Understanding Health Sector Reforms and Sexual and Reproductive Health Services: A Preliminary Framework

Abstract

To understand the implications of health sector reforms for sexual and reproductive health services, there are three major dimensions to consider. The first two relate to the context in which health sector reforms are introduced: the characteristics of the health system, and that of reproductive and sexual health services located within it. The third dimension has to do with the content and scope of health sector reforms introduced into this context, and the actors and processes through which it is introduced. The content, scope, actors and processes have in turn to be located and understood within the larger geopolitical context and the position within it of the country under consideration.

Résumé

Pour comprendre les conséquences des réformes du secteur de la santé sur les services de santé génésique, il faut examiner trois dimensions principales. Les deux premières se rapportent au contexte dans lequel ces réformes sont introduites: les caractéristiques du système de santé et celles des services de santé génésique qui y sont intégrés. La troisième dimension est liée au contenu et à la portée des réformes menées dans ce contexte, et aux acteurs et processus par lesquelles elles sont introduites. Le contenu, la portée, les acteurs et les processus doivent à leur tour être placés et compris dans le contexte géopolitique plus large et en fonction de la position que le pays étudié y occupe.

Resumen

Para comprender las implicaciones que tienen las reformas del sector salud con respecto a los servicios de salud sexual y reproductiva, hay que considerar tres dimensiones principales. Las dos primeras se refieren al contexto en el cual las reformas del sector salud estén introducidas: las caracterı́sticas del sistema de salud, y de los servicios de salud sexual y reproductiva dentro de este sistema. La tercera dimensión está relacionada con el contexto y con los actores y los procesos mediante los cuales las reformas se introduzcan: hay que localizar y comprender el contenido, el alcance, los actores y los procesos dentro del contexto geopolı́tico mayor y la posición que ocupa tal paı́s dentro de él.

Key Words:

• health sector reforms
• sexual and reproductive health services
• health policy and programmes
• geopolitics

In reading the burgeoning literature on the impact of health sector reforms, and contradictory findings on what works and what does not, I have felt the need to organise the information in a way that would help me make better sense of it all.

The framework I am about to present has emerged from this need, and is still evolving. All the same, I thought that it would provide a useful starting point to unpack the many factors that may result in health sector reforms unfolding in one direction in one country and in a completely different way in another.

There are three major dimensions to consider. The first two relate to the context in which health sector reforms are introduced: the characteristics of the health system, and that of reproductive and sexual health services located within it. The third dimension has to do with the content and scope of health sector reforms introduced into this context, and the actors and processes through which it is introduced. The content, scope, actors and processes have in turn to be located and understood within the larger geopolitical context and the position within it of the country under consideration.

Characteristics of the health system

A typology of national health systems based on the national economic level and the extent of state responsibility for the provision and organization of health services proposed by WHO in the early 1980s [1] appears to be a useful starting point. According to this typology, national health systems could be classified into one of nine categories – by high, medium and low GDPs and by high, medium and low level of state responsibility for the provision and organization of health services. A high level of state responsibility, for example, goes hand in hand with a major public sector in health, and a low level of state responsibility for health with a predominantly private sector-based health system. Needless to say, these characteristics change over time, and a country may move from one category to another. Also, there may be more than one type of health system in countries with a federal structure of governance.

Characteristics of sexual and reproductive health services

The nature of the health system itself would influence the characteristics of sexual and reproductive health services currently in place in any country. For example, the range of services available would depend on the resources available, and the extent of state involvement in provision of health services would determine whether a given service is available within the public or the private sector in health, or in both.

Other factors which are likely to influence the range of reproductive and sexual health services available, their distribution across the public and private sectors, and the mechanisms for financing sexual and reproductive health services include: the political priority accorded to maternal health and safe motherhood programmes; the country’s stance with respect to population control and induced abortion; and its track record in terms of actors involved in setting the sexual and reproductive health agenda: the relative bargaining positions of foreign donors, religious institutions and the women’s movement.

For example, the political priority accorded to maternal health services may determine whether pregnancy or essential obstetric care is subsidised by the state or covered by user fees. Again, countries with strong state-sponsored population control programmes would at least have the human and physical resources for service delivery in the public sector, as compared to settings where there has been no investment in any aspect of reproductive health. There may therefore be a comparative advantage in retaining these services within the public sector, rather than encouraging private sector provision of sexual and reproductive health services. To give another example, countries where the women’s health movement has had a strong influence in agenda setting may find it relatively less possible to introduce health sector reforms that could restrict women’s access to life-saving services.

Characteristics of health sector reforms

Nature and scope

Health sector reforms that have been introduced during the 1990s typically fall into one or more of the following categories, or a combination of some aspects of each:

•	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.
•	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.
•	Changes in organisational mechanisms: principally, a shift in the role of the state in the regulation and provision of health care services, usually in the direction of taking less responsibility for direct provision of health care and more responsibility for regulation. Experimentation with various types of public-private partnerships.
•	Accompanying changes in organisational mechanisms have included decentralisation, integration of services, including sector-wide approaches and reforms in logistics and supply systems.

Countries may introduce reforms in any one of the above categories, or in several of them simultaneously. They may start with one category of reforms, and move on to others. They may introduce reforms at the national level, or in one or two states within a federal structure. Reforms may cover the entire health sector, as in the sector-wide approaches, or be introduced in a few health programmes. The number of permutations and combinations that are possible make “health sector reforms” far from a homogenous package, and in effect, a mixed bag of interventions and policies varying across and within countries and over time.

Actors and processes

The nature and scope of reforms is likely to be influenced considerably by the range and nature of actors who have been involved in setting the reform agenda, and those who have made the final decisions. The range of actors has included international actors such as donors, financial institutions such as the World Bank, international NGOs and consultants contracted by donors; and in-country actors such national and provincial governments, the medical profession, the research community, the women’s health movement and other civil society organisations.

The processes through which the reform agenda is set are to a significant extent a function of the actors involved. The process could range from total non-consultation with in-country actors, with donors and consultants setting the agenda and leaving countries with little scope for manoeuvre, to very broad-based consultations with professional bodies and civil society actors within countries.

The larger geopolitical context within which the country is located is the backdrop against which all three dimensions need to be understood. These would include broadly:

•	the political context, such as the bargaining position of the country in the international setting, and the nature of its governance structure, which would determine the extent to which non-state actors are able to influence any policy;
•	the economic context, such as the level of external debt and financial stability or crisis; and
•	the historical context, especially in terms of past political structure and state role in health and social development in the past.

The reform process would mean something very different to erstwhile socialist countries that have had a well-organised, state-provided health service as compared to countries where there has always been little state involvement in the provision of health care.

The consequences of health sector reforms for sexual and reproductive health services depend on the nature of the three dimensions constituting this framework, as well as their interaction with each other. When comparing experiences of health sector reforms across different countries, it would be important to locate these experiences within the framework outlined, so that we can better understand what works or does not work, where, how and why.

Acknowledgements

This paper was one of the introductory presentations to the RHM meeting on Health Sector Reforms: Implications for Sexual and Reproductive Health Services, Bellagio, Italy, 25 February 2002.