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Budget transparency on maternal health spending: a case study in five Latin American countries.

Abstract: Progress in reducing maternal mortality has been slow and uneven, including in Latin America, where 23,000 women die each year from preventable causes. This article is about the challenges civil society organizations in Latin America faced in assessing budget transparency on government spending on specific aspects of maternity care, in order to hold them accountable for reducing maternal deaths. The study was carried out by the lnternational Planned Parenthood, Western Hemisphere Region and the lnternational Budget Partnership in five Latin American countries--Costa Rita, EI Salvador, Guatemala, Panama and Peru. It found that only in Peru was most of the information they sought available publicly (from a government website). In the other four countries, none of the information was available publicly, and although it was possible to obtain at least some data from ministry and health system sources, the search process often took a complex course. The data collected in each country were very different, depending not only on the level of budget transparency, but also on the existence and form of government data collection systems. The obstacles that these civil society organizations faced in monitoring national and local budget allocations for maternal health must be addressed through better budgeting modalities on the part of governments. Concrete guidelines are also needed for how governments can better capture data and track local and national progress.

Keywords: reproductive health policy and programmes, maternal health services, health financing, health planning and management, accountability and transparency, non-governmental organizations, Latin America

Resume

Les progres dans la reduction de la mortalite maternelle ont etc lents et inegaux, meme en Amerique latine, ou 23 000 femmes meurent chaque annie de causes evitables. Cet article decrit les obstacles que les organisations de la societe civile rencontrent en Amerique latine pour evaluer la transparence des depenses gouvernementales pour des aspects specifiques des soins de maternite, afin de les rendre comptables de la reduction des decks maternels. L'etude a etc menee par la Federation internationale pour la planification familiale, region de l'hemisphere occidental, et le Partenariat budgetaire international, dans cinq pays d'Amerique latine : Costa Rica, EI Salvador, Guatemala, Panama et Perou. Elle a revele que la plupart des informations recherchees n'etaient disponibles publiquement qu'au Perou (sur un site Internet du Gouvernement). Dans les quatre autres pays, ces informations n'etaient pas accessibles publiquement et s'il etait possible d'obtenir quelques donnees aupres de sources ministerielles et du systeme de sante, le processus de recherche etait souvent complexe. Les donnees recueillies dans chaque pays etaient tres differentes, en fonction non seulement du niveau de transparence budgetaire, mais aussi de l'existence et de la forme des systemes gouvernementaux de recueil de donnees. Les obstacles que ces organisations de la societe civile ont rencontres pour surveiller les allocations budgetaires nationales et locales pour la sante maternelle doivent etre leves avec de meilleures modalites budgetaires de la partdes autorites. Des directives concretes sont aussi requises sur les moyens permettant aux gouvernements de mieux collecter des donnees et suivre les progres locaux et nationaux.

Resumen

Los avances en la disminuci6n de la mortalidad materna han sido lentos y desiguales, incluso en Latinoamerica, donde cada ano mueren 23,000 mujeres por causas evitables. Este articulo trata sobre los retos que las organizaciones de la sociedad civil en Latinoamerica enfrentaron al evaluar la transparencia presupuestaria de los gastos gubernamentales en aspectos especificos de la atencion materna, a fin de imputarles la responsabilidad de disminuir las tasas de muertes maternas. EI estudio fue realizado por la Federacion Internacional de Planificacion de la Familia/Region del Hemisferio Occidental e lnternational Budget Partnership, en cinco paises latinoamericanos: Costa Rica, EI Salvador, Guatemala, Panama y Perth. Se encontro que solo en Peru la mayoria de la informacion que buscaban estaba disponible al publico (en un sitio web gubernamental). En los otros cuatro paises, ninguna de la informacion estaba disponible al publico y, aunque era posible obtener por Io menos algunos datos del ministerio y sistema de salud, el proceso de busqueda generalmente tomo un rumbo complejo. Los datos recolectados en cada pais fueron muy diferentes, dependiendo no solo del nivel de transparencia presupuestaria, sino tambien de la existencia y tipo de sistemas gubernamentales para la recoleccion de datos. Los obstaculos que encontraron estas organizaciones de la sociedad civil para monitorear asignaciones presupuestarias nacionales y locales a la salud materna deben abordarse mediante mejores modalidades presupuestarias por parte de los gobiernos. Ademas, los gobiernos necesitan directrices concretas sobre la mejor manera de capturar los datos y seguir los avances locales y nacionales.

**********

Addressing unacceptably high levels of maternal mortality has been a cornerstone of global health and development policy since the 1980s. In recent years, the issue has seen a surge of media attention and funding from governments and global health donors. In 2000, governments committed to reducing the maternal mortality ratio by 75% by 2015 as part of Millennium Development Goal 5 (MDG 5).

Progress has been slow and uneven, however, including in Latin America where 23,000 women die each year from preventable causes. (1) Globally, progress towards reducing maternal deaths is well short of the 5.5% annual decline needed to meet the MDG target (2) and prevent 358,000 women and girls dying each year, almost all in developing countries. (3) In response, the UN launched the Global Strategy for Women's and Children's Health (Global Strategy) in September 2010, garnering member state commitment, particularly from poorer countries, to intensify existing women's and children's health programmes.

While there are many ways to improve maternal health, there is agreement at the global level that ending maternal mortality requires a comprehensive, integrated package of essential interventions and health services, including family planning, safe abortion services, antenatal care, skilled birth attendance, emergency obstetric and post-partum care. (4) There is also consensus that governments must have a clear strategy for reducing maternal mortality. This includes the resources to improve services and make them accessible, affordable and of high quality; and the skilled health professionals required for implementation.

With only three years left until the target date for achieving the Millennium Development Goals, assessing and monitoring information on the extent and effectiveness of maternal health investments is crucial, and a task that civil society organizations (CSOs) should be involved in. Why? First, the creation of the Global Strategy has directed additional resources, both from national budgets and multilateral aid, towards maternal, newborn and child health. Second, the Global Strategy establishes mechanisms to hold governments accountable for results and use of resources, which can only be achieved through analysis of transparent public financing. Third, greater information on budget allocations and programmes would allow governments to better track their own expenditures, assess the effectiveness of programmes and ensure that these resources reach their intended recipients.

Challenges to tracking progress

Despite global agreements, ensuring implementation of these strategies and evaluating progress remains a complex challenge in Latin America. One of the main factors is that there is usually no single budget line for sexual and reproductive health that can be followed within national health budgets, much less a specific line for maternal health--even where maternal health programmes and policies exist.

In Latin America, a significant amount of funding for sexual and reproductive health comes from multilateral donors, such as UNFPA and the Pan American Health Organization (PAHO). These donors have called on governments to improve data collection for maternal health grants they receive, (5) to better determine how much aid has been directed to specific interventions within national reproductive health programmes. Even in countries where specific budget lines exist for contraceptives--as is the case in Guatemala and EI Salvador--they contain only aggregated data and are not broken down into specific budget lines for other aspects of maternal health, such as medicines or training of personnel.

Similarly, given the vertical nature of global health programmes and funding, national governments and agencies are required to report to multiple stakeholders and to donors that often have different requirements. Perhaps most importantly, health workers are overburdened by excessive data and reporting demands from multiple and often un-coordinated sub-systems. (6) These multiple reporting systems add complexity to health accounts, and contribute to less than optimal analysis and diminished government transparency. As the Health Metric Network describes in its publication Country Health Information Systems: A Review of the Current Situation and Trends, (7) although most countries are using indicators and targets to monitor progress on maternal health, the availability and quality of data do not allow them to do so effectively.

These factors all contribute to the complexities governments face in collecting and reporting information, which in turn hinder the ability of CSOs to access accurate and complete data and demand accountability. The lnternational Budget Partnership (IBP) works to build the capacity of civil society to successfully use budget analysis as an advocacy tool. In 2010, the IBP launched the Ask Your Government initiative, a pilot involving 100 CSOs in 86 countries. Participating CSOs requested detailed budget information on specific health and development issues, two of which were related to maternal health. Only 27 out of 84 governments were willing and able to provide some information about their investment in life-saving interventions linked to maternal health, evidencing the difficulties CSOs face in tracking government budgets and spending. (8)

Measuring budget transparency on maternal health: a pilot study

In recent decades, civil society organizations have been working to better understand and influence government budgets. In recognition of the need for increased capacity to be able to do so effectively among sexual and reproductive health and rights organizations in Latin America, the IPPFIWHR and IBP developed a pilot study that was carried out in 2010 by IBP researchers and IPPFIWHR programme staff. The purpose of the study was to determine the extent to which CSOs in five Latin American countries (Costa Rica, EI Salvador, Guatemala, Panama and Peru) could access and monitor government budgets and spending for maternal health. The study highlighted the challenges CSOs faced in collecting information on government spending for maternity care. Based on the findings, this paper presents recommendations on how information and budgeting systems need to be improved to allow for better monitoring. *

Countries were chosen on the basis of two criteria: that they represented a wide range of maternal mortality ratios (9) and different levels of country budget transparency according to the Open Budget Index developed by the IBP. (10) The countries and CSOs chosen were:
Country       Civil society organization

Costa Rica    Asociacion Demografica Costarricense
              (ADC)

El Salvador   Fundacion Nacional para el Desarrollo
              (FUNDE) and Asociacion Demografica
              Salvadorena (ADS)

Guatemala     Asociacion Pro Bienestar de la Familia
              de Guatemala (APROFAM) and Centro
              Internacional para Investigaciones en
              Derechos Humanos (CIIDH)

Panama        Asociacion Panamena para el
              Planeamiento de la Familia (APLAFA)

Peru          Ciudadanos al Dia (CAD) and Instituto
              Peruano de Paternidad Responsable
              (INPPARES)


Methodology

Although the final goal of information-gathering was to enhance advocacy effectiveness, the main purpose of the case study was the information-gathering process itself. Its aim was to enhance the groups' knowledge of where and how to seek planning and budget information, and with it to assess the level of government accountability related to maternal health.

Even though the search process to gather information varied from country to country, a standard form was used to record each organization's findings. Similarly, organizations followed the same steps to determine whether the government produced and published information about maternal health spending. First, they searched for all available documentation on the websites of national ministries and international agencies such as PAHO for information on their governments' specific policies and commitments related to maternal health, e.g. national strategic plans to reduce maternal and perinatal morbidity and mortality. In all cases, participants were able to find existing policies and programmes designed to reduce maternal mortality and improve reproductive health services. After locating these documents, they then shifted their attention to searching for corresponding budget lines. To ensure consistency and to provide a framework during the information gathering process, it was agreed that they would seek specific budget information in the following categories: (11-15)

* Integrated reproductive health care: budget for contraceptive methods disaggregated by type, and budget for folic acid and iron supplements;

* Skilled attendance at delivery: budget for in-service training for health workers (nurses and midwives);

* Emergency obstetric care (during and after delivery): budget for supply of essential medicines (uterotonics--oxytocin, misoprostol and ergotamine, saline solution and magnesium sulfate), blood banks, and in some cases investment in manual vacuum aspiration equipment.

The next step was then to look for budget information available on the internet, that is, information on websites of the Ministries of Finance and Health, and other governmental units. If this information was not available on the internet, the CSOs then submitted information requests to the Ministries of Finance and Health in their countries under the auspices of national Freedom of Information Acts.

As a further step, in order to follow up these requests or if they were not answered, they made informal contact with and had meetings with civil servants, which constituted their main sources of information. In general, these meetings were with technical staff within the Ministry of Health, such as staff working in national departments of reproductive health. These contacts then provided the requested information, or requested it from health units or other departments.

To develop a systematic report for each country, participants completed logbooks that described all the information requested and obtained at each step of the process. Lastly, each country team assessed the information gaps they found and analysed how the information available needed to be improved, in order to be able to track public spending on maternal health.

Findings

Findings varied depending on the level of transparency and detail of information contained in each government's budgets. CSOs in Costa Rica, Guatemala and Peru obtained substantial policy and budget data directly from their governments' websites. CSOs in EI Salvador and Panama were able to gather policy data through external websites but only a limited amount of budget information (see Tables 1-5 for summary findings from each country).

Costa Rita did not have a single programme that addressed maternal mortality, but rather specific plans and guidelines that established government commitments to ensure maternal health care, including access to integrated reproductive health care, skilled personnel and emergency obstetric care during and after pregnancy (Table I). However, the guidelines, procurement and tools necessary for quality and timely service provision were centralized in a single institution, the Social Security Administration. Each of the health units developed their procurement plan and the Social Security Administration compiled and defined the final procurement plan, which included the budget for all types of contraceptives and medical and equipment supplies. Through Costa Rica's Freedom of Information Act, the CSO identified the Office of Planning for Goods and Services as the appropriate entity from whom to request the information, including items such as equipment for manual vacuum aspiration, uterotonics and contraceptives. The organization filed multiple requests and interviewed the Office director to explain their objectives. As a result, they were able to obtain around 70% of the detailed information requested. The only information they could not obtain was on the budget for training of personnel (the agency in charge of training and professional development for the health sector did not respond to their request).

In El Salvador, the information-gathering process required numerous meetings with Ministry of Health staff, as there was no single person responsible for handling Freedom of Information requests, and clear processes for how to use and enforce the Freedom of Information Act were also lacking. Personal contacts, such as with the Vice Minister, the Head of the Family Planning Programme Unit and the Head of the Integrated Care for Women Unit, were necessary to request the information. The Ministry staff explained that they did not manage or produce consolidated budgetary information on maternal health. After several attempts, the CSOs were able to obtain detailed information on contraceptive method expenditures and some expenditure information on instruments and equipment (such as forceps and speculums) distributed to hospitals for maternity care. No information on essential medicines for obstetric care was provided, however (Table 2). The research showed that existing budgetary information for the country's Plan to Reduce Maternal Mortality was insufficient even for those responsible for the Plan's implementation.

In Guatemala, the CSO was able to start the search on the internet utilizing the General Planning Secretariat's restricted access webpage, as they were given the password. The webpage had sufficient information to identify the budget line for contraceptives funded by international donors, but the information was not disaggregated by method. Other budget lines were grouped by general pools of resources, such as the medicines and supplies budget, that included not only those for obstetric care, such as oxytocin and misoprostol, but also other non-maternal health-related medicines. As a result, further information was requested under Freedom of Information. The Access to Information Unit of the Ministry of Health referred the requests to each of the National Hospitals and Regional Health Departments, which in turn, sent detailed information on the funds they had spent the previous year on medicines for emergency obstetric care and training of midwives and nurses (Table 3). As there was no one at the Ministry of Health responsible for gathering and systematizing this information, the various health entities sent the information requested to the Access to Information Unit, which was in multiple files in a variety of formats, which were then forwarded on to the CSOs. This large volume of information was very difficult to manage and analyze.

In Panama, the search process was particularly difficult, both because the budget and policy information was not available on the internet and because formal requests submitted under Freedom of Information went unanswered. Initial interviews with Ministry of Health staff resulted in referrals to 14 local health units across Panama that produced their own information, which it was neither feasible nor reasonable for the CSOs to try to gather and analyze. Upon a subsequent request, the Ministry of Health provided aggregated information that was difficult to interpret (Table 4). For instance, information on medicines and supplies for obstetric care fell under "medical and dental equipment", and the Reproductive Health Programme budget came under the Population Department, with no information on specific reproductive health budget allocations. The Head of the Reproductive Health Programme explained that there was no budget, and that instead, they managed a general pool of resources that were transferred to local health units as needed. However, there were no mechanisms for local health units to report back to the Department on how they had spent those funds. In this case, the lack of available budgetary information and planning at the Ministry level, as well as the absence of expenditure reports by local health units, made budget tracking nearly impossible for the CSO concerned.

In Peru, most of the maternal health budgetary information was available online under the Maternal Mortality Strategic Plan budget line (Table 5). The "Economic Transparency" website provided information on budget and expenditures for each category of the Plan, such as usage of antenatal care and number of skilled personnel who attended normal and complicated deliveries. However, the information was aggregated, with no specific budgetary data on, for example, staff training or funds allocated to purchase uterotonics or folic acid. After accessing this basic information on the website, the CSO submitted a request under Freedom of Information and met with staff from the Ministries of Health and Finance. The Ministry of Finance claimed they did not have more detailed information and referred them to the Ministry of Health, who in turn did not provide any information.

As the tables show it was only in Peru that most of the information was available publicly, that is, from a government website. In the other four countries, none of the information was available publicly, and although it was possible to obtain at least some data on maternal health budgets from government and health system sources, the search process took a complex course in most cases. The data collected in each country were very different, depending not only on the level of budget transparency, but also on the existence and form of the data collection systems that the governments themselves utilized. For instance, when a budget item was under the scrutiny of international donor organizations, as was the case with contraceptives in Guatemala and EI Salvador, specific budgets were often earmarked for this purpose which made it easier to find the budget information requested. But this was often not the case otherwise.

In many cases, governments did not produce the requested information to the level of detail requested, and therefore, their responses were often indirect or only aggregated information was provided. Only some information on emergency obstetric care and antenatal care was provided with the detail specified in the request for information, and very little data on skilled attendance at delivery were provided. Overall, considering all the categories and types of information requested, we can say that on average, only about half the information requested was provided.

This study showed that it was necessary for the CSOs to utilize not only national laws on freedom of access to information but personal contacts within government--particularly within health ministries--to gather budgetary information on maternal health services. There is still a long way to go before governments themselves--let alone civil society--are able to gather and put together all the information necessary to analyze and assess their investments in maternal health. The resulting lack of information available meant, for civil society, that their ability to monitor public budgets and programme implementation was greatly hindered as well.

Discussion

The ultimate goal of maternity services is to prevent and reduce to a minimum maternal deaths related to pregnancy and childbirth. To support and work with governments to achieve this goal, CSOs need access to government policies, plans and budgets on maternal health, not only to influence them, but also to hold governments accountable. Indeed, this holds true also for reducing abortion deaths, which constitute 15% of maternal deaths in the Latin American region, (1) and for improving access to family planning and to all reproductive and sexual health care, of which maternal health care is an important part.

This case study has shown that there is a clear need for governments to improve information systems and transparency on maternal health spending and to further examine and improve their information systems on all reproductive and sexual health care. Furthermore, governments should ensure that information is made public in a timely way, and is accessible and comprehensive. Only then will CSOs be able to monitor spending on implementation of services and hold governments accountable.

Since the information the CSOs were looking for in this case was often spread out among different ministries or among different sections within the same ministry, or was available only from district or local departments and hospitals, CSOs had to make multiple requests for information, in some cases from all of these sources and in some cases, were still not able to obtain comprehensive information.

Since maternal health care funds are often disseminated in a decentralized way, it is critical to have a system for local governments and local health units to report to central government so that central government can effectively assess local and overall implementation of maternal health policies, accurately account for spending on these programmes, and plan ahead accordingly.

Focusing on specific aspects of maternal health-from contraceptive supplies to skilled personnel, to essential medicines for antenatal and emergency obstetric care-captured a significant amount of useful data, but there are other factors that also greatly affect maternal health. For instance, government policies and investments to address gender inequality and improve public transport should be considered when designing accountability and monitoring systems and the bodies responsible for them.

Despite the difficulties that arose during this case study, there are reasons to be optimistic. The Global Strategy, and the establishment of the related Commission on Information and Accountability for Women's and Children's Health, represents a clear opportunity for scaling up analysis of maternal health investments. Following a recommendation of the Commission, the UN Secretary General recently appointed an independent Expert Review Group, which will issue reports on information and accountability to the General Assembly over the next three years. It is crucial that this group addresses the obstacles to CSO monitoring of the Global Strategy at the national and subnational level, and maximizes the opportunity for CSOs to inform the Expert Group's reports. (16)

An active civil society voice is a key element in ensuring government spending is transparent and is being used effectively to implement--and improve--existing policies and programmes. Civil society, in particular sexual and reproductive health and rights organizations, that have real-life knowledge and programmatic experience in addressing the barriers to achieving maternal health need to be able to play an essential role in tracking their governments' progress in preventing maternal deaths.

Acknowledgements

We wish to thank the following for their critical eye, insightful comments, excellent edits and their support and time: Giselle Carino and Flor Hunt, lnternational Planned Parenthood Federation/Western Hemisphere Region; Manuela Garza, lnternational Budget Partnership; and Ukaid, Department for lnternational Development, and the Hewlett Foundation for their support.

References

(1.) Acosta A, Cabezas E, Chaparro J. Present and future of maternal mortality in Latin America. lnternational Journal of Gynecology 8: Obstetrics 2000;70:125-31.

(2.) UN Department of Public Information. We can end poverty: 2015 Millennium Development Goal. September 2010. At: http://www.un.orglmillenniumgoals/ pdf/MDG_FS_ 5_ EN_ new.pdf.

(3.) World Health Organization. Women and Health, today's evidence tomorrow's agenda. 2009. At: http://whqlibdoc. who.int/publications/2009/9789241563857_eng.pdf.

(4.) World Health Organization. Global Strategy for Women's and Children's health. 2010. At: http://www.who.int/ pmnch/topics/maternal/201009_globalstrategy_wch/en/.

(5.) Germain A. Ensuring the complementarity of country ownership and accountability for results in relation to donor aid: a response. Reproductive Health Matters 2011;19(38):141-45.

(6.) World Health Organization. Framework and standards for country health information systems. Health MetricsNetwork, 2008. At: http://www.who.int/ healthmetrics/documents/hmn_framework200803.pdf.

(7.) World Health Organization. Country health information systems: a review of the current situation and trends. Health Metrics Network, 2011. At: www.who.int/entity/healthmetrics/news/chis_ report.pdf.

(8.) Garza M, Alemu B, Lakin J. Toward Accountability for Resources: Independent Budget Monitoring of the Global Strategy for Women's and Children's Commitments. Washington, DC: IBP, 2010.

(9.) United Nations Population Fund. State of the World Population 2008, UNFPA, 2008. At: http://www.unfpa. org/webdav/site/global/shared/documents/publicationsl 2008/swp08_ eng .pdf.

(10.) lnternational Budget Partnership. Open Budget Survey, 2010. At: internationalbudget.org/what-we-do/ open-budget-survey/rankings-key-findings/rankings.

(11.) World Health Organization, UNICEF, UNFPA, World Bank. Packages of interventions. Family planning, safe abortion care, maternal, newborn and child health. WHO/FCH/10.06. Geneva: WHO, 2010.

(12.) World Health Organization. WHO recommended interventions for improving maternal and newborn health. Geneva: WHO, 2007. At: http://whqlibdoc.who. int/hq/2007/who_mps_07.05_eng.pdf.

(13.) Partnership for Maternal, Newborn and Child Health. Consensus for Maternal, Newborn and Child Health. Geneva: WHO, 2009.

(14.) Keith-Brown K. Investing for life: making the link between public spending and the reduction of maternal mortality. Mexico DF: Fundar, Centro de Analisis e Investigacion, 2005.

(15.) Cohen S. Promoting sexual and reproductive health advances maternal health. Guttmacher Policy Review 2009;3(2). At: www.guttmacher.org/pubs/gpr/12/2/ gpr120208.html.

(16.) Commission on Information and Accountability for Women's and Children's Health, WHO. Keeping promises, measuring results. 2011. At: www.everywomaneverychild. org/images/content/files/accountability_commission/final_ report/Final_ EN_ Web.pdf.

* It is not the purpose of this paper to present a methodology on how to track maternal health expenditures, but rather a methodology to assess how much budget information is available, from which civil society can learn how much governments are spending. A next step might be to use this information to track whether or not programmes are being implemented effectively, but the first step was to consider whether or not it was possible to obtain the information in the first place.

Laura Malajovich, (a) Maria Antonieta Alcalde, (b) Kelly Castagnaro, (c) Carmen Barroso (d)

(a) Regional Advocacy Officer, International Planned Parenthood Federation, Western Hemisphere Region (IPPF WHR), New York NY, USA. Correspondence: Imalajovich@ippfwhr.org

(b) Deputy Director, Public Affairs, IPPF WHR, New York NY, USA

(c) Senior Communications Officer, IPPF WHR, New York NY, USA

(d) Regional Director, IPPF WHR, New York NY, USA

Doi: 10.1016/S0968-8080(12)39607-9
Table 1. Information gathered in Costa Rica (a)

Category         Policies             Interventions    Budget lines

Integrated       Comprehensive        Promote          Folic acid
reproductive     guide for            antenatal        iron tablets
health care      antenatal,           consultations
                 delivery and
                 post-partum care
                 for women and
                 children (b)

                 Programme of         Basic family     Contraceptive
                 integrated care      planning         methods
                 for adolescents      supplies
                 (c)

Skilled          Plan for provision   Training and     In-service
attendance       of quality and       progress plan    training of
at delivery      accessible           for human        personnel
                 infrastructure,      resources
                 human, financial
                 and technological
                 resources (d)

Emergency        Comprehensive        Detection and    Uterotonics
obstetric care   guide for            treatment of
                 antenatal,           anaemia,         Saline solution
                 delivery and         post-partum
                 post-partum care     haemorrhage      Magnesium
                 for women and        pre-eclampsia,   sulfate
                 children (b)         urinary tract
                                      infection

                                      Immediate        Blood banks
                                      post-partum
                                      care (arterial   MVA
                                      temperature,     equipment
                                      bleeding)

Category         Provided          Sources
                 after request
Integrated       Yes               i) Through Access to
reproductive                       Information Act.
health care
                                   ii) Social Security
                                   Department
                                   (Caja Costarricense
                                   de la
                                   Seguridad
                 Yes, by           Social) provided detailed
                 method type       information on the
                                   Procurement Plan.

Skilled          No, information
attendance       provided only
at delivery      on new staff
                 hired

Emergency        Yes               i) Through Access to
obstetric care                     Information Act.
                 Yes
                                   ii) Social Security
                 Yes               Department (Caja
                                   Costarricense de la
                                   Seguridad Social)
                                   provided detailed
                                   information on the
                 Yes               Procurement Plan.

                 Yes

(a) None of this information was available publicly.

(b) Obtained from: www.ministeriodesalud.go.cr-index.php-
servicios-capacitadores-ms-doc details-l262-guia-de-atencion-
integral-a-las-mujeres-ninas-y-ninas-en-el-periodo-prenatal-
parto-y-posparto.

(c) Obtained from:
www.binasss.sa.cr/adolescencia/adolescenciacostarricense.htm

(d) Obtained from: www.lib.utexas.edu/benson/lagovdocs/costarica/
federal/salud/pei08-10.pdf

Table 2. Information gathered in El Salvador (a)

Category      Policies

Integrated    Plan to Reduce Maternal
reproductive  Mortality 2011-1015 (b)
health care

Skilled
attendance
at delivery

Emergency     Plan to Reduce Maternal
obstetric     Mortality 2011-1015
care
              Guide to implementing
              the Delivery Plan that
              aims contribute to
              reducing maternal and
              perinatal mortality (c)

Category      Interventions    Budget lines    Provided   Sources
                                               after
                                               request

Integrated    Guides and       Folic acid      No
reproductive  services to      and iron
health care   ensure optimal   tablets
              perinatal care

              Ensure           Contraceptive   Yes, by    Information
              access to        methods         method     provided by
              contraceptives                   type       the Head of
                                                          Family
                                                          Planning
                                                          Programme

Skilled       Training         In-service      No
attendance    personnel in     training of
at delivery   perinatal        midwives and
              care,            nurses
              obstetric care
              and family
              planning

Emergency     Offer services   Uterotonics     No         Vice
obstetric     to provide                                  Ministry of
care          quality                                     Health
              emergency                                   provided
              obstetric care                              detailed
              and basic                                   and random
              obstetric care                              information
                                                          on
                                                          equipment
                                                          but no
                                                          budget
                                                          information
                                                          on supplies
                                                          even after
                                                          phone calls
                                                          and
                                                          meetings

              Ensure           Magnesium       No
              medicines,       sulfate
              and
              equipment
              human            Blood banks     No
              to resources
              operationalize
              emergency and    MVA             Yes
              basic            equipment
              obstetric care

(a) None of this information was available publicly.

(b) Obtained from: www.salud.gob.sv-index.php-novedades-
noticias-noticias-ciudadanosas-138-febrero-2011-816--11-02-2011-
ministra-de-salud-oficializa-plan-de-reduccion-de-la-mortalidad-
materna-perinatal-y-neonatal.

(c) Obtained from: www.fosalud.gob.sv/phocadownload/Guia-
estrategia-plan-parto sv.pdf.

Table 3. Information gathered in Guatemala (a)

Category      Policies

Integrated    Plan of Action to Reduce
reproductive  Maternal and Neonatal
health        and Mortality Improve
care          Reproductive Health
              2010-2015 (b)

Skilled
attendance
at delivery

Emergency
obstetric
care

Category      Interventions  Budget lines   Provided   Sources
                                            after
                                            request

Integrated    Strengthen     Folic acid     No
reproductive  Ministry of    and iron
health        Health to      tablets
care
              provide        Contraceptive  Yes, but   From
              reproductive   methods        only       Secretary
              health care                   aggregate  of Planning
                                            levels     website,
                                                       password
                                                       required.
                                                       Information
                                                       was only
                                                       available
                                                       for donor-
                                                       funded
                                                       projects
                                                       and
                                                       initiatives,
                                                       and
                                                       information
                                                       was only
                                                       presented
                                                       at the
                                                       aggregate
                                                       level.

Skilled       Strengthen     In-service     Yes        Information
attendance    health         training of               provided by
at delivery   sector         midwives and              Health Unit
              personnel      nurses                    through
              development                              Freedom of
                                                       information
                                                       Act and
                                                       meetings
                                                       with the
                                                       Access to
                                                       information
                                                       Unit
                                                       Director,
                                                       Ministry of
                                                       Health

Emergency     Guarantee      Uterotonics    Yes        Information
obstetric     quality of                               provided by
care          care at all                              Health Unit
              levels of                                through
              health care                              Freedom of
                                                       Information
              Strengthen     Magnesium      Yes        Act and
              logistics to   sulfate                   meetings
              ensure access                            with the
              to medicines   Blood banks    No         Access
              and                                      Information
to
              equipment      MVA                       Unit
                             equipment      No         Director,
                                                       Ministry of
                                                       Health.
                                                       Information
                                                       inconsistent
                                                       provided
                                                       was across
                                                       different
                                                       health
                                                       units, and
                                                       was
                                                       provided in
                                                       multiple
                                                       formats.

(a) None of this information was available publicly.

(b) Obtained from: http://new.paho.org/gut/index.php?option=com_
docman&task=doc_download&gid=403&Itemid=.

(c) Obtained from:
http://snip.segeplan.gob.gt/guest/SNPGPL$MODULO.indice

Table 4. Information gathered in Panama (a)

Category      Policies

Integrated    National Programme of
reproductive  Sexual and Reproductive
health care   Health (b)

Skilled       Plan to Reduce Maternal
attendance    Mortality 2006-2009c
at delivery

Emergency     Plan to Reduce Maternal
obstetric     Mortality 2006-2009
care

Category      Interventions   Budget lines   Provided  Sources
                                             after
                                             request

Integrated    Ensure          Folic acid     No        Through
reproductive  qualified       and iron                 Freedom of
health care   prenatal care   tablets                  Information
                                                       Act and
                                                       meetings
                                                       the
                                                       Ministry of
                                                       Health
                                                       provided
                                                       general
                                                       information.
                                                       Total
                                                       budget for
                                                       medicines
                                                       and
                                                       supplies
                                                       for RH, not
                                                       detail on
                                                       contraceptives

              Ensure          Contraceptive  No
              access to       methods
              contraceptives

Skilled       Ensure          In-service     Yes       Through
attendance    qualified       training of              Freedom of
at delivery   personnel at    personnel                Information
              delivery                                 Act and
                                                       meetings,
                                                       the
                                                       Ministry of
                                                       Health
                                                       provided
                                                       information
                                                       on
                                                       trainings
                                                       conducted
                                                       in 2009

Emergency     Offer services  Uterotonics    No        Through
obstetric     to provide                               Freedom of
care          quality                                  Information
              emergency                                Act and
              obstetric care                           meetings,
              and basic                                the
              obstetric care                           Ministry of
              and equipment                            Health
                                                       provided
              Provide         Magnesium      Yes       information
              infrastructure  sulfate                  and budgets
              for obstetric                            and
              care            Blood banks    No        distribution
                                                       of blood
                              MVA            No        banks, MVA
                              equipment                equipment,
                                                       and
                                                       oxytocin
                                                       but not for
                                                       these last
                                                       budgets
                                                       three

(a) None of this information was available publicly.

(b) www.minsa.gob.pa/minsa/tl_files/documents/programas/
ninez_adolecencia/COMPILACION%20DE%2000NVENIOS%20INTERNACIONALES
%20Y%20LEYES%20NACIONALES%20.pdf

(c) http://new.paho.org/pan/index.php?option=com docman&task=doc
details&gid=29&Itemid=224

Table 5. Information gathered in Peru (a)

Category      Policies

Integrated    Strategic Plan to Reduce
reproductive  Maternal Mortality
health care   2009-2015 (b)

Skilled
attendance
at delivery

Emergency
obstetric
care

Category      Interventions   Budget lines   Provided    Sources
                                             after
                                             request

Integrated    Antenatal care  Folic acid     Yes, but    Total budget
reproductive                  and iron       only        for antenatal
health care                   tablets        aggregate   care
                                             levels of   available on
                                             antenatal   website. (c)
                                             care
                                                         Details not
                                                         provided upon
                                                         request.

              Ensure          Contraceptive  Yes         Total budget
              access to       methods                    for
              contraceptives                             contraceptives
                                                         available on
                                                         website. (c)

                                                         Details not
                                                         provided upon
                                                         request.

Skilled       Training for    In-service     No          Total budget
attendance    personnel for   training of                for access to
at delivery   delivery        personnel                  skilled
              (including                                 personnel
              vertical                                   available on
              delivery)                                  website.c
                                                         Details not
                                                         provided upon
                                                         request.

Emergency     Access to       Uterotonics    Yes, but    Total budget
obstetric     referral                       only        for access to
care          systems                        aggregate   safe blood
                                             levels of   banks, access
              Provide access  Magnesium      access      to maternal
              to blood banks  sulfate        health to   referral and
                                             care        counter
                                             services    referral and
                                             for         access to
                                             deliveries  health care
                                                         services for
              Access to       Blood banks    Yes, but    normal and
              personnel and                  only        complicated
              equipment                      aggregate   deliveries,
              after normal                   levels      but
              delivery and                               aggregated
              with            MVA            No          levels
              complications   equipment                  available on
                                                         website. (c)

                                                         Details not
                                                         provided upon
                                                         request.

(a) Most of this information was available publicly, but
medicines for antenatal care were not.

(b) Obtained from:
www.minsa.gob.pe/servicios/serums/2009/normas/1_penrmm.pdf.

(c) Obtained from:
http://ofi.mef.gob.pe/transparencia/Navegador/default.aspx.

(d) Obtained from: http://ofi.mef.gob.pe/transparencia/Navegador/
default.aspx total budget for contraceptive
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Author:Malajovich, Laura; Alcalde, Maria Antonieta; Castagnaro, Kelly; Barroso, Carmen
Publication:Reproductive Health Matters
Article Type:Report
Geographic Code:0LATI
Date:May 1, 2012
Words:5954
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