Shobha Shukla
The COVID-19 pandemic has exposed the fragility of weak health systems that were ill prepared to withstand the onslaught of the pandemic. As documented by the Pulse survey of the WHO, the pandemic has resulted in disruption of essential health services, including sexual and reproductive health services, in most countries. Weak and perpetually poorly resourced health systems have escalated the woes of the public, more so in low- and lower-middle income countries. This disaster has reinforced the need for countries to not only increase their public health spending, but also explore innovative ways of financing healthcare systems.
More than 50% of countries in the Asia and the Pacific region come under the category of low- and lower-middle income countries. While there has been economic growth in the region resulting in corresponding improvements in health service delivery systems, in many countries these gains are unjustly reserved for the elite few in terms of quality and timely services, says Dr Ashish Bajracharya, Population Council’s Deputy Director for global country strategy and regional representative for South and East Asia. Large parts of our populations still have an unmet need in sexual and reproductive health and out-of-pocket expenditures continue to pay for most of the healthcare expenditures. For Dr Bajracharya, it is critical to work towards universal health coverage and to promote sustainable financing strategies, including heightening of commitments of state resources for sexual and reproductive health.
Dr Bajracharya was Chairing the sixth session of the ongoing virtual series of 10th Asia Pacific Conference on Reproductive and Sexual Health and Rights (APCRSHR10). Two interesting studies were presented in this APCRSHR10 session from Pakistan and Philippines. The first study was presented by Dr Moazzam Ali, noted epidemiologist at the World Health Organization (WHO), who shared the results of a research project on “demand side financing” implemented in two districts of Punjab province of Pakistan to meet birth spacing needs of the underserved.
What is demand side financing?
Dr Ali explains that the three key components of any demand side financing project are (i) a pre-specified target group, like, pregnant women, children under five years of age, poor households, etc; (ii) a financial transfer to the beneficiaries through the government, the private sector, NGOs or some other mechanism. It can be a direct conditional cash transfer or it can be via vouchers; and (iii) a very clear rationale for the choice of services covered, for example, immunisation, family planning, cancer screening etc. Any intervention that meets these three conditions qualifies to be a demand side financing.
This particular study was done to assess the effectiveness of free, single-purpose vouchers for increasing the uptake, use and better targeting of modern contraceptives among women from the lowest two wealth quintiles in rural and urban communities in Pakistan. The project tried to see if vouchers can contribute in achieving universal health coverage, especially in the context of sexual and reproductive health and, more specifically, for family planning.
The study was implemented across an intervention (Chakwal) and a control (Bhakkar) district in Punjab province. 1276 married women of reproductive age were enrolled in each arm. The single purpose voucher was from Marie Stopes International branch in Pakistan. Services included follow ups/ side effects management, services regarding the modern contraceptives and the removal services (for the implants and Intrauterine devices-IUDs).
Did the intervention enhance equity, especially among the poor?
Project results show that compared to baseline, use of modern contraceptive methods increased by 30% in the intervention area as against 14% in the control area. Specifically, in the intervention area IUD use increased from 2% to 20% (national level use of IUD is 1-2%) and condom use increased from 7% to 13%. Vouchers also resulted in an increase of 16% in current contraceptive use and 26% increase in modern methods use. Intervention area also reported low method-specific discontinuation (13.7%) and high method-specific switching rates (46.6%) amongst modern contraceptive users. The corresponding figures for control area were 26.8% and 13.3% respectively. Many of those who switched to modern methods, switched to IUDs, implants, injectables and pills, which are far more effective compared to the traditional family planning methods. Also, the underserved population utilized the modern methods more than their affluent counterparts.
The study outcomes prove that vouchers increase the use of modern contraception methods (especially the long acting reversible contraception methods) along with other modern methods like pills and injectables. Vouchers also decrease discontinuation and increase switching. Voucher use seemed to reduce the inequality in access to modern methods across wealth quintiles and enhanced equity by reaching out to the poor who began using them more.
“Vouchers can be a highly effective tool to increase access to, and use of, family planning and reproductive health services. Long term use of vouchers can strengthen the health system capacity and provide a pathway to the strategic purchasing power such as insurance or contracting in the long run and contributing in the context of universal health coverage in the low and middle income countries”, Dr Ali said to CNS (Citizen News Service).
The second example of innovative financing was from the Philippines on “Public-Private Partnership Bridge Funding”. Loida Almendares, Programme Manager at DKT International in Philippines, shared the concept of “bridge financing”.
What is bridge financing?
The Philippine Responsible Parenthood and Reproductive Health Law calls for engagement of the civil society by the government to address the unmet need for family planning. The Department of Health allocates funds for this purpose. However, the process of transferring government funds to private organizations is cumbersome and often results in delays in fund release.
Bridge financing is a mechanism to address this gap and to allow civil society organizations to implement family planning and reproductive health activities without unnecessary delays. It allows family planning services to be provided even while the government is yet to release project funds for the civil society organizations. Bridge financing is a “no interest loan” given to civil society organizations with existing project contracts and is to be strictly used for project implementation. It is to the tune of 30-35% of the total project fund. The money has to be returned to the Bridge Fund provider – which could be any financing entity – at the end of the project at zero interest. Philippines government laws support public and private partnerships or engagement of civil society organizations and private sectors to actively participate in the development processes of the state.
There could be different public-private partnership models utilising the bridge financing mechanism. Almendares shared the outcomes of one such model developed in the Philippines jointly by the Cooperative Movement for Encouraging No-Scalpel Vasectomy (CMEN), Pangasinan Province civil society organization and the government.
This public-private partnership with bridge financing reached more than 13000 women with unmet family planning needs. Of them, 61% were provided with long acting and permanent methods – which is more than triple the national average of 14% for these methods. For the HIV programme, the project was able to reach out to underserved populations, including LGBTIQ+ community, students, pregnant women and people who inject drugs and test 678 people in three months. Persons who tested positive for HIV were then referred to treatment hubs for immediate care. All of the loans received under bridge funding were repaid.
Almendares says that public-private partnership is important to escalate delivery of quality sexual and reproductive health services with financial resources from the government and human resources from the civil society organizations or private sector. She lists several advantages of public-private partnership through Bridge Funding: “It is an intermediate financing to address the gap due to fund delays and allows civil society organizations to provide reproductive and sexual health services to a vast number of people in communities and key populations even while the government is yet to release project funds for civil society organizations.”
COVID-19 has changed the expectations and outlook of healthcare worldwide. India’s public health expenditure is dismally low at less than 1.5% of the gross domestic product and this warrants a drastic increase. Quality healthcare should be a fundamental right of every citizen of our country as well as of other countries.
Innovative health financing makes good business sense
Zahra Fathi Geshnigani, senior gender equality advocate and former CEO of Family Health Association of Iran puts it very succinctly that health enables people to learn and earn, creates jobs, drives productivity, stimulates inclusive growth, and protects economies from the impacts of outbreaks and other emergencies. So innovative health financing that aligns with the vision of inclusive and sustainable health services makes good business sense.
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