Tk Sundari Ravindran

Food decision-making is a complex process and varies according to the setting, based on cultural and contextual factors. The study aimed to understand the process of food decision-making in households in rural Kerala, India, to inform the design of a dietary behaviour change intervention. Three focus group discussions (FGDs) and 17 individual interviews were conducted from September 2010 to January 2011 among 13 men and 40 women, between 23 and 75 years of age. An interview guide facilitated the process to understand: 1) food choices and decision-making in households, with particular reference to access; and 2) beliefs about foods, particularly fruits, vegetables, salt, sugar and oil. The interviews and FGDs were transcribed verbatim and analysed using qualitative content analysis. The analysis revealed one main theme: ‘Balancing expectations amidst limitations’ with two sub-themes: ‘Counting and meeting the costs’; and ‘Finding the balance’. Food decisions were made at the household level, with money, time and effort costs weighed against the benefits, estimated in terms of household needs, satisfaction and expectations. The most crucial decisional point was affordability in terms of money costs, followed by food preferences of husband and children. Health and the risk of acquiring chronic diseases was not a major consideration in the decision-making process. Foods perceived as essential for children were purchased irrespective of cost, reportedly owing to the influence of food advertisements. The role of the woman as the homemaker has gendered implications, as the women disproportionately bore the burden of balancing the needs and expectations of all the household members within the available means. The food decision-making process occurred at household level, and within the household, by the preferences of spouse and children, and cost considerations. The socio-economic status of households was identified as limiting their ability to manoeuvre this fine balance. The study has important policy implications in terms of the need to raise public awareness of the strong link between diet and chronic non-communicable diseases.

Interventions having a strong theoretical basis are more efficacious, providing a strong argument for incorporating theory into intervention planning. The objective of this study was to develop a conceptual model to facilitate the planning of dietary intervention strategies at the household level in rural Kerala.

Universal access to sexual and reproductive health services is one of the goals of the International Conference on Population and Development of 1994. The Millennium Development Goals were intended above all to end poverty. Universal access to health and health services are among the goals being considered for the post-2015 agenda, replacing or augmenting the MDGs. Yet we are not only far from reaching any of these goals but also appear to have lost our way somewhere along the line. Poverty and lack of food security have, through their multiple linkages to health and access to health care, deterred progress towards universal access to health services, including for sexual and reproductive health needs. A more insidious influence is neoliberal globalisation. This paper describes neoliberal globalisation and the economic policies it has engendered, the ways in which it influences poverty and food security, and the often unequal impact it has had on women as compared to men. It explores the effects of neoliberal economic policies on health, health systems, and universal access to health care services, and the implications for access to sexual and reproductive health. To be an advocate for universal access to health and health care is to become an advocate against neoliberal globalisation.

Universal coverage by health services is one of the core obligations that any legitimate government should fulfil vis-à-vis its citizens. However, universal coverage may not in itself ensure universal access to health care. Among the many challenges to ensuring universal coverage as well as access to health care are structural inequalities by caste, race, ethnicity and gender. Based on a review of published literature and applying a gender-analysis framework, this paper highlights ways in which the policies aimed at promoting universal coverage may not benefit women to the same extent as men because of gender-based differentials and inequalities in societies. It also explores how ‘gender-blind’ organisation and delivery of health care services may deny universal access to women even when universal coverage has been nominally achieved. The paper then makes recommendations for addressing these.

A social franchise in health is a network of for-profit private health practitioners linked through contracts to provide socially beneficial services under a common brand. The early 21st century has seen considerable donor enthusiasm for promoting social franchises for the provision of reproductive health services. Based on a compendium of descriptive information on 45 clinical social franchises, located in 27 countries of Africa, Asia and Latin America, this paper examines their contribution to universal access to comprehensive reproductive health services. It finds that these franchises have not widened the range of reproductive health services, but have mainly focused on contraceptive services, and to a lesser extent, maternal health care and abortion. In many instances, coverage had not been extended to new areas. Measures taken to ensure sustainability ran counter to the objective of access for low-income groups. In almost two-thirds of the franchises, the full cost of all services had to be paid out of pocket and was unaffordable for low-income women. While standards and protocols for quality assurance were in place in all franchises, evidence on adherence to these was limited. Informal interviews with patients indicated satisfaction with services. However, factors such as difficulties in recruiting franchisees and significant attrition, franchisees' inability to attend training programmes, use of lay health workers to deliver services without support or supervision, and logistical problems with applying quality assurance tools, all raise concerns. The contribution of social franchises to universal access to reproductive health services appears to be uncertain. Continued investment in them for the provision of reproductive health services does not appear to be justified until and unless further evidence of their value is forthcoming.

Orissa state in eastern India accounts for the highest malaria burden to the nation. However, evidences are limited on its treatment-seeking behaviour in the state. We assessed the treatment-seeking behaviour towards febrile illness in a malaria endemic district in Orissa.

Privatisation in Pakistan's health sector was part of the Structural Adjustment Programme that started in 1998 following the country's acute foreign exchange crisis. This paper examines three examples of privatisation which have taken place in service delivery, management and capacity-building functions in the health sector: 1) large-scale contracting out of publicly-funded health services to private, not-for-profit organisations; 2) social marketing/franchising networks providing reproductive health services; and 3) a public-private partnership involving a consortium of private players and the government of Pakistan. It assesses the extent to which these initiatives have contributed to promoting equitable access to good quality, comprehensive reproductive health services. The paper concludes that these forms of privatisation in Pakistan's health sector have at best made available a limited range of fragmented reproductive health services, often of sub-optimal quality, to a fraction of the population, with poor returns in terms of health and survival, especially for women. This analysis has exposed a deep-rooted malaise within the health system as an important contributor to this situation. Sustained investment in health system strengthening is called for, where resources from both public and private sectors are channelled towards achieving health equity, under the stewardship of the state and with active participation by and accountability to members of civil society.

This paper reviews published literature on experiences in mainstreaming gender within the health sector since the 1990s. Although much has been written about the need for mainstreaming gender, and on how to go about it, the gap between intention and practice is palpable. National health policies and programmes that have gender integrally woven into their objectives and activities are rare. Health research to generate gender and sex-specific data, and integrating gender in health provider training, have received scarce attention. Mainstreaming gender within institutions has remained superficial, investing more on form than on content. The apparent lack of progress in mainstreaming gender in health may be attributed to: depoliticization and delinking of gender mainstreaming from social transformation and social justice agendas; adoption of top-down approaches to mainstreaming; growing hostility within the global policy environment to justice and equity concerns; and increasing privatization and retraction of the state's role in health. This paper suggests that the way forward would be to frame gender concerns in the language of equity, rights, and justice; to set agendas which consider gender inequity within the context of inequities by caste, class, ethnicity, and other sources of health inequalities; and to work alongside other movements for social justice.

This study in rural Tamil Nadu, India, explored the reasons why many married women in India undergo induced abortions rather than use reversible contraception to space or limit births in terms of women's sexual and reproductive rights within marriage, and in the context of gender relations between couples more generally. It is based on in-depth interviews with two generations of ever-married women, some of whom had had abortions and others who had not, from 98 rural hamlets. The respondents were 66 women and 44 of their husbands. Non-consensual sex, sexual violence and women's inability to refuse their husband's sexual demands appeared to underlie the need for abortion in both younger and older women. Many men seemed to believe that sex within marriage was their right, and that women had no say in the matter. The findings raise questions about the presumed association between legal abortion and the enjoyment of reproductive and sexual rights. A large number of women who had abortions in this study were denied their sexual rights but were permitted, even forced, to terminate their pregnancies for reasons unrelated to their right to choose abortion. The study brings home the need for activism to promote women's sexual rights and a campaign against sexual violence in marriage.

To understand the implications of health sector reforms for sexual and reproductive health services, there are three major dimensions to consider. The first two relate to the context in which health sector reforms are introduced: the characteristics of the health system, and that of reproductive and sexual health services located within it. The third dimension has to do with the content and scope of health sector reforms introduced into this context, and the actors and processes through which it is introduced. The content, scope, actors and processes have in turn to be located and understood within the larger geopolitical context and the position within it of the country under consideration. Pour comprendre les conséquences des réformes du secteur de la santé sur les services de santé génésique, il faut examiner trois dimensions principales. Les deux premières se rapportent au contexte dans lequel ces réformes sont introduites: les caractéristiques du système de santé et celles des services de santé génésique qui y sont intégrés. La troisième dimension est liée au contenu et à la portée des réformes menées dans ce contexte, et aux acteurs et processus par lesquelles elles sont introduites. Le contenu, la portée, les acteurs et les processus doivent à leur tour être placés et compris dans le contexte géopolitique plus large et en fonction de la position que le pays étudié y occupe. Para comprender las implicaciones que tienen las reformas del sector salud con respecto a los servicios de salud sexual y reproductiva, hay que considerar tres dimensiones principales. Las dos primeras se refieren al contexto en el cual las reformas del sector salud estén introducidas: las caracterı́sticas del sistema de salud, y de los servicios de salud sexual y reproductiva dentro de este sistema. La tercera dimensión está relacionada con el contexto y con los actores y los procesos mediante los cuales las reformas se introduzcan: hay que localizar y comprender el contenido, el alcance, los actores y los procesos dentro del contexto geopolı́tico mayor y la posición que ocupa tal paı́s dentro de él.