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The macroeconomic environment and sexual and reproductive health: a review of trends over the last 30 years.

Abstract: The social services provided in any country are determined by resource allocation. How money is spent, the way in which programmes are organised, and the services that are prioritised can have important implications for health, including the sexual and reproductive health of men and women. Choices in how resources are allocated are influenced by a number of factors. Covering the years from the late 1970s to the current time, this article reviews the contexts that have influenced the provision of sexual and reproductive health services and provides examples of instances where decisions about resource allocation are not evidence-based. The role of donors in determining how services are provided and their lack of accountability is discussed. We conclude that sexual and reproductive health and rights activists need to engage with and take into account the macroeconomic environment in their efforts to improve sexual and reproductive health outcomes. [c] 2011 Reproductive Health Matters. All rights reserved.

Keywords: macroeconornic context and health, sexual and reproductive health services, social determinants of health, health sector reforms, global health initiatives, access and equity, donor accountability

Resume

Les services sociaux foumis dans tous les pays sont determines par l'allocation de ressources. La maniere dont les fonds sont depenses, l'organisation des programmes et les services juges prioritaires peuvent avoir des repercussions importantes sur la sante, y compris la sante genesique des hommes et des femmes. Les choix en matiere d'allocation des ressources sont influences par plusieurs facteurs. L'article examine les contextes qui ont influe sur la prestation de services de sante genesique depuis la fin des annees 70 jusqu'a aujourd' hui, et donne des exemples de cas off les decisions sur l'allocation des ressources ne sont pas fondees sur les faits. Il debat du role des donateurs pour determiner comment les services sont assures et leur manque de responsabilisation. Nous concluons que les activistes en faveur de la sante et des droits genesiques doivent interagir avec l'environnement macroeconomique et que leurs efforts pour ameliorer l'etat de sante genesique doivent tenir compte de cet environnement.

Resumen

Los servicios sociales proporcionados en un pais se determinan por asignacion de recursos. La manera en que se gasta el dinero y en que se organizan los programas y los servicios priorizados pueden tener importantes implicaciones para la salud, incluida la salud reproductiva de hombres y mujeres. Numerosos factores influyen en las opciones de asignacion de recursos. En este articulo, que abarca desde finales de la decada de los setenta hasta la actualidad, se revisan los contextos que han influido en la prestacion de servicios de salud reproductiva y se exponen ejemplos de casos en que las decisiones sobre la asignacion de recursos no estaban basadas en evidencia. Se examina el papel que desempetian las agencias donantes en determinar como se proporcionan los servicios, asi como su falta de responsabilidad. Concluimos que los activistas a favor de la salud y los derechos sexuales y reproductivos deben estar al tanto dei ambiente macroeconomico y tomarlo en cuenta en sus esfuerzos por mejorar los resultados relacionados con la salud sexual y reproductiva.

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THE political economy of health has been discussed and critiqued over many years. More recently globalisation and its effects on health and health services have been well documented. (1-3) Economic trends, from the post Second World War Keynesian approach--a developmental approach to rebuild war-ravaged countries--to the neo-liberal approach of the early 1980s, which prioritised economic growth over other considerations, to the views expressed in the 2008 Commission on Growth and Development which tried to find a balance between these two poles--can be found in many articles; a succinct version is presented by Kanbur. (4) This is an important backdrop to the provision of social services.

Why consider the macroeconomic environment?

From 1994, post the ICPD conference, the reproductive health and rights lobby aimed to get their countries to implement a comprehensive package of sexual and reproductive health services. International agreements and rights instruments that the majority of nation states are signatories to--form the basis of these demands. However, while countries may be signatories to these agreements, the commitments they contain may not take priority in decision-making on resource allocation. For example, the Millennium Development Goals are an international reference point, and governments are conversant with them. Jill Sheffield told the 2010 Women Deliver conference delegates that the economic arguments (to invest in maternal health) were "dramatic" (5) and the Secretary-General of the United Nations announced "a new joint action plan to accelerate progress toward achieving the UN's Millennium Development Goals". He called on the world's governments to work with the UN to save the lives of more than 10 million women and children by 2015. (6) Yet at the African Ministers of Finance meeting held in Malawi at the end of March 2010, they "deleted any reference to budgetary targets for education, health, agriculture and water in the Common Position on MDGs in the conference report and resolutions". (7)

A study covering Asia, Africa and Latin America, where the majority of the burden of sexual and reproductive ill-health is borne, was undertaken to strengthen the knowledge base regarding the impact of macroeconomic changes and health sector reform on sexual and reproductive rights and health. The authors commented that:

"We [women's health and rights activists] rarely concerned ourselves with how this new array of [comprehensive reproductive health] services was to be financed, organised or managed, whether the health systems in many developing countries had the capacity to establish and run such services effectively, and how macroeconomic changes were affecting countries' ability to fulfil their Cairo commitment." (8)

Hence, in order to lobby effectively and influence policy and policy implementation, understanding and influencing global economic issues and the broader environment within which public services are provided, beyond sexual and reproductive health alone, are essential for sexual and reproductive health activists. Further, we believe that sexual and reproductive health activists must be able to identify other activists and advocates with whom it would make sense to form an alliance in order address some of the underlying issues that limit achieving improved sexual and reproductive health outcomes. Below, we highlight some elements of the macroeconomic environment and the political economy of health relevant to understanding the current environment in which sexual and reproductive health services are being offered.

Money, debt and debt repayment

The 1979 oil crisis was a pivotal point in recent economic history; that period and the economic response to it has had an enduring effect on health services today. The energy crisis resulted in increased oil prices, loans to buy oil were required for non-oil-producing countries and borrowing money became more expensive. Loans to governments were and are provided through the International Monetary Fund (IMF). Interest rates increased and resulted in a heretofore unprecedented inflationary crisis. Poor countries were left heavily indebted. Honouring loan repayments was seen by the IMF as fundamental to a stable world economy. Thus, access to loans was conditional on certain "structural adjustments". In brief, the adjustments aimed at reducing the public budget deficit; decreasing the amount of money available, for example, by making interest on loans high; decreasing inflation, for example, by keeping wages low; and currency devaluation to attract investment. Among other things this brought down civil servants' wages (either directly or through the effect of currency devaluation), decreased the number of people employed in the public sector, and decreased investment in public sector services from infrastructure to health and education. The structural adjustment programmes, however, did not have the desired impact, and poor countries have remained poor. (9) This legacy remains today.

After the 2008 financial crisis, the role of the IMF has been reasserted. The more nuanced approach suggested in the Commission on Growth and Development has had little if any effect on the policies of the IMF, which still pursues a neoliberal agenda that ultimately limits spending on social services, including health services. (l0, 11) In relation to health systems, while they were not universally robust or well-developed prior to the imposition of structural adjustment, there is evidence of a negative effect of these economic policies on health systems. (12) In sub-Saharan Africa the scaling up of HIV treatment services has been dramatic; however, there is still limited access to services and a major limitation is an inadequate workforce. (13) Macroeconomic solutions such as changes to the ceiling on the total public sector wage bill are required, both to pay existing staff a living wage and to bring new staff into the system. (14)

The decreased status and power of the state

A significant assumption of the neoliberal discourse is that the unfettered free market is a more efficient way of ensuring growth and providing services. In a globalised world, which services are provided is no longer primarily decided by national governments.

"The term 'global' [health] is ... associated with the growing importance o factors beyond governmental or intergovernmental organisations and agencies--[and now includes] for example, the media, internationally influential foundations, and transnational corporations." (15)

As the power of organised corporate capital grew through globalisation in the 1990s, the corporate sector sought to have a greater voice in international organisations, in order to protect corporate business interests internationally. The International Chamber of Commerce established a systematic dialogue with the UN, aiming to "establish global rules for an ordered liberalism". (16) In the health sector, the pharmaceutical industry in particular was interested in evolving international regulations that would prevail over national regulatory mechanisms to protect business interests. Public-private partnerships provided the pharmaceutical industry with a bargaining chip for implementing Trade Related aspects of Intellectual Property Rights (TRIPs) agreements, and to prevent compulsory licensing (17) * of essential medicines by governments on public health grounds. (16) This aimed to help these companies maintain high levels of profitability from medicines and other health care products they had developed. (18)

Among the many efforts to penetrate and develop new markets, the Global Sustainable Development Facility, a partnership between leading corporations and the UN Development Programme (UNDP), aims to include two billion new people in the global market economy by 2020. (16) Hindustan Lever in India, for example, has invested in water and sanitation development in the country because this would contribute to the creation of a market for its soaps and hygiene products. Similarly, Glaxo Smith Kline has invested in hygiene and sanitation activities across Africa so that there is greater awareness about worm disease, and consequently, a greater demand for the drugs produced by the company for treating it. (19) Corporations also gain credibility from participating in public-private partnerships with UNDP.

The 2011 UN AIDS summit adopted a declaration that seeks to double the number of people on antiretroviral (ARV) treatment to 15 million, end mother-to-child transmission of H1V, halve tuberculosis-related deaths in people living with HIV, and increase preventive measures for the most vulnerable populations by 2015. ([dagger]) This at the same time as they acknowledged that funding for this is not available. The policy/advocacy director of the Access Campaign at Medecins sans Frontieres said that free-trade agreements were a barrier to "price-busting genetic competition and threaten access to affordable newer medicines": (19)

"Countries are making promises to treat AIDS in one meeting, and working hard to keep [medicine] prices out of reach behind closed doors in other meetings." (20)

One of the concrete manifestations of the increasing support for collaborating with the private sector for the promotion of global health goals is the emergence of several global public-private partnerships in the late 1990s and early 2000s. These partnerships involve several entities--multilateral and bilateral agencies, international NG0s and profit-making organisations, usually manufacturers of pharmaceuticals, medical equipment and supplies. Many of these partnerships involve the World Health Organization in significant ways. (21) The terminology for these partnerships was replaced in the early 2000s with "Global Health Initiatives" (GHIs). One of the features of GHIs is their focus on specific diseases, or on selected interventions, commodities or services. (22) The successful public-private partnership led by the World Health Organization] Tropical Diseases Research Programme for developing, testing and distributing the medicine ivermectin to control onchocerciasis provided a model for other such partnerships. (23,24) The Global Health Initiatives led an international call to arms around specific health problems and made it almost morally important to contribute to them. Donor money flowed into these funding instruments. Rather than deal with fundamentals such as trade agreements, which made it difficult for countries to produce their own more affordable generics, funds from donors and governments in rich pharmaceutical-producing countries were donated to the Global Health Initiatives so that they could buy the medicines and other products needed to treat people in poor countries.

Comprehensive vs. selective health care services

The single-issue, technology-driven approach of the Global Health Initiatives explains in part why the fight for comprehensive reproductive health services has been sidelined. This trend, however, predated these initiatives.

"... the 1980s saw a number of international agencies attracted to funding short-term deliverables in disease-specific programmes implemented through fragmented, vertical programmes with their own lines of accountability, clear budgets, and with little co-ordination amongst other such programmes or with government-run services".25

The International Conference on Population and Development (ICPD) Programme of Action articulated a rights-based approach to sexual and reproductive health and the provision of comprehensive sexual and reproductive health services. This is consistent with the vision of the primary health care approach articulated in the Alma Ata Declaration of 1978, which both stresses the importance of providing comprehensive services and underlines the fact that attaining health is much broader than providing health services. The Declaration also emphasises the need to address the social determinants of health, such as access to water and sanitation, the centrality of community participation in health, and the key role of equity in achieving positive health outcomes. (26) The World Health Organization (WHO) has recently re-asserted the need for this approach. (27) However, this is at odds with the dominant discourse, which in the late 1970s moved away from a developmental to a neoliberal approach.

In 1979 selective primary health care was proposed.28 This selective approach aimed at disease control of the most prevalent diseases, so as to achieve quicker returns than could be expected from the incremental changes that Alma Ata envisaged. Selective primary health care popularised the notion of technological interventions focusing on a single disease in vertical programmes, the approach that still dominates today. Donors, international agencies and foundations promote this approach in spite of the evidence which suggests that this approach undermines health systems. Criticisms include that donor-driven vertical programmes take a "one-size-fits-all-approach" and may not be locally appropriate. They often duplicate and work around existing health care systems and undermine already weak systems by drawing health workers towards the flavour-of-the-month, better-funded health interventions, rather than building the overall health system to serve the multiple health needs in a particular country. (22,29) Findings published in a number of WHO's World Health Reports note that the reason many vertical, technology-based interventions have under-achieved is because of weak health systems. (30-33) Nonetheless, the disease-specific, technology-based programmes that are implemented continue to be vertical programmes. This is in spite of the evidence that integration of services is important, e.g. maternal health services need to be integrated with HIV, tuberculosis and contraceptive services to improve maternal health outcomes. (34,35)

Despite the call to arms by WHO, among others, to develop health systems, this has been largely rhetorical. Donors see this as the job of governments, yet the funders of vertical programmes are not held accountable for the way in which their continued support for their own "special interest" programmes, such as dedicated H1V funding, undermines the ability of governments to build their health systems. This is true in spite of findings that bypassing weak health systems and building parallel duplicate systems around them, as well as the various reporting and management demands of the Global Health Initiatives, make unreasonable demands on national health systems. (29)

There is consensus that for many countries insufficient investment of national funds into health systems is problematic. For example, in the 2001 Abuja Declaration, African Union heads of state committed to allocating 15% of their annual budgets to improving their health sectors. A ten-year review in 2011 found that, 27 of the 54 member countries had increased their proportion of spending on health but only two had reached the 15% target. It is perhaps significant that the Abuja commitments were made by heads of state and not the Ministers of Finance who negotiate loans and allocate national budgets. Moreover, research has indicated that IMF pressures discourage national investment in health. (36) Thus:

"World Bank and IMF macroeconomic policies, which specifically advise governments to divert aid to reserves to cope with aid volatility and keep government spending low." and

"On average, health system spending grew at about half the speed when countries were exposed to the IMF than when they were not. " (37)

Reforms of health systems

Health system reform has been a constant feature over many years. We isolate here the health sector reforms of the late 1980s and early 1990s, which were motivated, we believe, primarily by the move from state-controlled to market-oriented economies, consistent with the rising dominance of the neoliberal discourse. The expressed aim of this health sector reform was to improve health system efficiency, sustainability, quality, equity and client (sic) responsivehess.37 Four major mechanisms to achieve this were variously implemented in Africa, Asia and Latin America:

"I. Changes in financing mechanisms, resulting in a shift in balance between the respective shares of tax revenue, social or private insurance, user fees and external aid in financing the health sector, and a conscious effort to increase the involvement of the private sector in health.

2. Changes in priority setting mechanisms, resulting in a shift in the range of services provided in the public and private sectors and the mechanisms through which they are financed.

3. Changes in organisational mechanisms: principally, a shift in the role of the state ... usually towards a gradual abdication of responsibility for direct provision of health care and more responsibility for regulation. Experimentation with various types of public-private partnerships.

4. Accompanying changes in organisational mechanisms, including decentralisation, sector-wide approaches (SWAps) and reforms in logistics and supply systems. " (38)

The interventions proposed under these mechanisms have had varying endurance, with some elements still current and others less prominent today. In relation to reproductive health services, decentralisation, for example, offered opportunities for improved service provision, in which local community priorities could potentially have a voice. However, that voice (and the particular needs expressed) could lose out to competing needs and demands. A review of decentralisation in Latin America, Asia and Africa, conducted by researchers from those regions, concluded that reproductive health service provision is prioritised when

"... mechanisms to ensure equity in resource allocation are deliberately instituted, including the retention of national government control over resource allocation. " (39)

In fact, the provision of conditional grants to local health services specifically, for example HIV services--a feature of Global Health Initiatives--is controlled by national Departments of Health or national Treasuries, and this has deprioritised decentralisation. Similarly, reforms in logistics and supply systems have to a large extent been superceded by the impact of massive funding for Global Health Initiatives, which have bypassed and undermined these routines within health systems, so much so that decentralisation and proposed reforms to supply systems are no longer prominent.

A review of priority setting within health and sexual and reproductive health illustrates a number of important points:

* national decision-making authority about what to finance and how to offer programmes is often limited by the role and power of global lending institutions, whose priorities may not coincide with national priorities;

* a small global policy elite, located predominantly in the USA and UK (indeed a small number of identifiable individuals within a limited number of institutions within those countries) drive the prioritisation debate in collaboration with a few global agencies (WHO's Health Systems Department, Pan American Health Organization, Abt Associates, USAID, Harvard and Johns Hopkins Universities, London School of Hygiene and Tropical Medicine, World Bank's Population, Health, and Nutrition Department, UNICEF and DFID);

* tools used to prioritise what services are offered are usually based on calculation of burden of disease and cost-effectiveness. (40)

The use of burden of disease as the basis for priority setting by global actors has been particularly problematic because of the relatively lower priority accorded to reproductive health. A critical analysis of the calculation of DALYs in reproductive health identified that missing and inadequate data, inability to deal with co-morbidities and lack of transparency in assigning weights to calculate DALYs led to an underestimate of the burden. (41) Yet this approach to burden of disease calculations still has currency. On the other hand, a narrow focus on specific aspects of reproductive health, i.e. maternity care and very recently contraceptive services within the context of the Millennium Development Project, has received much attention and significant investment.

Forces promoting privatisation

The most enduring aspect of the health sector reform movement of the late 1980s has been the push towards privatisation. (42) The notion that markets are the most efficient mechanism to allocate scarce resources to best meet the interests of consumers is not new. In the area of health, proponents of the free market have argued that there is no justification for government financing or provision except for those services which can be characterised as "public goods". Services such as health education are considered public goods in economic theory, because they are non-excludable and non-rival. Non-excludable means that it is impossible to exclude those who have not contributed towards the cost of the good from benefitting from it; non-rival implies that the benefit gained by one person from the service does not reduce the benefit that others can gain. From this perspective, governments should not be involved in any curative service, and many other services, e.g. contraception or abortion services, are not pure public goods. (43)

In the late 1980s and early 1990s the World Bank and other international organisations proposed and actively championed expanding the role of the private sector in health as the best strategy to advance population health, in view of the failure of the public health sector in many low- and middle-income countries. The major arguments made by those favouring privatisation of health systems run as follows:

* Many developing countries already have a large private sector in health. It is the responsibility of governments to harness and channel these resources to promote the common good of better health for all, and especially the poorest in the poor countries of the world. Besides the provision of services for public goods, the government should limit its role to financing and should purchase health care from a number of potential providers, who compete with each other.

* The private sector is competent in making initiatives and projects sustainable, which will help ensure stability and long-term sustenance of health programmes.

* Public-private partnerships will bring benefits from the private sector's expertise in reaching and motivating consumers. This could help achieve wider population coverage with health promotion messages, services and products.

* Privatisation will vastly improve health sector efficiency. Competition between public and private sectors will ensure that resources are allocated more efficiently in the health sector. Moreover, private for-profit institutions bring with them a way of doing business which is more effective and efficient. Government public health interventions could be restricted to areas where there is market failure.

* Privatisation would contribute to health equity. Those able to pay will use private services while public resources are targeted to reach those who cannot pay. On the other hand, not engaging with the private sector proactively could exacerbate inequity because of the negative impact of private providers on household incomes because of catastrophic health expenditures.

* The quality of health and allied services will improve because the monopoly for provision of goods and services by the public sector will be replaced with competition between public and private sectors. (16,19,21,44,45)

These assertions were theory-driven rather than based on empirical evidence. Where evidence has been brought to bear it is not always obvious that privatisation is the best option. For example, in South Korea in 1977, the performance of semi-privatised hospitals was compared with non-privatised hospitals. The evidence indicated that privatisation did not improve working conditions and pushed up costs, and this evidence was used to stop government plans for further hospital privatisation. (46) Another instructive example is Thailand. The 1997 economic crisis affecting the "Asian tigers" presented an opportunity in Thailand to review their health system. The most significant development was the 1997 Constitutional recognition of health as a human right to be protected by the state. The resulting changes included guaranteeing citizens' access to an adequate quality of health care for all and protection and empowerment of users of health care. (47) This is an example of a different underlying value system from that which informs USAID's push towards privatisation. At the same time as Thailand encouraged the growth of the private sector it also increased public investment in health substantially. For reproductive health this has meant universal access to a wide range of sexual and reproductive health services. However, the public sector has been the source of services for the majority of the women. (48) Similarly, the Thai government has not hesitated to take on transnational pharmaceutical companies by issuing compulsory licenses for HIV drugs, so that care is affordable. For all advocates for universal access to comprehensive sexual and reproductive health services, Thailand's policy of pursuing universal coverage without completely clamping down on privatisation is one worth keeping track of and drawing lessons from.

A number of factors appear to have contributed to the dramatic increase in the private sector's role in health starting from the 1990s. In developing countries, policies that promoted the growth of the private sector were frequently the result of the budget deficits that followed the 1980s inflationary crisis. One of its first forms was the private management of public hospitals and health centres. Starting in the 1980s, under the Reagan administration, USMD allocated significant technical and financial resources to promoting the involvement of the private sector in health, especially in family planning. Many national family planning associations were initiated by USAID and other donor agencies that supported NG0s working in association with the public or private sector at the national level. (49) After that, the 1990s reforms financed by the World Bank actively promoted public-private interactions. The World Bank appears to have been prompted by financial imperatives (besides the ideological position). According to an address by the World Bank's President to a conference on public-private partnerships in the early 2000s, bilateral support to the International Development Assistance, the World Bank's concessional lending arm, was plunging, and the private sector increasingly filled this vacuum. (50)

As the corporate health sector's degree of influence eclipsed that of nation states, it became important for international organisations--the UN and WHO among them--to engage with the corporate health sector. Further, at a time when funds for the UN were drying up, the opportunity to raise resources from the private sector could hardly be ignored. Private foundations were catalysts in the emergence of public-private partnerships at a global level. For example, the establishment of the United Nations Foundation Inc in 1998, and a vast endowment to it from the Bill & Melinda Gates Foundation, were instrumental in the formation of public-private partnerships involving WHO. In her report to the Executive Board of WHO in 1999, the then WHO Director-General Gro Harlem Brundtland mentioned that "both these foundations have made partnerships and collaboration with the private sector a key feature of their grant giving". The amounts awarded to WHO were very large--US$100 million annually was committed by the UN Foundation for a period of ten years, while the Gates Foundation made an endowment grant of US$17 thousand million. (51)

[ILLUSTRATION OMITTED]

Privatisation has been ongoing and continues apace. The World Trade Organization, formed in 1995, has a significant influence on how privatisation takes place. (18) Privatisation in health may happen in the area of financing of health care, in service delivery, or in both. The term public-private interactions is a generic term to describe all relationships between the public and private sectors that have emerged as a part of the privatisation effort in the health sector, at the national as well as international levels.

Evidence of the impact of privatisation on access to quality sexual and reproductive health services

The call internationally for evidence-based interventions is de rigueur and so we turn now to exploring the impact of various forms of privatisation on sexual and reproductive health services from the 1980s to today. What are the consequences of privatisation for access to services, in particular for the poor and marginalised and what is the quality of those services?

User fees

While user fees are no longer promoted, they still exist. The impact of withdrawing them may result in "informal" fees becoming more common. Withdrawing them without concomitant interventions to pay for services in a different way and secure access to quality services is a concern. (52) At the time of their introduction, there was no evidence of the impact of user fees, rather a supposition on the basis of economic theory that the impact would be positive. In more than 60% of low-income countries (those with per capita income below US$1000), out-of-pocket spending on health rose to 40% or more of the total spending on health. (30,53) There is also evidence from some countries that women systematically incur more out-of-pocket expenditure than men. (54) Childbirth services and other reproductive health services, as well as the burden of chronic diseases in women, may account for this.

Childbirth services, which the great majority of women need, are unaffordable for many of them, even in settings where services are nominally "free". In Dhaka, Bangladesh, a 1995 study found that the cost of "free" maternity care in public hospitals was in fact catastrophic for many. For 21% of the families in the study, accessing care cost 51-100% of their monthly income, and two to eight times their monthly income for 27% of the families. More than half the families did not have enough money to pay for these services, and of this group, 79% had to borrow from a money lender or relative. (55) Similarly, a study in Madagascar in 2007-08 found that out-of-pocket costs to access caesarean sections and care for neonates were catastrophic for low-and middle-income women. (56)

The increased burden of out-of-pocket payments is likely to stop more women than men utilising health services for gender-related reasons. Econometric studies based on household survey data have found that vulnerable groups without access to financial resources, e.g. adolescents, the elderly and women not engaged in the formal economy, have greater price elasticity for health care services as compared to the rich. (57) This means that when fees are introduced or increased, or when costs to access care rise (e.g. transport costs) these groups of people will be less able to afford the fees and so will be discouraged from using health services, both preventive and curative.

While cost definitely discourages service use by women from the lowest income groups, gender-based inequalities in access to and control over resources are also a factor. In Bangladesh in 1997, when user fees were introduced for family planning services, men expressed unwillingness to spend on preventive care and treatment for women, including for family planning, despite their awareness of the importance of fertility control. (58) A 1999 review of experiences with cost-recovery in family planning programmes in sub-Saharan Africa concluded that introduction of user fees for contraception at levels that would have any revenue-generating potential could dampen demand significantly. (59)

Private insurance and pre-payment schemes

In terms of coverage, the poorest and those without access to cash--including women--are less likely to be able to participate in voluntary health insurance schemes, even when these involve relatively modest payments, as in micro-insurance schemes. (60) Premium payments by the indigent and those with limited ability to pay need to be partially or completely subsidised in order to be able to cover the most vulnerable sections of society, of which women constitute a large component. (61)

Moreover, private health insurance schemes may have gender discriminatory dimensions which act as barriers to coverage. A 2008 report from the USA, based on an analysis of 3,500 individual insurance plans, found that women who bought individual insurance coverage--about 18% of all women in the country--faced many forms of gender discrimination. Many insurance plans practised "gender ratings" and charged women higher premiums than men of the same age. Insurance companies could reject applications for reasons that were specific to women: for example, women survivors of domestic violence and women with a previous caesarean section were rejected coverage by some insurers. (62) Gender ratings were made illegal by the health-insurance reform package passed in March 2010. Discrimination on the grounds of sex, race, national origin, ethnicity or disability has been explicitly prohibited, which may make it difficult to reject women based on a history of claims related to domestic violence. The point here is that regulation is important to achieve access to care for those in need.

Private insurance schemes can be selective of what they cover, however, subject to legislation in the county concerned. From a profitability point of view they aim to cover health conditions that are low-probability, random events, such as an accident or surgery. High-probability and non-random health events are considered unprofitable and maybe uninsurable unless there is universal coverage--where the rich and healthy subsidise the sick and poor. (63) Many reproductive health services are uninsurable as stand-alone benefits. For example, pregnancy is a non-random event; contraceptive services are high-probability services. They can only be efficiently covered if they are part of a broader benefits package. (63)

Micro-insurance schemes may also be similarly limited in the benefits packages they are able to offer. In most instances these mechanisms do not include coverage for a wide range of essential reproductive health services such as normal delivery, contraception, and in-patient gynaecological care, or some of the most risky health events for women, such as delivery complications. A 2004 study of 13 mutual health organisations (MH0s) which are community-based, pre-payment schemes in West Africa, found that only some of them included family planning services as part of the benefits package. inclusion of family planning services in the benefits package was more common in MHOs initiated by women, and influenced mainly by demand from members. MHOs that did not offer family planning services were initiated by men or mixed groups. (64)

Social marketing for reproductive health

Programmes providing subsidies for the delivery of contraceptives through commercial distribution systems--known popularly as "social marketing"--began as early as the 1960s. Their rapid development started in 1981 with USAID's first worldwide Contraceptive Social Marketing technical assistance effort. A second programme, Social Marketing for Change, was launched in 1984, also by USAID. Other well-known international social marketing organisations include the TIPPS Project, the PROFIT project, and the Commercial Markets Projects, all funded by USAID. (65)

Social marketing of condoms has been an important component of AIDS control programmes since the mid-1980s. By 1999, at least 71 different social marketing programmes for male and female condoms were active in $9 developing countries as part of H1V/AIDS prevention efforts. (66) USAID funds many of these. For example, in Indonesia, the "expanded access to and promotion of preventive devices" component of the USAID-funded HIV/AIDS Prevention Project is aimed specifically at involving the private sector in increasing condom use among sex workers and their clients, and making them widely available through an increased number and range of outlets. (67)

Medical abortion pills are available through social marketing channels in some countries. For example, Marie Stopes International markets its own brand of medical abortion pills in India. (68,69) Many new health products are now available through social marketing channels. Population Services International (PSI) distributes a prepackaged therapy to treat male urethritis. In India, PSI social markets a clean delivery kit, and a similar product has been launched in Uganda. (53)

Most recent data indicate that social marketing programmes for contraceptives, condoms, treatment for sexually transmitted diseases, behaviour change communication messages for HIV, delivery care kits, and medical abortion are present in more than 70 countries in Asia, Africa and Latin America. All clinical social franchises which provide contraceptive or medical abortion services are also involved in social marketing of these products, in addition to other channels of social marketing within these same countries. PSI, Marie Stopes International, DKT International and Constella Futures Group are the main actors involved. (70-73)

With social marketing, as with commercial marketing, the predominant interest is to encourage consumers to consume. Does this sometimes lead agents to underplay any risks of methods and medicines? Do they give good enough instructions on proper use, e.g. with antibiotics to treat urethritis or safe delivery kits or home use of medical abortion pills?

On the other hand, social marketing has the potential to increase coverage of reproductive health products to areas and sections of the population that have unmet need and the ability to pay. At the same time, it also has the potential to widen inequalities in access to products. This is because the products are usually targeted at those who can afford to pay at least part of the cost, and increasingly, cost-recovery and sustainability are primary considerations. The products are also usually marketed through commercial outlets, which may be located only in places where there is adequate purchasing power, and places connected adequately by roads and transportation. This selection bias will leave out those in poorer areas and also those living in scattered and smaller population settlements. Social marketing therefore is not an arrangement that serves low-income groups in the population. The extent of success in meeting the needs of those in greatest need and with the highest risk of mortality has not been demonstrated. (74) Moreover, the existence of social marketing may discourage governments from taking responsibility for reaching the poor or hard to reach.

Improving population-level sexual and reproductive health: equity is essential

To make an impact on sexual and reproductive health, high service coverage is required. All women who want to access contraceptives must be able to access them. Cervical cancer screening will only have a population-level impact if the great majority of the population of women at risk are screened. (75) Every pregnancy, delivery and newborn, and every abortion, require skilled care. A proportion of deliveries require emergency obstetric care, so referral systems for complications have to be operational. Cognisance must be taken of the fact that those most at risk of reproductive ill-health and mortality are not evenly distributed in society, and poor and hard-to-reach women bear a disproportionate burden. A review of the South Africa Demographic and Health Survey data indicated that "while 14% of all births in the five years preceding the survey were delivered without help of a medically trained attendant, 1.6% of these were in the wealthiest quintile compared to 30% in the poorest quintile". (76) To improve population-level reproductive health it is essential to reach those most at risk of poor health outcomes.

What are the equity implications of a growing private sector in sexual and reproductive health services? The answer depends on the availability of these services in the public sector. A study conducted in Bangladesh, Ghana, Kenya, Morocco and Indonesia found that inequalities in contraceptive use did not increase due to expanding private sector contraceptive services but because the public sector also expanded (albeit to a smaller extent) and because the contraceptive needs of the vast majority of women from the lowest income quintiles were met by the public sector. (77) In Thailand, expanding the private sector was actively promoted yet high coverage rates for contraceptives, universal access to antenatal care and skilled birth attendance were maintained with little disparity between socioeconomic groups. Again this was because investment in the public sector continued, and it was the public sector that was the main service point for this care. (48)

This will not be true for countries where investment in the public sector declines as the private sector expands. One reason why public sector investment may decline is that donor funding is being invested in expanding the private sector, whereas the public sector may have previously benefited from this investment. Where this has been done with consideration to potential consequences for the poor, it may have less impact on those most in need, as appears to be the case in Viet Nam. (78) However, when privatisation is pursued without ensuring access to services for the poor, this seems to have a negative impact on the poor. (79)

In the absence or non-availability of many sexual and reproductive health services in the public sector, both poor and non-poor women and men have had to meet their sexual and reproductive health care needs from private sources. Thus, the vast majority of low-income women in developing countries are still delivered by traditional birth attendants and are treated for their sexual and reproductive health problems by traditional and informal sector health providers. Those who can afford to pay use the for-profit private sector. (80,81) This unequal access to quality sexual and reproductive health services can be exacerbated or reduced through deliberate policy decisions.

Promoting the growth of the private sector in health care provision has often led to a draining of human resources from the public to the private sector. Human resources for the provision of sexual and reproductive health services are already concentrated in the for-profit private sector in many countries. An overarching equity issue is that donor funds are being utilised more for market creation, and through it, catering for those who can afford to pay. The recent WHO UNICEF 2015 Countdown report has documented continued inequity in access to services for women and children. (82) In the absence of evidence that creating markets for health improves equity and therefore meets the needs of those at greatest risk of premature mortality, and in the face of evidence that women access reproductive health services from the public sector when they can do so, it follows that donor funds may be more effectively invested in the public sector.

The usual argument made in the literature is that market-creation efforts would shift utilisation of public sector services, by those with the ability to pay, to the private sector. According to this argument, government resources would be freed up to be invested in programmes for the poor and vulnerable groups. But there is an absence of evidence that this actually happens. The reality is one of shrinking resources. The private sector serves those who can pay, with the risk that the public sector remains under-resourced and steadily deteriorates.

Conclusion

The historical perspective presented here illustrates that the dominance of the current economic paradigm is relatively new. Today's sexual and reproductive health activists, government officials and donor agency programme officers would benefit from an understanding of this background as it heralded a number of inter-related initiatives that have shaped the approach to providing sexual and reproductive health services internationally.

We have illustrated that a confluence of factors--prioritising debt repayment, the rising importance and leverage of multinational corporations, a weakened role of the nation state, a particular approach to health sector reform, and a move toward technologically driven vertical programmes--have all militated against realising comprehensive sexual and reproductive health services, in particular for those most in need. Governments today have a very complex globalised environment to negotiate where externalities such as loan conditions, trade agreements and donor preference for single issue, short-term results impede incremental health systems development aimed at meeting multiple interlinked health needs of populations. This, however, does not remove the obligation of governments to allocate sufficient resources to health or address inefficiencies in their health systems.

The continuing commitment to privatisation without the kind of evidence that is usually required for the introduction of new interventions represents a double standard. Similarly the single-issue-vertical-programme-approach, in spite of evidence that this undermines health systems and that weak health systems undermine what vertical programmes could achieve, needs to be confronted. In particular, donors need to be held accountable for promoting vertical programmes.

Taking an ideological stand for or against privatisation is not helpful. Privatisation for the sake of developing a market in health without evidence of how it will improve coverage, equity, access or quality is not acceptable. Privatisation has increased access to some reproductive health services, albeit not comprehensive services, for at least a proportion of the population of some countries. Improved equity, however, does not appear to have been achieved. (83)

It is time for progressive forces within the reproductive health movement to build alliances with progressive health systems reformers who are working towards health equity more generally. We need to do the research that illustrates why and how a health systems approach based on the principles of public health, human rights and Alma Ata would improve health and sexual and reproductive health.

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Sharon Fonn, (a) TK Sundari Ravindran (b)

(a) Professor & Head of School, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

(b) Professor, Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India

* See Cottingham and Beret (2011) for a discussion of compulsory licensing and the industry today. (17)

([dagger]) See: <http:1/daccess-dds-ny.un.org/doc/UNDOC/LTD/ N11/367/84/PDF/N1136784.pdf?OpenElement>.

DOI: 10.1016/S0968-8080(11)38584-9
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