Tough choices for low-income countries on road to UHC

NEW YORK — The hard work of negotiating a universal health coverage agreement is done. But the next task — implementing plans at the country level — comes with a new set of challenges, according to global health experts and advocates.

“These types of declarations are important for advocates on the ground. It is something advocates can hold their governments accountable on, saying, ‘Look, you agreed to this in New York. How do we implement this within country? How do we translate this?’” Nina Renshaw, policy and advocacy director at the NCD Alliance, told Devex on the sidelines of the high-level UHC meeting at the U.N. in September.

But there’s no one-size-fits-all approach for closing the gap on UHC access, which almost half the world’s population lacks.

The national government in Bangladesh, for example, is stocking community clinics with more medicine and increasing the number of trained nurses and health workers across the country, according to Morseda Chowdhury, associate director of the BRAC Bangladesh health, nutrition, and population program. It’s part of the work to achieve UHC by 2032 in Bangladesh, which has seen major health indicators improve in the last decade, and is expected to graduate from least developed-country status by 2024.

Structural changes are underway, but it might take time for that change to become visible at the patient level, Chowdhury said. BRAC has 43,000 local women health volunteers and 4,300 women health workers across Bangladesh, and serves about 110 million people annually with primary health care and referral services. BRAC works to fill in gaps for government services, but there are still many people — including women in urban and rural areas, for example — who struggle to access routine care.

“We can see change is coming and we can see some things happening at the structural level. But the outcome level will take time. People have to build confidence in the system and that does not grow overnight,” Chowdhury said. “The problem is the monitoring and continuity of the service. This system is flawed and people have sometimes lost their confidence in it.”

Clear goals

Many of the countries that signed on to the UHC agreement last month in New York already had UHC plans in place, according to experts. These countries face a common challenge of balancing a tension of priorities, according to Amanda Glassman, executive vice president of the Center for Global Development.

“The goals are clear — financial protection and greater equity of health care — but it is more about the sequence of it, especially because it is really not clear what UHC means in low- and middle-income countries, and how feasible it is for them to have money to offer basic services for the whole population,” Glassman said in a phone interview with Devex.

Bangladesh was one of the 83 countries that took the floor in September during the opening of the U.N. General Assembly and signed on to the UHC agreement, which U.N. Secretary-General António Guterres called the “most comprehensive agreement ever reached on global health.”

The agreement went through about 15 iterations and “extremely tough negotiations,” said World Health Organization Assistant Director-General Ranieri Guerra, during a recent panel discussion in Washington, D.C. on what’s next for UHC.

The goals of the declaration are “eye-popping,” J. Stephen Morrison, senior vice president at the Center for Strategic and International Studies, remarked during the October panel discussion. The “big asks” include covering 1 billion additional people by 2023 — and 2 billion by 2030 — with quality health services, and reversing the trend of “catastrophic” out-of-pocket health expenditures.  

“Those are big asks. It does place primary health care at the very center of the discussion on the stage,” Morrison said.

Kenya is among the countries rolling out new UHC schemes. Access remains a challenge for many who cannot afford private health care, according to Patricia Nudi Orawo, an advocacy officer at the NGO Kisumu Medical and Education Trust.

“We are not doing well with staff capacity, and this is across all the counties that UHC work has been piloted [in]. The gap is really huge. We feel it has not been prioritized at all, in terms of implementation. Prioritizing it would be investing more in community health services than drugs and commodities,” Nudi Orawo told Devex.

“The big challenge for people right now is the quality of care. You go to the health facility and can wait from 9 a.m. until 9 p.m. to get services,” she continued. “The political declaration brought something that was under the carpet to the surface. People are beginning to talk. I believe we are making progress from people starting to realize we need to stand up and demand what needs to be done.”

Tough choices

Advocates have pointed to gaps in other national UHC plans. In South Africa, for example, UHC and insurance schemes are linked to residency and do not include migrants. And in Rwanda, UHC does not guarantee sexual and reproductive health care for girls under the age of 18. Some girls, though, become sexually active as young as 15, according to Chantal Umuhoza, executive director of SPECTRA Young Feminists Activism.

“It is about investing in prevention rather than dealing with things that have already happened. The general understanding is that young girls [need] to have access to services. It should not be limited for anyone involved,” Umuhoza told Devex.

Financing UHC is one challenge — an estimated $3.9 trillion in additional resources is needed by 2030, according to Morrison. But there are many other issues, such as closing the health care access gap between rural and urban populations, according to Glassman. The CGD is consulting with some countries, such as Rwanda, on how to fund health care decisions in a “more systematic way,” Glassman said.

“There are countries that have prioritized rural issues — like Thailand and Mexico — and the question is, are countries like Ghana or Ethiopia going to follow that road?” Glassman said.

“It comes down to the issue of trade-offs; whether your change in administration or payment actually leads to a larger package of services being offered and incentives to improve the quality of care.”

It is not clear how countries will handle these trade-offs, Glassman explained.

“It is very hard to achieve equity in terms of services covered without very, very tough choices,” Glassman said.