Improving reproductive health services: Is integration with primary healthcare better than vertical programmes?

Objective of the paper was to assess OPE incurred by beneficiaries in accessing maternal health services and the extent to which Janani Suraksha Yojana (JSY) incentives could share the burden of total cost incurred. A community based study was conducted in an Indian State on 424 women, who delivered in last one year. Data was also collected from state government’s record on yearly expenditure under JSY. Study was funded by UNFPA, Bangkok.

The OPE per delivery was USD 28.8 if conducted at home; USD 72.5 at public facility and USD 155.4 at private facility. OPE varied by type of delivery, delivery with or without complications and place of ANC. The cost was USD 44.0 and 149.7 for normal and complicated delivery, respectively.

Direct and indirect expenditure incurred by government per delivery was USD 34.5 and 11.5 respectively. After deducting government expenditure from OPE, new OPE per delivery came out to be USD 9.5 for normal delivery (without complication) and USD 115.2 for complicated delivery. The government shared 55% of the total cost (OPE) per delivery. In case of the normal delivery the share increased to 83% whereas in case of complicated delivery it reduced to 29%.

Studies on the contextual determinants of maternal health services use have highlighted the importance of sociocultural norms that limit the role and place of women. In this study, we develop a measure for latent sociocultural norms related to violence against women and analyze their influence on the use of prenatal care and skilled birth attendance in rural Africa using DHS data from Ghana, Kenya, Uganda, and Tanzania. Measured from respondents’ perceptions of violence against women, our sociocultural contextual variable has good statistical reliability (Cronbach's alpha > 0.8). Moreover, it has a negative influence on women's autonomy in all countries, hence its utility for identifying sociocultural norms in these contexts. The results of multilevel structural equation models show that these sociocultural norms have a significant negative influence on the use of skilled birth attendance in Uganda and Ghana (results for prenatal care used are not yet available). In Ghana, we also note an indirect effect that involves reducing women's autonomy. These results have important implications for policymakers.

Concentration of poor health among the deprived and cost restriction to access health care services lead to higher utilization of public health facilities by the poor than the rich. Supply centric public health policy usually not advancing the poor’s health. Thus, for effective health care utilization government should simultaneously address the supply factor and demand barriers. Using data from 3rd round of District Level Health Survey (DLHS-3, 2007-08), we have endeavored to find out the supply factor and demand barriers for antenatal care (ANC) services by women aged 15-49 years. We have focused ANC because it is the best and cost effective strategy to achieve both MDG4 (under-5 mortality) and MDG5 (maternal mortality). Result shows that 55% women did not go for ANC due to demand side barrier of not necessary. On the supply side 24% women could not go for ANC due to too much cost of ANC services. Importance of custom and knowledge barrier decreases with socioeconomic status, but feeling not necessary to demand ANC increases. Result suggests that public health intervention should simultaneous address the supply and demand side barriers for the effective utilization of health care (ANC) services.

In sub-Saharan Africa, pregnancy and HIV are “transmitted” in primarily the same way: through unprotected, heterosexual sex. And in most African countries, there are more pregnancies than desired, and certainly too many new cases of HIV. These similarities, patterns of health care access, and differential availability of funding suggest that integrating family planning and HIV services should lead to better outcomes. But despite years of talk about the benefits to integration, it remains more rhetoric than reality. Why? To answer this question, I conducted interviews with more than 90 programmers working for federal ministries, donor organizations, and local nongovernmental organizations in Malawi, Nigeria, and Senegal. The opinions of these programmers are crucial to successful outcomes as it is they who will have to promote integration efforts to their ministers and funders as well as to those who actually implement health care. I show that the primary perceived obstacles to integration are the bureaucratic structure of donor organizations and government ministries, combined with overburdened primary health care providers. I find, however, that in Malawi and Senegal, programmers are trying to use the distinctions between pregnancy and HIV prevention to benefit those they serve.

Background
Integrating sexual and reproductive health (SRH) and HIV services improves service utilization and enables health systems respond to client’s needs. Traditional capacity building approaches such as offsite training workshops are costly, interrupts service delivery and providers rarely share new skills and knowledge acquired through such workshops. To address this, the Integra Initiative introduced mentorship as part of interventions activities in study aimed at assessing the benefits and cost of integrating HIV and RH services.
Overall objective: To describe service providers experiences and perceptions of peer mentorship approach used as a method of capacity building for integrating HIV into RH services
Study location: Fourteen health facilities in three districts in Kenya
Methodology: Stratified sampling technique was employed. Using interview guide in depth interviews were conducted with sixteen mentors and 25 mentees. Data was code and analyzed using NVIVO 9

Results: Mentoring improves knowledge and skills in HIV and HIV integration thus improving the access of a wide range of services to the clients. Adequate RH and HIV supplies/commodities; and supportive management necessary for effective mentoring.
Conclusion: Mentorship improves providers’ skills and scope of practice in integrated RH and HIV

Women in India are at risk for HIV/STI primarily through the behavior of their spouse. This paper will describes, a multilevel intervention involving individual women, wives and husbands, the health system and the community that is aimed at prevention of HIV/STI transmission within marriage and reduction of sexual risk behavior. A Women’s Health Clinic was organized at the primary care center to treat women’s gynecological and STI related problems. Individual women presenting with the culturally based symptoms of vaginal discharge (safed pani) and related problems to the WHC are randomized into receiving treatment plus individual counseling (IC), group couples intervention (CI), both IC and CI and a control receiving standard care. The Women’s Structured Survey (WSS) was administered to assess women at baseline, six-month and one-year post intervention from 2009-2012. HLM model was used for data analysis and preliminary analysis comparing WSS baseline with WSS 6-month follow-up (N=886) and one year follow-up WSS (N=-866) comparing those involved in the intervention against the control. On the major outcome variables have shown that the intervention group shows better Sexual Health (p <.001), greater knowledge about STIs (p <.001), less sexual problems, (p <.001) better treatment seeking in health problems (p <.001).

Over the past decade indeed, there is a near-absence of studies that have identified the determinants of consistent use of institutional delivery services for all births within a woman. Hence, the objective of this study is to explain the consistency of institutional delivery in the country by considering all births within women using NFHS 2005-06 data. To fulfil the objective multilevel binary logistic regression model and multivariate multilevel analytical approach has been applied. Result shows that children, born 2-4 years back from the date of survey were less likely to deliver in an institution than recent born child. Compare to second order birth, first order birth were more likely to deliver in an institution. A strong positive effect of women education and wealth index on all three births in an institutional delivery was also pronounced. Significant economic differentials were found for institutional delivery for all three births. Mother belongs to upper wealth quintile had less more chance to deliver all three births in an institution. Result shows that child those who have born 2-4 years back from the date of survey were less likely to deliver in an institution than recent born child. For third last birth place of delivery, child age had no important effect.

Overall contraceptive prevalence rate in India has steadily increased, in spite of these gains, fertility is still high and many couples are unable to effectively choose the number and timing of their births. Most of the researchers have tried to show the impact of utilization of antenatal care services on ever-use of family planning methods. Nevertheless, research investigating the nature of this relationship is not well understood, in the sense that ever use of contraceptive is a weak indicator to capture this aspect. In the present study, with the help of a five years reproductive calendar which is first time available in National Family Health Survey 2005-06, concerted attempt will be made to examine whether utilization of maternal and child health care services is one of the major networks for adoption of contraceptive use. We will examine the type and duration of specific contraceptive use, after utilization of maternal and child health care services. Analysis shows that the intensity of antenatal service and institutional delivery service use does have a causal impact on subsequent spacing contraceptive continuation, after controlling other important socio-economic and demography factors. Result of this research work will improve policymakers understanding of determinants of maternal and child health care utilization.

Considerable number of demographically laggard countries will forego MDGs 4 and 5, and Nepal is not an exception to it. International reports reveal that, lack of adequate birth preparedness is one of greatest encumbrance in failure to reach MDGs 4 and 5. In this context, this study estimated birth preparedness among Nepali women and its association with institutional delivery and postnatal care by using latest demographic health survey data for Nepal. The study used latest round of Nepal Demographic and Health Survey Data. Bivariate and multivariate models are applied as the methods of data analyses. Results reveal that the overall level of birth preparedness is greater among women with pregnancy complications, lower age group, higher education and economic status and with greater women autonomy. Findings reveal that birth preparedness is one of the critical factors in determining the likelihood of having institutional delivery and checkups after delivery. At policy perspective, this study reinstates that laggard countries like Nepal have to ensure adequate and universal birth preparedness in order to achieve not only goal 4 and 5 of MDGs, but have to catch the standards set by developed countries in terms of maternal and child health outcome.

The aim of this paper is to investigate the association between reproductive health service provision and its differentials. The study used data from Demographic and Health Surveys and Utilization of Essential Service Delivery Survey of Bangladesh. Public facilities still the major source of modern contraceptive methods among the poor women (66.6%) as compared to the women from richest quintile (26.8%). Seeking of ANC from medically trained providers is significantly higher among the richest quintile (87.4%) as compared to 30.4 percent among the poorest quintile. The well-off usually rely on the private facilities for ANC services as compared to the poor. The socio-economic status has positive impact on the likelihood of delivering at a health facility. The likelihood of preferring private facility relative to public facility in terms of family planning services is increasing over time given the other variables in the model are held constant. Despite expansion of the private sector and NGO sector, the public sector remains an important source of supply for poor women. More attention should be given to the determinants of reproductive health, associated with their interaction with service provision, to reduce maternal mortality and to achieve the MDG for maternal mortality.