Q&A: How to achieve universal health coverage in Africa

Matshidiso Moeti, the WHO regional director for Africa
Matshidiso Moeti, the WHO regional director for Africa Copyright: WHO

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  • Despite some efforts, Africa is grappling with achieving universal health coverage
  • Good governance and adequate healthcare workers are key to achieving UHC
  • More research is needed to find creative ways of financing healthcare in Africa

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Universal health coverage (UHC) ensures that individuals and communities receive the health services they need without suffering financial hardships. UHC is about ensuring a progressive expansion of coverage of health services and financial protection as more resources become available.

Achieving universal health coverage is a critical goal that most African countries are striving to achieve. Plausible strides have been made in some cases but a number of challenges still need to be addressed.

SciDev.Net on 7 April, the World Health Day, interviewed Matshidiso Moeti, the WHO regional director for Africa, on the continent’s efforts at the provision of UHC, challenges and efforts at achieving UHC.
What are the main challenges and barriers to attaining UHC?
In 2015, global estimates of minimum per capita expenditure on health indicated that countries need at least US$86 per capita to invest in delivery of essential health services and health systems strengthening. A few African countries such as Algeria, Equatorial Guinea, Mauritius and Seychelles are spending more than this target but many other countries have not yet hit this mark.

In addition, in 2001, whilst in Abuja, Nigeria, African heads of states committed to spending at least 15 per cent of each country’s budget on health. However, many countries in the region are not meeting this target.

“Of the 50 countries globally with the number of healthcare workers below the minimum 2.3 per 1,000 population, 36 are in Africa.”

Matshidiso Moeti, WHO Regional Office for Africa

Another challenge to achieving UHC is the number of healthcare workers. More than 18 million additional healthcare workers will be needed by 2030 globally to meet the health workforce requirements of the Sustainable Development Goals (SDGs) and UHC, with gaps concentrated in low- and-middle-income countries.

Weak stewardship and regulatory capacity in Africa is a key bottleneck to the attainment of UHC because even if all the other inputs including financing and health workforce are in place but are not well coordinated, we cannot achieve the UHC goals.
Africa is the region with the least number of healthcare workers per 1,000 population. For example, of the 50 countries globally with the number of healthcare workers below the minimum 2.3 per 1,000 population, 36 are in Africa. Also, we see that the healthcare workers are not well distributed, with many of them in urban areas and few in hard-to-reach and rural areas, which undermines equitable access to health services.
Poor and disintegrated information systems also undermine UHC.
What should Africa do to achieve UHC?
All UN member states have agreed to try to achieve UHC by 2030, as part of the Sustainable Development Goals. Good governance, sound systems of procurement and supply of medicines, health technologies, and well-functioning health information systems are key to achieving UHC. A strong health system is required for achieving Universal Health Coverage.
The oversight and coordination mechanisms and instruments such as policies, plans and laws should be present and enforced to ensure they work and that health services are funded in a manner that is sustainable, equitable and efficient so that we are able to get value for money.
It also means that skilled health workers such as doctors, pharmacists, nurses, midwives, anaesthetists and more are available in adequate numbers and that people have access to essential, good quality medicines and vaccines when needed.
In addition, good quality, disaggregated data and information are necessary for achieving UHC. Good and integrated information systems are key to producing evidence which informs policy and decision-making on who is benefitting from health services, status of financial protection and areas that need strengthening.
Strong district and community health systems are important to ensuring UHC because this is the point at which implementation and service delivery happen.
There is a need to foster the value of evidence and information for decision-making.
Research is needed to find better ways of using available interventions such as antenatal care, immunisation coverage and use of bednets to reach the intended people. Moreover, more research is needed to find innovative ways to finance health in such a way that medicines will be cheap and out-of-pocket expenditure will be reduced.

How can countries raise sustainable funding to accelerate universal health coverage? 
The need to ensure greater public financing from domestic resources is critical to sustainable financing. Thus, in accordance with the Abuja target of 2001, countries are encouraged to increase their share of government spending for health to a minimum of 15 per cent.
In addition, given that for many of the countries in the region, out of pocket payments tend to provide the greatest contribution to total health expenditure, it is crucial to mobilise this money in a way that does not impoverish households. This is best done through health insurance rather than having people pay at the point of use of the health services.
With health insurance we can guarantee cross-subsidisation where the rich, the healthy and the young are able to share the burden of costs with the poor, sick and elderly respectively.  The key is to have the necessary institutional capacities and technical skills to ensure that the health insurance mechanism works for all.
The health insurance schemes should ideally cover those in the informal sector and the poor who cannot pay for the services.
Also, for countries that are reliant on external financing for health, it is important to ensure that this financing is aligned to national health priorities, is pooled together or managed in a manner that avoids duplication of efforts and minimises waste.
The ways services are purchased is critical to ensuring greater efficiency. It is critical that countries are able to define a package of essential services that can be guaranteed to all citizens irrespective of ability to pay. This should be done in a manner informed by evidence of the financial envelop available. This ensures affordability of services and prevents concerns of sustainability as a result of expenditure overrunning revenue.

“Good governance, sound systems of procurement and supply of medicines, health technologies, and well-functioning health information systems are key to achieving UHC. nec”

Matshidiso Moeti, WHO Regional Office for Africa.

It is also important to have the benefit package regularly reviewed, bearing in mind the disease patterns and resource availability.  Attention to provider payment mechanisms that prevent escalation of costs while maximising quantity and quality of outputs is critical to ensuring efficiency and equity or in greater value for money. Countries such as Ghana and Rwanda have made some strides towards this. 
Lastly, it is important to note that sustainable financing for health is dependent on good evidence. It is crucial for countries to develop evidence of what the biggest drivers of expenditure are, and whether funding mechanisms are reaching the prioritised populations and conditions.

How is the WHO addressing high out-of-pocket expenses on health in Africa?
WHO is actively working with countries to provide guidance on the amelioration of out-of-pocket expenditures through capacity building for and support for the implementation of reforms such as health insurance. In particular, we encourage countries in the process of reform to work towards including the informal sector and the poor.
We are supporting countries by building their capacity to monitor the proportion of out-of-pocket expenditure through the institutionalisation of national health accounts.
In addition we are building capacity for countries to monitor the extent and distribution of catastrophic health expenditure by different equity stratifiers such as socioeconomic status, geographical local (urban-rural), gender and education status to determine whether reforms instituted are working.

We are also working globally with the World Bank to monitor annually, the progress on UHC as part of the monitoring efforts for the SDGs.
Private healthcare is increasing in Africa while public health sector remains under-funded. How concerned is WHO about this?
Addressing this concern will take a multi-pronged approach from governments. It highlights the critical need for mechanisms for financial risk protection to be expanded in countries to ensure that those who need healthcare are able to get access it. Efforts must be made to scale up availability of health services and the quality of healthcare both in public and private sector providers.
A significant proportion of the population is accessing services from the private sector. While this is good in some ways because it augments the role of the public sector, which may be constrained in some cases, there is a need to ensure that the services provided are of good quality and are affordable, especially for the poor.
This requires strong regulatory capacity from the government for accreditation of private health services, price regulation and more. It also requires that private sector providers are included in any financial protection mechanism such as national health insurance.
The WHO recognises the important role that the private sector is playing in service delivery and is currently working on guidance for countries on effective mechanisms for engaging the private sector for achieving UHC.
Q&As are edited for length and clarity.
This piece was produced by SciDev.Net’s Sub-Saharan Africa English desk.