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This paper discusses health sector reforms and what they have meant for sexual and reproductive health advocacy in low-income countries. Beginning in the late 1980s, it outlines the main macro-economic shifts and policy trends which affect countries dependent on external aid and the main health sector reforms taking place. It then considers the implications of successive macro-economic and reform agendas for reproductive and sexual health advocacy. International debate today is focused on the conditions necessary for socio-economic development and the role of governments in these, and how to improve the performance of health sector bureaucracies and delivery systems. A critical challenge is how to re-negotiate the policy and financial space for sexual and reproductive health services within national health systems and at international level. Advocacy for sexual and reproductive health has to tread the line between a vision of reproductive health for all and action on priority conditions, which means articulating an informed view on needs and priorities. In pressing for greater funding for reproductive health, advocates need to find an appropriate balance between concern with health systems strengthening and service delivery and programmes, and create alliances with progressive health sector reformers.

The Global Financial Crisis (GFC) of 2008/2009 was the largest economic slowdown since the Great Depression. It undermined the growth and development prospects of developing countries. Several recent studies estimate the impact of economic shocks on the poor and vulnerable, especially women and children. Infant and child mortality rates are still likely to continue to decline, but at lower rates than would have been the case in the absence of the GFC.Asia faces special challenges. Despite having been the fastest growing region in the world for decades, and even before the current crisis, this region accounted for nearly 34% of global deaths of children under 5, more than 40% of maternal deaths and 60% of newborn deaths. Global development goals cannot be achieved without much faster and deeper progress in Asia.Current health financing systems in much of Asia are not well placed to respond to the needs of women and their children, or the recent global financial and economic slowdown. Public expenditure is often already too low, and high levels of out-of-pocket health expenditure are an independent cause of inequity and impoverishment for women and their children. The GFC highlights the need for reforms that will improve health outcomes for the poor, protect the vulnerable from financial distress, improve public expenditure patterns and resource allocation decisions, and so strengthen health systems.This paper aims to highlight the most recent assessments of how economic shocks, including the GFC, affect the poor in developing countries, especially vulnerable women and children in Asia. It concludes that conditional cash transfers, increasing taxation on tobacco and increasing the level, and quality, of public expenditure through well-designed investment programmes are particularly relevant in the context of an economic shock. That is because these initiatives simultaneously improve health outcomes for the poor and vulnerable, protect them from further financial distress, improve public financing and/or provide a much-needed counter-cyclical stimulus at times of economic slowdown. [ABSTRACT FROM AUTHOR]

Abstract: The paper compares healthcare reforms in China, South Korea, Singapore and Thailand with the purpose of drawing useable lessons about the appropriate role of the state in the sector. It argues that healthcare reforms in China and Korea offer many negative lessons for healthcare reformers while Singapore and Thailand offer positive lessons that may be considered for emulation elsewhere. The fundamental lesson to emerge from the successful reform experiences is that a large and active state role in various aspects of healthcare provision and financing is essential for containing expenditures and maintaining access. Public ownership of providers and prospective payments are particularly effective in controlling expenditures while direct government financing promotes equitable access. The cases also show that political economy matters: the Singapore and Thai states’ strong presence in the healthcare sector is a vital reason for their superior performance. [ABSTRACT FROM AUTHOR]

This paper examines the concept and practice of community participation in World Bank-supported health sector reforms in Asia, and how far such participation has strengthened accountability with regard to provision of sexual and reproductive health (SRH) services. It argues that the envisaged scope of community participation within a majority of reforms in Asia has been limited to programme management and service delivery, and it is occurring within the boundaries of priorities that are defined through non-participatory processes. Setting up of community health structures, decentralization and community financing are three important strategies used for promoting participation and accountability within reforms. The scant evidence on the impact of these strategies suggests that marginalized groups and sexual and reproductive rights based groups are poorly represented in the forums for participation, and that hierarchies of power between and amongst health personnel and the public play out in these forums. Community financing has not lead to enhanced service accountability. As a result of the above limitations, community participation in health sector reforms has rarely strengthened accountability with respect to provision of comprehensive SRH services. In this context, rights (including sexual and reproductive) based groups and researchers need to engage with design, monitoring and evaluation of health sector reforms, both from inside as participants and outside as pressure groups. Participation contracts enhancing powers of civil society representatives, quotas for participation (for women, other marginalized groups and rights-based organizations), and investment in capacity building of these stakeholders on leadership and sexual reproductive rights and health are pre-requisites if participation is to lead to health and SRH service accountability. Community participation and service accountability hence requires more and not less investment of resources by the state. [ABSTRACT FROM AUTHOR]