This presentation will highlight the advantages and challenges of harmonizing indicators, based on the Reproductive Health Supplies Coalition’s experience getting the family planning community to “speak the same language” about stockouts and availability of contraceptives.

The purpose of this work is to ensure reliable data on stockouts that can be used more effectively for programmatic and advocacy purposes.

First, we conducted a landscape analysis of existing indicators – through surveys, interviews, and a document review. We found many differences both in the indicators that organizations use and in their definitions.

Based on the findings, we developed a draft list of indicators. To determine their utility and feasibility, we tested these indicators in Bangladesh using data from an electronic logistics management information system and in Zambia through facility visits.

Based on the field test findings, we streamlined the indicator list and developed indicator definitions. The harmonized indicator suite now includes twelve indicators in four categories: family planning methods offered, range of methods available, point-in-time stockouts, and frequency and duration of stockouts over time. One of these indicators is highlighted as the universal indicator for all organizations to collect.

Two of the indicators have been adopted by FP2020; 69 countries will be asked to report on these indicators. The Coalition’s Take Stock campaign will further promote the use of the harmonized indicators.

We hope that greater clarity in the language of stockouts will help draw attention to and understanding of the issue, and ultimately help increase people’s access to family planning products.

USAID/Haiti funded a Savings and Internal Lending Communities (SILC) activity from 2009-2013. The implementing partner worked through community-based organizations (CBOs) that employed community mobilizers to set up and mentor self-selected SILC groups. After the program ended, USAID commissioned an external retrospective qualitative assessment to assess whether SILC met members’ needs; had an impact on individual, child and household well-being; and whether SILC groups continued after donor support ended, and why or why not.  The study was approved by a local ethics review board. Researchers conducted in-depth interviews (IDI) and focus group discussions (FGDs) with SILC group members (n=56 IDIs, n=14 FGD), community mobilizers (n=14 IDIs), CBO staff (n=9 IDIs), and implementing partner staff (n=9 IDIs).  Interviews and discussions were conducted in Creole, transcribed, and translated verbatim into English. Transcripts were uploaded and analyzed in Atlas-TI.  The majority of respondents felt that the SILC access to flexible community-adapted savings and loans was highly successful; filled an important needs gap; and had a positive impact on community small businesses, households, and children.  Many groups remain active and new groups were created after donor support ended. However, others disbanded when the stipends for community mobilizers ceased, due to lack of support, motivation, or the economic situation. The key factor ensuring success and sustainability was groups’ sense of ownership over their capital and the SILC methodology.  These findings suggest the need for continued training and support for SILC groups in Haiti and other similar contexts.

Background: The Government of Botswana is implementing a broad set of reforms aimed at diversifying the economy. The MoH launched a privatization plan to increase efficiencies in public hospitals by outsourcing non-clinical services and developing public-private partnerships.  

Objective: To document the privatization policy, diversification of the health sector industry, and private health market development.

Methods: Using a health policy analytical framework we examine the privatization policy from design to implementation and analyze challenges and opportunities related to: (1) governance, (2) finance and (3) institutional strengthening.

Results: A legal framework, regulation, procurement rules, and funding were in place to support the process; however, the policy was initiated in seven hospitals before all the technical instruments such as contracts, service level agreements and key performance indicators were ready. Lack of managerial experience in the procurement and management of service level agreements represented a major limitation. Major challenges include the absence of reference costs and benchmark prices, lack of communication with hospital employees, and a nascent market with very few providers for these hospital services. 

Conclusions: Outsourcing non-core services represents a major change in hospital operations seeking to improve service quality and the efficient use of public resources. This bottom-up strategy, though modest, is helping to develop a domestic private market within the larger objective of diversifying the domestic economy and addressing the volatility of its main source of domestic revenue, diamonds. These reforms also represent an opportunity to increase female labor force participation and incentivize women’s entrepreneurship in the wider economy.

Background: Like many countries in sub-Saharan Africa, over 95 percent of pregnant women in Ghana go for at least one antenatal care (ANC) visit. Yet, only about half deliver with a skilled birth attendant (SBA)—a critical intervention to reduce maternal mortality. Why do some women go for ANC but do not deliver with a SBA? Access plays a role; but other health system factors may be contributing to the coverage gap between ANC and skilled attendance at delivery. There are also wide disparities in use of SBAs by socioeconomic status (SES) and rural/urban residence—less so for ANC attendance. Prior studies have shown disparities in ANC quality by SES, rural/urban residence, and type of antenatal facility. These disparities in ANC quality may be contributing to the disparities in use of SBAs.

Aim: This study examines factors associated with use of SBAs among women who attend ANC in Ghana, focusing on the mediating role of ANC quality.

Methods: Data are from the Ghana Maternal Health Survey (N=4,868). Quality of antenatal care is measured by an index based on receipt (or otherwise) of nine essential antenatal services during the last pregnancy. Analytic techniques include multilevel linear regression with mediation analysis to examine intervening effects.

Results: Among women who go for an ANC visit, those who receive higher quality ANC are more likely to deliver with a SBA than those who receive lower quality ANC. Urban residence, higher SES, frequent ANC visits, and receiving ANC in a higher-level or private health facility increases the odds of delivering with a SBA. ANC quality partially mediates the effects of these factors on use of SBAs.

Implications: Targeted policies and programs to increase ANC quality, especially in the lower-level health facilities and among low SES women, will help improve coverage and reduce disparities in use of SBAs.

Objectives: To evaluate the impact of a large-scale combined economic and food security intervention on health outcomes and HIV vulnerability in rural Malawi.

Methods: The SAGE4Health study employed a quasi-experimental non-equivalent control group design to compare intervention participants (N=600) with people participating in unrelated programs in distinct but similar geographical areas (control, N=300). We conducted participant interviews at baseline, 18-, and 36-months on HIV vulnerability and related health outcomes, food security, and economic vulnerability. Randomly selected households (N=1000) were interviewed in the intervention and control areas at baseline and 36 months to control for historical trends and geographical confounds.

Results:  Compared to the control group, the intervention led to increased HIV testing (OR=1.90; 95% CI=1.29-2.78) and HIV case finding (OR=2.13; 95% CI=1.07 – 4.22);decreased food insecurity (OR=0.74; 95% CI=0.63-0.87), increased STI diagnoses, and improved economic resilience to shocks. Most effects were sustained over a 3-year period. 

Conclusions: These results cannot be explained by more general trends during the study timeframe. Although there were general trends toward improvement in the study area, only intervention participants’ outcomes were significantly better. Our study indicates a multi-level structural intervention can improve economic/food security and HIV vulnerability through increased testing and case finding.. We encourage further rigorous, controlled research on the effects of a variety of real-world economic development programs on HIV and other health outcomes. Leveraging the resources of NGOs to deliver locally developed programs with scientific funding to conduct controlled evaluations has the potential to accelerate the likelihood of positive impacts of economic programs on health.