A new framework for performance analysis
Universal health coverage (UHC) is financial and technically feasible. So what remains to be done? Governance.
Space for civic engagement, access to information and evidence, structures for transparency and accountability and multi-stakeholder and multi-sector action are crucial aspects of governance that will strengthen health systems and enable sustainable progress to UHC. These were some of the key messages to emerge from a side event at the 72nd World Health Assembly in Geneva on 22 May 2019.
The event was co-organised by Japan, Kenya and Thailand with the support of Laos, Germany, Georgia, Luxembourg and Spain. The event provided an opportunity to advocate for multi-sectoral and participatory governance as a core area where action is both challenging and directly needed for countries to be able to effectively and sustainably move towards UHC.
Governance is not often a topic for discussion: most people think of UHC in terms of health financing and service delivery, but good health system governance, or the lack of it, can make or break UHC reforms. The experience of Japan, Thailand and Kenya, who have all embarked on the journey towards UHC at different points in time demonstrate the importance of good governance in order to succeed.
Dr. Githinji Gitahi, UHC2030 Co-chair and CEO of AMREF Health Africa moderated the event and emphasised that here we have the opportunity to promote social participation as a core principle in UHC reforms. This is why partners of the UHC movement are calling on political leaders, as part of their set of Key Asks, to “Move together and establish multi-stakeholder mechanisms for engaging the whole of society for a healthier world.”
He also mentioned that the UHC2030 Civil Society Engagement Mechanism, the Health Systems Governance Collaborative, WHO and a range of experts are collaborating through a social participation technical network to better support governments in how they engage civil society, communities and populations in national planning and policy processes for UHC.
Prof. Emeritus Piyasakol Sakolsatayadorn, Minister of Public Health shared lessons learned from the experience in Thailand and the importance of governance in building efficient, responsive and reliable services that people can trust and use. “Governance helps build trust and sustain UHC,” he said.
Ms. Sicily Kariuki, Cabinet Secretary for Health reiterated Kenya’s commitment to strengthen citizen engagement through community health strategies. “Engagement of citizens is key to develop UHC schemes that are responsive to people’s needs and priorities,” she said.
Mr. David Sergeenko, Minister of Internally Displaced Persons from the Occupied Territories, Labour, Health and Social Affairs, Georgia, referred to the challenges faced by Georgia in strengthening health systems during the transition from a central planning political system. “With political will, teams of professionals and good partnerships, we can address any challenge” he said.
Dr. Yasuhiro Suzuki, Chief Medical & Global Health Officer, Vice-Minister for Health, Japan, shared the challenging experience his country faced to maintain the affordability of the health system for the government. It took 30 years to introduce fixed out-of-pocket payment rates for elderly people to replace free care, which was no longer sustainable for the government . “A viable way forward is more coverage, fewer out-of-pocket payments” he said.
Dr Agnes Soucat delivered remarks on behalf of Dr. Tedros Adhanom Ghebreyesus, Director-General, emphasising the importance of good governance to create a health system that is co-owned by populations, communities and civil society and rests on redistribution, social justice and rights, ensuring the inclusion of the most vulnerable and marginalised groups. “This requires a social contract. It means bringing society together as an expression of solidarity between people who can pay and those who cannot, people who are healthy and those who are not, people who have access to services and those who do not,” she said. To support countries to engage in meaningful policy dialogue, WHO is developing a handbook on social participation for UHC, with to engage civil society organisations and communities in the design, implementation and follow-up of national road maps and related health strategies and plans.
Moderated panel discussion
A rich panel discussion took place with perspectives from government, private sector, civil society and academia. Panellists discussed what good governance for UHC looks like, what it takes to promote good governance for UHC and design multi-sectoral action and what can be done to overcome the pitfalls and engage all stakeholders meaningfully.
Dr. Jadej Thamatacharee, Deputy Secretary General, National Health Security Office, Thailand reiterated the importance of having a legislative framework to promote good governance. He mentioned that three dimensions are required: participation of all stakeholders, evidence and political will.
Mr. Thomas B. Cueni, Director General, IFPMA, referred to the responsibility of the private sector in making affordable medicines more accessible. This requires effective policies, financing mechanisms and institutional capacity.
Ms. Kirsten Mathieson, Head of Health, Save the Children highlighted the necessary governance dimensions needed for UHC: space for civic engagement; systems to deliver on the right to health for all without discrimination and responding to the needs of all, including those left behind; accountability structures (such as inclusive health committees, complaint mechanisms and feedback loops), accountability to vulnerable communities; participatory and inclusive decision-making processes, opening up the space at decision-making and budget tables for communities so they have a voice and can meaningfully engage in planning, implementing and monitoring; and openness, transparency and access to information and data, including budget information, to be able to engage in decision-making and hold different actors to account.
Dr. David B. Evans, Swiss Tropical and Public Health Institute, University of Basel outlined that governance requires: leadership to set direction and develop strategies, levers and tools, institutions and people for implementation, information for evidence-based policies and monitoring. In the context of UHC, the involvement of ministries beyond health is critical, not the least to mobilising the necessary public financing.
The Health Systems Governance Collaborative is is a group of practitioners, policy makers, academics, civil society representatives, agencies, decision-makers and other committed citizens seeking to connect and engage about important health systems governance issues.