1. 1Management Sciences for Health Stronger health systems. Greater health impact. Health systems approach to integration of family planning: A critical look Reconvening Bangkok : 2007 to 2010 Halida H. Akhter, Global Technical Lead FP/RH March 6-11, 2010, Bangkok, Thailand

2. 2Management Sciences for Health HUMAN RESOURCES MEDICINE AND TECHNOLOGIES FINANCING INFORMATION LEADERSHIP AND GOVERNANCE SERVICE DELIVERY Six Building Blocks of Health Systems (WHO)

3. 3Management Sciences for Health Stronger Health Systems save lives and improve health Stronger health systems. 1.Leadership, management, & governance 2.Health service delivery 3.Human resources for health 4.Pharmaceutical management 5.Health care financing 6.Health information Greater health impact. 1.HIV & AIDS 2.Tuberculosis 3.Communicable diseases: malaria, avian & pandemic influenza 4. Maternal, newborn, child health 5. Family planning / reproductive health

4. 4Management Sciences for Health Barriers are overcome using six health systems building blocks Access Choice Quality Barriers to FP and RH services Fragmented services Socio- cultural norms Cost Process Physical Inappropriate eligibility criteria Poor CPR Provider bias Knowledge Location Time 1. Leadership, management & governance 2.Health service delivery 3.Human resources for health 4.Pharmaceutical management 5.Health care financing 6.Health information 6 pillars of health systems

5. 5Management Sciences for Health Six pillars of health systems 1.Leadership, management & governance Policy support reinforcing advocacy efforts with factual evidence leading to enabling policies, strategies, approaches and guidelines. 2.Health service delivery Sustainable use of integrated FP/RH services—Fully Functional Districts with technical and operational support and referral system. Services through a mix of delivery points gets methods to potential users. 3. Human resources for health High performing staff, task-shifting and improving performance cultivates a sustainable health care workforce..

6. 6Management Sciences for Health 4.Pharmaceutical management A strong logistics system, including procurement, sufficient equipment, drugs, supplies and infrastructure and, a plan for contraceptive security - ensure method availability 5. Health care financing Social marketing, incentive based partnerships with private sector, CBO and NGO. 6. Health information Evidence-based programming yields important information to guide program decision-making. Well designed MIS needs to be in place. Six pillars of health systems

7. 7Management Sciences for Health A strong health system helps integrate services to offer greater health impact  Integration means offering multiple health care services at the same facility or through a community-based program to benefit clients, providers, programs  Integrated services are more efficient and ensure financial sustainability.  Combination of well selected interventions address a range of health needs, creates synergies, enhance impact.  They demand a strong political commitment and additional resources

8. 8Management Sciences for Health Integration of FP and reproductive health: Bangladesh case Bangladesh Family planning program created a success story  1965: Started as a vertical program  Early ‘80s: MCH was integrated with Family planning  Post-ICPD: Reproductive Health was integrated  1996: HPSS, Health and Population Sector Strategy  A five year (1998-2003) HPSP: A Sector-Wide Approach ($3 bill budget)  Moved from Project approach to Program approach.  HPSP: sector as a whole

9. 9Management Sciences for Health Integrated sector-wide approach of HPSP HPSP: world’s first example of Sector-Wide Approach (SWAP)  donors pooled resources  implementation and annual operations plan (AOP) to  cover a range of integrated services (e.g., health, FP) HPSP emphasized structural reform i.e. unification as indicator of program success as opposed to health outcome  Unify two Directorates : Health and Family Planning (lower levels)  Merged functions: BCC, logistics, and Information Systems  Transition: domiciliary FP to static community clinics (CCs)  Focus: Essential Services Package (ESP)  Delivered from facilities close to the population affected

10. 10Management Sciences for Health Essential Service Package: RH care content Essential Service Package (ESP )elements: 1. Reproductive health care 2.Child health care 3.Communicable diseases control 4.Simple curative care 5.Behavior change communication(BCC) HPSP Reproductive Health Care: 1.Safe motherhood 2.Family planning 3.Prevention and control of RTI/STD/AIDS 4.Maternal nutrition 5.Adolescent care 6.Neonatal care

11. 11Management Sciences for Health HPSP’s Reproductive Health Strategy HPSP’s reproductive health strategy matched well with the WHO recommendations, Identified 5 key areas of action 1.strengthening health system capacity 2.mobilizing political will 3.creating supportive legislative and regulatory frameworks 4.improving information for setting priorities 5.strengthening monitoring, evaluation, and accountability.

12. 12Management Sciences for Health The integration and merger of health and population sector components  Health and Family Planning MIS were merged  Former projects were grouped together under a small number of Line Directors  Financial authority was transferred from former Project Directors to Line Directors  Procurement of drugs, vaccines, and equipment centralized;  Training Procurement was centralized (not project- based)

13. 13Management Sciences for Health Effects of merger reform HPSP contained long list of reforms  Policy reforms of the systems, changing attitudes  Operational definition of SWAP during HPSP Many elements of the reform faced opposition - However, MOHW moved quickly to implement difficult structural changes--it  unified health & family planning services at lowest admin tiers  Initiated ‘one stop’ community clinics to provide Essential Service Package.

14. 14Management Sciences for Health Impact of reform on nationwide program Effects of these changes in the functioning of the health system included:  Outreach services - disrupted by changes to service delivery Difficulties of restructuring health system  Some FP indicators became stagnant.  Govt. lost a modest share of family planning service provision,  Transfer to Community Clinics needed more time.

15. 15Management Sciences for Health Impact of reform on community  Household visits for family planning by GOB fieldworkers started to decline leading to low client worker contacts.  Community clinics were yet to be fully functioning Trends of Worker Client Contact

16. 16Management Sciences for Health Effect on national FP indicators  “Stagnation" in fertility reduction:; TFR plateaued, although CPR went up, the use of clinical contraceptive declined TFR 0 1 2 3 4 5 6 7 1971-751984-881986-88 1989-91 1993-94 1996-97 199-00 2004 CPR among married women Source: BDHS: 2004 0 10 20 30 40 50 60 1975 19831985 1989 1991 1993-94 1996-97 1999-00 2004

17. 17Management Sciences for Health Benefits from a comprehensive reproductive health strategy In spite of the short dip in some FP indicators, the Bangladesh case exemplifies the benefits from a comprehensive reproductive health strategy  During HPSP (1998–2003), MMR declined from 440 to 322 deaths per 100,000 live births  ANC grew from 26% to 56%  Use of EOC rose from 5% to 27%  Contraceptive Prevalence Rate went up--  Because, as the household visits by GOB workers reduced, the couples switched to private outlets, pharmacies, NGOs

18. 18Management Sciences for Health Critical lessons learned The critical issue related to integration of services or programs:  Lack of ownership to the policy  Lack of commitment and support from domestic forces severely affects implementation Integration will not bring desired impact unless --- enough lead time is provided to strengthen health systems i.e. policy changes, creating strategies and guidelines for service delivery  strengthening motivation and capacity of appropriate human resources is instrumental to the success.

19. 19Management Sciences for Health Lessons from Bangladesh experience 1.Political commitment is key to success of Integration 2.The people who design and implement health care policies and programs need to pay attention to both technical and political feasibility. 3.Strong systems in place help backup minor short falls 4. Improving governance is key to improving service delivery. 5. A major critical ingredient to use of public health services is leadership and governance strengths.

20. 20Management Sciences for Health References Jahan, R. 2003, "Restructuring the health system: Experiences of advocates for gender equity in Bangladesh", Reproductive health matters, vol. 11, no. 21, pp. 183-191. Kamal, S.M. M., Akhter, S., Islam, A. "The Role of Proximate Determinants of Fertility Transition in Bangladesh”. Osman, F.A. 2005, "Implementation Constrained by a Lack of Policy Ownership: Evidence from Bangladesh", The Asia Pacific Journal of Public Administration, vol. 27, no. 1, pp. 19-36. Pearson, M. 1999, "Bangladesh - Health Briefing Paper", Department for International Development Health Systems Resource Centre. Streatfield, P.K., Arifeen, S.E., Al-Sabir A. 2004, “Policy Implications of the 2004 BDHS.” USAID 2009, "Health Systems Report to Congress", Sustaining Health Gains - Building Systems. WHO 2007, "Everybody's Business: Strengthening Health Systems to Improve Health Outcomes; WHO's Framework for Action".

21. 21Management Sciences for Health Stronger health systems. Greater health impact. Saving lives and improving the health of the world’s poorest and most vulnerable people by closing the gap between knowledge and action in public health.