Family Planning in Universal Health Coverage schemes


A literature review


Cynthia Eldridge & Mara Hansen Staples, Impact for Health

Commissioned by Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH on behalf of the German Federal Ministry for Economic Cooperation and Development, December 2018


Around 2011 the global reproductive health community became interested in ways to effectively embed family planning (FP) services in the movements to expand access to care through universal health coverage (UHC). Since then several initiatives have been funded, projects launched, and lessons learned.

A purposeful review of recent literature reveals challenges to incorporating FP into UHC agendas in five categories:

  • People: Most schemes do not cover the people the development community cares most about the poor, vulnerable and adolescents.
  • Providers: In many countries the providers where people commonly seek FP commodities and services are not included in the health financing schemes.
  • Payment: Provider payment mechanisms and reimbursements often act as a disincentive to quality and choice.
  • Package: FP is often not included in the benefit packages of emerging insurance schemes. When it is included, the package may not cover the labor and commodity costs for the full range of methods. Additionally, communication around the package is often poor, creating confusion about what is covered by different mechanisms.
  • Politics: Pathways towards UHC that preference coverage of priority commodities and services (like FP) for poor and vulnerable populations first may not be politically tenable, or appropriately respond to politicians’ practical considerations.

The recent literature also highlights several key lessons including:

  1. the need to define approaches towards integrating FP in UHC in response to country’s FP, health financing and political contexts;
  2. the diversity in FP methods suggests that optimal financing mechanisms for varying methods will be, out of necessity, different;
  3. the need for financing mechanisms to respond to a patients’ changing needs over the course of their life and address key barriers to access at each stage;
  4. the recognition that financing mechanisms are best at addressing financing barriers; other non-financial barriers still exist for FP and will need to be addressed and financed separately; quality should be financed effectively throughout all approaches; and
  5. acknowledgement that no clear economic argument has been made to governments to shift FP from its current supply-side approach to demand-side mechanisms.

Countries (and sub-national geographies) fall on a spectrum of maturity levels in both their FP use and health financing contexts. Across the maturity spectrums, the opportunities to support progress vary. Some examples of the type of activities that may be appropriate in nascent, emerging and mature contexts include:

  • Countries with low use of modern contraceptives and nascent health financing structures require a continued focus on demand generation for modern contraceptives, addressing non-financial barriers to FP use, and working within the existing supply-side financing mechanisms for FP to lay the groundwork for more strategic purchasing.
  • Contexts with moderate use of modern contraceptives and emergent health financing maturity have high potential for growth in the use of contraception. In this context a plurality of health financing mechanisms can be employed to expand coverage of priority FP products and services to key populations. Moving away from supply-side financing through increased use of more strategic purchasing mechanisms to support a progressive pathway towards UHC is critical.
  • Countries with high use of modern contraceptives and mature health financing structures require diligent attention to improving equity and increasing reliance on domestic funds for FP. In this context development of financing mechanisms that can effectively cover user-controlled commodities such as emergency contraception or self-injected DMPA are needed. Moving these products away from their current reliance on out-of-pocket expenditure could help improve equity of access and use.

Programming by global health actors should be flexible enough to respond to both countries’ maturity levels and the political windows of opportunity that arise to move a progressive UHC agenda forward. Organizations that are able to respond nimbly with financing and programming are likely to be able to capitalize on opportunities to advance the integration of FP in progressive UHC agendas in a scalable fashion.

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