1. Imbalance in the health care system
a. Health facilities
There is a growing consensus that a better balance of services is needed among health facilities at various levels. Within provinces or districts, health facilities typically consist of the sub-centre (a clinic or dispensary) at the periphery, then the health centre, and up to the district (rural) or provincial hospital. In many countries, the upper end of the system, consisting of large, urban hospitals serving a small and relatively affluent portion of the total population, is unduly preponderant with a virtual monopoly over resources.5 This makes the balanced development of more basic health care facilities impossible. Those concerned for health service coverage for an entire population urge that a strong brake be placed on further development of large hospitals, in order to free resources for a rapid expansion of a network of smaller primary health care institutions.
The area of reproductive health suffers most from this unbalanced structure. Reproductive health care differs from other types of medical care in that it is not an occasional need for an unfortunate few. It is a universal requirement of all healthy people who need, among other services, fertility regulation, protection against sexuallytransmitted infections, and safe motherhood. To provide universal access to this care, a better balanced structure is required in health care systems.
b. Human resources
Regarding human resources for health, there are four kinds of imbalances that may be encountered in health care systems:
1. under-supply (or over-supply) of a specific category of personnel for a country‟s
2. mismatch between training and job requirements, especially inadequate preparation of
providers for their potential role in promoting health;
3. poor „mix‟ of categories (usually too few nurses per doctor);
4. poor geographical distribution of existing providers, seen as a marked disparity in
access to basic services not only between under-served and other areas/ populations
within almost every country, but also among countries, and among medical specialties.
The World Health Organization estimates the number of physicians per 10 000 population, during the period 1994-1996, to have been as follows:
13.2 for the world;
24.6 for developed market economies;
34.6 for economies in transition;
7.4 for all developing countries;
1.0 for least developing countries; and
8.9 for other developing countries.
Comparable figures for nurses were as follows:
36 for the world;
81.8 for developed market economies;
87.7 for economies in transition;
7.2 for all developing countries;
2.7 for least developed countries and
8.5 for other developing countries.
c. Hospital beds
There are large disparities in hospital bed availability both within countries, availability being much greater in the larger cities than in most rural areas, and between countries at different economic levels of development. According to WHO estimates in 1994, the number of hospital beds per 10 000 population was:
37 in the world;
96 in developed countries;
15 in developing countries; and
7 in least developed countries.
2. Inefficiency in the health care system
Basically, one can differentiate three patterns of inefficiency: deficiency, underutilization, and over-medicalization 9 These patterns of inadequacy apply to the whole field of health care, but they are particularly prominent in the area of reproductive health.
Deficiency is only partly due to lack of resources. It is also due to inefficient allocation of resources. According to a WHO evaluation of the implementation of the global strategy of health for all, the coverage of health care services in developing countries is deficient, with a distinct urban bias. Levels of coverage of maternal health care remain inadequate in most developing countries. In developed market economies and economies in transition, well over 90% of pregnant women receive antenatal care and are assisted by a person trained in midwifery during childbirth.10 In the least developed countries, only 50% receive antenatal care, and only 30% deliver with the help of a skilled birth attendant. In other developing countries the figures are about 70% and 60%
respectively. Levels of postpartum coverage are particularly low: below 30% for many developing countries.
In 1965, only about 9% of all married women of reproductive age in developing countries, or their partners, were using a reliable method of contraception. Today, this figure is approaching 60%.11 In spite of this increase in the use of fertility regulation over the past 30 years worldwide, there remain marked differences between the developed and developing parts of the world, and among regions within the developing part. There are still large segments of the world‟s population whose needs of fertility regulation are not met by the currently available methods and services. In 1990, it was estimated that 200 million couples were using methods of family planning that they considered unsatisfactory or unreliable, contributing to the estimated 30 million unintended pregnancies that occur each year among people practicing contraception.12 In addition, at least another 100-120 million couples were not using any method of contraception even
though they wanted to space their pregnancies or limit their fertility. Finally, contraceptive choices available to couples in developing countries are often very limited, with heavy reliance on permanent methods (male and female sterilization), which account for nearly 50% of use.
The under-utilization of the health care system is a distressing phenomenon in some developing countries. Culturally inappropriate, alien, socially non- relevant health care services are bound to be rejected. Where different societies have their own traditions of disease prevention and sickness care, the introduction of the concepts and technologies of modern scientific medicine will be most effective only through adaptation and accommodation to these existing systems. Health care professionals find it easy to blame patients when they do not utilize the service, and advocate their better education. It is less palatable to health professionals, but more true, to fault the health care system. The question should not be why patients do not accept the services they offer, but rather why health professionals do not offer patients the services they will accept.
Over-medicalization of the health care system is becoming typical of affluent societies. Technology utilization is lurching from appropriate use into indiscriminate use. The thirst for technology and medical over-consumption are raising the costs of health care to staggering heights. Women are also voicing their concerns about the overmedicalization of physiological events in their lives. There is a need to keep normal labour normal.
3. Inadequate responsiveness to women‟s expectations and perspectives
a. A health system that cares
It is not enough that the health care system is properly in place and that it provides modern services. People‟s perceptions of the services and their rightful expectations also matter.
Among other important criteria in assessing the performance of the health care system, and the respect paid to the right to health, are respect for the dignity of the person, not humiliating or demeaning persons, confidentiality or the right to determine who has access to one‟s personal health information, access to social support networksfamily and friends- for people receiving care and autonomy to participate in decisions about one‟s health. It is not overall perception that matters, but each instance of care. It can be that some people are treated with courtesy, while other groups in the population are humiliated.
Most of these elements do not have cost implications. There is thus scope for improving this aspect of the performance of the health care system without the need to infuse any significant amount of new resources.
The Platform for Action of the Fourth World Conference on Women, 1995, commented that “The quality of women‟s health care is often deficient in various ways, depending on local circumstances. Women are frequently not treated with respect, nor are they guaranteed privacy and confidentiality, nor do they always receive full information about the options and services available. Furthermore, in some countries, overmedicating of women‟s life events is common, leading to unnecessary surgical interventions and inappropriate medication.”
Throughout human history, medicine has been recognized as a profession for both care and cure. This was the way it was when the medical man or woman was also the religious or spiritual guide and/or the magician. This was also how it continued to be when the medical profession diverged from religion and from magic. A reader of the history of medicine would realize that our physician ancestors, for the major part of human history, had really little in their hands that could influence the process of disease or prevent deaths. Their treatments had an equal chance, in many cases more than an equal chance, of being more harmful than useful. In spite of the clumsy performance of our ancestor physicians in the function of cure, they continued to command respect and prestige in the societies they served, and societies continued to invest in their activities. This was because they did so well in the function of care. Their pastoral/ supportive
function may be described as the provision of psychological help and „tender loving care‟ to anxious patients. This psycho-emotional support and reassurance more than compensated for the shortcomings in treatment.
Unfortunately, the personally supportive, pastoral aspects of medical care tend to be squeezed out by our thirst for technology. „Pride‟ in the application of scientific knowledge and biomedical technology is now creating an „emotional gap‟ in the care of patients. Machines now stand between doctors and their patients.
The loss of the physicians‟ caring function is no more evident than in the field of reproductive health. In exercising normal functions, women are often in need of more care than cure. They are receiving instead depersonalized, mechanized, mystery-clouded medical services. Women are objecting to being objectified in one of their fundamental physiological roles, and they are right to object.
b. Women as ends and not means
A major shortcoming in reproductive health care within the health care system was in the philosophy with which services were provided. Women were considered as means in the process of reproduction, and as targets in the process of fertility control. Services were not provided to women as ends in themselves. Women benefited from the process, but were not at its centre. They were objects, and not subjects.
The needs of women in reproduction have been traditionally addressed within the concept of maternal and child health (MCH). The needs of women were submerged in their needs as mothers. MCH programmes and services have played, and continue to play, an important role in promotive, preventive and curative health care of mothers and children. MCH services tend to focus on a healthy child as the desired outcome. While mothers care very much for this desired outcome because of the investment they make in the process of reproduction, this focus resulted in less emphasis being put on caring about the health risks to which mothers are liable during pregnancy and childbirth, and on putting in place the essential obstetric services and facilities to deal with them. As a result, the tragedy of maternal mortality in developing countries has now risen to dimensions that can no longer be ignored.
Despite all their benefits to the quality of life of women, family planning programmes have left women with some genuine concerns as well as unmet needs. Women have more at stake in fertility control than men have. Contraceptives are meant to be used by women to empower themselves by maximizing their choices, and controlling their fertility, their sexuality, their health and thus their lives. Family planning, however, can be used, and has been used by governments and others, to control rather than to empower women. The family planning movement has been largely demographically driven. As far as policymakers were concerned, women were often considered as targets. Some governments were so short-sighted as not to see that when women are given a real choice, and the information and means to implement their choice, they will make the most rational decisions for themselves, for their communities and ultimately for the world at large.
With women as only means and not ends, health care related to reproduction has been fragmented, and important health needs have been left unmet. The concept of MCH focuses special attention on women when and if they are reproducing, to ensure that society gets a healthy child, but often neglects women‟s other reproduction-related health needs. Infertility may not be a serious hazard as far as physical health is concerned, but can be a major cause of mental and social ill-health, so that infertility denies „health‟ as understood by the World Health Organization. It is not fair that a society should provide care to women who are capable of reproduction, but should neglect the suffering of those who are unable to conceive. Sexual intercourse exposes women to the risk of unwanted pregnancy. It also exposes many women to another serious or more serious risk, that of sexually-transmitted infections, including HIV infection. If a family planning programme has an exclusive demographic focus, it may not see the point of meeting this important need for women‟s protection. Women‟s reproduction-related health needs are not limited to the reproductive years of their lives. The girl child, the adolescent girl, and the mature adult and older woman have health needs related to their future or past reproductive
function. Men have their reproductive health needs too, and male participation and responsibility are important for women‟s health.
The societal attitude of looking at women as means to produce children and not ends is even more pervasive. Services offered to women often have something of a „veterinary‟ quality. Proponents of the education of girls cite the advantages that such education will have for the survival and health of their children, and the impact education will have on reducing birth rates. Nutrition of women is justified because of the needs of the fetus and the nursing child. Even with the tragedy of maternal mortality, a justification put forward for investment in keeping mothers alive is that their survival is critical for the survival of their children.
c. A fragmentary response to a totality of needs
The concept of reproductive health illustrates that health in reproduction is a package. People cannot be healthy if they have one element of health but miss another. Moreover, the various elements of reproductive health are strongly inter-related. Improvements in one element can result in potential improvements in other elements. Similarly, lack of improvement in one element can hinder progress in other elements.
Pelvic infection, for example, accounts for about one-third of all cases of infertility worldwide, and for a much higher percentage in sub-Saharan Africa.17 The resultant infertility is also the most difficult to treat. The magnitude of the problem of infertility will not be ameliorated except by a reduction of sexually transmitted diseases (STDs), by safer births that avoid postpartum infection, and by decreasing the need for or the resort to unsafe abortion practices.
Infant and child survival, growth and development cannot be improved without good maternity care. Proper planning of births, including adequate child spacing, is a basic ingredient of any child survival package. Unless adequately controlled, STDs, and in particular HIV infection, can impede further progress in child survival.
Fertility regulation is a major element in any safe motherhood strategy. It reduces the number of unwanted pregnancies, with a resultant decrease in total exposure to the risks of pregnancy, and decreases the number of unsafe abortions. Proper planning of births can also decrease the number of high risk pregnancies.
The different needs in reproductive health are not isolated from each other. They are simultaneous or consecutive, related needs. Adolescent health care serves as a good illustrative example. Adolescents need sex education, and at the same time they need to protect themselves against STDs and against unwanted pregnancies, while preserving their fertility potential. If they become pregnant, they need to be safeguarded from the special hazards of pregnancy and childbirth, and to be helped to care for their infants and children.
According to a recent WHO evaluation, related reproductive health interventions often come to be delivered over time as separate and discrete activities, rather than as a comprehensive response to people‟s needs at different stages of their lives.18 Thus, for example, family planning clinics often function independently of those catering to other aspects of maternal and child health. A woman attending a clinic session for child immunization can not, at the same time, obtain care for her own health needs; she will be asked to come back on a different day, or even to go to a different health facility.
E. Mainstreaming the gender perspective in the health care system
Sex is determined by individuals‟ biological characteristics. Gender is the term used to distinguish those features of females and males that are socially constructed from those that are biologically determined. Women and men are differentiated by social characteristics, on the one hand, and by biological characteristics on the other. Gender issues are not just of concern to women. Men‟s health too is affected by gender divisions in both positive and negative ways. Despite their commonalities, women and men have their own particular needs, and these different needs have to be met in a gender-sensitive approach.
The Committee on the Elimination of Discrimination Against Women (CEDAW), established under the UN Women‟s Convention, has issued a General Recommendation on Women and Health that explains how different kinds of risk factors may affect women and men. These factors include:
biological factors that vary between women and men according to their reproductive functions, such as pregnancy and childbirth;
socio-economic factors that can vary according to sex, race and age, such as widely prevalent marriages of adolescent girls;
psycho-social factors that can vary according to sex, such as postpartum depression; and
health system factors such as maintaining legal and practical obstacles to access to services and denying confidentiality when women seek services (see General Recommendation, Part III, 6.b., para. 12).
Lack of awareness, or gender blindness, frequently leads to gender bias and to the prioritization of male interests in decision-making. The mainstreaming of gender concerns is vital in policy formulation, health planning, health service delivery, monitoring and evaluation.
Chapter 6 includes further discussion on the human right to non-discrimination as it relates to sex and gender.
F. Challenges in the implementation of reproductive health care
For implementation of reproductive health care, the health care system needs to unpack the reproductive health package. This has to be handled with care, because some components are fragile and more sensitive than others. Different components of the package pose different challenges in implementation.
One part of the package includes traditional services with which health care systems already have experience. These include maternal and child health services and family planning. The challenge will be how to expand the coverage and improve the quality of the services.
In other parts of the package, the system is challenged to meet new and emerging needs. Among the new needs, we have to face the new pandemic of HIV/AIDS, the dilemma of unsafe abortion, gender-based violence and sexual abuse in all its offensive forms. The challenge is how to approach sensitive and socially divisive issues, how to overcome tradition and social barriers to improved care, and how to influence human behaviour.
In another part of the package, the system is challenged to serve new customers. Among the new customers the system is challenged to reach and serve are men, adolescents and, unfortunately, the growing number of displaced persons and refugees. Services, including information and education, need to be tailored to serve the needs of these new customers. At 1.05 billion worldwide, today‟s is the biggest-ever generation of young people aged between 15 and 24, and this age group is rapidly expanding in many countries.
Another part of the reproductive health care package stands out because the services needed are more expensive, and to some countries may seem to be unaffordable. These include treatment of HIV-positive pregnant women to prevent transmission of the infection to the fetus and newborn; infertility management; and detection and management of reproductive cancers. The challenge is to develop and test new costeffective interventions that can be implemented in resource-poor settings.
G. Health care systems and the law
1. Legal principles governing health care delivery
Laws and policies may facilitate or inhibit women‟s access to reproductive health care. Most systems have core principles of medical law that protect the right to informed and free decision-making by patients, their privacy and confidentiality, the competent delivery of services and the safety and efficacy of products. Systems vary, however, in the extent to which these principles are applied to reproductive health services, including obstetric care. Moreover, the enforcement of laws that entitle women to obstetric services that oblige governmental or other agencies to deliver them and to create accountability for their absence, also vary significantly across national boundaries. Laws may make husbands obliged to provide their wives with necessary health care, but are difficult to enforce when families are impoverished.
The core principles of medical law governing heath care delivery assume more importance in the case of reproductive health care.
Women sometimes refuse to seek health services that are available, because they believe that their medical confidentiality will not be sufficiently respected. This may be particularly so in smaller communities where personal relationships among patients and clinic personnel exist in social life outside the clinic setting. Women‟s perceptions that their confidentiality may be breached might be usefully addressed by ensuring that clinic policies on legal duties of confidentiality are carefully explained to all those seeking health care. Careful training of health professionals on how to protect confidentiality, both by themselves and by their assistant personnel, particularly in sensitive matters of reproduction and sexuality, will equip them to avoid breaches that occur in good faith or through negligence. Emphasis on professional duties of confidentiality, through professional disciplinary committees and/or courts, would reduce the risk of individual breaches, and also instruct members of professions in their ethical and legal responsibilities of confidentiality. Safe motherhood would be promoted through assuring women that they can trust that reproductive health services will be delivered in professional confidence.
There may be other deterrents to women, or some sub-groups of women, seeking obstetric services. For example, indigenous women experiencing obstetric complications may refuse to go to governmental hospitals for fear of being sterilized postpartum without their consent. Moreover, suspicion and fear of improper practices may persist long after they have been eradicated.
2. Obstructive laws
Laws and policies may facilitate or inhibit women‟s access to reproductive health care. Health professionals have to abide by the laws in their countries. They, however, have two obligations. First, they have to understand the limits of the law, which may not be as restrictive as sometimes perceived. Second, where the laws appear to be dysfunctional in practice, and contributing adversely to women‟s health, health professionals have an obligation to work with the legal profession, women groups and other progressive forces in the society to demonstrate the need for legal reform.
Laws governing reproductive health care are not generally contained within a separate body of law. General laws have to be applied. There are exceptions where countries develop laws with a particular goal in reproductive health care. For instance, countries may reform laws that criminalize abortion. Countries may adopt laws to prohibit female genital cutting. Countries have also adopted laws and policies to regulate access to medically assisted reproduction.
Laws that obstruct women‟s access to information and care can function as causes of maternal mortality. Preventing access to services are laws that criminalize medical procedures that only women request and that may be indicated to save their lives and health, such as those that govern contraception and abortion. While often tied to social or religious concerns, these criminal laws put women at risk when they prohibit or deter performance of treatment necessary to save the lives of pregnant women. When tested in courts, many of these restrictively worded laws are interpreted to have exceptions where procedures are undertaken in good faith to preserve women‟s lives or health, but unless so interpreted, their prohibitive language and severe punishments deter physicians from undertaking therapeutic interventions in pregnancy. Laws that prohibit medical procedures but that do not have clearly stated or indeed any exceptions where women‟s
lives or physical and mental health are at risk can be shown to violate human rights requirements.
Another dysfunction found in laws and health regulations or policies is that they require unnecessarily high qualifications of health service providers for reproductive health care. Different from health care for other disease systems, which is required by relatively small numbers of people, the need for reproductive health care is a universal need by all people. Such laws are often enacted in the belief that they are necessary for women‟s protection. However, they frequently unduly obstruct care, or make it unavailable because of limits of facilities, personnel or women‟s financial means to meet unnecessarily high costs. Such regulations may apply to maternity services. Requirements in terms of special facilities or qualifications of personnel may restrict access to pregnancy termination services, where these services are not against the law.
Some countries have codified laws that entrench women in roles subservient to their brothers and husbands. They require, for instance, that women requesting health services obtain their husbands‟ authorization, or that adolescent girls seeking health services obtain parental authorization, thereby obstructing medically indicated care and placing women and girls at risk. Often, permission is impossible to receive, or women are afraid or embarrassed to seek it.
Systems of health law and policies that restrict women‟s reproductive choices are usually based on historical connections between sexuality and morality. Many restrictive policies reflect the idea that women‟s sexuality and access to birth control endanger morality and family security. Legislation against the provision of contraceptive services and means has historically been expressed in terms of preservation of morality. Some national laws still characterize the provision of birth-control information and contraceptives as an offence against morality.
3. The health profession and human rights law
a. Literacy in human rights law
There is perhaps no better place to begin to impart an awareness of human rights and human dignity than in the small world of the doctor-patient relationship.21 Long before human rights principles have been articulated and universally adopted, it has been the tradition since Hippocrates that those who enter the profession of health care should commit themselves to maintaining the highest standards of personal integrity and competence and to having compassion for those placed in their care. Medical students have traditionally been asked to recite a version of the Hippocratic Oath on graduation.
When Eleanor Roosevelt spoke to the United Nations on the tenth anniversary of the Universal Declaration of Human Rights, she said: “where, after all, do universal human rights begin?. In small places, close to home- so close, so small that they cannot be seen on any map of the world…unless these rights have meaning here, they have little meaning anywhere.”
Human rights laws have been gender blind. They tended to focus on the public sphere of men and to miss the private sphere in which most live and have specific concerns. As will be discussed in Chapter 6, human rights are applicable to situations in sexual and reproductive health.
b. Compliance with human rights law
Members of the health profession have been involved in the past in violations of human rights. Although eugenics programmes are usually associated with Nazi Germany, they could, and did, happen everywhere.22 The Eugenics movement, including demands for sterilization of people considered unfit, blossomed in the United States, Canada, Britain, Scandinavia and other countries.
Members of the health profession have been involved in atrocities and torture.23 The Truth and Reconciliation Commission looked specifically at the role of the health professions in Apartheid South Africa in human rights abuses.24 Human rights abuses have been committed in the name of medical research.
c. Advocacy for human rights
Providers and their professional associations may invoke laws, particularly human rights laws, to advocate for better reproductive health services on behalf of their patients. When resources that patients require are denied, providers should learn to use human rights principles to make reasoned representations to institutional, governmental, private insurance and other agencies that allocate resources, explaining why such agencies should serve their patients‟ needs. Human rights laws may thereby operate to strengthen systems of health care.
The General Assembly of the International Federation of Gynecology and Obstetrics (FIGO), in its meeting in Washington D.C. on September 5, 2000, adopted a resolution on “women‟s rights relating to reproductive and sexual health.”
The resolution affirmed “that improvements in women‟s health need more than better science and health care; they require state action to correct injustices to women.” The resolution called upon FIGO member societies to make their expertise available to health, educational and legal professional associations and to collaborate with women‟s and human rights groups to promote a working partnership, in order to foster compliance with human rights relating to reproductive and sexual health, by:
Proposing and promoting guidelines for obstetrician/gynecologists for the respect of these rights; Playing an active role in educating the public, and making expertise available to policy makers and legislators, about the health dimension of women‟s rights and their impact on society at large; and Proposing national standards for the respect of these rights.
The resolution called upon all members of the profession to respect and protect women‟s rights in their daily practice, including women‟s sexual and reproductive rights.
H. The question of resources
1. Overall resources
Health care systems now represent one of the largest sectors in the world economy. Global spending on health care was estimated to be about $2985 billion in 1997, or almost 8% of world gross domestic product.27 The International Labour Organization estimates that there were about 35 million health workers worldwide a decade ago. Employment in health services now is likely to be substantially higher.
The level of financial resources a country devotes to the health sector depends on a variety of factors. Important determinants include income levels, the relative priority given to health in comparison with other sectors, the price of inputs such as labour, and the size of the private-for-profit sector.
Per capita spending on health services reflects the level of resources made available for health. According to World Health Organization estimated figures for 1995, the total health expenditure per capita in US$ was as follows.
2701 in developed market economies;
122 in economies in transition;
177 in middle income developing countries;
23 in low income developing countries; and
8 in least developed countries.
Government health expenditure as a percentage of total government expenditure was estimated for 1995 to be as follows:
15.6% for developed market economies;
3.6% for economies in transition;
5.0% for middle income developing countries;
1.1% for low income developing countries; and
5.5% for least developed countries.
The resources devoted to health care systems are very unequally distributed, and not at all in proportion to the distribution of health problems. The World Health Organization estimated that in 1990 the developed market economies accounted for over 86% of all health spending. The United States of America alone, constituting only 5% of the world‟s population, accounted for 41% of total expenditures, while sub-Saharan Africa, with 10% of the world‟s population, accounted for only 1%.29
Within governments, many health ministries focus on the public sector, often disregarding the – frequently much larger- private finance and provision of care. A growing challenge is for governments to harness the energies of the private and voluntary sectors in achieving better levels of health systems performance, while offsetting the failures of private markets.
The relative mix of public and private financing for health services reveals both the extent to which governments have the resources to intervene in the health sector, and (particularly in the richer world) governments‟ views on the appropriate level of public involvement. For example, in the USA in 1995, 58% of total health spending came from private sources, while in Norway the figure was only 6%.30 While the USA gives greater weight to consumer choice and market mechanisms, leaving tens of millions of its population without access to affordable services, Norway believes that intervention to ensure access for all takes priority. Contrary to what some people may think, the poorest countries rely the most on private financing, with an average of 59% (compared to 30% for developed market economies, 22% for economies in transition, 49% for middle income economies, and 46% for developing countries). With the inability or failure of
governments to finance comprehensive health services for the entire population, the private sector often grows by default. Since the debt crisis in the early 1980s, many governments have been forced to introduce user charges for drugs and visits to public health facilities. The World Health Organization estimated that in half of the world‟s countries, health spending from private sources increased from 37% in 1990 to 42% in 1992.
Lack of resources is not always a valid excuse for governments not to invest in health. There is no country that is so poor that it cannot do something to improve the reproductive health of its people. A look at military expenditure shows how resources are abused even in poor developing countries. As a United Nations Development Programme (UNDP) report reveals, their military expenditures rose three times as fast as those of industrialized countries between 1960 and 1987 – from $24 billion to $145 billion – including a staggering $95 billion a year in some of the world‟s poorest countries.32 In developing countries, the chances of dying from social neglect (from malnutrition and preventable diseases) are 33 times greater than the chance of dying in a war from external aggression.
External support for the health sector amounted to approximately 3% of total health expenditures in developing countries in 1990, with 38.5% of the total (equal to US$ 2.45 per capita) going to Africa.33 Almost half of donor aid is spent on the development of infrastructure through grants for hospitals and health services. The other 50% is directed towards specific health programmes, particularly leprosy, onchocerciasis, HIV and STD infections and blindness conditions. External aid is particularly important in countries in a state of conflict, or in the immediate aftermath of conflict such as Mozambique and Angola. In Cambodia, aid accounted for 60% of total government expenditure in 1990.
Contrary to a popular belief, the proportion of official development assistance (ODA) allocated for Population, including reproductive health, is only a small fraction of the total, estimated in 1993 to be an average of just 1.4%.
2. Fair allocation of resources
The critical measure of the performance of the health system in a country is its achievement relative to resources. Each health system should be judged according to the resources actually at its disposal, not according to other resources that could have been put at its disposal. Dollar for dollar spent on health, many countries are falling short of their performance potential. The result is a large number of preventable deaths, and lives stunted by disability. The impact of the failure is borne disproportionately by the poor.
Fair financing in health systems means that the risks each household faces due to the costs of healthcare are distributed according to ability to pay rather than to the risk of illness. According to the World Health Report 2000, the way health care is financed is perfectly fair if the ratio of total health contribution to total non-food spending is identical for all households, independently of their income, their health status or their use of the health system.
It is not enough that the health care system should be good. It should also be fair.
3. Priorities in the allocation of resources
Setting priorities among health problems, for allocation of resources, is not an easy task. It has to take into consideration not only the prevalence of the health problem but also its seriousness. Seriousness does not mean only the risk of mortality. It has also to take into consideration the risk of morbidity or disability, short and long-term. The age at which the health problem strikes should also be factored in the equation. A health problem which affects only old people is different from one that affects people in the prime of their lives. The World Bank in a 1993 report tried to quantify all the above considerations, to arrive at an estimate of the burden of disease expressed as “disabilityadjusted life years. (DALYs) lost for each health problem.
Estimation of the burden of disease is not enough to make decisions on the priority for allocation of resources. Much will depend on the availability of cost-effective interventions to deal with the particular health problem. The World Bank considers that an intervention is cost-effective if it can substantially control the problem at a cost of less than US$100 per DALY saved.
For young women (aged 15-44) in demographically developing countries, maternity ranked as the number one cause of the disease burden (accounting for 18% of the disease burden). Sexually transmitted diseases ranked as number two, accounting for 8.9% of the disease burden. Both conditions can be controlled by cost-effective interventions.
4. Reproductive health is special
Using the DALYs for estimation of the burden of disease has to take into consideration that reproductive health is special in a number of ways.
Mortality and physical disability are not the only costs a woman may pay for a health problem. A woman with an unwanted pregnancy may not die and her pregnancy may leave her with no physical disability. But from a woman‟s perspective, the condition is serious enough that every year almost 20 million women risk their health or life by undergoing an unsafe abortion for an unwanted pregnancy. A woman with infertility may have no disease condition but her suffering, in many communities, is real, judging by what she is willing to go through, in terms of discomfort, risk and cost, to have a wanted child. A woman may be raped but she may have no serious injuries or physical health sequelae.
The impact of a reproductive health problem often goes beyond the persons concerned. Sexually-transmitted infections are not just a disease burden on the person affected. They can be transmitted to others. They can also pass from mother to fetus. Survival and health of a mother impacts on the health and survival of her children. Unwanted pregnancy impacts on the whole family, community, country and even the world at large.
In the counting of DALYs, conditions of perinatal mortality and morbidity are counted as paediatric health problems. In fact, however, they are part of the burden of disease on women, who have made a major investment of themselves in the pregnancy and who will suffer for the care of a disabled child.
Finally, maternity is not a disease, to be ranked for priority with other disease problems. Maternity is the means of propagation of our species. It is a risky business which women undertake. Women have a right to be protected when they go through risks for survival of our species.
5. The cost of not providing reproductive health services
Although we may not know exactly how much money it will cost to provide reproductive health services for all, we have a better idea about what it will cost in women‟s lives and health if we do not make reproductive health care universally available. The following are some of the costs.
-515,000 women- almost one every minute- each year will die worldwide from causes related to pregnancy.
-70,000 women each year will die as a result of unsafe abortion; an unknown number will suffer from infection and other adverse health consequences.
-In developed countries (where average desired family size is small), of the 28 million pregnancies occurring every year, an estimated 49% will be unplanned, and 36% will end in abortion. In developing countries (where average desired family size is still relatively large), of the 182 million pregnancies occurring every year, an estimated 36% will be unplanned, and 20% will end in abortion.
-Six out of ten women in many countries will have a sexually transmitted disease (STD). All will face a higher risk of infertility, cervical cancer, or other serious health problems.
-Based on 1998 figures, there will be nearly 6 million new cases of HIV infection.39 Every minute of every day, around 11 people will become newly infected with HIV. One of 10 of those who became infected during 1998 was a child under the age of 15 years. The vast majority were in sub-Saharan Africa, and most have acquired the virus from their mothers. About half of all new infections past infancy are in young people below the age of 25 years, very many of them still teenagers.
-2 million young girls will be at risk of female genital cutting. The international community and individual governments have condemned the practice, yet it remains widespread in many countries, and is spreading to immigrant communities.
-Rape and other forms of sexual violence will continue to increase. Unfortunately, the stigma of rape keeps all but a very small percentage of cases from being reported.
-An increasing number of refugees will be denied access to a basic package of reproductive health care.
-The “Day of 6 Billion” was observed in 1999. Human numbers will certainly reach seven billion, but whether world population then goes on to 8, 10 or 12 billion will depend on policy decisions and individual actions, within the reproductive health approach, in the next decade. Whatever its size, over 90% of the net addition will be in today‟s developing countries.
I. The commitment
“All countries should strive to make accessible through the primary health-care system, reproductive health to all individuals of appropriate ages as soon as possible and no later than the year 2015.”
The solemn commitment to make reproductive health care universally available no later than the year 2015 was a consensus approved by the governments of 179 countries, in their meeting under the umbrella of the United Nations in Cairo, 5-13 September 1994. It should be noted that the commitment about reproductive health was not made in a conference about health. It was made in a conference about population and development. Reproductive health is not only a serious health issue; it is a development issue.
Concern about reproductive health at the international level is a reflection of our increasing global consciousness. The great technological revolution in transport and communication has made the world smaller and brought it closer together. Moreover, we have realized, more ever than before, how interdependent we are, and that the attainment of health and development by people in any one country directly concerns and benefits every other country.
Five years after the Cairo International Conference on Population and Development, where the commitment to reproductive health was made, the United Nations General Assembly discussed in its Twenty-first special session on June 30-July 2, 1999, an overall review and appraisal of the implementation of the Programme of Action of the 1994 Conference. The United Nations General Assembly re-affirmed the commitment to the goal of reproductive health for all, and stated that.
“At least 40 per cent of all birthsshould be assisted by skilled attendants where the maternal mortality is very high, and 80 per cent globally by 2005; these figures should be 50 and 85 per cent, respectively by 2010 and 60 and 90 percent by 2015.”
“The gap between the proportion of individuals using contraceptives and the proportion expressing a desire to space or limit their families should be reduced by half by 2005, by 75 per cent by 2010, and by 100 percent by 2015. Recruitment targets or quotas should not be used in attempting to reach this goal.”
“To reduce the vulnerability to HIV/AIDS infection, at least 90 percent of young men and women, aged 15-24, should have access by 2005 to preventive methods such as female and male condoms, voluntary testing, counseling and follow-up, and at least 95 per cent by 2010. HIV infection rates in persons 15-24 years of age should be reduced by 25 per cent in the most affected countries by 2005, and by 25 per cent globally by 2010.”
The reaffirmed international consensus about making reproductive health care universally available is, however, not enough to make it happen. The will has to be backed by the wallet. The necessary resources must be mobilized.