Taking Steps to Advance Universal Access to Family Planning: Key Lessons from 16 Francophone Countries
By: Elise Lang, Health Policy Plus, Palladium
Developing countries in francophone Africa and Latin America face significant challenges in meeting the reproductive health and family planning needs of their citizens — data from demographic surveys suggest only 31.8 percent of demand for modern contraceptive methods is met in 16 of these countries. The average modern contraceptive prevalence rate is 15.1 percent among married women, the lowest for any region in the world. In addition, these countries continue to rely heavily on external funding for their family planning programs. The US and UK governments are two of the largest donors of contraceptives worldwide, but their funding is plateauing. It is critical that countries start preparing to cover the long-term resource needs of providing family planning contraceptives and services before this external support starts to substantially decline.
Recently, Family Planning 2020 convened representatives from 15 francophone African countries and Haiti — from government, civil society, development partners, and youth — to discuss the future of family planning and draft the year’s objectives. Unsurprisingly, sustainable financing for family planning was one of the main topics of conversation. I had the privilege of attending this meeting, which left me with a few thoughts about the importance of finding sustainable sources for funding family planning programs. While each country has its own context, there are several common challenges and lessons learned among them:
Establish a legal framework that helps include family planning in the reforms aimed at universal health coverage
Family planning is often not considered in the decisions around setting up health insurance schemes and other reforms oriented toward universal health coverage. This is partially the case because family planning is often considered an externally funded program. To deepen the inclusion of family planning in these reforms and achieve the most positive impact possible, decisionmakers must start with developing a common vision for financing health, including family planning. A legal framework supports implementation of the vision and provides protection from political shifts. Togo and Cameroon recently established their vision for universal health coverage and developed legal frameworks for their national health insurance schemes. Stakeholders discussed the importance of including family planning in these frameworks as a service that is not only covered, but made widely available and affordable across a range of modern methods. A meeting participant from Benin was concerned that adolescents and young people were not considered vulnerable populations under the country’s user fee exemption program and, therefore, may face higher out-of-pocket costs than they can afford. The Health Policy Plus (HP+) project, funded by USAID, has developed a guide for countries to identify and address the legal, regulatory, and policy barriers to including family planning in universal health coverage schemes. This is one tool countries could use to ensure a strong enabling environment for family planning financing.
Use evidence and advocacy to make the case for including family planning in health insurance benefits packages
Several participants mentioned that their governments provide family planning services at little-to-no cost to users at public facilities. This is common and, as a result, decisionmakers often argue that there is no pressing need for family planning to be included as part of a health insurance benefits package. Also, since family planning commodities are heavily subsidized by external financing, decisionmakers often argue that providing family planning through health insurance isn’t needed to increase the availability of essential contraceptives. Yet decisionmakers should be concerned about availability. External funding is a short-term solution. In the long term, governments will need to take over responsibility for contraceptives and the costs of service delivery, especially for long-acting reversible and permanent methods, using domestic financing.
Providing decisionmakers with clear evidence of the health and economic benefits of family planning can strengthen advocacy for inclusion of these benefits under insurance. In Burkina Faso, the Ministry of Health conducted a study similar to one conducted in Ghana to show the health and financial impact of including family planning as part of their government’s health insurance scheme. The results showed that the benefits to users more than outweighed the cost of reimbursements to providers for family planning services in the benefits package. Advocates have had success convincing their governments to include family planning by generating evidence through tools like the ImpactNow model or conducting studies to show the opportunities for including family planning in a health insurance scheme, as was done in Ethiopia.
Strengthen the capacity of stakeholders to understand and manage a health financing scheme
Lastly, a vision for universal health coverage inclusive of family planning cannot be implemented without the active involvement and support of diverse stakeholders beyond the health sector. Most francophone African and Latin America countries are, for the first time, developing visions for universal health coverage and health insurance scale-up. Meeting participants highlighted the importance of a transparent and inclusive process that develops a common understanding among all those involved and the need to strengthen the capacity of stakeholders to better understand key definitions, explore lessons learned, and evaluate and discuss potential reform options. At the meeting it was also agreed that processes to shape common visions of universal health coverage should include not only decisionmakers at the central level (like senior representatives from ministries of health, finance, and labor) but those at the sub-national level responsible for implementation, management, and monitoring of new health system mechanisms. HP+ has been supporting the government of Madagascar, which was present in the Dakar meeting, to establish a health insurance mechanism targeting the poor and informal sectors. The project supported the country’s Ministry of Health to train hundreds of government managers, clinicians, and community health workers on the specifics and operations of the scheme so they could pilot it. Madagascar, like many other developing countries, does not have a culture of pre-payment for health. With over 70 percent of the population living in poverty, the Malagasy have some hesitation to pre-pay for a service they feel they don’t yet need. Meeting participants agreed that creating a culture of prepayment for services like healthcare will take time, but is critical. Creating this culture requires strong communication, assurance of high quality of care at the health facility level, and transparency and accountability around the reimbursements made to providers.
While there is still a long way to go for many francophone countries to achieve universal health coverage and to ensure accessible, affordable, and high-quality family planning services, these countries already have experiences and lessons learned that they can share and build on. There is no magic bullet for reaching most of the population with high-quality and affordable healthcare, and every country’s path is going to be different. However, we do have the opportunity to learn and be enriched through cross-country sharing of experiences.
