Financial Protection and Social and Behavior Change: Strengthening financial protection programs through behavior change approaches

Despite global progress towards UHC, the number of people facing financial hardship from out-of-pocket health spending has increased. Financial protection programs employ approaches such as establishing insurance systems, capping out-of-pocket spending, relying on prepayment and pooled funds to finance health care, and allowing fee exemptions for vulnerable groups. However, a purely economic approach to financial protection is unlikely to lead to UHC on its own, as it does not account for cultural, social, religious, and gender factors that may modify the effect of financial incentives. Successful reforms to health financing systems require behavior changes by purchasers, providers, patients, and communities. Therefore, financial protection programs should consider incorporating social and behavior change (SBC) approaches to support UHC progress. SBC approaches use systematic, evidence-driven practices to improve and sustain changes in behaviors, norms, and the enabling environment. They are a critical component of effective and sustainable health system strengthening (HSS) programming. Including SBC methodologies and approaches in financial protection efforts can help address the social and behavioral drivers that impact the effectiveness of implementation. The USAID HSS Vision 2030 emphasizes the need for robust, integrated, and viable systems of financial protection. Health financing programs for financial protection are implemented and managed by financing agents, which allocate resources for health services provided through the health system. Financial protection results from lowering people's direct payments for services at the time of care, and is achieved via prepayment and pooling of resources and risks. Financial protection programs can be organized into four categories: government financing schemes, social health insurance (SHI), community-based health insurance (CBHI), and social protection programs outside of mainstream health financing programs like cash transfers. Each category may include a unique package of benefits, focal population, financing agents or institutional units that manage them, service delivery mechanisms, and implementation context. A 2021 literature review conducted by USAID's Local Health System Sustainability Project (LHSS) on financial protection for underserved and socially excluded populations found mixed implementation results, scalability issues, and the need for financial protection programs to better consider contextual factors and non-financial barriers. These findings illustrate the potential benefit of incorporating behavioral insights into the design, implementation, and evaluation of financial protection programs. The four categories of financial protection programs are defined using the Organization for Economic Co-operation and Development's (OECD) System of Health Accounts classifications. Government financing schemes are funded by domestic revenues allocated for health spending and automatically enroll the eligible population. SHI schemes are ring-fenced funds that finance and manage health care on behalf of their enrollees. CBHI is a type of voluntary health insurance designed for informal sector households, usually managed at the community level. Social protection activities like cash transfers and vouchers are a financial protection approach that may be financed and managed outside the health financing system. Integrating systematic insights about the behaviors of individuals, communities, and institutions can lead to more effective programming that is responsive to the social drivers of and barriers to financial protection. The behavioral aspects of financial protection are critical to consider and can be influenced through the tailored application of behavioral science principles, community engagement approaches, social and behavioral change communication (SBCC) strategies, and use of the socio-ecological model.