Bill & Melinda Gates Foundation

Delivering a new era of reproductive health services

July 06, 2015

The views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of the Bill & Melinda Gates Foundation.”

Universal health coverage will have a profound impact on how the service delivery sector does business, a shift that is firmly embraced by Marie Stopes International. 

Only governments can ensure that universal health coverage (UHC) is achieved so that everyone can access the health services they need without suffering financial hardship. 

But this doesn’t mean that the rest of us should leave governments to their own devices while we wait for UHC reforms to roll out. UHC will – and should - have profound impact on how our service delivery sector does business and organisations need to be ready to embrace that shift.

Marie Stopes International has always had the long-term vision that we will integrate with domestic financing as health systems develop. In the UK, where we opened our first ever clinic, we work on more than 70 NHS contracts. This represents 84% of Marie Stopes UK’s income, which means we can serve the vast majority of our clients free of charge. We know we can emulate this model in the rest of the world when the time is ripe, and this time is drawing nearer, driven largely by the UHC movement.

Domestic financing

The UHC goal is that everyone has access to the health services they need without suffering financial hardship. Pursuing this goal very quickly leads governments to the need for dramatic health financing reforms. In particular, UHC is giving rise to national insurance initiatives that allow health budgets to be spent on strategic purchasing of health services, rather than on keeping the doors open at public facilities alone. And this is key. In many developing and middle income countries, between 40 – 70 per cent of all health spending comes directly from people’s pockets and a large share of it is spent at private facilities. Tackling this problem in mixed health systems like India, Nigeria and Kenya requires replacing out-of-pocket expenditure with public financing in both public and private sectors.

We are entering an era where domestic financing and particularly the public share of that financing is on the cusp of a considerable scale up. Global service delivery organisations must be ready for this transition to remain relevant. To date, Marie Stopes International’s contraception and other reproductive health programmes are already partially financed by public funds in 11 countries: Vietnam, South Africa, Papua New Guinea, India, Nepal, Ghana, China, Bolivia, Kenya, Australia and the UK. We prioritise our ability to adapt to financing changes in the market so that we can ensure continuity of care to our clients.

Aside from gearing up for domestic financing, how else can a global service delivery organisation participate in UHC reforms? As it turns out, more countries are still in planning and piloting phases for UHC. These countries have expressed a desire for delivery’s experience and skill set at the table. So in these years of transition, there are a few key areas where organisations can make a distinct contribution.

Cost-effective service package

The first is to support and influence benefits package decision-making, to help ensure the best value-for-money and greatest health impact for UHC reforms. Few services are as cost-effective to both health and economic development as contraception, and as such, contraception must be prioritised for universal access. In some cases, there is a trend towards more curative than preventative coverage. This means coverage for family planning might be omitted. Service delivery organisations need to play their part to put contraception and reproductive health back up the UHC agenda on behalf of clients.

Making UHC work for the low-level private sector

As we enter the UHC era, we need to make sure that lower-level private facilities, which are a frequent lifeline to their communities, are not forgotten in public financing reforms. In the Philippines, we have assisted nearly 200 midwives through the arduous accreditation process into the national health insurance scheme, operated by PhilHealth. Once accredited, these small maternity homes are able to serve their communities free of change with maternal health and family planning services and receive PhilHealth reimbursements. Most of these midwives report not having adequate knowledge or capital to get through the accreditation process alone, making Marie Stopes International’s franchising quality assurance and support role the bridge to private sector inclusion in UHC.

Meanwhile, in countries like Ghana, we see another role for private sector support and advocacy related to UHC roll-out. The shift to public financing can mean slow and low payments that can cripple a clinic’s cash flow. Under the African Health Market for Equity (AHME) project, we are seeking to link private providers’ cash flow and other financial product solutions to may ease the teething pains of working with public financed national insurance schemes.

Advocating for financing by doing

Finally, in countries that are not yet taking great strides in UHC, organisations can still contribute to progress through proof-of-concept interim financing projects, like large-scale voucher programmes that demonstrate the power of removing client financial barriers, while simultaneously reimbursing all types of health providers, such as faith-based, for-profit, or public, for the quality assured services they offer. We can show that the market takes off and dramatic results are achieved with this financing strategy – serving as testimony for the potential power of UHC reforms.

In all of this, we laud many of our donors who are helping governments but also service delivery organisations like ours to do our part towards UHC objectives. The UK’s Department for International Development (DFID), the United States Agency for International Development (USAID) and the Gates Foundation have all bravely helped us move into the next level of family planning/ reproductive health programming complexity by frequently including a health financing and health system integration focus.

In summary, working with emerging domestic financing systems can be messy, but we all need to roll our sleeves up and get busy. Marie Stopes International has never seen so much opportunity for service delivery organisations to fulfil their mission and serve their clients both sustainably and equitably.

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