1. Gender, Health and Poverty: Critical Factors Beyond the Health Sector Arlette Campbell White World Bank Institute

2. What is needed? Understanding that:  Reproductive health outcomes are affected by risk factors at many levels, including the health sector and beyond  These factors may worsen or help to improve RH outcomes.

3. Objectives of this session  Consider how community and societal forces, e.g. gender attitudes and norms, affect RH outcomes  Identify actions to address these factors through policy change and program design  Track factors affecting a specific RH outcome (maternal survival) through a case example

4. Review: Pathways to RH Outcomes The “Pathways” framework helps us identify factors affecting risks and barriers to better RH outcomes at three levels: — households and communities — the health system and other sectors affecting RH outcomes — government policies and actions

5. Government policies & actions Health sys- tem & other sectors Pathways to Improved RH Outcomes RH out- comes RH outcomes Households/ Communities Household behaviors & risk factors Health service supply Health reforms Other parts of health system Supply in related sectors House- hold resources Community factors Actions in other sectors

6. Addressing factors outside the health system Let’s focus on the following parts of the Pathways framework:  forces at the community level  actions in other sectors that affect health outcomes  government policies and actions

7. Government policies & actions Health sys- tem & other sectors Pathways to Improved RH Outcomes RH out- comes RH outcomes Households/ Communities Household behaviors & risk factors Health service supply Health reforms Other parts of health system Supply in related sectors House- hold resources Community factors Actions in other sectors

8. Community Factors

9. Community Factors and Lower MMRs Lower MMR HNP outcomes Households/ Communities Household behaviors & risk factors House- hold resources Community factors Community factors: Gender norms and practices Existence of effective community groups--social cohesion Community access to pubic services (inside and outside health sector) Community factors: Gender norms and practices Existence of effective community groups--social cohesion Community access to pubic services (inside and outside health sector)

10. Maternal deaths HNP outcomes Households/ Communities Household behaviors & risk factors House- hold resources Community factors Community factors affecting risk of mothers dying during delivery: Distance from referral facility Availability of transport Tradition of delivering at home Community factors affecting risk of mothers dying during delivery: Distance from referral facility Availability of transport Tradition of delivering at home Community factors affecting maternal deaths

11. Risk factor: more home deliveries by poor women 35 32 96 98 81 83 92 93 96 69 73 78 62 0 20 40 60 80 100 120 Poorest 20% Second Middle Fourth Richest 20% Bangladesh Niger Uganda Percent Percent of deliveries at home

12. Factors that exacerbate risks  Obstetric emergencies are difficult to predict; when they occur during a home delivery, getting the mother to a hospital is critical.  Distance, poor roads and lack of ambulances or other means of transport delay management of life- threatening complications.  Problems are exacerbated for such difficult-to-anticipate complications as hemorrhage, which is usually fatal beyond 4 hours.

13. What measures might help to reduce MMR risks? In addition to training birth attendant how to manage risk factors: Risk pooling: community funds for emergencies Innovative approaches to transport and communications Community mobilization to respond to emergencies

14. Take-home messages  As in the case of households, the forces inside and outside the health system interact  Health-system interventions can take advantage of positive forces, for example strong social cohesion  They can also help mitigate some of the negative forces, e.g. gender bias

15. Supply in Other Sectors

16. The Pathways framework again: the health system and other sectors  Health care supply, including outreach, referral, curative care  Other health services, including drug supply and health education  Supply in other sectors, for example, education, social protection, water & sanitation, transport & communication

17. Health sys- tem & other sectors Let’s consider how: Lower MMRs RH outcomes Households/ Communities Household behaviors & risk factors Health service supply Other parts of health system Supply in related sectors House- hold resources Community factors Supply in related sectors affect MMRs: Schooling for girls Roads and vehicles Food availability Power supply, communications Supply in related sectors affect MMRs: Schooling for girls Roads and vehicles Food availability Power supply, communications

18. We know that educating girls can improve RH outcomes  Mothers’ education positively correlated with better RH outcomes: lower fertility, better nutrition, lower maternal mortality and morbidity.  Better educated mothers more likely to practice positive behaviors, avoid health risks.  Education empowers mothers to seek health care for themselves and their children.

19. The gender gap in education is greater for poor households

20. Better roads/transport can reduce delays that cause maternal deaths  In a Tanzania study, 63 percent of women who died after reaching a hospital had traveled 10 kilometers or more for treatment.  A study of maternal deaths in India showed that half of maternal deaths occurred before the woman reached a treatment facility; most had come by bus, rickshaw, bullock cart—only 9 percent by ambulance.  Generally, a high proportion of deaths in hospitals can be traced to arrivals that are too late for effective treatment.

21. Take-home messages  Supply in other sectors, particularly education and infrastructure, clearly impact on maternal health outcomes  These effects interact with forces at other levels (households, health system-- e.g. health & nutrition BCC)  A key challenge is to identify the most important synergies and remove obstacles to their effective action

22. Government Policies and Actions in Other Sectors

23. Pathways to HNP outcomes: policies in health & other sectors  Health reforms, including new financing and provision schemes  Actions in other sectors, including  Reforms leading to private provision of other public services (transport, power), and  Economic policies, for example tariffs on drugs, health goods

24. Government policies & actions Health sys- tem & other sectors Reminder: health policy matters RH out- comes RH outcomes Households/ Communities Household behaviors & risk factors Health service supply Health reforms Other parts of health system Supply in related sectors House- hold resources Community factors Actions in other sectors Health policy: Community funds, performance contracts Contracts with NGOs when government is less effective Appropriate treatment norms Health policy: Community funds, performance contracts Contracts with NGOs when government is less effective Appropriate treatment norms

25. Government policies & actions Health sys- tem & other sectors So does policy outside health sector RH out- comes RH outcomes Households/ Communities Household behaviors & risk factors Health service supply Health reforms Other parts of health system Supply in related sectors House- hold resources Community factors Actions in other sectors Actions in other sectors: Communications infrastructure, water and sanitation Macroeconomic policy (exchange rates, trade policy, etc.) Actions in other sectors: Communications infrastructure, water and sanitation Macroeconomic policy (exchange rates, trade policy, etc.)

26. How policies can affect efforts to reduce health risks for the poor  Tariffs and taxes on drugs and health- sector goods can push prices beyond the reach of the poor or limit the providers’ capacity to procure adequate supplies of commodities.  Public sector investments in infrastructure (roads and communication networks) may reduce the delays in managing emergencies that threaten poor women’s lives.

27. Case example: why did Safar Banu die?  Safar Banu, a 43 year old mother of 9 living in rural Bangladesh, died as a result of complications in delivering her 10 th child  Physicians attributed her death to anemia and edema  Using the Pathways framework, let us explore the factors that contributed to her death and changes which might save the lives of mothers like her