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Universal Health Coverage: How can we best support local change agents, whether they are in DC or Dhaka?

December 12: UHC Day

Photo © Karen Dias for CHMI/Swasth Health Clinic

Photo © Karen Dias for CHMI/Swasth Health Clinic

Today is Universal Health Coverage (UHC) Day — a global day dedicated to generating awareness and support for the movement to ensure that all people have access to affordable, high-quality health care — and I find myself thinking most about the dedicated change agents around the world who are working tirelessly to move their countries closer to UHC. They are government workers, civil society leaders and social innovators, and they are working in challenging, resource-constrained environments. These change agents are motivated by a conviction that no one should miss out on lifesaving health care because they can’t afford to pay, or because quality services are not available. It’s a conviction I share, too.

The good news is momentum for UHC has grown in recent years, with increasing commitments from various governments and, most notably, the inclusion of UHC in the Sustainable Development Goals. But achieving UHC is a lofty goal, and moving the needle requires more than political rhetoric. The nuts and bolts of UHC — developing feasible policies, implementing them effectively and adapting to changes and shocks — requires long-term hard work from a range of stakeholders, over many years.

The challenge for many of us who work in global development is how best to support the change agents who are driving progress in their countries. As we consider this question, I have been reflecting on my own experience working to expand health coverage in the U.S.

Health reform in Washington, D.C.

From 2003 to 2006, I was the senior health policy advisor to Mayor Anthony A. Williams and his City Administrator Robert C. Bobb in Washington. The Mayor and City Administrator set the goal to extend health coverage and improve health care for low-income residents, including families, homeless people and undocumented immigrants, while putting the city’s finances on a sustainable path. I was assigned leadership for the health goal.

First, my staff and I developed policy options. Throughout this process, we benefitted enormously from the counsel of advisors from several local think tanks (RAND, Brookings, and the Urban Institute) who introduced us to examples of reforms in other states and cities around the U.S.

Ultimately, we had to design a reform that would be feasible to implement for a government that had never before managed a health coverage program, and which could secure the support of all major stakeholders. We developed three alternative options and over the course of a year, led a review process to engage key stakeholder groups, including the local hospital association, the local primary care association, hospital administrators and leaders of community health centers, as well as advocates for the city’s low-income population and homeless, the city’s chief financial officer, and government staff across several implementing agencies.

After a lengthy consultative process, we selected an approach and the D.C. Council voted to approve it. Next, we began the challenging process of implementation including change management. This required coordinating multiple activities across multiple government agencies and participation from a number of private health care delivery and civil society organizations. It also required advice and support from people and organizations outside of government with deep technical knowledge in key areas. This advice and support needed to be coordinated and channeled through a central sequenced implementation process.

Throughout it all, we held monthly meetings with key stakeholders. We tracked progress on implementation, reviewed financial and medical performance data and worked to identify and solve key challenges. We encountered and then worked together to solve many detailed and often-unexpected issues and obstacles. As a result, over time, trust and the ability to work together among stakeholders grew. Finally, we were able to offer comprehensive free health care coverage to all District residents in low-income groups. A study by RAND found that adults with continuous health insurance rose from about 79 percent in 2001 to over 86 percent in 2005. This amounted to roughly 20,000 more people with health coverage in a city of about 600,000 residents. A study published by Brookings noted that the reforms “reduced the gaping hole in access to primary and specialty care and thus eliminated some of the disparities between the affluent and the lower-income residents of the District.”

That experience taught me a lot about what reformers need to support their success. Government leaders in countries around the world who are working on UHC are now going through similar processes. The details may be different, but the themes and challenges are the same.

What local change agents need most to advance UHC

Change agents engaging in reform need sources of external ideas and evidence to push their thinking. But they must also know and design for their own context. They need informative data about the performance of their system, assessments of current capacity, and deep knowledge of the stakeholder landscape, including the perspectives of people who will benefit from the system. This means engaging key stakeholders in decision-making about policy and problem-solving through what must be a coordinated implementation phase.

We can be supportive partners by developing mechanisms that help change agents manage the big picture over time — creating an overall roadmap and processes to get from design, to political passage, to effective implementation — always considering both policy and politics while engaging stakeholders appropriately.

We also can ensure that leaders get specific technical support on key aspects of implementation at the time and in the format they need it — not according to our own needs as development partners. And we can also help government leaders stay personally motivated through challenging situations. A network of peers, thought-partners and supportive coaches can be invaluable.

At Results for Development (R4D), we manage a number of different programs that support change agents in their efforts to achieve UHC. In 2010, we helped launched the Joint Learning Network for Universal Health Coverage (the JLN) and, today, we continue to serve as a network coordinator alongside the World Bank and ACCESS Health International. The JLN now includes 27 mainly low- and middle-income countries who come together to learn from and be inspired by the experiences of their peers in other countries.

We also manage the Center for Health Market Innovations, which offers inspiration for how the private sector can be engaged in UHC. Our efforts with the Bill and Melinda Gates Foundation, World Bank, WHO, and Ariadne Labs through the Primary Health Care Performance Initiative are supporting the development of better systems to measure and improve service delivery. These global public goods are complemented by our direct support of more than a dozen governments in Africa and Asia, including countries such as Nigeria, Ghana, and Vietnam.

I’m also very excited about new related and complementary programs we recently launched to further advance UHC:

  • To help make limited funds for health work harder in low- and middle-income countries, we will incubate the Strategic Purchasing Africa Resource Center (SPARC) within a not-yet-selected African institution. The resource center, funded by the Bill & Melinda Gates Foundation, will offer an Africa-based network of experts (institutions and individuals) to provide coaching and other support to government officials on strategic health purchasing and navigating political economy challenges in sub-Saharan Africa.

    SPARC builds on evidence that the countries that are most successful in expanding access to health services and improving health outcomes with limited funds, including Chile, Kyrgyzstan, Rwanda and Thailand, use the power of a public purchaser to shape the health care market and service delivery system. In these countries, strategic purchasing helps drive high-quality responsive care and efficient service delivery. Over time, we hope SPARC will both directly and indirectly strengthen primary health care and shift resources and utilization to that part of the health system.

  • SPARC will be highly integrated with another effort we recently launched with funding from USAID — the African Collaborative for Health Financing Solutions (ACS). ACS will support efforts to advance UHC in sub-Saharan Africa by convening and facilitating collaboration among regional and country-level stakeholders to share knowledge, improve accountability, and adapt effective health financing policies and processes to country contexts. This new initiative also aims to address some of the root causes that hamper implementation of UHC-related strategies, including the fact that important parties with vested interests are often excluded from UHC dialogue, and accountability mechanisms at the regional and country-level are often lacking or underused. The goal over five years is to strengthen skills and momentum within several countries and at the regional level that lead to tangible UHC progress.

Today, governments and their private sector counterparts and development partners are reaffirming the ambitious global goal of Health for All. As we collectively face the daunting, but attainable task of making UHC a reality in countries around the world, let’s push ourselves to continue to develop better models for supporting national change agents with their technical, political and operational challenges. We will continue to experiment with new models of support while constantly seeking feedback from our country partners to learn from these efforts. We commit to sharing evidence and implementation experience for what works and what doesn’t, and we will continue to collaborate with and learn from other development partners who support the advancement of UHC. Throughout it all, our focus must be on supporting local change agents and the myriad challenges they face on the road to UHC.

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