Cost and Benefits of Approving Male Sterilization Policy

in

Public Health Sector

For

Reducing Maternal Mortality

In partial fulfillment in the Course

PAf 201 (Political Economy)

Submitted to Prof. Rolando T. Bello,

Institute of Community Education, College of Public Affairs
University of Philippines Los Banos

Submitted by:
Hla Myat Tun
2009-2010 First Semester
2008-96531

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I. Introduction

The total population of Myanmar is estimated at 55.4 millions with annual growth rate of
2.02 percent in 2006.1 Population growth is not a problem and population control is not
prior to the country but there is a high incidence of Maternal Mortality Ratio (MMR)
because of inadequate birth spacing programmes. The government has committed to
achieve the objective of Millennium Development Goals (MDGs) No. 5: Reduce
maternal mortality by 2015. Supportive men’s role in reproductive health and birth
spacing programmes must be emphasized to meet the targeted aim within 6 years. In the
public health sector, birth spacing services have long been offered mostly through the
existing outlets of maternal and child health centers. These centers were only visited by
women and mother. This may be due to the fact that public policy decision makers,
development, population and health agencies have largely ignored men’s participation in
birth spacing.

The government provides birth spacing services in health centers since 1991. The
contraceptive prevalence rate (modern methods) among married women in reproductive
age (15-49) is only 32.8 percent in 2001.2 The government aims to achieve a better
quality of life for all, by giving attention to the improvement of reproductive health
status. However, male’s access to contraception and roles or participation has not been
stipulated in existing policies. The high-level decision makers have not considered the
participation of male in birth spacing activities or programmes to reduce MMR. Men are
not conscious of their responsibility and birth spacing programmes. The general
perception and knowledge among men on the need for contraception is primarily for the
prevention of HIV/AIDS and Sexually Transmitted Infections (STIs). No appreciation on
the use of condom for birth spacing purpose. Generally, men have yet to be informed and
educated on sexuality, reproduction, and use of contraceptive. They also need the
confidence and guidance on how to share responsibility with their partners in the goal of
reducing MMR. Political commitment, supportive policy and programmes are to enhance

1
Statistical Year Book 2006, Central Statistical Organization, Ministry of National Planning and economic
Development, The Government of the Union of Myanmar
2
UNFPA Statistics < http://www.unfpa.org/worldwide/indicator.do?filter=getIndicatorValues>, (9
November 2008)

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male participation and birth spacing programmes particularly with the use of sterilization
among married population. The role Ministry of Health is important since maternal health
was seen as positive externality in the health market. Dissemination of information,
education, communication and providing services for male participation in birth spacing
programmes are the most important component of the role of government to the
implementation of the policy.

II. Statement of the Problem

In Myanmar, abortion is illegal but the rate of occurrence of this practice is significant.
This tends to be the leading cause of maternal mortality because of unintended
pregnancies. At least 50 percent of maternal death and 20% of all hospital admission
have resulted from complication of unsafe abortion. The lack of access to contraceptive
methods and the insufficient male support in birth spacing are the major factors of
increasing abortion rate across the country3. The use of illegal and unsafe abortion
methods are in large part the result of unmet contraceptive need among women.
Maternal mortality rate is significantly high that must be reduced if not totally eliminated.
It is estimated that one in three deaths related to pregnancy and childbirth could be
avoided if all the people in community had access to contraceptive services. The unmet
need for contraception is estimated at 16.8 per cent among married population. 4 The
government set a target of 56 per 1000 live births on MMR by 2015 based on 2001 data.
The MMR was 361 per 100,000 live births in 2005.5 One study found that the smaller the
health institution in an area, the higher the abortion rate in the surrounding area due to
lack of access to contraceptive methods.

The Fertility and Reproductive Health Survey (FRHS) 2001, found that 20% of women
did not want to get pregnant but were not using contraceptives. And thus at risk of
pregnancy 14% of them wanted to limit their births. This suggests the lack of acceptable
long-term methods of contraception. To reduce MMR within 6 years is challenging task.
3
Fertility and Reproductive Health Survey (FRHS), 2001. Preliminary Report, Ministry of Immigration and
Population, Yangon 2003
4
Nationwide Cause Specific Maternal Mortality Survey 2004-2005
5
Fertility and Reproductive Health Survey (FRHS), 2001. Preliminary Report, Ministry of Immigration and
Population, Yangon 2003

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Thus, male has a significant role in saving women’s life by taking responsibility in birth
spacing among married population.

Both men and women make important contributions and co-equal responsibility in
reproductive health. However, birth spacing programmes have been tended to focus on
women alone in the country. Men participation in birth spacing has been neglected even
though birth spacing methods have been available in public sector since 1991 and male
involvement programmes in reproductive health have been initiated since 2004.
Nevertheless, there is high demand on contraceptive services for married women and
men. Limited access to birth spacing services to women and men lead to increase the risk
of unsafe abortion and maternal death.
Knowledge on condom increased to prevent transmission of HIV/AIDS and sexually
transmitted infections for use by men with sex workers; they are not seen as a birth
spacing methods. There is a gap between male shared-responsibility in existing birth
spacing programmes. Major roles for the government interventions to expend male
involvement programmes for birth spacing are:
Political commitment – High level decision makers have not yet to take the necessary
steps to set up male involvement in existing programmes and actions.
Policy obstruction – Outdated policies and regulations obstruct male
and female access to contraception such as strict eligibility criteria for
obtaining sterilization. Female sterilization is only available after
approval by a sterilization board. Male sterilization is restricted by law
to those men whose wives have been approved but are unable to
undergo sterilization for medical reasons.

III. Present and Past policies on Contraceptives

The National Health Policy, which changed pro-nationalist policy to health-oriented

policy to integrate birth spacing with the aim of improving the health status of women
and children and raising awareness on birth spacing in the community, was developed
with initiation and guidance of NHC in 1993.

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Myanmar’s Reproductive Health Policy was formulated in 2002 and approved by the
Ministry of Health in 2003. The government is aiming to achieve a better quality of life
for all, by giving focus attention on the improvement of reproductive health status. The
policies for birth spacing are stated as;
 Daily combined contraceptives, progesterone-only-pills, three-monthly injectable
contraceptives, Intra-uterine devices and condoms will be available and accessible
to all individuals of reproductive age and provided with informed choice.
 Other contraceptive methods such as monthly injectable and implants may be
introduced to broaden choice and to improve quality of birth spacing services
after considering evidenced based information, the needs of the community and
the cost effectiveness.
 Easy access to sterilization will be encouraged for those women requiring
permanent contraception on medical ground.
 Introduction of emergency contraceptive methods into the existing birth spacing
services will be considered.
 Service providers in public and private sectors will be trained in the provision of
quality birth spacing services.
 Mechanism will be sought to review and revise the existing rules and regulations
periodically, impacting the availability of commodities to ensure that safe and
effective birth spacing methods are easily available

Men’s role in reproductive health was stated as follow in Myanmar Reproductive

Health Policy:
 Awareness of critical reproductive health needs and the importance of
enhancement of men’s reproductive health status in improving the reproductive
health of the family will be raised.
 Men’s role in promotion of birth spacing service, prevention of transmissions of
RTI/STI and in supporting reproductive health service for the family and the
community will be strengthened.
Access to male contraception was not mentioned in existing policies even though
men’s role in reproductive health is growing and their participation specifically in birth

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 spacing for reducing MMR is becoming an important agenda for the country. On World
Population Day 2008, the Minister of Immigration and Population in Myanmar stated
“In our country, each and every family has the right to decide their family size based on
the choices of each individual and couple.” According to his statement, having the right
to decide the desired family size, there have to be provided with choices for both male
and female contraceptive methods including male sterilization which is the only one
option for long-term or permanent methods for married population. Besides, for
reducing MMR, the women’s health movement has to be supported by men’s effective
reproductive responsibility. However, access to male contraception was not mentioned
in existing Myanmar Reproductive Health Policy.

V. Policy Alternatives for reducing Maternal Mortality Ratio

There are several policy alternatives to reduce unwanted pregnancies and unsafe
abortions which lead to maternal deaths resulting from unwanted births. They are;
1). Allow abortion to women (both married and unmarried women) with specific
criteria. Although it seems to take place in Buddhism country, and also with culture
and religion, it can contribute in reducing unsafe abortion in the community. Specific
criteria will need to have access abortion for instance; when the women were being
raped, to preserve physical health of women, to preserve mental health, etc..;.
2). Allow voluntary Male Sterilization to married men by providing easily accessible
to services and reduce strict criteria for obtain vasectomies. It can be effectively
address the current issues regarding unwanted/unplanned pregnancies in the
community especially married couple living in rural and remote areas and they
already have enough children and needing effective contraception.
3). Provide Women Sterilization with least criteria to mothers who already have
finished child bearing by removing strict policies and regulations. It can provide the
needs of the women in an effective way and also the way of encouraging women for
their rights to decide their desired family size.

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VI. Analysis on Cost and Benefits of Policy Alternatives

Cost analysis and Benefits analysis to individual and government of the policy
alternatives are presented in tables.

VI. 1. Cost Analysis for the Policy Alternatives

Input costs can be classified in four pairs of terms commonly used to classify costs: direct
and indirect costs, joint and non-joint costs, average and marginal costs, and capital and
recurrent costs.
1.) Direct and indirect costs
Direct costs correspond to resources that can be explicitly identified with a service or
product. Indirect costs cannot be directly identified with a service or product, but are the
costs of supporting the direct activities. These costs typically are incurred to administer or
evaluate programs.
2.) Joint and Non-joint costs
Non-joint costs which are cost of resources that are used only for one client, and are
either fully consumed or thrown away at the end of the visit. Joint costs can be defined as
the costs of clinic resources used by more than one client.
3.) Average and marginal costs
Average cost is defined as the total cost divided by the number of units of output,
whereas Marginal cost is the additional cost required producing one more unit of output.

4.) Recurrent and capital costs

The key issue in distinguishing between recurrent and capital costs is the life expectancy
of project inputs. “Recurrent costs” usually are defined as the costs associated with inputs
that will be consumed or replaced in one year or less, while “capital costs” are defined as
the annual costs of resources that have a life expectancy of more than one year, such as
equipment or buildings. Recurrent and capital costs may be either direct or indirect.
Cost Analysis for Policy Alternatives is shown in table 1.

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 Table.1. Cost Analysis for Policy Alternatives
Atternative
Classification of Costs Alternative 2 Alternative 3
1
Direct and indirect costs
staff salaries (surgeons, assitant doctor to surgeons,
nurses, programme administrators, etc.,) 3 1 3
Cost of method 3 1 3
Infrastructure 3 1 3
Joint and Non-joint costs
staff salaries (surgeons, assitant doctor to surgeons,
nurses, programme administrators, etc.,) 3 1 3
Medical supplies (e.g. cotton balls, antiseptic solutions,
and utensils used for operation) 3 1 3
Average and marginal costs
no. of operation performed during working hours 1 3 2
no. of operation rooms equipped to provide operation 3 1 3
provided no. of counseling visits pre-operative visits,
follow up visits and post-operative visits 3 1 2
no. of hospitalization days after operation 3 1 3
provided no. follow up after operation 3 1 3
medical materials and supplies 3 1 3
office supplies, utilities and staff salaries 3 1 3
clinic space, operating room equipment and vehicle for
transportation 3 1 3
training and refresher training for staffs 3 2 2
Total 40 17 39
3 – High; 2 – Average; 1 – Low

According to the results of cost analysis, policy option (2): Allow Male Sterilization to
married men has the least cost comparing to the other two options. Thus, allowing male
sterilization is the favorable option because it does not need new infrastructure and
setting. It can be performed with minimal facilities (does not mean poor and inadequate
facilities) and staff meaning recruiting new staff or constructing new infrastructure are
not necessary. It needs dedicated space for counseling and surgical procedure, utilities,
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and adequate and well-maintained equipment which can be done and provided by sharing
existing settings and facilities. Male sterilization services can suit almost any setting,
from a doctor’s office to a hospital or mobile teams can visit towns and villages.
Therefore, it can be assumed that the cost is practically low for the government and the
individuals.

V.2 Analysis on Benefits of the Policy Alternatives

Analysis on Benefits to individuals and government of the policy alternatives are shown
in table.2.

Table.2. Analysis on Benefits of Policy Alternatives

Alternative Alternative Alternative

Benefits to individual and government
1 2 3
Reduce unsafe abortion 1 3 2
Reduce unwanted pregnancies 1 3 3
Reduce maternal death 1 3 2
Less Surgery risk 1 3 2
Less post-operation complication 1 3 2
Simplicity for process 1 3 1
Save Time consuming 1 3 1
Effectiveness 2 3 3
Less conflict with religion, cultural and social
norms 1 2 3
Encourage men's participation 0 3 1
Promote Gender Equality 0 3 1
Suitability to any health setting (from doctor's
office to hospital) 1 3 1
Total 11 35 22
0 – None, 1 – Low, 2 – Medium, 3 - High

As shown in table.2, policy alternative 2 (male sterilization) has the highest benefits
among the 3 alternatives. Even though all of the policies can reduce unsafe abortion,
unwanted pregnancies and maternal death, they have different levels of benefits. Male
sterilization has more benefits compare to other two options regarding to religion, culture

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 and social concerns. Besides, for the individuals, there are several negative social and
health consequences on women for policy alternative 1 and 3.
The followings are the negative affects of the policy options 1 and 3;
• discrimination (option 1)
• being misunderstood by the society (option 1)
• infertility problems (option 1)
• conflict with religion, cultural and social norms (option 1)
• long-term side effects (option 1)
• encourage male irresponsibility in reproductive health
• against providing gender equity and equality in reproductive health
• neglect men’s needs for contraception
• encourage putting burden on women for contraception

According to the analysis of cost and benefits, male sterilization, which has the least cost
and high benefits, is the most appropriate for every couple who no longer want more
children. Many men are interested in contraception and want to take responsibility in
family planning or share responsibility with their partners. According to Family and
Reproductive Health Survey 2001 Myanmar, the percentage of male sterilization is 1.5%
and which is higher than usage of condom 0.3% among married population even though
male sterilization is illegal. Besides, male sterilization, specifically No-scalpel
vasectomy, is the most cost-effective contraceptive methods. The one-time procedure
continues to protect against pregnancy throughout a couple’s reproductive years. Within
several years, vasectomy becomes more economical than other methods—particularly
methods that require continuous supplies, such as pills or condoms. An analysis in the
United States compared the costs of various contraceptive methods, including the cost of
supplying the method, the cost of treating complications and other medical events, and
the cost of prenatal and delivery care for pregnancies when a method fails. After just two
years of use, vasectomy cost less than any other method. An analysis in Iran produced
similar results: When all program costs were considered, vasectomy was the cheapest
method, on average, per year of contraceptive protection. Because vasectomy is so cost-
effective, offering the method might help programs save money—which could be used to

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support services for others. According to Population Report of Johns Hopkins,
Bloomberg, School of Public Affairs, June 2008, vasectomy costs one-quarter to one-half
as much as female sterilization women relying on female sterilization worldwide is seven
times more than the number relying on vasectomy.

VI. Experiences of Male Sterilization programmes in Asian countries and

possibilities in Myanmar

In Asia there are several countries engaging male sterilization as one of the contraceptive
options. Most of these countries have legalized male sterilization policy and programmes
and they have some constraints while implementing programmes. In all countries,
vasectomy was supported by national reproductive health programs and participation of
male is rarely observed due to various factors such as, ignorance, fear, misconceptions
and lack of information at the beginning of the programme interventions.
In India, one of the main purposes of the vasectomy programmes is to control
population. Thus the Indian government provides cash incentive to men as one of the
programme promotion approaches. So the Indian Government has cost for the cash
incentives. According to PathFinder.com, every Indian male who undergoes male
sterilization were provided with post-operative counseling and medicines, and given the
1100 rupee incentive. TIMES ONLINE reported on March 21, 2008 that Indian
Government offers firearms permits for vasectomy. In India, Shivpuri district in the state
of Madhya Pradesh, an overpopulated area renowned for its machismo culture, has
started to offer fast-tracked gun licenses for those who agree to be sterilized. Manish
Shrivastav, the administrative chief of Shivpuri district and originator of the lateral
thinking behind the plan, said “This is a state with a high number of crimes, where people
like to keep rifles. It also has a low level of vasectomies because of a perceived notion of
manliness. I decided to match that with a bigger symbol of manliness — a gun license. It
has been a success.”

In Thailand, physicians performed vasectomies monthly in rural areas via a mobile

vasectomy campaign under the government administration and programmes. The
campaign consisted of motivation and service teams. Private sector groups also involved

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with mobile vasectomy included the Population and Community Development
Association and the Thai Association of Voluntary Sterilization. The Population and
Community Development Association (PDA) of Thailand used a modified commercial
marketing technique to inform people about its free vasectomy program. It has modified
the 4 Ps marketing technique (product, promotion, program, and pricing) of the business
sector to carry on promotion activities. Promoting specialists design and present posters,
leaflets, and advertising spots on radio and TV. Other promotion activities include the
PDA vasectomy festivals on Australian and Chinese national holidays, May Day,
Mothers' day, and King's birthday. This PDA program also operates out of clinics and
mobile vans so the clients can seek vasectomy services when and where they wish. Its
marketing technique has allowed it to surmount earlier obstacles and misconceptions
about vasectomy in Thailand.

In Philippines, Reproductive Health Bill has been pending for many years because of the
religious barriers and being republican country. Religious barrier is the most difficult to
handle for the government. As a republican country, agreement from the many political
leaders is necessary for approving bill. As results, from negative side, it can delay the
progress of decision making for such bill which can really effective for the people.

In Myanmar, as mentioned above, population growth is not a prior problem, thus

Myanmar government will not need to provide the cost for cash incentives. The issues of
cash incentive may not exist in Myanmar male sterilization programmes framework.
Disseminating information on male sterilization can be provided through existing health
education and promoting programme supported by National Health Programme. Several
nationwide campaigns had been promoted and have significant successes in all
campaigns such as mass measles campaign, polio campaign and vitamin ‘A’ campaign
etc. And also medical missions, medical touring etc, have been organizing across the
country led by ministry of health. These mobile clinics to rural and remote areas are
implementing very often in every places of the country. Therefore, male sterilization
programme can be included in these existing programmes without adding much cost for
the government. On the other hand, people from the areas will not have travel cost, time
for the travel and loss time for their work. These mobile programmes can be effectively

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performed in the areas without costly for both individual and government, called win-win
situation.
Myanmar, as a Buddhism country, there are no religious barriers for any contraceptive
programmes unlike other countries such as Philippines (Catholic country). Buddhism
community has no restrictions for any contraceptive methods including male sterilization
but there are myths on male sterilization like other countries. However, these misbelieves
can be corrected by information, education and communication (IEC) programmes which
are currently implementing supported by National Health Programmes together with UN
and International NGOs across the country.

According to the governing system, Myanmar government can easily decide to approve
policy and implement such programmes because of less processes for approving bills for
instance, as mentioned above; Myanmar Reproductive Health Policy was formed within 1
year which was formulated in 2003 and approved in 2003. Reducing MMR to targeted
aim within 6 years becomes an issue need urgent attention for the government. It means
the government has not much time for making decision, approving and implementing
processes. For this reason, as Myanmar government, male sterilization programmes with
the intension of reducing MMR can be implemented in short time compare to other
countries and these programmes can contribute to reduce maternal mortality.

According to Detailed Analysis Report (2004) of Myanmar Fertility and Reproductive

Health Survey 2001, the population of married women (40-49) in rural areas is 22.8%.
The women in that age group (40-49) can be assumed as they have finished child bearing
and already have their desired family size. Thus, their husband can undergo male
sterilization. Men those are only in rural areas are 22.8% of total population. It means that
estimated 22.8% of men in the country can have benefits if male sterilization was
legalized and promoted as contraceptive method for married population. But it can
contribute as an effective method for reducing maternal death due to the unwanted and
unplanned pregnancies among married population. As mentioned above, at least 50% of
maternal death and 20% of hospital admission resulting from complication from unsafe
abortion due to lack of long-term contraceptive methods among married population. By

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approving male sterilization for contraception, maternal death rate can be reduced
estimated up to 50%. As a result, targeted MMR will meet by 2015.

VII. CONCLUSION

Male-involvement elements are needed in reproductive health programmes in all stages

of development--from the early stages in which community and political support is
critical to later stages that focus on expanding and improving services. Specifically,
men’s participating in contraception is the key to improve women’s health and health
status of the country by reducing MMR. There is increasing evidence that male
sterilization programmes can be effective in improving female reproductive health.
Men’s issues in contraception should not be ignored in the public health sectors because
men are lacking need for contraception even though they have aware of their
responsibility for women’s health.

The government has been implementing contraceptive programmes collaborating with

UN agencies and internal organization since 1991 but reducing MMR is challenging.
Myanmar can not meet targeted goal without men’s support in women’s health. To have
men’s effective support, men have to be provided with supportive policy and
programmes. Male sterilization is the only best option for effective long-term
contraception both for male and female but has not considered as one of the birth spacing
choices for married population. Male sterilization has been ignored for many years and
even though there are no significant barriers regarding to cultural and religion. Myanmar
government can easily approve, promote and provide information and services within
shorter time compare to other countries. This also is the best option for both government
and community regarding to cost and benefits of the policy and programme.

Thus, it is the time to be aware of men contraception and the government has to provide
men with supportive policy and programmes with the intension of reducing MMR which
is the consequence unsafe abortion due to the lack of long-term contraception among
married population. And it is also the best way to promote male involvement by sharing
responsibility in family health which equalizes gender inequality in contraception. In

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addition, this is the best option to reduce MMR within 6 years as the government is
facing with challenges to improve maternal health in the region.

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REFERENCES

Books

1. Myanmar Reproductive Health Policy, Maternal and Child Health Department,

Ministry of Health, the Government of the Union of Myanmar
2. Myanmar Fertility and Reproductive Health Survey, 2001, Preliminary Report,
Ministry of Immigration and Population, Yangon, Myanmar 2003
3. World Health Organization South-East Asia Regional Office (WHO/SEARO)
2004. Family Planning Fact Sheet: Myanmar and Birth Spacing: An Overview
4. Nationwide Cause Specific Maternal Mortality Survey 2004-2005
5. Statistical Year Book 2006, Central Statistical Organization, Ministry Of National
planning and Economic Development, The Government of the Union of Myanmar
6. In Their Own Right, Addressing the Sexual and Reproductive Health Needs of
Men World Wide, The Alan Guttmacher Institute 2003
7. Male Involvement in Reproductive Health, Including Family Planning and Sexual
Health, UNFPA Technical Report, No. 28
8. It takes 2, Partnering with Men in Reproductive and Sexual Health, United
Nations Population Fund
9. Contraception: An Investment in Lives, Health and Development, 2008 Series,
No.5. United Nations Population Fund
10. Men: Key Partners in Reproductive Health, Bryant Robey, Elizabeth Thomas,
Soulimane Baro, Sidki Kone, and Guy Kpakpo 1998
11. Absent and Problematic Men: Demographic Accounts of Male Reproductive
Roles, Margaret E. Greene & Ann E. Biddlecom, 1997 No. 103, Population
Council
12. Population Report of Johns Hopkins, Bloomberg, School of Public Affairs, June
2008
13. Methods for Costing Family Planning Services, Barbara Janowitz & John H.
Bratt, United Nations Population Funds and Family Health International, 1994

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 14. Responses to the list of issues and question with regard to the consideration of the
combined second and third periodic report by Convention on Elimination of All
Forms of Discrimination against Women (CEDAW), 14 October 2008

Electronic Sources

1. United Nations Population Fund

www.unfpa.org

2. United Nations Population Fund, Myanmar Country Office

http://myanmar.unfpa.org

3. United Nations Population Division

http://www.un.org/esa/population/unpop.htm

4. Population Reference Bureau

http://www.prb.org

5. JOHNS HOPKINS BLOOMBERG, Scholl of Public Affairs

http://www.popline.org
6. Times Online

http://www.timesonline.com/

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