Self-Care is a Key Pillar to Realizing UHC—And Advocacy Can Help Us Get There

As the global health community prepares to celebrate Universal Health Coverage (UHC) Day 2020 we have the chance to reflect on one of this year’s key lessons: self-care for sexual and reproductive health and rights is a key part of reaching our goal to #ProtectEveryone. You don’t need me to tell you how difficult this year has been; the COVID-19 pandemic has challenged communities and health systems around the world in unprecedented ways. As the result of the strain COVID-19 placed on our existing health systems, the pandemic has highlighted the importance of self-care for sexual and reproductive health (SRH). In the context of these opportunities and challenges, advocacy for self-care is more important than ever for achieving UHC goals. 

UHC envisions health systems grounded in the principles of equity, quality, responsiveness, efficiency, and resilience. Self-care is not an alternative to a robust health system, but simply a key component within that system that allows individuals to make the SRH care choices that best suit their unique needs and circumstances.  

When it comes to family planning, we know what’s needed to ensure universal access to contraceptives, including: more funding for contraceptive supplies, inclusion of contraceptives in UHC health packages, robust supply chains, and national policies that get commodities where users need them to be. This is true for provider-based care, as well as self-care, such as self-administration of oral contraceptive pills, emergency contraception, and condoms, or the self-injection of subcutaneous depot-medroxyprogesterone acetate (DMPA-SC). The Advance Family Planning (AFP) initiative has successfully implemented the SMART approach to advocacy for family planning and reproductive health since 2009, and we know evidence-based advocacy works to secure funding, remove barriers, create policies, and gain more support for family planning. 

AFP advocacy for self-care focuses on policies that ensure quality, informed decision, and contraceptive method choice. As a result of our ongoing efforts to expand SRH self-care, we have learned there are many opportunities and entry points for advocacy for self-care at the global, national, and sub-national levels. Family planning advocacy efforts to mobilize domestic budgets, revise training curricula, expand SRH access for adolescents and young people, or update data collection tools for service statistics can all contribute to moving the self-care agenda forward. Advocacy  

Within efforts to expand method choice, AFP partners have successfully advocated for community access to DMPA-SC, an injectable contraceptive that can be safely and effectively self-injected by the user, in Kenya, Nigeria, and Uganda. Through this work, we’ve also learned that advocacy for self-care for SRH presents means working across a variety of institutions and decisionmakers. The results of DMPA-SC advocacy, as illustrated in selected examples below, suggest tactics and opportunities for progress on self-care for other contraceptive methods and SRH issues: 

• Securing national approval for self-injection is a critical first step for DMPA-SC in Kenya. After successful advocacy by AFP partner Jhpiego Kenya, Kenya’s Pharmacy and Poisons Board approved an application by Pfizer Laboratories Ltd for a change of label to allow self-injection of DMPA-SC in May 2018. AFP partners are now advocating for validation of the DMPA-SC roadmap, updating guidelines to allow for self-administration, collecting DMPA-SC data in HMIS systems, and working with county governments to implement the guidelines. Most recently, they made sure that DMPA-SC and self-injection were included in a new national training package for pharmacists and pharmaceutical technologists.  

• Bringing contraceptives into community drug shops in Uganda facilitates access for self-injection of DMPA-SC. In July 2017, as a result of advocacy by AFP partners FHI360 and Reproductive Health Uganda, the Ugandan National Drug Authority (NDA) Board authorized the stocking of injectable contraceptives, including DMPA-SC, in private drug shops in 20 select districts. The NDA later extended the pilot to include 20 more districts. While drug shop operators acted as providers of DMPA-SC initially, after the method was approved for self-injection in 2019, clients are now able to obtain DMPA-SC for self-injection from drug shops operators in their communities. Last month, the NDA approved national scale-up of DMPA-SC provision in drug shops. There are nearly three times as many drug shops as there are health facilities in Uganda, making them more accessible to many Ugandans than formal clinics.1,2  

• National level policies expanding access to DMPA-SC pave the way for state-level implementation in Nigeria. While DMPA-SC was added to the country’s Essential Medicines List (EML) in September 2018, AFP partner Pathfinder International Nigeria, along with other family planning organizations, saw an important gap in access to the method, which is approved for self-injection in Nigeria. While inclusion on the EML authorizes public sector access, most women access family planning through the private sector, and 38% specifically get family planning methods from Patent and Proprietary Medicine Vendors (PPMVs), which are owner-operated drug retail outlets.3 AFP and other advocates worked together to secure approval DMPA-SC in the Approved Patent Medicines List (APML), which regulates the drugs PPMVs can sell. The May 2019 authorization allows women to access DMPA-SC for self-injection from PPMVs, already popular access points for millions of Nigerian women. 

  After the Ministry of Health launched National Guidelines for the Introduction and Scale-Up of DMPA-SC Self-Injection in April 2019, AFP partner, Pathfinder Nigeria, has advocated with state governments to adopt state-level scale-up plans. Gombe and Nasarawa states launched their plans in December 2019 and January 2020, respectively. Both states are now in the process of training providers to administer the method and to train women on self-injection; leaders in both states also pledged to release state funds to continue and expand these trainings. These state-level efforts will expand access to DMPA-SC for provider- and self-injection in the public and private sectors in Gombe and Nasarawa. 

In addition to DMPA-SC, many methods of family planning are appropriate for self-care, including oral contraceptive pills and emergency contraception.4 In Zambia, advocates supported by AFP’s Opportunity Fund worked closely with the Zambian government to include pills, implants, injectables, IUDs, and emergency contraception in the country’s Universal Health Coverage (UHC) benefits package. As the first UHC financing reform in the region to cover family planning, including methods suited to self-care, Zambia sets an exciting example for neighboring countries working on UHC packages of their own.  

As we work towards UHC and #ProtectEveryone, we must include self-care as a critical part of the healthcare system. Advocacy opportunities for self-care are plentiful. We need funding for commodity procurement and distribution; training of providers to support and assist individuals utilizing self-care; policies and regulations that allow self-care and connect self-care users with the formal health system as needed; incorporation of self-care into existing data collection systems; and more. To realize this vision, everyone has a role to play—clients, providers, trainers, regulators, data analyzers, funders—and advocacy can help secure the funding, policy, and data needed to make self-care and UHC a reality.