By Okikiolu Badejo, HSG Africa Regional Network Coordinator
Following the High-Level Meeting on Universal Health Coverage (UHC) UN member states are expected to show more financial and political commitment to accelerate progress towards UHC. The meeting is hoped to provide the basis for increased global co-operation for UHC, while reaffirming the central role of governments to significantly scale up efforts to deliver UHC by 2030. This is highly relevant for African countries, many of which have the most gaps to close to achieve ‘health for all’.
Different pathways for African countries to UHC
Given the broadness of the UHC objective and differing contextual needs across Africa, pathways to UHC are expected to differ between African countries. Examples of the different approaches taken by different countries in Africa demonstrates this reality. Rwanda, for example, has exemplified how that mandating affordable health finance and insurance mechanisms – financed by both the national government and individuals – is a crucial driver for UHC. In this arrangement community-based health insurance has been used to great effect for progress towards UHC.
In December 2018, Kenya also unveiled a grand plan for reaching UHC by 2022 by piloting UHC in four counties. Nationwide coverage is expected in 18 months. Initial results looks promising but newer challenges are being confronted in terms of mechanisms to cope with the necessary structural, administrative and fiscal adjustments.
In contrast, Nigeria’s vision to use the National Health Insurance Scheme (NHIS) as the vehicle to UHC has not been that successful, 14 years after its inception. Currently, only five per cent of Nigeria’s 196 million people are covered under the NHIS. Recent actions by the government suggest that lessons are being learned from this failure and that necessary improvements are being made. However, the recent implementation of the Basic Healthcare Provision Fund (BHCPF) to substantially increase revenue and improve Primary Health Care (PHC) services, as stipulated in the National Health Act of 2014, is a really important step forward.
There are other indications that the Nigerian Government is moving forward. They have dedicated 1 per cent of the Consolidated Revenue Funding (CRF) to healthcare and have also started state-owned health-insurance schemes. Some states are attempting mandatory health insurance, but questions remain about the feasibility for this, given the large size of Nigeria’s informal sector. Further challenges also exist for these steps to translate to tangible results for UHC. Some of these revolve around increased accountability to address the common problems of delayed transfer of funds, poor data management and the capacity of the sub-national local Government Health Authorities to manage the increased funding toward PHC.
African governments’ commitment to use evidence should be at the local, country and regional levels
The Nigeria, Rwanda and Kenya cases demonstrate there are clearly not shortages of policy options towards UHC. However, the prioritization of such policy options and the ways to implement them require context-dependent balancing act that should be grounded in the correct application of evidence to decision-making processes. Based on the messages and asks developed by HSG’s members, we are therefore calling on global leaders to commit to the use of evidence and invest in practitioners, policymakers and researchers to generate and act on evidence together. But, to ensure that the commitment of Health Policy and Systems Research (HPSR), these messages have to be interpreted and translated at the regional and country level. In order to advance UHC achievement there are number of ways that African governments can act.
Developing local, country or regional capacities for research and facilitating collaboration between researchers, communities, policymakers, and health practitioners, is fundamental to achieving UHC in Africa. It cannot be done at a removed level, whereby those at the heart of the community are neither equipped to generate and create evidence, or not involved in the conversation at all. For meaningful and effective policies and programs, they must be context specific. Collective knowledge and experiences must be at the heart of decision-making for UHC. This ensures that evidence generated is relevant and aligned with the needs of policy makers. It also guarantees a high uptake of the information into the policymaking process, leading to actions that are evidence-informed.
Although there have been recent increases in HPSR expertise, platforms and quantity of evidence-generation in Africa, there are still very few HPSR individuals and organizations. Even where these organizations exist these organizations are not well established, and not interconnected enough for the role that HPSR should play.
African governments can build their commitment by working with and investing in existing networks, such as the West African Network of Emerging Leaders (WANEL) and the HSG African Regional Networks. However, these networks are currently funded mostly through individual and bilateral funding arrangements. The chances of sustainably achieving these objectives are higher if the ownership and funding for these efforts are local or regional, for example through the ECOWAS, West African Health Organization and the African Union.
Greater investment to improve integrate evidence generation into decision-making processes and apparatus
To embed research within decision-making structures, governments and donors could coordinate staff rotations between research institutions and health ministries, departments and agencies. Such strategy sensitizes HPSR researchers to the complex processes of decision-making while at the same time exposing decision-makers to the value of HPSR to decision-making processes.
Embedding can also facilitate knowledge co-production and capacity-transfer, ultimately bringing together the two-worlds of research and policymaking. Pilot studies from Nigeria already demonstrate the feasibility of embedding strategies to facilitate evidence informed policymaking. African governments should also prioritize continued education by increasing the learning scope of HPSR within existing training programmes for public policy. Education program should be encouraged to develop courses or modules on HPSR and its application to the policy-development process.
UHC is a global priority, but the responsibility to achieve it lies primarily with governments. For African countries, multiple shifts and adaptations will be necessary. Such shifts include building individual and institutional capabilities for generating and using evidence to support value-based design and implementation of relevant system-level policy reforms for UHC. HPSR has significant role to play in guiding countries through these required adjustments.
Image: A female health worker helps a new mother with her infant in rural Kenya. © 2018 Lisa Russell, Courtesy of Photoshare