sadia chowdhury the world bank december 7, 2009 the world bank’s reproductive health action plan...

Sadia ChowdhuryThe World BankDecember 7, 2009

The World Bank’sReproductive Health Action

Plan2010-2015

Draft for Discussion


Plan2010-2015

Draft for Discussion

Draft - Not for Quotation

RH is Key for Human Development

Improved RH outcomes have broad-based individual, family, and societal benefits, including:• A healthier and more productive workforce• Greater financial and other resources for each

child (“quantity-quality” trade-off)• Enabling young women to delay child-bearing

until they have been able to achieve education and other goals

• A potential demographic “dividend”: lower-dependency ratios, higher savings rates which can be powerful stimulant for economic growth

• Ensuring women’s full participation in the development process

12/03/2009 Draft - Not for Quotation 2

Appalling Lack of Progress in RH outcomes

MMR has declined at less than 1% per year during 1990-2005• 500,000 women die each year during child-birth,

mainly in sub-Saharan Africa and South Asia • 70,000 of these are due to unsafe abortion

High fertility continues to constrain human development• In 28 countries, mainly in sub-Saharan Africa,

fertility rates are in excess of 5

Incidence of STIs (including HIV) among women 15-24 is unacceptably high• 29 countries have HIV prevalence greater than 1.3%

among women 15-24

12/03/2009 3Draft - Not for

Quotation

RH Issues Losing Prominence Original MDG framework had no targets related

to RH (except for MMR)• RH targets such as contraceptive prevalence rates,

adolescent fertility rates, unmet need for family planning, and antenatal coverage included in MDGs included only in 2007

High-burden countries themselves have not focused enough attention on RH issues

Although levels of ODA for RH have increased somewhat, share of health ODA to RH has declined• Similar trend in evidence at the Bank as well


RH Issues Losing Prominence

Draft - Not for Quotation 5

HIV/AIDS

Total health

RH050

0010

000

1500

0co

nsta

nt U

S$

mill

ions

1995 1998 2001 2004 2007Year

ODA commitments for health, 1995-2007All recipients

1020

30P

erc

ent

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

Share of health ODA to RH, 1995-2007All recipients

HIV/AIDS

Total health

RH050

0010

000

1500

0co

nsta

nt U

S$

mill

ions

1995 1998 2001 2004 2007Year

ODA commitments for health, 1995-2007High MMR-High TFR countries

1020

30P

erc

ent

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

Share of health ODA to RH, 1995-2007High MMR-High TFR countries

Source: OECD DAC

12/03/2009

Emerging Consensus, Window of Opportunity

Emerging global consensus has re-focused attention on RH, offering an unprecedented opportunity to redress the neglect of RH

Key interventions (and costs) for improving RH outcomes are known:• Access to family planning• Skilled attendance at birth• Emergency obstetric care

Challenge is to translate knowledge to action and scale-up:• Strong political commitment and leadership to

ensure focus and resources for RH• Incentives for performance and accountability for

results• Women’s education and empowerment12/03/2009 Draft - Not for Quotation 6

The Bank’s RH Action Plan The Action Plan is aimed at reinvigorating the Bank’s

commitment to help countries improve their RH outcomes, particularly for the poor and the vulnerable and in the context of the Bank’s overall strategy for poverty alleviation

The HNP Strategy defines population and reproductive health as: a. “Reproductive, maternal, and sexual health issues

and the health services that are concerned with addressing them.

b. Levels and trends in births, deaths, and migration that determine population growth and age structure, and frequently have an impact on economic growth, poverty, labor markets, and other sectors.”

This RH Action Plan is a detailed operationalization of the RH component of the Bank’s HNP Strategy


Maternal Mortality and Fertility are Correlated

12/03/2009 8Draft - Not for

Quotation

Belize

Botswana

EthiopiaNigeria

Chad

Uganda

Ukraine

Brazil

Mali

Niger

China

IndonesiaIndia

Mexico

Poland

Bangladesh

Egypt

550

100

220

500

1500

Mat

ern

al m

ort

alit

y ra

tio (

MM

R)

1 1.5 2 2.5 3 4 5 6 7Total fertility rate (TFR)

Source: WDINote: Median TFR=3; Median MMR=220Note: Colors mark HIV prevalence among females aged 15-24Red=high prevalence (greater than 1.3%)Yellow=middle prevalence (between 0.3% and 1.3%)Green=low prevalence (less than 0.3%)

Maternal mortality vs fertility in developing countries, 2005

Heterogeneity within Quadrants

12/03/2009 9

24

68

24

68

1960 1970 1980 1990 2000 2007 1960 1970 1980 1990 2000 2007

Chad Mali

Niger Uganda

Tota

l fer

tility

rat

e

YearSource: WDI

In some countries, RH outcomes have been stagnant


Heterogeneity within Quadrants

12/03/200910


Benin

DjiboutiEthiopia

IndonesiaIndia

Kenya

Mali

Niger

Nigeria

Peru

Chad

South Africa

Afghanistan

Angola

Bangladesh

Botswana

Congo

Guatemala

Nepal

Sierra Leone

Uganda

22

050

010

00

15

00

20

00

Mate

rna

l m

ort

alit

y r

atio

(M

MR

)

0 20 40 60 80 100Skilled birth attendance (%)

MMR vs skilled birth attendance

Bangladesh

Egypt

Ethiopia

India

Niger

Nigeria

Chad

Ukraine

Benin

Congo

Indonesia

Kenya

Mali

Nepal

Uganda

12

34

56

78

Tota

l fe

rtili

ty r

ate

(T

FR

)

0 10 20 30 40Unmet need for contraception (%)

TFR vs unmet need for contraception

Source: WDI & DHS

In-Country Variations Can Be Significant


Kerala

Tamil Nadu

Rajasthan

Uttar Pradesh

Chattisgarh

020

4060

8010

0P

erce

ntag

e in

stitu

tion

al d

eliv

erie

s (%

)

0 20 40 60Percent of births of parity 3 or higher (%)

Source: DLHS-III

Institutional deliveries vs fertility rates across districts in India, 2007-08

Country Wealth quintile

Lowest Second Middle Fourth Highest Total

Bangladesh 2007 3.2 3.1 2.7 2.5 2.2 2.7

Colombia 2005 4.1 2.8 2.4 1.8 1.4 2.4

India 2006 3.9 3.2 2.6 2.2 1.8 2.7

Namibia 2007 5.1 4.3 4.1 2.8 2.4 3.6

Philippines 2003 5.9 4.6 3.5 2.8 2.0 3.5

12/03/2009

11

Strategic policy objectives:• Helping countries address high fertility• Helping countries to improve pregnancy outcomes• Helping countries reduce sexually transmitted

infections

How would Bank contribute to the above?• Leveraging partners to give high priority to RH

issues and increase financing• Strengthening country health systems and multi-

sectoral approaches to improve RH outcomes• Promoting high-level policy dialogue on RH at global

and national levels12/03/2009 Draft - Not for

Quotation

The Bank’s RH Action Plan highlights SIX focus areas

12

Helping countries address high fertility

Strengthen family planning policies and program management

Ensure availability of contraceptives, including supply-chain management

Support provision of quality family planning services

Enhance knowledge and awareness and other interventions to generate demand

Draft - Not for Quotation12/03/2009

13

Helping countries improve pregnancy outcomes

Ensure all deliveries are attended by trained personnel

Ensure access to and promote utilization of antenatal, emergency obstetric, post-natal and neonatal care

Promote awareness of pregnancy-related health risks and proper nutrition during pregnancy

12/03/2009 14Draft - Not for Quotation

Helping countries reduce STIs

Implement programs aimed at prevention of mother-to-child transmission of HIV

Promote use of condoms for protection against STIs and prevention

Support provision of voluntary counseling and testing

Ensuring appropriate focus on men as well as women


Strategic Policy ObjectivesObjective Final

outcomes (country level)

Intermediate indicators (country level)[1]

How does the Bank contribute to these results?

Reducing high fertility

TFR reduced CPR in target countries increased to allow women to reach desired family size. Current level: 26%

Unmet need for contraception in target countries reduced to eliminate mistimed or unwanted births. Current level: 24%

Number of target countries with family planning policies developed. Current level: X

Number of target countries with no stock outs of contraceptives in the preceding year. Current level: X

Leveraging partners-Strengthen engagement with global partners including H4, PMNCH, IHP+, WB-GAVI-GF HSS platform-Develop/update joint H4 National Work Plan in targeted countries-Facilitate procurement of contraceptives and other RH supplies through existing agreements with UN agencies -Convene partners in countries to harmonize and finance RH activities

Support development & strengthen capacity in:-Contraceptive and RH supplies logistics and supply chain management- RH program management including quality of care-HR management plans including training and deployment , especially of midwives

(continued on next slide)

[1] Targets for intermediate country outcomes should be developed on the basis of current levels and trends, additional inputs, and country commitment and capacity.

Strategic Policy Objectives (contd.)Objective

Final outcomes (country level)

Intermediate indicators (country level)[1]

How does the Bank contribute to these results?

Improvingpregnancy outcomes

MMR reduced Births attended by skilled health personnel in target countries increased. Current level: 43%

Adolescent fertility rate in target countries reduced. Current level: 99 births per 1,000 women aged 15-19

Pregnant women receiving prenatal care in target countries increased. Current level: 78%

Newborns protected against tetanus in target countries increased. Current level: 80

(…continued from previous slide)

Support development and strengthening of capacity in:- Community-based outreach RH services- Health information systems for evidence based decision making and monitoring of progress

Promoting high-level policy dialogue- Ensure that country CASs, CEMs, PERs, and PRSPs address RH issues and identify appropriate actions - Help countries set RH as a priority in national budgets and development plans through engagement with MOF/MOP/MOH- Target lending operations to address key RH issues- Promote engagement with CSOs in country dialogue on RH issues

Reducing STIs

HIV infections reduced

Number of target countries with PMTCT programs increased. Current level: X

Number of target countries promoting RH-HIV linkages increased. Current level: X

[1] Targets for intermediate country outcomes should be developed on the basis of current levels and trends, additional inputs, and country commitment and capacity.

Leveraging partners

Strengthen engagement with global partners including H4, PMNCH, IHP+, WB-GAVI-GF HSS platform

Develop/update joint H4 National Work Plan in targeted countries

Facilitate procurement of contraceptives and other RH supplies through existing agreements with UN agencies

Convene partners in countries to harmonize and finance RH activities


Strengthening health systems to improve RH outcomes

Support development and strengthening of capacity in:• Contraceptive and RH supplies logistics and supply

chain management• RH program management including quality of care• HR management plans including training and

deployment, especially of midwives• Community-based outreach RH services• Health information systems for evidence based

decision making and monitoring of progress• Address governance issues

Going beyond the health sector (e.g., microfinance)12/03/2009 19Draft - Not for Quotation

Promoting high-level policy dialogue

Ensure that country CASs, CEMs, PERs, and PRSPs address RH issues and identify appropriate actions

Help countries set RH as a priority in national budgets and development plans through engagement with MOF/MOP/MOH

Promote engagement with CSOs in country dialogue on RH issues

Recognition and engagement with other private sector actors

Draft - Not for Quotation 2012/03/2009

Issues on which we seek guidance and feedback

Have we covered all the critical RH issues in this action plan?

Do we have the right model and approach in our thinking?

Do we have the right interactions and partnership arrangements?

What outcome indicators should we track? Should lending levels for RH be a target?

How will we know that we have been successful?

Draft - Not for Quotation 2112/03/2009

Sadia [email protected]


Plan2010-2015

Comments and Suggestions


Plan2010-2015

Comments and Suggestions


2212/03/2009

sadia chowdhury the world bank december 7, 2009 the world bank’s reproductive health action plan...

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