UN Population Division, Department of Economic and Social Affairs,
with support from the UN Population Fund (UNFPA)
|
| UN Population Division, Department of Economic and Social Affairs, with support from the UN Population Fund (UNFPA) |
|
|~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~|
| |
| POPULATION NETWORK NEWS |
| |
| A Forum for the World Bank Population Community |
| No. 4, July 1993 |
| |
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PHN FY93 Population Lending
============================
While further verification is still to come, preliminary
calculations estimate that of twenty-five PHN projects
approved by the Board in FY93, fifteen support family
planning and population activities, to the tune of about
$170 million in lending and $320 million in total project
costs. This sum represents an increase of about $65
million over the FY92 lending figure.
Of these projects, only one - the Papua New Guinea
Population Project - is a stand-alone population project.
The rest support family planning activities through
integrated health and social development projects. One,
the India Social Safety Nets project, is a sector
adjustment credit, which means that disbursement is tied
to achievement of specific policy goals, not specific
investments. Brief descriptions of those projects that
were not covered in previous editions of PNN are
included below.
On a regional level, the FY93 portfolio holds some
surprises. The Middle East and North Africa region,
which has historically done very little in the population
field, received almost 40 percent of the Bank lending for
population, with projects approved in Iran, Jordan, and
Yemen (see chart opposite). Another unlikely candidate,
Latin America and the Caribbean, led the pack in the
number of projects that included population - four of the
fifteen approved were in LAC. Three such projects were
approved in each of Africa, East Asia, and MNA; two in
South Asia; and none in ECA.
Population-Related Bank Projects Approved in FY93
=================================================
The Philippines Urban Health and Nutrition project will
address poverty in slum areas by focusing on service
delivery in health and nutrition, including family
planning. The project seeks to build the capacity of
local governments to manage services and to support
community mobilization through grants to local NGOs
and other fora designed to bring community views into
the planning and service delivery process. A policy
research and evaluation component will support
operations research studies to test and evaluate the
progress of alternative delivery models. The project
will also finance provision of contraceptives.
Yemen Family Health. One of the major goals of this
project is to help the government implement the national
population policy. Focusing on rural areas, the project
will strengthen both lower-level primary health clinics
and district level hospitals that serve as referral facilities.
In addition, pilot activities will evaluate alternative ways
to improve services in very remote areas through the use
of mobile teams and/or promotion of community
involvement in health care.
Colombia Municipal Health. This project seeks to
further the decentralization process currently underway
in the health sector by supporting institutional
development and delivery of primary health care at the
municipal level. The project will finance sub-projects
developed by municipal health authorities and targeted at
providing a basic package of services for all ages. One
element of this package is maternal and infant care,
including family planning.
Angola First Health. Following a protracted civil war,
Angola is now seeking to rehabilitate and expand its
health care services. While the bulk of this project will
focus on rehabilitation of clinics and training institutions
and strengthening of capacities in health sector policy
and management, it will also finance studies to determine
the future of program efforts in the areas of family
planning and AIDS prevention. These studies may be
used in preparation of a second health project.
The Burundi Social Action program represents an
integrated approach to poverty alleviation through the
financing of sub-projects in priority areas. The activities
to be financed include income-generation schemes;
rehabilitation of basic social infrastructure (e.g., schools
and health clinics); enhancement of physical
infrastructure; promotion of family planning, literacy,
and food supplementation; and development of local
NGOs. The social action program will be accompanied
by a poverty monitoring component.
Guinea Bissau Social Sector. Through the Social
Action Fund, the project will allow NGOs to compete
for funds and provide a variety of services, including
family planning, to the grass-roots level. The Fund
will be complemented by activities designed to improve
public health services through training, IEC campaigns,
and health facilities improvements.
Building on the experience of other social investment
funds in Latin America, the Guatemala Social Investment
Fund will allow the government to finance activities,
including family planning and reproductive health
services, in poor communities. By relying on sub-
projects, the government can support poverty alleviation
efforts identified by the communities themselves.
Other FY93 projects are described in previous editions of
PNN. They include:
..Iran - Primary Health Care and Family Planning
..Pakistan - Second Family Health Project
..Papua New Guinea - Population and Family Planning
..Ecuador - Second Social Development Project
..Indonesia - Third Community Health and Nutrition
..Jordan - Health Management
..Honduras - Nutrition and Health
PHN Projects in FY92: Summary Report
======================================
For those still wondering what happened in FY92, the
PHN Department just published Population, Health, and
Nutrition, Annual Operational Review for Fiscal 1992.
This publication reviews the PHN projects approved in
FY92, noting trends and providing historical data on
lending in the subsectors of population, health, and
nutrition. In addition to summary information on
lending, the FY92 review includes chapters on evaluating
PHN's contribution to the Bank's poverty alleviation
objective and determining the quality of PHN projects.
The annexes provide useful statistics PHN lending and
its subsectoral components, including cofinancing and
integrated social sector approaches.
Development Report 1993: Family Planning is an Essential Service
================================================================
Family planning information and contraceptive services
figure prominently in the package of essential health
interventions recommended by the 1993 World
Development Report. The emphasis on family planning
is due to the significant effects it can have the health of
women and children. According to WDR estimates,
"satisfying the expressed wish of women to space or to
limit future births might each year avert as many as
145,000 maternal deaths and 180,000 deaths among
children under five." These benefits can also be
achieved at relatively low costs, making them attractive
investments in improving health.
In addition, the WDR considers abortion to be
important as a back-up to contraception.
"Contraceptive use is the best way to avoid unwanted
pregnancies, but it is not foolproof. For women who
wish to terminate their pregnancies, access to safe
abortion as a complement to contraceptive services is
a health matter." This position results from the
increasing evidence of the severe toll unsafe and illegal
abortion takes on women's lives each year (see related
story on the safe motherhood guidelines, p. 6). Other
elements of the essential package of public health and
clinical services include immunizations and sick child
management; health and nutrition information,
including school health; tobacco and alcohol control;
vector control for communicable diseases; STD
treatment and prevention, including AIDS; treatment of
infection and minor trauma; and general assessment,
advice and pain alleviation.
How did the WDR team decide on the composition of
the essential package of health services?
Building on the truism that good health is a primary
input into the development process, the 1993 WDR set
out to determine the best role for the public sector and
the best use of limited health care dollars. The first
step in this process is determining the relative
contribution of various diseases to the global burden of
disease by calculating the "disability-adjusted life
years" (DALYs) taken away by each one. The second
step is to estimate the costs associated with preventing
or treating each disease and the effectiveness of those
interventions. By combining the two, one can calculate
the number of "DALYs" gained per dollar of
intervention, a measure of cost-effectiveness.
Family planning services delivered through a community-
based distribution scheme can have a cost per DALY
gained as low as $5, as calculated for Mali. In other
countries with lower rates of fertility and mortality, costs
will be higher. But even in middle-income countries
such as Colombia or Thailand, such programs have been
estimated to cost as little as $25 per DALY gained. In
comparison, the most cost-effective intervention, Vitamin
A supplementation, costs $1 per DALY saved.
By considering the most cost-effective interventions, a
package of essential services can be defined, and its
costs estimated. Recognizing that costs will depend on
individual settings due to differences in the price of local
inputs and other factors, the WDR estimates the cost of
the recommended package of essential services for both
low- and middle-income countries.
The WDR 1993 is available at the World Bank Bookstore.
Reproductive Health in the Americas
===================================
Noting that the "region of the Americas provides a
unique assortment or even a microcosm of the prevailing
reproductive patterns in the world as a whole," PAHO
recently published a comprehensive book on reproductive
health in the region. Two facets of reproductive health
that receive special attention in the report are adolescent
pregnancies and abortion. Adolescent pregnancy is seen
as a "priority" issue, given the extent of the problem--in
Latin America, over 3.3 million children are born to teen
mothers each year--and the social and health
consequences of adolescent pregnancy for the mother and
the child. On abortion, the report acknowledges the
extent and consequences of illegal abortion in the region,
where only Cuba allows abortion on request.
For more information, see Reproductive Health in the
Americas, edited by Abdel R. Omran, et. al.
WHO's Human Reproduction Program Meets
======================================
The WHO's Special Programme of Research,
Development and Research Training in Human
Reproduction (HRP) held its annual Policy and
Coordination Committee (PCC) meeting in Geneva
from June 23-25. The Bank is a sponsor and major
contributor to the program, which plays an important
role in the development and introduction of new contra-
ceptive methods. This was the sixth meeting of PCC
and the first under the leadership of HRP's new
Director, Dr. Giuseppe Benagiano.
Members of the PCC reviewed HRP's progress over the
past year in such areas as the development of post-
ovulatory methods and vaccines for fertility regulation
and discussed HRP's proposed budget for 1994-1995.
Findings were presented from a review of HRP's social
science research on fertility regulation, along with a
detailed presentation on approaches to the introduction
of contraceptives that addressed issues of program
quality and reproductive health concerns. The PCC
requested that WHO review its overall approach to
reproductive health and report the implications of this
review for its special programmes (HRP, Family
Health, Global Programme on AIDS).
International Conference on Population and Development (ICPD)
============================================================
The Second Preparatory Committee of the ICPD 1994,
commonly referred to as PrepCom II, was held from
May 10-21 in New York. The event, attended by
representatives of 160 governments and over 400 NGOs,
marked the end of the series of expert group and regional
meetings.
The PrepCom participants, including Tom Merrick,
reviewed the recommendations of the previous meetings
and debated the proposed conceptual framework for the
final document to be considered at the Cairo conference
next September. This document is meant to provide a
new plan of action for addressing population issues in
their proper development perspective, embracing the
Conference theme of population, sustained economic
growth, and sustainable development.
The PrepCom began on a contentious note, witnessing an
initial confrontation between women's health advocates
led by the International Women's Health Coalition, and
the Chair of the PrepCom, Fred Sai (former Population
Adviser at the Bank), over the relative weight that should
be given to women's health concerns versus other
elements of the population question. Other hotly debated
issues included the place of environmental issues and the
imperative of reconciling individual rights and
responsibilities with societal-level goals and
interventions.
Over the course of the PrepCom, however, the
participants coalesced around a document structure that
balances the many issues involved in addressing
population in the context of development. The document
outline ultimately approved includes a set of principles
to be laid out up front, and fifteen specific chapters of
recommendations divided into four thematic groupings:
Choices and Responsibilities, Means of Implementation,
Partnership in Population - Actors and Resources, and
From Commitment to Action. Staff at the United
Nations will be responsible for drafting the document,
with significant peer review.
The next official meeting in the lead-up to the
Conference is PrepCom III (to be held in New York
from 11-22 April, 1994), to evaluate the status of
preparations for the Cairo conference.
Safe Motherhood Guidelines
==========================
Developing country governments and donor agencies rely
on indicators to determine priorities and allocate
resources. Of all the human development indicators
measured, the one which shows the greatest disparity
between developed and developing countries is the
maternal mortality ratio (MMR, defined as the number of
pregnancy-related deaths to women per 100,000 live
births). The gap between North and South can reach a
magnitude of 200 times when the industrialized countries
are compared to parts of Africa or South Asia. In total,
an estimated 500,000 developing country women die
each year from causes related to pregnancy and child
birth.
To assist Bank staff, governments, and other agencies to
lower the toll of maternal mortality, the Safe Motherhood
Initiative recently published Making Motherhood Safe,
also known as the safe motherhood guidelines.
The guidelines provide a practical outline of the essential
elements of a safe motherhood program, which include
activities to prevent maternal morbidity and mortality,
recognize and treat complications as they arise, and
promote the health of women and their newborn
children.
Recognizing the vast differences in conditions
throughout the developing world, the guidelines make
recommendations tailored to meet the needs of
countries at three different stages of development, as
determined by the level of health care and social
benefits available to women.
Among other messages, the guidelines stress that
women need a continuum of care to provide routine
services and detect and treat complications. The
necessary range of services includes basic family
planning and maternal care at the community level,
access (including transport) to a well-equipped health
center for clinical methods of family planning,
treatment of complications, and referral (including
transport) to a hospital or other large health center for
care of obstetric emergencies.
Anne Tinker, coauthor of the paper, had this to say
about the goals of the guidelines: "We hope that the
paper will serve as a practical tool for policy dialogue,
sector work, and project preparation in maternal health
and family planning. With accelerated action at the
field level, women will no longer need to risk death to
give life."
Contraceptive News
==================
*The Population Council has received a license from
Roussel-Uclaf to develop the capability and seek
approval to produce and sell RU 486 in the United
States. The Population Council will locate a
manufacturer and shepherd the drug through the U.S.
Food and Drug Administration approval process. If all
goes well, the drug should be available within two years.
(The New York Times, April 21, 1993).
*On June 17, 1993 the U.S. Food and Drug
Administration approved an extension of the shelf life
of the Copper T 380A IUD from four to seven years.
The extension also applies to an earlier model, Copper
T 200B. Both models have been and are distributed
for public sector use in developing countries
(Population Council news release, July 14, 1993).
*The U.S. FDA is now considering a "chemical
vasectomy" for use by veterinarians. The technique
consists of a non-invasive zinc injection which leads to
permanent sterilization without affecting hormone
levels or sex drive. The technique, developed by Dr.
Mostasa Fahim at the University of Missouri, may
eventually be modified for use by humans (Open File,
May 1993).
Demographic and Health Survey Results: Madagascar
=================================================
The national population policy of Madagascar seeks to
reduce its TFR from its current level of 6.1 to 4.0 by
the year 2000. The preliminary report of the 1992
DHS indicates that achieving that goal may be quite
difficult given the low level of contraceptive use and
knowledge in the country. The contraceptive
prevalence rate for all women is 3.7 percent for modern
methods and 13.8 percent for any method. Knowledge
of methods is substantially higher, with 62.4 percent of
women knowing of at least one method (modern or
traditional), but only 45.8 percent knowing where to
obtain it.
One of the most important predictors of contraceptive
use and fertility in Madagascar is place of residence.
In the capital of Malagasy, the TFR is 3.2, while in
rural areas it is more than twice as high at 6.7. The
TFR for all urban areas is 3.8. Similarly, use of any
contraceptive is 51.1 percent in the capital (20.9
percent for modern methods) and only 11.9 percent in
rural areas (2.9 percent for modern methods).
Approximately 80 percent of the population lives in
rural areas, resulting in a high TFR for the country as
a whole.
The State of World Population 1993--The Individual and the World:
Population, Migration and Development in the 1990s
=================================================================
UNFPA's 1993 report on the state of world population
takes as its theme migration, both internal and
international. After a review of the global trends and
patterns of migration, the report looks at the costs and
benefits of migration for migrants themselves, sending
countries, and receiving countries. The rights and
responsibilities of all affected groups are also explored as
essential considerations in the definition of appropriate
migration policies.
To elucidate the effects of specific policies on migration
trends, the report focuses on the individual. From this
optic, migration patterns are seen to be a collective
expression of millions of individual and family decisions
made for economic, social and political reasons, including
some forced to seek asylum.
Through this lens, the report perceives the real impact
and potential of development policies to shape migration
patterns to be exercised through their effects on
individual abilities and opportunities. To influence
migration decisions, policies must be focused on the
"individual dimension of development," including special
attention to women's issues. "The individual woman and
man is both the object and the agent of every effective
development program: strengthening their capacity and
widening their range of choice is the best guarantee of
balanced, sustainable development."
Programs that would have such an effect include
provision of social services, including education, health
care and family planning; attention to infrastructure and
services to the poor in rural areas, combined with
fostering of medium-sized cities and rural development;
and examination of the impact of the economic, trade,
and development policies of industrialized countries on
the migration decisions of individuals in developing
countries.
Adolescent Fertility: Recent Reports
====================================
The last few years have witnessed a growing
recognition of the extent and consequences of increases
in adolescent sexual activity around the globe. The
reason for concern and action in providing services to
teens was also acknowledged in the WDR: "special
efforts are appropriate to address the needs of
adolescents, both because they tend to be poorly
informed about reproductive health risks and because
they often misjudge the consequences of early
childbearing." Many NGOs, advocacy, and research
groups have focused their attention on this age group,
as noted in the following publications:
*Youth for Youth, a program coordinated by IPPF,
and funded by UNFPA, with technical assistance from
WHO. The project, which has the ultimate goal of
bringing "together young people and other interested
groups and individuals to work towards improving the
reproductive health of adolescents," is currently being
implemented in Senegal, Jamaica, Sri Lanka, Egypt,
Colombia, and Sierra Leone. A report on activities has
just been published (Contact: IPPF).
*The Program Department and the Africa Regional
Office of IPPF have recently published reviews of pilot
youth programs conducted by affiliates in Ethiopia and
Kenya (Contact: IPPF).
*The Population Reference Bureau has produced two
publications providing a regional look at adolescent
fertility, one in Latin America and the Caribbean and
the other in Africa (Contact: PRB).
*The IPPF 1992-93 Annual Report includes a special
report on adolescent sexuality (Contact: IPPF).