The SARS-CoV-2 pandemic has laid bare the challenges for health systems across all
countries to deal with major shocks while simultaneously prioritising and maintaining
critical services, including essential sexual and reproductive health (SRH) services.
Just six months prior to the outbreak, the international community reinforced its
commitment to Universal Health Coverage (UHC), under the Sustainable Development Goals
(SDGs) for Agenda 2030 through the 2019 UN General Assembly declaration on UHC. UHC
includes improved service coverage, quality and financial risk protection, ensuring
that people access quality care on the basis of need without suffering financial hardship.
In the UHC declaration governments committed to equitable delivery of a package of
essential services, including SRH services, medicines and vaccines to the entire population,
irrespective of their ability to pay.
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Even before the SARS-CoV-2 pandemic, it was clear that achieving UHC will require
investments in countries’ health delivery systems, and reform of financing and sub-national
management systems close to the point of care to achieve improvements in access and
utilisation for the most vulnerable groups. However, one of the first steps towards
UHC should be to define what services can and will be offered and to whom. Some governments
have taken the step of defining a package of essential health services which will
have the greatest impact on health outcomes, health equity and financial protection,
resonating the UHC targets. This package is defined based on all resources available
and the specific burden of disease faced: an explicit health benefits package, known
and understood by officials, providers and people which the government commits to
provide. Such benefits packages should include affordable, cost-effective, quality
primary care and prevention interventions.
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As governments unite behind the commitment to UHC we argue that SRHR interventions
should address some of the most pressing – and consistent – gaps for women, girls
and adolescents serving essential, common and recurring health needs and target vulnerable
segments of society with poor access to resources and services. This is particularly
the case for preventive and promotive activities such as contraceptives, but also
many other interventions including maternal health, cervical cancer treatment and
antiretroviral treatment for HIV. Estimates of the cost to deliver a package of essential
SRH services suggest that this could provide excellent value for money
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and that such services are cost-effective.
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Therefore, in low-resource settings, many components of this package are often highly
prioritised on the pathway to UHC.
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In recent work, we looked at the content of country health benefits packages in six
countries in sub-Saharan Africa; Eswatini, Ethiopia, Malawi, Nigeria, Rwanda and South
Africa. In comparison with the Guttmacher-Lancet Commission’s proposed package of
essential SRHR interventions, we found that the health benefits packages across these
countries include many services around maternal health, HIV and STIs, while areas
relating to gender-based violence, comprehensive sexuality education and infertility
were omitted or not captured completely, and inclusion of safe abortion services varied
depending on the legal and social environment.
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Based on the case studies we found other more systemic characteristics, which provide
five general lessons.
Funding for health is scattered which complicates resource allocation for health benefits
packages
In Malawi, there are 249 financing sources and 227 implementing partners in the health
sector.
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Although there is a well-articulated Essential Health Package, the levels of fragmentation
in both funding and implementation make it very difficult to coordinate financing
flows behind a single, good-quality package. The issue of fragmentation in financing
is common across many countries, even where donor reliance is not so high. For example,
in South Africa, approximately 50% of health spending is concentrated on less than
15% of the population, who receive services through private sector insurance schemes,
and within the public sector there is further fragmentation by province and programme.
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This fragmentation is a source of inefficiency, as resources can be spent on duplicative,
inconsistent and cost-ineffective interventions and the government lacks oversight
of resource allocation at national, sub-national and facility levels and even down
to services in communities. The creation of a benefits package can help to align resources
around a common set of priority interventions, but pooling or other financing reforms
may also be needed to significantly make the efficiency and equity gains necessary
for UHC. Development partners must also be prepared to provide funding in a manner
that allows for reallocation of resources between priority areas and cost categories.
2. Processes for health benefits packages are complex and involve several institutions
Every country is taking its own approach to UHC, and to priority setting and the development
of benefit packages. Some countries are creating national insurance agencies, some
benefit packages are developed and prioritised by the Ministry of Health alone, and
others involve Ministries of Finance, Education, Local Government and other related
Ministries. In Rwanda, the Mutuelle de Santé package is financed and managed through
the Rwanda Social Security Board to reimburse an Essential Health Package designed
by the Ministry of Health, which informs clinical practice guidelines and guides health
providers on what they should be providing at each level of service delivery. There
are often stakeholder groups created to appraise and contribute to the design process,
which may involve medical associations, civil society, academic institutions and members
of the public. The variety and often lack of integration and concertation fora can
make these processes confusing and difficult to engage in for SRHR stakeholders, but
their voice, including that of professional associations, patient rights groups and
other advocacy groups, is essential for an equitable approach to UHC.
3. Better country level data is needed, but also more capacity to analyse existing
data and use it to improve last mile implementation
Generating high-quality, disaggregated data (including by gender, socio-economic status,
sexual orientation, disability) at country level is key to making priority setting
decisions. There are large contextual differences between countries and between populations
within countries in terms of disease burden, access to SRHR services and socio-economic
factors affecting utilisation of these services. However, there is often limited local
clinical efficacy and economic data, as well as limited capacity, systems or information,
to disaggregate data to ensure equity is considered in the prioritisation. For example,
in Malawi only 87 of the Essential Health Package’s 250+ interventions were supported
by sufficient data on disease burden, efficacy of interventions or cost of implementation
for consideration in the cost-effectiveness analysis framework.
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More and better information is needed on the cost of delivering services in a specific
country and clinical efficacy. There is also a need to improve capacity and systems
for disaggregating data to ensure that equity is considered in the prioritisation
process.
4. Supply-side challenges exist for delivering on prioritised services
Even in countries where a prioritised benefit package exists, service delivery is
often disconnected from national level policies and packages, as the interventions
that can be carried out are reliant upon more practical considerations such as the
training and guidelines for health providers regarding diagnosis and treatment, and
the personnel, drugs and equipment available at facilities. In order to advance delivery
of universal health coverage, it is therefore not sufficient to ensure that services
are included in health benefit plans. In most cases, significant additional health
systems investments are required to ensure the resources are in place to deliver the
package. Rwanda, among other countries, has recognised this and is explicitly mobilising
resources to invest in their health system along priorities set out in their benefit
package.
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An explicit benefits package can act as a vehicle to make the investment case for
health as it demonstrates an evidence-based, rational approach to optimising health
returns, in a fiscal environment where health has to compete with other sectors for
resources. This is likely to be increasingly important in the aftermath of the SARS-CoV-2
pandemic, as economic crises evolve into fiscal constraints.
5. Prioritised services should also be reflected in clinical guidelines and essential
medicines lists
A benefits package, once developed and prioritised, does not necessarily influence
what services are available in reality. For example, Eswatini’s Essential Health Care
Package is not prescriptive and not directly used to exclude or include services by
level of care. To implement the package, the existing pathways through which policy
affects implementation should be the primary levers to deliver UHC. Health workers
operate according to clinical guidelines that outline care pathways, and facilities
are stocked with medicines according to Essential Medicines Lists; these policies
and regulations should therefore reflect the priorities of the health benefits package.
The National Health Insurance Bill in South Africa commits to delivering at a minimum
the services already available in the public sector. Thus a first step towards developing
a benefit package is to list explicitly all services based upon the Standard Treatment
Guidelines which are closely linked to the Essential Medicines List and are already
used to guide service delivery in the public sector.
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SRHR stakeholders that seek to engage with the UHC process in any given country should
take advantage of these existing tools and guidelines and ensure that the Essential
Medicines List contains the recommended SRHR commodities, consider the WHO Model List
of Essential Medicines, and ensure that clinical guidance is in line with regional
and global norms and standards.
During and after the SARS-CoV-2 pandemic response, the principles motivating an explicit
benefits package will be even more important for enabling progress towards UHC and
universal access to SRHR. The ongoing pandemic has placed both economic and health
systems under tremendous stress and countries have redirected resources to the pandemic
response. In consequence, health systems in lower- and middle-income countries are
reconfiguring their priorities around urgent needs for testing, hospitalisation and
critical care, and infection protection and control measures, as well as broader economic
and social interventions. With this dominant focus on combating COVID-19, there is
a risk of reallocation of resources away from essential services, including SRHR priorities,
at least in the short term, and considerable opportunity costs of this reallocation
upon population health.
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The response to Ebola illustrated that the neglect of routine services like SRHR and
immunisation, for example, leads to much added misery especially for the poor. Any
re-prioritisation, as well as additional costs of existing essential services, should
be explicitly built into the benefits package so that these decisions are being made
system-wide, rationally and transparently, without increasing verticalisation of programmes
or fragmentation of resources. There will likely be even greater need to focus on
cost-effectiveness, quality of care and equity, given the likely fiscal contractions
mentioned above, already fragile health finances and the anticipated disproportionate
impact upon those living in poverty. Innovative solutions such as self-care should
be leveraged, and increased efforts are needed to support multisectoral health promotion
strategies to prevent downstream costs to already stretched health systems.
When a fair and transparent priority setting process considers the best available
evidence, burden of disease, and cost effectiveness, and is underpinned by ethical
values such as equity, gender equality and right to health, SRHR services will, to
a large extent, be included in health benefits packages as being essential for progress
towards UHC. If these benefit packages are used to guide how resources are allocated
to health facilities and providers in practice, they will translate into increased
access to SRHR services. Therefore, health benefits packages have the potential to
advance access to essential SRHR interventions within the health sector and contribute
to the UHC goal of realising the right to the highest attainable standard of health
without suffering financial hardship, including meeting the unique needs of women,
girls and adolescents.