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Insight into Country-level Sexual and Reproductive Health Advocacy in Zambia’s Universal Health Coverage Financing Reforms

In January 2020, the government of Zambia unveiled a national health insurance benefits package that covers birth control pills, implants, injectables, intrauterine devices and emergency contraception. This is the first universal health coverage (UHC) financing reform in the region to include family planning (FP) and the first major country-level advocacy win for sexual and reproductive health and rights (SRHR) following the 2019 United Nations High-Level Meeting on UHC.

The development of Zambia’s first-ever National Health Insurance Scheme (NHIS) is key to realizing its UHC objectives. Civil society action led by the Centre for Reproductive Health and Education (CRHE) and its partners was crucial to highlight the importance of SRHR in the NHIS benefits package. Together, this group designed and implemented a nimble advocacy strategy calling for the inclusion of FP and representation of civil society organizations (CSOs) in the national UHC agenda.

GLOBAL AND LOCAL UHC CONTEXT

Globally, advocates have increasingly focused on navigating UHC specifics and comprehending its implications for universal access to SRHR. While the SRHR community continues this work, country-level UHC policy processes are advancing, and often without deliberate CSO engagement — even though these policies directly impact the rights of women and girls to access critical services.

In 2018, PAI supported CRHE and partners to respond to the Zambian government’s fast-tracked health financing policy for UHC. At the heart of this engagement was the understanding that the design and implementation of this major policy reform would have ramifications for women’s and girls’ access to sexual and reproductive health services and commodities, including FP.

The government originally announced a plan to launch its UHC scheme in January 2019. However, both the financing policy process and engagement opportunities were unclear to SRHR CSOs. Recognizing the short policy timeline, PAI worked with CRHE to provide technical analysis and support as CRHE convened stakeholders to identify areas for CSO engagement with the Ministry of Health (MoH) in the remaining decision-making process and implementation.

 

HOW ADVOCATES TOOK ACTION

The NHIS impacts the availability, quality, affordability and equity of health services and commodities in Zambia. The structure of the insurance scheme also determines which facilities it covers, how providers are paid and how resources get to the community. Over the 18 months after the NHIS legislation was passed, CRHE and partners mobilized a collective to identify opportunities to engage with policymakers throughout the remaining decision-making process.

Through a network of CSOs and UHC allies, this collective developed an FP-UHC advocacy agenda to highlight the benefits and cost-effectiveness of FP and related services and supplies, and ultimately, to ensure the prioritization of FP access by influencing the UHC policymaking process. The FP-UHC advocacy strategy involved:

  • Advocating for the inclusion of FP in the current benefits package and related health insurance policy processes;
  • Tracking the development of the new National Health Insurance Management Authority (NHIMA), the management institution for the scheme, and identifying opportunities where civil society could occupy seats on its governance board and technical working groups; and
  • Collaborating with the government on an NHIS communications strategy and information dissemination plan to inform the Zambian public about the NHIS at the community level — its structure, benefits and implications.

Developing this strong, timely advocacy strategy — while the Zambian government’s NHIS rollout was delayed by several months — enabled CRHE and partners to effectively make the case for CSO engagement and act as brokers between citizens and the government. This broad constituency is well-positioned to engage with the MoH, NHIMA and government stakeholders to improve access to quality health services. CRHE played a pivotal role in convening this collective with officials from the MoH and NHIMA to discuss opportunities to improve the NHIS benefits package and advance UHC in Zambia.

 

THE STRATEGIC ESSENTIALS

Involving Government from the Beginning

At the outset, CRHE and partners proactively engaged government officials — including colleagues from the MoH, the Ministry of Planning and Ministry of Finance — as they worked to understand the UHC financing landscape, NHIS plans and opportunities to advance FP. CRHE invited officials from the MoH and Ministry of Planning to the first joint health financing and advocacy workshop in 2018, both to participate in the dialogue and share their policy progress and timelines. This gesture signaled the desire to build a constructive partnership and illustrated the value of CSO representation in decision-making processes. As a result, the MoH recognized the importance of engaging CSOs throughout the remaining policy timeline and began partnering with the collective on UHC.

Grounding Action in the Health Financing Policy Landscape

Partners began by investing time to explore health financing and anchor their FP advocacy strategy in this broader policy landscape. Demystifying health financing was instrumental in helping SRHR advocates understand Zambia’s health financing policy within the context of UHC, as well as the NHIS and its significance to women’s and girls’ SRHR access. The collective worked together with technical experts to review the NHIS legislation, the plans to unveil Zambia’s largest health policy reform in decades, the role of the MoH and new decision-makers, as well as forthcoming policy steps and timelines. By approaching its FP-UHC advocacy strategy from a health systems angle, the collective was able to understand the scope of opportunity afforded by broader health policy and subsequently shape the strategy to ensure that SRHR is prioritized.

Equipped with this new understanding, the advocates reinforced their credibility with government officials outside of traditional FP technical working groups and catalyzed opportunities to engage with policymakers in health financing decisions. This led the MoH to invite the group to co-convene at follow-up meetings with the Department of Health Care Financing, where the collective discussed NHIS priorities, including the benefits package. These ongoing meetings between government officials and advocates caught the attention of decision-makers at the highest level, including the minister of health.

Utilizing the AFP SMART Approach to Advocacy

After assessing the health financing and political landscapes, CRHE and partners adopted the AFP SMART approach, a strategy that identifies and refines the most important, near-term advocacy objectives. This was especially critical during the first strategy session, where the Zambian CSOs determined opportunities to advance SRHR in the NHIS policy process. Together, advocates mapped out the UHC decision-makers to better understand the policymaking audience and tailor their advocacy messages. The collective also made connections to the government’s existing Family Planning 2020 commitments and broader health and development strategies, which fortified the advocacy asks for FP inclusion in the benefits package and reduced dependency on donor financing. Ultimately, CRHE and partners used the SMART approach to develop a realistic, targeted advocacy strategy. With these SMART principles, the collective easily adapted its strategy for new decision-makers across sectors, delayed timelines and reframed asks along the way.

Leveraging the Collective Strengths of Partners

CRHE convened a broad constituency representing diverse perspectives across and beyond SRHR advocacy and service delivery organizations. Many of these stakeholders — including legal experts, health economists, academics from the University of Zambia and the Zambia Medical Association — were connected to key MoH decision-makers and contributed to a successful launch of the strategy. CRHE also engaged the full FP Technical Working Group, and later, general health CSOs and youth networks. This constituency was strengthened by its overall health financing knowledge, which reinforced the credibility of its advocacy strategy and facilitated successful engagements with the MoH and NHIMA. The collective adapted thoughtful processes to ensure a unified approach and message, ranging from inclusive organizational representation in formal communication to full participation in presentations to the MoH and NHIMA.

Developing Timely Tools to Capture and Circulate Key Ideas After Meetings

Following the initial workshop, PAI and CRHE immediately developed a meeting report to advance the collective’s agenda. This proved to be an instrumental advocacy tool, garnering formal meetings with the minister of health, permanent secretary and Department of Health Financing within the MoH. Distilling takeaways from the health financing meetings helped inform strategies to communicate about the NHIS with the public.

 

THE ROAD AHEAD

CRHE and partners will continue to advance their FP-UHC agenda by maintaining ongoing, intentional communication with advocacy CSOs, UHC allies and government champions. Their initial FP advocacy asks successfully appealed to the Zambian government, but the collective must consistently monitor the UHC policy process to maintain momentum. As the NHIMA commissions reviews every six months, this implementation process and policy refinement will be iterative and likely span several years. Throughout policy implementation, there will be important opportunities for civil society to remain a central partner by leveraging and strengthening its long-term relationships with government officials to guarantee that the NHIS delivers increased SRHR access for women and girls in Zambia’s journey toward UHC.

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