Manuella De Allegri (University of Heidelberg) and Isidore Sieleunou were in Berlin last week at the GIC Forum on Health and Social Protection. They enjoyed this conference on Universal Health Coverage, but were really surprised by the fact that user fee removal was not discussed. An oversight or a bias?
Last week, we had the opportunity to take part in a Forum organized by the German Cooperation on Social Health Protection, the title being Universal Health Coverage: From Promise to Practice. The Forum gathered international experts across the policy, the implementation, and the research arena. Health financing “veterans” of the level of David Evans, Joe Kutzin, and Tim Evans were invited to meet experts working for the German Cooperation, their policy and implementing partners across the world, and a selected number of researchers to discuss the challenge of moving countries towards universal health coverage (UHC) and possible strategies towards this end.
The forum provided the opportunity for extensive exchange, with provocative discussions and innovative thinking characterizing the two days spent in Bonn. We definitely took home a number of inspiring ideas. Notwithstanding the number of very interesting sessions, however, we were left to wonder how it was possible to spend two days discussing UHC and not once mention user fee abolition. The forum simply overlooked the experience of countries which have recently implemented user fee abolition as an initial step towards UHC. A wide range of strategies targeting all dimensions of UHC (population coverage, access, and financial protection) were discussed from efficient service purchasing to insurance systems, from cash transfers to vouchers … just no mention of user fee abolition.
In her key note speech, Dr. Speciosa Wandira-Kazibe, the former Vice President of Uganda, repeatedly stressed that UHC is all about responding to increasing demands for better health services, no matter what path towards the goal is chosen. She insisted on keeping open to all policy options, adjusting to the specific circumstances of each country. Therefore, we later found the omission of user fee abolition somewhat surprising considering that the evidence on the impact of user fee abolition on improved access to health services and financial protection is by now quite substantial. While it is true that some countries might have rushed into user fee abolition without carefully preparing its implementation and might have therefore encountered problems to keep up the promise of improved access to quality services, other countries, such as Ghana or Burkina Faso, have successfully worked on the careful progressive implementation of user fee abolition (or reduction, as for Burkina Faso) for selected services and/or population groups. Interestingly, such countries have explicitly implemented user fee abolition/reduction with the intent of advancing population coverage on a limited spectrum of services, while preparing further-reaching health policy reforms aimed at advancing progress towards broader UHC goals.
We were left to wonder what could motivate a community that gathers to discuss strategies towards UHC to overlook user fee abolition. One thought that immediately comes to mind is that discussions on UHC are largely dominated by what sociologists would define as culturally dominant paradigms. The concept of cultural hegemony refers to how power is indirectly reflected in the ideas that we, as society, hold to be the most prominent. It is to say that the ideas of those who enjoy power in a community receive more attention and ultimately end up being the ideas that the collectivity holds to be true. User fee abolition has largely emerged as an endogenous movement within African states, one that only recently gained explicit support from international UN agencies and the World Bank. As such, one could see it as a movement that is simply not part of the dominant paradigm, as African states are not known to be the ones who hold the most power in the international arena. One could further postulate that the natural consequence is that user fee abolition is not deemed to be worth of the same attention as vouchers or conditional cash transfers, strategies to UHC largely supported by the exogenous international community. The discourse at the forum might have simply reflected the distribution of power at the global level, with some reforms endogenous to African states, such as user fee removal, receiving less attention than those widely promoted by the international community.
Moreover, the forum devoted ample space to discussions of the link between evidence and policy, paying specific attention to the function of knowledge brokerage. The community at the forum amply engaged in discussions on the role of the encounter between research and policy and on the need for knowledge brokers to facilitate this encounter, by enhancing two-way communication between the two. Still, we are left to wonder, how can effective knowledge brokerage take place in a context dominated by cultural hegemony? How do we even start discussing the path towards UHC in a fair way if the options we bring to the table are only the ones deemed worth of discussion within the framework of a dominant paradigm? Are we doing justice to UHC if we overlook a selected set of endogenous strategies?
We have no answer, but surely many questions to reflect upon as researchers committed to the production of the evidence for policy, beyond power relations and political concerns. Personally, we are looking forward to the conference organized by the Financial Access to Health Services Community of Practice in November in Ouagadougou. We look forward to the opportunity to discuss financial strategies to enhance access to maternal and neonatal health services, beyond dominant paradigms of what may be deemed and what may not be deemed worth our attention as we all strive together towards UHC.