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Applying Developmental Evaluation to Bring an Enhanced Equity Focus on Maternal Health Interventions

Session: The Role of Evaluations in Bridging Equities: Experiences from Latin America, Asia and Africa

Presenter: Arnab Dey, Sambodhi

Access to maternal health services and its outcomes have varied significantly depending on the determinants of socio-economic status of women in India. The gap in equity is more pronounced in Uttar Pradesh, where caste and religion forms a major aspect of the social structure and position in society. Uttar Pradesh hosts a number of equity-focused interventions, some of which are the endeavors of the Uttar Pradesh Technical Support Unit (UP-TSU). UP-TSU envisages to address the inequities in the reproductive, maternal, newborn and child health (RMNCH) outcomes by providing equitable health care opportunities to the heterogeneous population of the state. A number of its interventions at the community, health facility and system level work in concert to bridge the equity gap in the state. Evaluators are embedded within the program team (support team) to provide feedback on course correction on a near real-time basis. This paper describes an application of the developmental evaluation approach to explore, test and improve the equity focus of the intervention. Developmental evaluation is relevant given the complex dynamic realities of the health system interventions in UP and also the broader dynamic changes in the social, political and economic conditions in UP and the changes in the TSU over time. Maternal health interventions focusing on equity are often based on key assumptions of pathways of impacts. The developmental evaluation approach helps with interrogating crucial assumptions, such as coordination between health workers and uptake of data for decision-making. Most evaluations of health inequity initiatives have focused on how programmatic interventions have contributed to impacting equities. There has been far limited self-reflection on the pathways by which evaluations themselves can contribute to reducing inequities. The approach adopted by this evaluation goes beyond ‘use’ and explicates the notion of evaluation as an influence generating action to support equity.

The Utility of a Realist Evaluation Approach in Interrogating Implicit Assumptions of Maternal Health Interventions: Ensuring Equity and Human Rights of Marginalized Communities in Maternal Health Programming

Session: The Role of Evaluations in Bridging Equities: Experiences from Latin America, Asia and Africa

Presenter: Abhijit Das, Centre for Health and Social Justice
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All programs make implicit assumptions that are critical to the successful implementation of the program.  Taking a realist evaluation approach, we interrogate assumptions in key conditional transfer programs focused on maternal health in India. Using two examples of interventions, we identify the “boundary conditions” under which the assumptions will work—we demonstrate that the underlying assumptions work for the educated urban middle to lower middle class who live in a monetized economy with some access to economic and social security and access to quality services. When a program is being implemented successfully, i.e. the input and output parameters are as expected, we can assume that our initial ‘assumptions’ in terms of health care, social/cultural and economic were appropriate. However when the program doesn’t work, the program manager is left with a dilemma about what needs to be done. The usual approach is to intensify inputs with the assumption that lack of success was a result of lack of adequate inputs or responsiveness to the inputs. However this may not be the case. It is possible that the socio-cultural and economic assumptions made in the first case were ‘wrong.’ For example the tribal woman may not only be far away physically from services, but her community may have a completely different set of beliefs about what constitutes safe conception, pregnancy, delivery and post-natal care.  In such cases intensifying the inputs, and at the same time stigmatizing their actions which are appropriate for their realities, may compound the inequity which is built into a monolithic understanding of what constitutes the appropriate policy or programmatic intervention. The presentation will make explicit the current maternal and neonatal health paradigm that is being promoted in India. The realist approach will demonstrate the “contexts, mechanisms and outcomes configurations” associated with successful implementation of maternal health programs.

Evaluating the Contribution of Governance in Addressing Maternal and Child Health Inequities

Session: The Role of Evaluations in Bridging Equities: Experiences from Latin America, Asia and Africa

Presenter: Marie-Gloriose Ingabire, International Development Research Centre
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The Governance for Equity in Health Systems (GEHS) at Canada’s International Development Research Centre (IDRC) has supported research projects across the globe, to address maternal and child health inequities with a focus on governance issues. In particular, GEHS programming aims to ensure that the core challenges of decision-making, resource allocation, and power distribution in health systems are addressed to improve health outcomes. Challenges of governance and equity are evident in addressing maternal and child health. The limited effective involvement of communities and state stewardship in ensuring equitable and timely access to quality health services has contributed to the poor maternal and child health outcomes. A focus on governance for equity in health systems allows analyses of root problems and addresses the multiple levels and their interrelationships at which these problems operate. Examples of projects in Asia, Africa, Latin America and the Caribbean will be shared and the strategies they adopted to address governance issues to address the root problems that result in inequities will be discussed.  The role of evaluations in assessing the role of governance in addressing problems of maternal and health inequities will be discussed. Based on IDRC’s experience, a critical question explored in this paper are the ‘support’ contexts that are necessary for governance to work. The presentation will highlight examples of evaluations of GEHS programs in which good governance has led to successful impacts on maternal and child health inequities.

Knowledge Translational Implications of the Contextual, Multilevel Nature of Maternal Health Inequities: How should interventions respond to such knowledge?

Session: The Role of Evaluations in Bridging Equities: Experiences from Latin America, Asia and Africa

Presenter: Sanjeev Sridharan, The Evaluation Centre for Complex Health Interventions
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Maternal health inequities have multiple levels of drivers: community or area level factors include community norms, social practices, area-level poverty, as well as individual level factors such as employment status, literacy, religion and caste. Given the multilevel nature of the maternal health inequities, it is important to explore if and how programs disrupt such multiple levels of factors and also explore the synergistic impacts of cross-level factors.  In this presentation we explore the multilevel drivers of maternal health inequities in Uttar Pradesh (UP), the most populated state of India with comparatively poor performance on several development indicators. The UP Technical Support Unit (TSU) provides a range of “techno-managerial” assistance to support the Government in addressing the inequities in the reproductive, maternal, newborn and child health (RMNCH) outcomes in 100 blocks of the state. For the most part, this intervention’s theory of change has a limited a priori understanding of multilevel contexts in which the program is likely to work.  Using the baseline data from this project, this paper explores the factors associated with existing health outcome inequities and the approach of the UP-TSU in addressing them. Multilevel models were developed to explore measures of access to health care and health outcomes through the continuum of care. Contextual factors that were explored included block-level measures on literacy, sex-ratios and employment rates.   Innovative features of our application are the use of multilevel models to identify blocks that “buck” the general trend, and the combination of the multilevel-model data with the qualitative data to validate and triangulate the results.  We discuss whether the intervention is responding to the knowledge of context. The findings emphasize the need to pay attention to local context and the need to have a heterogeneous package of program supports to address inequities in maternal health.

An Experiment on Building Evaluation Capacity to Address Maternal Health Inequities in China

Session: The Role of Evaluations in Bridging Equities: Experiences from Latin America, Asia and Africa

Presenter: Kun Zhao, China National Health Development and Research Center
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This presentation will discuss lessons for evaluators from a project titled, “Building Health Equity in China through Evaluation Capacity Building.” This paper describes an experiment to explore if evaluation — both in the form of evaluative thinking and applications of evaluation approaches and methods — can be used as an intervention to help precipitate thinking and also lead to action about health inequities. A case study of an intervention called “Equalization of the basic public health services” from the city of Qingdao, with a focus on maternal health equity, will be the focus of the presentation.  This experiment is being conducted at both the national and provincial levels in China; it includes evaluation projects in three provinces in China. Policy makers, practitioners and evaluators from the national, provincial, and local levels are involved in this project.  The question that this Qingdao case study raises is:  Can a program of evaluation help raise the salience of maternal health equities as important criteria for judging health systems performance in a setting like China? China serves as an interesting setting for such an experiment.  The primary view of accountability of health systems is driven by notions of effectiveness and efficiency. There is a spurt of interest from Chinese policy makers and academics on evaluating the health systems reform and also the impact of such reform on health inequities. There has been a far more limited focus on inequities as a performance dimension of health systems. This is paradoxical because the health system reform efforts have been driven by aspirations of reducing health inequities between urban and rural areas. This presentation will discuss efforts in Qingdao to raise additional focus on maternal health equities as a performance dimension for the local health system.

Applying Theory Driven Evaluation to Policy Redesign to Impact Maternal Health Inequities: Lessons from Chile

Session: The Role of Evaluations in Bridging Equities: Experiences from Latin America, Asia and Africa

Presenter: Orielle Solar, FLASCO

This paper summarizes some experiences from Chile in reorienting public health programs to integrate health equity into the policy design, guided by theory-driven evaluation orientations. During 2008-2010, the Ministry of Health of Chile adapted the work of the Priority Public Health Conditions Knowledge Network (PPHC) of the Commission on Social Determinants of Health combined with evaluation theory using the results chain. As part of their national strategy for health equity, six health programs were chosen for re-design and review so that they would better address socially determined health inequities. The redesign of public health programs involves the review of its theory of change, rationale, objectives, interventions, achievements, targets and indicators. While every program is based on theory, the underlying theory is often not explicitly understood, especially if it has not been explicitly described. The theory needs to be surfaced through a reflection process involving stakeholders. The review involves the analysis of the relationship between the program and other sectors, as well as its vertical integration and the participation of social actors in the program’s formulation, implementation, monitoring and evaluation and continuous development. The review process draws from methodological guides to help teams assess how the program works in practice, for whom and under what circumstances and who is left behind in the process. Based on the findings from the review, program managers agree on priorities and objectives for the redesign/reorientation phase. A key contribution of this presentation will be to leverage the Chilean experience to highlight the importance of an elaborate theory of change in health system reform efforts.

Clients’ Perspectives on Quality of Abortion Services in Specific Rural Areas in Nepal

Session: Improving Access and Quality of Safe Abortion Services: Global Lessons and Questions

Presenter: Swadesh Gurung, Ipas
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Nepal is one of the countries on track for achieving the Millennium Development Goal 5 for reducing maternal mortality by 80 percent by 2015. As acknowledged by the White Ribbon Alliance this goal is being achieved in Nepal, in part, by making safe abortion services, treatment of incomplete abortion and postabortion contraception available, accessible and high quality for women who otherwise would resort to unsafe abortion.  Following liberalization of the abortion law in 2002, under the umbrella of Safe Motherhood, comprehensive abortion care has been integrated into national health and development plans, emergency obstetric care and safe abortion care training for auxiliary nurse midwives, and decentralization of services to all 75 districts in the country. To further meet the needs of rural and marginalized women, services are being further scaled up to reach women at health posts in their communities through provision of medical abortion.  Results of assessments of women’s perceptions and experiences with abortion care underscore the importance of proximity of services, affordability, and privacy and confidentiality for rural women, young women and marginalized women, such as commercial sex workers. Even with liberalizing the abortion law, women fear being stigmatized for using abortion and contraceptive services.  To address one of the key barriers to women’s access, the government of Nepal recently passed a policy making safe abortion care services free of charge. Going forward, Nepal will continue to work to ensure women’s equitable access to care and to improve the quality of abortion care to meet women’s needs. Nepal’s successes in addressing this key cause of maternal mortality serve as a model for how other countries can address this entirely preventable cause of maternal mortality as part of Sustainable Development Goals, the Global Strategy for Women’s, Children’s and Adolescents’ Health, and the post-2015 development agenda.

Experience on the Provision of Safe Abortion Services in the Context of Mexico City, Following the Legalization of the Procedure

Session: Improving Access and Quality of Safe Abortion Services: Global Lessons and Questions

Presenter: Patricio Sanhueza, Ministry of Health, Mexico City

Right after the legalization of abortion in Mexico City in 2007, provision of quality abortion services proved to be a challenge. The Legal Termination of Pregnancy Program (ILE, in Spanish) in the public sector has continuously evolved since its implementation to meet the high demand for abortion services, as a result of the law approval in the city. From initially performing now-outdated procedures and offering the services only at the hospital level, to the use of the latest evidence-based technologies and shifting the services to the primary care level, we have succeeded in meeting this high demand while still keeping the quality of services women deserve. Currently, our program provides approximately 85% of the abortion procedures through medical abortion and most of the clients are attended in our four primary care clinics.

Incidence of Abortion Among Adolescents, Worldwide: Levels and Recent Trends

Session: Improving Access and Quality of Safe Abortion Services: Global Lessons and Questions

Presenter: Ann Starrs, Guttmacher Institute
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Background: Teen abortion and pregnancy have been the topic of much research, policy and program discussion, and debate. Obtaining solid evidence can help monitor progress in meeting adolescents’ need for sexual and reproductive health information and services.

Methodology: We examine abortion incidence among adolescents (15-to-19 years old) in all countries for which recent information could be obtained. We present estimates primarily for 2011 and assess trends in these rates since the mid-1990s. Information was obtained from countries’ vital statistics reports, the United Nations Statistics Division, or other published estimates. A literature review on adolescent abortion services in developing regions was also conducted.

Results: Since the mid-1990s adolescent abortion rates have declined in most developed countries with reliable trend data.  Among countries with complete abortion records, the highest adolescent abortion rate was in England and Wales (20 per 1,000 females), and Sweden (20), with the lowest in Switzerland (5). In half of these countries the proportion of pregnancies that ended in abortion ranged from 35-55%. In Mexico and the countries in Sub-Saharan Africa, where abortion is largely illegal, the adolescent abortion rate ranged from 11 in Ethiopia to 44 in Mexico, and rates tended to higher than in countries with liberal abortion laws. The proportion of teen pregnancies ending in abortion ranged from 9% in Ethiopia to 24% in Mexico. In developing countries cost and privacy are two of the biggest barriers adolescents face to accessing abortion care. Adolescents are less likely than older women to obtain safe abortions, and more likely to terminate pregnancies after the first trimester.

Conclusion: Despite recent declines, abortion rates remain high in many countries and adolescents continue to face barriers to accessing abortion services. Research on factors that determine how adolescents resolve their pregnancies could inform policy and programmatic efforts to improve teen pregnancy outcomes.