Review of the inclusion of SRHR interventions in essential packages of health services in low- and lower-middle income countries.

Sexual and reproductive health and rights (SRHR) and universal health coverage (UHC) are fundamental to health as a human right. One way that countries operationalise UHC is through the development of an essential package of health services (EPHS), which describes a list of clinical and public health services that a government aspires to provide for their population. This study reviews the contents of 46 countries' EPHS against the standard of the Guttmacher-Lancet Report's (GLR) nine essential SRHR interventions. The analysis is conducted in two steps; EPHS are first categorised according to the level of specificity of their contents using a case classification scheme, then the most detailed EPHS are mapped onto the GLR's nine essential SRHR interventions. The results highlight the variations of EPHS and provide information on the inclusion of the GLR nine essential SRHR interventions in low- and lower-middle income countries' EPHS. This study also proposes a case classification scheme as an analytical tool to conceptualise how EPHS fall along a spectrum of specificity and defines a set of keywords for evaluating the contents of policies against the standard of the GLR. These analytical tools and findings can be relevant for policymakers, researchers, and organisations involved in SRHR advocacy to better understand the variations in detail among countries' EPHS and compare governments' commitment to SRHR as a human right.

Introduction

In 2019, the UN General Assembly declared Universal Health Coverage (UHC) necessary for achieving the sustainable development goals (SDGs) by 2030.[1] The same year, at the Nairobi Summit, the international community gathered to take stock of the unfinished business from the International Conference on Population and Development (ICPD) Programme of Action.[2] There countries re-committed to a forward-looking sexual and reproductive health and rights (SRHR) agenda to achieve the SDGs,[3] including target 3.7, the achievement of universal access to sexual and reproductive health under UHC.[4] By reaffirming health as a human right, UHC aims to give everyone everywhere access to essential health services without undue financial hardship.[1,5] While UHC remains a priority of the global community, the COVID-19 pandemic has disrupted health systems globally, as countries work to simultaneously prioritise and maintain critical services, including essential sexual and reproductive health services.[6] The COVID-19 pandemic highlights the fact that all countries have finite resources, and therefore must decide what services to prioritise within their UHC reform.[7,8]

UHC and SRHR have been described as “mutually reinforcing”,[9] and SRHR is more frequently being recognised as a fundamental aspect of UHC.[3,10] For countries working to operationalise UHC, an initial step is the development of an essential package of health services (EPHS),[11] particularly one which includes a holistic set of SRHR interventions.[8] The term EPHS describes “a list of clinical and public health services that a government has determined as priority for the country … (and) that the government is providing or aspiring to provide to its citizens in an equitable manner”.[12] The contents of an EPHS are designed to reflect the unique contexts which produce them.[13] Perhaps because of this, EPHS have been observed to vary widely in their level of detail and the specificity of their contents.[12,13]

Published in 2018, Accelerate progress (GLR), proposed a comprehensive definition of SRHR which goes beyond the ICPD definition to cover sexual rights and includes a package of nine essential interventions (Table 1) selected to address the central aspects of SRHR.[14] These nine interventions have been described as “ … a benchmark to measure countries’ progress towards delivering an essential package of SRHR services”.[8] Furthermore, several of these SRHR interventions have been described as cost-effective, cost-saving, and inexpensive,[8,14] suggesting that these interventions should form part of a set of investments for low-income countries (LICs) and lower-middle income countries (LMICs) who must meet the needs of growing populations on limited public health budgets.[8,14,15]

Table 1.

The Report of the Guttmacher-Lancet Commission's essential package of sexual and reproductive health interventions

GLR 1	Comprehensive sexuality education
GLR 2	Counselling and services for a range of modern contraceptives, with a defined minimum number and types of methods
GLR 3	Antenatal, childbirth, and postnatal care, including emergency obstetric and newborn care
GLR 4	Safe abortion services and treatment of complications of unsafe abortions
GLR 5	Prevention and treatment of HIV and other sexually transmitted infections
GLR 6	Prevention, detection, immediate services, and referrals for cases of sexual and gender-based violence
GLR 7	Prevention, detection, and management of reproductive cancers, especially cervical cancer
GLR 8	Information, counselling, and services for subfertility and infertility
GLR 9	Information, counselling, and services for sexual health and wellbeing

Source: Starrs et al.[14]

Previous research has investigated the inclusion of different services within the contents of EPHS. Wright and Holtz[12] used the Partnership for Maternal, Child, and Newborn Health’s (PMNCH) priority reproductive, maternal, newborn, and child health (RMNCH) interventions as a framework to examine the inclusion of RMNCH interventions within 24 low- and lower-middle income countries’ EPHS. Later, a study published by the PMNCH[8] used the GLR’s nine essential SRHR interventions as a standard to investigate how six sub-Saharan African countries prioritised SRHR interventions within their EPHS. Based on reviews of existing literature however, no known research has examined the inclusion of essential SRHR interventions within a larger sample of countries’ EPHS.

This study analyses the extent to which the GLR’s nine essential SRHR interventions are currently included in the essential packages of health services of low- and lower-middle income countries. The analysis focuses on the content of 46 low- and lower-middle income countries’ EPHS to further the understanding of how countries are incorporating SRHR in their UHC reform.

Methods

Study design

This study reviews the contents of countries’ essential packages of health services using a two-step analysis. As it has been well established that the contents of EPHS vary,[7,12,13] the first step of the analysis categorises EPHS according to the level of detail of their contents using a case classification scheme. The second step analyses the contents of the EPHS which contain a list of clinical and public health services using a high-level matching. The high-level matching analysis was conducted by tagging EPHS using a set of keywords developed by the authors (Appendix 1). The two-step analysis was performed twice to improve the trustworthiness of the results.[16] Peer-debrief consultations with authors from similar studies were held to gain feedback on the analysis and increase its credibility.

Delimitations

While previous studies by Wright and Holtz[12] and the PMNCH[8] investigated the implementation and prioritisation processes of 24 and six countries’ EPHS, respectively, this study chose to focus solely on the explicit contents of countries’ EPHS in order to capture data from a larger study population (51 countries). Because the analysis is limited to the contents of countries’ EPHS this study cannot speak to the development processes behind countries’ EPHS or how countries are translating these policies into practice. Rather, this study identifies larger trends within contents of low- and lower-middle income countries’ EPHS, both in the level of detail of their contents, and the essential SRHR interventions they include. It is also important to recognise that, while EPHS are a commonly used tool to operationalise UHC,[11] they are but one way in which countries operationalise UHC and are not necessarily a comprehensive representation of countries’ work towards UHC, nor of how countries are integrating SRHR interventions into their UHC work.

Study population

Similar to a study by Stenberg et al.[15] we included all 31 countries classified as LICs and the 20 most populous LMICs in the study population. The study population was chosen as these countries face relatively large health burdens, challenges in resource mobilisation, and urgent needs in effective use of resources.[15] The World Bank Country and Lending Groups[17] was used as a reference for countries’ income classification. The final study sample consisted of 46 countries as data from five countries could not be located.

Data collection

Data was collected in January and February of 2020 from publicly available policy documents which outlined countries’ EPHS. Countries’ EPHS go by many names, are not uniform, and can be found in a wide variety of documents. Most often EPHS were found in documents such as (but not limited to) health sector strategic plans, health development plans, and national health policies (Appendix 2). Documents were retrieved through exhaustive internet searches using Google and relevant government and health agency websites using iterations of the following search terms: “essential package of health services”, “essential health service package”, “minimum health package”, “basic health service package”, “national health service package”, “essential health benefits package”, “essential universal health coverage package” and “universal health coverage plan”. Documents were collected in English, French, Portuguese, and Ukrainian, with documents not in English translated using Google Translate.

The final study sample consisted of 47 documents from 46 countries; one document per country other than Afghanistan, whose EPHS was very clearly divided across two documents, which therefore were taken together and treated as one EPHS in the analysis. Priority was given to primary sources (i.e. government policy documents) and documents which included a list of clinical and public health services. In the cases where newer documents were alluded to but were not possible to retrieve, available older documents were selected for analysis. The collected documents were published between 2005 and 2018; only the documents from Egypt and Ukraine did not specify a publishing date. Of the collected documents, 30 specified a date range for the period of time they covered. For a comprehensive list of the documents used in the analysis, see Appendix 2.

First level of analysis: case classification

The first step of the analysis reviewed the contents of the collected EPHS to determine which were detailed enough for the second level of analysis. For the first level of analysis, a case classification scheme was developed (Figure 1), which categorised EPHS into four different cases (Case 1–4) according to the level of detail of their contents.

Figure 1.

Case classification scheme on which essential packages of health services (EPHS) were categorised

Second level of analysis: the high-level matching

The second level of analysis, the high-level matching, was performed to identify the GLR nine essential SRHR interventions within the contents of countries’ EPHS. To be eligible for the second level of analysis, a country’s EPHS had to include a list of clinical and public health services and be classified as a Case 4 during the first level of analysis.

The high-level matching was conducted by tagging the contents of the EPHS using keywords, (see Appendix 1 for a comprehensive list of the keywords used). The keywords were developed using the GLR and related literature[8,14] and were designed to include services conceptually related to, and capture the essence of, each of the GLR’s essential SRHR interventions. For example, “family planning”, “contraceptive pills”, and “fe/male condoms” were among the keywords selected to identify interventions related to modern contraception (GLR 2).

It was sufficient for an EPHS to contain one keyword for the corresponding intervention to be marked as included. In cases where none of the corresponding keywords were present, an intervention was marked as excluded. All EPHS were analysed twice, and tags were double-checked to ensure that the results of the high-level matching were representative of the EPHS’ contents. An audit trail of the analysis was kept in the form of Excel spreadsheets.

As a final step a sensitivity test was performed by re-tagging the Case 4 EPHS with an alternative, more stringent, inclusion criteria for GLR 4, “Safe abortion services and treatment of complications of unsafe abortion”. The sensitivity test was performed to test how changes to the keywords affected the results. For the sensitivity test, the set of keywords for GLR 4 were modified, and only EPHS which contained the keywords “medical vacuum aspiration (MVA)”, “safe abortion” and/or “medical abortion” were marked as including GLR 4.

Results

Case classification

No EPHS were located for five countries (10%) and therefore these countries were categorised as having Case 1 EPHS. Seventeen countries’ (33%) EPHS were categorised as Case 2, and 12 countries’ (24%) EPHS were categorised as Case 3. Finally, 17 countries’ (33%) EPHS were categorised as Case 4. Table 2 shows the results of the case classification disaggregated by country income status.

Table 2.

Case Classification results disaggregated by country income status

	Benin		Afghanistan
	Burkina Faso		D.R.C.
	Guinea-Bissau		Ethiopia
	Mozambique		Haiti
	Nepal		Liberia
	Somalia	Burundi	Malawi
	Tanzania	Chad	North Korea
	Togo	Eritrea	Rwanda
	Uganda	Guinea	Sierra Leone
	Angola	Madagascar	South Sudan
	Cameroon	Mali	Bangladesh
	Côte d’Ivoire	Niger	Ghana
C.A.R.	Egypt	Tajikistan	India
Syria	Philippines	The Gambia	Indonesia
Yemen	Ukraine	Myanmar	Kenya
Morocco	Vietnam	Sudan	Nigeria
Pakistan	Zambia	Uzbekistan	Republic of the Congo
Case 1 (5)	Case 2 (17)	Case 3 (12)	Case 4 (17)

Key: Light grey = LIC, Dark grey = LMIC; C.A.R. = Central African Republic; D.R.C. = Democratic Republic of the Congo

The high-level matching

The Case 4 EPHS (n = 17) were eligible for the high-level matching as these included a list of clinical and public health services. This category comprised 10 LICs and seven LMICs; 36% of the population of LICs, and 39% of the population of LMICs, respectively. All Case 4 EPHS included interventions related to modern contraception (GLR 2), antenatal, childbirth, and postnatal care (GLR 3), and prevention and treatment of HIV and other STIs (GLR 5). The intervention most frequently missing from Case 4 countries’ EPHS was comprehensive sexuality education (GLR 1), which appeared in only six (35%) countries’ EPHS. Interventions related to sub- and infertility (GLR 8) and sexual health and wellbeing (GLR 9) were also frequently missing, each respectively included in only eight (47%) EPHS (Table 3).

Table 3.

Inclusion of the Guttmacher-Lancet Report’s nine essential SRHR interventions within Case 4 essential packages of health services (EPHS) disaggregated by country income status and arranged from most to least interventions included

LIC	GLR 1	GLR 2	GLR 3	GLR 4	GLR 5	GLR 6	GLR 7	GLR 8	GLR 9	# GLR interventions within country’s EPHS
Liberia	–	✓	✓	✓	✓	✓	✓	✓	✓	8
Afghanistan	✓	✓	✓	✓	✓	✓	–	✓	–	7
Haiti	–	✓	✓	✓	✓	✓	✓	✓	–	7
Sierra Leon	–	✓	✓	✓	✓	✓	✓	✓	–	7
Malawi	–	✓	✓	✓	✓	✓	✓	–	–	6
Rwanda	–	✓	✓	✓	✓	✓	–	✓	–	6
South Sudan	✓	✓	✓	✓	✓	✓	–	–	–	6
D.R.C.	–	✓	✓	–	✓	✓	–	–	✓	5
Ethiopia	–	✓	✓	✓	✓	–	–	–	✓	5
North Korea	–	✓	✓	✓	✓	–	✓	–	–	5
Total *	2	10	10	9	10	8	5	5	7
LMIC	GLR 1	GLR 2	GLR 3	GLR 4	GLR 5	GLR 6	GLR 7	GLR 8	GLR 9	# GLR interventions within country’s EPHS
Bangladesh	✓	✓	✓	✓	✓	✓	✓	✓	✓	9
India	–	✓	✓	✓	✓	✓	✓	✓	✓	8
Ghana	✓	✓	✓	✓	✓	–	✓	–	✓	7
Indonesia	–	✓	✓	✓	✓	✓	–	✓	✓	7
Nigeria	✓	✓	✓	✓	✓	✓	✓	–	–	7
Kenya	✓	✓	✓	–	✓	✓	✓	–	–	6
Republic of the Congo	–	✓	✓	–	✓	–	✓	–	✓	5
Total *	4	7	7	5	7	5	6	3	5

Key: Within country's EPHS, (✓) = inclusion of intervention, (–) = absence of intervention; * # of EPHS which include the intervention; GLR = Guttmacher-Lancet Report; D.R.C = Democratic Republic of the Congo.

GLR nine essential SRHR interventions:

GLR 1: Comprehensive sexuality education

GLR 2: Counselling and services for a range of modern contraceptives, with a defined minimum number and types of methods

GLR 3: Antenatal, childbirth, and postnatal care, including emergency obstetric and newborn care

GLR 4: Safe abortion services and treatment of complications of unsafe abortion

GLR 5: Prevention and treatment of HIV and other sexually transmitted infections

GLR 6: Prevention, detection, immediate services, and referrals for cases of sexual and gender-based violence

GLR 7: Prevention, detection, and management of reproductive cancers, especially cervical cancer

GLR 8: Information, counselling, and services for subfertility and infertility

GLR 9: Information, counselling, and services for sexual health and wellbeing

Bangladesh was the only country from the high-level matching which included all of the GLR’s nine essential SRHR interventions in their EPHS. India’s and Liberia’s EPHS included all interventions except for comprehensive sexuality education (GLR 1). Over half (53%) of the countries included seven or more interventions in their EPHS. The Democratic Republic of Congo, Ethiopia, North Korea, and The Republic of the Congo included the least number of interventions in their EPHS, with five out of nine interventions respectively. As such, all countries from the high-level matching included at least five of the GLR’s nine essential SRHR interventions in their EPHS. However, which interventions were included varied by country.

The results of the sensitivity test showed the number of Case 4 EPHS (n = 17) which included safe abortion services (GLR 4) dropped from 82% (n = 14) to 47% (n = 8) under the test’s modified set of keywords (Table 4).

Table 4.

Results of the Sensitivity Analysis compared to the results of the High-Level Matching for safe abortion (GLR 4)

Country	Liberal inclusion criteria*	Strict inclusion criteria**
Liberia	✓	✓
Afghanistan	✓	–
Haiti	✓	✓
Sierra Leone	✓	–
Malawi	✓	–
Rwanda	✓	✓
South Sudan	✓	✓
D.R.C.	–	–
Ethiopia	✓	✓
North Korea	✓	✓
Bangladesh	✓	✓
India	✓	✓
Ghana	✓	–
Indonesia	✓	–
Nigeria	✓	–
Kenya	–	–
Republic of the Congo	–	–
Total: 17	14	8

Key: (✓) = included, (–) = not included; Light grey = LIC, Dark grey = LMIC; D.R.C. = Democratic Republic of the Congo; Liberal inclusion criteria* = results of the High-Level Matching; Strict inclusion criteria** = results of the Sensitivity Analysis.

Discussion

Despite the fact that EPHS are widely defined as including a defined list of clinical and public health services,[7,11,12,18] findings from this study show that most EPHS do not fit this definition. From the study population of 51 countries, 90% (n = 46) have an EPHS; however, most are not detailed enough to analyse which SRHR interventions they include. Only the Case 4 countries from the case classification, i.e. 33% (n = 17) of the collected EPHS, fit this definition and contained a list of clinical and public health services. Findings from the case classification highlight the discrepancy between theory and practice and demonstrate that, in reality, EPHS range from very specific and detailed to less specific and aspirational.

The relationship between the specificity and the value of EPHS has been discussed in different directions. However, the inclusion of a defined list of services is largely agreed to be an accountability issue, as this can inform citizens what services are available, and equally important, not available, to them under UHC policies.[7,19] As countries work towards UHC, Glassman et al.[19] argue that the creation of an explicit health benefits package may help manage progress towards UHC, and that it is essential for creating a sustainable system of UHC. Others state that increases in the administrative detail within EPHS may increase the quality of services[20] and that “ … governments have a fundamental responsibility for ensuring universal access to an essential package of clinical services, with special attention to reaching the poor” [p.108].[18] On the other hand, Wright and Holtz[12] argue that EPHS often represent a broad policy statement, and Waddington[13] claims that EPHS are most useful when used as a political, rather than technical tool. Some also argue that EPHS should strike a middle ground in terms of level of detail.[21] Despite different positions on the relationship between the specificity and value of EPHS, findings from the case classification corroborate previous literature,[8,12,13,21] providing evidence on the sizeable variations which exist among EPHS in terms of the level of detail of their contents.

As all countries are different, no single EPHS is appropriate for every country, just as there is no one path which countries must follow to achieve UHC.[8] Instead, EPHS are designed to reflect the context from which they are born as “countries vary with respect to disease burden, level of poverty and inequality, moral code, social preferences, operational challenges, [and] financial challenges”.[12] However, it has been noted that if countries’ prioritisation processes were based on gender- and equity-adjusted cost-effectiveness models using the best available evidence, SRHR interventions would naturally be included in countries’ EPHS across all contexts.[8]

The results of the high-level matching show that despite countries’ commitments to UHC[1,22] to health and SRHR as a human right,[2,4,23] and the availability of the GLR as a standard,[8,14] the vast majority of countries’ EPHS do not include a comprehensive list of essential SRHR interventions. Bangladesh was the only country to include services related to all of the GLR nine essential SRHR interventions in their EPHS, something which previous research had not been able to identify.[8] That this study identified only one EPHS with a comprehensive list of essential SRHR interventions indicates that there is still much work to be done to integrate SRHR into UHC reform. Beyond the challenges of integrating essential SRHR services into UHC policies, previous research also highlights the challenges of translating policies around access to essential SRHR interventions to the implementation of services.[8]

Results from the high-level matching also speak to larger trends in the inclusion of essential SRHR interventions across low- and lower-middle income countries (Table 3). The universal inclusion of services relating to contraception (GLR 2), maternal and newborn health (GLR 3), and HIV/AIDS (GLR 5), was consistent across all countries and reflects larger trends in prioritisation within the field of SRHR.[14] Other trends differed across country income groups; for example, comprehensive sexuality education (GLR 1) was the least common intervention among LICs, while information, counselling, and services for subfertility and infertility (GLR 8) was the least common intervention among LMICs. These results provide an overview of how essential SRHR interventions are currently included in specific countries’ EPHS.

To test the sensitivity of the results to the keywords, a sensitivity analysis was performed on safe abortion (GLR 4). Safe abortion (GLR 4) was chosen for the test as the language surrounding this intervention has been contentious historically. When required to include terminology explicitly related to abortion, i.e. “medical vacuum aspiration (MVA)” or “medical abortion”, the number of EPHS which included safe abortion (GLR 4) dropped from 82% (n = 14) to 47% (n = 8). These results, together with the study by the PMNCH,[8] demonstrate the importance of language to policy, the accountability issues which many countries face around access to safe abortion services, and the limitation of content analysis to tell the full story of what is on paper versus what is practiced in reality.

Finally, this study contributes a novel case classification scheme which conceptualises the varying level of detail among EPHS and illustrates how EPHS fall along a spectrum of specificity. Additionally, this study defines a set of keywords (Appendix 1) which are useful for evaluating policies against the benchmark of the GLR. Previously, evaluations of policies against the GLR were based on researchers’ interpretations of what each intervention covered. By putting forth a defined set of keywords for each of the GLR nine essential interventions, this study allows for more systematic policy evaluations. These analytical tools can be used by policymakers, researchers, and others involved in SRHR advocacy.

Limitations

The inclusion of an intervention within a country’s EPHS cannot tell us whether it is available or accessible at the point of service delivery. Conversely, services that are not included in an EPHS might still be available to those who need them. As the presence of a single keyword was considered sufficient for an intervention to be marked as included, the results of the high-level matching illustrate the minimum SRHR interventions which countries appear to have prioritised within a component of UHC reform. The collection of EPHS was limited to what was publicly available through online sources. Because many EPHS in the analysis pre-date the publication of the GLR in 2018, future iterations of countries’ EPHS may have different alignment with the GLR’s essential SRHR interventions.

Conclusions

Most countries have an EPHS, but most are not specific enough to allow for an analysis of what SRHR services governments offer, or aspire to provide, and the content ranges from vague to very specific. Results from the high-level matching illustrate that countries’ inclusion of SRHR interventions echo larger trends in prioritisation within the field of SRHR. However, despite countries’ commitments to UHC, to SRHR as a human right, and the availability of the GLR as a standard, a comprehensive set of essential SRHR interventions is not included in the vast majority of low- and lower-middle income countries’ EPHS.