Access to SRH care: new delivery models & radically new financing
COVID-19-related restrictions on the movement of products and people are anticipated to cause significant disruptions in the provision of timely, high quality and user-centred sexual and reproductive health services.  However, alternative delivery models may offer opportunities to shape health outcomes in contexts with the requisite supporting infrastructure. These include chatbots, virtual care platforms, clinic finders, quality scanners, pharmacy-led care and direct-to-consumer delivery of contraceptives and other critical products. Many of these solutions connect users to information, products and services in non-traditional ways, offering ‘demedicalised’ models for delivery. 
To examine the landscape of potential opportunity, we took a quick look at a set of proxy indicators for the infrastructure to scale alternative models in several countries, with staff at the Children’s Investment Fund Foundation (CIFF). Of the countries included, South Africa, Kenya, Nigeria, India and Ghana appear to exhibit potential for demedicalised solutions, as demonstrated by: a relatively low reliance on clinical services for SRH care, presence of direct-to-consumer companies, widespread mobile phone penetration, and a supportive digital health ecosystem. In these settings, a shift toward de–medicalised approaches like pharmacy-led care, direct-to-consumer delivery models and contactless counselling hold promise. In fact, early findings point to a growing demand for these alternative delivery methods as societies cope with the destabilizing effects of the outbreak. In South Africa, Right ePharmacy is currently installing 70 new medication collection sites, or Smart Lockers, to enable the dispensation of medication for stable HIV patients in community settings. Accra-based MedRx has witnessed an increase of 30% in users ordering medications for delivery from pharmacies through their platform in the past weeks. In Nigeria, the RxDelivered platform (which batch certifies product quality from a network of licensed wholesalers and manufacturers) reports a 10x increase in week-on-week registrations.
Of course, innovative models are subject to a range of constraints common to healthcare organizations in these markets. Health product supply chains for the countries profiled rely heavily on generic medicines, rendering them vulnerable to acute stock outs caused by interruptions in production and delivery related to COVID-19.  Strict containment measures implemented in South Africa, Nigeria, and Kenya, where complete lockdowns have been enforced, could severely limit the ability of businesses to sustain operations and generate revenue.  While political windows of opportunity have been noted in some countries (such as Kenya, where SRH has been newly declared an “essential service” , and India, where the MoH has released official guidelines for the practice of telemedicine and remote consultations by providers ), other countries show no such advancements. Finally – and most critically – although the countries highlighted here have relatively high income levels as compared to other countries included in the analysis, consumer purchasing power (with the exception of South Africa) is expected to be low amidst the crisis. Given that demedicalised or digital models are rarely covered by public financing, efforts to leverage these models will require us to carefully consider how poor and vulnerable users will gain access.
While supply-side subsidies of products and services have dominated funding for SRH to date, the context of the COVID-19 crisis demands us to contemplate how we might rapidly shift public money (donor and government) into the hands of users. The humanitarian sector has acknowledged for years the efficiency and effectiveness of transferring purchasing power to people: the World Food Programme now provides 35 percent of its aid in the form of cash transfers.  Within SRH, providing women purchasing power (often through vouchers) to select and pay for the care of their choice has long been understood to boost utilization.  At the level of the health system, financing schemes that link payments to patients through mechanisms such as insurance are globally recognized as representing an important step towards achieving universal coverage. And yet, the bulk of $1.3B dollars in annual donor expenditure in family planning is not programmed to directly increase women’s choice and agency, by transferring her the means she needs to obtain the care she wants.  With the true power of choice in her hands, it would be fascinating to see if and how demedicalised and digital approaches grow.
The potential loss of access to SRH care amidst COVID-19 is horrifying. But will we act boldly to directly empower women to shape health care markets in response to their SRH needs? Or is this business as usual?
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