Universal health coverage (UHC) characterizes an ideal where all people have access to the health services they need, when and where they need them, without financial hardship. In the same way that the long-term consequences of the COVID-19 pandemic will place a heavy burden on health systems, so too will the lack of reproductive health care.
As the COVID-19 pandemic ravaged the US and much of the western world, fraying health care systems and inequitable distribution of testing and vaccines have pushed the concept of universal health coverage (UHC) to the forefront of discussions where previously it has been an afterthought. For those who have worked globally on family planning, it is a reminder that the dream of universal health care is important no matter where you live and no matter what your health care needs are.
UHC characterizes an ideal where all people have access to the health services they need, when and where they need them, without financial hardship. In the same way that the long-term consequences of the pandemic will place a heavy burden on health systems, so too will the lack of reproductive health care. Currently 270 million women worldwide do not have access to modern contraception, a reminder that we are far from realizing the dream of universal health coverage.
“There is a misconception in the UHC world that it is about immediate life-saving interventions,” says Dr. Victor Igharo, Chief of Party, The Challenge Initiative, Nigeria. “Family planning, unfortunately, risks being left out of the agenda as its effects are long term.” Dr. Diana Nambatya Nsubuga agrees. She is the UHC Co-Chair in Africa and Regional Deputy Director, Policy and Advocacy at Living Goods. She asks, “If universal health coverage is about leaving no one behind, how can we achieve this if the unmet need for family planning is so high in Africa and other parts of the world?”
UHC is not a new idea, but the packaging of the best ideas that public health has learned over the years. Central to UHC is primary health care (PHC). Simple, novel, and powerful, PHC has revolutionized health care’s efficacy worldwide, offering the most basic package of essential services and products to prevent disease, promote health, and manage illness. Unfortunately, however, much of primary health care is still aimed at treating illness rather than maintaining a person’s health. And, significantly, much of primary health care is not people-centered.
In pursuit of UHC, as outlined within the Sustainable Development Goals (SDGs), countries have made gains, though sometimes in an unbalanced manner. Poorer countries, in particular, have improved the spread of infectious diseases. However, they have made fewer gains in securing the same results in providing reproductive, maternal, child, and adolescent health services. The pace of progress has been far from desirable. Major impediments to achieving UHC are the usual suspects: growing out-of-pocket expenditures, weak health systems, and entrenched gender norms and power relations.
As nations and communities grapple with the idea of UHC, how does family planning fit into the picture? Amos Mwale, Executive Director of the Centre for Reproductive Health and Education in Zambia, emphasizes that “UHC is not just about ‘coverage.’ It is truly about giving people the ‘choice’ and delivering what they want and not just what is available.” Countries that understand that UHC is a means of empowerment cannot afford to ignore family planning, which epitomizes choice and need.
The UHC/family planning nexus provides profound benefits beyond merely improved health and choice. Family planning expands opportunities for education, empowers women, sustains population growth, and accelerates national development. For its part, UHC restores equality, promotes social cohesion, and contributes to meeting a country’s development goals. And family planning plays a vital role in achieving the goals of primary health care.
The World Health Organization’s 2019 Monitoring Report on UHC deems weak health systems the greatest challenge to achieving UHC. Failures to meet the fundamentals of health systems manifest as obstacles to advancing the family planning agenda. Mwale says that COVID-19 has been a wake-up call to countries, lamenting, “Countries which fail to invest in universal health coverage and equip their health systems accordingly are going to lose precious lives. People will suffer.”
Among the health system gaps that must be addressed are:
While human resource gaps and low trust in health care practitioners remain a barrier in attaining UHC in general, lack of human resources to provide long-acting family planning methods and provider bias against some methods are principal barriers for universal access to family planning.
Overall financial protection for UHC and family planning is not showing a positive trend. While household contributions dominate UHC and family planning, the latter is additionally affected by heavy reliance on donor funding in many countries.
Data systems of many countries are functioning at sub-optimal levels. Available data does not permit researchers to understand the equity gaps among population sub-groups. In particular, health and family planning data on peri-urban poor, migrants, refugees, and other marginalized populations is sparsely available.
Poor health care infrastructure and lack of equipment and essential commodities hamper progress toward UHC. In the case of family planning, the availability of contraceptives is generally improving. However, too many countries still struggle to make contraceptives available to their most impoverished communities. Even when available, the choice of methods is limited.
Leadership and governance are central to reaching UHC and meeting the unmet need for family planning among populations worldwide. Once formidable, family planning programs are now losing political interest as countries fear having a low stationary/declining demographic phase. Lack of adequate political commitment coupled with existing cultural and religious opposition to family planning prevents communities from realizing their fertility goals.
Gender-based barriers to service delivery include a lack of privacy and confidentiality for women and girls in health facilities, unbalanced gender composition of the health workforce, and a widespread gender pay gap among health workers. Also impeding UHC and family planning, the questionable quality of services provided in the facilities – lack of respectful care for women – has discouraged services uptake.
It is clear there are, and will continue to be, challenges ahead in achieving UHC, but today’s interest and momentum can be harnessed for a more equitable tomorrow. But that tomorrow does not arrive without addressing family planning today. Many governments and civil society agencies exemplify how achieving family planning goals can lead to UHC in the long run. These governments and agencies communicate to the world that UHC is attainable if three things happen in family planning programs: innovation, collaboration, and acceleration.
Innovations are not just new, groundbreaking technological advancements – but a combination of commitment, creative thinking, and execution. It is not only about doing different things, but about doing things differently. Doing things differently remains a challenge to innovation within existing national systems. Dr. Nsubuga expresses optimism and caution: “We cannot go to scale without innovating, but we have to innovate within the current system and with resources.” Dr. Igharo adds, “Innovation is seeing government as primary agents of social impact; it is about deploying tools to meet the needs of communities.”
A case in point is the lack of surgical capacity to provide a basic surgical services package, a vital component to UHC. This shortage has to be examined under the context of declining tubal ligation and vasectomies worldwide. With a stagnating need for “limiting” among women in many parts of the world, easy availability and accessibility to tubal ligation and vasectomy would be a step in the right direction. The Lancet Commission on Global Surgery suggests that “the large burden of surgical disorders, cost-effectiveness of essential surgery, and strong public demand for surgical services suggest that universal coverage of essential surgery should be financed early on the path to UHC.” Taking a cue from this, countries such as Nepal and Kenya have embarked on training family and primary care physicians in basic surgical, obstetric, and anesthetic skills. There is growing evidence of surgical task-shifting in at least 29 countries in Sub-Saharan Africa and ten countries in Asia. Rather than waiting for opportunities to come, by embarking on surgical task-shifting, these countries are showing how producing simple, practical, and cost-effective innovations can strengthen health systems within the larger goal of UHC.
Another example of innovative solutions shaping the pathway toward UHC is Nigeria’s The Challenge Initiative (TCI). Set in the context of a declining trend in donor funding for Nigeria, TCI is a promising co-financing initiative for bridging the gap in funding family planning programs. Instead of a top-down model of donors picking states to work in, TCI encourages states to opt-in to participate in the program. A technical team guides the states to develop a family planning program plan featuring high-impact interventions. States then receive catalytic funds to facilitate the implementation of the plan. Soon, states commit funds to match TCI for the start-up, scale-up, and surge phases of the plan over a span of three years. States that live up to the commitments are further incentivized, and those that don’t are disincentivized. By the first fiscal year after implementation, 88% of the funds committed by the 11 states were spent through this innovative model. Dr. Igharo emphasizes that “TCI is a demand-driven model which provides all-around financial, programmatic, and technical support…this holistic approach putting the government in the driver’s seat is TCI’s niche.” Innovation for family planning and UHC can come in different forms, but collaboration and partnerships will only help take it to scale.
Collaboration and partnerships hold the key to addressing family planning within the larger scope of UHC. For example, FP2020 is a partnership that harnesses the potential of donors, UN agencies, NGOs, governments, civil society, and advocates – including youth – at global and country levels. Indonesia, for example, allocated $458 million in 2019 for family planning—an 80% increase from 2017—thanks to the collaboration fostered through FP2020. Indonesia has also included family planning in its national health scheme in the form of postpartum and postabortion services, and engaged the private sector to work in tandem with its efforts.
It should be noted that “working with the private sector” can have different meanings in different contexts and countries. It could refer to private practitioners who provide family planning services in one instance, or garment factories where women and girls work, or even private philanthropic organizations. Determining exactly what the private sector refers to is key in designing interventions. No matter what the definition is, Igharo believes that “scalability and sustainability of UHC depend on how successful we are getting the service providers in the private sector on board.” Collaboration is vital. For example, given the greater reliance of many countries on private practitioners and pharmacies for the provision of family planning services, it is critical to ensure they are a part of UHC.
The Global Financing Facility (GFF), another example of a successful global partnership, establishes a working relationship with ministries of finance at the national level to leverage domestic resources to co-finance investment cases. In Cameroon, the investment case centers on improving allocative efficiency and ensuring equitable distribution of resources. Redistributing resources with the catalytic support of GFF ensured Cameroon’s share of the national health budget for primary and secondary care rose from 8% of the 2017 health budget to almost 27% in 2019. These resources were allocated to the most underserved populations.
Patrick Mugirwa, Program Manager, Partners in Population and Development (Africa Regional Office), says that financing for family planning has gained a lot of traction recently. This happened when countries developed their costed implementation plans (CIPs) for family planning as a pathway for achieving their FP2020 commitments. This foundation makes available a ready-made financial package for including in their UHC roadmaps. Dr. Nsubuga sees an opportunity for “true integration” here. She believes that family planning programs have been donor-funded projects and programs for too long. UHC calls for government leadership in fulfilling health care promises to citizens and residents, and it’s time for financing for family planning to become an integral part of UHC roadmaps.
Agencies are increasingly appreciating the value of partnerships and are showing greater awareness of working together to achieve UHC. The recently announced Global Action Plan for Healthy Lives and Well-Being for All brings together 12 multilateral health, development, and humanitarian agencies managing one-third of global development assistance for health. The plan is a formidable partnership that can reduce inefficiencies in support of countries.
Global partnerships are needed for coordinated and consistent advocacy, generally through an effective national and community partnership. Living Goods Uganda has been able to achieve exactly that. “At Living Goods, we digitally empower community health workers to provide integrated health services, including family planning, at the doorsteps of people they serve,” says Dr. Nsubuga. The agency believes that collaborating with the Ministry of Health and providing integrated services to communities in a way that empowers them is the key to their success. This provision of integrated services, including family planning, has played a role in reducing under-5 mortality by 27% and stunting by 7% in areas where they work. This has been accomplished at a cost of less than $2 per person annually. The success of Living Goods has compelled the Ministry of Health to make policy commitments, including expanding the community health workers’ programs and providing compensation to the workers.
Accelerating family programs to realize UHC is all about political commitment. Many countries that have developed UHC roadmaps are nonetheless falling behind due to poor implementation. Acceleration of efforts is needed to catch up and reach UHC goals by 2030.
Zambia is a sterling example of political commitment transformed into concrete action toward family planning and, ultimately, UHC. The Government of Zambia’s decision to include oral contraceptives, implants, injectables, intrauterine devices, and emergency contraception in the national health insurance benefits package has been a result of sustained civil society action. The Centre for Reproductive Health Education in Zambia (CRHE) led advocacy efforts with a strong coalition of partners to leverage existing mechanisms. Mwale, its Executive Director, calls for “right policies, right allocation, right tracking, and right systems with a particular emphasis on right human resources” to ensure that the UHC agenda is a success. He believes that inclusion of family planning within the health insurance scheme is a measure of empowerment that people can now truly demand services. The Zambia model sets a strong precedent for other countries embarking on UHC reforms to follow. The efforts of CRHE and its partners to devote themselves to evidence-based advocacy are a story of belief in collection action.
Achieving UHC in Uganda remains a work in progress. The call for acceleration of efforts toward inclusion of family planning within the UHC agenda is coming from within the government. The Housing and Urban Development Minister, Dr. Chris Baryomunsi, is a champion of family planning who made a passionate plea to members of Parliament to take “cardinal responsibility” to ensure that the FP2020 commitments are fulfilled.
Political commitment must be translated into investments in financial resources and demonstrations of accountability. Mugirwa asserts, “‘Political commitment’ is often-used language in UHC, but we need to define this better – I’d say political commitment is a time-bound, measurable, written commitment. Only if the commitment is documented can we attach accountability to it.”
Advocacy from civil society organizations or champions within governments can give shape and momentum to commitments. But the power to enact change does not lie solely in the hands of officials. “Communities also have a responsibility,” says Mugirwa. “There needs to be mutual accountability in the pursuit of UHC. Governments should invest and communities should own. Gatekeepers can serve as catalysts.”
The 2021 International Conference on Family Planning featured a timely theme of UHC: Not Without Family Planning. Both the achievement of UHC and the inclusion of family planning have their challenges, and yet some agencies and countries have converted these challenges into opportunities – and are showing groundbreaking progress. There is a constant need for problem-solving to advance family planning within the larger context of UHC. The countries that are leaving populations behind need to: Innovate. Collaborate. Accelerate. Now! Dr. Igharo, of The Challenge Initiative, concludes: “There is an air of freshness with UHC – we are now for the first time discussing the investment needs for sustainability and scalability including private sector engagement, not just short-term funding for project needs in the public sector.”
In short, it is time to flip the two-sided coin that is UHC and family planning, and evidence indicates it is a win either way.