Logros de 50 años de planificación familiar en América Latina y el Caribe
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Jane T. Bertrand, PhD, MBA Victoria ward y Roberto Santiso (co-autores)
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Logros de 50 años de planificación familiar en América Latina y el Caribe
- 1. 1 Planificación familiar en América Latina y el Caribe: Logros de 50 Años JANE T. BERTRAND, PHD, MBA VICTORIA WARD Y ROBERTO SANTISO (CO-AUTORES)
- 2. 2 Objetivos del estudio • Documentar el cambio marcado a través de 50 años: • Tasas de fecundidad y de prevalencia de anticoncepción con métodos modernos • Progreso social, económico, y educativo • Analizar la función catalizadora de los gobiernos, ONGs, USAID y otros en la PF • Identificar los factores claves que han influido en estos cambios • Potencialmente aplicables en otras regiones • Reconocer los retos pendientes en la región
- 3. 3 Metodología y disponibilidad de los resultados oMas de 100 entrevistas con informantes claves: • USAID, UNFPA, IPPF, y otros • MSP, Seguridad Social • Sociedad civil, líderes oRevisión bibliográfica oAnálisis de estudios DHS, RHS, y nacionales oDisponibilidad de los resultados: • Informe completo (inglés) • Resumen ejecutivo (inglés, español) • 8 estudios de caso: • Colombia • República Dominicana • El Salvador • Guatemala • Haití • México • Nicaragua • Paraguay
- 4. 4 Tasa de fecundidad global en países de la región LAC 2 3 4 5 6 1986-89 1990-93 1994-97 1998-2001 2002-05 2006-09 2010-12 Bolivia Colombia Rep Dominicana El Salvador Guatemala Haití México Nicaragua Paraguay Perú
- 5. 5 Tasa de prevalencia anticonceptiva con métodos modernos en países de la región LAC 10 20 30 40 50 60 70 80 90 Percent Years Costa Rica Rep. Dominicana El Salvador Guatemala Haití Honduras Jamaica México Nicaragua Panama 20 30 40 50 60 70 80 90 Percent Year Bolivia Brazil Chile Colombia Ecuador Guyana Paraguay Perú Venezuela
- 6. 6 Tasa de fecundidad entre adolescentes: tendencias preocupantes o A pesar de los logros en el uso de anticonceptivos entre personas casadas en todos los países: La tasa de fecundidad entre adolescentes de 15 a 19 años sigue siendo muy alta 79 nacimientos/1,000 mujeres de 15-19 años (únicamente es superada por África) Las adolescentes de más escasos recursos tienen tasas más altas que aquellas en con mayores recursos económicos
- 7. 77 1960s • IPPF fomenta interés en PF • USAID provee apoyo técnico y financiero • Clínicas abren en áreas urbanas (con píldoras, DIU y preservativos) • Gobiernos se mantienen reticentes Cronología de la PF en la región LAC
- 8. 88 Cronología de la PF en la región LAC 1960s • Expansión a programas de distribución comunitaria y de mercadeo social • Introducción/expansión de métodos permanentes • Incremento en la participación de los gobiernos a la provisión de servicios 1970s
- 9. 99 1960s • Expansión de servicios (urbano/rural) • Múltiples actores, apoyados por las agencias de cooperación de la USAID • Uso del DHS/RHS en muchos países • Negativo: la “política de la Ciudad de México” 1970s 1980s Cronología de la PF en la región LAC
- 10. 1010 1960s • Transición hacia mayor auto-sostenibilidad • USAID empieza a retirar gradualmente su asistencia financiera (“phase-out”) • Incremento en el rol del sector público • Cairo – movimiento hacia la salud sexual y reproductiva 1970s 1980s 1990s Cronología de la PF en la región LAC
- 11. 1111 1960s • Enfoque hacia la disponibilidad asegurada de anticonceptivos • USAID formaliza el proceso de “graduación” • Incremento en el rol de UNFPA en la adquisición de métodos anticonceptivos • Sector público: fuente principal de los anticonceptivos • PF cubierta por seguros médicos, seguridad social y otras fuentes públicas 1970s 1980s 1990s 2000s Cronología de la PF en la región LAC
- 12. 1212 1960s • Tasa global de fecundidad = 2.2 • Tasa de prevalencia anticonceptiva de métodos modernos = 67% • Tasa de nacimientos entre adolescentes: 79 por 1000 mujeres de 15-19 años • Únicamente Guatemala y Haití reciben ayuda bilateral de la USAID para PF 1970s 1980s 1990s 2000s 2014 Cronología de la PF en la región LAC
- 13. 13 10 factores que han influido en los logros de PF en la región LAC
- 14. 14 1. ONGs y grupos de mujeres capaces Pioneros y campeones defensores de la PF Alianzas entre el gobierno, las ONG, los grupos de mujeres y el sector privado Papel actual: responsabilizar a los gobiernos
- 15. 15 2. Ambiente socio-político y normativo cada vez más favorable Alfabetismo y urbanización generalizados Influencia importante de radio y televisión en el cambio de normas Varios países reconocen el derecho a la salud sexual y reproductiva en sus constituciones o legislación
- 16. 16 3. Apoyo externo sostenido y firme • Fuerte inversión de USAID desde 1965 hasta finales de 1990 • IPPF provee apoyo a las Asociaciones; UNFPA a los gobiernos • Graduación sistemática de apoyo de USAID en la mayoría de los países • Inversiones estratégicas para la sustentabilidad: asegurar la disponibilidad de métodos anticonceptivos y actividades de abogacía
- 17. 17 4. Coordinación entre los gobiernos, la sociedad civil y las agencias externas •Comisiones de coordinación y otros mecanismos •Grupos coordinadores para canalizar la asistencia técnica •Comités DAIA (Disponibilidad Asegurada de Insumos Anticonceptivos)
- 18. 18 5. Desarrollo de áreas de especialización clave •Prestación de servicios clínicos y comunitarios •Administración de los sistemas de salud •Información, educación y comunicación •Mercadeo social •Adquisición de anticonceptivos y logística de suministros •Apoyo a las políticas de planificación familiar
- 19. 19 6. Información para la toma de decisiones e incidencia • Primeros programas se centraron en la investigación • Investigación operativa • Inversiones en sistemas de información • EDS (DHS) desde la década de 1980
- 20. 7. La comunicación estratégica • El uso innovador de canales de comunicación • 1969: el uso de la radio de Colombia • 1970s: telenovelas (México) • 1970s-80s: campañas de mercadeo social • 1990s: aumento en el uso de la comunicación estratégica • Década del 2000: existe una demanda elevada; menos apoyo a Comunicación para Cambio de Comportamiento (BCC)
- 21. 21 8. Evolución de los mecanismos financieros • ONG - Diversificación y subvenciones cruzadas • Asociaciones público-privadas • Sistemas de seguro de salud públicos que cubren la planificación familiar • Legislación y regulación innovadora que obligan a incluir líneas presupuestarias para la anticoncepción
- 22. 22 9. Incidencia política efectiva •Marcos políticos con mayor apoyo en comparación a algunas otras regiones •Barreras normativas para el acceso de la juventud y la esterilización femenina (el consentimiento del marido) •Desafíos para el acceso a la anticoncepción de emergencia •Coaliciones cada vez más fuertes
- 23. 23 10. Adquisición de anticonceptivos Adquisición casi universal por parte del sector público Datos sobre las necesidades de los grupos marginados utilizado para movilizar a los gobiernos Iniciativas del sector privado (segmentación del mercado)
- 24. 24 Desafíos pendientes Disminuir las altas tasas de embarazo entre las adolescentes Fortalecer la educación sexual integral en las escuelas Cierre de brechas en acceso a anticonceptivos para poblaciones pobres, rurales y las minorías étnicas (indígenas) Asegurar el compromiso continuo y la capacidad de planificación familiar dentro de los sistemas de salud altamente descentralizados Continuar fortaleciendo y desarrollando los recursos humanos apropiados para la planificación familiar Asegurar la disponibilidad de información programática para la toma de decisiones dentro de la SSR y en el contexto general de salud materna
- 25. 25 Agradecimientos • USAID/LAC: • Veronica Valdivieso, Susan Thollaug, Kimberly Cole • Marguerite Farrell, Lindsay Stewart, Mary Vandenbroucke • Más de 100 informantes clave de la region ALC • MEASURE Evaluation: Bates Buckner, Erin Luben, Nash Herndon (University of North Carolina at Chapel Hill) • Asistentes de investigación en Tulane: Kime McClintock, Jerry Parks, Nicole Carter • Todas las fotos provienen de K4Health Photoshare
- 26. 26 Proyecto financiado por MEASURE Evaluation o MEASURE Evaluation es el principal vehículo de la Oficina de Salud Global de la USAID para apoyar las mejoras en la supervisión y evaluación de la población, la salud y la nutrición en todo el mundo. o Esta presentación fue producida con el apoyo de la Agencia de los Estados Unidos para el Desarrollo Internacional (USAID), bajo las condiciones de MEASURE Evaluation, conforme al acuerdo de cooperación AID-OAA-L-14-00004. MEASURE Evaluation fue implementado por el Centro de Población Carolina de la Universidad de Carolina del Norte en Chapel Hill en asociación con ICF International; John Snow, Inc.; Management Sciences for Health; Palladium; y la Universidad de Tulane. Las opiniones expresadas en esta publicación no reflejan necesariamente el punto de vista de la USAID ni del gobierno de los Estados Unidos. Informe disponible: www.measureevaluation.org http://www.measureevaluation.org/measure /resources/publications/tr-15-101
Editor's Notes
- Family Planning in Latin America and the Caribbean: Achievements of 50 Years – Bertrand et al.
- USAID funding in the region began in 1965 and was instrumental in providing support to local CHAMPIONS…. Often based in the local IPPF Member Association. Usually doctors who had to see the negative consequences of abortion-related mortality and morbidity were the drivers. RESEARCH was important from the beginning.
- Demographic concerns were openly driving the movement by the 1970s and more programs were initiated with Profamilia Colombia taking the lead in the private sector programs and Mexico taking the lead in the public sector. INNOVATION… community-based distribution and contraceptive social marketing; also use of radio to educate and motivate.
- By the mid-1980´s complex national programs with multiple actors were taking shape in most countries. Many countries initiated some type of coordinating mechanism…often led by the private sector and usually funded by USAID. The DHS/RHS began providing an important means of tracking progress, learning about method mix and source of methods. Just as many countries had gained momentum in FP, the U.S. issued the Mexico City Policy, which created an unwelcome distraction to the NGOs working in FP.
- For most countries the ¨Golden Age¨ and period of most rapid growth (coinciding with the highest levels of funding occurred in the late 1980s and1990s. USAID assistance levels were high and dozens of CAS were involved in assisting local MOHs and NGOs. The paradigm-shift of ICPD, with a move to a broader, more rights-based focus on sexual and reproductive health predated Cairo in the region. It brought together broader coalitions of actors in many countries. Demographic concerns were openly driving the movement by the 1970s and more programs were initiated with Profamilia Colombia taking the lead in the private sector programs and Mexico taking the lead in the public sector. INNOVATION… community-based distribution and contraceptive social marketing; also use of radio to educate and motivate.
- By the early 2000s ---external funding decline, contraceptive security, graduation. Vertical FP programs were largely integrated into efforts to reduce maternal mortality. Mirrored the decline in interest in FP globally. Universal health insurance schemes increasingly covering free contraceptive services…however, training of service providers and promotion declined in many countries. TODAY IN 2014 ALL OF THE CASE STUDY COUNTRIES EXCEPT HAITI ARE RESPONSIBLE FOR PROCURING THEIR OWN CONTRACEPTIVES By the early 2000s ---external funding decline, contraceptive security, graduation. Vertical FP programs were largely integrated into efforts to reduce maternal mortality. Mirrored the decline in interest in FP globally. Universal health insurance schemes increasingly covering free contraceptive services…however, training of service providers and promotion declined in many countries. TODAY IN 2014 ALL OF THE CASE STUDY COUNTRIES EXCEPT HAITI ARE RESPONSIBLE FOR PROCURING THEIR OWN CONTRACEPTIVES
- The results achieved in 2014 are impressive.
- The early pioneers were enthusiastic champions usually based in NGOs or research organizations (although here in Mexico many were in the public sector). These committed individuals created a real movement. Eventually alliances developed with governments and with women groups who have been particularly influential in the post ICPD era While NGOs no longer play the dominant role they once did in service provision they are still important in order to hold governments accountable for sexual and reproductive health services, to innovate and to advocate.
- Increased levels of literacy and urbanization have contributed to changing norms around family size and contraception. Similarly widespread access to radio and television…especially the popular soap operas (telenovelas) that frequently show smaller families and deal with themes related to unwanted pregnancies contributed to the change in norms. 21
- No history of family planning in the region would be complete without acknowledging the role of external support to the development of robust family planning programs. USAID was by far the largest donor, but UNFPA, IPPF, PAHO and several foundations also contributed. Graduation from USAID support was systematic and gradual in most countries. It was based on numerous indicators of country readiness and took place only after strategic investments to strengthen local abilities had been made.
- In most countries committees led by govt included civil society organizations and planned jointly to avoid duplication of efforts and expand coverage.. In several countries USAID created umbrella groups that were able to channel funding and technical assistance to small NGOs and community – based organizations. Some of these networks, such as PROCOSI in Bolivia and NICASALUD in Nicaragua have continued as sustainable organizations. In many countries, multisectoral Contraceptive Security Committees have been vital to advocacy efforts and to ensuring continuity of technical support for contraceptive security as governments changed.
- One of the greatest legacies of the extensive investment by USAID and other donors has been the strong cadre of highly – skilled professionals that were trained in a variety of key areas listed here.
- Research played an important role in convincing policy makers to begin to work on family planning and the family planning field in the region has been characterized by a culture of respect for data. There is widespread recognition that information, whether from large-scale surveys, OR, information systems or evaluations contribute enormously to program success. Since the 1970s, countries in the LAC region have conducted 34 DHS and nine RHS surveys. National ‘level health surveys have continued in many countries even after USAIDs withdrawal.
- Strategic communication activities were key in the early years. Colombia{s Profamilia pioneered the use of radio to promote family planning in 1969 and in the 1970s the Mexican government began using educational “telenovelas” (soap operas) that promoted family planning and resulted in measurable increases in visits to government family planning clinics. These efforts evolved to encompass a broad array of social marketing and behavior change techniques by the 1990s. By the late 2000s with demand already high, communication activities declined markedly in many countries.
- In the early years, international donors (USAID in particular) provided most of the funding for FP in the LAC region, NGOs became sustainable by selling a diverse range of services and developing social marketing or commercialization approaches. In some cases they cross-subsidize, using revenue from clinics serving populations who can pay to subsidize services to young people and the poorest sectors. For governments, the health sector reforms of the last 20 years have put a premium on universal health coverage and family planning has become one component of integrated primary health care services, rather than the vertical programs of the early years. While this poses some challenges, financing for these activities have increasingly come from traditional government revenue sources.
- While Latin America never had legislation barring family planning, such as occurs in some Francophone African countries, in some cases the laws and regulations governing contraception limit access to specific groups or for specific contraceptive methods: For instance, a number of countries prohibit the provision of contraceptives to minors without explicit parental consent and voluntary surgical contraception requires husband’s consent or is subject to age and parity limitations. In recent years advocacy has focused on contraceptive security. In addition, national and regional coalitions have formed around specific issues including comprehensive sexuality education, emergency contraception and safe motherhood. Persistent attempts on the part of the Roman Catholic Church to ban modern FP services, especially EC have been successfully thwarted by organized advocates in many countries.
- The 10th and final factor we identified as key was strengthening contraceptive procurement capacities… Currently, with the exception of Haiti, all countries in the region procure their own contraceptives. Strategies such as collecting data on the needs of marginalized groups and advocating for them have helped government’s maintain their commitments to providing contraceptives. In response to concerns over the potential inability of governments to meet projected needs, one strategy was to encourage market segmentation and strengthen the role of the private sector as well as social security institutions to provide contraceptives, thus reducing the burden for the Ministries of Health.