HEALTH SECTOR REFORMS AND SRH SERVICES Lessons and Research Gaps Emerging from the Initiative for Se

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HEALTH SECTOR REFORMS AND SRH SERVICESLessons
and Research Gaps Emerging from the Initiative
for Sexual and Reproductive Rights in Health
Reforms

• Ranjani.K.Murthy with
• Helen de Pinho, Sundari T.K.Ravindran and Mariana
  Romero

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REFORMS NOT NEW

• Reforms to address limited health resources,
  inequities, and poor coverage, quality, and
  accountability not new but perspectives differ
• The lobby demanding reforms in the context of
  strong state presence in provisioning, financing
  and regulating has existed for long Alma Ata,
  78, ICPD, 94 and SRHR lobby since 1980s (rights
  lobby)
• The lobby demanding reforms in the context of
  rolling back of state in provisioning and
  financing is new- late 1980s/1990s World Bank
  and its allies (neo-liberal reform lobby)

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CONTEXT OF THIS PAPER

• The two lobbies have been largely uninformed of
  each others agenda.
• Rights and Reforms initiative emerged to bridge
  the gap in understanding (Ford and Mac Arthur).
• Activities so far Desk research to strengthen
  knowledge base on impact of reforms on SRH
• Proposed Research, capacity building advocacy
• The paper summarises findings from research so
  far, gaps in knowledge, and research topics

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DEFINITIONS AND FRAMEWORK

• SRH services refers to health services related
  to reproduction and sexuality
• full and comprehensive range (ICPD,94)
• and a few beyond
• Heaven/hell ones
• Low/high priority ones
• Low/high priority groups

• HSRs to neo liberal reforms that began in the
  late 1980s which led to changes in
• Financing
• Priority setting
• Organisation
• Accompanying changes in organisaiton
• (Krasovec K and Shaw P, 2000)

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REFORMS HAPPENING IN VARIED CONTEXTS

• Strong pressure from social movements to reform
  state apparatus (e.g. Latin America)
• Transition from socialist to market economies
  (e.g Vietnam, China)
• Rebuild services after conflicts (Cambodia)
• Structural Adjustment programme (Africa, Asia)
• Also different socio-economic, health system
  context

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THE INITIATIVES FOCUS

• Financing reforms
• Priority setting reforms
• Public-private interactions
• Decentralization
• Integration
• Participation and accountability
• How have reforms in above affected availability,
  accessibility, coverage affordability, equity and
  quality?

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FINANCING STRATEGIES

• Public
• Taxes
• Social insurance
• Private
• User fees
• Prepayments
• Private insurance
• Public or private
• Donor aid (less in Latin America)

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FIANCING REFORMS DEMANDED BY TWO LOBBIES

• Demands of SRHR lobby
• Expanding public financing
• 7 of GNP for SRH services (ICPD, 94), reduction
  in arms
• Unconditional Debt relief

• Demands of reform lobby
• Diversity financing
• In Asia and Africa- expanding private financing
• In Latin America integrating insurance systems
• Conditional debt relief

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IMPACT OF FINANCING REFORMS ON SRH SERVICES

• Positive benefits
• Seen where SRH services are covered as part of
• prepayment (China-revamped) and
• universal social insurance packages (Bolivia and
  Thailand)

• Negative impact
• User fees reduces affordability, utilisation and
  equity (parts of China, India, Bangladesh,
  Africa)
• Insurance excludes many women, informal sector
  workers, and SRH services over medica-lisation
  (parts of India)
• No evidence that they have expanded resources for
  SRH services

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RESEARCH GAPS-FINANCING

• Country studies on how different SRH services are
  financed for different groups,
• Price elasticity of demand for different SRH
  services for different groups,
• Experiences of prepayment and insurance schemes
  that have included SRH services,
• Studies that examine how contexts and financing
  reforms interact together,
• Studies on the financing arrangements in
  developing countries with good SRH performance,

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PUBLIC PRIVATE INTERACTIONS

• The nature of relationship between public and
  private sector
• parallel activities,
• competitive activities,
• complementary activities, and
• collaborative activities
• Global PPIs product development/distribution,
  health programmes, and health service delivery
• Country PPIs social marketing, franchising and
  contracting (Asia and Africa)

PPIs
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PPIs differing demands?

• SRHR lobby
• PPIs mainly with NGOs to ensure universal access
  and availability
• Private for profit sector should channel funds to
  SRHR NGOs
• (Chapter XV, POA)

• Reform lobby
• PPIs with for profit and NGOs to expand
  resources, access, availability, coverage,
  equity, quality
• Government- restrict themselves to market
  failures

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IMPACT OF PPIS ON SRH SERVICES

• Positive
• PPIs with NGOs does have potential to reach under
  served areas, but not all NGOs have capacity
  (Africa)
• Negative
• Reduced availability of integrated SRH services
• Quality and viability varies, weak accountability
• Limited services (heaven, high priority?)
• Reduced donor funds for public services
• Increased inequities (few exceptions)
• PPIs with for profit sector has not improved
  coverage of poor

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RESEARCH GAPS-PPIs

• Size, features, service range, clients and
  quality of private sector in SRH services how it
  compares with public,
• Different types of PPIs and their implications
  for SRH services (Triple As, Q and E),
• Document successful PPIs to understand the
  underlying reasons,
• Political economy of PPIs at global and national
  levels,
• Global PPIs and their impact on national health
  systems and SRH services, and
• Regulation mechanisms for PPIs at global and
  local levels and strategies for strengthening
  these

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DECENTRALIZATION

• Decentralization is a change in power relations
  between the central government and actors at
  lower levels
• Impetus for decentralization has come from
  political (Latin America) and technical concerns
  (Asia and Africa)
• SRHR lobby address specific challenges that SRH
  poses for decentralization, and vice versa
• HSR lobby address efficiency, effectiveness, and
  (of late) equity issues in decentralization,

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IMPACT OF DECENTRALIZATION FOR SRH SERVICES

• Positive
• Expanded opportunities for participation
• Negative
• Devolution often captured by local elites.
• Devolution affected staff morale/referrals
• Decentralization increases inequities
• Decentralization reduced availability of SRH
  services (in particular- controversial)
• Safeguards can reduce the negative impact
• Mixed
• Impact on Health resources

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RESEARCH GAPS DECENTRALIZATION

• Modifications to existing frameworks for
  assessing impact of decentralization on SRH
  services,
•  Cross-country studies form, scope,
  implementation, decision-making, and impact on
  SRH services,
•  Appropriate decentralization models,
  decision-space, and incentives for different SRH
  services and different groups,
• Role of civil society in strengthening
  accountability of decentralisation to SRH
  services,
•  In countries with similar levels of income, but
  contrasting SRH outcomes how have SRH services
  been organised     

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PRIORITY SETTING

• Is the process through which government
  identifies which of the needs of the population
  has to be prioritised for the allocation of
  public resources, and how these should be met.
• The SRHR lobby has called for a rights based
  perspective to, and participation of rights based
  groups in, priority setting
• The reform lobby has called for use of cost
  effectiveness methods for priority setting. Six
  variant methods for SRH services.

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IMPACT OF PRIORITY SETTING ON SRH SERVICES

• Negative
• Globalisation of health and SRH policy,
• DALYs and others conceptual and computations
  limitations,
• These limitations have greater impact on SRH
  services,
• Few SRH-specific limitations of DALYs,
• ESPs have ignored low priority and hell SRH
  services,
• SRHR and marginalised groups not involved

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RESEARCH PRIORITIES

• Research on actual process of priority setting in
  developing countries with different contexts,
• In developing countries where SRH services have
  been prioritised, what were the priority setting
  methods used,
• Possible SRH-friendly priority setting methods
• Cross-country/group research on burden of
  excluded SRH morbidity and mortality
• Crass country research on benefits of absence of
  SRH diseases, and costs of prevention
• Measuring, in different contexts, burden of
  violations of SR rights, benefits and costs of
  fulfillment

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INTEGRATION

• Integration - three categories
• Integrated provisioning of health services,
• Integration of health administrative functions
• Integration across sectors and organisations
• SRHR lobby pressing for type 1 integration (and
  part of 3), with specific reference to SRH
  services
• Reformers pressing for type 2 and 3

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INTEGRATION WITHIN REFORMS AND SRH

• Most countries moving on paper towards
  integra-tion of SRH services, though varies (LA
  ahead).
• Few reforms have called for integration of SRH
  services, also little evidence on impact
• Administrative integration under reforms may be
  vulnerable to set backs with regime change
• Evidence that PPIs and priority setting reforms
  have an adverse impact on integration of SRH
  services, user fees may reduce the offtake, and
  decentralization could have mixed impact

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RESEARCH

• In the few reforms that have prioritised
  integration (type 1), what were the facilitators,
• The differences in integration and its impact in
  the context of reforms and outside,
• The incidental SRH service impact of integration
  of type 2 and 3 under reforms, and
• Documentation of impact of PPIs, priority
  setting, financing and decentrlization reforms on
  integration, and financing on offtake.

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PARTICIPATION AND ACCOUNTABILITY

• SRHR lobby
• Citizen
• Policy/management
• Decision making
• Accountability of all levels through
• Citizen Inputs into policy
• Public hearings
• Expenditure audits
• PIL, regulation
• decentralization

• Reform lobby
• Client, community
• Management/delivery
• Consultation
• Accountability of workers/providers thro
• User fees, client monitoring, co-production
• Strengthening voices,
• Community provisioning and monitoring

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PARTICIPATION AND ACCOUNTABILITY IN REFORMS

• 64 of 44 HSRs- mention community participation
• 47 of 44 HSRs- mention accountability
• Strategies community financing (CF),
  decentralization, participation structures, of
  late regulation,
• Marginalised and SRHR groups less found,
• CF has not strengthened health accountability,
  impact of decentralization and participation
  structures mixed. Little evidence on regulation
• Downplayed provisioning of controversial and low
  priority SRH services, and services to
  adolescents and elderly
• Cant be added in all contexts requires strong
  state and resources,

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RESEARCH

• Cross country/context studies on community
  participation in reforms, its SRH service impact
• Studies on differences between demanded and
  invited participation in reforms and their impact
  on SRH services
• Comparison of participation and accountability in
  reforms with strong and weak component of SRH
• Comparison of participation/accountability in
  reforms and outside impacts and lessons (SRH
  lens)
• Studies on politics of representation
• Studies on costs of participation
• Studies on non-participatory accountability
  strategies

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CROSS THEMATIC FINDINGS

• Reforms do not appear to have solved the problems
  it set out to, in particular with regard to
• - controversial SRH issues
• - low priority SRH issues
• - SRH services for controversial groups
• General Reasons
• - lack of prioritisation of equity amongst
  different goals
• - contradiction between different reform
  elements
• - contradiction between rolling back of
  state, and some of goals
• SRH-specific reasons
• - no reform element pro-SRH, some anti SRH,
  some neutral
• - rights and equity vs. efficiency and cost
  effectiveness

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CROSS THEMATIC RESEARCH

• Movers and shakers of reforms and rights,
• Framework, measures and data for assessing impact
  of reforms on SRH services.
• How different elements of reforms interact and
  affect SRH services at a point, and over time,
• Impact of contexts on overall directions of
  reforms and how to foster these,
• Mechanisms for monitoring reforms that are more
  accountable with regard to SRH services,
• What are the reforms-in heath and outside-
  initiated by developing countries that have done
  better on SRH services/outcomes when compared to
  other similar ones