Family planning and national health insurance schemes

Julia Kaufman, Policy Analyst for Global Health Policy at the Center for Global Development (CGD)

“Channeling external resources through governments – and increasing domestic spending – are key to sustainable family planning financing.”

Family planning services are often organised and delivered through vertical programmes with dedicated or earmarked funding that relies heavily on donors, NGOs, and out-of-pocket payments. This approach can position family planning in competition with other health services, intensifying financing risks related to fragmentation, limited government co-financing, and aid volatility.

Including contraception in health benefits packages (HBPs) is one promising way to shift from an off-budget, vertical model toward more integration within universal health coverage systems. Such inclusion also provides a bridge between the health financing and family planning communities. In their endeavors to advance universal health coverage (UHC) through HBPs, essential medicines lists, and other reforms, health financing officials must weigh competing health priorities and align HBP costs with the reality of limited budgets—especially amid current macroeconomic challenges. To this end, cost-effectiveness criteria is ideally used to prioritise interventions for public subsidy and maximum health impact.

Encouragingly, existing evidence suggests that contraception typically generates significant cost-savings for public payers and thus can increase the overall comprehensiveness of HBPs. But outside of a handful of high-income countries, evidence is limited. Further, comparing contraception to other health interventions is fraught with methodological complexities, including how to account for its non-health benefits and define and quantify the value of method choice.

If informed by continued improvements in data collection and analysis, budget impact analysis can be used as a valuable tool to demonstrate the relatively modest net cost—or, likely, cost savings—of (1) including status quo provision (e.g., from donors and other financiers) within the UHC package; and (2) rolling in phased method, delivery, and quality expansions. Channeling external resources through governments—and increasing domestic spending—are key to sustainable family planning financing. New types of analysis that resonate with health financing counterparts are essential to this endeavor.

Esi Asare Prah, Advocacy and Donor Relations Manager, MSI Reproductive Choices, Ghana

“In Ghana, we recently had a breakthrough in this work: family planning is now included in Ghana’s National Health Insurance Scheme’s benefit package!”

Cost remains a major barrier to people accessing reproductive healthcare. When people are forced to pay out-of-pocket, it can place a significant financial burden on them, limit choice or prevent access altogether. To achieve health for all, people need to be able to access services without financial stress.

That’s why, across the MSI global partnership, we’ve been trying to find ways that reproductive healthcare can be subsidised and funded to increase the choice and quality of services. This work is called health financing. We partner with governments, civil society organisations and the private sector to make the case for why they should include reproductive healthcare in their health insurance coverage.

In Ghana, we recently had a breakthrough in this work: family planning is now included in Ghana’s National Health Insurance Scheme’s benefit package! This means free access for all insured women and girls, so millions will now be able to get the family planning services they need without paying out-of-pocket.

This monumental achievement was the culmination of several years of targeted advocacy and collaboration with the national government, the Ghana Health Service, ‘National Health Insurance Authority’ (NHIS), NGOs and research partners. As part of this, we advanced a two-year pilot study that tested the inclusion of various family planning methods (permanent methods, long-acting reversible contraceptives, and short-acting reversible contraceptives) in Ghana’s NHIS benefit package. Results from the pilot confirmed that funding reproductive healthcare is a “development best-buy” with direct healthcare cost savings.

Seeing the positive results from their jointly led pilot, the Ghanaian government approved its continuation in the pilot districts in 2020 and a nationwide rollout in 2022. It’s one of the most positive reforms for Ghanaian women in a generation, broadening choice and opportunities for them, their families, and communities, while reaping other health and economic benefits too. It really shows what can happen when we work together and fund health.

Michael Olawuyi, Health Financing Lead, Options Consultancy Services

“Governments must establish supportive political and legal frameworks that enable change to happen. However, sometimes, where government is balancing competing priorities, they may need a nudge.”

Achieving health for all is an ambition that requires careful planning and execution based on the context of each community (province, state, or country). Governments must establish supportive political and legal frameworks that enable change to happen. However, sometimes, where government is balancing competing priorities, they may need a nudge. This was the case in Jigawa, Nigeria, where development partners supported the Jigawa State Government to promulgate a law that established the Jigawa Contributory Health Scheme.

Once a law is in place, three steps have to be taken.

First, social barriers to establishing a health insurance scheme must be overcome. In Jigawa, religious and traditional gatekeepers were concerned that the scheme would usurp the power of God based on their religious conviction that only God can protect (insure) you against future risks. To achieve this, we sensitized stakeholders to the concept that a social protection mechanism is not morally wrong. This included:

• Advancing arguments about how the proposed Scheme was comparable to “adashi”- a traditional form of contribution in Northern Nigeria where a group of people contribute to informal savings for mutual benefits.
• Proposing that the word ‘insurance’ was dropped from the name and instead, the Scheme be branded as the Jigawa Contributory Health Scheme by Jigawa Contributory Health Management Authority.

Second, economic barriers for citizens to take part in the scheme must also be overcome. In Jigawa state, about 80% of the population are poor. This meant the health insurance scheme needed to be a hybrid of:

• A contributory programme, where those who can afford to pay contribute, and
• Equity programmes where government pays contributions on behalf of the poorest of the poor.

Finally, partners may need to provide support in developing the capacity of the state to develop operational manuals and monitoring/evaluation plans for the scheme and should be ready to provide mentorship on data management, training on health financing functions (resource mobilisation, pooling, and strategic purchasing of essential services, including family planning and sexual and reproductive health). These are critical elements to ensure that the scheme is well-designed and operationalised.