Can National Health Insurance Improve Access to Quality Family Planning for Those Most in Need?

11 June 2021

Written by Matt Boxshall and Jennifer Santisi at ThinkWell, this blog summarizes expert discussions on family planning and national health insurance at the recent ThinkWell Counterpoint webinar, access the recording here.

“I’m passionate about family planning; empowering women to have children by choice, not by chance, can transform societies for the better,” said Matt Boxshall, Program Director at ThinkWell. “To achieve this, it’s clear that governments must invest in improving access to quality family planning (FP) services.  But it’s also clear that the way those investments are made – how that money is spent – is critical.  As more governments choose national health insurance (NHI) to support the drive to universal health coverage (UHC), we ask if NHI is the right tool to ensure that those most in need have access to quality FP services.”

Matt opened the first webinar, “Putting the ‘Universal’ into ‘UHC Schemes’ for Family Planning,” in ThinkWell’s Counterpoint series. Health professionals from around the world attended the webinar on June 3, 2021, to hear from leading experts in health financing and FP.

When deciding whether to finance FP through health insurance, first ask “Who will benefit?”

“UHC is a goal, not a scheme,” said Joe Kutzin, who leads the World Health Organization’s Health Financing Team in Geneva. He reiterated that every country can make progress towards the goals of UHC, reducing the gap between need and utilization, improving quality, and increasing financial protection. To do so, however, it is important to consider the performance of the health system as a whole, rather than focusing on a particular scheme in isolation.  With this framing, Joe described a cascade of decisions about whether to include a specific service (like FP) within a health insurance scheme. The first, and critical, decision is based on whether the entitlement to services under the insurance scheme is universal or restricted to those who contribute to the scheme. If entitlement is linked to contributions, as in social health insurance schemes, integration should not be considered.

Beware early financing decisions that ignore sexual and reproductive health and rights – they may be hard to undo.

Brendan Hayes, a Senior Health Specialist at the Global Financing Facility, picked this up in his comments; “UHC is not a scheme, it’s a series of goals we’re trying to achieve…It’s really important we’re keeping those goals front of mind, so we’re constantly sense checking the theory of change.” Initial decisions made by policymakers shape the pathway toward UHC.  If those decisions are based on the desire to raise revenue, for example through formal sector contributions to health insurance, they are unlikely to be responsive to the sexual and reproductive health needs of women and girls – and those initial decisions can inadvertently lock in certain priorities.  “Too often, we’re coming in at a later stage to reappraise those initial policy decisions,” said Brendan.

Poor women and girls rarely benefit from health insurance in sub-Saharan Africa.

In sub-Saharan Africa (SSA), countries are “turning to public contributory health insurance as a mechanism to remove financial barriers to accessing health care services,” explained Jacob Kuzungu, a Research Officer at KEMRI Wellcome Trust. Over the last 10 years, 38% of SSA countries have established national health insurance (NHI) schemes. In an analysis of 36 SSA countries, data shows that on average, only 8 in 100 people are covered by any health insurance, and only 4 of the 36 countries currently cover more than 20% of their population. Disparities exist across socioeconomic status, location, gender, and employment status – poor women and girls are amongst those least likely to be covered. Hence, SSA countries should reconsider voluntary contributory health insurance mechanisms, Kazungu argued. They should instead reorient health financing toward non-contributory tax-funded arrangements to increase coverage and reduce inequalities.

Indonesia has good health insurance coverage, but this hasn’t helped improve the uptake of FP.

In contrast to most of SSA, Indonesia’s national health insurance, JKN, covers 80% of the population. JKN began in 2014 with a comprehensive benefits package that includes FP. However, data shows that despite FP services offered, modern contraceptive prevalence rate has decreased since 2014, shared Prastuti Soewondo, a Special Advisor to Indonesia’s Minister of Health. Including FP in the benefit package did not solve the challenge of access to services. In Indonesia, injectable contraceptives are most used, often accessed through private midwives who are not contracted by JKN. The Government of Indonesia is committed to improving access to FP, incorporating more midwives into JKN, and clarifying the responsibilities of the national FP program (BKKBN) and JKN.

Translating health insurance cover into FP choice is complex and difficult.

“There are many challenges in terms of getting equitable coverage for national health insurance,” said Sophie Witter, Professor of International Health Financing and Health Systems at Queen Margaret University, Edinburgh. Only 45% of women are employed compared to 71% of men and 90% of employed women in SSA work in the informal sector, which poses huge challenges to countries where health care is based on formal employment status. Other barriers include age, education, religion, and refugee status. Even if someone is covered, can they access health services? The answer depends on many factors, but challenges in accessing benefits from formal insurance schemes include awareness of benefits, provider attitudes, stigma, safety, and practical issues like access to health insurance ID cards.

Financial protection is a key goal to UHC, every speaker emphasized. But a recent systematic review concluded that only 26 out of 46 studies of health insurance schemes showed there were improvements in financial protection for members. Financial commitment to health has been too limited to support equitable UHC in many settings. “When there is a mismatch between the promise and the reality, there is always a consequence to the user,” added Witter.

Community voices are needed to hold governments accountable, to ensure that national health insurance schemes benefit those most in need.

“One thing I haven’t heard yet is the role of communities and the end users of these services in holding governments accountable,” said Elisha Dunn-Georgiou, Vice President of Policy and Advocacy at PAI, in her reflection on the presentations. “Not in opposition to governments, but in partnership with them.” Insurance programs might have the potential to empower their members, but this can only work for women and girls if their voice is heard and their needs prioritized in the development of the schemes.

Better data, stronger evidence, and clearer messages are needed if health financing reforms are to benefit women and girls.

Nomi Rachael Fuchs-Montgomery, Deputy Director for Driving Impact at Scale at the Bill and Melinda Gates Foundation agreed that involving communities in decision-making processes, including in the development of insurance schemes, is an important piece of the puzzle. She added we must also push for better and more robust data in order to further understand FP integration and quality and equity issues, given the number of barriers women face. “When we decided to partner with ThinkWell, there wasn’t a collective effort to hone in on that evidence…. The information shared today is important to shedding light on providing access at scale,” said Fuchs-Montgomery.

“Repetition is very important. By the time members of parliament cannot hear the debate anymore, that’s probably when the general public is hearing the message for the first time,” said Caitlin Mazzilli, Senior Program Officer from the Bill & Melinda Gates Foundation in her closing remarks. It is important to repeat the message and continue educating others.

We need to work together to challenge the status quo and to find better solutions.

Several participants reiterated the need for the FP community and health financing specialists to work together to find solutions that will help women and girls access quality family planning services in the UHC era. We at ThinkWell could not agree more. We believe that health financing reform is a critical step on the road to UHC, and also for the sexual and reproductive health and rights that are an essential part of UHC. Improvements in the way that governments spend money to pay for services –making purchasing more strategic – is central to these reforms and can send strong signals to providers about the importance of offering high quality, rights-based family planning choices.  Purchasing reforms can also remove user fees for those most in need, and expand access by contracting private providers.

But if getting FP into nascent contributory health insurance schemes isn’t the best way to secure universal access to FP, then where does that leave us as we seek to use strategic purchasing to improve FP service delivery? And what is the right mix of purchasing approaches for FP services in countries with more mature NHI schemes like Indonesia?  Perhaps breaking the link between formal membership and benefits is an important step, and we can learn a lot from the UHC Law in the Philippines, which has made PhilHealth benefits a right for all.  What about other national schemes where benefits are universal for targeted population groups like pregnant women, or children under 5, but payments are linked to performance?  Schemes like Gratuité in Burkina Faso, or Linda Mama in Kenya hold important lessons.

One thing is for sure – to solve these puzzles we will need strong partnerships across different communities of practice, the openness to learn from each other, and the courage to examine evidence that challenges our own preconceptions.