Sexual and Reproductive Health Services

1. Sexual and Reproductive Health Services The Changing Policy and Programme Environment Marge Berer Editor Reproductive Health Matters

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. Implementing ICPD at country level • Nigeria -- Adolescent health policy • FGM banned in 1/3 of African countries • South Africa -- new safe abortion law, free antenatal care, right to contraception on request over age 14 • India -- Reproductive and Child Health Programme • Brazil -- National Commission on Population and Development • Argentina -- National Programme for Sexual Health and Responsible Procreation; B.A. Programme for Responsible Sexuality

4. 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)

5. 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 (+ cut costs)

6. Health sector reforms bring changes: • Changes in financing mechanisms (balance between tax revenue, social/private insurance, user fees/out-of-pocket payments, external aid, external loans) • Changes in priority setting mechanisms (e.g. which diseases get priority, which services are offered, preventive vs. curative care, primary vs. tertiary care, which regions or population groups get priority) • Changes in organizational mechanisms (sector-wide approaches, decentralization, logistics and supply systems, role of the state in service provision)

7. Context • Political context (nature of governance, ideology of the party in power, bargaining position in the international setting, political power exercised by health professionals etc.) • Economic context (financial stability or crisis, external debt, structural adjustment, per capita income/poverty level, gap between rich and poor) • Historical context (transformation in political structure, role of the state in health and social development )

8. Interaction between health sector reform and SRH services TK Sundari Ravindran • Level of economic development – high, medium, low • Health systeminto 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

9. 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. ***** Current reformers propose to keep SRH services to a minimum package based on a flawed form of priority setting that has placed SRH lower than many other pressing health problems, including many to which SRH is intimately connected.

10. Why do SRH advocates and HSRers need to dialogue? (2) 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.

11. 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, though each of may result in serious complications. At the same time, there are chronic and debilitating disorders, and serious, potentially fatal diseases and conditions. • They require a broad range of skills, but most could be provided at primary level by trained mid-level providers, e.g. midwives, nurse-practitioners and GPs. Specialists are required for serious conditions and major complications.

12. Particularities • SRH services are governed by a range of laws, policies and regulations which may (be designed to) create (insuperable) barriers to obtaining services. • Services may be provided in a clandestine or unregulated manner, by untrained providers, involving sub-standard treatment, abuse and negligence, under-the-table payments, the police, the courts and prison sentences.

13. 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. abortion, or to receiving them, 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. • Deep-rooted attitudes towards sexuality and child bearing (e.g. pronatalism) affect health service providers, health policy-makers, health economists, and the community.

14. Ultraconservative and religious opposition to SRH services • Bush government • Global Gag Rule – to de-fund NGOs who “perform or actively promote abortion as a method of family planning” • War on teen sex/pregnancy = war on drugs = war on abortion • Vatican and other ultraconservative religious (Catholic, Muslim, Buddhist, Christian) and independent groups • 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 • opposition to all forms of assisted conception • Countries with lack of separation between church, state and political parties, religious courts.

15. Country cases (forthcoming in RHM) • India: high unmet need for reproductive health services, especially among the poor; also limited choice of methods for fertility regulation. • China: health reforms in China have centred on cost recovery, with fee-for-service revenue replacing public budget funding; the share of public funding for maternal health services was reduced greatly, forcing an increasing proportion of pregnant women to pay for deliveries and treatment of pregnancy-related complications out-of-pocket, as most had no health insurance to cover these costs • The Philippines: devolution of health services has had mixed results for women’s health, for example:

16. Philippines: women’s health services since devolutionLakshminarayanan R. RHM 2003; 11(21). Draft. • Mixed results in terms of equity, quality, effectiveness, efficiency and sustainability. Gains in health outcomes relatively stagnant overall. • Workload of midwives increased significantly. • Benefits package of National Health Insurance Plan skewed against some key women’s health issues; low coverage of indigents and informal sector affects women disproportionately. • Many women access private health services, which are unregulated. • Escalating costs of drugs for RTIs. • Family planning services remain primarily donor funded.

17. Philippines: women’s health services since devolution(2) • No clear, central vision for women’s health; centre unable to negotiate effectively 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.

18. Priority setting process is problematic: The measures used by health economists to set priorities are not the only valid ones or even the most important. • Recognise the unique importance of sex and reproduction to the human race and for its healthy continuation. • Meet public health goals -- although prevention of HIV MTCT is cost-effective, many infants will not survive without their mothers (Burkina Faso). • Justice – While prevention of mother-to-child transmission of HIV may be cost-effective, post-exposure prophylaxis after rape in high HIV prevalence settings is a form of justice following a crime that is unlikely to be punished. • Recognise human rights, gender equity and importance of advocacy for the needs of vulnerable and less visible groups.

19. Get priority-setting right Burden of disease measures are inadequate in the face of the particularities of sexual and reproductive health and contain hidden biases: • Disease is not the only health condition that deserves to be taken into account. Measuring only disease hides the contribution to health of averting disease through preventive services and the cumulative effect of co-morbidity with other conditions, e.g. pregnancy-induced hypertension. • From a different perspective but with the same effect, privatisation has been shown to favour curative services over preventative services, and tertiary care over primary care. • Take context into account in assessing burden of disease; otherwise, weighting will favour developed countries (Allotey & Reidpath 2002).

20. 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. • The MDGs and the few indicators chosen to measure them are the safe leftovers of political negotiation and do not erase other important goals and indicators, or international agreements, that came before them.

21. Policy and management issues • Ensure the health of health workers, who are mostly women, and who may also have HIV and sexual and reproductive health problems. • Take account of the impact of reforms on health sector workers. Recognise that public health service workers often also work in and provide private sector services (Pelto & Ramachandar). Confront the problem of migration to the private sector and to more developed countries as a major reason for poor public health services. • Recognise other dimensions of institutional transformation e.g. the need for communications systems between managers/staff and participatory decision-making systems, so staff feel accountable for their actions and spending (Klugman B, McIntyre D, 2002).

22. A gender lens on financing • Costs driving reforms but SRH cost-saving possible: drugs, tertiary vs. primary care, ob/gyns vs. mid-level providers, • Cuts in essential spending = poorer outcomes and reduced equity for women = greater burden of home care. • Paying out of pocket for health services = most regressive option, worse for women. Focus on meeting SRH needs of poorest women, adolescents, marginalised groups. • Women least supported by social/private insurance schemes, especially those based on risk (pregnancy/ birth are a risk = pay extra) rather than need. • Link priorities to budgets. Ring-fence funds for health promotion and other agreed national priorities.

23. 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 = dependency. • Accountability of donors -- to whom? • Loans, even at 0% interest = still 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. • Contract culture (bilaterals) distorts role and purpose of academia/ NGOs, who are now employees of donors. • Global funds = consolidation of finance, control of disbursement into fewer hands.

24. Questions to think about during the rest of the course: • Reforms, yes -- but what kind? • Why “scarcity”? • Is the aim national autonomy and control?

25. Recommendations • Support dialogue between SRH and reformers at national, regional and international level. Include all stakeholders. • Focus first and foremost on the woman/child/man who requires the health services. Focus equally strongly on those who provide the services. • If you want to know where women’s health advocates get their information in the absence of the kind of data you are used to, don’t dismiss the problem; ask them to take you to the grassroots so you can see for yourself what they’re talking about.

26. … Thank you very much