Kudzai Mhishi, Health Policy Research Fellow – WACI Health

On October 13, 2017 WACI Health, the Health NGOs Network in Kenya (HENNET) and partners including KANCO, National Network of People Living with HIV – NEPHAK, International Community of Women Living with HIV (ICW+), Health Rights Advocacy Forum (HERAF), AIDS Healthcare Foundation (AHF), African Centre for Global Health and Social Transformation (ACHEST), Social Welfare Development program (SOWED), Program for Appropriate Technology in Health (PATH), Global TB caucus, HENNET, CBM, INERELA+, ADDK, Kibera Integrated Community Self Help Program (KICOSHEP), Malteser International, Medecins Sans Frontieres (MSF)- Belgium and National Organisation of Peer Educators (NOPE) convened for a consultation on Universal Health Coverage (UHC) advocacy and accountability with a specific focus on civil society engagement in the UHC2030 movement. This forum brought members from various civil society and community organizations and networks including the Ministry of Health (MoH) was also present at the consultation to provide updates on the country progress on UHC as well as give insights as to what the ministry sees as the role and entry points for civil society.

The consultation came at a critical point when counties would be getting into renewing their strategic plans. This presented a great opportunity for civil society to advocate for and persuade County Governments to place UHC high on the agenda by incorporating relevant indicators into their next 5-year County-specific strategic documents.

Discussions not only focused on UHC progress in Kenya but also the role of CSOs in advocacy and accountability and means of working better together through a coordinated Civil Society Engagement Mechanism (CSEM) at country level.

There were three key expected outcomes from this consultation:

1. Key recommendations on how to address the health systems strengthening (HSS)/UHC advocacy issues identified.
2. Recommendations on how UHC 2030 initiative can strengthen citizens’ voices and empower communities to demand accountability and take health actions.
3. Recommendations on how CSOs can work together for UHC advocacy and accountability in Kenya.

Dr. Margaret Makumi, an expert in strengthening Health Systems in Kenya, introduced UHC emphasizing that all citizens from any community had the right to access quality health services be it promotive, preventive, curative, rehabilitative and palliative health care without incurring financial hardship – ‘that’s the basis of UHC!’. Since health is a basic human right enshrined in the constitution of Kenya, Dr. Makumi encouraged CSOs to get involved at both national and county level through dialogue, influencing decision-making for a conducive policy environment for UHC.

She stressed on three important elements of UHC, equity in access to health services – everyone who needs services should get them not only those who can pay for them. In Kenya, for example the free maternal and child health services, free or minimal pay for primary health care (PHC) services though to some extent. Quality health services which should be good enough to improve the health of those receiving these services and the community should be protected against financial-risk, ensuring that the cost of using services does not put those accessing it at risk of financial harm

Moving towards UHC in Kenya: perspectives from the Ministry of Health

A representative from the Ministry of Health (MoH), Mr. Julius Mutiso affirmed the government’s continued commitment in implementing health systems reforms for UHC. Part of the reforms include employing adequate policies, legal and institutional frameworks such as Bills of Right (chapter 4) and the Constitution of Kenya 2010 (pp 31-38). This, he said, was the citizens’ right to health and a long-term development goal of Kenya Vision 2030. Again, it was highlighted that health services must not expose its citizens to financial risk.

Towards UHC, the MoH so far has done numerous actions such as introducing free maternity services, upgrading healthcare in informal settlements and providing more support in HIV/TB and Malaria programs. This, he said, has contributed to decreased maternal and infant mortality rate, improved uptake of health services (TB detection, ART treatment etc.) and improved utilisation insecticide treated nets. He further highlighted the following as key next steps towards UHC by the ministry:

Participants noted that while the government of Kenya has set up various programs towards making progress on UHC, civil society has not adequately engaged in such UHC discussions hence the need to organize and coordinate effectively as a way to strengthening CSO engagement.

A discussion on CSEM and coordination of UHC advocacy and accountability work brought forward the following key highlights:

Civil society must work together in engaging the government on UHC through accountability and advocacy efforts. This engagement could include: helping to identify who the marginalized in the population are; establish whether health services are reaching the vulnerable and whether programs are purposively targeting those that can easily be left behind; monitoring budgets and expenditure; participating in public information sharing forums and tracking results among other areas. It was agreed that through proper documentation, CSOs must ascertain what has worked well and what has not worked in the past and build upon this through a coordinated CSEM.

In conclusion, participants provided a set of recommendations on how CSOs in Kenya can work better together; how UHC2030 can strengthen citizen voices; and how to strengthen country CSEM.  As a next step civil society will reconvene to jointly develop an Action Plan to guide the country CSEM according to the recommendations of this consultation.

In 2015, the international community officially enshrined universal health coverage (UHC) in the Sustainable Development Goals which guides development efforts through 2030. A strong primary health care (PHC) system is the first step toward achieving UHC and we must address the funding shortfall as well as develop innovative financing strategies.

In many countries in Africa, health services remain unaffordable; often far from home, and quality can be uneven. Crises such as the Ebola epidemic bring into sharp focus how communities and individuals struggle in getting the care they need, sometimes resulting in death that could have been prevented. Primary health care ensures that all people in a community stay healthy and receive care when they need it.

I serve as a Policy Advisor at WACI Health whose mandate is to create political good will to end life threatening epidemics and the improvement of health for all in Africa. PHC is critical to achieving our vision and mission. As an advocate, I engage with Governments and the citizens to embrace PHC and for each of the parties to play their roles to ensure PHC is a functional system. This is not an easy task especially where there is so much mistrust of PHC by a large number of middle income citizens who prefer out of pocket spending for example over the counter drugs rather than seek services from the public facilities. This practice comprises the health outcomes of individuals due to missed or wrong diagnosis and treatment hence end up bearing heavy costs for specialized treatment when the complications occurs leading to draining of family resources increasing the likelihood of poverty.

We are also advocating for increased domestic resources, for example in Kenya where the devolved system of Government has health as a nearly fully devolved function with the exception of policy formulation to ensure that County Governments allocate resources to PHC and that they strengthen the systems such that their citizen can access the services they require at the nearest facilities to where they live.

Earlier this year, I found myself immersed in rich conversations on PHC with other civil society advocates, technical experts and development partners. I participated in a consultation hosted by PAI and Save the Children UK, convened in Johannesburg, South Africa. The three-day consultation, sharpened my understanding of the complexities that countries face in the quest for affordable, accessible and quality primary health care. Common threads in the conversation included: the need to address access, financing, removal of barriers, strengthening health systems and engaging citizens to make PHC work. It was however, clear to me that it is up to each country to define their own meaning and understanding of PHC.

The challenges confronting the health sector range from the spread of non-communicable diseases to inadequate funding of health interventions and over reliance to the international aid rather than domestic funding. A few key messages stood out for me from this consultation:

· A high-functioning PHC system is key to ensure a productive and a healthy population. Millions of people in Africa are driven to poverty by healthcare-related expenditures and in return poverty predisposes them to disease slowing all aspects of growth in the economy. Strengthening healthcare systems to increase access to affordable, appropriate and quality health services in any country is a prerequisite for long-term development and structural transformation.

· Basic curative, preventive and promotive healthcare should be available and accessible to all if we are to achieve the Sustainable Development Goals by 2030.

· Financing for health falls short of the 2001 Abuja Declaration, where nations committed to allocating 15 per cent of their national budget to health.

The verticalization of health programs has a negative effect to the health system, leading to the prioritization of certain services or diseases causing a fragmentation of PHC services. Rather, government and other support to PHC is more beneficial in addressing issues of access to services by all.

Countries must define PHC in their own context, based in essential health services with a clear funding stream and develop indicators and outcomes to measure progress and success.

The report and recommendations from the Primary Health Care Expenditure and Budget Advocacy Consultation is available here.

With the launch of the new Sustainable Development Goals, health and development experts around the world are reflecting on what it will take to accomplish them. As a global community, this is a unique opportunity to think carefully about what works and what doesn’t, and to use the new goals to redouble our efforts to support programmes, solutions, and systems that work.

To fuel progress in global development, we need catalysts that cut across multiple challenges and support multiple development interests. There is a widespread understanding among decision-makers in low- and middle-income countries that high-performing primary health-care systems play that catalytic role. These systems are central to reaching global and country-specific goals, achieving universal health coverage, and meeting the majority of individual and community health needs before they become emergencies. A healthy population in turn sets the stage for gains in education, economies, and peace and security.

Providing sexual and reproductive health services in the context of primary health care is a long-established principle and practice. The 1994 International Conference on Population and Development (ICPD) Programme of Action called for ensuring access to reproductive health through primary health care. Similarly, a 2008 UNFPA publication stated that achieving progress towards sexual and reproductive health and rights depends on a strong and functional health system in every country, especially at the primary and first referral levels.

With respect to HIV, tuberculosis, and malaria, the 2006 Abuja Call for Accelerated Action Towards Univeral Access called for the promotion and integration of access to prevention, treatment, care, and support in primary health-care services. High-performing primary health-care systems enable countries to maximise the impact of core investments in programmes to defeat these and other infectious and non-communicable diseases. For example, primary health-care systems can be the basis for the scale-up of essential HIV and AIDS services in hard-to-reach areas and among underserved populations.

Unfortunately, despite broad global agreement on the value of robust primary health care, there is not a simple recipe to achieve it. Domestic financing and country ownership are critical elements, and it is time for countries to set priorities and budgets that explicitly aim to strengthen primary health-care systems, complementing the efforts of donors. Civil society also has a key role to play, not only holding decision-makers accountable but also working with them to develop strong systems that can be reached by all.

To enact policies and budgets that lead to measurable primary health-care improvements, however, decision-makers need better information about the components of high-performing primary health-care systems, particularly their poorly understood service delivery elements – such as the quality of care, and patients’ ability to access the system, and the degree of coordination among various care providers. A new partnership called the Primary Health Care Performance Initiative (PHCPI) seeks to address this gap in information, giving decision-makers the tools to adopt policies and practices based on evidence.

We are excited about PHCPI because it presents an opportunity for collaboration among diverse communities working to address other issues of global health and development. This is a chance to look ahead to where improvements to primary health-care systems can take us all in the future. We can rise above disputes over which health issues deserve the most attention, or what set of indicators gives us the best picture of a system’s health. We can harness data to make policy decisions about health care that are truly responsive to communities’ needs. We can unite around the opportunity to dramatically improve the health of millions of people by focusing on primary health care, the frontline of health in people’s communities.