We, members of independent Civil Society in Africa including members of the People’s Health Movement (PHM)[i], are committed to Comprehensive Primary Health Care and addressing the Social, Environmental and Economic Determinants of Health. The Alma Ata Declaration of 1978 defined Primary Health Care (PHC) as “essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation in the spirit of self-determination”. It continues to guide and inform independent civil society work. We make a special reference to the Alternative Civil Society Astana statement on PHC (see link here) which reaffirms the commitment to PHC and calls for action at all levels and in all sectors to develop and implement PHC throughout the world and particularly in low and middle income countries in a spirit of technical cooperation and in keeping with a sustainable and equitable economic order.
To make health care accessible to all, African governments are considering or have implemented policy reforms with a focus on achieving Universal Health Coverage (UHC). Examples include, the Community Based Health and Planning Services (CHPS) and National Health Insurance Scheme in Ghana; National Health Insurance Scheme in Uganda, expansion of the National Hospital Insurance Fund in Kenya, National Health Insurance in South Africa and Health Financing Policy and Strategy in Zimbabwe[ii]. These policy reforms in different ways aim to provide health financing to protect populations from impoverishing health care costs.
Despite this momentum, many African countries still provide limited access to quality health services and only a small percentage of the population is protected from financial risks associated with health care costs. Health care is still expensively provided in most African countries and individuals especially the poor and marginalised quite often struggle to meet the high fees related to the need to treat illnesses, let alone the indirect costs of accessing health services. This is evidenced by continuing poor health care outcomes and increasing inequalities in health within and between countries in the region. Moreover, the dialogue on UHC in Africa is strongly influenced by the World Bank and other multilateral and bilateral donors, which promote UHC as predominantly a health financing mechanism. Issues of health equity, including a focus on access for the ‘uncovered’ poor, community participation and the strengthening of public health systems are largely ignored
In these cases, UHC is seen as “a health financing system based on pooling of funds to provide health coverage for a country’s entire population, often in the form of a ‘basic package’ of services made available through health insurance and provided by a growing private sector”[iii]. Here UHC is framed as a health financing issue, rather than a human right or public good, and supports charging the poor for health coverage and the creation of health markets (privatisation). Secure finances for health care are a necessary but insufficient condition for systems that are equitable and provide good quality care. Finances need to be channeled through well-designed public systems if they are to be spent efficiently. UHC is not only about financing, it is about training health workers, community participation including through Health Centre Committees ensuring equity in healthcare coverage, providing functional, accessible health facilities and affordable medicines. Creation of separate schemes for different members of society exacerbates health inequalities within populations and continues to widen the socioeconomic gap and worsens disparities while weakening solidarity and capacity for subsidization across different income groups.
We emphasise that PHC is the key to achieving health for all. Efforts to achieve UHC should prioritise reviving and strengthening public health systems in African countries within the Primary Health Care framework which permeates all levels of health care including addressing social determinants of health.
This civil society statement on UHC in Africa therefore puts forth the following actions to strengthen UHC within a Comprehensive Primary Health Care framework:
Action needed to ensure that UHC actually brings Primary Health Care for all, especially the poor
Action to address social determinants of health ultimately improves health and everyone should have access to quality health services good enough to treat or prevent the health problems of people who receive them. That can only happen when the UHC debate shifts from predominantly financing to services and population.
- Primary health care: policies for UHC need to clearly prioritise PHC at the primary and community levels. Countries that are already struggling to pay for a portion of their health costs must reduce those costs, through health promotion and preventive services within a robust community health system, so that people have less need to access costly services. A model of UHC built around community-based PHC is both appropriate and sustainable, and most closely aligns with health rights enshrined in national constitutions and international conventions and treaties.
- Social determinants of health: A whole of government approach must be applied to support UHC, including Health in All Policies, so that all ministries and departments of government are coordinated in promoting healthier working and living conditions and healthy lifestyles, preventing causes of disease and mortality, and supporting equitable access to health services. Government policies and actions must be coordinated by the highest level of political leadership, to act on improving the social determinants of health.
- Abuja commitment: Governments should increase health sector spending to at least 15% of national budgets, as agreed in the 2001 Abuja Declaration, while directing expenditure to community-level PHC so that national funds are not wasted on expensive treatments for diseases that could have been prevented.
- Public financing: Increase fiscal space by expanding and improving current tax collection measures; as well as implementing new taxes that ensure progressiveness and sustainability. Countries can choose from a wide variety of innovative revenue generation mechanisms as «sin taxes», levies on mining industries, environmental taxes, and a range of progressive taxation on air travel, financial transactions, luxury goods and solidarity levies.
- Pro-poor financing: Promote health financing systems that eliminate out-of-pocket expenditure by strengthening prepayment mechanisms that pool resources, for instance financing from general or targeted tax revenue without charging users at the point of delivery.
- Eliminate out-of-pocket expenditure for PHC, including UHC: Public financing should account for the majority of total health expenditure, ensuring subsidization of services for the poor and vulnerable populations. Evidence shows that private (and public) voluntary insurance schemes are not good models for providing UHC so countries should not rely on insurance as a financing mechanism. Instead, statutory coverage of the entire population, including citizens, legal residents and refugees, is both more efficient and effective in ensuring health for all, even at lower cost. Statutory protection is more efficient by eliminating administrative and bureaucratic checks.
- Rational funds allocation: Allocate national health funds according to population health needs, ensuring a higher proportion of resources go to primary health care, health promotion and community services - thereby preventing disease and illness that require more expensive, facility-based treatment later.
- Transparency and Accountability Promote transparency and accountability in governance and management of health sector resources and in-service delivery. As an essential step, governments must involve independent civil society organizations, labour unions, health workers’ associations, media and communities to take part in health policy consultations and budget allocation processes; and to monitor budget expenditure and service delivery quality.
- Leave no one behind: Strengthen the health decentralization strategy through subnational governments to improve health service delivery and identify the hard to reach remote areas and populations with poor access to and availability of quality healthcare. Ensure all citizens and residents have equitable access to quality health services across the country, even with subnational health service provision. Support national level coordination and support to subnational health service provision, and reduce administrative costs of health care provision across subnational authorities.
Many international agencies and NGOs do not understand the African context, and advocate for a UHC model developed by Western institutions. African governments need the support of independent civil society - groups that are not funded by the international agencies and donors - with their own African model of UHC. In order to develop an African solution that provides health for all, the first step is to ensure that independent civil society has a strong voice in the discussions about UHC in Africa.[1]
[i] www.phmovement.org [ii] Input from PHM Country circles in Africa (Kenya, Uganda, South Africa, Ghana, Tanzania and Zimbabwe) [iii] OccasionalPaper20_Sengupta_Universal_Health_Coverage_Beyond_Rhetoric_Nov2013Download the pdf of the African Civil Society Statement on Universal Health Coverage
Watch a video explaining our critics to UHC: https://www.municipalservicesproject.org/universal-health-coverage-0