Universal Health Coverage and how health systems in low and middle-income countries can rise to the challenges of actualizing UHC

Universal Health Coverage and how health systems in low and middle-income countries can rise to the challenges of actualizing UHC

Ken B

Introduction

Kenyans through The constitution of Kenya, under the Bill of Rights, give are guaranteed of the right to the highest attainable standards of health in line with the WHO Constitution which declares health a fundamental human right, thereby committing to ensuring the highest attainable level of health for all. Target 3.8 of the Sustainable Development Goals (SDGs) emphasizes the need for Universal health coverage (UHC) with a clear goal of ensuring that individuals and communities receive the health services they need without suffering financial hardship. This includes the provision of essential, quality health services, from health promotion to prevention, treatment, rehabilitation, and palliative care. UHC will ensure progress towards other health-related targets and towards equity and social inclusion In line with the 1948 WHO Constitution, which declared health a fundamental human right with nations committing to ensuring the highest attainable level of health for all.

During the 58th World Health Assembly of 2005 (WHO, 2005) and In pursuance of the human right to health nations were urged to aim at providing universally accessible health care to all members of the population based on the principles of equity and solidarity therefore in line with this the human right to health has been enshrined in Kenya’s Constitution 2010 and development agenda outlined in the governments Vision 2030. ?(MOH, 2016)

Universal health coverage (UHC) is defined as access to safe, effective, quality essential health care services, including affordable essential medicines and vaccines for all without going into poverty. In Kenya, There have been deliberate efforts to increase access and demand for healthcare services?with an Emphasis on improving the quality of health services needs to be prioritized in order to achieve UHC this is why Mechanisms to enforce quality of services need to be institutionalized and legislated at all levels if, at all universal health, coverage will be affected.?(MOH, 2016)

per capita outpatient utilization rate is on the increase signifying an improvement in ?Access to health care services in Kenya ?however there are still substantial differences within the country?(MOH, 2020)

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There has been an increase in facilities that provide high-level, specialized care in the counties. To ensure national wide hospital access, the national community health strategy has been revised and updated. The country has also developed a national referral strategy that provides clear guidelines on referral processes. Abolishment of user fees at primary-level facilities that provide basic health care to the lowers segment of the population and maternity services and grants with a focus on improving access to quality Primary health care (PHC) and Reproductive, Maternal, Neonatal, Child and Adolescent Health (RMNCAH) services by supporting operation and maintenance costs of primary health care facilities has created ease of service seeking by most individual’s and families.

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Discussion

The concept of universal health care is meant to mainstream the right for all by the year 2030 as envisaged in SDG3.4 And the agenda 2030.this means that all the people of the world have access to health services they need, everywhere they need it from without financial hardships UHC includes a range of services e.g. health promotion treatment, rehabilitation and palliative care

WHO reports that at the end of the year 2015, 400 million people globally lacked access to one or more essential health services a further 100 million per year were pushed into poverty and 150 million people suffered financial catastrophe because of out-of-pocket expenditure on health services.?(WHO, 2006)

?In a 2016 report, the United Nations Secretary-General’s High-Level Panel on Access to Medicines noted that some of the barriers to accessing medicine and healthcare include under-funded healthcare systems, a lack of investment in developing qualified and skilled healthcare workers, deep inequalities within as well as between countries, discrimination, exclusion, stigma, and exclusive marketing rights to different medicines.[1] Two indicators have been chosen to measure the progress towards universal health coverage: i. the average coverage of essential health services ii. the proportion of people covered by health insurance or a public health system. It is estimated that 18 million additional health workers will be needed by 2030 to attain effective coverage of the broad range of health services necessary to ensure healthy lives for all.[2] In addition, every 5 years, 1 billion more people will need to be covered by health insurance. [3]

SDG3 has 9 specific targets whose point of convergence is health rights for all, target 3.1 focuses on reducing the global maternal mortality ratio to less than 70 per 100,000 live births by 2030, this targets reduction of o deaths due to complications from pregnancy or childbirth. (WHO, 2006)

Over 90 per cent of maternal death occurrences live in low- and middle-income countries. Achieving the SDG target 3.1. envisions to reduce maternal mortality to less than 70 maternal deaths per 100,000 live births by 2030 thus requiring increased investment and attention to reduce the number of deaths at an annual rate of 7.5 per cent. This could save more than one million lives over the course of a decade towards achievement of health risks for women in all regions of the world. (WHO, 2006)

The rights of children both born and unborn is well elaborated in the target 3.3 which seeks to end preventable deaths of new-born and children under 5 years of age, with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1,000 live births and under-5 mortality to at least as low as 25 per 1,000 live births by year2030.?(WHO, 2006)

To assure the rights to highest attainable health care, There has been important progress on increasing access to clean water and sanitation and reducing communicable diseases such as malaria, tuberculosis and the spread of HIV/ AIDS all this underscores the implementation of SDG target 3.3 which seeks to end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases, this also relate to target 3.4 in which nations committed to reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being, Non-communicable diseases have increased in low and middle-income countries, threatening to ‘overwhelm fragile health systems unless rapid investments are made in disease prevention and health promotion.(WHO.2006)

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Implications ?

According to WHO, at least half of the world population do not receive the health services as per their needs, due to pocket spending at least 100 million people are pushed to extreme poverty each year, there is need to make health for all a reality and this will be realized when individuals and communities who have quality affordable health services will be able to take care of their families, health facilities will have enough skilled?health care workers to offer quality health care that is people centred and drafters and implementers of policies will be committed to invest in universal health coverage

?Universal health coverage is based on strong, people-centred primary health care with a strong community collaboration in shaping the health dynamics of the entire society therefore good health systems are rooted in the communities they servein a model where communities take active roles in offering health care services to themselves through the community health strategy model. This model focuses not only on preventing and treating disease and illness, but also on helping to improve well-being and quality of life.

The sustainable development goals have adopted a comprehensive approach that aims at strengthening health systems as envisaged in the target on universal health care. Access and use of quality healthcare services is only one factor affecting the health rights of individuals and communities. Whether people are healthy or not is determined by the conditions in which they are born, grow, work, live and age. These conditions are known as ‘social determinants of health’. The Sustainable Development Goals address many of these underlying determinants in the targets of SDG 3. (WHO, 2006)

In late 2018, the Government of Kenya launched the Afya Care Universal Health Coverage (UHC) pilot program in four counties in Kenya. Under the initiative, county governments discontinued all user fees at secondary public hospitals and, in return, received commodities and additional funds from the National Government. User fees have been an important source of revenue for public health facilities in Kenya for nearly three decades however, to ensure universal health coverage for all. (Mbuthia et al. 2019) these funds were fundamental in operating budget of public sector hospitals, health centers and dispensaries, respectively (Onsomu et al. 2014).The National Government set aside funds to compensate public facilities for the user fees foregone. The Ministry of Health (MOH) initially paid facilities directly but given the constitutional requirement for national funds to be transferred into the County Revenue Fund1 , the reimbursements for user fees foregone were converted into conditional grants to the counties, the National Government?therefore releases the conditional grant to counties with instructions on how much should be transferred to specific level 2 and 3 facilities as compensation for user fees, based on service utilization data from the health information system. In December 2018, President Kenyatta announced the launch of Afya Care – the UHC pilot program – to give Kenyan’s access to quality health care services without suffering from financial hardship. (Ministry of Health, 2018). The pilot was intended to run for one year starting December 13, 2018 (MOH 2020). The National Government stated the intent to scale up the program to the rest of the country following the review of the pilot, with the final goal of reaching 100% population coverage by 2022 (Nzwili 2018). The design of the scheme involved households in Isiolo, Kisumu, Machakos and Nyeri ?counties for Afya Care. Following registration, households would receive a card that would entitle them to access free services in public facilities. The card would also prevent residents from other counties in Kenya from accessing services in the four pilot counties. The National Government would then use conditional grants to reimburse the four counties for the lost revenue from the user fees foregone, with support from development partners (Mbuthia et al. 2019).

The Ministry of Health provided additional guidelines on the use of funds ?to the counties Resources under the category of public health services were exclusively allocated to County Health Management Teams (CHMTs) for service quality control, data collection, and surveillance. The funds for community health services were intended to support training of and supplies for community health workers (CHWs) for sustainable universal coverage to the grassroots. Most of the funds under the category of health system strengthening were allocated to support recruitment of health workers, preferably on a contract basis to boost the human resourses for health coverage . The remainder of funds were for the provision of basic medical equipment in health facilities through the Kenya Medical Supplies Authority. The guidelines stated that a minimum of 5% of the resources for health system strengthening must be used for performance-based financing (PBF) at the facility level (60% allocated to health workers and 40% allocated to improve the working conditions in health facilities).

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Conclusion

The UHC pilot ?has documented many significant achievements. First, the UHC pilot program managed to reach most of the population, granting them access to services free of charge. The community played an important role in the registration process. ??UHC funds flowed down to health facilities, who in turn used them to improve infrastructure so that they provide better services. ?Commodity stockouts of medicines and supplies at health facilities reduced considerably during the pilot. However, the pilot counties faced several challenges during the implementation of the program, which are worth considering for the scale-up. First, there was massive delay in disbursement of funds from the national government resulting in partial implementation of activities under the UHC pilot program. Most stakeholders suggested that a simplified process to access and use funds will most likely lead to better performance they also mentioned that the UHC steering committee that was supposed to be formed at county-level, was not constituted because of the lack of funds allocated to support this. additionally, the technical working groups for the UHC pilot program were formed but never met also due to lack of funds and lack of coordination as the UHC steering committees were never constituted. Its evident therefore that county-level committee to manage funds is of paramount importance.

The learnings from linda mama and programs like NICHE can be of good help in enhancing the roll-up of universal health coverage, in my opinion, having worked in all levels of health acre provision in various capacities, the success of universal health coverage will depend mostly on the speed at which county and national government health management is able to change the old model midset and embrace the Spirit of UHC, for instance primary health care models MUST be aligned to the UHC model of health care provision, there exist a big gap in terms of onboarding the enablers of UHC to take charge in actualization of the approaches ostensibly due to apathy in vacating from the existing model of health care provision in kenya.

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REFERENCES

1.????Chuma, Jane, Janet Musimbi, Vincent Okungu, Catherine Goodman, and Catherine Molyneux. 2009. “Reducing User Fees for Primary Health Care in Kenya: Policy on Paper or Policy in Practice?” International Journal for Equity in Health 8 (May): 15. https://doi.org/10.1186/1475-9276-8-15.

2.????Chuma, Jane, and Maina Thomas. 2013. “Free Maternal Care and Removal of User Fees at Primary-Level Facilities in Kenya: Monitoring the Implementation and Impact: Baseline Report.” Washington DC: Health Policy Project, Futures Group. County Government of Kisumu. 2019. “Universal Health Coverage Implementation. Challenges and Way Forward: Kisumu Story.” Kisumu: County Government of Kisumu. MANI Project, Options, and Marie Stopes International. 2018. “Autonomy in the Bungoma County Health System: Effects on Health System Performance. MANI Evidence Brief.”

3.????Mbuthia, Boniface, Ileana Vilcu, Nirmala Ravishankar, and Joanne Ondera. 2019. “Purchasing at the County Level in Kenya.” Washington DC: ThinkWell.

4.????McCollum, Rosalind, Ralalicia Limato, Lilian Otiso, Sally Theobald, and Miriam Taegtmeyer. 2018. “Health System Governance Following Devolution: Comparing Experiences of Decentralisation in Kenya and Indonesia.”

5.?????BMJ Global Health 3 (5): e000939. https://doi.org/10.1136/bmjgh-2018- 000939. Ministry of Health. 2018. “President Uhuru Launches Universal Health Coverage Pilot Program Nairobi, (KENYA) December 13, 2018.” 2018. https://www.health.go.ke/pre’

[1] Report of the United Nations Secretary-General’s High Level Panel on Access to Medicines, Promoting Innovation and Access to Health Technologies, High Level Panel on Access to Medicines, p. 15 (2016), available at: https://static1.squarespace.com/static/562094dee4b0d00c1a3ef761/t/57d9c6ebf5e231b2f02cd3d4/1473890031320/ UNSG+HLP+Report+FINAL+12+Sept+2016.pdf

[2] The Sustainable Development Goals Report 2017, United Nations, p. 23 (2017), available at: https://unstats.un.org/sdgs/files/report/2017/ TheSustainableDevelopmentGoalsReport2017.pd

[3] Draft Thirteenth General Programme of Work, 2019-2023, Promote Health, keep the World Safe, Serve the Vulnerable, World Health Organisation, A71/4, p. 7 (2018), available at: https://apps.who.int/gb/ebwha/pdf_files/WHA71/A7