Health Sector Reform and Sexual and Reproductive Health

1. Health Sector Reform and Sexual and Reproductive Health TK Sundari Ravindran Based on work done as part of the ‘Rights and Reforms’ Initiative

2. Outline of presentation • Health Sector Reform of the 1990s in South Asian Countries • Implications for Sexual and reproductive health services • An agenda for advocacy and action

3. Health expenditure: Select Asian countries (2001) BGD India Nepal Pakistan Sri Lanka Per capita (PPP US $) 58 80 63 85 122 Public Exp (% of THE) 45.4 15.3 20.6 22.9 49.5 Private Exp (% of THE) 54.6 84.7 79.5 77.1 50.5 Source: WHO 2002

4. Sources of public and private financing • In all countries, tax revenue is the major source of public financing. In Nepal, a third of public expenditure is financed by external aid, and 8% in Bangladesh, less then 5% in the remaining countries. • In all countries, Out-of-pocket expenditure by households forms the major source of private financing of health. In other words, in all countries except Sri Lanka, more than 75% of resources for the health sector are raised through payments made by individual households when they use health services

5. HSR in South Asia in the 1990s • In many developing regions including ours, HSR of the 1990s was driven by an ideological shift which upheld increased role of the market in health care; the state’s role was to create a supportive policy environment for the increased participation of the market. • The reforms of the 1990s, or HSR have been led by the World Bank, with other bilateral donors joining-in.

6. Nature of health sector reform • Changes in financing mechanisms • Changes in priority setting mechanisms • Changes in organizational mechanisms such as decentralisation and SWAp, oversight and management

7. HSR: Broad directions • Financing reform from the backbone of HSR, mainly through increase in cost-sharing by users of services • Small experiments in pre-payment schemes • Increased role for the private sector through contracting out of clinical and non-clinical services; investments by the private sector in public hospitals; other forms of public-private partnerships with the for-profit and not-for-profit private sectors.

8. HSR: Broad directions • Sector wide approach introduced in Bangladesh and in some states of India • Decentralisation in the health sector has generally been a part of larger political decentralisation processes, unlike in the African region where decentralisation was introduced specifically in the health sector. • Hospital autonomy (or responsibility for keeping afloat financially) introduced in many hospitals.

9. Specific forms of public-private partnerships in SRH services • Social marketing of contraceptives, condoms and other reproductive health products (e.g.safe delivery kits) • Social ‘franchising’- forming a network of private sector providers identifiable by a ‘brand’ identity and supporting them to provide some SRH services and products.

10. Changes in Priority setting mechanisms • Underlying logic: governments should not attempt comprehensive health care because they cannot afford it. Besides, it is inefficient to do so. They must select only those which matter most at least cost, the driving concept behind priority setting in health sector reform. • Minimum essential services package to be developed for provision through public sector services. What matters most at least cost will be known through the Burden of Disease and cost efficiency computations (World Bank 1993).

11. What have health financing reforms achieved? • User fees have not been able to raise significant revenue, and have often resulted in decreased access for the poor • Prepayment schemes appear to work where there is - a large number of subscribers - possibility for risk pooling through enrolment of poor and non-poor, high and low risk populations - co-financing by government and/or donors

12. Access to SRH services constrained by cost-sharing • Reduces access to SRH services for the poor • Even in government facilities (India, BGD) delivery services could cost 2-8 times the monthly income of the poorest 25% of the population. • Treating one episode of RTI in a government facility costs more than the average monthly income of a Rajasthan household; and abortion costs are 2-3 times the monthly income.

13. Financing reproductive health in Rajasthan, India (2000)Source: Financing reproductive and child health care in Rajasthan, IIHMR and Policy project, 2000. p. 18 (50)

14. Public-private partnerships • For-profit Private sector is unlikely to function where there is no purchasing power. Poorer regions and districts will therefore remain underserved. • For-profit private sector accessible only to those who can pay, no arrangement made for those who cannot pay. • Contractual relationships call for high level of managerial and supervisory capabilities. • Scope for effective partnerships with Not-for-profit private sector

15. Public-private partnerships and SRH services • Delivery services and RTI/STI services for the general population a major neglected area • Quality of services remains an issue: e.g. private services in public facilities likely to create double standards in care-giving. social marketing programmes limit contraceptive choice. Social franchising programmes currently in operation include large numbers of pharmacists and paramedics. • Has diverted large volumes of donor funds away from the public sector into creation of a market for specific categories of RH services and products. USAID at the helm of this trend but soon followed by other bilateral donors.

16. Priority setting in SRH

17. Priority setting and SRH services • A long way off-course from the ICPD vision of comprehensive reproductive health services • Priority-setting has become a global exercise, with similar prescriptions for all countries, based on calculations of DALYs saved derived from scanty data available for a limited set of developing countries

18. Organisational reforms and SRH services • SWAp – a mixed blessing overall. A lot of logistical and administrative issues to be sorted out before we will know whether the concept is worth pursuing. May have resulted in greater donor control over country health agendas. • Only ESP gets funded and broader SRH services lose out chances of funding from specific donors interested in these issues.

19. Decentralisation and SRH services • Experience from Philippines found • some local governments did not fund FP and STI services and diverted the funding • Under-funding for preventive care as a result of local political pressures • Resource inequities were exacerbated • Quality of care suffered because of lack of technical support and guidance to devolved workers • Limited voice for women in local governments even though their voices were heard at national forums and could influence national priorities

20. Overall findings -1 • Many components of HSR have become barriers to operationalising the ICPD agenda • Financial reforms have not mobilised additional resources for expanding coverage or for expanding the range of SRH services • Privatisation and promotion of health care markets have introduced additional financial barriers to access and is likely to have increased health inequalities. • Private sector partnership has not ‘freed-up’ government resources that can be better spent on the needy. Private sector caters to those who can pay while the public sector remains as it was- under-funded and over-burdened.

21. Overall findings -2 • Priority-setting mechanisms have narrowed the range of reproductive health services to be made universally available. • SRH services are in danger of being fragmented across public and private sectors, preventive and curative services and ‘essential’ and ‘non-essential’ services. Whither integration? • The concept of accountability to citizens is being fast replaced by accountability only to paying consumers.

22. The Right Reforms ? -1 ADVOCACY AND POLITICAL PRESSURE BY ALL CONCERNED FOR • Increased public funding of health sector to alleviate the burden of out-of-pocket expenses • Maternal health services including delivery care to and EmOC be publicly financed especially for low-income groups. • Expanded range of sexual and reproductive health services to be financed by a combination of tax revenue and pre-payment schemes at the primary care and secondary care levels.

23. The Right Reforms ? -2 • Any public-private partnership should serve the purpose of expanding access to services for the under-served populations and/or provide services that fall heavily short of demand • Regulation of the private sector to ensure that it upholds and contributes to national health goals in the area of SRH • Investment to increase government capability to play an effective regulatory and stewardship role, harnessing the already considerable private sector resources. • NO to creation and promotion of health-care markets • NO to diversion of donor funds for the above purposes • NO to global priority-setting and NO to donor-driven SRH packages based on such an exercise