In Africa and elsewhere, many countries have embarked on the UHC journey. It is now clear that there is not one single path to progress towards UHC, but rather several possible pathways. It is up to each country to find its own path. This implies at least one universal guiding principle: the need for the government, and the ministries in charge of UHC in particular, to develop a national capacity to (1) collect information useful for UHC, (2) interpret it and (3) make decisions accordingly. These are the three main characteristics of a learning process.
At the initiative of the Financial Access to Health Services and Performance Based Financing Communities of Practice (CoP), and with the support of France (French Muskoka Fund and P4H), 11 delegations from Francophone African countries gathered at the National School of Public Health in Rabat, Morocco, end of 2014. The objective was to develop a methodology to measure, in a participatory way, the extent to which a particular country has a systemic learning capacity for UHC. To this end, it was agreed that the delegations should be composed of officials from the ministries involved in UHC as well as researchers.
The methodological proposal developed by the workshop participants is based on three main ideas.
The first one is that it is possible to identify a "UHC system" in each country, i.e. a set of actors (ministries, insurance funds, partners, academic institutions, etc.) involved in the implementation of the UHC agenda. To assess the reality of a learning system, it is the ideas, daily behavior and practices of these actors that need to be studied.
The second idea is that it is possible to measure to what extent this "UHC system" meets the criteria of a learning system by building on the previous work of researchers specialized in the study of learning organizations. We conducted a review of the literature (to be published soon) and identified the framework developed by David Garvin of the Harvard Business School as the best reference for our own study object. We also retained his empirical strategy: to ask the members of the organization (or here, the system) studied to give a rating to a series of observable practices. It was of course necessary to adapt Garvin’s questions to the issue of UHC. This was done in Rabat by the workshop participants. In essence, the grid includes a series of 92 statements which the respondent has to score in terms of accuracy.
The third idea is that by using a common framework, it would be possible to compare countries with each other. This comparison would make it possible to identify countries that are more advanced in one aspect, but also spot the weaknesses found in all or most countries.
Implementation of the study
One of the challenges of this multi-country research was the limited budget available to us. Each delegation thus had to find local funding for data collection. In the months that followed, six delegations managed to access funding to conduct the study in their own countries: Benin, Burkina Faso, Cameroon, Morocco, DRC and Togo.
Data collection took place in 2015 and for some respondents early 2016. For all countries together, we were able to obtain the opinion of 239 respondents. On average, 40 informants participated in the country self-assessment. While this sample may appear to be small, one needs to keep in mind that the main aim was to collect the assessment of people directly involved in the UHC agenda. This core of people is not necessarily much larger than 40 experts per country.
Our research produced many results. Country-specific results will be presented in the coming months on this blog. Here, we already share some overall results with you.
A first result is that the six countries achieved fairly similar scores: none stood out as significantly better or much worse than the others. Also, in all countries, substantial progress can still be made. According to our study, Burkina Faso has the strongest UHC learning system capacity.
A second result is that the countries have similar scores on several aspects. All countries got a high score for the presence of strong political leadership in favor of UHC. On the other hand, all countries are rather weak on issues such as the use of quantitative data (in particular routine data), the use of digital technologies and strategic purchasing. Our study also documented a major structural weakness in what we have referred to as the ‘UHC Learning Agenda’. So far, no country has a real strategy to coordinate the learning needed for the UHC agenda. Learning occurs in an unsystematic and random way: it depends on consultancies, decentralized initiatives, not well-connected research groups. No one has the overview. Nobody cares about creating a collective and coordinated dynamic at the national level. We would like to work on this gap with the CoPs from 2017 on, notably through country hubs. As you will read in future blogs, some interesting things are in fact already happening in some countries.
Finally, this study has also proved that our CoPs are potentially a new force for multi-country research. On the one hand, our strong anchoring in countries allows us to identify issues neglected by others. It was interesting for us to discover that the themes we already work on (such as the empowerment of decentralized actors through data, with the Health Service Delivery CoP) or on which we want to work in the near future (e.g. strategic purchasing) have been identified as systemic weaknesses by our 239 respondents. On the other hand, our strong links with national actors, and ministries of health in particular, allow us to carry out action-oriented research, right from the start. This was clear in the three national validation workshops we attended. In short: there is a bright future for such participatory studies.
Our gratitude goes to the Muskoka French Fund (UNICEF), P4H, the DGD (Belgium), the Ministry of Labor, Public Service and Social Protection of Burkina Faso, Cordaid and GIZ for supporting this research.