ImpactNow: Identifying the Near-term Benefits of Family Planning Investment in the Amhara Region—Results Dissemination Workshop

Publication date: 2014

This publication was prepared by Aragaw Lamesgin of the Health Policy Project. IMPACTNOW: IDENTIFYING THE NEAR-TERM BENEFITS OF FAMILY PLANNING INVESTMENT IN THE AMHARA REGION Results Dissemination Workshop Bahir Dar, Ethiopia May 22, 2014 August 2014 HEALTH POL ICY P R O J E C T Suggested citation: Lamesgin, A. 2014. ImpactNow: Identifying the Near-Term Benefits of Family Planning Investment in the Amhara Region—Results Dissemination Workshop, Bahir Dar, Ethiopia, May 22, 2014. Washington, DC: Futures Group, Health Policy Project. The Health Policy Project is a five-year cooperative agreement funded by the U.S. Agency for International Development under Agreement No. AID-OAA-A-10-00067, beginning September 30, 2010. It is implemented by Futures Group, in collaboration with Plan International USA, Futures Institute, Partners in Population and Development, Africa Regional Office (PPD ARO), Population Reference Bureau (PRB), RTI International, and the White Ribbon Alliance for Safe Motherhood (WRA). ImpactNow: Identifying the Near- Term Benefits of Family Planning Investment in the Amhara Region Results Dissemination Workshop Bahir Dar, Ethiopia May 22, 2014 AUGUST 2014 This publication was prepared by Aragaw Lamesgin1 of the Health Policy Project. 1 Futures Group The information provided in this document is not official U.S. Government information and does not necessarily represent the views or positions of the U.S. Agency for International Development. iii CONTENTS Acknowledgments . iv Executive Summary . v Abbreviations . vi Introduction . 1 Background . 1 Purpose of the Workshop . 1 Methodology of the Model Application in Amhara . 2 Model Scenarios and Assumptions . 3 Results . 4 Health Benefits of Family Planning . 4 Children’s lives saved . 4 Mothers’ lives saved . 4 Economic Benefits of Family Planning . 5 Annual FP program costs in Amhara . 5 Cost-benefit analysis . 5 Discussion . 6 ImpactNow Policy Implications . 6 How to Achieve the MCH Goals in Amhara . 6 Panel Discussion . 7 Next Steps. 9 Annex 1: Workshop Agenda . 10 Annex 2. Lists of Participants . 11 iv ACKNOWLEDGMENTS The ImpactNow modeling work in the Amhara Region of Ethiopia benefits from the valuable contributions of numerous Health Policy Project staff, including Aparna Jain, Alexander Paxton, Aragaw Lamesgin, Abebaw Ferede, Teklehiamot Mulualem, Kurabachew Abera, and Carol Miller. In addition, several in-country organizations and representatives of government bureaus—including Desalegn Akal and Mesfin G/Medhin from Amhara Regional Bureau of Finance and Economic Development; Mulusew Lijalem and Zebideru Zewude from the Amhara Regional Health Bureau (RHB)—serve as a driving force behind the ImpactNow work and dissemination of its results. The workshop documentation was compiled and reviewed by Aragaw Lamesgin, Amy Stickler, and Ellen Smith. v EXECUTIVE SUMMARY ImpactNow—a new model developed by the USAID-funded Health Policy Project (HPP)—helps decisionmakers and policy advocates make the case for investment in family planning (FP) by demonstrating the near-term (2–7 years) benefits associated with increased FP use. The model fills an important knowledge gap in the FP policy and advocacy landscapes. Without this near-term evidence, policymakers and program planners have found it difficult to establish achievable goals or secure the funding needed to expand access to high-quality FP services. HPP is currently implementing ImpactNow in three countries: Ethiopia, Kenya, and Zimbabwe. In Ethiopia, the model is being applied initially in the Amhara Region, where stakeholders have placed a particular emphasis on the linkages between FP uptake and the reduction in maternal and child deaths. The ImpactNow results in Amhara demonstrate the health and economic benefits of family planning, including averting an estimated 19,000 child deaths and 1,400 maternal deaths by 2020, due to longer birth spacing. Achieving these benefits—using current trend data, with no change in FP method mix— will require the Amhara government to invest US$17.8 million in family planning by 2020. An increase in the contraceptive prevalence rate and a shift in the method mix toward long-acting and permanent methods (LAPMs) would substantially reduce the cost to US$13.7 million by 2020. Despite the investments needed to increase FP use, both the medium and high progress scenarios would result in cost savings when compared to the current scenario. This is because LAPMs, while more costly upfront, are more cost-effective in the long term as they offer protection over a longer period of time. Stakeholders engaged in extensive discussions to decide which policy goals to model and what assumptions to use. After conducting the model application and undertaking a long review and analysis process, HPP held the first results dissemination workshop on May 22, 2014. The workshop objective was to provide a brief overview of the ImpactNow model and to present the initial results of the modeling activity for comments and feedback. The participants included 50 national and regional government officials, as well as by representatives from nongovernmental organizations (NGOs). The workshop helped stakeholders to understand the policy and program implications of the model. The most important follow-up actions identified related to the need to • Strengthen FP advocacy on LAPMs • Change the methods mix to move from short-term FP methods toward LAPMs • Increase health workers’ capacity to provide LAPMs and counseling • Involve private sector actors and NGOs in scaling up the provision of LAPMs and FP service integration with other health services vi ABBREVIATIONS ANC antenatal care BOFED Bureau of Finance and Economic Development CPR Contraceptive Prevalence Rate CORHA Consortium for Reproductive Health Associations CSO civil society organization EDHS Ethiopian Demographic and Health Survey FBO faith-based organization FMOH Federal Ministry of Health FP family planning HPP Health Policy Project HSDP Health Sector Development Plan IUD intrauterine device LAPM long-acting and permanent method MCH maternal and child health MNCH maternal, neonatal, and child health MWRA married women of reproductive age NGO nongovernmental organization PNC postnatal care RH reproductive health RHB Regional Heath Bureau UNFPA United Nations Population Fund USAID United States of Agency for International Development WHO World Health Organization 1 INTRODUCTION Background Ethiopia has made significant progress in its provision of family planning (FP) services as well as in its maternal and child healthcare in the last several years. According to the Ethiopia’s Demographic and Health Surveys (EDHS), the national contraceptive prevalence rate (CPR) has doubled over the past five years from 15 percent in 2005 to 29 percent in 2011; and in the Amhara Region, progress has been even greater, with CPR estimated at 33 percent for married women of reproductive age (MWRA) (15–49 years old).1 However, despite the significant effort and achievements, the CPR is highly dependent on short- term FP methods; injectables account for nearly 80 percent of contraceptive use, and unmet need for family planning is still high at 19 percent in Amhara and 23 percent nationally for all MWRA. The EDHS 2011 showed that the method mix relies heavily on injectables and is not compatible with the high proportion of women who desire to limit or space births. Long-acting permanent methods (LAPMs) are more effective and cheaper in the long run and are therefore more compatible in comparison. The long-term impacts of expanded contraceptive choice and improved contraceptive use on maternal health are already well established. What policymakers in Amhara need is concrete information on the near-term benefits of family planning to advocate for an increase in the newly established FP budget line item. Without this evidence, policymakers and program planners have difficulty establishing realistic, achievable goals or to secure the funding needed to expand access to high-quality FP services. ImpactNow—a new model developed by the USAID-funded Health Policy Project (HPP)—helps decisionmakers and policy advocates make the case for investment in family planning by demonstrating the near-term (2–7 years) benefits associated with increased FP use. ImpactNow fills an important knowledge gap in the FP/reproductive health (RH) advocacy landscape, as existing models have focused on demonstrating the long-term gain generated by increasing FP uptake. HPP is currently implementing ImpactNow in three countries: Ethiopia, Kenya and Zimbabwe. In Ethiopia, the model is being applied initially in the Amhara Region, where stakeholders including the Amhara Region Health Bureau (RHB) and Amhara Bureau of Finance and Economic Development (BOFED) have placed a particular emphasis on the linkages between FP uptake and reduction in maternal and child deaths. On May 22, 2014, HPP held a workshop to disseminate the results of the initial application. Thus, the report summarizes the results and analysis presented at the workshop, as well as stakeholder reactions and next steps. Purpose of the Workshop The workshop’s objective was to provide a brief overview of ImpactNow and to present the initial results of the modeling activity for comments and feedback from stakeholders. The participants included 50 government officials and NGO representatives, including the Federal Ministry of Health (FMOH)/Maternal, Neonatal, and Child Health (MNCH) Directorate Director; regional bureau deputy heads; and program planners, association leaders, program directors, and country representatives, including from the Consortium for Reproductive Health Associations (CORHA), United Nations Population Fund (UNFPA), Packard Foundation, World Vision, Family Guidance Association Ethiopia (FGAE), Marie Stopes International, Save the Children, and East and Awi Zone Health Department Heads. 1 Central Statistical Agency (CSA) and ORC Macro. 2006. Ethiopia Demographic and Health Survey 2005. Addis Ababa, Ethiopia: CSA; and Calverton, MD: ORC Macro; CSA and ICF International. 2012. Ethiopia Demographic and Health Survey 2011. Addis Ababa, Ethiopia: CSA; and Calverton, MD: ICF International. ImpactNow: Identifying the Near-Term Benefits of Family Planning Investment in the Amhara Region 2 Methodology of the Model Application in Amhara The ImpactNow application involved many stages of review, including introducing the model to stakeholders and in-country team members to provide input on which policy goals to model and, based on these goals, what assumptions about the future would be made. Assumptions were related to policy goals on FP use, unmet need for family planning, funding for family planning, and patterns of contraceptive use, especially regarding method mix and FP costs. The input data for ImpactNow—region-specific when possible—were related to maternal health, patterns of contraceptive use, pregnancy and birth-related healthcare utilization and costs, and FP costs. When region-specific data inputs were not available, the model populated default input data after the user selected the country and years. The validity, applicability, and representation of model inputs, including region-specific secondary data, national data, and default data were validated in a workshop organized for this purpose. The regional (Amhara) and national data, as well as some default proxy data, were also reviewed and validated at the workshop. In some instances, data on maternal and child health service costs were assessed at various service delivery points (referral hospitals, district hospitals, and health centers) and cross-checked with the default data for consistency and representation. In consultation with senior government officials, HPP decided on three policy scenarios for analysis: (1) “business-as-usual” or current trend, (2) medium progress, and (3) high progress, based on changes in CPR and method mix over time. The method mix inputs, timeframe, and policy scenarios were deliberately aligned to key national and international commitments, such as those made in the Health Sector Development Plan (HSDP) and EDHS and at the London FP2020 Summit. As a result, the model application and dissemination workshop, as part of the larger HPP program goal, contribute to (1) efforts under the excellence in leadership and governance strategic theme in the HSDP, especially for FP/RH and related health outcomes and (2) the capacity development of leadership to increase demand for and use of evidence for FP/RH and related strategic planning, monitoring, and evaluation in the Amhara Region. 3 MODEL SCENARIOS AND ASSUMPTIONS Using baseline data from the EDHS 2011 and 2005, ImpactNow modeled three possible scenarios for contraceptive prevalence and method mix in Amhara: current trend, medium progress, and high progress (see Figure 1). Currently, 42 percent of MWRA in Amhara are using a contraceptive method. Under the three scenarios, by 2020, the CPR would increase to 60 percent (current trend, assuming a 2.9 percentage point increase in the CPR annually); 66 percent (medium progress, assuming a 3.9 percentage point increase in the CPR annually); and 73 percent (high progress—assuming a 5.1 percentage point increase in the CPR annually, meeting the national goal). In the medium and high progress scenarios, it was assumed that the method mix would change significantly, shifting from short-term methods to long-acting methods. Based on the 2012 Intercensal Population Survey (medium fertility variant), the model also assumed the population of women of reproductive age in Amhara to be nearly 5 million2—of which, 62 percent are married.3 In addition, the model used the current maternal mortality ratio in Ethiopia—420 deaths per 100,000 live births4—as a baseline, and set it to decline to 200 by 2020, in line with the national HSDP target. Figure 1. Model scenarios and assumptions for Amhara Baseline 2014 Scenario 1: Current Trends Scenario 2: Medium Progress Scenario 3: High Progress CPR 42.3 60.1 66.0 73.0 Method Mix (% of users) Condoms 0 0 0 0 Females sterilization 2.2 2.2 2.2 2.2 Injectables 80.1 80.1 60.1 28.9 Implants 15.3 15.3 25.3 30.3 Intrauterine devices (IUDs) 0.9 0.9 10.9 35.9 Male sterilization 0 0 0 0 Oral contraceptives 0 0 0 0 Traditional 1.5 1.5 1.5 1.5 2 Central Statistical Agency. 2013. Population Projections for Ethiopia 2007–2037. Addis Ababa: CSA. 3 CSA and ICF International. 2012. Ethiopia Demographic and Health Survey 2011. Addis Ababa, Ethiopia: CSA; and Calverton, MD: ICF International. 4 World Health Organization (WHO), United Nations Children’s Fund, United Nations Population Fund, The World Bank, and the United Nations Population Division. 2014. Trends in Maternal Mortality: 1990 to 2013. Estimates by WHO, UNICEF, UNFPA, The World Bank and the United Nations Population Division. Geneva: WHO. 4 RESULTS Health Benefits of Family Planning The ImpactNow results were presented by Mr. Mulusew Lijalem, Process Owner, Regional Health Bureau (RHB)/Health Promotion and Diseases Prevention. Shown together, the three modeling scenarios demonstrate that family planning has important health and economics benefits in Amhara in both the short and long term. Children’s lives saved The 2011 EDHS estimated that 1 in every 11 children in Ethiopia did not live to see his or her fifth birthday. Shorter birth intervals are associated with high child mortality. ImpactNow estimates that, currently, more than 10,000 children’s lives are saved each year in the region due to birth spacing through FP uptake. Under the current trend scenario, this number will continue to increase; and by 2020, the cumulative total number of children’s lives saved per year is estimated to be 93,000, which is laudable and puts Ethiopia on track to achieve Millennium Development Goal 4 to reduce child mortality. However, with increased access to family planning and shifts to more effective methods, the number of lives saved could be even greater. By 2020, under the medium progress scenario (66% CPR), a cumulative 102,000 lives could be saved, and under the high progress scenario (73% CPR), a cumulative 112,000 lives could be saved. This represents 19,000 additional children saved over the current pace of FP scale-up through better access to family planning. Mothers’ lives saved As stated earlier, an estimated 420 women die per every 100,000 live births in Ethiopia. ImpactNow estimated the number of unintended pregnancies averted by satisfying unmet need for family planning, thus reducing the number of times each woman is exposed to the health risks associated with pregnancy and childbirth. Results show that, currently, FP use saves the lives of approximately 1,200 women in Amhara each year. Under the current trend scenario, a cumulative 7,700 maternal lives would be saved by 2020. Reaching the goals associated with the medium and high progress scenarios could save an additional 600 or 1,400 lives, respectively, by 2020. Figure 2. Mothers’ and children’s lives saved, 2014–2020 93 102 112 0 20 40 60 80 100 120 Current Medium High Th ou sa nd s Scenarios Children 7.7 8.3 9.1 0 2 4 6 8 10 Current Medium High Th ou sa nd s Scenarios Mothers Results 5 Economic Benefits of Family Planning Annual FP program costs in Amhara ImpactNow estimates that the cost of supplying FP commodities and program support to MWRA in Amhara in 2014 is US$11.3 million or about 223.7 million Ethiopian birr (ETB). This estimate is based on the total number of FP users and the particular methods that women use. As more women adopt family planning, these costs may increase overall but may decrease per user. Under the current trend scenario, it is estimated that costs will increase by 57 percent to US$17.8 million (352.4 million ETB) by 2020. Under the medium progress scenario—in which the CPR has increased to 66 percent and method choice has shifted moderately from short-term contraceptive methods to long-acting methods—the annual cost of family planning would increase to US$17.4 million (345.5 million ETB) (slightly lower than under the current trend scenario). This is important to note as long-acting methods are more costly initially but, over time, cost less per user per year. Therefore, these methods provide a more cost-effective option for the regional government—supplying more women with more effective methods using the same amount of resources. In the high progress scenario—in which the CPR has increased to 73 percent and the majority of women have switched to long-acting methods (primarily IUDs and implants)—the annual cost of family planning would increase to US$13.7 million (271.3 million ETB) (23% lower than under the current trend scenario). Cost-benefit analysis The ImpactNow model also estimates the healthcare costs savings realized by the reduction in unintended pregnancies as a result of increased FP use. Maintaining the current trend in FP use would save US$112 million in maternal and newborn costs in Amhara by 2020. By achieving the high progress scenario, Amhara can save an additional US$22 million in costs—for a cumulative US$134 million saved. Finally, ImpactNow estimates the healthcare savings per dollar spent on family planning (see Figure 3). Currently, every US$1 spent on family planning saves US$1.10 in direct healthcare costs in Amhara. The medium progress scenario shows that every US$1 spent on family planning saves US$1.31, and the high progress scenario demonstrates that shifting the method mix toward long-acting methods can increase these savings to US$1.92 per dollar spent. Figure 3. Healthcare savings per dollar spent on family planning in Amhara, 2020 6 DISCUSSION Workshop participants were divided into four groups and were assigned to discuss either (1) the policy implications of ImpactNow in Amhara or (2) the actions needed to achieve maternal and child health (MCH) targets in the region. Each group included a mix of participants, representing government, NGOs, universities, and civil society organizations (CSOs). Following the small group discussions, a panel discussion was held to elaborate on the major FP commitments needed to accelerate progress. ImpactNow Policy Implications Participants discussed the implications of the ImpactNow results and the usefulness of the model in informing FP policies and programs. The ImpactNow results created substantial interest and motivation among participants, including program planners, FP advocators, policymakers, and decision-makers at all levels. Participants stressed the need for coordination and the alignment of priorities among the government, NGOs, universities, and CSOs to ensure greater access to FP services in rural areas. They also emphasized the need for increased involvement of private health service providers and NGOs in expanding FP service provision, particularly for LAPMs. Regarding the utility of ImpactNow, the groups agreed that the model helps to • Inform decisionmakers of valuable alternative policy directions for FP/RH • Inform the direction of family planning in the post–Millennium Development Goal period • Provide input on resource mobilization for service delivery, human resource development, and facility expansion • Reinforce existing policy implementation in support of a shift towards LAPMs • Show the impact of family planning on other health programs and health goals • Explore opportunities for additional partner involvement in expanding LAPMs service provision • Provide advocates with information to engage religious institutions and faith-based organizations (FBOs) on FP/RH • Provide a foundation for additional research on FP/RH • Inform efforts to integrate family planning, antenatal care (ANC), prenatal care (PNC), prevention of mother-to-child transmission, and delivery services How to Achieve the MCH Goals in Amhara With the ImpactNow results in mind, participants discussed how to achieve the MCH goals in Amhara. The group indicated that the MCH goals could largely be met by reaching the FP goals: a reduction in the number of unintended and high-risk pregnancies would result in improved maternal and child health. Participants also stated that the likelihood of achieving the MCH goals would increase if family planning, PNC, ANC, delivery, and childcare services were scaled up and integrated with other health services. Therefore, to achieve a 73 percent CPR by 2020 (the high progress scenario), participants recommended that stakeholders, both in Amhara and nationally, take the following actions: • Increase stakeholder (government and nongovernment) and intersectoral collaboration • Use the regional Population Affairs Council as a source of population data • Align regional- and national-level policy objectives and increase FP advocacy • Establish more bilateral and multilateral partnerships Discussion 7 • Involve partners in achieving regional MCH goals • Ensure the availability of all methods/choices of contraceptive commodities at all levels of the health system • Strengthen human resources for health training (e.g., the Bahir Dar and Gondar universities are interested in integrating ImpactNow and other HPP tools into their MPH/RH specialty curricula) • Ensure that FP services meet the needs of the large youth population • Engage existing community-based organizations, such as the Women’s Development Army, the Health Development Army, and Youth League, in advocacy and community mobilization activities • Increase resource mobilization and advocacy to maintain and continue progress in FP/RH • Monitor and evaluate all programs both regionally and nationally • Organize joint meetings to review progress, document achievements, and address challenges • Increase the uptake of LAPMs • Train, coach, and monitor health extension workers to provide different FP methods • Integrate FP services with other health services • Strengthen referral systems • Improve integrated management of maternal, neonatal, and child illness; immunization; and maternal and child nutrition • Improve service delivery standards Panel Discussion The panel discussion was chaired by Dr. Teodros, FMOH/MNCH Directorate Director; Dr. Kurabachew, Futures Group Country Director; and Ali Geneyehu, RHB Deputy Bureau Head. All participants agreed that ImpactNow generates key information for evidence-based decision making, as well as for planning and monitoring the progress of FP and MCH services. The group committed to achieving the high progress scenario and made the following key points: Revision of the method mix targets: With vast experience in the field of FP and MNCH, Dr. Teodros Bekele recommended increasing targets for LAPMs to approximately 75–80 percent for further analysis. He then went on to say that the FMOH has already begun expanding the method mix in hospitals and selected health centers in Ethiopia and is working to offer long-acting methods (implants and IUDs) to 20 percent of all FP clients. In line with rights-based voluntary family planning principles, Dr. Teodros added that the FMOH would advise service delivery points to include oral contraceptive pills and condoms in the method mix targets. Raising the awareness of condoms as a viable FP method could help to engage men in FP decision making and improve partner involvement. FP advocacy strategy: All concerned organizations should use this opportunity to develop FP advocacy strategies, approaches, and methods that enable individuals, families, groups, organizations, and communities to play an active role in achieving and sustaining their own proper healthcare systems. Such FP promotion could help us to approach and engage FBOs and others that use family planning to save the lives of mothers and children. The advocacy process at the community and household levels needs to empower people to make decisions, modify behaviors, and change social conditions at large. FP promotion activities need to be developed based on needs assessments, sound educational and rights- based principles, and periodic evaluation. They should be developed using a clear set of goals and ImpactNow: Identifying the Near-Term Benefits of Family Planning Investment in the Amhara Region 8 objectives, with the aim of shifting from short-term to long-acting methods through the process of educating, persuading, and disseminating information to people to positively influence their behavior. FP service expansion: To expand FP service provision at the regional level, Ethiopia has already formulated a national FP strategy that prioritizes family planning throughout the health system. It states that all health institutions in Ethiopia—rural and urban and public and private hospitals, health centers, and health posts—shall provide FP services. FP services are delivered through the following modalities: community-based services through health extension workers, facility-based services, social marketing, and outreach services. In this respect, the government has recognized the role of LAPMs and is scaling up the provision of implants and IUDs to reach 20 percent. The government will continue to monitor the scale-up of LAPMs and train health workers to provide a range of methods and proper counselling. Institutional capacity building: HPP technical support and institutional capacity building should concentrate on the transfer of skills, responsibilities, and ownership to regional and national partners, including research institutions and universities focused the application of ImpactNow and other HPP tools. HPP also needs to further disseminate the ImpactNow results through policy briefs and a broader dissemination plan. 9 NEXT STEPS The workshop helped to identify the following key priority issues for follow-up and action by the respective organizations: • Strengthen FP advocacy and create a behavior change and communication plan that targets policymakers, service providers, and communities to facilitate a shift from short-term to long- acting FP methods (RHB) • Further disseminate the ImpactNow results through new program/policy briefs and a broader dissemination plan, and build the capacity of local institutions to use ImpactNow and other HPP tools (HPP) • Build the capacity of health workers to provide LAPMs and strengthen and/or improve the FP commodity and supply chain-management system (RHB) • Increase the availability of permanent contraceptive methods at health centers and involve the private sector and NGOs in efforts to reach the method mix targets (Partners & RHB) • Improve the quality of data from the Health Information Management System, and conduct operational research to evaluate the effectiveness and equity of current FP/RH-related strategies (RHB) 10 ANNEX 1: WORKSHOP AGENDA Session Presenter/Moderator Registration Ato Teklehamanot Mulualem, HPP Opening and Key Note Speeches Ato Ali Gebeyehu, Deputy Bureau Head, RHB Dr. Tewodros Bekele, MCH Director, FMOH Ato Desalegn Akal, Population Affairs, BOFED Kurabachew Abera, HPP Linda Cahaelen, USAID

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