Posted on behalf of Mona Sharan:
The Bank’s HNP strategy emphasizes strengthening health systems in areas including financing, governance, insurance, logistics, provider-payment and incentive mechanisms, human resources, basic infrastructure and supplies (World Bank 2007). While strengthening health systems is integral to the attainment of the MDGs, some have argued that an exclusive focus on financing, human resource and supply chains tends to neglect reproductive health priorities (Standing 2002). Key elements for linking health sector reform efforts to desired health outcomes have been identified in the reproductive health literature (Ramachandran 2002).
Some critical missing links include:
• Quality of care: Utilization and effectiveness of maternal and child health services and health outcomes depend heavily on quality of care.
• Health worker capacity: Health sector reform, particularly the emphasis on increasing demand for care may place disproportionate burden on nurse-midwives and maternal and child health workers who are already overworked.
• Health worker skills: Nurse-midwives and maternal and child health workers are responsible for providing MCH services, especially where doctors are not available, but they are not equipped with appropriate skills and resources.
• Legal restrictions: Laws restricting abortion compel women to seek unsafe abortion from quacks. Complications of abortion is a leading cause of maternal mortality (A recent survey shows that 46 percent of obstetric complications treated at health
facilities in Eritrea in 2007 were due to abortion)
• Referral linkages: In most countries, lower-level facilities which are most accessible to women cannot treat complications and patients are always referred to hospitals but transport and communications are major barriers to timely and effective care.
• Inadequate infrastructure: Hospitals are over-crowded because they receive a large number of complicated cases and increased pressure on inadequate infrastructure could further deteriorate quality of care and increase case-fatality rates.
• Lack of women-friendly services: Prevailing institutional cultures within health systems may continue to deter women from seeking care unless services are made “women-friendly”, for example, privacy, respect for women’s rights and dignity.
• Inadequate client focus: Strategies such as improving logistics and supply of contraceptives may not be effective unless it is part of a comprehensive assessment of the supply side, the service provider and the user, for example, preference for some family planning methods and service delivery arrangements.
Typically, health sector reformers have seen reproductive health as a vertical program and reproductive health experts have focused on advocacy and service delivery, thereby paying scant focus to systemic issues (Standing 2000). The two policy networks, although distinct, should be engaged in a constructive debate because health sector reform that does not
incorporate reproductive health priorities can be detrimental to reproductive health and fail to have the desired impact (Lubben 2002).
The framework by Krasovec and Shaw (2000) places the reproductive health agenda within broader health sector reform efforts, arguing that the first step to advancing the reproductive health agenda in context of health sector reform is to identify desired outcomes, then focus on system-wide causes that underpin them. The second step is to determine the mix of inputs, processes and structure that would need to be in place to produce change in the desired direction. The third step is to understand key reform levers and their scope of influence, then reconfigure resources to move the health system in the right direction.
The Bank’s HSS strategy focuses on specific elements in the framework, including those categorized under reform levers and some that are a part of health system and program change. Several other priorities have not yet been addressed, especially those related to system-wide performance. Country-specific data from both users and service providers on each of these missing links can be used to make health systems strengthening effective and results-oriented. Data from users can shed light on barriers to care-seeking, satisfaction with health services, and improvements desired in service delivery and data from providers will provide an assessment of their roles, constraints, attitudes, skills and capacities.
“From the perspective of poor women and men as well as service providers, health sector reform should take a worm’s eye view and not a bird’s eye view of the systemic changes that are necessary to make a system work.” (Ramachandran 2000)
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Krasovec, K. and R. P. Shaw. Reproductive health and health sector reform: linking outcomes to action. WBI working papers, 2002. Washington DC, World Bank Institute.
Lubben M et al. Reproductive health and health sector reform in developing countries: establishing a framework for dialogue. Bulletin of the World Health Organization, 2002 80(8): 667-674.
Ramachandran V. Incorporating women’s health concerns in health sector reforms: key areas of strategic advocacy and citizen participation. Globalization, Health Sector Reform, Gender and Reproductive Health, 2001. New York: Ford Foundation.
Standing, H. An overview of changing agendas in health sector reform. Reproductive Health Matters 2002, 10(20): 19-28.
World Bank. Healthy Development: The World Bank strategy for Health Nutrition & Population Results, 2007. Washington DC, The World Bank.