In a recent blog, Allison Kelley shared the results of a collaborative research project on universal health coverage (UHC). The most important finding was that health financing today is hopelessly fragmented in Francophone Africa. For Bruno Meessen (Institute of Tropical Medicine, Antwerp), this means that it is time that the different actors mobilised around UHC re-evaluate their approaches. It is time to “do” health financing differently. In this blogpost, Bruno focuses on individual experts’ capacities. In a later post, he’ll reflect more on organisational capacities.
In Francophone Africa, as elsewhere, many countries have joined the ambitious campaign for universal health coverage (UHC). The recent study carried out by Allison Kelley and her multinational team confirms that health financing in Francophone Africa today is extremely fragmented and varied. The truth is that filling the famous UHC “cube” will mean aligning small and very diverse boxes one atop the next. The biggest challenge will be making more of a coherent whole of what coverage schemes already exist.
Urban planners wanted!
UHC will not be built on virgin territory: construction is already underway; there are roads, squares, and people who “live” in this new place we are trying to build. If you will, this is more about urban planning than it is about architecture!
Amongst the community of health financing “architects” today, we have designed and built a lot over the past 20 years. We have busied ourselves with scheme design and implementation. Some of us (the old timers!) put in place cost recovery; a bit later, others of us supported the launch of 'mutuelles'; and even later, some put their energies into fee exemptions, while others focused on mechanisms to reach the poorest and most vulnerable (vouchers, health equity funds, etc) ; still many others of us have been busy building performance-based financing schemes. One of the original findings of the multi-country study though, was to document that a lot of health financing schemes have been put in place far from the playing field of health economists – I am thinking especially of vertical programs that have imposed their own fee exemption rules, their parallel drug supply systems….
As the study showed, all of these efforts have marked the health financing landscape in a number of countries. In Cameroon for example, you will find almost all of these different schemes. In some respects, this mix of health financing schemes is interesting, as a number of them are potentially complementary. Yet the cross-country analysis documents that the reality is more often a lack of coherence among schemes, gaps in coverage, unexploited synergies, and a heavy administrative burden.
Architects and urban planners: two different skillsets
Policies to move toward UHC will inevitably require bringing order to this fragmented reality on the ground. And this is new. Both experts and organisations will have to develop different skillsets.
The architect listens to his client (his wishes, his present needs…), designs a house from scratch, then oversees its construction to ensure that the plans are followed to a tee. Today it is even possible to buy a “kit” house!
The urban planner faces a different set of challenges. First, the land for which she must plan rarely belongs to just one person: she must factor in the rights of its inhabitants. And those people may well choose to defend their interests in a variety of ways, both formal and informal.
Far more than the architect, the urban planner must take into account the needs of the collective. She must make choices: sometimes she must favour protecting or saving a particular structure because of what it brings to the city as a whole. But she might also have to recommend tearing down certain structures to make space for the new. The Paris that we all know and love we owe to Hausmann, who took the decision to remove vestiges of medieval Paris to make room for wide avenues and tall buildings.
To make these choices with such profound and lasting consequences, the urban planner must be able to anticipate. She must consider future needs (demography, new modes of transportation…) and be able to plan for a functional city. Achieving such a vision requires calling in all manner of different kinds of experts: architects, engineers, demographers, sociologists, political scientists, economists, psychologists, public health specialists….
A sea change for many of us
If we are to achieve UHC, we must work on updating ourselves. We have to seriously re-think health financing. Key words will become convergence, harmonisation, dialogue and anticipation. Our research focuses must shift. As discussed in a previous blog (in French only), there is an urgent need for health economists to take more of an interest in political economy, the poor stepchild of our discipline.
We all need to better understand how to mobilise different stakeholders. Policy makers must also learn to make hard choices. There are numerous health financing schemes today that work at cross-purposes. One example that comes to mind is the small voluntary 'mutuelles', which, unless significantly subsidized and harmonised by government, are likely to go the route of medieval Paris. The fact is that with a commitment to UHC, inevitable questions of scale and ensuring equal rights for all become all-important.
Experts working in development agencies will also be obliged to align their assistance with what it takes to support countries’ initiatives to move toward UHC. As the cross-country analysis showed, agency priorities have weighed heavily on the health financing landscape in Francophone Africa. There is a glaring gap between all of the hype around UHC and the reality of aid agencies’ behavior, as they earmark their funding for vertical programs.
Communities of practice must also think about continuously updating themselves. Not knowing what the future holds (although we would hope a long life for CoPs, which will of course depend on partners’ support), we feel sure we can play a role in helping bring about this transition to broader, more holistic health financing expertise. Stay tuned for our initial ideas on this in an upcoming blog.