Leufak AM, Ndwandwe D. Applying innovative strategies to achieve Universal Health Coverage in the African Region. (Position paper). SEEJPH 2021, posted: 18 May 2021. DOI: 10.11576/seejph-4447 1 POSITION PAPER Applying innovative strategies to achieve Universal Health Coverage in the African Region Arlette Mouako Leufak1, Duduzile Ndwandwe2 1Department of Global Health, Stellenbosch University, Francie van Zijl Drive, Tygerberg 7505, Cape Town, South Africa 2Cochrane South Africa, South African Medical Research Council, Francie van Zijl Drive, Parow Valley 7501, Cape Town, South Africa Corresponding Author: Arlette Mouako Leufak; Address: 6 Robyn Court, 9 Steenbras Street Parow, Cape Town, 7500, South Africa; Email: arlettemouako@gmail.com Leufak AM, Ndwandwe D. Applying innovative strategies to achieve Universal Health Coverage in the African Region. (Position paper). SEEJPH 2021, posted: 18 May 2021. DOI: 10.11576/seejph-4447 2 Abstract Universal health coverage is defined as ensuring that all people have access to needed health services of sufficient quality to be effective while ensuring that these services do not expose the user the financial hardship. Universal health coverage includes three related objectives: equity in access to health services (everyone who needs services should get them, not only those who can pay for them); the quality of health services should be good enough to improve the health of those receiving services; and people should be protected against financial risk, ensuring that the cost of using services does not put people at risk of financial harm. Africa still has a long way to go to achieve these objectives. Many barriers limit the progress of the African Region towards building the robust health systems needed for universal health coverage. Such barriers include poor infrastructure, high out-of-pocket payments and catastrophic health expenditures, shortages and inequitable distribution of qualified healthcare workers, poor quality of care delivery, high cost of quality medicines, and lack of innovative technologies appropriate to the range of settings where care is delivered, health financing and governance. This paper aims to propose innovative strategies that could be applied to improve health systems in the Africa Region, which progress towards the continent attaining universal health coverage. Keywords: Innovative strategies, Universal health coverage, African Region Leufak AM, Ndwandwe D. Applying innovative strategies to achieve Universal Health Coverage in the African Region. (Position paper). SEEJPH 2021, posted: 18 May 2021. DOI: 10.11576/seejph-4447 3 Introduction The desire of all communities is to receive good quality healthcare service at an affordable price and to live in good conditions. To fulfil this desire, in 2015 the United Nations (UN) adopted 17 life- changing goals, known as Sustainable Development Goals (SDGs) to improve the planet and the lives of all communities by 2030 (see figure 1) (1). Goal 3, which is SDG 3 includes 9 targets to be achieved by 2030 (2). Of these targets is SDG 3.8, which seeks to achieve universal health coverage (UHC) (2). UHC is comprised of ensuring financial risk protection, access to quality essential healthcare services, and access to safe, effective, quality, and affordable essential medicines and vaccines for all (3). Recently, the World Health Organisation (WHO) reported that achieving UHC by 2030 may not be achievable (3). At least half of the world’s population still do not have full coverage of essential health services (3), approximately 100 million people further pushed into extreme poverty due to having to pay for health care (3). This is seen in around 930 million people globally spend at least 10% of their household budgets to pay for health care (3). Thus, the first UN high-level meeting on UHC was held in September 2019 to renew the movement towards UHC (4). Member States adopted a political declaration, “Universal health coverage: moving together to build a healthier world,” to show their commitment to achieving UHC and reached the Sustainable development Goal 3 (SDG3) by 2030 (4). The declaration encourages each country to prioritise and implement its national UHC package, tailored to patient needs and considering current health system capacities (4). The WHO defines UHC as a condition where all people who need health services (prevention, promotion, treatment, rehabilitation, and palliative care) receive them without incurring financial hardship (5). UHC allow everyone to access the health services that address the most important causes of disease and death and ensures that the quality of those services is adequate to improve the health of the people receiving them (3). Protecting people from the financial consequences of paying for health services out of their own pockets avoids pushing poor people to extreme poverty (3). Many countries, including Japan, France, Thailand, Brazil, Turkey, have made significant progress towards UHC (6). In African countries, people continue to experience undue financial hardship while receiving health services (7). The unwarranted financial burden is a result of weak healthcare systems. The African region faces unique challenges that slow the progress of building robust healthcare systems for UHC. Such challenges include poor infrastructure; high out-of-pocket payments and catastrophic health expenditures; shortages and inequitable distribution of qualified healthcare workers; poor quality of care delivery; high cost of quality medicines; lack of innovative technologies appropriate to the range of settings where care is delivered; health financing; gaps in governance, leadership, and management (8). This begs the question of which innovative strategies should we apply to drive the African Region towards UHC attainment? Leufak AM, Ndwandwe D. Applying innovative strategies to achieve Universal Health Coverage in the African Region. (Position paper). SEEJPH 2021, posted: 18 May 2021. DOI: 10.11576/seejph-4447 4 Figure 1: Sustainable Development Goals Leufak AM, Ndwandwe D. Applying innovative strategies to achieve Universal Health Coverage in the African Region. (Position paper). SEEJPH 2021, posted: 18 May 2021. DOI: 10.11576/seejph-4447 5 Findings Lack of adequate or modern infrastructure and equipment remains a major concern in Africa. Most Africans health facilities still relying on old equipment, which sometimes are not very effective. Even with old equipment, some health facilities, especially those in rural and remote areas, face challenges in providing health services to patients. Therefore, patients are usually referred to a health facility in the city to receive better healthcare. Even in the city, some are referred to as a developed country where they can find complete access to first-class tools and excellent technology required for treatment. In our opinion, each African government needs to conduct a health infrastructure survey in each province of their countries to identify which infrastructures to innovate, which first-class equipment to implement. The survey should include health professionals, health policymakers, and patients/population. Additionally, out-of-pocket spending on healthcare by households continues to be high in Africa, contributing to the causing poverty in the continent (3, 9). Some African countries like Ghana, Nigeria, have implemented national medical insurance schemes to reduce out-of-pocket spending on health, yet this scheme covers only a minority (9). Only a third of the population receives medical insurance under the country’s National Health Insurance Scheme in Ghana. Nigeria’s national scheme covers less than 3% of its citizens. Given that only a few people are covered in the African continent and poverty is widespread, reducing out-of-pocket payments in Africa might help ameliorate health conditions and eliminate or prevent poverty. We suggest that to reduce out-of- pocket health payments in Africa, each African government should revise its health policies to establish a National Health Insurance System that will provide free health care to all citizens or cover at least all the leading communicable diseases (HIV/AIDS, Tuberculosis, Malaria) and non-communicable diseases (hypertension, heart disease, diabetes), and all preventable childhood illness. The National Health Insurance System should not leave anyone behind. Besides high out-of-pocket health payments in Africa, human resources for health is limited in Africa. Over half of Africa’s population lacks access to essential health services, and the continent’s population is estimated to reach 2.5 billion by 2050 (3, 7). The lack of access to essential health services is attributable to the limited human resources for healthcare and their poor distribution in most African countries. The shortage of human resources for healthcare crucially affects healthcare service delivery in the African Region (9). Many health professionals have left Africa overseas because of low wages, poor working conditions, and insecurity (9). According to WHO, Africa bears more than 24% of the global burden of disease but has access to only 3% of health workers (9). To improve the number of health professionals, we proposed that each African government first assess the number of his health professionals and then see how many are needed to fill the gap. The next step should be to subvention the training of the required health professionals for some time. Once the training is done, trainees should be recruited, and their salaries should be considerable. We further suggest that remote and rural areas should not be left behind while planning for training and recruiting. Most of remote and rural areas lack highly qualified health professionals. Consequently, people living in such areas do not benefit from some of the important health services. To achieve this, public sector should work together with the private sector. The public sector should provide Leufak AM, Ndwandwe D. Applying innovative strategies to achieve Universal Health Coverage in the African Region. (Position paper). SEEJPH 2021, posted: 18 May 2021. DOI: 10.11576/seejph-4447 6 opportunities or encourage the private sector to invest in the training of health professionals and the construction of medicals health centres in each province. There should be at least two public Faculty of Health Science and Medicine in each area in the African Countries. We believe that this might help increase the number of health workers and the quality of health care service delivery in the region. Further, our proposition might limit the emigration of health professionals overseas. In the others hand, many people are still dying in Africa due to a lack of access to medicine. The key to the three leading causes of death (malaria, Tuberculosis and HIV/AIDS) in Africa remain scarce or expensive (9). The scarcity or the high cost of medicines is a result of most medicines being imported to Africa. Many African countries do not have the technical, financial or human resources required for high–scale drug production. From our perspective, if African governments make an effort to invest more in pharmaceutical research and development and local production, the access to medicine will increase, and the cost will be reduced. However, this cannot be successful without adequate infrastructure, innovative technology, training and retaining of Africans scientists. Most healthcare settings, especially primary healthcare settings, lack innovative technology that might be useful for increasing healthcare service delivery. For instance, a life-saving device such as mobile Vscan ultrasound is not very well- known in many healthcare facilities in Africa (10). Vscan ultrasound is a non- invasive device with the size of a smartphone, which provides real-time high- resolution images that can be used in medical fields such as cardiology and obstetrics and gynaecology. Mobile Vscan has been proven to diagnose health conditions and diseases more efficiently and accurately than current practices using standard equipment (10). Given the high rate of maternal and new-born mortality overall in the African Region, such a device might be useful to prevent deaths of new- borns and children under 5 years of age and reduce neonatal and maternal mortality, especially in settings where access to healthcare service is difficult. To our mind, African governments should consider including the budgets for innovative technologies in their agenda. Innovative technologies will thus play a vital role in changing African health. Researchers suggest that to improve health financing in Africa, each African government should increase its revenues mainly through efficient and progressive taxation and increase spending on health, considering long-term fiscal space (11). Expand pooling arrangements progressively to reorient private spending into pooled financing arrangements; avoid the fragmentation of financing systems into separate schemes with different levels of funding and benefits for different population groups; target resources to the removal of financial barriers facing the poor and most vulnerable to access priority services (11). Manage public funds transparently for better accountability; allocate resources toward inputs and services that generate better results at a lower cost; develop and implement policies and regulations that ensure the efficient use of resources and use incentives in provider payment mechanisms and strengthen provider autonomy and facility management (11). Authors proposed that to ameliorate African governance, African governments should introduce mechanisms of voice and community empowerment in health service delivery and establish citizens’ platforms to formulate and review national health policies, strategies and plans, and priority setting and decisions on resource allocation (11). Ensure citizens’ access to data and information on UHC freely and adopt a core set of indicators formally to monitor UHC progress and incorporate them in national Leufak AM, Ndwandwe D. Applying innovative strategies to achieve Universal Health Coverage in the African Region. (Position paper). SEEJPH 2021, posted: 18 May 2021. DOI: 10.11576/seejph-4447 7 monitoring and evaluation systems (11). Provide and enforce fair, transparent, and effective regulatory frameworks and accreditation systems to maximise the reach, affordability, and quality of health services for all (11). Develop national whole-of-government multisectoral plans, establish mechanisms for community mobilisation and coordinate across ministries and other stakeholders, and engage with the private sectors effectively to address health risks and promote health (11). Initiate, organise and finance collective action on research, tool development, norms and standards, and mutual learning and sharing of experiences on health system strengthening across countries regardless of development status (11). Deliver relevant products with an effective interaction of R&D between public and private sectors and strengthen regulatory systems and a skilled workforce to use technology transfer effectively (11). Conclusions Not much is known about which innovative strategies to employ in the African Region to drive the goals of SDGs and UHC. This paper seeks to inform policymakers, African Leaders on strategies to apply to improve health systems in the African Region and drive the continent towards UHC attainment. There is a gap in knowledge about achieving UHC in Africa. We anticipate that the proposed approaches will contribute to filling the knowledge gap on how to achieve UHC in African countries and tailored interventions that could be applied to improve health conditions and services delivery in African communities. However, the proposed strategies might not be applicable to all African countries as each country has its own context even if the challenges faced might be similar. To achieve UHC in the African Region, health needs to remain a top priority for all African countries. We have no doubt that if African Governments strongly invest in their health system, progress will be made towards UHC in the African Region. Reinforcing health systems will demand to mobilize more resources for health. 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