RH is most basic human needs for human. But there is a great inequities which is injustice in RH services,

1. MD. ZAKIUL ALAM
DPSDU
UNIVERSITY OF DHAKA

2. Program Strategies for Reducing
Inequities in Reproductive Health
Services

3. OBJECTIVES OF THIS PRESENTATION
(ON THE BASIS OF ARTICLE)
To address what is inequity in the perspective of RH
To address the descriptors (Indicators) of inequity in RH
To address the program strategies for reducing inequities in RH
And finally to address ethical issues related to program strategies of RH

4. INTRODUCTION: INEQUITY AND
INEQUITY
Inequality:
Inequality is just unequal distribution in health, wealth, income, status etc.
Inequity:
Inequity is injustice, unfair etc.
For example,
Income difference between “educated and uneducated” but
difference in “male and female”.

5. INEQUITY IN RH
Inequity justice framework analyzes how the ability of any woman to
determine her own reproductive outcomes is linked directly to the conditions
in her community—
 that is, to conditions that are not just a matter of individual choice and access
rather integrated.
Reproductive justice addresses the reality of inequality— specifically, the
inequality of opportunities that control reproductive outcomes (Ross 2005).

6. INEQUITY INDICATORS
(DESCRIPTORS):
Inequity is often expressed as the difference in an outcome variable by
categories of descriptors such as
1. age (young–old),
2. sex (female–male),
3. wealth (lowest–highest quintile),
4. ethnicity (indigenous–nonindigenous),
5. and location of residence (urban–rural) etc.
For example,
 In 2005 women from poor countries had a maternal mortality rate of about 650 deaths per
100,000 live births, compared with 9 deaths for women from wealthier countries (WHO 2007).
 In 2005 that a 15yearold female would die from a complication related to pregnancy or
childbirth during her lifetime was one in seven in Niger (the country with the highest rate),
compared with a lifetime risk of one death in 48,000 live births for a girl of the same age in
Ireland.

7. INEQUALITY INDICATORS
(DESCRIPTORS) CONTD.
• Some descriptors are based upon
• self identifiers, such as ethnicity or sexual identity,
• whereas others are based upon observable measures of wealth, such as housing
type.
• Some are not amenable to change, such as age, whereas others may be
difficult to change at a group level, such as rural residence.
• Indeed, many of the indicators of more vulnerable groups may be highly
correlated.
• For example, indigenous women are more likely to be poor and to live in rural areas.

8. PROGRAM STRATEGIES FOR
REDUCING INEQUITIES
Efforts to reduce inequity can be undertaken within program operations
through actions at three different phases:
1. 1st phase: through better understanding at the development stage,
2. 2nd Phase: through better program design,
3. 3rd Phase: through post program evaluation of the distribution of benefits.
It is just the process of Behavior Change Communication (BCC) for

9. DEVELOPMENT PHASE:
PRE-INTERVENTION STAGE
1. Selection of target area on the basis of severity
E.g. CPR increase in Sylhet area.
2. Selection of target population:
Specify the target population on the basis of
a) age e.g. (15-49) for women
b) sex
c) and wealth (income)

10. PRE-INTERVENTION STAGE CONTD
3. Objectives and goals of the interventions:
a) What are the principal outcomes that we want to
achieve?
b) and what parts of the health system must be engaged with to have the
greatest effect on program coverage, potential impact, and financial
sustainability?
4. Timing:
Selection of appropriate timing
5. Preliminary analysis:
Conducting preliminary analyses to better target the intervention often leads to
greater impact and better use of limited resources.

11. 2. REDUCING INEQUITY USING
INTERVENTION DESIGN:
INTERVENTION PHASE
The second approach to reducing inequity is to incorporate reduction of
inequity into
1. program design
2. and public policy.
Development economists offer a range of strategies for this approach,
including
1. the provision of universal health insurance coverage,
2. increased public spending on health care (on the assumption that the poor will
benefit disproportionately),
3. and better targeting of programs and services to populations in need.

12. REDUCING INEQUITY IN ACCESS
TO FAMILY PLANNING
• Access to family planning can vary greatly as a result of diverse strategies for
achieving coverage— e.g. clinic versus community efforts.
For Example, Since 1984, little difference has been observed in the
contraceptive prevalence rate in Bangladesh according to wealth quintile,
compared with Kenya.
But why?
• Bangladesh emphasize on universal coverage of family planning services
through community outreach efforts, especially for the poor,
• whereas in Kenya the commitment to expanding family planning through
community based distribution (CBD) programs. When Kenya failed to maintain its
CBD program.

13. REDUCING THE INCIDENCE OF EARLY
MARRIAGE AND ITS HEALTH
CONSEQUENCES FOR YOUNG WOMEN
• Early marriage is highly correlated with a series of undesirable, often
devastating health outcomes.
For example, ranging from the risk of early pregnancy to obstetric fistula due to
obstructed labor.
• Erulkar and her colleagues (2006) are examining means of addressing the
vulnerability of young Ethiopian girls aged 10–14 by delaying marriage and
seeking alternative transitions to adulthood through
a) education,
b) livelihoods training,
c) and community involvement activities.

14. INCREASING SKILLED ATTENDANCE AT
CHILDBIRTH AMONG THE POOR
The provision of skilled childbirth attendants where prenatal care is poor and
maternal mortality rates are high is one of the most inequitable of health
services.
• This inequity exists because of the costs associated with addressing delivery
complications in public and private hospitals in many developing countries.
• How it can be reduced?
1. Addressing the affordability of these services through the use of coupons or vouchers
given to the poorest women expands their reach.
2. A financing mechanism such as vouchers for women who meet poverty standards is
an effective way to increase the use of hospital services rapidly.

15. INCREASING SKILLED ATTENDANCE AT
CHILDBIRTH AMONG THE POOR
• Incentive programs such as the JSY (Janani Suraksha Yojana) safemother
hood intervention in India, efforts in Rwanda supported by the World Bank,
and programs supported by KfW (the German development bank) in
Bangladesh, Kenya, and Uganda are working to determine how to make
these services accessible to those who need them most.
• Experience to date in several countries suggests that the use of vouchers
increases women’s demand for hospital childbirth services.

16. 3. ADDRESSING INEQUITIES BY
IMPROVING EVALUATION OF
DISTRIBUTIVE BENEFITS AND COSTS:
EVALUATION PHASE
• The third approach focuses on the necessity of assessing whether the
benefits planned reached those who are most vulnerable within the target
areas.
• For policies to be effective in the long run, determining the effects of early
investments is important in order to ensure that the funds set aside were used
effectively and that those groups who were to receive the benefits of the
interventions were exposed to them.
• The best intentions built into a program’s design do not always have the
anticipated effects. Weiner and his collaborators employed rapid
assessments and analysis creatively to examine who makes use of youth
centers in countries around the world (Weiner 2007).

17. M&E QUESTIONS
• Monitoring questions
• What is being done?
• By whom?
• Target population?
• When?
• How much?
• How often?
• Additional outputs?
• Resources used? (Staff, funds,
materials, etc.)

18. THE ETHICS OF INEQUITY AND
INACTION
• Any discussion of the issue of inequity should take…..
1. Ethics,
2. Accountability,
3. and the role of reproductive justice into consideration.
• The ICPD Program of Action calls for all societies and individuals to have
access to the benefits of scientific innovation (UNFPA 1994).
• Expanding the stream of these benefits to all requires that the principle of
reproductive justice be applied to research and service models to ensure
the inclusion of those individuals who are commonly left out.
• Policymakers and program planners must take into account the
disproportionate burden of diseases among certain segments of the
population that can be ameliorated through public investments in health.

19. THE ETHICS OF INEQUITY AND
INACTION CONTD.
• we must ask: How do families, communities, and social norms support or
inhibit the provision of these benefits to those who are most vulnerable and
most in need of the interventions?
• Accountability is a major part of good governance.
• By employing reproductive justice frameworks, programs can achieve
greater marginal impacts, improve their efficiency, and attain a better grasp
on monitoring the distributive benefits and costs of interventions.
• The result of focusing on inequity is that societies achieve better devel-opment
outcomes by making smart investments in reproductive health.

20. CONCLUSION
• One practical way of approaching the process of reducing or eliminating
inequity is to use the techniques of market segmentation.
• The focus of our investments, then, should be on the social norms and
program operations that affect these outcomes.

21. THANK YOU EVERYONE
FOR YOUR PATIENCES.
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