Recently, the WHO Regional Office for Africa held a Forum entitled “Health systems strengthening for Universal Health Coverage (UHC) and the Sustainable Development Goals (SDGs)”, in Abidjan, Côte d’Ivoire (12-16 November 2018). The Forum brought together health systems and services (HSS) focal persons in WHO country offices, and Directors of planning from the ministries of health from 45 out of the 47 member states of the WHO African Region, as well as HSS experts from WHO Headquarters and UNICEF. The Forum is designed to be an annual event to provide a platform for senior health systems technical leaders and policymakers of ministries of health and their key stakeholders to review, discuss and coordinate country and inter-country health systems strengthening efforts. This year’s event was the third, following a first forum which saw the development of a Framework of Actions for HSS towards UHC and the SDGs in November 2016, Windhoek, Namibia, and a second Forum in November 2017 in Brazzaville, Republic of Congo.
Over 120 delegates gathered to discuss options to accelerate the implementation of UHC and other health related SDG goals and targets in the WHO African Region. More specifically, they reviewed progress towards UHC and other health SDG targets and shared experiences and lessons learnt in strengthening health systems for UHC. Delegates highlighted processes and actions they deemed important. High on the agenda was the need to align planning processes in countries. UHC is a multi-sectoral issue, and although important, the health sector is just one of the sectors involved. In this regard, emphasis was thus put on ensuring that health sector planning aligns with the government development agenda and with other relevant line ministries. Within the health sector, the alignment of program strategies with strategic and operational planning, as well as with the budget cycle was emphasised as a way of ensuring that objectives and activities are aligned.
The issue of essential versus basic packages of health services was also discussed and it was concluded that country specificities and contextualised evidence should inform the content of an essential and basic package of services in a given country. The concept of a basic package of health services is well known in most countries; such a package contains a limited set of interventions that the government can guarantee given available funding. Concerns relating to the design of these packages include restricted budgets for the health sector, donor priorities, and the fact that they are largely defined by technocrats who do not pay adequate attention to the level of investment required for their delivery.
An essential package of health services on the other hand, is defined based on the health needs of the population and takes into consideration the required investments for its delivery. Understandably, in resource-constrained settings, the realisation of such an essential health package will be a gradual process. A country should develop a roadmap detailing how additional services will be introduced, given increases in health sector funding and health system capacities, until such a point as when the population has access to a full essential package. The move towards UHC means that countries need to be more ambitious in planning the availability of services needed by all for their health and well-being.
Delegates appreciated the big strides made by the WHO African Region office in providing tools, guides and standards to support countries. Among these are tools to strengthen monitoring and evaluation, and facilitate country level performance assessment primarily, and global reporting secondarily. The planning guide was also well received by delegates given the attempts made therein to address previous weaknesses in the planning cycle. Although largely seen as a positive development, some concerns related to the use of the tools were also raised, for example how to handle cases of missing data and the need to adapt tools to suit local contexts, which calls for building local expertise. Political instability, frequent changes in governments and disease outbreaks are some of the additional challenges. These definitely need other interventions in addition to the tools.
Delegates alluded to the recently launched Astana Declaration and noted the need for evidence to guide implementation, a paradigm shift in the way PHC is perceived and implemented, innovation in meeting the health needs of some groups including the youth who comprise the bulk of Africa’s population and the elderly who are currently not well catered for (and whose numbers are likely to increase further given improvements in life expectancy). Several challenging issues were also discussed, including: multisectoral approaches – although the need for them is widely acknowledged, implementation is anything but straightforward; raising domestic funding for health – in as much as the Abuja target of allocating 15% of the national budget to health was agreed 18 years ago, a majority of countries are yet to do so; and fragmentation in health information systems which affects the overall quality of data and performance assessment. Finally, while everybody agrees on the importance of engaging with civil society organisations, some caution is warranted. In the words of a delegate: “One must distinguish between civil society organisations that have political ambitions, and those who care to improve the health of the population. That distinction is not always clear”.
A few themes resonated throughout the forum, among others, “health systems strengthening is central to attaining the health goals in the SDG agenda”; the “need for contextual solutions given the uniqueness of the different countries – as noted by a delegate, ‘there is no single UHC model to recommend; each country has specificities”; “the role of evidence on the road to UHC”; “the need for innovation”; “the role of communities as beneficiaries and partners”; and the importance of “ensuring financial risk protection given low government funding for health”.
Areas for further exploration were also highlighted. One of these was the role of traditional medicine in UHC. While this may sound a bit abstract for a global audience, in Africa, it is a subject that cannot be ignored, given the large percentage of people who use traditional medicine as their first option when sick. Secondly, the question of ‘how to increase insurance coverage’ also warrants further exploration – there are many types of insurance schemes currently being developed in the Region, both private and public ones, but their coverage remains very low in a majority of countries.
We felt encouraged by the remarkable success stories of Namibia which managed to reduce malaria from 19% to 2% in a very short period of time, and Carbo Verde with skilled birth attendance now at 98%.
The forum ended on a positive note that “UHC is possible”. We fully agree.