E-Book Social Determinants

7/28/2019 E-Book Social Determinants

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Editors

Erik Blas, Johannes Sommerfeld and Anand Sivasankara Kurup

Social

determinantsapproaches topublic health:from conceptto practice


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Editors

Erik Blas, Johannes Sommerfeld and Anand Sivasankara Kurup

Social determinantsapproaches to public health:from concept to practice


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WHO Library Cataloguing-in-Publication Data

Social determinants approaches to public health: rom concept to practice / edited by Erik Blas [et al].

1.Socioeconomic actors. 2.Health care rationing. 3.Patient advocacy. 4.Public health. I.Blas, E. II.Sommereld, Johannes. III.Sivasankara Kurup, A.IV.World Health Organization.

ISBN 978 92 4 156413 7 (NLM classication: WA 525)

World Health Organization 2011

All rights reserved. Publications o the World Health Organization can be obtained rom WHO Press, World Health Organization, 20 Avenue Appia,1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; ax: +41 22 791 4857; e-mail: [email protected]). Requests or permission to reproduce ortranslate WHO publications whether or sale or or noncommercial distribution should be addressed to WHO Press, at the above address (ax:+41 22 791 4806; e-mail: [email protected]).

Te designations employed and the presentation o the material in this publication do not imply the expression o any opinion whatsoever onthe part o the World Health Organization concerning the legal status o any country, territory, city or area or o its authorities, or concerning thedelimitation o its rontiers or boundaries. Dotted lines on maps represent approximate border lines or which there may not yet be ull agreement.

Te mention o specic companies or o certain manuacturers products does not imply that they are endorsed or recommended by the WorldHealth Organization in preerence to others o a similar nature that are not mentioned. Errors and omissions excepted, the names o proprietaryproducts are distinguished by initial capital letters.

All reasonable precautions have been taken by the World Health Organization to veriy the inormation contained in this publication. However, thepublished material is being distributed without warranty o any kind, either expressed or implied. Te responsibility or the interpretation and use othe material lies with the reader. In no event shall the World Health Organization be liable or damages arising rom its use.

Te named authors alone are responsible or the views expressed in this publication.

Printed in Malta.

Cover photos: Column 1. (1) WHO/Erik Blas; Column 2. (1) WHO/Armando Waak; (2) Muhammed al-Jabri/IRIN; Column 3. (1) WHO/Olivier Asselin; (2) David Swanson/IRIN; Column 4. (1) Jason Gutierrez/IRIN; (2) WHO/Evelyn Hockstein; Column 5. (1) WHO/HaroldRuiz; (2) WHO/H. Bower; Column 6. (1) Jaspreet Kindra/IRIN; Column 7. (1) WHO/Chris de Bode; (2) WHO/Christopher Black.

Te photographs in this material are used or illustrative purposes only; they do not imply any particular health status, attitudes, behaviours, oractions on the part o any person who appears in the photographs.

For further information, please contact:

Department o Ethics, Equity, rade, and Human Rights Health (EH)World Health Organization20, Avenue Appia, CH-1211 Geneva 27, SWIZERLAND

http://www.who.int/social_determinantse-mail: [email protected]

About this book

The thirteen case studies contained in this publication were commissioned by the research node of the Knowledge Network on PriorityPublic Health Conditions (PPHC-KN), a WHO-based interdepartmental working group associated with the WHO Commission on Social

Determinants of Health. The publication is a joint product of the Department of Ethics, Equity, Trade and Human Rights (ETH), Special

Programme for Research and Training in Tropical Diseases (TDR), Special Programme of Research, Development and Research Training

in Human Reproduction (HRP), and Alliance for Health Policy and Systems Research (AHPSR). The case studies describe a wealth of

experiences with implementing public health programmes that intend to address social determinants and to have a great impact on

health equity. They also document the real-life challenges in implementing such programmes, including those in scaling up, managing

policy changes, managing intersectoral processes, adjusting design and ensuring sustainability.

This publication complements the previous publication by the Department of Ethics, Equity, Trade and Human Rights entitled Equity,

social determinants and public health programmes, which analysed social determinants and health equity issues in 13 public health

programmes, and identified possible entry points for interventions to address those social determinants and inequities at the levels of

socioeconomic context, exposure, vulnerability, health outcomes and health consequences.


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Te book is a joint initiative o the WHO Department o Ethics, Equity, rade and Human

Rights (EH), Special Programme o Research, Development and Research raining in

Human Reproduction (HRP), Special Programme or Research and raining in ropical

Diseases (DR), and the Alliance or Health Policy and Systems Research (AHPSR).

Te authors o the various chapters o the book are listed below:

Carlos Acosta-Saal, Ajmal Agha, Irene Agurto, Halida Hanum Akhter, Laura C. Altobelli,

Erik Blas, Chris Bonell, Joanna Busza, Jia Cheng, Uche Ezeoke, Abigail Hatcher, James

Hargreaves, Patrick Harris, Sara Javanparast, Heidi Bart Johnston, Kausar S Khan,

Julia Kim, Kathi Avery Kinew, Jaap Koot, Amanda Meawasige, Romanus Mtunge, JaneMiller, Linda Morison, Joel Negin, Elizabeth Oliveras, Obinna Onwujekwe, Benjamin

Onwughalu, Godrey Phetla, John Porter, Paul Pronyk, Lorena Rodriguez, Anna

Schurmann, Evie Sopacua, Stephanie Sinclair, Johannes Sommereld, Siswanto Siswanto,

Anand Sivasankara Kurup, ony Lower, Jan Ritchie, Vicki Strange, Graham abi, Yeim

ozan, Daniel Umeh, Benjamin Uzochukwu, James Ogola Wariero, Charlotte Watts, Su

Xu, Isabel Zacaras, Shaokang Zhan and Chanjuan Zhuang.

Te study design and implementation team consisted o Erik Blas, Johannes Sommereld,

Sara Bennett, Shawn Malarcher and Anand Sivasankara Kurup. Bo Eriksson, Jens

Aagaard-Hansen and Norman Hearst reviewed and provided inputs to the publication at

dierent stages. Valuable inputs in terms o contributions, peer reviews and suggestionson various chapters were also received rom a number o WHO sta at headquarters,

regional oces and country oces, as well as other partners and collaborators. Te

editors would like to acknowledge specically the contributions o Marco Ackerman,

Anjana Bhushan, Davison Munodawaa, Benjamin Nganda, Sarah Simpson, Susan Watts,

Erio Ziglio and Ramesh Shademani. Te editorial team consisted o Erik Blas, Johannes

Sommereld and Anand Sivasankara Kurup.

Te text was copyedited by Bandana Malhotra and publication design and layout was

done by Netra Shyam.

iii

Acknowledgements


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v

Te health o a population is measured by the level o health and how this health is

distributed within the population. Te WHO publication rom early 2010, entitled Equity,

social determinants and public health programmes analysed rom the perspective o thirteen

priority public health conditions their social determinants and explored possible entry

points or addressing the avoidable and unair inequities at the levels o socioeconomic

context, exposure, vulnerability, health-care outcome and social consequences. However,

the analysis needs to go beyond concepts to explore how the social determinants o health

and equity can be addressed in the real world. Tis publication takes the discussion on

social determinants o health and health equity to a practical level o how programmeshave actually addressed the challenges aced during implementation.

Social determinants approaches to public health: from concept to practice is a joint

publication o the Department o Ethics, Equity, rade and Human Rights (EH), Special

Programme or Research and raining in ropical Diseases (DR), Special Programme

o Research, Development and Research raining in Human Reproduction (HRP), and

Alliance or Health Policy and Systems Research (AHPSR). Te case studies presented in

this volume cover public health programme implementation in widely varied settings,

ranging rom menstrual regulation in Bangladesh and suicide prevention in Canada

to malaria control in anzania and prevention o chronic noncommunicable diseases

in Vanuatu.

Te book does not provide a one-size-ts-all blueprint or success; rather, it analyses

rom dierent perspectives and within dierent contexts programmatic approaches that

led to success or to ailure. Te nal chapter synthesizes these experiences and draws

the combined lessons learned. Tese lessons include: the need or understanding equity

as a key value in public health programming and or working not only across sectors

but also across health conditions. Tis requires a combination o visionary technical and

political leadership, an appreciation that long-term sustainability depends on integration

and institutionalization, and that there are no quick xes to public health challenges.

Programmes must get out o their comort zones and, in addition to applying traditional

biomedical and programmatic tools, they have to learn to address the economic, social,

cultural and political realities in which public health conditions and inequities exist.

A common lesson learned rom all the analysed cases is to not wait to identiy what went

right or wrong until afer the programme has elapsed or ailed. Research is a necessary

component o any implementation to routinely explore, gauge, and adjust strategies and

approaches in a timely manner. We believe that this publication will inspire programme

managers, policy-makers and researchers to work hand-in-hand to launch new and

better public health programmes and to urther strengthen existing ones.

Erik Blas Johannes Sommerfeld Anand Sivasankara Kurup

Foreword


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vi

AHPSR Alliance or Health Policy and Systems Research

AKU Aga Khan University

ALGON Association o Local Governments o Nigeria

AMC Assembly o Manitoba Chies

ANIS I Anthropometric Nutritional Indicators Survey

ARI acute respiratory inections

ASIS applied suicide intervention skills training

AusAID Australian Agency or International DevelopmentBAPSA Bangladesh Association or the Prevention o Septic Abortion

BCC behaviour change communication

BWHC Bangladesh Womens Health Coalition

CEPS cultural, economic, political and social

CHEW community health extension worker

CIE communication, inormation and education

CLAS* Local Health Administration Communities

CLS community-led total sanitation

CNCDs chronic non-communicable diseases

CO community organizer

CSDH Commission on Social Determinants o Health

DFID Department or International Development (UK)

DGFP Directorate General o Family Planning

DHS Demographic and Health Survey

DIRESA* Regional Health Directorate

DP3 diphtheria, pertussis and tetanus third dose

DSNC District School Nutrition CommitteeERC Research Ethics Review Committee

ERC Expert Review Committee

FANA ederally administered northern areas

FAA ederally administered tribal areas

FGD ocus group discussion

FMOH Federal Ministry o Health

FNIHB First Nations and Inuit Health Branch

FW eld worker

Acronyms and abbreviations


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SOCIAL DETERMINANTS APPROACHES TO PUBLIC HEALTH: rom concept to practice vii

FWV amily welare visitor

GAVI Global Alliance or Vaccines and Immunizations

HMIS Health Management Inormation System

HNPSP Health and Nutrition Population Sector Programme

HPSP Health and Population Sector Programme

HRP Special Programme o Research, Development and Researchraining in Human Reproduction

IBRD International Bank or Reconstruction and Development

ICC Interagency Coordinating Committee

ICDDR,B International Centre or Diarrhoeal Disease Research, Bangladesh

ICPD International Conerence on Population and Development

IDB Inter-American Development BankIDRC International Development Research Centre

IMAGE Intervention with Micronance or AIDS and Gender Equity

IMCI Integrated Management o Childhood Illnesses

INAC Indian and Northern Aairs

IPD immunization plus days

IPV intimate-partner violence

IRKs insecticide retreatment kits

IN insecticide-treated nets

KINE Kilombero Net Project

KYI Keewatin Youth Initiative

LGA local government area

LLIN long-lasting insecticidal net

MCH Maternal and Child Health

MDG Millennium Development Goal

MEF Ministry o Economy and Finance

MFI micronance initiative

MFN Manitoba First Nations

MOE Ministry o Education

MOH Ministry o Health

MOHFW Ministry o Health and Family Welare

MOHSW Ministry o Health and Social Welare

MoWD Ministry o Women and Development

MR Menstrual Regulation

MRSP Menstrual Regulation raining and Services Programme

MSF Medecins sans Frontieres


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viii SOCIAL DETERMINANTS APPROACHES TO PUBLIC HEALTH: rom concept to practice

MVP Millennium Villages Project

MVU mobile video unit

NAB National Accountability Bureau

NANES National Insecticide reated Nets programme

NAYSPS National Aboriginal Youth Suicide Prevention Strategy

NCD noncommunicable disease

NGO nongovernmental organization

NIPOR National Institute o Population Research and raining

NIU National Implementation Unit

NMCP National Malaria Control Programme

NPC National Population Commission

NPHCDA National Primary Health Care Development Agency

NPI National Programme on Immunization

NWFP North West Frontier Province

OR oral rehydration therapy

PAC* Shared Administration Programme

PACFARM* Shared Administration Programme or Pharmaceuticals

PAHP Pacic Action or Health Project

PAH Planning Alternative omorrows with Hope

PBM Pakistan Baitul Maal

PHC primary health care

PMI Presidents Malaria Initiative

PPHC Priority Public Health Conditions

PSBP* Basic Health or All Programme

PSI Population Services International

PSL* Local Health Plan

PSRL Programmatic Social Reorm Loan

RADAR Rural AIDS & Development Action Research ProgrammeREC Reaching Every Child

RED Reach Every District

REW Reach Every Ward

RHSEP Reproductive Health Services raining and Education Programme

SDH social determinants o health

SEF Small Enterprise Foundation

SEG* Free School Insurance

SES socioeconomic strata

SFL Sisters-or-Lie


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SOCIAL DETERMINANTS APPROACHES TO PUBLIC HEALTH: rom concept to practice ix

* Spanish acronym

SIA supplemental immunization activity

Sida Swedish International Development Cooperation Agency

SIS* Integrated Health Insurance

SMI* MaternalChild Insurance

SMOH State Ministries o Health

SNP School Nutrition Project

SC School awana Committee

DR Special Programme or Research and raining in ropical Diseases

FI ask Force on Immunization

NVS anzanian National Voucher Scheme

O training o trainers

UNDP United Nations Development Programme

UNICEF United Nations Childrens Fund

USAID United States Agency or International Development

VC voluntary counselling and testing

W/U weighed/under-ves

WFP World Food Programme

WHO World Health Organization

WSP-EAP Water and Sanitation Programme East Asia and Pacic

YAC Youth Advisory Council

YSPI Youth Suicide Prevention Initiative


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x

1. Introduction and methods o workErik Blas, Johannes Sommerfeld and Anand Sivasankara Kurup..............................................1

2. Scaled up and marginalized: a review o Bangladeshs menstrual regulationprogramme and its impactHeidi Bart Johnston, Anna Schurmann, Elizabeth Oliveras and Halida Hanum Akhter..........9

3. Youth or Youtha model or youth suicide prevention: case study o the Assemblyo Manitoba Chies Youth Council and Secretariat, CanadaStephanie Sinclair, Amanda Meawasige and Kathi Avery Kinew.............................................25

4. Food and vegetable promotion and the 5-a-day programme in Chile or theprevention o chronic non-communicable diseases: across-sector relationships andpublicprivate partnershipsIrene Agurto, Lorena Rodriguez and Isabel Zacaras................................................................39

5. Dedicated delivery centre or migrants in Minhang District, Shanghai: interventionon the social determinants o health and equity in pregnancy outcome or internalmigrants in Shanghai, ChinaSu Xu, Jia Cheng, Chanjuan Zhuang, Shaokang Zhan and Erik Blas .....................................49

6. Reviving health posts as an entry point or community development: a case study o

the Gerbangmasmovement in Lumajang district, IndonesiaSiswanto Siswanto and Evie Sopacua........................................................................................63

7. Child malnutritionengaging health and other sectors: the case o IranSara Javanparast........................................................................................................................77

8. Te Millennium Villages Project: improving health and eliminating extreme povertyin rural Arican communitiesYeim Tozan, Joel Negin and James Ogola Wariero...................................................................91

9. Immunization programme in Anambra State, Nigeria: an analysis o policydevelopment and implementation o the reaching every ward strategy

Benjamin Uzochukwu, Benjamin Onwughalu, Erik Blas, Obinna Onwujekwe, Daniel Umehand Uche Ezeoke......................................................................................................................105

10. Womens empowerment and its challenges: review o a multi-partner nationalproject to reduce malnutrition in rural girls in PakistanKausar S Khan and Ajmal Agha.............................................................................................117

11. Local Health Administration Committees (CLAS): opportunity and empowermentor equity in health in PerLaura C. Altobelli and Carlos Acosta-Saal..............................................................................129

12. What happens aer a trial? Replicating a cross-sectoral intervention addressing the

social determinants o health: the case o the Intervention with Microfnance orAIDS and Gender Equity (IMAGE) in South AricaJames Hargreaves, Abigail Hatcher, Joanna Busza, Vicki Strange, Godfrey Phetla, Julia Kim,

Charlotte Watts, Linda Morison, John Porter, Paul Pronyk and Chris Bonell.......................147

Contents


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SOCIAL DETERMINANTS APPROACHES TO PUBLIC HEALTH: rom concept to practice xi

13. Insecticide-treated nets in anzania mainland: challenges in reaching the mostvulnerable, most exposed and poorest groupsJaap Koot, Romanus Mtunge and Jane Miller..................................................................................161

14. Addressing the social determinants o alcohol use and abuse with adolescents in a PacifcIsland country (Vanuatu)Patrick Harris, Jan Ritchie, Graham Tabi and Tony Lower.............................................................175

15. From concept to practice: synthesis o fndingsErik Blas............................................................................................................................................187

Annexes to Chapter 14

Annex 1: Programme logic ramework mapping PAHPs original aims and objectives against

the implementation processes on the ground in Vanuatu, and their impact andoutcomes...............................................................................................................................204

Annex 2: Intervention scheme template (Vanuatu).........................................................................206


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Introduction and methods o work

Erik Blas,1 Anand Sivasankara Kurup,1,* and Johannes Sommerfeld1,2

1.1 Background......2

1.2 Rationale......3

1.3 Process and methods......4

1.4 Case study themes......4

Going to scale......4Managing policy change......5

Managing intersectoral processes......5

Adjusting design......5Ensuring sustainability......5

1.5 Summary......5

Reerences......7

1 World Health Organization (WHO)2 Special Programme for Research and Training in Tropical Diseases (TDR)

* Corresponding author: [email protected]


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2 SOCIAL DETERMINANTS APPROACHES TO PUBLIC HEALTH: rom concept to practice

1.1 Background

Achieving greater equity in health is a goal in itsel,and achieving the various specic global health anddevelopment targets without ensuring equitabledistribution across and within populations is olimited value (Blas and and Sivasankara Kurup, 2010).Although many public health programmes have achievedconsiderable success in reducing mortality and morbidity,they oten ail to capitalize on interventions that addressthe social context and conditions in which people live, i.e.interventions that have a potential to contribute to greaterhealth equity. Moreover, national-level statistics otenmask unair disparities within and between populationgroups in terms o health outcomes resulting romunequal access, extreme vulnerabilities and exposure tovarious risk actors. It has also been acknowledged thatmany key public health targets, including the health-related Millennium Development Goals (MDGs), arenot easily attainable even i there is a massive scale-up oavailable technologies (Maher et al., 2007; Lnnroth etal., 2010). Oten, even simple and eective tools, such asvaccines against childhood diseases, are unable to reachthose most in need due to several social and structuralactors (United Nations, 2010). This calls or a broader

approach that addresses the social determinants toreduce inequities in programme perormance and healthoutcomes through intersectoral action, communityparticipation and empowerment o populations that aremost vulnerable to health threats (Hasan et al., 2005).

Health equity has increasingly been on the agenda othe World Health Organization (WHO) in recent years.As part o a comprehensive eort to promote greaterequity in global health, in a spirit o social justice, theCommission on Social Determinants o Health (CSDH)

was convened by WHO to gather and review evidence onwhat needs to be done to reduce health inequities andprovide guidance or Member States and WHO itsel onhow to reduce those avoidable, unair and remediabledierences in health outcomes between populationgroups both within and among countries (Lee, 2004).The CSDH submitted its report in 2008 with overarchingrecommendations to close the equity gap in a generationby improving daily living conditions, tackling inequitabledistribution o power, money and resources, measuringand understanding the problem, and assessing the impact

o action (CSDH, 2008). Apart rom this, the Worldhealth report in 2008 placed health equity as the centralvalue underpinning the renewal o primary health care(PHC) and called or priority public health programmes

to align with the associated principles and approaches(WHO, 2008). In May 2009, the World Health Assemblycalled upon the international community and urgedWHO Member States to tackle health inequities withinand across countries through political commitment tothe main principles o closing the gap in a generation.It emphasized the need to generate new, or make useo existing, methods and evidence, tailored to nationalcontexts in order to address the social determinantsand social gradients o health and health inequities.The Assembly requested the WHO Director-General topromote addressing o the social determinants o healthto reduce health inequities as an objective o all areaso the Organizations work, especially priority public

health programmes, and research on eective policiesand interventions (World Health Assembly o the WorldHealth Organization, 2009).

Eectively addressing inequities in health involves notonly new sets o interventions, but modications tothe way that public health programmes are organizedand operate, as well as redenition o what constitutesa public health intervention (Blas and SivasankaraKurup, 2010). The Priority Public Health ConditionsKnowledge Network (PPHC-KN) (WHO, 2007), one

o nine Knowledge Networks supporting the CSDH,was established as an interdepartmental working groupinvolving 16 public health programmes o WHO. ThePPHC-KN has helped to widen the discussion on whatconstitutes public health interventions by identiyinginequities in the social determinants o health, andpromoting appropriate interventions to address thoseinequities through public health programmes (Blas andSivasankara Kurup, 2010).

To analyse issues related to social determinants andequity within public health programmes, the PPHC-

KN developed and applied a ve-level ramework,inormed by discussion papers prepared or the WHORegional Oce or Europe (Dahlgren and Whitehead,2006; Diderichsen et al., 2001; and the comprehensiveconceptual ramework o the CSDH [Solar and Irwin,2007]). The ramework has ve levels o analysis:socioeconomic context and position, dierentialexposure, dierential vulnerability, dierential healthoutcomes and dierential consequences (Blas andSivasankara Kurup, 2010). For each level, the analysisestablished and documented the social determinants

at play and their contribution to inequity, or example,pathways, magnitude and social gradients in outcomes;promising entry points or intervention; potential adverseeects o eventual change; possible sources o resistance


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3Introduction and methods of work

to change; and what has been tried and what were thelessons learned.

As part o the WHO-led PPHC-KN, a research nodewas created and charged with substantiating, throughempirical case study research, how specic public healthprogrammes have addressed issues related to the social

determinants o health and equity. This eort involved13 institutions and more than 40 researchers. The currentvolume is a compilation and synthesis o these 13 casestudies. The case studies examine the implementationchallenges o addressing the social determinants o health,especially in low- and middle-income settings.

1.2 Rationale

To have meaning in public health, ideas and concepts need

to be translated into concrete action, and interventionsneed to be implemented at the scale o populations. Thetransition rom the drawing board, the experiment, orthe pilot project into the real-lie situation has challenged

many a public health programme. This is particularlytrue when programmes address social determinantso health conditions and how health is distributed in apopulation. Programmes will inevitably have to dealwith undamental structures o societies, including whocontrols power and resources. One can appear to do allthe right things and still not get the right results. It may be

tempting to do a two-by-two matrix.

Figure 1: Priority public health conditions analytical ramework

Source: Blas and Sivasankara Kurup, 2010, p. 7

Socioeconomic context and position

(society)

Differential exposure

(social and physical environment)

Differential vulnerability(population group)

Differential health outcomes

(individual)

Differential consequences

(individual)

INTERVENE ANALYSE MEASURE


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The matrix indicates that i we have the right interventionsand implement them in the right way, we get the rightresults. While this is hard to dispute, when it comes to thereal world, there may be no such thing as 100% right orwrong; instead, there may be a range o nuances and greyzones. There is a lot o learning to be done rom exampleswhere both the interventions and the implementationwere right. However, these cases are rare, and there maybe much more learning rom cases where interventionsand their implementation were almost right and wherethe results were almost there than rom cases o completeperection or ailure.

A critical phase in most programmes is that o going to

scale moving rom the experiment or pilot project tothe ull-scale intervention required to have an impact atthe population level. Another critical phase is when theprogramme is to be sustained, or example, to be undedand institutionalized or the long term and to operatewithout the day-to-day involvement o those whoconceived the project and worked in it. This transitionprocess may also oer many insights and opportunitiesor learning.

Most research on the social determinants o health and

equity has ocused on possible causal relationships. The seto case studies presented here ocused on programmaticissues concerning the organization o public healthprogrammes and the process o implementation. Inparticular, the case studies document the challenges acedand how they were dealt with in practical local situations.

1.3 Process and methods

In order to commission case studies on a wide range o

public health programmes and a representative set ocountries, a call or letters o interest was issued jointlyby the WHO Department o Ethics, Equity, Tradeand Human Rights in collaboration with the SpecialProgramme o Research, Development and ResearchTraining in Human Reproduction (HRP), the SpecialProgramme or Research and Training in TropicalDiseases (TDR), and the Alliance or Health Policy andSystems Research (AHPSR). The call attracted 70 letterso interest rom all WHO Regions. All letters o interestwere peer reviewed and scored on a set o pre-established

selection criteria. Evaluation o the proposals includedcriteria such as the quality o the proposal, easibility andpotential to contribute new knowledge on implementing

programmes addressing the social determinants o healthand health inequities. Mean scores were computed andthe 14 highest-ranking projects were then selected toexamine the implementation challenges aced by themin addressing the social determinants o health in publichealth programmes. Thirteen studies were completedand are included in this volume.

The studies used a variety o standard methods incase study research (Yin, 2003), including interviewswith key inormants involved at the policy level and inimplementing the respective programmes, documentreview o ocial and unocial statistics, projectdocuments and reports, and the published literature.

Review and clearance or research involving humansubjects was obtained rom the Research Ethics ReviewCommittee (ERC) o WHO, and rom national orinstitutional review boards o the participating researchinstitutions.

1.4 Case study themes

The primary objective o undertaking these case studieswas to review their implementation processes and to

draw lessons that can be learned by others embarkingon the dicult path to correct inequities in health byaddressing the social determinants. The objective wasthus not to evaluate the perormance and outcomes othese programmes, but to understand how they addressedthe challenges to implementation. Thereore, the casestudies ocused on the ollowing ve types o processes oimplementation, and the learning and challenges thereo going to scale, managing policy change, managingintersectoral processes, adjusting design and ensuringsustainability.

Going to scale

Many successul programmes are oten conceived byvisionaries, and carried orward by dedicated personnel,who understand the ideas, purposes and ideologiesbehind the programmes. However, while moving romsmall-scale pilot programmes to large interventionscovering and beneting a whole population, theseprogrammes oten ace considerable challenges. The casestudies documented the learning rom such projects on

the processes o moving rom a small to a large scale, thechallenges encountered on the way, how they overcamethe challenges, and what were the barriers and acilitators.


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Managing policy change

It is important to understand the challenges associatedwith policy ormulation and change, particularly inrelation to policies beneting the poor and vulnerable,the infuence o the political environment, the role oindividuals as policy champions, and managing opposingproessional views. The case studies documented howthese processes were managed rom the initial evidenceo the need or change to completion o the policyormulation process, e.g. in relation to shiting resourcesor power rom one group to another. Several o thecase studies also assessed the infuence o the politicalenvironment, and the roles and eect on the process o

individuals as policy champions.

Managing intersectoral processes

In order to create a comprehensive response to publichealth challenges, including addressing the socialdeterminants o health and health inequities, managingintersectoral processes is a key challenge. It requiresspecic skills and methods that public health proessionalsoten lack and, in the process, they oten ail. Learningrom managing the stewardship challenges in workingwith other sectors can guide new programmes.

Adjusting design

Any programme that aims to address inequity shouldadapt not only to the changing needs and priorities othe population that it proposes to address, but also to theprogrammatic challenges and opportunities experiencedduring implementation. Integral elements o managingprogrammes include designing and redesigning them

according to experiences gained and making adjustmentsto the original design during implementation. Theissues, reasons and sequence o various elements o suchadjustments to the programme, and their eects on thedesign, were also documented through the case studies.

Ensuring sustainability

Considerations regarding nancial and institutionalsustainability have to be built into the programmes romthe start. Dierent concepts o sustainability, the lessons

learned and issues in securing ongoing nancial supportor the programme, as well as promoting institutionalsustainability, are discussed in the case studies.

1.5 Summary

The individual case studies are presented in Chapters 2 to14 o the volume, and a synthesis on the lessons learnedis presented in Chapter 15.

Chapter 2. BangladeshBangladeshs menstrual regulation programme

Collaborative work between donors, the governmentand NGOs increased the countrys capacity to address animportant element o equity in health, namely, increasedaccess to sae abortion, and or women to be part o a

decision that aects their health and lives. The case studydocumented the learning rom a three-pronged approachinvolving the government, NGO and donor. Thisapproach has been skillully and successully pursued inthe menstrual regulation programme in Bangladesh ormore than three decades.

Chapter 3. CanadaManitoba First Nations suicide preventionprogramme

When the socially excluded try to do something abouttheir situation, they are aced with a double burden: theexclusion itsel, and being excluded rom dealing with theexclusion. The Canada case study documents the learningrom the Manitoba First Nations suicide preventionprogramme. It describes the eects o leadership, whichhave been nurtured and developed over time, both withindisadvantaged population groups and through ormationo strategic alliances with outsiders who are willing tolend some o their leadership capacity to the programme.

Chapter 4. ChileFood and vegetable promotion and the 5-a-dayprogramme

It is imperative to oster intersectoral action in orderto ensure equity. Structural interventions need to be inplace to address equity, with improved coordinationbetween the ministries o Health, Education andAgriculture to increase consumption o healthy oodand vegetables among the most vulnerable populations.The Chile experience o intersectoral collaboration

and publicprivate partnerships or ruit and vegetableconsumption to prevent noncommunicable diseasesis an indicator that intragovernment leadership and


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commitment is necessary or multisectoral policydevelopment, implementation and monitoring, andeective scaling up.

Chapter 5. ChinaDedicated delivery centre for migrants inMinhang District, Shanghai

Lessons learned rom the China case study suggest thata values-based project requires particular considerationsto go to scale. Policy change requires innovativethinking, questioning o conventional wisdom, anddiligently taking on both higher authorities and healthproessionals. In the practical implementation, priority-setting, technical approaches, values and sta, andinstitutional development had to be considered andaddressed simultaneously. The case demonstrates thatinequity in pregnancy outcomes between migrants andresidents is avoidable, and that at least some among thepublic, authorities and within the health-care proession

nd them unair.

Chapter 6. IndonesiaReviving health posts as an entry point for

community development: Gerbangmasmovement in Lumajang district, Indonesia

The Gerbangmas movement in Lumajang district,Indonesia is an innovation within a decentralized healthsystem. The policy change o the Gerbangmasinitiativewas an incremental process that took approximatelyve years. The Gerbangmasmovement has encouragedmultiple sectors to set programmes or communityempowerment and to bring these together througha common indicator ramework controlled by thecommunity. The study suggests that or conducting

community empowerment to address the socialdeterminants o health, it is o importance to use a non-sectoral mechanism that can accommodate multisectoralinterests.

Chapter 7. IranChild malnutrition: engaging health and othersectors

Intersectoral collaboration becomes dicult whenresources are limited. Highest-level governmentcommitment is a must when going to scale. Establishingeective intersectoral action needs more than buildingorganizational capacity through upgrading sta

knowledge and skills; it also requires health objectivesto be translated into the interests o and institutionalizedwithin government sectors as well as communityorganizations. Having a visionary and energeticchampion, i not a must, will greatly acilitate the process.

Chapter 8. Kenya

The Millennium Villages Project to improvehealth and eliminate extreme poverty in ruralAfrican communities

This case study reviews early experience with amultisectoral development project, the MillenniumVillages Project (MVP), in rural Arican communities.The MVP tests the key recommendations o the UNMillennium Project and demonstrates in practice at thevillage level how to achieve the Millennium DevelopmentGoals (MDGs). It demonstrates that integratedinterventions that simultaneously target the availability,acceptability and accessibility dimensions are easible andcan lead to high-impact programmes at the village levelbut there are important contextual constraints as well.

Chapter 9. Nigeria

Immunization programme in Anambra State

Despite continued attempts, routine immunizationcoverage in some areas o Nigeria has remained verylow. Local ownership o the programme is the key tosustainability o the programme; involvement at thepolitical level is necessary but not sucient. Local-leveladministrative integration is indispensable. This studyexplores the roles o stakeholders in the developmentand implementation o the Reaching Every Ward (REW)policy or delivering immunization services in Nigeria,and the actors infuencing their roles in keeping and not

keeping the ocus o the REW.

Chapter 10. PakistanMultipartner national project to reducemalnutrition among rural girls in Pakistan Tawana

Malnutrition gures or children below the age o 5 yearshave been stagnant in Pakistan over the past several years.The Tawana project, initiated by the Federal Ministryo Women and Development, ollowing a pilot projectundertaken by the Aga Khan University, was a nationalproject launched in 29 districts. It ocused on empoweringlocal women by giving them the opportunity to plan and


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manage a eeding programme, and demonstrates howmalnutrition could be reduced. Enrolment and retentiono girls in government primary schools increasedthrough a concerted approach. However, the projectalso demonstrated that showing results and impact isnot sucient to maintain political and administrativesupport.

Chapter 11. Peru

Local Health Administration Committees (CLAS)

Local Health Administration Communities (CLAS)in Peru are non-prot civil associations that enter into

agreements with the government and receive publicunds to administer PHC services, applying private sectorlaw or contracting and purchasing. It is an example o astrategy that eectively addresses the social determinantso health. These reer to social, cultural and economicbarriers at the local level which keep people romeectively utilizing health-care services. This case studydescribes the political and proessional opportunities aswell as threats that such programmes ace in the long run.

Chapter 12. South AfricaIntervention with Microfinance for AIDS andGender Equity (IMAGE)

The Intervention with Micronance or AIDS andGender Equity (IMAGE) was an attempt to design,implement and evaluate a cross-sectoral interventionthat aimed to improve health outcomes by targetingtheir social determinants in rural South Arica. Theintervention combined an established micronanceprogramme with gender and HIV/AIDS training, andactivities to support community mobilization. The case

study highlights key lessons rom the experiences odeveloping an intersectoral collaboration, expandingthe scale o intervention delivery ollowing a trial, andexploring models or long-term sustainable delivery.

Chapter 13. TanzaniaInsecticide-treated nets in Tanzania

This case study analyses the national programme orinsecticide-treated nets (ITNs) in Tanzania during theperiod 19952008, ocusing on implementation issues inrelation to the social determinants o health and how tobenet the poorest, most exposed and most vulnerablegroups in society. The case study describes the importance

o monitoring and research in such programmes aswell as the infuence o shiting donor interests andapproaches.

Chapter 14. VanuatuPacific Action for Health Project: addressing thesocial determinants of alcohol use and abusewith adolescents

Young people in the Republic o Vanuatu areincreasingly being aced with rapid urbanization, lacko education, consumption o unhealthy oods, limited

job opportunities, and the widespread availability and

accessibility o inexpensive cigarettes and alcohol. Thiscase study covers an integrated health promotion andcommunity development programme, the Pacic Actionor Health Project (PAHP), set up to address the socialdeterminants or noncommunicable diseases in thecapital o Vanuatu, Port Vila.

Chapter 15. From concept to practice synthesis of findings

The synthesis process involved analysing the ve key

aspects o the programmes that have been covered bythe case studies: going to scale, managing policy change,managing intersectoral processes, adjusting design andensuring sustainability. It looked closely at the commonlessons learned under each o these ve aspects o theprogramme. Among the key messages emerging rom thesynthesis are: the importance o evidence and baseline;that in the long haul, the battle or equity takes place inthe public space through intelligent use o the evidenceand partners; and nally, that scale-up should considerthree phases providing proo o principle; testing the

scalability o the programme with particular ocus onthe drivers o expansion and how to transer the valuestorch; and roll-out with systematic monitoring, repeatedevaluation and timely adjustments to the programme.

References1. Blas E and Sivasankara Kurup A (2010). Equity, social

determinants and public health programmes. Geneva, WorldHealth Organization.

2. CSDH (2008). Closing the gap in a generation: health equitythrough action on the social determinants o health. Finalreport o the Commission on Social Determinants o Health.Geneva, World Health Organization.


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3. Dahlgren G, Whitehead M (2006). Levelling up: a discussionpaper on European strategies or tackling social inequities in

health (part 2). Copenhagen, WHO Regional Oce or

Europe.4. Diderichsen F, Evans T, Whitehead M (2001). The

social basis o disparities in health. In: Evans T et al., eds.Challenging inequities in health. New York, Oxord UniversityPress:1223.

5. Hasan A, Patel S, Satterthwait D (2005). How to meet theMillennium Development Goals (MDGs) in urban areas.Environment and Urbanization, 17:319.

6. Lee JW (2004). Address to the 57th World Health Assembly,17 May 2004. Geneva, World Health Organization. (http://www.who.int/dg/lee/speeches/2004/wha57/en/index.html,accessed on 06 November 2010).

7. Lnnroth K et al. (2010). Tuberculosis: the role o risk actorsand social determinants. In: Blas E and Sivasankara Kurup A,eds. Equity, social determinants and public health programmes.Geneva, World Health Organization:219241.

8. Maher D et al. (2007). Planning to improve global health:the next decade o tuberculosis control. Bulletin o the WorldHealth Organization, 85:341347.

9. Solar O, Irwin A (2007). A conceptual ramework or action

on the social determinants o health. Discussion paper or the

Commission on Social Determinants o Health. Geneva,

World Health Organization.

10. United Nations (2010). The Millennium Development Goals

report. New York, United Nations.

11. Yin RK (2003). Case study research design and methods.

Thousand Oaks, Caliornia, Sage Publications Inc.

12. WHO (2008). The world health report 2008. Primary

health care: now more than ever. Geneva, World Health

Organization.

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Resolution WHA62.14. Reducing health inequities through

action on the social determinants o health. Geneva, World

Health Organization, 2009:2125. (http://apps.who.int/gb/ebwha/pd_les/WHA62-REC1/WHA62_REC1-en-P2.pd,

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Heidi Bart Johnston,2,* Anna Schurmann,3 Elizabeth Oliveras,4 and Halida Hanum Akhter5

1 This work was made possible through funding provided by the World Health Organization (WHO)

and the UK Department for International Development (DFID) to ICDDR,B.2 Independent Consultant, previously at ICDDR,B, Dhaka, Bangladesh3 Carolina Population Center, University of North Carolina Chapel Hill, USA4 Pathfinder International, Watertown, MA, USA. Previously at ICDDR,B, Dhaka, Bangladesh5 Retired. Previously at Family Planning Association of Bangladesh

* Corresponding author: [email protected]

2.1 Background......10

2.2 Methods......11

2.3 Findings......11

Evolution o the MR programme in three phases......11

Phase 1: Conceptualization (19711981)......11

Phase 2: Distancing o MR activities rom the State (19821997)......13

Phase 3: The marginalization o MR (1998till date)......14

Impact o the MR Programme......16

Socioeconomic context: barriers to equitable access......17

2.4 Discussion......19

Going to scale......19

Managing policy change......19

Managing intersectoral processes......20

Adjusting design......20

Ensuring sustainability......21

2.5 Conclusion......21

Acknowledgements......22

Reerences......22

Scaled up and marginalized

A review o Bangladeshs menstrual

regulation programme and its impact1


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2.1 Background

Access to contraception and sae abortion services iscritical to gender equity, particularly in contexts inwhich women bear the primary responsibility or childcare, and orgo educational and career opportunities iunplanned or mistimed pregnancy and childbirth takesplace. By legally restricting sae methods o ertilitycontrol, womens lives, careers and utures can beundamentally altered by pregnancy and childbirth.In these environments, women who try to take controlo their uture by terminating a mistimed pregnancy,particularly those with ew socioeconomic resources, risk

their lives and health.

Deaths rom unsae abortion one o the ve leadingcauses o maternal mortality vividly illustrate inequityin access to health care. Internationally, 98% o theestimated 66 500 abortion-related deaths that occureach year take place in developing countries (WorldHealth Organization, 2007a). Socioeconomic disparitiesin mortality and morbidity related to unsae abortioncontinue at all levels, rom regional to national tocommunity. In rural Bangladesh, an analysis showed

that women rom the poorest-asset quintile were morethan twice as likely to die rom complications o abortioncompared with women rom the wealthiest-asset quintile;those with no ormal education were more than 11 times

more likely to die o unsae abortion than those with 8 ormore years o ormal education (Chowdhury et al., 2007).

Guaranteeing equitable access to contraceptive and saeabortion services would prevent the vast majority o thesedeaths, and provide women and couples with the meanso determining the timing and spacing o their children.

To address the high rates o mortality and morbidityrom unsae abortion, governments at the InternationalConerence on Population and Development (ICPD)

ve-year anniversary Special Session o the UnitedNations General Assembly in June 1999 strengthenedthe 1994 ICPD Program o Action Language on

abortion, agreeing that where abortion is legal it shouldbe sae and accessible. In 2003, the World Health

Organization (WHO) published a guidance o bestpractices to support this 1999 agreement (WHO, 2003).The recommendations include interventions such asproviding abortion services at primary-care acilities and,

to enable this, ostering mid-level clinician provision oabortion, and replacing dilatation and curettage withsaer and simpler vacuum aspiration or medical abortiontechnology or uterine evacuation. The guidance urther

recommends contraceptive counselling and servicesbeore abortion clients leave a health-care acility todecrease the likelihood o a subsequent unintendedpregnancy.

Abstract

Every year, globally, an estimated 66 500 women die attempting to terminate a pregnancy.

To the extent that womens lives and futures are influenced by childbirth, access to

contraception and safe abortion services is fundamental to gender equity. Yet many countries

legally restrict access to safe abortion. In these countries, women with a socioeconomic

advantage are more able to circumvent restrictive abortion laws and access safe abortion

services; poor and less educated women are more likely to use unsafe methods and suffer

serious morbidity and death. This is particularly egregious as deaths from unsafe abortion

are entirely preventable, given access to modern contraception and safe abortion services.

Bangladeshs Menstrual Regulation (MR) Programme is an example of a programme with

the potential to reduce morbidity and mortality related to unsafe abortion in the context

of a restrictive abortion law. We describe how Bangladeshs MR Programme evolved

from an urban-based relief effort in 1972 to a nationwide primary care-level programme;

review intersectoral processes that have and continue to influence policy developmentand programme implementation; assess the impact of the programme; explore contextual

factors that have influenced the potential of the programme over time; and comment on

issues of programme sustainability and replicability in settings beyond Bangladesh. Available

evidence suggests that the MR Programme has contributed to a reduction in maternal

mortality; however, mortality from unsafe abortion continues to disproportionately impact

the socioeconomically disadvantaged.


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11Bangladesh: A review o the menstrual regulation programme and its impact

Most o these recommendations have been in placein Bangladesh or over 30 years. In Bangladesh, whereabortion is illegal except to save a womans lie, mid-levelclinicians in the MR Programme have been using vacuumaspiration or uterine evacuation at the primary-carelevel since 1977. The government has mandated that MRservices be available at all o the more than 4500 UnionHealth and Family Welare Centres, as well as secondary-and tertiary-care acilities to make MR services accessiblethroughout the country (Akhter, 2001). Since 1975,ertility has dropped rom 6.9 to 2.7 births per woman(NIPORT et al., 2007) and, while the number o MR andabortions has increased, deaths rom unsae abortionhave decreased (Oliveras et al., 2008).

In this chapter, we describe how the MR Programmeevolved rom an urban-based relie eort in 1972 to anationwide primary-care level programme. We reviewthe intersectoral processes that infuenced and continueto infuence policy development and programmeimplementation; assess the impact o the programme;explore the social, economic, political and cultural actorsthat have infuenced the potential o the programme overtime; and comment on programme sustainability andreplicability in settings beyond Bangladesh.

2.2 Methods

Our study questions were:

1. How did Bangladeshs MR Programme develop, andwhat key actors infuenced its evolution over time?

2. Is the strategy o MR service delivery in a restrictiveabortion law environment sustainable i implementedby a strong public sectorNGOdonor partnership?

I so, what are the orces that sustain the programme?I not, what necessary orces are missing?

3. Has the MR Programme had a positive and equitableimpact on reducing mortality and morbidityrom abortion complications? What are the social,economic, political and cultural barriers andacilitators to programme success?

4. What lessons, i any, can be transerred rom theMR Programme experience to other countries withhigh maternal mortality rom unsae abortion and

restrictive abortion laws?

We employed a case study design to acilitate in-depthexploration o the orces that have shaped and continue

to shape the MR Programme. We conducted an extensivereview o the published and peer-reviewed literature,and grey literature related to the MR Programme. Wecollected the grey literature via a systematic search ordocuments relating to the MR Programme, includingocial government publications, agendas and minuteso relevant meetings, ormal studies and evaluations othe MR Programme, and conducted act-checking withdierent levels o MR Programme stakeholders, includingprogramme managers, service providers and researchers.

2.3 Findings

Evolution of the MR programme in threephases

In Bangladesh, the British Penal Code o 1860, Section312, criminalizes abortion except to save the lie othe woman, and penalizes providers o abortion withnes and imprisonment (Ministry o Law, Justice andParliamentary Aairs, 1977). Yet MR, or evacuationo the uterus o a woman at risk o being pregnant toensure a state o non-pregnancy, is sanctioned by the

government, and provided by public sector cliniciansat primary, secondary and tertiary levels o the health-care system (Population Control and Family PlanningDivision, 1979).

The evolution o Bangladeshs MR Programmecan be divided into three phases: conceptualization(19711981); distancing o MR activities rom the State(19821998); and marginalization o MR (1998till date).

Phase 1: Conceptualization (19711981)

The MR Programme was conceptualized in the earlyyears o Bangladeshs Independence as part o a solutionto unsustainable population growth. Three leadingorces drove the early stages o the MR Programme: thetemporary waiving o the strict abortion law immediatelypost Independence; concern regarding populationgrowth; and the development o new uterine evacuationtechnology. In this section, we describe the context inwhich the Programme was initiated and implemented,identiying drivers o change and barriers to success.

The liberation war

In 1971, Bangladesh ought a nine-month war o


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liberation with Pakistan. Pakistani orces raped 200 000400 000 Bangladeshi women, prompting internationalmedia coverage that highlighted or the rst time theuse o rape as a weapon o war (Drummond, 1971;Brownmiller, 1975; Mookherjee, 2008), and national andinternational support or the rape victims.

In 1972, the restrictive abortion law was waived orheroines o war who had been raped and werepregnant. International eminist and aid organizationsarranged or medical teams rom India, Australia andthe UK to perorm medical terminations o pregnancyat district hospitals in Bangladesh (Akhter, 1988; Ross,2002). While working with the international medical

teams, the Bangladeshi doctors received not onlytechnical training but also exposure to the concept oabortion as a womans right (Ross, 2002). This temporarysanctioning o abortion eased public opinion towarduterine evacuation procedures and solidied a cadre oproessional elite prepared to deend a womans rightto control her ertility (Potts and Diggory, 1977; Amin,1996; Piet-Pelon, 1998; Khan, 2000).

The population control agenda

At Independence, Bangladesh was one o the most denselypopulated countries in the world; it had a population o70 million and a ertility rate o almost seven childrenper woman. In the 1970s, concern with rapid populationgrowth dominated the international development agenda(Donaldson and Tsui, 1990). Bangladesh was heavilyreliant on donor support to recover rom the cyclone o1970, the liberation war o 1971 and the amine o 1974,and was under pressure to curb population growth. Thispressure intensied ater the amine gave rise to ears o aMalthusian crisis (Lee et al., 1995).

The Bangladeshi Government embraced the populationcontrol agenda and allocated 6% o the developmentbudget and 5% o the revenue budget to amily planningbetween 197475 and 198687 (Islam and Tahir, 2002;Lee et al., 1995). In 1978, the Government o Bangladeshdeclared population control the countrys main priority.Resource allocation or the rst our ve-year healthand population programmes privileged vertical amilyplanning service delivery above all other health priorities.Within the Ministry o Health and Population Control,abortion was seen as an important complement to amilyplanning in terms o the population control agenda. Inthe early 1970s, the modern contraception prevalencerate was 4.7% (Ministry o Health and PopulationControl, 1978).

Development o service inrastructure or saepregnancy terminations

During the 1970s, an inrastructure or sae, voluntarypregnancy termination was established. In 1974, thegovernment encouraged the introduction o a pilotuterine evacuation programme in a ew amily planningclinics. This was unded by the United States Agencyor International Development (USAID) through thenongovernmental organization (NGO) The PathnderFund, as part o a national postpartum programme thatincluded provision o contraception and amily planningservices (Piet-Pelon, 1998).

The Pathnder Fund played a lead role in the campaign totrain paramedics called amily welare visitors (FWVs) in uterine evacuation care. FWVs have a minimum o10 years o basic education, ollowed by 18 months oreproductive health training. Some have an additionalthree months o training in uterine evacuation. Whilethe medical community resisted the authorization oparamedics to provide uterine evacuation services,arguments to employ FWVs to make the simpleprocedure accessible to women in rural and less afuentareas prevailed (Ross, 2002).

Vacuum aspiration using the Karman cannularevolutionized pregnancy termination service delivery,allowing uterine evacuation without the need oranaesthetics or an operating theatre (Karman, 1972;Ekwempu, 1990). Vacuum aspiration is saer thandilatation and curettage, recovery is ast (WHO, 2003),it can be perormed saely by mid-level providers atoutpatient acilities (Bhatia et al., 1980; Warriner etal., 2006), and the equipment is portable and does notrequire electricity.

In 1978, the Ministry o Health and Population Controlin collaboration with The Pathnder Fund initiated auterine evacuation training and services programmein seven government medical colleges and two districthospitals or government doctors, FWVs and a ewprivate doctors (Akhter, 1988). American medicalconsultants came to Bangladesh to train providers in theuse o manual vacuum aspiration, and doctors were alsosent to Singapore or training (Piet-Pelon, 1998; Ross,2002).

Policy developmentThe combination o multiple actors described earliercontributed to a policy environment conducive to aliberalization o the abortion law.


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In 1973, the rst ve-year plan highlighted the importanceo abortion as an important means o controllingertility despite social censure, putting it rmly on thecountrys policy agenda. The 1976 National PopulationPolicy Outline (Government o the Peoples Republic oBangladesh, 1976) proposed the legalization o medicaltermination o pregnancy as it was practised at the time.Though the Population Policy Outline recommendedliberalization o the abortion law up to 12 weeks opregnancy, this recommendation was not acted upon.

Legalization o abortion was considered urther in 1977when the Population Control and Family PlanningDivision commissioned the Bangladesh Institute o Law

and International Aairs to report on the laws pertainingto population growth, and recommend new legislationas necessary. The report suggested legalizing abortion orthe rst 12 weeks o pregnancy by licensed paramedicsor medical doctors under sae medical conditions onthe basis o humanitarian, eugenic, socioeconomic, orcontraceptive ailure according to the best judgemento the clinician. However, in 1977, General Zia assumedthe presidency, augmenting his political support byappealing to religious conservatives (Lee et al., 1995).As with the National Population Policy Outline, the

recommendations o the Institute o Law were notenacted, on the basis that uterine evacuation was alreadyavailable, and a concern that explicit legislation mightarouse religious opposition (Ross, 2002).

Responding to domestic and international interests, thegovernment gradually introduced a uterine evacuationtraining and service delivery programme. In 1979, thePopulation Control and Family Planning Division o theMinistry o Health and Population Control circulateda memorandum with a legal interpretation by theBangladesh Institute o Law and International Aairsto authorize MR services to be included in the nationalamily planning programme (Ali et al., 1978; Ross, 2002).Technically competent and politically savvy champions inthe Ministry o Health and Population Control providedstrong support or the MR Programme, ordering medicaldoctors and paramedics to oer MR services in allgovernment hospitals, and at primary care-level healthand amily planning complexes throughout the country.

Phase 2: Distancing of MR activities from

the State (19821997)

Since inception, the MR Programme in Bangladesh hasbeen vulnerable to donors changing priorities. Three

important international policy changes during thissecond phase impacted the MR Programme: an increasedemphasis on unding NGOs rather than the State; theUS Governments restrictive Mexico City Policy, and thereproductive health and rights approach to populationpromulgated by the 1994 ICPD.

Tensions in donor priorities: the United StatesMexico City Policy and the InternationalConerence on Population and DevelopmentProgramme o Action

In the 1980s, ertility decline had begun in Bangladesh anddonors moved away rom their strong emphasis on ertility

control. Population dynamics came to be regarded in amore nuanced way, as the eects o population pressureson poverty and health proved dicult to quantiy(Lakshminaranayan, 2007). In 1994, the ICPD calledor, and Bangladesh signed onto, expanding womenslie choices, achieving gender equity, and paying greaterattention to sexual and reproductive health and rights(Germain, 1998). This more comprehensive approachsuperseded vertical programmes with their narrow ocuson ertility control (Lakshminaranayan, 2007).

Until 1983, USAID supported the MR Programmethrough the NGO The Pathnder Fund. Increasedreligious conservatism in the United States led to theimposition o the Reagan administrations Mexico CityPolicy in 1984. This policy bars US nancial and technicalamily planning assistance to oreign NGOs which, withtheir own unds, provide sae abortion services, reerralsto abortion services or any kind o advocacy aroundabortion issues (Blane and Friedman, 1990; Crane andDusenberry, 2004). The Pathnder Fund relinquished allMR-related activities. The model MR clinics and trainingprogramme became a special project o the Ministryo Health, called the Menstrual Regulation Trainingand Services Programme (MRTSP, which later becamethe RHSTEP1). The programme was run by a steeringcommittee o doctors and government bureaucratschaired by the secretary o health (Ross, 2002). Financingo the MR Programme was taken over by the PopulationCrisis Committee, the Ford Foundation, and the SwedishInternational Development Cooperation Agency (Sida).By 1998, the other donors had pulled out o Bangladeshand Sida was the sole donor supporting the MRProgramme.

1In 2003, MRTSP changed its name to Reproductive Health ServicesTraining Education Project, or RHSTEP. To minimize conusionin this paper, we will reer to the organization as RHSTEP.


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Devolution rom the State to NGOs

From the 1980s, NGOs in Bangladesh became

increasingly responsible or the essential unctions o theMR Programme. A confuence o actors contributed tothe transition o the MR Programme rom a purely publicsector programme to a publicNGO sector partnership.First, a key MR Programme champion within the Ministryo Health and Population Control let the Ministry to takea position at an international organization (Ross, 2002).The weight o programme leadership was then in theNGO sector. A confict between the government and ThePathnder Fund over the training o paramedics in MRservices delivery possibly contributed to the transition,

as did strong conservative religious and even specicanti-abortion sentiment rom important internationalpolitical and economic partners. The transition wasnot unique, as the 1980s saw a trend in internationaldevelopment programming o increasing investmentsin NGO rather than public sector programmes (White,1999; Schurmann and Mahmud, 2009).

Three dierent NGOs were established to manage theMR Programme, all with complementary roles. In 1982,The Pathnder Fund assisted in the establishment othe Bangladesh Association or the Prevention o SepticAbortion (BAPSA) to research and monitor the MRProgramme, and contribute to programme logistics(Dixon-Mueller, 1988; Ross, 2002). The BangladeshWomens Health Coalition (BWHC) was also ormedat this time to provide MR training, service deliveryand advocacy. In 1991, RHSTEP became a nationallyregistered NGO when the Ministry o Health eliminatedall special projects. Donors unded these NGOs directly,and provided no nancial or technical MR Programmesupport to the government. While the aim o the FordFoundation and Sida was to have the Ministry o

Health and Family Welare (MOHFW) eventually takeover responsibility or the MR Programme, under thisstructure, government involvement with the essentialtraining, service delivery and logistical aspects o theprogramme diminished (Ross, 2002; Paulin and Ahsan,2003).

The MR Programme was and continues to beadministratively based in the Directorate General oFamily Planning (DGFP) within the MOHFW. The

DGFP works closely with the three NGOs RHSTEP,BAPSA and BWHC in implementing the programme.The MOHFW provides considerable support to theNGOs in the orm o clinic space and equipment orMR training and services (Akhter, 2001). RHSTEPremains the primary MR training organization in thecountry with training acilities located in 18 medicalcollege and district hospitals (RHSTEP, 2006); BAPSAremains responsible or coordinating the logistics o theMR Programme including liaising between MR traineesand training institutions, monitoring the distribution oMR equipment, and publishing the quarterly newsletterHealth and Rights2 (BAPSA, 2006; Hossain, 2008). BWHCcontinues to provide MR services and paramedic FWV

training in MR and other reproductive health services(Ahmed and Aroze, 2006).

As well as the three implementing NGOs, severalcommittees are in place to advise and supervise theMR Programme. The Coordination Committee o MRActivities in Bangladesh was established in 1987 with themembership o our MR organizations. The TechnicalAdvisory Committee or MR Activities was establishedin 1990 with the Director General o the DGFP aschairperson, and the Line Director o Maternal and Child

Health as secretary. While well designed in principle, inpractice these committees rarely meet and have littleimpact on programme coordination.

In 1997, a National Reproductive Health Strategy wasdeveloped, prioritizing our services in the area oreproductive health: sae motherhood, amily planning,MR and post-abortion care, and the management oreproductive tract inections and sexually transmittedinections. This was ollowed by the Maternal HealthStrategy in 2001, which gave less emphasis to MR. Boththese documents were designed to inorm the Health andPopulation Sector Programme (HPSP). Since 1997, MRis mentioned less requently and less explicitly in policydocuments.

Phase 3: The marginalization of MR(1998till date)

During the current phase, characterized by theimplementation o health sector reorm, the ocial

2 FormerlyThe MR Newsletter, Health and Rightsis distributed to 13 000 readers each quarter, and has our main aims: (1) provide clinicianswith essential inormation on sexual and reproductive health and rights; (2) sensitize public opinion on the consequences o septic abortion,(3) provide clinicians with updated technical knowledge and guidance in order to acilitate improvement in the quality o services, and(4) highlight the MR training needs among the potential providers o MR (BAPSA, 2005).


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language in the 2000 National Population Policy shitedrom the legalization language o 1976 to languageemphasizing the need to reduce unsae abortion.A continued conservative climate internationally,driven in part by the re-instituted US Mexico CityPolicy, contributed to the limited dynamism o theMR Programme. NGOs receiving USAID unds andproviding MR services lost unding; monitoring andevaluation o the programme came to a near standstill.Feminist and womens organizations in Bangladesh havenot embraced the MR agenda (Ross, 2002). Despite thesehurdles, at present there is a nascent sense o optimismor the provision o MR services in Bangladesh.

Health sector reorm

The health sector reorm process o the HPSP (19982003) presents another chapter in the evolution oreproductive health policy in Bangladesh. The goals o thepolicy in line with the ICPD agenda were primarily toreduce maternal and inant mortality and morbidity byreducing ertility to replacement level by the year 2005and by improving nutritional status (Germain, 1997;Bates et al., 2003). The reorm process was coordinatedby the World Bank and included a consortium o other

donors and the Government o Bangladesh. Donorinvestment was over US$ 350 million between 1999 and2003. The most signicant change o the HPSP was themerging o the Health and Family Planning Directorateso the MOHFW, which allowed or sectorwide provisiono amily planning and primary health-care services(however, this merging never eectively occurred). Theintegrated programme replaced the 125 vertical projectspreviously managed under the MOHFW (Chowdhury etal., 2003).

With the implementation o the HPSP in 1998, Sida andother donors began contributing non-earmarked undsdirectly to the MOHFW. Allocation o unds was to beguided by the ve-year sectorwide programme, with theshared assumption that the MOHFW would continue toissue contracts with the three MR NGOs as outlined in theHPSP Programme Implementation Plan. One expectedbenet was enhanced government ownership, and thusenhanced sustainability o the programme (Ross, 2002).However, the mechanism or unding the MR NGOswas unclear. Ater a lengthy competitive bidding processduring which the MR NGOs received no unding, in June

2002, the MOHFW signed a contract with one o theMR NGOs or the last year o the ve-year HPSP. Thisunding gap brought the MR NGOs to a near-collapse,and the quality o service provision was compromised

(Chowdhury et al., 2003; Johnston, 2004). In 2003,the MOHFW ormally requested Sida to renew directsupport to the MR NGOs. Sida responded positively andagreed to und the MR NGOs or one more year (Paulinand Ahsan, 2003).

Sida revised its unding strategy to reimburse NGOs orthe number o services perormed. Tellingly, and in linewith this implicit emphasis on service delivery, BAPSA,the MR research and monitoring organization, shitedits agenda to service delivery with some monitoring andlogistics unctions.

The 2001 reimposition o the US Governments Mexico

City Policy had a more widespread eect on MR servicedelivery compared with the original 1984 impositionbecause, over time in Bangladesh, numerous health-care service delivery NGOs had grown to play a role inMR service delivery. These NGOs tended to interpretthe policy cautiously, ending MR service provision andminimizing collaborations with MR NGOs in areassuch as training, workshops and reerrals, leading to theisolation o the MR NGOs rom the wider reproductivehealth proessionals community.

While USAID actively opposed MR service deliveryunder the Mexico City Policy, most other donors havebeen more neutral in their attitude toward MR. Donorneutrality has had the negative eect o allowing lesscontroversial priorities, such as Sae Motherhood, toconsume the MOHFWs nite resources and attention,leaving MR services relatively neglected. One example othis neglect is that no new FWVs have been recruited since1994. As the last generation o FWVs nears retirement, nonew cadre o paramedic providers is being trained in MRservices. Such a provider gap will cripple the programme.

The HPSP was ollowed by the Health and NutritionPopulation Sector Programme (HNPSP: 20032010),which ormally re-established amily planning andprimary health programmes as separate programmes.With delays in the implementation o the new plan, Sidaagreed to continue to provide unding to the three MRNGOs rom 2003 to 2010.

There is a sense o optimism or MR service delivery due tothe growth o internationally aliated Bangladeshi-runNGOs (Marie Stopes Clinical Society and Family Planning

Association o Bangladesh) making a commitment toscale up sae MR services. Additionally, internationaldonors including Sida and the Royal NetherlandsEmbassy have demonstrated their commitment to a


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sustainable MR Programme (Paulin and Ahsan, 2003;Johnson et al., 2006). The Asian Development Bank is alsosupporting MR as a core service in its widespread publicprivate partnership Urban Primary Health Care Project.However, the private sector remains largely unregulated,and untrained providers oer what may seem to the clientto be convenient and relatively inexpensive services. Thisis considered in the ollowing discussion on programmeimpact.

Impact of the MR Programme

The challenges o collecting data on abortion, a

marginalized and stigmatized topic in Bangladesh, limitour ability to assess the impact o the MR Programmeon reducing abortion-related mortality and morbidityor the equitability o impact. However, we can identiygeneral trends. For example, abortion data rom theInternational Centre or Diarrhoeal Disease Research,Bangladesh (ICDDR,B) demographic surveillance sites inthe predominately rural areas o Matlab, Abhoynagar andMirsarai suggest that marital abortion ratios (the numbero reported abortions divided by the number o reportedbirths in a given time period) and total marital abortionrates (the number o abortions a married woman wouldhave over her lietime i current age-specic abortion ratesprevailed) have on the whole increased over the time. Inthe rural riverine area o Matlab, with a population oaround 200 000, ICDDR,B administers an intensive amilyplanning programme in hal othe surveillance site, the otherhal benets rom the governmentprogramme and is consideredmore representative o nationaltrends. In the Matlab surveillancearea under the government amily

planning programme, the maritalabortion ratio has increased morethan veold rom the early 1980s,when it was close to 20 abortionsper 1000 live births, to over 100abortions per 1000 live births in2004 (Oliveras et al., 2008).

Abortion-related deaths havedecreased dramatically rom 17.7to 2.4 per 100 000 women o

reproductive age annually rom1976 to 2005 in the ICDDR,Bprogramme area, and rom 16.8

to 2.2 per 100 000 in the government programme area oICDDR,Bs Matlab Demographic Surveillance (Figure 1).The decrease in mortality is in part attributable to increase

in the use o contraception in both areas, rom 46% in1984 to 71% in 2005 in the ICDDR,B programme area,and rom 16% in 1984 to 47% in 2005 in the governmentprogramme area (see Rahman et al., 2001). That thedierences in rates o abortion-related mortality areminimal between the two areas while the dierences inrates o contraceptive prevalence are substantial suggeststhat actors in addition to contraceptive use are at workin reducing abortion-related mortality.

Verbal autopsy data rom the Matlab ICDDR,B

programme area show a decrease in abortion-relatedmortality as a percentage o maternal mortality, rom 24%o maternal mortality in the decade 19761985 to 11%o maternal mortality in the period 19962005. The shithas been less dramatic in the comparison area, rom 17%o maternal mortality to 15% o maternal mortality in thesame time periods (data not shown) (Chowdhury et al.,2007; Oliveras et al., 2008). The Matlab government areaestimate o 15% o maternal mortality caused by unsaeabortion is considered the best estimate o abortion-related mortality as a percentage o maternal mortalityor Bangladesh.

These data show that along with the scale up o the MRProgramme, there has been an increase in reported MRand a decrease in deaths rom unsae abortion. While

20

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16

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10

8

6

4

2

0

17.7

16.8

7.9

8.8

2.4

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199620051986199519761985

ICDDR,B area Government area

ICDDRB Area

Figure 1. Abortion-related deaths per 100 000 women o reproductive age, Matlab 19762005

Data sources: ICDDR,Bs Matlab maternal mortality verbal autopsy 19762005dataset and ICDDR,B Matlab health and demographic surveillance system dataset


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this does not imply causality, it is consistent with MRProgramme success in reducing mortality related tounsae abortion (Oliveras et al., 2008).

The volume o services provided also speaks o theimpact o this programme. The MOHFW reports 124 045MR procedures perormed at government and MR NGOacilities in 2006. About hal o these were perormed atgovernment clinics, and hal at the MR NGO acilities.MR NGOs reported providing over 60 000 MR services in200405 and 200506, with the bulk o these proceduresperormed at RHSTEP clinics located in governmentacilities. These data are widely believed to substantiallyunderestimate the number o MR procedures provided

in the public and NGO sectors and do not include MRsperormed in the or-prot private sector (Begum et al.,1987; Amin et al., 1989; Chowdhury et al., 2003).

While ew studies have been conducted, the available datasuggest that vulnerable populations remain at relativelyhigh risk o death rom unsae abortion. Complementingquantitative data rom Matlab, which highlight therelationships between socioeconomic status and unsaeabortion, qualitative data suggest that materiallyimpoverished women preer inormal sector services as

providers in the public sector are rude to poor women(Johnston, 1999).

In a study conducted in 1997 in rural Bangladesh,women reported that the readily available, inormallytrained, unauthorized private sector providers in theircommunities better met their priorities o condentialservices, good behaviour to the client, and low cost at least initially. The study showed that among the108 attempted pregnancy terminations that werereported, 27 women (25%) accessed care rom the

trained government provider. Thirty-one women (29%)attempted to sel-induce abortion; 29 women (27%) usedvillage homeopath techniques to abort; 13 women (12%)used techniques rom the inormally trained villagepharmacist; and 8 (7%) went to the kabirajor traditionalhealer or an abortion. Sixty-two per cent o rst attemptsat abortion ailed, leaving women to attempt abortion asecond and, or some, a third time (Johnston, 1999). Theleading medical college hospital in the capital city, Dhaka,reports that the majority o patients in their obstetricsand gynaecology ward are women presenting with

complications o unsae abortion (Rashid M, Proessorand Head, Department o Obstetrics and Gynecology,Dhaka Medical College and Hospital, Dhaka, Bangladesh,personal communication, 28 March 2009).

Despite the successes o the MR Programme, manysocially and economically disadvantaged women stilldo not access government services and, or a number oreasons considered below, turn to the inormal sector orpregnancy termination. That an estimated 15% o 21 000pregnancy-related deaths (Oliveras et al., 2008; WHO,2007b), or 3150 lives in Bangladesh are lost annually tounsae abortion, and that these deaths are concentratedamong the poor and uneducated, demonstrates a needto rethink the strategies o this innovative and lie-saving programme to make it better meet the needs o allwomen, regardless o socioeconomic status.

Socioeconomic context: barriers toequitable access

For the programme to meet the needs o womenregardless o socioeconomic status, the strategies o theMR Programme must reach beyond the health systemand address the social, cultural, political and economicdeterminants o health. In this section, we briefydescribe the societal barriers that can prevent womenrom accessing sae MR care.

Poor quality o care can turn clients away rom publicsector acilities. Qualitative studies indicate that cliniciansprovide an uneven quality o services depending on thecharacteristics o the client. Examples o poor qualityservice include clinicians not eliciting patient histories,not listening to patients, allowing patients to plead orservices and charging or services that are meant to beree (Schuler and Hossain, 1998). Clinicians sometimesunairly reuse to provide MR especially in circumstancesin which the client is unmarried or the pregnancy is theresult o rape (Begum et al., 1987).

Despite MR services ostensibly being provided ree ocharge in government clinics, ew women pay nothing. Inone study, only 11% o women reported receiving servicesree o charge (Akhter, 1988). Reported expendituresvaried greatly 19% paid less than 100 taka (US$ 1.47),18% paid 5001000 taka (US$ 7.3514.70) and 19% paidover 1000 taka. Other evidence suggests that MR servicescan be reused in the ree clinic and instead provided aterhours at a charge, sometimes using the public acilities(Piet-Pelon, 1998; Caldwell et al., 1999).

Unocial ees oten coexist with ree services inBangladesh. Illegal ees inordinately aect the poor, whoare less likely to question the provider or understand thehealth-care system. The lowest income category has been


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ound to pay 143% o the charges o the highest incomecategory or public sector care (Killingsworth et al., 1999).

The high level o variation in ees refects inequity inaccess to services. Reasons or variation in patient eesor MR include: marital status, with unmarried womenpaying more; duration o gestation, with women withlonger gestation periods paying more; and the dierenttypes o pain management provided. In addition to suchees are the cost o patient travel, opportunity costs andlost income or the client and accompanying caregivers,drugs, and clinic or hospital admission ees. Fees or thetreatment o abortion complications ollow a similarpattern.

In Bangladesh, clientpatron relationships shape powerhierarchies. As such, clients are beneciaries o patronavours rather than citizens with rights (Blair, 2005).Patronclient relationships impact the health sector asclients rely on personal relationships to get better qualityor lower cost services, through waiving o unocial ees,or example. Schuler et al. (2002) ound a perceptionthat without such a relationship, service quality or thepoor would be lower and the price higher, and that onlythe wealthy can get good health care. The wealthy are

less oten approached or unocial ees, and are betterpositioned to demand quality services due

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