AFRICA'S JOURNEY TOWARDS UNIVERSAL HEALTH COVERAGE
Dear Colleagues,
Here is our topic for July and August, 2014.
During the last week of June 2014, the government of Uganda convened a National Symposium on Universal Health Coverage (UHC) sponsored jointly with the East Central and Southern Africa Health Community Secretariat.
ACHEST provided Technical support to the two day event. This provided a platform to reflect on issues that African countries face on their way to achieving UHC, and internalize opportunities for achieving this key pillar of the post 2015 global development agenda. How can we simplify the message of UHC so that it is understood clearly, in the same way by all actors?
The key point that came through to me is that UHC is not new. Uganda and other African countries are already on the journey to UHC. It is a mission for a specific vision. The vision is to achieve the highest attainable standard of health and quality of life for all people. The mission is to provide access to fair and affordable quality health care services equitably to the whole population.. The previous and current efforts on Sector Wide Approaches (Swaps), Poverty Reduction Strategy Papers (PRSPs), Comprehensive National Development plans the long term national vision such as Vision 2030 or 2040 are all in reality movements towards UHC. They all envision the creation of conditions in countries that lift the whole
population out of poverty and address issues of equity, social justice, health, quality of life and inclusive growth through the provision of packages of basic health and other social services for the whole population, leaving no one behind. Indeed most national constitutions in Africa have language which calls upon governments to ensure the provision of basic health services to their populations. The questions that need answers in the countries are: what packages of services? for whom?, how to
finance and deliver them? How to organize and provide social safety nets for all?
Let’s address each of these in the reverse order. Delivery mechanisms are the most challenging to identify and implement. In order for them to work effectively, they must first and foremost be owned by the beneficiaries both in design and implementation. Ownership and leadership of the UHC initiatives by the heads of governments and state is critical and this ownership and leadership then cascades all the way down to the communities and households. Responsibility for the national health agenda under UHC is a matter for the entire population and should be embedded in the way that society is governed and implemented not by health professionals alone but by all the arms of government and society, crossing culture, religion and socio economic status. Contracting, regulating, supervising, quality assurance of service providers and fund managers; as well as management of payers and users, l all pose real challenges that need to be overcome collectively. Therefore for all this to happen, UHC has to be part of an ongoing national dialogue over which political elections are won and lost.
It was instructive to listen to the Ministry of Gender Labour and Social Services in Uganda articulate their vision for social protection, responding to social needs, providing direct support and promoting
national awareness for social support needs.
It will be critical to cost the packages of services for UHC so as to appropriately mobilize adequate financing for them. African households contribute 40 – 60% of total health expenditure as “out of pocket at the time of need”. Other sources are tax revenues, health insurance and community based contributions and external donors. Financing UHC is often misunderstood to mean health insurance, but it is broader than this. It is more about organizing and integrating multiple diverse sources of health finance into funding pools to guarantee access to healthcare for all, at minimal or at no cost to them, at the time of use. Some developed countries use a fully tax-revenue based approach or payroll based health insurance but in Africa most countries use the mixed approach. At the Kampala symposium it emerged that some have proposed to make offers of in-kind contributions such as of bananas, maize, milk and other local produce contributed by rural populations during harvest time to support contributory coverage schemes. Persuading households to pool resources is only possible when there is ownership by them and when the management is competent and trusted with services actually accessible when needed.
The identification of the package of health services and targeting population groups is once again determined with the beneficiaries based on felt needs and available evidence. The process of ongoing national dialogue needs to be evidence based which introduces roles for academic and research institutions that need to be an integral part of UHC. Africa is already on the road to UHC, the speed of travel needs to be accelerated through awareness creation to drive increased demand, as well as
committed and competent leadership at all levels. The UHC agenda is broader than the health sector. To ensure success, it is critical to actively engage all actors in society, all sectors in the economy and that
driving the agenda is led by heads of governments. Successful implementation of UHC creates a unique social dynamic that is good for society.
How can Africa accelerate progress towards UHC?
This topic is at the heart of all our efforts. It would be immensely helpful to receive comments from all of you; both in Africa and developed countries.
Sincerely,
Francis.
Comments (1)
1. Dr. David OKELLO
Indeed, Universal Health Coverage is not new. The efforts in the same vein date back to the era of Alma-Ata Declaration on Primary Health care in 1978, the global strategy for health for all by the year 2000 adopted in 1979, the health sector reforms (World Bank Report of 1993), the health for all policy for the 21st century adopted in 1998, the UN Millennium Declaration adopted in 2000 with MDGs and a host of other initiatives like child survival decade of OAU, child survival call to action, A Promise Renewed, decade of vaccines, etc. Despite these efforts, a lot more needs to be done to reach the ultimate health for all. We need to examine the experiences with these initiatives and learn from them in terms of what worked and what did not work.
Looking at the title of the topic for discussion, we need to reflect on the journey. If the journey is Africa’s, then Africa needs to have a common concept of the journey including
i. the aim of the journey,
ii. the destination,
iii. the route to take
iv. the means to use
v. how long the journey is likely to take
vi. what it takes for us to go through the journey to our destination
vii. understanding what the obstacles are currently and which are likely to come during the journey.
The other important aspect we should not lose sight of is to decide whether indeed the journey is Africa’s. We are all aware that we are in a global village. The global agenda does influence what happens in the various continents and countries. More often than note Africa’s role in determining and/or influencing the global agenda is minimal and rather the global agenda tends to dictate Africa’s health agenda. The global agenda tends to be influenced by the rich global health initiatives with heavy western influence a well as by evidence generated from mostly western research and higher learning institutions. Even where initiatives are started in Africa, like the first human heart transplant by Dr Christiaan Neethling Barnard in South Africa in 1967, sustaining these initiatives to their fruition remains a challenge. For example forty-seven years after that 1st human heart transplant, done in Africa, the bulk of patients in need of such service are referred overseas.
To obtain a common concept on UHC, there need to be opportunities to discuss UHC at technical, political and popular levels involving regional, sub-regional, national and sub-national fora. Although a number of consultations were held on the post-2015 development agenda, including health in this agenda based on UHC, culminating in the global adoption of a resolution A/67/L36 “Moving Towards Universal Health Coverage”in the United Nations General Assembly in 2012 that emphasizes health as an essential element of international development and urges governments to move towards providing all people with access to affordable, quality health-care services, not much discussion and dialogue has taken place at national and sub-national level. Even where such fora exist, the discussions are not widened up to wider audiences and stakeholders both within and outside the countries. The dialogue on UHC in Kampala could have attracted more participation from other stakeholders even outside the country.
The definition and understanding of UHC is challenging. The 58thWorld Health Assembly that adopted a resolution in 2005 pertaining to Universal coverage did so under resolution WHA58.33 “Sustainable health financing, universal coverage and social healthinsurance” with quite an emphasis on health financing and referring to transition to universal health coverage. Thereafter, the World Health Report 2010 rightly discussed health systems financing as a path to universal health coverage? Prior to this, in 2008 the World Health Report discussed the theme “ Primary Health Care: Now more than ever” that advocated for 4 Primary Health Care reforms, namely Universal Coverage reforms, Service Delivery reforms, Leadership reforms and Public Policy Reforms. It would be an error to look at each of these documents separately. In order to have a clear understanding of universal health coverage, a synthesis from these basic documents may be required. I hasten to add that at times the presentation of materials is confusing. For example in the World Health Report 2008, although there are 4 PHC reforms advocated, to achieve the one on Universal coverage, it is important to have the other 3 reforms in place. I therefore do agree that UHC needs a simple and easy to understand message. Whichever message is adopted, it should emphasise timely availability, accessibility and utilization of affordable appropriate quality health services for all.
It is surely important and necessary to define the health service packages, how they are financed and delivered and by whom, taking into consideration appropriate social safety nets. However, the problem does not only lie in defining the packages and describing how they are delivered but more so on the effective implementation of these policies and initiatives. Often, one will find that countries do have fairly good health policies and strategic plans, but over the period covered by these policies and plans the implementation remains inadequate. The dialogue on UHC should examine the factors behind inadequate implementation of the good policies and plans. For example, sometimes plans are developed without being properly costed; annual budgets may not speak to the health strategic plans and even when they speak to the plans, the final allocation to the sector may not allow realization of the intended annual plans. The issue of how Government priorities are arrived at and how to influence these priorities needs to be discussed. As rightly mentioned, this is where the interface with politics and politicians takes place. The crucial role of good governance is paramount as it is only then that policy decisions taken obtain commitment for actualization (availing appropriate resources and enabling political, social and legal environment).
The statement that UHC should be part of ongoing dialogue over which political elections are won or lost is a good ideal. It can only be as good as it is able to be done. It can only succeed after priming of the populations to understand that their voice is important and counts. As long as the cheap politics pervades a number of the African countries, this will remain wishful thinking. Having said that, it is important to note that such culture can gradually be instilled/nurtured in the population. This can be achieved through active participation of civil society groups and creating fora that bring politicians together with the electorate to regularly discuss health and developmental issues. However, such fora need appropriate facilitators that may not been seen to align to any specific political inclination.
To accelerate progress towards UHC, with support from the AU, RECs and Development Partners, African countries need to do the following, among others:
1. Review previous experiences (within and outside countries and even from other developing countries outside Africa) of efforts towards health for all and similar initiatives and draw lessons from them
2. Create and promote fora at all levels (national and sub-national) to discuss health and development and in particular development through UHC
a. Intra and inter-sectoral
b. Between different levels of Government
c. Between Government and development partners
d. Between Government and civil society
e. Between Government and private sector
3.Create an environment for all stakeholders to actively participate
4. Develop an action oriented long-term agenda towards UHC with appropriate targets and milestones
5. Improve governance for better vision, guidance, commitment and support
6. Establish mechanisms for accountability for health from the home to national level
To conclude, it is important to underscore the issue mentioned in passing on the importance of Government leadership. The role of Government is not just to provide the right policy environment, but to push for its full implementation. It is also equally important to appreciate the reality that solving health concerns is not the only demand of our people. There are usually many competing demands at the household level. UHC will not be achieved in isolation if other equally pressing socio-economic demands are not addressed.
Best regards.
Dr David OKELLO
WHO/Zimbabwe