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Research Questions

  1. What is the magnitude of the future gap between the demand for sexual reproductive health (SRH) services and the supply of SRH services, particularly services provided by nurse practitioners (NPs)?
  2. What are the barriers to increasing the supply and use of NPs delivering high-quality SRH services?
  3. What policy options could enhance the availability of high-quality SRH services?

Use of Sexual and Reproductive Health (SRH) services is projected to grow between 10 and 20 percent from 2006 to 2020. This growth is driven largely by changes in the racial/ethnic make-up of the population of women of reproductive age and an increase in the number of people with insurance coverage because of new health care legislation.

Trends in supply and demand for SRH services, particularly for low-income individuals, suggest demand will outstrip supply in the next decade. Nurse Practitioners (NPs) with a women's health focus are key providers of SRH care in Title X-funded clinics, which deliver a significant proportion of U.S. family planning and SRH services to low-income populations. This report looks at why numbers of women's health NPs (WHNPs) have been declining, and are projected to continue to decline, despite significant growth in total numbers of NPs. Barriers to increasing the supply of NPs competent in SRH care — such as reduced funding for WHNP training, increased funding for primary care and geriatric NP training, and a shrinking proportion of WHNPs choosing to work in public health, clinics, and family planning — are identified.

From the standpoint that the evolution of the health care delivery system may serve as an opportunity to optimize the delivery of SRH services in the United States, a comprehensive set of options spanning education, federal and state regulations, and emerging models of care delivery are explored to reverse this trend of too few WHNPs, particularly for servicing Title X facilities and their patients.

Key Findings

Overall, between 2006 and 2020, demand for most SRH services is projected to grow by 10 percent to 20 percent.

Trends in the supply of NPs who provide SRH services, particularly for low-income individuals, suggest that demand will outstrip supply in the next decade.

Barriers to increasing the supply of NPs competent in SRH care include the following:

  • SRH care and the providers of that care are fragmented—a “silo” that is not integrated within the rest of health care.
  • There are a lack of core standards and competencies for SRH that integrate population and gender-based health care across public health and primary care.
  • A shrinking proportion of NPs choose to work in public health, community clinics, and there are declining education and training opportunities in women's health and SRH.
  • Restrictive pathways to clinician credentialing impose barriers to SRH certification.


Education and training

  • Curricula and competency-based training should be standardized to allow for better integration of SRH and primary care training.

Federal regulation and financing

  • Federal options include supporting federally funded (Title X) clinics to take a more formal role as training and residency sites for postgraduate clinical training and allowing Title X clinicians to participate in federal loan forgiveness programs.

State regulation and financing

  • Because nurse practice laws in some states limit the types of providers permitted to perform SRH care or because state facility regulations limit SRH care integration with primary care, state Medicaid policy could explicitly reimburse SRH services at higher rates or account for SRH services in setting global payments for primary care, thus affording SRH care the same enhanced status afforded to primary care.

Responding to emerging models of care delivery

  • As accountable care organizations and other integrated models develop, several enabling actions could promote greater integration of SRH care into these models. These actions might include co-locating SRH-competent providers in primary care clinics, such as federally qualified health centers or community health centers; expanding retail clinics and nurse-managed health centers with SRH services; and setting payment rates based on services rather than provider type. Existing models in the UK and United States are described in the report that can inform strategies to align SRH education, practice, and credentialing within public health and primary care.

This work was sponsored by an anonymous private foundation. The research was conducted in RAND Health, a unit of the RAND Corporation.

This report is part of the RAND technical report series. RAND technical reports may include research findings on a specific topic that is limited in scope or intended for a narrow audience; present discussions of the methodology employed in research; provide literature reviews, survey instruments, modeling exercises, guidelines for practitioners and research professionals, and supporting documentation; or deliver preliminary findings. All RAND reports undergo rigorous peer review to ensure that they meet high standards for research quality and objectivity.

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