Reproductive Health Interventions Report of a Meeting (1996) / Chapter Skim
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Issues for Health Services
Issues for Health Services
Pages 2-14
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The other set of issues concerns the impacts on reproductive health of efforts carried on largely outside the structure of health services, such as efforts to deal with sexual coercion, education, and mass communication. Participants in the meeting gave short presentations based on one or more previously prepared papers, summaries of relevant literature prepared for the meeting, or their own work in progress.
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(See Murray, 1994, for details of calculation.) Some of the reproductive health interventions examined by the World Development Report analysts family planning, prevention of sexually transmitted diseases (STDs)
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But the World Development Report analysts found that many types of interventions differed in their estimated cost-effectiveness (cost per DALY) by orders of magnitude.
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In Bobadilla's view, the practical conclusions are little affected by discounting considerations. Several participants felt that the models in the World Development Report are too optimistic about effective demand for services, especially for relatively new reproductive health interventions.
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The incremental costs of new reproductive health services would lie below the average costs for existing family planning services but they would not be zero. Antenatal and delivery care were treated as a single intervention for these estimates, because much of the value of antenatal care consists in imparting information about warning signs of premature or complicated labor and about appropriate delivery care.
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From page 7... ...
The World Bank estimates presented by Bobadilla and Cowley showed a package of essential reproductive health services costing about 20 percent of current health care expenditures in Mexico and 25 percent in Ghana, but 66 percent of current health care expenditures in Tanzania. 7 Quality Assessment and Assurance Both in family planning and in other health sectors, and in rich as well as poor countries, there has been a resurgence of interest in recent years in ways to assess and improve the quality of services provided.
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From page 8... ...
Winikoff cited studies in Brazil showing poor technical quality of care the wrong intravenous fluids used, wrong decisions about procedures (Costa and Vessey, 19931. In many countries, including India, induced abortion is legal under various circumstances, but many hospitals have no provisions for referrals or for performing the procedure; for many women, the right to a safe abortion exists only de jure, not de facto.
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Quality assurance should not be treated as a research activity but as a routine management responsibility. Efforts to improve quality used to depend on material inputs and relatively scarce technical expertise, which led many decision makers to think of quality as unaffordable in poor countries.
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Pierre Mercenier drew on experience in several types of health services for guidelines that could be useful for those who must decide whether to add new reproductive health services to the repertoire of existing organizations and providers or to seek specialization. He began by noting the characteristics that define general health services as they exist in both rural and urban areas: they offer comprehensive services, have continuous contact with the population (at least those near enough to a facility to be served)
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Integration of a new program into the general health services works well when it brings visible results and the new skill increases the confidence of the workers and of the community. These positive attributes make many proposed reproductive health initiatives good candidates for integration into general health services.
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Simmons gave examples from the family planning program in Vietnam, which relies heavily on IUDs. The family planning clinics can provide initial treatment for reproductive tract infections, but women are then reluctant to follow up the referrals to health clinics, since they know that the health workers will usually advise removal of the IUD while the infection is treated.
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From page 13... ...
This has extended even beyond the health sector, as some of the clinics organize women's literacy programs, and many clients seek referrals to sources of legal assistance or credit. Treatment of reproductive tract infections (chlamydia being most common)
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From page 14... ...
Cates felt that the linkages with family planning have probably brought into STD control a greater concern with the interpersonal relations with clients. Beverly Winikoff pointed out that, in most developing countries, enhancing treatment of reproductive tract infections or linking safe abortion to contraceptive services would not involve merging existing bureaucracies, since these typically do not yet exist.
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