Towards universal health coverage in Africa

Just over a year to the home stretch! The eight internationally agreed Millennium Development Goals, adopted in 2000, have mobilized unmatched resources and attention, resulting in significant progress for global health. Many countries in Africa are on track to reduce  significantly mortality from major killers: HIV/AIDS, TB, and Malaria as well as cut by half, preventable deaths of children and pregnant women. Beyond the aggregate measures, lie an uneven picture of success within and across countries, and goals. Even with additional efforts, many countries would likely miss their sanitation targets.

So far, the gains that have been achieved reveal profound weaknesses in the system for delivering quality care to billions of unserved and underserved populations. For example, the chronic shortage of health workers, estimated by the World Health Organization to reach 4.2 million worldwide, 1.2 million of them needed in Africa, alone.  Already overwhelmed by an unfinished ‘business’ of addressing major communicable diseases, health systems in resource limited settings, are further undermined by a new challenge of epidemic proportion. Added to millions of people receiving lifesaving and long-term HIV treatments, non-communicable diseases (NCDs) are placing new and overwhelming demands for chronic care, a double burden on already weakened health systems. 

Long linked to affluence, lifelong chronic diseases are emerging as the biggest killers, even in the poorest countries. Thanks in part to globalisation, a rapid spread of modifiable risks factors— including tobacco, high caloric foods, physical inactivity and ageing — drives the surge in NCDs.  According to the World Health Organisation, over 80 percent of premature deaths from hypertension, diabetes and cancers occur in low and middle income countries. Already a major killer, by 2020, the largest increases in NCDs deaths worldwide will occur in Africa. In fact, by 2030, deaths from NCDs in the continent will exceed those from infectious, maternal and children preventable diseases, combine.

NCDs are a drain on economies, too. According to the World Economic Forum estimates, each 10 percent rise of NCDs reduces 0.5 percentage point from growth. While generous donors money are enabling millions of Africans to access cheep, lifesaving HIV/AIDS drugs, an even greater number are pushed yearly into poverty by the catastrophic cost of  treatments for NCDs . Even for those who can afford, they postpone treatment, seeking care only when conditions are already worse, advanced and more expensive to treat.

Working towards a long-term development agenda beyond 2015, the international health community has proposed universal health coverage as a target. Building on the strengths of the MDG approach, UHC as an indicator of a well-functioning health system brings renewed focus to the unfinished priority of eradicating communicable diseases. But most importantly, it inspires effective actions to tackle chronic diseases in countries: Putting people rather than diseases at the heart of healthcare delivery; enhancing coordination across building blocks of healthcare system; facilitating much needed shift from disease focused interventions to strengthening broken parts of health systems in countries. The goal offers an opportunity to transform the system of delivering care, prioritizing actions on the ‘causes of the cause’ of illnesses— poverty, power, inequality and degraded environments. 

Besides health, UHC could be the  glue to hold together the three pillars of sustainable development— economy, environment and social— in a balanced and harmonious manner. A healthy population is the cornerstone of sustainable economic growth, social cohesion and environmental protection.

To formulate a limited set of unified global development goals, the international community has agreed to merge the separate post-MDGs  and follow up of Rio + 20 sustainable development tracks into a single process. As an outcome oriented goal, UHC could get around key methodological and conceptual challenges standing in the way of combining the two agendas. In recent deliberations led by the United Nations, planetary boundary has emerged as a possible organizing concept for framing the long-term goals.  The proposed ‘social floor’ for health services imply in the UHC sits well with the nine identified ‘planetary ceilings,’ beyond which the earth risks irreparable environmental damage, from human activities.  

Like most international negotiations, politics may come before evidence-based proposals for action. The 193 Member States of the UN would have to compromise on their varied interests, values, capacities as well as integrate the changed geopolitical landscape— with rising influence of emerging economies —  which was absent when the MDGs were adopted. They would have to consider the influence of non-state actors, too, including the private sector foundations which have played an important role in scaling up MDGs. Member States will have to draw from their own experiences, too.

While guarantee equitable coverage, irrespective of financial means, remains front and center, the path to universal health coverage is going to be unique for each country. Some African countries have already taken important steps towards protecting their citizens against risks of financial catastrophe from out-of-pocket expenditure for health care at the moment of need.   Ghana, Tanzania and South Africa have instituted, albeit in varying degrees, national health insurance schemes. Coverage differs in the proportion of population covered, percentage of cost shared, and type of services included. Countries also use a range of  innovative methods for financing. For example, in Thailand, a 'sin tax' on tobacco is earmarked to fund health promotion activities.

Whether the lessons coming from countries will make their way into the final post-2015 outcome remains unclear. Initial discussions around UHC raise key concerns. What is the balance between preventive public health interventions and curative services ? What role for non-health sectors such as trade, agriculture, transport including food and tobacco industries, increasingly associated with the spread of the risks factors? What is the capacity of health ministries to effectively influence the work of those key economic sectors? What is the balance between state-led interventions and market-based approaches? What is the appropriate time frame for realizing universal coverage?