Cost and Benefits of Approving Male Sterilization Policy

in

Public Health Sector

For

Reducing Maternal Mortality

In partial fulfillment in the Course

PAf 201 (Political Economy)

Submitted to Prof. Rolando T. Bello,

Institute of Community Education, College of Public Affairs

University of Philippines Los Banos

Submitted by:

Hla Myat Tun

2009-2010 First Semester

2008-96531

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I. Introduction

The total population of Myanmar is estimated at 55.4 millions with annual growth rate of

2.02 percent in 2006.1 Population growth is not a problem and population control is not

prior to the country but there is a high incidence of Maternal Mortality Ratio (MMR)

because of inadequate birth spacing programmes. The government has committed to

achieve the objective of Millennium Development Goals (MDGs) No. 5: Reduce

maternal mortality by 2015. Supportive men’s role in reproductive health and birth

spacing programmes must be emphasized to meet the targeted aim within 6 years. In the

public health sector, birth spacing services have long been offered mostly through the

existing outlets of maternal and child health centers. These centers were only visited by

women and mother. This may be due to the fact that public policy decision makers,

development, population and health agencies have largely ignored men’s participation in

birth spacing.

The government provides birth spacing services in health centers since 1991. The

contraceptive prevalence rate (modern methods) among married women in reproductive

age (15-49) is only 32.8 percent in 2001.2 The government aims to achieve a better

quality of life for all, by giving attention to the improvement of reproductive health

status. However, male’s access to contraception and roles or participation has not been

stipulated in existing policies. The high-level decision makers have not considered the

participation of male in birth spacing activities or programmes to reduce MMR. Men are

not conscious of their responsibility and birth spacing programmes. The general

perception and knowledge among men on the need for contraception is primarily for the

prevention of HIV/AIDS and Sexually Transmitted Infections (STIs). No appreciation on

the use of condom for birth spacing purpose. Generally, men have yet to be informed and

educated on sexuality, reproduction, and use of contraceptive. They also need the

confidence and guidance on how to share responsibility with their partners in the goal of

1 Statistical Year Book 2006, Central Statistical Organization, Ministry of National Planning and economic Development, The Government of the Union of Myanmar2 UNFPA Statistics < http://www.unfpa.org/worldwide/indicator.do?filter=getIndicatorValues>, (9 November 2008)

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reducing MMR. Political commitment, supportive policy and programmes are to enhance

male participation and birth spacing programmes particularly with the use of sterilization

among married population. The role Ministry of Health is important since maternal health

was seen as positive externality in the health market. Dissemination of information,

education, communication and providing services for male participation in birth spacing

programmes are the most important component of the role of government to the

implementation of the policy.

II. Statement of the Problem

In Myanmar, abortion is illegal but the rate of occurrence of this practice is significant.

This tends to be the leading cause of maternal mortality because of unintended

pregnancies. At least 50 percent of maternal death and 20% of all hospital admission

have resulted from complication of unsafe abortion. The lack of access to contraceptive

methods and the insufficient male support in birth spacing are the major factors of

increasing abortion rate across the country3. The use of illegal and unsafe abortion

methods are in large part the result of unmet contraceptive need among women.

Maternal mortality rate is significantly high that must be reduced if not totally eliminated.

It is estimated that one in three deaths related to pregnancy and childbirth could be

avoided if all the people in community had access to contraceptive services. The unmet

need for contraception is estimated at 16.8 per cent among married population.4 The

government set a target of 56 per 1000 live births on MMR by 2015 based on 2001 data.

The MMR was 361 per 100,000 live births in 2005.5 One study found that the smaller the

health institution in an area, the higher the abortion rate in the surrounding area due to

lack of access to contraceptive methods.

The Fertility and Reproductive Health Survey (FRHS) 2001, found that 20% of women

did not want to get pregnant but were not using contraceptives. And thus at risk of

pregnancy 14% of them wanted to limit their births. This suggests the lack of acceptable

3 Fertility and Reproductive Health Survey (FRHS), 2001. Preliminary Report, Ministry of Immigration and Population, Yangon 20034 Nationwide Cause Specific Maternal Mortality Survey 2004-20055 Fertility and Reproductive Health Survey (FRHS), 2001. Preliminary Report, Ministry of Immigration and Population, Yangon 2003

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long-term methods of contraception. To reduce MMR within 6 years is challenging task.

Thus, male has a significant role in saving women’s life by taking responsibility in birth

spacing among married population.

Both men and women make important contributions and co-equal responsibility in

reproductive health. However, birth spacing programmes have been tended to focus on

women alone in the country. Men participation in birth spacing has been neglected even

though birth spacing methods have been available in public sector since 1991 and male

involvement programmes in reproductive health have been initiated since 2004.

Nevertheless, there is high demand on contraceptive services for married women and

men. Limited access to birth spacing services to women and men lead to increase the risk

of unsafe abortion and maternal death.

Knowledge on condom increased to prevent transmission of HIV/AIDS and sexually

transmitted infections for use by men with sex workers; they are not seen as a birth

spacing methods. There is a gap between male shared-responsibility in existing birth

spacing programmes. Major roles for the government interventions to expend male

involvement programmes for birth spacing are:

Political commitment – High level decision makers have not yet to take the necessary

steps to set up male involvement in existing programmes and actions.

Policy obstruction – Outdated policies and regulations obstruct male

and female access to contraception such as strict eligibility criteria for

obtaining sterilization. Female sterilization is only available after

approval by a sterilization board. Male sterilization is restricted by law

to those men whose wives have been approved but are unable to

undergo sterilization for medical reasons.

III. Present and Past policies on Contraceptives

The National Health Policy, which changed pro-nationalist policy to health-oriented

policy to integrate birth spacing with the aim of improving the health status of women

and children and raising awareness on birth spacing in the community, was developed

with initiation and guidance of NHC in 1993.

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Myanmar’s Reproductive Health Policy was formulated in 2002 and approved by the

Ministry of Health in 2003. The government is aiming to achieve a better quality of life

for all, by giving focus attention on the improvement of reproductive health status. The

policies for birth spacing are stated as;

Daily combined contraceptives, progesterone-only-pills, three-monthly injectable

contraceptives, Intra-uterine devices and condoms will be available and accessible

to all individuals of reproductive age and provided with informed choice.

Other contraceptive methods such as monthly injectable and implants may be

introduced to broaden choice and to improve quality of birth spacing services

after considering evidenced based information, the needs of the community and

the cost effectiveness.

Easy access to sterilization will be encouraged for those women requiring

permanent contraception on medical ground.

Introduction of emergency contraceptive methods into the existing birth spacing

services will be considered.

Service providers in public and private sectors will be trained in the provision of

quality birth spacing services.

Mechanism will be sought to review and revise the existing rules and regulations

periodically, impacting the availability of commodities to ensure that safe and

effective birth spacing methods are easily available

Men’s role in reproductive health was stated as follow in Myanmar Reproductive

Health Policy:

Awareness of critical reproductive health needs and the importance of

enhancement of men’s reproductive health status in improving the reproductive

health of the family will be raised.

Men’s role in promotion of birth spacing service, prevention of transmissions of

RTI/STI and in supporting reproductive health service for the family and the

community will be strengthened.

Access to male contraception was not mentioned in existing policies even though

men’s role in reproductive health is growing and their participation specifically in birth

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spacing for reducing MMR is becoming an important agenda for the country. On World

Population Day 2008, the Minister of Immigration and Population in Myanmar stated

“In our country, each and every family has the right to decide their family size based on

the choices of each individual and couple.” According to his statement, having the right

to decide the desired family size, there have to be provided with choices for both male

and female contraceptive methods including male sterilization which is the only one

option for long-term or permanent methods for married population. Besides, for

reducing MMR, the women’s health movement has to be supported by men’s effective

reproductive responsibility. However, access to male contraception was not mentioned

in existing Myanmar Reproductive Health Policy.

V. Policy Alternatives for reducing Maternal Mortality Ratio

There are several policy alternatives to reduce unwanted pregnancies and unsafe

abortions which lead to maternal deaths resulting from unwanted births. They are;

1). Allow abortion to women (both married and unmarried women) with specific

criteria. Although it seems to take place in Buddhism country, and also with culture

and religion, it can contribute in reducing unsafe abortion in the community. Specific

criteria will need to have access abortion for instance; when the women were being

raped, to preserve physical health of women, to preserve mental health, etc..;.

2). Allow voluntary Male Sterilization to married men by providing easily accessible

to services and reduce strict criteria for obtain vasectomies. It can be effectively

address the current issues regarding unwanted/unplanned pregnancies in the

community especially married couple living in rural and remote areas and they

already have enough children and needing effective contraception.

3). Provide Women Sterilization with least criteria to mothers who already have

finished child bearing by removing strict policies and regulations. It can provide the

needs of the women in an effective way and also the way of encouraging women for

their rights to decide their desired family size.

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VI. Analysis on Cost and Benefits of Policy Alternatives

Cost analysis and Benefits analysis to individual and government of the policy

alternatives are presented in tables.

VI. 1. Cost Analysis for the Policy Alternatives

Input costs can be classified in four pairs of terms commonly used to classify costs: direct

and indirect costs, joint and non-joint costs, average and marginal costs, and capital and

recurrent costs.

1.) Direct and indirect costs

Direct costs correspond to resources that can be explicitly identified with a service or

product. Indirect costs cannot be directly identified with a service or product, but are the

costs of supporting the direct activities. These costs typically are incurred to administer or

evaluate programs.

2.) Joint and Non-joint costs

Non-joint costs which are cost of resources that are used only for one client, and are

either fully consumed or thrown away at the end of the visit. Joint costs can be defined as

the costs of clinic resources used by more than one client.

3.) Average and marginal costs

Average cost is defined as the total cost divided by the number of units of output,

whereas Marginal cost is the additional cost required producing one more unit of output.

4.) Recurrent and capital costs

The key issue in distinguishing between recurrent and capital costs is the life expectancy

of project inputs. “Recurrent costs” usually are defined as the costs associated with inputs

that will be consumed or replaced in one year or less, while “capital costs” are defined as

the annual costs of resources that have a life expectancy of more than one year, such as

equipment or buildings. Recurrent and capital costs may be either direct or indirect.

Cost Analysis for Policy Alternatives is shown in table 1.

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Table.1. Cost Analysis for Policy Alternatives

Classification of CostsAtternative

1Alternative 2 Alternative 3

Direct and indirect costs      

staff salaries (surgeons, assitant doctor to surgeons, nurses, programme administrators, etc.,)

3 1 3

Cost of method 3 1 3

Infrastructure 3 1 3

Joint and Non-joint costs      

staff salaries (surgeons, assitant doctor to surgeons, nurses, programme administrators, etc.,) 3 1 3

Medical supplies (e.g. cotton balls, antiseptic solutions, and utensils used for operation) 3 1 3

Average and marginal costs      

no. of operation performed during working hours 1 3 2

no. of operation rooms equipped to provide operation 3 1 3

provided no. of counseling visits pre-operative visits, follow up visits and post-operative visits

3 1 2

no. of hospitalization days after operation 3 1 3

provided no. follow up after operation 3 1 3

medical materials and supplies 3 1 3

office supplies, utilities and staff salaries3 1 3

clinic space, operating room equipment and vehicle for transportation 3 1 3

training and refresher training for staffs 3 2 2

Total 40 17 39

3 – High; 2 – Average; 1 – Low

According to the results of cost analysis, policy option (2): Allow Male Sterilization to

married men has the least cost comparing to the other two options. Thus, allowing male

sterilization is the favorable option because it does not need new infrastructure and

setting. It can be performed with minimal facilities (does not mean poor and inadequate

facilities) and staff meaning recruiting new staff or constructing new infrastructure are

not necessary. It needs dedicated space for counseling and surgical procedure, utilities,

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and adequate and well-maintained equipment which can be done and provided by sharing

existing settings and facilities. Male sterilization services can suit almost any setting,

from a doctor’s office to a hospital or mobile teams can visit towns and villages.

Therefore, it can be assumed that the cost is practically low for the government and the

individuals.

V.2 Analysis on Benefits of the Policy Alternatives

Analysis on Benefits to individuals and government of the policy alternatives are shown

in table.2.

Table.2. Analysis on Benefits of Policy Alternatives

Benefits to individual and government Alternative

1Alternative

2Alternative

3

Reduce unsafe abortion 1 3 2

Reduce unwanted pregnancies 1 3 3

Reduce maternal death 1 3 2

Less Surgery risk 1 3 2

Less post-operation complication 1 3 2

Simplicity for process 1 3 1

Save Time consuming 1 3 1

Effectiveness 2 3 3

Less conflict with religion, cultural and social norms 1 2 3

Encourage men's participation 0 3 1

Promote Gender Equality 0 3 1

Suitability to any health setting (from doctor's office to hospital) 1 3 1

Total 11 35 22

0 – None, 1 – Low, 2 – Medium, 3 - High

As shown in table.2, policy alternative 2 (male sterilization) has the highest benefits

among the 3 alternatives. Even though all of the policies can reduce unsafe abortion,

unwanted pregnancies and maternal death, they have different levels of benefits. Male

sterilization has more benefits compare to other two options regarding to religion, culture

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and social concerns. Besides, for the individuals, there are several negative social and

health consequences on women for policy alternative 1 and 3.

The followings are the negative affects of the policy options 1 and 3;

discrimination (option 1)

being misunderstood by the society (option 1)

infertility problems (option 1)

conflict with religion, cultural and social norms (option 1)

long-term side effects (option 1)

encourage male irresponsibility in reproductive health

against providing gender equity and equality in reproductive health

neglect men’s needs for contraception

encourage putting burden on women for contraception

According to the analysis of cost and benefits, male sterilization, which has the least cost

and high benefits, is the most appropriate for every couple who no longer want more

children. Many men are interested in contraception and want to take responsibility in

family planning or share responsibility with their partners. According to Family and

Reproductive Health Survey 2001 Myanmar, the percentage of male sterilization is 1.5%

and which is higher than usage of condom 0.3% among married population even though

male sterilization is illegal. Besides, male sterilization, specifically No-scalpel

vasectomy, is the most cost-effective contraceptive methods. The one-time procedure

continues to protect against pregnancy throughout a couple’s reproductive years. Within

several years, vasectomy becomes more economical than other methods—particularly

methods that require continuous supplies, such as pills or condoms. An analysis in the

United States compared the costs of various contraceptive methods, including the cost of

supplying the method, the cost of treating complications and other medical events, and

the cost of prenatal and delivery care for pregnancies when a method fails. After just two

years of use, vasectomy cost less than any other method. An analysis in Iran produced

similar results: When all program costs were considered, vasectomy was the cheapest

method, on average, per year of contraceptive protection. Because vasectomy is so cost-

effective, offering the method might help programs save money—which could be used to

support services for others. According to Population Report of Johns Hopkins,

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Bloomberg, School of Public Affairs, June 2008, vasectomy costs one-quarter to one-half

as much as female sterilization women relying on female sterilization worldwide is seven

times more than the number relying on vasectomy.

VI. Experiences of Male Sterilization programmes in Asian countries and

possibilities in Myanmar

In Asia there are several countries engaging male sterilization as one of the contraceptive

options. Most of these countries have legalized male sterilization policy and programmes

and they have some constraints while implementing programmes. In all countries,

vasectomy was supported by national reproductive health programs and participation of

male is rarely observed due to various factors such as, ignorance, fear, misconceptions

and lack of information at the beginning of the programme interventions.

In India, one of the main purposes of the vasectomy programmes is to control

population. Thus the Indian government provides cash incentive to men as one of the

programme promotion approaches. So the Indian Government has cost for the cash

incentives. According to PathFinder.com, every Indian male who undergoes male

sterilization were provided with post-operative counseling and medicines, and given the

1100 rupee incentive. TIMES ONLINE reported on March 21, 2008 that Indian

Government offers firearms permits for vasectomy. In India, Shivpuri district in the state

of Madhya Pradesh, an overpopulated area renowned for its machismo culture, has

started to offer fast-tracked gun licenses for those who agree to be sterilized. Manish

Shrivastav, the administrative chief of Shivpuri district and originator of the lateral

thinking behind the plan, said “This is a state with a high number of crimes, where people

like to keep rifles. It also has a low level of vasectomies because of a perceived notion of

manliness. I decided to match that with a bigger symbol of manliness — a gun license. It

has been a success.”

In Thailand, physicians performed vasectomies monthly in rural areas via a mobile

vasectomy campaign under the government administration and programmes. The

campaign consisted of motivation and service teams. Private sector groups also involved

with mobile vasectomy included the Population and Community Development

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Association and the Thai Association of Voluntary Sterilization. The Population and

Community Development Association (PDA) of Thailand used a modified commercial

marketing technique to inform people about its free vasectomy program. It has modified

the 4 Ps marketing technique (product, promotion, program, and pricing) of the business

sector to carry on promotion activities. Promoting specialists design and present posters,

leaflets, and advertising spots on radio and TV. Other promotion activities include the

PDA vasectomy festivals on Australian and Chinese national holidays, May Day,

Mothers' day, and King's birthday. This PDA program also operates out of clinics and

mobile vans so the clients can seek vasectomy services when and where they wish. Its

marketing technique has allowed it to surmount earlier obstacles and misconceptions

about vasectomy in Thailand.

In Philippines, Reproductive Health Bill has been pending for many years because of the

religious barriers and being republican country. Religious barrier is the most difficult to

handle for the government. As a republican country, agreement from the many political

leaders is necessary for approving bill. As results, from negative side, it can delay the

progress of decision making for such bill which can really effective for the people.

In Myanmar, as mentioned above, population growth is not a prior problem, thus

Myanmar government will not need to provide the cost for cash incentives. The issues of

cash incentive may not exist in Myanmar male sterilization programmes framework.

Disseminating information on male sterilization can be provided through existing health

education and promoting programme supported by National Health Programme. Several

nationwide campaigns had been promoted and have significant successes in all

campaigns such as mass measles campaign, polio campaign and vitamin ‘A’ campaign

etc. And also medical missions, medical touring etc, have been organizing across the

country led by ministry of health. These mobile clinics to rural and remote areas are

implementing very often in every places of the country. Therefore, male sterilization

programme can be included in these existing programmes without adding much cost for

the government. On the other hand, people from the areas will not have travel cost, time

for the travel and loss time for their work. These mobile programmes can be effectively

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performed in the areas without costly for both individual and government, called win-win

situation.

Myanmar, as a Buddhism country, there are no religious barriers for any contraceptive

programmes unlike other countries such as Philippines (Catholic country). Buddhism

community has no restrictions for any contraceptive methods including male sterilization

but there are myths on male sterilization like other countries. However, these misbelieves

can be corrected by information, education and communication (IEC) programmes which

are currently implementing supported by National Health Programmes together with UN

and International NGOs across the country.

According to the governing system, Myanmar government can easily decide to approve

policy and implement such programmes because of less processes for approving bills for

instance, as mentioned above; Myanmar Reproductive Health Policy was formed within 1

year which was formulated in 2003 and approved in 2003. Reducing MMR to targeted

aim within 6 years becomes an issue need urgent attention for the government. It means

the government has not much time for making decision, approving and implementing

processes. For this reason, as Myanmar government, male sterilization programmes with

the intension of reducing MMR can be implemented in short time compare to other

countries and these programmes can contribute to reduce maternal mortality.

According to Detailed Analysis Report (2004) of Myanmar Fertility and Reproductive

Health Survey 2001, the population of married women (40-49) in rural areas is 22.8%.

The women in that age group (40-49) can be assumed as they have finished child bearing

and already have their desired family size. Thus, their husband can undergo male

sterilization. Men those are only in rural areas are 22.8% of total population. It means that

estimated 22.8% of men in the country can have benefits if male sterilization was

legalized and promoted as contraceptive method for married population. But it can

contribute as an effective method for reducing maternal death due to the unwanted and

unplanned pregnancies among married population. As mentioned above, at least 50% of

maternal death and 20% of hospital admission resulting from complication from unsafe

abortion due to lack of long-term contraceptive methods among married population. By

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approving male sterilization for contraception, maternal death rate can be reduced

estimated up to 50%. As a result, targeted MMR will meet by 2015.

VII. CONCLUSION

Male-involvement elements are needed in reproductive health programmes in all stages

of development--from the early stages in which community and political support is

critical to later stages that focus on expanding and improving services. Specifically,

men’s participating in contraception is the key to improve women’s health and health

status of the country by reducing MMR. There is increasing evidence that male

sterilization programmes can be effective in improving female reproductive health.

Men’s issues in contraception should not be ignored in the public health sectors because

men are lacking need for contraception even though they have aware of their

responsibility for women’s health.

The government has been implementing contraceptive programmes collaborating with

UN agencies and internal organization since 1991 but reducing MMR is challenging.

Myanmar can not meet targeted goal without men’s support in women’s health. To have

men’s effective support, men have to be provided with supportive policy and

programmes. Male sterilization is the only best option for effective long-term

contraception both for male and female but has not considered as one of the birth spacing

choices for married population. Male sterilization has been ignored for many years and

even though there are no significant barriers regarding to cultural and religion. Myanmar

government can easily approve, promote and provide information and services within

shorter time compare to other countries. This also is the best option for both government

and community regarding to cost and benefits of the policy and programme.

Thus, it is the time to be aware of men contraception and the government has to provide

men with supportive policy and programmes with the intension of reducing MMR which

is the consequence unsafe abortion due to the lack of long-term contraception among

married population. And it is also the best way to promote male involvement by sharing

responsibility in family health which equalizes gender inequality in contraception. In

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addition, this is the best option to reduce MMR within 6 years as the government is

facing with challenges to improve maternal health in the region.

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REFERENCES

Books

1. Myanmar Reproductive Health Policy, Maternal and Child Health Department,

Ministry of Health, the Government of the Union of Myanmar

2. Myanmar Fertility and Reproductive Health Survey, 2001, Preliminary Report,

Ministry of Immigration and Population, Yangon, Myanmar 2003

3. World Health Organization South-East Asia Regional Office (WHO/SEARO)

2004. Family Planning Fact Sheet: Myanmar and Birth Spacing: An Overview

4. Nationwide Cause Specific Maternal Mortality Survey 2004-2005

5. Statistical Year Book 2006, Central Statistical Organization, Ministry Of National

planning and Economic Development, The Government of the Union of Myanmar

6. In Their Own Right, Addressing the Sexual and Reproductive Health Needs of

Men World Wide, The Alan Guttmacher Institute 2003

7. Male Involvement in Reproductive Health, Including Family Planning and Sexual

Health, UNFPA Technical Report, No. 28

8. It takes 2, Partnering with Men in Reproductive and Sexual Health, United

Nations Population Fund

9. Contraception: An Investment in Lives, Health and Development, 2008 Series,

No.5. United Nations Population Fund

10. Men: Key Partners in Reproductive Health, Bryant Robey, Elizabeth Thomas,

Soulimane Baro, Sidki Kone, and Guy Kpakpo 1998

11. Absent and Problematic Men: Demographic Accounts of Male Reproductive

Roles, Margaret E. Greene & Ann E. Biddlecom, 1997 No. 103, Population

Council

12. Population Report of Johns Hopkins, Bloomberg, School of Public Affairs, June

2008

13. Methods for Costing Family Planning Services, Barbara Janowitz & John H.

Bratt, United Nations Population Funds and Family Health International, 1994

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14. Responses to the list of issues and question with regard to the consideration of the

combined second and third periodic report by Convention on Elimination of All

Forms of Discrimination against Women (CEDAW), 14 October 2008

Electronic Sources

1. United Nations Population Fund

www.unfpa.org

2. United Nations Population Fund, Myanmar Country Office

http://myanmar.unfpa.org

3. United Nations Population Division

http://www.un.org/esa/population/unpop.htm

4. Population Reference Bureau

http://www.prb.org

5. JOHNS HOPKINS BLOOMBERG, Scholl of Public Affairs

http://www.popline.org

6. Times Online

http://www.timesonline.com/

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