Implementing reproductive health services in an era of health sector reform

Few examples exist of successful reform that have had a favorable effect on RH programs. A notable exception is Zambia. Also, experience with the Bamako Initiative in Africa shows that reforms can succeed and that RH services can be added at little cost to the minimum services packages already supported under the initiative. Brazil offers an instructive example of the mixed effects of health reform on RH services. In the late 1980s, political turmoil and economic crises hampered both health sector reform and RH activities; after the world conferences on population (1994) and on women (1995), however, RH and reproductive rights gained visibility and legitimacy and the unified health system has undergone reform. The government approved additional financing for health care and accelerated the decentralization of services. As a result, RH health care is increasingly being integrated with municipal-level primary health services. In Brazil, on the other hand, adolescent RH health programs have not fared so well. According to a recent study, the consequences of structural adjustment policies and health sector reform (i.e., higher numbers of uninsured persons, cuts in public spending for health, reduction in health care personnel, and shortage of medical supplies) have impeded implementation of high-quality health services for adolescents. The paper also shows that health sector reform is complex and requires time, political commitment, an initial investment of resources, and a favorable policy environment. Reform affects every administrative, managerial, and operational aspect of the health service delivery system, including vertical programs such as FP, MCH, and HIV/AIDS. Without proper planning and implementation, health sector reform is unlikely to be entirely successful and may even waste resources. It is imperative that the reform process, particularly as it relates to RH services, be monitored and evaluated; a handbook, complete with indicators, has been developed for these purposes. Finally, countries need more information on such issues as the ability of various types of providers to sustain improvements in efficiency and quality; the impact of cost-recovery initiatives on access to and use of RH health services; and the costs and cost- effectiveness of the various mechanisms for improving the efficiency of RH programs. Also needed is a wider sharing of information on successful programs such as the Bamako Initiative. (Author abstract, modified)