Universal access to sexual and reproductive health in Asia-Pacific How far away are we from the goal post?

1
Universal access to sexual and reproductive
health in Asia-PacificHow far away are we from
the goal post?

• TK Sundari Ravindran
• Achuta Menon Centre for Health Science Studies,
  India
• Presented by
• B Subha Sri
• Rural Women's Social Education Centre, India

2
All countries should strive to make accessible,
through the Primary Health Care system,
reproductive health to all individuals of
appropriate ages as soon as possible and no later
than the year 2015. (ICPD PoA paragraph 7.6)
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Background

• Universal Access to Reproductive Health Services
• Lack of political will
• Outright opposition
• Inadequate commitment of financial resources
• Omission of SRH in the MDGs

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• Concepts and definitions
• Universal access
• Sexual and reproductive health services
• Progress towards universal access to
  reproductive health services in the Region
  Analysis of available data
• Major barriers to achieving universal access
• Advocacy agenda

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Concepts and definitionsUniversal access

• Information and services are available,
  accessible and acceptable to meet the different
  needs of all individuals
• Absence of geographic, financial, organizational,
  socio-cultural and gender-based barriers to care
• Factors that influence access
• Supply-side or health system factors -
  affordability, availability, acceptability and
  quality
• Demand-side factors - lack of information and
  decision-making power, restrictions on mobility,
  social exclusion and discrimination
• Measured usually by use of health services

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Concepts and definitionsUniversal coverage

• Financing and organizational arrangements are
  sufficient to cover the entire population,
  removing ability to pay as a barrier to accessing
  health services and protecting people from
  financial risks
• Implies attempts to remove financial barriers to
  access through suitable health financing
  mechanisms adopted by the health system
• Universal coverage is a necessary but not
  sufficient condition for universal access

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Universal access to reproductive health or
sexual and reproductive health or sexual and
reproductive health services?
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Universal Access to Sexual and Reproductive Health

• The equal ability of all persons according to
  their need to receive appropriate information,
  screening, treatment and care in a timely manner,
  across the reproductive life course, that will
  ensure their capacity, regardless of age, sex,
  social class, place of living or ethnicity to
• Decide freely how many and when to have children
  and to delay and prevent pregnancy
• Conceive, deliver safely, and raise healthy
  children and manage problems of infertility
• Prevent, treat and manage major reproductive
  tract infections and sexually transmitted
  infections including HIV/AIDS, and other
  reproductive tract morbidities such as cancer
  and
• Enjoy a healthy, safe and satisfying sexual
  relationship which contributes to the enhancement
  of life and personal relations.

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Access to reproductive and sexual health in the
Asia-Pacific

• Indicators used for tracking MDG 5 and 5b
• Health indicators - Adolescent birth rates and
  maternal mortality ratio
• Health care indicators - Proportion of births
  attended by skilled birth attendants,
  Contraceptive prevalence rate, Antenatal coverage
  (at least one visit, four visits)
• In this presentation
• Access to SRH services
• Women. Limited data for men/sexuality minorities

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Access to fertility control
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Fertility Rates

• Total and wanted fertility rates in selected
  countries, Asia-Pacific, various years, Source
  Latest Demographic and Health Surveys

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Contraceptive prevalence

• Use of modern method of contraception (18
  countries) Source World Contraceptive Use survey
  2011
• Less than 50 use 12 countries (Afghanistan,
  Bangladesh Burma, Cambodia, India, Kiribati, Lao
  PDR, Maldives, Nepal, Pakistan, Philippines,
  Samoa)
• 50 - 66 use 4 countries (Bhutan, Indonesia,
  Sri Lanka, Vietnam)
• More than 66 - 2 countries (China, Thailand)

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Unmet need for contraception

• Unmet need for contraception in women in
  reproductive ages (14 countries) Source World
  Contraceptive Use survey 2011
• More than 20 - 6 countries (Cambodia, Lao PDR,
  Nepal, Pakistan, Philippines, Samoa)
• 10 20 - 3 countries (Bangladesh, Burma,
  India)
• Less than 10 - 5 countries (China, Indonesia,
  Sri Lanka, Thailand, Vietnam)

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Access to maternal health services
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Maternal mortality

• ICPD target for MMR reduction by 2015
• Intermediate mortality countries 60/100000 live
  births
• Highest level mortality countries 75/100000
  live births
• ICPD target achieved? (20 countries, 2008 data,
  United Nations MDG database)
• Yes 7 countries (China, Fiji, Malaysia,
  Maldives, Sri Lanka, Thailand, Vietnam)
• No 13 countries (Afghanistan, Bangladesh,
  Bhutan, Burma, Cambodia, India, Indonesia, Lao
  PDR, Nepal, Pakistan, Philippines, PNG, Samoa)

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Skilled birth attendance

• ICPD target - By 2005, 80 of deliveries to be
  attended by skilled birth attendance
• Proportion of women who had skilled birth
  attendance at delivery (21 countries, 2008 data,
  United Nations MDG database)
• More than 80 - 8 countries (China, Fiji,
  Malaysia, Maldives, Samoa, Sri Lanka, Thailand,
  Vietnam)
• 50 - 80 - 7 countries (Bhutan, Burma, India,
  Indonesia, Kiribati, Philippines, PNG)
• 25 50 - 2 countries (Cambodia, Pakistan)
• Less than 25 - 4 countries (Afghanistan,
  Bangladesh, Lao PDR, Nepal)

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Access to safe abortion services
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Unsafe abortionEstimates of annual incidence of
unsafe abortion and associated mortality in 2003.
Rates and ratios calculated for all countries
and, in parenthesis, only for countries with
evidence of unsafe abortion (WHO, 2007)
Unsafe abortion Unsafe abortion Unsafe abortion Mortality due to unsafe abortion Mortality due to unsafe abortion Mortality due to unsafe abortion
Number (rounded) Incidence rate (per 1000 women aged 15-44 years) Incidence ratio (per 100 live births) Number of deaths (rounded) of all maternal deaths Mortality ratio (per 100,000 live births)
East Asia negligible negligible negligible negligible negligible negligible
South-central Asia 6,300,000 18 16 24,300 13 60
South-eastern Asia 3,100,000 23(27) 27(31) 3,200 14 (16) 30
Oceania 20,000 11 8 lt100 10 20
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Access to sexual health care
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Antiretroviral treatment of persons living with
HIV

• Coverage by antiretroviral treatment of persons
  living with HIV (19 countries, UNAIDS 2011)
• More than 90 - Only Cambodia
• More than 50 - 5 countries (Lao PDR,
  Philippines, PNG, Thailand, Vietnam)
• Less than 50 - 13 countries (Bangladesh, Bhutan,
  Burma, China, Fiji, India, Indonesia, Malaysia,
  Maldives, Nepal, Sri Lanka, Afghanistan, Pakistan
  (less than 5))

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Adolescent reproductive and sexual health
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Access to sexuality education

• Review of sexuality education policies in the
  Asia- Pacific Region (UNESCO, 2012)
• Sexuality education is part of the national
  secondary school curriculum in 19 of 20 countries
  (not in Pakistan)
• Both coverage and content varied widely across
  countries
• Emphasis on knowledge and less on imparting life
  skills

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Adolescent birth rate

• Very high to high (above 100) in four countries
  Afghanistan, Bangladesh, Lao PDR and Nepal
• Very low (10 or less) in two countries China and
  Maldives (World Health Statistics 2011)
• Indicative of
• Health risks
• Lack of access to information
• Lack of access to methods of fertility control

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Barriers to universal access to sexual and
reproductive health services

• Financial barriers
• Supply-side barriers influencing availability of
  services
• Demand side barriers

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Financial barriers to universal access
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Out-of-pocket expenditure on health

• Out-of-pocket (OOP) expenditure on health as of
  total health expenditure
• Very low (lt 10) to low (11-25) - 6 countries
  (Kiribati, Papua New Guinea, Samoa, Fiji,
  Thailand, Bhutan)
• Medium OOP share (26-50) - 6 countries (China,
  Indonesia, Malaysia, Nepal, Sri Lanka, Maldives)
• High (51-65) or very high (66 and above) 9
  countries (Afghanistan, Bangladesh, Burma,
  Cambodia, India, Lao PDR, Pakistan,Philippines,
  Vietnam)

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Out-of-pocket expenditure on health

• When out-of-pocket expenditure is the main source
  of paying for health care, ability to pay becomes
  the major determinant of whether or not a person
  is able to access health care when s/he needs it
  most
• Comparing countries share of OOP with their
  achievements in access to sexual and reproductive
  health (health care)
• Low OOP does not guarantee better access to
  services
• High OOP is definitely a deterrent

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Out-of-pocket expenditure on healthEvidence from
small scale studies

• High levels of out-of-pocket expenditure are an
  important deterrent to access to reproductive
  health care
• Cambodia
• getting money needed for treatment mentioned by
  75 of the women of childbearing age as the most
  important reason why women were unable to access
  pregnancy and delivery care services
• Poorest women most affected 86 of women from
  the lowest wealth quintile vs 54 in the highest
  wealth quintile

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Out-of-pocket expenditure on healthEvidence from
small scale studies

• Urban Nepal (2006)
• Cost of delivery care in public sector facilities
  - US 39-42
• Cost of receiving an abortion - US 34.4
• Cost of treating an episode of reproductive tract
  infection US 52
• Average per capita monthly expenditure of
  households - US 40
• Poverty line US 12 25 below this

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Interventions to reduce financial barriers

1. Targeted interventions to protect low income
   groups
2. Conditional cash transfers
3. Universal Health Care coverage

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Targeted interventions to protect low-income
groups

• New Co-operative Medical Scheme (NCMS) in China
• Attempt to protect the population from
  catastrophic health expenditure
• Started in 2003
• Voluntary membership In 2008, 92 of rural
  population enrolled
• Financed by funding from Central and local
  government and individual contributions
• Benefit package includes maternal health care
• After introduction of NCMS
• Facility-based deliveries increased dramatically
  from 45 to 80
• Differences across income groups narrowed
• OOP for delivery care decreased but lowest income
  group still bore substantial financial burden

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Targeted interventions to protect low-income
groups

• Health equity Fund (HEF) in Cambodia
• Reimburses health facilities the fees they forego
  by not charging the poor
• Health staff get a share of total user fees
  earned
• Studies
• Almost all who have received HEF support are
  poor, who have been able to access inpatient
  services that were unaffordable in the past
• More than half (51.6) of the poorest 40 not
  supported by HEF
• Covered only 40 and 56 respectively of total
  average spending by the poor and poorest groups
  respectively
• Up to 36 of HEF patients from rural areas still
  borrowed money for the current episode of care

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Conditional Cash-Transfers

• Making cash payment to households or individuals
  from groups identified as under-served,
  conditional on their adopting desirable health
  behaviours
• Imposition of conditionality for receiving
  services violation of womens right to health care

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Conditional Cash-Transfers

• Muthulakshmi Reddy Maternity Benefit Scheme in
  Tamil Nadu, India
• Substantial cash incentive to low-income women
  conditional on institutional delivery, for the
  first two deliveries
• Increased rates of institutional delivery
  especially among the poorest women
• Women from the poorest and most socially
  marginalised households disproportionately
  represented among those excluded from the Scheme
  - pregnancy of higher than second order, not
  being able to produce documentary proof of
  poverty status and of residence

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Conditional Cash-Transfers

• Safe Delivery Incentive Programme (SDIP) in
  Nepal
• Doubled the rate of institutional deliveries
• Substantially increased the use of skilled birth
  attendants
• Better-off benefited more than the poor -
  wealthiest 20 received 60 of the conditional
  cash transfer
• Offered little protection against catastrophic
  payments - cash incentive amount of Nepal Rupees
  1000 given covered no more than 25 of the cost
  of a normal delivery and 5 of the cost of a
  caesarean section

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Universal Health Care Coverage in Thailand

• Adopted in 2001
• Financing from tax revenue
• Entire households are covered
• Benefits package comprehensive - includes
  preventive, promotive, curative and
  rehabilitative services
• Wide range of sexual and reproductive health
  services covered
• Safe abortion service covered only for rape
  victims and for those whose health is at risk
• Essential obstetric care covered only for the
  first two deliveries.

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Universal Health Care Coverage in Thailand

• Incidence of catastrophic health expenditure
  reduced from 5.4 in 2000 to 2 in 2006
• Not a single household had experienced
  impoverishment due to health expenditure in 21 of
  76 provinces in 2008
• Almost no rich-poor gaps in access to maternal
  health care and contraceptive services
• Limitations to Universal Access
• Restrictions on some essential reproductive
  health services such as safe abortion care and
  essential obstetric care for women of parity
  three or higher
• Supply-side limitations - unequal distribution of
  service delivery points across different regions
  and rural-urban locations, availability of drugs
  and equipment
• Gender and other social barriers limiting demand
  to care

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Supply side barriers Availability of
personnel, facilities and supplies
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Availability of personnel

• To achieve a skilled birth attendance coverage of
  80 would need the availability of at least 23
  professional care providers per 10,000 people
  (World Health Report 2006)
• Met this requirement (World Health Statistics
  Annual 2011)
• Yes 8 (China, Fiji, Indonesia, Kiribati,
  Malaysia, Maldives, Philippines and Sri Lanka)
• Vietnam 22.3
• No 12 countries (Afghanistan, Bangladesh,
  Bhutan, Burma, Cambodia, India, Lao PDR, Nepal,
  Pakistan, PNG, Samoa, Thailand)Less than 10

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Availability of maternity beds

• Benchmark (WHO) 10 beds per 1000 pregnant women
  No data available
• Availability of hospital beds - WHO benchmark
  25 beds per 10,000 population
• Met this requirement 5 countries (China,
  Maldives, Nepal, Sri Lanka, Vietnam)
• Skewed distribution towards urban areas
• Wide within country disparities in distribution
  of facilities and personnel

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Availability of reproductive health commodities

• Range of contraceptives, other essential drugs,
  equipments, reagents and supplies
• Essential life-saving drugs oxytocin/ergometrine
  /misoprostol, magnesium sulphate, antibiotics
• Reasons for non availability
• Absolute short supply
• Lapses in procurement and supply-chain management
• Poor storage of drugs leading to damage or loss
  of efficacy
• Interruptions in donor funding

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Social franchises

• Network of for-profit private health
  practitioners linked through contracts to provide
  a specific package of health services, usually
  contraceptive and a few other reproductive/
  sexual health services
• Deemed to offer the possibility of sustainable
  provision of priority reproductive health
  services
• Seen as an effective model of harnessing
  resources from the private sector towards
  achieving universal access to reproductive health
  services by 2015

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Social franchises the evidence

• Assessment based on descriptive data on 45 social
  franchises from 27 countries of Asia, Africa and
  Latin America
• Have not added much to the range of reproductive
  health services offered
• Have focused on making existing services more
  widely available
• Address non-availability of services in rural and
  remote areas
• Not added additional service delivery points in
  places where none existed
• Do not remove financial barriers to access -
  Out-of-pocket payment dominant mode of payment

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Legal and other restrictions

• Legal status of abortion in 21 countries
• On request - only in 4 countries (Cambodia,
  China, Nepal, Vietnam)
• To preserve the physical and mental health of the
  women 7 countries (Fiji, India, Malaysia,
  Pakistan, PNG, Samoa, Thailand)
• Only to save the life of a woman 7 countries
  (Afghanistan, Bangladesh, Burma, Indonesia,
  Kiribati, Philippines, Sri Lanka)

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Demand side barriers
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Gender-power inequalities

• Limit womens ability to make decisions related
  to their own health care
• Decisions of women's health care made without
  their participation (Percentage of households)
• Nepal 72.7
• Bangladesh 54.3
• India 48.5

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Decision making and Reproductive Health

• Women who are more involved in household
  decision-making are more likely to use a modern
  method of contraception

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Intimate partner violence and Reproductive Health

• Partner ever tried to stop family planning
  (ever-partnered women aged 15-49 years)
  Secretariat of the Pacific Community (SPC). 2010

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Gender norms as barriers

• Gender norms about appropriate behaviour for
  women create barriers
• Need to take permission
• Having to take transportation
• Not wanting to go alone
• Getting money needed for treatment
• Concern that there would be no female provider
• Perceived poor quality of care - concerned that
  there may be no provider or drugs
• Also health system-related -Functioning health
  system (which has availability of drugs and
  providers) that is responsive to gender-based
  disadvantages experienced by women would design
  programmes to reach women closer to their homes
  at affordable prices and ensure availability of
  female providers

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What would be the way forward in addressing these
barriers? How do we get from here to universal
access?
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An agenda for actionUniversal access to overall
health care

• Universal Access to Reproductive Health is only
  realisable as a part of Universal Access to
  Health Care overall. When the health system is
  not geared to provide universal access to
  essential preventive, promotive, curative and
  rehabilitative health care, it can hardly be
  competent to do so for one aspect of health
  alone. Siloed approaches that narrowly focus
  on one specific area such as reproductive health
  or HIV/AIDS could result in inefficient
  investment of resources in weak health systems
  (and may even result in their further weakening)
  and not achieve the desired goal.

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An agenda for actionReducing financial barriers

• Reducing the proportion of health expenditure
  from out-of-pocket payment and increasing the
  proportion of government spending
• Tax-revenue based funding aimed at universal
  rather than targeted coverage, and including a
  reasonably wide range of sexual and reproductive
  health services to offer adequate financial
  protection
• For countries with a narrow tax base, beginning
  with a narrower essential services package with a
  commitment to progressively widening the package

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An agenda for actionStrengthening health systems

• Substantial investment in increasing availability
  of services overall and prioritizing closing the
  gap in distribution of services across
  rural/urban locations and geographic regions of
  the country
• Resources used for social franchises may be
  better invested in strengthening availability and
  better distribution of health care services,
  increasing the availability of human resources
  and achieving reproductive commodity security

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An agenda for actionAddressing gender inequities

• Investment and action needed in increasing health
  system responsiveness to gender-based
  inequalities
• Organizing services at times and locations that
  are convenient to women
• Ensuring visual and auditory privacy and
  confidentiality
• Integrating services for example maternal
  health and family planning with HIV/AIDS
• According greater autonomy to women seeking
  health care

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Thank you