UHC Forward: Towards Universal Health Coverage

There is no doubt in my mind that there is real momentum today in the quest for universal health coverage in Africa. Health financing has become a priority topic for discussion at the international and national levels, sometimes even catapulting onto the agenda for campaigning presidential candidates. It has not always been so. One tangible manifestation of this new and timely interest in health financing is the vibrant and growing communities of practice (CoP) spawned by Harmonization for Health in Africa.

As the facilitator for the Financial Access to Health Services CoP (FAHS CoP), I am becoming increasingly aware of the responsibility we share in making the most of this newfound interest – which may prove fleeting – to capitalize on the myriad initiatives underway to improve health financing and to ensure (1) that they actually translate into real gains toward universal health coverage, and (2) efficiency and equity. This is a tall order.

With the increased attention, comes ideology, and the international health care financing debate has grown heated and sometimes polarized (free care versus insurance, for example). New actors (such as Amnesty International) have joined the scene no longer reserved for health economists, ruffling some feathers with new language and ideas (eg health care as a human right). At the country level, political leadership on health care financing is proving a double-edged sword; on the one hand providing unprecedented opportunities for reform (eg pledges to remove fees overnight for deliveries), and on the other creating a slew of problems overnight for technical implementers (eg whose health facilities may operate on cost recovery and whose staff is likely inadequate to meet a spike in demand).

In this strange context of simultaneous opportunity and danger for health systems, a multitude of strategies to improve financial access to health are being planned, implemented, studied and supported by NGOs, multilateral agencies, and development projects; usually with some coordination at the national level, but more often at a decentralized level, and in some cases rather unilaterally. What is it all adding up to? Are we making any real progress toward universal health coverage?

Policy makers, front-line health providers, researchers, economists, and maternal health experts from 10 African countries gathered for three days in Bamako November 17-19 at the first technical workshop of the FAHS CoP to exchange in-depth their experiences on one specific in health care financing – the benefits package for the rapidly spreading maternal health fee exemptions. If the lessons about their formulation and implementation are becoming fairly clear (cite docs), how to ensure that their financing and results are sustainable is ambiguous at best. The workshop posed some serious questions that CoP members will seek to answer together as we move ahead. How can national level technicians effectively interfacing with political leaders to inform and then prepare reforms? How do we make sure providers are not only adequately motivated, but also engaged in decisions about health care financing? Can we really afford to make priority services free for everyone, even those who are able to pay?

But for me, one overarching question remains a top priority. Given that there are a number of potentially powerful health care financing mechanisms - fee exemptions, insurance, solidarity funds, and performance-based financing just to cite a few – that most countries are experimenting with (in an uncoordinated way), how do we link them for maximum impact, coverage, and sustainability? Most countries will need to use multiple such financing mechanisms to attain universal health coverage, so it is high time we begin the challenging but necessary process of putting the health care financing puzzle together so that the resources available are used in the most efficient, effective, and equitable way possible, and according to coordinated national health care financing strategies that go beyond 2015.