A health clinic in Kenya. The Makueni County Government is set to study the outsourcing of operations of three primary health clinics in the county per a new agreement: Amref Health Africa will offer capacity building and health worker training working with Philips, which is responsible for providing the health system infrastructure and the medical equipment in the clinics. Makueni County will be responsible for policy, regulation and quality management, and the Dutch development bank FMO is providing legal and business expertise. (Photo courtesy of Amref Health Africa)
The first step towards addressing the health challenges of our time is for people to understand and appreciate that health is a basic human right.
With those words, Dr. Githinji Gitahi conveys why he is such a passionate advocate for pro-poor universal health coverage (UHC).
Dr. Gitahi joined Amref Health Africa as Group CEO in 2015. Founded in 1957, Amref Health Africa is the largest African-led international organization on the continent, reaching more than 9 million people through about 150 health-focused projects across 35 countries.
From March 5 to 7 in Kigali, Rwanda, Amref Health Africa and the Rwandan Ministry of Health are convening for the Africa Health Agenda International Conference (Africa Health 2019 – #AHAIC2019 Africa Health 2019) – a platform to foster “new ideas and home-grown solutions” to the most pressing health challenges in Africa, with a focus on achieving UHC in Africa by 2030.Africa Health 2019 is viewed as a key opportunity to map a pathway from commitment to action and to build momentum for UHC among policymakers, civil society, technical experts, innovators, thought leaders, academics and youth leaders. The event is a milestone in the run-up to the UN high-level meeting on UHC in September, where the global commitment to UHC will be galvanized through a political declaration agreed upon by UN member states.
Dr. Gitahi began his career as a medical doctor practicing in obstetrics and gynaecology, witnessing both the progress in health outcomes in his native Kenya and the gaps that remain. With 100 million people globally being pushed into extreme poverty each year due to high out-of-pocket payments, the goal of “health for all” is more urgent than ever, he says. Through his work at Amref Health Africa, Dr. Gitahi champions “affordable, quality healthcare for every person, everywhere.” His global leadership earned him an appointment as co-chair of the UHC2030 Steering Committee, a global World Bank and World Health Organization (WHO) initiative in support of UHC.
At Elsevier, we sat down with Dr. Gitahi to learn more about Africa’s path to UHC and what to expect at Africa’s largest health conference.
Q: What do you mean by universal health coverage, and why are you motivated to be a leading voice on this issue?
A: UHC is a critical aspect of realizing individuals’ rights to health. Its core principle is that everyone should have access to essential health services without financial hardship. It is therefore a crucial and often cost-effective element in any strategy seeking to address poverty and social exclusion.
As a medical doctor and as someone who has worked in the health industry for many years, I am interested in the key drivers of lasting health change. I believe that the focus on UHC and the international momentum around it give us a roadmap to achieving better health for all people. I am passionate about UHC and I want to work with others so that I can see UHC become a reality in my lifetime.
Q: The UN high-level meeting on UHC in September is expected to result in a historic UN General Assembly declaration in support of health for all. What are the most important aspects that should be reflected in the declaration?
A: On the road towards UHC, I see a risk that the focus of the global community will be predominantly on approaches that are rooted in a “universality” perspective, clearly aimed at achieving universal coverage. However, when talking about universal coverage, it is an easy mistake to assume uniformity of populations at the community level. We know different population groups have different health needs. We know that equity measures for marginalized groups are needed to ensure that all people can access the health services they need. We know that these equity measures can be very specific. The problem is that the voices of these population groups in the process of defining these equity measures often get lost in statistical data, where they always remain a small minority.
This is why I have been advocating for a seventh building block of health systems in addition to the current six building blocks used by WHO to describe health systems – one that incorporates communities and citizen needs. Therefore, UN member states should put communities at the forefront of the political declaration in September.
Q: What kind of investments need to be made in order to achieve UHC? Does this mean investing in infrastructure, such as building hospitals?
A: The key issue is not building new hospitals or even adding more doctors. While these things are ultimately necessary for achieving better health systems, it is not UHC until we have decided what we want to universally provide for all, how to provide it and how to finance it. In other words: UHC means a sustainable level of health services provided in an equitable manner, meaning that all people are equal in the guarantee of UHC.
The second step is to ask ourselves what specific investments respond to that essential health package at the highest quality possible. Based on that, we would create service contracts, protocols and guidelines, drug purchasing strategies and everything else that is needed to support delivering that health package. We need to ask ourselves questions like: ‘What human resources are needed? Doctors, nurses, community health workers?’
In the African context, community health workers (CHWs), are a critical cadre in achieving UHC. CHWs bridge the gap between their communities and the formal health system, bringing health care as close as possible to where people live and work. Yet they are often treated as volunteers. Their role must be integrated into health systems if those are to successfully respond to the disease burden that exists in African countries.
Q: Why are community health workers left to work without payment?
A: Despite the fact that CHWs are critical in expanding access to primary care, they are often not recognized in the formal health system. Because of this, the work of CHWs is often done on a voluntary basis or with very little pay. Volunteerism in this form is not a long-term sustainable option: CHWs are generally poor and their work requires an income.
The lack of recognition stems from a lack of political will and investment, even though there is a return on this investment: according to WHO, investing $1 in a community-based health workforce in sub-Saharan Africa can produce an economic return to society of $10. Amref Health Africa, together with our partners, advocates for recognition and remuneration of community health workers throughout Africa, so that community health workers are accessible to everyone, everywhere. This is the only manner in which we can achieve UHC.
Ethiopia’s Health Extension Program, for example, takes a community-based approach to healthcare and service delivery, deploying more than 38,000 salaried health extension workers who provide services at fixed health posts as well as through home visits in their communities. These investments have paid off – Ethiopia has seen remarkable achievements in health outcomes since the launch of the program, including drastic reductions in maternal and child deaths. Similarly, in Rwanda, approximately 45,000 CHWs provide health promotion activities as well as preventive and curative care to rural communities, and we can attribute much of the progress in health outcomes that has been achieved in Rwanda to their dedication.
In Liberia, bold reforms were made to the national CHW program following the Ebola epidemic. Many remote communities relied on community health volunteers for essential health services, but because they were unpaid and under-supported, many dropped out of the program. In 2016, Liberia’s Ministry of Health launched its revamped National Community Health Assistant (CHA) program. CHAs are now paid, and their work is overseen by nurses or other clinic-based health professionals. As of March 2018, Liberia had hired and trained almost 3,000 CHAs, and many counties are already reporting improvements from their services.
Now other countries in Africa are following suit, and the African Union plans to train 2 million CHWs across Africa by 2020. The WHO has recently released guidelines on health policy and system support to optimize community-based health worker programmes, which are a very useful starting point for countries.
Q: UHC seems to be an umbrella term. Are there any specific topics within UHC that require extra attention?
A: Governments should not only put communities at the heart of UHC, but also the needs of women and girls within these communities. In many communities in Africa, women are not the final decision-makers even in matters of their own health. This inequality has devastating effects on the health of women and girls. Gender inequality and unequal gender norms influence access to health services. The imbalance in power between men and women is the single most important cause of the higher rates of HIV and other sexually transmitted infections in women. Women do not always have the power to ensure safe sex; in fact they may not have the ability to choose when and with whom to have sex and or to decide if or when to have children. The proportion of women who have an unmet need for modern contraception is highest in sub-Saharan Africa – it stands at 21 percent. More than 200 million women are not using modern contraception methods while they would like to avoid a pregnancy.
UHC is not only about access and affordability. Even if women are empowered to make decisions about their own health, they may not have the resources to pursue their health needs. Governments have a responsibility to ensure effective systems are in place to provide a continuum of care for girls and women, including access to sexual and reproductive healthcare. Without an intentional, relentless commitment to gender equality, even well-meaning plans to advance UHC can leave girls and women behind.
Q: The Africa Health 2019 conference in Kigali is a few weeks away. What are some of the successes and commitments you hope the conference will deliver?
A: The 2019 conference, which is focused on accelerating UHC in Africa, is geared to be one of the largest health meetings on the continent, with over 1,500 participants expected. It is an African-led conference that will serve as a key opportunity to map a pathway for progress on UHC from commitment to action, and to build momentum for UHC among policymakers, civil society, technical experts, innovators, thought leaders, scientists and youth leaders. I hope that all these actors will commit to taking active steps towards the achievement of UHC.
This conference is just one milestone in the run-up to the high-level UN General Assembly meeting on UHC in September. It’s exciting to be part of this movement at a time when there is so much political attention to it. But we have to work strategically in order to ensure that these commitments translate into real improvements at the ground level. In the coming months, I will call upon governments in Africa to put their communities at the center of their UHC strategies. In order to do so, there needs to be a level of accountability: citizens need to be informed about their rights and need to be able to hold their governments accountable when their right to health is not being realised. We also need multi-sectoral collaboration, meaning that governments should work together with other entities across sectors, including the private sector, to make UHC a reality.
These steps are the only way we can achieve lasting health change by 2030, and fulfil the promise made by every UN member state during the adoption of the Sustainable Development Goals: to guarantee the right to health for all and leave no one behind.
This article was first published here by ELSEVIER on 4 March, 2019.