63543 May 2010 The World Bank Better Health for Women and Families: The World Bank's Reproductive Health Action Plan 2010–2015 Better Health for Women and Families: The World Bank’s Reproductive Health Action Plan 2010–2015 June 2010 iii Contents Foreword v Acronyms and Abbreviations viii Acknowledgments x Introduction 1 Context 3 Challenges and Solutions 11 The Bank’s Action Plan 20 Country focus 20 Health System Strengthening 23 Reaching the Poor 28 Reaching Adolescents 29 Working with Partners and Civil Society 32 Results Framework 33 Annex A. Consultations on the Reproductive Health Action Plan 38 Main Outcomes of External Consultations 38 Consultation Logistics: Locations, Dates, and Participants 47 Annex B. Outline of African Region Population and Reproductive Health Strategic Plan 50 Background 50 Recent Developments 52 The Way Forward 53 Expected Results and Outcomes 55 Annex C. Global Consensus on Maternal, Newborn and Child Health 56 Annex D. Joint World Bank, WHO, UNICEF and UNFPA Statement on MNCH 57 Annex E. Acknowledgments – Longer Version 58 End Notes 62 iv Boxes Box 1. How Many Maternal Deaths in the World? 3 Box 2. Countries Classified According to MMR and TFR 22 Box 3. Reaching the Poor — Lessons from Success Stories 31 Figures Figure 1. Trends in Fertility by Region, 1950–2000 5 Figure 2. Trends in Total Fertility Rates in Chad, Mali, Niger, and Uganda, 1960–2007 6 Figure 3. Infant Mortality and Total Fertility Rates in Developing Countries, 2005 7 Figure 4. Desired and Actual Total Fertility Rate in Selected Countries 8 Figure 5. Official Development Assistance for Health and its Composition, 1995–2007 12 Figure 6. Deliveries by C-Section 15 Figure 7. Physicians per 10,000 Population 16 Figure 8. Percentage of Births Attended by Skilled Personnel and the Maternal Mortality Ratio (per 100,000 births) 17 Figure 9. Government Effectiveness (percentile rank) 18 Figure 10. Maternal Mortality Ratios Versus Total Fertility Rates in Developing Countries, 2005 21 Figure 11. Countries Classified According to MMR and TFR 23 Tables Table 1. Total fertility Rates by Wealth Quintiles (selected countries) 6 Table 2. Proportion of Births Attended by Skilled Health Personnel 14 Table 3. Country Characteristics Based on MMR and TFR Classifications 21 Table 4. Percentage of Currently Married Women (15–49) Using a Modern Family Planning Method 28 Table 5. Menu of Pro-poor Policies 30 Table 6. Results Framework for the Reproductive Health Action Plan 35 Better Health for Women and Families | The World Bank’s Reproductive Health Action Plan 2010–2015 v Foreword V astly better health for women and fam- 35 highest-fertility countries in Africa, Asia, ilies lies at the heart of the transfor- and the Middle East, aid for women’s family mational promise of the Millennium planning and reproductive programs started Development Goals (MDGs) for 2015. The at US$150 million in 1995 and increased to landmark 1994 Cairo International Confer- US$432 million in 2007, while overall aid for ence for Population and Development had health in these countries went from US$915 earlier recognized the vital importance of million to US$4.9 billion. women’s health to development progress in Over the last 18 months, however, the de- calling for a comprehensive approach to re- velopment community has put reproductive productive health. In the years immediately health back in the vanguard of development following the conference, reproductive health priorities, spurred on by the realization that as gained much-needed prominence. But by the the 2015 deadline for the Millennium Devel- turn of the century, family planning and other opment Goals gets closer, MDG 5—reducing reproductive health programs vital to poor maternal mortality and achieving universal ac- women had fallen off the development radar cess to reproductive health—has shown the of many countries, donors, and aid agencies. least progress of all the MDGs. This inattention was despite the reproductive For its part, the World Bank has released health ordeal lived out by women in many a new five-year Action Plan to help 57 coun- low-income countries worldwide. tries with high maternal death and fertility Globally, more than 350,000 women die rates improve their reproductive health ser- each year because of pregnancy and childbirth vices and prevent the widespread deaths of complications, 99 percent of them in devel- mothers and children. Given the weak state of oping countries. Thirty-five poor countries, health systems in many countries, the Bank is mainly in Sub-Saharan Africa, have the world’s working closely with governments, aid donors highest birth rates (more than five children per and agencies, and other partners to strengthen mother). They are also home to some of the these systems so that women gain significantly world’s poorest social and economic results, better access to quality family planning and with low levels of education, high death rates, other reproductive health services, skilled mid- and extreme poverty. wives at their births, emergency obstetric care, Many poor women turn to abortion as and postnatal care for mothers and newborns. a last-resort means of birth control. Some Under its new Action Plan, which bene- 68,000 women die each year from unsafe fited greatly from extensive consultations with abortions, while another 5.3 million suffer global and national partners as well as civil temporary or permanent disability. In the society organizations, the Bank will help im- vi prove reproductive health systems in the fol- death rates in North Africa, East Asia, South- lowing ways: east Asia, and Latin America and the Carib- bean share many common features: greater More contraception—The first step to avoid use of contraception to delay and limit child- maternal deaths is to ensure that women bearing and better access to high-quality ob- have access to modern contraceptives and the stetric care services. ability to plan their families. At the country level, a sound logistics system can distribute Expand girls’ education—High birth rates are contraceptives and other reproductive health closely allied with fragile health, little or no supplies efficiently so that each clinic or phar- education, and entrenched poverty. Analysis of macy has enough stock on hand to meet cli- demographic and health surveys in all regions ents’ needs. shows that women with secondary or higher education have fewer children than women Skilled attendance at birth—Women who con- with primary or no education. Time and tinue pregnancies need care during this critical again we see how girls’ education provides life- period for their and their babies’ health. Since saving knowledge, builds job skills that allow the 1990s, the presence of skilled birth atten- women to join the workforce and marry later dants at delivery has increased in all devel- in life, and gives them the power to say how oping regions, though the percentage of births many children they want and when. These attended by skilled health personnel stands at are enduring qualities that women will hand only 44 percent in Sub-Saharan Africa and 42 down to their daughters as well. percent in Southern Asia. Work closely with lead health agencies—The Spread preventive knowledge—Most maternal new Bank Action Plan strongly welcomes the deaths are avoidable, and the health care so- re-emergence of maternal and child health as lutions to prevent or manage the complica- a priority among countries, donors, and other tions are well known. It is widely recognized partners, which has jumpstarted more than that skilled care at childbirth is most impor- 80 new national and international partner- tant for the survival of women and their ba- ships, including the Partnership for Maternal, bies, and that the availability of qualified and Newborn and Child Health. In addition, an trained health personnel to assist deliveries informal group of heads of four health-related can ensure better pregnancy outcomes. Yet a organizations (WHO, UNICEF, UNFPA, third of all deliveries occur without a skilled and the World Bank—called the “H-4”) attendant. meets regularly on measures to strengthen country efforts to improve maternal and child Train new health workers—An important way health and avoid fragmentation of donor ef- to strengthen health systems is to train new forts and financing (such as harmonizing and health workers, strengthen the skills of the ex- coordinating the efforts of donors at country isting health workers with midwifery skills, level to support countries to improve ma- and deploy them effectively. Falling maternal ternal health). Better Health for Women and Families | The World Bank’s Reproductive Health Action Plan 2010–2015 vii Investing in family planning is also im- productive Health Action Plan reaffirms the portant for HIV prevention, especially by World Bank’s commitment to helping coun- preventing mother-to-child transmission. tries mobilize the financing and the technical Women’s economic empowerment is a big part expertise they will need to achieve the two tar- of the fight against poverty, and better repro- gets of MDG 5: to reduce maternal mortality ductive health affords women and their fami- and achieve universal access to reproductive lies a better chance to achieve that. Healthier health by 2015. mothers can take better care of themselves and their children, invest in their well-being, and help them become more productive members Tamar Manuelyan Atinc of society as adults. Vice President With 2010 marking the start of the five- Human Development Network year countdown to the MDGs, this new Re- The World Bank viii Acronyms and Abbreviations AAA Analytic and Advisory Services ICR Implementation Completion Report AFR Africa IDA International Development CAS Country Assistance Strategy Association CCT Conditional Cash Transfers IEG Independent Evaluation Group CSO Civil Society Organization IHME Institute for Health Metrics and DALY Disability Adjusted Life Years Evaluation DEC Development Economics IHP International Health Partnership DHS Demographic and Health Survey IHP+ International Health Partnership DPT 3 Diphtheria Polio Tetanus 3 and related initiatives EAP East Asia and Pacific IUD Intra-uterine Device ECA Europe and Central Asia LCR Latin America and Caribbean FIGO International Federation of MDG Millennium Development Goal Gynecology and Obstetrics MMR Maternal Mortality Ratio GAVI Global Alliance for Vaccines and MNA Middle East and North Africa Immunization MNH Maternal and Neonatal Health GDP Gross Domestic Product MTCT Mother to Child Transmission GFATM Global Fund for AIDS, MTR Mid-Term Review Tuberculosis and Malaria NGO Non-governmental Organization GNI Gross National Income ODA Official Development Assistance HDN Human Development Network PMNCH Partnership for Maternal, Newborn HDNHE Human Development Network and Child Health Health PMTCT Prevention of Mother to Child HIV Human Immunodeficiency Virus Transmission HIV/AIDS Human Immunodeficiency Virus/ PREMGE Poverty Reduction and Economic Acquired Immunodeficiency Management Network, Gender Syndrome QER Quality Enhancement Review HLTF High Level Task Force on RBF Results Based Financing Innovative Financing RH Reproductive Health HNP Health, Nutrition, and Population RHAP Reproductive Health Action Plan HSO Health Systems for Outcomes RHSC Reproductive Health Supplies ICM International Council of Midwives Coalition ICPD International Conference on SAR South Asia Region Population and Development SBA Skilled Birth Attendant Better Health for Women and Families | The World Bank’s Reproductive Health Action Plan 2010–2015 ix SGA Small for Gestational Age UNFPA United Nations Population Fund SRH Sexual and Reproductive Health UNICEF United Nations Children’s Fund SSA Sub-Saharan Africa USAID United States Agency for STI Sexually Transmitted Infection International Development TFR Total Fertility Rate WBI World Bank Institute UNAIDS United Nations Joint Programme WDI World Development Indicators on HIV/AIDS WHO World Health Organization x Acknowledgments T he World Bank’s Reproductive Health (Director, Strategy and Operations, AFRVP), Action Plan was prepared by a team Shahrokh Fardoust (Director, Operations and led by Sadia A. Chowdhury (Senior Strategy DECOS), Hartwig Schafer (Director, Health Specialist, HDNHE), and composed Strategy and Operations, SDNSO), Penelope of Ajay Tandon (Senior Health Economist, J. Brook (Director, Indicators and Analysis, EASHH), Eduard Bos (Lead Population Spe- FPDVP), Emmanuel Jimenez (Sector Di- cialist, HDNHE), Samuel Mills (Consul- rector, EASHD), Mayra Buvinic (Sector Di- tant, HDNHE), Seemeen Saadat (Consultant, rector, PRMGE), Juan Pablo Uribe (Sector HDNHE), Geir Solve Sande Lie (Junior Pro- Manager, EASHH), Julie McLaughlin (Sector fessional Associate), and Victoriano Arias Manager, SASHN), Eva Jarawan (Sector Man- (Program Assistant, HDNHE). ager, AFTHE), Abdo Yazbeck (Sector Man- The team is grateful for the intense inputs ager, ECSH1), Akiko Maeda (Sector Manager, and overall guidance provided by Julian Sch- Health, Nutrition and Population, MNSHD), weitzer (Acting Vice President, HDNVP, and and Adam Wagstaff (Research Manager, Sector Director, Health, Nutrition, and Popu- DECHD). We are especially grateful for the lation) and Mukesh Chawla (Sector Manager, detailed comments and continued feedback HDNHE). provided by colleagues from the Africa and Overall guidance was also provided by Pa- South Asia regions as well as the Gender Unit mela Cox (Regional Vice President, LCRVP), of the Poverty Reduction and Economic Man- Philippe Le Houérou (Regional Vice President, agement network. A comprehensive list of ac- ECAVP), James W. Adams (Regional Vice Pres- knowledgements is in annex E. ident, EAPVP), Jeffrey S. Gutman (Vice Presi- Special gratitude is due to the government dent and Head of Network, OPCVP), Axel officials, global partners, civil society organi- Van Trotsenburg (Vice President, CFPVP), zations, academia, and the Bank management Marwan Muasher (Senior Vice President, and staff who generously provided the team EXTVP), Milan Brahmbhatt (Adviser and with valuable recommendations and guidance Acting Vice President, PRMVP), Axel Peuker on how the Bank can better support client (Acting Vice President and Corporate Sec- countries to improve reproductive health out- retary, SECVP), Vinod Thomas (Director- comes. General and Senior Vice-President, IEGDG), The team would also like to thank Global Rakesh Nangia (Director, Strategy and Op- Health Council, Harvard Global Equity Ini- erations, HDNVP), Xian Zhu (Director, Op- tiative, the Organizers of the International erations and Strategy, SARVP), Colin Bruce Conference on Family Planning in Kampala, Better Health for Women and Families | The World Bank’s Reproductive Health Action Plan 2010–2015 xi Uganda (November 2009), and Bank staff, es- paring the manuscript, Bruce Ross-Larson at pecially Phillip J Hay (Communications Ad- Communications Development Incorporated visor HDNOP), Carolyn Reynolds (Senior for editing, and Jana Krystene Brooks (Con- Communications Officer, HDNOP), Sukanya sultant, HDNHE) for designing the cover, Venkataraman (Program Assistant, HDNOP), and Erika Yanick (Information Specialist, and Melanie Mayhew (Communications Of- HDNHE) for the webpage. ficer, HDNOP) for their support and assis- We would also like to thank the govern- tance in making the external consultations ment of the Netherlands, which provided possible. financial support through the World Bank- We would like to acknowledge the Of- Netherlands Partnership Program (BNPP) for fice of the Publisher, The World Bank, for pre- background analysis and country profiles. 1 Introduction R eproductive health is a key facet of Improvements in reproductive health human development. Improved repro- have generally lagged improvements in ductive health outcomes—lower fertility other health outcomes in many low-income rates, better pregnancy outcomes, and fewer countries. The Millennium Development sexually transmitted infections—have broader Goal (MDG) for maternal health has seen the individual, family, and societal benefits. The least progress of all the MDGs.4 Many low-in- benefits include a healthier and more produc- come countries continue to have high fertility, tive work force, greater financial and other re- high rates of unmet need for contraceptive sources for each child in smaller families, and services, and very high maternal mortality. enabling young women to delay childbearing Twenty-eight countries—mostly in Sub-Sa- until they have achieved educational and haran African—have total fertility rates (TFR) other goals.1 Many studies have demonstrated in excess of five births per woman.5 Even in that poor reproductive health outcomes— countries with relatively good reproductive early pregnancies, unintended pregnancies, health outcomes, access to family planning, excess fertility, and poorly managed obstetric antenatal care, and delivery assistance among complications—adversely affect the opportu- the poor and other vulnerable groups tends to nities for poor women and their families to be far worse than the national average.6 escape poverty.2 Reproductive health issues have only Women’s full and equal participation in recently begun to be a priority in the de- the development process is contingent on velopment agenda. Even though official accessing essential reproductive health ser- development assistance (ODA) for repro- vices, including the ability to make volun- ductive health has increased, the share of tary and informed decisions about fertility. health ODA going to reproductive health Men also play an important role in supporting declined in the past decade. A similar trend a couple’s reproductive health needs, especially is evident at the World Bank, where the share since they often influence the effective use of of reproductive health in the health portfolio contraceptive methods and seeking maternal declined from 18 percent in 1995 to 10 per- health care services.3 Reductions in fertility cent in 2007, even though some of the decline lead to low youth dependency and a high ratio has been offset by increases in commitments of working people to total population, cre- for health system strengthening. The reduced ating a demographic window of opportunity focus on reproductive health at the Bank is not for output per capita to rise and countries to limited to financing: a recent IEG evaluation enjoy a demographic dividend. found that substantive analyses of reproductive 2 health issues rarely figured in the Bank’s pov- This document presents a detailed op- erty assessments, even in high TFR countries.7 erationalization of the reproductive health A renewed global consensus on the component of the Bank’s 2007 Health, Nu- need to make progress on MDG 5, to- trition, and Population (HNP) Strategy.9 gether with greater attention to gender In tandem with the global re-emphasis of re- issues within and outside the Bank, is re- productive health and in recognition of its focusing attention on reproductive health importance for human development, this Ac- and offering an unprecedented opportu- tion Plan aims to reinvigorate the Bank’s com- nity to redress the neglect of the previous mitment to helping client countries improve decade. Notable among these developments their reproductive health outcomes, particu- is that the UN fully incorporated reproduc- larly for the poor and the vulnerable and in tive health in the MDG framework in 2007. the context of the Bank’s overall strategy for There is now a new Partnership for Ma- poverty alleviation. It underscores the Bank’s ternal, Newborn, and Child Health aimed strong commitment to reproductive health at raising awareness and advocacy related to in line with the Program of Action of the reproductive and child health. New initia- 1994 International Conference on Popula- tives, including the Global Campaign for the tion and Development and presents specific Health MDGs, focus specifically on maternal activities—global and national—to improve and child health. The High Level Task Force reproductive health outcomes in target coun- on Innovative Financing, co-chaired by the tries.10 The Action Plan outlines activities that Bank, has recently helped raise awareness and the Bank will undertake to serve client coun- suggested options for helping bridge national tries in their efforts to improve reproductive financing gaps for attaining MDGs 4 and 5. health outcomes. Within the broader frame- The Bank, together with UNFPA, UNICEF, work of health system strengthening, the Plan and WHO, has signed the UN Joint State- proposes helping countries to address high ment on Maternal and Neonatal Health, for fertility, improve pregnancy outcomes, and re- the four organizations to work with country duce sexually transmitted infections.11 governments to ensure that core interven- The remainder of this document is orga- tions for addressing maternal and neonatal nized as follows. Section 2 describes the con- health are addressed in the national health text for this Action Plan. Section 3 discusses plans, including IHP+ compacts, and that some of the challenges that may constrain this is translated into action on the ground.8 countries and development partners in finding In addition, the Bank has renewed its com- solutions to reproductive health issues. Details mitment to increase investments in gender of the Action Plan are presented in section 4. through addressing adolescent motherhood as A Results Framework is in section 5. The de- a priority area for the sixteenth replenishment velopment of the Action Plan has been guided of IDA resources. by an extensive internal and external consulta- tive process; full details are in annex A. Better Health for Women and Families | The World Bank’s Reproductive Health Action Plan 2010–2015 3 Context M illennium Development Goal 5 calls Republic of the Congo, Guinea-Bissau, Li- for a reduction in the maternal mor- beria, Malawi, Niger, Nigeria, Rwanda, Sierra tality ratio (MMR) by three-quarters Leone, and Somalia.13 Globally, more than between 1990 and 2015, equivalent to an half a million women die each year because of annual decrease of about 5.5 percent; and complications related to pregnancy and child- for universal access to reproductive health birth (box 1). Of the estimated 536,000 ma- care by 2015. Against this target, the current ternal deaths worldwide in 2009, developing global average rate of reduction is under 1 per- countries, with 85 percent of the population, cent—only 0.1 percent in Sub-Saharan Af- accounted for 99 percent. About half the ma- rica, where mortality is the highest. And at the ternal deaths (265,000) were in Sub-Saharan present rate of progress, the world will fall well Africa and a third took place in South Asia short of achieving this MDG. (187,000).14 The average MMR in developing coun- Women die from a wide range of com- tries is 450 deaths per 100,000 live births, plications in pregnancy, childbirth, or the compared with 9 in developed countries. postpartum period, many because of their Fourteen countries—13 are in Sub-Saharan pregnant status and some because preg- Africa—have MMR12 of at least 1,000 per nancy aggravates an existing disease.15 The 100,000 live births: Afghanistan, Angola, four major killers are severe bleeding (pre Burundi, Cameroon, Chad, Democratic and post delivery), infections or sepsis, hy- Box 1 | How Many Maternal Deaths in the World? The data on the number of maternal deaths and the maternal mortality ratio used in this Action Plan are those estimated for 2005 by an interagency group of WHO, UNICEF, UNFPA, and the World Bank. Re- cently, estimates for 2008 have been issued by the Institute for Health Metrics and Evaluation, based on a new modeling approach and an expanded dataset. The findings show a decline from 526,000 deaths in 1990 to 343,000 in 2008. If confirmed, such a decline would be welcome news. But this and similar studies highlight the poor qual- ity of health data, which are frequently incomplete or absent and make evidence-based decision-making difficult. Given the uncertain quality of the data, it will be important to validate the numbers against those being updated by the interagency group, which will be published in mid-2010. Source: Hogan MC, and others, 2010. “Maternal mortality for 181 countries, 1980–2009: A Systematic Analyis of Progress towards Millennium Development Goal 5.” www.thelancet.com, published online 12April. 4 pertensive disorders including eclampsia, and lampsia, and infections. Poor maternal health obstructed labor. Complications of unsafe and nutrition and diseases that have not been abortion cause 13 percent of deaths. Glob- adequately treated before or during pregnancy ally, about 80 percent of maternal deaths are contribute not only to intrapartum death, but due to these causes, and 99 percent are a result also to babies being born preterm and with of poor access to quality obstetric care—and low birth weight. Among the babies born alive are preventable.16 Among the indirect causes each year, 2.8 million die in the first week of (20 percent) of maternal death are diseases life and slightly fewer than 1 million in the fol- that complicate pregnancy or are aggravated lowing three weeks. Very many die in Africa by pregnancy, such as malaria, anemia, and and Asia, very few in high-income countries. HIV. Women also die because of poor health The rates vary from 7 per 1,000 births in high- and nutrition at conception and a lack of ad- income countries to 74 per 1,000 births in equate care needed for the healthy outcome of central Africa. Maternal and perinatal deaths the pregnancy for themselves and their babies. (stillbirths and first-week deaths) together add Women in developing countries have more up to 6.3 million lives lost every year.22 pregnancies on average than women in high- Data show that fewer than 60 percent income countries, and thus have a higher life- of women in developing countries receive time risk of maternal death.17 assistance from a skilled health worker Overall, reproductive health-related when giving birth. This means that 50 mil- mortality and morbidity account for al- lion home deliveries each year are not assisted most a third of the global burden of dis- by skilled health personnel.23 In high-income ease among women of reproductive age and countries, virtually all women have at least a fifth of the burden of disease among the four antenatal care visits, are attended by a world’s population overall.18 Globally, an midwife or a doctor for childbirth, and receive estimated 10 to 20 million women develop postnatal care. In low- and middle-income physical or mental disabilities every year as a countries, just above two-thirds of women result of poor access to quality obstetric care get one or more antenatal visits, but in some for complicated pregnancies and deliveries. countries fewer than a third get just one an- For example, it is estimated that each year at tenatal care visit. Even fewer women have the least 75,000 women develop obstetric fistula birth attended by a skilled health worker. The and about 2 million women live with an un- 63 percent average for low- and middle-in- treated obstetric fistula.19 The UN expects the come countries covers large differences: from burden to increase by 40 percent by 2050, as 34 percent in Eastern Africa to 89 percent in record numbers of young people enter their Latin America and the Caribbean.24 prime reproductive years.20 Many countries have achieved remark- Every year more than 133 million babies able reductions in TFR in the last three de- are born, 3 million of them stillborn, almost cades. Overall, the average TFR in developing a quarter dying in childbirth.21 The causes countries has declined from about 6 in 1960 of these deaths are similar to the causes of ma- to 2.6 in 2006.25 Bangladesh brought down ternal deaths: obstructed or very long labor, ec- its rate from 6.8 in 1960 to 2.8 in 2007, Better Health for Women and Families | The World Bank’s Reproductive Health Action Plan 2010–2015 5 Kenya from 8 to almost 5.26 TFR are lowest nificant decrease in the MMR, as well as the in the Europe and Central Asia region, which lifetime risk of dying from maternal causes. had a population-weighted average TFR of But TFR have declined at a very slow only 1.7 in 2007, and highest in the Sub-Sa- pace in 28 of the least developed coun- haran Africa region which had a population- tries—mostly in Sub-Saharan Africa— weighted TFR of 5.1 in 2007 (figure 1).27 which have TFR above 5. In Chad, Mali, Fertility reduction is accompanied by Niger, and Uganda, TFR are in excess of 6, a downward trend in maternal mortality, with little or no decline over the past five de- largely because the decline in fertility re- cades (figure 2). Social and economic indi- duces the exposure to the risk of pregnancy cators are generally poor in these countries, and pregnancy-related mortality. Family which also have low educational attainment, planning programs have contributed to this high gender inequalities, high mortality, and downward trend and can make further con- high levels of poverty. Several of the high tributions in countries with high fertility—in TFR countries have experienced or are expe- two ways. First, pregnancies that carry a partic- riencing conflict, making it difficult to deliver ularly high risk (those that are closely spaced, basic health and education services. Low con- or occur at very young or older ages) can be traceptive use in many of the high TFR coun- averted through contraception. Second, an tries stems more from a desire to have more overall fertility reduction leads to a reduction children rather than from a lack of awareness in the exposure to the risk of maternal mor- about fertility control or a lack of access to tality. The fertility decline has resulted in a sig- contraception. Figure 1 | Trends in Fertility by Region, 1950–2000 8 7 6 5 4 TFR 3 2 1 0 1950– 1955– 1960– 1965– 1970– 1975– 1980– 1985– 1990– 1995– 2000– 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 High income East Asia & Pacific Middle East & North Africa Europe & Central Asia South Asia Latin America & Caribbean Middle Africa Western Africa Eastern Africa Southern Africa Source: World Development Indicators. 6 Figure 2 | Trends in Total Fertility Rates in Chad, Mali, Niger, and Uganda, 1960–2007 Chad Mali 8 6 4 Total fertility rate 2 Niger Uganda 8 6 4 2 1960 1970 1980 1990 2000 2007 1960 1970 1980 1990 2000 2007 Year Source: World Development Indicators. In addition to the differences between There has been a huge increase in the countries, there are large disparities within prevalence of contraceptive use among countries between people with high and low women, from less than 10 percent in 1960 income and between rural and urban pop- to nearly 60 percent in 2005, but unmet ulations. In Columbia, Demographic and need is still high in countries with high fer- Health Survey data reveal big differences in tility rates. Unmet need for contraception for TFR by economic status: the rate is 1.4 in the spacing and limiting births is typically higher highest wealth quintile and 4.1 in the lowest, for women living in the poorest households, suggesting significantly higher unmet needs or though in some countries unit is uniformly higher desired fertility among the latter popu- low or high for poor and rich. The unmet lation subgroup (table 1). need for the poorest households is often Table 1 | Total Fertility Rates by Wealth Quintiles (selected countries) Wealth quintiles Country 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 Source: DHS surveys (various years). Better Health for Women and Families | The World Bank’s Reproductive Health Action Plan 2010–2015 7 much higher in countries where the transi- lated outcomes. In countries with high in- tion to lower fertility has been under way for fant mortality, high TFR is a natural response some time (such as Zimbabwe, Namibia, and to achieving a given desired family size. But Kenya). The lower unmet need for the poor the association goes the other way, too: high- is associated with the earlier stages of decline, parity women are more likely to have births in which more educated, urban women want with shorter interpregnancy intervals and, to space or limit births but are unable to ob- therefore, would be prone to the adverse ef- tain a suitable contraceptive method (such fects of such frequent births. For instance, as Benin, Nigeria, and Central African Re- short interpregnancy intervals (in particular, public). In some other countries, unmet need those less than six months) are known to be is either high or low for all wealth quintiles a risk factor for low birth weight, pre-term (such as Mali and Mozambique). Contracep- births, and small for gestational age.29 This in- tive use, by contrast, is consistently higher creases the likelihood of fetal death, neonatal for women in wealthier households, who are death, maternal death, and anemia in preg- more likely to use family planning irrespective nancies. These effects have been attributed to of the overall contraceptive prevalence in the maternal protein-calorie and micronutrient country. The steepness of this curve—the rate depletion from closely spaced pregnancies.30 of increase of contraceptive use when com- High fertility rates are also linked paring women in poorer and wealthier house- with gender inequality, particularly par- holds—varies considerably, indicating greater ents’ preference for sons. Evidence from sev- inequities in access to appropriate contracep- eral countries suggests that parents respond tion in some countries. to the absence of sons with continued child High fertility rates are closely linked bearing.31 There could be several reasons for with high infant mortality rates (figure 3). this preference including the differences in the This is, in large part, a result of weak health costs of raising boys and girls. For one, par- systems and poor socio-economic conditions, ents’ expected benefits from investing in sons which influence mortality and fertility-re- could be larger than the benefits of investing Figure 3 | Infant Mortality and Total Fertility Rates in Developing Countries, 2005 250 Infant mortality rate 100 Ethiopia Bangladesh Uganda 50 Indonesia Egypt China Brazil Belize 5 1.0 1.5 2.0 2.5 3.0 4.0 5.0 6.0 7.0 Total fertility rate (TFR) Source: World Development Indicators. 8 in daughters if men earn higher wages in the respectively (figure 4). Niger has a high de- labor market or if female labor force participa- sired family size of 8.8 as opposed to a desired tion is low. Parents might also expect higher family size of 5 for Uganda. Similarly, Chad benefits from investing in boys because sons has a high desired family size relative to the are the providers of support in old age. In prevailing TFR in the country. In such set- some cultures, the practices of dowry and ex- tings, improving access to reproductive health ogamous marriage effectively reduce girls’ ex- services may not be enough, and the focus pected contribution to their natal homes. would also need to be on multisectoral inter- Finally, parents may also value sons more not ventions to influence desired fertility. just for their economic contribution but also HIV is the leading cause of death and for their role in customs and in maintaining disease among women of reproductive age the family line. Son preference and its effect (15–49 years) worldwide. Sexual transmission on fertility is particularly high in Central Asia remains the main mode of transmission fueling and South Asia. the HIV epidemic across the world. In 2008, In many situations, fertility rates are 71 percent of all new infections occurred in high not because of unmet need for con- Sub-Saharan Africa. Each year, approximately traception but because desired fertility is 1.4 million HIV infected women become itself high, sometimes as a result of cul- pregnant. HIV among childbearing women is tural and religious factors, or as a poverty the main cause of HIV infection among chil- coping mechanism, or even because infant dren, with more than 90 percent of infant and mortality rates are high. Niger has a rela- young child infections through mother-to- tively low unmet need for family planning of child transmission, either during pregnancy, 15.8 percent in contrast to Uganda at 40.6 labor and delivery, or breastfeeding. percent, even though the two countries have Adolescent reproductive health pres- similar TFR of 7 and 6.8 births per woman, ents yet another challenge. In many devel- Figure 4 | Desired and Actual Total Fertility Rate in Selected Countries 10 8 Niger 2006 Total fertility rate Uganda 2006 Zambia 2007 6 Mozambique 2003 Chad 2004 Lesotho Ghana Senegal 2005 Nigeria 2003 Bolivia 2003 2004 2003 Congo, Rep. 2005 4 Bangladesh 2004 Zimbabwe 2006 Morocco 2004 2 Ukraine 2007 0 0 2 4 6 8 10 Desired family size Source: DHS Note: Dashed line is 45 degrees; Selected countries highlighted. Better Health for Women and Families | The World Bank’s Reproductive Health Action Plan 2010–2015 9 oping countries, adolescent fertility remains married to older men,34 who have a higher important despite an overall decline in fer- chance of being infected through risky sex tility. Moreover, in many of the countries with partners outside marriage.35 Risky with high TFR or high MMR, births to sexual behavior is more likely among poor 15–24 year olds account for between 30 to youth, who are in a weaker position to ne- 50 percent of all births. An early transition gotiate safe sex and more likely to experience to motherhood can potentially reduce young sex for exchange.36 women’s life chances and opportunities by re- People under the age of 25 also ac- ducing their schooling, future employment count for more than 100 million sexually opportunities, and earnings.32 A mother’s transmitted infections, other than HIV education and income, in turn, affects her each year.37 Even though most sexually trans- children’s school enrollment and attainment mitted infections are easily treated, many go and their health and nutrition outcomes. So, unnoticed, and many of the young, especially addressing adolescent pregnancy will also women and girls, do not seek services, espe- contribute to prevent intergenerational trans- cially where premarital sex is frowned upon mission of poverty—a powerful reason to or if they believe that the facility staff is hos- target adolescent fertility. tile or judgmental or because of high cost.38 More than half the young in many In Ghana, for instance, services were denied countries are sexually active, and the pro- to young or unmarried clients, and to married portion who become sexually active before women who could not demonstrate the con- the age of 15 is increasing.33 Unprotected sent of their spouses. In South Africa, many sexual activity can lead to sexually trans- reproductive health services are not easily ac- mitted infections and their consequences. cessible by youth, and young people feel that Studies show that less than half of sexu- facility staff is judgmental and hostile. In Ni- ally active young people use condoms, even geria, adolescents who contracted a sexually though, in addition to pregnancies, unpro- transmitted infection would rather go to a tra- tected sex is the greatest risk factor for HIV ditional healer than use formal reproductive transmission in most areas of the world. In health services because of the high cost and Mozambique, a country with moderately low quality.39 high HIV prevalence, sexual activity among Adolescent pregnancies carry a higher youth is common, but condom use is low. risk of obstetric complications, such as ob- The share of sexually active boys using con- structed labor, eclampsia, and fistula, and doms ranges from 20 percent in Mali to yet girls are less likely to receive adequate about 50 percent in Zambia. Condom use antenatal or obstetric care, making them is higher among unmarried sexually active twice as likely to die during childbirth as girls than among married girls, but fewer women more than 20 years old. The risks than half of married young girls use con- faced by a young woman living in a low re- doms. Unprotected sex increases the risk that source country are further compounded when married young girls will become infected, the pregnancy is unintended or unwanted and especially since many younger women are she seeks an abortion.40 10 Each year a large number of young Complications of pregnancy and childbirth women undergo unsafe and illegal abor- are the leading cause of death and disability tions, essentially because pregnancies bring among women of reproductive age, and im- immense social costs for unmarried women proving women’s health and nutrition could in societies where family networks do not save millions of women in developing coun- support out-of-wedlock births. In Sub-Sa- tries from needless suffering or premature haran Africa, about 60 percent of women who death in developing countries. Women’s health have unsafe abortions are 15–24 years old.41 is influenced by complex biological, social, In Latin America and the Caribbean, young and cultural factors that are interrelated. Sig- women make up about 40 percent of those nificant progress can be achieved by strength- who undergo unsafe abortions.42 In Kenya, ening and expanding an essential package Nigeria, and Tanzania, adolescent girls make of health services for women, improving the up more than half the women admitted to policy environment, and promoting more the hospital for complications following illicit positive attitudes and behavior toward wom- abortions, adding to the costs of an already en’s health. The Millennium Development under-resourced health system.43 Goal for maternal health is one where the least So, many low-income countries con- progress has been made to date, and strong tinue to have very high maternal morbidity concerted actions need to be taken to achieve and mortality, high fertility, and high rates significant progress as we enter the last five of unmet need for contraceptive services. years of the MDG countdown phase. Better Health for Women and Families | The World Bank’s Reproductive Health Action Plan 2010–2015 11 Challenges and Solutions D espite the fact that technical solutions the broader ICPD agenda have all contributed to most of the problems associated to declining attention and funding.46 At the with mortality and morbidity in preg- same time, HIV/AIDS, TB, and malaria—the nancy and childbirth are well known, more major causes of the disease burden in devel- than half a million women still die due to oping countries—have attracted a major share complications developed during pregnancy of available resources for health. A UNFPA and childbirth every year. The Global Safe study in 2003 identified that half of the re- Motherhood Initiative was launched by the sources being provided for population was World Bank, WHO, and UNFPA in 1987, now going for HIV/AIDS-related activities.47 but since then more than 11 million women All this reduced the share of develop- have died and another 10 to 20 million ment assistance for reproductive health ac- women suffer serious illness or disability each tivities. While total ODA for health rose year. There is a widespread consensus that a fivefold from US$3,823 million in 1995 majority of these deaths could have been pre- to US$15,264 million in 2007, commit- vented and most of the morbidity could have ments for reproductive health increased only been managed if women had access to quality about 61 percent, from US$1,143 million to maternal healthcare before, during and after US$1,835 million.48 And only a third of ODA childbirth. So, why have maternal deaths not for reproductive health has targeted countries fallen over the last two decades? with high MMR and high TFR (figure 5). Most maternal morbidity and mortality Some of the biggest recipients of ODA for re- of the last two decades could have been pre- productive health in 2007—India and Bangla- vented with a coordinated set of actions, desh, for example—now have fairly low TFR resources, strong leadership, and political (less than 3). will. For a variety of reasons, maternal health Within the World Bank Group as well, has not emerged as a political priority. Even the share of reproductive health commit- though there is growing shared understanding ments in overall health fell from about 18 on the solution set, it has not been framed in a percent in 1995 to fewer than 10 percent way that could generate political commitment by 2007. Although the Bank has continued and subsequent action.44 A variety of reasons to finance a broader range of projects that explain the waning global attention accorded address different aspects of the reproductive to maternal health issues45. Successful reduc- health agenda, there has been less of a focus tions in TFR in many countries, the rise of on the delivery of family planning services.49 competing priorities, and the unintended loss Lending to reduce high fertility or improve of focus on family planning services within access to family planning accounted for only 12 Figure 5 | Official Development Assistance for Health and its Composition, 1995–2007 ODA commitments for health, ODA commitments for health, 1995–2007 1995–2007All recipients High MMR-High TFR countries 15000 15000 constant US$ millions constant US$ millions ODA commitments, ODA commitments, 10000 10000 5000 5000 0 0 1995 1998 2001 2004 2007 1995 1998 2001 2004 2007 Year Year Total Health HIV/AIDS RH Source: OECD DAC. 4 percent of the Bank’s health portfolio in the effective in addressing high fertility and rapid last decade, dropping by two-thirds between population growth.50 the first and second half of the decade, when The announcement of the MDGs in the need for such support was high. Popu- 2000 stimulated renewed activity, with lation support was directed to only about maternal health getting its own MDG di- a quarter of the countries the Bank identi- rected at reducing the global maternal mor- fied as having the highest TFR (with rates tality ratio by 75 percent over 1990 levels above 5). Though 75 percent of the country by 2015. Maternal health started figuring assistance strategies (CASs) in high fertility more actively within the global development countries discussed population issues in their community, including among AIDS activ- analytical frameworks, only half the health ists, proponents of human rights, and those programs in these countries actually ad- who focused on public health policy on behalf dressed high fertility as a strategic focus for of women or newborns. The surge to combat Bank lending. Where the Bank identified maternal and child mortality spawned more high fertility and population growth as a stra- than 80 new national and international part- tegic focus for the CAS, only 61 percent of nerships, including the Partnership for Ma- such CASs included a population indicator ternal, Newborn and Child Health, which (such as the TFR, population growth, or brought together three existing partners. Re- contraceptive prevalence rate) in the results alizing the need for renewed and consistent matrix. The majority of CASs did not pro- push in achieving the health-related MDGs, vide specific recommendations and guidance an informal group of heads of eight health- about the type of lending that would be most related organizations (WHO, UNICEF, Better Health for Women and Families | The World Bank’s Reproductive Health Action Plan 2010–2015 13 UNFPA, UNAIDS, GFATM, GAVI, Bill & only 22 percent in 2008 (though almost twice Melinda Gates Foundation, and the World the 12 percent in 1990). In many countries, Bank—the ‘H8’) was formed and meets reg- the proportion of demand for birth spacing or ularly. The White Ribbon Alliance—with limiting being met by use of modern contra- Sarah Brown, wife of the former British Prime ception is closely linked to household wealth Minister, as the Chief Patron—launched its and location. Among the wealthiest quintiles, Mothers Day Every Day campaign in part- this proportion of demand satisfied is rarely nership with CARE. Funding also started less than 80 percent. But in the poorest quin- increasing, with renewed support for com- tiles, levels are at par with aggregate contra- prehensive reproductive health services and ceptive prevalence. In Sub-Saharan Africa, the overall health infrastructure in the developing unmet need for family planning exceeds 24 world from a number of donor countries. percent. Overall, less than half the demand for The significant increase in attention to spacing and limiting—and less than a quarter reproductive health issues through greater among the poorest quintile—is being met. awareness, better internal cohesion, and By further increasing contraception high-level political engagement underscores coverage and reducing the unmet need for the need to ensure that investments are di- family planning, the reduction of closely rected toward solutions that are seen tech- spaced births, unwanted pregnancies, and nically as essential to reducing maternal unsafe abortions will improve health out- mortality and morbidity. At the minimum, comes for women and children. Estimates this solution set would include improved ac- suggest that if all interbirth intervals of less cess to quality family planning and other than 24 months were increased to at least that reproductive health services, skilled birth at- length, the lives of 0.9 million children under tendance, emergency obstetric care, and post- the age of 5 could be saved. Increasing the in- natal care for mothers and newborns. terval to 33 months would save an additional The first step in avoiding maternal 0.9 million lives, for a total of 1.8 million. deaths is to ensure that women have access The women who continue pregnan- to modern contraceptives and the ability to cies need care during this critical period for plan their families. In 2008, of the 1.4 bil- their health and for the health of the babies lion women in the developing world of re- they are bearing. Since the 1990s, the propor- productive age (15–49 years), more than 800 tion of pregnant women in the developing re- million women wanted to avoid pregnancy gions who had at least one antenatal care visit and thus had a need for contraception. Of this increased from about 64 percent to 79 percent. number, 600 million were using modern con- But fewer than 50 percent of pregnant women traceptives, which prevented 188 million un- in the period 2003–08 were attended to at least intended pregnancies, 1.2 million newborn four times during their pregnancy by skilled deaths, and 230,000 maternal deaths. Con- health personnel, as recommended by WHO traceptive use has increased in all developing and UNICEF. In 2007, only 61 percent of regions, but remains low in Sub-Saharan Af- women in developing countries delivered with rica, where contraceptive prevalence was still the help of skilled birth attendants. Since the 14 1990s, the presence of skilled birth attendants at delivery has increased in all developing re- Table 2 | ProportionHealth Personnel by Skilled of Births Attended gions, though the percentage of births attended Around Around by skilled health personnel was only 44 per- 1990 2007 cent in Sub-Saharan Africa and 42 percent in World 58 64 Southern Asia (table 2). Developing regions 53 61 Most maternal deaths are avoidable, Northern Africa 45 79 and the health care solutions to prevent or Sub-Saharan Africa 42 44 manage the complications are well known. Latin America and the 70 87 Caribbean Severe bleeding after birth, which can rapidly Eastern Asia 94 98 become fatal, can be controlled by drugs such Southern Asia 29 42 as oxytocin. Sepsis, the second most frequent Southern Asia excluding India 15 30 cause of maternal death, can be eliminated South-Eastern Asia 46 68 if treated early. Eclampsia can be detected Western Asia 62 77 during pregnancy, and drugs such as magne- Commonwealth of 98 99 sium sulfate can lower the risk of developing Independent States (CIS) fatal convulsions. Obstructed labor can be rec- Developed regions 99 99 ognized by practitioners skilled in following Transition countries of 99 98 the progress of labor and the maternal and South-Eastern Europe fetal condition, and ensure that Caesarean Source: WHO, 2008, Proportion of birth attended by a skilled health worker. 2008 updates, Geneva. sections are performed on time to save the mother and the baby. But since complications are not predictable, all women need care from section typically have many life-threatening skilled health professionals during pregnancy, complications that are not receiving the neces- childbirth, and the weeks after delivery.51 sary care.53 A large number of countries, many Since complications can occur without with the highest MMR, have C-Section rates warning at any time during pregnancy and lower than 5 percent (figure 6). childbirth, prompt access to quality obstetric The continuum of care from pre-preg- services equipped to provide lifesaving drugs, nancy to two years postpartum for women antibiotics, and transfusions and to perform and their children provides many points for Caesarean sections and other surgical inter- intervention, but gaps in the capacity and ventions is critical.52 An indicator of whether quality of health systems and barriers to ac- such emergency obstetric services are available cessing health services need to be identified in a country is the rate of Caesarean section (or and tackled. Different countries have ap- C-section) deliveries. Estimates from UNICEF, proached this challenge with varying success, WHO, and UNFPA suggest that a minimum but in all cases the emphasis has been on rap- of 5 percent of deliveries will likely to require idly reaching populations in need of family a C-section to preserve the life and health of planning and speeding access to appropriate mother or infant, which implies that countries skilled care, including emergency obstetric care, reporting fewer than 5 percent of births by C- for women during pregnancy and delivery. Better Health for Women and Families | The World Bank’s Reproductive Health Action Plan 2010–2015 15 Figure 6 | Deliveries by C-Section 25 20 15 Percent 10 5 0 Chad Madagascar Ethiopia Mali Nepal Burkina Faso Yemen Eritrea Central Afr Rep Zambia Guinea Togo Benin Senegal Uganda Mozambique Tanzania Uzbekistan Vietnam Nigeria Cameroon Indonesia Netherlands Norway Sweden Denmark Finland Belgium United kingdom France Austria New Zealand Ireland Canada Germany United States Australia Source: DHS (various years). Strategies to rapidly reach populations in need The decline in maternal mortality in of family planning include relying on first-level North Africa, East Asia, South East Asia, health providers to provide contraceptives. One and Latin America and the Caribbean shares such example has been the provision of inject- many common features: increased use of able contraceptives, which has doubled in the contraception to delay and limit child- last 10 years (to 35 million worldwide) the bearing and better access to high quality ob- number of women worldwide who use inject- stetric care services. Experiences from China, able contraceptives to prevent pregnancies. Iran, Malaysia, and Sri Lanka, and from proj- Countries around the world are experi- ects in India and Tanzania, show that out- menting with innovative ways to speed access comes in reproductive, maternal, newborn, to appropriate skilled care by women during and child health can be improved through in- pregnancy and delivery. In a supply-side in- tegrated packages that are gradually introduced tervention, Mozambique’s “Road Map to within the health system. Such packages in- Accelerate the Reduction of Maternal, New- clude community-based interventions along born and Child Deaths” provides a temporary with social protection and actions in other so- home to pregnant women with good nutri- cial sectors. Appropriate and supported decen- tion. In India, the National Rural Health Mis- tralization of roles and finances aids localized sion has used demand-side financing to ensure planning and implementation. Many of these that the public system delivers high-quality elements can be discerned in the reductions in maternity services as part of the Janani Surak- child mortality and improvements in health shya Yojana, or Maternity Safety Plan. The re- outcomes for women in Rwanda. sult has been an increase in the number of Effective reproductive health services women using the services—from 700,000 in delivery—including access to quality family 2005–06 to more than 7 million in 2007–08. planning and reproductive health services, 16 skilled birth attendance, emergency ob- plies, current clinical guidelines, and opera- stetric care, and postnatal care for mothers tional policies. and newborns—depend on the strength of Well-resourced health systems include the overall health system. On the ground, appropriate numbers of skilled health this means putting together the right chain of workers and managers who are spatially events (financing, regulatory framework for distributed according to need. But many private-public collaboration, governance, in- countries, especially in Africa, have short- surance, logistics, provider payment and in- ages estimated at 2.4 million doctors, nurses centive mechanisms, information, well-trained and midwives. The shortage is especially acute personnel, basic infrastructure, and supplies) in countries with high MMR and high TFR, to ensure equitable access to effective interven- which typically have fewer health personnel tions and a continuum of care to save and im- per 10,000 population relative to other groups prove lives. Achieving strong and sustainable of countries (figure 7).54 The percentage of reproductive health results requires a well-or- births attended by qualified health personnel ganized and sustainable country health system, is also low in these countries relative to other capable of responding to the needs of women, groups of countries, which underscores the children, and families. Inputs for health care importance of adequate supply and availability delivery include financial resources, competent of skilled health professionals and is another health care staff, adequate physical facilities indicator of weaknesses in the health system and equipment, essential medicines and sup- (figure 8). Figure 7 | Physicians per 10,000 Population Low MMR – Low TFR Georgia Bulgaria Argentina Turkmenistan Turkey Colombia Albania Iran Thailand Peru Indonesia Honduras High MMR – High TFR Lao PDR Nigeria Cameroon Ghana Mauritania Uganda Rwanda Somalia Liberia Malawi 0 10 20 30 40 50 Source: World Development Indicators. Better Health for Women and Families | The World Bank’s Reproductive Health Action Plan 2010–2015 17 Figure 8 | Percentage of Births100,000 births)Skilled Personnel and the Maternal Mortality Ratio (per Attended by Maternal Mortality ratio 2000 (per 100,000 births) 1500 1000 500 0 0 20 40 60 80 100 Percentage of births attended by skilled health personnel Source: World Development Indicators. Another aspect of strong health systems The 2009 Global Consensus on Ma- is the quality of overall governance, which ternal and Neonatal Health, signed by 41 directly affects the environment for health bilateral and multilateral development systems to operate and the ability of gov- agencies, including the Bank, provides a ernment health officials to exercise their re- checklist of policies and priority interven- sponsibilities. Governance can be broadly tions to ensure improved outcomes.56 The defined as the set of traditions and institutions Global Consensus recognizes that MDGs 4 by which authority is exercised. It includes the and 5 will not be reached without country capacity of the government to effectively for- leadership and setting reproductive, maternal, mulate and implement sound policies, and the and newborn health as priorities at country respect of citizens, private organizations, and level. The Global Consensus proposes a five- the state for the institutions that govern their point plan that includes: economic and social interactions. In the area of government effectiveness (which measures ÆÆPolitical, operational, and community the quality of public services, the quality of the leadership and engagement. civil service and the degree of its independence A ÆÆ package of evidence-based interventions from political pressures, the quality of policy through effective health systems along a formulation and implementation, and the continuum of good quality care, with a credibility of the government’s commitment priority on quality care at birth. to such policies), countries in the high MMR- ÆÆServices for women and children free at high TFR group rank consistently lower than the point of use if countries choose to other groups of countries (figure 9).55 Where provide them. countries have made strides in addressing TFR ÆÆSkilled and motivated health workers in and MMR, government interest and owner- the right place at the right time, with sup- ship have been critical for these successes and porting infrastructure, drugs, and equip- for ensuring that these are sustained. ment. 18 Figure 9 | Government Effectiveness (percentile rank) Latvia Low MMR – Low TFR China Thailand Macedonia Viet Nam Kazakhstan Uzbekistan Cape Verde Morocco Ghana Tanzania Madagascar High MMR – High TFR Burkina Faso Niger Lao PDR Republic of Yemen Haiti Guinea Chad Somalia 0 20 40 60 80 100 Source: World Bank’s Worldwide Governance Indicators database ÆÆAccountability for results with robust holds, this would include increasing the de- monitoring and evaluation. mand for services and removing financial and geographic barriers to maternal health ser- Sustained political commitment and vices. For health service delivery, it would re- leadership, especially at the national and quire effective human resource management local levels, are vital to scale up care, en- to ensure health personnel attend to deliveries, sure translation of commitments into over- upgrading and equipping health facilities, and coming of implementation bottlenecks, strengthening health management informa- effective service delivery, and financial pro- tion systems for monitoring and evaluation. tection for all mothers and children. So are For health sector policy and strategic man- multisectoral commitments to tackle the root agement level, strategic public-private part- causes of poor maternal and neonatal health, nerships to ensure universal access to health including inequity, poverty, gender inequality, services. For public policies cutting across sec- the low education status of women, and lack tors, promoting education of girls, expanding of respect for women’s human rights. road networks, and making available affordable In broader terms, implementing the transport. For remedying fragmentation of foregoing interventions would require ad- donor efforts and financing, harmonizing and dressing implementation constraints at coordinating the efforts of donors at country various levels.57 For communities and house- level to support countries to improve maternal Better Health for Women and Families | The World Bank’s Reproductive Health Action Plan 2010–2015 19 health. The World Bank is in a unique position phasizing reproductive health within health to address these constraints simultaneously. Its system strengthening, focusing on the poor Action Plan brings together these dimensions and the adolescents, and leveraging partner- through targeting high burden countries, em- ships, including those with civil society.  20 The Bank’s Action Plan T he economic, poverty reduction, and Country focus equity rationales for the Bank’s focus In general, MMR, TFR, STI, and other re- on reproductive health are compelling. productive health outcomes tend to be highly Improved outcomes—lower fertility rates, im- correlated across countries: high MMR coun- proved pregnancy outcomes, and lower sex- tries also tend to have high TFR and relatively ually-transmitted infections—have broader high HIV prevalence among young women, individual, family, and societal benefits. The and vice-versa. Exceptions include Bangladesh benefits include a healthier and more produc- and Indonesia, which have lower total fertility tive work force, greater financial and other re- and HIV but high MMR, and Egypt and Be- sources for each child in smaller families, and lize, which have lower MMR but high TFR. enabling young women to delay childbearing Figure 10 highlights the different quadrants until they have achieved educational and other countries fall in based on MMR (greater than or goals.58 Women endure a disproportionate equal to the median MMR 220 being high) and burden of poor reproductive health outcomes, TFR values (greater than or equal to the median but investments in reproductive health have TFR of 3 being high).60 Box 2 and figure 11 de- multiple payoffs for families, communities, and pict the countries in these quadrants. the national economy. Poor reproductive health Countries with high MMR, high TFR, outcomes—early pregnancies, unintended preg- and high STIS also have weak health systems nancies, excess fertility, and poorly managed and low implementation capacities. Almost obstetric complications—adversely affect the all high MMR-high TFR-high STI countries opportunities for poor women and their fami- fall in the bottom two groups for two or more lies to escape poverty.59 In particular, reproduc- of the following three health system indica- tive health has a significant effect on the health tors: DPT3 vaccination coverage, skilled birth and productivity of the next generation, in ad- attendance, and physicians per capita (table dition to the benefits for the current generation. 3)61. Countries that have high MMRs and high Women can fully and equally participate in TFRs are also predominantly low-income, with the development process if they have access to generally poorer socio-economic indicators quality reproductive health services, including and implementation capacities. By contrast, the ability to make voluntary and informed de- low MMR and low TFR countries are gener- cisions about fertility. Overall, investing in re- ally upper middle-income, with relatively high productive health confers widespread benefits to levels of female literacy, physicians per capita, society and contributes to sustainable develop- DPT3 vaccination coverage rates, and skilled ment through improving equity, economic po- birth attendance rates—and very few of them tential, and the quality of life. have weak health systems.62 Better Health for Women and Families | The World Bank’s Reproductive Health Action Plan 2010–2015 21 Figure 10 | Maternal Mortality Ratios Versus Total Fertility Rates in Developing Countries, 2005 Niger 1500 Chad Maternal mortality ratio (MMR) Nigeria Ethiopia Mali 500 Bangladesh India Botswana Uganda Indonesia 220 Brazil Egypt 100 50 Mexico Belize China Ukraine Poland 5 1 1.5 2 2.5 3 4 5 6 7 Total fertility rate (TFR) High prevalence Middle prevalence Low prevalence No HIV prevalence data (greater than 1.3%) (between 0.3% and 1.3%) (less than 0.3%) available in the WDI Source: WDI Note: Median TFR=3; Median MMR=220 Colors mark HIV prevalence among females aged 15–24 In terms of geographic prioritization, stagnant, or rising. In high TFR countries al- the Bank will focus on the 57 countries ready experiencing the beginnings of fertility with high MMR and high TFR and, within decline, it would be necessary to accelerate the this group, on countries where MMR and pace of fertility decline through, say, targeted TFR have remained high over extended pe- awareness-generation and media campaigns to riods. Interventions would necessarily vary, provide information on the benefits of having depending on whether rates are declining, smaller families and on improving access to a Table 3 | Country Characteristics Based on MMR and TFR Classifications GNI Health Female per expenditure literacy Physicians DPT3 Skilled birth Proportion with capita per capita rates per 1000 vaccinations attendance “weak” health Classification (US$) (US$) (%) population (%) (%) systems (%) High MMR-High $862 $47 52 0.18 72 48 98 TFR High MMR-Low $1,783 $91 65 0.71 85 64 70 TFR Low MMR-High $2,927 $152 81 1.32 90 83 44 TFR Low MMR-Low $4,120 $279 92 2.16 93 96 9 TFR 22 variety of quality family planning services.63 tries, strategies for addressing high MMR But in countries such as Uganda, where unmet will be the same as for countries in the high need for family planning is high and the total MMR-high TFR quadrant. But family plan- fertility is higher than the desired family size, ning approaches will be targeted on popu- the approach will be to improve access to lation subgroups and subnational areas that quality family planning services. Similarly, the have higher TFR. MMR is declining in many countries (Bo- In the group of countries with low tswana, Tanzania, and Peru), and the focus in MMR and high TFR as well as those with these countries will be on sustaining the prog- low MMR and low TFR, it will be impor- ress to date. In other countries, where MMR tant not to lose sight of population sub- have been high and stagnant, interventions groups that may still have outcomes similar would focus on addressing the health system to those in the high burden countries. Ac- issues such as human resources, availability of cordingly, the focus on the nine countries with quality emergency obstetric care services, and a low MMR and high TFR will be to address political commitment to bring about a change. the unmet need for contraceptives with the The next group of focus countries have same kind of approaches as for countries with high MMR but low TFR. In these 10 coun- high MMR and high TFR. Strategies for ad- Box 2 | Countries Classified According to MMR and TFR This list is restricted to countries that had MMR estimates in 2005. It excludes countries with populations less than 250,000 and a few others for which estimates were not available. The countries that are High MMR-High TFR and High MMR-Low TFR are also the same countries that have been identified for tracking progress on maternal, neonatal, and child health indicators for the Countdown to 2015 and H4 joint work program. High MMR-High TFR (TFR 3 or more; MMR 220 or more): Afghanistan, Angola, Burundi, Benin, Burkina Faso, Bolivia, Botswana, Central African Republic, Côte d’Ivoire, Cameroon, Congo, Rep., Comoros, Djibouti, Eritrea, Ethiopia, Gabon, Ghana, Guinea, Gambia, The, Guinea-Bissau, Equatorial Guinea, Guatemala, Hon- duras, Haiti, Iraq, Kenya, Cambodia, Lao PDR, Liberia, Lesotho, Madagascar, Mali, Mozambique, Mauritania, Malawi, Niger, Nigeria, Nepal, Pakistan, Philippines, Papua New Guinea, Rwanda, Sudan, Senegal, Solomon Islands, Sierra Leone, Somalia, Swaziland, Chad, Togo, Timor-Leste, Tanzania, Uganda, Yemen, Rep., Congo, Dem. Rep., Zambia, Zimbabwe. High MMR-Low TFR (TFR less than 3; MMR 220 or more): Bangladesh, Bhutan, Guyana, Indonesia, India, Morocco, Myanmar, Peru, Korea, Dem. Rep., South Africa. Low MMR-High TFR (TFR 3 or more; MMR less than 220): Belize, Cape Verde, Egypt, Arab Rep., Jordan, Namibia, Oman, Paraguay, Syrian Arab Republic, Tajikistan. Low MMR-Low TFR (TFR less than 3; MMR less than 220): Albania, Argentina, Armenia, Azerbaijan, Bul- garia, Bosnia and Herzegovina, Belarus, Brazil, Barbados, Chile, China, Colombia, Costa Rica, Cuba, Czech Republic, Dominican Republic, Algeria, Ecuador, Estonia, Fiji, Georgia, Croatia, Hungary, Iran, Islamic Rep., Jamaica, Kazakhstan, Kyrgyz Republic, Lebanon, Libya, Sri Lanka, Lithuania, Latvia, Moldova, Maldives, Mexico, Macedonia, FYR, Mongolia, Mauritius, Malaysia, Nicaragua, Panama, Poland, Romania, Russian Federation, El Salvador, Suriname, Slovak Republic, Thailand, Turkmenistan, Trinidad and Tobago, Tunisia, Turkey, Ukraine, Uruguay, Uzbekistan, Venezuela, RB, Vietnam. Better Health for Women and Families | The World Bank’s Reproductive Health Action Plan 2010–2015 Figure 11 | Countries Classified According to MMR and TFR This map was produced by the Map Design Unit of The World Bank. The boundaries, colors, denominations and any other information shown on this map do not imply, on the part of The World Bank Group, any judgment ICELAND on the legal status of any territory, or NORWAY any endorsement or acceptance of FINLAND SWEDEN RUSSIAN FEDERATION such boundaries. THE NETHERLANDS ESTONIA CANADA DENMARK LATVIA LITHUANIA IRELAND U.K. POLAND BELARUS BELGIUM UKRAINE LUXEMBOURG MOLDOVA KAZAKHSTAN LIECHTENSTEIN FRANCE ROMANIA MONGOLIA SWITZERLAND BULGARIA GEORGIA UZBEKISTAN ANDORRA AZERBAIJAN KYRGYZ REP. D. P. R. UNITED STATES PORTUGAL SPAIN MONACO TURKEY ARMENIA TURKMENISTAN TAJIKISTAN OF KOREA GREECE SYRIAN MALTA CYPRUS REP. OF JAPAN A.R. I.R. OF IRAN AFGHANISTAN CHINA KOREA MOROCCO TUNISIA LEBANON IRAQ JORDAN KUWAIT BHUTAN West Bank and Gaza ALGERIA BAHRAIN PAKISTAN NEPAL THE BAHAMAS LIBYA ARAB REP. ISRAEL SAUDI QATAR BELIZE OF EGYPT BANGLADESH ARABIA U.A.E. CUBA INDIA MEXICO CAPE VERDE OMAN MYANMAR LAO JAMAICA MAURITANIA P.D.R. MALI NIGER HONDURAS HAITI SENEGAL CHAD ERITREA REP. OF YEMEN THAILAND VIETNAM GUATEMALA BURKINA SUDAN NICARAGUA THE GAMBIA FASO DJIBOUTI CAMBODIA PHILIPPINES FED. STATES OF MICRONESIA MARSHALL ISL. EL SALVADOR PANAMA GUYANA GUINEA COSTA RICA R.B. DE GUINEA-BISSAU GHANA NIGERIA ETHIOPIA SRI SURINAME CÔTE CENTRAL BRUNEI VENEZUELA SIERRA LEONE LANKA PALAU LIBERIA D’IVOIRE CAMEROON AFRICAN REP. SOMALIA COLOMBIA MALAYSIA TOGO UGANDA KENYA MALDIVES KIRIBATI BENIN RWANDA NAURU ECUADOR GABON BURUNDI SINGAPORE KIRIBATI SÃO TOMÉ AND PRÍNCIPE CONGO DEM. REP. SOLOMON OF CONGO SEYCHELLES INDONESIA PAPUA TUVALU EQUATORIAL GUINEA TANZANIA COMOROS NEW GUINEA ISLANDS SAMOA PERU BRAZIL ANGOLA TIMOR-LESTE ZAMBIA MALAWI FIJI VANUATU BOLIVIA MADAGASCAR TONGA NAMIBIA ZIMBABWE MAURITIUS FIJI PARAGUAY BOTSWANA MOZAMBIQUE SWAZILAND AUSTRALIA SOUTH LESOTHO URUGUAY AFRICA DOMINICAN CHILE ARGENTINA POLAND NEW REP. CZECH REP. ZEALAND ANTIGUA AND SLOVAK REP. GERMANY UKRAINE BARBUDA ST. KITTS AND NEVIS AUSTRIA HUNGARY DOMINICA SLOVENIA CROATIA ROMANIA ST. LUCIA BOSNIA & BARBADOS SAN HERZ. SERBIA ST. VINCENT & BULG. GRENADA MARINO MONT. FYR GRENADINES KOSOVO MAC. TRINIDAD VATICAN ALBANIA LOW MMR − LOW TFR (MMR < 220; TFR < 3) CITY ITALY GREECE R.B. DE VENEZUELA AND TOBAGO LOW MMR − HIGH TFR (MMR < 220; TFR > 3) HIGH MMR − LOW TFR (MMR > 220; TFR < 3) HIGH MMR − HIGH TFR (MMR > 220; TFR > 3) NOT COUNTRY OF FOCUS FOR THE RHAP JULY 2010 IBRD 37942 23 24 dressing maternal morbidity and mortality, as combination, can address deficiencies in well as high fertility, will be targeted on pop- performance that relate both to the lack of ulation subgroups and subnational areas that essential inputs as well as the behavioral have higher MMR or high TFR. In the group drivers of effectiveness and efficiency. These of countries with low MMR and low TFR, the areas of policy design and implementation are emphasis will also be on learning from their financing, payment, organization, regulation, experiences and generating lessons on how and persuasion. these countries have successfully maintained improvements in reproductive health. ÆÆFinancing refers to the ways in which funding is generated, pooled, and man- Health System Strengthening aged for health systems. In line with its HNP strategy, the Bank will ÆÆPayment relates to the use of financial in- work closely with countries and develop- centives for both providers and consumers. ment partners to strengthen health systems ÆÆOrganization is concerned primarily with to improve access to quality family plan- the arrangements for health service de- ning and other reproductive health services, livery and the production of essential skilled birth attendance, emergency ob- inputs to service provision such as phar- stetric care, and postnatal care for mothers maceuticals, human resources, and phys- and newborns. As discussed earlier, a well-or- ical infrastructure. ganized and sustainable health system, capable ÆÆRegulation encompasses the efforts, of responding to the needs of women, children, mainly by governments, to use laws and and families, is necessary to ensure production administrative rules to improve health sys- and delivery of reproductive health services. In tems and protect the public. practical terms, this means identifying and put- ÆÆPersuasion includes other approaches to ting in place a set of actions that ensure that behavior change for both providers and appropriate health goods and services are pro- consumers, such as communications, so- duced, financed, delivered and utilized in order cial marketing, and the like. to address all the challenges of high fertility and high maternal morbidity and mortality. The Together, these health system control World Health Organization provides a useful knobs provide a menu of policy and action framework that identifies the central elements strategies that will be used by the Bank staff to of health system strengthening as six “building design, plan, implement, and evaluate health blocks” that make up the system: service de- system performance for improving reproduc- livery; health workforce; information; medical tive health outcomes. products, vaccines, and technologies; financing; The Bank’s support for health system and leadership and governance.64 strengthening for reproductive health out- The World Bank Institute’s Flagship comes will seek an appropriate and client- Program on Health Sector Reform and Sus- focused balance of essential inputs and tainable Financing highlights five health innovations for results. In developing strat- system “control knobs” that, in appropriate egies for health system strengthening, it is Better Health for Women and Families | The World Bank’s Reproductive Health Action Plan 2010–2015 25 important to distinguish between the invest- complications, provide preventive measures, ments needed to ensure an adequate supply monitor the progress of labor during delivery, of essential inputs such as human resources, manage complications such as breech deliv- pharmaceuticals and supplies, and buildings eries, provide post-natal care, counseling on and vehicles—and the financing of strategies postnatal contraception, and prevent mother- to improve the productivity, quality, and eq- to-child transmission of HIV.66 uity in the use of inputs. These latter strategies A key health system strengthening in- can include management improvements and tervention is thus to train new health a wide range of innovative approaches to im- workers and strengthen the skills of the ex- prove performance through incentives and ac- isting health workers with midwifery skills countability mechanisms. The Bank supports and effectively deploy them. Training pro- both types of investments. Certainly many grams for traditional birth attendants have not low-income countries lack adequate levels of yielded the expected results and have generally essential inputs, and these must be increased been unsuccessful in reducing maternal mor- to improve outcomes. Increasing inputs does tality. Working closely with all high mater- not necessarily mean using traditional invest- nity mortality countries, the Bank will focus ment lending, especially since other types on identifying the gaps in the availability of of lending instruments may be more appro- health workers skilled in midwifery as well as priate and effective in many cases. The Bank doctors with obstetric skills, task shifting, and will support innovative approaches to improve setting in place training programs aimed at performance engaging with both the state and meeting the shortage. nonstate sectors. These include results-based Bridging the health worker gap may re- financing, demand-generation strategies, de- quire changes in the incentive systems gov- mand-side financing, and strengthening com- erning the recruitment and deployment of munity-based services and accountability. health workers with midwifery skills and Skilled care at childbirth is most im- doctors with obstetric training. Policies and portant for the survival of women and their interventions that change the incentive struc- babies. And the availability of qualified and tures typically involve using the “payment con- trained health personnel to assist deliveries is trol knob” to change relative payment levels key to ensuring optimal pregnancy outcomes. and realign incentives. One way of achieving Yet a third of all deliveries take place without a this realignment of incentives is through re- skilled attendant. While doctors are necessary sults-based financing, which combines the use for the management of most complications, of incentives for health-related behaviors with health professionals “educated and trained a strong focus on results, and can support ef- to proficiency in the skills needed to manage forts to achieve the MDGs. Early evidence normal (uncomplicated) pregnancies, child- suggests that when health workers and facilities birth and the immediate postnatal period, and are paid according to achievement of targets, in the identification, management and referral those targets tend to be met. of complications in women and newborns”65 In Haiti, a government scheme sup- are required to monitor pregnancies, detect ported by USAID paid NGO health pro- 26 viders that agreed to reach certain targets oping programmatic guidelines based on past such as proportion of children fully immu- experience and knowledge. nized and pregnant women receiving prenatal Pregnancies that result in complications care. In the seven years the program has been that cannot be addressed by skilled birth at- operating, huge improvements in key health tendants need attention and treatment at indicators have been achieved (including a well-staffed and equipped health facilities, remarkable 13 percentage point increase in where many newborns who might otherwise full immunization coverage). In Rwanda, the die can be saved. About one in seven preg- national government selected features from nancies results in a complication that would three donor-supported pilots to construct a need this higher level of care, a statistic en- national, unified approach for paying public hanced by random and unpredictable com- and NGO service providers based on ser- plications. Timing is critical in preventing vices provided. Between 2001 and 2004, cu- maternal death and disability during compli- rative care visits per person increased from cations. Post-partum hemorrhage can kill a 22 percent to 55 percent and institutional woman in less than two hours, while for most deliveries nearly doubled (from 12 percent other complications, a woman has between 6 to 23 percent). Such results-based financing and 12 hours or more to get life-saving emer- moves funding away from inputs—salaries, gency care. Similarly, most perinatal deaths construction, training, and equipment—to occur during labor and delivery, or within the results, and creates a whole new set of incen- first 48 hours thereafter. tives for providers. The aspirational goal would thus be that In addition, the Bank recognizes that in- all births should take place in well-equipped centives to providers for family planning ser- health facilities. In the short-run and until this vices also need to be studied. The Bank will is possible, it would be necessary to ensure commence work on developing programmatic that all women with complications have rapid guidelines to avoid negative consequences access to emergency obstetric care if mean- of incentives, based on past experience and ingful reductions in maternal mortality and knowledge. Using the recently established morbidity are to be achieved. Where rapid ac- Norway and UK-funded Results-Based Fi- cess to such a facility is not possible, some nancing Trust Fund, the Bank will support countries have set up waiting homes near the aggressive use of results-based financing these facilities where women can spend sev- to modify incentives for skilled birth atten- eral days before delivery so that obstetric care dants and doctors to meet the 100 percent is available when needed. In Cambodia and target for skilled attendance at birth. This Malawi, high-risk mothers from remote rural strategy may also be extended to delivery of areas are encouraged to stay in a safe and clean contraceptive services. This would need to waiting home before delivering in the provin- be carefully implemented, to ensure that any cial hospital with all facilities. negative consequences of incentives for con- Joint guidelines and recommendations traceptive services are avoided. Recognizing from WHO, UNICEF, and UNFPA have this, the Bank will commence work on devel- been issued for the number and type of emer- Better Health for Women and Families | The World Bank’s Reproductive Health Action Plan 2010–2015 27 gency obstetric centers and well-equipped total program budget of US$2.8 billion (by health facilities, and the Bank will support 2005 for a total of 5 million household benefi- countries in the high MMR, high TFR groups ciaries) represented less that 1 percent of Mex- seeking resources to meet these guidelines. ico’s GDP. Numerous evaluations of Mexico’s Existing facilities can often, with just a few Oportunidades program have shown that it in- changes, be upgraded to provide emergency creased the use of health services and improved obstetric and newborn care, and the Bank will maternal health outcomes. The Bank will sup- support countries in identifying and refur- port countries in high MMR and high TFR bishing these facilities. groups planning to introduce conditional cash Also important is promoting awareness of transfers to influence patient behavior and in- pregnancy-related health risks and enhancing crease the use of maternal health services. the care-seeking behavior of pregnant women. A reliable and adequate supply of Results-based financing has been shown to good-quality contraceptives—including increase patient demand for health services. intrauterine devices, oral contraceptives, Evaluations of large-scale conditional cash condoms, emergency contraceptives, and transfer programs in Latin America and the injectables—is essential for reproductive Caribbean show greater use of clinic services health services. Increases in demand for con- for children (Honduras, Nicaragua, and Co- traceptives, shortages of funds, and weak- lombia) and prenatal care (Mexico, Honduras) nesses in the supply chain are all contributing and less childhood stunting (Mexico, Nica- to the inability of many developing coun- ragua, and Colombia). tries to maintain a secure supply of contracep- In 1997 Mexico introduced Oportuni- tives. The Bank will work closely with country dades, a large-scale conditional cash transfer governments, agencies and partners such as program, aimed in part at improving birth USAID, UNFPA, UNICEF, and the Repro- outcomes by providing cash transfers to ben- ductive Health Supplies Coalition to establish eficiary households conditioned on pregnant robust logistical, regulatory, and quality assur- women’s completing at least four antenatal ance systems—all of which are key elements care visits, two post-partum care visits, and at- of a strong health system—to minimize stock- tending health and nutrition lectures. A key outs, shipment delays, and the undersupply or objective of both the educational sessions and oversupply of certain contraceptives. the meetings with the elected beneficiary rep- Integrating HIV prevention into repro- resentatives was to inform beneficiary women ductive health services provides an essential of their right to social services and to empower entry point to improve health and behavior women on how to make the best out of their outcomes, reduce sexual transmission and interaction with health care providers. The maternal mortality, as well as mother to payment mechanism is cash at program-spe- child HIV infection. Without intervention, cific payment points, and program compliance one in three children born to an HIV infected is via certification at public clinics and schools. mother will be infected. In 2008, 430,000 ba- The program’s average cost per family benefi- bies were born with HIV in Africa. Evidence ciary of $4.67 was affordable given that the shows that timely administration of anti- 28 retroviral prophylaxis to HIV-positive preg- were failing to protect poor women in many nant women significantly reduces the risk of parts of the developing world. The poorest HIV transmission to their babies. Currently, women have almost twice the number of chil- only 45 percentage of HIV-positive pregnant dren as the wealthiest, the poorest adoles- women are receiving antiretroviral therapy cents are 2.4 times as likely to give birth as the prophylaxis in low- and middle-income coun- wealthiest, and the wealthiest women are two- tries. Integrated HIV prevention and sexual and-half time more likely to have trained de- and reproductive health services can pro- livery attendance as the poorest.67 vide dual protection for women attending Poor reproductive health outcomes con- antenatal care clinics: HIV prevention and tribute to poverty in different ways, mainly birth control. In India’s high-HIV-prevalence through the negative impact on overall southern and western states, Bank-supported health. In addition, large family size promotes targeted interventions among sex workers and poverty by slowing economic growth and dis- their clients have helped to reduce HIV prev- torts the distribution of income to the detri- alence among young women attending ante- ment of the poor. Early childbearing disrupts natal clinics by approximately half. Prevalence schooling and affects future employment op- came down from about 2 percent in 2000 to portunities for female adolescents. Adoles- less than 1 percent in 2007. cent mothers also tend to have poorer health during pregnancy, through less use of health- Reaching the Poor care services and the biological constraints as- There is widespread evidence that poor sociated with their age. Table 4 shows the people suffer from far higher morbidity, inequalities in use of modern family planning mortality, and malnutrition than do the methods in four countries. The poor also use better-off; and their inadequate health is considerably less of the basic maternal and one of the factors for their being poor. An health services—such as antenatal care, oral analysis of DHS datasets shows a strong cor- rehydration therapy, immunization, attended relation between maternal health and poverty. delivery, and treatment of fever. Services related to reproductive health were Ensuring access to family planning and more inequitable than any other cluster of ser- maternal services among the poor can re- vices, suggesting that the public health sectors duce inequality and improve the health Table 4 | Percentage of Currently Married Women (15–49) Using a Modern Family Planning Method Wealth quintile Malawi (2000) Zambia (2002) Kenya (2003) Guatemala (1999) Poorest 19.8 10.8 11.8 5.4 Second 24.2 13.2 24.2 11.9 Third 24.9 19.7 33.4 24.5 Fourth 25.3 31.3 41.0 45.0 Richest 36.2 52.5 44.5 59.7 Better Health for Women and Families | The World Bank’s Reproductive Health Action Plan 2010–2015 29 status of women in the lower wealth quin- vide technical assistance and support to tiles. Bolivia has aggressively implemented countries in their effort to reach women in social insurance schemes that have ensured the lower two wealth quintiles and ensure access to reproductive health services for all that they have access to the full range of ma- women of reproductive age, including the ternal and family planning services. poor. This has been supported by a strong supply chain that ensures the arrival of prod- Reaching Adolescents ucts to remote service delivery points. As a re- More than half the youth in many countries sult, births in health facilities have increased are sexually active.68 Among sexually active in the last decade, and there have been marked young men and young women, the use of con- reductions in inequality in using family plan- doms is low, increasing their risk of acquiring ning and antenatal care services. By contrast, sexually transmitted infections. Demographic countries such as Guatemala, which have not and Health Survey data show that the share been as aggressive in pursuing strategies to en- of sexually active boys using condoms ranges sure access to reproductive health services for from about 20 percent in Mali to a high of 50 the poor, continue to have huge inequalities percent in Zambia. Among girls, condom use in access and use. Recent legislation in 2004 is higher among unmarried sexually active girls mandating that 15 percent of the tax on al- than among married girls.69 As mentioned ear- coholic beverages be used for reproductive lier, people under the age of 25 account for health, family planning, and alcoholism pro- more than 100 million sexually transmitted grams has started improving access, but the infections annually. Most are easily treated, momentum will need to be sustained for a but many go unnoticed, and when the effects longer period for a significant change in use become apparent, many of the young people among the poor. may not even seek the services, fearing pro- The link between reproductive health hibitive costs, refusal, and judgmental facility and poverty reduction has important im- staff.70 The Bank will support countries to im- plications for policies and program re- prove access to reproductive health services for sponses in developing countries. A menu the youth, especially for the treatment of sexu- of pro-poor policies provides a useful frame- ally transmitted infections. work for thinking about potential inter- Service providers often ignore reproduc- ventions in areas of financing, provider tive issues not because they discount their payments, organization, regulation and per- importance, but because they may not know suasion—and highlights the scope of the how to talk about reproductive and sexual impact of these interventions at the macro health concerns in sensitive and engaging level, health system level and the micro com- ways, especially with the youth. It is critical munity and facility level (table 5). And suc- that young people get knowledge on ways to cessful interventions in low-income countries prevent unwanted pregnancy and information can also be tailored to specifically meet the on contraceptive methods and reproductive reproductive health of women in lower health services. Information and services could wealth quintiles (box 3). The Bank will pro- be delivered through youth-friendly health ser- 30 Table 5 | Menu of Pro-poor Policies Provider Finance payment Organization Regulation Persuasion Macro level Expand insurance Integrated ap- Monitoring Charter of rights (overall policy coverage for the proaches (health, tools (Public for the poor and finance) poor safety nets, expenditure Targeted Geographic tar- education roads, reviews/benefit conditional cash and so on) incidence geting (allocation) transfers (the analysis) Needs-based tar- conditional part) geting (allocation) Poverty map cre- ation and update Targeted conditional cash transfers (the cash part) Health Level of care Contracting in- Pro-poor benefits Standards for Social marketing system level targeting centives to serve package facilities serving Health education the poor (allocation-input the poor focus Balanced balance) Equity-related human resource Input market Strengthening Voucher systems performance- allocation regulation (drugs, outreach for the poor based allocation equipment, and Generating Hardship pay- the like) demand ments for locat- ing providers Micro level Exemption Provider payment Local or commu- Local or commu- Community (community policies for the linked to use by nity management nity oversight mobilization and facility) poor poor of services Supervision of Health education Facility equity Community- Participatory facilities serving campaigns funds based planning the poor mechanisms for Campaign mode Active identifying the delivery identification of poor the poor Mobile delivery approaches Source: Yazbeck, AS, 2009. Attacking Inequality in the Health Sector—A Synthesis of Evidence and Tools. Washington, DC: World Bank. Of the estimated 200 million preg- mated 20 million unsafe abortions each year nancies every year, some 20 million end in are for women aged 15 to 19.72 Consequently, unsafe abortions, which put women at sub- the Bank considers that unsafe abortion is a stantial risk of lasting injury or death. In serious public health issue for women and low-income countries where abortion is re- supports family planning services, including stricted or illegal, deaths from unsafe abortion emergency contraception, which helps to pre- practices can be substantial, accounting for 13 vent or reduce unsafe abortion as part of a percent of maternal mortality globally, and in country’s basic health program. In addition, some countries as many as 25 percent of ma- access to safe abortion services and post-abor- ternal deaths.71 At least a fourth of the esti- tion care will greatly reduce the health risks Better Health for Women and Families | The World Bank’s Reproductive Health Action Plan 2010–2015 31 Box 3 | Reaching the Poor — Lessons from Success Stories Finance reforms—both resource mobilization and allocation 1. Delink payment by the poor from use. In a number of evaluated reforms, policy actions decreased in- equality if they minimized or eliminated the financial disincentives for poor households to seek care. Exam- ples include expansion of health insurance coverage to the poor (Colombia, Mexico, and Rwanda) and fee exemption mechanisms for cost recovery (Cambodia health equity funds, Indonesia health card program). 2. Make the money follow the poor. Some of the successful reforms reviewed included policy actions that reoriented resource allocation mechanisms to serve the poor. Examples include geographic targeting (Bra- zil), targeted conditional cash transfers (Chile and Mexico), vouchers, and targeting facility levels that serve the poor (the Kyrgyz Republic). Provider payment reforms 3. Link provider payment to use by the poor. The growing literature on the impact of reforms shows that creat- ing explicit links between provider compensation and service use by the poor decreases inequality. Examples include incentives to municipalities to increase use by the poor (Brazil), incentives to contracted nongovern- mental organizations (NGOs) that reach the poor and payment to hospitals serving the poor (Cambodia). Organizational reforms 4. Close the distance between the poor and services. The case studies confirmed that reforms that brought services geographically closer to the poor had a positive impact on inequality. A number of programs defined a benefits package to serve the needs of the poor (Brazil, Cambodia contracting, Colombia, Mexico, Nepal, and Rwanda). Social distance between providers and the poor is also an important factor. Effective methods to close the social distance in health services include use of familiar and trusted community mem- bers to provide health services (India Self-Employed Women’s Association), engagement of the community in service management (Rwanda), and collaboration with the community in program design. Regulatory reforms 5. Amplify the voice of the poor. A number of the evaluated policies successfully reduced inequality by engaging the poor in the design and implementation of health sector reforms. Examples include participa- tory planning (Nepal), community oversight (Rwanda), community identification of the poor (Cambodia health equity fund), research on the needs and preferences of the poor (Tanzania), household-level planning (Chile), and community mobilization (Kenya). Persuasion reforms—behavior change 6. Close the gap between need and demand by the poor. Closing the need-to-demand gap may require information, persuasion, and incentives. Examples include conditional cash transfers (Chile, Mexico), social marketing (Tanzania), and outreach health education (Brazil, Cambodia, Chile, Kenya). Source: Yazbeck, AS, 2009. Attacking Inequality in the Health Sector – A Synthesis of Evidence and Tools. Washington, DC: World Bank. vices programs and school programs for both to women of unplanned pregnancies. Where in- and out-of-school adolescents. The Bank countries permit abortion and request help, will work closely with countries and develop- the Bank will support their national efforts to ment partners in providing training to doctors provide safe abortion and post-abortion ser- and nurses to deal with the special reproduc- vices to women. In addition to expanding tive health needs of young clients. information and knowledge about family 32 planning and avoiding HIV/AIDS and sexu- level and country systems, and mutual ac- ally transmitted infections, the Bank will help countability among all stakeholders in the countries to motivate young women to stay existing national planning and monitoring in school and pursue their studies and acquire processes. Better and coordinated use of ex- life skills before starting their families.73 isting and new funds will improve results on the ground, while better and improved coor- Working with Partners and Civil dination among development partners will re- Society duce fragmentation and avoid duplication. Guided by the principles of the Paris Dec- The reproductive health Action Plan will ben- laration on Aid Effectiveness and the Accra efit from ongoing efforts by the GAVI Alli- Agenda for Action, the Bank will work ance, Global Fund, World Bank, and World closely with partners to support country- Health Organization to develop a Health Sys- led health system strengthening strategies tems Funding Platform, which aims at sup- to produce, finance, deliver, and increase porting country progress toward national the use of reproductive health services. health goals and the MDGs. Mobilizing and With just five years until 2015, many coun- streamlining the flow of existing and new in- tries are still struggling to achieve the vastly ternational resources to support health system better health results and development poten- components of national health plans will tial signified in the MDG targets. Progress strengthen country capacity to deliver repro- has been especially slow in achieving MDG 5, ductive health programs to all, especially to and it is important that reproductive health the poor and vulnerable. strategies and actions be strongly aligned with Together with UNFPA, UNICEF, and national systems in their design and imple- WHO, the Bank, as a part of the H4, is mentation to maximize the synergies and po- committed to work with country govern- tential outcomes. ments and civil societies to strengthen na- Besides national ownership and align- tional capacity to achieve MDG 5. Building ment with national systems, implemen- on its core competencies and areas of compar- tation of the reproductive health Action ative advantage, the Bank will use its unique Plan at the country level will be guided by leveraging position to maximize individual the IHP+ focus on results, harmonization and collective efforts to tackle the root causes among development partners at the country of maternal morbidity and mortality. Better Health for Women and Families | The World Bank’s Reproductive Health Action Plan 2010–2015 33 Results Framework T his Action Plan will contribute to re- To assist the countries in the renewed ducing high fertility, improving preg- push toward meeting MDG 5, the Bank will nancy outcomes, and reducing sexually strengthen its capacity and expertise across transmitted infections, particularly in the several core competencies. The Bank will countries with high MMR or TFR. This will seek to increase its expertise by training ex- be achieved chiefly through efforts directed isting HNP specialists in reproductive health at helping countries develop strong and ro- issues, identifying reproductive health focal bust health systems by focusing on the five points in all Bank regions, and hiring new areas just noted. Several inputs, processes, HNP specialists with expertise in reproductive and output indicators will be used in the lead health. The Bank’s Africa region has already up to the desired outcomes. Table 6 presents initiated the development of a population and the results framework for this reproductive reproductive health strategy for the region (see health Action Plan, which is closely aligned annex B). Further, the Bank will increase the with the country outcomes, intermediate in- emphasis on analytical work to provide the dicators, and processes included in the HNP basis for assisting countries, informing policy Sector Strategy. dialogues, and raising awareness on repro- The Results Framework in table 6 has ductive health issues. Examples of analytical three tiers. The first includes country-level de- work include analyzing of country-specific velopment outcomes, which are final outcomes constraints for reproductive health; tracking (such as declines in mortality and fertility) de- resource flows for reproductive health and termined by action in many sectors, the overall identifying financing gaps, and documenting macroeconomic environment, and technolog- success stories and “good practices” to learn ical change. The second tier covers indicators from positive experiences. In addition, the measuring Bank outputs and outcomes that, 2012 World Development Report, Develop- together with the activities of countries and ment and Gender Equity, will include repro- development partners, lead to better coverage ductive health issues. The Bank will increase with interventions known to contribute to the level and effectiveness of lending and sup- country outcomes. Indicators in this tier will port for health system strengthening and mul- be disaggregated by age, poverty quintile, and tisectoral interventions to address reproductive urban-rural, when data are available to do so. health in priority countries. The third tier lists Bank activities and concrete The Bank will focus on improving data actions to improve its efficiency, quality, and collection and monitoring of trends in fer- effectiveness to enable achieving the interme- tility and maternal mortality. The use of new diate coverage indicators. information and communication technologies 34 holds promise for improving timely referrals, ognized that such efforts are key to improving health records, and computerized decision countries’ overall statistical development in support. This will require investing in civil many areas.74 To address the data gaps in the registration systems that are too incomplete to meantime, several other data collection tools provide usable information on vital statistics. will be incorporated into the Bank’s lending, Strengthening such systems is a challenge that including household surveys, facility surveys, will take time to address, but it is widely rec- and public expenditure tracking surveys. Better Health for Women and Families | The World Bank’s Reproductive Health Action Plan 2010–2015 Table 6 | Results Framework for the Reproductive Health Action Plan 1. Country Development Outcomes Priority Area Indicators and Targetsa Reducing high fertility Total fertility rate reduced (HNP Sector Strategy indicator) Improving pregnancy Maternal mortality ratio reduced (HNP Sector Strategy indicator) outcomes Reducing sexually Reduced morbidity and mortality from HIV/AIDS and other priority STIs (HNP Sector Strategy indicator) transmitted infections 2. How The Bank Contributes: Intermediate Outcome Indicators Priority Area Indicators and Targetsa Reducing high fertility Adolescent fertility rate in target countries reducedb (HNP Sector Strategy indicator) Contraceptive prevalence rate increased to allow women to reach desired family size (HNP Sector Strategy indicator) Number of target countries with reproductive health strategic plans incorporated in national health strategies Number of target countries with no stock outs of contraceptives in the preceding year Improving pregnancy Births attended by skilled health personnel in target countries increased (HNP Sector Strategy indicator) outcomes Newborns protected against tetanus in target countries increased (HNP Sector Strategy indicator) Pregnant women receiving prenatal care in target countries increased (HNP Sector Strategy indicator) Reducing sexually Pregnant women living with HIV who received antiretrovirals to reduce the risk of mother-to-child transmission increased transmitted infections Number of target countries promoting contraceptive availability for HIV positive women increased. Number of target countries with programs on STI prevention, treatment, and counseling for adolescents ( both male and female) increase 3. Agency Effectiveness: World Bank Activities That Contribute to Country and Intermediate Outcomes Activities Indicators and Targets Responsibility Analytical and Advi- Conduct analytical work to identify Percentage of CASs scheduled for 2010–2015 that PRMGE, HDNHE, HNP Regions sory Activities to fa- country specific RH constraints to feed have been informed by country-specific gender analysis cilitate policy dialogue into Country Assistance Strategies including reproductive health in target countries (Target: (CASs) and lending operations. 100%)b (continue to next page) 35 36 Table 6 | Results Framework for the Reproductive Health Action Plan (continued) Percentage of health projects scheduled for 2010–15 in HDNHE, HNP Regions countries with high MMR or high TFR that address high fer- tility or maternal mortality (no target but track annually) Track resource flow for RH and identify Number of National Health reproductive health subac- HDNHE, HNP Regions, Develop- financing gaps for RH using NHA counts developed for selected countries (track annually) ment Partners framework Conduct and disseminate regional Disseminate the South Asia report Sparing Lives (by De- SASHD flagship AAAs in Africa, Europe and cember 2010). AFTHE Central Asia region, South Asia, Middle Africa Region flagship report completed and disseminated East and North Africa, and East Asia ECSHD (by December 2012) and Pacific regions—addressing repro- EASHH Better Health for Women and Families ductive health issues Europe and Central Asia region flagship report completed and disseminated (by December 2012) MNAHD East Asia and Pacific region flagship report completed and disseminated (by December 2011) Middle East and North Africa region flagship report com- pleted and disseminated (by June 2013) Ensure reproductive health issues are in- Reproductive health issues incorporated in 2012 World DEC, PREM, HDNHE, HNP cluded in the 2012 World Development Development Report Development and Gender Equity Regions Report Development and Gender Equity Develop case studies to document Number of case studies reports disseminated (ongoing) HDNHE, HNP Regions success stories and best practices Develop Bank capac- Establish reproductive health expert Expert team on reproductive health issues, including repre- HNP Sector Board ity and expertise in team including representation from sentatives from PREM, DEC, education, and other relevant reproductive health other sectors sectors established (by June 2010) Strengthen skills of existing staff in Reproductive health focal points in all Bank regions identified HNP Sector Board reproductive health and recruit new Recruit new HNP specialists with strong skills in reproduc- HNP Sector Board staff as necessary tive health for Africa, South-Asia and HDNHE as required by operational needs Develop and disseminate FAQs and FAQs and guidance notes developed, disseminated, and HDNHE, HNP Regions guidance notes for addressing repro- available on HNP website (ongoing) ductive health constraints | The World Bank’s Reproductive Health Action Plan 2010–2015 (continue to next page) Table 6 | Results Framework for the Reproductive Health Action Plan (continued) Review and strengthen the existing Number of TTLs in countries with high MMR or high TFR HDNHE, WBI, HNP Regions flagship course on reproductive health who have completed flagship courses (track annually) Develop learning session for HDN Short course on reproductive health delivered during the HDNHE, HNP Regions learning week Nov 2010 learning week Development Marketplace for repro- Conduct Development Marketplace in reproductive health SAR, AFTHE, HDNHE ductive health in Africa and South Asia regions Improving portfolio Prepare monthly updates of the list of Matrix of list of pipeline projects and CASs shared with HDNHE, HNP Regions Monitoring pipeline projects and CASs to identify regional reproductive health focal points monthly countries for AAAs and reproductive health technical support Prepare monthly updates of the list of Matrix of list of projects with upcoming mid-term reviews HDNHE, HNP Regions ongoing projects to identify projects and implementation completion reports shared with re- due for mid-term reviews and imple- gional reproductive health focal points monthly mentation completion reports Develop a list of countries with high Matrix of list of countries without current or pipeline proj- HDNHE, HNP Regions MMR or high TFR that do not have ects shared with regional reproductive health focal points current or pipeline projects for AAAs monthly or policy dialogue with countries Track key reproductive health indica- List of reproductive health indicators for monitoring country HDNHE, HNP Regions tors (as identified earlier) by poverty reproductive health outcomes developed and annually quintiles in countries with high MMR updated or high TFR Participation in Quality Enhancement Number of panels with reproductive health expertise par- HNP Quality team, HDNHE, HNP Review Panel of projects under prepa- ticipating in quality enhancement review (ongoing) Regions ration with Pop/RH theme in countries with high MMR or high TFR Participation in mid-term reviews or Number of midterm reviews with reproductive health exper- HNP Quality team, HDNHE, HNP implementation completion reports of tise participating in each mid-term review or implementa- Regions health projects with Pop/RH theme in tion completion reports (ongoing) countries with high MMR or high TFR a The country level reproductive health outcomes do not have targets because countries and other development partners will also contribute to these outcomes. b In the Results Framework for Gender in IDA16, Operational Policy OP4.20 stipulates gender assessments in all CASs. 37 38 Annex A. Consultations on the Reproductive Health Action Plan Main Outcomes of External in different ways—toward sexual health, Consultations women and health, human rights, and The Reproductive Health Action Plan has health systems. been developed through a consultative pro- The ÆÆ discussion on ICPD 1994 refers to a cess. Four consultations were held with donor shift in focus from reproductive health be- organizations, UN agencies, academia, think cause of the broader human rights frame- tanks, and civil society organizations. The works posed by ICPD 1994. While this can main outcomes include the following. be misinterpreted as a criticism of ICPD 1994 POA, it in fact highlights a reality. 1. Conceptual and definitional issues ÆÆICPD was a compromise that brought to- ÆÆ World Bank’s definition of sexual and The gether a variety of stakeholders. Within reproductive health includes pregnancy the ICPD, three different frameworks and pre-pregnancy related care, neonatal resonate with stakeholders and how they care, contraception, delivery, post-partum, translate into policy: women’s rights, sexually transmitted infections, and public health, and population growth and building linkages with HIV/AIDS and demography. with gender and youth. ÆÆCairo’s concepts were broad—Cairo is ÆÆReproductive health should not be framed not a convention or treaty, but a norma- purely as a health issue. It is important to tive statement debated by governments. recognize and leverage cross-sectoral links This breadth is a strength for bringing to- in addressing reproductive health (trans- gether different political constituencies, port, communications, women’s empow- but it has also generated issues and chal- erment, girls’ education, human rights, lenges. These range from confusion over and poverty). This is an area where the program components, particularly in the World Bank has a comparative advantage. relative emphasis on family planning— ÆÆ 1994 International Conference on The to measurement problems over inputs Population and Development (ICPD), a and results. In the World Bank’s Action unique event, was central to establishing Plan, there is a need to be specific without definitions and concepts of reproduc- being reductionist. tive health. One major innovation was A ÆÆ critical challenge coming out of ICPD’s incorporating human rights into health. broad approach is in how to set priorities The field has moved forward since then in country programs. Reproductive health Better Health for Women and Families | The World Bank’s Reproductive Health Action Plan 2010–2015 39 programs have long struggled with devel- to the ICPD’s broad consensus because it oping effective measurement tools to as- considers women and women’s rights at sist with priority setting. The unfinished the outer circle but then focuses in to ma- agenda of the MDGs provides a focus for ternal health and attempts to drive specific current efforts, but in the longer term, changes in concrete measurable outcomes. ICPD encompasses emerging agendas At ÆÆ the same time, the role of men as deci- such as linking reproductive health to sionmakers in households, and as partners noncommunicable disease. in choices about family planning, needs to ÆÆLanguage and word choices matter in the be incorporated into the framework. signals they give to partners, emphasizing ÆÆResources for reproductive health and the need for conceptual clarity. Repro- family planning have stayed flat in recent ductive health encompasses some pro- years and not met Cairo goals. The chal- found ideological differences, and the use lenges of tracking resources for reproduc- of certain language can be perceived to le- tive health have been made more difficult gitimize activities seen as controversial. Sci- by a lack of definitional clarity over repro- entifically derived evidence can be a good ductive health and its subcomponents. arbiter in these ideological discussions. The ÆÆ World Bank remains committed ÆÆOne way to think about how to bridge the to ICPD, a commitment reaffirmed in multiple concepts that Cairo brought to- its 2007 HNP strategy. The Bank’s ap- gether in an actionable way is to envision proach is to start from ICPD, but within a series of concentric circles (figure below). that, the Bank’s comparative advantage This framework could emphasize the mes- is through a public health and health sage that the World Bank has responded system approach. From there, the World Bank can build links to related sectors supporting women’s empowerment and A Conceptual Framework for Women gender equality that support ICPD. The and Health final decision about the types of interven- tions on reproductive health rests with the countries and would consider social and Women and health cultural issues. In this respect, engaging in Women’s health dialogue based on scientific research can roductive health Rep yield more convincing results. Maternal health 2. Using the health system strengthening platform ÆÆHealth system strengthening has devel- oped out of the tensions between vertical disease-specific programs and horizontal systemwide programs. Many global health initiatives have hesitated to use system- 40 wide approaches because of concern that ÆÆUsing the language of entitlements in de- the health system is a black box, a black signing a package of services is a concrete hole, or a laundry list. Vertical programs, step in implementing a human rights ap- meanwhile, can create parallel structures proach. This makes the rights approach that are disruptive to an effective country operational because these entitlements can health system. be acted upon. ÆÆHealth system strengthening needs to ÆÆThere is a need to quantify and address happen, biased toward sexual and repro- the potential spillover effects of health ductive health—and the outcomes will be system strengthening for reproductive dramatic. A diagonal approach seeks to health. The family planning community focus on using investments on specific in- has done a good job of articulating the terventions such as reproductive health in- multiple benefits of family planning. To terventions to strengthen health systems. be able to demonstrate the broader impact This approach maintains the focus of the of work done in a narrow spectrum would global health community on achieving provide compelling evidence to ministries results for definable outcomes while in- of health and finance. vesting in the development of necessary ÆÆStrengthening health information sys- systems. tems is a necessary part of health system ÆÆHealth system strengthening and the diag- strengthening. For MMR, this could onal approach are appropriate strategies in mean starting with better case-finding and which the Bank can fulfill its reproductive estimates. At the beginning, this could health commitments while building on lead to higher estimates of MMR, but its comparative advantages. One recom- the result of more accurate estimates is a mendation in implementing the diagonal stronger health information system. This approach would be to have health system is a clear example of the spillover effects. strengthening interventions as the main Capacity development data collection, framework, with the diagonal approach analysis, and use should be in the plan. coming in to look at reproductive health ÆÆGovernance and accountability of health outcomes that guide these interventions. systems are also key issues. The Action The ÆÆ development of a package of service Plan needs to detail how exactly the Bank and entitlements is a core tool for the di- will work with countries on governance agonal approach. Every good package issues. Some suggestions include the pro- should have “a clinical overview” with ca- cess of decentralizing service delivery and pabilities at least for diagnosis, palliation, a system of peer review. and referral. Rather than an aggregation ÆÆThere are several pitfalls to be aware of of interventions, the package in the diag- in adopting health system strengthening onal approach is a resource allocation tool as a core framework. It is possible to that considers workforce, information, lose some focus on the immediate needs and other inputs and processes needed to and requirements of strong reproduc- implement it. tive health interventions in the push to- Better Health for Women and Families | The World Bank’s Reproductive Health Action Plan 2010–2015 41 ward system strengthening. And as health programs that should not be ignored or system strengthening becomes more dismantled. Instead, the focus should be mainstreamed, there is a danger of dupli- on how to integrate them into health sys- cation or verticalization of health system tems. strengthening as its own separate pro- In ÆÆ countries like Nepal, with hard-to-reach gram, rather than as a key theme linking a remote areas, about 80 percent of births range of global health agendas. are home deliveries. Reaching health fa- ÆÆEffective coverage was proposed as a pos- cilities and skilled birth attendants is hard. sible measurement approach to adopt Expecting them to have access to facility- in assessing progress on health system based service delivery is unrealistic. There strengthening for reproductive health. needs to be a clear strategy on how to best Rather than focus on an ultimate out- reach women in these remote pockets. come—MMR, which is difficult to Low-cost high-output community-based monitor day-to-day—effective coverage approaches may be most efficient for re- focuses on those interventions proven to ducing the total fertility rate. For ex- be highly correlated with positive out- ample, in Nepal there are a large number comes. By measuring this process, it is of female community health volunteers. possible to get an approximate measure of Training them to provide injectable con- the outcome. traceptives at the community level would ÆÆBuilding these metrics will require fur- be a fast and efficient way to increase con- ther research on the effectiveness of core traceptive use and reduce unmet need. reproductive health interventions, such ÆÆHealth policy in many developing coun- as skilled birth attendance. Filling this tries restricts reproductive health services knowledge gap will be a global public doctors only, including very simple ones good. The perfect, however, should not be such as counseling women on the best the enemy of the good, and implemen- form of family planning. However, nurses tation of the World Bank’s Action Plan and mid-level providers, given the right should not wait on the development of training, are perfectly capable of providing ideal metrics. family planning counseling, inserting and ÆÆOther donors are also grappling with removing intraurine devices, and indeed these challenges. USAID, for example, performing all the essential components has the idea of a dual-track approach that of emergency obstetric care. Task-shifting focuses on identifying quick wins along downward and changing health policy with longer term investments. Coordina- so that mid-level providers can access tion across agencies and donors is needed training and legitimately provide repro- to avoid confusion as to what country can ductive health services would remove an apply for resources and from whom and enormous bottleneck. how the assistance platform is designed. ÆÆWhile ensuring contraceptive supplies and ÆÆThere are many successful examples of logistics including supply chain manage- functioning vertical reproductive health ment is area of comparative advantage for 42 Bank. Support should also be provided exists within the United States as well for the procurement of contraceptives. To (members of Congress question need avoid the long lead time for Bank pro- to include maternity care in the U.S. curement, UN partners, such as UNFPA/ health bill). But Secretary of State Hillary UNICEF, can do this. Clinton really gets this issue and is one ÆÆMany of the drivers of poor reproduc- of the main reasons why the U.S. is in- tive health are the same as the drivers as cluding maternal health in new policies. HIV infections—and the responses often Her leadership should be leveraged to overlap, particularly with family planning help further this cause. programming and HIV prevention pro- The ÆÆ role of men in reproductive health grams. Combining these services has ben- as decision makers in political legislature efits in efficiency and in reaching women was also brought up. There is a need for living with HIV and preventing mother- their capacity development and technical to-child transmission. These links should engagement to try to educate political be made stronger in the Bank’s strategy. leaders on the needs to address some of A ÆÆ major bottleneck is that public health these issues. services have given very low priority to re- ÆÆBuy-in has to come from members of par- productive health in the past, and as such liament as well as NGOs and civil society a lot of reproductive health provision exists organizations for ownership in setting pri- in the non-state sector. Many NGOs and orities, especially for reproductive health private healthcare providers offer reproduc- and sexual and reproductive health. This tive health services. Supporting govern- requires at a minimum access to decision ments to regulate these nonstate providers making procedures—if not a place at the and incorporate them in the public sector decision making table. Beginning with a has potential for creating greater synergies matrix of options that gives structure and in reaching the target populations. priority would be a useful tool. The ÆÆ Action Plan also has to recognize and ÆÆThere is a need for legal frameworks sur- leverage the private sector’s involvement rounding reproductive health for several in reproductive health, especially since the reasons. Legal frameworks should en- private sector is the primary source of ser- sure reproductive health as a right in all vices in most of the focus countries. There the nations through long-term commit- is also a need to recognize that the private ment of state governments to ensuring sector is not monolithic. safe-motherhood and other reproduc- tive health rights. And training for non- 3. Stewardship medical staff for provision of reproductive ÆÆMaternal health has not received the at- health services is vital in countries like tention it deserves—for several reasons. Nepal. These legal frameworks should There is a lack of political will because of be flexible enough to review and meet an unwillingness to talk about anything new challenges for meeting the demand related to sex. The perception problem for services. The Bank has a role to play Better Health for Women and Families | The World Bank’s Reproductive Health Action Plan 2010–2015 43 here—as in including reproductive health comparative advantage in stewardship and in social protection programs. governance. The ÆÆ problem also exists with the current ÆÆStrengthening Ministries of Health can priority-setting tools that measure the contribute to operationalizing health burden of disease. Maternal health doesn’t system strengthening at the local level by rank high when compared with malaria improving coordination and communica- and TB. There is a need to develop and tion about priorities. use better tools to accurately assess the im- pact of maternal mortality and morbidity 5. Advocacy and resource tracking on countries’ development. Employment The ÆÆ World Bank has a convening role in of DALYs as a measure of lost produc- stimulating global dialogue on reproduc- tivity due to reproductive health-related tive health. This could reenergize discus- mortality and morbidity is one option. sions of the theoretical understanding of ÆÆHealth systems have several functions, links between reproductive health and with service provision is part of the larger development as well as considerations of system. The weakest health system func- how to operationalize reproductive health tion in many countries is stewardship: in countries. health workers at the end of the line re- The ÆÆ need for funding was brought up in ceive uncoordinated approaches, and do- all consultations (by civil society in Gua- nors completely bypass local structures. temala, especially in reference to reaching ÆÆUsing the diagonal approach requires indigenous populations). The Bank can planning and priority-setting skills, impor- advocate with partners for a reallocation tant features of stewardship. In the World of resources within the existing health Bank’s 28 priority countries, the ability to system for reproductive health. This in- build a plan at the national level and set cludes ensuring that reproductive health priorities may be particularly lacking. interventions are included in the basic The ÆÆ H4, which includes the World Bank, packages financed, particularly those has a window of opportunity to deliver as under International Health Partnership one on maternal and child health—and to and within HHA countries. provide the leadership needed to achieve ÆÆSome agreements on the ground are get- the MDG-5 targets. The Bank has a very ting no traction (such as the Maputo central role in this work. Plan, agreed to by heads of state in 50 Af- rican countries, about to be renewed in 4. Strengthening the role of Ministries January). Under the Maputo plan, African of Health Union Health Ministers have already ÆÆOne of the key strategies in the diagonal drafted a Comprehensive Plan for Sexual approach is to strengthen the Ministry Reproductive Health and Rights, which of Health to improve stewardship. The was ratified by the Executive Council of World Bank has played this role previ- the African Union. It is now incumbent ously with Ministries of Finance and has a on member states to implement the Plan. 44 But there are no resources to implement at the country level. These actions will it. Providing resources to support the Ma- contribute to the global public good of a puto Plan could ensure that the Bank’s better knowledge base. Reproductive Health Action Plan gets na- The ÆÆ World Bank can make an important tional ownership within Africa. difference in capacity building. One out- The ÆÆ World Bank is uniquely positioned come indicator could be to see where re- at the country level to advocate for repro- productive health or health in general is ductive health, particularly in reaching put forward as a focal area in the poverty Ministers of Finance. This will require reduction strategy papers or the country using the World Bank’s economic anal- strategy papers. ysis and technical resources to marshal The ÆÆ World Bank has a critical role in arguments for investing in reproduc- tracking resources, in coordination with tive health. Bank’s country directors have such agencies as the WHO, UNFPA, and key role in making reproductive health a OECD involved in similar exercises. Sys- country priority through their policy dia- tematic data teasing out health expendi- logue with governments. tures by governments, nongovernmental On ÆÆ cultural barriers, it was pointed out organizations, and households are needed that the reproductive health bill in Ni- to assist in tracking resources flowing to geria, presented to the Parliament four or reproductive health. five times, has always been rejected be- ÆÆNational health accounts with reproduc- cause it is equated with abortion, raising tive health subaccounts are an important moral and religious questions. tool for tracking resources, but different The ÆÆ Action Plan should build on existing approaches are used to make estimates, re- indicators while doing the necessary work quiring greater harmonization. The Bank to improve measurement, another com- should support countries with necessary parative advantage of the World Bank. expertise and build capacity in countries Reproductive health and health system that lack it. Support for budget estima- strengthening bring together several com- tions based on actual needs has to be em- plementary challenges in measuring effec- phasized. There should be a budget line tive interventions, effective processes, and for reproductive health in the health effective delivery mechanisms. budget. ÆÆ World Bank has tended to work more The ÆÆTracking resources through national on the upstream side of health systems. health accounts have also allowed to Its strength has been not in devising tech- identify potential problems. For ex- nical content, but in governance and fi- ample, the recent national health of ac- nancing. From this position, the World counts show that health expenditure in Bank can review health system indicators Niger has increased from $10 per capita from a reproductive health perspective to about $44 per capita. But the re- and identify success stories for health sys- sources are focused mainly on tertiary tems and reproductive health to intersect services, when more primary health care Better Health for Women and Families | The World Bank’s Reproductive Health Action Plan 2010–2015 45 and referral services would have greater ÆÆDemand-side financing, such as condi- impacts. Being able to gauge these sorts tional cash transfers, has been shown to of issues quickly is important in ensuring be effective with positive reproductive and remedial actions. child health outcomes. This knowledge ÆÆTime is another dimension to factor into base was developed because the interven- country programs and funding. We should tion was rigorously evaluated with a solid ensure that we don’t write off countries research design that allowed for inferences that are immediately successful—we have about attribution. The Bank is in a posi- seen a complete reversal or backsliding on tion to ensure that whatever policy is im- reproductive health in certain countries plemented is based on evidence and is not when funding was removed. driven by ideology. It ÆÆ is important to track demand for ser- 6. Fiscal and other economic vices. In Niger, indicators incorporated in incentives the national framework that tracks results ÆÆInnovations in financing should be incor- have allowed for annual monitoring and porated into the Action Plan. The World evaluation to find out the progress on re- Bank has a comparative advantage in this productive health, rather than waiting for area because of expertise and connections the next DHS or other survey. with Ministries of Finance. ÆÆIncentives can generate demand. There ÆÆBoth system inputs and system processes have been a lot of experiences in the field need to be considered in health system (as in Nepal) with subsidizing and giving strengthening. We need to understand the incentives for reducing financial barriers dynamic aspects of how inputs are trans- to obstetric care. This discussion needs to lated into services and outcomes. These continue. include incentives and different delivery platforms. 7. Keeping engaged – next steps ÆÆConsumer mobilization is important, ÆÆThere should be regular meetings between generating demand for health services Global Health Council members, and the such as antenatal and postnatal care, and World Bank. institution-based deliveries. Civil society ÆÆEmphasis should be on improving the actors can mobilize the communities quality of care, including that of ex- through information, social audits, and isting facilities, reducing barriers to access monitoring and evaluation, such strategy whether financial, physical, or cultural, also makes sense from the point of gov- and improving monitoring systems for ernance. maternal and newborn health. ÆÆWomen’s health is often neglected even The ÆÆ Action Plan should look at the big when they have access to health care facili- picture. Reproductive health has a gender ties. For example, women will bring their dimension as well. Political stability is im- children for checkups and immunization, portant for improving reproductive health but receive little postnatal care. outcomes. MMR and TFR are correlated 46 with the quality of state health systems would be welcomed by technical spe- and poverty, and child survival is related cialists and civil society as a signal of the to the total fertility rate. The World Bank World Bank’s commitments and as a tech- should look at reproductive health not nical contribution to the field. only from the health perspective but also ÆÆMalnutrition is a major issue in Nepal. along the dimensions of poverty, educa- Nutrition should be a key component of tion and gender. the package to improve the pregnancy ÆÆThere should be a flexible approach that outcome. This includes linking neonatal takes country context into account. Each health with reproductive health. Other country has its own values, and dif- areas include HIV/AIDS, gender based ferent issues are interlinked differently. A violence, and adolescent sexual and repro- broader strategy is easier to translate into ductive health. the social and cultural contexts at the ÆÆReproductive morbidity should be ad- country level. dressed, including cancer of the cervix ÆÆImplementation research should be built and fistula, rarely addressed in Nepal. into the design of interventions. The World Bank could bring lessons ÆÆ Action Plan should build on existing The from other countries on how this has platforms, such as the Global Fund and been incorporated into national health GAVI’s collaborative actions with the systems. World Bank on health system strength- For ÆÆ family planning, it may be useful to ening. The Action Plan should also link to have a profile of the target populations. the recent High Level Taskforce on Inno- For example, in Nepal, migrant couples vations in Financing, particularly to work have higher contraceptive prevalence rates in the priority countries identified by the than the general reproductive age group. Taskforce. This type of knowledge is important in ÆÆ Action Plan should be rooted in the The determining target groups and how to Aid Effectiveness Agenda and that should reach them. be stated up front. It would be easier ÆÆPreferences for family planning methods to find solutions to financing payments may also be an area for further work: or human resources within this context Why are some methods more easily ad- rather than isolation. opted or more popular in certain set- ÆÆ Action Plan should build on the The tings? same indicators as those created for the ÆÆMarginalized or vulnerable populations MDGs and the Countdown to 2015 pro- also need a special focus. There is a need cess. Because they are compiled regularly for better understanding of the require- and published in Lancet, these indicators ments and preferences of indigenous could act as a baseline for the Bank’s Ac- populations—and of what is culturally tion Plan to measure progress. relevant to bring indigenous women into ÆÆ World Development Report on repro- A the fold of reproductive health service ductive health or women’s health in 2012 delivery. Education is particularly rel- Better Health for Women and Families | The World Bank’s Reproductive Health Action Plan 2010–2015 47 evant, especially to reduce teenage preg- Consultation Logistics: Locations, nancies and the incidence of HIV/AIDS. Dates, and Participants The Bank’s comparative advantage is in having safeguards in its multisec- Global Health Council toral projects that foster the protection Washington DC and development of women. Partici- November 4, 2009 pants stressed the importance of child and youth education and incorporating Participants: Jeff Sturchio (GHC), Bev sexual and reproductive health into the Johnson (USAID), Crystal Landers (CEDPA), Bank’s education projects (as in Guate- Susan Ehlers (PAI), Deborah Gordis (CARE), mala). Janet Fleischman (CSIS), Claudia Morrissey, ÆÆGender issues—such as poor female mo- Jeff Meer (PPFA), Alex Garita, Susan Cohen bility and financial and cultural bar- (AGI), Jennifer Redner, Jill Sheffield (Family riers—may be preventing women from Care International), Craig Lasher (PAI), Smita institutional deliveries and need to be in- Brauha (GHC), Chris Bennett (GHC), Julian cluded in the reproductive health Action Schweitzer (World Bank), Mukesh Chawla Plan. (World Bank), Sadia A Chowdhury (World ÆÆLearning from best practices was empha- Bank), Ajay Tandon (World Bank), Ed Bos sized, including successes in reproduc- (World Bank), Tom Merrick (World Bank), tive health, and in other health subsectors. Carolyn Reynolds (World Bank), Sam Mills What can we learn from HIV programs (World Bank), Seemeen Saadat (World Bank). that we can then bring into reproductive health? Harvard Global Equity Initiative ÆÆAnother area could be integration of the Boston, MA voices of civil society organizations at the November 6, 2009 national level. They have been integrated successfully into policy dialogue at the in- Participants: Julio Frenk (Harvard Uni- ternational level, but not as much at the versity), Lincoln Chen (China Medical national level. Since these grassroots or- Board), Felicia Knaul (HGEI), Flavia Bus- ganizations have access to ground level treo (PMNCH), Werner Haug (UNFPA), outcomes and activities, they can help in John Bongaarts (Population Council), John measuring success. Townsend (Population Council), Gilda The ÆÆ Action Plan has identified key pri- Sedgh (AGI), Amy Tsui (JHSPH), Eli Adashi ority areas. The next step should be to (Brown University), Kenneth Hill (Harvard have participatory country-specific ac- University), Ana Langer (EngenderHealth), tion plans to determine the interventions Marina Njelekela (Muhimbili University), in each country. To further the national Rachel Nugent (CGD), Ann Starrs (Family action plans, the World Bank’s would fa- Care International), Mindy J Roseman (Har- cilitate knowledge sharing on innovations vard University), Joanne Manrique (GHC), and best practices. Gustavo Nigenda (NIPH, Mexico), Ramiro 48 Guerrera (HGEI), Afsan Bhadelia (HGEI), sociation), Marieke Boot (EU), Maaike van Julian Schweitzer (World Bank), Mukesh Min (EU), An Huybrechts (IPPF Europe), Eef Chawla (World Bank), Sadia A Chowdhury Wuyts (IPPF Europe), Dr. Michel Lavollay, (World Bank), Ajay Tandon (World Bank), Alix Masson (World Scout Bureau), Ra- Carolyn Reynolds (World Bank), Sam Mills chel Hammonds (Helene de Beir Founda- (World Bank), Seemeen Saadat (World Bank). tion), Senator Marleen Temmerman, Arthur de Kermel (World Scout Bureau); Catherine International Family Planning Olier (Red Cross); Natasha Sirrieh (German Conference Foundation for World Population – DSW), Kampala, Uganda Johanna Stratmann (German Foundation for November 17, 2009 World Population – DSW), Catherine Gi- boin (Medecins du Monde France), Nadine Participants: Eliya Msiyaphazi Zulu (African Krysostan (European Parliamentary Forum on Institute for Development Policy), Kebede Population and Development). Kassa (African Union, Ethiopia), Ulrike Neu- bert (DSW, Germany), Barbara Seligman (Abt Guatemala City (GUATEMALA): Anabela Assoc., USA), Nancy P Harris (JSI, Mada- Garcia-Abreu (Chair), Carlos Perez-Brito gascar), Alex Todd-Lippak (USAID), Cynthia (World Bank), Myrna Montengro (Reproduc- Eldridge (Marie Stopes Int’l, Kenya), Karen tive Health Women Observatory), Veronica M Jacquin (PSI, USA), Anna Bakilana (World Buch (Indigenous Women Alianza for Repro- Bank), Eduard Bos (World Bank), Sadia A ductive Health), Silvia Ximico (Indigenous Chowdhury (World Bank). Women Alianza for Reproductive Health), Nadine Gasman (UNFPA), Isabel Stout Video-Conference with Countries (USAID), Jaqueline Lavidali (Reproductive Washington DC, Nigeria, Kenya, Nepal, Gua- Health Unit, Ministry of Health), Virginia temala, Geneva, London, Brussels, Paris Moscoso (Maternal-Infant Health and Nutri- tion Project). December 7, 2009 Kathmandu (NEPAL): Albertus Voetberg Participants by Location (Chair); Nastu Sharma (World Bank); Dr. Laximi Raj Pathak (Chief PPICD, MOHP), Abuja (NIGERIA): Anne Okigbo (Chair), Dr. Naresh Pratap K.C (Director, Family Chinwe Ogbonna (UNFPA), Esther Obinya Health Division, DOHS); Dr BR Marasini (UNICEF). (MOHP), Shanta Lall Mulmi (Center for Pri- mary Health Care, Nepal), Dr. Arju Deuba Brussels (BELGIUM): Sandor Sipos (Chair), Rana (Safe Motherhood NGO Network), Guggi Laryea (World Bank), Dr Philip Da- Pedan Pradhan (UNFPA), Sutaram Depkota vies (European Cervical Cancer Association), (USAID), Susan Clapham (DFID), Navine Isabel Litwin (European Cervical Cancer As- Toppa (Family Planning Association); Better Health for Women and Families | The World Bank’s Reproductive Health Action Plan 2010–2015 49 London (UNITED KINGDOM): Leo Bryant Paris (FRANCE) – Observers only: Barbara (Chair; Marie Stopes International); Riva Es- Genevaz (World Bank); Rachel Winter Jones kinazy (IPPF); Helena Lindberg (DFID); (World Bank). Fionnuala Murphy (Interact Worldwide), Re- becka Rosenquist (Action for Global Health), Geneva (SWITZERLAND): Dr Monir Islam Christina Pagel (UCL Institute for Child (WHO). Health); Susan Crane (International Health Research Programme), John Nduba (AMREF), Washington, DC (USA): Mukesh Chawla Regina Keith (World Vision), Frank Smith (World Bank), Sadia A Chowdhury (World (Child Health Now Global Campaign), Bank), Ajay Tandon (World Bank), Carolyn Nouria Brikci (Save the Children), Anna Mar- Reynolds (World Bank), Eduard Bos (World riot (Oxfam GB), Riva Eskinazy (IPPF), Toby Bank) Marcelo Bortman (World Bank), Dinesh Akroyd (Population Sustainability Network). Nair (World Bank), Ramesh Govindaraj (World Bank), Seemeen Saadat (World Bank). Nairobi (KENYA): Chris Lovelace (Chair); Patricia Odero (GTZ), Muthoni Ndung’u (PPFA), Dr. Sarah Onyango (PPFA), Dr. Kigen Barmasai (MoH), Dr. Mutungi (Uni- versity of Nairobi). 50 Annex B. Outline of African Region Population and Reproductive Health Strategic Plan T he outline of this Sub-Saharan Africa Sub-Saharan Africa hosts 25 of the 28 Strategic Plan for Population and Re- high fertility countries, defined by a total productive Health has been prepared fertility rate higher than five children per by the Africa Region at the World Bank. woman. The fertility transition of the 49 The purpose is to complement the Reproduc- least developed countries (LDCs) is lagging tive Health Action Plan prepared by the HNP 30 to 50 years behind the fertility declines in Anchor. This Africa-specific Strategic Plan was Latin America, the Caribbean, and Asia—and discussed by the Africa Region during a pre- among the LDCs, Sub-Saharan Africa’s fer- sentation chaired by the Sector Manager for tility transition is lagging even further behind. Health, Nutrition, and Population, with the Southern Africa (7 percent of the Sub-Saharan Africa Region Chief Economist as the discus- population) is most advanced in its fertility sant. This meeting was attended by 60 staff transition while Eastern, Western, and Central from the various sectors, representing both the Africa are less advanced (they are ranked by Africa Region and the Anchor. the decreasing degree of completion of their fertility transition). This reflects the impor- Background tance of the various cultural and gender set- Sub-Saharan Africa faces huge challenges to tings within Sub-Saharan Africa. integrate into the world economy, increase The high levels of population growth in its rate of economic growth, and lift its men Sub-Saharan Africa are fueled by rapidly de- and women out of poverty. To achieve these clining levels of mortality despite the HIV/ goals, Africa must improve its governance, AIDS epidemic, and by high levels of fer- build its human capital, improve the health tility that are decreasing only slowly and of its citizens, trigger an education revolu- irregularly. Since the 1960s, Sub-Saharan Af- tion, manage the rapid pace of urbanization, rica’s population has grown at 2.5 percent a increase its agricultural productivity, protect year, implying a doubling time of 28 years. its environment, and adapt to global climate Demographic growth has been even faster for change. The rapid growth of the Sub-Saharan younger age groups. In the last 50 years, the population is exacerbating all these challenges, number of children 0–4 has increased 3.5 times making more difficult the achievement of the and the number of children hoping to go to Millennium Development Goals (MDGs). school (age 5–14) has increased almost 4 times. Better Health for Women and Families | The World Bank’s Reproductive Health Action Plan 2010–2015 51 Current use of contraception is low, and maternal mortality ratios are in Angola, Ma- the rate of increase of contraceptive use is lawi, Mali, Niger, Rwanda, Sierra Leone, Tan- very slow. Less than one woman in five uses a zania, and the rate of decline has stalled. modern contraceptive. Moreover, the rate of Sub-Saharan women want to have ac- increase of the contraceptive prevalence rate is cess to family planning services, as demon- estimated at only 0.5 percentage point a year. strated by the high levels of unmet needs for However, a few countries have increased their family planning. Such unmet needs are es- contraceptive prevalence rates at a faster pace: timated at 25 percent of women on average. the Southern African countries and, more re- This illustrates the double denial of the rights cently, Madagascar, Malawi, Rwanda, and of the African women: the right to have infor- Ethiopia. Their success could be a benchmark mation on family planning (and express their for other Sub-Saharan countries. views on the issue) and the right to have access Poor access to family planning ser- to family planning services. Although Sub- vices results in high numbers of unwanted Saharan women have on average more than pregnancies and induced abortions. The 5 children, fertility levels for some men have low levels of contraceptive use bring two di- been 13 children or more. rect consequences. First, half of all pregnan- Since the mid-1990s, African govern- cies are at risk because they are too early, ments and their development partners have too numerous, and too close. Second, Af- not been fully committed to population and rican women are often compelled to seek un- reproductive health issues. Many miscon- safe abortions to regulate their fertility. A ceptions prevail, such as old-fashioned fears of recent study shows that, of the 20 million population control, complacency about alleg- unsafe abortions worldwide every year, 5 mil- edly low population densities, and the miscon- lion are in Sub-Saharan Africa. About 44 per- strued belief that large markets by themselves cent of pregnancy-related deaths in Africa will foster economic growth. Moreover, in- are due to unsafe abortion. Bank work in Er- ternational and African attention has shifted itrea, Malawi, and Niger identified abortion as to other urgent issues, such as the HIV/AIDS the leading obstetric complication treated at epidemic, humanitarian crises, good gover- health facilities. Both pregnancies at risk and nance—and, more recently, climate change, unsafe abortions are detrimental to the health the food crisis, and the financial crisis. As a re- and the survival of African women. sult, the funding of population and reproduc- Maternal mortality ratios are highest tive health programs has been neglected. in Sub-Saharan Africa. Its average maternal This lack of attention to population mortality ratio (824 per 100,000) far exceeds and reproductive health issues is most un- that in other regions (Asia 329; Latin America fortunate because the rapid pace of popula- 132). About half of all maternal deaths are tion growth affects four major dimensions occur in Sub-Saharan Africa, 247.000 of related to human and socioeconomic de- 529,000 every year. Women there face a 1 in velopment. First, as explained, rapid popu- 16 chance of dying due to causes related to lation growth and high levels of fertility are pregnancy and childbirth. Some of the highest detrimental to the health of women, especially 52 maternal mortality and the survival of their for sub-Saharan Africa as well, most recently children. Second, rapid population growth in the seminal study by Benno Ndulu and col- jeopardizes the formation of human capital leagues, Challenges of African Growth (World (education and health), which creates ten- Bank 2007). See also the ESW on Ethiopia, sions in the fiscal space. Third, rapid popula- Capturing the Demographic Bonus by Christi- tion growth perpetuates high levels of poverty, aensen, May et al. (World Bank 2005). especially among the poorest households. And The World Bank Africa Region is in- fourth, additional population pressure stresses creasing its work with countries to address even further the fragile ecosystems (such as ac- population and reproductive health. The cess to land, deforestation, and water supply). Region has completed three ESWs on Popu- Although socioeconomic development lation (Niger, Ethiopia, and Mali) and one on is by far the best contraceptive, contracep- maternal health (covering Eritrea, Malawi, and tives are also necessary for socioeconomic Niger). It has prepared several background development, particularly when demo- chapters or papers on demography to feed graphic growth is too fast. To be sure, the into CASs (Madagascar and Burkina Faso), relationship between declining fertility and CEMs (Uganda, Burkina Faso, and Burundi), economic growth goes both ways. But should and country programs (Rwanda). It has main- we let economic growth alone bring down streamed population and reproductive health high fertility levels in Sub-Saharan Africa? Or issues in some PRSPs (such as Ethiopia). It has should we also provide public interventions to prepared or is preparing free-standing projects address “market failures,” such as the lack of on population and reproductive health (Niger correct information on contraceptives? Such and Burkina Faso). And it is providing tech- questions still divide development practitio- nical assistance in population issues (Burkina ners. But they need to be addressed squarely Faso and Mali). to justify public investments in population A supply-driven family planning ap- and reproductive health. proach has worked in several countries. Madagascar, Malawi, Ethiopia, and Rwanda Recent Developments are among the family planning success stories There is a new discourse on population and (and are best practices for other Sub-Saharan reproductive health in Sub-Saharan Africa. countries). Success hinges around a high level A “new demography” has emerged from the of commitment of the leadership, raised aware- body of research on the East Asian experience. ness of the population about the benefits of It stresses the importance of age structure, de- family planning, and a secure supply of family pendency ratios, the demographic dividend, planning services. Madagascar exemplifies this. and the links between demographic trends The President pushed a family planning break- and socioeconomic outcomes. And the human through, as indicated by the new emphasis in rights agenda, which includes access to repro- the name of the Ministry of Health and Family ductive health and family planning services, has Planning. This was followed by year-long in- gained prominence in recent years. The impor- formation, education, and communication and tance of the demographic factor was established behavioral communication for change cam- Better Health for Women and Families | The World Bank’s Reproductive Health Action Plan 2010–2015 53 paigns. These efforts were backed up by a se- a production function will need to be identi- cure supply-chain for contraceptives. So does fied for the declining fertility, to be able to run Ethiopia, which deployed thousands of com- models such as the DEC MAMs (Maquette for munity health workers, delivered injectables MDG simulation) to simulate the effects of fer- at the community level, and changed its legal tility changes on development outcomes, as is texts on reproductive health. It also addressed already done for education and health. the logistical supply of contraceptives and long- Focus on population and reproductive term methods. health issues in the 25 high TFR Sub-Sa- The Health Systems for Outcomes haran countries. A mechanism will be estab- (HSO) initiative has helped countries lished to monitor key strategic documents and achieve faster rates of contraceptive cov- lending activities. In particular, it will follow erage. In Rwanda, the strengthening of the up on all CASs in the pipeline, so that pop- health system has made possible impressive ulation and reproductive health issues are gains in the supply of family planning services. brought into all development and poverty re- The results-based financing, the expansion of duction strategies. Furthermore, no CEM and health insurance, and the decentralization of no PRSP for Sub-Saharan high TFR countries the health system all contributed to the im- can ignore population and reproductive health provements both in health coverage and health dimensions. Poverty papers should also factor services delivery. All types of health personnel in demographic issues. Key sector operations, have been trained in delivering all family plan- such as education, gender, and social protec- ning services, including long-term methods. tion, need to be informed with correct and Thanks to better management and strong sup- realistic demographic data and analyses. In ad- port from the developments partners, contra- dition, it is proposed to prepare briefs on pop- ceptive commodities stock-outs are now very ulation and reproductive health issues, to share rare (the government has started to use its own with country directors and country terms. resources to buy contraceptives). Finally, more Sharpen health system for outcome ap- women have been encouraged to deliver in proaches, to gear them better delivery of health centers, and more than 50 percent do so. reproductive health and family planning services. First, the pace of increase of the con- The Way Forward traceptive prevalence rate will need to triple to Update the respective positions of econo- grab the “low hanging fruits” and cover unmet mists and population specialists on the needs over the next 15 years (reliable costing demographic factor for socioeconomic devel- estimates will be needed). Second, MDG-5 opment. Recent analytical work on East Asia has galvanized a renewed focus on the search has demonstrated that demographic changes, for solutions to preventing maternal mor- particularly rapid declines in fertility, have tality, and Sub-Saharan Africa will be the key brought about a demographic dividend caused battleground. The reduction in the number of by more favorable dependency ratios and a maternal deaths will be achieved in part by in- larger share of the labor force. But measuring creasing the percentage of women delivered by this will require additional work. In particular, skilled attendants. Today, 61 percent of African 54 women are still delivered by unskilled practi- USAID, including the RAPID model (now tioners and financial and cultural barriers are being updated). The Population Reference Bu- still major determinants of low utilization of reau has developed a new ENGAGE model safe delivery. But in several Sub-Saharan coun- as well as simple brochures on population tries, maternal mortality remains high despite and reproductive health. The Bank is devel- high maternal health care use. This will re- oping similar tools in Mali and Burkina Faso. quire a closer examination of the failures in the All this will entail renewed efforts to enhance health service delivery system that may explain data quality and measurement. In particular, maternal deaths among women who do reach a more coherent data collection strategy will health facilities: the shortage of personnel, the need to be put forward (censuses, surveys, and lack of drugs, equipment, and blood supplies, civil registration data). the administrative delays, the problems in re- Renew the policy dialogue to guide in- ferral provision, and the clinical mismanage- vestments in population and reproductive ment of patients. health issues. A Concept Note for a new re- Differentiate between family planning gional AAA study on Sub-Saharan population services and services to reduce maternal and reproductive health issues was devel- mortality. Good evidence does exist for family oped in March/April 2010 for funding in July planning service delivery, but better evidence is 2010. The Bank’s last paper of this nature, needed for maternal mortality reduction inter- Population Growth and Policies in Sub-Saharan ventions (this should be done in parallel with Africa, was prepared in 1986. The new paper current models to assist in planning other as- will build on the “new demography” from the pects of health and education). Such evidence East Asian experience. It will help rationalize will help guide client governments about in- and solidify the new discourse on popula- vestments to reduce high fertility and maternal tion and reproductive health issues and the mortality. The synergy between various sector new approaches piloted so far. And it will also interventions and potential of the private offer a detailed Action Plan on how to tackle sector should both be tapped to enhance and population and reproductive health issues ef- complement the public sector’s efforts. fectively. Strengthen the evidence base to bring Rekindle other partners’ efforts in pop- population and reproductive health issues ulation and reproductive health. The Af- to the core of the socioeconomic develop- rica Region will leverage its efforts with other ment agenda, for use in policy dialogues partners’ endeavors, in particular those of and communication tools. Such tools will USAID, UNFPA, and the other major bilat- help convince political leaders, policy makers, eral partners. The time to do so is particularly civil society representatives, and religious propitious as the new U.S. Administration leaders as well as the development commu- is fully reengaged on population and repro- nity about the importance of population and ductive health issues under its Global Health reproductive health issues. Bank partners Initiative. Other prominent NGOs and foun- have already developed such tools, such as the dations have either rejoined the field or giving SPECTRUM family of models funded under it serious thoughts. Better Health for Women and Families | The World Bank’s Reproductive Health Action Plan 2010–2015 55 Address urgently the population and Human Development. PREM will also be re- reproductive health expertise crisis in the engaged on macro-demographic issues, closely World Bank Africa Region and strengthen linked to the issues of labor force, human cap- the ability to respond to clients needs. The ital investments, and poverty reduction. These Africa Region will soon lose its only demog- efforts will be supported through additional rapher. Nor does it have much expertise left nonlending programs of technical assistance in reproductive health. There is an urgent (10 countries will be covered in five years). need to re-establish a solid population and re- Renewed and sustained Bank efforts productive health work program in the Af- in Sub-Saharan reproductive health and rica Region, which means more professionally family planning programs will help posi- qualified staff, some attracted from other re- tion at least half of the high fertility as the gions in the Bank. Funding will need to come incipient stage of fertility transition in the from the Bank Budget as well as Trust Funds. next 10 to 15 years (defined as a contracep- A stop-gap measure would be to ask a devel- tive prevalence rates for modern methods opment partner (such as USAID) to second a of 25 to 30 percent). This will be achieved population and reproductive health expert to by addressing health system for outcome is- the Africa Region. sues and creating the conditions for faster uptakes of family planning services. An ex- Expected Results and Outcomes pected result will be the improvement of key Population and reproductive health issues in indicators. The contraceptive prevalence rate high fertility countries will be brought back will improve (using the benchmark of a 1.5 to the socio-economic development agenda percentage point increase per year) as will and become central to poverty reduction the other indicators for Targets 5a and 5b of strategies and operations. As a result, they MDG-5, especially those pertaining to ma- will no longer be confined to the HNP Tech- ternal mortality. All this will help fulfill the nical Family but will become a concern of the reproductive health rights of the women in Education and Social Protection streams within Sub-Saharan Africa. 56 Annex C. Global Consensus on Maternal, Newborn and Child Health Annex C. Global consensus on maternal, newborn and child health Better Health for Women and Families | The World Bank’s Reproductive Health Action Plan 2010–2015 57 Annex D. Joint World Bank, WHO, Annex D. Joint World Bank, WHO, UNICEF and UNFPA statement on MNCH UNICEF and UNFPA Statement on MNCH 64 58 Annex E. Acknowledgments – Longer Version T he World Bank’s Reproductive Health rector, Operations and Strategy, SARVP), Action Plan was prepared by a team Colin Bruce (Director, Strategy and Opera- led by Sadia A. Chowdhury (Senior tions, AFRVP), Shahrokh Fardoust (Director, Health Specialist, HDNHE), and composed Operations and Strategy DECOS), Hartwig of Eduard Bos (Lead Population Specialist, Schafer (Director, Strategy and Operations, HDNHE), Ajay Tandon (Senior Health SDNSO), Penelope J. Brook (Director, In- Economist, EASHH), Samuel Mills (Consul- dicators and Analysis, FPDVP), Mayra Bu- tant, HDNHE), Seemeen Saadat (Consul- vinic (Sector Director, PRMGE), Emmanuel tant, HDNHE), Geir Solve Sande Lie (Junior Jimenez (Sector Director, EASHD), Juan Professional Associate), and Victoriano Arias Pablo Uribe (Sector Manager, EASHH), Julie (Program Assistant, HDNHE). McLaughlin (Sector Manager, SASHN), Eva The team is grateful for the intense inputs Jarawan (Sector Manager, AFTHE), Abdo and overall guidance provided by Julian Sch- Yazbeck (Sector Manager, ECSH1), Akiko weitzer (Sector Director, Health, Nutrition Maeda (Sector Manager, Health, Nutrition and Population, and Acting Vice President, and Population, MNSHD), and Adam Wag- HDNVP), and Mukesh Chawla (Sector Man- staff (Research Manager, DECHD). ager, HDNHE). We are especially grateful for the detailed Overall guidance was also provided by Pa- comments and continued feedback provided mela Cox (Regional Vice President, LCRVP), by colleagues from the Africa and South Asia Philippe Le Houérou (Regional Vice Presi- regions as well as the Gender Unit of the Pov- dent, ECAVP), James W. Adams (Regional erty Reduction and Economic Management Vice President, EAPVP), Jeffrey S. Gutman network. John May (Lead Population Spe- (Vice President and Head of Network, cialist, AFTHE), Christopher D Walker (Lead OPCVP), Axel Van Trotsenburg (Vice Presi- Specialist, AFTHE), Sangeeta Raja (Senior dent, CFPVP), Marwan Muasher (Senior Vice Public Health Specialist, AFTHE), Gandham President, EXTVP), Milan Brahmbhatt (Ad- NV Ramana (Lead Health Specialist, viser and Acting Vice President, PRMVP), AFTHE), Ok Pannenborg (Retd., Senior Ad- Axel Peuker (Acting Vice President and Cor- visor, AFTHE), James Christopher Lovelace porate Secretary, SECVP), Vinod Thomas (Advisor, AFTHE), Anne U Okigbo (Senior (Director-General and Senior Vice-President, Operations Office, AFTHE), Dinesh Nair IEGDG), Rakesh Nangia (Director, Strategy (Senior Health Specialist, AFTHE), Cornelis and Operations, HDNVP), Xian Zhu (Di- P Kostermans (Lead Public Health Specialist, Better Health for Women and Families | The World Bank’s Reproductive Health Action Plan 2010–2015 59 SASHN), Sameh El-Saharty (Senior Health Halsey Rogers (Senior Economist, DECHD), Specialist, SASHN), Emanuele Capobianco Monica Das Gupta (Senior Social Scientist, (Senior Health Specialist, SASHN), Sandra DECHD), Khama Odera Rogo (Lead Health Rosenhouse (Senior Population and Health Specialist, CICHE), Julie Babinard (Envi- Specialist, SASHN), Tekabe A Belay (Senior ronmental and Social Development Spe- Health Economist, SASHN), Preeti Kudesia cialist, ETWTR), Hnin Hnin Pyne (Senior (Senior Public Health Specialist, SASHN), Public Health Specialist, ETWWP), Mary- Vikram Rajan (Health Specialist, SASHN), anne Leblanc (Senior Public Health Specialist, Albertus Voetberg (Lead Health Specialist, ETWWA), Juri Oka (Senior Operations Of- SASHN), Ramesh Govindaraj (Senior Health ficer, SECPO), T Michael Dompas (Op- Specialist, SASHN), Nastu P Sharma (Public erations Officer, SECPO), Mary T Mulusa Health Specialist, SASHN), Nistha Sinha (Senior Operations Officer, CFPIR), Ozan (Economist, PRMGE), and Gisela Garcia Sevimli (Operations Officer, OPCDM), Law- (Consultant, PRMGE). rence Bouton (Senior Economist, OPCCE), The team is thankful for the comments Sandor Sipos (Special Representative to the provided by Armin Fidler (Advisor, Policy and European Union, EXTBR), Guggi Laryea Strategy, HDNHE), Arianna Legovini (Head, (Communications Officer, EXTBR), Barbara DIME, DECOS), Manuela V Ferro (Man- Genevaz (Senior External Affairs Counselor, ager, OPCCE), Peter Berman (Lead Health EXTEU), Rachel Winter Jones (Senior Com- Economist, HDNHE), Finn EB Schleimann munications Officer, EXTEU), M Colleen (Senior Health Specialist, HDNHE), Rama Gorove-Dreyhaupt (Senior Communications Lakshminarayan (Senior Health Specialist, Officer, EXTOC) and John Garrison (Senior HDNHE), Leslie K Elder (Senior nutrition Communications Officer, EXTIA). Specialist, HDNHE), Gyorgy Bela Fritsche Special gratitude is due to the government (Senior Health Specialist, HDNHE), Thomas officials of client countries, global partners, W Merrick (Consultant, WBIHS), Fernando civil society organizations, and the Bank man- Montenegro Torres(Senior Health Economist, agement and staff who generously provided LCSHH), Patricio V Marquez (Lead Health the team with valuable recommendations and Specialist, ECSH1), Abeyah Al-Omair (Public guidance on how the Bank can better sup- Health Specialist, ECSH1), Anne Margreth port client countries to improve reproductive Bakilana (Economist, ECSH1), Wezi M health outcomes: Jeff Sturchio (Global Health Msisha (Health Specialist, ECSHD), Eliza- Council), Beverly Johnson (USAID), Crystal beth L Lule (Manager, AFTQK), Anabela Landers (CEDPA), Suzanne Ehlers (Popula- Abreu (Country Manager, LCCGT), Carlos tion Action International), Deborah Gordis Marcelo Bortman (Senior Public Health Spe- (CARE), Janet Fleischman (CSIS), Claudia cialist, LCSHH), Carlos Perez-Brito (Con- Morrissey (Saving Newborn Lives/Save the sultant, LCSHD), Alexandre Marc (Lead Children), Jeff Meer (PPFA), Alexandra Social Development Specialist, SDV), Martha Garita (International Women’s Health Coali- Ainsworth (Advisor, IEGWB), Kai-Alex- tion), Susan Cohen (Alan Guttmacher Insti- ander Kaiser (Senior Economist, PRMPS), F tute), Jennifer Redner (International Women’s 60 Health Coalition), Jill Sheffield (Family Care (World Scout Bureau), Rachel Hammonds International), Craig Lasher (Population Ac- (Helene de Beir Foundation), Senator Mar- tion International), Smita Brauha (Global leen Temmerman (Government of Belgium), Health Council), Chris Bennett (Global Arthur de Kermel (World Scout Bureau), Health Council), Julio Frenk (Harvard Uni- Catherine Olier (Red Cross), Natasha Sirrieh versity), Lincoln Chen (China Medical (German Foundation for World Population), Board), Felicia Knaul (Harvard Global Eq- Johanna Stratmann (German Foundation for uity Initiative), Flavia Bustreo (PMNCH), World Population), Catherine Giboin (Me- Werner Haug (UNFPA), John Bongaarts decins du Monde France), Nadine Krysostan (Population Council), John Townsend (Popu- (European Parliamentary Forum on Popula- lation Council), Gilda Sedgh (Alan Guttm- tion and Development), Myrna Montengro acher Institute), Amy Tsui (Johns Hopkins (Reproductive Health Women Observatory), School of Public Health), Eli Adashi (Brown Veronica Buch (Indigenous Women Alianza University), Kenneth Hill (Harvard Univer- for Reproductive Health), Silvia Ximico (In- sity), Ana Langer (EngenderHealth), Marina digenous Women Alianza for Reproductive Njelekela (Muhimbili University), Rachel Nu- Health), Nadine Gasman (UNFPA), Isabel gent (Center for Global Development), Ann Stout (USAID), Jaqueline Lavidali (Repro- Starrs (Family Care International), Mindy J ductive Health Unit, Ministry of Health), Roseman (Harvard University), Joanne Man- Virginia Moscoso (Maternal-Infant Health rique (Global Health Council), Gustavo and Nutrition Project), Dr. Laximi Raj Nigenda (NIPH, Mexico), Ramiro Guerrera Pathak (Chief PPICD, MOHP), Dr. Naresh (Harvard Global Equity Initiative), Afsan Bh- Pratap K.C (Director, Family Health Divi- adelia (Harvard Global Equity Initiative), sion, Department of Health Services, Govern- Eliya Msiyaphazi Zulu (African Institute for ment of Nepal), Dr BR Marasini (Ministry Development Policy), Kebede Kassa (African of Health and Population, Government of Union, Ethiopia), Ulrike Neubert (German Nepal), Shanta Lall Mulmi (Center for Pri- Foundation for World Population), Barbara mary Health Care, Nepal), Dr. Arju Deuba Seligman (Abt Associates, USA), Nancy P Rana (Safe Motherhood NGO Network), Harris (John Snow Inc., Madagascar), Alex Pedan Pradhan (UNFPA), Sutaram Dep- Todd-Lippak (USAID), Cynthia Eldridge kota (USAID), Susan Clapham (DFID), (Marie Stopes International, Kenya), Karen M Navine Toppa (Family Planning Associa- Jacquin (PSI, USA), Leo Bryant (Marie Stopes tion), Riva Eskinazy (IPPF), Helena Lindberg International), Chinwe Ogbonna (UNFPA), (DFID), Fionnuala Murphy (Interact World- Esther Obinya (UNICEF), Dr Philip Davies wide), Rebecka Rosenquist (Action for Global (European Cervical Cancer Association), Is- Health), Christina Pagel (UCL Institute for abel Litwin (European Cervical Cancer As- Child Health), Susan Crane (International sociation), Marieke Boot (European Union), Health Research Programme), John Nduba Maaike van Min (European Union), An Huy- (AMREF), Regina Keith (World Vision), brechts (IPPF Europe), Eef Wuyts (IPPF Eu- Frank Smith (Child Health Now Global Cam- rope), Dr. Michel Lavollay, Alix Masson paign), Nouria Brikci (Save the Children), Better Health for Women and Families | The World Bank’s Reproductive Health Action Plan 2010–2015 61 Anna Marriot (Oxfam GB), Riva Eskinazy ficer, HDNOP) for their support and assis- (IPPF), Toby Akroyd (Population Sustain- tance in making the external consultations ability Network), Patricia Odero (GTZ), Mu- possible. thoni Ndung’u (PPFA), Dr. Sarah Onyango We would like to acknowledge the Of- (PPFA), Dr. Kigen Barmasai (Ministry of fice of the Publisher, The World Bank, for- Health, Kenya), Dr. Mutungi (University of preparing the manuscript for publication, Nairobi), and Dr Monir Islam (WHO). Bruce Ross-Larson at Communications De- The team would also like to thank Global velopment Incorporated for editing, and Jana Health Council, Harvard Global Equity Ini- Krystene Brooks (Consultant, HDNHE) for tiative, the Organizers of the International designing the cover, and Erika Yanick (In- Conference on Family Planning in Kampala, formation Specialist, HDNHE) for the web- Uganda (November 2009) and Bank staff, es- page. pecially Phillip J Hay (Communications Ad- We would also like to thank the govern- visor HDNOP), Carolyn Reynolds (Senior ment of the Netherlands, which provided Communications Officer, HDNOP), Sukanya financial support through the World Bank- Venkataraman (Program Assistant, HDNOP) Netherlands Partnership Program (BNPP) for and Melanie Mayhew (Communications Of- background analysis and country profiles. 62 End Notes 1 Singh, S, JE Darroch, M Vlassoff, and J 8 World Bank, 2009. Implementation of the Nadeau, 2004. Adding it up: the Benefits of World Bank’s Strategy for Health, Nutrition, Investing in Sexual and Reproductive Health and Population (HNP) Results: Achievements, Care. New York: UNFPA /Alan Guttmacher Challenges, and the Way Forward. Wash- Institute. ington, DC: World Bank. 2 Greene, ME, and TW Merrick, 2005. Pov- 9 World Bank, 2007. Health Development: erty Reduction: Does Reproductive Health The World Bank Strategy for Health, Nu- Matter? HNP Discussion Paper Series. trition, and Population. Washington, DC: Washington, DC: World Bank. World Bank. 3 Family Health International, 1998. Men 10 The ICPD Program of Action called for and Reproductive Health. Network Quar- achieving broader development goals terly Bulletin 18 (3). Durham, NC: FHI. through empowering women and meeting 4 The maternal mortality MDG calls for a their needs for education and health, espe- three-fourths reduction in the maternal cially safe motherhood and sexual and re- mortality ratio over 1990–2015. For a re- productive health. It recommended that cent update on the status of MDGs, see health systems provide a package of services, World Bank, 2009. Global Monitoring Re- including family planning, prevention of port: A Global Emergency. Washington, DC: unwanted pregnancy, and prevention of un- World Bank. safe abortion and dealing with its health im- 5 This is based on 2005 data from the World pact, safe pregnancy and delivery, postnatal Development Indicators database; 2005 is care, as well as the prevention and treatment the latest year for which data on both total of reproductive-tract infections and sexually fertility rates and maternal mortality rates transmitted diseases, including HIV/AIDS. are available. 11 The development of the Action Plan has 6 Gwatkin, DR, S Rutstein, K Johnson, E Su- been guided by an extensive internal and liman, A Wagstaff, and A Amouzou, 2007. external consultative process, full details of Socio-Economic Differences in Health, Nu- which can be found in annex A. trition, and Population within Developing 12 The maternal mortality ratio is the annual Countries. Washington, DC: World Bank. number of female deaths from any cause 7 World Bank, 2009. Improving Effective- related to or aggravated by pregnancy or ness and Outcomes for the Poor in Health, its management (excluding accidental or Nutrition, and Population. Washington, incidental causes) during pregnancy and DC: World Bank, Independent Evaluation childbirth or within 42 days of termination Group. of pregnancy, irrespective of the duration Better Health for Women and Families | The World Bank’s Reproductive Health Action Plan 2010–2015 63 and site of the pregnancy, for a specified 21 World Health Organization, 2005. World year (expressed per 100,000 live births). It Health Report 2005: Make Every Mother should not be confused with the maternal and Child Count. Geneva. mortality rate (whose denominator is the 22 Ibid. number of women of reproductive age), 23 United Nations Children’s Fund, 2008. Op. which measures the likelihood of both be- cit. coming pregnant and dying during preg- 24 World Development Indicators. www. nancy or six weeks after delivery. worldbank.org. Accessed February 2010. 13 World Health Organization, 2007. Ma- 25 United Nations Children’s Fund, 2008. Op. ternal Mortality in 2005: Estimates devel- cit. oped by WHO, UNICEF, UNFPA, and the 26 World Development Indicators. www. World Bank. Geneva. worldbank.org. Accessed February 2010. 14 United Nations Children’s Fund, 2008. 27 United Nations, 2004. World Population Progress for Children: Report Card on Prospects. United Nations Department of Maternal Mortality, No. 7. New York: Economic and Social Affairs Population Di- UNICEF. vision. New York. 15 World Health Organization, 2005. World 28 The inter-pregnancy interval is the interval Health Report 2005: Make Every Mother between a woman’s last delivery and the and Child Count. Geneva. next conception. 16 Ibid. 29 Small for gestational age babies are those 17 Lifetime risk of maternal death varies on whose birth weight, length, or head circum- average from one in 7,300 in developed ference lies below the 10th percentile for countries to as high as one in 75 in devel- that gestational age. Small for gestational oping countries. These averages understate age babies have usually been the subject of the range, which varies from one in seven in intrauterine growth restriction. Niger to one in 48,000 in Ireland. 30 Smits, LJ, and GG Essed, 2001. “Short In- 18 Singh, S, JE Darroch, M Vlassoff, and J terpregnancy Intervals and Unfavorable Nadeau, 2004. Adding it Up: The Benefits of Pregnancy Outcomes: Role of Folate Deple- Investing in Sexual and Reproductive Health tion.” Lancet 358: 2074-2077; King, JC, Care. New York: UNFPA/Alan Guttmacher 2003. “The Risk of Maternal Nutritional Institute. Depletion and Poor Outcomes Increases 19 United Nations Children’s Fund, 2008. in Early or Closely Spaced Pregnancies.” Progress for Children: Report Card on Journal of Nutrition 133:1732S-1736S; Maternal Mortality, No. 7. New York: Zhu, BP, 2005. “Effect of Interpregnancy UNICEF. Interval on Birth Outcomes: Findings from 20 Speidel, J, E Maguire, M Neuse, D Gil- Three Recent U.S. studies.” International lespie, and S Sinding, 2009. Making the Journal of Gynecological Obstetrics 89 (Suppl Case for US International Family Planning 1): S25–33. Assistance. Baltimore: Johns Hopkins Uni- 31 Filmer, D, JA Friedman, and N Schady, versity/Gates Institute. 2009. “Development, Modernization, 64 and Son Preference in Fertility Decisions.” 37 World Health Organization, 2005. Effec- World Bank Policy Research Working Paper tiveness of Drug Dependence Treatment in No. 4716. Washington, DC: World Bank. Preventing HIV among Injecting Drug Users. 32 Greene, ME, and T Merrick, 2005, “Pov- Geneva. erty Reduction: Does Reproductive Health 38 Stanback, J, and KA Twum-Baah, 2001. Matter?” Health, Nutrition and Popula- “Why Do Family Planning Providers Re- tion Discussion Paper. Washington, DC: strict Access to Services? An Examination in World Bank; Singh, K, 1998. “Part-time Ghana.” International Family Planning Per- employment in high-school and its effects spectives 27(1):37–41. on academic achievement.” The Journal 39 Okonofua, FE, P Coplan, S Collins, F of Educational Research 91(3): 131-139; Oronsaye, D Ogunsakin, JT Ogonor, JA Lloyd, CB, 2005. Growing up Global: The Kaufman, and K Heggenhougen, 2003. Changing Transition to Adulthood in Devel- “Impact of an Intervention to Improve oping Countries. Washington, DC: National Treatment-seeking Behavior and Prevent Academies Press. Sexually Transmitted Diseases among Nige- 33 Singh, S, and JE Darroch, 2000. “Adoles- rian Youths.” International Journal of Infec- cent Pregnancy and Childbearing: Levels tious Diseases 7(1):61–73. and Trends in Developed Countries.” 40 Lule, E, S Singh, and SA Chowdhury, Family Planning Perspectives 32(1):14–23. 2007. “Fertility regulation behavior and 34 Clark, S, 2004. “Early Marriage and HIV Their Costs: Contraception and unintended Risks in Sub-Saharan Africa.” Studies in Pregnancies in Africa, Eastern Europe and Family Planning 35 (3): 149–60. Central Asia.” Health, Nutrition and Pop- 35 One study in rural Uganda found that the ulation (HNP) Discussion Paper. Wash- HIV infection rate among married women ington, DC: World Bank. under 20 was nearly three times that of un- 41 World Bank, 2007. Population Issues in the married women under 20; Konde-Lule, JK, 21st Century: The Role of the World Bank. N Sewankambo, and M Morris, 1997. “Ad- Washington, DC. olescent Sexual Networking and HIV Trans- 42 Shah, I, and E Ahman, 2004a. “Age Pat- mission in Rural Uganda.” Health Transition terns of Unsafe Abortion in Developing Review 7(Suppl):89–100. Country Regions.” Reproductive Health 36 National Research Council and Institute of Matters 12 (24 (Abortion law, policy and Medicine, 2005. Growing Up Global: The practice supplement)): 9–17. Changing Transitions to Adulthood in De- 43 World Health Organization, 1998. The veloping Countries. Panel on Transitions to Second Decade: Improving Adolescent Health Adulthood in Developing Countries. Cyn- and Development. Geneva. Available online thia B. Lloyd, ed. Committee on Popula- at http://www.who.int/reproductive-health/ tion and Board on Children, Youth, and docs/adolescenthealth.html. Families. Division of Behavioral and Social 44 Shiffman, J, and S Smith, 2007. “Gen- Sciences and Education. Washington, DC: eration of Political Priority for Global The National Academies Press. Health Initiatives: A Framework and Case Better Health for Women and Families | The World Bank’s Reproductive Health Action Plan 2010–2015 65 Study of Maternal Mortality.” Lancet 370 the fetus and newborn, leading to an esti- (9595):1370–1379. mated 8 million infant deaths a year (more 45 United Nations Population Fund, 2006. than half of them fetal deaths) occurring Meeting the Need: Strengthening Family Plan- just before or during delivery or in the first ning Programs. New York: UNFPA/PATH. week of life. 46 Speidel, J, E Maguire, M Neuse, D Gil- 53 Rates higher than 15 percent suggest inap- lespie, and S Sinding, 2009. Making the propriate use of C-Sections. Case for US International Family Planning 54 Ratios of physicians, nurses, or midwives Assistance. Baltimore: Johns Hopkins Uni- per 10,000 population are important indi- versity/Gates Institute. cators, but by themselves do not sufficiently 47 UNFPA, 2003. State of the World Popu- measure health care coverage. Adequate lation: Making 1 billion count: Investing in numbers of all cadres of health care profes- Adolescents’ Health and Rights. New York: sionals as well as their appropriate distribu- United Nations Population Fund. tion throughout the country are needed to 48 Dennis, S, 2009. “Making Aid Effective- ensure coverage. This indicator is useful for ness Work for Family Planning and Repro- cross-country comparisons, for monitoring ductive Health.” PAI Working Paper. New targets, and for measuring against interna- York: Population Action International. tional standards. 49 While some of this decline has been offset 55 Data on governance presented here are by increases in commitments for health drawn from the World Bank’s Worldwide system strengthening, reproductive health Governance Indicators database since spe- issues are not fully addressed within cific data related to governance in the health the current emphasis on health system sector are not available. The percentile rank strengthening. indicates the percentage of countries world- 50 A recent IEG evaluation found that sub- wide that rate below the selected country. stantive analysis of population issues rarely While these indicators are for overall gover- figured in the Bank’s poverty assessments. nance in a country, they are relevant to the 51 The foundations for maternal risk are often health sector. laid in girlhood. Women whose growth has 56 Government of Norway, 2009. Leading been stunted by chronic malnutrition are by Example- Protecting the most Vulnerable vulnerable to obstructed labor. Anemia pre- during the Economic Crisis – The Global disposes to hemorrhage and sepsis during Campaign for the Health Millennium Goals, delivery and has been implicated in at least 2009 Second Year Report. Oslo: Office of 20 percent of post-partum maternal deaths the Prime Minister of Norway, June 2009. in Africa and Asia. The risk of childbirth 57 International Health Partnership, 2009. is even greater for women who have un- Constraints to Scaling Up and Costs. Technical dergone female genital mutilation, an esti- Report of the Working Group 1 for the High mated 2 million girls every year. Level Task Force on Innovative International 52 The factors that cause maternal morbidity Financing for Health Systems, 5 June 2009. and death also affect the survival chances of Available at: http://www.internationalhealth- 66 partnership.net/taskforce.html. Accessed 24 67 Greene, ME, and TW Merrick, 2005. Pov- September 2009. erty Reduction: Does Reproductive Health 58 Singh, S, JE Darroch, M Vlassoff, and J Matter? HNP Discussion Paper Series. Nadeau, 2004. Adding it up: the Benefits of Washington, DC: World Bank. Investing in Sexual and Reproductive Health 68 Singh, S, and JE Darroch, 2000. “Adoles- Care. New York: UNFPA /Alan Guttmacher cent Pregnancy and Childbearing: Levels Institute. and Trends in Developed Countries.” 59 Greene, ME, and TW Merrick, 2005. Pov- Family Planning Perspectives 32(1):14–23. erty Reduction: Does Reproductive Health 69 World Bank, 2007. World Development Matter? HNP Discussion Paper Series. Report: Development and the Next Genera- Washington, DC: World Bank. tion. Washington, DC. 60 There is considerable heterogeneity within 70 Stanback, J, and KA Twum-Baah, 2001. these indicative quadrants. In the high “Why Do Family Planning Providers Re- MMR-high TFR quadrant, for example, strict Access to Services? An Examination in in some countries MMR and TFR are de- Ghana.” International Family Planning Per- clining while in others these indicators are spectives 27(1):37–41. relatively stagnant. 71 World Health Organization, 2004. Global 61 The maternal mortality rate is often in of it- and Regional Estimates of the Incidence of self considered to be a proxy of the state of Unsafe Abortion and Associated Mortality in the health system in a country. But mea- 2000. Geneva. surement challenges make it difficult to be 72 Lule, E, S Singh, and SA Chowdhury, 2007. used as a tracer indicator. Fertility Regulation Behavior and Their 62 See Ranson, MK, K Hanson, V Oliveira- Costs: Contraception and Unintended Preg- Cruz, and A Mills, 2003. “Constraints to nancies in Africa, Eastern Europe, and Cen- Expanding Access to Health Interventions.” tral Asia. Washington, DC: World Bank. Journal of International Development 15: 73 This section draws heavily on World Bank, 15–39. 2007. World Development Report: Devel- 63 Das Gupta, M, 2009. “The Arguments opment and the Next Generation. Wash- against Donor Involvement in Family Plan- ington, DC, which makes a compelling ning: How Valid Are They?” DECRG pre- case for investing in the youth, including in sentation. Washington, DC: World Bank. health and education. 64 WHO, 2007. “Strengthening Health Systems 74 Mahapatra, P, K Shibuya, AD Lopez, F to Improve Health Outcomes.” Geneva. Coullare, FC Notzon, C Rao, and S Szreter, 65 See “Making pregnancy safer: the critical 2007. “Civil registration systems and vital role of the skilled attendant” joint state- statistics: successes and missed opportuni- ment by WHO, ICM, and FIGO. Geneva: ties.” Lancet 370 (9599): 1653–63, 10 No- WHO, 2004. vember 2007. 66 Ibid. Better Health for Women and Families | The World Bank’s Reproductive Health Action Plan 2010–2015 The World Bank For more information about the RHAP, please contact Sadia A. Chowdhury, schowdhury3@worldbank.org Web page: http://go.worldbank.org/SA1BXMTB70