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Contraception Overview of the DCPP Chapter

Contraception Overview of the DCPP Chapter. Gaverick Matheny Dept Health Policy & Mgmt Johns Hopkins University World Bank, 12 July 2007. Outline. Disease Control Priorities Project Contraceptive use and health Patterns of fertility and contraceptive use Meeting the demand

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Contraception Overview of the DCPP Chapter

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  1. ContraceptionOverview of the DCPP Chapter Gaverick Matheny Dept Health Policy & Mgmt Johns Hopkins University World Bank, 12 July 2007

  2. Outline • Disease Control Priorities Project • Contraceptive use and health • Patterns of fertility and contraceptive use • Meeting the demand • Cost-effectiveness of contraception • Research priorities

  3. Disease Control Priorities Project • Cost-effectiveness analysis to inform priority-setting in international health • 1993: DCP1, WB WDR • 2006: DCP2, Priorities in Health • Contraception (Levine, Langer, Birdsall, Matheny, Wright, Bayer) • http://www.dcp2.org/pubs/DCP/57/

  4. Health Benefits of Contraceptive Use • Prevent unsafe abortions • Prevent pregnancies that are: • Underspaced • To women too young or too old • High parity • 25-50% reduction in maternal mortality • 10-29% reduction in infant mortality • 21-35% reduction in <5 mortality WHO, 2001; Conde-Agudelo and Belizan, 2000; Fraser, Brockert, and Ward, 1995; Rutstein, 2003, Conde-Agudelo and Belizan, 2003; Muhuri and Menken, 1997; Tsui, Wasserheit, and Haaga, 1997; Walsh et al., 1993; Trussell and Pebley, 1984.

  5. Health Benefits of Contraceptive Use • STIs • Condoms for dual-protection • FP: 10-15% of all condoms • Some groups: low risk perception of STIs, high risk perception of pregnancy • PMTCT via FP • $5 / DALY (Stover 2003) UNAIDS, 1999; Agha, 2002; Van Rossem and Meekers, 2000; Stover, 2003; Marseille et al., 1999; King et al., 1995.

  6. Health Benefits of Contraceptive Use Population growth linked to environmental health: • Urban air pollution (1% of global mortality) • Urban water pollution • Global climate change • Pop growth ~half of increase in greenhouse gas emissions over next 25 yrs • Health effects: infectious diseases, cardiovascular and respiratory disease from thermal extremes, malnutrition from crop losses WHO, 2002; Shi, 2001; Brockerhoff and Brennan, 1998; Bongaarts, 1992; Birdsall, 1994.

  7. Health Benefits of Contraceptive Use Health affected by economic development / economic outcomes affected by pop growth: • Dependency ratios • Dilution of natural capital • Costs of environmental remediation • However, pop size = source of labor & taxes Bloom, Canning, Sevilla, 2002; Nordhaus and Boyer, 1998; Lee and Miller, 1991.

  8. Current Total Fertility Rates by RegionAmong Women Ages 15-49 *Among 60 developing countries (excludes data from Eastern Europe & Central Asia).

  9. Contraceptive Use Grows in Developing Countries *Weighted by population size.

  10. Developing Areas Developed Areas Worldwide 100 90 80 70 60 Percent Currently Using 50 40 30 20 10 0 Any Method Any Modern Method Any Traditional Methoda Type of Method Estimate of Contraceptive Use WorldwideAmong Married Women ages 15-49, 2000 Percentages are weighted by population size and use the most recent data from the DHS and RHS and, for countries without these surveys, data from the United Nations, the US Census Bureau’s International Database, and other nationally representative surveys. a Includes periodic abstinence and withdrawal.

  11. Fertility Levels Closely Correspondto Levels of Contraceptive Use

  12. Percent with Unmet Need for Family Planning Among Married Women Ages 15-49, 1990-2001

  13. Contraceptive Method Mix • Four methods account for almost 75% of total contraceptive use among married women: • Female sterilization • Oral contraceptives • Injectables • Intrauterine device • Other methods are used little • Vaginal method use averages <1% of total contraceptive use • Male sterilization use generally less than 1% • Implant use highest in Indonesia (6%) and Haiti (1%) • Female condom use <1%

  14. Cost-Effectiveness Analysis • Why CEA? • Resources are finite • Have to make difficult choices • Where is the “biggest bang for the buck”? How can I prevent the most misery with $XB? • If every life has equal value, should spend $ on most cost-effective projects

  15. Cost-Effectiveness Analysis • Dearth of FP CEAs • Most programs measure average costs, not marginal costs • Most programs measure output (CYPs), not impact (lives saved) • Brand/method substitution: need client-intercepts

  16. Data • Alan Guttmacher Institute et al (2000) • Used country-level data for 68 developing countries • Variety of interventions, settings, scales • Estimated public sector FP costs per maternal and infant death averted

  17. Data • Traditional method users moving to modern methods • No method users moving to modern methods • % of unintended pregnancies that end in birth • % of unintended pregnancies that end in abortion • % of unintended pregnancies that end in miscarriage • Estimated number of unintended births averted • Estimated number of induced abortions averted • Estimated number of miscarriages averted • Non-abortion maternal mortality per 100,000 births • Estimated non-abortion maternal deaths averted • Abortion mortality per 100,000 abortions • Estimated abortion deaths averted • Infant mortality per 1,000 births • Maternal deaths averted • Infant deaths averted

  18. Methods • Regional averages: country data population-weighted by # rep age women in each country • Converted deaths into DALYs, using regional death-DALY ratios for FP-related conditions, regional life expectancies, 3% discount rate and no age-weighting • Adjusted to 2001 dollars

  19. Cost-effectiveness of FP 2001 US dollars. Based on AGI et al (2000). Costs per deaths averted into cost per DALY using regional life expectancies and death-DALY ratios, with 3% discount rate and no age-weighting.

  20. Included in CEA • Preventing unsafe abortions • Preventing pregnancies that are: • Underspaced • To women too young or too old • High parity

  21. Excluded from CEA • Condoms for dual-protection • PMTCT via FP • Population links to environmental health • Economic effects of fertility

  22. Implementation • Should not over-generalize • Identify local needs through market research • Who has unmet need? • Where do they receive health services/products? • What are barriers to their contraceptive use? • Target through market segmentation • Non-poor currently receive most subsidized services • Geographical and media targeting • How does commercial sector reach this group? • Offer several methods

  23. Contraceptive methods • No single method is best • Simple cost-per-CYP measures aren’t measuring impact • Offer choice

  24. Reducing unmet need • Most common causes of “unmet need”: • Lack of knowledge • Health concerns • Social disapproval • Not price • Information is key • IEC/BCC activities are cost-effective: $1-$3 per new user (price subsidies: ~$100) • Educate couples about child health benefits of birth spacing • Encourage private sector supply/service (social marketing, social franchising) Matheny 2004

  25. Research Priorities • “You control only what you measure” • Standardized O.R. instruments useful to local programs: • Tools to identify local barriers to contraceptive use (current misfit between reported barriers and programs) • Marketing research to develop program strategies and materials • Market segmentation to reduce leakage • Accounting to measure programs' marginal costs • Monitoring & evaluation to measure programs' marginal effectiveness

  26. Research Priorities • Biomedical • Better contraceptives so women can protect themselves from pregnancy and HIV • Policy • Relationships between economic outcomes and population dynamics - macro and micro levels • Stakeholder analysis: How can local governments be encouraged to increase their investments in FP? What info do they need?

  27. FP: lessons learned • Decline in unmet need: great success story in public health • Key elements: • Education (esp of men) • Choice of many methods • Donor commitment • Future progress will depend on keener use of private sector, effective communication to men, better targeting, and integration with STI services/supplies Levine 2004

  28. Integration in RH • More profitable services can subsidize less profitable services • Increases # of clients, reducing fixed costs per client • Offer FP at prenatal, delivery, post-partum, (post-)abortion care sites • Offer FP at STI care sites

  29. Thank you! • jmatheny@jhsph.edu

  30. References • Alan Guttmacher Institute (AGI), The Futures Group International, Population Action International, the Population Reference Bureau, the Population Council. The Potential Impact of Increased Family Planning Funding on the Lives of Women and their Families. Washington, DC: AGI; 2000. • Attanayake N, Fauveau V, Chakraborty J. Cost-effectiveness of the Matlab MCH-FP Project in Bangaldesh. Health Policy and Planning 1993;8(4):327-338. • Birdsall N. Another look at population and global warming. In United Nations, Population, Environment, and Development. New York: United Nations; 1994. p. 39-54. • Bloom D, Canning D, Sevilla J, The Demographic Dividend: A New Perspective on the Economic Consequences of Population Change. Rand Population Matters series, 2002. • Bongaarts J. Population Growth and Global Warming. Population and Development Review 1992;18:299-319. • Brennan E. Air and Water Pollution Issues in the Mega-Cities. In: Ramphal S, Sinding S, editors. Population Growth and Environmental Issues, Westport, Conn.: Praeger Publishers; 1996.

  31. Cochrane S, Sai F. Excess Fertility. In Jamison DT, Mosley WH, Measham AR, Bobadilla JL, editors. Disease Control Priorities in Developing Countries. Oxford: Oxford University Press; 1993. p. 333-361. • Conde-Agudelo A, Belizan JM. Maternal morbidity and mortality associated with interpregnancy interval: cross sectional study. British Medical Journal (Clinical Research Ed.) 2000;321(7271):1255-1259. • Haaga JG, Tsui AO. Resource Allocation for Family Planning in Developing Countries. Washington DC: National Academy Press; 1995. • Lee, R.D. and T. Miller (1991), "Population Growth, Externalities to Childbearing, and Fertility Policy in Developing Countries," Proceedings of the Annual Bank Conference on Development Economics 1990 (Supplement to the World Bank Economic Review), 275-304. • Marseille E, Kahn JG, Mmiro F, Guay L, Musoke P, Fowler MG, Jackson JB. Cost effectiveness of single-dose nevirapine regimen for mothers and babies to decrease vertical HIV-1 transmission in sub-Saharan Africa. Lancet 1999;354:803-809 • Matheny JG (2004) Family planning programs: getting the most for the money. International Family Planning Perspectives 30(3). • Muhuri PK, Menken J. Adverse effects of next birth, gender, and family composition on child survival in rural Bangladesh. Population Studies 1997;51(3):279-294.

  32. Nordhaus WD, Boyer J. What are the external costs of more rapid population growth? Theoretical issues and empirical estimates. Paper presented at the 150th Anniversary Meetings of the American Association for the Advancement of Science. February 15, 1998. • Rutstein SO. Effect of Birth Intervals on Mortality and Health. Calverton, MD: Measure/DHS+/Macro International; 2003. • Stover J. Costs and benefits of providing family planning services at PMTCT and VCT sites. Washington, D.C.: Futures Group; 2003. • Sullivan JM, Rutstein SO, Bicego GT. Infant and child mortality. DHS Comparative Studies No. 15. Calverton MD: Macro International; 1994. • Trussell J, Pebley A. The potential impact of changes in fertility on infant, child, and maternal mortality. Studies in Family Planning 1984;15(6):267-280. • UNAIDS. Prevention of HIV transmission from mother to child: Strategic options. Geneva: UNAIDS; 1999. • Walsh JA, Naschuk, CN, Meaham AR, Gertler PJ. Maternal Health. In Jamison DT, Mosley WH, Measham AR, Bobadilla JL, editors. Disease Control Priorities in Developing Countries. Oxford: Oxford University Press; 1993. p. 363-390. • World Bank. Investing in Health: World Development Report 1993. New York: Oxford University Press; 1993. • World Health Organization. Global Burden of Disease estimates for 2001 by region and sub-region. http://www3.who.int/whosis/menu.cfm?path=evidence,burden Accessed on 18 April, 2004.

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