Bruno Meessen


In this blog post, Bruno Meessen (ITM, Antwerp) revisits the gaps in the implementation of fee exemption policies in numerous African countries. He attempts to draw useful lessons for the universal health coverage agenda, for African governments, the international community and researchers. 


In 2009, at the request of UNICEF, I was fortunate to be able to coordinate a study on fee exemption policies in 6 African countries. The results were published in a supplement of Health Policy & Planning, alongside other articles on the same topic. Our multi-country study had relatively modest ambitions: we were not trying to document the impact of these policies, but rather try to understand to what extent their formulation and implementation were based on good public policy practices. Overall, our evaluation was not very positive. While the study confirmed the good intentions of country leaders to take strong measure to reduce financial barriers, it highlighted the precipitous manner in which such measures were put in place without adequate preparation (in terms of time, financing, accompanying measures, and technical expertise) for national technicians to ensure that these policies were well conceived and well implemented. We expressed concern about the consequences these weaknesses would have on the policies’ efficacy and sustainability.

This study had at least one tangible effect: it made it clear that a lot of work remained to be done in terms of sharing and spreading knowledge regarding the implementation of health financing policies. At the dissemination meeting for the study in New York, the idea for creating a community of practice around fee exemption policies was launched. In due time, the Financial Access to Health Services CoP was launched. You are likely already familiar with its work if you follow this blog.

Implementation of fee exemption policies: what we know in 2013

The topic of formulating and implementing fee exemption policies has been relatively intensely researched in the past few years. This is not only the case for the FAHS CoP as a group (note the Bamako CoP workshop in 2011, but also a forthcoming conference in Ouagadougou in November 2013), but also for several teams of researchers.  Let me specifically mention recent studies by Valéry Ridde (University of Montréal) and Sophie Witter (University of Aberdeen), two prolific authors whose work also contributed to the multi-country study.

In a very recent edition of Afrique Contemporaine (in French), the results of a mixed method research led by Jean-Pierre Olivier de Sardan and Valéry Ridde were published. The supplement reports on the different observations made by research teams, notably LASDEL, on fee exemption policies in Burkina Faso, Mali, and Niger. Several noteworthy articles include one on the perceptions of various actors in Mali, a mapping of fee exemption policies in West Africa (showing that all countries have them), and a study from Niger investigating the problem of decapitalization in health centers.

The introductory synthesis is entitled “Fee exemptions in Burkina Faso, Mali and Niger: public policy contradictions.” This title reflects the overall tone of the supplement. Here is an excerpt.

Fee exemptions are decisions taken at a national level, defended as sovereign, and implemented by national technicians without any particular external assistance, something rather rare in the history of health policy. But these reforms have been made hastily. The decision has been political rather than technical, announced suddenly and publically, taking not only field technicians but also those in the Ministry completely by surprise. 
                                                                                                                                               (Olivier de Sardan & Ridde 2012 - our translation)

A few months earlier, Valéry Ridde, Ludovic Queuille and Yamba Kafando had just finished the final report of their project, “Capitalizing fee exemption policies for health services in West Africa.” This project is worth mentioning for several reasons: beyond the knowledge that it generated, it had the merit of being based on country experts (Ministry of Health professionals, researchers, and NGO experts involved in fee exemption programs). The transversal study centered on 7 countries (Benin, Burkina Faso, Ghana, Mali, Niger, Sénégal et Togo ). It also focused on implementation. 

The book’s tone is more positive than the supplement cited above. The synthesis chapter, which is also available in English, identifies for six of the countries studied, the major problems encountered during implementation but also the innovations. An excerpt:

"While the principles underlying these policies appear to be well appreciated, health workers did not hide their dissatisfaction regarding the policies’ implementation. In Burkina Faso, they complained of a lack of medical and technical supplies, while in Senegal and Niger the complaints were regarding significant delays in reimbursement of free services provided to patients. Finally, in most cases, workers were calling for financial bonuses to compensate for increases in their clinical or administrative activities resulting from user fees exemption policies. These financial aspects of bonuses for health workers were not taken into account in any of the policies."
                                                                                                             (Ridde et al. 2012)

Elsewhere in 2012, Sophie Witter published a study on the fee exemption policy for Caesarean sections and for children under five years old in Sudan, a country little documented in international health. Her study once again highlights major weaknesses in implementation.

"The fee exemption policy for Caesarean sections and for children under five years old, launched in 2008, clearly suffered from a number of constraints that led to uneven and often poor implementation. Notable among these constraints is a lack of adequate financing and clear implementation guidelines."   
                                                                                                                                                                                                      (Witter et al 2012)

Let me make four comments before giving my own read of the situation. First, one can observe that the general tone of these studies on fee exemptions remains relatively positive. Neither the authors of these studies nor I intend to discredit these national policies. Second, these studies show that there is a certain heterogeneity in countries’ experiences: countries that have had better implementation than others have shown some good results. Third, when one identifies weaknesses in either formulation or implementation, one should not write those policies off entirely. We know that certain policies that have begun badly have later been reformed to better reach the most vulnerable. The example of Burundi – which combined its fee exemptions with its performance-based financing program– is the best known case. Fourth, it appears that countries having launched their fee exemption programs later have been able to benefit from recommendations to better prepare for the policy. This is certainly the case of Sierra Leone, even though challenges remain. 

All of that said, here we are all the same with a sample of 11 documented country experiences telling the same story: fee exemption policies in Africa over the last 10 years have been public policies launched on presidential initiative, using national resources, but formulated in haste without adequately and rigorously taking into account technical and operational considerations. Those that are under-financed are nonetheless in danger. 

 What has changed at the country level

It is important to note that these policies have marked renewed initiative among African presidents and governments to re-engage in the health sector. In a number of countries, other than health personnel salaries, the State had basically been absent in the health sector for two decades; cost recovery, the rise of the private health sector, and international assistance having left the impression that health financing could manage without public funding (well, it is also true that, to put it bluntly, State coffers were empty).

Today we are coming full circle: user fees – which will likely continue to play a role despite wide criticism – have shown their limitations; the rise of the private health sector in many countries has been poorly regulated by the State, and the global financial crisis in wealthy countries hardly paints a hopeful picture for international assistance.  But more fundamentally, economic growth is creating new financing possibilities within public budgets across the continent.  

We must, however, ensure that this re-engagement by national leaders happens in the most productive way possible, with budgets matching not only declarations, but technical rigor and long-term vision. It should be possible to build on the pledges made jointly by health and finance Ministers in Tunis in July 2012. We can also make the most of the international interest and support for Universal Health Coverage. But to build the future, we must not forget lessons from recent experience. 

Two reflections for the political agenda for UHC

A first lesson is for the ears of political leaders (if they read us!): remember that haste is a resource to use with caution when it comes to health financing. Leadership and boosts in momentum are welcome, but should not compromise the initiative itself, nor all of the health system strengthening efforts that have preceded it. UHC won’t be built on a few announcements, but through perseverance.

The lack of dialogue that accompanies political precipitation breeds unnecessary antagonism. It would be a shame for those who work tirelessly to strengthen health systems – whether they are frontline workers, implementers at the regional or national level or advisors – to become a force of opposition to UHC. The lively debate within the PBF CoP after the UN General Assembly’s resolution on UHC reflect this reality.  

There is also a lesson there for international actors advocating for UHC. It is perhaps the time to re-evaluate the relative effort you are putting into advocacy versus actual technical assistance.  Our impression is that advocacy predominates when it comes to UHC: while Twitter is buzzing, people are mobilizing in Beijing, and at the UN they are promoting UHC, the aid community is providing precious little support to UHC on the ground. We should thus not be surprised as presidents are getting on the bandwagon and the political machine is activated that they “put the cart before the horse.”

Focusing exclusively on advocacy for UHC makes sense maybe for middle-income countries – they have the financial resources and technical capacity in line with such ambitions. But in poor countries, advocacy alone is problematic. And yet it is virtually impossible to compartmentalize the world when it comes to advocacy, messages pass far and wide. 

You get my point: we are arguing for an approach with a much more context specific analysis of the challenges many African countries are facing, especially those where governance is still being strengthened. We are not, however, advocating for some super-agency for UHC; that model is outdated. We are convinced that appropriate assistance should be based on a more collaborative model that builds on the growing expertise present on the continent, such as HHA has promoted and is being implemented through communities of practice. We would be happy to see more collaboration and support, especially from the UHC flag-bearing institutions.

Ideas for researchers

Our third point addresses researchers. Thanks to your hard work, we know much more about the last ten years’ experience with fee exemptions in Africa. Of course, many questions remain, but it seems fair to say that at least in terms of retrospective studies on the formulation and implementation of country fee exemption policies, we are reaching a data saturation point. 

For some observers, these fee exemption policies are just a step on the path toward UHC. Shouldn’t that point to another research topic: how have these policies evolved and are they in-line with UHC objectives; are they actually an effective starting point on the road to UHC?  

I see at least two possible directions.

It would be interesting to pull together knowledge on the policy process, especially on the dialogue between the political and technical levels. Are they eventually able to transcend their initial lack of dialogue? Have presidents drawn lessons about the importance of this dialogue? Or on the contrary, are the same errors being repeated? If the same problems persist, what are the determinants of such political haste? What options exist for actors wishing to improve these processes? What are the lessons for the next phases toward UHC?  

We can also identify the stakes when it comes to policy design. Researchers really need to help us all reflect on how these fee exemption initiatives – often multiple in the same country - relate to other financing schemes to form a coherent strategy that provides health coverage to all. In many countries, there is a complex mix of coverage schemes: public financing (traditional or PBF), health insurance for civil servants, mutuelles for those in the informal sector, and various fee exemptions for different population groups, age ranges, health problems, and even treatment regimen! For reasons of efficiency, equity, not to mention limited available resources, it becomes critical to better harmonize health financing schemes. We could begin by documenting the situation at the country level and by identifying some potential solutions.  Can any of you help countries in this way? It will certainly be a top priority for the CoPs in 2013.

Translation: Allison Kelley

On December 12th, a resolution called “Global health and foreign policy” was voted at the United Nations. This declaration, whose main focus is universal health coverage (UHC), triggered a debate on the online discussion forum of the Performance-Based Financing Community of Practice. Most of the discussion focused on the usefulness of such resolutions. Several members are concerned about the possible negative impact in low-income countries. This blog post summarizes the main points of the discussion. 

Collection, editing, titling and introduction: Emmanuel Ngabire, February 4th 2013.


The UN UHC resolution: yet more havoc in low-income countries to be expected...?

The debate was launched on December 13 2012 by Alex Hakuzimana, from Rwanda, when he forwarded a UHC Forward message entitled “U.N. votes in favor of universal health coverage resolution” to the PBF CoP. Exchanges followed each other up very rapidly - by the end of the 1st day of the debate we already counted 12 interventions. Overall, the discussion was constructive, and if occasionally a more offensive style was used, other participants (or the CoP facilitator) tried to refocus the debate in a gentle but firm way. In a very measured response, for example, towards the end of the discussion, Jurien Toonen acknowledged that having this “PBF & UHC” discussion was very valuable, as this is what the CoP is all about. Yet, he also emphasized that the discussion could be even more useful if some structure was brought to it, avoiding a mix up of roles and mandates in the discussion– between international organizations, policy makers in LMIC, implementers, academics and beneficiaries. Surely something to consider in future CoP discussions. But first things first. Who really got the discussion going? Well, Robert Soeters (from SINA Health International) was the first to react to Alex’ forwarded mail – so credit goes to him for triggering the discussion.  Pointedly, he noted that ambitious declarations are all very nice and wonderful but their problem is that they typically do not clarify who will bear the financial responsibilities for all these lofty aims – i.e. “who will pay the bill” - nor do they look at the cost-effectiveness and sustainability issue. He further stressed the risk that populist politicians may confound UHC with free healthcare and launch rather populist policies based on the declaration, the way it happened with Burundi’s pre-payment system, “Carte d’Assistance Maladie” (CAM). In resource-poor settings (like low and middle-income countries), a PBF mechanism can boost cost effectiveness

The issue of “who will pay” was reiterated by different CoP members who also noted that we have seen similar lofty international and national statements and declarations before (like Alma Ata (Health for All) or the Abuja Declaration). In their interventions, not all discussion participants made a clear distinction between UHC and universal health care, not unlike what happens in the general UHC debate.

Laurent Musango from WHO AFRO then intervened to bring attention to the entire health system: changes in one health system component can and do affect other components in different ways, he argued. So the discussion shouldn’t only focus on health financing, but should also take into account other health system components, and preferably so in a synergic manner. With the new declaration, the direction of health systems is clear, though: Universal Health Coverage. Along the same lines, Pascal Birindabagabo added that the UHC momentum should be supported. He also proposed that middle-income and developing countries should mobilize domestic funds to support UHC in their countries.

… or a crucial means to keep governments accountable?

The risk that the UHC declaration remains just a set of fancy words without much operational significance was also recognized by Joseph Kutzin from WHO Geneva. However, he strongly emphasized the importance of such resolutions. His experience has taught him that resolutions like these are tools that civil society organizations can use to hold countries accountable for their commitments. It’s a gentle “stick” to align country decision makers’ actions with the declaration. After highlighting the added value of such UN resolution, Joe also clarified the meaning of UHC as conceived in the World Health Report 2010. In the report, WHO did not say that UHC means “everything for everyone, free of charge”. The definition WHO uses means instead that everyone gets the services that they need, of good quality, and at cost that doesn’t impoverish them. If you operationalize this concept, Joe continued, it’s clear that UHC should be understood as a direction rather than a destination. No country - not even the richest one - is able to fully close the gap between the need for and use of services, but all countries want to reduce that gap, to improve quality and improve financial protection. Context-specific policy measures addressing the health and development priorities of a given country then become possible.

Joe acknowledged PBF has obvious appeal for him as he sees strong potential links between the PBF approach and a core message on health financing for UHC: the need for a coordinated approach to policy rather than single-instrument “magic bullets”. PBF is a means for system building through coordinated policy action. The Burundi experience of linking PBF to free care was a case in point, he argues, as it’s an example of coordinated policy.

Do such lofty resolutions really take our reality into account?

According to Longin Gashubije from the ministry of health in Burundi, UN delegations who promote these declarations in New York tend to live far from the reality on the ground in low-income countries. Since Alma Ata, UHC has been dreamed of but unfortunately not reached in countries like Burundi. This is due to various reasons including repeated wars, expectations which were set too high, weak economic growth, lack of societal and cultural progress etc. All these factors can explain the failure to reach the previous declarations on UHC. To these root causes, Mohammad Muhammad from Nigeria added another factor, corruption. He called on African leaders to open their eyes: they need to realize that UHC is not realistic in corruption-prone countries characterized by a myriad of developmental needs and scarce resources.  Longin also argued that today the financial gap is far too big (more than 50% of the government budget), and as two thirds of the people live below the poverty line, government priorities can’t be too ambitious in countries like Burundi and should focus on the poor’s needs first of all. Obviously, the health financing burden is too heavy for the government, and Burundi’s partners will have to step in, he continued. But external resources can’t solve everything. Cultural progress is at least as important, he concluded.

Seize the global window of opportunity, promote good practices

Bruno Meessen from the Institute of Tropical Medicine at Antwerp then chipped in. In his opinion, the UHC resolution goes in the right direction as it opens the window of opportunity even further for the CoP members who develop better health care financing systems at country level. Bruno also advised CoP members to read again carefully the WHO Report 2010 as it clearly stresses the need to find mechanisms to be more efficient with resources. Hence, PBF can and should capitalize on the current UHC momentum, even more so now that the world is increasingly moving away from simple “blue prints”. The complexity of UHC and the need for context-specific approaches are more and more acknowledged nowadays. Furthermore, Bruno reminded people that the declaration is not just relevant to Africa but also to middle-income countries, where UHC has gained momentum recently in countries as diverse as China and Mexico. UHC is even relevant for high-income countries like the US (“Obamacare”), so it’s very much a Universal Declaration. Like many other economists, Bruno also hopes that in a not too distant future, the fiscal space for UHC will  increase in many African countries. Soon, ministries of finance might invest national resources and increased revenue more in innovative schemes like PBF, he argued. Nevertheless, he agreed that in many African countries we need more than just nice words. In this respect, he also referred to the perspective of the AIDS movement, which is apparently also not very happy with the declaration, as the declaration’s section on “sustainable financing mechanisms for universal health coverage” fails to mention international health financing.  Many AIDS advocates ((like Gorik Ooms)  call instead for a mechanism enforcing structural transfers from rich countries to poor countries, from a right to health perspective.

Robert Soeters made a second intervention on December 14th pointing out the consequences of - what he called - the “sweeping generalized statements” of these declarations. Country realities differ in terms of resources, organization and culture, yet, lofty declarations often inspire Ministries of Health or Presidencies to ignore this reality. Robert emphasized that this may then create opportunities for populist decisions that can destroy the quality of existing health services. He gave the example of Burundi where the CAM pre-payment system was promoted and “conceptually endorsed by WHO” without defining how to finance it. The predictable result was the degradation of health facilities and reference to extremely expensive private services.

On the responsibilities of those setting the agenda at global level (and WHO in particular)

In his opinion, advocates of UHC should develop more realistic and responsible proposals adapted to the context of low- and middle-income countries. Efficiency also matters, Robert argued, and there he called on international organizations such as the WHO to also consider PBF as this approach has increased the motivation of many people in low-income countries. Alluding to 2011 skeptical articles in the WHO Bulletin and a recent Cochrane Review (which basically concluded “we need more evidence”) he stressed that criticism of PBF without coming up with good alternatives on how to finance quality health services is rather irresponsible – in fact, it can lead to situations like in Zanzibar MoH, where, despite quite some initial enthusiasm about PBF, they are now in a health policy limbo as they were told to doubt PBF given recent literature on the approach. Dr. Soeters encourages debate about social aims in the PBF CoP, but only if necessary nuance on cost, efficiency and sustainability is foreseen. In his opinion, for example, the sustainability of health systems requires that they cannot be simply financed by external aid agencies in LICs.

In a second intervention, Joseph Kutzin then explained that UN resolutions by their very nature cannot contain details like sources of funds. They are inevitably a compromise and can’t be very specific, that’s the price you pay for broad support. So it’s important to have realistic expectations about what can come from a UN resolution. The resolution is a sign of growing political support for Universal Coverage, Joe said. These declarations do not provide details but, they are nice instruments to hold governments accountable and they can be more powerful when picked up by – national and/or international - civil society groups.

Joe also rebutted some of the claims Robert Soeters made about so called “WHO positions”. Unlike what Dr Soeters implied in his intervention, WHO did not “conceptually endorse” Burundi’s CAM, as this is a voluntary health insurance arrangement. Both the WHR 2010 and Kutzin’s recent article in the Bulletin made it abundantly clear that voluntary health insurance is not a viable path to universal coverage.

According to Joe, Robert also suggested WHO is not very interested in efficiency. In response, Kutzin referred to the World Health Report 2010 where a whole section (“more health for the money”) focused on efficiency. He also referred to his recent Bulletin article in which he also argued that you can’t simply “spend your way to universal coverage”; costs have to be managed and addressing the leading causes of inefficiency need to be priority targets for reform.

A good dialogue requires a common platform but also an understanding of our respective roles

The debate continued with a contribution from Bruno Meessen connecting the positions of decision-makers and technicians. He reminded CoP members that getting the voices of practitioners and implementers heard is a major concern of (and in fact one of the rationales behind) the PBF CoP. He acknowledged the frustration caused by inappropriately designed and underfunded policies and mentioned that too often country leaders fail to listen to their technicians. He highlighted that nevertheless, political leaders willing to introduce UHC should be fully supported as they can mobilize their citizens. So PBF proponents need to surf on the current UHC wave. Also, bridges with decision makers need to be built so that technicians will be heard in time and mistakes prevented. He believes one day the CoP – intended as a platform to bring together agenda setters, policy makers and implementers – will ensure such a relationship of trust. Having said that, for the moment the emphasis of the UHC movement is too much on agenda setting, Bruno continued. It’s time to match this with an equal effort to address the stages of policy formulation and implementation: the ones in charge of formulation and implementation also need to be supported and properly resourced.

Jurien Toonen (KIT, Amsterdam) then highlighted the need to bring some structure to the discussion, and avoid a mix up of roles and mandates in the discussion on health financing and providing care and social protection, between international organizations, policy makers in LMICs, implementers, academics, advocates and beneficiaries. He elaborated on the role and mandate of each of these actors. International organizations have a role in developing a vision and strategies to bring coherence to different types of health strategies. Alma Ata, Investing in Health (World Development Report 93), the MDG for Health,… all provided impetus, even if they all had flaws. Now, perhaps one might think UHC is “the world’s new flavour of the week”, but it is because the world has learned something: UHC is more health system-wide than its predecessors, and pays more attention to the most vulnerable people. Or as Tim Evans put it in Bangkok: UHC’s starting point is “the unbearable injustice that too many have no access to health care”. Anyway, there’s no need to blame international organizations (and certainly not WHO) for providing vision, Jurien argues. As for policy makers in LMICs, they have chosen to embark on UHC, even if they live in countries not comparable to China and the US. They might struggle to make it happen, but the good news is that they are finally more able to get the Ministry of Finance interested in health care because of UHC. Unfortunately, the Ministry of Finance people often think, wrongly, that UHC is like free health care or health insurance, but things are improving. In many countries, a dialogue is starting on sound health financing – stakeholders are trying to find the right mix between different health financing instruments (tax-based and other ones). Implementers will suffer the most, Jurien argued, if design issues are not well addressed. PBF also suffers from design and implementation issues in several places, and they need to be overcome. There’s also no need to blame the academics, Jurien continued. Academics are there to provide evidence if PBF works, and if it works, why, how and where it works. The same is true for UHC by the way. Support for either PBF or UHC should thus be based on evidence, and this evidence should be challenged by implementers, strategists and other academics. Instead of lamenting a Cochrane review because it comes to the conclusion that evidence on PBF is thin, we need to take up the glove and make evidence strong, Jurien argued. Even if you know that things “work”, evidence is necessary to prove it. He reminded CoP members that research can support successful implementation like in Thailand, where implementing UHC was much underpinned by academic work. As for the advocates then, they should do what they do best: communicate, bring up discussions, even in a provocative way, make people think and react. But as advocates, they have limitations, just like the other actors do. Finally, UHC is all about the beneficiaries, “the man and woman under the baobab”, as Jurien called them, and their health status. That group, their interests, should be the starting point for the discussions.

An illustration of UHC and some clarifications on the CAM in Burundi

In other interventions, debaters clarified the concept of UHC further (Bruno Meessen, Gyuri Fritsche, referring to a field visit to Mayo-Ine Health Centre in Adamawa State in Nigeria, “This is what UHC is about: to find customized solutions to get more people accessing services, and to have metrics to prove it”, …). More clarification was also provided on the health insurance scheme in Burundi (by Olivier Basenya, Longin Gashubije, Bruno Meessen). Olivier underlined that CAM is a health assistance system rather than health insurance and he explained steps undertaken since its introduction in 1984 to improve its efficiency towards UHC.

Conclusion

After a wide-ranging and generally respectful discussion, it emerges that the UN resolution provides an opportunity for civil society organizations to put decision makers under pressure and hold them accountable. In addition, UHC provides an obvious opportunity for PBF proponents too, if we think strategically. Jurien Toonen summarized the window of opportunity like this, for example: “If we want to head for UHC, we will need health services that perform well, hence PBF”. Some challenges to implementing this declaration were also pointed out, however. Debaters mentioned the distance to the reality on the ground, endless wars, unrealistic expectations, cultural issues, inadequate (both domestic and international) financing, corruption etc. Nevertheless, one can hope that fiscal space for UHC in African countries will improve in a not too distant future. Finally, the discussion also emphasized the role of research in supporting implementation and providing more evidence on what works, how and why.

The debate was suspended on December 17, 2012 when the CoP was informed of the death of Guylain Kilenga who was participating in a PBF training course at Bujumbura. RIP.

From 24th to 27th September 2012 , the Financial Access to Health Services Community of Practice co-organized, with Ministry of Health of Morocco and JLN, a workshop entitled "Equity in Universal Health Coverage: How to reach the poorest" in Marrakesh, Morocco. The workshop gathered policy makers, scheme managers, agency representatives, scholars and members of parliament. At the end of the workshop, a declaration was issued. The declaration engages participants, not the agencies or governments they work for. It marks their personal commitment to work for better access to health services for the poorest in Africa. You also can adhere to the Declaration on our facebook page. Join the movement and make your own personal commitment, even the most modest one.


We, as participants of the workshop on “Equity in UHC: How to reach the poorest”,
We as members of the communities of practice affiliated to “Harmonization for Health in Africa”,
We as experts involved in health systems in Africa,

Are conscious of the deep inequalities in terms of access to health care in our countries,
Are conscious of the impact of these inequalities on the health of the poorest,
Are conscious that access to health care for the poorest is dependent on our health systems,
Are conscious that assisting the indigents, the excluded, the poorest of the poor is inscribed in our shared human dignity.

We are enthusiastic about the growing interest of the African States and their partners in their efforts to improve universal health coverage.
We consider essential that this interest be translated as rapidly as possible into actions and concrete measures in order to benefit the poorest.

Consequently, we commit to taking action personally:
By supporting the implementation of strategies to improve access to health care for the poor.
By building on and accompanying the mechanisms to extend universal health coverage.
Finally, by continuing to focus all our energy on facilitating equitable access to health care in our countries.

Issued in Marrakesh, Morocco, September 27th 2012.

By Richard Alia

In this blog post, Richard Alia (from the Great Lakes Initiative on AIDS, Kigali, Rwanda) reports on the recent conference on Social Health Protection in Kigali. He is worried that the goal of Universal Health Coverage may not be achieved in the near future in the East Africa Region due to weak health systems, poor road infrastructure and lack or high cost of transport to the care and treatment centers for the rural population. Besides, health expenditure is escalating and technology is one of the major reasons.


Social health protection (SHP) is critical to human welfare and sustained economic development. It also contributes to global peace and security. Yet in some countries up to 11% of the population suffers from catastrophic medical expenses each year and up to 5% is forced into poverty. In 2005, the World Health Assembly resolved that everyone should have access to health services without having to suffer from financial hardship in the process. This was reinforced by the 2010 World Health Report, Health Systems Financing: the Path to Universal Coverage; and further, by a 2011 World Health Assembly resolution, Sustainable Health Financing Structures and Universal Health Coverage (UHC).  

Regional Conference on SHP in East African Community

A 2-day conference on SHP in the East African Community (EAC) was held in Kigali, Rwanda from September 11-13, 2012. It focused on the efforts of EAC countries to provide SHP to their respective populations and their achievements and challenges. The event also provided recommendations on how to effectively support the development and harmonization of SHP and SHP mechanisms in the EAC region.

The overall objective of the  conference  was to highlight  various  approaches for the development and implementation of  comprehensive  and equitable  SHP systems  for  the EAC and to recommend  policy options in developing regional mechanisms  aimed at building  a strong and harmonized system of SHP. Specifically, the conference contributed to the ongoing evidence-based approach of the EAC to meet SHP needs of its population, as the region strives towards UHC and access to health services. Consultations were also made on effective harmonized implementation of SHP and how to collaborate towards a stronger regional system of SHP.

The Conference targeted key stakeholders of SHP in Burundi, Kenya, Rwanda, Tanzania and Uganda. This included government policy makers from health and health related ministries, EAC officials and national authorities, SHP/health insurance organizations, representatives of health care providers, civil society organizations, Community of Practice members, academic institutions and development partners.

Key note speeches were delivered by guest speakers , including Joe Kutzin (WHO – Geneva), Jean Olivier Schmidt (GIZ), Richard Sezibera (SG of EAC), Claude Sekabaraga (World Bank), Lydia Dsane-Selby (Ghana National Health Authority),  and Jens Holst (EU). In addition, representatives from the EAC countries shared experiences from their respective countries. Ministers of Health from the EAC countries also held a closed-door discussion and produced a Ministerial Statement on SHP/UHC in the EAC Region.

Some of the key observations made on SHP/UHC during this conference.

Everybody agreed that the main goal of SHP/UHC is to improve health outcomes, productivity hence economic development. Kutzin emphasized that UHC is not a new concept but emerged in particular after World War II where Europe began pushing for social cohesion, Japan for a concept of human security; and the WHO Alma Ata conference coined the slogan of Health for All by the Year 2000.

Participants agreed that UHC is a destination, it might take a bit of time to get there, but every country must aim at the same goal although they might be at various levels/stages at any one time. The pillars of UHC are: Access, Quality, and Financial Protection, but even developed countries cannot meet these objectives all at once. The situation is worse in developing countries. However, UHC is a journey that all the EAC countries are already on; this must be commended.

It was clear from this conference that SHP is a pre-requisite for UHC  and that quality of services is part and parcel of SHP/UHC.  There is a relationship between financing and the quality of health care services. Community Based Health Insurance and Performance Based Financing play key roles here.

Some of the requirements for SHP/UHC are: vision, leadership/strong governance and legal framework; there is a need for a whole health system approach going beyond health financing e.g. capacity building for human resources for health and service infrastructure development. For instance, the success of Thailand with UHC was built on long term programmes including capacity building and service infrastructure development.

Overall assessment of the conference

This was a good conference in the sense that it brought together policy makers and key stakeholders from the same region to discuss the roadmap to SHP/UHC. By identifying key strengths, opportunities, and weaknesses in this region together and finding ways of utilizing or mitigating them accordingly, a great job was done. Besides, by involving the development partners in the EAC region such as GIZ, WHO, USAID, Clinton Foundation, MSH, and BTC, a clear message was sent that the journey of SHP/UHC is a joint venture.

One of the objectives of the conference was to make progress towards harmonization of some strategies in the EAC region. However, as it was clear from the conference experiences of EAC Member States in providing SHP vary: some have well established compulsory, publicly managed, health insurance programs with substantial transfers from general budget revenues; some governments also fund services, often directly through the supply side, but others also use PBF methods; and some even have robust private health insurance markets. These differences highlighted the fact that the specific path towards SHP/UHC differs from country to country; hence there is no single best solution that applies to all of them. However, best practices and lessons learned during the implementation processes are important to be shared in order to improve EAC systems for SHP to meet each country’s specific needs, but also to enhance harmonization across the region. According to Jens Holst who shared the experience of harmonization of SHP in the European Union, harmonization can take place without having the same system. Therefore, harmonization of SHP strategies within the EAC Region is feasible.  

Another challenge that the EAC faces in its journey towards SHP/UHC is the status of its health systems. As mentioned above, UHC is not just a health financing issue. My worry is that given the fact that the health systems in this region are still weak – as evidenced by poor infrastructure, lack of human resources, and frequent lack of drugs and other health commodities in most health facilities - and the fact that the costs of healthcare are escalating due to new technology, achieving SHP/UHC objectives is still a long way to go.  In addition, poor road infrastructure and lack or cost of transport in the rural areas will still be a challenge to accessing health care by the poor. Nevertheless, it was agreed during this conference that a situation analysis and feasibility studies be conducted in the EAC countries to establish the status of SHP/UHC in each country and thereafter plan the strategies for harmonization of approaches of SHP/UHC in the East Africa Sub Region.

As for the ways forward, country cases of course inspired much of the discussion in Kigali. The cases of Rwanda which combined community based health insurance and PBF or Burundi which linked PBF to selective free health care got their fair share of attention. However, complementary schemes such as conditional cash transfers, cash refunds, voucher cards, strengthening community health systems,  scaling up outreach services, etc. should be considered if we are to reach the poorest. Nevertheless, all conference participants agreed that UHC does not mean everything is free for everyone, everywhere, and all the time.