By Helen Anyasi
Using marriage as an analogy, it is possible for a sincere commitment to be made to an ideal that has not been fully conceived. This is not to say that Country Representatives at the September 2019 UN High-Level Meeting (UN HLM) on Universal Health Coverage in New York were insincere or naïve as to what Universal Health Coverage (UHC) means, but, comments and excerpts from discussions that followed the declaration show that countries do not have a harmonized view as to the ‘what’ and ‘how’ in keeping the UHC promise.
It is not unusual for UHC to have wide-ranging meanings spanning from humanitarian, to sociopolitical and economic viewpoints; attempts at trying to coalesce these positions sometimes lead to an overly simplified message that boils down to “free health care for all, especially the poor”. Defining UHC in terms of costs, service and population alone may be too simplistic a view to hold and does not adequately reflect other principles of UHC which include acceptability, access, availability, adaptability and equity. Still, landmark events are great for advancing a movement, as it starts up conversations that spark ideas and action toward some progress.
Learning from the global HIV response
One landmark declaration that has marked global health history is the Millennium Declaration, which included a specific goal to reverse the spread of HIV, malaria and TB. Since that point, we have witnessed one of global health’s most successful embarkments. It is because of this that it has been posited that the UHC movement should take lessons from the global HIV response. The HIV response in many countries has led to advances in many health systems, including the establishment of data management information systems, decentralization of health care systems with implementation of high-performing task-shifting policies, improved service delivery models, and better governance with enhanced collaborations between communities, stakeholders, public and private partners. Therefore, it is wise to tacitly study the scale-up of HIV services and shape approaches along some of its guiding principles of good governance, leadership, meaningful engagement and partnership with civil societies, and human rights-based approaches to promoting prevention, care, treatment and support – all of this based on the best evidence-based research and knowledge.
But we cannot just draw parallels, as some of the denominators that aid the HIV response are not as present in the UHC movement. Factors such as the grass-roots activism driven by obvious stigma and discrimination against people living with HIV and massive development assistance for low-middle income countries who were drowning in the weight of the epidemic. These factors mitigated the movement; so, what will be the rallying call for UHC?
When we look at country examples of UHC implementation we note a few things: we see that there is overwhelming support for UHC even as governments struggle with political and technical delineations. It is understood that decisions for Universal Health Coverage are not just socio-economical; there are political aspects of UHC which should not be shied away from; these aspects should be brought to bear in all discussions around UHC. Advances in UHC in many countries coincide with periods of reform, crises, changes in governments, elections etc. These kinds of opportunities should serve as policy windows to get the agenda firmly on the table. There needs to be more advocacy to remind governments that countries with strong, healthy populations served by a strong health system leads to strong economies. UHC can serve governments well as a medium through which they can exhibit their abilities to put their political will behind a goal with specific, target-driven objectives.
An example of contextualizing UHC can be seen in one of Rwanda’s strategies which includes investing in local leaders and community health care workers to encourage enrollment into the community health insurance scheme – over 90% of the population are now covered by the scheme. This is the type consideration that should be given when prioritizing essential package of services and mapping service delivery models. Needs differ across countries, indeed among communities within countries. Also, country health systems have different strengths and weaknesses so progress towards UHC is bound to be iterative. Room needs to be made for this by constant evaluation and re-innovating. Therefore, while global goals, country examples and universal frameworks exist to aid countries along their UHC journey, they serve as templates on which countries come to define UHC in contextual ways that lead to indigenous, home-grown solutions.
Helping governments to “keep the promise”
Thailand launched UHC on a strong public health care system that had been built over decades; but progress was impeded by long periods of slow, incremental policy evolution that spanned decades. Success has been attributed to the persistence of progressive Ministry of Public Health bureaucrats who negotiated using evidence generated from strong institutional networks. It is a show of strong political will when countries can back technical strategies and goals with progressive action. Progress must be made in actively deriving evidence generated by countries at varying points in their journey, and ensuring this evidence is used to propose guidelines that countries can use as frameworks. Hence, to get governments to “keep the promise” on UHC, there must be a collective understanding of the politics that underpins government decision-making and use this understanding to propose tailored country-specific policies.