|17. Maternal Health and Health Sector Reform: Opportunities and Challenges|
There is a growing body of literature describing the impact of HSR on Reproductive Health (RH) status (Population Council 1998, Langer et al . 2000, Lush et al . 1999, Hardee & Smith 2000, Papineau 2000, Langer et al . 2000). However, few authors have focused specifically on the impact of HSR initiatives on maternal health and services, although interest does appear to be growing (Goodburn & Campbell 2001, World Bank 1999, Aitkin 1999). Much of the available literature is conceptual in nature with little formally documented operational evidence. The former focus on using maternal mortality to measure the impact of changes in health care systems may be partly to blame for this situation. It is now accepted that measuring maternal mortality is expensive and impractical at programme level, and that proxy, service delivery, indicators are required. However, systems for collecting service delivery data are still in the development phase in many countries, and so these data are often not yet available for use. Perhaps because of this lack of data, the academic literature is distinctly polarised with health reform protagonists and antagonists firmly positioned in their respective camps.
There is no clear definition or universally agreed package of HSR. This means that disparate activities are being grouped together, termed HSR, and then pronounced a success or failure without any consistent definition of cause or effect. There is probably no justification for trying to promote a uniform HSR package, as HSR is a process not a collection of activities. Nevertheless, it is important to disaggregate the individual interventions usually included in HSR and look for evidence of effect so that lessons can be incorporated into future policy and practice. In such a diverse field, clarity of meaning is important. We noted a number of incidents of confused terminology, particularly between HSR and SWAps. SWAps may be part of a reform agenda or may include reform activities as part of the agreed strategy, but they are not synonymous with HSR.
It is true that many HSR initiatives are more focused on process than health outcomes (WHO 1999, Foster et al . 2000b). However, many of the processes involved in HSR also provide opportunities. Evidence from key informants suggests that the process of discussing the components of a sector strategy, or an essential service package, highlights the issues surrounding the delivery of maternal health services, even if these issues are not immediately resolved (McDonagh et al . 2000). This means that it is important to participate early and positively in HSR initiatives in order to be strategically positioned to influence the process (McDonagh et al . 2000).
One of the most important challenges facing HSR initiatives is to ensure they become more outcome focused. Process indicators, such as deliveries conducted by a skilled attendant and met need for essential obstetric care, can be used to track progress towards maternal mortality reduction goals. These indicators, which measure changes in the availability and quality of services, can potentially be used to measure changes occurring as a result of health systems reform.
Donors are increasingly attracted towards working through SWAps. However, there continues to be considerable misunderstanding and misinformation about this approach. The opportunities and challenges of working within a SWAp merit a particular focus. The philosophy of the SWAp process is that government leads it, as political commitment is an essential ingredient for a successful reform agenda, SWAps have the potential to be an effective process for reform activities (Cassels 1996, World Bank 1999). One of the opportunities of a SWAp is that it provides donors with a greater opportunity to address deeper systemic problems, permitting donors to work within a wider policy context of civil service reform and efforts to improve the budget process. (Foster et al . 2000, Johanson 2000).
Donors with a special interest in reproductive health sometimes voice concerns that participation in SWAps will dilute the focus and funding for specific services such as family planning. This concern increases when pooled or basket funding is proposed. There is certainly a risk that governments may choose different priorities than donors. This may lead to the view that the process has been a failure when in reality it is a difference in expectations. The solution is to ensure that mechanisms exist which can be used to protect particular services if necessary, such as ring fencing or ear marking particular funds within the overall budget.
SWAps highlight some of the fundamental weaknesses in the traditional model of funding projects and challenge donors to relinquish some of their power. However, a recent review of SWAp programmes found significant similarities between SWAp programme content and implementation plans between countries, which may suggest that donor agendas are stronger than government leadership (Foster et al . 2000b). SWAps require donors to give governments the space to make policy, to support their priorities without imposing their own, and to back off from the detail of decision making and implementation. This process is likely to be slow and many donors still behave as if they are managing projects rather than supporting programmes (Foster et al . 2000b).
The role and importance of efficient health systems in reducing maternal mortality is now generally accepted (World Bank 1999, Goodburn & Campbell 2001, Papineau Salim 2000). HSR initiatives, particularly SWAps, provide the opportunity for donors to work together, in support of policies and strategies leading to the development of effective and efficient health systems. There are of course major challenges in working through a reform agenda, one of which is that there are no blue prints or quick fixes. There is no substitute for a good institutional analysis of the health system that seeks out the potential for, and the ability of the system to change (Cassels 1998, Johanson 2000). The result in most cases is likely to be a mix of new reform initiatives and old practices, with a phased implementation approach dependant on the development of capacity and performance.