Globalization, Health Sector Reform, Gender and ... - Ford Foundation

and health. Health financing strategies now consider risk, vulnerabilityand exclusion to develop safety-net mechanisms to protectthe poorer segments of the population. Gender implications areyet to be explored.These new components have presented an opportunity for a varietyof civil society groups, such as NGOs and other independentorganizations, to develop advocacy strategies and to participateactively in planning, service delivery and/or monitoring. However,many stakeholders are not yet involved in discussions abouthealth sector reform or sector-wide approaches. Realizing theparticipation and active involvement of multiple partners who havedifferent mandates, organizational foci, work styles and budgetsrequires a thorough stakeholder analysis (DGIS, 1999).At the district level, operations are more flexible to tailoring ofsexual and reproductive health services to suit local needs. Whiledecentralization opens possibilities for further development of thedistrict health system, it also poses new challenges, particularlyto primary stakeholders. Aitken (1998) questions the impacts ofdecentralization on sexual and reproductive health when governmentcommitments to the 1994 Cairo Agenda are not implementedat the local level, either because resources are not budgeted orbecause of conflicting interests and views between the center andthe periphery.For instance, hiring and firing of staff, procurement and disbursementof funds, and acceptance of donations are all heavily centralizedin the capital cities and subject to slow and complicatedprocedures. Difficulties also arise in the selection of local representativesand delegation of authority to them. Political traditionand motives may hamper the delegation of power, and as a result,most essential decision-making and executive authority continuesto be retained by the central government.Paradoxically, as more power is conferred upon local representatives,the power is brought closer to the people, and thus the powerand the nature of the administration actually is legitimized. However,conferring power on incompetent local representatives canalso have the undesired effect of deepening existing gender andhealth inequities. In addition, local will can be influenced by conservatismand prejudice, particularly in the case of services suchas management of incomplete abortions or sexual health servicesfor adolescents.42