RESUMO
Access to assisted reproductive technology (ART) and fertility preservation remains restricted in middle and low income countries. We sought to review the status of ART and fertility preservation in Brazil, considering social indicators and legislative issues that may hinder the universal access to these services. Although the Brazilian Constitution expressly provides the right to health, and ordinary law ensures the state is obliged to support family planning, access to services related to ART and fertility preservation is neither easy nor egalitarian in Brazil. Only a handful of public hospitals provide free ART, and their capacity far from meets demand. Health insurance does not cover ART, and the cost of private care is unaffordable to most people. Brazilian law supports, but does not command, the state provision of ART and fertility preservation to guarantee the right to family planning; therefore, the availability of state-funded treatments is still scarce, reinforcing social disparities. Economic projections suggest that including ART in the Brazilian health system is affordable and may actually become profitable to the state in the long term, not to mention the ethical imperative of recognizing infertility as a disease, with no reason to be excluded from a health system that claims to be 'universal'.
Assuntos
Preservação da Fertilidade , Acessibilidade aos Serviços de Saúde , Técnicas de Reprodução Assistida , Brasil , Serviços de Planejamento Familiar/economia , Serviços de Planejamento Familiar/ética , Serviços de Planejamento Familiar/legislação & jurisprudência , Feminino , Preservação da Fertilidade/ética , Preservação da Fertilidade/legislação & jurisprudência , Acessibilidade aos Serviços de Saúde/ética , Acessibilidade aos Serviços de Saúde/legislação & jurisprudência , Disparidades em Assistência à Saúde/ética , Disparidades em Assistência à Saúde/legislação & jurisprudência , Humanos , Recém-Nascido , Infertilidade/economia , Infertilidade/epidemiologia , Infertilidade/terapia , Masculino , Gravidez , Direitos Sexuais e Reprodutivos/ética , Direitos Sexuais e Reprodutivos/legislação & jurisprudência , Técnicas de Reprodução Assistida/economia , Técnicas de Reprodução Assistida/ética , Técnicas de Reprodução Assistida/legislação & jurisprudênciaRESUMO
The purpose of this study was to assess whether government policies to expand the coverage of maternal health and family planning (MHFP) services were benefiting the adolescents in need. To this end, we estimated government MHFP expenditure for 10- to 19-year-old adolescents without social security (SS) coverage between 2003 and 2015. We evaluated its evolution and distribution nationally and sub-nationally by level of marginalization, as well as its relationship with demand indicators. Using Jointpoint regressions, we estimated the average annual percent change (AAPC) nationally and among states. Expenditure for adolescents without SS coverage registered 15% for AAPC for the period 2003-2011 and was stable for the remaining years, with 88% of spending allocated to maternal health. Growth in MHFP expenditure reduced the ratio of spending by 13% among groups of states with greater/lesser marginalization; nonetheless, the poorest states continued to show the lowest levels of expenditure. Although adolescents without SS coverage benefited from greater MHFP expenditure as a consequence of health policies directed at achieving universal health coverage, gaps persisted in its distribution among states, since those with similar demand indicators exhibited different levels of expenditure. Further actions are required to improve resource allocation to disadvantaged states and to reinforce the use of FP services by adolescents.
Assuntos
Serviços de Planejamento Familiar/economia , Financiamento Governamental , Gastos em Saúde , Serviços de Saúde Materna/economia , Adolescente , Criança , Feminino , Humanos , Saúde Materna , México , Gravidez , Adulto JovemRESUMO
INTRODUCTION: Family planning (FP) is one of the key services provided by health care systems. Extending beyond matters of sexual and reproductive health, its area of influence impacts directly on the development of individuals and nations. After 60 years of intense FP activities in Mexico, and in light of recent restructuring of health service supply and financing, services need to be assessed from a user perspective. OBJECTIVE: Based on a comprehensive conceptual framework, this article assesses the quality of the FP services provided by the Mexican Ministry of Health (MoH). Analysis considers not only accessibility and availability but also the users' perceptions of the care process, particularly as regards the interpersonal relations they experience with staff and the type of information they are provided. MATERIAL AND METHODS: This study used a descriptive, qualitative design based on maximum variation sampling in six Mexican states. It included visits to 12 clinics in urban and rural areas. Thematic analysis was performed on 86 semi-structured interviews administered to FP service users. RESULTS: While access was described by users as "easy," their experiences revealed normalized barriers. One of our key findings referred to inverse availability, meaning that the contraceptive methods available were generally not the ones preferred by users, with their selection therefore being shaped by shortage of supplies. Challenges included disrespect for the free choice of FP users and coercion during consultations for contraception post obstetric event. Finally, information provided to users left considerable room for improvement. CONCLUSIONS: After six decades of FP service supply, results indicate a series of quality issues that may lie at the heart of the unmet demand reported in the literature. Based on a comprehensive conceptual scheme, the present study analyzes the quality of services, highlighting areas for improvement that should be considered by the MoH in future efforts.
Assuntos
Serviços de Planejamento Familiar/normas , Adolescente , Adulto , Anticoncepção/métodos , Aconselhamento , Serviços de Planejamento Familiar/economia , Serviços de Planejamento Familiar/provisão & distribuição , Feminino , Planejamento em Saúde , Acessibilidade aos Serviços de Saúde , Humanos , Masculino , México , Pessoa de Meia-Idade , Gravidez , Relações Profissional-Paciente , Avaliação de Programas e Projetos de Saúde , Qualidade da Assistência à Saúde , Educação Sexual , Adulto JovemRESUMO
BACKGROUND: The previously-named Mexico City Policy (MCP) - which prohibited non U.S.-based non-governmental organizations (NGOs) from receiving U.S. family planning (FP) funding if they advocated, provided, counseled, or referred clients for abortions, even with non-U.S. funds - was reinstated and expanded in 2017. For the first time, the expanded MCP (EMCP) applies to HIV funding through the President's Emergency Plan for AIDS Relief (PEPFAR) in addition to FP funding. Previous, and more limited, iterations of the policy forced clinic closures and decreased contraceptive access, prompting the need to examine where and how the EMCP may impact FP/HIV service integration. METHODS: The likelihood of FP/HIV service de-integration under the EMCP was quantified using a composite risk index for 31 PEPFAR-funded countries. The index combines six standardized indicators from publically available sources organized into three sub-indexes: 1) The importance of PEPFAR for in-country service delivery of HIV and FP services; 2) The susceptibility of implementing partners to the EMCP; and 3) The integration of FP/HIV funds and programming through PEPFAR and USAID. RESULTS: Countries with the highest overall risk scores included Zambia (3.3) Cambodia (3.2), Uganda (3.1), South Africa (2.9), Haiti (2.8), Lesotho (2.8), Swaziland (2.1), and Burundi (1.5). Zambia's risk score is driven by sub-index 1, having a high proportion of country HIV expenditures provided by PEPFAR (86.3%). Cambodia and Uganda's scores are driven sub-index 3, with both countries reporting 100% of PEPFAR supported HIV delivery sites were providing integrated FP services in 2017. South Africa's risk score is driven by sub-index 2, where roughly 60% of PEPFAR funding is to non U.S.-based NGOs. Of the countries with the highest risk scores, Swaziland, Lesotho, and South Africa, are also in the top quartile of PEPFAR countries for HIV prevalence and unintended pregnancies among young women. CONCLUSION: This analysis highlights where and why the EMCP may have the greatest impact on FP/HIV service integration. The possible disruption of service integration in countries with generalized HIV epidemics highlights significant risks. Researchers, national governments, and non-U.S. funders can consider these risk factors to help target their responses to the EMCP and mitigate potential harms of the policy.
Assuntos
Serviços de Planejamento Familiar/economia , Saúde Global/economia , Infecções por HIV/economia , Política de Saúde/legislação & jurisprudência , Cooperação Internacional/legislação & jurisprudência , Aborto Induzido/legislação & jurisprudência , Países em Desenvolvimento , Serviços de Planejamento Familiar/organização & administração , Feminino , Infecções por HIV/prevenção & controle , Humanos , Gravidez , Risco , Estados UnidosRESUMO
BACKGROUND: Countries in Latin America and the Caribbean (LAC) have substantially improved access to family planning over the past 50 years. Many have also recently adopted explicit declarations of universal rights to health and universal health coverage (UHC) and have begun implementing UHC-oriented health financing schemes. These schemes will have important implications for the sustainability and further growth of family planning programs throughout the region. METHODS: We examined the status of contraceptive methods in major health delivery and financing schemes in 9 LAC countries. Using a set of 37 indicators on family planning coverage, family planning financing, health financing, and family planning inclusion in UHC-oriented schemes, we conducted a desk review of secondary sources, including population surveys, health financing assessments, insurance enrollment reports, and unit cost estimates, and interviewed in-country experts.Findings: Although the modern contraceptive prevalence rate (mCPR) has continued to increase in the majority of LAC countries, substantial disparities in access for marginalized groups remain. On average, mCPR is 20% lower among indigenous women than the general population, 5% lower among uninsured women than insured, and 7% lower among the poorest women than the wealthiest. Among the poorest quintile of women, insured women had an mCPR 16.5 percentage points higher than that of uninsured women, suggesting that expansion of insurance coverage is associated with increased family planning access and use. In the high- and upper-middle-income countries we reviewed, all modern contraceptive methods are typically available through the social health insurance schemes that cover a majority of the population. However, in low- and lower-middle-income countries, despite free provision of most family planning services in public health facilities, stock-outs and implicit rationing present substantial barriers that prevent clients from accessing their preferred method or force them to pay out of pocket. CONCLUSION: Leveraging UHC-oriented schemes to sustain and further increase family planning progress will require that governments take deliberate steps to (1) target poor and informal sector populations, (2) include family planning in benefits packages, (3) ensure sufficient financing for family planning, and (4) reduce nonfinancial barriers to access. Through these steps, countries can increase financial protection for family planning and better ensure the right to health of poor and marginalized populations.
Assuntos
Serviços de Planejamento Familiar/organização & administração , Cobertura Universal do Seguro de Saúde , Coeficiente de Natalidade , Chile , Colômbia , Anticoncepção/métodos , Anticoncepção/estatística & dados numéricos , Costa Rica , República Dominicana , Serviços de Planejamento Familiar/economia , Feminino , Guatemala , Haiti , Acessibilidade aos Serviços de Saúde/organização & administração , Financiamento da Assistência à Saúde , Honduras , Humanos , Cobertura do Seguro/estatística & dados numéricos , Jamaica , América Latina/epidemiologia , Masculino , Direitos do Paciente , Peru , Cobertura Universal do Seguro de Saúde/economia , Cobertura Universal do Seguro de Saúde/organização & administraçãoRESUMO
OBJECTIVE: To analyze whether the changes observed in the level and distribution of resources for maternal health and family planning (MHFP) programs from 2003 to 2012 were consistent with the financial goals of the related policies. MATERIALS AND METHODS: A longitudinal descriptive analysis of the Mexican Reproductive Health Subaccounts 2003-2012 was performed by financing scheme and health function. Financing schemes included social security, government schemes, household out-of-pocket (OOP) payments, and private insurance plans. Functions were preventive care, including family planning, antenatal and puerperium health services, normal and cesarean deliveries, and treatment of complications. Changes in the financial imbalance indicators covered by MHFP policy were tracked: (a) public and OOP expenditures as percentages of total MHFP spending; (b) public expenditure per woman of reproductive age (WoRA, 15-49 years) by financing scheme; (c) public expenditure on treating complications as a percentage of preventive care; and (d) public expenditure on WoRA at state level. Statistical analyses of trends and distributions were performed. RESULTS: Public expenditure on government schemes grew by approximately 300%, and the financial imbalance between populations covered by social security and government schemes decreased. The financial burden on households declined, particularly among households without social security. Expenditure on preventive care grew by 16%, narrowing the financing gap between treatment of complications and preventive care. Finally, public expenditure per WoRA for government schemes nearly doubled at the state level, although considerable disparities persist. CONCLUSIONS: Changes in the level and distribution of MHFP funding from 2003 to 2012 were consistent with the relevant policy goals. However, improving efficiency requires further analysis to ascertain the impact of investments on health outcomes. This, in turn, will require better financial data systems as a precondition for improving the monitoring and accountability functions in Mexico.
Assuntos
Serviços de Planejamento Familiar/economia , Serviços de Planejamento Familiar/normas , Saúde Materna/economia , Feminino , Humanos , Seguro Saúde/economia , Estudos Longitudinais , MéxicoRESUMO
Objetives: To identify the costs of family planning care in adolescents. Material and methods: Longitudinal study of the cost of care for family planning carried out in 2015 in a group of individuals with age limits of 10 and 19 years in a unit first level of health care in the state of Queretaro, Mexico. The profile of use of family planning (FP) was created for the teen was performed services through counseling, provision of contraception and review of intrauterine device (IUD) in a year; cost projections for the population of adolescents and different coverage scenarios between 5 and 100% were made. Results: The average annual cost was 228.84 Mexican pesos. Ideally the identified cost was 2,708.94 pesos. The projection with 20 % coverage was 207,251,330 pesos. The average annual family planning consultations was 0.9. The most commonly used method was with medroxyprogesterone-estradiol at doses of 25 and 5 mg. Conclusion: The cost of planning in adolescents is low, taking into account the costs that the care of high-risk pregnancies and associated comorbidities.
Assuntos
Anticoncepção/economia , Anticoncepcionais Femininos/economia , Serviços de Planejamento Familiar/economia , Dispositivos Intrauterinos/economia , Adolescente , Criança , Anticoncepção/métodos , Anticoncepcionais Femininos/administração & dosagem , Combinação de Medicamentos , Estradiol/administração & dosagem , Estradiol/economia , Feminino , Humanos , Estudos Longitudinais , Masculino , Acetato de Medroxiprogesterona/administração & dosagem , Acetato de Medroxiprogesterona/economia , México , Adulto JovemRESUMO
Contraceptive use is an important determinant of unintended pregnancy, but little is known about the social and structural factors that determine women's contraceptive use in rural Honduras. In this study, we aim to characterise the individual and social determinants of contraceptive use among women in rural Honduras. In 2011 and 2012, we conducted 14 interviews and 2 focus groups with women 18 years and older. In our analysis, we created a family-planning narrative for each participant and coded transcripts around key emergent themes related to these determinants. We found that social determinants--including poverty, gender dynamics and availability of family-planning methods--had a strong influence on contraceptive use among women in our sample. Study participants stated that they were faced with a difficult economic situation compounded by rising prices of basic goods and diminishing job opportunities. Paradoxically, at the same time that the economic situation led women to seek contraception, it also contributed to the structural barriers that limited their ability to obtain their method of choice and maintain continuous contraceptive use. Our findings suggest the need for multi-level efforts to create an enabling and sustainable environment for family planning among women in rural Honduras.
Assuntos
Anticoncepção/estatística & dados numéricos , Serviços de Planejamento Familiar/provisão & distribuição , Acessibilidade aos Serviços de Saúde/tendências , Determinantes Sociais da Saúde , Saúde da Mulher/estatística & dados numéricos , Direitos da Mulher/tendências , Adolescente , Adulto , Anticoncepção/economia , Anticoncepção/métodos , Serviços de Planejamento Familiar/economia , Feminino , Grupos Focais , Acessibilidade aos Serviços de Saúde/economia , Honduras , Humanos , Entrevistas como Assunto , Pessoa de Meia-Idade , Pobreza , Gravidez , Gravidez não Planejada , Pesquisa Qualitativa , Saúde da População Rural/economia , Saúde da População Rural/estatística & dados numéricos , Saúde da Mulher/economia , Direitos da Mulher/economia , Adulto JovemRESUMO
CONTEXT: Oportunidades is a large conditional cash transfer program in Mexico. It is important to examine whether the program has any direct effect on pregnancy experience and contraceptive use among young rural women, apart from those through education. METHODS: Data from the 1992, 2006 and 2009 waves of a nationally representative, population-based survey were used to describe trends in pregnancy experience, contraceptive use and education among rural adolescent (15-19) and young adult (20-24) women in Mexico. To examine differences in pregnancy experience and current modern contraceptive use among young women, multivariable logistic regression analyses were conducted between matched 2006 samples of women with and without exposure to Oportunidades, predicted probabilities were calculated and indirect effects were estimated. RESULTS: Over the three survey waves, the proportion of adolescent and young adult women reporting ever being pregnant stayed flat (33-36%) and contraceptive use increased steadily (from 13% in 1992 to 19% in 2009). Educational attainment rose dramatically: The proportion of women with a secondary education increased from 28% in 1992 to 46% in 2009. In multivariable analyses, exposure to Oportunidades was not associated with pregnancy experience among adolescents. Educational attainment, marital status, pregnancy experience and access to health insurance--but not exposure to Oportunidades--were positively associated with current modern contraceptive use among adolescent and young adult women. CONCLUSION: Through its effect on education, Oportunidades indirectly influences fertility among adolescents. It is important for Mexico to focus on strategies to increase contraceptive use among young rural nulliparous women, regardless of whether they are enrolled in Oportunidades.