At the global level, the UHC 2030 International Health Partnership commits signatories to the global compact to ensure that no one is left behind; transparency and accountability for results; a clear health sector strategic vision with government leadership; collective action in strengthening the health system and international cooperation based on mutual learning across countries. The global health community is also already looking forward to the UN High-Level meeting on UHC, end of September in New York, an event that will surely provide even more momentum to the UHC movement.

At the continental level, the sixth Tokyo International Conference on African Development (TICAD VI) conference held during August 27-28, 2016 in Nairobi – Kenya, committed African government leaders and partners to strengthening their health systems to attain UHC.^. The World Bank publication “UHC in Africa: A Framework for Action” (2016) makes a case for investing in UHC asserting that it is a moral obligation as well as a good investment with positive returns in terms of human productivity, poverty reduction and economic growth.  The African Union call to action “Universal Health Coverage in Africa: From Concept to Action” (2014) reaffirmed the commitment of the African States setting a more ambitious target of 2025 for Member States to attain UHC. Like in the rest of the world, Dr. Tedros, the Director General of WHO has engaged Heads of State in Africa, as well as Ministers of Health and partners, imploring all of them to work towards attaining UHC for their populations while emphasising the crucial role of political commitment, prioritized domestic financing for health and context specific approaches. His recent visit to Kenya related to the launch of the UHC road map attests to his commitment and indeed in his meeting with President Uhuru Kenyatta and the Kenya team, he stated that “You all know how passionate I am about UHC. I want to see what the Kenyan government is doing to ensure it is achieved.” At the WHO African Region level, Dr. Matshidiso Moeti’s commitment to UHC is evidenced by her engagement with the Ministers of Health.  During the sixty- seventh WHO Regional Committee for Africa held 28 August-1 September 2017 in Victoria Falls, Zimbabwe, the African Health Ministers of the 47 member states committed to attaining UHC and endorsed a Framework for health systems development towards UHC in the context of the Sustainable Development Goals in the African Region. Dr. Moeti further launched “The Africa Health Transformation Programme, 2015 – 2020 – A vision for Universal Health Coverage” whose goal is to ensure  universal access to essential health sciences in all member states of the WHO African Region.

Turning to the Eastern and Southern Africa subregion, then, we continue to witness an unprecedented commitment to UHC. Nine out of the 20 countries in the subregion are signatories to the UHC 2030 Global compact. Seven out of the 20 countries have developed consensual multisectoral UHC roadmaps in a highly participatory manner. Further, some countries have witnessed national level launches of their UHC roadmaps as well as events to mark “UHC day” (12 December) with extensive media coverage. By way of example, South Africa’s President hosted a Presidential Health summit  19^th – 20^th Oct 2018 which brought together over 600 delegates. The major aim of the summit was to galvanise stakeholders’ efforts to tackle challenges in the sector and collectively define a roadmap towards UHC, demonstrating high level political commitment to UHC. The summit agreed to develop a Presidential health compact to ensure implementation of agreed recommendations.  While closing the summit, the Deputy President stated that “May this be the beginning of a rich and fulfilling journey towards a transformed, accessible, equitable and quality health care system in South Africa”.  Similarly, in Kenya, President Uhuru Kenyatta launched the “UHC Road map” for the country and remarked that “Today marks a key milestone; a historic journey for our nation as we inch closer towards the realisation of health for all”. He reiterated his commitment to ensuring that all Kenyans enjoy the highest level of health as provided for in the constitution and, situated good health in the socio economic development agenda of the country. Indeed UHC is one of the key ingredients of the President’s “Big 4 agenda” for development, the others being food security, affordable housing and manufacturing. Uganda has also witnessed high visibility of UHC events with extensive media coverage.  

Admittedly, all these high level events for UHC allude to the (many) challenges that must be tackled on the journey towards UHC – most of these have plagued health sectors within the African Region for over a decade. The low investment in health, inadequate and inequitably distributed human resources for health, fragmented health information systems, weak infrastructure and medicines stock outs are hurdles to overcome. Limited fiscal space has been a major challenge to increasing domestic financing for health in the majority of African countries but the projected positive economic growth in Sub-Saharan Africa forecasted to rise from 3.1% in 2018 to an average of 3.6% in 2019–20 offers a ray of hope. However, considerable variations across countries must also be highlighted in this respect. This notwithstanding, the message has consistently been that all countries, irrespective of their level of economic development can work towards UHC. Indeed Dr. Tedros asserts that “Universal Health Coverage is a political choice. It takes vision, courage, and long-term thinking”. He’s damned right.

We must admit that countries making commitments at global, continental and national levels is not a new phenomenon. For example, the Abuja declaration committing African countries to allocate 15% of the national budgets to health dates as far back as 2001 but by 2014, only 4 countries had attained this target on the continent. The same could be said of the Maputo declaration on HIV/AIDS Tuberculosis, malaria and other related infectious diseases (2003); the Algiers declaration of health research (2008) and several others. So more than a few observers might wonder whether this time will be different. Currently, however, we are observing a trend that we have not witnessed before and this gives us a reason to rejoice.  National launches, extensive media coverage, presidential summits, presidential compacts to ensure accountability and monitor progress and consensual intersectoral plans send a ray of hope and for these we rejoice.  At the start of a new year, we’re sure you understand!

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.

Generating and getting evidence into policy requires time and investment.  Learning from work undertaken in Uganda and other published literature, it is clear that there is no simple formula for improving evidence uptake, but a better understanding of facilitating factors and interactions of stakeholders can help researchers and policy actors improve KT. The focus should be on maximizing the facilitating factors on the one hand while mitigating barriers on the other.

In many LIC countries the rapidly changing political context limits the long term horizon of decision makers because they are not certain how long they will stay in office. The need for votes to return to office influences decision making, leaning more towards quick fixes with popular support, as opposed to a strategic long term and sustainable approach. Kingdon argues that a decision is taken when the political, policy and problem streams meet. The political window will provide different opportunities for KT based on the political implications of the decision. In one particular case for Uganda, for example, evidence on the disadvantages of user fees for health was available and had been discussed already without making a decision. Presidential elections in 2001 provided an opportunity. So this case is a clear example of Kingdon’s problem, political and policy streams coming together to form a window of opportunity. In the problem stream, there was a lot of agitation to try to get policy makers to focus on the problem of user fees. The agitation came from the community in the form of complaints. These complaints were presented to politicians, including those campaigning for the presidency at the time. In the political stream, the issue of user fees for health care was included in the election manifesto of the two presidential candidates. Several proposals were floating in the policy stream, like the proposal of civil society organizations to abolish user fees as a means to improve access to health services by the poor. Presidential elections provided thus an opportunity for the three streams to meet and a window presented itself for a policy decision on user fee removal.

When we talk of evidence, we need to be mindful of the fact that there are different types of evidence and that different actors attach different importance to each. There is no consensus as to which type of evidence is deemed most important, and the issue under consideration will influence the nature of evidence that drives decision making. Looking at biomedical policies, like the case of malaria treatment policy change in Uganda in 2006, as compared to a social policy concerning people’s welfare, like the abolition of user fees, we saw very clearly that actors attach different emphasis to different types of evidence in the two cases.  In the case of malaria treatment policy change, actors put a lot of emphasis on evidence from efficacy studies  while in the case of user fee abolition, politicians listened very carefully to community complaints.

This withstanding, evidence must be of good quality, comprehensive enough to inform different aspects of decision making, and provided in a timely manner. Who generated the evidence is another topical issue as researchers must be viewed as credible and independent. Where this is lacking, or seems to be lacking, however good the evidence is, if there are suspicions regarding the researchers involved, evidence will be seen in the same light, presenting a missed opportunity for KT.  The abolition of user fees in Uganda is a case in point where evidence generated by the World Bank was judged as `misleading the policy makers`. This stemmed from the fact that the World Bank was supporting retention of user fees of which the introduction had been supported by them as a way to guarantee loan sustainability. The evidence they generated at the time was in line with their prior position.

Inadequate attention has been paid to ensuring effective dissemination. How do we reach decision makers and influential stakeholders? Targeted dissemination and face to face interactions are important but the easier thing to do is sharing a research report and/or holding a dissemination workshop whose impact tends to be limited. Influential stakeholders, who can be mobilized through targeted engagement, are often not fully exploited, for example the politicians, village chiefs and the media.  In the case of the malaria treatment policy change in Uganda, effective and targeted dissemination was one of the facilitating factors for KT.

Evidence generation and its uptake in policy development occur amidst stakeholder interaction and this takes us to another important point: the need for KT partnerships.  Ssengooba et al noted   that shared platforms for learning and decision making among stakeholders enhanced the uptake of evidence from prevention of mother to child transmission (PMTCT) studies into policy. Similarly, in our study  looking at the malaria treatment policy change in Uganda, partnerships bringing together researchers, policy makers, civil society, donors and implementers provided an opportunity to discuss all available evidence and make policy decisions in line with the evidence.

Partnerships need to encompass the whole process right from evidence synthesis up to application. Partnerships must be inclusive; there must be mutual trust and sharing of evidence coupled with open discussion. This provides an opportunity of discussing the different types of evidence in order to come to the most appropriate decision given other contextual issues. In addition, conflicts of interest can be openly handled within such partnerships.

Who owns the KT process in countries? The Paris Declaration and the Accra Agenda for Action emphasize Government ownership of the health development agenda. Hence, the strengthened capacity of the Ministry of Health to lead the KT process is essential. In the case of the malaria treatment policy change in Uganda, the ministry of health, whose capacity had been strengthened by the East African Network on Monitoring Antimalarial Treatment (EANMAT), fully owned the KT process, convened partners and chaired all working groups which enhanced KT.

Contextual issues also merit attention and these include systemic factors encompassing political, economic, and social dimensions which may be at the national or international level.  Research recommendations which are contrary to cultural and social norms are unlikely to influence policy. Medical male circumcision in Uganda is a case in point: despite the availability of high quality evidence, influencing policy was not an easy path.  Lack of appreciation of the benefits by the intended beneficiaries, and politicians openly contesting the evidence were among the challenges.

This raises the issue of local research capacity whereby local researchers, who know the context well and interact with decision makers more often, may be more influential in KT than international researchers.  Given the weak research capacity in low income countries, partnerships in research need to be strengthened through North to South collaborations but also through South to South collaboration by building regional capacity since contextual issues within a given region may not differ significantly. In this regard, regional professional bodies play a role and indeed have been instrumental in some cases like the case of change of malaria treatment policies in East African countries.

To conclude, we noted that KT is a process that has to be institutionalised, planned for, properly funded, requires capacity building, but which also needs to be tailored to the nature of the policy issue. Evidence concerning non-contested technical issues tends to be taken up more easily than evidence pertaining to more controversial policy issues. There is a need to map the actors involved and ensure targeted dissemination noting that different actors define evidence in different ways, hence the need to take this diversity into consideration in the dissemination. Partnerships are important in that they provide an opportunity for actors to come together, review the different pieces of evidence and come to the most appropriate decision in a given context.  These however need to be built on mutual trust and must have mechanisms for managing conflicts of interest. Stakeholder involvement from the start, already at the evidence synthesis stage, is vital; it takes more effort and time if the issue is contested (low agreement). However, one needs to pay attention to the nature of the issue under consideration as this will influence stakeholder interactions and KT processes, whether the policy issue is contested or not.