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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