Q&A: Why universal health coverage needs to be redefined

When it comes to universal health coverage, the sector should be “tracking the trend lines not the headline,” said Dr. Githinji Gitahi, group CEO of Amref Health Africa, and co-chair of the UHC2030 Steering Committee.

The goal of access to health care for all without financial hardship, may be the headline, but given its “utopian” nature, there are other things that should be being monitored, Gitahi said. “Are we reducing out-of-pocket expenditure consistently over time? Are we tracking the number of impoverished households? How would we drive that toward zero? It’s more about the trend lines than moving to the 100% of all services and 100% of all population.”

Wanting to redefine UHC, Gitahi said the most important thing is to identify those most left behind — such as the lowest-income families, people who are living in conflict states, people living with a disability — and focus on providing them with the services they need. “Then you could say you’ve achieved UHC, even as you try to cover the others,” Gitahi said.

“We may celebrate participation of the sector, but we still haven’t managed to find a sustainable model of private sector engagement beyond service delivery.”

— Dr. Githinji Gitahi, group CEO, Amref Health Africa

“In a country where you have 40% of people living below the poverty line, the objective should be: how do you provide all services to all people living below the poverty line? That would be a great goal to achieve and then you progress so you can know when you are achieving the milestones,” he added.

Speaking to Devex, Gitahi explained the private sector’s role in helping to achieve the “trend lines,” specifically in the area of reproductive, maternal, newborn, child, and adolescent health, or RMNCAH, and how further integration of the local private sector into the broader health system can advance UHC.

This conversation has been edited for length and clarity.

How would you describe progress to-date toward achieving UHC?

UHC is a goal and all of us have to find a journey. The goal is very utopian: that everyone, everywhere has access to the quality services they need to give them their desired outcome without financial difficulty. Now, that’s a very utopian statement because we know that it’s very difficult to completely achieve that goal.

Secondly, the dimension within UHC assumes all services can be provided … Defining the dimension of services to the 100% of all services and defining how all those are paid up to 100% of the needs is very difficult.

How can further integration of the local private sector into the broader health system advance UHC?

When you talk about UHC, we’re talking about three key principles: access to needed health services, especially where people live and work; quality of the services; and financial protection.

It’s important to place the private sector conversation within the context of the fact that there’s no homogenous private sector, it’s a very heterogeneous sector. You have national and multinational, private sector for-profit and private sector not-for-profit, formal or informal, non-state actors as private sector, mission hospitals, NGOs, and faith-based hospitals. They’re all private sector.

If you’re to look at the lowest denominator, which is local and informal … they must be supplementary to the public health system, so that you have one health system. You don’t have a private and a public health system, you have one health system that has different stakeholders, and the health system objective is providing accessible, quality health care. The different stakeholders may have different interests and those are the interests the state needs to consider and lead a conversation around how to address those interests …

So the question around the private sector is more a question about how to address the interests of the different players rather than addressing the service delivery. By so doing, you then make sure that people can access health services where they are, where they need, as long as the question around affordability and financial protection is addressed. And those become extremely important, because if you are a mission hospital in a slum area, you’re providing access to quality services for that community. That is part of UHC. The question is who pays for it?

The conversation [should be] on financial protection policy, legislation around quality services, ensuring the quality of services provided by both public and private, ensuring the data is owned by the state, and a complementary financing strategy.

Prior to the pandemic, there was a significant shortfall in RMNCAH services in Africa. How do you think the private sector could help fill the pre-existing gaps in basic services, which have been exacerbated by COVID-19?

We may celebrate participation of the sector, but we still haven’t managed to find a sustainable model of private sector engagement beyond service delivery … While the private sector is critical in the health system as a major service provider, and really in charge of innovation and production of commodities, we’ve not been able to find a good model that makes primary health care investable.

At Amref, we’re trying several models working with, for example, General Electric in Ethiopia to see whether production of diagnostics like a handheld ultrasound and the delivery of portable incubators for children that don’t require electricity, can be rolled out on a large scale. How do you create a financing model for that? Is it government that’s going to buy them? Are the people going to pay for them out-of-pocket? Or is there blended financing that comes into it? I think the question is: how do we create scalability beyond philanthropy?

That’s the model that needs to be discovered as we move forward. That’s what we really need to work on and I think there’s hope. We’ve seen models and feasibility studies. It can work, but there are various barriers in the way to scaling.

Do you think there are specific policy and environment changes that would help governments better integrate innovative solutions while also strengthening health systems?

Government public procurement has never been very good at procuring innovation. This is because of the scale at which governments purchase; the higher the scale, the more checks and balances to ensure there’s no fraud and that there’s transparency and accountability. Those things create procurement policies that are best suited for the purchase of commodities or human resources rather than innovation.

Of course, the private sector already supplies governments in big ways with commodities — all drugs purchased by governments are fact-checked, researched, developed, and manufactured by the private sector. At a commodity level, that works well and there’s a good relationship, but that relationship is a procurement relationship.

When you get down to improvement of service delivery through innovative models and innovation like technology, the challenge is: how does the government use its well-oiled procurement machinery to purchase innovation? And yet innovation is proprietary, and the government doesn’t have mechanisms for purchasing privately initiated innovations … So, yes there are policy, regulation, and legislative changes that need to happen, but they will require an enabling political environment to achieve them.

Article first published on devex.com