How Can Health Financing Reforms Improve Access to FP Services For Those Most in Need?

When the family planning community gathered in Pattaya last November for the International Conference on Family Planning (ICFP), we recommitted to the idea that family planning is a core and essential part of Universal Health Coverage (UHC). This is a powerful and important message, but it is important that we don’t let the UHC brand get in the way of working towards the UHC goal of providing health services that people need where and when they need them without a financial burden.

The UHC brand is sometimes applied to social health insurance schemes – ‘UHC schemes’ – which pool funds from contributors, and share benefits amongst those who contribute. But if most of these beneficiaries are relatively wealthy people working in the formal economy, then whatever the label, these ‘UHC schemes’ may not advance the goal of UHC. Including family planning in these schemes should not be our priority unless we are confident that those most in need of family planning services will benefit.

The family planning community should hold policy-makers accountable for ensuring that health financing reforms under the UHC name deliver quality family planning services to those most in need.

Health Financing Reform Can Help Us Move Towards UHC.

According to the World Health Organization, the goal of UHC is for “all people to have access to the full range of quality health services they need, when and where they need them, without financial hardship.” Using a rights-based approach, the global family planning community agrees that this “full range of quality health services” must include family planning. And the “without financial hardship” clause points to the need for health financing reforms. But UHC is a goal of the health system as a whole, and even in the health financing space, moving towards UHC is not about adding a new health insurance scheme on top of existing systems. Rather it is about supporting the system-wide transition away from “out of pocket” payments towards “pooled financing”, to which citizens contribute according to their ability, and from which all citizens (not just those who contribute) benefit according to their needs, as described in this 2013 paper by Joseph Kutzin in the Bulletin of the World Health Organization.

Health Insurance As Not A Magic Money Tree.

This idea of “pooled financing”¹ can sound like health insurance, but in many countries, “pooling” is achieved by governments collecting revenue through general taxation, and then using this to pay public sector staff to deliver health services. If pooled funding comes mainly from general taxation, can adding a specific government-led health insurance scheme gather contributions to generate more money for health? It certainly seems like an attractive idea, and this is likely one reason for the political popularity of such schemes. However, according to many economists (including this Yazbeck et al article from 2020), since so many individuals in low- and middle-income countries work outside of the formal economy, labor tax financed social health insurance is not an effective way to raise funds for health care programs.

Pooling funds through general taxation and paying for services through the public sector typically creates a universal entitlement – meaning, at least in principle, all citizens can benefit. And most countries make at least some effort to direct these resources toward those most in need. Health insurance schemes can do this as well, but many do not; social health insurance schemes pool funds from contributors, but share benefits only among those who contribute – the members of the scheme.

One common way to get a government health insurance scheme started is to make contributions mandatory for those who are already paying income tax, and then to expand the scheme by encouraging informal sector workers to buy in. The plan is to use this revenue to subsidize membership for those who cannot afford to pay.

Sadly, too often this strategy gets stuck in the first phase. People in the informal sector only pay their insurance premiums when they know they will need services—for example, when they are already sick, or when a baby is on the way—and so their contributions do not cover their costs. In the formal sector, powerful interests (public sector labor unions, for example) may demand more and more benefits from their contributions. If these additional benefits are granted, the cost of services goes up, and instead of the insurance scheme generating extra revenue to subsidize membership for the poor, the government ends up having to bail the insurer out. High costs and low revenue means that there is none of the profit needed to subsidize membership for the poor. And so those people for whom subsidized or free family planning services could really make a difference are likely not even part of the scheme.

What Does the Evidence Show? Perspectives From Africa

Well, so much for the theory – how do things look in practice? A recent BMJ Global Health paper by Barasa et al looked at insurance coverage across 36 countries in sub-Saharan Africa. They found only four countries where national health insurance coverage was more than 20 percent of the population. And what stood out about those four countries? None of them relied on members’ contributions for the cost of the insurance scheme – they all paid for it primarily through general taxation, and so they avoided the trap described above.

What about equity – who benefits from these schemes? Well, across all 36 countries— especially those where coverage was low and relied on contributions—the more wealthy one was, the more likely they were to benefit from health insurance. The very last people to benefit from most of these schemes are low income, poorly educated, rural women and girls. Which begs the question – why should they be concerned whether family planning is in the benefit package of a ‘UHC scheme’?

Some Optimism – A Positive Example!

But this is not all doom and gloom – some countries are making really important steps forward. A key decision towards equity is to break the direct link between contributors and beneficiaries.

For example, the government of Kenya is channeling general revenue into its health insurance institution, the National Health Insurance Fund (NHIF), and telling the NHIF to use that money to purchase services for the most vulnerable. This is still in its early stages, and there are many challenges to sort through – identifying and enrolling the right people, making sure citizens know their benefits and can access them, figuring out how best to pay providers, promoting transparency and accountability in the insurer and, of course, finding enough money. But the scheme is rolling out, with the target of reaching a million low income households across Kenya. This scheme is known to one and all as the “UHC scheme”, and, with all the caveats above, it might genuinely make a contribution towards the goal of UHC.

And importantly, FP is included in the benefits package of the Kenyan “UHC scheme”—which is great news. The next actionable step is to ensure that the scheme is actually delivering quality, comprehensive, rights-based FP to those most in need. It isn’t yet, and there is plenty more for us to do…

An Agenda for Family Planning Advocates

The family planning community has a powerful voice, especially when we work together through movements like FP2030. We must continue to make sure that no major health reform neglects the sexual and reproductive health rights of women and girls. In the complicated field of health financing reform, we need to remind policy makers that FP should always be prioritized. We also need to hold them accountable to ensure that the reforms they are planning stay true to the very concept of UHC by delivering these key services, first and foremost, to those women and girls most in need.