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.