RECLAIMING REDEFINING RIGHTS Thematic Studies Series 2: Pathways to Universal Access to Reproductive Health Care in Asia By TK Sundari Ravindran Secretary RUWSEC and Professor, Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum. © ASIAN-PACIFIC RESOURCE & RESEARCH CENTRE FOR WOMEN Any part of the publication may be photocopied, reproduced, stored in a retrieval system or transmitted in any form by any means, or adapted to meet local needs, without the intention of gaining material profits. All forms of copies, reproductions, adaptations and translations through mechanical, electrical or electronic means, should acknowledge ARROW as the source. A copy of the reproduction, adaptation and/or translation should be sent to ARROW. ISBN: 983-44234-8-3 Published by: Asian-Pacific Resource & Research Centre for Women (ARROW) 1 & 2, Jalan Scott, Brickfields, 50470 Kuala Lumpur, Malaysia. Tel: (603) 2273 9913/9914/9915 Fax: (603) 2273 9916 Email: [email protected] Website: www.arrow.org.my Project Coordinators: Sivananthi Thanenthiran and Sai Jyothirmai Racherla Cover and layout design: TM. Ali Basir Ampersand design: Ng See Lok and Soo Wei Han Printer: MAC NOGAS Sdn Bhd 2 CONTENTS LIST OF BOXES LIST OF TABLES 4 LIST OF FIGURES GLOSSARY 5 ACKNOWLEDGEMENTS 7 INTRODUCTION 9 Chapter 1 CAMBODIA 15 Chapter 2 LAO PDR 41 Chapter 3 paKistan 57 Chapter 4 THAILAND 75 REFERENCES 88 3 List of Boxes List of Tables Box 1: Women’s experiences Table 1: Details of organisations Table 10: Partners in the of accessing delivery care in involved in running 24 HEFs in PAIMAN Project and their Cambodia 2006 respective roles p17 p23 p66 Table 2: Benefits package of Table 11: Incidence of SKY CBHI catastrophic health expenditure by quintile of consumption p27 expenditure p List of Table 3: Rural-Urban and 80 wealth-based inequalities in Table 12: Summary of the nine maternal and reproductive Figures ICPD sexual and reproductive health care health services and the UC Figure 1: Average referral p28 package coverage hospital bed occupancy rate by type of district p81 Table 4: Mean change in health p24 service coverage indicators in Table 13: Odds ratios of MCH contacting in and contracting service coverage of richest to Figure 2: Comparison of facility out districts as compared to poorest quintiles and urban to deliveries in three groups of control districts: 1999-2003 rural areas, Thailand, 2005-06 ODs in Kampong Cham 2006- 2008 p29 p82 p31 Table 5: A comparison of government spending on health Figure 3: Social protection and education, Lao PDR, coverage in Lao PDR, 2007 2003-06 p47 p44 Table 6: Cost recovery as a proportion of total health budget and total recurrent cost, northern provinces of Lao PDR, 2006 p45 Table 7: Utilisation rates for existing HEF programmes, 1st semester, 2007 p48 Table 8: Access to health services in villages of Lao PDR p49 Table 9: Sample Services Packages by Health System Level Assuming the Availability of Inputs p50 4 Glossary ADB Asian Development Bank HIV/AIDS Human Immunodeficiency Virus/Acquired AFD French Agency for Development Immunodeficiency Syndrome ART Anti-Retroviral Treatment HNI HealthNet International ARV Anti-Retrovirus HSIP Health System Improvement Project BCC Behaviour Change Communication HSSP Health Sector Support Project BHUs Basic Health Units ICPD International Conference on Population CAAFW Cambodian Association for Assistance to and Development Families and Widows IEC Information, Education, Communication CBHI Community-based Health Insurance ILO International Labour Organisation CBO Community Based Organisation IUCD Intrauterine Contraceptive Device CEDAW Convention on Elimination of All Forms of IUD Intra-uterine device Discrimination Against Women JFPR Japan Fund for Poverty Reduction CFDS Cambodian Family Development Services JHU/CCP John Hopkins University Center for CHHRA Cambodian Health and Human Communications Progra,s Rights Alliance JSI John Snow Inc Research and CI Contracting In Training Institute CIDA Canadian International Development Agency KfW Kreditanstalt fur Wiederaufbau CO Contracting Out KSM Key Social Marketing CRC Convention on Rights of the Child LDC Least Developed Country CSES Cambodia Socio-economic Survey LHV Lady Health Visitor CSI Civil Servant Insurance LHW Lady Health Worker CSMBS Civil Servant Medical Benefit Scheme LPRP Lao People’s Revolutionary Party CUPs Contracting Units for Primary Care MCH Maternal and Child Health CYPs Couple Years of Protection MDG Millennium Development Goal DALY Disability-adjusted life year MMR Maternal Mortality Ratio DFID UK Department for International Development MoF Ministry of Finance DHS Demographic Health Survey MOH Ministry of Health DOT Directly Observed Treatment MOPW Ministry of Population Welfare DPT Diphtheria, Pertussis and Tetanus Vaccination MSF Medecin sans Frontiers DRG Diagnosis-related-group NEM New Economic Mechanism EmOC Emergency Obstetric Care NGO Non-Governmental Organisation ESSIs Employee Social Security Institutions NHA National Health Assembly EU European Union NHSO National Health Security Office FATA Federally Administered Trial Areas NSDP National Strategic Development Plan FMO Female Medical Officer NSEDP National Socio-Economic Development Plan GDI Gender Development Index NWFP North West Frontier Province GDP Gross Domestic Product ODs Operational Districts GEM Gender Empowerment Measure PAIMAN Pakistan Initiative for Mothers and Newborns GOP Government of Pakistan PAVHNA Pakistan Voluntary Health and GRET Group de Rechereches et d’Echanges Nutrition Association Technologiques PBC Performance Based Contracting GSM Green Star Marketing PDR People’s Democratic Republic GTZ German Technical Co-operation PH Provincial Hospital HDI Human Development Index PHA People’s Health Assembly HEFs Health Equity Funds PHCEP Primary Health Care Expansion Project 5 Glossary PPP Purchasing Power Parity STI Sexually Transmitted Disease PRSP Punjab Rural Support Programme TBA Traditional Birth Attendants PSI Population Services International UC Universal Health Coverage Scheme RACHA Reproductive and Child Health Alliance UHN United Health Network RHAC Reproductive Health Association UNICEF United Nations Children’s Fund of Cambodia USAID US Agency for International Development RHCs Rural Health Centres VCT Voluntary Counselling and Testing SHI Social Health Insurance VHVs Village Health Volunteers SKY Insurance for our families VMA Voucher Management Agencies (Acronym in Khmer language) WB World Bank SMP Social Marketing Pakistan WHO World Health Organisation SQH Sun Quality Health SRH Sexual and Reproductive Health SSO Social Security Organisation SSS Social Security Scheme STD Sexually Transmitted Disease 6 Acknowledgements This report was written by TK Sundari Ravindran. We are also indebted to the following reviewers: Dr Sylvia Estrada- Claudio for her review of the Introduction chapter; Dr. Ouk Vong Vathiny for her review of the first chapter on Cambodia; Dr. Vanphanom Sychareun for her review of the second chapter on Lao PDR; Khawar Mumtaz for her review of the third chapter on Pakistan; Dr. Siriwan Grisurapong and Dr. Pimpawun Boonmongkon for their review of the fourth chapter on Thailand. A summary version of the third chapter on Pakistan appeared in Reproductive Health Matters. We are grateful to Marge Berer, editor of Reproductive Health Matters, for her extensive comments on the article, which informed the revision of the final version of the case study appearing in this report. We would also like to thank Anu Nair and Shalini Kaliyath who did extensive web searches for identifying the source materials to prepare the case studies. We are indebted to the copy-editor, Ms. Charity Yang for her work. The design and the layout of this book is the result of the creative vision of TM Ali Basir. This project and report were funded by Ford Foundation, while this publication was funded by SIDA. vii 8 INTRODUCTION Pathways to Universal Access to Reproductive Health Care: Case studies of four countries from Asia 9 2015 in order to make available a comprehensive 1. Pathways to Universal package of maternal health, family planning and Access to Reproductive Health sex-education interventions.4 Average donor- funding for reproductive health since 2005 is a Care: Case studies of four paltry one-fifth of the average annual donor shares needed through 2015.5 The major responsibility for countries from Asia harnessing resources to finance universal access to reproductive health services clearly rests with national governments. It is against this backdrop that this monograph documents the trajectories traversed by four Asian countries in terms of health 1.1 Universal access to reproductive system reforms and ways in which this has facilitated health – a pipe dream? or impeded universal access to reproductive health care. The historic 1994 International Conference on Population and Development (ICPD) identified, 1.2 Locating universal access to in its Programme of Action, “Universal Access to Reproductive Health” as a goal to be achieved reproductive health care within the by 2014.1 The road to the implementation of the framework of universal health care Programme of Action has been all but smooth and marked by stiff political opposition from powerful coverage countries, failure by donors to honour their funding commitments and sidelining of reproductive health We strongly endorse this view upheld by several in the Millennium Development Goals (MDGs). After reproductive