More than 250 experts gathered in Nairobi between 11th and 13th March 2014. The occasion was the 3rd scientific conference of the Africa Health Economics and Policy Association (AfHEA), an association that promotes and strengthens health economics and policy thinking and analysis that contributes towards “better and equitable health for Africans”. This conference brought together economists, policy makers and analysts living or working in health economics and related fields in Africa to share information and exchange as well as foster healthy debate on opportunities and challenges for universal health coverage (UHC) post-2015 in Africa.
The choice of the venue could not have been better. The Kenyan health sector is at a crossroad, going through a historical change – moving towards devolved governance, in line with the 2010 Constitution. As a result, the topic of UHC has become central to the health and development policy discussions. The theme of this conference – “The Post-2015 African Health Agenda and UHC: Opportunities and Challenges” – is of particular interest to the citizenry, policy makers, academics and politicians, among others. Without unnecessarily claiming to be an extensive report of this conference, this blog reflects my personal impressions (and certainly the caveat that “the eye sees what it knows” holds!).
In the context of Africa, what does UHC mean? Cognisant that UHC is a means to an end and not an end in itself, it was variously argued that – in the context of Africa – adopting it as the sole post-2015 health goal would be simplistic. This is a view that has been emphasised by the report “Health in the post-2015 development agenda”. Also, various African analysts have argued so. Strikingly, from most of the conference presentations and the ensuing discussions, the participants felt UHC offers a strategic opportunity to improve health systems under each country’s own stewardship. Whereas most discussions largely dwelt on the importance of UHC and the technical and practical considerations needed to bring UHC closer to reality, I am of the view that there was little acknowledgement (and certainly guidance) around the inextricable complexities of UHC’s political economy. Based on my experience as a policy analyst in Africa, I’m convinced that the politics and economics of UHC are very interconnected. Regrettably this reality received little recognition at the conference, which I believe is due to an inadvertent neglect of the “politics of UHC” by policy honchos in the analytical tools currently available. Or is politics too sensitive on the African continent to be incorporated into economic analysis?
Effectively utilising the various avenues for networking that the conference offered, I informally interacted with fellow Emerging Voices for Global Health and members of the Financial Access to Health Services Community of Practice, among others. We engaged in passionate and powerful economic arguments making a plea for smart investments in global health. Drawing from these discussions, it is increasingly becoming clear that there is a big inclination to position market mechanisms and yardstick competition centre stage – as key policy levers for moving African countries towards UHC. These arguments, in my view, come at the expense of other values, those underpinning UHC (such as equity, which is sometimes presented as opposed to the efficiency objective). In my view, the work by Stéphane Verguet and colleagues at Disease Control Priorities (DCP3) that “extends” traditional cost-effectiveness health evaluations (through the so called Extended Cost Effectiveness Analysis (ECEA)) is groundbreaking by concurrently incorporating equity and financial protection considerations in economic evaluations. For UHC, this powerful tool offers an opportunity to understand the context in which an intervention is implemented and its effect on distinct groups of people.
In the pre-final plenary session, a couple of critical questions popped up, finally. Yes, we all agree that UHC is needed. But we also know – notably from a recent AfHEA/WHO-AFRO/Rockefeller Foundation study cited at the conference – that our financial and governance capacities are weak, that our human resources are of low quality and so are our health information systems, that we lack leadership, that we are bad at targeting and that good research in Africa is hard to find. So, how do we proceed? No conclusive answer was provided. Second, we were presented pros and cons of the omnipresent performance-based financing (PBF), but do we agree on any conclusion? One panel member gave it a try: we should consider PBF as one means among many others, not as a panacea.
As a way of conclusion, yes, UHC is a possibility in our lifetime. A number of African countries are on the move, in the right direction, towards UHC. Dr. Agnes Soucat of the African Development Bank (and one of the Lancet CIH Commissioners) noted, while presenting on the Global Health Convergence Agenda at the pre-conference, that “Universal health coverage is increasingly a major political issue in Africa”. The pressing issues facing African countries’ pathways to UHC require we utilise state of the art analytical tools that are alive to the realities of both the economics and politics of UHC. This way, the transition to UHC can be assured.