Successful strategies, public health impact, lessons learned and remaining challenges

Підсумкова конференція проекту “Разом до здоров’я” 2005-2011 рр.

Successful strategies, public health impact, lessons learned and remaining

challengesLaurentiu Stan

JSI Research and Training Institute, Inc.

www.tfh.jsi.com 2

The Together for Health (TfH)

Project Background

www.tfh.jsi.com 3

• Six-year project (Oct. 2005 – Nov. 2011) – $12.3 million

• Implemented by JSI Research & Training Institute Inc. in collaboration with: – The Academy for Educational Development

– Harvard School of Public Health

• Goal: Abortions , unintended pregnancies

Sexually transmitted infections

• …by improved provision & access to quality FP/RH services, in public and private sectors

Together for Health (TfH)

www.tfh.jsi.com 4

FP/RH Service Provision in Ukraine at baseline

• Numerous health professionals (> 12,200 ObGyn’s) and health facilities

• FP/RH service provision: mainly by Ob-Gyn’s through a vertical network of FP centers and WCC

• GOU concerned of needs for health reforms:– Emerging primary health care

– Decentralization towards regional level and below

• Over-reliance on traditional methods & abortions

• Providers & population perpetuated misconceptions about contraception, especially hormonals

• Low access to modern contraceptives (no donations, reduced GOU procurements) & geographic inequalities

www.tfh.jsi.com 5

Suboptimal access to information on FP/RH in the health sector for its clients

4%

10%

44%

0%

10%

20%

30%

40%

50%

women who were visited byhealth worker who discussed

FP

women who visited a healthfacility&discussed FP

women who visited a healthfacility&did not discuss FP/RH

Source: UDHS, 2007

www.tfh.jsi.com 6

TfH Objectives & Intended Results

1. Increase health providers’ knowledge & skills (clinical and counseling) training

2. Improve clients’ knowledge and attitudes regarding FP/RH services & supplies IEC/BCC interventions

3. Improve availability, accessibility & affordability of contraceptives commodities

4. Strengthen capacity of public & private sectors to support policies & systems for improved RH policy

www.tfh.jsi.com 7

TfH Coverage by 2011(15 out of 27 regions - 65% of Ukrainian population)

www.tfh.jsi.com 8

….State Program Reproductive Health of the Nation (SPRHN)

TfH Implementation Strategies (1) - Working under the Umbrella of….

To support its FP/RH objectives and activities, at the national and oblast levels.

www.tfh.jsi.com 9

TfH Implementation Strategies (2) - Comprehensive approach, branding of the

FP program/interventions

Change Behavior ofPopulation/

Clients

Capacity Building of

Health Providers

Contraceptive Availability in

Pharmacies and Public Sector

“Ask the doctor about FP methods”

“Have you asked the doctor about FP methods?”

www.tfh.jsi.com 10

The Together for Health (TfH)

Public Health Impact

www.tfh.jsi.com 11

Building capacity for quality service provision in Primary Health Care

Ob-Gyns, 34.7%

Family Doctors,

26.6%

Nurses, 12.4%

Midwives, 24.0%

Others, 1.3%

Ob-Gyns

Family DoctorsNurses

Midwives

Others

• over 9,000 health professionals trained since 2006• ~ 2/3 were PHC providers (FDs and non-Ob-Gyns’)

Source: TfH, 2011

www.tfh.jsi.com 12

Improved availability of FP services and supplies at the community level

8.4%13.2%

22.8%

0.6%

27.8%

55.6%

47.3%

14.8%

0%

20%

40%

60%

80%

COCs Condoms (male) I UDs I njectable (Depo-Provera)

Baseline

Endline

Increased availability of free contraceptives at

health facilities

Source: TfH, 2011

www.tfh.jsi.com 13

Percent reduction of abortion rates in project-assisted regions, 2005-2010

-10,4%

-15,1%

-16,4%-18,5%

-21,3%-26,0%

-26,4%

-26,6%-29,0%

-29,3%

-29,7%-34,1%

-28,6%

-45,8%-38,5%

-35,3%

-50% -45% -40% -35% -30% -25% -20% -15% -10% -5% 0%

Ukraine

Sevastopol

Khmelnytsk

Ivano-Frankivsk

Cherkassy

Vinnitsa

Volyn

Lviv

Donetsk

AR Crimea

Poltava

Dnipropetrovsk

Kharkiv

Rivne

Zaporizhzhya

Odessa

Source: Ukraine MOH, 2005-2010

www.tfh.jsi.com 14

Average annual reduction of abortion rates in project assisted

regions

2,6%

- 14.1%

- 12.1%

- 12.1%

- 9.1%

- 6.7%

- 6.4%

- 6.3%

- 6.3%

- 6.0%

- 5.3%

- 4.8%

- 4.7%

- 3.6%

- 0.5%

- 6.3%

-20% -15% -10% -5% 0% 5%

Ukraine

Cherkassy

Ivano-Frankivsk

Vinnitsa

Donetsk

Volyn

Khmelnytsk

Poltava

Dnipropetrovsk

Lviv

AR Crimea

Kharkiv

Zaporizhzhya

Rivne

Sevastopol

Odessa

RegionsBaseline

Year

Years in the TfH-exposed

cohort

Lviv 2006 4 years

Kharkiv 2006 4 years

Vinnitsa 2006 4 years

Volyn 2006 4 years

Dnipropetrovsk 2006 4 years

Poltava 2006 4 years

Odessa 2007 3 years

Donetsk 2007 3 years

Zaporizhzhya 2007 3 years

Rivne 2007 3 years

Khmelnytsk 2007 3 years

Ivano-Frankivsk 2008 2 years

Cherkassy 2008 2 years

AR Crimea 2009 1 year

Sevastopol 2009 1 year

www.tfh.jsi.com 15

Contraception, steadily replacing abortion

Source: Support for Market Development, 2005 – 2011Ukraine MOH, 2005 – 2010

www.tfh.jsi.com 16

Contraception, steadily replacing abortion with positive demographic changes

(Ab. decrease; contraceptive increase; birth rates increase)

DNIPROPETROVSK

21,315,9

9,8 10,6

268,55303,66

0

7

14

21

28

2006 2010

0

80

160

240

320

Abortion rate (per 1,000 WRA) Birth rate (per 1,000 population)

KHMELNYTSKY

13,911,710,1 10,8

390,93425,28

0

6

12

18

2007 2010

0

110

220

330

440

Use of modern contraceptive rate (IUDs and hormonal contraceptive users inhealth facilities per 1,000 WRA)

Dnipropetrovsk

- 25% Ab. Rate decline

+ 8% Birth Rate increase

Khmelnytsky

- 16% Ab. Rate decline

+ 7% Birth Rate increase

Source: Ukraine MOH, 2005-2010

www.tfh.jsi.com 17

Decline of incidence of child abandonment (ICA) higher in the TfH-assisted regions

3.3

1.4

2.6

1.5

9.0

10.8

9.3

10.9

0

2

4

6

8

10

12

0.0

1.0

2.0

3.0

4.0

5.0

2005 2010

Line

s: B

irth

rate

(per

1,0

00 p

opul

ation

)

Bars

: In

ciden

ce o

f ch

ild a

ban

don

men

t in

m

ate

rnit

y/at bir

th (

per

1,0

00

live-b

irth

s)

ICA TfH Oblasts

ICA Non-TfH Oblasts

Birth rate TfH Oblasts

Birth rate Non-TfH Oblasts

Source: Ukraine MOH, 2005-2010

www.tfh.jsi.com 18

The Together for Health (TfH)

Key Lessons Learned

www.tfh.jsi.com 19

Importance of FP/RH in the Gov’t health agenda dictates allocations at national & regional levels

80.3%

58.1%

29.8%

72.1%

33.5%

7.5%

0%

20%

40%

60%

80%

100%

Central budget TfH Regions Non-TfH Regions

Total FP

Contraceptive procurement

Proportion of expenditures vs. alloted (FP Objective)Central budget; TfH vs. non-TfH Regions (Local budgets)

Cumulative data 2008-2010

Source: MOH/TfH, 2011

Source: TfH, 2011

www.tfh.jsi.com 20

Partnership and coordination with various stakeholders

• National level institutions - to foster nationwide dissemination and programs’ sustainability

• Local level counterparts (governmental & NGOs) - to coordinate efforts and maximize results (e.g. best reach the most vulnerable groups)

• Private sector partners - to ensure coordinated messages, dissemination to non-project areas, and for leveraging additional resources

• Higher educational institutions - to ensure institutionalization of FP/RH education for doctors and nurses.

THREE EXAMPLES SELECTED FURTHER THREE EXAMPLES SELECTED FURTHER

www.tfh.jsi.com 21

USAID’s TfH Partnership with national level institutions and authorities

Professor Nina Goyda, Pro-Rector

• Sustainable policy development: programs, protocols, guidelines (SPRHN approval and implementation)

• Nationwide dissemination—reaching additional beneficiaries from ALL regions

• Facilitation of communication between providers – regional authorities – national level health authorities

• Institutionalization of project-developed approaches: service provision systems, curricula, M&E tools, etc.

• Ensure coordination of messages when reaching various types of professionals: university professors, doctors, health managers and administrators

www.tfh.jsi.com 22

USAID TfH’s Partnership & coordination with Regional level NGOs

to reach certain targeted groups/communities

Maria Didenko, board member of NGO "Youth center for development", BCC trainer

• At local level, NGOs and non-health structures are key partners to reach target population groups

• However, NGOs experience with FP/RH and health providers is still in its infancy

• NGOs can serve a networking forum with other NGOs active in social areas and on HIV/AIDS prevention

• Social services for youth and the Department of education are key partners with experience in reaching certain vulnerable groups/target communities

www.tfh.jsi.com 23

USAID’s TFH Partnership & coordination with private sector Bayer Health Care

Dr. Vladislav GolovinovProduct Manager, Business Unit Women's Healthcare

• Development and dissemination of evidence-based information and resources for health professionals

• Awareness raising and educational campaigns for youth

• Continuous medical education events (CMEs)

• Worldwide partnership to assist governments and health ministries to provide access to subsidized contraceptives to vulnerable groups

www.tfh.jsi.com 24

Create the momentum and build upon it

• Substantial experience accumulated during the TfH implementation- basis for further improvements

• To achieve change there is a need for a range of actions with continuous investment /TA ~ ”reinvent ourselves”

• Providers’ capacity building

• Behavior change of population

• Policy / SPRHN

• Advocacy for adopting new approaches to sustain current public health achievements

www.tfh.jsi.com 25

Main challenges ahead in

improving FP/RH in Ukraine

www.tfh.jsi.com 26

Ukraine, still high abortion-related Maternal Mortality

• Ukraine DHS,2007 : “…almost half of the women undergoing one abortion reported having had 2-3 during their lifetime”

Proportion of Maternal Deaths due to Abortive Outcomes (incl. medical and illegal abortions and

extra-uterine pregnancy)

10.7%

4.3%

2.1%

11.4%

6.0%

0%

5%

10%

15%

2005 2006 2007 2009 2010

Source: Ukraine MOH, 2005 - 2010

Enhanced focus on behavior change and on standards of abortion procedures

www.tfh.jsi.com 27

Need to deeper focus on rural population

• Ukraine DHS, 2007: “…women who live in the capital and large cities have lower first abortion rates than those in smaller cities or towns” (Levchuck, 2009)

• Ukraine MOH data from 2009: “… percentage of live births to mothers aged 19 years old and younger is almost double in rural areas (12.8%) than in urban areas (6.7%)” (Tefft, 2011)

www.tfh.jsi.com 28

Population ability to pay for contraceptives is much lower than in 2005

(Source: Support for Market Development and Statistic Committee)

1,5% 1,4%1,7%

2,1%

3,1%

2,4%

298,5362,5

430,0

527,5

651,0

887,0

0%

1%

2%

3%

4%

5%

2005 2006 2007 2008 2009 2010

Co

st o

f O

Cs

(as

% o

f m

inim

um

wag

e)

by

usi

ng

th

e lo

wes

t p

rice

d

con

trac

epti

ve p

ill

0

100

200

300

400

500

600

700

800

900

Min

imu

m w

age/

mo

nth

Percentage cost of oralcontraception (lowest priced brand)

Minimum wage/month (UAH)

Minimum wage could buy: 66 cycles of lowest priced OCs in 2005 44 cycles of lowest priced OCs in 2010

www.tfh.jsi.com 29

Advocacy for improved funding for FP/RH within governmental programs

• Need for a renewed call to action for “revival” of the SPRHN and Regional FP/RH programs

• Inclusion of FP/RH interventions within the governmental and donors‘ initiatives:

– Presidential Initiative “New Life”

– Government efforts to reform the health system

– UN/WHO lead “Beyond the numbers” initiative

www.tfh.jsi.com 30

Building Partnerships

HEALTH MANAGERS

COMMUNITIES

COMMUNITIESHEALTH PROFESSIONALS

ACADEMICINSTITUTIONS

HEALTHMANAGERS

Healthprofessionals

Policy makers

POLICY MAKERS

Academic institutions

Підсумкова конференція проекту “Разом до здоров’я” 2005-2011 рр.

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