Short-Changing Reproductive Health

Abstract

Health sector reformers, particularly the economists among them, are prone to reject calls for more financial support for reproductive health as “special pleading” even when the argument is made that reproductive health is a basic human right. Reproductive health is not alone in this. Up to now, however, the idea that the right to reproductive health care should take precedence over other health rights has not been put on the table. Economists ask how much interventions cost and whether there is enough money to cover all of the interventions being proposed; if not, they ask which interventions will be funded. Basing decisions about spending for health on evidence about the burden of disease is a way of using the principles of economics to improve health systems performance. However, this methodology poses some special problems for reproductive health as pregnancy is not a disease. Further, economic principles are not the only valid criteria for decisions about health care funding. Those who are concerned about reproductive health need to remain vigilant about the impact of these changes and counter with their own evidence on how they may or may not be contributing to improved health system performance and to reproductive health and rights.

Résumé

Les réformateurs du secteur de la santé, particulièrement les économistes, tendent à rejeter comme «argument spécieux» les demandes d’un accroissement du soutien financier pour la santé génésique au motif que la santé génésique est un droit fondamental. La santé génésique n’est pas la seule dans ce cas. Néanmoins, l’idée selon laquelle le droit à la santé génésique devrait avoir priorité sur d’autres droits à la santé n’a pas encore été étudiée. Les économistes demandent combien coûtent les interventions et s’il y a assez d’argent pour toutes les couvrir; sinon, ils demandent quelles interventions seront financées. Décider des dépenses en fonction de la charge de morbidité permet d’utiliser les principes économiques pour améliorer les résultats des systèmes de santé. Toutefois, cette méthodologie pose des problèmes particuliers pour la santé génésique puisque la grossesse n’est pas une maladie. De plus, les principes économiques ne sont pas les seuls critères pour décider du financement des soins. Les personnes concernées par la santé génésique doivent surveiller l’impact de ces changements et y répondre avec leurs propres informations sur la manière dont ils peuvent ou non améliorer les résultats du système de santé et contribuer à la santé et aux droits génésiques.

Resumen

Los economistas entre reformadores del sector salud tienden a rechazar las llamadas a más apoyo financiero para la salud reproductiva, por ser esta un derecho humano básico, porque consideran este argumento un “alegato especial”. La salud reproductiva no es el único caso de este tipo. Sin embargo, la idea de que el derecho a la atención en salud reproductiva debe tener precedencia sobre los otros derechos de la salud no ha estado sobre la mesa. Los economistas preguntan cuánto cuestan las intervenciones y si hay suficiente dinero para cubrir todas las intervenciones propuestas. Si no lo hay, entonces preguntan cuáles intervenciones se financiarán. Basar las decisiones sobre los gastos de salud en los datos sobre la carga de morbilidad es una manera de utilizar los principios económicos para mejorar el desempeño de los sistemas de salud. Pero esta metodologı́a presenta problemas especialmente en relación a la salud reproductiva porque el embarazo no es una enfermedad. Además, los principios económicos no son los únicos criterios válidos al decidir el financiamiento de la atención en salud. Quienes se preocupan por la salud reproductiva deben vigilar el impacto de estos cambios y responder con sus propios datos mostrando cómo dichas reformas contribuyan o no al mejoramiento del desempeño del sistema de salud, y a la salud y los derechos reproductivos.

Health sector reformers, particularly the economists among them, are prone to reject calls for more financial support from the champions of reproductive health as “special pleading.” Reproductive health is not alone in this. Whatever the need (e.g. more vaccinations, more child health care), the reformers argue that decisions to spend scarce public funding on one or another need should be based on evidence about the relative burden of death and disability attributable to the particular condition and not on those that get most public outcry or political support.

Reformers say the focus should be on improving health system performance – better health outcomes and more equitable, higher quality and cost-effective, consumer-oriented services. They also seek to keep people from becoming impoverished when a medical emergency occurs.

All this sounds like something that the champions of reproductive health and rights would want to support. In fact, poor health system performance is one of the reasons for poor reproductive health outcomes. Reforms can have potentially beneficial effects, but they also involve risks. Reproductive health advocates need to keep an eye on the risks associated with specific reform initiatives.

The accusation of “special pleading” arises from changes in the way reformers allocate health resources. Economists and health professionals approach allocation issues with different mindsets. Health professionals see health problems and identify interventions to address them. Economists ask how much those interventions cost and whether there is enough money to cover all of the interventions being proposed; if not, they ask which interventions will be funded and which not [1].

When confronted with the argument that reproductive health is a basic human right, they may agree about a generic right to health, but counter by asking reproductive rights advocates which other rights criteria should be used to decide among needs when resources are not available to fund the interventions required to address all of them [2]. Up to now, the idea that the right to reproductive health care should take precedence over other health rights has not been put on the table. The champions of reproductive health need to articulate why reproductive health rights should have such precedence – for example, on grounds that pregnancy and delivery subject women to risks that arise from their unique role in reproducing the human race [3].

Basing decisions about spending for health on evidence about the burden of disease has been promoted as a way of using the principles of economics to improve the performance of health systems. One of the problems in applying these principles is how to compare widely differing types of health problems. Health reformers have sought to find a measure that could express a range of health problems in a single metric that will allow such comparisons. The disability-adjusted life year (DALY) is such a metric. It measures the burden of disease in terms of the number of healthy years of living lost through premature death or disability attributable to each disease category.

As a quantitative measure that applies to all disease categories, the DALY appears to satisfy the economists’ need for an evidence-based criterion for allocating resources. In fact, the DALY falls far short of this. Calculation of the DALY requires far more information about causes of death and disability than most countries have, so DALY tables published by the World Health Organization are based largely on estimates for countries at similar levels of overall life expectancy in the region in which a country is located [4]. The severity of diseases/disabilities (relative to death) is set by panels of experts and applied across all countries and will often miss critical contextual factors in particular locales [5].

The DALY methodology poses special problems for reproductive health. Pregnancy is not a disease, and the benefits of enabling couples to decide when and how many children to have go well beyond avoidance of the health problems of unplanned pregnancy. Reproductive morbidities are often poorly measured, especially for poor women who endure life-long health consequences of poorly managed obstetric problems. The ways in which these problems affect the lives of individuals and their families vary enormously depending on their economic and social conditions [6].

DALY proponents admit to its shortcomings, but argue that the approach is better than letting those who have the most political clout have the greatest influence on funding decisions. They see themselves as arbiters among conflicting claims on scarce resources and argue that priority setting should be based on evidence that demonstrates which interventions will bring the greatest gains in disability-adjusted life years. What can the champions of reproductive health do, then, to ensure that the decision-making process does not short-change them?

It is important that they do not leave resource allocation decisions up to the economists and financial people. They, along with other health professionals, need to be at the table when such decisions are made. To do this they need to be familiar with the language and analytical tools of reform so that they can demonstrate to decision makers that reformed allocation methods will not achieve better and more equitable health outcomes if they fail to support reproductive health.

This requires a stronger evidence base on the social and economic consequences of poor reproductive health outcomes. It also requires that women who suffer from adverse reproductive health conditions have a voice in setting the severity weights for those conditions in the measurement of the burden of disease in their countries.

Reproductive health advocates also need to remind economists that while evidence-based approaches are better than political influence, economic principles are not the only valid criteria for decisions about health care funding. Beneficiaries and health providers are stakeholders in this process and have a legitimate claim to represent their views. An important message for economists and public health professionals is that while health reform has its technical aspects, it also needs to be responsive to societal values and commitments.

Resource allocation processes are not the only type of health reform that creates risks for reproductive health and rights. Attempts to mobilize additional resources through user fees and insurance schemes also carry risks, as do new organizational approaches such as decentralization and contracting out of provision to private providers. Those who are concerned about reproductive health need to remain vigilant about the impact of these changes and counter with their own evidence on how they may or may not be contributing to improvements in both health system performance and reproductive health and rights.