By Lethia Bernard
Research and Policy Analyst
Family planning is one of the most effective development interventions, improving the health and well-being of women and girls, increasing their social mobility and earning potential by helping them stay in school, and contributing to numerous other benefits for communities. These include reducing maternal mortality, increasing child survival and even building resilience in the face of external shocks such as food insecurity and climate change. In fact, access to comprehensive, high quality sexual and reproductive health (SRH) services and supplies is critical to achieving Sustainable Development Goals (SDGs) one through five, as well as goals eight, 10 and 11—just to name a few.
Yet, in most low-income countries, family planning is donor-dependent and heavily subsidized by users themselves. However, donor funding is insufficient and stagnant. At the same time, many low-income countries are graduating to middle-income status and losing eligibility for donor funds. As a result, public financing is necessary to ensure sustainability of sexual and reproductive health and rights (SRHR) investments.
In response, many sexual and reproductive health advocates have focused on domestic resource mobilization (DRM) from the perspective of creating budget lines and tracking associated allocations and expenditures at the national and subnational levels. Fewer, however, have been engaged in DRM with respect to health financing strategies under the umbrella of achieving universal health coverage (UHC). Yet, not only are the principles behind these strategies consistent with the achievement of sexual and reproductive health and rights; they perhaps represent the next best opportunity to shore up funding for sexual and reproductive health in the current funding and political environment.
A large part of UHC will involve establishing or reforming countries’ insurance schemes. These discussions will dictate whether insurance systems are pro-poor, include SRH services in benefits packages, or pay for certain or all portions of services. To ensure financial sustainability and equitable access, insurance schemes and respective packages of services must include SRH information and services including family planning, safe abortion and post-abortion care, pregnancy-related services and STI prevention and treatment—and now is the time to advocate for their inclusion. This environment represents an opportunity for SRHR priorities that champions of SRH cannot afford to miss.
Universal health coverage is gaining momentum at the global and national levels as one of the key health Sustainable Development Goals. Many countries are therefore embarking on large-scale policy reforms and restructuring their health system priorities and national health financing strategies to achieve universal health coverage by, or near, the 2030 SDG target date. They are either proposing major reforms to the existing health insurance schemes or creating them for the first time with the specific goal of using them as a mechanism to achieve UHC. Benefits packages may or may not include family planning and SRH services. Though the timeframe is 2030 achievement, these reforms take time to construct, implement, and yield results. That means governments are defining the structure of insurance systems and benefits packages that will implicate women’s access to family planning and SRH services right now.
SDG target 3.8: “Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all.”
Uganda, for example, has framed the most recent health sector strategic plan and health financing strategy in the name of achieving UHC by 2025 and plans to roll out a new health insurance scheme by then. Tanzania is developing the first national health financing strategy to outline a new health financing system to increase access and financial protection by raising domestic sources of funding and creating a new health insurance scheme. Zambia is also developing a national health financing strategy, which will include a new social health insurance scheme for UHC.
Some countries already connect the inclusion of family planning in national health insurance schemes in their FP2020 commitments. For example, Indonesia’s commitment reads, “The Government of Indonesia will ensure the provision of family planning services and contraceptives through the National Health Insurance scheme towards Universal Health Coverage by 2019.” Ghana’s first commitment is to revisit the national health insurance benefits package to include clinical methods of family planning services and supplies.
This shift has important implications for SRHR priorities, and champions must understand the opportunities presented by UHC to advance SRHR-inclusive policies and financing in country-level reforms that are happening now.
A Formula for Universal Health Coverage
At the core, UHC is both a process and goal that countries set out to achieve through their policies and programs. This involves ensuring equitable access to quality health services and financial risk protection. It is a country-specific endeavor that requires sustainable financing solutions, which are dependent upon each country’s unique situation.
“All roads should lead to universal health coverage.”
—Dr Tedros Adhanom Ghebreyesus, director general of the World Health Organization
According to the WHO, “UHC means all people receiving the health services they need, including health initiatives designed to promote better health, prevent illness, and to provide treatment, rehabilitation, and palliative care of sufficient quality to be effective while at the same time ensuring that the use of these services does not expose the user to financial hardship.”
Simply put, UHC is all people receiving needed quality health services with financial protection. In this way, it is helpful to consider UHC as an equation—needing both quality health services and financial protection to achieve the ultimate goal for all.
Quality Health Services + Financial Protection = Universal Health Coverage
Quality health services: Quality health services relates to people’s access to services and delivery of those services. Access depends on the availability, accessibility, acceptability and quality of services. This means that the services and goods—and health facilities and workforce that provide them—must be available; are physically and economically accessible (affordable); are ethically and culturally appropriate; and of sound quality. Service delivery requires strong health systems—including primary health care systems, where many people access preventive and promotive services.
Financial protection: Financial protection means protecting people from out-of-pocket spending and possible impoverishment from accessing those quality health services. The key to protecting people from financial hardship is to ensure prepayment and pooling of resources for health, rather than relying on people to pay for health services out-of-pocket at the time of service. Essential elements to improving financial protection are an expansion of prepayment and risk pooling schemes to cover everyone, elimination of out-of-pocket expenses at the point of service delivery and provision of a comprehensive benefit package.
Both components also comprise key drivers of unmet need for family planning. Meeting the needs of women and girls relies on quality health services, high-functioning supply chains and strong provider networks. Likewise, eliminating out-of-pocket expenditure alleviates the undue burden many women and girls with limited resources face when seeking contraception or other SRH services.
Currently, the financial protection aspect of UHC is most prominent in global and national policy dialogues, specifically because financing UHC requires domestic resource mobilization. The recent UHC Forum, jointly organized by the government of Japan, World Bank, WHO, UNICEF and UHC2030 in December 2017, reinforced that those resources should come from public sources of funding. Risk pooling, or health insurance, is ultimately the mechanism through which countries will achieve universal health coverage. Building insurance schemes by pooling public resources into a single, mandatory fund—via progressive taxation or social health insurance—is the most equitable way of doing so. The corresponding benefit package of health care, services and medicines must be comprehensive to meet the needs of all people. This must also include coverage for family planning and broader SRH services.
Areas of Action
While the reform process related to UHC will unfold differently for each country, citizen-led policy research, monitoring and advocacy at the country level will be important across all of them. Below are immediate opportunities:
1. Track country-level progress toward UHC-related reforms and opportunities to advance SRH-inclusive benefits packages
It is critical to understand how countries are raising their own revenue for their health systems, whether or not revenue generation is equitable, and how they are pooling those funds in the form of insurance schemes and then making coverage determinations, specifically related to family planning and SRH services. A keen understanding of the breadth and depth of this coverage will provide insight into how countries are planning to reduce out-of-pocket expenditure and increase access to SRH services. Some research shows varying coverage of family planning in insurance schemes in countries in West Africa and Latin America, but not broader SRH services. Likewise, tracking policy developments and engaging in policy advocacy to shape emerging national health financing policies and SRHR-inclusion is important. Research will also be helpful to capture country experiences and generate and share lessons learned between countries.
2. Monitor the quality of SRH services
There is little documentation on the quality of SRH services funded through emerging risk-pooling schemes. Monitoring the quality of SRH services is essential, given that quality health services are central to achieving UHC. This is a large endeavor because it requires granular, facility- and/or community-level examination, but will be important to identify. Monitoring this is also important for equity to ensure quality does not vary among facilities, communities and countries.
3. Hold governments accountable
Civil society organizations (CSOs) must hold their governments to account for ensuring equitable access to high-quality family planning and SRH services. CSOs should ensure that national governments produce policies in support of access, affordability and equity as they build out coverage and financing schemes in the name of UHC. Each country’s path toward achieving UHC will be individualized and vary from the other, but CSOs occupy a platform to best understand their health systems and youth and women’s experience within them, and inform impactful policy.