Priority-setting to integrate sexual and reproductive health into universal health coverage: the case of Malaysia

Abstract

Despite increasing calls to integrate and prioritise sexual and reproductive health (SRH) services in universal health coverage (UHC) processes, several SRH services have remained a low priority in countries' UHC plans. This study aims to understand the priority-setting process of SRH interventions in the context of UHC, drawing on the Malaysian experience. A realist evaluation framework was adopted to examine the priority-setting process for three SRH tracer interventions: pregnancy, safe delivery and post-natal care; gender-based violence (GBV) services; and abortion-related services. The study used a qualitative multimethod design, including a literature and document review, and 20 in-depth key informant interviews, to explore the context-mechanism-outcome configurations that influenced and explained the priority-setting process. Four key advocacy strategies were identified for the effective prioritisation of SRH services, namely: (1) generating public demand and social support, (2) linking SRH issues with public agendas or international commitments, (3) engaging champions that are internal and external to the public health sector, and (4) reframing SRH issues as public health issues. While these strategies successfully triggered mechanisms, such as mutual understanding and increased buy-in of policymakers to prioritise SRH services, the level and extent of prioritisation was affected by both inner and outer contextual factors, in particular the socio-cultural and political context. Priority-setting is a political decision-making process that reflects societal values and norms. Efforts to integrate SRH services in UHC processes need both to make technical arguments and to find strategies to overcome barriers related to societal values (including certain socio-cultural and religious norms). This is particularly important for sensitive SRH services, like GBV and safe abortion, and for certain populations.

Healthcare Priority-Setting in Essential Health Packages for Sexual Reproductive Health: Going Beyond the Commonly Prioritised Services

“…Comprehensive sexuality education is effectively absent, with weak reference to SRH awareness and counselling (Ravindran & Govender, 2020). These findings have been supported elsewhere (Akazili et al, 2020;Lim et al, 2020;Love-Koh et al, 2020).…”

“…Within the category of SRH services, pregnancy-related care, family planning and HIV/AIDS have been prioritized alongside other disease program areas in EHPs (Huchko et al, 2015;Pillay et al, 2020). However, gender-based violence, safe abortion, reproductive cancers, infertility services, comprehensive sexuality education, sexuality services, and STI's other than HIV, have received limited prioritization in EHPs (Gilby et al, 2021;Lim et al, 2020;Starrs et al, 2018). Furthermore, for services included in EHPs, key populations such as the unmarried, adolescents, Men who have Sex with Men, sex workers, LBGTQIA community, persons living with HIV/AIDS, persons with disabilities and migrants still have unmet SRH service needs (Lim et al, 2020;Ravindran & Govender, 2020;Starrs et al, 2018).…”

“…However, gender-based violence, safe abortion, reproductive cancers, infertility services, comprehensive sexuality education, sexuality services, and STI's other than HIV, have received limited prioritization in EHPs (Gilby et al, 2021;Lim et al, 2020;Starrs et al, 2018). Furthermore, for services included in EHPs, key populations such as the unmarried, adolescents, Men who have Sex with Men, sex workers, LBGTQIA community, persons living with HIV/AIDS, persons with disabilities and migrants still have unmet SRH service needs (Lim et al, 2020;Ravindran & Govender, 2020;Starrs et al, 2018). The lack of access to the commonly unprioritized SRH services threatens universal health coverage (UHC) objectives with the risk of increased inequities in coverage for financial protection, health services and quality healthcare (Ravindran & Govender, 2020).…”

“…Systematic and transparent tradeoffs have to be balanced off on competing criteria with consultation and inputs from relevant stakeholders on health technology assessment evidence (HTA) (World Health Organization et al, 2021). However, in many LMICs the stalling on progress for the unmet SRH services has been attributed to challenges related to dominant sociocultural norms and inequities in access to health services which has influenced healthcare priority setting processes (Clark & Weale, 2012;Lim et al, 2020;Starrs et al, 2018). More recently, the onset of SAS-CoV-2 (COVID-19) has declined economic performance and fiscal spaces for public financing and inevitably revealed gaps in priority-setting approaches (Otu et al, 2021;Šehović & Govender, 2021;Tang et al, 2020).…”

“Imagining the world anew”: a transformative, rights-based agenda for UHC and SRHR in 2021 and beyond

“…For instance, the Malaysia case study by Lim et al identifies key advocacy strategies for the effective prioritisation of SRH services – including GBV services and abortion and post-abortion care – in UHC packages. 14 Several strategies, including linking SRH issues with international commitments, engaging champions and reframing SRH issues as public health issues, have proven effective to varying degrees in overcoming resistance and elevating these issues in the hierarchy of priorities. The Malaysian case study also highlights the importance of a rights-based approach to SRH and UHC: despite the country’s relative success in reducing maternal mortality over the past decades, the MMR has stalled for the past 15 years at approximately 2.5–3 times its MDG target, largely due to the exclusion of certain high-risk populations, including adolescents, migrants and refugees.…”