Many paths, one direction: Strategies for achieving Universal Health Coverage

Each year, nearly 100 million people find themselves pushed into extreme poverty because of health-related expenditures, according to a report by the World Health Organization and the World Bank.

Achieving Universal Health Coverage (UHC), including access to affordable health services and financial risk protection, is the objective of the Sustainable Development Goal target 3.8. When the SDGs were adopted in 2015, all 193 UN member states committed to defining their own strategies for achieving these ambitious and universal goals.

Against this backdrop, Capacity4dev spoke to health programme managers at the EU Delegations to Nigeria, Ethiopia, South Africa and Timor-Leste to find out what strategies each country has adopted to reach the UHC target, and how the EU is supporting these processes.

Building capacity to sustain primary health care reforms in Nigeria

Maternal and child health centre in Shinkafi, Nigeria © Ochai Samuel/EU Delegation to Nigeria

Nigeria, the most populous country in Africa, has made significant improvements in its public health system in recent years.

Despite notable progress, however, the country faces significant challenges when it comes to ensuring affordable and quality health coverage for all its citizens.

Home to one-fifth of Africa’s population, Nigeria has some of the world’s highest maternal and child mortality rates, and did not achieve the Millennium Development Goal targets on health and nutrition. Critically, it also suffers from limited access to basic health services, according to Anthony Ayeke, Project Officer at the EU Delegation to Nigeria.

Among the key bottlenecks to achieving sustainable health improvements, Ayeke pointed to the insufficient coordination and lack of accountability on project management, but also weak allocation of finances and poor data management.

In that respect, the National Health Act has proven to be a milestone, said Ayeke. Signed into law in 2014, the Act commits one percent of the national budget to the Basic Health Care Provision Fund, with the aim of increasing revenue and improving primary health services. One percent may not sound like much, Ayeke added, but in a country with significant oil revenues “it’s quite significant”.

The national and regional governments see primary health care as key to achieving universal health coverage in the country. Around the time Nigeria signed the National Health Act into law, it also adopted the Primary Health Care Revitalization programme with 10,000 Primary health care centres identified for rehabilitation and revitalisation by 2020. “The government is seriously focused on primary health,” Ayeke said. “It’s a crucial part of achieving UHC.”

In February 2017, the EU agreed a €70 million grant, the bulk of which will support maternal, new-born and child health and nutrition in Adamawa, Bauchi and Kebbi states. Meanwhile, €20 million will go towards strengthening health systems towards UHC in Anambra and Sokoto states.

“Considering the challenge of severe acute malnutrition in some parts of the country, Nigeria is not self-sufficient in terms of ready-to-use therapeutic foods (RUTF) and related food items – for various reasons,” Ayeke said. “At the moment, the quality of many of the foodstuffs on the market is simply unknown, perhaps due to the absence of effective oversight by the appropriate authorities such that harmful or fatal food contamination by aflatoxins still occurs every year.”  

Funds from development partners represent only 4% of Nigeria’s health budget... so they must be extremely strategic to be valuable

But funds from development partners represent only a small share of Nigeria’s health budget – just over four percent, according to OECD – so they must be extremely strategic to be valuable. “In the Nigerian case,” Ayeke said, “the development partners’ strategic approach focuses on strengthening the capacity of existing institutions to deliver services.”

Though the EU does not provide budget support to the country, it works closely with the Ministry of Budget and National Planning and other line ministries on strengthening existing primary health initiatives. “In the past, we used to provide technical assistance on individual projects, but this worked through a parallel implementing unit,” Ayeke said. “The challenge was that when the project ended, our support would end as well.”

Now, he added, the EU Delegation’s support is embedded within the government structures, focusing on building capacity. “At present, we work through interventions lasting 3 to 5 years, to address the specific needs or gaps within the health system,” Ayeke explained. “We build the capacity of our counterparts in the government, so they can continue with the implementation even after the project ends.”

According to Ayeke, a more targeted approach by development partners could focus on strengthening government capacity for data management and health expenditure, and should improve tracking at national and sub-national levels. “We need to make better use of resources, ensure more health for the money,” he said. “From my perspective, the priorities are accountability, better management of projects, financing, and data – quality, reliable data is crucial to informed policy-making.”

However, he added, “more specific priorities for the country could include making progress towards UHC, eradicating polio, prioritising nutrition, taking ownership of HIV care and treatment programmes and ensuring health security.

“Health, as a cross-cutting issue, is affected amongst others by such factors as the quality, availability and accessibility of food, and by access to clean water and sanitation. For instance, only about 40% of the Nigerian population have access to clean water on a continuous basis.”

Expanding equitable access to health services in Ethiopia

Temegn Wasihun, a health extension officer giving advice at a health post in Hamusit, northern Ethiopia © Nahom Tesfaye/UNICEF Ethiopia

Ethiopia, the second largest country in Africa, has experienced more than 10 years of rapid economic development growth. Nevertheless, it is still among the Least Developed Countries in the world.

The EU and other development partners continue to support the Ethiopian government in its efforts towards achieving UHC, in conjunction with measures targeting nutrition, food security, water and sanitation.

The EU Delegation’s support comes mainly in the form of budget support. “Together with the government, we’ve identified the main challenges in health to figure out which areas need strengthening,” said Habtamu Adane, Programme Manager at the EU Delegation to the country.

Adane pointed out that the country met most of the health MDGs, but continues to face a number of issues and challenges, as the MDG targets were established from a very low baseline. “There is inequity between the different regional states, and the quality of services is lacking,” he said. “There is also the issue of health financing, which is dependent on external resources [currently at 37%] and relatively high out of pocket expenditure [33%]. Domestic resource mobilisation is still quite weak.”

Another key challenge is the limited access to quality health services, but the country made important steps in overcoming the critical shortage of health workforce and has developed quality improvement strategies. For the last two decades, efforts have also been made to expand access to health services – particularly in rural areas – with the implementation of the Health Extension Programme (HEP).

The HEP created the role of Health Extension Workers (HEWs), female community health workers who go through a one-year training course focused on the prevention and health education, handling of some basic curative measures, and mainly referring to the next levels of the health system.

The Health Extension Workers are deployed at village (‘kebele’) level, where they perform home-to-home visits and provide basic-level health services, including treatment of most common diseases among children, and monitoring of ante-natal health of pregnant women.

The HEP has seen more than 30,000 health extension workers trained and mobilised in rural areas, where the majority of the population lives, leading to an increased access to primary health care across Ethiopia’s nine regional states and two city administrations.

“The programme introduced 16 packages of essential health interventions in four areas, including disease prevention and control, family health, hygiene and environmental sanitation, health education and communication,” said Adane.

The country’s healthcare financing reform from 1998 introduced a fee waiver system for providing services to the poorest free of charge, as well as through the free provision of selected public health services.

“With the waiver system, the regional governments allocate some money for people who are the poorest of the poor,” Adane said.  “Patients receive a card from the local administration with which they can access health services from the nearby facilities. The service costs are reimbursed to health facilities from the allocated budget. That is how the government is trying to provide the poorest people with access to health services.”

But 30 percent of Ethiopia’s population lives below the national poverty line, according to the World Bank, and a vast segment of them is not yet benefitting from improved access to services and financial protection, Adane added.

“The waiver system only ensures coverage for approximately 10% of the population below the poverty line; the majority is not yet actually included,” he said. “As utilisation is quite low, there is a need to encourage more people to use the service. People need to be made aware of their rights and how they can get access to the health facilities.”

Currently, Adane added, Ethiopia is also piloting community-based health insurance scheme through which the poorest segments of the population get access to health service free with the government subsidy to the scheme. 

Supporting the creation of the National Health Insurance in South Africa

Health clinic in South Africa © EU Delegation to South Africa

South Africa, the continent’s second largest economy, has taken ambitious steps towards ensuring quality, affordable and universal health coverage for its population of 53 million, according to Flora Bertizzolo, Health Attaché at the EU Delegation to the country. Grappling with the legacy of apartheid, however, the country still faces huge disparities among population segments and equity measures – also when it comes to health.

“Only around 20 percent of South Africans have private medical insurance, but they consume close to 80 percent of all the health expenditure in the country,” Bertizzolo said. “The other 80 percent are much poorer; they don’t have regular jobs. They rely on services offered by the public health sector, which is not only perceived to be of poor quality, but is also expensive for the government.”

According to the OECD, Bertizzolo explained, compared to the average of upper middle-income countries (UMICs), South Africa’s government allocates more resources to health as a share of total government expenditures (14% versus 11%).

Over the last 15 years, the country’s government has been working towards health system strengthening and a publically-funded National Health Insurance (NHI) fund to provide coverage to all citizens, irrespective of their income. “The health department has understood that it cannot solve the health challenges while keeping the country divided,” Bertizzolo said. “Under the NHI, people will have access to health services based on their needs, not their revenue. NHI is essentially South Africa’s version of the Universal Health Coverage.”

The EU Delegation has supported South Africa in implementing NHI, and, since 2011, has provided budget support to the Ministry of Finance and the Department of Health for pilot projects within the scope of the programme.

As part of the Universal Health Coverage Partnership (UHC Partnership), the EU also provides technical assistance in developing the legal framework and facilitating policy dialogue around the NHI.

Despite the progress, there are still many challenges on South Africa’s path to achieving UHC, not least in terms of bridging the divide between the haves and the have-nots. “NHI remains a very controversial topic,” Bertizzolo said. “The 20% of South Africans benefiting from the private health insurance will have to give up some of the entitlements. This will require a cultural paradigm shift, which is never easy to achieve.”

Capacity development in Timor-Leste

Olinda Aguida Centre © EU Delegation to Timor-Leste

The violent path to independence in 2002 left Timor-Leste with many profound challenges. Some eighty percent of the country’s health infrastructure had been destroyed, leaving almost no equipment and facilities; many professional workers fled the country and the remaining health services were reduced to the bare minimum.

Today, the young country of 1.1 million has the highest maternal and under-5 mortality rates in Southeast Asia. In addition, the prevalence of malnutrition is among the highest in the world, and more than 40% of the population lives in poverty.

“The country is very ambitious when it comes to health, and people have really high expectations,” said Paolo Barduagni, health programme officer at the EU Delegation to Timor-Leste. “On the other hand, there is a critical lack of skilled health personnel.”

Other issues arise from the difficult geography and social dynamics of the country. Many of the communities live in isolated areas, making service provision much more difficult, according to Barduagni. “Even though there are many health facilities throughout the country, people have difficulty accessing them – some have to travel for four or five hours on a motorbike just to get there.”

As a result, he added, each facility serves only a small number of people. “This is what we call low-volume service delivery.”

With the support from development partners like the EU, the country’s government has developed health policies that are in line with international standards and the SDGs. “They’re of high quality and up-to-date, but translating them into practice remains the biggest challenge,” Barduagni said.

The National Health Sector Coordination Committee, developed with the support from the UHC Partnership, serves as a forum for the Ministry of Health, development partners and other stakeholders to discuss health policies and challenges in the health sector and to oversee the implementation of projects and programmes guided by National Health Sector Strategic Plan 2011-2030.

The EU has provided support to the country since the early days of independence. Under the 10th European Development Fund (EDF), health and nutrition related programmes focused on health service provision and institutional capacity building. The programmes ended in December 2017, reaching €20 million.

Timor-Leste also benefits from the EU support for ACP Portuguese-speaking countries, the Pacific Regional Programme, and the EU’s instruments for human rights and non-state actors and other budget lines, such as climate change.

In addition to the need for capacity development and a crucial shortage of health workforce, another key bottleneck is related to health financing. “The national state budget is 80% oil revenues, so it fluctuates with the market, and that affects the health budget,” said Barduagni.

Apart from this, he added, the share of public funding allocated to health (2.9% of GDP in 2013) is below the average for lower middle income countries, and not sufficient to ensure an adequate delivery of health services.

The EU Delegation works closely with Portugal, the only Member State active in the country, and with Germany’s development agency GIZ. Under the 11^th EDF, about one third of EUD funds are proposed to be disbursed through budget support.

“From a political perspective, budget support is great... but, at a technical level, it poses challenges”

“From a political perspective, budget support is great,” Barduagni said. “But, at a technical level, it poses challenges when it comes to setting the targets. If the targets are set too high, then the country might not have the capacity to comply, and we run the risk of not actually helping the people in need.”

Barduagni advocates the use of trust funds or pool funding, which he views as one of the best modalities for increasing the effectiveness of development assistance. “It really enhances the dialogue, having the government and development partners agreed on one programme aligned to national strategies,” he said. “Pool funding also avoids duplication or segmentation and reduces the transaction costs. It unifies all the different agendas under a single set of activities and ensures national ownership and enhances good governance and transparency".

This collaborative piece was written by Capacity4dev’s Coordination Team, with input from the B4 Unit at DG DEVCO and the Health Advisory Service.