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
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Six Building Blocks of Health Systems (WHO)
SERVICE
DELIVERY
LEADERSHIP AND
GOVERNANCE
INFORMATION
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HUMAN
RESOURCES
MEDICINE AND
TECHNOLOGIES
FINANCING
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Stronger Health Systems
save lives and improve health
Stronger health systems.
Greater health impact.
1. Leadership,
management,
& governance
2. Health service
delivery
3. Human resources for
health
4. Pharmaceutical
management
5. Health care financing
6. Health information
1. HIV & AIDS
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2. Tuberculosis
3. Communicable diseases:
malaria, avian & pandemic
influenza
4. Maternal, newborn, child health
5. Family planning / reproductive
health
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Barriers are overcome using
six health systems building blocks
Barriers to FP and RH services
Knowledge
Physical
Location
Cost
Inappropriate
eligibility
criteria
Time
Fragmented
services
Poor
CPR
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Process
Sociocultural
norms
Provider
bias
6 pillars of health systems
1. Leadership,
management &
governance
2.Health service
delivery
3.Human resources
for health
4.Pharmaceutical
management
Access
Choice
Quality
5.Health care
financing
6.Health
information
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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.
.
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Six pillars of health systems
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.
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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
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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
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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
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Essential Service Package: RH care content
Essential Service Package
(ESP )elements:
HPSP Reproductive Health
Care:
1. 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
2. Child health care
3. Communicable diseases
control
4. Simple curative care
5. Behavior change
communication(BCC)
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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.
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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 projectbased)
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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.
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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.
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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
Trends of Worker Client Contact
to be fully functioning
50.0
45.0
43.0
40.0
35.0
35.2
30.0
25.0
21.2
20.0
18.2
15.0
10.0
5.0
0.0
1993-94
1996-97
1999-2000
2004
Field Worker Contact
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Effect on national FP indicators
 “Stagnation" in fertility reduction:; TFR plateaued, although
CPR went up, the use of clinical contraceptive declined
CPR among married women
TFR
7
60
6
50
5
40
4
30
3
20
2
10
2004
199-00
1996-97
1993-94
1989-91
1986-88
1984-88
0
1971-75
2004
1999-00
1996-97
1993-94
1991
1989
1985
1983
1975
0
1
Source: BDHS: 2004
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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
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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.
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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.
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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".
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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.
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