David Evans: putting universal health coverage on the agenda

MotivationTurkey has been acknowledged as a “successful” example of Universal Health Coverage (UHC) reforms and has recently gained donor “darling status.” While the literature on UHC and health reforms in various countries has increased significantly in recent years, there is still little research on the political dynamics of the rise of UHC in national and global development agendas.PurposeThis study examines the politics of UHC in Turkey’s Health Transformation Program (HTP). It investigates how various policy actors, such as international organizations, policy experts and national political leaders, use UHC framing for different purposes.Approach & MethodsThe article develops an interdisciplinary conceptual framework that combines elements of ideational scholarship and critical policy analysis. The analysis is based on a review of the secondary literature and primary sources. Qualitative content analysis is used to identify major themes and analyse patterns of interactions across the various policy levels.FindingsThe article’s main findings demonstrate the ways in which international actors and national policy‐makers engage in policy work and use their relationships, global policy ideas and experiences to build legitimacy and support for their respective agendas. Reforms in Turkey were proposed and implemented before the rise of UHC in the global agenda, suggesting an ex post facto rebranding of its reforms as UHC. For Turkey’s policy‐makers, rebranding worked to tie their policy solutions, summarized in the HTP, to UHC as a widely accepted cultural symbol. The Ministry of Health’s deliberate strategy to encourage data collection and monitoring was also a key part of its efforts to construct a success narrative in collaboration with global policy actors. For the global‐level advocates of UHC, Turkey provided evidence that UHC works. Before it became a target under the health‐related Social Development Goals (SDGs), advocates needed to demonstrate that they had the right framing and metrics for a UHC agenda. After 2015, successful examples have served as strategic tools for building support and political momentum as the agenda was diffused, and as these diverse agendas and interests overlapped.Policy ImplicationsThis article contributes to the current debates on policy diffusion, translation and implementation of the UHC agenda. It unpacks the use of success stories to navigate the political dynamics among national governments and global policy communities. Success stories, alongside an emphasis on country ownership, may serve to encourage the co‐production of policy across local, national and global levels.

The Special Programme for Research and Training in Tropical Diseases developed a massive open online course (MOOC) on implementation research with a focus on infectious diseases of poverty (IDPs) to reinforce the explanation of implementation research concepts through real case studies. The target MOOC participant group included public health officers, researchers and students. By reshaping institutions and building resilience in communities and systems, implementation research will allow progress towards universal health coverage and sustainable development goals. This study evaluates learners’ knowledge in implementation research after completing the MOOC using anonymous exit survey responses. Of the almost 4000 enrolled in the two sessions of the MOOC in 2018, about 30% completed all five modules and the assessments, and were awarded certificates. The majority of the participants were early to mid-career professionals, under the age of 40, and from low- and middle-income countries. They were slightly more likely to be men (56%) with a Bachelor or a Master’s degree. Participants were public health researchers (45%), public health officers (11%) or students (11%). On completion of the course, an exit survey revealed that 80.9% of respondents indicated significant improvement to strong and very strong implementation research knowledge. This evaluation clearly shows the usefulness of the MOOC on implementation research for reaching out to field researchers and public health practitioners who are facing problems in the implementation of control programmes in low- and middle-income countries.

Learning is increasingly seen as an essential component to spur progress towards universal health coverage (UHC) in low- and middle-income countries (LMICs). However, learning remains an elusive concept, with different understandings and uses that vary from one person or organisation to another. Specifically, it appears that ‘learning for UHC’ is dominated by the teacher mode — notably scientists and experts as ‘teachers’ conveying to local decision/policy-makers as ‘learners’ what to do. This article shows that, to meet countries’ needs, it is important to acknowledge that UHC learning situations are not restricted to the most visible epistemic learning approach practiced today. This article draws on an analytical framework proposed by Dunlop and Radaelli, whereby they identified four learning modes that can emerge according to the specific characteristics of the policy process: epistemic learning, learning in the shadow of hierarchy, learning through bargaining and reflexive learning. These learning modes look relevant to help widen the learning prospects that LMICs need to advance their UHC agenda. Actually, they open up new perspectives in a research field that, until now, has appeared scattered and relatively blurry.

BackgroundDiseases transmitted to humans by vectors account for 17% of all infectious diseases and remain significant public health problems. Through the years, great strides have been taken towards combatting vector-borne diseases (VBDs), most notably through large scale and coordinated control programmes, which have contributed to the decline of the global mortality attributed to VBDs. However, with environmental changes, including climate change, the impact on VBDs is anticipated to be significant, in terms of VBD-related hazards, vulnerabilities and exposure. While there is growing awareness on the vulnerability of the African continent to VBDs in the context of climate change, there is still a paucity of research being undertaken in this area, and impeding the formulation of evidence-based health policy change.Main bodyOne way in which the gap in knowledge and evidence can be filled is for donor institutions to support research in this area. The collaboration between the WHO Special Programme for Research and Training in Tropical Diseases (TDR) and the International Centre for Research and Development (IDRC) builds on more than 10 years of partnership in research capacity-building in the field of tropical diseases. From this partnership was born yet another research initiative on VBDs and the impact of climate change in the Sahel and sub-Saharan Africa. This paper lists the projects supported under this research initiative and provides a brief on some of the policy and good practice recommendations emerging from the ongoing implementation of the research projects.ConclusionData generated from the research initiative are expected to be uptaken by stakeholders (including communities, policy makers, public health practitioners and other relevant partners) to contribute to a better understanding of the impacts of social, environmental and climate change on VBDs(i.e. the nature of the hazard, vulnerabilities, exposure), and improve the ability of African countries to adapt to and reduce the effects of these changes in ways that benefit their most vulnerable populations.

Medicines and universal health coverage: challenges and opportunities.

Recent years have demonstrated the resurgence of a global commitment toward universal health coverage (UHC). The first step toward developing a sustainable primary health care (PHC)-oriented UHC program is the creation and service delivery of an explicit essential health care benefit package (EHCP). This paper aims to describe the development, features, and progress of the EHCP in Lebanon, in addition to outlining barriers, facilitators, and next steps. Building on the investments made in the PHC network, the ministry of public health in Lebanon piloted an essential PHC package program in 2016 targeting vulnerable Lebanese and was able to enroll over 87% of targeted population to date. In order to scale up the EHCP to the national level and achieve UHC, modifications need to be made to the package entitlements, provider payment mechanisms, and implementation arrangements. The paper also notes that further advocacy and lobbying are needed in order to place UHC and the EHCP on the national agenda and stimulate public demand.

To provide information about preventive measures and treatment seeking behaviour as well as an estimate of the malaria burden in different epidemiological settings for effective monitoring and evaluation of the ongoing efforts. Cross-sectional survey carried out in four areas representing different levels of transmission to explore the use of preventive measures, care-seeking behaviour and accessibility in addition to point prevalence was followed by a follow-up phase in which the health workers registered and reported all fever cases including malaria. The relation between the reported malaria incidence, the product of symptomatic/asymptomatic ratio and the prevalence of confirmed malaria cases was used to develop the equation that could predict the true malaria incidence. Thousand households and 3628 individuals were surveyed. The presence of any net varied between 6.6% and 40%; the percentage of people who reportedly slept under mosquito nets in the previous night varied between 35 and 80. Prompt use of medications ranged between 14 and 48% with a delay of more than 24 h noticed in different areas. The mean number of individuals per household who reported use of anti-malarial drugs in the last 2 weeks ranged between 0.6 (SD = 0.92) and 1.2 (SD = 1.1), with variable cost per treatment and affordability. The prevalence of asymptomatic parasitaemia, fever and confirmed malaria at time of the survey differed by area. The incidence of malaria during the follow-up period was estimated to be 8.5, 178.6, 23.7 and 10.3 episodes per 1000 population in Malakal, Elrank, Elhosh and El Matama, respectively. Based on this, a prediction equation was developed. We found suboptimal health care seeking behaviour, coverage and use of preventive measures with a high malaria burden. We developed a model for future estimation of malaria episodes.

Universal health coverage: friend or foe of health equity?

Suicide Prevention in an International Context.

An adequate, performing health workforce is vital for improving health service coverage and health outcomes.1 Yet the availability, distribution, capacity and performance of human resources for health (HRH) varies widely and many countries have fewer health workers than needed for high coverage of essential health services, according to the World health report 2006.2 Signs of progress are emerging, though; several countries are successfully addressing their problems in the area of HRH, resulting in improvements in health outcomes.3 These gains are, however, vulnerable: shortages of and inequitable access to health workers still thwart many countries’ attempts to achieve the Millennium Development Goals (MDGs) and their efforts to scale up their response against noncommunicable diseases and attain universal health coverage. Universal Health Care (UHC) was defined by the World Health organization in 2005.4 Since then it has gained increased recognition as a framework for embracing various global health priorities. New evidence, policy options and advocacy5 in support of the progressive achievement of UHC have been the focus of the World health report: health systems financing6 and of numerous global health events.7,8 In 2011 the World Health Assembly adopted a resolution on UHC,9 and in 2012 a United Nations General Assembly resolution bolstered political momentum in support of UHC and underscored the need for an “adequate, skilled, well-trained and motivated workforce”.10 In this context ensuring that appropriate HRH strategies and priorities are embedded in the UHC and post-MDG agenda becomes crucial. As health systems progressively broaden their scope to cover noncommunicable diseases and other priorities, health workers will face new demands for more comprehensive and equitable service delivery. The challenge lies in addressing past and present gaps while simultaneously anticipating future actions to strengthen the health workforce as an integral part of health systems. The HRH needs demand renewed attention, strategic intelligence and action. Gaps in health worker distribution, competency, quality, motivation and performance need to be addressed in addition to sheer numbers. Fundamental changes in the way in which health workers are trained, managed, regulated and supported and in the role of the public sector in shaping labour market forces will be necessary. Against this background, the Bulletin will publish a theme issue on HRH and universal health coverage to provide an opportunity to identify the changes in HRH investment, production, deployment and retention required to achieve UHC. Its publication will coincide with the Third Global Forum on Human Resources for Health, to be held in Recife, Brazil, on 10–13 November 2013. The Third Global Forum is convened by the Global Health Workforce Alliance (GHWA) – a multisectoral partnership established in 2006 to spearhead the response to HRH challenges – in conjunction with WHO, the Pan American Health Organization and the Government of Brazil. The First Global Forum (Uganda, 2008) resulted in the development of a global HRH roadmap;11 at the Second Global Forum (Thailand, 2011), countries and stakeholders reconvened to review progress and renew their commitments towards increased investment, sustained leadership and the adoption of effective HRH policies. The Third Global Forum will provide an opportunity to update the HRH agenda, to make it more relevant to the current global health policy discourse, including the focus on achieving the health MDGs, the objective of UHC and the emerging debate on the post-2015 agenda. Additionally, countries and HRH stakeholders will be invited to explicitly commit to HRH actions as the basis for an inclusive accountability framework. The Third Global Forum’s programme will position health workforce development as a critical requirement for effective UHC and will be designed around one overarching theme – “human resources for health: foundation for universal health coverage and the post-2015 development agenda” – as well as five sub-themes and their corresponding tracks: (i) leadership, partnerships and accountability for HRH development; (ii) impact-driven HRH investments towards UHC; (iii) a supportive HRH legal and regulatory landscape for UHC; (iv) empowerment of health workers by overcoming policy, social and cultural barriers; (v) the harnessing of HRH innovation and research through new management models and technologies.12 To provide a solid evidence base and background to the Third Global Forum’s proceedings, the theme issue will feature commissioned as well as independently submitted articles that will set the scene for and generate innovative thinking on HRH for UHC. GHWA and WHO welcome contributions on the Forum’s general theme, five sub-themes and tracks, especially those emphasizing aspects of HRH directly related to achieving UHC. Submission of relevant country experiences is particularly encouraged. The deadline for submissions is 10 March 2013. Manuscripts should respect the Bulletin’s Guidelines for contributors (available at: http://submit.bwho.org) and mention this call for papers in the cover letter. All submissions will be reviewed by peers.

Background The relatively low universal health coverage (UHC) effective coverage indices in most African countries is a cause for concern. Some African countries have effective coverage indices as low as 25 when the global average is 44-48. Although several African countries have initiated UHC activities, their implementation paces and approaches vary. The aim of this systematic mapping study is to describe the publication frequencies on UHC-related activities across African countries. The revealed publication patterns can guide the enhancement of UHC research, implementation, and publication in Africa. Methods This systematic mapping study was conducted by first establishing a research scope. Then, relevant publications were identified from PubMed, Google Scholar, Google, WHO, and uhc2030 search engines. A classification scheme was developed to guide the systematic mapping of the selected 202 publications. This systematic mapping study describes the variations in UHC-related publication types, contributions, focus areas, and dimensions between 2013 and 2023 across African countries. Results Analyzing the publications based on the developed classification scheme revealed that WHO was the most frequent author with 17 publications. Secondly, primary research articles (28.2%, n = 57) were the commonest while legislation (0.5%, n = 1) were the rarest. Most of the publications were on the financing and performance of health systems. Conclusions Overall, publication numbers and evidence value increased as time progressed from 2013 to 2023. The generated systematic maps indicate opportunities for UHC-promoting publication activities. Supporting the development of legislation and authoring systematic reviews are some of the opportunities that stakeholders can leverage to steer UHC in Africa.

BackgroundIf there is one universal recommendation to countries wanting to make progress towards Universal Health Coverage (UHC), it is to develop the learning capacities that will enable them to ‘find their own way’ – this is especially true for countries struggling with fragmented health financing systems. This paper explores results from a multi-country study whose main aim was to assess the extent to which UHC systems and processes at country level operate as ‘learning systems’.MethodThis study is part of a multi-year action-research project implemented by two communities of practice active in Africa. For this specific investigation, we adapted the concept of the learning organisation to so-called ‘UHC systems’. Our framework organises the assessment around 92 questions divided into blocks, sub-blocks and levels of learning, with a seven scale score in a standardised questionnaire developed during a protocol and methodology workshop attended by all the research teams. The study was implemented in six francophone African countries by national research teams involving researchers and cadres of the ministries involved in the UHC policy. Across the six countries, the questionnaire was administrated to 239 UHC actors. Data were analysed per country, per blocks and sub-blocks, by levels of learning and per question.ResultsThe study confirms the feasibility and relevance of adapting the learning organisation framework to UHC systems. All countries scored between 4 and 5 for all the sub-blocks of the learning system. The study and the validation workshops organised in the six countries indicate that the tool is particularly powerful to assess weaknesses within a specific country. However, some remarkable patterns also emerge from the cross-country analysis. Our respondents recognise the leadership developed at governmental level for UHC, but they also report some major weaknesses in the UHC system, especially the absence of a learning agenda and the limited use of data.ConclusionCountries will not progress towards UHC without strong learning systems. Our tool has allowed us to document the situation in six countries, create some awareness at country level and initiate a participatory action-oriented process.

BackgroundThere is a paucity of empiric data evaluating whether Tuberculosis (TB) is a useful surrogate measure for Universal Health Coverage (UHC), despite recognition of the importance of TB control efforts as part of the broader UHC agenda. We hypothesized that indicators of TB burden and coverage are sensitive tracers of UHC, when compared to other disease-specific indicators of service provision.MethodsLinear regression models were used to determine the extent to which variability in UHC Service Coverage Index (SCI) was accounted for by (1) TB incidence rates and (2) TB mortality rates across 183 countries. Dominance analyses, stratifying countries by World Bank income criteria and TB burden, were used to determine the importance of TB treatment coverage in predicting UHC SCI scores, relative to other disease-specific indicators of service provision.ResultsAcross 183 countries, TB incidence rate and TB mortality rate were negatively correlated, with UHC SCI score, (r = -0.67 and r = -0.74, respectively). In linear regression models including all 183 countries, TB incidence rates explained 45% of the variability in SCI scores; TB mortality rate explained 55% of variability. Restricting models to the 30 highest TB burden countries, both incidence and mortality explained less of the variability in SCI score (16% and 36%, respectively). In dominance analysis, comparing 13 disease-specific indicators of service provision, TB effective treatment coverage, ranked ninth overall. In dominance analysis stratified by TB burden, the TB treatment coverage estimate was ranked ninth in the 30 high burden countries and sixth in the 153 non-high burden countries. In separate analyses stratified by world bank income status, TB coverage ranked as third most important variable in LICs and fifth in LMICs and UMICs, but was less important in analysis restricted HICs (ranked seventh).ConclusionsCompared to other disease-specific indicators of service provision, TB coverage was an important indicator of overall UHC service coverage, especially in low-income countries. These findings highlight that national-level inequities in TB-coverage may be an important tracer of universal health coverage.

ABSTRACTThis article provides an overview of health financing structures in Arab countries in the context of their preparedness for universal health coverage. Current arrangements have left large swathes of the population shouldering high financial burdens and facing hardships when using healthcare, with significant impoverishing and deterrent effects. Health protection schemes are most comprehensive for those who can afford healthcare; they are mainly based on contributions and formal employment and thus fail to cater for the poor and the rural and informal sectors. Financing systems also lack the operational bases and institutional prerequisites for effective resource pooling and risk sharing, with segmentation and fragmentation worsening horizontal and vertical inequities. The neglect of public health systems has reinforced inequities by widening the gap between needs and provision, and by emphasizing the ability to pay as a basis for accessing quality care. In a context of informality and poverty, focusing reforms on health insurance is not a panacea. Rather, moving towards universal health coverage and reducing health inequities will require changes in the level of political tolerance for social injustice, and a paradigm shift to a more equity‐based political economy which views health as an investment and an entitlement.

Global attention has recently converged on the need for countries to achieve universal health coverage (UHC), which aims to guarantee that all persons are able to access needed and effective healthcare without facing financial ruin by using services. In the attempt to move towards UHC, several low- and middle-income countries are developing more sustainable revenue sources, expanding pooling arrangements and employing more efficient and sustainable purchasing strategies. Their experiences represent a growing evidence of the application of mandatory (social), private and community-based health insurance in low- and middle-income countries and their potential contribution to UHC. UHC reforms are an inherently political process, and public health advocates will need to do more to promote not only the health benefits of public health interventions but also the economic and political benefits too. Crucially, as UHC continues to be championed and rolled out globally, all people working in global health need to reinforce the importance of including the full scope of public health in health system reforms; only then can the full potential of UHC be realized—a true reduction in health inequities. However, implementation of a UHC is not an easy phenomenon, rather it needs proper design of a good health insurance system by integrating both the public and private health care providers. The influence of good governance and a sustainable health financing system is fundamental to establish UHC in the developing countries. This review Paper encompasses recent developments and future challenges in the implementation of Universal Health Coverage Policy framework in some countries.