Setting up a research agenda for financing sexual and reproductive health services toward achieving universal health coverage in South Asia

Figures & data

Under population coverage and equity, it is important to know:

– Are the programmes covering beneficiaries in actual need, or do some eligibility criteria exclude disadvantaged segments who need the programme? – Are rural residents, economically disadvantaged populations, migrants, youth, and differently-abled persons covered under the programme? Desk review of policy documents, programme implementation plans, guidelines, government orders, meeting minutes, and reports published by the entity that designs and/or implements the programme could answer these questions of policy intent. To examine if the programmes are reaching the intended beneficiaries, we need to explore: – What proportion of the various population segments satisfy the eligibility criteria for availing the programme? – What proportion of eligible individuals, who are supposed to be covered by the programme, could enlist themselves? – What proportion of the population is accessing essential SRH services? – Are the intended beneficiaries in different population subgroups accessing the services in equal proportions? – Is there any gender inequity in terms of coverage? The methodologies that may help answer these questions include secondary analysis of population-level data (such as DHS), indirect estimates using programme monitoring data (such as HMIS, DHIS), community-level surveys, and interviews with beneficiaries.

Under service coverage, integration of all the nine components of SRHR within UHC is limited. It is, therefore, important to explore the scope of the health benefits package of the programme. Some illustrative questions are:

– What components of SRHR services, as per the Guttmacher-Lancet Commission, are covered or missing under the UHC programme? – Other than FP, MCH, and HIV services, what are the preventive, promotive, curative, and rehabilitative services provided? – Are the SRHR services that are not covered within the UHC programme being offered on a pilot/project basis or in a phased manner? – What kind of care (in-patient/outpatient or primary/secondary/tertiary) is included? Available policy documents, programme documents, and interviews with policymakers and programme managers can help answer these questions. In terms of programme implementation, we need to know: – What components of SRHR services, as per the Guttmacher-Lancet Commission, are covered or missing during implementation? Programme monitoring data, community-level surveys, and evaluations can help answer this question.The other important issues to address under implementation include knowledge of entitlements and quality of services. For this, the research questions could include: – Do intended beneficiaries know about the SRHR services and associated components/benefits that are included and those that are not included in the UHC programme? – Do intended beneficiaries know where and how to access services? – What is the quality of care and services provided under the programme? Community-level surveys and quantitative and qualitative research among beneficiaries and providers can generate evidence to answer these questions.

Regarding financial protection, reducing OOP expenditure and ensuring that disadvantaged groups are not left behind in terms of accessing entitlements, it is important to examine:

– Which financing models – such as community financing and community-based health insurance; conditional and unconditional cash transfer; introducing, removing, or changing OOP costs or user fees; result-based financing, performance-based incentives, and social protection programmes that provide a voucher subsidy or subsidised products – have a greater potential to reduce OOP while ensuring sustainability? – What are the mechanisms to make the system accountable for the implementation of the programme? The key methodology is a desk review of policy documents, programme implementation plans, and guidelines and reports published by the entity that designs and/or implements the programme. From the implementation perspective, it is crucial to assess people’s ability and willingness to pay: – What proportion of the population expressed their willingness to pay, and what amount they were willing to spend for the services? For service utilisation, we need to examine: – What proportion of the enlisted/entitled population is utilising the benefits under the programme? – What proportion of the population spends a large amount of household income on health? – Are there differentials by gender, age, rural/urban, and other background variables? For accountability of the system: – Are there appropriately established mechanisms in place to assess and monitor the programme's functionality in terms of service coverage with quality and provision of grievance redressal? Community-level surveys, a survey among the entitled population/beneficiaries, concurrent assessment of programme monitoring data, evaluations based on cost-effectiveness and cost–benefit analysis of various interventions and government investments can help answer these questions.