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This post originally appeared on Sexual and Reproductive Health Matters here.

Written by Matt Boxshall, Anooj Pattnaik, and Nirmala Ravishankar

The global FP community recently gathered under the banner “UHC: not without FP.” A virtual plenary of the International Conference of Family Planning looked to “demonstrate why integrating FP into UHC is essential to its success”. As passionate believers in the power of FP, we could not agree more – but there is a trap here. Plans for making progress towards the goal of UHC may be wrapped up in rhetoric about ‘UHC schemes.’[1] In many countries – including in sub-Saharan Africa – these plans rely on scaling-up national health insurance (NHI), promising a defined package of benefits to contributors. Much energy has been expended on making sure that FP services are included (and clearly defined) in these benefits packages. Not enough has been spent on asking who gets these benefits.

Before we fight for inclusion of FP in benefit packages, we need to ask whether the women and girls most in need of high-quality FP services are going to benefit from these insurance-based ‘UHC schemes’. Sadly, if we look across sub-Saharan Africa, the answer to that question is a resounding ‘no’. Only four countries in the region cover more than 20% of their population though any kind of health insurance, and what coverage there is remains highly inequitable[2]. For FP to be the cornerstone of UHC that it should be, we need to look beyond the rhetoric of ‘UHC schemes’ and find the most effective ways to finance services so that they reach those most in need.

To understand why so-called UHC schemes are not always the right answer for FP, it is useful to reflect on the motivation behind the schemes. To ensure that everyone receives the health services they need without financial hardship, UHC requires pooling and redistribution of funds to those most in need, and so health financing reform is a key driver of UHC. Governments in most low- and middle-income countries operate a traditional national health service, wherein a government department allocates general revenue through input-based budgets to a network of government-owned health facilities to cover staff salaries, medicines, and operating costs. Most also have ‘vertical’ or disease-specific programs (including for FP), which channel commodities and other supplies to providers. These purchasing arrangements still account for the majority of government spending on health in sub-Saharan Africa.

The challenges of the traditional national health service approach – including poor management, limited accountability, and low productivity in service delivery – are well known. To address these challenges, countries in the region are introducing new purchasing or payment arrangements, which are often referred to as ‘UHC schemes’ as they are wrapped up within broader reforms related to the goal of achieving UHC. These schemes typically layer over traditional government supply-side financing.

Emerging ‘UHC schemes’ in Africa are largely based on health insurance models. While there are multiple reasons for this, a critical driver leading African governments to choose insurance approaches is simply the desire to generate more domestic resources for health. Insurance premiums seem to offer the promise of additional financing for the sector (although in fact they are unlikely to succeed in highly informal economies). A national insurance agency can also seem an attractive way to generate more flexible funds, which can be earmarked for health, outside the budget cycle, and perhaps not subject to all public financial management requirements. And of course, political reasons are also important, both in terms of the attractiveness of offering voters health insurance and the conflation of NHI with the global UHC movement.

So ‘UHC schemes’ based on health insurance are proliferating. In a 2017 review, 14 of 32 countries across sub-Saharan Africa either had or were developing some form of NHI, and more have started since. These schemes often enroll formal sector employees, and many also attempt to enroll the poor through government subsidy of premiums. This follows the model of the Philippines or Indonesia, for example, where roughly half of the population benefits from subsidized membership in NHI programs. But if the justification for the scheme is to raise additional funds for health, and existing health budgets are ‘locked-in’ for salaries, commodities and other inputs, these efforts at subsidy quickly run into problems. Kenya, for example, has tried to subsidize membership for the poor in the National Hospital Insurance Fund (NHIF) through donor support in the past (the Health Insurance Subsidy Program) and again this year by investing general revenue through the Government’s latest UHC initiative. But this new ‘UHC scheme’ is far from universal – it targets 1 million households (3.9 million people) in 2021, in a country where roughly 18 million people live below the national poverty line. While the Government has stated an ambition to progressively expand population coverage, this is an expensive proposition, which will test Kenya’s fiscal capacity and will certainly take time.

In summary, we find that across sub-Saharan Africa, nascent NHI schemes do not currently cover the poor. Seeking to deliver FP services through these schemes will not only fail to reach those most in need, but because most beneficiaries are relatively well off, this approach could risk undermining the legitimacy of spending government funds on FP. There is even, perhaps, a risk that governments consider that they have FP covered in NHI, and cut back on commitments through other, better targeted channels.

So, is there an alternative way to think about this? When it comes to targeting very specific population groups with services, it may be that input-based budgets and vertical programs are still the most effective mechanisms. However, this is not an argument for status quo – we recognize that health services financed in this way have had limited success in the region. The impetus to move away from legacy systems, where line-item budgets channel funds based on historical precedent and irrespective of performance, is indeed desirable. The World Health Organization defines purchasing as ‘strategic’ when decisions about the allocation of funds are based on information about provider behavior and population health needs in order to maximize health system goals. It is not necessary to restrict purchasing to enrolled members of an NHI to gain the advantages of more strategic purchasing; health authorities can still improve access, equity, and quality by making smart decisions about what to purchase, who to purchase from (including private providers), and how to pay them. Successful schemes, like Plan Nacer in Argentina, started by focussing on a narrow benefits package of the most important and cost-effective services, funded by government revenue, and explicitly incentivizing service uptake and quality. The Linda Mama maternity scheme, managed by NHIF in Kenya, contracts public and private providers to offer free universal access to maternal, newborn, and child health services, and provides immediate, on the spot, cover for all women. The Gratuité scheme in Burkina Faso does the same – a defined package of services is provided for all, and contracted facilities are reimbursed based on the services they provide, including, as of July 2020, family planning.

Finding the best approach to paying for FP services requires careful thought in any context. UHC, #NotWithoutFP, absolutely! But UHC is universal health coverage, not health coverage for a few formal sector employees enrolled in a NHI scheme (and the small fraction of the poor whose coverage governments are able to subsidize). As a FP community, we know how critical it is to improve access to high quality FP and sexual and reproductive health services for marginalized women and girls, and so we must focus our efforts on the purchasing mechanisms best suited to reaching those most in need. NHI in which only members have the chance to benefit is unlikely to be that mechanism in low-income countries with highly informal labor markets. Finding the best solutions means partnering with experts in health financing and diving deep to understand what is practical in the local context. Together, we must think carefully about how best to direct our advocacy and technical support, and not be trapped into thinking that the latest ‘UHC scheme’ will deliver FP for those we care about most.

[1] We use the word ‘scheme’ here as it is used in common parlance to mean a government program, which is different from the definition of health financing schemes in the System of Health Accounts.

[2] Edwine Barasa, Jacob Kazungu, Peter Nguhiu and Nirmala Ravishankar. Examining the level and inequality in health insurance coverage in 36 Sub-Sarahan African Countries (unpublished manuscript).

Two years ago, we tragically lost ThinkWell analyst Samya Rose Stumo at age 24 in the crash of Ethiopian Airlines Flight 302. Samya was an emerging leader in global health who cared most about treating all people and patients as human beings, particularly in the context of their culture, family, and individuality. She was infectiously vibrant, intensely curious, and lived her life to the fullest. Shortly after her death, Samya’s family and ThinkWell Institute (ThinkWell) colleagues began raising funds for the Samya Rose Stumo Memorial Fellowship for Global Health in her honor.

Today we are launching the Samya Rose Stumo Memorial Fellowship for Global Health. The fellowship is for extraordinary young women change-makers who have inventive ideas that look to revolutionize global health. The fellowship will support the entrepreneurial ideas of young women who may otherwise have never had the opportunity. We are honored to offer a platform to inspire fellows, incubate their ideas, and launch their careers.

Fellows, initially from Kenya, Indonesia, Bangladesh, and the Philippines, will be part of an inaugural 12-month cohort where they will be mentored by leading ThinkWell global health experts, experience health systems challenges first-hand, and have support to build their own professional networks. These women will exhibit a burning desire to pursue an idea in global health, have demonstrated leadership in their communities, and exhibit a commitment to reform existing systems of health—all qualities that Samya embodied.

To learn more about the fellowship, please visit here. The deadline for the 2021 fellowship is April 26.

A year after the Covid-19 crisis really took hold in the Philippines, we sat down with Technical Advisor Helena Alvior, who supports ThinkWell’s Strategic Purchasing for Primary Health Care project, to chat about what life has been like for her and other Filipinos over the past 12 months.

How has life changed over the past year for you and for most Filipinos?

I wouldn’t compare my experience to the experience of most Filipinos. The pandemic has been much harder for less fortunate people. When the lockdown first happened, malls were closed so people who had entrepreneurial micro-businesses were very affected. Another challenge for people who still had to commute for work was that since public transportation ridership decreased, the fares were increased.

I have three boys, ages seven, five, and one. When school was canceled, they had to stay home. So that was hard because I was working virtually and trying to keep them quiet and look out for them. It was a big help to have husband and family here, but still it was difficult to not have a boundary between work hours and family hours. But for most Filipinos it’s been more difficult than it’s been for me.

What has been the greatest health systems challenge that the Philippines has faced in the past year while fighting Covid?

Before Covid, our health system was fragmented because of devolution. The health system issues have become even more glaring during Covid. Before the pandemic started, the Universal Health Care (UHC) law was passed so there was health system support buy-in from stakeholders, health leaders, and government. Because of that, officials were better prepared to implement Covid response actions because they had been discussing health system and UHC issues for a long time. The UHC preparations created more dialogue between actors at different levels of the health system. We’ve worked with health system leaders to show them how innovations they’ve implemented for the Covid response can be applied to addressing universal health care challenges.

A large challenge is that social media is a hotspot for misinformation. Everyone thinks they’re an expert in epidemiology and medicine! Misinformation has been a challenge in the face of disseminating accurate information about Covid. One of the largest problems is that misinformation around vaccines on social media contributes to vaccine hesitancy.

In terms of my experiences, a lot of my work for ThinkWell is grounded in strong inter-personal relationships and face-to-face conversations with Filipino health stakeholders. Filipinos aren’t used to working virtually because you normally have to sit down with someone if you want to get something done. That’s been a big challenge to overcome.

Has there been anything that’s inspired you during the pandemic in the Philippines?

In April, May, and June of last year, was a large community mobilization in Western Visayas, a region, to address pandemic needs at the community level. Science high schools created alcohol and distributed it across hospitals. Engineering schools mass produced face shields. Then there were a lot of food drives during lockdown.

Guimaras, an island province, that is world renowned for mangos has its harvest in the summer. Due to lockdowns and reduced global demand for mangos, there was a surplus of mangos, so the local economy was struggling. The local government lowered the prices for the mangos so neighboring provinces could afford to purchase mangos. Because of that, the mangos didn’t go to waste and the farmers got paid!

What does vaccine roll-out look like in the Philippines?

The global vaccine access inequities are quite sad. Philippines just received a donation of vaccine from China but we haven’t procured any yet. Vaccine preparations in the Philippines are ongoing. Filipinos have been surveyed on whether they would take a vaccine and about 60-70 percent of people are willing, but some don’t want vaccine from China. Of course, the best vaccine is the one that is available to you.

What has it meant for you to both be working on Covid-related issues and be directly impacted by the pandemic? In other words, how has your work on the pandemic affected how you experience the pandemic?

My team and I helped the Department of Health and other health stakeholders make sense of Covid data and communicate the data via policy notes. (Read more here.)

After the initial four months of strict lockdown, we picked back up our UHC work with provinces. We helped provincial health leaders see how the integration work they’ve done for the Covid response can be applied to UHC.

Some of my work involves meeting with health workers and people who work with health workers. So I’ve been worried about potentially getting Covid from my work and then transmitting it to my family. It’s nerve-wracking, the anxiety of potentially exposing people because of the nature of your work.

What is your personal biggest lesson learned from the past 12 months?

Before Covid, we took for granted the liberties that we have. We could travel freely and have meals wherever we wanted. With the lockdown, you get to see what the essentials things are in your life. I’m grateful to not be in metro Manila, the capital. I live in Iloilo City and I’m grateful to be in an area with nature, open spaces, and beaches nearby.

Finally, on a personal note, where do you want to travel to once it’s safe to travel? 

I haven’t been outside of the country before, so I want to travel internationally, perhaps on assignment for ThinkWell!

Across the world, ThinkWell staff are moving the needle on improving health and well-being around the globe. We wanted to take a moment to introduce you to some of our staff in Mozambique.

Yara Cumbi, Program Analyst

yara cumbi

Why did you decide to join ThinkWell?

Right before I came to ThinkWell in 2018 I had taken a break from public health to work in the private sector. It gave me a great understanding of how things work in Mozambique. There were a lot of things I had never considered much, such as how markets can affect health outcomes, how difficult operations and logistics are, and how these things are affected by policy. This experience gave me renewed interest in exploring these aspects of the health sector. Luckily, ThinkWell was advertising a job in medical commodity delivery.

What do you view as the greatest challenge to improving health and well-being in your country?

Currently, I think the biggest threats are the triple threats from a violent insurgency in northern Mozambique, the pandemic, and the climate crisis. These are all interlinked and the root causes need to be addressed. If I had to pick one, I would say the climate crisis is becoming too big to ignore. It is affecting Mozambicans daily through extreme weather events like hurricanes and cyclones as well as rising temperatures that create environments for more and new pathogens/diseases. This creates scarcity such as through droughts and lack of harvests.

What makes you hopeful about health progress in your country?

Working in health right now has been an eye opener. I recall people now knowing what public health was before the pandemic. I hope that this is teaching us all to value health more and to be more responsible for our communities and our own health. I have seen a renewed sense of urgency in the health sector that has inspired some innovate ways of working, such as faster funding flows. I think that is a much-needed improvement; donors should be better at responding to the immediate needs on the ground, and not just during emergencies.

What’s been the most meaningful lesson that you’ve learned during your health career?

I have been faced with a number of experiences that reminded me to stay humble and compassionate. As important as the work is, it’s not more important than listening to those you are trying to help and treating everyone with the dignity they deserve.

What’s a health statistic or fact that you can’t get out of your head? Why should everyone know it?

I think the alarming statistic is that there isn’t enough data! With more robust data we could learn more about who is affected most, how, when, and where. Unfortunately, this information often isn’t available and that is deeply concerning to me.

Antonio Candeiro, Senior Technical Advisor

Why did you decide to join ThinkWell?

Before ThinkWell, I was a HIV/AIDS care and treatment advisor. I joined ThinkWell because I like the exceptional team’s commitment to achieving universal health coverage (UHC). I also joined because I want to continue to support and contribute to the control of the HIV/AIDS epidemic in my country. Through the ECHO project (Efficiency for Clinical HIV Outcomes), I’m helping to identify the major gaps that hinder progress in controlling the HIV epidemic. I’m also helping to implement innovative and accurate initiatives to be able to solve them, while taking into account the equity of health care for the recipient of care.

What do you view as the greatest challenge to improving health and well-being in your country?

The biggest challenge to improving health and well-being in Mozambique is equitable and qualitative access to preventive and curative health care, as we still have problems with access to health care in some regions.

What’s a health statistic or fact that you can’t get out of your head? Why should everyone know it?

During my clinical practice at the district level where I worked as District Chief Physician, we had an outbreak of diarrheal disease at the community level. I had to provide health education to the community around the use of Chlorine, which we call “Cloro” in Portuguese, for water purification. But the population misinterpreted what we were saying and thought that we were bringing Cholera to the community and that would lead to more diarrheal cases. This taught me the importance of really understanding the cultural context of the community that you’re trying to educate before you begin the work.

Aurora Milice, Program Analyst

Why did you decide to join ThinkWell?

I decided to join ThinkWell because of the great work culture and the encouragement provided to make sure we excel and have work-life balance.

What do you view as the greatest challenge to improving health and wellbeing in your country?

In Mozambique the greatest challenge is for HIV to be taken seriously and addressed rapidly and adequately. The HIV epidemic in Mozambique is expanding fast and its impact on society and families is drastically resulting in economic losses and substantial reductions in life expectancy.

What makes you hopeful about health progress in your country?

The progress made in improving Mozambicans’ health began when the government started to rebuild the health sector, restructuring the National Health System (NHS), and improving service delivery. As result, more health care facilities have been rehabilitated or newly built, many health posts were upgraded to health centers with maternity facilities. This helped increase life expectancy and reduce some of the common diseases associated with child and maternal mortality. But more efforts are needed, such as providing more efficient funding of health systems and improved sanitation/hygiene.

What’s been the most meaningful lesson that you’ve learned during your health career?

The most meaningful lesson I’ve learned are:

  1. I can’t succeed without failing: I learned that I must accept that failure is inevitable and approach every situation as a learning opportunity. More importantly, I learned that failing shows me how to succeed.
  2. I am never done learning: No matter how many degrees I have or how successful I am in my career, there is always room for growth.

What’s a health issue that you can’t get out of your head? Why should everyone know it?

I can’t get mental health issues out of my head. Mental health issues are actually very common and make it difficult for people to cope with the ordinary demands of life.

Jorge Moiane, Technical Advisor

Why did you decide to join ThinkWell?

I feel that at ThinkWell, the ideas of employees are respectfully heard. When I applied, I found it quite interesting to see a young organization growing as fast as ThinkWell. I also believe that the principles that guide its employees are really successful.

What do you see as the biggest challenge to improve health and well-being in your country?

Health is the most precious asset we have. It’s extremely important that we address health issues like HIV, tuberculosis, diarrheal diseases, and Covid. Our health system faces many challenges addressing these issues, especially given limited financial resources.

What makes you hopeful about health progress in your country?

Mozambicans are better understanding the diseases that most affect us. As a result, people are changing their social habits to prevent and control diseases.

What was the most significant lesson you learned during your healthcare career?

During the 13 years that I’ve work in health, I learned that the most important thing is to give thanks for the gift of life, because it is all we have.

What is a statistic or health fact that you can’t get out of your head? Why should everyone know this?

Recently, Covid cases have increased exponentially. More needs to be done to raise awareness among the public and teach people prevention strategies.

Salomão Lourenco, Senior Program Manager

Why did you decide to join ThinkWell?

Before I joined ThinkWell I was completely unmotivated in the job I was in. ThinkWell appeared as a breath of fresh air for the innovative way it does business.

What do you view as the greatest challenge to improving health and wellbeing in your country?

In Mozambique, there is a lack of strategic allocation of resources, lack of appropriate integration of different sectors of the economy, and poor performance of budgets due to corruption and other unethical behavior.

What makes you hopeful about health progress in your country?

I’m hopeful about a few things:

  • Current public financial management reforms around result-oriented budgets
  • Ongoing reforms in the health sector that will help make progress towards universal health coverage
  • The ongoing decentralization process that will enable local governments to make decisions about heath services at the local level

What’s a health statistic or fact that you can’t get out of your head? Why should everyone know it?

Despite the increase in institutional births, maternal mortality remains high in Mozambique.

Sheila Muxlhanga, Program Analyst

Why did you decide to join ThinkWell?

One of the reasons that led me to join ThinkWell was the fact that it was a renowned institution and that I could grow professionally. Plus, I already knew some colleagues at ThinkWell with whom I had very good working relationships—this contributed a lot to me embracing this challenge.

What do you view as the greatest challenge to improving health and wellbeing in your country?

The biggest challenge to improving health and well-being in my country is increasing the number of hospitals so the entire population has access to hospitals.

What makes you hopeful about health progress in your country?

Young people are embracing public health professions!

What was the most significant lesson you learned during your healthcare career?

The most important thing is life. Nothing else is a priority when it comes to saving lives.

What’s a health statistic or fact that you can’t get out of your head? Why should everyone know it?

Even today, there are those who do not believe that Covid-19 is a reality. I think that everyone should be aware of this reality because this disease is decimating lives day after day.

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