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

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?

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