Where Do We Go from Here? Entry Points for Action

1. Where Do We Go from Here? Entry Points for Action Tom Merrick, World Bank Institute

2. How Do We Deal With Changes? • New vision -- reproductive health and rights, gender, poverty reduction • New challenges -- new and unfinished agendas, going beyond care • New program environments -- • reforms, sector-wide funding, • economic crises • Recognize changes as challenges as well as opportunities for RH • Tools to address challenges -- policy analysis, service matrix, costing and priority setting, benefit incidence, etc.

3. We’ve seen that there are many actors • Politicians • Economists and financiers • Consumers • Civil society institutions • Providers, their unions • Donors • You

4. They bring many viewpoints: • Politicians want to be re-elected • Economists follow the money • Labor unions protect jobs • Consumers want good services • Civil society institutions are concerned about rights and equity • You (I hope) are concerned about the effects of reform on reproductive health and rights

5. Why should you be concerned about reforms? Many common goals: • More equity in health and health care • Improved gender equality • Address key public health needs • Respond to consumer demands • Financial and organizational sustainability • Better coordination of donor roles • So what’s the problem?

6. Design & implementation of reforms may help or hurt reproductive health • Financing schemes should free resources for poor, but could limit access to poor women; insurance may not cover repro health • Decentralization gives community more say, but women may not have voice • Private providers may be more interested in profit than serving the poor • Reorganization may weaken central government support of reproductive health and rights, reduce focus on cross-cutting factors

7. How to address reproductive health and rights (RHR) in reform settings? • Evidence base on how health reform initiatives affect RHR is weak • Identify key points of intersection between reform and RHR • Assess impacts through operational research/monitoring and evaluation • Mitigate adverse effects; strengthen positive ones

9. A lot of common ground: • Agree to focus on outcomes • Agree on need to improve performance: • equity, efficiency, sustainable financing, quality, accountable to clients • Agree on need for evidence-based policy and program design (burden of disease, good indicators, etc.)

10. Also differences: • On priorities -- tradeoffs between equity and efficiency • On how to set priorities -- who decides daly weights • On how to manage -- donors desire for sectoral approach • On boundaries -- what’s included in health systems, reproductive health

11. Pathways to Improved Health Outcomes Health sys-tem & other sectors Government policies & actions Households/ Communities Health outcomes Health service supply Household behaviors & risk factors Health reforms Repro-ductive health out- comes Other parts of health system House-hold resources Actions in other sectors Supply in related sectors Community factors

12. When we disagree, what to do? • Say it’s too complicated and leave it to the economists, or • Close our minds to viewpoints we don’t like and go about our business, or • Get a place at the table, make sure our allies are there, understand the opposition and counter with evidence-based remedies that protect reproductive health and rights, and • If necessary, hire our own economists

13. Evaluation criteria, tools • Health impact: reduced burden of disease • Equity: how do reforms affect access of poor women and children (DHS tabs, benefit incidence analysis); do reforms reduce financial risks of poor families? • Quality: how do reforms affect performance of health providers? • Efficiency: is public sector spending its money on the right things, reducing waste? • Sustainability: effect on donor dependency?

14. WAYS TO MITIGATE THE RISKS TO REPRO HEALTH • Involve all stakeholders (including providers) in setting goals/defining the reform process • Pay close attention to standards, regulation and accountability mechanisms • Advocacy to ensure that RH gets resources, quality maintained • Involve the community, women’s groups in monitoring reforms at local level

15. When we’re at the table: • What is our vision for RH and its relation to health reform? • What will we do differently as a result of the course that will help us realize this vision? • What difference to we expect our actions to have on reproductive health and rights? • What actions will we take?

16. Community of practice • Read the rest of the materials • Communicate with WBI and your colleagues via email and the website • Use the website or CD-rom for materials • Read and contribute to the newsletter • Join WBI distance-learning follow up