202 million, about $10 per capita. Of this, about $36 million represent recurrent government expenses, another $36 million recurrent donor expenses, with the remaining $130 million being household expenditures. Nongovernmental organizations provide about 60 percent of the health care in Uganda and are often highly dependent on donor funding. There is very limited private-sector provision of modern health care outside urban areas, and few alternatives to public-sector services. Despite the large proportion of public expenditure currently spent on hospitals, increased emphasis on primary care is an official priority. User fees are charged in most public-sector facilities. Although revenues collected are currently low and financial management procedures and controls are weak, the Ministry of Health now places a priority on local revenue generation, alternative financing mechanisms such as insurance, and increased private-sector provision of care. The new reproductive/maternal health initiative has four specific objectives. The first is to increase the availability of services by expanding the number of public and private-sector clinical staff capable of providing an integrated package of reproductive/maternal health services. Integrated services will include: family planning; prenatal care, including screening for pregnancy complications; 5   This section draws heavily on U.S. Agency for International Development (1996).

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Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions 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. This first objective will support the provision of in-service training in the above areas as well as the improvement of preservice training capability at nursing, medical and paramedical schools. Community volunteers, including traditional birth attendants, will be trained to provide education and counseling related to family planning; maternal and infant health and nutrition, including the promotion of breastfeeding and proper weaning practices; and HIV and other STDs and to refer clients to clinics with trained providers. Volunteers will also sell condoms and oral contraceptives that are provided through a social marketing program. Traditional birth attendants are also to be trained to recognize signs of pregnancy complications and supervised by trained midwives. Continued emphasis will be placed on social marketing to increase the number of outlets selling contraceptives and antibiotics for STD treatment, as well as on upgrading the MCH logistics system that distributes such supplies to public facilities. The second objective is improved quality of services, including improved, routine supervision of clinic and community-based service providers. Trained providers are to be observed during service delivery to assess compliance with formal standards and education and counseling techniques learned during training. The government plans to coordinate with and train district authorities and facility personnel to maintain and accurately report service statistics related to maternal and child health. This will enable monitoring the quantity of various services provided, their provision in an integrated manner, and compliance with service-delivery protocols (including those for STD treatment). The third objective, enhanced sustainability of services, is to be achieved through several strategies, including standardized financial management systems at health facilities. The last objective is to increase individuals' desire to use services and

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Reproductive Health in Developing Countries: Expanding Dimensions, Building Solutions adopt behaviors to improve reproductive/maternal health. Service utilization is to be promoted directly by providing accurate information about services and outlet location. Information, education, and communication efforts will concentrate on reducing perceived barriers to service use (such as rumors and misconceptions) and broadening public awareness of the availability and utility of HIV counseling and testing and the link between STDs and HIV. Other desired behavior changes (e.g., correct infant feeding, improved maternal nutrition, condom use, reduction in sexual partners, delayed sexual debut, spousal communication on reproductive health) are to be promoted by encouraging people to assess their risk for unwanted pregnancy, poor pregnancy outcomes, and HIV infection and to obtain care accordingly. Behavior change will also be promoted through mass media campaigns, including talk radio, serial dramas, and music and through similar local activities such as dramas, video shows, and music competitions.