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Commonwealth Health Partnerships 2015

Essential ingredients for UHC: Political and technical leadership Commonwealth Health Partnerships 2015 115 In recent years, countries around the globe have committed to striving for universal health coverage (UHC) to ensure effective coverage of essential health services for all populations – young and old, healthy and sick, rich and poor – without risk of financial impoverishment. Realising the goal of UHC depends on strong political and technical leadership. As David de Ferranti, president of the Results for Development Institute (R4D), has noted, implementing UHC is often 90 per cent about politics and ten per cent about technical design. Countries such as Brazil, Chile, Mexico, Thailand, Rwanda and Turkey have achieved – or nearly achieved – UHC and serve as an inspiration to the next wave of countries on the path to UHC. Behind these examples of success are stories of strong leaders and institutions that established bold visions and clear roadmaps for achieving UHC in their countries. They also built the technical knowledge and developed the implementation methods needed to realise their visions. Through our work with the Joint Learning Network for Universal Health Coverage (JLN) and our previous work with the Ministerial Leadership Initiative for Global Health (MLI), we have learned that progressing towards UHC requires strong political leadership as well as technical expertise and implementation ‘know-how’. Health reform is extremely complex and countries face myriad political and technical challenges on the path to UHC. For example, country leaders need to make the case for, and secure, increased public spending on health care, ensure that care is delivered in an effective and efficient manner, and stay accountable to their populations, providers and partners (who often have conflicting interests). Issues of health reform are frequently inter-connected, meaning that reforming one dimension can have a ripple effect on many other aspects of the health care system. UHC can also take many years – sometimes decades – to achieve. A shifting landscape Alongside the UHC movement, countries face demographic, epidemiologic and health financing transitions that present both challenges and opportunities. Health spending is increasing, largely due to growing demands for health services as populations become wealthier, and so is the supply of health services, due to new treatments and interventions. Surprisingly, the growth in populations over the age of 60 is not a strong factor in explaining the growth in health expenditure. As discussed at the January 2015 Commonwealth Secretariat meeting on the right to health in the context of UHC, countries need ‘progressive public financing’. The good news is that countries’ health spending is increasingly pooled, with diminishing reliance on direct out-of-pocket payments. This trend presents opportunities for greater equity and improved health outcomes (Savedoff, 2012). In Ghana and India, two Commonwealth countries that are also founding members of the JLN, there have been increases in government spending as a percentage of total health expenditure (by five per cent in Ghana and three per cent in India in the period 2004–11) and reductions in out-of-pocket spending since reforms were implemented.1 These countries rely more heavily on tax revenues (for example, Ghana’s value-added tax and India’s general government revenues). As countries dedicate more public resources to achieving UHC, the need for strong leadership and stewardship becomes even more critical. Leadership for UHC Strong political leadership is an essential ingredient for policy reform victories. At the ministerial meeting on UHC organised by the WHO and the World Bank in February 2013, many country delegates spoke about the importance of high-level political commitment for UHC. However, we often find that the need for strong leadership and stewardship in UHC receives little attention or investment. Through our work with five MLI countries (Ethiopia, Mali, Nepal, Senegal and Sierra Leone), we found that ministries of health are full of talented leaders whose talents often are not harnessed effectively. Ministries of health are frequently overwhelmed with responsibilities and competing priorities, and are significantly understaffed and under-resourced. Reforms are often derailed or delayed due to long political processes, strong stakeholder influence and leadership transitions (among the five countries in MLI, tenures of health ministers averaged less than two years). All these challenges meant that policy reform delays were inevitable and achieving measurable progress could take years. Ethiopia’s Federal Ministry of Health sought to combat these challenges through a bold strategic and performance-management initiative led by the Minister of Health and his senior team (see Box: ‘Ethiopia’s Balanced Scorecard initiative’). Recently, a group of African leaders participated in a P4H Social Health Protection Network Leadership for UHC programme designed to equip leaders to better respond to the complex tasks and conflicting interests they face when working towards UHC. Common leadership challenges this initiative documented include: • Different stakeholders sometimes having their own UHC-related strategies and lack a shared vision • Co-operation among the relevant ministries often being limited and roles of key institutions sometimes being unclear or even conflicting Amanda Folsom


Commonwealth Health Partnerships 2015
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