By Arush Lal, 2018 Emerging Voice for Global Health
You wouldn’t know it just by looking at her, but Angela Kisakye has just about seen it all when it comes to the most glaring gaps in health systems.
I first met Angela as part of the Emerging Voices for Global Health fellowship, where she opened up to me about her experiences as a young, female researcher in Uganda. One story stood out because it perfectly portrayed the complex web of barriers that prevent the world’s most vulnerable communities from accessing essential primary health services, the foundation for universal health coverage (UHC), as well as the importance of intersectionality among health professionals as stewards of UHC.
During a visit to a rural clinic in northeast Uganda, she arrived to find a long queue of patients frustrated that the health worker on duty was nowhere to be found. After tracking him down, Angela was shocked to discover that the man the entire community depended on for healthcare was listed as the clinic’s security guard. Investigating further, she learned that for weeks no health workers had showed up at the clinic. Seeing this, the security guard took it upon himself to act, diagnosing each patient with malaria and sending them home with a dose of Coartem.
His explanation for this? “Well, what else could I do?”
On the heels of the Astana Declaration on Primary Health Care, Angela’s story uncovers some hard truths about just how far we are from realizing the vision of UHC. Here are three ways civil society partners can strengthen primary health care to ensure no one is left behind:
Step 1: Value the key role of frontline health workers by supporting their needs.
Without frontline health workers, UHC is impossible to achieve. But simply employing health workers doesn’t yield adequate primary health care either. Angela’s story highlights the countless barriers that prevent health workers from effectively doing their jobs. Programs must consider their needs too — including sufficient compensation to improve motivation, providing decent facilities to prevent rural to urban emigration, and promoting effective management to combat absenteeism, following examples from organizations like IntraHealth International. Furthermore, strong data systems are needed to gauge gaps in health worker cadres, plan for essential health services, and train health workers as leaders of UHC in their own communities.
Step 2: Empower community voices, particularly those of women and youth.
Health systems are most successful when we put people at the center. But civil society organizations (CSOs) have a spotty track record of doing this, largely because we fail to engage those who have been marginalized the most. Because her supervisors empowered Angela, a young female researcher living close to the communities she serves, root causes of human resources for health (HRH) gaps often overlooked were brought to the fore during her explorations. And by empowering local communities to speak up themselves, Angela could more effectively determine sustainable, people-centric solutions.
The voices of those that are young, female, impoverished, and/or living in rural areas are far too often left out of decision-making, ultimately leading to massive fractures in health systems. Men, particularly those in power, have a big role to play in passing the mic; an important first step can be making commitments with groups like Women in Global Health. By spotlighting less-visible voices at all levels, CSOs will progress much faster on achieving UHC.
Step 3: Commit to an intersectional approach. Always.
A paradigm shift is needed to ensure CSOs understand that their impact on all UN Sustainable Development Goals (SDGs) impacts progress for UHC. For example, it’s not enough to develop reproductive health programs for women if they continue to sideline LGBT+ communities or ethnic minorities. Health worker training programs must meaningfully engage the growing youth population and those in poverty with decent jobs and employment. An immunization campaign partnering with pharmaceutical companies that pollute the environment or discriminate against women in leadership is simply not sustainable.
It can be challenging to advocate for multiple issues at once, but being committed to intersectionality accelerates progress on all global goals, particularly in the provision of primary healthcare. And if we don’t develop programs that highlight intersectionality in health systems, we cannot expect policymakers to develop holistic solutions either.
The vision of UHC is ambitious, and the SDGs go even further. But the right to health for all hinges on these shared global goals.
Recognizing that diverse teams of trained and supported health workers are the bedrock for UHC is paramount. And by placing those long removed from decision-making at the center of the table, whether young and female like Angela or rural and poor like the security guard, we can learn vital lessons that accelerate progress toward UHC. Combined with an intersectional lens that truly commits to leaving no one behind, and we actually have a shot at meeting our targets by 2030.
As we barrel toward the UN High-Level Meeting on Universal Health Coverage and reflect on commitments made during the 40th Anniversary of the Alma-Ata Declaration, let’s keep these important lessons in mind. Universal health coverage is possible, but the status quo we’ve relied on will no longer work. And it will take an army of young, female leaders like Angela and forward-thinking civil society partners that support her to make it happen.