ARROW is engaging with the 63rd Commission on the Status of Women (#CSW63) taking place at the UN headquarters in New York City. Our team will be bringing you thoughts on the deliberations from different perspectives in order to share with you what we are learning at this venue.

The ARROW team landed in a bitter, cold, foggy New York for #CSW63. CSW never ceases to amaze me – the rich, intimate, insightful discussions from women’s rights NGOs on the outside of the UN building. This year’s theme was social protection systems which included social protection in a range of areas – education, transport, infrastructure, health, work, economy.

In the sexual and reproductive health and rights agenda, we know full well that governments in the region, and UN agencies are deep in discussions around Universal Health Coverage, as an essential part of social protection for health for citizens. SRHR advocates (including us) are gearing up to ensure that sexual and reproductive health services are adequately covered within the ambit of universal health coverage.

Universal coverage is defined as “access to adequate health care for all at affordable prices”. Universal health coverage is now almost being universally touted as THE core obligation of governments in order to fulfill the health care needs of citizens. UHC should ideally cover three key areas(i) :
• Removing financial barriers to accessing care and providing financial protection from catastrophic costs to users of health care services;
• Increasing the extent of health care coverage: what services are included in an Essential Services Package and provided at subsidised/no costs;
• Increasing the extent of population coverage: who is covered.

These three areas can be extrapolated for discussion to understand what some ways in which a UHC approach may be useful and necessary at country levels. Removing financial barriers and providing financial protection from catastrophic costs is a key driver. The costs of healthcare are high especially for the poor and especially when health is seen as an out-of-pocket (OOP) expenditure. In our region, many countries report high OOP expenditures – some reporting 60-80% of private expenditure on health being out of pocket. Illness and death can send poor families into debt. But what exactly are these illnesses which will do so?

This leads to the second point – what will constitute the essential services package at country level – differs from country to country. Each country will choose a set of services depending on the aims of the UHC programme and other key parameters such as the burden of disease, cost-effectiveness. The essential services package can be divided into three basic tiers – one tier, free for all, and usually financed by governments (either through tax revenue or donor funding); shared costs (between government and patient, either through government run health insurance schemes or or user fees); and the third tier – entirely financed by user fees.

Tax revenue is essential as health services are to be paid through that, and in developing countries the base for tax revenue is usually small; and health services have to compete with other sectors for funding. In the time of resource crunches and austerity measures health services would most likely to receive lesser funding.

There is a strong likelihood then, that the first tier of services may be a very basic, limited set of services. A narrow range of services would then exclude sexual and reproductive health services as part and parcel of an essential services package. Amongst some of the key services – maternal deliveries for example, are sometimes so cost prohibitive that it can and does fall under the catastrophic costs. ARROW’s study in Cambodia showed that even women in the highest wealth quintile found it difficult to pay for maternity delivery services.

Within health insurance schemes at country level, on the overall there is lack of full understanding on how insurance schemes fully work, when do payments have to be made, what is reimbursable or not, and who is covered. In families where women and girls receive fewer allocation of resources – then families utilising resources to ensure that these women and girls are covered by some form of insurance is not likely unless these come out of the concerns of employers and types of employment.

Even then, insurance schemes do not usually cover many reproductive health services which are “uninsurable” as stand-alone benefits because they are non-random and/or are high probability events. For example, pregnancy is a non-random event, and contraceptive services are high-probability services.

In addition, Social Protection Schemes may be needed, covering specific population groups identified as ‘vulnerable’: low-income groups, indigenous populations, mothers and children, adolescents, sexual minorities.

Universal access to sexual and reproductive health services, therefore, appears to be dependent on the government in taking the responsibility to provide a broad package of services that goes beyond maternal health care and contraception.

Even as universal health care coverage has begun to take root in many parts of the world as a fundamental human right, there are global forces diametrically pushing countries in the opposite direction.

But while we work hard to ensure that sexual and reproductive health is covered within the UHC discourse and is captured as part and parcel of any essential services package – we need to be mindful that UHC is only one part of the actual obligation of governments to fulfil the right to health for its citizens. Right to health is what we should actually be championing, and the right to health is a fundamental, inalienable human right which governments cannot abrogate, but need to protect and uphold. The right to health provides the platform for the overall development and prosperity of people, communities and countries. Some countries have a constitutional guarantee to a right to health, which is redolent of the commitments in the Universal Declaration of Human Rights, and echoed in other human rights covenants – ICERD, CEDAW, CESCR, CRC and CRPD. In Alma Ata, the government commitment was to ensuring 5-7% of the GDP is allocated to health, it will be interesting to compare whether full costing of UHC at country level meet or surpass these amounts.

(i) TK Sundari Ravindran, Reclaiming & Redefining Rights: Pathways to Universal Access to Reproductive Health Care in Asia. ARROW

by Sivananthi Thanenthiran

Executive Director, ARROW