Progressing toward Universal Health Coverage: Perceptions, Challenges and Opportunities for Innovation

To read/download the country consultation reports and the synthesis report, visit the resources pages in either English or French.

Globally, at least 3.5 billion people lack access to essential health services, and more than 800 million people spend more than ten percent of their household budget on health. Lack of access to care, catastrophic household health expenditures and a desire to continue the progress made on Millennium Development Goal indicators are some of the reasons why universal health coverage (UHC) is a target of Sustainable Development Goal 3.

UHC is defined as when all people have the ability to obtain the quality health services they need without suffering financial hardship. Although many governments, global organizations, foundations and partnerships have committed to achieving UHC by 2030, countries face a number of challenges, including low effective coverage, fragmented and insufficient financial resources, and limited technical ability and capacity to provide high-quality health services to the population. There are also implementation challenges related to accountability, collaboration and learning exchange, which can be complex and are particularly acute in low- and middle-income countries.

Launched in 2017, the African Collaborative for Health Financing Solutions (ACS) aims to facilitate collaborative, country-led processes to seek to identify and address implementation challenges of policies, and strategies designed to advance UHC in the region. ACS seeks to raise the vital voices of stakeholders who may be excluded from the UHC dialogue, including members of the private sector and social entrepreneurs, such as Lilian Makoi of Jamii Africa in Tanzania, and community representatives like Dr. Stella Iwuagwu of the Centre for the Right to Health in Nigeria.

In its first year, ACS engaged in an extensive five-country consultation phase to uncover priority challenges and potential ways that ACS could support UHC advancement. A multidisciplinary team from the ACS project visited Burkina Faso, Nigeria, Senegal, Tanzania, and Uganda between September and December 2017. They also interviewed regional and global actors working in the UHC space. The team conducted more than 200 semi-structured interviews with a broad array of people involved in various aspects of implementing UHC-related policies and strategies from across sectors such as government, civil society, the private sector, frontline healthcare providers, and community-level leadership.

Our Findings: Technical and Non-Technical Barriers to Progress

We asked stakeholders what they thought UHC meant. Universality, accessibility, and availability of health services were the most commonly cited components of UHC. Several stakeholders also highlighted quality, financial protection, and affordability, but less often than the previous components.

Stakeholders reported on what areas of focus could improve accountability, learning, and collaboration for UHC. They perceived deficiencies in knowledge sharing and visible policy implementation as barriers. In many cases, interviewees noted technical barriers, such as insufficient resources and inefficient allocation of existing resources, as limiting factors to implementing policies and programs designed to advance UHC. Interviewees also noted several non-technical barriers to advancing UHC, such as low health workforce levels and skills capacity. Other key barriers are listed below.

  • Accountability: limited ability to translate policy to implementation and lack of clear implementation strategies; lack of ownership, commitment, and stewardship for greater public-sector leadership
  • Learning: lack of a standard, functional processes and platforms for information sharing and knowledge management; organizational or cultural barriers to knowledge exchange and lack of or insufficient translation of evidence to guide decision-making or research
  • Collaboration: ineffective engagement, poor stakeholder inclusion, fragmentation of effort and poor coordination of UHC platforms or the strategic initiatives of the health sector, donor partners and other sectors.

Despite the barriers, all countries we engaged with are developing in-country solutions to address health financing for UHC. These include Tanzania’s direct facility financing program and Nigeria’s use of impact bonds for health. Other countries in the region are developing models that may be applicable elsewhere. Gabon’s implementation of taxes on money transfers, Kenya’s application of mHealth technology for mobile payments, and South Africa’s development of public-private partnerships within hospitals and health systems are a few examples that were cited. Respondents also noted areas where more work can be done, including developing accountability frameworks, evidence sharing platforms, and broader stakeholder engagement mechanisms. Other networks, like Innovations in Healthcare and the Center for Health Market Innovations, provide promising examples of how innovation for UHC can begin at the grassroots level around the world.

The Opportunity: Breaking Down Silos, Diversifying Stakeholder Engagement, Creating Learning Exchanges

There is a clear need, and a desire for, solutions that can increase access to care, improve the quality of care, and better use scarce resources to accelerate progress toward UHC. ACS sees this as an opportunity for innovation and for the development of new methods of collaboration and process facilitation to help countries to overcome the challenges they face as they work towards UHC. ACS will support their journey by:

  • Promoting mechanisms for sustained stakeholder inclusion;
  • Supporting peer-learning and knowledge sharing around challenges and good practices related to domestic resource mobilization, efficient allocation of resources, collaborative processes, care delivery, and policy implementation; and
  • Creating actionable and evidence-based research, frameworks and instruments to strengthen accountability and support advocacy efforts to build and sustain movement toward UHC.

Learn more about the project here. Results for Development is leading ACS, in partnership with the Duke Global Health Innovation Center and Feed the Children. The project is funded by the USAID, Bureau for Africa.

Note: Visit the Resources Pages (English and French)  to read the country reports and download them.