Universal Health Coverage: From aspirations to reality

Implementing UHC in East and Southern Africa

East and Southern African (ESA) countries are at various stages of implementation of UHC, revealing many challenges and some successes. Country challenges include declining investment in public systems and limited fiscal space, resulting in underfunded and under-resourced public sector health facilities and productivity gaps. Buildings are dilapidated, water and sanitation supply systems are insufficient, essential medical supplies are in short supply and health providers are geographically maldistributed. These are aggravated by the increasing burden of largely preventable non-communicable diseases, which add to the prevailing burdens of communicable diseases and unmet demands for reproductive, sexual, maternal and child health. The rising disease burden and service aspirations outstrip available resources and capacities (EQUINET: TARSC and IHI, 2018).

Health financing in many ESA countries is often fragmented, with multiple health insurance schemes with different benefit packages, provider payment methods, expenditure and performance. Many ESA countries are exploring diverse financial risk protection systems, including non-contributory and contributory systems. A number are introducing new social or national health insurance schemes or creating incentives for informal workers to join existing ones. Some are exploring or widening voluntary prepaid community or private health insurance options (Doherty, 2019). Many ESA health systems, however, are reliant on unpredictable external bilateral and multilateral funding, sometimes conditional or delivered through vertical initiatives which limit service integration, undermine national planning and may be unresponsive to local conditions and needs (EQUINET: TARSC and IHI, 2018). Service coverage for the uninsured is low and OOP expenditures are high, a key factor driving households into poverty. Systems are stretched and there is the danger of shifting an increasing burden of unfunded care down to the household, and thus largely to women.

Four decades after the 1978 Alma-Ata Declaration promoted universal PHC as a key global goal, PHC systems lack investment, and the most disadvantaged people continue to be deprived of affordable and quality essential services. This is a major impediment to achieving UHC. Global challenges add complexity. Health systems need to mitigate the impacts of climate change. Political conflicts and the activities of extractive industries displace people and result in significant levels of forced migration. Land and market pressures lead to epidemic risks, as occurred with Ebola in West Africa, and ageing societies alongside rapid urbanization pose new health challenges. The rising tide of communicable, non-communicable, infectious and chronic diseases driven by these challenges cannot simply be met by curative systems. Strong public health interventions as well as cross-sectoral action to promote health outside the health sector, as was envisaged in PHC, are required. ² This includes, for example, addressing diet and lifestyle in tackling childhood obesity, reducing stress and increasing livelihood security among other determinants of mental health issues, and addressing diet, alcohol consumption, smoking and other lifestyle issues in the prevention and control of chronic diseases. Yet, many underfunded health systems focus almost exclusively on curative care.

Domestic resource mobilization and publicly financed PHC-led reforms will be the most progressive and sustainable source of financing for UHC. This requires enlightened leadership and dialogue, between finance, health and other sectors, involving political actors, health workers, the private sector and communities. Adding piecemeal funding without pooling resources can lead to segmented systems and inequities; where pooling is feasible, even greater calls for transparency and trust in public institutions is required.

Achieving full UHC is a daunting task. To ensure equity in essential health benefits (EHBs), services that can be guaranteed and offered broadly and affordably to all citizens by the government need to be defined, known and claimed. Making a package of EHB clear and costing it can help to align private services to public goals and encourage strategic purchasing and social accountability for services delivered. The EHB should be regularly reviewed to respond to the changing population health profile, and explicitly used to operationalize PHC and UHC, and to promote equity in the strategies to achieve these goals. While most ESA countries include the definition of EHBs within their national health strategies, evidence from African-led multi-country EQUINET research with health ministries (Loewenson et al., 2018) suggested that implementation remains weak, in part due to capacity and resource gaps. While EHBs have been used to inform local government planning, and to develop guidelines for quality, service provision, staffing and infrastructure norms, they have not been adequately used to cost services, inform budget negotiations nor in purchasing services or monitoring performance. Underfunding of the sector has led to EHBs being used more as a rationing than an allocative tool, and the trajectory from minimum benefits to comprehensive coverage remains unclear.

The journey towards UHC is path dependent and context specific. Each country may have their own particular challenges in extending the three dimensions of the UHC cube: population coverage, benefit coverage and financial risk protection. But experiences from pioneering countries in their UHC journey (such as Thailand) can present valuable learning opportunities for others on the initiatives, processes, measures and strategies that need to be in place. This may cover issues such as

Underpinning the UHC agenda is the belief that access to health care is a fundamental human right that advances equality and safeguards human dignity. Achieving UHC is a huge endeavour and requires buy-in at all levels of the system. It calls for strategic leadership, evidence and review. There has been a significant expansion in the technical information and knowledge available to support UHC. Making progress towards achieving it is, however, not simply a technical issue: it is an issue of power, political choice and leadership.