Universal Health Coverage, Is it a mirage?
By Joseph Kagiri and Malama Mwilwa
Senior Manager, Government and Public Sector, PwC Kenya | Associate - Transactions Advisory services, PwC Zambia
Introduction
Health is a critical part of the Sustainable Development Goals (SDGs). The SDG 3 targets to “achieve universal health coverage, including financial risk protection, access to quality essential health care services, and access to safe, effective, quality, and affordable essential medicines and vaccines for all,” it reflects the overall ambition of good health and well-being for all, at all ages.
Universal Health Coverage (UHC) catalyzes social inclusion, gender equality, poverty eradication, economic growth and human dignity. This inputs into SDG 1, which calls to “end poverty in all its forms everywhere”, without UHC, SDG 1 is at risk.
One of the indicators used to monitor progress towards UHC is Service Coverage Index (SCI), with countries having a value from 0 (no service coverage) to 100 (full-service coverage with all essential services).
UHC SCI is built from 14 tracer indicators, extracted from various sources and organized around four components of service coverage, which include: Reproductive, maternal, newborn, and child health (RMNCH); infectious diseases; noncommunicable diseases (NCDs); and service capacity and access.
Based on the World Health Organisation (WHO) Report, Tracking Universal Health Coverage in the WHO African Region, 2022, in 2019, the UHC SCI ranged from 28 to 75 across the 47 Member States. Of these, seven had high service coverage (index of 60 and above), 29 had a service coverage index value of between 40 and 59, and 12 had low coverage (index between 20 and 39). No country had very low coverage (index below 20).
There has been substantial progress made in the UHC SCI over the past two decades across the WHO African Region. Based on the WHO report 2021, the regional population-weighted UHC SCI was 46 in 2019, up from 24 in 2000. Thirteen countries had a UHC SCI of under 20 in 2000, with only three countries with a UHC SCI above 40 then.
The most significant progress was observed in the Eastern African subregion (24 index points), followed by the Western and Southern African subregions (23 index points). Regarding the SCI subcomponents, the infectious disease subindex saw the most improvement between 2000 and 2019 (from 6 to 48), with a noticeable acceleration in 2005 due to the rapid scale-up of HIV, tuberculosis and malaria services. This could be attributed to significant investments by governments and development partners in the fight against the three diseases.
Although Africa has seen notable improvements in health outcomes, many countries face huge unmet health needs and pressures on health systems are expected to increase. There is also an urgent need to remove remaining barriers in order to enable access to health care for all.
Key barriers to UHC progress include but not limited to:
- Poor infrastructure;
- Limited availability of basic amenities;
- Weaknesses in the design of coverage policies to limit the harmful effects of out of pocket payments particularly for the poor and those with chronic health service needs;
- Shortages and inefficient distribution of qualified health workers;
- Prohibitively expensive good quality medicines and medical products; and
Lack of access to digital health and innovative technologies and threats from emerging epidemics among others.
More needs to be done apart from health financing
Investment in Africa’s health systems is key to inclusive and sustainable growth and most African countries have integrated UHC as a goal in their national health strategies. This has led to the implementation of national health insurance schemes which are financed by mandatory deductions on the payslips of employees in the formal sector and increased government allocations in the health sector.
There is a need to ensure that the expanded domestic resource for health translates into equitable and quality health services and increased financial protection. For example, despite making hefty investments in the healthcare system, South Africa retains the highest death rate. This gives an indication that Sub-Saharan Africa is to move away from the ideology that investing more finances equates improved medical service delivery, and also pay attention to the quality of health service provided, if it is to attain UHC.
The Impact of COVID-19
The COVID-19 pandemic has subsequently led to significant disruptions in the delivery of essential health services. Rising poverty and shrinking incomes resulting from the global economic recession are likely to increase financial barriers to accessing care and financial hardship owing to out of pocket health spending for those seeking care, particularly among disadvantaged populations. The pre-COVID challenges, combined with additional difficulties arising from the pandemic, brings an even greater urgency to the quest for UHC.
Conclusion
Is it a Mirage?
Accelerating progress toward UHC in Africa is not a mirage, it is within reach, despite the financial challenges on the road to UHC and emerging pandemics, but will require political leadership and a clear strategic vision.
More than ever before, strong political commitment from world leaders and partners organizations is the essential ingredient for overcoming barriers.
The COVID-19 pandemic response has demonstrated why that commitment is so important, and why, as the world responds to and recovers from the pandemic, we must all pursue it with more determination, innovation and collaboration.
As stated by the WHO Director General, Dr. Tedros Adhanom Ghebreyesus in his opening remarks at the Special Session of the World Health Assembly on 29 November 2021, “The COVID-19 pandemic is a powerful demonstration that health is not a luxury, but a human right; not a cost, but an investment; not simply an outcome of development, but the foundation of social, economic and political stability and security.” Strengthening health systems based on strong primary health care is pivotal to building back better and accelerating progress towards UHC and health security.
Some possible approaches that could aid the attainment of UHC include:
- Implementing a phased approach that makes primary health care and laboratory services universally accessible before making other levels of health care accessible. This would allow for lessons to be learnt and measures taken to improve any weaknesses at one phase before expanding the programme to another phase.
- Prevention and control of communicable diseases and non-communicable diseases taking center stage by implementing health programmes to eradicate the diseases.
- Promoting Public Private Partnerships (PPP) to promote the development of health infrastructure and training institutions. This will facilitate the growth of infrastructure while taking advantage of the efficiencies of the private sector.
- Enhancing preparedness for future pandemics so that the gains achieved in building health systems are not eroded.
With the lessons learnt from the Covid-19 Pandemic, the importance of improving accessibility of universal health care so that the gains achieved in building health systems are not eroded cannot be overstated.
