September 2001, Vol. 7, No. 3

Health Care Reform
Linking Health-sector Reform and Reproductive Health

In many countries in Latin America and the Caribbean—and around the world—health sectors are being transformed by two forces: reforms to expand the provision of health services and make them more equitable, effective, and efficient, and the adoption of a broad-based reproductive health care model in accordance with international agreements. While theoretically these two movements dovetail, a recent study in Latin America found that crucial opportunities for cooperation between the two camps are being missed. The study was conducted by Ana Langer, Population Council regional director in Latin America and the Caribbean, Gustavo Nigenda of the National Institute of Public Health, Jennifer Catino, Council program associate in Mexico, and Ingvild Belle and other colleagues from the Inter American Development Bank. 

Langer, Nigenda, and Catino assessed and compared reproductive health status and the state of the health sector in countries of Latin America and the Caribbean. They then led three regional workshops to discuss these findings and identify ways in which health-sector reform can be used as an opportunity to improve the quality of—and access to—reproductive health services in the region. 

Health-sector reform vs. reproductive health
The reform of the health sector in most areas of Latin America and the Caribbean has grown out of an attempt to expand coverage, increase effectiveness, and establish equity in the provision of health care services while controlling health care spending. The reproductive health approach, on the other hand, represents a critical shift of focus in health and population policies and programs from a primary emphasis on achieving demographic targets to a focus on improving the quality of life for individuals.

“The priorities of reproductive health advocates resemble those of health-sector reform in a variety of ways,” says Nigenda. For example, both groups advocate improved health status through equitable access to high-quality care, integrated approaches to primary health care, and decentralization of authority through community participation in setting priorities. However, experiences from a number of countries discussed at the workshops suggest that implementing these two policies is complex and that elements of health reform have not always facilitated the realization of the reproductive health agenda. 

“Take decentralization, for example. Both movements seek to give more authority to local-level stakeholders because they are the ones who are most aware of local needs,” says Langer. “In some situations, however, such a move can be problematic. If local policymakers are more conservative than national policymakers, family planning services might suffer. We have received reports that in some areas funds for providing free contraceptives may be threatened, putting women’s reproductive health in jeopardy.” 

Problems may also arise if national policymakers resist the redistribution of power or if local-level managers and providers lack the skills needed to solicit and use community input or to implement gender-sensitive policies. 

Nongovernmental organizations (NGOs) are playing a major role in implementing the reproductive health approach in Latin America. Because they work outside the government, they are often able to address such vital public health issues as unsafe abortion and adolescent reproductive health, which may be too sensitive for other types of providers to take on. Moreover, NGOs have gained valuable experience over the years and may be able to lend expertise to strengthen the capacity of local-level managers and providers to implement the reproductive health approach.

Paying for programs
Financing programs can pose challenges for both public- and private-sector providers. A main goal of health-sector reform is securing sustainable funding for services. To achieve this end clinics have instituted user fees for a number of services. In theory, this strategy can improve service efficiency and quality. For example, charging for services with largely private benefits, such as ultrasound, can help subsidize services with higher social benefits, such as programs to prevent the spread of sexually transmitted infections. Workshop discussions revealed, however, that in many cases clinics charge for critical services, reducing use by those who need them most. 

International aid organizations can play a crucial role in this situation by helping to ensure that reproductive health issues are given priority. But these efforts may be thwarted if donors and program managers do not coordinate their efforts in reproductive health with those of the broader health reform program. 

Many of these issues could be addressed more easily if policymakers from both movements cooperate on and communicate about reaching their common goals. In fact, however, “these two movements are proceeding in parallel; communication between stakeholders is practically nonexistent,” says Catino. Finding ways to increase communication, between policymakers within countries and among officials throughout Latin America, should be a high priority.  According to the researchers, a great need also exists for further social science research on the effects of health-sector reform and the adoption of the reproductive health care model. 

Sources
Langer, Ana and Gustavo Nigenda. 2000. “Salud sexual y reproductiva y reforma del sector salud en América Latina y el Caribe: Desafíos y oportunidades” [Sexual and reproductive health and health-sector reform in Latin America and the Caribbean: Challenges and opportunities], Research Report. Mexico City, Mexico: Inter American Development Bank, Population Council, and Instituto Nacional de Salud Pública. 

Langer, A., G. Nigenda, and J. Catino. 2000. “Health sector reform and reproductive health in Latin America and the Caribbean: Strengthening the links,” Bulletin of the World Health Organization 78(5): 667–676.

Outside funding
The Inter American Development Bank