Universal health coverage movement, alliance or partnership?

In 2007, donors, developing country governments and civil society organizations came together to align their work with national health plans — and to combat the practice of burdening country governments with the implementation of projects that didn’t jive with their own priorities. They called it International Health Partnerships, or IHP+. Ten years later, however, discussions have moved from largely focusing on disease-specific interventions to overall health systems strengthening and universal health coverage — largely due to the Ebola crisis and the adoption of the Sustainable Development Goals. One of the targets under SDG 3 is to achieve universal health coverage, which helped garner support behind a proposal of creating a partnership — now with a wider set of players — that would boost efforts to achieve strong and resilient health systems to achieve UHC. The World Health Organization together with the World Bank, which hosts the IHP+ Secretariat, circulated a letter in March 2016 asking all 66 signatories to the partnership what they think of the idea of transforming IHP+ to cater to a UHC partnership. The answer, Devex has learned from a source close to the matter, was unanimous: Yes, we are in favor of expanding the IHP+’s mandate to accommodate these emerging priorities. The journey toward that goal has been less straightforward. It required two key steering committee meetings to ensure that everyone was in agreement on this direction in light of the SDGs, and to vote on next steps. And this is only the beginning. At the first multistakeholder consultation meeting in Geneva in June, which Devex attended as the sole media representation, the WHO and the World Bank solicited participants’ ideas and input on the partnership’s mandate, role and activities. The two-day discussions amassed a wealth of ideas from nearly 100 participants, composed of donor representatives, government health officials, multilateral institutions, NGOs, civil society, members of the academe and the private sector. Generally, the partnership can be a platform for knowledge sharing on HSS and UHC, create common understanding across different actors on what UHC means, help bring in technical capacity to developing country governments and civil society actors, and push for accountability among the different health actors, participants said. As per monitoring and evaluation, one participant suggested establishing a periodic analysis of how different bilateral and multilateral organizations are supporting and investing in health systems strengthening, which is a key element in achieving UHC. Another delegate floated the idea of country-to-country peer reviews — much like that of the Organization for Economic Cooperation and Development’s — which could be a useful tool for countries to learn from each other. But toward the end of the consultations, more questions emerged. What, exactly, are they trying to create? In its draft concept note shared with meeting participants, the IHP+ Core Team referred to the expanded partnership as UHC 2030, calling it a “working title.” This isn’t much of a departure from the original idea supported by the Group of Seven countries. In their declaration at the Ise-Shima summit in May in Japan, the G-7 leaders said they support the establishment of “UHC 2030.” But confusion arose during the opening session of the consultation meeting in Geneva, when Amir Hagos, Ethiopia’s state minister of health and co-chair of the IHP+ Steering Committee, revealed an entirely different name in his presentation: IHP for UHC2030. To communications and branding experts, the name comes across as a hodgepodge of acronyms that’s unlikely to garner attention, much less understanding. “I think some simpler name that resonates with the people around the world and connects well to the meaning might be more helpful,” said George Gotsadze, executive director of Curatio International Foundation, which hosts the Secretariat of Health Systems Global, a global membership organization promoting health systems research and knowledge translation. Gotsadze said in today’s world, particularly in the development space, “branding does matter.” But for several actors in attendance, the sudden name change meant more than a branding exercise. Simon Wright, head of child survival at Save the Children U.K., was in favor of UHC2030 and thought using this for the new partnership would help get countries’ current focus away from aid. “Everybody said UHC is about domestic resource mobilization,” he told participants in the meeting. “And yet some of you can’t let go of that donor-recipient relationship.” But several developing countries felt strongly about retaining IHP in the name, for purposes of “continuity,” as they felt introducing a new name or initiative would not have as strong a pull at the country level. Throughout the two-day meeting, some would refer to it as an alliance — although Devex learned there was an aversion in using the terminology given its World War II linkages — and others a movement. Some, such as Lola Dare, founder and president of Chestrad International based in Nigeria, called it a partnership or a program, saying she “didn’t see a movement.” “The name itself will suffer attrition. People will either drop IHP+ in the name, or drop UHC 2030 in the name, depending on what suits them… I think there was a lot of politics in deciding the name. I think the steering committee generally had a tension and just decided to resolve that tension by keeping both names and keeping everybody happy on the table. Is that a good strategy? Probably. It depends on what IHP for UHC 2030 ends up doing,” she said. Whatever they decide on, Brenda Killen, deputy director of the Development Cooperation Directorate at the OECD, hopes they don’t lose sight of IHP, as it was “much more precise and focus on aid effectiveness in strengthening health systems.” The new partnership would also need the same energy that went behind IHP. “I don’t know how they are going to sort this out, but there’s something there to build on. It’s good to see innovation and see people say I support something big and let’s move toward that direction,” she said. But what is universal health coverage? The WHO defines UHC as “ensuring that all people have access to needed promotive, preventive, curative and rehabilitative health services, of sufficient quality to be effective, while also ensuring that people do not suffer financial hardship when paying for these services.” Yet, despite the availability of this definition, several participants voiced confusion over what areas of health care should receive their efforts, for example. “I’m concerned about my own country; a country should know where it should focus. And at BRAC, we’re quite a large organization. So we mostly do primary health care. So I kept on thinking: What is the definition? Are we going to focus on primary health care?” Kaosar Afsana, director of NGO BRAC in Bangladesh, asked. In addition, other stakeholders questioned what it means when, in the context of UHC, people reference “leaving no one behind.” “If you just give a little treatment to a person, it doesn’t cover everything, and if you think that’s universal health coverage … it’s not effective coverage,” Afsana explained. Aleksandra Blagojevic, program officer at the Inter-Parliamentary Union, posed the same question during a panel on the role of UHC 2030 in strengthening advocacy and accountability locally and globally. “I hear a lot of people here speak about ‘no one left behind,’ but I’m still not sure what this means,” she said. “And I think for this agenda to move forward it’s important to humanize it and understand who are the people who are not supposed to be left behind.” A number of people often cite WHO’s definition when asked what UHC means, but Jesse Bump, lecturer on global health policy at the Harvard School of Public Health, argued that is mainly out of convenience. It’s “inclusive vagueness” has facilitated agreement at the global level just because it accommodates everyone’s perception of what UHC means, but it’s during implementation that people seek details. “For countries, this specificity is produced by domestic political processes, so each ends up with its own version. There are often shared characteristics, but there is no intrinsic need for countries to do the same things,” he explained. What role will the expanded partnership play? The consultation discussed current realities faced by different health actors on the ground, and stakeholders recognized that while there have been some successes in terms of aid alignment and country ownership, more needs to be done. More discussions need to take place in terms of aid management and coordination, for example, according to Isaac Adams, director of research, statistics and information management at the Ministry of Health in Ghana. Despite several agreements and discussions on the topic, “we’re still not making a headway,” he told Devex. “If U.S. decides they are [going] to support family planning, it’s already a decision taken. So when they come to the country and family planning is not your priority, you’ll be disappointed. Sometimes, that’s why we need to veer away from our own health programs to accommodate,” he said. But maybe the UHC 2030 can help bring real partnerships and change dynamics between development partners and countries, the government official said, although he acknowledged the traditional donor-recipient dynamic cannot be broken down so suddenly. The idea fits into the potential added values of IHP for UHC 2030 that the IHP+ Core Team gathered from the two-day consultation meeting, which include being a platform for collaboration and coordination, learning and exchange, accountability and advocacy. Kanitsorn Sumriddetchkajorn, director at the National Health Security Office of Thailand, thinks IHP for UHC 2030 can synergize the distinct roles of all partners and realign their objectives under one overarching goal; help get partners to jointly assess and jointly design countries’ strategic action plan by involving countries’ domestic resources; and lastly, be a platform to share knowledge — although he felt the meeting lacked specifics on the mechanisms to move forward with these. “I hoped it would have gone deeper, as to what exactly is the new structure and new governance, what it would do and how countries would relate to it,” Dare said of the meeting in Geneva. Wright of Save the Children U.K. desired more of a sense on what will be different under UHC 2030 — the name he prefers to call it — than what IHP+ is already doing. But some argue it may not have been the purpose of the meeting. The consultations have just started, and at this point, it’s very much an evolving process. So while it’s also important to clarify boundaries and not just put everything under the basket of UHC, or define what counts and what doesn’t when it comes to tracking aid for UHC, Brenda Killen from OECD understands that the partnership is not yet at that stage of pinning things down. The focus at this point, as she understands it, is creating a movement to move toward achieving UHC. “I got the sense the meeting was more about a movement of people committed to a goal coming together, but we’ve yet to have the conversations to decide what actually are we talking about,” she said. That conversation, however, will be involved. There are already questions on how organizations can encourage people to rally behind the concept of UHC, how they can continue focusing in their own areas of interest while also looking at the bigger picture, as well as what the partnership’s governance will look like. The consultation has kicked off an important discussion on moving the agenda of UHC forward. But as Adams from Ghana said, UHC is going to be a long journey. Read more international development news online, and subscribe to The Development Newswire to receive the latest from the world’s leading donors and decision-makers — emailed to you FREE every business day.