Title: Priya Nanda Center for Health and Gender Equity India Habitat Center, New Delhi, March 7th, 2003
1Priya 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
2Reproductive 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
3Underlying 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
4Contextualizing 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
6Decentralization 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
7Shortage 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
8Cost-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)
9Integration 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)
10Process 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
11Why 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
12Essentials 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
13Study 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
14Conceptual 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 -
15Overall 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
16Sites 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
17Exploring Linkages
GLOBAL NATIONAL STATE
Primary Health Care
Panchayati Raj Institutions
Community
18Methods 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