What Does It Take to Achieve Universal Health Coverage?

What Does It Take to Achieve Universal Health Coverage?

{Photo credit: Todd Shapera.}Photo credit: Todd Shapera.

In a health clinic outside Nairobi, Kenya, Janet* waits to see a doctor. Janet is a 32-year-old widow and mother of four from Kibera, a neighborhood of Nairobi. Her 11-year-old daughter, Jane*, isn’t feeling well. Both mother and daughter are HIV-positive.

Janet and Jane are lucky to live walking distance to the Langata Health Center, where they receive high-quality health care for free. Jane has been on antiretroviral medication for more than two years. Janet hasn’t paid a shilling. Around the world, millions of people living with HIV struggle to pay for care, or receive none at all. But Janet and Jane are among the 600,000 Kenyans whose HIV care is free through programs from the Government of Kenya, US President's Emergency Plan for AIDS Relief (PEPFAR) program, and The Global Fund to Fight AIDS, TB and Malaria.

Janet wishes everyone could receive the same care that she does at Langata. But even for her, the system just barely works. She explains:

The doctor is only one, and we are many.

Patients at Langata face long waits to see a doctor or pick up their medications. Patients like Janet spend hours away from work and may have to arrange for child care.

Health is an integral part of our daily lives. Yet around the world—including in the US, where I live—health services can be uncertain, expensive, or unavailable. To address these shortcomings, we at Management Sciences for Health (MSH) support universal health coverage (UHC), the goal that all people should have access to the quality health services they need.

On a recent trip to Kenya, I was pleased to observe the country’s important recent steps towards health for all.

Working together for universal health coverage

There is an unprecedented opportunity in Kenya right now. Through the 2010 constitution affirming the right to health services and the Vision 2030 development plan, the Government of Kenya has committed to achieving UHC. Efforts by The World Bank, Japan International Cooperation Agency (JICA), US Agency for International Development (USAID), World Health Organization (WHO), The Rockefeller Foundation, as well as civil society partners such as MSH, support the realization of this vision.

Ultimately, success will depend on three factors: (1) a national-level vision and institutional structures, (2) political and health sector leadership at the local level, and (3) engagement from communities and civil society.

National government

The national government has committed to achieving UHC in Kenya. It has already taken steps to make health care more accessible and available to people like Janet. A new Household Insurance Subsidy Program (HISP) to expand coverage to the very poor is under development. Another initiative is expanding National Hospital Insurance Fund (NHIF) coverage to the informal sector. In Kisii County alone (population 1.2 million), the government is aiming to cover 100,000 households with the NHIF by the end of next month.

Despite these initiatives, millions of people lack health insurance or other financial risk protection; facilities and health workers are too few; and the quality of leadership and governance is inconsistent across the health system. The national government alone can’t solve these problems. Kenya’s 2010 constitution devolved the health system. It purposely increased autonomy and accountability at the county level. Progress will depend on a great number of leaders throughout the system.

Local leaders

Kenya can look to the experience of other countries building toward UHC within a devolved governance structure. In the Philippines, for example, few health benefits were realized immediately following decentralization due to a lack of management and governance at the local level. Subsequent health sector reforms and strengthening programs increased the capacity of local government units (LGUs). Since then, LGUs have been key in enrolling their populations in a national health insurance program—especially the poor. LGUs also play a primary role in improving service delivery for health priorities such as family planning, child health, TB, HIV, and other areas.

With devolution comes greater involvement of local governments with primary and secondary health facilities. It’s in the best interest of both local politicians and health leaders to come together to bring more people in their communities into the health system. Improving health is not only beneficial in and of itself, but it also has positive effects on things such as education and economic development. Coordinated efforts at national and county levels will help citizens to realize the benefits of devolution sooner. And it will take strong leadership and governance to make that happen.

Toward that end, with support from USAID through the Leadership, Management and Sustainability Project/Kenya Associate Award (LMS/Kenya), MSH has partnered with Strathmore Business School in Nairobi. Leading High-Performing Healthcare Organizations is a training program that has attracted leaders from public and private sectors. Dr. Geoffrey Otomo, County Health Director for Kisii County, is an alumnus. He says the program facilitated his work with local leaders to assess health challenges and develop a strategic plan that accounts for community needs.

Now they’re working together to improve the health system in his county.

Non-governmental actors

Communities and civil society organizations have a role to play, too. People must be aware of their right to health, and of their government’s commitment to achieve UHC, to hold their leaders accountable. With support from The Rockefeller Foundation, MSH is coordinating the Health for All: Campaign for Universal Health Coverage in Africa in Nigeria, Ethiopia, and Kenya. The campaign is bringing the UHC conversation into communities, building awareness and generating demand for better health. At the global level, we’re also advocating for UHC in the post-2015 UN development framework.

Toward a healthier future

It’s an exciting time in global health, as more and more countries set off toward health for all. In Kenya, UHC would mean millions more people could walk into a health clinic and receive health services, without prohibitive fees. People like Janet, who already receive care, could receive more efficient, higher quality services. That’s something all Kenyans, from parliamentarians to local leaders and families like Janet’s, care about. Working together at all levels, that vision can become real—not just in Kenya, but in all countries around the world.

*Names withheld for confidentiality.