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world' and so discussions can often be like disturbing a Hornet's Nest. ... 22. THE RIGHT REFORMS? Health Sector Reforms and Sexual and Reproductive ...
THE RIGHT REFORMS? Health Sector Reforms and Sexual and Reproductive Health TRAINING MANUAL

The Initiative for Sexual & Reproductive Rights in Health Reforms Women's Health Project School of Public Health , University of the Witwatersrand South Africa Funded by Ford Foundation & MacArthur Foundation

T HE R I G H T R E F O R M S ? H e a l t h S e c t o r Re f o r m s a n d S e x u a l a n d Re p r o d u c t i v e H e a l t h

Copyright: Women’s Health Project, 2005. This publication may be reviewed, abstracted or reproduced in part when fully referenced, but may not be sold or used for commercial purposes. Publisher: Women’s Health Project School of Public Health University of the Witwatersrand 10th Floor Medical School 7 York Road Parktown, 2193 Johannesburg, South Africa Date of publication: September 2005 Rights and Reform Team Members: The Initiative for Sexual and Reproductive Rights in Health Reforms was coordinated by the Women’s Health Project, School of Public Health, University of the Witwatersrand in South Africa. Representatives from Africa included Barbara Klugman, Julia Moorman, Mary Kawonga, Khin San Tint and Susan Holland-Muter (Women’s Health Project), madeleine kennedy-macfoy and Jessica Horn (Amanitare – the African women’s sexual and reproductive health and rights (SRHR) network, an initiative of the African-led NGO, Rainbo) and independent researcher, Helen de Pinho. Representatives from Asia included Rashida Abdullah and Nalini Keshavaraj from the Asia-Pacific Resource and Research Centre for Women (ARROW); Fatima Alvarez-Castillo from the University of the Philippines, Manila and independent researchers Ranjani K. Murthy and TK Sundari Ravindran. Representatives from Latin America and the Caribbean included Silvina Ramos, Mariana Romero, Silvana Weller (Center for the Study of State and Society, CEDES), Esperanza Cerón and Sandra Castan˜eda Martínez from the Latin American and Caribbean Women’s Health Network (LACWHN); and Peter Fajans and Dale Huntington from the Reproductive Health and Research Department of the World Health Organization (WHO). Contact details can be found on the project’s web page: www.wits.ac.za/whp/rightsandreforms. Authors Folami Harris Ranjani K. Murthy Mariana Romero Silvina Ramos Susan Holland-Muter with contributions from the Rights and Reforms team. Edited by Debbie Budlender, Community Agency for Social Enquiry (CASE) This project was funded by the Ford Foundation and the MacArthur Foundation.

T HE R I G H T R E F O R M S ? H e a l t h S e c t o r Re f o r m s a n d S e x u a l a n d Re p r o d u c t i v e H e a l t h

Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 Module 1: Setting the context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4 Session 1: Sexual and reproductive health . . . . . . . . . . . . . . . . . . . . . . . .5 Session 2: Sexual and reproductive rights . . . . . . . . . . . . . . . . . . . . . . .15 Session 3: Health sector reforms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22 Module 2: The implications of health sector reforms for sexual and reproductive health and rights . . . . . . . . . . . . . . . . . . . . . . . . . . . .42 Session 1: Conceptual framework: HSR & SRH . . . . . . . . . . . . . . . . . . . .45 Session 2: Understanding health systems . . . . . . . . . . . . . . . . . . . . . . .50 Session 3: SRH service provisioning . . . . . . . . . . . . . . . . . . . . . . . . . . . .58 Session 4: Health sector reforms - nature, scope and actors . . . . . . . . .70 Session 5: Financing reforms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .80 Session 6: Decentralisation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .89 Session 7: Public-private interactions . . . . . . . . . . . . . . . . . . . . . . . . . .104 Session 8: Impact of health sector reforms on SRH services . . . . . . . .116 Module 3: Organising for change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .117 Session 1: Understanding policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .118 Session 2: Advocacy tools and strategy . . . . . . . . . . . . . . . . . . . . . . . .123 Session 3: Planning steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .129 Session 4: Developing a plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .132

T HE R I G H T R E F O R M S ? H e a l t h S e c t o r Re f o r m s a n d S e x u a l a n d Re p r o d u c t i v e H e a l t h

T HE R I G H T R E F O R M S ? H e a l t h S e c t o r Re f o r m s a n d S e x u a l a n d Re p r o d u c t i v e H e a l t h

Introduction

Background and purpose of the manual The Initiative for Sexual and Reproductive Health and Rights in Health Sector Reforms is an international research, capacity building and advocacy project (also known as the Rights and Reforms Initiative). It aims to promote health sector reforms (HSR) that are conducive to implementing the 1994 International Conference on Population and Development’s (ICPD) Programme of Action, are driven by in-country actors, and are responsive to the needs of the people of the country, especially poor women. The Initiative is coordinated by the Women’s Health Project in Johannesburg, South Africa, and led by an international team based in Africa, Asia, Latin America and the Caribbean. The Rights and Reforms team is made up of researchers (NGOs and individuals) and regional sexual and reproductive health and rights networks. The main purpose of the Initiative is to strengthen understanding amongst activists and decision-makers of the role of global social and economic changes and specifically of health sector reforms in facilitating or undermining efforts to achieve sexual and reproductive rights in health policies and programmes. The first phase of the Rights and Reforms Initiative (2002-2004) focused on strengthening the knowledge base regarding the impact of HSR on women’s access to sexual and reproductive health services. Three research teams from Africa, Asia and Latin America and the Caribbean respectively carried out a systematic review of information sources on each of six issues related to HSR, namely Financing, Public-Private Interactions, Priority-Setting, Decentralisation, Integration of services and Accountability. Three regional papers on each of the six topics were produced, except for a paper on Integration of services in Africa. The regional papers on each topic were subsequently integrated into a ‘global’ paper on each topic and are published in the book, The Right Reforms? Health Sector Reforms and Women’s Sexual and Reproductive Health. Policy briefs on each of the topics have been developed; highlighting key issues and recommending further research needs and possible areas for advocacy. All the project’s material can be accessed on its web page, www.wits.ac.za/whp/rightsandreforms. The project’s materials include three regional volumes, a global volume, seven policy briefs and a training manual.

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T HE R I G H T R E F O R M S ? H e a l t h S e c t o r Re f o r m s a n d S e x u a l a n d Re p r o d u c t i v e H e a l t h

This training manual was developed based on the conceptual framework, analyses and findings of the regional and global volume and policy briefs. It aims to: • Build capacity of actors and particularly of NGOs in the sexual and reproductive rights and health field to • understand the social, economic and political context which shapes sexual and reproductive rights and health as well as health services • identify whether health sector reforms facilitate or constrain the development and implementation of policies and programmes which support sexual and reproductive rights and health; and • identify windows of opportunity for interventions to improve sexual and reproductive rights and health • build understanding amongst actors in the human rights, health and development fields of why SRHR need to be included in the health sector reforms agenda.

The long-term goal of this capacity building initiative is to contribute to creating a critical mass of organisations and individuals who understand the (to date negative) impact of health sector reforms on women’s access to sexual and reproductive health services. The aim is to develop a constructive critique of the neo-liberal framework of the institutions and policy-makers that constitute the driving force behind current health sector reforms; and to advocate for viable alternative policies and processes in various country, regional and international contexts.

Content and method The full training course is made up of three modules to be implemented over five days. Depending on the time available and the specific needs of the trainer and the target audience, it may be reduced and certain sessions could be used as standalones, or as modules within other training courses on related topics. The training course can be geared to be either country specific or with a regional focus. In addition to the general objectives of the training course outlined above, each module has its specific objectives (outlined below) and several sessions with their relevant activities. Sub-sections on "Handouts and teaching materials" and "Slides" have been included and the format of the manual means that you can simply photocopy these for participants. Trainers should prepare by reading through the entire manual beforehand. In each section there are readings that the trainer MUST read beforehand, and at times additional readings are provided to enhance understanding, which are optional. The methodology is participatory, based on the participants’ regional and country realities and their organizational experience. It aims to provide new inputs and insights in the field of health sector reforms. It includes tools of analysis on the basis of country case studies – dealing with health sector reforms and their impact on sexual and reproductive health and rights. It provides analytical and methodological tools for the development of action plans geared towards influencing health sector reforms and their monitoring and evaluation. Module One, designed to be implemented over one day, Sets the Context. Its objectives include: • Understand the broader socio-economic and political context in which the implementation of health sector reforms, demands for the implementation of the ICPD programme of action and the introduction of measures to achieve the Millennium Development Goals are simultaneously taking place. • Understand what health sector reforms are – the main characteristics, underlying ideologies of HSR from the mid 1980s to the present, and the main actors behind the reforms. • Understand what sexual and reproductive health and rights are – including the provisions of the ICPD Programme of Action, and the main actors behind this agenda. • Understand the range of SRHR and HSR in the respective regions. Module Two, designed to be implemented over two and a half days, is entitled: The implications of health sector reforms for sexual and reproductive health and rights. Its objectives include: • Understand the conceptual framework for analysing health sector reform and sexual and reproductive health and rights. • Understand the range of approaches to specific components of HSR, namely: financing, public-private

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T HE R I G H T R E F O R M S ? H e a l t h S e c t o r Re f o r m s a n d S e x u a l a n d Re p r o d u c t i v e H e a l t h



interactions and decentralisation, including the relationships between them. Understand the implications of the above components of reform for SRH services, and the following components of HSR: priority setting, integration and accountability and community participation; and the broader implications for achieving the ICPD POA.

Module Three, designed to be implemented over one and a half days, is entitled Organising for Change. It’s objectives include: • Share examples of effective strategies for demanding reforms. • Design plans of action in order to take our demands for SRH further within the context of HSR.

Who should use this manual? This manual has been developed for skilled trainers. It is anticipated that trainers will follow, and adapt when necessary, the modules and activities presented. Trainers are required to have an in-depth understanding of gender, sexual and reproductive health and rights as well as a health sector reforms in the particular country or regional context. Trainers should be skilled in participatory adult learning methods and able to facilitate group learning. Trainers require advanced conceptual skills to assist participants to critically assess the impact of health sector reforms on women’s access to sexual and reproductive health services.

Target group for training The target group for training includes member organisations of the sexual and reproductive health and rights networks and organisations, human rights and development NGOs, professional health and consumer organisations interested in gender issues, civil servants in relevant ministries, gender and rights sensitive individuals working in the area of health. The ideal training course participant would have sound knowledge of their country/provincial situation with regard to sexual and reproductive health and rights, have a sound knowledge of their organisation’s mission, vision and strategies, programmes and projects and have the decision-making authority to commit their organisation to working on the plan of action which will be developed during the training course. Although it is recognised that the action plans developed during the training course may require consultation with the organisation after the training course, an in-principle decision to participate in post workshop activities is necessary. It is hoped that participants will also have the commitment to work on the issue after the workshop in the adopted plan of action. Training participants should ideally not exceed 25, and it is expected that participants should attend every session.

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T HE R I G H T R E F O R M S ? H e a l t h S e c t o r Re f o r m s a n d S e x u a l a n d Re p r o d u c t i v e H e a l t h

Module 1: Setting the Context

Objectives: •

To deepen participants’ understanding of the socio-economic contexts that gave rise to the Programme of Action of the International Conference on Population Development (ICPD) and health sector reforms (HSR) To lay the foundation for assessing obstacles to, and opportunities for, securing sexual and reproductive health and rights (SRHR) within the HSR agenda



SESSION 3

SESSION 2

SESSION 1

Session title

4

Learning objectives

Methods

Time

Sexual & reproductive health

• develop a shared definition of ‘health’, sexual health & reproductive health • explore determinants of health, including sexual & reproductive health

• • • •

Sexual & reproductive rights

• deepen understanding of ‘rights’ in general and sexual & reproductive rights in particular • review international instruments on SRHR & major viewpoints

• role play • small group exercises • modified lecture

150 mins

Health sector reforms

• explore factors that led to health sector reform • review the goals of health sector reform & its leading proponents • share the ways in which health sector reform is experienced in participants’ countries

• game • group discussion • modified lecture

150 mins

story telling small group discussion group exercise modified lecture

120 mins

T HE R I G H T R E F O R M S ? H e a l t h S e c t o r Re f o r m s a n d S e x u a l a n d Re p r o d u c t i v e H e a l t h

Session 1: Sexual and reproductive health Estimated time: 120 minutes

Learning objectives After participating in this session, participants will: • have a shared definition of health, sexual health & reproductive health • have explored the determinants of health, including sexual & reproductive health.

Preparation by facilitator •



Read the assigned texts: • Werner D & Bower B. 2001. Helping Health Workers Learn. California, Hesperian Foundation: Chapter 26 "Looking at How Human Relations Affect Health" • Wilkinson, R & Marmot M (eds). 2003. Social Determinants of Health, 2nd Edition. Copenhagen, World Health Organization: Introduction, Chapter 1 "The Social Gradient" and Chapter 4 "Social Exclusion". Write up the objectives for the session on newsprint before the session.

Materials required • • • • • • • •

newsprint, markers & masking tape copies of Group exercise 1.1 copies of Handout 1.1.1: Leslie’s story wallchart cards for responses overhead projector Slides 1.1.1: Determinants of health Slides 1.1.2: Sexual & reproductive health

Instructions for the facilitator • •



Ask a volunteer to read out the session objectives written on the newsprint. (5 minutes) Distribute Handout 1.1.1: Leslie’s story. Read the full story out loud by going around the room asking each participant to read one paragraph. (10 minutes) Ask the group: What caused Leslie’s death?

Follow each response with a ‘why’ question to probe deeper into the chain of factors that contributed to Leslie’s death. If the group focuses on one set of factors only (for example, only biological or physical factors), rephrase the ‘why’ questions so that other causative factors are explored. (20 minutes) •



Divide participant in groups of 4-5 and distribute Group exercise 1.1 with the response cards. Read the instructions out loud and ask each group to spend 25 minutes discussing. By the end of the 25 minutes they must have written each of their responses on a separate response card. (30 minutes) Invite each group, in turn, to place their response cards under the categories you have created on the wall chart, as illustrated below. (15 minutes)

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T HE R I G H T R E F O R M S ? H e a l t h S e c t o r Re f o r m s a n d S e x u a l a n d Re p r o d u c t i v e H e a l t h

DETERMINANTS OF HEALTH BIOLOGICAL

SOCIAL Economic



Cultural

Political

Summarise the key learning points from the session. Use Slides 1.1.1: Determinants of health to guide the summary: • reinforce the definition of health • point to the determinants of health • demonstrate the relationship between characteristics such as sex, ethnicity, level of national development and people’s health/illness experience. For example, note that life expectancy is generally greater for people in developed than developing countries, hypertension is more likely for males than females, sexual violence is more likely for females than males, and so on. At each point in the presentation, allow for discussion, and for disagreements and alternative viewpoints. (15 minutes)



Tell the group that you will now look specifically at sexual and reproductive health. Invite volunteers to define/describe what is meant by: • sexual health • reproductive health. Ask participants to review the wallchart developed earlier. Ask: • Are sexual & reproductive health influenced by the same factors that determine health in general? • Are there additional factors that affect sexual & reproductive health that are reflected on the chart? If participants say that there are additional factors, record them on cards and place them in the appropriate column. You may need to add another column such as ‘gender’ or ‘sex’. Ask participants which factors exert the most influence on sexual and reproductive health? What are those factors? Why do they exert so much influence on sexual & reproductive health? (30 minutes)



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Use Slides 1.1.2 Sexual & reproductive health to summarise definitions. Emphasise that sexual & reproductive health is fundamental to any individual’s health. As with the previous presentation, encourage participants to discuss, add to and disagree with what you present. (20 minutes)

T HE R I G H T R E F O R M S ? H e a l t h S e c t o r Re f o r m s a n d S e x u a l a n d Re p r o d u c t i v e H e a l t h

Handout 1.1: Leslie’s story Leslie was a 32-year old business executive who lived with her family in a suburb 45 km outside Lusaka in Zambia. She found the level of rents and crime in Lusaka high so she preferred to commute from a safer, less expensive place some distance away. The roads she travelled between work and home were mostly unlit and in varying states of decay. This made travel difficult, especially after dark. In addition, the widespread disregard for traffic rules and car safety standards made travel even more hazardous. The city council said it had limited resources and could not afford better road maintenance and more traffic police. Leslie and her husband Lubasi, an IT specialist, had two children, 6 and 8 years old. Leslie bore most of the responsibility for childcare. She employed a helper to look after the children during the day and arranged her work so that she was home by 5:30pm each day. One day, Leslie was delayed at the office in a high-level meeting that ran overtime. She was worried about the delay, and therefore phoned her husband to see if he could relieve the helper on her behalf. He said he could not, explaining he had another commitment with friends later that evening. He pointed out, in addition, that childcare was a mother’s responsibility. Leslie rushed to leave the office. Halfway home, her car hit a pothole when she tried to avoid colliding with a car at the side of the road. She fractured her collarbone, broke an arm and suffered a nasty blow to the head. She spent a week in hospital recovering. Apart from her broken bones, the hospital did not investigate her for any other conditions. Two months later, Leslie was readmitted to hospital for a severe headache. Although she had been feeling dizzy during the previous three weeks, her childcare responsibilities and job duties did not leave her enough time to seek healthcare. When she shared her symptoms with her family, her mother told her she had been bewitched by jealous workmates. Leslie died several hours after being admitted to hospital. The autopsy showed that she had suffered a stroke from a blood clot blocking the blood vessels to her brain.

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T HE R I G H T R E F O R M S ? H e a l t h S e c t o r Re f o r m s a n d S e x u a l a n d Re p r o d u c t i v e H e a l t h

Group exercise 1.1: Biological & social determinants of health Biological: caused by a living organism such as a virus (HIV), bacteria (gonorrhoea), parasite (malaria) or fungus (thrush) Social: caused by human factors such as distribution of resources (economics), attitudes & customs (culture), exercise of power (laws, policy, politics) Directions: Reflect on Leslie’s Story. Now think about health and wellness in your country. Think about the kinds of illness conditions that are prevalent in your country. Using the same chain of reasoning employed in Leslie’s story, identify the factors that determine health and wellness for: • the individual • communities • the country as a whole. Discuss among yourselves and record each factor identified on one of the cards you were given, writing one factor per card. Write the responses in bold, clear lettering so that they can be easily read by others in the group. Choose someone to report back to the larger group. This person will share your list of determinants of health by placing the cards on a wall chart that the facilitator has prepared.

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"The health of the poor often depends on questions of justice." David Werner

World Health Organization

Health is the "state of complete physical, mental and social well-being; and not merely the absence of disease and infirmity."

How is health defined?

Slide 1.1.1: Determinants of health (1) T HE R I G H T R E F O R M S ? H e a l t h S e c t o r Re f o r m s a n d S e x u a l a n d Re p r o d u c t i v e H e a l t h

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10



Public policy can play a big role in shaping the social environment so that it is more conducive to health.

structural factors like unemployment, access to medical care, poverty



Health is very sensitive to our social environment:



behavioural factors like the quality of parenting, eating habits, exercise

Health differences between different social groups have widened or narrowed as social and economic conditions have changed.





People who are less well off have substantially shorter life expectancies and more illnesses than the rich …even in the most affluent countries.



Slide 1.1.1: Determinants of health (2)

T HE R I G H T R E F O R M S ? H e a l t h S e c t o r Re f o r m s a n d S e x u a l a n d Re p r o d u c t i v e H e a l t h

Life Probability of GDP per Population Population expectancy not surviving capita living on