Assessing evidence on health sector reforms.

The motivation underlying health sector reforms (HSR) which swept the Asia-Pacific region in the late 1980s was to increase health system efficiency, sustainability, quality and equity as governments faced shortage of funds to meet the health needs and demands of their nations. Inherently a political process, HSR have led to changes in financing and priority-setting mechanisms. Other components of reforms have come in the shape of decentralisation and public-private partnerships.

In 1997, the World Development Report, The State in a Changing World called for governments to only invest in what developing countries could best afford in the area of primary health services. Instead of viewing health as a right, focus was now on consumer demand. The World Bank initiated health reforms have emphasised market style solutions. Developing countries dependent on credit and soft loans given by international lending agencies were often in a limited bargaining position to oppose advice to introduce or expand cost recovery strategies that often involved a public-private mix for provision of health services.

The ICPD Programme of Action is viewed as a call of action to reprioritise health and population policies to ensure a focus on women's rights and gender equity within reproductive healthcare. The ICPD calls on governments to ensure universal access to quality reproductive healthcare within the broader context of health sector reforms and to integrate reproductive health programmes more fully into national health systems.

Health financing reforms initiated to address financing of healthcare in the area of sexual and reproductive health services focused on: 1) increase in or introducing of user fees; 2) introducing community-based or social health insurance in systems currently financed through tax revenue and user fees and 3) governments separating their financing function from service delivery function through public-private partnerships. Proponents like the World Bank have argued that the introduction of these cost-sharing mechanisms may be necessary to sustain existing programmes to include sexual and reproductive health services (SRH) beyond maternal and child health (MCH) and family planning. Since governments are unable to invest adequately, even to maintain existing services at reasonable standards, the revenue raised through user fees may contribute to the improvements of the quality of services. Social health insurance may help pay for specific high cost reproductive health services such as emergency obstetric care.

Impact of Financing Reforms

However, there appears to be little evidence that financing reforms is having a positive effect on the provision and utilisation of SRH services. According to a literature review assessment of Bangladesh, India, Sri Lanka, Thailand, Philippines, Indonesia, China and Vietnam by the Initiative for Sexual and Reproductive Rights in Health Reforms, a common core package of financial reforms has been the introduction of user fees and the encouragement of private sector involvement. Furthermore, in most countries, out-of-pocket expenditure, not public funds has emerged as the main source of health financing. Only in Thailand is social insurance coverage part of the overall health financing package, and extended to those in the informal sector. In one of the poorest states of India, Rajasthan, the out-of-pocket burden has had an adverse impact on the utilisation of SRH services. A study on households in 1999 reported that 45 per cent of mothers in the bottom two income groups with children under two years of age did not have antenatal care and 80 per cent of them delivered at home without a skilled birth attendant. Furthermore, only 20 per cent of women who reported Reproductive Tract Infection (RTIs) symptoms sought any care. In the Yunnan province in China where user fees now account for 50 per cent of MCH costs, utilisation of SRH services has fallen. Out-of-pocket burden of healthcare services for pregnancy, delivery or postpartum is now around 26 per cent and 17.5 per cent for gynaelogical related complications. Due to increasing operating costs and government cutbacks, cost recovery through user fees has not resulted in any improvement in the quality of services as had been envisaged under HSR (Studies indicate that at best revenue from user fees has only contributed five to ten per cent of recurrent costs, not enough to have any real impact on quality of services). User fees may aid cost recovery, but simultaneously reduces access for poor, vulnerable and marginal groups. In contrast, in spite of the impact of an economic crisis in the late 1990s in Thailand, a universal health insurance scheme which covers all reproductive health services (except obstetric services beyond the second pregnancy and infertility treatment), has resulted in increased utilisation of contraceptive services.

Impact of Reform Components

The mechanism used for priority-setting in health is inherently gender-biased as the computation for the burden of disease does not take into account gender-based vulnerabilities. This in turn has led to SRH services being under-prioritised and less public funds allocated. Public-private partnerships in service delivery in Asia have focused mainly on the promotion and marketing of contraception including condoms (for HIV/AIDS prevention rather than family planning) and social franchising for the delivery of family planning programmes, and not on integrated provisioning of SRH services. Reforms have further impacted the post Cairo trend towards selective integration of SRH services. This is evidenced in the case of the Philippines where decentralisation did not lead to integration of SRH services. Local bodies, vulnerable to conservative forces that oppose contraception and abortion, chose instead to prioritise curative health services over preventive. Integration efforts have been confined to administrative functions (like planning and budgeting), and not on the integration of SRH services at the primary level as envisaged under ICPD. World Bank assisted projects like the Philippines Women's Health and Safe Motherhood Initiative which offers comprehensive service delivery in the area of maternal care, family planning, diagnosis and treatment of RTIs and Sexually Transmitted Diseases, and detection and treatment of cervical cancer has not led to better health access for women as SRH services and drug costs remain prohibitively high for poor women. The poor implementation in integrating new services in the region can be attributed generally to the fragmentation of the various services across different programmes, limited resources available to the health sector and the legacy of dependence on donors for implementation of family planning, safe motherhood and more recently, HIV/AIDS programmes. To address the deterioration in women's access of SRH services, the following actions should be undertaken by NGOs, governments, donors and development institutions:

* NGO advocacy is needed to stop the introduction of user fees for priority SRH services such as antenatal care, abortion, delivery and family planning services.

* Provide social insurance which includes priority SRH services for a large section of the population, especially the low income.

* The impact of HSR initiated by the World Bank and other development institutions like the Asian Development Bank need to be evaluated.

* Research at national level should be done as soon as possible to understand country specific impact of HSR.

* Governments need to prioritise resources to provide public SRH services at minimal cost to poor women.

* Donor funding should be channelled to underresourced SRH services of high priority such as abortion, youth SRH services and delivery care.

* The ability of public-private partnerships in providing comprehensive SRH services should be assessed.

* Comprehensive SRH services should be included by the World Bank as part of priority-setting mechanisms.

* The World Bank should encourage integration efforts to move beyond functional/administrative focus to include service integration of SRH services.

* Endnotes

Sundari Ravindran. 2003. Health Financing Reforms in Asia and the Impact on Reproductive and Sexual Health Services. Johannesburg. Initiative for Sexual and Reproductive Rights in Health Reforms. Women's Health Project.

* Compiled by Rathi Ramanathan, Programme Officer, Asian-Pacific Resource and Research Centre for Women. ARROW is a member of the Coordinating Team of the Initiative for Sexual and Reproductive Rights in Health Reforms.