India

The Center for Health and Gender Equity1 Studies on the Implications of Health Sector Reforms for Reproductive Health and Rights in India and Tanzania An Update on Current Research Efforts June 2002 Introduction For the last four years the Center for Health and Gender Equity (CHANGE) has been developing its program on understanding the implications of health sector reforms for reproductive health and rights. The basic purpose of this effort is to provide documented evidence on how the processes and outcomes of health sector reforms affect reproductive health and rights concerns in the interest of informing both government and donor agency policies. There are three operational objectives for this work:  Conduct multi-country research on the implications of health reforms on reproductive health services to provide more evidence-based research and analysis Provide a conceptual framework for understanding the health reforms from a reproductive health and rights perspective. Engage with policy makers in bilateral and multilateral aid agencies, especially of the US government, to advance reproductive health and rights in health sector reform processes and provide technical assistance/support to organizations and individuals within civil society seeking to engage with governments and international donor agencies in shaping approaches to health sector reform.   Backdrop: Health Sector Reforms and Reproductive Health and Rights Reproductive policies and programs worldwide are being shaped by two overarching global agendas that have emerged in last two decades. One is the reproductive health and rights agenda articulated at the 1994 International Conference on Population and Development (ICPD)2. The second is the process of health sector reform, promoted in many countries to improve the efficiency, equity and performance of health services and systems. The 1994 International Conference on Population and Development (ICPD) mandate emerged from the diffusion and sharing of ideology and experience trans-nationally amongst feminists and reproductive health advocates. The ICPD mandate responds to global concerns of lack of access to good quality sexual and reproductive health services, and to lack of attention to reproductive and sexual rights. It calls for changes within national health and population policies 1 The Center for Health and Gender Equity is a U.S.-based international reproductive health and rights organization. We seek to make reproductive health and rights objectives integral to all relevant U.S. international population and health policies and programs and to find new means of applying public health and human rights principles to health programs such that these focus on poverty reduction, women’s empowerment and greatly expanded access to reproductive health care, especially for women. Health reforms now underway in many countries are intended to improve the efficiency, equity and performance of health services and systems. Through these reforms, governments and donor agencies seek to streamline budgets and rationalize health care services. In theory, sector reforms are meant to simultaneously promote equity and efficiency in the delivery of health care services, and to democratize the processes through which decisions about health care priorities are made. Health sector reforms are seen as necessary to rationalize health care because the services available in a given setting often do not match the priority health needs of a population. In many countries, for example, there has been proportionately more investment in secondary and tertiary care than in primary health care services, especially for rural populations. This has created stark regional disparities in the delivery of primary health care services. Moreover, even where primary health care services are available, weak infrastructure and inefficient resource use inhibit delivery of good quality essential services. Sector reforms are meant to address these and other imbalances. The strategies for sector reform vary widely, and include, among other things, the shift of services from the public to the private sector; the decentralization of power from national governments to provincial, state, or district bodies; and the establishment of cost recovery mechanisms such as user fees for services previously offered at no charge by government health services. Yet there is little evidence as to whether and how sector reforms are achieving their intended goals. By virtue of their sheer scope and influence on entire health systems, sector reform strategies have already and will continue to affect both the make-up of and access to reproductive health services throughout the world. On the surface, it appears that the priorities of reproductive health advocates parallel those of the proponents of health sector reforms. For example, both groups are concerned with equity and access to care. Both advocate integrated approaches to primary health care, whether at the system and the clinic level. And both advocate the democratization of power through participatory processes that engage civil society in setting priorities over health care spending. In practice, however, the ICPD agenda has not been integral to the logic and implementation of reforms, partly due to the fact that health sector reforms have, in many cases, preceded the ICPD mandate and partly due to the resistance among policy makers to integrating reproductive and sexual health and rights into national health systems. Experience also indicates that in practice the outcome of sector reforms in many settings may be divergent with the goals of the reproductive health agenda. For example, efforts to decentralize decision-making authority for setting health priorities and allocating funds may result in the transfer of power to local elites that do not represent the interests of poor women and other vulnerable groups. Other concerns include the apparent lack of capacity among local bodies to set priorities and manage complex health delivery systems and among representatives of civil society to engage in debates around sector reforms; the lack of adequate data to set health care priorities; the lack of consistent standards for quality of care; the lack of mechanisms to ensure accountability; and the lack of systematic training, among other things. These concerns indicate that, despite the best intentions, current efforts to reform health systems may not be contributing consistently to achievement of the ICPD Plan of Action. Although reforms have been a subject of current debate among program planners, advocates, researchers, and donors, there is still little information on just how well or how poorly reproductive health priorities fare in the context of reforms. The need to document the experiences of countries undergoing health sector reforms while simultaneously attempting to fulfill the ICPD agenda is critically important, especially for poorer countries in the early stages of reforms. The need is also enhanced by the fact that national and global resources for health are diminishing in relation to the needs of health sectors that are faced with deteriorating or low performance health systems and increased morbidity, both from new and reemerging diseases. Multi-Country Health Sector Reforms Research Studies in India and Tanzania In response to these needs, the Center for Health and Gender Equity (CHANGE) is currently spearheading a multi-dimensional research and advocacy effort aimed at the development of reform strategies that promote positive reproductive health and rights outcomes. Under the guidance of Senior Program Associate Dr. Priya Nanda, we have initiated a multi-site study on the implications of reforms for health and rights agendas, with field research now underway in two states in India (Kerala and Tamil Nadu) and in two districts in Tanzania. This work is aimed at answering such critical questions as:    What are the current reform efforts underway and in what way do they facilitate the ICPD agenda? What are the effects of cost recovery strategies, such as user fees on women's access to health care? How well do decentralization processes enable local priority setting and do these processes enable the decentralized health systems to better respond to community health needs? How are reforms affecting critical health programs and services, such as access to safe abortion, access to STI diagnostics and treatment, and access to contraceptive supplies? What are the implications of the context specific reforms for quality of health care in those settings?   In the first phase of this project (2000- 2001) we laid the groundwork for the study by evaluating the stage and progress of sector reforms in India and Tanzania and establishing partnerships with key research and advocacy organizations in each country. These countries were been chosen based on a variety of considerations, including donor activity pertaining to health sector reforms, need to build and strengthen a strong advocacy and rights based movement, and our contacts with various stakeholders, including civil society organizations, within those countries. Partnerships were developed in part with individuals and organizations with whom we already work, and in part through a process of identifying additional partners. With our partners we developed a joint plan and methodology for research, policy analysis, dissemination and advocacy. We are now in the Phase Two of this work, and we are working with our partners in each setting to:       carry out the field research designed in Phase One; analyze and synthesize the data; publish briefing papers and articles stemming from the findings in each setting as well as a synthesis of findings across sites; craft policy recommendations; disseminate findings and recommendations at the state, national, and international levels; and, create and carry out in conjunction with our partners’ specific advocacy strategies following from our findings in each setting and directed toward informing government and donor policies in each setting. The main goal for an analysis of the implication of health reforms for reproductive health and rights, to be conducted through multi-site studies, is to advocate for health sector reform strategies that promote and protect reproductive health and rights and advance the goals of the Programme of Action of the 1994 International Conference on Population and Development (ICPD). What follows are more details on the research CHANGE is conducting in India (in Tamil Nadu and Kerala) and in Tanzania. Study 1: Stakeholder Analysis of Health Reforms in India In the last decade India has undergone dramatic shifts in its population policies and programs. In recent years, these shifts have clearly been influenced by the international reproductive health and rights agenda. However, there is still little progress on key indicators of reproductive health and gender equity (as evidenced by declining sex ratios, limited access to safe abortions services, persistently high maternal mortality and high fertility in many states, and lack of choice within the family planning program). Population policy debates in India have been ongoing, and are influenced by international mandates and discourse, though to a lesser degree in implementation than in rhetoric. There has been, however, very little debate on the current state of the health sector and the potential need for health sector reforms. The few debates and consultations that have taken place among some stakeholders on health restructuring have largely involved government agencies, and have not led to a coherent articulation or application of health sector reform processes. Today, for example, there is no clear blueprint for health reforms at the national level in India. Moreover, India has not formulated a new national health policy (the last national health policy was formulated in 1983 and a new policy is currently in a draft form). Health reforms therefore appear to be occurring in the absence of a coherent or systematic approach to health care, equity, and other considerations. Despite the lack of an articulated agenda of reforms, it is clear that India is in fact undergoing broad scale shifts in and reforms of its health sector. Perhaps the single most important driving force behind the reforms is the process of structural adjustment and economic liberalization begun in 1991. Economic restructuring opened the door to the liberalization of the health sector. The World Bank in India has laid increasing emphasis on cost efficiency in the health sector, as well as a greater role of the public-private mix. This has led to a general trend of reducing the role of the public sector in health, and advocacy for fostering partnership between the public and the private sector as well as overall privatization of health care (the process of shifting costs to the users). There are other specific though seemingly uncoordinated changes in national policies and programs which potentially affect the performance of the health system in India. For example, the integrated Reproductive and Child Health (RCH) program and the separate process of political decentralization are occurring simultaneously with the development of a new national population policy. Another example is the 73rd amendment to the Indian constitution, which conveys greater political and decision-making authority over a range of issues, including health, to locally elected bodies called Panchayats. Such shifts in power may have dramatic effects on health priorities and health spending in any given setting. CHANGE is working with Dr. Rama Baru, Head of the Center for Social Medicine and Community Health at JNU University, Delhi to conduct a national-level policy analysis of health sector reforms in India. Some of the questions we are addressing include:    What types of policy level reforms or changes of the health sector are underway at the national and state level in India? What are the objectives of these reforms? In what ways do these reforms converge or diverge with the international mandate for gender equity and reproductive health and rights? Have the objectives of the ICPD mandate been internalized and carried out through reforms in India, such as the Reproductive and Child Health Program? If not, why not and what more needs to be done to make these consistent? The studies at the state level, in Tamil Nadu and Kerala, will document the implementation of reform processes underway and identify the potential opportunities and obstacles for improving access to quality reproductive health care and improving the context of reproductive rights within the context of health care delivery. Study 2: Implementation of the National Integrated Reproductive and Child Health Program in Tamil Nadu Tamil Nadu, with a population of 62.1 million (2001 Census), is an economically and industrially developed state located in the South of India. Although 65 percent of its population is rural and predominantly dependent on agriculture, the state has experienced rapid industrial growth since the mid sixties. The major industries include stainless steel and textiles. Tamil Nadu has achieved remarkable progress in terms of the demographic transition, with a total fertility rate of 2.2 children. The objective of the Tamil Nadu Reproductive and Child Health Program (RCH) program are to reduce morbidities, both maternal and infant, provide services to reduce pregnancy wastage and infections, and eliminate female infanticide. In order to fulfill these objectives, the state government proposes to strengthen and provide quality maternal and child health services by carrying out construction and repairs of buildings, supplying of equipment, providing training to staff, strengthening first referral units, and creating awareness in the community for utilization of services and active participation in the reproductive and child health program. Prior to the launch of the National RCH program, Tamil Nadu had already achieved a ‘fertility transition’ or decline. Although the state government claimed that full credit was due to the Family Planning program (which preceded the RCH program), subsequent analysis has shown that the reduction in fertility fell disproportionately on socially disadvantaged groups and younger women. Also, within the family planning program there was an excessive reliance on one terminal method female sterilization, with spacing methods having only a minor role, while the issue of age at marriage was not addressed at all by the program. Recent literature suggests Tamil women do not enjoy as much autonomy as is assumed in literature on Tamil Nadu's demographic success. Women continue to face disadvantages such as restrictions following menarche, no freedom in decision-making with respect to marriage, childbearing, the abuse of domestic violence, exertion of male authority and control especially over sexuality, the problems associated with dowry, etc. Women from the scheduled castes suffer these disadvantages doubly. In Tamil Nadu CHANGE is working with a team of senior researchers from IndiaCLEN and the SNDT Women’s College, Mumbai. Our objectives are:  To understand the structures that supports the National RCH program in Tamil Nadu.      To understand provider perceptions on issues of quality of care with respect to reproductive health To understand perceptions of the community on issues of service delivery and quality of health care To assess community’s access to and utilization of reproductive health care. To explore social vulnerabilities of women that serve as constraints to contraceptive use, pregnancy care, and fulfilling other reproductive health needs To study the status of political and financial decentralization in Tamil Nadu and its implications to the RCH program Study 3: Political Decentralization and Implications for Reproductive Health in Kerala Kerala is a state of 33 million, known for its communist leadership since 1957. It boasts some of the lowest maternal mortality and fertility rates in India. However, recent studies show very high rates of domestic violence for women in Kerala, and anecdotal evidence also suggests that there are many social restrictions placed on women’s mobility, sexual and reproductive and rights. Also, women’s visibility in positions of leadership and enterprise is much lower than in less-developed states in India. In 1996 Kerala opted for complete decentralization through a political initiative called the People’s Plan Campaign (PPC). This decision moved the responsibility for health policy and programs from the State to Panchayati Raj Institutions (PRIs), which unlike in Tamil Nadu are very strong in Kerala. PRIs are expected to allocate 15% of their budget for the social sector, which includes education and health. Because of low representation of women in political power, PRIs have made a systematic effort to increase the participation of women. If indeed reproductive health is a felt need of the community, ideally this process would facilitate the creation of programs at the local level. Currently, all 14 districts of Kerala have implemented the World Bank-assisted RCH program. The PPC and the RCH approach do share several similarities in terms of the identification of community needs assessment and community participation in program implementation. PPC has the potential to facilitate the implementation of the RCH programme at all levels. There has been no specific initiative for health sector reform in Kerala. In the absence of definitive health sector reform, the process of decentralisation takes on the role of the catalyst in all sectors, including health. To examine these issues CHANGE is collaborating with the Achuta Menon Center for Heath Sciences, a part of the Sree Chitra Tirunal Institute for Medical Sciences and Technology. Our goals in Kerala are:     To study the structures and processes within the health sector, vis-à-vis women’s reproductive health To examine the role of the primary health care system in delivering reproductive health care services To examine the role of the people’s plan campaign in improving local priority setting for women’s reproductive health needs To examine the dynamics of women’s reproductive health care seeking in terms of socioeconomic, culture and gender factors Study 4: The implications of decentralizations and community health financing for improving reproductive health care for women in Tanzania With a population of around 30 million and a per capita annual income estimated at $120, Tanzania is amongst the poorest countries in the world. Talks about reforming the health sector began in 1991 as part of Structural Adjustment Policies, and were formalized in the Health Sector Action Plan in 1995. The process of all the public sector reforms is mostly donor funded (World Bank, Denmark, UK, Switzerland and other bilateral agencies). There is a range of health reform components in Tanzania but of particular concern are decentralization and cost recovery comprising of health insurance (community health funds and a national insurance scheme), drug financing and ‘user fees’. Decentralization of public administration was an integral component of the development policies promoted immediately after independence to achieve self-reliance, meet basic human needs and distribute the benefits of economic growth equitably. Under the 1996 Civil Service Reform all government departments at the district level, earlier under the direct supervision of the line Ministries, were to be supervised by local government authorities. Local district councils were held responsible in theory for decentralized planning and management of primary health care in the districts. As a result parallel hierarchical institutional structures were created over time under the Ministry of Health. Despite significant steps taken towards decentralization, vertical program (e.g. TB, leprosy) still exist creating separate, centralized, lines of organization and management. These programs were initially developed by central Ministry of Health, with substantial donor support, in response to the apparent preference of district councils to support (plan and budget for) curative health care services rather than preventive services. There is increasing donor support for SWAPs (Sector Wide Approach or ‘basket funding’) whereby both donors and government commit funds to a common basket of priority services identified by the MOH through a process of district planning based on local needs, existing resources and competing demands. This could facilitate decentralization through a move away from strong vertical organized programs, though a number of major donors remain outside the SWAPs process. As a part of health reforms, the Government of Tanzania has also introduced cost recovery to enhance health system sustainability, improve availability of drugs, reduce inefficiency (e.g. by discouraging unnecessary use and preventing by-passing of lower level facilities) and improve equity (through its impact on utilization). However, to what degree these objectives have been achieved remains a matter of debate and research. Community health funds at this point are still being piloted. However user fees are fully operational at all levels. There are exemptions in place for vulnerable groups. Also, some illnesses (e.g. HIV/AIDS, tuberculosis and other communicable diseases) are treated free of charge irrespective of people’s ability to pay due to public health considerations. A system of exemptions has been also established for maternal/child health and family planning services, as well as for children under the age of five, together with waivers for the most indigent patients. While cost sharing in government facilities has exempted MCH/FP services, other areas of women’s reproductive health, like gynecology or treatment for infectious diseases, are not exempt (for contraceptive methods like Norplant and voluntary sterilization, in some regions, the only available services are offered at NGO-run clinics where women pay fees for these services). Even though there are exemptions in place, there is no formal procedure for informing clients about them and most of the clients obtain information about waivers informally from health staff, friends, or relatives. Health providers also seem to have little incentive to publicize the waiver system because of the paucity of funds at the health centers. According to some studies quality of care and utilization have decreased since the onset of health sector reforms. To examine these issues, CHANGE is working with the National Institute of Medical Research (NIMRI), and the Department of Sociology, University of Dar es Salaam. The objectives of the study are:    To examine the implication of decentralized structures and process on gender and equity with respect to reproductive health care in the Bukoba Rural districts in North Tanzania. To examine the implications of decentralization on local needs and priority setting. To examine the role of community health financing in improving quality of reproductive health care and gender equity in above district. Methodology for the HSR Studies The policy analysis, field research, and data analysis to be carried out include the use of a variety of methods and instruments, as well as review of existing information and data. These include:        Review of existing policy documents, policy reviews, and national and state budgets; Stakeholder analysis based on interviews with key policy makers at all levels: national, state and district. District and health system level information and analysis developed through semi structured interviews with district health management, policy makers and health care providers; Facility-level information and analyses based on structured facility level situation analysis; Documentation of provider perceptions and practices through semi-structured interviews and focus groups with health care providers; Community perceptions through in-depth and semi-structured interviews and focus groups discussions with women, men and other key stakeholders in selected villages Action research through role-plays, dramas and workshops at the community level at the end of data collection in each site. This component consists of facilitating interactions/communication between community, their respective health centers, and providers for each of the selected sites. These studies are cross sectional in nature and use a variety of qualitative and quantitative data collection methods. In all studies data collection began in February 2002. We hope to be able to share preliminary results in November/December of 2002. Research Teams in India and Tanzania This muti-site research effort is headed by Dr. Priya Nanda, Senior Program Associate at CHANGE, who has a doctorate in public health with a specialization in health economics. In India, Dr. Rama Baru, faculty at the Center of Social Medicine and Community Health, JNU University, Delhi, is conducting the national level policy analysis of health sector reforms. In Tamil Nadu the research team is comprised of senior researchers from IndiaCLEN, which is a regional network of INCLEN. Three of the research partners in this site are members of IndiaCLEN; Dr. Shuba Kumar is a social scientist and the coordinator of IndiaCLEN; Dr. Jeyaseelan is the Head of the Biostatistics Department at the Christian Medical College, Vellore; Dr. Sarada is a pediatrician and faculty at the Kilpauk Medical College in Chennai. Our fourth team member, Dr. Gopal, is an anthropologist and faculty at the SNDT University, Mumbai. For the Kerala study our collaborating institution is the Achuta Menon Center for Heath Sciences, a part of the Sree Chitra Tirunal Institute for Medical Sciences and Technology. Dr. Mala Ramanathan a demographer, Dr. Varathrajan a health economist and Dr. Sukanya a community medicine specialist are all faculty in this center. Our fourth team member, Ms. Aleyamma Vijayan, runs a women’s resource center, Sakhi, in Trivandrum. She brings skills in advocacy, gender issues and experience in working with the process of decentralization underway in Kerala. Our partner institutions in Tanzania are the National Institute of Medical Research (NIMRI) and the Department of Sociology, University of Dar es Salaam. The principal researchers here are Mr. Emanuel Makundi, is a health systems researcher from the NIMRI, and Ms. Joyce Nyoni, a sociologist on the faculty of the University of Dar es Salaam. Questions about this work can be directed to pnanda@genderhealth.org.