Scaling-up a public health innovation: A comparative study of post-abortion care in Bolivia and Mexico

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Abstract

Post-abortion care (PAC), an innovation for treating women with complications of unsafe abortion, has been introduced in public health systems around the world since the 1994 International Conference on Population and Development (ICPD). This article analyzes the process of scaling-up two of the three key elements of the original PAC model: providing prompt clinical treatment to women with abortion complications and offering post-abortion contraceptive counseling and methods in Bolivia and Mexico. The conceptual framework developed from this comparative analysis includes the environmental context for PAC scale-up; the major influences on start-up, expansion, and institutionalization of PAC; and the health, financial, and social impacts of institutionalization. Start-up in both Bolivia and Mexico was facilitated by innovative leaders or catalyzers who were committed to introducing PAC services into public health care settings, collaboration between international organizations and public health institutions, and financial resources. Important processes for successful PAC expansion included strengthening political commitment to PAC services through research, advocacy, and partnerships; improving health system capacity through training, supervision, and development of service guidelines; and facilitating health system access to essential technologies. Institutionalization of PAC has been more successful in Bolivia than Mexico, as measured by a series of proposed indicators. The positive health and financial impacts of PAC institutionalization have been partially measured in Bolivia and Mexico. Other hypotheses—that scaling-up PAC will significantly reduce maternal mortality and morbidity, decrease abortion-related stigma, and prepare the way for efforts to reform restrictive abortion laws and policies—have yet to be tested.

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.

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