A reproductive health needs assessment in Myanmar

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A Reproductive Health Needs Assessment in Myanmar Costs Throughout the assessment, both women and service providers mentioned the cost of contraception as a major factor influencing use and choice of effective and appropriate methods. In terms of hormonal methods, cost is a serious consideration not only in the decision of whether or not to use a method, but also of brand. Many women choose the cheapest available brand of her chosen product (i.e. pills or injections), regardless of the perceived effectiveness or health risks. Others will make the decision between pills or injectables based on affordability. Other women report that they just cannot afford to buy any method, or that when they have money they will use contraception, but that they cannot afford it all of the time. A range of prices was given for injectables and pills, and often an additional charge will be made for administering the injection. There was a greater range in the price of pills than there was in that of injectables, with daily pills selling for between 15 and 160 kyats per month. Difference between prices of pills was generally related to the brand of pill, although geographic variations were also seen. The cheapest of the daily pills seen on the market was referred to as the “Finger” pill, and reported to be the new version of the more expensive and popular Combination 5. The daily oral pill from China was generally the cheapest oral pill, being between 14 and 20 kyats in the drug shops visited by the assessment team. Prices for the three-monthly injectable were in the range of 100 to 200 kyats, and for the one-monthly injectable the price was approximately 20 kyats. Even in townships with a birth spacing programme, women report that cost is a significant barrier to use, and that it is significantly more expensive to get injectables from the sub-centre (250 kyats) than to buy it from the drug shop (125 kyats). In addition to the complicated nature of the application process and the time delay between application and approval, cost is a major barrier to the use of female sterilisation. Officially women are only expected to pay for the drugs and equipment used during the procedure. In reality, however, the financial burden is much greater and gifts are given to providers throughout the process. Some women said that the total cost could be as high as 10,000 kyats. The cost to the client includes procedure costs, transportation, and costs related to five to seven days stay in hospital. The cost of condoms was not mentioned as a reason for them not to be used. The team found, however, that there was often a wide gap between the price of condoms as mentioned by men, and the price quoted in drug shops. Men often thought the price of condoms was three to four times as expensive as was quoted in drug shops. This in itself may prevent them from using the method. As with the hormonal methods, a range of prices was seen in the drug shops for condoms of different brands (from 2 to 20 kyats per piece). The cost of both the IUD itself and the insertion is prohibitive for many women. In birth spacing townships the charge is generally between 100 and 200 kyats. If a woman has to buy the method from a drug shop and then pay a private provider to insert the IUD, the costs could be much higher. In the drug shops visited by the team, when available, a Multiload 36
A Reproductive Health Needs Assessment in Myanmar IUD could be bought for between 1,000 and 1,300 kyats. A number of CuTS were also seen, and were said to be between 165 and 220 kyats. Cost sharing is one mechanism through which the public sector has sought to provide contraceptive methods and services at affordable prices. The assessment team found, however, that, in the project townships visited, cost sharing was understood in a variety of different ways. In some instances, there is one amount charged under the cost-sharing system, for example by the midwife. In other instances there is an additional cost added at more than one level, for example at township level and again at provider level. Quality of care During the fieldwork, the team identified a number of issues related to the quality of care in the provision of birth spacing services. Inadequate skills and knowledge, limited time for counselling, and a number of missed opportunities were observed to be reasons for the low quality of care in general. The quality of care seems to be better in the birth spacing programme townships where counselling is a formal part of the service provision. Providers at all level were found to have only a superficial knowledge of the contraceptive products they provide. This was particularly true of drug shop dispensers, from whom most women get their contraceptives. General practitioners tend to provide better quality information, but are generally untrained in birth spacing, and therefore not fully informed. In either case, providers report only giving women detailed information when they specifically ask. Public sector providers in non-programme townships, particularly basic health staff, were found to have superficial knowledge of contraception, which inevitably affects their ability to adequately counsel the women they are in contact with. The timing of a woman’s visit to a service provider also limits the provider’s ability to provide quality counselling on a range of contraceptive methods. When a woman visits a private general practitioner, she has usually already made a decision regarding the method she wishes to use. For example, women will buy a contraceptive injection or IUD from a drug shop, then visit a private provider for the injection or insertion. One lady health visitor interviewed said that she cannot give a woman contraceptive advice before pregnancy because her first contact with the woman is during antenatal visits, once the woman is already pregnant. Despite these limitations reported by providers, the team noted a number of missed opportunities for birth spacing counselling. Most providers reported that they only discussed birth spacing issues with women if they specifically came for such advice. Providers do not perceive the importance of discussing birth spacing with women who consult for other medical services. Even when discussing other areas of reproductive health, providers appear reluctant to bring up the subject of birth spacing and contraception. For example, counselling on birth spacing for women with complications of induced abortion, or for women in the post natal period, was found to be superficial if provided at all. The quality of commodities available in the private sector was difficult for the team to determine. A recent assessment conducted by the Ministry of Health (1997) identified a number of issues in relation to the quality of contraceptive products, including the availability of hormonal methods for which safety and efficacy had not been adequately tested. The current assessment identified the labelling of products to be a factor limiting the appropriate 37
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ANNEX I Summary of Reproductive Hea
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Agency UNHCR Programme Local Reinte
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ANNEX III Summary Reproductive Heal
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Assuming that: (1) TFR in 1990 was
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