Priya Nanda Center for Health and Gender Equity India Habitat Center, New Delhi, March 7th, 2003 - PowerPoint PPT Presentation

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Priya Nanda Center for Health and Gender Equity India Habitat Center, New Delhi, March 7th, 2003

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Title: Priya Nanda Center for Health and Gender Equity India Habitat Center, New Delhi, March 7th, 2003


1
Priya Nanda Center for Health and
Gender EquityIndia Habitat Center, New Delhi,
March 7th, 2003
Health Sector Reforms and Reproductive Health and
Rights Building evidence based analysis
2
Reproductive Health and Health Sector Reform-a
conceptual disconnect?
  • Concurrence of the two global agendas with
    overlapping rhetorical goals of improving equity,
    quality, access, and greater democratization of
    power
  • Reformers have tended to exclude important
    stakeholders (RH advocates and researchers) that
    have often a different understanding of
    reproductive health and gender priorities and how
    they should be tackled
  • Often a resistance to integrate sexual and
    reproductive health into national health systems

3
Underlying Issues and Premise
  • Recognition that health reforms will influence
    the allocation of resources and priority setting
    for reproductive health and rights
  • Belief that ICPD adds an important dimension of
    rights and gender equity missing in the theory
    and practice of reforms
  • Potential to fully implement these agendas is
    constrained by diminishing national and global
    resources for health
  • Reforms are meant to respond to the dual burden
    of poverty and disease and the gender dimensions
    of these issues

4
Contextualizing RH and Rights Issues
  • Lack of infrastructure e.g. drugs, privacy,
    female staff, screening facilities for STD/HIV
  • Provider biases e.g. acknowledgement of sexuality
    amongst adolescents
  • Women and providers lack complete information
    about laws and changes in policies e.g. abortion,
    exemptions
  • Insufficient training of providers to deal with
    gender sensitive health issues like violence,
    adolescent sexuality
  • Traditional practices affecting reproductive
    health concerns and services (e.g. dry sex)
  • Womens health concerns span child birth,
    infertility, sexual coercion and violence,
    stress, osteoporosis

5
Concerns from a Gendered Perspective
  • Women s labour characterized by flexibility,
    feminization, and non-monetary compensation
  • Access to health conditioned by cultural factors,
    lack of decision making, economic constraints and
    provider biases
  • Women as providers of home based care in high HIV
    settings
  • Young girls more vulnerable than boys to HIV in a
    context of high poverty (high dropout rates from
    school coupled with economic necessity)
  • Low literacy, customary laws, gender inequality
    and poverty that increase womens vulnerability
    overall

6
Decentralization to districts and local priority
setting
  • Inadequacies and breakdown in management due to
    lack of clear roles and responsibilities
  • Loss of power, conflict between local
    administrative bodies and political bodies at
    decentralized level
  • Limited training for developing plans based on
    facility level data
  • Frustration with devising need based local plans
    with inadequate resources

7
Shortage of Drugs and Quality of Care
  • Chronic drug shortages marked decline in per
    capita expenditure on drugs
  • Leakage of commodities from public distribution
    to the parallel market is common
  • Rationing of drugs for STD patients due to
    provider biases and trade-offs
  • Lack of essential commodities like gloves,
    syringes and life saving drugs like insulin and
    antibiotics create greater risks in the context
    of high HIV prevalence

8
Cost-Sharing and Equity
  • Cost recovery is low with rates varying from 1-5
    on the average less than 5 of recurrent costs
    recovery
  • Considerable variation in actual fee charged with
    no consistent pattern between districts
  • Not enough incentive to enforce exemptions
  • Lack of access to cash, especially for women, and
    shortage of drugs at clinics are clear
    disincentive to seek user fee dependent health
    care
  • We have no cash ...we could pay with maize
    (Rural woman in Kafue health center)

9
Integration of Vertical Programs
  • Expertise from disbanded vertical programs
    underutilized
  • Diffusion of resources from priority needs such
    as Malaria or TB
  • Inefficiencies duplication of HMIS, parallel
    drug systems for FP and other health care
  • Integration may not work well for sensitive
    groups
  • Lack of understanding of the concept and
    inadequate infrastructure and facilities
  • HSR have taught us a lot. we can potentially
    deliver integrated services if we had
    transportation and regular supply of drugsour
    clinics do not even have privacy to insert IUDs.
    (Nurse at Kafue)

10
Process of Restructuring of Staff
  • Job uncertainty, sporadic payment schedules, and
    lack of infrastructure and facilities dehumanize
    work of health care providers
  • Low morale of staff under these conditions had
    resulted in innumerable strikes in the last few
    years -demands for better wages, work conditions
    and resolution of drug shortages
  • Innovative proposals potentially undermined by
    the negative attitude of health workers towards
    reforms

11
Why Reforms may not facilitate a Reproductive
Health and Rights agenda
  • Many countries struggling with diminishing
    internal resources, largely donor dependent
    health budgets Gender mainstreaming is still a
    conceptual footnote in health policies and
    programs
  • Priority setting based on cost-effectiveness and
    DALYs that may undermine reproductive health
  • Cost recovery may conflict with goals of gender
    equity and access to reproductive health
  • Lack of strategic civil society engagement
  • Lack of real community involvement in shaping
    reforms

12
Essentials Values for this Analysis
  • Bridge the gap between rhetoric and reality
  • Share information and build capacity of civil
    society (at local, regional, national and
    international level) to advocate for reforms that
    promote concerns of equity, reproductive rights
  • Document the process of change and transition
  • Process of research involving all stakeholders
    can build morale and consensus for the agenda as
    well as advocate for a more equitable agenda
  • Pool research efforts, methodologies and results
    -avoid duplication and build on information gaps

13
Study Sites
  • India and Tanzania categorized low to high reform
    settings
  • Criteria were countries at early phase of
    reforms, donor involvement in reproductive health
    and an active reproductive health and rights
    community
  • Focus is on the public health care system due to
    its potential to outreach women in the
    community, its potential to provide service to
    the most vulnerable and those who cannot afford
    any care and the need to look at reforms in the
    primary health care system to attain health for
    all

14
Conceptual Framework for the India Studies
  • In the absence of an articulated health sector
    reform policy or process in the country, the RCH
    Programme is viewed as a lens to understand
    potential for reforms within the health sector
  • In theory the RCH programme combines health
    reform strategies (decentralization, contracting
    out to the private sector, user fees at tertiary
    levels) with integrated reproductive health and
    rights approach

15
Overall objectives
  • Examine the relationship of existing gaps in
    health service delivery to larger policy and
    programmatic environment
  • Identify how and what kind of reforms can improve
    access and quality of RH and rights

16
Sites Selection in India
  • Tamil Nadu as a state cited as a high performer
    relative to other states for the implementation
    of the RCH programme
  • Kerala as one of the only states with an active
    process of political decentralization in health
    underway

17
Exploring Linkages
GLOBAL NATIONAL STATE
Primary Health Care
Panchayati Raj Institutions
Community
18
Methods for the studies
  • Stakeholder analysis
  • Situation analysis of the PHCs
  • Quantitative Survey in one site
  • Semi structured with providers, MOs, ANMs, VHNS,
    DMO, DHMT etc-semi structured
  • Womens in depth interviews
  • Review of gram sabha minutes, development reports
  • Semi structured and FGDs with Panchayat members
  • Secondary data
  • Documentary review
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