Universal health coverage for sexual and reproductive health: evidence brief
Publication date: 2020
Universal health coverage for sexual and reproductive health Financing sexual and reproductive health services under universal health coverage Evidence brief This brief highlights the evidence on the current critical issues in the financing of SRH services under UHC. The evidence presented draws particular attention to the funding gap for SRH services, the potential and the limitations of available mechanisms for funding SRH, and the approaches, including strategic purchasing, for improving the efficiency and equity of existing resources in the context of resource-constrained settings. Financing sexual and reproductive health services Fully meeting all women’s needs in low- and middle- income countries for contraceptive, maternal and newborn care would cost as little as about US$ 9 per capita annually (1). Yet a persistent underfunding of services means that more than 4 billion people globally will in the course of their lives face a lack of access to at least one key SRH service (1) (see Box 1). This is in spite of the commitment made by United Nations Member States in the programme of action of the International Conference on Population and Development (ICPD) to ensure universal access to SRH services through a combination of domestic resources and official development assistance (3). Key messages ` Progressing towards universal health coverage (UHC) and improved access to sexual and reproductive health (SRH) services requires shifting the burden of financing away from individuals, especially women and girls, towards increased domestic public funding that combines tax revenue and prepayment schemes. ` SRH services beyond maternal health and family planning are not explicitly recognized in health benefit packages in many countries, leading to inequitable access to other critical SRH services. ` Improvements in the use of existing public resources for service delivery are important for efficiency, quality and equity gains, even where the context constrains funding for SRH services. ` Improved measurement and tracking of the resource flows for SRH services and products is needed for monitoring financial contributions from governments, donors, insurance companies and households. Box 1 Components of sexual and reproductive health services (2) • Contraception counselling and provision • Fertility care • Antenatal, intrapartum and postnatal care • Safe abortion care • Sexual function and psychosexual counselling • Comprehensive education and information • Gender-based violence prevention, support and care • Prevention and control of HIV and other sexually transmissible infections (includes reproductive cancers) These commitments were reaffirmed in 2015, when Member States adopted the Sustainable Development Goals (SDGs), which included the goals to ensure healthy lives and promote the well-being of all at all ages (SDG 3), and to achieve gender equality and – 2 – – 3 – women’s empowerment (SDG 5).i Combined, these goals are significant drivers for countries to increase access to SRH services, ensure their affordability and advance gender equality. Progress towards universal access to SRH services is severely challenged, however, by funding gaps. These arise through a combination of insufficient government spending, particularly in low-income countries, and fluctuations in external funding from donors (4). Total global domestic expenditures for the ICPD-costed packageii remains funded mostly through out-of-pocket payments, with only a small proportion funded by domestic public funding (4). In low-income countries in particular, which carry the highest health burdens, external donor funding continues to be a significant source of funding for SRH services. Reproductive health services (maternal and perinatal health, and family planning) receive 9% of global donor funding for health (5). To address the funding gap, global initiatives such as the Global Financing Facility (GFF) support national ministries of health to identify and scale up high-impact, cost-effective interventions that can be sustainably funded through a combination of increased domestic and increased international funding (6). Although blended financing,iii and specifically financing supported by GFF, has enabled the inclusion and prioritization of SRH services (6), several concerns arise. These include concerns that there has been too much focus on maternal health and family planning services to the exclusion of other critical services (such as safe abortion, and sexual and gender-based violence) (8, 9). In addition, the focus on domestic financing in the absence of viable domestic public funding can shift the burden of financing SRH services and products onto the poorest and most vulnerable people (8). Increasing domestic public funding for SRH services To progress towards UHC – and to ensure both overall sustainability and access to health services and financial protection – health services should be funded i Target 3.7 commits to ensuring universal access to sexual and reproductive health-care services, target 3.8 commits to the achievement of UHC, and target 5.6 reaffirms the ICPD commitment to universal access to sexual and reproductive health and reproductive rights. ii The ICPD costed package includes family planning services; basic reproductive health services; sexually transmitted infection and HIV prevention activities; and basic research, data and population and development policy analysis (4). iii Blended finance is the use of development finance and philanthropic funds to attract private capital, according to the concept developed by the World Economic Forum and the Organisation for Economic Cooperation and Development (7). predominantly through domestic public funding that combines taxes and prepayment mechanisms (10). While public spending on health per capita has increased substantially in upper- and middle-income countries between 2000 and 2016, it has barely increased in low-income countries (5), and the predominant financing mechanism for SRH services unfortunately remains out-of-pocket payments. Insufficient attention to the design of health financing policy (both insurance- and tax-based policy) can contribute to excluding the most vulnerable people (displaced populations, immigrant women, people with same-sex sexual orientation, and female sex workers, for example [11–13]). It can also systematically increase gender inequities. Providing insurance-premium or user-fee exemptions may help to ensure vulnerable groups are included, but any evidence that fee exemptions successfully address financial barriers and improve access is mixed. The challenges with exemptions include, among others, inefficient mechanisms for targeting beneficiaries, and a lack of information given to them about benefits packages and entitlements (14). There are also social- and gender-related barriers to access, including restrictions on the abilities of women and adolescents to travel to access services, or to make decisions about whether to seek health care, and there are concerns about confidentiality, stigma and discrimination in health settings (15). Tax-funding health services to provide key services that are free to everyone at the point of care may be more appropriate than giving exemptions – and, without the need to identify exempted groups, there are fewer administrative procedures. Improving efficiency and equity of existing resources There is increasing evidence that improvements in the use of existing public resources for service delivery are important for efficiency, quality and equity gains, even where funding for SRH services is constrained. For safe abortion services and post-abortion care, for example, task-shifting is increasingly applied to address critical shortages in the health workforce. This optimizes the available workforce, mitigates shortages of specialized health-care professionals, and improves the equity of access to health-care services and the acceptability of these services to users (16). Strategic purchasing has emerged as one of the main principles guiding health financing towards UHC. It is understood as promoting efficient, high-quality service – 3 – provision through a transfer of funds to providers that is linked to provider performance or the health needs of the population they serve (17). Strategic purchasing also enhances the transparency and accountability of providers and purchasers to the population. This model can be applied to a number of key activities, including benefit package design and the selection of providers, plus the methods of provider payment (18). Provider payment mechanisms aim to improve access to, and the quality of, services for the targeted population by motivating the behaviour of health-care providers through payment mechanisms (19). Different mechanisms have different implications for both the quantity and quality of services provided. For example, the risk of unnecessary caesarean sections may increase under fee-for-service models (20–22). There is also evidence that delivery of care is influenced by whether the purchaser is public or private. Where governments have been the primary payers for care delivery, rates of caesarean delivery, for example, have been lower than where private insurers have been primary payers, or where there has been a mix of public and private insurance coverage (23). The use of purchasing vouchers has largely focused on improving access to, and the affordability of, a subset of SRH services, including maternal and child health services, and contraceptives for targeted populations (e.g. adolescents, individuals with low incomes, sex workers) (24). The evidence suggests that vouchers are effective overall in reducing the financial barriers to access and increasing the uptake of prioritized health services. They can also drive service quality and access by targeting public funding to specific population groups and can improve efficiency in the use of domestic resources. Such improvements are contingent, however, on services being available and of sufficient quality (25). Although strategic purchasing is a widely adopted policy tool in high-income countries, there is a need for increased research that considers the implications of strategic purchasing for improving access to and the provision of high-quality SRH services in low- and middle-income countries. Conclusion The enormous funding gaps remain one of the key challenges for progress towards SRH and UHC in the SDG era. Although the uncertainty around external funding for SRH services remains a key challenge, current UHC commitments to increased domestic funding present an unprecedented opportunity for increasing funding for a comprehensive range of SRH services across the life course. This requires actions from global actors to meet current funding commitments, and national governments to increase domestic public financing. It also requires health financing reforms and improvements in the efficiency of existing resources. This demands paying specific attention to strategic purchasing as a potentially efficient mechanism for improving access, efficiency, quality and financial protection. These actions require: 1. investing in improved measurement and tracking of resource flows for SRH services, including out-of- pocket payments, disaggregated by gender and key equity indicators; and 2. strengthening the evidence base on the impact of health financing reforms on access to SRH services and on health outcomes. There are significant evidence gaps on providing SRH services in the context of UHC. These include the need to build the evidence base on financing a comprehensive range of SRH services in a health benefit package, on the implementation of strategic purchasing, and on engagement with the private health sector. Addressing the funding and evidence gaps are key actions for advancing on the commitments to UHC and sexual and reproductive health and reproductive rights, and to ensuring access to comprehensive SRH services. Box 2 How WHO is responding for advancing sexual and reproductive health and reproductive rights WHO supports health systems strengthening by countries progressing towards UHC and advancing SRH. This requires focus on the following areas. • Developing normative guidelines and tools to support regional and country-level efforts to integrate SRH within national health strategies. • Building and strengthening the evidence base on the implications of health financing and wider health system reforms for SRH – to more effectively support policy and programme design and implementation. • Providing technical support to countries that are integrating SRH into UHC national strategies. • Building momentum and political action to advance sexual and reproductive health and reproductive rights through partnership with key partners and stakeholders. – 4 – – PB – Contact us: Department of Sexual and Reproductive Health and Research World Health Organization Avenue Appia 20, 1211 Geneva 27, Switzerland Email: firstname.lastname@example.org www.who.int/reproductivehealth Photo: UNICEF/Shehzad Noorani WHO/SRH/20.1 © World Health Organization 2020. Some rights reserved. 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