On December 16, a summit on Universal Health Coverage (UHC) was being held in Tokyo. The very same day, but on a much smaller scale, a workshop organised by the Health Service Delivery Community of Practice on strengthening local health systems in Africa began in Cotonou. This coincidence in timing inspired the cartoon below. On behalf of the three Communities of Practice (CoP) they facilitate, Bruno Meessen, Basile Keugoung and Allison Gamble Kelley are trying out a different take on New Year's Greetings.
As for many, for us the week of December 14 was the last frenetic gasp of activities for the year. We were in Cotonou (Benin) for a number of different CoP activities, one of which a workshop following on from our 2013 Dakar conference (a workshop about which you will hear more very shortly). It was also a week where we were very active on Twitter and Facebook: we shared the winning scenarios from our “How would you draw Universal Health Coverage” contest. You may remember that we had asked experts from around the world to propose ideas for scenarios related to UHC to be drawn by the cartoonist Damien Glez. No doubt you have seen the results by now (if not, check out our blog).
The very same week in Tokyo, the umpteenth UHC summit was being held. Like many such events before it, the meeting brought together what some might call the “global health aristocracy”: a relatively stable list of agency directors and experts, for the most part Western, Anglo-Saxon men.
First and foremost, we want to express our sincere gratitude to those who have tirelessly advocated for UHC these past years. No doubt the fact that UHC was included in the Sustainable Development Goals is in large part thanks to them. We also understand that advocacy has its constraints, among them the need to have an active presence in countries leading this global effort both financially and politically. The fact that Japan will host the next G7 summit was certainly an opportunity to seize. And yet, on the evening of December 17, we shared a meal with a high-level officer from the Ministry of Health in one West African country; his heart was heavy as he spoke to us about the decline of the UHC agenda in his country, especially in terms of the confidence and commitment of national players.
That evening, we were especially struck by the huge gap between the global health “stratosphere” and those working at the field level. We felt we needed to speak up. So we asked Glez to quickly finalise one of the cartoons he was working on (the one at the bottom of this blog). We also commissioned a new cartoon depicting the “global health face” of the UHC movement: the one you see at the top of this blog. We decided to make these two drawings the stuff of our New Year’s wishes.
A growing gap between words and action
As Community of Practice facilitators, our New Year’s wish is quite simple: may the real implementation challenges being faced at the country level be given much more attention by those working on and advocating for UHC.
In Tokyo, World Bank President Jim Yong Kim recognised that "We have not done well so far on this journey to UHC...we have fallen short of expectations" (see here). We think that his assessment, most likely expressed on behalf of multiple agencies, is right on target (1).
While there has been some progress here and there toward UHC, it has not been significant enough to bridge the growing gap between national and international declarations versus what has actually been achieved at the country level. This is especially the case on the African continent. As an expert from Democratic Republic of Congo captured so well in his scenario, it is vital that history not repeat itself.
We read Richard Horton’s tweets from Tokyo. Yes, UHC is political; yes, it would be great to make it a global cause like climate change. But we are not there yet. Real, tangible progress is proving slow. There are multiple causes for this. One is no doubt that the global movement seems to be lacking a bit of inspiration: it seems to us that to date we are mostly reproducing what we know how to do: advocacy, global reports, mobilising resources…all of which may be useful, but which do not constitute a theory of change, especially for poor countries.
While fully acknowledging the political aspects of UHC, our experience as CoP facilitators has convinced us of its technicity. There are huge challenges at the implementation level, not all of which seem to have made it onto the radar of the international agencies. Linking the political and the technical at the national level needs to receive a lot more attention: in point of fact, we know very little about that interaction. If we don’t understand the mechanics of societal and systems-level change, we are likely to be sorely disillusioned. If UHC is to become a reality at the country level, we believe it will need to become a much more inclusive process (incorporating the social innovations that go along with it).
All of this will require that we all revisit our approaches and actions, including within the CoPs. And this is the hypothesis we will deepen and develop in 2016.
We wish you a productive 2016!
- Mr President of the World Bank, we would also be keen to have the chance to share with you our analysis of the ‘science of delivery’ – a concept you spoke of early in your tenure that seems, to us, underexploited for the moment.