Table 1.
Implications of sexual and reproductive health self care interventions for efficiency, financing and access
| Consideration | Evidence | |
|---|---|---|
| Costs, resources, use, and efficiency | Patient/user costs (research/information seeking, transport, lost income, financial cost of commodity/intervention, informal fees) | Use of self injecting hormonal contraceptives by women in Burkina Faso, Uganda, and Senegal had lower direct non-medical costs (travel and time costs) than community and facility based delivery7 |
| HIV self testing reduced client non-medical costs in Malawi 8 and travel costs, clinical costs, or time away from work in Tanzanian men compared with testing by healthcare providers9 | ||
| Home pregnancy test in the US saved workers’ time, and avoided clinic visits and time off work (if test was negative)10 | ||
| Health system costs (direct healthcare utilisation, indirect costs over the life course) | Self administered misoprostol for very early medical abortion had significantly lower time and costs for hospital observation and follow-up, while no differences in outcomes were found between the self administration and hospital administration groups in China11 | |
| Direct health provider costs of HIV self testing in Malawi were comparable with costs of facility based testing.8 Modelling suggested modest healthcare cost savings where a generalised epidemic exists and in a low income country12 | ||
| Self sampling for HPV testing cost more to deliver in France and the Netherlands than a “recall” intervention or conventional cytology screening (because of extra medical consultation fees, postal fees, and costs of the self sampling device), but it also had higher participation and detection rates resulting in similar or lower costs for each extra woman screened and each cervical lesion detected13 14 | ||
| Emergency contraception saved costs in modelling studies that compared spending on emergency contraception with spending on direct medical care for abortions and unintended pregnancies in Australia, Canada, and the US.15 In the US, expansion of access to emergency contraception also reduced immediate health system costs by shifting provision from hospital emergency departments to pharmacies16 | ||
| Better health outcomes at the same, lower, or acceptable higher costs (allocation efficiency) | Internet based STI self sampling cost more but was more effective at detecting STIs than clinic based sampling in the US.17 A US study that considered medical costs averted by the prevention of pelvic inflammatory disease and complications of untreated chlamydia infection estimated that the self administered intervention would be less costly and more effective than the health provider administered intervention18 | |
| HIV self testing had higher use and detection rates in multiple settings.19 However, in Malawi, self testing was less cost effective for each individual identified with HIV than health provider testing8 | ||
| Financing | User or patient out-of-pocket payments (part of the cost of the commodity or intervention paid by the user) | Demand for emergency contraception in Scotland and Spain was not affected by price and did not change when it was made available free of charge, suggesting non-financial barriers may prevent access20 |
| Respondents in the US would be willing to pay for self tests for chlamydia and gonorrhoea if they became available on the market, regardless of their age and insurance coverage21 | ||
| Subsidised public financing (domestic or external assistance) | Use of HIV self testing may need to be subsidised because the price people were willing to pay for test kits was lower than the market price in all income settings22 | |
| For condoms and contraceptives, mixed public subsidies, social marketing, and commercial provision was the most sustainable and effective way to increase coverage23 without negatively affecting equity in a multicountry study in Bangladesh, Ghana, Kenya, Indonesia, and Morocco24 | ||
| The success of national screening programmes may require government financing to include HPV self sampling as an option, as done in the Netherlands13 | ||
| Access, use, and equity | Improved access for marginalised, at risk, and vulnerable groups | HIV self testing increased use and frequency of testing in Australia, Hong Kong, Kenya, and the US19 It had a wider reach among those who may not otherwise test, including men who have sex with men in Canada19 25 |
| Studies in North America and Europe reported increased uptake of HPV testing where self sampling was offered, particularly among poor, hard to reach, and high risk populations13 26 | ||
| Self injection of hormonal contraceptive could increase access in remote areas in Uganda, where women have relatively less education and access to health information and services27 | ||
| Better access for rich people because of information or technological requirements for use | M-health self awareness interventions for sexual and reproductive health increased access to sexual and reproductive health information in men, improved couple communication and service uptake in studies in developing countries (mostly sub-Saharan Africa).28 For women, self care interventions using mobile technologies for health promotion increased access by avoiding the need for husband’s permission or financial support for transport and clinic attendance28 | |
| Demand for and supply of financial incentives to increase use | Cash payments on condition of remaining free of STIs reduced the prevalence of STIs in Tanzania and Lesotho when the amount was large enough29 |
HPV=human papillomavirus, STI=sexually transmitted infection.