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Public Disclosure Authorized BETTER REPRODUCTIVE HEALTH FOR POOR WOMEN IN SOUTH ASIA Public Disclosure Authorized Public Disclosure Authorized Report of the South Asia Region Public Disclosure Authorized Analytical and Advisory Activity MAY 2007 Authors Meera Chatterjee Ruth Levine Shreelata Rao-Seshadri Nirmala Murthy Team Meera Chattejee (Team Leader) Ruth Levine (Adviser) Bina Valaydon (Bangladesh) Farial Mahmud (Bangladesh) Tirtha Rana (Nepal) Shahnaz Kazi (Pakistan) Kumari Navaratne (Sri Lanka) G. Srihari (Program Assistant) Research Analysts Pranita Achyut P.N. Rajna Ruhi Saith Anabela Abreu: Sector Manager, SASHD Julian Schweitzer: Sector Director, SASHD Praful Patel: Vice President, South Asia Region Consultants Bangladesh International Center for Diarrheal Disease Research, Bangladesh Data International, Bangladesh India Indicus Analytics, New Delhi Foundation for Research in Health Systems, Bangalore Nepal New Era, Kathmandu Maureen Dar Iang, Kathmandu Pakistan Population Council, Pakistan Sri Lanka Medistat, Colombo Institute for Participation in Development, Colombo Institute of Policy Studies, Sri Lanka This study and report were financed by a grant from the Bank-Netherlands Partnership Program (BNPP) BETTER REPRODUCTIVE HEALTH FOR POOR WOMEN IN SOUTH ASIA CONTENTS ACRONYMSAND ABBREVIATIONS .................................................................................. V Chapter 1. Reproductive Health in South Asia: Poor and Unequal... 1 WHY FOCUS ON REPRODUCTIVE HEALTH INSOUTH ASIA? ........................ 2 HOW THIS REVIEW WAS DONE ........................................................................ 3 THE SOUTH ASIAN CONTEXT ........................ ... .............................................. 5 ADOLESCENT REPRODUCTIVE HEALTH ................... .. .................................... 7 SEXUALLY-ACTIVE ADULTS .......................... .. ............................................. 11 THE MATERNAL STAGE.................................................................................... 16 OLDER WOMEN'S HEALTH................................................................................. 22 IMPROVING REPRODUCTIVE OUTCOMES .................. .. ................................... 22 Chapter 2. Reproductive Health Services: Inadequate and Unused. 25 2.1 UNDERSTANDING USE OF HEALTH CARE ................... .... ............................. 26 2.2 USE OF REPRODUCTIVE HEALTH SERVICES..................................................... 27 2.3 REPRODUCTIVE HEALTH SERVICE SYSTEMS................. .. .............................. 34 2.4 INCREASING USE OF SERVICES....................... .. ............................................ 41 Chapter 3 . Planning and Practicing Better Reproductive Health 45 3.1 DECENTRALIZATION TO BRIDGE INEQUALITIES ........................... ............. 46 3.2 DECENTRALIZED ACTION PLANNING ............................................................. 47 3.3 PROMISING GLOBAL PRACTICES..................................................................... 50 3.4 MOVING FORWARD INSOUTH ASIA ............................................................... 62 Chapter 4 . Financing Reproductive Health for Poor Women ...........65 4.1 THE POLICY CONTEXT.................. .... .......................................................... 66 4.2 RESOURCE MOBILIZATION FOR REPRODUCTIVE HEALTH .............................. 66 4.3 RESOURCE ALLOCATIONS WITHIN REPRODUCTIVE HEALTH.................... .. .... 70 4.4 IMPROVING REPRODUCTIVE HEALTH FINANCING............ ...... .................... 74 Chapter 5. Improving Poor Women's Reproductive Health............. 83 5.1 WHAT NEEDS TO BE DONE AND HOW.............................................................. 84 5.2 REFORMS THAT COUNT FOR REPRODUCTIVE HEALTH............. .. ................. 93 5.3 OTHERS MATTERS ARISING ............................................................................. 99 DEFINITIONS ................................................................................................................ 101 BACKGROUND REPORTS ..................................................................................................... 105 REFERENCES..................................................................................................................... 107 POVERTY AND REPRODUCTIVE HEALTH STUDY METHODOLOGY TABLES ON REPRODUCTIVE HEALTH STATUS THE ESSENTIAL PACKAGE OF REPRODUCTIVE HEALTH SERVICES TABLES ON USE OF REPRODUCTIVE HEALTH SERVICES PUBLIC HEALTH SYSTEMS INSOUTH ASIA EXAMPLES OF PROMISING PRACTICES FOR SOUTH ASIA TABLES ON REPRODUCTIVE HEALTH EXPENDITURES POLICIES RELATED TO REPRODUCTIVE HEALTH KEY ACTIONS TO IMPROVE REPRODUCTIVE HEALTH HEALTH SECTOR REFORMS RELATED TO REPRODUCTIVE HEALTH Acronyms and Abbreviations ADB Asian Development Bank AIDS Acquired Immuno-deficiency Syndrome AM0 Assistant Medical Officer ANC Antenatal Care ANM Auxiliary Nurse Midwife ARI Acute Respiratory Infection ASFR Age-specific Fertility Rate ASHA Accredited Social Health Activist AYUSH Ayurveda, Yoga, Unani, Siddha and Homeopathy (Indian medical systems) BBS Bangladesh Bureau of Statistics BCC Behavior Change Communication BD Bangladesh BDHS Bangladesh Demographic Health Survey BEmOC Basic Emergency Obstetric Care BHU Basic Health Unit BINP Bangladesh Integrated Nutrition Program BMI Body Mass Index BMMS Bangladesh Maternal Health Services and Maternal Mortality Survey BNNP Bangladesh National Nutrition Program BSPAS Bangladesh Service Provision Assessment Survey CAC Comprehensive Abortion Care CBFPT Clinic-based Family Planning Project CDP Community Drug Program CEmOC Comprehensive Emergency Obstetric Care CHC Community Health Center CIET Canadian Institute of Education and Training CMH Commission on Macro-economics and Health CM R Child Mortality Rate CNA Community Needs Assessment CPR Contraceptive Prevalence Rate (earlier Couple Protection Rate) CREHPA Center for Research on Environment, Health and Population Activities CSSM Child Survival and Safe Motherhood CSW Commercial Sex Worker D&C Dilatation and Curettage DAP Decentralized Action Planning DCPP Disease Control Priorities Project DCS Department of Census and Statistics (Bangladesh) DGFP Directorate General of Family Planning DGHS Directorate General of Health Services DHAP District Health Action Planning DHM District Health Mission DHS Directorate of Health Services DHS Demographic and Health Survey DHS Department of Health Services ED0 Executive District Officer EmOC Emergency Obstetric Care EOC Essential Obstetric Care EPI Expanded Program of Immunization ESP Essential Services Package FP Family Planning FCHV Female Community Health Volunteer FFPAM Federation of Family Planning Associations of Malaysia FG D Focus Group Discussion FH B Family Health Bureau FHD Family Health Division FP Family Planning FPAN Family Planning Association of Nepal FPASL Family Planning Association of Sri Lanka FPI Family Planning Inspector FPW Family Planning Worker FRU First Referral Unit FWA Family Welfare Assistant FWC Family Welfare Center FWV Family Welfare Visitor GDP Gross Domestic Product GOB Government of Bangladesh GO1 Government of India GON Government of Nepal GOP Government of Pakistan GOSL Government of Sri Lanka GOTN Government of Tamil Nadu GTZ Gesellschaft fur Technische Zusammenarbeit (German Agency for Technical Cooperation) HA Health Assistant HIV Human Immuno-deficiency Virus HLSP Health and Life Sciences Program HPSP Health and Population Sector Program ICDS Integrated Child Development Services' Program ICPD International Conference on Population and Development IDU Injecting Drug User IEC Information, Education and Communication IFA Iron Folic Acid IIPS International Institute of Population Sciences (India) IMR Infant Mortality Rate IN India IPS Institute of Policy Studies (Sri Lanka) IUCD Intra-Uterine Contraceptive Device IUD Intra-Uterine Device LBW Low Birth Weight LHV Lady Health Visitor LH W Lady Health Worker LHWP Lady Health Worker Program LLP Local Level Planning MAM Median Age at Marriage MAQ Measuring Access and Quality MCH Maternal and Child Health MDG Millennium Development Goal MICS Multiple Indicator Cluster Survey MMR Maternal Mortality Ratio M0 Medical Officer MOH Ministry of Health MOHFW Ministry of Health and Family Welfare MOHP Ministry of Health and Population MOPW Ministry of Population Welfare MPA Maternal and Perinatal Audit MPHW Multi-Purpose Health Worker MR Menstrual Regulation MSM Men who have Sex with Men MSU Mobile Service Unit MTP Medical Termination of Pregnancy MVA Manual Vacuum Aspiration NACO National AIDS Control Organization (India) NACP National AIDS Control Program (India) NAFCI National Adolescent-Friendly Clinic Initiative NFHS National Family Health Survey (India) NGO Non-Governmental Organization NHA National Health Accounts NIPORT National Institute of Population Research and Training (Bangladesh) NIPS National Institute of Population Studies (Pakistan) NNMR Neonatal Mortality Rate NP Nepal NPS National Planning Secretariat (Nepal) NRHM National Rural Health Mission (India) NSACP National Sexually-Transmitted Diseases and AIDS Control Program (SriLanka) NSS National Sample Survey (India) NSV Non-Scalpel Vasectomy OC Oral Contraceptives OPD Out Patient Department 0 R Odds Ratio PAC Post Abortion Care PC Population Council PDHS Provincial Director of Health Services PFLEU Population and Family Life Education Unit PHC Primary Health Center PHI Public Health Inspector PHM Public Health Midwife PHNS Public 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