Sexual and reproductive health services in universal health coverage: a review of recent evidence from low- and middle-income countries

Abstract

If universal health coverage (UHC) cannot be achieved without the sexual and reproductive health (SRH) needs of the population being met, what then is the current situation vis-à-vis universal coverage of SRH services, and the extent to which SRH services have been prioritised in national UHC plans and processes? This was the central question that guided this critical review of more than 200 publications between 2010 and 2019. The findings are the following. The Essential Package of Healthcare Services (EPHS) across many countries excludes several critical SRH services (e.g. safe abortion services, reproductive cancers) that are already poorly available. Inadequate international and domestic public funding of SRH services contributes to a sustained burden of out-of-pocket expenditure (OOPE) and inequities in access to SRH services. Policy and legal barriers, restrictive gender norms and gender-based inequalities challenge the delivery and access to quality SRH services. The evidence is mixed as to whether an expanded role and scope of the private sector improves availability and access to services of underserved populations. As momentum gathers towards SRH and UHC, the following actions are necessary and urgent. Advocacy for greater priority for SRH in government EPHS and health budgets aligned with SRH and UHC goals is needed. Implementation of stable and sustained financing mechanisms that would reduce the proportion of SRH-financing from OOPE is a priority. Evidence, moving from descriptive towards explanatory studies which provide insights into the “hows” and “whys” of processes and pathways are essential for guiding policy and programme actions.

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

“…47 In the case of GBV, the international movements created momentum for the women's movement in the country. In contrast to Ravindran and Govender's findings on the involvement of civil society organisations and communities in priority-EPHS, 7 a robust network of women-led NGOs was formed, with individual political champions' support, and led to the passing of the Domestic Violence Act (DVA) in 1994, which subsequently provided legitimacy for the OSCC pilot. 43 The country's subsequent commitment to international agendas, such as the MDGs and SDGs, also provided a justification for policy-makers to continue the financial allocation for pregnancy and delivery services, as well as to expand it for unmarried women and address unsafe abortion to further reduce the MMR.…”

“…1,5,6 While maternal health services, including obstetric emergencies, and family planning are typically included in these packages, others such as safe abortion, gender-based violence (GBV), cancer screening and fertility care have been given less attention and are mainly financed through out-of-pocket expenditure (OOPE) or external donor funding. [7][8][9][10] This raises serious concerns for effective coverage, equity and financial protection. Globally, almost all 4.3 billion people of reproductive age will lack access to adequate SRH services at some point in their lifetime.…”

“…11 Low-income households also bear a heavier financial burden when seeking SRH services, compared to higherincome households, 12 and a higher incidence of catastrophic expenditures. 7 Universal access to SRH services will require increased government prioritisation and public financing, as part of a clearly defined pathway towards UHC that addresses people's unique SRH needs. 1,9 SRH issues need to become political priorities, and their solutions need to be adequately resourced by the health system.…”

“…11 There is limited evidence on why certain SRH interventions or services are being prioritised in UHC plans, what the most effective strategies have been to enable this prioritisation, and what it takes for this to happen in specific contexts. 7,13 1.1. Malaysia as a case study Since its independence in 1957, Malaysia has made remarkable progress in extending health service coverage, and improving health outcomes, particularly for maternal and child health.…”

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

“…The extent of their exclusion is very much dependent on prevailing legal and social environments. 8,9 The constraints imposed by restrictive legal and social environments may be mitigated, and comprehensive SRH services included in EHSPs or HBPs, as Pillay et al recommend, through " … fair and transparent priority setting process [es] [which] consider the best available evidence, burden of disease, and cost effectiveness … underpinned by ethical values such as equity, gender equality and right to health". 8 However, this integral recommendation is challenging to put into practice.…”