Scaling-up a public health innovation: A comparative study of post-abortion care in Bolivia and Mexico
Introduction
Resources to achieve a wide range of challenging and ambitious health goals throughout the world are limited. Policy and key decision-makers, therefore, are drawn to successful interventions that can be replicated on a large scale in a cost-effective manner. A public health innovation that appears to meet these criteria is post-abortion care (PAC). The PAC concept was developed in the early 1990s as a way to reduce maternal mortality and morbidity in countries where abortion laws are restrictive and women suffer disproportionately from the complications of unsafe abortion.1 Global awareness and support for PAC as a reproductive health intervention grew as a result of the International Conference on Population and Development (ICPD) in 1994.
Despite initiatives to implement PAC services post-ICPD, there has been little systematic documentation of PAC scale-up and its impact on women's lives, health services and systems, and society at-large (EngenderHealth & Ipas, 2001; Huntington & Nawar, 2003; USAID, 2004). The work presented in this article was prompted by the desire to begin to address this gap. The main objectives are to present a conceptual framework for PAC scale-up that is grounded in the experiences of two countries that have implemented significant PAC programs in their public health systems since ICPD—Bolivia and Mexico—and to assess the impact of PAC institutionalization through a series of selected health, financial and social indicators. The framework can help stakeholders aiming to implement and scale-up PAC services in different settings.
Section snippets
Background
Despite evidence that making abortion services legal and accessible to women contributes to a decrease in maternal mortality (Jewkes & Rees, 2005; Meyer & Buescher, 1994; WHO, 2003), abortion continues to be legally restricted and inaccessible to women in many countries. Thus, unsafe abortion continues to be a serious public health problem. The World Health Organization estimates that approximately 19 million abortions performed each year are unsafe, resulting in roughly 68,000 women dying each
Methods
Analysis is based on case studies developed for each country by the authors, one of whom made site visits and conducted a total of 49 in-depth interviews in Bolivia and Mexico with key health ministry and non-governmental organization (NGO) officials, health care providers, and advocates and researchers from a wide variety of organizations and institutions. Data also were drawn from organizational documents, especially project and trip reports from Ipas, an international NGO that has worked on
Conceptual framework for PAC scale-up in public sector health care systems
Although no consensus definition of “scale-up” exists in the literature, there is general agreement among researchers and practitioners that scaling-up does not simply refer to increasing the number of service-delivery points in any given place (Westley & Eschen, 2000). Rather, it is an interactive process in which different stakeholders participate to ensure that innovations have a deep and broad-based impact and are sustainable over time (DeJong, 2001; Smith & Colvin, 2000). When innovations
How did PAC scale-up take place?
In their conceptual framework, Cooley and Kohl (2006) suggest three typologies for scaling-up: replication, collaboration, and expansion. Both collaboration and expansion best describe the ways in which PAC scale-up has taken place in Bolivia and Mexico. Collaboration through formal partnerships and strategic alliances between international NGOs and public health sector institutions have facilitated the efficient use of scarce human and financial resources. Expansion refers to “taking a model
The conceptual framework
In the following sections, we discuss the environmental contextual variables that affect PAC scale-up in public sector health care systems, followed by discussion of the start-up, expansion and institutionalization phases for each case study country. As observed by Greenberg (2006), the environmental context influences the success or failure of innovations and the pace at which they are adopted at each stage of scale-up.
The start-up phase—pre-1994
For PAC to “start-up” in public sector health services, policymakers and program managers need to be convinced that the innovation under discussion is a worthwhile investment (Cooley & Kohl, 2006; Shiffman, 2003) As conceptualized in Fig. 1, catalyzers for the introduction of PAC into public health care systems were strong, persuasive, and strategically positioned in both Bolivia and Mexico. These ‘catalyzers’ were poised to bring the issue of unsafe abortion and proposals for addressing it to
Expansion, 1994 to the present
Progress in expanding the PAC model in public sector health systems is influenced by three inter-related factors: strengthening political commitment and advocacy, improving health system capacity, and improving access to technologies and equipment (Fig. 1).
Institutionalization of scaled-up PAC services
Indicators of institutionalized PAC are outlined in Fig. 1 and in Table 2 we present an institutionalization index for Bolivia and Mexico. Bolivia has made significant strides towards institutionalizing PAC in public sector health services while Mexico must increase its efforts in several areas and across institutions to maintain advances made over the years. This same set of indicators and scoring system can be used by stakeholders in other settings to assess which components are strongest and
Lessons learned and conclusions
PAC meets the basic criteria for scalability (Cooley & Kohl, 2006; Gericke, Kurowski, Ranson, & Mills, 2005; Simmons & Shiffman, 2002): PAC is cost-effective, simple and replicable. It is credible and relevant for addressing a persistent public health problem in a politically acceptable manner and is compatible with existing legal frameworks and conservative societal norms related to abortion. Introducing the first two elements of the PAC model improves services that often already exist in some
Acknowledgments
We would like to thank all of the respondents who graciously shared their time and experiences with us. Thanks to the Ipas offices in Bolivia and Mexico for helping to set up the appropriate interviews and providing primary information needed for this study. Special thanks go to the following people for reviewing the manuscript: Gustavo Quiroz, Joan Healy, Maribel Manibo, and Eliana Del Pozo.
References (55)
- et al.
Costs and resource utilization for the treatment of incomplete abortion in Kenya and Mexico
Social Science & Medicine
(1993) Generating political will for safe motherhood in Indonesia
Social Science & Medicine
(2003)Easing the pain: Pain management in the treatment of incomplete abortion
Reproductive Health Matters
(2000)- et al.
Cuentas nacionales en salud reproductiva y equidad de género
(2005) - et al.
Improving quality and lowering costs in an integrated post-abortion care model in Peru: Final report
(1998) - et al.
Post-abortion care in Latin America: A summary of a decade of operations research
Health Policy and Planning
(2005) - et al.
Testing a model for the delivery of post-abortion care in the Bolivian public health system: Final report
(2001) - et al.
Comparing the quality of three models of post-abortion care models in public hospitals in Mexico City
International Family Planning Perspectives
(2003) - et al.
Estimating costs of post-abortion services at Dr. Aurelio Valdivieso general hospital, Oaxaca, Mexico
- et al.
Current strategies for the reduction of maternal mortality
BJOG: An International Journal of Obstetrics and Gynaecology
(2005)
Cuadernos de salud reproductiva
Informe de ejecución 2001–2003 del Programa Nacional de Población, 2001–2006
Scaling up—from vision to large-scale change. A management framework for practitioners
Essential elements of post-abortion care: Origins, evolution and future directions
International Family Planning Perspectives
Promises to keep: The toll of unwanted pregnancies on women's lives in the developing world
A question of scale? The challenge of expanding the impact of non-governmental organisations’ HIV/AIDS efforts in developing countries. Horizons Project
La experiencia en Bolivia de la atención post aborto
Taking post-abortion care services to scale: Quality, access, and sustainability. Report of an international workshop held in Mombasa, Kenya, May 15–18, 2000
An assessment of post-abortion care (PAC) services in the Bolivian public health system: A report of research findings to the Ministry of Health and Social Welfare
Intervention complexity—A conceptual framework to inform priority-setting in health
Bulletin of the World Health Organization
The diffusion of public health innovations: Editorial
American Journal of Public Health
Cited by (34)
What post-abortion care indicators don't measure: Global abortion politics and obstetric practice in Senegal
2020, Social Science and MedicineCitation Excerpt :Hospitals in need of new MVA kits had to send a representative to Dakar, obtain a signature from one of two high-level officials within the MOH's Division de la Santé de la Reproduction, and then purchase the syringe from the NGO (approximately 25, 000 CFA at the time of my fieldwork). Challenges in integrating MVA into national medical supply systems have been documented in other countries with restrictive abortion laws, including Bolivia, Burkina Faso, Guatemala, Guinea, Honduras, Malawi, Mali, Mexico, and Niger (Billings et al., 2007; Chinchilla et al., 2014; Dieng et al., 2008; Kestler et al., 2006; Cook et al., 2017). Second, the MOH limited the integration of MVA training into national medical education curricula.
Core strategies, social processes, and contextual influences of early phases of implementation and statewide scale-up of group prenatal care in South Carolina
2020, Evaluation and Program PlanningCitation Excerpt :Throughout the implementation and concurrent scale-up processes, stakeholders acted in ways that reflected their own, personal values and goals. Implementation and statewide CenteringPregnancy scale-up processes were similar to those found by Fixsen et al. (2005), and were influenced by external contextual elements (Adam & de Savigny, 2012; Billings et al., 2007; Fixsen et al., 2005). Local stakeholders made use of and created windows of opportunity at the individual health system level and at the statewide scale-up level (Kingdon, 2011; Lapping et al., 2012a).
Rewriting abortion: Deploying medical records in jurisdictional negotiation over a forbidden practice in Senegal
2014, Social Science and MedicineHidden realities: What women do when they want to terminate an unwanted pregnancy in Bolivia
2012, International Journal of Gynecology and ObstetricsAn evaluation of a national intervention to improve the postabortion care content of midwifery education in Nigeria
2010, International Journal of Gynecology and ObstetricsCitation Excerpt :Postabortion care (PAC) is a technologically simple intervention package for treating complications of unsafe abortion and spontaneous abortion with manual vacuum aspiration (MVA) or medical abortion, provision of contraceptives and counseling to prevent future unintended pregnancies, and linking women to additional reproductive health services they may need. The PAC concept was developed in the 1990s to address the disproportionate burden of maternal mortality and morbidity in countries with restrictive abortion laws [13]. The global success of the PAC intervention is well documented [12–14].