Getting ready for reduced donor dependency: the co-financing of family planning commodities.

Family planning (FP) programmes in low and lower-middle income countries are confronting the dual impact of reduced external donor commitments and stagnant or reduced domestic financing, worsened by economic consequences of the COVID-19 pandemic. Co-financing-a donor-government agreement to jointly fund aspects of a programme, with transition towards the government assuming increasing responsibility for total cost-can be a powerful tool to help build national ownership, fiscal sustainability and programme visibility. Using Gavi's successful co-financing model as reference, the current paper draws out a set of key considerations for developing policies on co-financing of FP commodities in resource-poor settings. Macroeconomic and contextual sensitivities must be incorporated while classifying countries and determining co-financing obligations-using the actual GNI per capita on a scale or sovereign credit ratings, in conjunction with programmatic indicators, may be preferred. It is also important for policies to allow sufficiently long time for countries to transition-dependent on the country context, may be up to 10 years as allowed under the US Agency for International Development FP graduation policy and flexibility to revisit the terms following externalities that can influence the fiscal space for health. Incentivizing new domestic financing to pay for co-financing dues is critical, so as not to displace government funding from related health or social sector programs. Pragmatic ways to ensure country compliance can include engaging both the ministries of health and finance as co-signatories to identify and address known administrative and fiscal challenges; establishing dedicated co-financing account with the finance ministry; and instituting a mutual monitoring mechanism. Lastly, the overall process of policymaking can benefit from an alignment of goals and interests of the key development partners.

Anestesia y analgesia epidural cervical para cirugía de miembro superior / Cervical epidural anesthesia and analgesia for upper limb surgery

Introducción: La anestesia epidural cervical se ha empleado con éxito para diversos tipos de procedimientos quirúrgicos involucrando cirugía de extremidad superior, cirugía de pared torácica, cirugía de arteria carótida y disecciones de cuello, manteniendo al paciente consciente, con menor pérdida hemática y un campo quirúrgico más exangüe, además, presenta menor tasa de fallos, menor dosis total de anestésico local y mantenimiento de analgesia postoperatorio mediante un catéter. Objetivo: Describir el manejo anestésico y la analgesia postoperatoria en paciente programado para cirugía de mano, empleando técnica epidural cervical. Métodos y resultados: Presentamos el caso de un paciente que se realizó osteosíntesis del quinto dedo de la mano derecha, y cuya técnica anestésica fue epidural cervical con catéter, empleando bupivacaína 0,25 % más lidocaína sin epinefrina 2 %, continuando con analgesia epidural postoperatoria por catéter en el que se utiliza morfina 5 mg, bupivacaína 50 mg y cloruro de sodio 90 cc en bomba elastomérica a 0,5 cc/h. Conclusiones: La anestesia epidural cervical es una técnica eficaz y segura para cirugía de miembros superiores, permitiendo brindar analgesia postoperatoria continua

Introduction: Cervical epidural anesthesia has been successfully used for various types of surgical procedures involving upper limb surgery, thoracic wall surgery, carotid artery surgery and neck dissections, keeping the patient conscious, with less blood loss and a surgical field more bloodless, also presents lower failure rate, lower total dose of local anesthesia and maintenance of postoperative analgesia through a catheter. Objective: To describe anesthetic management and postoperative analgesia in a patient scheduled for hand surgery, using a cervical epidural technique. Methods and results: We present the case of a patient who underwent osteosynthesis of the fifth finger of the right hand, and whose anesthetic technique was cervical epidural with catheter, using 0.25 % bupivacaine plus lidocaine without epinephrine 2 %, continuing with postoperative epidural analgesia by catheter in which uses morphine 5 mg, bupivacaine 50 mg and 90 cc sodium chloride in an elastomer pump at 0.5 cc/h. Conclusions: Cervical epidural anesthesia is an effective and safe technique for upper limb surgery, allowing continuous postoperative analgesia

Impact of Family Planning and Business Trainings on Private-Sector Health Care Providers in Nigeria.

CONTEXT: Private health care providers are an important source of modern contraceptives in Sub-Saharan Africa, yet they face many challenges that might be addressed through targeted training. METHODS: This study measures the impact of a package of trainings and supportive supervision activities targeted to private health care providers in Lagos State, Nigeria, on outcomes including range of contraceptive methods offered, providers' knowledge and quality of counseling, recordkeeping practices, access to credit and revenue. A total of 965 health care facilities were randomly assigned to treatment and control groups. Facilities in the treatment group-but not those in the control group-were offered a training package that included a contraceptive technology update and interventions to improve counseling and clinical skills and business practices. Multivariate regression analysis of data collected through facility and mystery client surveys was used to estimate effects. RESULTS: The training program had a positive effect on the range of contraceptive methods offered, with facilities in the treatment group providing more methods than facilities in the control group. The training program also had a positive impact on the quality of counseling services, especially on the range of contraceptive methods discussed by providers, their interpersonal skills and overall knowledge. Facilities in the treatment group were more likely than facilities in the control group to have good recordkeeping practices and to have obtained loans. No effect was found on revenue generation. CONCLUSION: Targeted training programs can be effective tools to improve the provision of family planning services through private providers.

Determinants of Quality of Family Planning Counseling among Private Health Facilities in Lagos.

We use a unique dataset that includes an objective measure of the quality of family planning counseling from 927 private health facilities in Lagos State, Nigeria, to determine which variables at the facility and provider levels are most closely correlated with the quality of family planning counseling. Our data on quality come from mystery client surveys in which the clients posed as women seeking family planning counseling. We find that quality is strongly associated with the cadre of provider, with doctors delivering substantially higher-quality counselling than nurses. Doctors not only outperform nurses overall, but also perform better on each category of quality and spend nearly three minutes longer on average counseling the mystery client. Location, fees charged for the service, and facility type are also strongly correlated with quality. The degree to which a facility specializes in family planning and facility size are only weakly predictive of quality.

Private providers' knowledge, attitudes and misconceptions related to long-acting and permanent contraceptive methods: a case study in Bangladesh.

OBJECTIVE: In Bangladesh, use of long-acting and permanent methods of contraception (LAPMs) remains stagnant. Providers' limited knowledge and biases may be a factor. We assessed private providers' knowledge, misconceptions and general attitudes towards LAPM in two urban areas. The ultimate goal is to shape programs and interventions to overcome these obstacles and improve full method choice in Bangladesh. STUDY DESIGN: Trained data collectors interviewed a convenience sample of 235 female doctors (obstetricians-gynecologists and general practitioners) and 150 female nurses from 194 commercial (for-profit) health care facilities in Chittagong City Corporation and Dhaka district. Data were collected on the nature of the practice, training received, knowledge about modern contraceptives and attitudes towards LAPM [including intrauterine device (IUDs), implants, female and male sterilization]. RESULTS: All providers, and especially doctors, lacked adequate knowledge regarding side effects for all LAPMs, particularly female and male sterilization. Providers had misconceptions about the effectiveness and convenience of LAPMs compared to short-acting contraceptive methods. Implants and IUDs were generally perceived more negatively than other methods. The majority of providers believed that husbands favor short-acting methods rather than LAPMs and that women should not use a method that their husbands do not approve of. CONCLUSIONS: Our findings document knowledge and attitudinal barriers among private for-profit providers in urban areas affecting their provision of accurate information about LAPM choices. Practitioners should be offered the necessary tools to provide women full access to all modern methods, especially LAPMs, in order to contribute to decreasing unmet need and improving full method choice in Bangladesh.

Is Household Wealth Associated With Use of Long-Acting Reversible and Permanent Methods of Contraception? A Multi-Country Analysis.

As programs continue to expand access to family planning information, services, and products, it is critical that these efforts be undertaken with an equity lens, ensuring that regardless of socioeconomic status, all women and couples can use the method that meets their needs. This study explores the relationship between household wealth and the use of long-acting and permanent methods (LAPMs) versus short-acting methods of contraception among modern method users, using multivariate analyses based on Demographic Health Survey data from 30 developing countries conducted between 2006 and 2013. Overall, and controlling for relevant individual and household characteristics including age, number of living children, education, and urban/rural residence, we found that wealthier women were more likely than poorer women to use LAPMs instead of short-acting methods: 20 of the 30 countries showed a positive and statistically significant association between wealth and LAPM use. For 10 of those countries, however, LAPM use was significantly higher only for the top (1 or 2) wealthiest quintiles. Eight countries showed no broad pattern of association, while in 2 countries-Bangladesh and India-poorer women were more likely to use LAPMs than wealthier women. The positive association between wealth and LAPM use was found most consistently in the Latin American and the Caribbean countries in our sample. These findings can help program implementers respond better to women's needs for modern contraception, especially in reaching women from lower- and middle-income households.

Regional trends in the use of short-acting and long-acting contraception accessed through the private and public sectors.

OBJECTIVE: To examine trends in the source of modern contraception (public versus private sector); method choice (long-acting or permanent methods versus short-acting methods); and method and source combined. METHODS: A retrospective analysis was conducted using data collected by national Demographic and Health Surveys and Reproductive Health Surveys during the period 1992-2012. The dataset included 18 low-income countries in Sub-Saharan Africa, 10 from Latin America and the Caribbean (LAC), and 8 from Asia. RESULTS: A substantial proportion-between 40% and 49%-of modern contraceptive users relied on the private sector in Asia and LAC in the last 20years, yet the proportion has been smaller in Sub-Saharan Africa, between 27% and 30%. Increased use of short-acting methods from both public and private sectors has driven the rise in contraceptive prevalence in Asia and LAC. Similarly, increased contraceptive prevalence in Sub-Saharan Africa reflected the increased use of short-acting methods obtained mainly through the public sector, with only limited use of long-acting or permanent methods through the private sector. CONCLUSION: The private sector has played a key role in the increase of modern CPR and the provision of modern contraceptives around the world, providing almost half of them in low-income countries. Yet, such increase was driven primarily by a more substantial role in the provision of short-acting methods than long acting and permanent methods.