• Sustainable financing

Sustainable financing

This brief discusses the steps health managers need to take to ensure that reproductive health objectives are met within the wider aims of health sector reforms. Produced by the Population Reference Bureau (PRB), it provides an overview of health sector reform, discussing its potential impact on reproductive health services and ways to incorporate reproductive health priorities into evolving health care systems.

The brief analyses the major components of health sector reform, which it broadly categorises as: alternative approaches to financing; organisational changes (decentralisation, public-private partnerships and integrating services); and policy change (setting priorities and providing oversight, and changing laws and regulations). It describes some typical reform measures, giving examples of how they have been applied. It then discusses what reproductive health managers and advocates need to do to improve the quality and sustainability of reproductive health services.

The brief finds that:

• Alternative financing approaches can influence the demand for and use of health services. Positive examples are given from Rwanda, Egypt, Mali and Bolivia.
• With decentralisation, to avoid the potential problem of inequitable distribution of health care, central governments could provide grants, or use weighted formulas to help districts with higher concentrations of "at-risk" or poor populations.
• In Ghana, public-private partnership has increased the coverage of family planning services: private providers in areas without public-sector facilities have started offering essential health services, with government assistance in training, equipment and logistics.
• The use, by some governments, of the population’s "burden of disease" to establish health spending priorities may undervalue reproductive health, since pregnancy is not a disease and the benefits of preventing unplanned births go well beyond preventing death and disability.
• Legal and regulatory reforms are key. For example, Chile, Morocco, Tunisia and Turkey are exploring or implementing ways to allow midwives and nurses to provide certain types of obstetric care that were previously provided only by physicians.
• Gaining political support for services that serve mainly women is challenging, given women’s more limited role in public policy debates. The people facing the most serious reproductive health risks, especially rural and illiterate women, are the least likely to be heard.

The brief concludes that, in order to influence reforms, reproductive health managers need to familiarise themselves with the objectives, principles and strategies of health sector reform and to take part in policy discussions at both national and local levels. In particular, they need to:

• Engage in a continuous dialogue with health planners (allies within the government can be essential)
• Convey clearly to policymakers that: reproductive health has social implications beyond the country’s overall disease burden; interventions for reproductive health are cost-effective; and gross inequalities in reproductive health status and resource allocation can and should be addressed
• Participate at the local level in public debate. The success of health sector reform depends partly on the participation of a range of stakeholders, so local health administrators need to know how to ask for and use their input.

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