Journal of Womens Health, Issues and Care ISSN: 2325-9795

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Review Article, J Womens Health Issues Care Vol: 4 Issue: 4

A Hybrid Model for Analysis of Policy Making: US Global Sexual and Reproductive Health Issues in Developing Countries Act of 2013

Cecilia Mengo* and Small Eusebius
School of Social Work University of Texas at Arlington, USA
Corresponding author : Cecilia Mengo
211 S. Cooper, Bld. A., Ste. 201, Arlington, Texas, TX 76019, USA
Tel: +1 (214) -643-9170
E-mail: [email protected]
Received: October 13, 2014 Accepted: June 23, 2015 Published: June 26,2015
Citation: Mengo C, Eusebius S (2015) A Hybrid Model for Analysis of Policy Making: US Global Sexual and Reproductive Health Issues in Developing Countries Act of 2013. J Womens Health, Issues Care 4:4. doi:10.4172/2325-9795.1000191

Abstract

A Hybrid Model for Analysis of Policy Making: US Global Sexual and Reproductive Health Issues in Developing Countries Act of 2013

This paper examines the United States Global and Reproductive Health Act of 2011 by identifying strengths, shortcomings and gaps in the policy and suggests key changes and recommendations. The framework of analysis of the proposed Act is based on its ability to address successful approaches that employ a comprehensive sexual and reproductive health care based on evidence from the field and its focus on reproductive health rights and justice. In doing so, this paper utilizes a hybrid model to describe a practical framework that can be used to analyze the process of policy making and implementation. The hybrid model can be used for policy making analysis with any social phenomena globally context; here it is illustrated for use with global sexual and reproductive health problems in developing countries.

Keywords:

Keywords

Developing countries; Policy models; Policy analysis; Reproductive health; Women

Problem Statement

Despite an upsurge in global health programs in developing countries in the last two decades, poor sexual and reproductive health remains one of the most prevalent causes of disease and death, especially for men and women between the ages of 15 and 44 in developing countries [1]. It also accounts for 20 per cent of the global disease burden for women and 15 percent for men of fertile age. An estimated 215, 000,000 women in developing countries have unmet needs for effective modern contraceptives [2]. Addressing these needs would save the lives of 251,000 women and 1,700,000 newborns, avert 53,000,000 unintended pregnancies, and prevent 14,500,000 unsafe abortions [3]. Multiple reasons exist for the high incidence of sexual and reproductive ill health. A broad classification of related sexual and reproductive health constructs explains the prevalent nature of reproductive health problem [1]. In many ways, defining sexual and reproductive health is complex because it cuts across operationalization of many constructs to include diseases such as AIDS, breast cancer, and other forms of cancer such as cervix cancer; as well as non-disease conditions (e.g. pregnancy, abortion and family planning. It may also include all forms of violence against women, gender-based violence, intimate partner violence, etc. [1]. Thus, sexual and reproductive health is a situation where women, especially, are free from disease and their overall health and wellbeing is promoted [1].
One of the groundbreaking strategies addressing sexual reproductive health challenges was the Programme of Action (PoA) adopted at the International Conference on Population and Development (ICPD) held in Cairo in 1994. The ICPD Cairo conference affirmed a public policy framework on sexual and reproductive health in which the need to promote women’s empowerment was moved to the front and center of international family planning and population movements. Individual member countries adopted eight Millennium Development Goals (MDGs) that are important to enhancing women empowerment, health and human rights. Second, nongovernmental organizations present at the ICPD meeting took the lead to affirm in the adopted PoA, the philosophy and idea that women have genderspecific right, rights as women, rather than being subsumed under universalizing declarations of human rights [4]. One would argue therefore, that the Cairo conference was the first stage in the heuristic policy framework (agenda setting, formulation, implementation and evaluation) [4]. This agenda-setting forum declared the following: to achieve universal access to sexual and reproductive health by 2015; protect reproductive rights; and eradication of HIV/AIDs. Compared to other forums prior to 1990, the ICPD Cairo conference specifically set the stage to the improvement of maternal mortality, access to life-saving antiretroviral drugs and use of contraceptive drugs [5]. Conversely, many developing countries around the world are experiencing growth in their gross domestic product, and half of the low-income countries in 2000 will be middle income by 2020s, all partly attributable to ICPD Cairo conference [5]. Despite these successes, there are areas where progress remains far too slow as vast inequities persist around the world especially disparities in the rights to reproductive healthcare services [1,6]. A lack of collaborative efforts among policy makers and misinterpretation of existing policies in funding comprehensive sexual and reproductive health programs are some of the probable reasons contributing to the slow progress [6].

Policy Responses towards Global Sexual and Reproductive Health

Sexual and reproductive health plays an important role in the overall health of a population. Recent studies have found that an overall improvement of individual health, especially women’s health, increases their reproductive health and improves their children’s wellbeing [6,5]. Reproductive health addresses reproductive processes, functions and systems at all stages of life and implies that people are able to have a responsible, satisfying and safe sex lives and that they have the capability to reproduce and the freedom to decide if, when, and how often to do so [3].
The United States Cosponsors of the Global Sexual and Reproductive Health Act have introduced this bill to the House and Senate in three consecutive years (2010, 2011 and 2013) in the recent past. The prelude to these Acts is the United States Foreign Assistance Act of 1961, which for almost 50 years, has governed U.S foreign assistance policy. Although the 1961 law has been amended many times, the provision on sexual and reproductive health has not been updated. While the 1961 law focused on fertility reduction and population stabilization as means of development, the language as promulgated is inattentive to the groundbreaking rights-based consensus reached on sexual and reproductive health policy outline in the Program of Action of the 1994 ICPD in Cairo. Thus, the objective of the Global Sexual and Reproductive Health Bill of 2010 was to update the U.S. foreign assistance policy as it relates to sexual and reproductive health in line with a rights-based approach [7]. The implementation of the law would ensure comprehensive sexual and reproductive health programs that are responsive to the full range of sexual and reproductive health need of women. That said, policy on sexual and reproductive health in the United States is often seen as a “black box” [8], frequently dominated by abortion and other social issues and fails to attend to the broader issues affecting women to include reproductive health rights and justice. As such, individuals and couples continue to experience “reproductive punishment” or “reproductive oppression” as has been observed by the Asian Communities for Reproductive Justice [9]. There is a need therefore, to formulate a practical framework that can comprehensively analyze components of family planning, reproductive health, maternal health, and HIV/AIDS under one policy framework.

Reproductive Health Rights

The Global Sexual and Reproductive Health Act of 2013 [10], defines reproductive rights as a basic right of all couples and individuals to decide freely and responsibly the number, spacing, and timing of their children; to have the information and means to do so, and to attain the highest standard of sexual and reproductive health. Feminist scholars of color have extended the discourse on reproductive rights to include the struggles and challenges of racism, classism and other oppressions [11]. Further, reproductive health movement is attentive to the limits of choice for women to abortion [12], or, the freedom to have or parent any child [12]; it highlights the dynamic relationship between the law, social movements and reproductive health [11]. Overall, reproductive health rights and justice are achieved when women, girls and individuals have the social, economic, and political power and resources, to make healthy decisions about their bodies, their sexuality and reproduction choices for themselves, their families and communities [9]. Thus, a focus on reproductive health rights and justice approach creates a paradigm shift that advocates for comprehensive frameworks that not only facilitates provision of reproductive health services but also recognizes and articulates the concept of reproductive health rights in policy generation. At first look at the 2013 Act, one notices some key perceived gaps: 1) a lack of comprehensive eligibility rules for the young people, 2) complexity of language, 3) a lack of cultural competence awareness guideline, 4) a lack of consideration of context and variations in countries’ laws and, 5) sustainability criteria. It is therefore vital for Congress to make the necessary amendments to create categories for cultural competency training; an accommodation for diversity needs within individual countries, and the sustainability piece for countries that are signatories to the Act. To do so, policy process making should be viewed as a rational, comprehensive and attentive framework. Consequently, this forms the basis of this policy analysis on the process of policy making and key things that US congress should consider when adopting policies that mainly impact developing countries.

A Hybrid Model for Analysis of Policy Making

This paper examines Global Sexual and Reproductive Health Act of 2013 through the lens of a comprehensive framework drawing on applicable elements of several unique models of policy analysis to create a hybrid model. The hybrid model describes: 1) the problem that arise requiring policy attention, 2) the people who participate in policy making process, 3) the process of policy making, 4) the actual policy goals and objectives, 5) the cost of policy options and how resources are allocated, 6) the implementation plan 7) the outcomes of the policy, 8) the value criteria, and 9) expected unintended consequences of the Act (Figure 1).
Figure 1: The Hybrid Model for Analysis in Policy Making.
The hybrid model is organized around common features of several models. Using the descriptive aspect of Moroney’s model [13], the existing past and current structural problems of sexual and reproductive health is analyzed. A gendered lens presented in feminist policy analysis frameworks [14] is used to analyze the assumed sources of social inequities that exist among the groups affected. Due to the complexity of decision making in global health policy making process, the framework explores alternative strategies and decision-making processes in ameliorating the problem using the rational and bounded rationality decision making models [15]. In doing this, Birkland, provides a comprehensive framework that decision makers can use to gather all possible information they can on the economic and societal costs and benefit of sexual and reproductive health programs in developing countries. The content and feasibility of the Act is analyzed using the ideas of Chambers and Bonk [16] to examine eligibility rules, administrative structures for service delivery,financing method, the intended implementation strategy and intended outcomes. Further, evidence on health service delivery is drawn from a country case study of Pakistan involving extensive NGO contracting for human immunodeficiency virus (HIV) prevention services supported by donor agencies [17]. Together, this combined policy model allows for the identification and exploration of complex considerations specific to Global Sexual and Reproductive Health Act of 2013. This hybrid model is rooted in the principles that provision of sexual and reproductive health is a right and not a privilege.

Historical Analysis of the Problem and Responses to Sexual and Reproductive Health

In examining the policy making process, phase I of the hybrid model utilizes Moroney’s model of policy making as a guide to locate the history and supportive evidence in research to support sexual and reproductive health. It is evident that sexual and reproductive health has remained a problem of the poor. During the 1960s, the United Nations Population Fund (UNFPA) was established with a mandate to raise awareness about population “problems” and to assist developing countries in addressing them. At that time the talk was of “standing room only” [18], “population bombs” [19], demographic entrapment [20] and scarcity of food, water and renewable resources [21]. Concern about burgeoning populations, particularly among the poor in the developing world, coincided with the rapid increase in availability of technologies for reducing fertility [22]. The push for population control was promoted and fronted by the US government who rewarded countries that utilized population control technologies and punished those that did not by withholding financial and material support [23]. These coercive and manipulative methods of medical technologies were often untested and risky, yet endorsed by American experts and activists as “family planning” programs [23]. Countries in Asia and others were offered Western loans and grants to pay for these programs whose focus was primarily population control rather than the implementation of comprehensive reproductive health services as a human right. In India, Pakistan, Bangladesh, and Indonesia, for example, Western donors financed sterilization programs while their consultants advised for the denial of health care and education to those who refused to be sterilized [23].
Although the national family planning programs that emerged in the 1960s and 1970s were greeted skeptically to affect fertility behavior, the dominant paradigm at the time was population control [24]. Experts argued that population growth would hinder development, cause poverty and sustain underdevelopment [25]. Thus, population control policies primarily focused on the need to restrain growth and very little on the aspects of population change that were structural or addressed migration patterns [22]. They were simply top-down, hierarchical models whose matrix of success was based on numeric goals of numbers of family planning acceptors, and the number of tubal ligations performed [22]. The impetus to show reliability and utility of the programs in reducing fertility, and the infrastructure support notwithstanding (e.g. administrative, staff and logistical support) created a false dichotomy of success [26-28].

The ICPD Consensus

In 1994, ICPD leaders strongly advocated that programs be broadened to embrace aspects of reproductive health beyond contraceptive use [1]. ICPD affirmed the basic reproductive health right of all couples and individuals. However, political compromises over issues like abortion were discussed, especially the health impacts of unsafe abortion. Six years after ICPD, the world converged again to craft an agenda to end extreme poverty [29]. At this time, 189 countries pledged to meet eight millennium development goals related to poverty, gender equality, maternal and child health, HIV/AIDs, and the environment [29]. The negotiators of the path-breaking ICPD agreement understood the interrelationships among these issues and the central importance of women’s empowerment, health and human rights [30]. Although sexual and reproductive health rights( SRHR) were comprehensively defined in ICPD and reiterated in subsequent international consensus documents, the only goal related to SRHR in the MDGs was MDG 5 which called for improvement in maternal health [31]. Notably in 2005, another target, MDG 5B, relating to universal access to reproductive health was added and the indicators for measuring target 5B were introduced in 2007 [32]. In particular, the negotiators of MDG 5B knew that achieving universal access to sexual and reproductive health and protecting reproductive rights is necessary to achieve all the other goals, including the eradication of HIV/AIDs [33].
Post-ICPD negotiations have brought about an increase in population policy projects such as RAPID (Resources for Awareness of Population Impacts on Development) which have proved very effective in convincing policy makers of the importance of addressing population growth in developing countries [8]. For example, since 2001, the president of Uganda, Yoweri Museveni, has relied in large part on the information on reproductive health and development that is derived from the RAPID model for his public statement, such as to the UN General Assembly Special Session on Children in May 2002, when he used projects generated by the RAPID model to state the need for attention on maternal health, child spacing and family planning [34]. Therefore, a key strength in the fight for reproductive health rights was in the mobilizing of the international community to address an important issue. However, there are shortcomings that continue to cloud the agenda and debate in reproductive health policies especially the once designed for foreign countries.
Although ICPD marked the jumping off point for the world to move forward, US policy on global reproductive health issues regressed in the years immediately following ICPD [1]. The takeover of House of Representative by Republican leadership not only opposed abortion rights but also a reduction of US funding levels for international family planning programs [35]. Indeed, MDG 5B was adopted against the strong political opposition of the Bush White House, among others and it is widely acknowledged to be the MDG that is most lagging in terms of progress [31]. In East Asian countries, however, MDG 5B is making encouraging progress [36].
The United States’ stance on reproductive health issues has continued to undermine its credibility and leadership as a global leader on this issue. The policy of the “global gag rule,: for example, prohibited US funding for family planning to indigenous groups overseas that engaged in services, dissemination of information, or advocacy activities on abortion [2]; undermining the human rights and democratic values that the US cares about. On the other hand, the US global support on health has experienced a remarkable progress through the US Global Health Initiative since 2009. This initiative has been strategic in combining the capacities of US Government agencies to address global health challenges that threaten lives at home and around the world. Through this initiative, state legislators have taken study tours to learn firsthand the role and impact of U.S. foreign assistance and policies on integrated and comprehensive sexual and reproductive health programs in developing countries. In Ethiopia for example, delegates learned about the U.S. approach to global health assistance that supports the Ethiopian government’s response to health and development challenges. They also learned how U.S. policies and assistance can continue to address global health challenges by working towards the achievement of MDGs and specifically MDG 5B. It is noteworthy that beyond the MDGs, there has been a recent resurgence of international family planning meetings and commitments, including the 2012 London Family Planning and Family Planning 2020 [FP,2020] [37] which supports access to family planning for women and girls in developing countries. This increases opportunities and life choices, and also supports the social and economic development of their families, communities and nations. At the center of FP 2020 is respect for reproductive rights by ensuring that women and girls in developing countries can have the freedom to access and use family planning, without coercion or discrimination [37].

Theoretical Perspectives

The key programs that are addressed by Global and Reproductive Health Act are rooted in feminism theory. The most salient element of feminist theory regardless of the type, (that is liberal, radical and socialist), is the attention paid to gender and power imbalances experienced by women. Feminist theory has specifically exposed the root cause of women’s economic disparities, diverse sexualities, health concerns, family complexities and women violence [38]. These issues have resulted to gender inequality and oppression, especially for women in developing societies. Further, studies have suggested that gender inequality results from structural barriers that lead to differences in human capital, such as education, skills, and expected length of labor-force participation [39]. Similarly, Sen [38] argues that existing social- cultural practices and economic systems tend to favor men, therefore resulting to patriarchy and this restrains women from obtaining social resources. In promoting a feminist intervention strategy of consciousness raising, the Global and Reproductive Health Act of 2013 has outlined programs and activities that can facilitate transmission of power to beneficiaries of programs and services to help them rise out of positions of helplessness and confusion, (re) claim control of their lives and discover their own inner strength [40]. The act has identified the internal and external obstacles that hinder women and youth empowerment. The activities outlined in the act show an inclusion of issues addressed in the feminist toolbox of addressing empowerment among oppressed populations [41]. These activities that include media literacy, anti-oppressive work, consciousness raising and dialogue between groups and individuals should be implemented in relation to the attainment of sexual and reproductive health [41]. Such activities help in deconstructing gender inequality and hence increasing access to sexual and reproductive health services among oppressed individuals.

Description of Policy Elements

Decision making
Phase II of the hybrid model examines the decision-making process. Birkland [15] states that the role of decision makers in policy making entails coming up with possible strategies to find the most viable approach to a given problem. This can be achieved by reviewing and analyzing policies that are already in force, setting the policy agenda and formulating the policy. The way the problem is stated influences the types of solutions that are proposed [8]. Based on Birkland’s perspectives, this section will discuss: 1) the role of decision makers on issues of reproductive health and rights in developing countries with an emphasis on a rational and incremental decision making process and 2) the role key stakeholders play in influencing the decision makers through dialogue and advocacy.
Rational comprehensive decision-making
Key decision makers on the issues of reproductive health in developing countries are still tasked with creating strategies that help in promoting reproductive health justice for all. Such decision makers and the institutions they represent have to come up with a solution [15]. Such solutions can only be achieved when decisions are made based on the best information that is available in eliminating reproductive health oppression [9] so as to achieve maximum social gains [15]. Birkland further states that when a problem is identified, it is hard to understand what goals various proponents or opponents of the policies have in mind. He further affirms that goals are left purposively ambiguous so that the legislation can gain passage; it is then left to the implementers to figure out what most important goal or goals are. Therefore, some solutions to a problem will foster political conflicts even if the solution seems rational [15].
From a societal perspective, some members of the US Congress will view the provision of reproductive health and services from a human rights perspective and as a way of improving access to reproductive health services to the less fortunate in the society. Some view this as an improper use of tax payers’ money by prioritizing foreign issues at the expense of addressing surging domestic problems. Some policy stakeholders state that teen pregnancy, for example, should be addressed through abstinence only, while others see the need for comprehensive sex and reproductive health education and access to means of protection against pregnancy and disease. Some argue that teenage pregnancy is not a problem at all, but a logical response to cultural conditions [8]. The same problem can be seen to have rather different opinions and goals. Such views spark considerable policy debates between decision makers and various stakeholders having different views on the appropriate policy responses. Therefore, decision making process must be viewed through the lens of incremental perspective.
Incremental decision-making process
Birkland [15] argues that the decision- making process can progress in relatively small increments rather than big leaps. The key sources of information on global reproductive health and rights include what we know about the current nature of the problem, our accumulated knowledge on what steps have been taken before if any and whether the steps appear to be successes or failures. Decision makers with regard to this policy will need to rely on information provided by different stakeholders over a period of time in considering alternatives for dealing with the problem that differs incrementally from existing policies [15]. The process of incremental decision making will require knowing the important roles and responsibilities of each stakeholder. For example: Who are the people affected by the problem? How is policy submitted for approval? Which states or institutions can draft policies? What institution can pass the law? Such questions help in identifying the strength of institutions and individuals to be involved in decision making as this can have a direct impact on the success of the policy [8].

Goals and Objectives

Goals and objectives is phase III of the hybrid model. The process of settings goals and outcomes in every policy making is critical. The goals and objectives may be general or narrow but should articulate the relevant activities and indicators by which they should be achieved [8]. The key goals should reflect the objectives of the different actors in the policy and ensure that goals are set in congruence with target population. A global commitment to reproductive health issues by US leadership has intensified now more than ever before. This commitment is evident in the goals that have been set to provide reproductive health services to impoverished communities in developing countries. Nevertheless, in many countries, there has been a tendency to focus on reproductive health services as the goal rather than on the provision of reproductive health service as a right [42].
The key goals as outlined in the Act are to: 1) ensure that couples and individual men and women in developing countries are provided with a continuum of sexual and reproductive health services that meet their needs and 2) improve the sexual and reproductive health of individuals and couples in developing countries. These goals are set based on the findings of the reports presented to the congress by [43-45]. Key findings from these reports show the need for a comprehensive framework that is inclusive of meeting most of the eight United Nations Millennium Development Goals (MDGs). In order for such a framework to exist, national policy contexts in developing countries are required to provide a platform where both local and global stakeholders in reproductive health can dialogue on key programs implementation issues.
Stakeholders collaboration
Non-Governmental Organizations (NGOs) and advocacy groups play a role in the process of formulating the policy by advocating for change, academic and research organizations provide data for decision making, donor organizations provide data for policy research, policy formulation and implementation [8]. International organizations also play a role in championing and supporting the programs outlined in the policy. Key international organizations like USAID, (that manage family planning, reproductive health and HIV/ AIDs on behalf of the US government), CHANGE, and UNFPA, have been very influential in championing the process of drafting Global and Reproductive Health Act of 2013. Their ability to access decision makers by providing evaluation reports and evidence based research to the US Congress has been very crucial. Through their reports and community based research, such organizations have ensured that the views of the people affected by the problem are included in policy drafting. Omitting such people runs the risk of developing an unrealistic, unfeasible policy. Nonetheless, high- level support within the government is crucial for policy change to occur. Thus the process of passing the Act into law will require a strong leadership by key individuals and a low level of organized opposition. As the largest donor in the area of sexual and reproductive health, the United States government has a unique role to play in averting unnecessary deaths and unintended pregnancies [35]. As a signatory to several human rights instruments, the U.S. also has a legal obligation to ensure that its commitments are upheld [1].
Feasibility analysis
This section will review phase IV of the hybrid model; the financial, physical and human resources that are needed to implement the Act. Following specific elements of Chamber & Bonk [16] model, expected benefits of services, eligibility rules, financing method and intended outcomes will be discussed. Implementation plan and start up times are discussed as well.
Cost effectiveness and benefits
Investing in sexual and reproductive health is critical for saving lives and reducing ill-health among women and children and fulfilling their internationally recognized right to good health [46]. Although, reports by CHANGE [35] and USAID, [5] indicate that there is no clear data yet establishing the cost effectiveness verses the benefits of the provision of comprehensive sexual and reproductive health services. However, the report by Singh, Darroch and Ashford provides more evidence that would convince policy makers that investing in sexual and reproductive health is indeed cost effective and necessary. Currently the total cost of providing a package of sexual and reproductive health services stands at $ 39.2 billion annually [46]. This amounts to $ 7 per person in the developing world. This investment has led to a decrease in unintended pregnancy, maternal and infant mortality and HIV prevalence and AIDs mortality in the last decade [46]. Notably, meeting all needs for modern contraceptives will cost an additional $5.3 billion per year more than is currently spent [46]. This reflects the magnitude of the improvements required to expand capacity and improve the quality of contraceptives in developing countries. Cochrane review on integration of sexual reproductive and HIV on the other hand, was a two study review that examined the cost effectiveness of reproductive health. The studies suggested net savings from HIV/STI prevention integrated into maternal and child health service [3]. Overall these reports have acknowledged a comprehensive framework that focuses on social benefits of provision of human rights. Therefore the type of benefit this Act is expected to offer is not only hard benefit (like cash or commodities) but a human rights benefit that respects dignity, autonomy and agency of a diverse client base including the very poor and marginalized. Most importantly, the benefit of saving lives and reducing ill health among women and children in developing countries [35,46].
Eligibility for assistance
Global and reproductive health act outlines the eligibility criteria based on the Foreign Assistance Act of 1961 (section 104, 104A, 104B and 104C). Under this, foreign NGOs shall be eligible for such assistance solely on the basis of health or medical service, including counseling and referral of service provided by such organizations with the non-US government funds if such services are permitted in the country in which they are being provided and would not violate United States federal law if provided in United States. The other rule for eligibility is that funds provided by US shall not be used for advocacy and lobbying activities other than those that apply to US NGOs receiving assistance under part one of the Foreign Assistance Act of 1961. It is noteworthy that US by law does not fund abortion as a method of family planning. It can and does provide assistance for treatment of incomplete or septic abortion, lessening the consequences of unsafe abortion. This eligibility rule has led to a limited access to safe abortion for women living in developing countries where unsafe abortion is on the rise [2]. Young people, individuals and couples living in many developing countries are eligible to receive sexual and reproductive health services with an exception of access to safe abortion for women and girls.
Financing method
Policies that are well written but do not have resources for implementation are too common [8]. In the United States, such policies are often called “unfunded mandates”; Global Sexual and Reproductive Health Act of 2013 could be given the same label. When developing and analyzing a policy, it is important to consider the level of finances necessary for proper implementation and whether these finances are allocated or need to be added for effective policy implementation [16]. Although sexual and reproductive health has proven to be a wise use of development dollars, donors and governments are not doing enough to mobilize additional funding and maximize impact of money spent [47]. Until now, funding falls short of commitments and needs. It will cost a minimum of US dollars 68-70 billion each year until 2015 to achieve the ICPD pledge to universal access to reproductive health [1]. Globally, two thirds of funding is expected to come from developing country government, Civil Society Organizations (CSO), the private sector and consumers, with the remaining one-third coming from the developed nations [48]. This funding is essential to pay for contraceptives and maternal health supplies, staff training and compensation facilities and strengthening overall service provision.
However, the effectiveness of previous financing mechanisms is still in question, in Ethiopia for example, US funding on HIV/AIDs pays two times government salaries, causing a drain of doctors and other health care providers in other sectors [35]. U.S policies and funding structures often pose significant obstacles to comprehensive care models [35]. Funding through the national government programs also poses great challenges due to the increase of private sectors that seek government contracts to provide reproductive health services [42]. Countries like Trinidad and Tobago, Mongolia and Nicaragua and an increasing number of other countries are encouraging competition for government contract for provision of services [42]. A public-private mix of service delivery already exists in Brazil, Egypt and the Philippines [35]. The contracting of discrete activities of service provision e.g. (antenatal care) and support activity (e.g. Transport services) to the private sector may lead to an increase in the number of separate organizational units in the field of reproductive health [42]. This may result in separation rather than integration of programs, which leads to a rise in user fees limiting access for such services by consumers especially the marginalized populations. Findings from a case study from Pakistan on NGOgovernment contracting for health service delivery indicate that contracting is a political policy affected by wider policy context, also wide scale contracting was mismatched with the capacity of local NGOs and also contracting can have unintended knock-on effects on both providers and purchasers [17]. Therefore as a result of public sector contracts, NGOs became more distanced from their grounded attributes.
To remedy such challenges, the 2013 Act has outlined the need to create financial sustainability for sexual and reproductive health programs that meet the needs of the people by offering free and subsidized services to the target population. This can only be achieved when national government is able to commit finances from their budget to support sexual and reproductive health programs. In Egypt for example, the Minister of Health noted that “putting money into family planning was a good investment as every Egyptian pound spent on family planning resulted in a savings of 30 pounds that would have to be spent on fulfilling the needs of a growing population” [34]. He concluded by requesting an increase in the budget allocations for the population and family planning program [34].
Implementation plan and start up time
Policies are often broad statements of intention and as such require supplemental implementation documents, including strategic plans, implementation plans, and operational policies to ensure that the policy is carried out [44,49,50,]. Programs have to be put in place to implement policies. Such programs have to take note on the role that context plays while implementing such policies. Therefore, many new and old stakeholders come into play demanding for an organizational structure including the lead implementing agency, or body, resources that support program implementation and activities required to implement the policy through programs [40]. If most of these stakeholders have not had an opportunity prior to implementation to influence the policy design, they are tasked with the implementation of a policy that they do not whole heartedly support and therefore the policy is more likely to be ineffective.
In many developing countries, provision of reproductive health services is currently being offered through international organizations, national government, private sectors and local nongovernmental organizations. In addition, countries already have local policies and strategic frameworks in place that can facilitate the implementation of the Act. In Nigeria for example, the minister of State for Health launched the National Reproductive Health Policy and the National Strategic Framework and Plan in November 2002 [34]. Overall, policy implementation is often multidimensional, fragmented and unpredictable. USAID has provided a framework that divides policy implementation into six tasks identified as; legitimization, constituency building, resources, organizational structure, mobilizing action and monitoring impact. Such a framework should focus on strengthening local skills; for example training and equipping traditional midwives to increase access to maternal health care services to marginalized populations. Reviewing and using such a framework during start-up can help to point out potential problems and obstacles to achieving policy reforms [51].

Outcomes

Effectiveness
The effectiveness and the success of the policy will be measured with particular emphasis on the perspective of reproductive health service users and access to these services as a right but not as a privilege. The effectiveness shall also be evaluated in relation to interactions between the policy elements, programs and activities for each program. This will entail evaluating these outcomes in relation to the goals and objectives set to be achieved in the Act. Haskins and Gallagher [52] notes that the translation of broad, general goals to specific objectives is not easy, For example, a general and vague goal of “providing sexual and reproductive health rights” might be difficult to measure. The challenge comes when the measurement scale of issues stated in the policy like empowerment does not measure the actual conceptualization of reproductive health rights. The Act should clearly conceptualize the term reproductive rights to ensure that the outcomes and indicators of reproductive health rights from the policy are easily measured. Nevertheless, the Act has plenty of opportunities to ensure effectiveness in the provision of sexual and reproductive health services. Opportunities for action as outlined in the policy include; establishment for standard sexual and reproductive health service delivery to the target population and conducting formative research to monitor and evaluate the effectiveness and efficiency of programs.

Unintended Consequences

The actual impact that a policy has on society may differ from the original goals and objectives; therefore, in policy analysis it is important to assess the unintended consequences that occurred as a result of the policy [53]. In the past reproductive health policies have excessively focused on ways and means to ensure the economic development and sufficiency which has produced some of the most well- recorded violations of human rights in the modern history [54]. As a result, economic development policies for improving reproductive health are now subjected to the scrutiny of human rights groups and agencies at national as well as international levels [55-57].
As such, the rights-based approach to development is a core concept in the current Act. However, this approach runs the risk of focusing on the rights of the individual to the exclusion of the wider context within which rights are defined and realized [58], such as access to economic and social resources.
For many of the world’s poorest communities, those who most need to benefit from reproductive health services–the threats of international intervention might outweigh the opportunities [59]. Coupled with already shaky social and economic infrastructures, including devastations caused by diseases such as AIDS, it is highly improbable that commitment to fund two thirds of reproductive health programs can raise the economic tide for these countries. This is simply an unintended consequence arising from philanthropic activities rather than a consequence of sustainable development. The control of private sectors for the provision of these services in target countries is beyond the scope and operations of policy makers at the international level; however, policy planners must begin to think on an internationalist rather than on an isolationist basis.

Discussion and Implications for Social Work

The models for analyzing policies that are already in place have been researched and utilized by a number of scholars and practitioners. The analysis of the Act using a Hybrid Policy making analysis model helps reposition the issues facing individual and couples and especially those who live in the margins in developing countries.
The criteria should be rooted in one if not all, of the principles of strength based policy as outlined by Rapp and colleagues [60]. In order to make the language in the act less complex and easily understood, the act should make provisions to educate intended consumers on the services being provided and educate them on the importance of advocating for their individual rights. For example, most women in developing countries especially in the rural areas are not aware that it is their right to access and demand maternal health care in local health centers. Public awareness campaigns, trainings, workshops should be used to ensure that people are aware of the services being provided. Health care facilities should provide rigorous trainings especially on cultural competency to health professionals and providers of reproductive health services before and during the implementation of programs outlined in the Act.
There were some limitations especially in lack of evaluation data since the Act has not been passed. Despite the gaps and limitations identified, this study infers a comprehensive analysis using the hybrid model of analysis of policy making. Using this model, policy makers, researchers, policy analysts and international social workers can integrate multiple issues and bring together constituencies that are more powerful and relevant in addressing reproductive health oppression. From analyzing existing policies to creating and implementing new ones, understanding the nuances of reproductive justice within specific communities allows us to make real changes in the lived experiences of the communities most impacted by reproductive oppression, rather than assuming that all communities are or will be affected equally.
Challenges can be found in each stage of policy making analysis found in the hybrid model, perhaps the problem was not well articulated, and perhaps there is strong opinion on how to address the problem. However, using the hybrid model can help to identify what aspects of the policy or the policy process need to be addressed to solve an identified problem. The hybrid model does not give an indication of the time each component will take, because it depends on the context and the issue to be addressed. Overall this model advocates for a policy making process that advances global health policy development by reviewing each stage with undivided attention.

Conclusion

There is a widening of the economic gap between the wealthy and the poor, thus creating greater class polarization [61]. There are unprecedented levels of unemployment, particularly in poor, developing countries. These have deepened poverty, affecting the needs of the poor and general population. Poverty, unemployment and changing family structures present policy makers with new and increasingly severe problems. Because providing funds for global reproductive health programs creates private corporations and a concentration of wealth in a few hands, many who are poor are left behind and there are less available resources for their needs. Overall, the hybrid model aims to facilitate a policy making approach that enables dialogue and consultation between stakeholders and decision makers in the initial stages of policy making. This model takes into account an incremental decision making approach where sexual and reproductive health programs are continually being developed and negotiated in consideration with competing interests socially, economically and politically. The model has also traced how the United States policy on reproductive health is modeled on the 1961 Foreign Assistance Act of 1961. Although the Cairo conference of 1994 outlined a progressive roadmap to achieving reproductive health for all, it requires a lot of governmental cooperation to its full implementation and realization.

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