Health Sector Reforms: Implications for Sexual and Reproductive Health Services

Since the mid-1980s, long before the International Conference on Population and Development (ICPD) in Cairo in 1994, fundamental changes have been taking place in the financing, management and structure of health care provision, described at length in the 1993 World Bank Report [1]. These changes include reforms in:

•	mechanisms for health financing, priority setting and accountability,
•	the structure of national health systems, and
•	the role of the state in health service provision.

These reforms have also been affected by changes in national and international allocation of resources to the health sector, the attribution of responsibility for health, and the increasing commodification of health in almost all countries [2].

Policy changes, some progressive, others retrogressive, wide-ranging biomedical and social research, and efforts to improve sexual and reproductive health service delivery in the face of cutbacks, have been taking place at the same time. Although the reforms have been to health systems as a whole and will have influenced the extent to which countries have been able to implement the ICPD Programme of Action, there is only limited evidence available on this to date and little interaction between the institutions and individuals involved. Moreover, there has been limited capacity to generate evidence on the impact of reforms on sexual and reproductive health services, not only to ensure that ICPD goals are reached.

In February 2002, RHM organised a multi-disciplinary meeting at the Bellagio Study and Conference Centre, Bellagio, Italy, attended by 25 people from all world regions, whose purpose was to examine the implications of health sector reforms for sexual and reproductive health services, with a focus on low-income countries. That meeting, which included participants with expertise in health sector reforms and participants with expertise in sexual and reproductive health issues, confirmed just how important it is for more dialogue to take place on these issues.

Some of the papers included in this journal issue were presented at the meeting and substantially revised in light of the insights gained there. Others were submitted and reviewed in the usual way. A further group of papers presented at the meeting will be included in the May 2003 issue of the journal, which will focus on the integration of sexual and reproductive health services as a health sector priority. This editorial summarises some of the insights that emerged during the meeting, which are linked to each of the papers in this journal issue.

Sex and reproduction are universal aspects of human life

The Programme of Action of the International Conference on Population and Development (ICPD) 1994 defined reproductive health care as:

“… the constellation of methods, techniques and services that contribute to reproductive health and well-being through preventing and solving reproductive health problems. It also includes sexual health, the purpose of which is the enhancement of life and personal relations, and not merely counseling and care related to reproduction and sexually transmitted diseases.” [3]

Eight years down the road, it is clear that the Programme of Action does not articulate in forceful enough terms the centrality of safe sex and healthy reproduction to global health, or at least not in the language used by health sector reformers today.

Neither the 1994 ICPD nor ICPD+5 in 1999, where key actions were further defined and targets set for achieving the ICPD Programme of Action, took account of changes in health systems policy all over the world, as they were overwhelmed by other exigencies. It has taken until quite recently, in fact, for the sexual and reproductive health field to wake up to what has been going on around us. We are light years away from Halfdan Mahler’s prescription that “health is more than just the absence of disease”. In fact, sexual and reproductive health as universal goals have been under threat since before they were agreed.

Why? In simple terms, economic crises in the 1980s led to a breakdown in health systems functioning in middle-and low-income countries. Structural adjustment programmes and subsequent safety nets that were introduced to alleviate the effects of these at the time [4] often did not work. Health economists from the developed world, mainly the USA but also the UK, then proposed health sector reform policies to try and jumpstart moribund health systems, and changed the face and politics of global health leadership beyond all recognition.

In line with these changes, new forms of priority setting, which are described as objective but which actually also involve value judgements [5], were conceptualised and introduced into the international health arena. When these were applied using existing global epidemiological and costing data, sexual and reproductive health needs lost out in competition with major killer diseases, first and foremost HIV/AIDS, malaria and tuberculosis. And “competition” is the operative word here, in view of the current scramble for money for health, the newest global economic growth area. No longer are multi-sectoral, broad-ranging public health goals considered to be the most apt for low-income countries, though that is what made “health for all” a reality for the vast majority in developed countries in the past 100 years.

What is a priority in health then?

Sex is a universal form of human behaviour, and getting pregnant and having babies is an almost universal experience for women. Both are necessary for the human race to have a future, and everyone in the world is intimately and deeply affected by them. It would be considered sheer insanity in the developed world to suggest not providing adequate services for contraception, abortion, sterilisation, pregnancy, delivery and post-partum care, emergency obstetric care, prevention and treatment of infertility and sexually transmitted diseases, including HIV/AIDS, detection and treatment of reproductive tract cancers and other diseases of the reproductive tract, services addressing violence and sexual violence, menstrual disorders or menopause, sex education, safer sex promotion or sexual dysfunction counselling and treatment. Women in rich countries owe their good health to these services to a large extent and have come to take them not only for granted but as their right.

Why then should most aspects of sexual and reproductive health be given low priority in low-income countries in comparison with other causes of morbidity and early death? The answer, we are told, is that the evidence base (apart from HIV/AIDS) is weak, and the claim that sexual and reproductive health are so important that they are a woman’s right is dismissed as a form of “special pleading” [6]. And it is true that if you remove HIV/AIDS, on which reporting is required in almost all countries, there are more limited, global numerical data on sexual and reproductive mortality and morbidity in low-income countries. However, let’s look again.

To start with, the proven good outcomes in high-income countries compared to the poor outcomes in low-income countries constitute one form of evidence that sexual and reproductive health problems are inter-connected and if not prevented or treated, have serious adverse effects, which are cumulative. The majority of those needing sexual and reproductive health services are not ill, however. Women seeking services for family planning, normal pregnancies, deliveries, abortion and many causes of infertility are more often than not well women. Their needs are not yet problems and cannot be counted in the same way as the numbers of people with a fatal disease or a non-fatal disabling condition.

Even so, pregnancies and deliveries which are not normal (up to 15% of the total), unsafe abortions and STDs can lead to serious, often life-threatening complications. At the same time, there are many chronic and debilitating disorders which affect huge numbers of women – such as menstrual pain, menorrhagia, osteoporosis and uterine prolapse – and others which get even less attention, such as endometriosis and vesico-vaginal fistulae. There are still others that are always fatal, particularly cancers of the breast and reproductive tract, which require early detection and treatment to save women’s lives. Are women to accept that all of these are low priority because of the way some new mathematical and financial calculations have been done?

DALYs were invented by health economists to measure years of healthy life lost due to fatal and non-fatal disease and disability. What about the number of years of healthy life not lost due to preventive health care and sex education? The extent of morbidity prevented over women’s lifetimes by modern contraceptive use and sterilisation alone, with coverage of up to 70% of women of reproductive age in a growing number of countries, or the numbers of women not harmed because of safe abortion services, or not infertile because of STD treatment or prevention due to consistent use of condoms, are astronomical. How are these being counted? Can they really be compared to the numbers with malaria or TB and found less important?

Although HIV/AIDS was separated off into a category of its own to emphasise its seriousness early in the DALY measurement exercises, it is above all a sexual and reproductive health problem. This vertical approach has helped to increased the priority accorded to HIV/AIDS in the last couple of years, and that is a very good thing. But was it treated as a priority in 1980–1990 before the epidemic had got out of control? The answer of course is no, because there were fewer identified deaths at the time and warnings were widely ignored. Diseases, like epidemics, often only become a priority when they have already escalated out of control. Where good preventive care for sexual and reproductive health problems exists, there doesn’t seem to be a problem. Furthermore, you can only measure what you already know exists. Some problems may be hidden, such as the extent of domestic and sexual violence and the sexual abuse of children, which have only emerged and been treated as public health issues in recent decades too [7].

AIDS has been described as “an epidemic of people who have sex” [8]. Furthermore, AIDS is not a “disease” but a syndrome of diseases, of which cervical cancer and chronic herpes simplex are but two sexual health manifestations in women [9]. HIV infection has a profound effect on pregnancy, and is undoing the work of two decades in reducing maternal and infant mortality and increasing life expectancy at birth in the hardest hit developing countries. To reduce the risk of sexual and vertical transmission of HIV, all of the following are required: sex education and safer sex; condom use; use of contraception and safe abortion; safe antenatal, delivery and post-partum care which include attention to HIV; and prevention of vertical transmission of HIV, including access to safe infant feeding [10][11]. Thus, while separating HIV/AIDS from sexual and reproductive health for measurement purposes may have its own logic, in relation to provision of prevention and treatment services, this separation represents a profound lack of understanding of the epidemic from a gender perspective, and of sexual and reproductive health needs and problems related to AIDS more broadly.

In terms of priority setting, what disease does a pregnant HIV-positive woman with anaemia and malaria have for the purposes of counting? It is value judgements like this which affect DALY calculations, which in turn may be used to determine which of these health problems will get priority attention in a health system [12]. Yet the simple fact is that a woman with these four health conditions will die very young unless all of them are attended to.

For burden of disease measurements to start taking better account of the particularities of sexual and reproductive health, they need to address:

•	the contribution to health of averting disease through preventive services;
•	the cumulative effect of co-morbidity with more than one condition; and
•	the context in which conditions are experienced and dealt with [12].

In this light, the following are examples of the types of data that exist. There are several decades of evidence on contraceptive prevalence rates in most countries, e.g. from the Demographic and Health Surveys [13]. There are global data based on best estimates, e.g. on maternal deaths [14] and unsafe abortions [15]. Fortney and Smith have outlined the different sources of data on maternal morbidity, but conclude that while there are important reasons to obtain better estimates of prevalence and incidence, “there are already sufficient data from existing measures for resource allocation to proceed, and for policies and services to be modified, extended and improved” [16]. There are combined quantitative and qualitative data from large studies such as the Giza study of reproductive morbidity in Egypt [17] and the Yunnan study in China [18], and from small studies, such as one on unmet need for reproductive health in India [19]. Further, there is historical data which began to be collected up to 100 years ago, when the now rich countries had the same poor sexual and reproductive health indicators as low-income countries have today [20]. Finally, there is a mass of qualitative data from all over the world, e.g. describing the context in which conditions are experienced and dealt with; Reproductive Health Matters alone contains many examples of this, and it is only one relatively new journal.

Still, it is true, there is a data gap, not least because the existing data about any one country or region are from different years, are mostly not comparable to those of other countries/regions, and have not been put together to provide an in-depth, coherent picture of the whole. Indeed, it was recognised at an expert consultation at WHO on DALYs and reproductive health in 1998 that more evidence of the type acceptable to health economists did need to be collected. However, the report from the meeting also states that reproductive health cuts across traditional lines for classifying diseases. It recommends that “a list of conditions, causes, behaviours and risk factors that adequately reflect the burden of reproductive ill-health should be established”. It further recommends that the second global burden of disease study in 2000 should consider a broader range of problems than were considered in 1990. It further recommends that the “underlying epidemiological data must be improved”, e.g. by improving the use of existing data sources, improving linkages between research groups, using better data collection methods, finding better ways of measuring deaths and disabilities, and providing best estimates where data are weak or lacking [21]. Yet there has been no major investment of time or resources to do any of this. Thus, the question must be asked whether it is the lack of a shared perspective on the meaning of data or a profound lack of interest in sexual and reproductive health needs and problems that is the more operative obstacle here; unfortunately, I believe it is both.

Cost-effectiveness is another form of measurement which by itself may lead to services that are extremely important being demoted. Thus, prevention of mother-to-child transmission of HIV using antiretroviral drugs has been deemed cost-effective on its own – and it certainly is in the short term if taken in isolation from its consequences. It has worked wonderfully in developed countries where the mother-to-child transmission rate of HIV is nearly nil, especially now that pregnant women are taking ongoing antiretroviral treatment and not breastfeeding. But there are now over 15 million AIDS orphans worldwide, more than 13 million in Africa alone, and the total is expected to rise to more than 25 million by 2010 [22]. Saving infants without keeping their mothers alive – which is the policy of prevention of mother-to-child transmission of HIV programmes in developing countries – brings only short-lived benefit to affected children. In Burkina Faso, for example, although there are 20,000 new infants being infected with HIV every year, there are several hundred thousand AIDS orphans surviving their parents [23]. How will these children fare with no one to ensure that they not only stay alive but are kept healthy, cared for and educated?

Not all the young women dying in Africa before their time have AIDS, however; many are still suffering and dying from other, more easily preventable morbidity and mortality, including from complications of unsafe, illegal abortions, and their numbers are not decreasing either [24].

“Public health is purchasable… A community can determine its own death rate… No duty of society is paramount to this obligation to attack the removable causes of disease.” [25]

Context

Health sector reforms have been taking place within the context of specific political, economic and historical trends and influences in the last decade, of which I will mention only three. One of the most important is the demise of support for the State as responsible for providing and running public health services for its whole population. The second has come from ultra-conservative religious institutions and movements such as the Vatican, Islamists and right-wing politicians, who have joined forces at global level to oppose sexual and reproductive health and rights. These two aspects of health politics, coming from entirely different quarters, are having a major influence on global health policies.

The third is the growth of neo-colonialist development aid policies, including on the part of even the most liberal of governments today. Although it is half a century since most developing countries became independent politically, all but a few have been kept economically dependent by global corporate policy (not least in agriculture) which supports, among other unfair practices, double standards in trade, with tariffs and subsidies acceptable for rich countries but not for poorer ones [26]. Rich countries’ governments too exercise influence and control over poorer countries, including through development aid for the health sector.

Sector-wide approaches in particular are intended to put national governments back in charge. Yet in crucial ways, international institutions and donors are taking a larger and larger role in determining the health sector policies and priorities of middle-and low-income countries, and have not always reached consensus with national governments on how best to do so [27]. The RHM meeting participants expressed concern about the long lists of demands being made by international lending institutions and donors, and the lack of control over health policy and programme decisions at national level, including the following:

•	the role of donors and lending institutions in causing or exacerbating fragmentation and conflict in health policy and programme development in countries, due to differing political and financing agendas. One colleague spoke about there being 130 health projects in his country being managed outside the national health management structure, for example. Another pointed out that it was the poorest countries who experience the most fragmentation and at the same time have the least sustainable systems and the least control over improving them;
•	the fact that donor aid is not guaranteed for the long-term, yet fosters dependency while it lasts, and causes chaos and setbacks – often the closure of excellent projects and programmes (not just ineffective ones) – when it is withdrawn;
•	the fact that large or small loans, even at 0% interest, mean still more external debt at a time when debt is supposed to be being reduced;
•	the existence of conditionalities on loans and aid and reverse resource flows to donor countries (you must apply our policies, buy our drugs and supplies, hire our consultants), which means that many grants end up straight back in the pockets of the givers. It was noted in the RHM meeting that as much as 40% of donor aid goes back to northern institutions in the form of overheads or institutional costs alone, and a colleague from Africa recently mentioned an instance where 70% of a particular aid package would have been sent back to the donor country in these ways, had the government not refused to accept it;
•	a contract culture that distorts both the role and purpose of academics and researchers and of NGOs, who have effectively become the employees of donors, though not formal employees with civil service employment rights. Indeed, an increasing number of individuals and NGOs with no discernible agenda of their own have set up primarily to sell their skills to obtain development aid consultancies from their own countries’ donors, effectively reducing the funds that might have been used for projects and for increasing the skills of people in developing countries instead.

Support for development through policies that are designed to reduce inequity between countries rather than maintain it, including in the flow of resources and goods, presumably need not have these downsides. But where NGOs as critics might have helped to improve these policies more effectively, they too are dependent on donors and lending institutions for grants, and many feel less able to criticise current policies openly. Now, as right-wing parties have entered government in a growing list of developed countries, these policies are being affected adversely in other ways too.

At the same time, although development took upwards of 100–150 years in rich countries, some donors and lending institutions are becoming impatient when, after a very few years, they do not see “measurable impact” in poor countries. One colleague recently asked: “Why do they set targets for us when there is no chance or time for us to reach them?” Perhaps we should be calling for a freeze on new priorities and targets until we have managed to achieve the ones already democratically agreed upon.

The ICPD Programme of Action is a 20-year programme which was supposed to be achieved by 2015 [28]. It has taken the better part of ten years for many governments to take the issues on board, and many have been working hard to develop good policies and programmes. Several of the Millenium Development Goals actually depend on the achievement of sexual and reproductive health, all of which means that the ICPD goals must remain on the agenda in spite of conservative opposition [29]. Yet because of the bullying of the Bush administration, the dominance of neo-liberal health and development politics, the Global Fund and other conflicting demands, some donors are beginning to talk of moving on. Sexual and reproductive health seems to be one of the areas they are threatening to de-prioritise, not least to pay for HIV/AIDS, just as many national governments are getting into a position where they can start to bring at least some ICPD goals to fruition.

Outcomes

Coming back to health sector reforms, let me take one step backwards and pose a question. Have health sector reforms and external funding for health resulted in trends towards improved outcomes in health (let alone “health for all”) in middle-and low-income countries, particularly for the poorest sectors?

According to the RHM meeting participants, the answer is ambivalent at best. Middle-income countries have fared far better than low-income countries. Urban areas have fared far better than rural ones. The middle classes have fared better than the poor, for whom there has been either no positive effect or a negative effect, especially in the poorest countries and the poorest social strata in all countries, including rich countries [30]. Women have fared worse, especially where out-of-pocket payments are required [31], where health insurance is based on formal employment or charged according to categories of risk (of which pregnancy is considered one), and where cuts in services have meant that more home care for family members is needed. In short, public health, equity and social justice all seem to have been sacrificed for other more questionable values, leaving the poorest and most vulnerable no better off than before. As regards the sexual and reproductive health problems of the poorest women, the answer of the meeting was again “no discernible improvement” at best in the poorest countries, obscured except in a few instances by a lack of comparable baseline data from before 1990 and now.

The group identified as underlying causes: weak leadership capacity at different levels of government, lack of national capacity to monitor and generate evidence on sexual and reproductive health achievements, negative reforms such as cost-recovery schemes dictated by donors, and the poaching of skilled professionals from national health services to work in donor-controlled projects.

The private health sector, both for-profit and not-for-profit, has had an increasingly important role to play in providing sexual and reproductive health services, from condom social marketing to safe abortions. Yet it is often the same public sector health workers and clinicians who are also working in the private sector, not least to make a decent living. Believing that the private sector offers better care, people are turning away from public sector services, which have indeed declined or remained inadequate and sub-standard [32]. Yet the private sector is diverse and largely unregulated in most developing countries and caters not only for the rich but also for the poor in the form of traditional practitioners, quacks and cheap but ineffective and sometimes clandestine treatments and procedures. Hence, the private sector cannot be assumed to be providing better quality of care. In fact, it is often responsible for dangerous and unnecessary treatments, as the paper on private provision of hysterectomy by Ranson and John, reprinted in this issue, shows [33]. Furthermore, paying out of pocket for health care is a major cause of impoverishment of the poor when a health crisis occurs [34].

What future for health sector reforms?

It is only by seeing health sector reforms in a larger context that it is possible to understand where they come from, why they have had particular effects and where they are likely to lead. What to do about them in future remains essentially a political decision. Countries are becoming acutely aware that they need to make informed decisions as to the way forward in relation to health systems financing, management, organisation and oversight. As Reichenbach convincingly shows in this issue [5], priority setting is determined on the basis of more than just economic calculations. The accountability of the health sector to improve health outcomes, first and foremost among the poorest, is still a matter of governmental responsibility, including for financing, no matter who provides the services. In fact, by whatever measure, national government remains the only body able to take responsibility for the health of its population, even if particular governments are unable or uncommitted to exercising that responsibility at particular points in time.

As regards the future of health sector reforms, participants in the RHM meeting agreed that one size does not fit all and argued that countries must take charge of and drive the process. All of us agreed that reforms were needed, but the question remained – what kind? Health systems are floundering in almost every country – including rich countries – as costs have gone up and demand for good quality care has increased astronomically. Well-off people in all countries are starting far ahead of the rest, however, and while their health is equally important, can better afford to “consume” the most care.

Up to now, costs have been driving reforms, but cost-saving in sexual and reproductive health programmes is possible. AIDS activists have shown that the cost of drugs is negotiable and that local production of generics can reduce the costs of care enormously [35]. Much care offered at tertiary level can and should be provided at primary level, where it would prevent problems before they occur and avoid serious and life-threatening complications which only a specialist can manage. Obstetrician/gynaecologists are expensive but primary level reproductive health care can be given in almost all instances by well-trained, mid-level providers, particularly trained midwives.

Health sector reforms and other health policies, imposed in both rich and poor countries alike since the mid-1980s, have shown themselves to be fallible. With hindsight, they constitute a massive experiment that was not always based on knowledge of what works. Other ideas are now being put forward to try and overcome both old problems that remain unresolved and new problems that have arisen. The question of what will succeed remains vexed, but economistic solutions alone are certainly not the answer. There are many influences at play and it is not possible to isolate one from the other. Certainly to blame health sector reforms alone for lack of improved outcomes would be a serious mistake. On the other hand, if improvements are not taking place, especially for those who need them the most, then health sector reforms urgently need rethinking. This time around, however, we must re-assess first principles, find out what has worked and what has not, and demand that more stakeholders sit at the table from the start.

Apparent beliefs that policies can be changed like underwear and that short-term funding can and must have a measurable impact in a short space of time are unrealistic, damaging and demoralising, and must be rejected. This is as true in the sexual and reproductive health field as elsewhere.

A multi-sectoral approach constructed by a wide range of stakeholders and with long-term, stable sources of funding – particularly tax revenue and universal coverage through insurance [36][37] – are the most likely to improve a country’s health and health system in the long term. But stability will never be possible in a situation of disenfranchised citizens and dependent economies and governments. “Development” means that countries’ own visions and financing capacities need to be developed first, with autonomy as the short-and long-term aim.

The local and district level is where health sector reforms are supposed to be happening, yet these levels may not have the skill base, the infrastructure, or the ability to raise sufficient funds to take sole responsibility for running and improving local and district health services [38]. Some participants in the RHM meeting said that they and members of their governments were greatly concerned about the damaging effects of decentralisation in the absence of sufficient resources, especially in the rural and poorest parts of their countries. The local level may have interests of its own, which may differ from those considered important at national level or in other districts and may treat health as its last priority with inadequate funding. National influence is needed to counter-balance these and support the strengthening of local political institutions to better manage budgets and services.

The RHM meeting also focused on the situation of health workers within health sector reforms. The turnover of health workers is currently very high, especially in poor countries, which is greatly crippling progress. Skilled health workers are migrating from poorer to more developed countries and to the private sector as well, draining the public sector of its lifeblood. Initiatives to increase sustainability of long-term employment in the public sector, starting with decent pay, are urgently needed. To achieve good health outcomes, the health of health workers, who are mostly women, must also receive attention. In Africa, a large number of health workers and teachers are dying of AIDS as well, and they should be considered a priority for antiretroviral treatment to keep them well, alive and at work. Account must be taken of the impact of other aspects of reforms on health workers as well.

The RHM meeting called for more and better use of health management information systems to track priority setting, and check whether agreed priorities are being implemented or not. It called for ring-fencing of funds for priority issues. Regulation of the private as well as the public sector and monitoring of spending were also stressed, as means of finding out whether access to care and utilisation of services are improving or not. Putting equity of access, especially for the poor and vulnerable, and good quality care first and foremost, not just efficiency, is the only way to improve the health of the poorest sectors while maintaining good health for all social strata. That is social justice. Finally, only an approach which recognises that all public health problems are inter-related and must be resolved, including the problems particular to 50% of the population of the earth, women, will succeed in the long run. Reproductive and sexual health needs pose precisely these challenges for health sector reforms.

The need for recognition and dialogue

Dialogue is a two-way street and the RHM meeting proved that sexual and reproductive health advocates and health sector reformers have a lot to offer each other. Sexual and reproductive health advocates have concentrated on getting the breadth of women’s and men’s needs and problems recognised, working for a broad range of services, improved quality of care, improved provider-patient relations and the removal of political and other barriers. Current health sector reformers currently propose to keep sexual and reproductive health services to a basic (minimum) package, based on a flawed form of priority setting that has put sexual and reproductive health lower than many other pressing health problems, including many to which sexual and reproductive health are intimately related, not least HIV and AIDS.

Sexual and reproductive health advocates have rightly been accused of refusing to recognise the validity of other serious health problems, even including HIV and AIDS. Indeed, some colleagues have only become interested in HIV/AIDS because that’s where the money now is. Sexual and reproductive health advocates get angry when told we have yet to prove our “case”, but we are accused in return of failing to recognise the validity and good faith of efforts to put health systems back on their feet. Certainly, until recently, it is true that sexual and reproductive health advocates have failed to address issues of health systems management, organisation, finance and regulation adequately. Some health sector reformers, on the other hand, have failed to understand the importance of certain principles of public health, social justice, gender equity, poverty reduction, multi-sectoral approaches and human rights for the achievement of good health, and not just finance, efficiency, management and organisation.

As countries approach the second decade for the implementation of the ICPD Programme of Action, and more consciously seek to achieve its goals within the health sector reform process, technical capacity will be needed to monitor sexual and reproductive health policies and programmes and the impact of reforms on sexual and reproductive health. As part of the political discussion to prepare for this decade of work, we might do well to start with the following questions:

•	Reforms, yes, but what kind and for whose benefit?
•	If not State responsibility, then whose and why?
•	Accountability, yes, but to whom?
•	Is the aim national autonomy and control, or not?
•	Why “scarcity”?

Acknowledgements

I am indebted to Marianne Haslegrave, TK Sundari Ravindran, Tom Merrick and Viroj Tangcharoensathien for incisive editorial suggestions.