Academic journal article Bulletin of the World Health Organization

Reproductive Health and Health Sector Reform in Developing Countries: Establishing a Framework for Dialogue. (Policy and Practice)

Academic journal article Bulletin of the World Health Organization

Reproductive Health and Health Sector Reform in Developing Countries: Establishing a Framework for Dialogue. (Policy and Practice)

Article excerpt

Voir page 673 le resume en francais. En la pagina 673 figura un resumen en espanol.

Introduction

Since the International Conference on Population and Development Development (ICPD), held in Cairo in 1994, policies on reproductive health have been influenced increasingly by questions of human rights and decreasingly by demographic considerations. To an ever greater degree, these policies are being implemented in a context of health sector reform promoted by development agencies. There have been significant changes in organization, financing, and resource management in this sector, often as part of broader restructuring and democratization of the public sector.

There has been a marked lack of dialogue on policymaking between the areas of reproductive health and reform of the health sector. Policies in each area have been developed by different actors, pursuing different objectives, through decision-making processes that have rarely coincided. Consequently, disjointed policy-making has tended to predominate. Health ministries typically lack robust and coherent systems of policy formulation and implementation. It is difficult to imagine how effective policies can be created through such a fragmentary process. Sectoral reform has a fundamental impact on the way in which health packages, including those in the field of reproductive health, are delivered. Furthermore, important lessons can be learnt by people engaged in sectoral reform from achievements in reproductive health care when seen as an approach rather than merely as a set of service activities.

This paper explores the need for communication on policy between the areas of reproductive health and reform of the health sector. Attempts to link them have been made in research projects (1-3) and policy analyses (4, 5), but they have tended to focus on specific components of reproductive health rather than on the process of policy implementation and linkage. Here we chart the ideological developments underlying the two policy areas and identify areas of tension and factors that hinder dialogue on policy. A framework is proposed for enhancing such dialogue and collaboration between the two fields, with reference to links between policy actors, an understanding of policy contexts, the development of common or compatible aims, the use of a policy/research matrix, and the need for institutional strengthening.

Ideology and debate

Multiple ideologies underpin the current agenda for policy on reproductive health and health sector reform, reflecting diverse actors and policy-making contexts.

Actors and ideologies

Two groups of actors have been particularly notable in defining the debate on reproductive health. Firstly, health and population economists have been concerned with improving the cost-effectiveness of reproductive health services in an increasingly constrained economic environment. They have also been promoting family planning as the spearhead of cost-effective reproductive health programmes and as a means of promoting national economic development in poor countries. This led to the development, by the mid-1980s, of a highly trained cadre of reproductive health specialists including medical clinicians, midwives, and family-planning nurses.

Secondly, women's health movements and nongovernmental organizations became more vociferous during the 1990s, emphasizing the need to move beyond the narrow goals of fertility reduction and embrace broader issues of women's empowerment. The creed of participatory development and much of the original primary health care ideology of the 1970s regained currency. In 1994 the ICPD called for an expanded framework to ensure that policy on reproductive health focused on the client and on democratization. This framework, demanding a change in programmes and policies so that a holistic agenda could be implemented, was largely promoted by a newly globalized coalition of nongovernmental organizations and empowerment groups (6-11). …

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