Pathway towards universal health coverage - block by block

When the SDGs on health highlighted universal health coverage (UHC), there was a renewed global commitment and momentum towards “health for all”.

Though more and more countries are aligned, in principle, on “leaving no one behind” health-wise, fewer countries are able to articulate what UHC means in their specific context. What is UHC – beyond the fancy cuboid framework shared on presentations? Is it universal health care or coverage: is there a difference and does the difference matter? What is included, or not? How does one determine the population or package of care suitable for their context?

Admittedly, these are weighty questions. However, the complexity deepens when we open the financing conversation. How much will it cost? Who and how to pay for it?

One of the FAH’s approach is to identify the key building blocks of UHC, ensure that these are well structured, funded and can provide valuable, practical lessons of how to “pay for UHC”. Primary healthcare, including community health, are crucial building blocks for UHC, globally.

When our team published the 10:1 return on investment case for well trained, equipped and supported CHWs in 2015, we not only demonstrated that we could save 3 million lives annually, we also demonstrated that there was an economic case for investment.

As a facilitator between the worlds' of health and finance in the public sector, we continue to frame the language to ensure that health, particularly primary and community health, is seen as both a social as well as a development agenda.

A healthy population builds a healthy economy.

The economic benefits are evident from grassroots/ community level to a national level.

·       At the community level:

1.      Reduced costs of care: CHWs increase access and utilization of services at a free or nominal costs and limits indirect costs.

2.      Value for money delivery: CHWs are a cost effective way to deliver preventive, promotive and basic curative care. Given HRH shortage, task sharing is cost efficient

3.      Cost savings throughout the system: Reduced financial barriers to access encourages earlier and regular health seeking behaviour. This reduces need to manage complications which are costly to the system. From services delivered and morbidity prevented, there are cost savings to the wider health systems

· At national level:

1.      Workforce productivity: CHWs promote prevention so fewer people get ill often and they can go to work and be productive

2.      Employment: When compensation is regularized, CHWs will contribute to increased employment and contributions to the GDP. This mainly empowers and economically engages vulnerable groups, including women and youth, reducing probabilities of radicalization and out migration .e.g. 100% of Ethiopia’s ~40,000 Health Extension Workers are women, supported by millions of other women in the Health Development Army

3.      Insurance: Prevention of epidemics and pandemics through community based surveillance will cushion from major economic losses e.g. we have great evidence of the impact of CHWs in the control of Ebola in West Africa

Despite the strong economic case for investment, at scale community health programmes in sub Saharan Africa are underfunded, with a US$2 Billion gap annually and significant fragmentation in the existent limited funds.

So why the sub optimal scaling of these effective health systems?

There are many reasons to be explored, but I will highlight just a few.

From our work, we have seen 3 broad categories of barriers to successful implementation and replication:

·       Misconceptions

·       Miscommunication

·       Missed opportunities

Misconception 1:

Community health is a new “vertical programme”:

No. In fact, community health systems are a great opportunity to integrate services by building a strong horizontal delivery platform, as part of the wider primary health system.

Misconception 2:

Community health workers should be volunteers:

No. CHWs provide a valuable contribution to the society, there needs to be an exchange of value in recognition to their contribution. Both Rwanda and Ethiopia achieved their health MDGs timely, given the contribution of their robust front line health workforce (FLHW). These workers were compensated for their time and skill.

Misconception 3:

Community health systems are “cheap”:

Why would one think a health workforce of ~15,000 in Sierra Leone, ~40,000 in Ethiopia, 45,000 in Rwanda and 60,000+ in South Africa would be cheap? The point is, rather, that they are value for money investments.

Misconception 4:

CHWs replace the need for other health workers:

CHWs are part of the continuum of care offered by a multi-disciplinary HRH team. We will still need specialized personnel to provide specialized care. One value add of CHWs is the task sharing that reduces the pressure on an already strained workforce and health system.

MISCOMMUNICATION

This mainly occurs because of the lack of an aligned language between the worlds of health and finance.

Health focuses on lives saved as an end goal while finance wants to understand the return on investment in more economic terms e.g. jobs created, contribution to the GDP etc.

Our team continues to work in this space to harmonize the language.

MISSED OPPORTUNITIES

Because of the framing of health as a social agenda, there historically has been an over reliance on donor grant funding.

There continues to be an opportunity to increase domestic resources towards health while deepening the private sector collaborations, beyond high capex/ infrastructure partnerships and exploring innovative finance for primary health.

There are several opportunities to co-invest in at scale CHW programmes with governments: from PPPs to impact bonds, blended financing to basket funds and everything in between. Our Community Health Financing Compendium explores a number of these opportunities in detail.

What other avenues can we explore to further countries progress towards UHC?