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  • The countries that agreed to the ICPD Programme of Action face a tremendous challenge in its implementation. Additional funds will help; however, in the face of scarce resources, countries also need to find ways to make existing resources go further. As countries strive to implement the reproductive health initiatives to which they agreed at Cairo, many are also undertaking health sector reform, a set of sweeping initiatives that affects all components of health, including decentralizing the management and provision of care, concentrating resources on cost-effective interventions (often through minimum or essential services packages), improving the performance of providers, expanding the role of the private sector, shifting the function of central ministries of health and improving their regulatory capacity, broadening financing, and shifting donor financing to support sector-wide health programs rather than vertical programs, such as family planning. Reproductive health initiatives and health sector reform share the goals of equity and quality. The question of interest to those working in reproductive health is whether the reform measures aimed at increasing efficiency will be sufficient to ensure universal access to high-quality reproductive health services by 2015, as outlined in the ICPD Programme of Action. This paper reviews evidence that addresses the question of the complementarity of reproductive health initiatives and health sector reform. Decentralization: While decentralization is sound in theory, it is not easy to implement in practice and may take as long as 10 to 20 years. Thus, the effect of decentralization on health care, including reproductive health care, is unclear. While some experiences with decentralization have been favorable, central governments have often transferred responsibility to local administrative levels without planning properly for implementation and without allocating adequate resources. In fact, existing human and technical resources are often underdeveloped at the local level. Decentralization may not promote equity, at least not in the short term. Local areas may have variable access to resources; thus, residents of poorer areas may receive less care than residents of wealthier areas. The need is clear for further analysis of health and equity outcomes related to decentralized management and provision of reproductive health. Integration: The ICPD promoted integration of services to ensure greater responsiveness to meeting clients' reproductive health needs. In the context of health sector reform, integration is more broadly defined; to reformers, integration of reproductive health as envisioned at the ICPD is just another vertical program. Integration is best suited for services targeted to a similar clientele, for example, family planning linked with postpartum services. A few examples of successful integration of reproductive health services can be found, most notably in programs of nongovernmental organizations (NGOs). Since ICPD, family planning and STD/HIV/AIDS are the two main reproductive health components that have undergone integration, particularly in Africa. However, many family planning clinics are not equipped to offer services for the detection and treatment of sexually transmitted diseases (STDs), and staff members are not properly trained. Essential Services Packages: Under health sector reform, more and more countries are implementing minimum or essential care packages of cost-effective interventions designed to reduce the burden of disease among the population. Essential services packages developed to date have generally included reproductive health components. Making Better Use of Existing Program Capacity: More efficient, high-quality care could attract additional clients for reproductive health services and thus save money. Without improvements in quality, however, utilization of reproductive health services may suffer, particularly if cost-recovery schemes are introduced. Further evaluation is required to determine whether improvements in quality (as distinct from the availability of drugs) will lead to increased demand for services, which, in turn, can translate into increased revenue. Evaluation of operational policies, including those affecting the provision of reproductive health services, often uncovers procedures that involve unnecessary and burdensome steps. Streamlining operational policies could make services more efficient. In addition, medical and other service barriers often inflate the cost of services. Many countries are updating their service delivery guidelines to reflect the recent international consensus on more streamlined but medically safe protocols for contraceptive and reproductive care. Role of Public and Private Providers: Health sector reform promotes separation of the financing of services from the provision of services. In theory, governments should delegate service provision to organizations closer to communities, including local governments and the private sector, if one exists. Family planning programs have had some success in encouraging wider participation of the private and commercial sectors in service provision. Ministries of health should focus on sector management by developing legal and regulatory frameworks that direct the actions of both local governments and private providers and promote preventive care. Many countries regulate the behavior of private health providers and the distribution of drugs; enforcement of regulations, however, is another matter. If governments remain in the business of service delivery, including reproductive health care, they should ensure a "level playing field" by providing similar subsidies and incentives to the private sector and NGOs as they provide for public sector services. Broadening Health Care Financing: Results of initiatives in cost recovery, particularly the use of user fees, have been mixed, even for family planning. Some studies show that small increases in user fees do not affect health care utilization rates, particularly if quality of care (and drug availability) is improved. Other studies, however, have shown that user fees have adversely affected women and children, forcing them to forgo needed health care. Some countries are seeking to promote equity in health care through prepayment schemes and risk-sharing mechanisms. Sector-Wide Assistance Programs: Donors and international financial institutions are testing various sector-wide assistance programs (SWAPs) to support health sector reform, in order to move from a narrow project focus to a sectoral focus and to help establish joint instead of donor-driven priorities. As with other aspects of health sector reform, SWAPs are not easy to implement and tend to function best in politically and economically stable environments, conditions absent in many developing countries. Discussion: Health sector reform is complex and to be successful, requires time, political commitment, an initial investment of resources, and a favorable policy environment. Without proper planning and implementation, reform is unlikely to be successful and may even waste resources. Within the context of health sector reform, several challenges exist in the design and implementation of reproductive health programs, including setting priorities, costing integrated services, determining new approaches for financing and providing services, and redefining the roles of central maternal and child health (MCH) and family planning divisions. With few current examples of successful reform positively affecting reproductive health programs, it is too soon to say whether health sector reform will promote efficient, effective, and equitable reproductive health care delivery, or whether reforms will result in the neglect of reproductive health in the face of other pressing health care issues. It is imperative that reform processes, including the reform of reproductive health services, be monitored, documented, and evaluated. Equity and access issues often get lost in the details of implementing programs to increase efficiency. Those involved in reproductive health programs, including client advocates at the local, national, and international levels, need to be "at the table" when decisions on reforms are made. In addition to promoting more efficient programs and services for reproductive health, those involved in decision making must ensure that equity and access to high-quality services are primary goals of reform programs if the ICPD Programme of Action is to be achieved.