Where Do We Go from Here? Entry Points for

Action

Tom Merrick, World Bank Institute

How Do We Deal With Changes? New vision -- reproductive health and

rights, gender, poverty reduction New challenges -- new and unfinished

agendas, going beyond care New program environments --

– reforms, sector-wide funding, – economic crises

Recognize changes as challenges as well as opportunities for RH

Tools to address challenges -- policy analysis, service matrix, costing and priority setting, benefit incidence, etc.

We’ve seen that there are many actors

Politicians Economists and financiers Consumers Civil society institutions Providers, their unions Donors You

They bring many viewpoints:

Politicians want to be re-elected Economists follow the money Labor unions protect jobs Consumers want good services Civil society institutions are

concerned about rights and equity You (I hope) are concerned about

the effects of reform on reproductive health and rights

Why should you be concerned about reforms? Many common

goals: More equity in health and health

care Improved gender equality Address key public health needs Respond to consumer demands Financial and organizational

sustainability Better coordination of donor roles

So what’s the problem?

Design & implementation of reforms may help or hurt

reproductive health Financing schemes should free resources

for poor, but could limit access to poor women; insurance may not cover repro health

Decentralization gives community more say, but women may not have voice

Private providers may be more interested in profit than serving the poor

Reorganization may weaken central government support of reproductive health and rights, reduce focus on cross-cutting factors

How to address reproductive health and rights (RHR) in reform

settings? Evidence base on how health

reform initiatives affect RHR is weak

Identify key points of intersection between reform and RHR

Assess impacts through operational research/monitoring and evaluation

Mitigate adverse effects; strengthen positive ones

Outcomes What RH outcomes need to be improved?

Why are reforms needed?

What are the reasons for poor health system performance?

Type of reform and example

Organization: Decentrali-zation, split financing from provision

Financing: User fees, insurance

Payments & Incentives: Performance contracts

Laws & Regulations: Norms for delivery of services

How reform is expected to improve the health system

Greater local control and ownership

Resources mobilized

Provides are rewarded for good performance

Technical quality of services improved

Potential risks for reproduc-tive health

How did the reform affect Quality? Equity? Financing? Efficiency? Sustainability? RH Outcomes?

How can risks be mitigated?

What measures can be taken to reduce adverse impacts of reform?

A lot of common ground:

Agree to focus on outcomes Agree on need to improve

performance:– equity, efficiency, sustainable

financing, quality, accountable to clients

Agree on need for evidence-based policy and program design (burden of disease, good indicators, etc.)

Also differences:

On priorities -- tradeoffs between equity and efficiency

On how to set priorities -- who decides daly weights

On how to manage -- donors desire for sectoral approach

On boundaries -- what’s included in health systems, reproductive health

Government policies &

actions

Health sys-tem & other

sectors

Pathways to Improved Health Outcomes

Repro-ductive health

out-comes

Health outcomes

Households/ Communities

Household behaviors

& risk factors

Health service supply Health

reforms

House-hold

resources

Other parts of health system

Supply in related

sectors Community

factors

Actions in other sectors

When we disagree, what to do? Say it’s too complicated and leave it to

the economists, or Close our minds to viewpoints we don’t

like and go about our business, or Get a place at the table, make sure our

allies are there, understand the opposition and counter with evidence-based remedies that protect reproductive health and rights, and

If necessary, hire our own economists

Evaluation criteria, tools Health impact: reduced burden of disease Equity: how do reforms affect access of

poor women and children (DHS tabs, benefit incidence analysis); do reforms reduce financial risks of poor families?

Quality: how do reforms affect performance of health providers?

Efficiency: is public sector spending its money on the right things, reducing waste?

Sustainability: effect on donor dependency?

WAYS TO MITIGATE THE RISKS TO REPRO HEALTH

Involve all stakeholders (including providers) in setting goals/defining the reform process

Pay close attention to standards, regulation and accountability mechanisms

Advocacy to ensure that RH gets resources, quality maintained

Involve the community, women’s groups in monitoring reforms at local level

When we’re at the table: What is our vision for RH and its

relation to health reform? What will we do differently as a

result of the course that will help us realize this vision?

What difference to we expect our actions to have on reproductive health and rights?

What actions will we take?

Community of practice

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