HEALTH SECTOR REFORM - What's in it for sexual and reproductive health? EntreNous The European Magazine for Sexual and Reproductive Health Entre Nous is published by: The Reproductive Health/Pregnancy and Gender Mainstreaming programme WHO Regional Office for Europe Scherfigsvej 8 DK-2100 Copenhagen 0 Denmark Tel: (+45) 3917 1341 Fax: (+45) 39171850 E-mail: entrenous@who.dk www.euro.who.int/entrenous Chief editor Dr Assia Brandrup-Lukanow Editor Jeffrey V. Lazarus Editorial assistant Dominique Gundelach Layout To om bord, Aarhus. www.toombord.dk Print Central tryk Hobro a/s Entre Nous is funded by the United Nations Population Fund (UNFPA), New York, with the assistance of the World Health Organization Regional Office for Europe, Copenhagen, Denmark. It is published three times a year. Present distri- bution figures stand at: 3,000 English, 2,000 Spanish, 2,000 Portuguese, 1,000 Bulgarian, 1 ,000 Russian and 500 Hungarian. Entre Nous is produced in: Bulgarian by the Ministry of Health in Bulgaria as a part of a UNFPA-funded project; Hungarian by the Department of Obstetrics and Gynaecology, University Medial School of Debrecen, PO Box 37, Debrecen, Hungary; Portuguese by the General Directorate for Health, Alameda Afonso Henriques 45, P-1056 Lisbon, Portugal; Russian by the WHO Information Centre for Health for the Central Asian Republics; Spanish by the lnstituto de la Mujer, Ministerio de Trabajo y Asuntos Sociales, Almagro 36, ES-2801 O Madrid, Spain. The Portuguese and Spanish'i~sues are distri- buted directly through UNFPA representatives and WHO regional offices to Portuguese and Spanish speaking countries in Africa and South America. Material from Entre Nous may be freely translat- ed into any national language and reprinted in journals, magazines and newspapers or placed on the Web provided due acknowledgement is made to Entre Nous, UNFPA and the WHO Regional Office for Europe. Articles appearing in Entre Nous do not necessarily reflect the views of UNFPA or WHO. Please address enquiries to the authors of the signed articles. For information on WHO-supported activities and WHO documents, please contact the Family and Community Health unit at the address given above. Please order WHO publications directly from the WHO sales agent in each country or from Marketing and Dissemination, WHO, CH-1211,Geneva 27,Switzerland ISSN: 1014-8485 CONTENTS Editorial By Dr Assia Brandrup-Lukanow Health sector reforms and reproductive health meeting How can we assess the impact of health sector reforms on reproductive health care and services in Europe? By Dr Frants Staugard and Charlotte Rosenberg The Making Pregnancy Safer Initiative Integrating reproductive health in the health reform process in Bosnia and Herzegovina By Dr Hedia Be/hadj New EU resolution on sexual and reproductive health and rights By Vicky Claeys Internet resources By Josh Gross and Jeffrey II. Lazarus Entre N ous is online: www.euro.who.int/ entrenous Page 5 Page 6 Page9 I Cover rllustration Cl Anne Mette Edeltoft Page 12 3 4 5 9 13 17 18 Page 15 THE ENTRE NOUS EDITORIAL ADVISORY BOARD Dr Evert Kettlng Netherlands School of Public Health Utrecht, The Netherlands Dr Malika Ladjali Senior Programme Specialist UNESCO/Headquarters Ms Nell Rasmussen Director PRO-Centret, Copenhagen Ms Lyn Thomas Deputy Director General International Planned Parenthood Federation (IPPF) London Dr Robert Thomson Adviser on sexuality, Reproductive Health & Advocacy UNFPA Country Technical Services Team for Europe (in Bratislava) Ms Alanna Armitage UNFPA, Honduras © World Health Organization 2002 Dear Entre Nous readers This issue of Entre Nous will be my last as Regional Adviser on Reproductive Health, as I will be leaving the WHO Regional Office for Europe to join the German Agency for Technical Cooperation in Eschborn, Germany, where I will be heading the Division for Health, Education and Social Protection. I would like to take this opportunity to say thank you for the last nine years of joint work and cooperation in the European Region. It has been an exciting time, and I believe that, together, we have much to be proud of. When I look back to the end of 1993, when I jo ined WHO, at that time as staff member of the UNFPA-TSS system, reproductive health was hardly on the European agenda. None of the WHO collaborative agree- ments with countries included reproduc- tive health, there were no UNFPA coun- try o r regional offices in the field, and we focussed solely on the implementation of UNFPA-funded country projects in Portugal, Turkey, Albania and Romania, as well as on the information project Entre Nous. Today, the situation is very different. The reproductive health needs of coun- tries in the Region have been well recog- nized, and on average 15 countries request technical assistance in this area of work in every biennium. Another reflec- tion of the recognition of needs has been the allocation of UNFPA resources for the establishment of several country and inter-country offices in the Region, which has made the implementation of multi - component, larger scale country pro- grammes more feasible. The content and profile of pro- grammes has also changed significantly over time. Initially, there were emergency programmes, which focussed on the pro- vision of contraceptives, essential mater- nity equipment and essential drugs, as well as on fast capacity build ing through fellowships and short courses in the countries of central and eastern Europe and the newly independent states. Today, programmes focus on the promotion of evidence-based medicine in reproductive health, the strengthening of sexual and reproductive rights, and the development and implementation of national strate- gies on sexual and reproductive health. Reproductive health programmes have moved from vertical family planning pro- grammes to becoming a more integral part of overall health policy develop- ment. This enhances their sustainability and visibility within the overall health policy discussion, which, in the past decade, has been governed by the quest to make health services more client-cen- tred and at the same time cost-effective by radically reforming the ways in which the health sector functions and the way it is financed. Much has been written about the impact of health secto r reforms on costs, and, in part, on health outcomes. To date, not as much systematic evidence has been collected on the impact of health care reforms on reproductive health. How does the introduction of user fees affect health care seeking behaviour in pregnancy? How does the introduction of insurance coverage impact on the use of contraceptives and abortions? What pro- visions are taken to protect the unem- ployed and those who do not have access to financial resources, many of whom are women working in the informal sector, or "dependants" in the sense that they have to rely on the income and insurance of their husbands. Have appropriate methodologies been developed to mea- sure the impact of all these changes on maternal health, on the sexual and repro- ductive health of young people, or on the incidence of STI infections? In this issue of Entre Nous, we try to reflect the present discussions in this field, which have also been the subject of the last global meeting of WHO Regional Advisers for Reproductive Health. The meeting stressed the need for more research on the impact of health sector reforms on reproductive health services and outcomes and on the sexual and reproductive health rights of individuals. We present a proposal for a study methodology field tested in several coun- tries of the Region by Dr. Staugaard, as a well as in-depth country case study on Bosnia-Herzegovina by Dr. Hedia Belhadj. In the Resources section, readers will find information on the HiT profiles pro- duced by the European Observatory on Health Care Systems, an initiative of WHO and eight other partners. To date, the health systems of more than 44 coun- No. 54 - 2002 tries have been comprehensively analysed by a team of international exp~ ts. HiTs provide an analytical descripti~n 0f each national health care system ana o f reform initiatives in progress-;,; under development. They aim to provide rele- vant comparative information to support policy-makers and analysts in the devel- opment of health care systems and reforms in the countries of Europe and beyond. Also in this issue of Entre Nous, we present the main areas of work of the global Making Pregnancy Safer Initiative in the European Region. Apart from the pilot country Moldova, many other countries in the Region have expressed an interest in joining the initiative, thus reflecting a greater political commitment to effectively improve maternal health and reduce maternal suffering and deaths. The inclusion of the recommend- ed health-sector related actions into ongoing health care reforms will be vital in achieving the Making Pregnancy Safer goals. We hope that Entre Nous can thus sup- port and stimulate the ongoing discus- sion and, as always, we look forward to our reader's comments, suggestions and experiences. Again, thanks to all for your commit- ment, cooperation, and friendship over the past years. I look forward to continu- ing to expand our joint work. On behalf of contributors and readers, I would like to express my sincere appreciation of the Entre Nous editorial team, Jeffrey Lazarus and q,ominique Gundelach, as well as the Editorial Board for their guidance and advice. Dr Assla Brandrup-Lukanow [assla.brandrup- lukanow@gtz.de] Chief editor _3_ 4 HEALTH SECTOR REFORMS AND REPRODUCTIVE HEALTH S111111110ry report o(tl,c 111ceti11g n_{\\'HO Regio110/ Arl Fisers i11 Rcprorl11ctivc I-Ieolth I \'/·/0 /~egio110/ Ojf1cc /or Europe, Cope11hogc11, DeJ1111ork, 26-28 A11g11st 2002 The Department of Reproductive Health and Research at WHO is developing a new research initia- tive that will focus on the impact of health reforms on access to and utiliza- tion of reproductive health services, as well as reproductive health outcomes. The goal will be to provide countries and donors with evidence-based advice on recommended approaches to the imple- mentation of health reforms related to sexual and reproductive health. A key issue highlighted at the meeting of WHO Regional Advisers on Reproductive Health was the need for a holistic definition of the concept of health sector reforms, which in accor- dance with the World Health Report 2000 were defined as "sustained, pur- poseful changes to improve the health sector". Some of the elements of this holistic concept are financing, resource allocation, reorganization of functions, decentralization and the legal environ- ment. Sexual and reproductive health (SRH) has been given lower priority in national and global health policies as exemplified in the omission of SRH in the Millen- nium Declaration and the decreasing allocations of funds not only to SRH but also to primary health care. A critical question is how policy-makers can proac- tively ensure maximum benefit of health sector reforms for SRH. Decentralization An assessment of the impact of decen- tralization on SRH was a priority and a need was expressed for the development of appropriate methodologies and tools for such an assessment. The approach termed "decision space" had been tested and should be considered. The decision space approach proposes a principle (individual or institution) with specific objectives and agents needed to imple- ment activities to achieve those objec- tives. The decision space approach thus concentrates on describing policy formu- lating and implementing agents. It has been observed with concern that in some cases decentralization of health management has led to a lower priority being given to SRH. A need was identi- fied to ensure that SRH was paid due attention as a key component of periph- eral health services and that sufficient resources were allocated to SRH as part of any decentralization process. TheimpactoffinancingonSRH A need was identified to develop opera- tional objectives for all elements of health sector reforms in order to facilitate their monitoring and evaluation. In this process the maternal mortality rate (MMR) is a key indicator of inequitable resource distribution. It was noted that some elements of health sector reforms impact positively on MMR - even in the absence of economic growth. It was emphasized, however, that reforms alone could not compensate for diminished resources. Some of the new insurance schemes were found to reduce access to SRH ser- vices for certain population groups, thereby aggravating inequity. There was a discussion on the issue of contracting for health services and it was noted that this approach might in some cases be a cost- effective strategy, but should be carefully monitored. Research needs • how to document resource flows; • how to measure and ensure accessibility; • how to measure the cost-effectiveness of health sector reform elements; • how to measure the magnitude of gen- der-based violence; • how to measure the cost-efficiency of health sector reforms. Critical issues in the field of policies and programmes • how to mobilize additional resources for SRH; • how to ensure a needs-based allocation of resources; • how to reduce inequity as part of health sector reforms; • how to ensure that all stakeholders are actively involved in planning and implementing reforms; • how to design reforms for countries recovering from conflicts. Reviewing sector-wide approaches A sector-wide approach (SWAPs) was viewed as a strategy for improved man- agement of development cooperation in order to achieve better value for money and improve outcomes. SWAPs therefore imply a structured and coordinated part- nership between national governments and the external development partners. It was noted at the meeting that this may be effective in implementing and sustaining health sector reforms, but must be based on a participatory process. Some critical questions were: • how to measure the impact of SWAPs on SRH; and • how to provide country specific docu- mentation of reform experience. Private and public partnerships The meeting made note of the fact that public-private partnerships (PPP) have gained increasing significance as part of health sector reforms. It was therefore important for governments to create sup- portive environments for PPP. However, it was noted that privatization may lead to gap-widening and distortion of priori· ties. Some critical questions remain to be addressed: • how can the impact of PPP on SRH services and outcomes be documented; • how is PPP of specific relevance to SRH? Sexual and reproductive rights The meeting emphasized the need for sexual health and rights to not be sepa- rated from reproductive rights. Moreover, the integration of the components of sex- ual health and the components of repro- ductive health in programmes and ser- vices was seen as crucial. Finally, the African and European Regional Offices of WHO have prepared ~egional SRH strategies. The European Union is in the process of developing such a strategy on SRH and it was seen as important to ensure optimal collabora- tion between WHO and regional govern- mental and non-governmental organiza- tions in SRH policy and strategy develop- ment. The full conference report Is available from: Dr Michael Mblzvo [mblzvom@who.lnt] World Health Organization Department of Reproductive Health and Research (RHR) Avenue Appia 20, CH-1211 Geneva 27, Switzerland Tel.: (+41) 22 791-4245/3305 Fax: (+41) 22 791-4171 HOW CAN WE ASSESS THE IMPACT OF HEALTH SECTOR REFORMS ON REPRODUCTIVE HEALTH CARE AND SERVICES IN EUROPE? By Frants Stnugard and Charlotte Rosenberg Is/1(i)y Health sector reforms in Europe have been generated by broad secular trends that cross national and sub-regional bound- aries. At least two categories of factors appear to have generat- ed these trends. First, pressures from outside the health sector have affected the basic framework of health policy formulation. A wide range of political, ideological, social, his- torical, cultural and maybe above all eco- nomic factors has determined the specific nature and contents of health reforms in each country. Second, existing health problems and in some cases the deterio- rating health status of certain groups of the population in addition to problems within the health services delivery system in each country have challenged policy makers and made health sector reforms necessary. A generic study protocol has been developed for the use of countries who wish to review specific elements of the health sector reforms with a potential direct or indirect impact on reproductive health services and outcomes. On the basis of such a review it will be possible for countries to modify or reinforce ele- ments of their health sector reforms, and thereby improve reproductive health indicators in the longer perspective. The generic study protocol has been piloted in two European countries, the Republic of Moldova and Slovakia, and is briefly presented in this article. Comprehensive reports with the findings from these two pilot studies have been published by the Sexual and Reproductive Health Programme at the WHO Regional Office for Europe, and copies of the reports are available upon request. Objectives, hypotheses and methods The pilot studies aim to: • assess the impact of health sector reforms on reproductive health services and outcomes; • analyse the correlation between specific elements of health sector reforms and one or more of the generic strategic areas or core elements of the national programme for sexual and reproductive health; • add views and perceptions of policy- makers, planners, health care providers, interest groups and beneficiaries No. 54 - 2002 regarding the impact of health sector reforms on sexual and reproductive health to national statistical cfa'ta. used for the monitoring of deye~~filent trends of standard indicators-tor sexual and reproductive health; · formulate rational proposals regarding modifications or amendments of spe- cific elements of the national health sector reforms, as appropriate, in order to positively influence on reproductive health services and outcomes. The specific study questions were formu- lated in two data collection tools: one focusing on keywords and indicators, and the other on interview questions, which were developed for the study protocol. These data collection tools are also avail- able on request. The questions were for- mulated on the basis of official WHO documents with guidelines for selection of national and global indicators for monitoring of reproductive health status as well as WHO literature, analysing cur- rent strategies of European health care reforms in general and strategies for the improvement of reproductive health in central and eastern Europe in particular. Four generic study hypotheses were defined for the pilot studies. Generic hypotheses must be modified for new studies where country specific hypotheses respecting the socio-economic situation and development trends of key indicators for sexual and reproductive health in each country should be added. The pilot country studies were guided by their operational objectives and divided into four study phases, which are reviewed below. The approach to implementing the pilot studies might be of use to researchers, who wish to conduct similar studies in other Member States. This country study approach is based on expe· rience already gained from the two pilot country studies. Study phase I: Literature review Initially, a desk study of all relevant and available literature and documents relat- ed to the specific country situation with regard to health sector reforms, sexual and reproductive health services, ovt- comes and indicators should be C' .rried out in order to provide a detailed picture of the sprci.fic country situation. The lit- erature search should be guided by key- 5 6 words, defined in the generic data collec- tion tools. The specific literature search should be accompanied by a systematic review of all existing elements of health legislation and of health sector reforms with rele- vance for one or more of the core strate- gic areas of a generic programme for sex- ual and reproductive health. Study phase II: Country specific study protocols For each country a specific study proto- col and set of data collection tools should be developed, taking into account Interviews with policy-makers, plan- ners, health care providers, interest groups and beneficiaries As the second activity in phase Ill, a series of interviews should be conducted with representatives of relevant govern- ment representatives, authorities, agen- cies and representatives of reproductive health care service providers in each of the participating countries. Following these initial interviews researchers should meet with and obtain relevant informa- tion from representatives of other authorities and agencies at the central, The purpose of complementing quan- titative data with qualitative information, from interviewing differe].t groups of informants, is to create aJriangulated picture of the reality of sexual and repro- ductive health in the specific country. This is relevant for each of the strategic areas of the national sexual and repro- ductive health programme as well as in relation to issues of equity, human rights, advocacy and gender mainstreaming. the scope and range of activities - -------- - ---.-- ---.---- -·· As part of each type of interview, as described above, attempts should be made to obtain views and perceptions regarding strengths, weakness- es, opportunities and threats in the national programme for sexual and reproductive health as well as the priority questions of the national study. Piloting data collection tools Following the development of the country specific study protocol and data collection tools the latter should be piloted in selected geo- graphical areas and among repre- sentative target groups, in order to allow for modifications of the data collection tools, if needed. Training of interviewers Prior to the onset of the actual collection of data, interviewers need training under the supervi- sion of experienced researchers. This may take place as part of the above process of piloting the pre- liminary data collection tools. Study phase III: Provision of updated statistical infor- mation on indicators for sexual and reproductive health As the first activity in phase Ill of the country specific study, all relevant hard- ware indicators and trends with regard to the strategic areas or core elements of a generic sexual and reproductive health programme should be documented. For the purpose of the pilot studies men- tioned above an additional strategic area or core element was included with the purpose of providing complementary information on country specific issues related to equity, human rights, advocacy and gender mainstreaming. Study Phase I _________ _.__ -,-_ .,._ _ -·-·--- --·-- (SWOT). This should be in _.._ ... t-ih ni:imD fflMl!I IIOdlir Ctffdtmcm:aot,M'lllllln ............_.......,. ·-· -- ·-·--·- ~-L--.--Study Phase II relation to current and future health sector reforms and their actual or potential impact on sexual and repro- ductive health services and outcomes. -- ·- ----- ----'--~- .,_ ____________ --- - regional and district level, involved in planning and managing different compo- nents of the health sector reforms as well as in planning and implementing repro- ductive health services activities. Appointments should also be made with representatives of non-governmental organizations and interest groups engaged in issues and problem related to sexual and reproductive behaviour. Perceptions of immediate beneficiaries with regard to the impact of the ongoing health sector reform process on various aspects of sexual and reproductive health and health services should be described as experienced in their own situation and added to the country study. Methods for qualitative data collection Focus groups, structured and semi-structured interviews are qualitative data collection tools that can be used alone or combined for the purpose of the study. Focus groups combine sev- eral advantages including flex- ibility, a relatively low cost, potentially quick results and a capacity to increase the size of a qualitative study. Focus groups are valid if they are used carefully for a problem that is suitable for this method. In relation to certain sexual and reproductive health issues there might be some country specific sensitive issues that can not be addressed directly and which can impact on the validity of the results. Focus groups also have certain limitations that can affect the quality of the results e.g. researchers have less con- trol than in individual interviews, data analyses are difficult, the group discus- sions are difficult to compare and some target groups may be difficult to convene for the holding of the focus group dis- cussions. A structured interview is characterised by a standardised questionnaire with closed- and/or open-ended questions, such as illustrated in the second data col- lection tool used in the pilot country studies. This tool is appropriate if the interviewer is not very experienced, due to its structured agenda. It is also less time and resource consuming than semi- structured interviews tend to be. The results might be affected by the limita- tions of the standardised questionnaire. A semi-structured interview is charac- terised by a more flexible agenda. The interviews usually take the form of a dia- logue with selected themes. This kind of interview is usually very rewarding with regards to capturing new perspec- tives and insights into the focus of the study. It calls for more experi- enced interviewers, who need to be both open and focused during the interviews. Study phase IV: Analysis of hardware data Analysis of both quantitative and qualitative study findings should form the first stage of phase IV of the study. On the basis of study findings, preliminary conclusions and recommendations regarding specific elements of health sector reforms may be formulated with the purpose of impacting positive- ly on sexual and reproductive health services and outcomes. While the analysis of hardware data, obtained from national and global databases, is comparatively simple and greatly facilitated by the availability of trends anaiyses in e.g. the WHO Health for all respondents' narratives. All phases of the method are described in detail in stan- dard textbooks, unlike other qualitative methods of analysis, which makes it very accessible for public health researchers. The disadvantage of using grounded the- ory is that all of the nuances in data do not get analysed and that quotations from the respondents can be taken out of context, if the analysis is not sufficiently detailed. In the process of coding and analysing data from the focus group, structured and/or semi-structured interviews con- database, the analysis of findings o Anne Mette Edettolt from software data from the open-ended ducted for the study, software programs questions in data collection tools for the such as Nvivo and Nud*ist may be used, country studies might be more compli- either separately or in combination. cated for the researchers as there is more Nud*ist is a simple program for coding room for interpretation. large amounts of data, whereas Nvivo is a Analysis of software data There are many different methods for analysing qualitative data. Grounded the- ory with open, axial and selective coding is the most commonly applied method among public health researchers. The advantage is the method's cogent and systematic way of processing data. It does not aim at interpreting the individual's narrative but rather at uncovering pat- terns and different contexts across later updated version of Nud*ist. The two programmes can easily be combined if a greater flexibility in handling data is required. One of the advantages of Nvivo is that researchers can combine work from different research sites. Qualitative elements can also be imported and exported to quantitative programs like SPSS or WHO databases for further analysis. Information about the software is available at www.QSR.com.au. Links to other qualitative software programmes No. 54 - 2002 can also be found at this website. Validity and reliability of study results are also important criteria. In !}'i-e -process of planning a focus group p r,~1iitictured and/or semi-structured interview, several considerations must be taken into account with regard to criteria for inclu- sion, sampling strategies and where and how the interviews should be conducted, e.g. respondents' private residence, tape- or video-recorded observations, notes and/or transcriptions. Considerations concerning ethical issues are also impor- tant and approval must be obtained from " relevant ethical science com- mittees and from all the dif- ferent parties involved. The personal, professional and theoretical experience of the researchers must also be considered and clarified. The qualitative researchers must acknowledge that they are not just affecting the process but become part of this process. It is essential that the way the researchers influence the analysis and hence the results be explicitly discussed. Development of draft report Following the completion of each country study a first draft report with the main findings, conclusions and rec- ommendations from the study should be developed. This country report should be submitted to authorities and other interested parties in each study country. Feedback obtained should then be integrated in the next draft, prior to the formulation of final recommendations regarding modifica- tions of specific elements of the health sector reforms. Hardware indicators at the national level Sexual and reproductive health output and outcome indicators are divided into two categories, of which the first could appropriately be termed hardware indica- tors, providing the study with officially and unofficially available data on the effectiveness of national sexual and reproductive health policies, strategies 7 8 and services. Indicators should be cate- gorised under each of the strategic ele- ments of the national sexual and repro- ductive health programme. Indicators should be sex-disaggregated, where appropriate and possible. Software indicators The second category of indicators could appropriately be termed software indica- tors, as this information should reflect the views and perceptions of policy-mak- ers, planners, health service providers, interest groups and beneficiaries of reproductive health services regarding the appropriateness, relevance, efficiency, availability and accessibility of reproduc- tive health services as well as the appro- priateness and relevance of reproductive health policies and strategies. The list of indicators should be developed on the basis of global criteria regarding the use- fulness, ethical standard, representativity, validity, sensitivity and specificity of any given indicator. Discussion on methodological prob- lems and issues The effectiveness and impact of health sector reforms on sexual and reproduc- tive health services and outcomes can only be assessed in a longer time perspec- tive. They are measured by assessing the level of success of reforms in terms of improving the sexual and reproductive health status of various groups of benefi- ciaries. In this process of evaluating the reform process over a longer period of time, the WHO list of national and glob- al indicators will prove valuable. However, detailed quantitative infor- mation on some of the defined global indicators is not easily available in national or global databases. Some infor- mation in these databases only provides researchers with proxy indicators of the effectiveness of health reforms on repro- ductive health. In the short term there is need for monitoring progress of the reform process by assessing the efficiency of implementation of those reform ele- ments which have a direct or indirect bearing on sexual and reproductive health services. This monitoring could take place through quantitative and qual- itative data collection on the process of implementing reforms with regard to decentralization of health services, strengthening of the primary health care sector, the role and function of gatekeep- ers in this sector, in particular the family physician, the quality, availability and accessibility of antenatal care and abor- tion services for different groups of bene- ficiaries, privatization of some health ser- vices, and the role and function of health insurance schemes on sexual and repro- ductive health services. However, process indicators of this nature, enabling researchers to assess the efficiency of the health reform process in general and the efficiency of reform elements with a direct or indirect bearing on sexual and reproductive health services in particular, are not generally available and often have to be collected through special surveys. Moreover, globally applicable indicators with regard to the efficiency of health reforms remain to be defined. Whether country specific studies on the impact of health reforms on sexual and reproductive health aim at assessing the effectiveness of reforms in the longer time perspective or in the shorter, it is highly relevant to add qualitative infor- mation on the views and perceptions of immediate beneficiaries and other target groups of the reforms to the quantitative information - and thus to opt for a trian- gulated study approach in each country specific study. Conclusions from the pilot studies In the hypotheses for the pilot country studies it was contended that it is possi- ble to identify a correlation - positive or negative - between specific elements of the health sector reform process on the one hand and sexual and reproductive health services and outcomes on the other, in any given country. However, a multitude of confounding factors impact upon indicators for health development and sexual and reproductive health indi- cators in general and on health indicators for particularly vulnerable groups in any society in particular. It is thus difficult and in the majority of cases impossible to establish causality of any given element of health sector reforms and sexual and reproductive health outcomes, measured by means of standard indicators. However, it is possible to draw tenta- tive conclusions as to a possible positive correlation between specific health sector reform elements and sexual and repro- ductive health services and outcomes. It should not be forgotten th'at.general socio-economic devc;JopJti"'oot trends in any given society- wliether negative or positive - are the most important deter- minants for trends in public health devel- opment in general and in sexual and reproductive health development in par- ticular. Nevertheless, there is merit in hypoth- esising that modifications of the health sector reform process might contribute to a reversal of negative trends of sexual and reproductive health indicators, despite deteriorating socio-economic development trends in the society at large. This hypothesis or assumption might be of particular relevance to those modifications of elements of the health sector reform process that specifically aim at targeting the most vulnerable groups of the population. The proposed study methodology might therefore pro- vide public health planners and decision- makers with an appropriate tool for improving the quality of sexual and reproductive health services and out- comes by identifying problems in rela- tion to sexual and reproductive health that may be approached, and in the best case solved, through modifications of ele- ments of health sector reforms, even in the absence of a general socio-economic improvement for the population in gen- eral and for members of particularly vul- nerable groups of the population in par- ticular. The full study protocol including the data collection tools, as well as the pilot studies are available from Frants Staug!rd. Frants Staugard MD, MPH, Dr Med Sci [frants_staugard@yahoo.se] Consultant, Sexual and Reproductive Health Programme WHO Regional Office for Europe Charlotte Rosenberg lshey BSc, MPH [cishoey@worldonline.dk]
Ill) 70 60 so 40 30 20 10 2S 20 15 ID Making Pregnacy Safer in Europe MPS was launched in the European region initiative in 2001. While maternal and perinatal mortality rates are relatively low in western Europe, the rates are ten- fold in other countries in the region. Specific challenges include the significant differences in access to health care, com- mon in centralized systems in which dif- ferent levels of care are not integrated; perinatal care that is not multidiscipli- nary in approach; the use of abortion to compensate for poor contraception; over- medicalization; an over-reliance on or inappropriate use of technology and drugs; and a lack of basic equipment and essential drugs. Political instability, war, displacement, migration and economic cri- sis can also contribute to substandard care. Maternal deaths per 100000 live births* 1970 lll75 . Moldova ru-.. . Cl!I! ....... 191111 1!185 1990 ms-.. . CAR ....... Painata1 deaths per 1000 butJ,st 1995 2000 2005 5 -+-~~~~~~~~~~~~~~~~~~ 1970 1973 . Moldoft . Bu-.. . CEEim:rap 191111 1!185 1990 N!Sa.wrage . CAR...nge 1995 2000 2005 *Last available data WHO has collaborated with its partners to prepare a regional MPS plan that builds on existing activities and pro- grammes and targets the region's specific challenges. The MPS initiative in the European Region builds on existing programmes like Promoting Effective Perinatal Care (PEPC). Perinatal care should: • be de-medicalized • use appropriate technology • be evidence based • be multidisciplinary • be holistic • centred on the family • involve women in decision-making • be culturally appropriate and • use a referral system. PEPC MPS in Moldova The Republic of Moldova is the pilot country for the MPS initiative in the European region. Much of the Moldovan population lives in poverty, and primary· health care providers are limited in their abilities both to diagnose complications and to refer patients to a higher level of care. There is also an insufficient use of evidence-based approaches in secondary and tertiary care, where most maternal and perinatal deaths occur. Emergency services are often delayed, especially in rural areas. Working witit fhe Ministry of Health and key natiqpal)md internation- al organizations, WHO hes developed a national MPS plan that builds off of on- going national perinatal and reproductive health activities. The plan identifies three primary areas of action: promoting the evidence-based care model, strengthening midwifery and supporting primary maternal and perinatal health care. -. REPUBLIC OF MOLDOVA --- - ·--. ·- · - Maternal and nc\\born indicators in Moldova Population' Life expectancy" GDP per capita (in USD)2 Live births per 1000 population• Maternal mortality rate, all causes, per 100 000 live births2 Perinatal mortality rate per 10002 Women receiving antenatal care' Deliveries in health facilities' Incidence of AIDS per 100 000 population• Incidence of syphilis per 100 000 population• Women using contraception• 1 Republic of Moldova: Common Coimtry Assessment UNDP 2000. 2 Health far All Database. WHO/EURO, January 2002. 4.26 million 67.75 353 10.15 27.07 15.23 >95% 98% 0.07 115.87 74% 3 Coverage of Maternity Care: A Listing of Available Information. Ge11eva, Wo rld Health Organization, 1996 (WHO/RHT/MSM/96.28). 4 The PAI Report Card, 2001. A World of Difference, Sexual and Repraductivt Health and Risks. Washington, DC, Population Action Inter11ationa~ 2001 . Regional capacity building MPS Tools workshop, Copenhagen, December 2001. Aimed to define how PEPC regional tools and global MPS tools should be integrat- ed. (See description of tools on page 4.) Regional '!raining of Trainers, Copenhagen, February 2002. Course using MPS/PEPC training tools revised and translated into Russian. Aimed to increase the number of region- al trainers, especially midwives, and to provide updated training methods. Activities in Moldova MPS Launch and Planning meeting in Chisinau Republic of Moldova, January 2002 Audit of Quality of Care Workshop: Examples of abortion and perinatal care. Key professionals and a consultant from the Royal College of Obstetrician Gynaecologists compared existing case management with published internation- al findings and recommended improve- ments of standards, clinical practices and laws. Setting up the MPS Documentation Centre, under the responsibility of the MPS National Professional Officer. The centre provides situation background assessment, collects relevant information sources electronically and on paper, and supports ongoing activities and biblio- graphic research in the field. .... .. -..:]' -.. MPS Evidence-Based Mother and Newborn Care Course, designed for the European region and translated into Russian. The first model course was held in Moldova in April 2002, with local top- level professionals working with Ministry of Health representatives to prepare clini- cal guidelines. The faculty was interna- tional, coming from Scotland, Georgia and Moldova. The course objectives were to introduce key concepts in evidence- based medicine, to develop skills in find- ing and critically appraising research evi- dence before applying it in clinical prac- tice, and to develop a replicable course to support the teaching and dissemination of evidence-based maternal and neonatal care. Cascade training with Moldovan trainers is now being implemented. Key tools The following training and follow-up tools, available in both Russian and English, have been updated and adapted to meet local needs in 2002. They are used in MPS/PEPC orientation, planning and implementation activities in the European region and are consistent with other tools used there. Managing Complications in Pregnancy and Childbirth women who become pregnant develop potential- ly fatal complica- tions during preg- nancy, childbirth or the immediate post partum period. These conditions are treated best in facilities providing com- prehensive emergency care. Unfortunately, women referred to health facilities for the emerge 0 ncy treatmen~ of such life-threatening complications are not always treated quickly or effectively. The interventions in this guide are based upon the latest findings available. Aimed at the rapid assessment and resolution of these complications, the text is arranged by symptom for quick reference. This manual is intended for midwives, physi- cians and other senior health workers responsible for managing the care of obstetrical and neonatal complications. It has been translated into Russian and adapted for the Region's needs. Essential Antenatal, Perinatal and Post Partum Eastern Europe (CEE), the Newly Indepen- dent States (NIS) and the Central Asian Republics (CAR) as part of the MPS/PEPC programme. It aims at improving health care providers' knowl- edge and practice of essential obstetric care. This manual, updated in 2002, offers clinical guidelines and suggests effective, evidence-based clinical proto- cols in topics such as anaemia, hyperten- sive disorders, partograph use and clinical designed to strengthen managerial skills at health care Essential Newborn Care and Breast- feeding This newly updated training tool is another part of the series devel- oped by WHO for CEE,NIS and CAR in the MPS/PEPC programme. It is intended to increase understanding of the principles and practice of essential newborn care, and to develop corre- sponding skills and attitudes among doc- tors, nurses and midwives in charge of delivery and neonatal care in health cen- tres and small hospitals. It also tries to inspire participants to action in their own health facility level by having them prepare an essential newborn care and breastfeeding plan. This manual offers updated guidelines for the management of asphyxia, hypothermia and low birth- weight, as well as for infection preven- tion, rooming-in, a friendly environment for childbirth, transferring newborn infants with com- Making Pregnancy Safer World Health Organization Regional Office for Europe Scherfigsvej 8 plica- tions and the pro- motion of breastfeed- ing and mother- infant bond- DK-2100 Copenhagen 0, Denmark Tel: (+45) 39 17 17 17 [postmaster@who.dk] www.euro.who.int Bosnia and Herzegovina is building its institutions and reforming its policies in order to achieve stable economic growth and social develop- ment through a shift from reconstruction to medium- term development. The country is composed of two entities: The Federation of Bosnia and Herzegovina and the Republica Srpska (which includes the District of Brocke). A recent strategic plan for the reform and reconstruction of the health systems of the two parts of the country has for the first time addressed the rationalization of the use of services, including hospitals, privatization, a basic package for health care for the poor, and the reallocation of resources. However, the reform strategy is not comprehensive and more needs to be done in the field of sexual and reproduc- tive health. In the 1980s Bosnia and Herzegovina had an infrastructure and health indica- tors that were relatively developed as compared to other central European countries. Independence in 1991 was fol- lowed by a war that destroyed most phys- ical assets and was associated with approximately one-quarter of a million people reported dead or missing. Altogether, the total population decreased from 4.39 million in 1991 (census date) to an estimated 3.36 mil- lion at the end of 2001, with approxi- mately one million people living as refugees. The high number of displaced persons and returnees is an exceptionally vulner- able group. Social structures, already lim- ited, are being overstretched and due to the redistribution of public resources and investments in curative care, this group is becoming further excluded. Support is being secured through international assistance, most of which is compart- mentalized and haphazard. Gender equality and equity for job opportunities and access to other resources are also problems the country must resolve. In spite of massive international aid, economic growth is low and the GDP is under 50% of the 1991 level. Moreover, the number of active insured persons is one-seventh of the total population, half of the pre-war figures. Better control over the informal sector, the establishment of regulatory systems and a rigorous taxa- tion system would provide the necessary revenue to address the public financing gaps. The proportion of young people under the age of 20 is 34%, down from 42% in 1991, while the 65-year olds and above accounts for 7.8% of the total popula- No 4 -DO? tion. The population age profile warrants a serious look at the type of infrastruc- ture and investment in the health sector as well as the social security sy~ms. For example, reproductive health data showed that three-quarters of young peo- ple begin sexual relationships between the ages of 16 and 19. Among these, 50% do not use contraception and are not aware of the risk of sexually transmitted infections (STis). A lack of sexual educa- tion in schools and access to youth friendly services equipped with skilled staff are at the root cause of this situa- tion. The accessibility of contraceptives is limited due to a lack of governmental regulation, resulting in high costs and irregular stocks. Vulnerability risk factors for HIV transmission among young peo- ple include unsafe sexual behaviour, injecting drug use and the existence of unregulated commercial sex. Moreover, there are many young women brought in from neighbouring countries that are coerced into commercial sex. A strong sub-regional strategy with full legislative support from the countries of origin and destination is needed to end this traffick- ing. Among the general population, knowl- edge and reproductive health (RH) prac- tices vary. The RH surveys undertaken in 1999 show that almost all women have heard of at least one modern family plan- ning method. Awareness about oral con- traception, condoms and the intrauterine device (IUD) is relatively high (around 95%). The least known methods are vasecto,my and the female condom. Reliance on traditional non-reliable methods such as withdrawal and the rhythm methods is high (74.3 and 50.5%). This is the cause of the high level of abortions, estimated at 35.6%. The highest age specific abortion ratio occurs among women aged 35-44 followed by the age groups 25-34 and 15-24. All women interviewed during the RH survey had heard about HIV/AIDS. However, misinformation about the means of transmission is still widespread. Systematic testing such as the Pap smear was also widely available in the past, however, this was not the case for mea- sures that would lead to lower morbidity, for example the promotion of safe sexual behaviour to curb STis, one of the main causes of cervical cancer. These results 13 show a great need to improve informa- tion about RH and to promote the health benefits of using RH services and improving access and quality of services, especially for adolescents. Currently, the health care reform pro- poses to address system sustainability, equity and solidarity, efficiency, the satis- faction of health workers and patients, and a smooth transition from self-man- agement to a market economy. Faced with scarce resources, the government needs to try to establish priorities in health care (a basic package) and intro- duce cost sharing (patient participation) in a climate of transparency. In that con- text, the United Nations Population Fund (UNFPA), working alongside the World Bank and the European Union, will con- tinue to support technical assistance to define and integrate a minimum package of reproductive health services that would ensure quality, affordability and access to all population groups with assurance of free services to underserved and vulnerable groups. The World Bank has assisted the Republica Srpska in final- izing a basic health package and work is near completion in the rest of the coun- try. Financing health and the role of primary health care The health system is characterized by a large number of trained physicians and female doctors, yet there is an uneven development of health facilities with large geographic disparities and an uneven distribution of medical staff. This situation has resulted in inequitable access to specialized care, particularly for rural and underserved regions, and a lim- ited role for health promotion. Funding is secured at the local level though cantons are expected to share a percentage of this amount with the cen- tral level redistribution to underfunded regions. Only limited information is available on this subject, as cantons determine their own priorities, which in some cases do not systematically follow those of the national plans. Health financing decreased by 50% between 1991 and 1997. Co-payments and com- pulsory contributions equally drawn from employers and employees only accounted for 1/25 of the per capita needed, reflecting a drastic decrease in the ability of the country to sustain its health budget from active payments of premiums. In spite of a health law proposal that prioritises war victims, basic hospital ser- vices targeting the poor and a health pro- gramme focusing on primary health care and public health, the criteria for allocat· ing annual budgets to health facilities depend on the number of health staff working in the facility, their level of training and number of years worked. Currently, quantity or quality of services is not considered among the criteria for allocation of resources. There are more incentives for hospitals and clinic admin- istrators to keep staff (often unnecessari- ly) and increase bed occupancy as it keeps allocations flowing. As for the use of the health system, due to the aforementioned low level of invest- ment in the primary health care system, when possible, the population tends to directly seek secondary and tertiary care. This leads to the overcrowding of hospi- tals in some areas and under-utilization of facilities in others. The Health Expenditure and Perceptions Survey, Federation of Bosnia and Herzegovina (1999), showed that the first non-hospi- tal contact is the pharmacist, the special- ist or the private doctor instead of gener- al practitioners (GPs) raising the ques- tion of the poor image that generalists and the public sector in general generate among the population in general. One-third of those who consulted a GP the first time also contacted a GP the second time, but more (43%) contacted a specialist. Two-thirds of those who con- tacted a specialist the first time also con- tacted a specialist the second time and only 8% a GP the second time. About a quarter of the respondents thought that the quality of care was very good although this varied widely from less than 20% of those who went to see a GP to over half of those who went to a private doctor. A subsequent household survey in Republica Srpska, with support from the World Bank, indicated that 73% of respondents think that fundamental change is needed to improve the health sector. One conclusion is that people are ready to pay more with the expectation of receiving higher quality services. Under the reform, as the primary health care system's role will increase, a new type of health provider, GPs or, ideally, family doctors, will beco~e the "gate- keeper". Any prospects t~kxpand the GPs' scope of action will ·need to look at how this is going to respond to the demand in terms of optimal equipment and supplies and appropriate training. In addition, the population needs to be made aware of the importance of respecting the referral system. Options for the future: Setting priorities The Household Perceptions Survey of Health Care in the Republika Srpska (2000) reported that the population in general agreed that some priority groups, such as the poor, war veterans, the elder- ly, the displaced and returnees should benefit more than others from free-of- charge services. Furthermore, 31 % stated that increased taxation was an option to offset payment costs. An optimal mix of an insurance scheme with government budget safety net arrangements has yet to be established. The Health Expenditure and Perceptions Survey (1999) conducted in the Federation of Bosnia and Herzegovina showed that households contribute significantly towards the cost of hospital and non-hospital care in each of the survey areas. Some of the key results, mentioned below, show the untenable relationship between income and cost of health care were: • 80% of individuals indicated that they ,. contributed towards the cost of hospital and non-hospital services; • the insurance status does not influence the level of payment for non-hospital consultations; • increased hospital spending is linked to longer lengths of stay; increased hospi- tal spending does not necessarily lead to higher levels of perceived quality; • average household income levels were around 211.68 and hospital admission could reach I 02.26; • private spending estimates suggest that health care spending is approximately So/oofGDP. As for the ability to pay, the same survey revealed a relationship between the age of the individuals and the levels of spend- ing. Nearly twice as many of those in the youngest age group spent nothing as compared to the oldest age group. However, due to the small sample size, these differences are not statistically sig- nificant. Those who were insured were more likely to have spent nothing because the insurance paid the costs. Over half of those who were not insured spent more than 61.4, a large propor- tion of an average monthly salary, but again the differences were not statistically significant. Those not covered by health insurance and who are poor can only receive health care with the help of humanitarian organizations. There is currently a strong debate regarding the non-existence of a real safety net for the poorest of the poor. Another angle of the debate is related to the large pro· portion of rural poor, who are left out of the insurance scheme, and the difficulty of obtaining insur· ance as a part of unemployment benefits. Finally, the limited avail - ability of services combined with the inability to pay for services pose the question of equity of access that the government must address through the policy reform. Within the health reform: mov· ing towards the RH strategy In this context the national authorities at the Ministry of Health agree that efforts should be invested in primary health care and in reproductive health. In payment exemptions for this group. Since 1995, the proportion of financ- ing of the health services from social insurance and the private sector has been increasing, even though the public sector contribution has remained significant. Private expenditures include direct pay- ments to doctors, treatment in private clinics, co-payment and payment of drugs bought from private pharmacies and the informal payment for some pub- lic providers of health care services. In order to receive better quality of care, spite of a delay in operationalizing o An..,M•n•Edeltoft the RH strategy, under government clients "top off" the payment to the clin- review since 2001, the goals of the RH ic, which provides them with better qual- component would be to decrease the ity in the same public facility, but cor- number of abortions, increase contracep- rupts the system and increases out-of- tive prevalence rates and decrease the pocket costs for the consumer. This is prevalence of reproductive tract infec- also a problem for RH services, e.g. in the tions and sexually transmitted infections. course of deliveries, abortion procedures, The structural reform, based on the above-perceived needs, would integrate an RH package that would improve the RH health status of the population through the provision of quality RH ser- vices, increase efficiency of the use of the funds through the decentralized funding mechanism; and reduce the proportion from state budget financing and universal equity by securing access for the poor, via etc. The second impediment to full access to reproductive health is what seems to be a barrier to the promotion of contra- ception by gynaecologists. As the public sector was no longer paying doctors on time, abortion became the most impor- tant source of income for gynaecologists. However, members of the society of gynaeco-obstetricians agree that a shift J\i) ( - towards contraception is the way to go and in order to discourage abo~ion, a price barrier was recently introduced. This barrier may lead wom~n tJ"'seek abortion among non-qualifielp~rsonnel and/or in inadequate health structures. The situation needs to be carefully moni· tored. One possibility would be to counteract the need for abortion by a strong con- sumer, client targeted information cam· paign that emphasizes the benefits of RH on the health of the child, the mother and the family in general. To increase access to RH commodi- ties it is essential that they become part of the essential drugs list and that they be offered in all Ministry of Health outlets. Similarly, the insurance schemes must cover at least a basic RH package that includes contraception, safe delivery and post-natal care, STI management and prevention and the treat- ment of gynaecological condi· tions. Another option is to involve other levels of health profession- als such as nurses and midwives in counselling and the service delivery of comprehensive RH services. A third option is to work in the context of the on- going national training pro- gramme of general practition- ers/family doctors. With appro- priate training and a change in ~ their image among the general public, GPs may acquire a greater role in preventive and family care and help achieve a wide scope of audi· ences, while limiting expenditures. Con· traceptive counselling and education on sexual health matters for adolescents and young women and men should form an integral part of their training. Securing SRH in an equitable, effi- cient system Bosnia and Herzegovina is undergoing reform at a time of competing priorities for reconstruction and infrastructure upgrading. The reform is assumed to complete the process of rationalizing the use of facilities and human power and the standardization of care. Lessons learned on the effects of reforms in other 15 16 countries show that reforms do not auto- matically result in a decrease in the level of health outcomes. Rather, they may affect equity principles by redistributing resources from middle and upper class to lower socio-economic groups (see the health sector reform and reproductive health care study protocol on pages 5-8). Policies that target the poor can work when there are options for fee for service for those who can afford them and if there is an effective regulatory system to enforce such a scenario. It is assumed that if achieved, these changes would also positively influence access to RH services. Whether for the health sector in gener- al or RH in particular, privatization will push towards an increased demand for sophisticated, high-cost services. For the competitive multi-payer system, universal coverage based on capitation can main- tain a balance among various levels of care and control of health care expendi- tures. Criteria for allocating resources should be performance-based, taking into account the needs of the population to be served, the level of sophistication of services needed and their development and maintenance costs. Consideration should also be made to monitor the qual- ity of RH services as assessed by indica- tors that inform about client satisfaction, and trends in the use of the facility, including treatment given. Fee-for-ser- vice payment mechanisms should be in place for those who can afford to pay, as well as a safety net mechanism to safe- guard access to services to those who cannot pay, based on a clear identifica- tion of the vulnerable groups. Continuity of care is also an element that needs to be considered at the outset due to the fragmentation of the various levels of care. Continuity is best attained when there are links between primary health care and referrals and standardised data reporting. In the context of sexual and reproductive health it will be impor- tant for GPs to be trained in, for exam- ple, contraceptive technologies, family planning, prevention and management of unsafe abortion, adolescent sexual and reproductive health, STI management and to identify and refer female victims of coercive sex. The high cost benefit of using nurses for the delivery of some types of primary care is also highly relevant for reproduc- tive health. Nurses and midwives are usually members of the community and their relationship with the clients of the services is closer. Substantial investments in up-grading nurses and nurse midwives working in women's consultations and polyclinics in reproductive technical and counselling skills could lead to a real health benefit, away from a "medicalized': curative centred approach, and con- tribute towards national goals to reduce abortion and its consequences on repro- ductive morbidity and mortality rates. Pluralism introducing privatization in health is ethically acceptable when it leaves room for a social approach to health care. At present, the government is committed to limit privatization to ambulantas (medical treatment centres) with the hope that this will motivate doc- tors to work in family medicine. The resource allocation policy of the govern- ment will need to rely on the contracting of services by improving regulatory mea- sures and generating economic motiva- tion for fulfilling health care (including SRH) objectives. This could be extended to nurses and midwives working in the private sector. Moreover, in order to ensure quality services, all curricula for family medicine, upper education and strategies related to standards should be addressed concomitantly. An alternative option to public cover- age of commodities and for financing RH services includes the social marketing of contraceptives, especially condoms. Social marketing programmes have the dual objective to increase demand by a well-designed information programme as well as access to commodities at a subsi- dized price. This process familiarizes the client with paying a symbolic fee for a commodity, establishing a sustainable relationship between the client and the private market place. Decentralized planning as applied in the Federation of Bosnia and Herze- govina is a very valuable approach. However, decentralization should be pro- gressive, leaving flexibility at the begin- ning to shift resources from the tertiary to the primary health care level. One condition for the success of privatization and public share is improved regulation of tax collection and the impact on the population's sense of responsibility for paying taxes to a government that pro- vides quality health care. In addition, consideration should be made to facili - tate the implementation df'the signed solidarity among cantonal'health insur- ance funds to close ineq~ty gaps. The Republica Srpska still has insurance and social security under the same umbrella and can potentially shift resources either way to close gaps. Ultimately, the long-term cost benefits of investing public resources into a pre- ventive system concentrated on primary health care, particularly sexual and repro- ductive health, must be considered. The system should ensure choice, efficiency and equity and monitor performance on the basis of health outcomes rather than inputs. The change will require a drastic shift from individual-centred interests to a broad social-centred interest catering to the needs of a healthy population. It will also require staff trained in multi-sectoral approaches (e.g. health costing, policy analysis and management of care), changes in legislation and in existing institutional arrangements, and, most importantly, a change of attitude towards a culture of results-based management, accountability and excellence. Political commitment and community participa- tion in decision-making about the types of services and the means to pay for them will be central. The author wishes to thank Dr. Haris Hajrulahovic, for his most valuable comments and ~uggestions. References are available from the author. Hedia Belhadj, MD, MPH [belhadjh@hotmail.com] Deputy to the Director, Division for Arab States and Europe in UNFPA, New York On 3 July 2002, the European Parliament voted in favour of the Resolution on Sexual and Reproductive Health and Rights in Europe introduced by Anne Van Lancker, MEP (Socialist, Belgium). Despite strong opposition fuelled by anti-choice activists, a clear majority of the European Parliament supported the Resolution on Sexual and Reproductive Health and Rights, sending a strong sig- nal to the international community that the European Parliament intends to fight for the right of all people to have healthy and satisfying sex lives. The Resolution was prepared in the context of commitments from European Union (EU) Member States and acces- sion countries to the agendas from the International Conference on Population and Development (!CPD, 1994 and 1999) and the Fourth World Conference on Women (1995 and 2000). Although many policy-makers believe that the outcomes of these international conferences only apply to developing countries, they do, in fact, have implications for all the coun- tries of Europe. There is certainly a need for commit- ment to sexual and reproductive health and rights in Europe, particularly in terms of the inequalities which exist between the east and the west. The aver- age contraceptive use in the EU is around 65%, but in the accession countries it is only around 35%. And in central and eastern Europe abortion still remains the principal means of fertility regulation. An abortion can, in principle, be obtained at very low cost or free of charge, but the price of contraceptives can be as high as a third of one month's salary in central and eastern Europe. Abortion rates across Europe (see Fig.I) range from the lowest rates in the world, found in Belgium, the Netherlands and Germany (around 7 per 1,000 women aged 15-45) to some of the highest abortion rates in the world, in the Russian Federation and Romania (between 50 and 60:1000). Fig. 1: Abortion rates In dlffltNnl countries In the European Region (Abortions per 1000 women aged 15-44) Belgium61 (The Netherlands 7 I Germany& 0 10 20 30 40 so 60 70 Sources: AG/ Readings on induced abortion: A World Review 2000 and Concise report on world population monitoring, United Notions 2002 The Resolution formulates specific rec- ommendations to the EU in a number of key areas. It requests the Member States and accession countries to improve the exchange of information and best prac- tices on the issues of unwanted pregnan- cies and abortion, adolescent sexual reproductive health and rights, and sexu- ality education, and on the development of sexual and reproductive health policies in general. '\lo. 54 - 2002 With respect to boys and men, the Resolution calls for the promotion of sci- entific research in the field of n'ia!e con- traception, in order to enspre.j q•nality between men and women as regards the effects of using contraceptive methods, and for the provision of sexuality educa- tion in a gender-sensitive way. A resolution from the European Parliament does not form a legal basis for action by the European Commission and it has been confirmed by Commissioner Byrne, Health, Environment and Consumer Protection, that, as stated in the Resolution, the Commission has no authority to engage in health care deliv- ery, including sexual and reproductive health services. However, it was stressed that sexual and reproductive health will be part of the new [EU) Health Strategy, which includes compiling and undertak- ing statistical, epidemiological investiga- tions on the basis of collected data. It is clear that this would form a good basis for the exchange of experience that the European Parliament wants to promote. Commissioner Byrne had a further message for the Member States, saying that he hoped that they would place greater emphasis on the education and information of men in this important area. He stated that the Resolution paid significant attention to the responsibility and rights of women in dealing with their health and well being, but that too often the importance of improving men's education so as to change behaviour, atti- tudes and involvement was overlooked. The;. European Parliament Resolution on Sexual and Reproductive Health and Rights in Europe is a useful resource and valuable advocacy tool for policy-makers, NGOs and family planning associations to help them bring this issue to the atten- tion of national governments and the European Union. The full text of the will be published on the European Parliament website: www.europarl.eu.int/plenary/default_en. htm Vicky Claeys is the advocacy manager of the International Planned Parenthood Federation European Network www.ippfen.org. 17 18 Links to sites dealing with health sector reform Center for the new Europe Ill http://www.centrefortheneweurope.org The Centre for the New Europe is a non- profit, non-partisan research foundation headquartered in Brussels and dealing with the practical implications of European Union policies. The website includes a number of downloadable doc- uments like The Health Care Revolution in Stockholm by Johan Hjertqvist as well as links to sites and events dealing with health sector reform, such as the lecture "Economic analysis in healthcare rationing" by Joe Zamrnit-Lucia in Brus- sels. Croatian Medical Journal -·""--.,, ....... ,., ... Jr-., lO• 'W'O''il',Q.JIC; www.cmj.hr The Croatian Medical Journal is an inter- national peer-reviewed journal open to scientists from all fields of medicine and related research. A sparsely designed but unique page, including news and a bul- letin board of upcoming events in the region. Two interesting reports (PDF) from August 2002 include: • Years of Potential Life Lost and Valued Years of Potential Life Lost in Assessing Premature Mortality in Slovenia by Jozica Seib Semerl and Janja Sesok • Reforms of Health Care System in Romania by Ana-Claudia Bara, Wun J. A. van den Heuvel and Johannes A. M. Maarse Two articles from the Interna- tional Labour Organization www.ilo.org I. The promotion and privatization of medical services in the Russian Federation, Ukraine and Georgia by Igor Vocatch-Boldyrev http://www.ilo.org/publideng/ish!employ· ment/ent/papers/ippred 15.htm Abstract: Privatization is a major com- ponent of health system reform in the former USSR. In creating the legal basis for the new health system, the other key elements of health reform are decentral- ization and a shift towards basic princi- ples of health insurance. A broad frame of reference must be adopted that con- siders privatization any measure of state disengagement from public health insti- tutions both in terms of tutelage or in terms of management of operating health structures and financial responsi- bility. . 2. The ills of Central and Eastern European health care, no. 42, 2002 http://www.ilo.org/publidenglish/bureau/in f!magazine/42/hea/thcare.htm Abstract: A grim picture of diminish- ing public health structures, deteriorating working conditions and staff pessimism emerges from a recent survey of central and eastern European health care. The situation is especially grave due to a severe deterioration in public health in much of the region over the last decade, in some cases with life expectancy plum- meting. Ordering From the Menu: How Central and East European States Cope with EU Demands for Institutional Reform by Wade Jacoby http://www.essex.ac.uk!ecpr/jointsessions/t urin/paperslws4/Jacoby.pdf A paper prepared for the ECPR Workshop4 Enlargement and European Governance ECPR Joint Session Workshops, Turin, 22-27 March 2002 A highly interesting and in-depth ( 46- page PDF) paper on economic reform in eastern Europe, with a large section on health-care reform. Publication: Dying breed: Health care in east- ern Europe ·~ - by Sam Vaknin, United~prJtmternational, 2002 . - 1111tO,.:.._, , H_._. .. Eamn.E..,. ,,,, o,-.,-} ..... ............ ,,~........uan Cat ___ ,,,...........,~ .............................. -........................ -.... ~-- a.tllffl.••:,t,tl!d~-~,.._ ........ ........................ -.... ~----- ait.JIUI----=---~ ...... ...... - .. - ....... -.....-..--........ ('lirl-.. -~ .. ~.u..,.,. http://samvak.tripod.com/pp 143.html Abstract: People lead brutish and nasty lives only to expire in their prime, often inebriated. In the republics of the former Yugoslavia, respiratory and digestive tract diseases run amok. Stress and pollution conspire to reap a grim harvest through- out the wastelands of eastern Europe. The rate of tuberculosis in Romania exceeds that of sub-Saharan Africa. As income deteriorated, plunging people into abject poverty, they found it increas- ingly difficult to maintain a healthy lifestyle. Crumbling health care systems, ridden by corruption and cronyism, ceased to provide even the appearance of rudimentary health services. The number of women who die at childbirth skyrock- eted. Health Reform Online (HRO) Health Reform.onllnl ----·----,- - .. - ... ..,_,...c-... - _ .,_,. ___ _ http://www.wor/dbank.org!hea/threform/ Health Reform Online (HRO) is an information resource for healthcare man- agers, analysts and decision-makers who want to learn more about the economics and financing of health care delivery in developing countries. The site is hosted by the World Bank. Public Services International Research Unit (PSIRU) I Public Services International Research Un it ·-·- ·- ·- ·- ·- ·- ·- ·- ·-·- ·-·- --,::;:;-- -::::::;=..-I::::':?- ---·--.·:~:.::.-~ ·- -=-~-=-= -.::..-..=-.=- ' -=-- ~~~..:ffi-~~::-.:::r.: --- :=:=::~ ... ·=---=-===-.:=-- _,, __.... ___ .,, ___ _ - ··- ..::-.-=:-.:..~-:.:::..."":'. __ ... __ .. ... __ ,,_, __ ·-·- ·- ·- ·- ·- ·- ·- · .... - ·-·-· www.psiru.org The PSIRU, based at the University of Greenwich, was set up in 1998 to carry out empirical research into privatization, public services, and globalization. PSIRU's research is based on the mainte- nance of an extensive database of infor- mation on the economic, political, finan- cial, social and technical experience with privatizations of public services world- wide. See article: Are Health Systems National? www.psiru.org/reports/2002-04-H-nation- al.doc The European Observatory on Health Care Systems www.observatory.dk The European Observatory on Health Care Systems supports and promotes evi - dence-based health policy-making through the comprehensive and rigor us analysis of the dynamics of health care systems in Europe. The Observatory's main publication is the Health Care System in Transition series of country profiles (HiTs), which provide an analyti- cal descriptio n of each European health care system and the reform initiatives in progress or under development. HiTs aim to provide relevant comparative information to support policy-makers and analysts in the development of health care systems and reforms in the countries of Europe and beyond and are used to: • learn in detail about different approaches to the financing, organiza- tion and delivery of health care services; · describe the process, content and implementation of health care reform programmes; World Report on Violence and Health www.who.int On 3 October 2002, WHO launched the first World Report on Violence and Health. The goals of the Report are to raise awareness about the problem of violence globally, to make the case that violence is preventable, and to highlight the crucial role that public health has to play in addressing its causes and conse- quences. There is a 30-page chapter on sexual vio- lence including trafficking, commercial sex workers, poverty, education, the link to HIV/AIDS, female genital mutilation and a wealth of resources in the 212 ref- erences, in addition to a general resources sections and a thorough statistical annex. This is mandatory fo r any health library and essential for all those working in public health. The entire report can be downloaded in PDF format at: http://www.who.int/violence_injury _pre- vention/ For further information, please contact: Department of Injuries and Violence • highlight common challenges and areas that require more in -depth analy5is; and • disseminate information on health systems and the exchange of experiences of reform strategies between pol - icy-makers and analysts in countries of the WHO European Region. In addition to the HiTs, the Observatory produces: · an at-a-glance summary of each coun- try profile (HiT); · studies, some of which are co-published with the Open University Press, on key policy issues and trends: Regulating entrepreneurial behaviour in health care systems; Hospitals in a changing Europe; Funding health care: options for Europe; Mental health policy and practice across Europe; Primary health care and organizational reform; Purchasing for health gain; No. 54 - 2002 Prevention World Health Organization 20 Avenue Appia CH- 12 11 Geneva 27 Switzerland ... Fax: 41 22 791 4332; Email: vip@who.int World Health Report 2002 - Reducing Risks, Promoting Healthy Life Released on 30 October 2002. Worldwide, healthy life expectancy can be increased by 5 to 10 years if govern- ments and individuals work together to reduce major health risks in each region. The World Health Report 2002 examines more than risks to health and identifies interventions that would reduce these risks, thereby increasing healthy life years. The risks to health include under- weight, unsafe sex, high blood pressure, tobacco, alcohol, unsafe water and sanita- tion, cholesterol, indoor smoke from solid fuels, iron deficiency and over- weight. The full report can be downloaded from www. who.int/whr. Pharmaceutical regulation in Europe; Health care in central Asia; Health and EU accession; Social health insurance; • a policy brief series summarising the findings in each study; • EuroHealth, a quarterly journal, and the EuroObserver, a quarterly newsletter; and · a monthly e-mail bulletin on Observatory news and findings. For more information about Observatory publications, con- tact Jeffrey V Lazarus ijla@who.dk] EntreNous The European Magazine for Sexual and Reproductive Health WHO Regional Office for Europe Family and Community Health unit Scherfigsvej 8 DK-2100 Copenhagen 0 Denmark Tel:(+45) 39171341 or 1451 Fax: (+45) 3917 1850 [entrenous@lwho.dk]