Introduction

Comprehensive sexual and reproductive health and rights (SRHR) programs include an array of services meant to address individuals’ needs throughout their life course. Access to these services is essential for sustainable development. Sustainable Development Goal (SDG) 3/Target 3.7 calls for, “universal access to sexual and reproductive health care services, including for family planning, information and education, and the integration of reproductive health into national strategies and programs” by 2030. Yet maintaining and increasing access have been challenged by the COVID-19 pandemic’s impact on service provision, health care financing and planning.

Efforts to achieve universal access to SRHR are aligned with parallel efforts to achieve another SDG target: universal health coverage (UHC) by 2030. Charting a path toward UHC requires an understanding of current coverage and costs, a strategy that sets targets for 2030, and a process for priority setting and progressive realisation given budget constraints. While establishing expectations for patient-level service delivery and its costs, it is also important to understand how service delivery is dependent on health programs and the health system more broadly.

Health systems encompass health condition-specific programs and the cross-cutting systems and support structures required for patient-level service delivery. Health systems include all the public and private institutions and resources mandated to “improve, maintain, or restore health” within a given geographic and political location. In contrast, health programs have been defined as the narrower “set of interventions that contribute to the prevention and control of a common health outcome – for example, HIV or non-communicable diseases (NCDs). This includes the structures and activities directed towards enhancing program quality, such as training, supervision visits, and monitoring and evaluation.

Country data on programs and system costs as a proportion of overall health care investment needs is difficult to find in the published literature. However, some international costing activities have shown that health programs and system costs may represent the majority of needed incremental investments. A 2017 analysis using the OneHealth Tool (OHT) to estimate the costs of achieving the health-related SDGs in low- and middle-income countries (LMICs) found that 75% of needed investments would be for programs and system elements, the largest being the health workforce and infrastructure. For SRHR, in 2019, programs and system costs were estimated to comprise 62% of the total projected costs of meeting all needs for modern contraception and 65% of total costs for meeting need for pregnancy-related and newborn care in all LMICs.

Despite the importance of programs and system elements, historically, these costs have often been excluded from costing activities and economic evaluations for SRHR, often due to missing information and methodological complexity. We highlight continued gaps in current practice and outline the potential pitfalls of not including programs and system elements when planning and budgeting for increased access to health care services. We then point out where tools and data exist to improve current practice. Finally, we aim to further efforts targeting universal access to SRHR and for building back better after the COVID-19 pandemic through recommendations for improvements in planning and budgeting for SRHR.