Leveraging Social Accountability to Include Family Planning in Country-Level Universal Health Coverage: Four Lessons Learned from PAI’s UHC Engage Project

Family planning (FP) is important not only in saving and safeguarding women’s lives but also for societal and economic reasons. It allows women to control their lives and exercise choices that affect their families, communities and societies. However, 218 million women of reproductive age (15–49) in low- and middle-income countries have an unmet need for modern contraceptives. Young women aged 15 to 19 have a higher unmet need for modern contraceptives when compared with all women of reproductive age (43% vs. 24%). Sub-Saharan Africa is one of the regions with the lowest proportion of use of modern methods among women who want to avoid pregnancy. Contraceptive use can prevent more than half of maternal deaths. This calls for a global obligation and collective action to advance access to sexual and reproductive health. Governments and other stakeholders are making concerted efforts to achieve universal access to sexual and reproductive health (SRH) services and education by integrating FP into national strategies and programs. While these actions are necessary, global and local civil society organizations (CSOs) must lead efforts to hold governments accountable to ensure equitable and accessible SRH services are embedded within an integrated health system.

PAI and our country-based partners are working to advance universal health coverage (UHC) and primary health care (PHC) that expands access to comprehensive SRH and FP services for all people while increasing demand. Through our UHC Engage project, PAI invested in civil society advocacy efforts to ensure FP services are included in UHC policy reforms across four countries.

• In countries where UHC commitments were made, but policies were not enacted, PAI’s CSO partners worked with a broad coalition of government and non-governmental organizations (NGOs) to enact UHC policies in the form of national health insurance schemes (NHIS).
• In countries where NHIS policies already existed, partners successfully advocated for including FP services in the essential benefits package.
• In areas where FP-inclusive NHIS policies are being implemented, partners strengthened social accountability processes to ensure access and improve the quality of FP and reproductive health services.

Here we highlight four lessons learned from our UHC Engage project, which works with CSOs to ensure that SRH is prioritized in country-level UHC policy reforms using accountability processes, mechanisms and practices.

1. Strategic civil society social accountability

Key to progress is a strategic social accountability approach that uses multiple complementary mechanisms and activities, including alliance/coalition building, budget and commitment monitoring tools, evidence-based advocacy and capacity development.

For example, Marie Stopes International Ghana (MSIG) established a strong governance structure — including a technical working group and a steering committee — to develop a pilot program showcasing the cost-effectiveness of including FP in the country’s decade-old NHIS. MSIG then combined advocacy and accountability to successfully scale up this pilot program nationwide.

And in Ethiopia, the Consortium of Reproductive Health Associations (CORHA) used multi-sectoral ministerial engagement to advance and achieve UHC and engaged the media to help hold government officials and policymakers accountable.

These approaches enabled PAI and our partners to build a stronger ecosystem of social accountability that enhanced their communication with national governments and their ministries, multi-stakeholder country platforms, CSOs and other stakeholders.

2. Multi-level and multi-stakeholder engagement

Another key lesson was the importance of engaging with diverse actors and stakeholders at different levels and across sectors to strengthen the ecosystem of accountability. This is a dynamic process with ongoing dialogue that holds states accountable for their obligations.

A prime example is PAI partner Sahayog Society for Participatory Rural Development (SAHAYOG) in India, where national and state governments have implemented an NHIS that includes FP and maternal, newborn and child health (MNCH) services. SAHAYOG’s advocacy and accountability activities involved multi-level engagements with state and district health teams and community leaders to identify gaps in FP and MNCH service delivery and regularly organized campaigns with the Patients’ Rights Campaign and Jan Swasthya Abhiyan (Indian Chapter of the People’s Health Movement) at the national level. These engagements generally increased collaboration and trust among CSOs, the government and other actors in the space. They significantly improved domestic resource mobilization and supported the achievement of FP commitments and implementation of UHC policies and FP budgets at the sub-national level.

Kisumu Medical and Education Trust (KMET) also illustrates how this engagement can lead to greater impact. KMET worked with members of the county’s legislature and the department of health to design and implement Marwa Kisumu Solidarity Health Cover in Kisumu County — the first-of-its-kind benefits package in Kenya. This package ensured that members of the poorest communities could access services, including FP, without paying monthly fees.

3. Data generation and advocacy

Advocacy and accountability are intertwined processes that complement each other when holding governments and stakeholders accountable. CSOs collect and generate data that underpins their work to track FP commitments and determine whether governments are being held accountable for these commitments. This process occurs in conjunction with advocacy efforts to plan, produce data and disseminate information on the budget cycle. This combination provides legitimacy, credibility, power and influence for CSOs as they advocate for policy reform, budget allocation and implementation.

For instance, Pathways Policy Institute (PPI) generated evidence that showed the average person spent USD $3 per FP visit, while the cost of UHC-funded integrated service delivery for a family of four covering all PHC services is $5. This evidence demonstrated significant cost savings to families and spurred the county government to include FP services in the implementation of Kenya’s National Hospital Insurance Fund program at the county level.

4. Capacity strengthening  

Strengthening the capacity of different groups to better understand UHC financing mechanisms, purchasing systems and advocacy/accountability strategies is critical to advancing FP in UHC and holding governments accountable for policy reforms.

As an example, CORHA worked with the media to help them frame these issues in a way that would compel action by government officials and policymakers. This helped illustrate the social impact of SRHR policy and investments and further encouraged national policymakers and other key decision-makers to respond to calls to action from the community.

Throughout the UHC Engage project, PAI provided continuous strategic technical and financial support to further strengthen UHC partners’ accountability and advocacy work. A huge component of this assistance was enabling clear avenues for knowledge exchange between partners. This included convening peer-to-peer learning opportunities; sharing resources and skills for greater advocacy; and creating platforms that could relay major changes to the local and global UHC landscape while also identifying and addressing the specific needs of each partner.

This type of support is critical for amplifying accountability and advocacy mechanisms at the global level and enhancing localization, enabling local CSOs to have more control and ownership of efforts to sustain these initiatives. These lines of communication also allowed UHC Engage partners and PAI to efficiently exchange critical country- and community-level insights that strengthen advocates as they engage with stakeholders both in the U.S. and on the global stage.