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.Citation1 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.Citation2
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 Citation3 and that such services are cost-effective. Citation4 Therefore, in low-resource settings, many components of this package are often highly prioritised on the pathway to UHC.Citation5
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.Citation5 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
2. Processes for health benefits packages are complex and involve several institutions
3. Better country level data is needed, but also more capacity to analyse existing data and use it to improve last mile implementation
4. Supply-side challenges exist for delivering on prioritised services
5. Prioritised services should also be reflected in clinical guidelines and essential medicines lists
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.Citation10 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.
References
- United Nations. Political declaration of the high-level meeting on universal health coverage “universal health coverage: moving together to build a healthier world” A/RES/74/2. New York: United Nations; 2019.
- Aman A, et al. Financing universal health coverage: four steps to go from aspiration to action. Lancet. 2019;394(10202):902–903. doi: 10.1016/S0140-6736(19)32095-1
- Starrs AM, Ezeh AC, Barker G, et al. Accelerate progress-sexual and reproductive health and rights for all: report of the Guttmacher-Lancet Commission. Lancet. 2018;391(10140):2642–2692. doi: 10.1016/S0140-6736(18)30293-9
- United Nations Populations Fund. Supplement to background paper on universal access to sexual and reproductive health and rights as an essential element of universal health coverage. 2019.
- The Partnership for Maternal Newborn and Child Health . Prioritizing essential packages of health services in six countries in sub-Saharan Africa: implications and lessons for SRHR. 2019.
- Republic of Malawi Ministry of health and population Malawi, Resource Mapping Round 6;15–20:2019.
- Health Systems Trust. South African Health Review. 2019, Republic of South Africa.
- Ochalek J, Revill1 P, Manthalu G, et al. Supporting the development of a health benefits package in Malawi. BMJ Glob Health. 2018;3(2):e000607. doi: 10.1136/bmjgh-2017-000607
- Ministry of Health Rwanda. Health Financing Strategic Plan 2018-2024. 2019, Republic of Rwanda.
- Governments of Sweden and South Africa on behalf of 39 signatories. Joint press statement Protecting Sexual and Reproductive Health and Rights and Promoting Gender-responsiveness in the COVID-19 crisis. 2020.