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  • Given the scarcity of resources available to implement the ICPD Programme of Action, this paper assesses effective interventions and their cost for three main components of reproductive health: family planning, safe motherhood, and STD/HIV/AIDS prevention and treatment. The paper also suggests some of the economic criteria governments can use to determine the role of the public sector in providing and/or financing reproductive health services. Family Planning Ensuring that individuals have access to a range of family planning methods and related information can help reduce unwanted pregnancy and thus maternal mortality. Promotion of condoms can help prevent the spread of sexually transmitted diseases (STDs). Family planning is most effectively provided through a range of channels, including clinics, community-based distribution, social marketing programs, and the private sector. Comparing the costs of service delivery approaches is problematic in that each channel tends to serve different clients. Contraceptive methods involve a range of costs; IUDs and sterilization tend to be the least expensive methods per couple-year of protection (CYP), although both have high "up-front" costs. The pill tends to be the least expensive supply method. Family planning, however, is most effective if a range of methods is available so that clients can select a method that matches their needs. One solution to the scarcity of resources may be for governments to subsidize all contraceptive methods for the poor and only lower cost methods for other groups and to require users to pay for the incremental cost of more expensive methods. Safe Motherhood An estimated 40 percent of pregnant women develop complications that require the assistance of a trained provider; 15 percent require medical care to avoid death or disability. Good prenatal care is important; given current screening tools, however, it is not prudent to spend resources on screening as the sole mechanism for predicting women's risk of developing complications. Instead, prenatal care should, among other activities, educate all women about danger signs, possible complications, and where to seek help. Micronutrient supplementation, including vitamin A, iron, folic acid, zinc, and calcium, show promising results in helping to improve pregnancy outcomes and reduce maternal mortality. The most crucial interventions for safe motherhood are to ensure that a health worker with midwifery skills is present at every birth, that transportation is available in case of emergency, and that quality and timely emergency care is available at the referral level. It is not only important that adequate access to emergency care be available but that women, families, and the community have confidence in the referral system and higher levels of care. Communities use emergency obstetric care services that they know to be functioning well. Nearly two-thirds of maternal deaths occur in the postpartum period; therefore, the World Health Organization (WHO) recommends that, if possible, community health workers visit women not attended at birth within 24 hours of delivery and again within three days. In many low-income countries, effective and safe postabortion care can significantly reduce maternal mortality rates by as much as one-fifth. Furthermore, such care can reduce overall health care costs as it is not uncommon for most beds in emergency gynecology wards to be occupied by women suffering from abortion complications, the treatment of which can cost five times the annual per capita health budget. The high cost of postabortion care can be reduced by switching from sharp curettage to manual vacuum aspiration (a safer and less expensive method), establishing referral systems and links with family planning and other reproductive health services, and preventing abortion through family planning. Substantial additional resources may not be required to improve emergency obstetric care. Most of the cost of providing such care is already paid through the maintenance of hospitals, health centers, and health care staff. Instead of creating new medical facilities and hiring new staff, emergency obstetric care can be improved by renovating existing facilities and training staff, including midwives and general practice physicians. STD/HIV/AIDS The best combination of STD/HIV/AIDS activities and services is general information and education, improved health-seeking behavior for STD treatment, wide access to condoms, and STD services with focused attention to core transmitters. WHO advocates the use of the syndromic management approach to managing STDs. This approach has limitations, however. It functions well for men with symptomatic urethral discharge and for women with genital ulcer disease, but not for women with vaginal discharge. The women who receive medical attention are often overtreated with drugs. More work is needed to develop cost-effective approaches to screening and treating reproductive tract infections. There are promising treatments to prevent mother-to-child transmission of HIV. Nevirapine has recently been shown to reduce transmission dramatically from mothers to infants at a fraction of the cost of treatment with Zidovudine (AZT) (US$4 compared with US$100), although universal HIV screening is not part of prenatal care in many developing countries and would raise the cost of prevention. Maternal syphilis diagnosis and treatment is also cost-effective. Blood screening for HIV/AIDS in high-prevalence areas has proven cost-effective. HAART (highly active antiretroviral therapy) for HIV/AIDS-infected individuals presently costs about US$8,000 to US$10,000 per person. Governments and donors will not be able to cover the cost of such treatment. In many developing countries, less than 1 percent of people living with AIDS will ever be treated, even if all reproductive health donor funds were allocated for that purpose. Information, Education, and Communication (IEC) and Behavior Change Communication (BCC) IEC and BCC have the potential to be highly effective in helping promote good reproductive health. Properly executed, IEC and BCC can encourage individuals to take preventive measures to protect their reproductive health as well as seek appropriate reproductive health services. IEC and BCC activities warrant government support if they convey appropriate messages to target audiences and are associated with services already in place. In the absence of these conditions, IEC and BCC activities are not only ineffective but also give rise to unsatisfied demand. Some Economic Criteria for Governments to Use in Deciding Whether They Will Provide and/or Fund Services From an economic standpoint, governments should intervene in reproductive health care if intervention increases efficiency and productivity in the health sector. Governments should redistribute resources to ensure equitable access to reproductive health services by all individuals. Governments should subsidize activities with large external or social benefits that go beyond the individual. Governments must regulate all sectors to ensure high-quality care and equitable access to reproductive health services. Government services are rarely more efficient than private sector services. Governments should encourage development of the private sector and provide subsidies to the poor so that they can afford needed services. To encourage development of the private sector, governments should provide similar subsidies to all providers (rather than only to government providers) either directly or through income transfers to individuals so that consumers can choose their own provider, thereby spurring competition and, it is hoped, better quality services for all. Governments should not provide subsidies to those able to pay for reproductive health services. Growing evidence suggests that some users, particularly in middle-income countries, can pay for family planning, maternal health, and postabortion care services. After reviewing implementation of the ICPD Programme of Action, the international community has reached consensus that certain basic services should be provided at the primary health care level and subsidized for those who cannot afford to pay for them. In low-income countries, where most individuals are too poor to pay for services, evidence suggests that it would be desirable for governments to subsidize family planning services, prenatal care that includes physical examinations, postpartum provision of family planning information and services, and postabortion services. In addition, skilled attendance at delivery and a functioning referral system and emergency care are essential to reduce maternal mortality. As for STD/HIV/AIDS, resources should be focused on prevention activities such as promotion and distribution of condoms to prevent STDs, STD treatment for high-risk groups, improved health-seeking behavior for STD treatment, and maternal syphilis treatment. Where HIV screening is part of prenatal care, provision of Nevirapine or AZT for infants of HIV-positive mothers may be feasible. While governments should strive to ensure that their citizens have access to reproductive health services as agreed at the ICPD and ICPD+5, policymakers will have to begin with a narrower set of interventions consistent with current resource and capacity levels and decide how to phase in additional services as resources become available. It is clear that a substantial amount of work on costing interventions and services and measuring their effectiveness is necessary before we can say, with greater assurance, what combination of services works at the most reasonable cost. Data collected in one country or service delivery setting may not apply in others, and further research is needed. Still, while the data are not comprehensive or perfect, policymakers and others can use the information at hand to help make difficult decisions, especially on what to provide to low-income clients through public sector facilities or financing.