Sexual and Reproductive Health Services

1. Sexual and Reproductive Health Services Health Sector Reforms Dr. Babar T Shaikh The Aga Khan University, Karachi

2. Sexual and Reproductive health (SRH) … reproductive health care is defined as the constellation of methods, techniques and services that contribute to reproductive health and well-being through preventing and solving reproductive health problems. It also includes sexual health, the purpose of which is the enhancement of life and personal relations, and not merely counselling and care related to reproduction and sexually transmitted diseases. (ICPD Programme of Action, 1994)

3. 1980-90s: what else was happening in global health? • Infant and under-5 mortality • STD/HIV epidemics • Tropical diseases • Malnutrition, anaemia and famine • Primary health care programmes (1980s) • Health sector reforms (1990s)

4. Reasons for reform of health systems • Fragmentation and duplication of funding and services • Distortions in allocation of resources • Poor management systems and organizational capacity • Improve accountability and local "ownership" • Improve organizational sustainability • Increase responsiveness to local needs • Improve efficiency, quality and effectiveness • Promote equity and cut costs

5. Health sector reforms bring changes: • Changes in financing mechanisms • Changes in priority setting mechanisms • Changes in organizational mechanisms

6. Interaction between health sector reform and SRH services • Level of economic development – high, medium, low • Health system into which reforms are introduced – predominantly public, mixed or predominantly private • Nature of SRH services within that system – range, quality and coverage of services • Distribution of SRH services by public vs. private sector • Distribution of SRH services by source of financing • Nature and scope of reforms being introduced

7. Why do SRH advocates and reformers need to dialogue? SRH advocates have concentrated on getting the breadth of women’s and men’s SRH needs recognised, working for a broad range of SRH services, improved quality of care, improved provider-patient relations and the removal of political and other barriers.

8. Why do SRH advocates and HSRers need to dialogue? SRH advocates have failed to address issues of health system management, organization, finance and regulation adequately. Reformers have failed to understand the importance of principles of public health, gender equity, poverty reduction and alleviation, multi-sectoral approaches and human rights to the achievement of health -- not just finance, management and organizational principles.

9. Characteristics of sexual and reproductive health needs and problems • They are inter-connected and often cumulative. • The majority of those needing services are not ill – e.g. for family planning, normal pregnancies, deliveries and abortions. • They require a broad range of skills, but most could be provided at primary level by trained mid-level providers.

10. Influence of non-health-related attitudes • Discriminatory views on marital status, youth, race and ethnicity, class and gender often influence who receives and who provides services. • Stigma is often attached to providing services, e.g. STIs and HIV. • Services are often denied (e.g. to young single women, sex workers) in spite of the public health implications, because of women's status and role in society and family. • Attitudes towards sexuality and child bearing affect health service providers, health policy-makers, health economists, and the community.

11. Conservative & Religious opposition to SRH services • opposition to condoms to prevent HIV transmission • opposition to “artificial” methods of contraception • abortion even to save life of woman not acceptable; fetus has right to life from conception

12. Reproductive health services since devolution • No clear, central vision for women’s health; • Local commitment to SRH programmes uneven. • Political reluctance at local level to deal with controversial issues. • Differences based mainly on local leadership commitment, financial status, size of the local government unit, pre-devolution state of health system.

13. Millennium Development Goals • Achieving sexual and reproductive health should be treated as a prerequisite for achieving the MDGs on maternal mortality and HIV/AIDS; • Use a range of sexual and reproductive health indicators under different goals -- e.g. universal sex and health education under the education goal; • Make health goals poverty-linked so they can only be achieved by reducing poverty.

14. Role of donors: major changes, major effects • Fragmentation and conflict often due to differing political and donor agendas. • Donor aid not guaranteed for long-term. • Accountability of donors. • Loans, even at low interest, means more debt. • Kickbacks to donor countries (use our consultants; buy our goods) mean money flows are reversed; development aid as a growth industry and neo-colonialism.

15. Questions??? • Reforms: what kind? • Why “constraints”? • What’s the ultimate aim?

16. Recommendations • A dialogue between SRH and reformers at national, regional and international level, including all stakeholders. • Focus on the woman/child/man who requires the health services. Focus equally strongly on those who provide the services.