Bridging the Gap between Health Financing and Family Planning: How to Effectively Advocate for Contraception in UHC

Early next month, policymakers, researchers, and family planning (FP) advocates will convene virtually for the Not Without FP Forum. The very title of the event is a call to action: elevate family planning as central to the universal health coverage (UHC) agenda to help ensure that all women can access FP services without financial hardship. One concrete step to promote sustainable access is including contraception in the health benefits package (HBP)—a defined list of health services to be funded with public monies. To design an HBP, policymakers must weigh competing priorities within the health sector and ensure alignment between the cost of the package and the reality of finite resources.

Yet thus far, the family planning community has remained largely disengaged and siloed from HBP and broader health financing discussions. International health guidance provides limited help; it suggests that contraception should be included in a UHC benefits package, but provides few details for how that package should prioritize among contraceptive services and between contraception and other health services, all within local context and resource constraints. Advocates for contraceptive access need more effective strategies to engage with HBP design and ensure contraceptive services receive appropriate priority, particularly as the economic fallout from COVID-19 increases pressure on government budgets.

Drawing from a workshop we convened in February 2020, our latest paper offers an evidence review and proposed approach to inform policymakers as they evaluate contraception for inclusion in HBPs. Here’s a summary of what we found:

Evidence suggests contraception typically generates significant cost-savings for the payer and can thus increase the comprehensiveness of the overall package…

Our rapid literature review identified 36 studies on the cost-effectiveness of contraception provision or expansion compared to current provision or non-use. Eighty-six percent found contraception to be cost-saving for the health system, mainly by averting unintended pregnancies and associated maternal health costs. For budget-holders responsible for the complete costs of pregnancy, birth, and lifetime care, the body of existing evidence suggests that covering contraception is likely to generate significant cost-savings when evaluated over a long-time horizon. Contraceptive coverage thus need not be framed as in competition with other health services, but as helping enable a more comprehensive and equitable overall HBP.

…yet evidence from LMICs is limited in both volume and applicability

Studies from LMICs on the cost-effectiveness of contraception as measured by DALYs—disability-adjusted life years, a public health measure widely used to quantify burden of disease—are scarce. Most evidence comes from high-income countries and employs contraceptive-specific outcome measures that hinder UHC policy relevance (e.g., cost per couple-years protection and cost per unintended pregnancy averted, although this measure can potentially be converted to DALYs). Further, these outcome measures assume that prevention of unintended pregnancy represents an unambiguously positive outcome, which may conflict with women’s individual experiences. More research on the cost-effectiveness of contraception utilizing DALYs is needed, especially given the relevance of such analyses to HBP design processes, the importance of comparable results between settings, and promising research thus far on the likelihood of cost-savings.

Evaluating the net cost-benefit of contraception is complicated…

Comparing contraception to other health interventions is fraught with methodological, ethical, and conceptual challenges, including the non-health benefits of contraception, how to define and quantify the value of method choice, differentiating between postponed pregnancies versus reduced lifetime fertility, and defining what would happen if contraception were not included in the package (e.g., a specific combination of private-sector usage and discontinuation)—all of which we discuss in detail throughout the paper.

…but even in nominal terms, contraception is relatively affordable

In LICs, spending on contraceptive supplies from donor, government, and private financing totals $191 million—less than 1 percent of total health expenditure. The proportion of total health expenditure used for contraceptive supplies is even lower in LMICs (0.36 percent) and UMICs (0.17 percent). In comparison, resource requirements for other health programs that receive substantial external aid, such as HIV, TB, malaria, and immunization, are often much greater. In Kenya, for example, family planning expenditures in 2015 were roughly $70 million, while HIV and malaria spending totaled $848 million and $118 million, respectively. Family planning expenditures in Myanmar were $24 million in 2018, while $59 million was spent on malaria and $53 million on TB in 2017.

Although eliminating all future unmet contraceptive needs would be more expensive, Guttmacher’s 2019 Adding It Up report estimates that meeting all needs for contraceptive care across LMICs would require $12.6 billion per year—under 1 percent of total health spending in LMICs. This represents a relatively modest sum compared to overall health expenditure and the costs of absorbing/fully funding other health programs or interventions (see table 1).

Table 1. Estimated annual costs of contraception products and services relative to total health spending per country income group (US$ millions)

Sources: *IHME 2020; ^†Commodity Gap Analysis 2019; ^‡Sully et al. 2020; ^§UN Population Division 2020.

Current treatment of contraception in LMIC HBPs is poorly documented

Previous efforts, including those by Marie Stopes International and the Health Finance and Governance Project, helped to survey country-level benefits listing decisions for contraceptive services in sub-Saharan Africa and Asia. Their findings illustrate that actual provision, purchasing, and even budgeting do not always reflect the written contents of HBPs, essential medicines lists, or other service packages; most emerging health insurance schemes exclude contraception from reimbursable benefits packages, even though contraception is almost always included in “essential packages of health services” (which are broader policy statements without specified cost-sharing requirements). A few countries offer contraception through capitation or input-based financing arrangements, but benefits tend to be weakly defined and refrain from specifying the contraceptive methods covered (Ghana and Zambia are now notable exceptions). Stay tuned for more from CGD in the coming months on where and how different health programs have historically “converged” into a set of essential health benefits.

To more effectively advocate for contraceptive inclusion, start with context-specific budget impact analysis

Given what we know—and particularly the compelling evidence that contraception can generate cost savings for the payer—how should policymakers and advocates evaluate contraceptives for inclusion in HBPs? In our suggested framework, we propose that policymakers start with budget impact analysis (BIA), a methodological approach that systematically evaluates the net cost or savings of an inclusion decision. Advocates can use BIA to demonstrate the relatively modest net cost—or, likely, cost savings—of both (1) including status quo provision (e.g. from donors and other financiers) within the UHC package; and (2) rolling in phased method and quality expansions, including additional method choice, new delivery channels, and quality improvements. Where such inclusion decisions would increase net costs, advocates should use phased cost-effectiveness analysis to evaluate whether the service expansion would be cost-effective.

If informed by continued improvements in data collection and analysis, BIA offers the family planning community a compelling tool to advocate for service expansions and equity considerations—for example, expanding access to vulnerable groups—in a way that is likely to link with broader health financing policies and resonate with health financing counterparts.

Given the scale of economic challenges facing policymakers, allocating domestic resources to the most effective uses is of paramount importance. Contraception represents a relatively low-cost, high-value investment. Now is the time to lay the groundwork for inclusion and make a compelling case that contraception provides strong value for money.

You can read the full paper here.