Simfukwe K, Adebisi YA, Oladunni AA, Mohammed Eltahir SE, Lucero-Prisno III DE. The role of health service delivery networks in achieving universal health coverage in Africa (Review articles). SEEJPH 2021, posted: 27 May 2021. DOI: 10.11576/seejph-4470 REVIEW ARTICLE The role of health service delivery networks in achieving universal health coverage in Africa Knovicks Simfukwe1, Yusuff Adebayo Adebisi2, Amos Abimbola Oladunni3, Salma Elmukashfi Eltahir Mohammed4, Don Eliseo Lucero-Prisno III5 1The University of Zambia, School of Veterinary Medicine, Lusaka, Zambia 2 University of Ibadan, Faculty of Pharmacy, Ibadan, Nigeria 3 Ahmadu Bello University, Faculty of Pharmacy, Nigeria 4Uppsala University, Department of Public Health and Caring Science, Uppsala, Sweden 5Global Health Focus-Africa Corresponding Author: Knovicks Simfukwe; Address: The University of Zambia, School of Veterinary Medicine, Great East Road, Lusaka, Zambia; Email: knovicks26simfukwe@gmail.com ABSTRACT mailto:knovicks26simfukwe@gmail.com Simfukwe K, Adebisi YA, Oladunni AA, Mohammed Eltahir SE, Lucero-Prisno III DE. The role of health service delivery networks in achieving universal health coverage in Africa (Review articles). SEEJPH 2021, posted: 27 May 2021. DOI: 10.11576/seejph-4470 Most countries in Africa are faced with health system problems that vary from one to the next. Countries with a low Human Development Index (HDI) seem to be more prone to challenges in health service delivery. To mark its 70th anniversary on World Health Day, the World Health Organization (WHO) selected the theme “Universal Health Coverage (UHC): Everyone, Every- where” and the slogan “Health for All. ”UHC refers to ensuring that all people have access to needed health services (including prevention, promotion, treatment, rehabilitation, and palliation) of sufficient quality to be effective while also ensuring that the use of these services does not ex- pose the user to financial hardship. UHC is a WHO’s priority objective. Most governments have made it their major goal. This paper provides a perspective on the challenges of achieving UHC in Sub-Saharan Africa (SSA). It also endeavors to spotlight the successful models of Health Service Delivery Networks (HSDNs) that make significant strides in making progress towards achieving UHC. HSDNs pro- pose models that facilitate the attainment of affordability and accessibility while maintaining quality in delivering health services. Additionally, it brings up to speed the challenges associated with setting up HSDNs in health systems in SSA. It then makes propositions of what measures and strategic approaches should be implemented to strengthen HSDNs in SSA. This paper fur- ther argues that UHC is not only technically feasible but it is also attainable if countries embrace HSDNs in SSA. Keywords: Health Systems, Human Development Index, Universal Health Coverage, Sub-Sa- haran Africa, Health Service Delivery Networks, World Health Organization. Simfukwe K, Adebisi YA, Oladunni AA, Mohammed Eltahir SE, Lucero-Prisno III DE. The role of health service delivery networks in achieving universal health coverage in Africa (Review articles). SEEJPH 2021, posted: 27 May 2021. DOI: 10.11576/seejph-4470 Introduction Achieving universal health coverage (UHC) is a core target of the Sustainable Develop- ment Goals (SDGs) (1). The World Health Organization (WHO) defined UHC as ensur- ing that all people have access to needed health services of “sufficient quality to be ef- fective while also ensuring that the use of these services does not expose the user to fi- nancial hardship.” (2). In low and middle-in- come countries (LMICs), UHC has become an integral aspect of health reforms (3). Un- fortunately, many people in developing coun- tries do not have access to quality health ser- vices, especially those living in poor and marginalized communities (4). In most coun- tries, challenges towards achieving this target range from reaching all population groups (coverage and accessibility) to the accommo- dation of all needed services (readiness) and achievement of a reasonable proportion of health service delivery covered (health finan- cial security) (2). Health outcomes in African countries remain poor despite commitments and efforts towards achieving UHC. There are expansive shortcomings across all build- ing blocks of health, and progress has been slow in LMICs. This is complicated by inad- equate resources, inequitable access to health services, and weak health system govern- ance. Other challenges such as poverty, un- employment, climate change, conflict, inse- curity, among others, have created distrac- tions that make prioritizing health difficult (5). Thus, health outcomes tend to correlate with donor support. Strengthened preventa- ble maternal and child deaths, strong resili- ence to public health emergencies, reduced financial insecurity and strengthened the foundation of long-term economic growth will be discerning attributes of countries that achieve UHC by 2030 (11). Unfortunately, the increasing population growth rates of countries in Africa pose a significant threat to long-term inclusive growth (6). This is fur- ther complicated by the double burden of communicable and non-communicable dis- eases (7). Population distribution and geogra- phy constitutes substantial challenges to de- livering quality health services in Africa (8), and accessibility, as well as coverage of es- sential health services, are very low in Africa. There is a lack of a sufficient health work- force to meet the demand of the growing pop- ulation (13), with a health workforce density of 2.3 healthcare workers per 1000 popula- tion (9). Other studies from Africa have also confirmed that wealth is also closely related to the place of delivery, i.e., the poorest women are least likely to use facility delivery services. Out of pocket expenditure on health has been attributed to limited access to health care in the under-served population (11). Concerning the shortage of skilled health workers, insufficient resource expenditure on training, poor working environment, difficult living expenses, and poor career path (12) are implicating factors. Therefore, there is need to secure greater access to skilled health workers that meet population demands, espe- cially in underserved communities. Momen- tum for UHC in Africa is building, and many African countries have already integrated UHC into their national health strategies. But with about 11 million Africans pushed into extreme poverty each year because of out-of- pocket health expenses, how can Africa achieve UHC, which delivers a quality pack- age of care for people living in Africa? To an- swer this question of significant importance, global health think-tanks and relevant stake- holders such as World Bank, WHO, etc., are not looking any further from Health Service Delivery Networks (HSDNs) as the prime so- lution. UHC requires well-functioning health systems that provide high-quality, affordable, accessible, and efficient health services. As such, HSDNs provide these strategies aimed at achieving UHC. Simfukwe K, Adebisi YA, Oladunni AA, Mohammed Eltahir SE, Lucero-Prisno III DE. The role of health service delivery networks in achieving universal health coverage in Africa (Review articles). SEEJPH 2021, posted: 27 May 2021. DOI: 10.11576/seejph-4470 What are health service delivery networks? It has become obvious to note that networks of collaborating organizations have become critical mechanisms for the effective delivery of healthcare (13). “The rise in network pop- ularity has come largely from the recognition that money alone cannot sufficiently improve the quality of health systems, and that the ma- jor health problems facing societies are un- likely to be successfully addressed by indi- vidual organizations acting in isolation.” (14, 15). Population health may improve only if resources, talents, and strategies are pooled from across a range of actors and organiza- tions (16). Networks are defined ‘as a set of nodes and the set of ties representing some relationship, or lack of relationship, between the nodes’ (16). Relationships between nodes are typically non-hierarchical and may be founded on many and varied factors, includ- ing formal or informal flows of resources, in- formation, people, or ideas (17). The Pan American Health Organization (PAHO) de- fines Health Service Delivery Networks (HSDNs) or Organized Health Services Sys- tems, or Clinically Integrated Systems, or In- tegrated Health Organizations, “As a net- work of organizations that provides, or makes arrangements to provide, equitable, compre- hensive, integrated, and continuous health services to a defined population and is willing to be held accountable for its clinical and eco- nomic outcomes and the health status of the population served” (14). This would include referrals between services and is based on the need to provide comprehensive services (18). The final aim is to improve health outcomes, and health services are the most proximate to that end. Additionally, health services in- clude infrastructure, human resources, and supplies and technologies necessary to pro- vide care to patients (19). HSDNs can be characterized as vertical, i.e., between differ- ent levels of service delivery from the com- munity level to the clinic and hospital level, or horizontal, i.e., with providers or organiza- tions working at the same level of service de- livery (20). Considering the wide range of health system contexts, it’s extremely diffi- cult to prescribe a single organizational model for HSDNs in Africa. Each country’s policymakers must design a model that meets each system’s specific organizational needs. Below is an illustration outlining the four do- mains of the attributes of HSDNs. Figure 1: Pan American Health Organiza- tion. Integrated Health Services Delivery Networks Concepts, Policy Options and a Road Map for Implementation in the Ameri- cas. (Series: Renewing Primary Health Care in the Americas No.4) Washington, DC, 2010, pp. 32-33) Simfukwe K, Adebisi YA, Oladunni AA, Mohammed Eltahir SE, Lucero-Prisno III DE. The role of health service delivery networks in achieving universal health coverage in Africa (Review articles). SEEJPH 2021, posted: 27 May 2021. DOI: 10.11576/seejph-4470 Methods A tt r ib u te s o f h e a lt h s e r v ic e d e li v e r y n e tw o r k s Financial allocation and incetives Adquate funding and financial incetives aligned with network goals. Organizati on and Manageme nt Result based management An integrated network system that links all network members with data dissagregated by sex,place of residence ethnic origin and other partinent variables. Sufficient, committed and competent human resources for health that are valuable by the network Integrated management of clinic, administrative and logistical support system Governan- ce and Strategy A unified system of governace for the entire network Broad social participation Intersectorial action that addresses wider determinant of health and equity in healthy Mode of Care Clear definition of the population territory covered and extensive knowledge of the health needs and preferences of this population, which determines the supply of health services Extensive network of health facilities that offers health promotion, disease prevention, diagnosis, treatment, disease management, rehabilitation and palliative care and that engages program targeting specific diseases, risk and populations as well as personal and public health needs A multi-disciplinary first level of care that covers the population, serves as a get way to the system and integrate and coordinates first level of care in additon to meeting most of the population health needs Existence of mechanism to co-ordinate health care throughout the health service continuum Delivery of specialized services of the most appropriate location, preferably in nonhospital settings Care that is person, family and community centered and that takes into account cultural and gender related characteristics and delivery Simfukwe K, Adebisi YA, Oladunni AA, Mohammed Eltahir SE, Lucero-Prisno III DE. The role of health service delivery networks in achieving universal health coverage in Africa (Review articles). SEEJPH 2021, posted: 27 May 2021. DOI: 10.11576/seejph-4470 Eligibility Criteria for Studies Included in the Review We considered studies on UHC with or with- out SSA. In this paper, We considered HSDNs as the exposure variable and UHC as the outcome variable. Only published articles in peered reviewed journals were considered. Articles in languages other than English weren’t considered. In duplicate publica- tions, the article with more complete data was included. Pubmed, Medline, Google scholar, and google search served as sources for these articles. Other articles we identified from ref- erence lists of related studies from the in- cluded study. Dates of coverage were speci- fied. Search terms that were used employed the use of Boolean operators “AND,” “OR,” and “NOT” to refine searches by limiting or combining terms. The key terms to search for articles were “universal health coverage,” “health service delivery networks,” “health systems,” and “Sub-Saharan Africa”. Ab- stract information served was the screening basis and the Cochrane Risk of bias tool was used to assess the risk of bias. Results Challenges of Setting up Health Service De- livery Networks in Africa HSDNs are distinct from a conventional or- ganizational structure that is devoid of shared commitments to meet the health care needs of the population (21). Therefore, organizations establishing HSDNs must be aware of poten- tial challenges (22). These challenges form foundations of disadvantages that potentially undermine the establishment of health system models that are compatible with HSDNs in Africa: the model of hospital care and man- agement, personnel training, governance, fi- nancing strategies, and use of technologies. Health care processes in Africa are frag- mented and are not integrated with other lev- els of care which generates a lack of quality and consistency in health (23). Although there is a wide distribution of public health sectors in Africa, patients prefer to seek health care in the private sector predomi- nantly due to the perception of confidentiality and quality service delivery in private health establishments compared to the public health sector. Private healthcare provision at the pri- mary health care (PHC) level has been an in- dependent set of service providers varying significantly in quality of health services with few linkages with a structured health system (24). The implication of this is that it estab- lishes a negative perception of incompetency and mistrust in public health hospitals among users of health care, thereby promoting health-seeking behavior in private establish- ments and contributing to high out-of-pocket spending. Figure 2: Health Systems in Africa Simfukwe K, Adebisi YA, Oladunni AA, Mohammed Eltahir SE, Lucero-Prisno III DE. The role of health service delivery networks in achieving universal health coverage in Africa (Review articles). SEEJPH 2021, posted: 27 May 2021. DOI: 10.11576/seejph-4470 Perceptions and Perspectives (WHO, 2012. WHO Regional Office for Africa, 2012). The imbalance between health service needs and health service utilization also constitutes a potential challenge to health HSDNs in Af- rica. This creates a deficit and inadequate re- sponse capacity at the first level of care in terms of resources (health workforce, medi- cation, and lab supplies) and a weak public hospital network (referral, counter-referral, and feedback system). The exclusive ten- dency of an international organization to de- termine health priorities limits the participa- tion of member states in the decision-making process (25,26). This focuses on health inter- vention projects on the specific disease (ver- tical programming) rather than community- oriented primary health care intervention (horizontal programming) (24). This situation poses a challenge to the implementation of HSDNs due to a lack of shared responsibility among multilateral organizations, NGOs, governments, communities, the private sec- tor, medical professionals, and other stake- holders (23). For this reason, there is a need to develop a mechanism that promotes the de- velopment of primary health care and im- prove collaborative network across healthcare levels in an integrated system con- text that improves accessibility, affordability, availability, and quality of care for the under- resourced population. Africa has the highest population growth rate (27) and lacks a suffi- cient health workforce to meet the demand of the growing population (28). This creates shortcomings in the distribution of skilled 0.10% 0% 1.50% 69% 54.90% 67% 30.90% 45.10% 31.50% 0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% Central africa0.1% East & Southern Africa West Africa Don't know Dissatfisfied Satisfied Simfukwe K, Adebisi YA, Oladunni AA, Mohammed Eltahir SE, Lucero-Prisno III DE. The role of health service delivery networks in achieving universal health coverage in Africa (Review articles). SEEJPH 2021, posted: 27 May 2021. DOI: 10.11576/seejph-4470 health workforce across the different levels of health care and constitutes a serious chal- lenge to establishing HSDNs. A review of the health workforce in five African countries (Mali, Sudan, Uganda, Botswana, and South Africa) revealed that a minority of doctors, nurses, and midwives are working in primary health centers (PHC) and shortage of skilled health personnel are the greatest in rural areas (29). A greater number of doctors trained in Mali, Uganda, and Sudan do not stay to work in government health establishments in their countries, let alone in primary health care, due to inadequate resource expenditure on re- cruiting or training, poor working environ- ment, difficult living expenses, and poor ca- reer path (30). These imbalances in the health workforce model can create a huge gap in health service readiness towards establishing sustainable HSDNs in Africa. Population dis- tribution and topography in SSA present many challenges for health care delivery (31) and HSDNs. A geocoded inventory of hospi- tal services across 48 countries in Africa re- veals that only 16 countries met the interna- tional recommendation of more than 80% of the population within a 2-h time of travel to a hospital (32). This situation creates a consid- erable gap between the demand and supply of health care services among a geographically marginalized population which potentially limits the implementation of HSDNs in af- fected African countries. Innovative ap- proaches for integrated HSDNs in healthcare delivery in Africa are required in specific ge- ographical locations, including improvement of ambulatory services, transportation modes, communication systems, and the number of quality health service centers. In- formation and Communication Technology (ICT) is integral in operationalizing HSDNs. Although technology in health has a potential beneficial impact on HSDNs, high imple- mentation cost and lack of technical skills (33), security and confidentiality concerns (33,34) are barriers to implementation of both in Africa. The major barrier to e-Health adop- tion and one that can potentially affect the im- plementation of HSDNs in Africa is the lack of cooperativeness between health infor- mation systems (HISs) (35). The presence of varying standards in HISs often creates a con- flict of interest which makes it quite difficult to establish cooperative governance that of- fers quality health services in a coordinated and timely fashion. Figure 3: Access to emergency hospital care Simfukwe K, Adebisi YA, Oladunni AA, Mohammed Eltahir SE, Lucero-Prisno III DE. The role of health service delivery networks in achieving universal health coverage in Africa (Review articles). SEEJPH 2021, posted: 27 May 2021. DOI: 10.11576/seejph-4470 Ouma et al. Access to emergency hospital care provided by the public sector in sub-Saharan Af- rica in 2015: a geocoded inventory and spatial analysis. Lanc glob health. 2018. Vol 6, Issue 3, E342-E350. https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(17)30488-6/fulltext Discussion Examples of Successful Models of Health Service Delivery Networks The referral pathway model Referral systems in healthcare are processes in which a health worker at one level of the health system with insufficient resources (drugs, equipment, skills) to manage a clini- cal condition seeks the assistance of a better- resourced facility at a higher level to assist him/her, or take over the management of, the client’s case (36). Clients/Patients in Ghana, just like in other African countries such as Mozambique, South Africa, and Zambia, among others, are expected to access services from primary services incrementally (e.g., the Community-based Health Planning Ser- vices, CHPS, and Health Centers), through to secondary facilities (e.g., district hospitals) and if required to the highest services (re- gional and tertiary hospitals) (37). 36.90% 23.30% 23.30% 46.90% 4.30% 17.40% 6.60% 51.50% 53.10% 3.40% 27.70% 34.40% 46.30% 16.70% 24.20% 57.40% 49.30% 16.40% 13.80% 38.50% 7.10% 43.30% 38.50% 53.40% 7.20% 36.20% 61.40% 49.90% 23.20% 57.20% 7.70% 11.20% 2.70% 39.70% 39.60% 39.60% 5.20% 77.20% 53.80% 6.10% 24.90% 14.70% 17.50% 40.10% 2.70% 20.70% 0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% 90.00% 100.00% % P O P U L A T IO N COUNTRIES https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(17)30488-6/fulltext#Figure Simfukwe K, Adebisi YA, Oladunni AA, Mohammed Eltahir SE, Lucero-Prisno III DE. The role of health service delivery networks in achieving universal health coverage in Africa (Review articles). SEEJPH 2021, posted: 27 May 2021. DOI: 10.11576/seejph-4470 Figure 4: The referral pathway model Amoah P.A, Philips D.R. 2017. Strengthening the referral system through social capital: A quali- tative inquiry in Ghana. Healthcare 2017, 5, 80. Social Marketing Model The marketing strategies used by the majority of these organizations include both promo- tion of these services to the poor and the de- sign of these services to meet the needs of this group. Social marketing refers to the applica- tion of marketing techniques to achieve be- havioral changes (38). The Population Ser- vices International (PSI) in Africa has been making use of this concept for many years. PSI runs programs that offer educational pro- grams on reproductive health for urban youth in Africa. Magazines, television spots, call-in radio shows, and radio drama serve as ave- nues to address the taboo subject of safe sex- ual behavior (39). Studies have shown that youths have been responsive to these pro- grams, and this resulted in increased contra- ceptive use and HIV testing (40). In a nut- shell, this concept has largely contributed to making health services accessible. Simfukwe K, Adebisi YA, Oladunni AA, Mohammed Eltahir SE, Lucero-Prisno III DE. The role of health service delivery networks in achieving universal health coverage in Africa (Review articles). SEEJPH 2021, posted: 27 May 2021. DOI: 10.11576/seejph-4470 Contracting out model This involves the delegation of a health-re- lated responsibility by the state to a private partner, and this can be a philanthropic or commercial basis (4,42). The private partner usually includes mining companies in Zam- bia and South Africa and faith-based based hospitals in Tanzania. These private partners tend to provide subsidized health services to the community, sometimes even those not covered in the contract. Type specificity, quantity, quality, and duration of services delegated are outlined in a contract (42). An- tenatal care, delivery and postnatal services, and the Prevention of Mother to Child Trans- mission of HIV (PMTCT) are among the ser- vices that are contracted out by the state to private partners. Because of the very nature of this model, there has been overwhelming evidence that it improves access to health ser- vices and some evidence on improved equity in access (43). Foreign-aided model Global Public-Private Partnership (GPPP) is a collaborative, three-way partnership, in- cluding international donors and recipient governments, usually funded by multina- tional health initiative through a substantial disbursement of funds, in which both govern- ment and non-governmental entities partici- pate in decision-making through a mutually agreed upon and well-defined division of la- bor (44). Most of the GPPP in African coun- tries such as Botswana, Malawi, Zambia, etc. is aimed at HIV prevention and care-such as the African Comprehensive HIV/AIDS Part- nership (ACHAP), and detection and treat- ment of women’s cancers -Pink Ribbon, Red Ribbon (with PEPFAR and the Gates Foun- dation). With regards to Botswana, GPPP has provided the urgently needed infrastructure, equipment, human resources, and training of healthcare providers (45). Consequently, GPPP cuts the cost of health services on na- tional budgets while improving the access, coverage and, quality of health services being delivered to the people. Lower operating costs through simplified medical services “Operating costs were lowered by simplify- ing the medical services provided and using less than fully qualified providers.” (46). For example, East Africa and some parts of Southern Africa have introduced a diploma in Clinical Medicine. These Clinical officers have contributed heavily to HIV/AIDS pre- vention and treatment initiatives in Africa (47). The use of community health workers (CHWs) is an excellent catalyst in providing “basic health promotion and healthcare within the communities in which they live” (48). CHWs are laypeople of varied back- ground, coming from, or based in the com- munities they serve, who have received brief training on a health problem they have volun- teered to engage with have been “cited as part of the solution to the shortage of health work- ers and lack of universal access to healthcare in low-income” (49, 50) and feature promi- nently in the WHO’s workforce 2030 strat- egy for human resources for health (50). Ul- timately, this model of HSDNs improves the accessibility of health services to poor peo- ple. High volume and low unit costs This model is very effective at improving the affordability of healthcare services through maximizing the use of infrastructure, and health personnel, and alternate use of cheaper medical procedures and equipment (51). Hospitals that implement this model tend to be located in high-density areas and target low-income groups requiring basic medical care. Since the available services are limited, there’s high patient throughput (100 patients per day per doctor). The high productivity of Simfukwe K, Adebisi YA, Oladunni AA, Mohammed Eltahir SE, Lucero-Prisno III DE. The role of health service delivery networks in achieving universal health coverage in Africa (Review articles). SEEJPH 2021, posted: 27 May 2021. DOI: 10.11576/seejph-4470 health personnel helps to make the services affordable. R-jolad Hospital in Nigeria, Nsambya hospital in Uganda, and Selian Lu- theran hospital in Tanzania are examples of successful case studies (52). Human resource optimization Healthcare organizations have expanded the use of laypeople who are then equipped with skills and help in the distribution of oral con- traceptive pills or eye exams. Aravind Eye system trains high school graduates into par- amedical staff like patient flow managers, providers of simple diagnostic procedures, etc. (53). Another example is the Kisumu Medical, and Educational Training (KEMT) model in Kenya embarks on improving the quality of care by leveraging human re- sources. KEMT trains existing health work- ers in a safe procedure (54). These models trek miles in improving access, coverage, and quality of health services. Increasing practice in rural areas model SSA experiences a disproportionate burden of access to health services. In its quest to reach the poor, Narayarana Hrudayala (NH) Heart Hospital provides health camps in rural areas of India. Healthcare workers in these camps provide a cardiac diagnosis with trans- portation to the hospital for patients who re- quire it (55). This model enhances accessibil- ity to health services. Recommended measures that can be imple- mented to strengthen health service delivery networks in sub-saharan Africa.  Empowering and engaging people and communities: This strategy allows for skill acquisition and places resources to people as a means of mak- ing them become empowered users of health services and advocates for a reformed health system. This is achieved through health edu- cation, engaging laypeople as community health workers. Empowering and engaging people is also about reaching the underserved and marginalized groups of the population to guarantee universal access to and benefit from quality services that are co-produced according to their specific needs.  Strengthening governance and accounta- bility: The requirements for strengthening govern- ance include a participatory approach to for- mulating policies, decision-making, and per- formance evaluation at all levels of the health system, from policy-making to the clinical in- tervention level. The need for good governance in ensuring the best possible results cannot be over-empha- sized. This demands that transparency, inclu- siveness, reduced vulnerability to corruption which facilitates the best use of available re- sources and information, become the norm in HSDNs.  Reorienting the model of care: This strategic approach prioritizes primary and community care services and the co-pro- duction of health. This brings about a shift in inpatient to outpatient and ambulatory care and from curative to preventive care. It re- quires investment in holistic and comprehen- sive care, including health promotion and ill- health prevention strategies that support peo- ple’s health and well-being. Reorienting the model of care ensures efficient healthcare services.  Coordinating services within and across sectors: The needs and demands of people serve as the basis for coordinating services within and across sectors. For this to be achieved, health care providers within and across health care settings, development of referral systems and networks among levels of care, and the crea- tion of linkages between health and other sec- Simfukwe K, Adebisi YA, Oladunni AA, Mohammed Eltahir SE, Lucero-Prisno III DE. The role of health service delivery networks in achieving universal health coverage in Africa (Review articles). SEEJPH 2021, posted: 27 May 2021. DOI: 10.11576/seejph-4470 tors should be integrated. This approach im- proves the delivery of care through the align- ment and harmonizing of the processes and information among the different services.  Creating an enabling environment: This complex strategy aims at effecting transformational change in leadership and management, information, methods to im- prove quality, reorientation of the workforce, legislative frameworks, financial arrange- ments, and incentives. 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