Assets on the construction of Universal Health Coverage

By: Christian Wilfrid Diankabakana

Quick reading

• The objective of UHC is to enable everyone to access health services

• UHC increases people's life expectancy, strengthening the economic growth of states

• Above all, countries must mobilize internal resources to finance the implementation of UHC

In accordance with the commitments made at the United Nations in 2015, many African countries have undertaken the implementation of universal health coverage (UHC). But, the road is still long and marked by multiple barriers such as the mobilization of financial resources. And few countries on the continent have already achieved this goal.

In this interview with SciDev.Net, doctor Hyppolite Kalambay Ntembwa, team leader "Integrated Services and Primary Health Care" at the World Health Organization (WHO) Regional Office for Africa analyzes the contours and challenges of the implementation of UHC in Africa.

Many countries in Africa such as Cameroon, Togo, the DRC and Congo have launched the process of implementing universal health coverage (UHC). What is UHC?

Universal health coverage means that everyone has access to the health services they need. These health services must be of sufficient quality to be effective and access to these services must not be accompanied by financial difficulties

What is UHC's interest in states and health systems?

Let's start with interest in States. As you know, several countries have mentioned in their Constitutions that health is a fundamental right for every citizen. From this point of view, universal health coverage is therefore a means for States and governments to fulfill their constitutional commitments.

"The current level of spending on health in several African countries is low to hope to achieve UHC. Countries must make more efforts to mobilize additional resources for health in order to accelerate progress towards UHC"

Hyppolite Kalambay Ntembwa, WHO Africa

Second, it has become clear that health is an important factor in economic growth. We saw it with COVID-19. The fact that people were not healthy or at risk of not being healthy caused the collapse of almost all economies around the world. This sufficiently demonstrates that health is an important determinant for sustained economic growth and universal health coverage contributes to it.

Regarding interest in health systems, it should be mentioned that the dynamics of universal health coverage will increase the resources allocated to the health sector. We hope that these resources will help strengthen health systems so that, on the one hand, they are able to provide the health services people need and, on the other hand, these resources will make health systems more resilient.

What are the benefits of UHC for collective populations and for individuals?

People in countries that will achieve universal health coverage will have the advantage of being healthy. At the individual level, people will see their life expectancy increase; that is, not only will they live a long time, but they will also live healthy for a long time. This will allow them to be economically active over many years during their lives.

In 2015, United Nations member countries committed to implementing Universal Health Coverage by 2030, as part of the Sustainable Development Goals (SDGs). Seven years later, few countries have achieved this goal on the continent. What comments inspires this observation and what are the obstacles to the implementation of UHC?

Almost all countries are somehow engaged in the process of universal health coverage. However, it is known that current efforts in several countries will not allow them to achieve universal health coverage. Countries need a new impetus, a new dynamic that requires political engagement at the top of the state to accelerate progress. This is what, from my point of view, makes the difference between African countries.

The other difficulty faced by African countries is that related to health financing. The current level of spending on health in several African countries is low to hope to achieve UHC. Countries must make more efforts to mobilize additional health resources to accelerate progress towards UHC.

What are the different mechanisms available to the countries of the continent to finance UHC?

First, I would like to talk about domestic resources that offer several possibilities. To finance UHC, countries will first have to rely on domestic resources because it is a program that will last for decades (not a 3- or 5-year project). From this point of view, countries have the opportunity to increase budget allocations for the health sector by improving tax revenues.

We have seen that some countries have set up dedicated funding and it works well. Dedicated funding is essentially taxes that are put in place and whose resources mobilized are allocated directly to the health sector. This is the case, for example, with taxes on tobacco, sugary drinks, mobile phones, etc. This is a path that is worth exploring.

Apart from that, there is private sector funding. We can see that the private sector is increasingly investing in health, especially in large cities in Africa. This funding can be well oriented so that people get the best possible benefit from it. Corporate Social Responsibility (CSR) is also a way to be exploited to mobilize resources to finance UHC. Where they settle, companies have a responsibility to invest in the social (including health) of the surrounding populations. Finally, there is international aid that can also be mobilized.

In your opinion, what measures can African countries take for the successful implementation of UHC?

The first mechanism from my point of view is political commitment to the summit of the State. UHC is a set of reforms that go beyond the health sector. There are reforms that concern the health sector, reforms that concern the Ministry of Social Protection, the Ministry of Finance, etc.

Without a political commitment at the top of the state, it will be difficult to make progress towards UHC because it is only the summit of the State, I mean the President of the Republic or the Prime Minister where there are, who is able to coherently drive these reforms in the different sectors concerned.

The mobilization of resources, including domestic financial resources, to finance UHC, is another important factor. Ensuring that every citizen can access the health services they need without suffering financial difficulties will cost governments dearly. Governments will have to mobilize additional resources.

The last success factor I would like to emphasize is the promotion of primary health care (PHC). Governments will have to invest enough in PHCs, which are now considered the cornerstone of strengthening health systems to accelerate progress towards UHC. This means, in simple terms, that PHC is the most effective and efficient way for the country to make progress towards UHC.

It is found in some countries that not all diseases are covered by UHC. How can this be explained?

One of the major differences between the Millennium Development Goals (MDGs) and the Sustainable Development Goals (SDGs) in the health sector is that the MDGs targeted diseases (such as HIV/AIDS, malaria, tuberculosis), while the SDGs target health and well-being. There is an important difference between the two. Universal health coverage must not target diseases as it is part of the SDGs. It must target health. Targeting the disease has resulted in some diseases being left behind and they have continued to kill and/or create disabilities in the population.

This is the case, for example, with diabetes and high blood pressure, which were not targeted at the time of the MDGs and these diseases continued to cause damage to the population. This is why universal health coverage must focus on improving health and not diseases.

How does the UHC coexist with health insurance without duplicating?

To better answer this question, it is necessary to understand the difference between UHC and health insurance. Many people and sometimes some health professionals confuse the two. I have defined UHC as a situation where people have access to the health services they need, these services must be of sufficient quality to be effective and the use of these services must not lead to financial difficulties.

This means that to implement universal health coverage, governments must work on two components. On the one hand, to ensure the availability of essential health services; on the other hand, to put in place provisions that protect the population from financial difficulties when accessing health services.

"Without a political commitment at the top of the state, it will be difficult to make progress towards UHC because there is only the summit of the state, I mean the President of the Republic or the Prime Minister where there are, who is able to coherently drive reforms in the different sectors concerned"

Hyppolite Kalambay Ntembwa, WHO Africa

Health insurance is one of the measures to protect the population from the financial risk associated with the disease. Health insurance is not the only device in this area, there is also, for example, medical assistance that allows people who do not have the financial means to join health insurance (indigent) to access to health services. From this point of view, health insurance is one of the tools to set up universal health coverage

There is therefore no duplication between UHC and health insurance since it is one of the means to be put in place to protect populations from the financial difficulties related to the disease and therefore one of the tools necessary to achieve UHC.

What are the particular assets that can eventually make UHC a success in sub-Saharan Africa?

One of the assets available to the countries of Sub-Saharan Africa is their experience in implementing PHC. SSPs are now considered the path to UHC as I mentioned above. The countries of sub-Saharan Africa can capitalize on this.

The second asset available to sub-Saharan African countries is the strength of the partnership between the government, non-governmental organizations and non-profit health associations. In several countries in sub-Saharan Africa, religious denominations have effective health services. In some countries they have up to 60% of front-line health services. This is an important asset on which the African countries concerned can build the future.

The other important asset is the dynamics of the private sector in the field of health. In some countries of sub-Saharan Africa, we see private individuals who invest in health training including tertiary reference health training. This is an important asset, an essential contribution to the establishment of UHC.

Finally, we must mention the commitment of local communities. They are ready to take their share of responsibility to support governments in their efforts to be made for the UHC of which they are the beneficiaries.

How can international organizations such as WHO support African countries in achieving this goal?

WHO acts at several levels to support countries in the African subregion to help them accelerate progress towards UHC. The first level of support is political advocacy to get governments to meet their commitments to UHC and the other SDGs. As I said above, political commitment to the top of the state is crucial in the march towards UHC. WHO is investing in this to make this a reality at the country level.

WHO's second level of support is technical. WHO provides countries with the expertise, technical resources and, to the extent possible, catalytic financial resources they need to develop and implement policies, strategies and plans that enable them to accelerate UHC progress.

WHO's third level of support is the mobilization of other technical and financial partners such as other United Nations agencies, the World Bank, other donors, etc. to make their contributions to the countries of the region and help them move towards UHC.