Download Population and Reproductive Health at the World Bank Action Plan

The World Bank’s
Reproductive Health Action Plan
2010-2015
Draft for Discussion
Sadia Chowdhury
The World Bank
December 7, 2009
Draft - Not for Quotation
RH is Key for Human Development

Improved RH outcomes have broad-based individual,
family, and societal benefits, including:
• A healthier and more productive workforce
• Greater financial and other resources for each child
•
•
•
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(“quantity-quality” trade-off)
Enabling young women to delay child-bearing until they
have been able to achieve education and other goals
A potential demographic “dividend”: lower-dependency
ratios, higher savings rates which can be powerful
stimulant for economic growth
Ensuring women’s full participation in the development
process
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Appalling Lack of Progress in RH outcomes
 MMR has declined at less than 1% per year during 19902005
• 500,000 women die each year during child-birth, mainly in
•
sub-Saharan Africa and South Asia
70,000 of these are due to unsafe abortion
 High fertility continues to constrain human development
• In 28 countries, mainly in sub-Saharan Africa, fertility rates
are in excess of 5
 Incidence of STIs (including HIV) among women 15-24 is
unacceptably high
• 29 countries have HIV prevalence greater than 1.3% among
women 15-24
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RH Issues Losing Prominence

Original MDG framework had no targets related to RH
(except for MMR)
• RH targets such as contraceptive prevalence rates,
adolescent fertility rates, unmet need for family planning,
and antenatal coverage included in MDGs included only
in 2007
 High-burden countries themselves have not focused
enough attention on RH issues

Although levels of ODA for RH have increased
somewhat, share of health ODA to RH has declined
• Similar trend in evidence at the Bank as well
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RH Issues Losing Prominence
Share of health ODA to RH, 1995-2007
All recipients
20
Percent
30
1000015000
ODA commitments for health, 1995-2007
All recipients
10
5000
Total health
HIV/AIDS
1995
1998
2001
Year
2004
2007
19
9
19 5
9
19 6
9
19 7
9
19 8
9
20 9
0
20 0
0
20 1
0
20 2
0
20 3
0
20 4
0
20 5
0
20 6
07
0
RH
Share of health ODA to RH, 1995-2007
High MMR-High TFR countries
Total health
20
10
5000
Percent
30
1000015000
ODA commitments for health, 1995-2007
High MMR-High TFR countries
1995
1998
2001
Year
2004
2007
19
9
19 5
9
19 6
9
19 7
9
19 8
9
20 9
0
20 0
0
20 1
0
20 2
0
20 3
0
20 4
0
20 5
0
20 6
07
0
HIV/AIDS
RH
Source: OECD DAC
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Emerging Consensus, Window of Opportunity


Emerging global consensus has re-focused attention
on RH, offering an unprecedented opportunity to
redress the neglect of RH
Key interventions (and costs) for improving RH
outcomes are known:
• Access to family planning
• Skilled attendance at birth
• Emergency obstetric care

Challenge is to translate knowledge to action and scale-up:
• Strong political commitment and leadership to ensure
focus and resources for RH
• Incentives for performance and accountability for results
• Women’s education and empowerment
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The Bank’s RH Action Plan
 The Action Plan is aimed at reinvigorating the Bank’s
commitment to help countries improve their RH outcomes,
particularly for the poor and the vulnerable and in the
context of the Bank’s overall strategy for poverty alleviation
 The HNP Strategy defines population and reproductive
health as:
a. “Reproductive, maternal, and sexual health issues and the health
services that are concerned with addressing them.
b. Levels and trends in births, deaths, and migration that determine
population growth and age structure, and frequently have an
impact on economic growth, poverty, labor markets, and other
sectors.”
 This RH Action Plan is a detailed operationalization of the
RH component of the Bank’s HNP Strategy
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Maternal Mortality and Fertility are Correlated
100 220 500
1500
Maternal mortality vs fertility in developing countries, 2005
Niger
Chad
Nigeria Mali
Ethiopia
Uganda
Bangladesh
India
Indonesia
Botswana
50
Brazil
China
Mexico
Egypt
Belize
Ukraine
5
Poland
1
1.5
2
2.5
3
Total fertility rate (TFR)
4
5
6
7
Source: WDI
Note: Median TFR=3; Median MMR=220
Note: Colors mark HIV prevalence among females aged 15-24
Red=high prevalence (greater than 1.3%)
Yellow=middle prevalence (between 0.3% and 1.3%)
Green=low prevalence (less than 0.3%)
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Heterogeneity within Quadrants
Mali
Niger
Uganda
2
4
6
8
2
4
6
8
Chad
1960
1970
1980
1990
2000 2007 1960
1970
1980
1990
2000 2007
Year
Source: WDI
In some countries, RH outcomes have been stagnant
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Heterogeneity within Quadrants
TFR vs unmet need for contraception
8
MMR vs skilled birth attendance
Afghanistan
Niger
7
2000
Sierra Leone
Niger
Mali
Bangladesh
Uganda
5
Nigeria
4
Mali
Benin
Congo
Djibouti
Egypt
Kenya
Nepal
India
Bangladesh
Indonesia
2
South Africa
Peru
Ukraine
1
220
0
Ethiopia
Congo
India Indonesia
Botswana
Guatemala
Benin
Kenya
Nigeria
3
1000
Angola
Ethiopia
500
Total fertility rate (TFR)
Chad
Nepal
Uganda
6
1500
Chad
20
40
60
80
Skilled birth attendance (%)
100
0
10
20
30
Unmet need for contraception (%)
40
Source: WDI & DHS
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In-Country Variations Can Be Significant
100
Institutional deliveries vs fertility rates across districts in India, 2007-08
80
Kerala
60
Tamil Nadu
40
Rajasthan
20
Uttar Pradesh
0
Chattisgarh
0
20
40
Percent of births of parity 3 or higher (%)
60
Source: DLHS-III
Country
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Wealth quintile
Lowest
Second
Middle
Fourth
Highest
Total
Bangladesh 2007
3.2
3.1
2.7
2.5
2.2
2.7
Colombia 2005
4.1
2.8
2.4
1.8
1.4
2.4
India 2006
3.9
3.2
2.6
2.2
1.8
2.7
Namibia 2007
5.1
4.3
4.1
2.8
2.4
3.6
Philippines 2003
5.9
4.6
3.5
2.8
2.0
3.5
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The Bank’s RH Action Plan highlights SIX focus areas
Strategic policy objectives:
• Helping countries address high fertility
• Helping countries to improve pregnancy outcomes
• Helping countries reduce sexually transmitted infections
How would Bank contribute to the above?
• Leveraging partners to give high priority to RH issues and
increase financing
• Strengthening country health systems and multi-sectoral
approaches to improve RH outcomes
• Promoting high-level policy dialogue on RH at global and
national levels
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Helping countries address high fertility
 Strengthen family planning policies and program
management
 Ensure availability of contraceptives, including supplychain management
 Support provision of quality family planning services
 Enhance knowledge and awareness and other
interventions to generate demand
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Helping countries improve pregnancy outcomes
 Ensure all deliveries are attended by trained personnel
 Ensure access to and promote utilization of antenatal,
emergency obstetric, post-natal and neonatal care
 Promote awareness of pregnancy-related health risks
and proper nutrition during pregnancy
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Helping countries reduce STIs
 Implement programs aimed at prevention of mother-tochild transmission of HIV
 Promote use of condoms for protection against STIs and
prevention
 Support provision of voluntary counseling and testing
 Ensuring appropriate focus on men as well as women
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Strategic Policy Objectives
Objective
Final outcomes
(country level)
Intermediate indicators
(country level)[1]
How does the Bank contribute to these
results?
Reducing
high fertility
TFR reduced
CPR in target countries
increased to allow women
to reach desired family size.
Current level: 26%
Leveraging partners
-Strengthen engagement with global
partners including H4, PMNCH, IHP+,
WB-GAVI-GF HSS platform
-Develop/update joint H4 National Work
Plan in targeted countries
-Facilitate procurement of contraceptives
and other RH supplies through existing
agreements with UN agencies
-Convene partners in countries to
harmonize and finance RH activities
Unmet need for
contraception in target
countries reduced to
eliminate mistimed or
unwanted births.
Current level: 24%
Number of target countries
with family planning
policies developed.
Current level: X
Number of target countries
with no stock outs of
contraceptives in the
preceding year.
Current level: X
Support development & strengthen
capacity in:
-Contraceptive and RH supplies logistics
and supply chain management
- RH program management including
quality of care
-HR management plans including
training and deployment , especially of
midwives
(continued on next slide)
Targets for intermediate country outcomes should be developed on the basis of current levels and trends, additional inputs,
and country commitment and capacity.
[1]
Strategic Policy Objectives (contd.)
Objective
Final outcomes
(country level)
Intermediate indicators
(country level)[1]
How does the Bank contribute to these
results?
Improving
pregnancy
outcomes
MMR reduced
Births attended by skilled health
personnel in target countries
increased. Current level: 43%
(…continued from previous slide)
Adolescent fertility rate in target
countries reduced. Current level:
99 births per 1,000 women aged
15-19
Pregnant women receiving
prenatal care in target countries
increased. Current level: 78%
Newborns protected against
tetanus in target countries
increased. Current level: 80
Reducing
STIs
HIV infections
reduced
Number of target countries with
PMTCT programs increased.
Current level: X
Number of target countries
promoting RH-HIV linkages
increased. Current level: X
[1]
Support development and
strengthening of capacity in:
- Community-based outreach RH
services
- Health information systems for
evidence based decision making and
monitoring of progress
Promoting high-level policy dialogue
- Ensure that country CASs, CEMs,
PERs, and PRSPs address RH issues
and identify appropriate actions
- Help countries set RH as a priority in
national budgets and development
plans through engagement with
MOF/MOP/MOH
- Target lending operations to address
key RH issues
- Promote engagement with CSOs in
country dialogue on RH issues
Targets for intermediate country outcomes should be developed on the basis of current levels and trends, additional inputs, and country
commitment and capacity.
Leveraging partners
 Strengthen engagement with global partners including
H4, PMNCH, IHP+, WB-GAVI-GF HSS platform
 Develop/update joint H4 National Work Plan in targeted
countries
 Facilitate procurement of contraceptives and other RH
supplies through existing agreements with UN agencies
 Convene partners in countries to harmonize and finance
RH activities
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Strengthening health systems to improve RH outcomes
 Support development and strengthening of capacity in:
• Contraceptive and RH supplies logistics and supply chain
management
• RH program management including quality of care
• HR management plans including training and deployment,
especially of midwives
• Community-based outreach RH services
• Health information systems for evidence based decision
making and monitoring of progress
• Address governance issues
 Going beyond the health sector (e.g., microfinance)
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Promoting high-level policy dialogue
 Ensure that country CASs, CEMs, PERs, and PRSPs
address RH issues and identify appropriate actions
 Help countries set RH as a priority in national budgets
and development plans through engagement with
MOF/MOP/MOH
 Promote engagement with CSOs in country dialogue on
RH issues
 Recognition and engagement with other private sector
actors
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Issues on which we seek guidance and feedback
 Have we covered all the critical RH issues in this action
plan?
 Do we have the right model and approach in our
thinking?
 Do we have the right interactions and partnership
arrangements?
 What outcome indicators should we track? Should
lending levels for RH be a target?
 How will we know that we have been successful?
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The World Bank’s
Reproductive Health Action Plan
2010-2015
Comments and Suggestions
Sadia Chowdhury
[email protected]
12/03/2009
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