Strategies for engaging the private sector in sexual and reproductive health: how effective are they?
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The private health sector provides a significant portion of sexual and reproductive health (SRH) services in developing countries. Yet little is known about which strategies for intervening with private providers can improve quality or coverage of services. We conducted a systematic review of the literature through PubMed from 1980 to 2003 to assess the effectiveness of private sector strategies for SRH services in developing countries. The strategies examined were regulating, contracting, financing, franchising, social marketing, training and collaborating. Over 700 studies were examined, though most were descriptive papers, with only 71 meeting our inclusion criteria of having a private sector strategy for one or more SRH services and the measurement of an outcome in the provider or the beneficiary. Nearly all studies (96%) had at least one positive association between SRH and the private sector strategy. About three-quarters of the studies involved training private providers, though combinations of strategies tended to give better results. Maternity services were most commonly addressed (55% of studies), followed by prevention and treatment of sexually transmitted diseases (32%). Using study design to rate the strength of evidence, we found that the evidence about effectiveness of private sector strategies on SRH services is weak. Most studies did not use comparison groups, or they relied on cross-sectional designs. Nearly all studies examined short-term effects, largely measuring changes in providers rather than changes in health status or other effects on beneficiaries. Five studies with more robust designs (randomized controlled trials) demonstrated that contraceptive use could be increased through supporting private providers, and showed cases where the knowledge and practices of private providers could be improved through training, regulation and incentives. Although tools to work with the private sector offer considerable promise, without stronger research designs, key questions regarding their feasibility and impact remain unanswered. (+info)
Family planning and sexual health organizations: management lessons for health system reform.
(18/211)
Advocates of health system reform are calling for, among other things, decentralized, autonomous managerial and financial control, use of contracting and incentives, and a greater reliance on market mechanisms in the delivery of health services. The family planning and sexual health (FP&SH) sector already has experience of these. In this paper, we set forth three typical means of service provision within the FP&SH sector since the mid-1900s: independent not-for-profit providers, vertical government programmes and social marketing programmes. In each case, we present the context within which the service delivery mechanism evolved, the management techniques that characterize it and the lessons learned in FP&SH that are applicable to the wider debate about improving health sector management. We conclude that the FP&SH sector can provide both positive and negative lessons in the areas of autonomous management, use of incentives to providers and acceptors, balancing of centralization against decentralization, and employing private sector marketing and distribution techniques for delivering health services. This experience has not been adequately acknowledged in the debates about how to improve the quality and quantity of health services for the poor in developing countries. Health sector reform advocates and FP&SH advocates should collaborate within countries and regions to apply these management lessons. (+info)
Designing a reproductive health services package in the universal health insurance scheme in Thailand: match and mismatch of need, demand and supply.
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In October 2001 Thailand introduced universal healthcare coverage (UC) financed by general tax revenue. This paper aims to assess the design and content of the UC benefit package, focusing on the part of the package concerned with sexual and reproductive health (SRH). The economic concept of need, demand and supply in the process of developing the SRH package was applied to the analysis. The analysis indicated that SRH constitutes a major part of the package, including the control of communicable and non-communicable diseases, the promotion and maintenance of reproductive health, and early detection and management of reproductive health problems. In addition, the authors identified seven areas within three overlapping spheres; namely need, demand and supply. The burden of disease on reproductive conditions was used as a proxy indicator of health needs in the population; the findings of a study of private obstetric practice in public hospitals as a proxy of patients' demands; and the SRH services offered in the UC package as a proxy of general healthcare supply. The authors recommend that in order to ensure that healthcare needs match consumer demand, the inclusion of SRH services not currently offered in the package (e.g. treatment of HIV infection, abortion services) should be considered, if additional resources can be made available. Where health needs exist but consumers do not express demand, and the appropriate SRH services would provide external benefits to society (e.g. the programme for prevention of sexual and gender-related violence), policymakers are encouraged to expand and offer these services. Efforts should be made to create consumer awareness and stimulate demand. Research can play an important role in identifying the services in which supply matches demand but does not necessarily reflect the health needs of the population (e.g. unnecessary investigations and prescriptions). Where only demand or supply exists (e.g. breast cosmetic procedures and unproven effective interventions), these SRH services should be excluded from the package and left to private financing and providers, the government playing a regulatory role. (+info)
Health sector reform and reproductive health services in poor rural China.
(20/211)
This paper describes and analyses the major reforms and changes that have occurred in the rural health sector of China. Key findings from a number of empirical studies on reproductive health service provision and utilization are summarized in order to assess the implications for reproductive health services of the ongoing health reform. The focus of this paper is what has actually been happening at the ground level, rather than what should have been happening as stated by rural health sector reform policies. It is argued that reproductive health is a missing component of the current health sector reform agenda. It also argued that the rural health sector reform in China is really a passive response to the changed rural socio-economic conditions rather than an active action aimed at improving the health status of the rural population. The ongoing rural health reform has produced both negative and positive implications for reproductive health services and there is a need for both the state, and for women, to play a much stronger role in this reform. Further studies and actions are required, however, to identify the specific type of roles and activities that the state and women need to undertake so as to fulfil the reproductive health goals and objectives set forth by the 1994 International Conference on Population and Development. (+info)
Sexual and reproductive health: challenges for priority-setting in Ghana's health reforms.
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Many countries are undertaking widespread structural change of their health sectors. There is mounting concern that priority-setting mechanisms used in planning the reforms are not suited to recognizing or taking account of the needs and priorities of sexual and reproductive health (SRH) services. The main aim of this research was to assess the sensitivity of the priority-setting tools and mechanisms used in the development of the health sector reforms in Ghana, to the needs and priorities of SRH services, and to consider how priority-setting mechanisms could be improved. We conclude that priority-setting tools in Ghana's reform process were rudimentary, and SRH donors and advocates were little involved. While it is tempting for a strong programme like Ghana's SRH programme to remain independent, we argue that closer involvement in system-wide reforms is a preferable long-term objective. Clearly, SRH priorities need safeguarding within a systems approach and we suggest a number of ways in which this can be achieved. Most importantly, the SRH community, in collaboration with the wider development community, needs to challenge current priority-setting mechanisms and the long-held view that traditional disease-ranking and cost-effectiveness measures are necessarily the best, most accurate way to measure health priorities. Traditional priority-setting tools do not adequately reflect the long-term benefits of preventive interventions such as family planning, and are therefore not an adequate reflection of holistic health sector planning needs. In response to this, there needs to be greater commitment from the international development and research communities to: (1) support collaboration between economists and reproductive health specialists to develop better measures for the effectiveness and impact of SRH services; and (2) in the interim, accept proxies for priority-setting which may include small-scale, qualitative research data combined with priorities identified by SRH specialists. To achieve this, the priority-setting processes need to become more inclusive and SRH specialists need to be proactive in their engagement with health sector decision-makers. (+info)
HIV/AIDS, sexual and reproductive health: intersections and implications for national programmes.
(22/211)
HIV and AIDS have a myriad of effects on sexual and reproductive health and rights, and sexual and reproductive health services are critical for women and men with HIV and AIDS. Yet there has been a dearth of visible, in-depth mainstream attention to the links between sexual and reproductive health and prevention and treatment of HIV/AIDS since the early 1990s among major stakeholders internationally. This paper argues that access to essential sexual and reproductive health care should be provided in HIV/AIDS prevention, care and treatment programmes, and appropriate forms of prevention and treatment of HIV/AIDS should be included in all sexual and reproductive health services as a public health priority, particularly in sex education, family planning and abortion services, pregnancy-related care, sexually transmitted infection (STI) services and services addressing sexual violence. The paper analyzes existing barriers to linking and integrating these services, e.g. at country level due to the traditional training of health workers to implement vertical programmes, separate sources of funding for National AIDS Control Programmes and sexual and reproductive health services, and in international donor programme and UN agency structures. This paper calls for leadership to be exercised by donors, all the UN agencies working together, governments, health service managers and providers, NGOs and advocates in both fields to develop and implement these linkages at country level. Finally, it is crucial that UNAIDS, WHO, UNFPA, UNICEF, the Global Fund to Fight AIDS, TB and Malaria and those working to reach the targets set by the Millennium Development Goals come on board in these efforts. (+info)
'It makes me want to run away to Saudi Arabia': management and implementation challenges for public financing reforms from a maternity ward perspective.
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Poor practice by health care workers has been identified as contributing to high levels of maternal mortality in South Africa. The country is undergoing substantial structural and financial reforms, yet the impact of these on health care workers performance and practice has not been studied. This study, which consisted of an ethnography of two labour wards (one rural and one urban), aimed to look at the factors that shaped everyday practice of midwives working in district hospitals in South Africa during the implementation of a public sector reform to improve financial management. The study found that the Public Financing Management Act, that aimed to improve the efficiency and accountability of public finance management, had the unintended consequence of causing the quality of maternal health services to deteriorate in the hospital wards studied. The article supports the need for increased dialogue between those working in the sexual and reproductive health and health systems policy arenas, and the importance of giving a voice to front-line health workers who implement systems changes. However, it cautions that there are no simple answers to how health systems should be organized in order to better provide sexual and reproductive health services, and suggests instead that more attention in the debate needs to be paid to the challenges of policy implementation and the socio-political context and process issues which affect the success or failure of the implementation. (+info)
Service accountability and community participation in the context of health sector reforms in Asia: implications for sexual and reproductive health services.
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This paper examines the concept and practice of community participation in World Bank-supported health sector reforms in Asia, and how far such participation has strengthened accountability with regard to provision of sexual and reproductive health (SRH) services. It argues that the envisaged scope of community participation within a majority of reforms in Asia has been limited to programme management and service delivery, and it is occurring within the boundaries of priorities that are defined through non-participatory processes. Setting up of community health structures, decentralization and community financing are three important strategies used for promoting participation and accountability within reforms. The scant evidence on the impact of these strategies suggests that marginalized groups and sexual and reproductive rights based groups are poorly represented in the forums for participation, and that hierarchies of power between and amongst health personnel and the public play out in these forums. Community financing has not lead to enhanced service accountability. As a result of the above limitations, community participation in health sector reforms has rarely strengthened accountability with respect to provision of comprehensive SRH services. In this context, rights (including sexual and reproductive) based groups and researchers need to engage with design, monitoring and evaluation of health sector reforms, both from inside as participants and outside as pressure groups. Participation contracts enhancing powers of civil society representatives, quotas for participation (for women, other marginalized groups and rights-based organizations), and investment in capacity building of these stakeholders on leadership and sexual reproductive rights and health are pre-requisites if participation is to lead to health and SRH service accountability. Community participation and service accountability hence requires more and not less investment of resources by the state. (+info)