Written by Matt Boxshall, Anooj Pattnaik, and Nirmala Ravishankar, who work on strategic purchasing for primary health care at ThinkWell. In this blog they review family planning (FP) in universal health coverage (UHC) schemes and argue that the first question we need to ask is “will this reach those most in need?”

The global FP community recently gathered under the banner “UHC: not without FP.” A virtual plenary of the International Conference of Family Planning looked to “demonstrate why integrating FP into UHC is essential to its success”. As passionate believers in the power of FP, we could not agree more – but there is a trap here. Plans for making progress towards the goal of UHC may be wrapped up in rhetoric about ‘UHC schemes.’[1] In many countries – including in sub-Saharan Africa – these plans rely on scaling-up national health insurance (NHI), promising a defined package of benefits to contributors. Much energy has been expended on making sure that FP services are included (and clearly defined) in these benefits packages. Not enough has been spent on asking who gets these benefits.

Before we fight for inclusion of FP in benefit packages, we need to ask whether the women and girls most in need of high-quality FP services are going to benefit from these insurance-based ‘UHC schemes’. Sadly, if we look across sub-Saharan Africa, the answer to that question is a resounding ‘no’. Only four countries in the region cover more than 20% of their population though any kind of health insurance, and what coverage there is remains highly inequitable[2]. For FP to be the cornerstone of UHC that it should be, we need to look beyond the rhetoric of ‘UHC schemes’ and find the most effective ways to finance services so that they reach those most in need.

To understand why so-called UHC schemes are not always the right answer for FP, it is useful to reflect on the motivation behind the schemes. To ensure that everyone receives the health services they need without financial hardship, UHC requires pooling and redistribution of funds to those most in need, and so health financing reform is a key driver of UHC. Governments in most low- and middle-income countries operate a traditional national health service, wherein a government department allocates general revenue through input-based budgets to a network of government-owned health facilities to cover staff salaries, medicines, and operating costs. Most also have ‘vertical’ or disease-specific programs (including for FP), which channel commodities and other supplies to providers. These purchasing arrangements still account for the majority of government spending on health in sub-Saharan Africa.

The challenges of the traditional national health service approach – including poor management, limited accountability, and low productivity in service delivery – are well known. To address these challenges, countries in the region are introducing new purchasing or payment arrangements, which are often referred to as ‘UHC schemes’ as they are wrapped up within broader reforms related to the goal of achieving UHC. These schemes typically layer over traditional government supply-side financing.

Emerging ‘UHC schemes’ in Africa are largely based on health insurance models. While there are multiple reasons for this, a critical driver leading African governments to choose insurance approaches is simply the desire to generate more domestic resources for health. Insurance premiums seem to offer the promise of additional financing for the sector (although in fact they are unlikely to succeed in highly informal economies). A national insurance agency can also seem an attractive way to generate more flexible funds, which can be earmarked for health, outside the budget cycle, and perhaps not subject to all public financial management requirements. And of course, political reasons are also important, both in terms of the attractiveness of offering voters health insurance and the conflation of NHI with the global UHC movement.

So ‘UHC schemes’ based on health insurance are proliferating. In a 2017 review, 14 of 32 countries across sub-Saharan Africa either had or were developing some form of NHI, and more have started since. These schemes often enroll formal sector employees, and many also attempt to enroll the poor through government subsidy of premiums. This follows the model of the Philippines or Indonesia, for example, where roughly half of the population benefits from subsidized membership in NHI programs. But if the justification for the scheme is to raise additional funds for health, and existing health budgets are ‘locked-in’ for salaries, commodities and other inputs, these efforts at subsidy quickly run into problems. Kenya, for example, has tried to subsidize membership for the poor in the National Hospital Insurance Fund (NHIF) through donor support in the past (the Health Insurance Subsidy Program) and again this year by investing general revenue through the Government’s latest UHC initiative. But this new ‘UHC scheme’ is far from universal – it targets 1 million households (3.9 million people) in 2021, in a country where roughly 18 million people live below the national poverty line. While the Government has stated an ambition to progressively expand population coverage, this is an expensive proposition, which will test Kenya’s fiscal capacity and will certainly take time.

In summary, we find that across sub-Saharan Africa, nascent NHI schemes do not currently cover the poor. Seeking to deliver FP services through these schemes will not only fail to reach those most in need, but because most beneficiaries are relatively well off, this approach could risk undermining the legitimacy of spending government funds on FP. There is even, perhaps, a risk that governments consider that they have FP covered in NHI, and cut back on commitments through other, better targeted channels.

So, is there an alternative way to think about this? When it comes to targeting very specific population groups with services, it may be that input-based budgets and vertical programs are still the most effective mechanisms. However, this is not an argument for status quo – we recognize that health services financed in this way have had limited success in the region. The impetus to move away from legacy systems, where line-item budgets channel funds based on historical precedent and irrespective of performance, is indeed desirable. The World Health Organization defines purchasing as ‘strategic’ when decisions about the allocation of funds are based on information about provider behavior and population health needs in order to maximize health system goals. It is not necessary to restrict purchasing to enrolled members of an NHI to gain the advantages of more strategic purchasing; health authorities can still improve access, equity, and quality by making smart decisions about what to purchase, who to purchase from (including private providers), and how to pay them. Successful schemes, like Plan Nacer in Argentina, started by focussing on a narrow benefits package of the most important and cost-effective services, funded by government revenue, and explicitly incentivizing service uptake and quality. The Linda Mama maternity scheme, managed by NHIF in Kenya, contracts public and private providers to offer free universal access to maternal, newborn, and child health services, and provides immediate, on the spot, cover for all women. The Gratuité scheme in Burkina Faso does the same – a defined package of services is provided for all, and contracted facilities are reimbursed based on the services they provide, including, as of July 2020, family planning.

Finding the best approach to paying for FP services requires careful thought in any context. UHC, #NotWithoutFP, absolutely! But UHC is universal health coverage, not health coverage for a few formal sector employees enrolled in a NHI scheme (and the small fraction of the poor whose coverage governments are able to subsidize). As a FP community, we know how critical it is to improve access to high quality FP and sexual and reproductive health services for marginalized women and girls, and so we must focus our efforts on the purchasing mechanisms best suited to reaching those most in need. NHI in which only members have the chance to benefit is unlikely to be that mechanism in low-income countries with highly informal labor markets. Finding the best solutions means partnering with experts in health financing and diving deep to understand what is practical in the local context. Together, we must think carefully about how best to direct our advocacy and technical support, and not be trapped into thinking that the latest ‘UHC scheme’ will deliver FP for those we care about most.

[1] We use the word ‘scheme’ here as it is used in common parlance to mean a government program, which is different from the definition of health financing schemes in the System of Health Accounts.

[2] Edwine Barasa, Jacob Kazungu, Peter Nguhiu and Nirmala Ravishankar. Examining the level and inequality in health insurance coverage in 36 Sub-Sarahan African Countries (unpublished manuscript).

Please note that blog posts are not peer-reviewed and do not necessarily reflect the views of SRHM as an organisation.