N Bakyaita1 N Mweemba16
1.World Health Organisation, Country Office, Lusaka, Zambia
Citation style for this article: Bakyaita N, Mweemba N. Universal Health Coverage: A perspective of the WHO country office in zambia. Health Press Zambia Bull. 2018 2(4); pp 5-16.
This paper provides a perspective of the WHO Country Office on Universal Health Coverage following the commemoration of the World Health Day 2018 on 7 April under the theme “Universal Health Coverage: Everyone, Everywhere” and the slogan “Health For all”. The World Health Day theme put a spotlight on the significance of Universal Health Coverage in health system strengthening and its importance in achieving health for and its importance to the 2030 sustainable development agenda. It argues that UHC is technically feasible and attainable. It highlights the how Zambia has integrated UHC in its health development agenda, success so far, challenges and how it can accelerate actions to move towards UHC using the existing international and regional frameworks. The role of WHO in supporting the country in moving towards UHC including monitoring progress is illustrated.
To mark its 70th anniversary on World Health Day, The World Health Organization selected the theme “Universal Health Coverage: Everyone, everywhere” and the slogan: “Health for All”. Universal Health Coverage (UHC) means that “all individuals and communities receive the health services they need without suffering financial hardship. It includes the full spectrum of essential, quality health services, from health promotion to prevention, treatment, rehabilitation, and palliative care” . The WHO Director General, Dr. Tedros Adhanom Ghebreyesus simply illustrated UHC when he said “No one should have to choose between death and financial hardship. No one should have to choose between buying medicine and buying food.” UHC is firmly based on the 1948 WHO Constitution , which declares health a fundamental human right and commits to ensuring the highest attainable level of health for all. “Health for All” has therefore been WHO’s guiding vision for more than seven decades.
According to the 2017 global monitoring report for tracking Universal Health Coverage released by the World Bank and WHO, at least half of the world’s population still does not have full coverage of essential health services. The World Bank also states that in the WHO African Region, there are wide disparities in UHC within countries while coverage gaps remain large for many critical services such as access to HIV, TB and malaria. In addition, financial protection is generally low and patients pay for health services from their own household income, so-called out-of-pocket (OOP) expenditure. Universal Health Coverage is therefore aimed at protecting people against the impoverishing effect of health payments. So in this 70th anniversary year, WHO is calling on world leaders to live up to the pledges they made when they agreed the Sustainable Development Goals in 2015, and commit to concrete steps to advance the health of all people.
The 2017 Tokyo Declaration at the Universal Health Coverage forum calls for greater global commitment to accelerate progress towards UHC by 2030. In the interim, by 2023, the world should have extended essential health coverage to 1 billion additional people and halve to 50 million the number of people being pushed into extreme poverty by health expenses. Countries are therefore urged to develop their own roadmaps towards UHC, with clear targets and indicators. They are also called upon to use country-led, multi-stakeholder coordination platforms in line with the UHC 2030 global compact principles. Equally, the Call to Action made at the African Health Forum in 2017, recognises that the sustainable development agenda requires health systems strengthening and calls upon countries to keep UHC as the overarching approach for attaining SDG3.
Why UHC Matters
Many countries in Africa continue to grapple with high levels of child and maternal mortality, communicable and non-communicable diseases. Health systems are also not able to deal effectively with epidemics and the growing burden of chronic diseases, such as cancer and diabetes. These challenges call for renewed commitments and accelerated progress toward Universal Health Coverage (UHC). Zambia faces a high burden of communicable and non-communicable diseases. In addition, structural and social deprivation including poverty, inequalities and marginalization remain major threats to health. By investing in UHC, Zambia can make a sound investment in human capital. According to the World Bank “Countries that achieve their UHC targets by 2030 will eliminate preventable maternal and child deaths, strengthen resilience to public health emergencies, reduce financial hardship linked to illness, and strengthen the foundations for long-term economic growth”. Progress towards Universal Health Coverage (UHC) is also critical to promote equity, basic rights, and human security in health and can lead to significant economic gains. In addition, strong health and disease surveillance systems have the ability of preventing and absorbing shocks of epidemics that can cause unnecessary deaths and disrupt society.
It is worth to note that the Seventh National Development Plan has prioritised health as a key economic investment and emphasizes that the successful attainment of Zambia’s goal of being a prosperous, middle-income country by 2030 as stipulated in its Vision 2030 is dependent upon having a healthy and productive population. The Ministry of Health is therefore committed to the provision of equitable access to cost effective, quality health services as close to the family as possible.
UHC and its significance to the 2030 SDGs Agenda
The importance of health in achieving international development goals and moving towards universal health coverage has been recognised by the United Nations even before the sustainable development goals were agreed in 2015. Globally, health is known to be at the centre of the Sustainable Development Goals (SDGs) because it is a cross cutting issue with direct and indirect links with other goals and targets. Goal 3 relates to the direct actions that influence health, while SDGs such as poverty, nutrition, education, gender, water and sanitation, inequality affect the achievement of health targets. All UN Member States have agreed to try to achieve Universal Health Coverage (UHC) by 2030, as part of the Sustainable Development Goals.
One of the targets under the sustainable development goal no. 3: (“ensuring healthy lives and promote well-being for all at all ages”) is to “achieve universal health coverage, including financial risk protection, access to quality essential health care services and access to safe, effective, quality and affordable essential medicines and vaccines for all.” Since UHC is the overarching target that should facilitate achievement of all the other health targets in SDG 3, it is in line with the key message of the SDGs of “Leaving No One Behind”. UHC also lays emphasis on addressing the needs of the most vulnerable groups in society particularly women and children, the older persons, refugees and other minority populations. Without UHC, many people would not have the opportunity to live full and productive lives, and risk impoverishment in their pursuit of health care.
How can Zambia move towards UHC?
It is a known fact that Universal Health Coverage is achieved when political will is strong, and that it also requires a clear strategic vision. Zambia has already integrated Universal Health Coverage as a goal in its national health strategies and is committed to the attainment of the SDG goals. The National Health Strategic Plan 2017-2021 clearly states the mission of the Ministry of Health as that of providing the population with equitable access to cost effective, quality health services as close to the family as possible. To achieve this, significant investments are being made in improving health service delivery, human resources for health, infrastructure development, health care financing and health information. The Social Health Insurance Scheme is also regarded as a major priority which will increase the resource envelope for health and enhance UHC in the country.
The country has seen improvement in the coverage of life saving interventions and improved health status. For example, the ZDHS shows that HIV prevalence declined from 14% in 2007 to 13.3% in 2013-2014, maternal mortality reduced from 591 deaths per 100,000 live births in 2007 to 398 deaths in 2013-2014 the child mortality rate dropped from 197 deaths per 1,000 live births in 1996 to 75 per 1,000 live births in 2013-14. Improvements in child health have been achieved on account of improved immunization coverage, exclusive breast-feeding, vitamin and mineral supplementation, and malaria prevention and treatment and prevention of mother-to-child transmission of HIV. The reduction in maternal deaths is a result of improved family planning services, improved referral systems, provision of and access to emergency obstetric care, increase in trained midwives and birth attendants and voluntary HIV counselling and testing.
Despite the improvements in coverage of health services, gaps remain which require acceleration of efforts towards UHC. Like many other African countries, financial protection in Zambia is still low requiring most patients to pay for health services from their own household income, so-called out-of-pocket (OOP) payments. The WHO Regional Office for Africa has developed a framework for strengthening health systems for UHC and the SDGs while leaving no one behind . The framework provides guidance on how Member States’ can re-align their health systems in a manner that facilitates movement towards UHC and attainment of their sustainable development aspirations. It has recommended six outcome areas which include: availability of essential services; coverage of essential services; health security financial risk protection, client satisfaction and coverage with interventions from SDGs. This framework builds upon the 2016 Tokyo International Conference on African Development (TICARD-VI) framework for action which set financing, governance, services, preparedness and equity as key action areas for UHC in Africa.
Accelerating the move towards universal health coverage in the country will therefore require strengthening the efficiency of the health system in providing the entire population with access to good quality services. WHO emphasizes UHC is not only what services are covered, but also how they are funded, managed, and delivered and recommends a fundamental shift in service delivery such that services are integrated and focused on the needs of people and communities. The transformative agenda being undertaken by the Ministry of Health focusing on Primary Health Care (PHC) and health promotion is a timely development which will enhance health and equity.
The role of WHO in supporting Zambia to move towards UHC
At country level, the role of WHO is to support the development of the health system to move towards and sustain UHC, and to monitor progress. WHO has continued to work with other partners in supporting the implementation of the National Health Strategic Plan in order to contribute to the attainment of the national goal of “improving the health status of people in order to contribute to increased productivity and socio-economic development”. The WHO Country Cooperation Strategy (CCS) which is the key instrument guiding the WHO Country Office’s support to the country shows that during the period 2017-2021, WHO will focus its efforts in Zambia on five broad strategic agendas one of which is “achieving and sustaining Universal Health Coverage (UHC) through a revitalized Primary Health Care (PHC) approach and sustainable service delivery through strengthening of health systems”.
The focus of WHO is also to strengthen actions aimed at accelerating actions towards the attainment of the targets of the Sustainable Development Goal number 3 on health. The CCS is therefore aligned with the NHSP and has prioritized the reduction of Maternal, Newborn, Child and Adolescent mortality; improving sexual and reproductive health; reducing further the burden of AIDS, tuberculosis, malaria, neglected tropical diseases, hepatitis, and other communicable diseases. Other priorities include: strengthening and re-orienting health and health-related systems to address the prevention and control of NCDs, including disabilities, injuries and mental health disorders, and the underlying social determinants; and strengthening preparedness, integrated disease surveillance and effective response to public health events/emergencies.
WHO is also working in collaboration with the European Union-Luxembourg-WHO Partnership for UHC to strengthen efforts aimed at moving UHC. With support from DFID, WHO is supporting the implementation of a programme on Emergency Preparedness and Control aimed at strengthening national capacities for responding to outbreaks and health emergencies. It is also working in collaboration with the Ministry of Health through the National Public Health Institute (ZNPHI) to strengthen the core capacities for implementing the International Health Regulations 2005.
Monitoring progress towards UHC
Together with the World Bank, WHO has developed the Global Monitoring Framework to track the progress of UHC. The framework monitors the proportion of a population that can access essential quality health services and the proportion of the population that spends a large amount of household income on health using a uniform measurement methodology for UHC indicators. It also takes into account both the overall level and the extent to which UHC is equitable, service coverage including financial protection the population, such as the poor or those living in remote rural areas. WHO uses 4 categories as indicators of the level and equity of coverage in countries: Reproductive, maternal, newborn and child health: infectious diseases: Non-communicable diseases and service capacity and access.
The monitoring system also emphasizes the importance of strengthening the breadth and depth of data at the national and subnational levels, including disaggregated data, to inform evidence based policymaking and to assess progress, as well as strengthening the capacity of local stakeholders to analyse and use data. At regional level, the WHO Regional Office for Africa has also set the overall targets that, by 2030 at least 80% of Member States will have health systems that are performing optimally for effective delivery of essential package of health and related services. In the interim, by 2021 50% of all Member States will show evidence of improving population coverage of agreed standards and assessments. By 2025 80% of Member States will show evidence improving population coverage of agreed standards and assessments.
The theme of the World Health Day 2018 has put a spotlight on the need for renewed commitment to accelerate the efforts for moving towards Universal Health Coverage and the attainment of the Sustainable Development Goals. Although countries have made progress in improving coverage for life saving interventions, significant gaps still exist and many people still suffer financial cost. The call made to countries at the Tokyo Declaration in 2017 to accelerate progress towards UHC by making specific plans with indicators was timely. Using the existing implementation frameworks for UHC and the Global UHC monitoring framework by WHO and the World Bank, many countries can make a difference in improving health and equity. Moving towards UHC will involve ensuring adequate health care budgets, financial protection mechanisms, human resources, information systems, health infrastructure and health technologies and adequate stocks of essential drugs. WHO therefore remains committed to continue working with other partners in supporting efforts aimed at bringing quality healthcare services to the population in an equitable manner and to support monitoring of UHC. Universal Health Coverage is both technically and financially feasible and is the best investment for a safer, fairer and healthier world for everyone.
1.World Health Organization (2017) Universal Health Coverage (UHC). WHO Fact Sheet. WHO, Geneva Switzerland. http://www.who.int/en/news-room/fact-sheets/detail/universal-health-coverage-(uhc) Accessed on 25 April 2018.
2.World Health Organization (1946) The Constitution of WHO. https://www.loc.gov/law/help/us-treaties/bevans/m-ust000004-0119.pdf Accessed on 26 April 2018.
3. World Health Organization and International Bank for Reconstruction and Development / The World Bank (2017) Tracking universal health coverage: 2017 global monitoring report. Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data.CIP data are available at http://apps.who. int/iris.
4. World Bank. (2016) UHC in Africa: A Framework for Action. World Bank, Washington, DC. © World Bank. https://openknowledge.worldbank.org/handle/10986/26072 License: CC BY 3.0 IGO.” Accessed on 26 April 2018.
5. World Health Organization (2017) Tokyo Declaration on Universal Health Coverage: All Together to accelerate progress towards UHC. http://www.who.int/universal_health_coverage/tokyo-decleration-uhc.pdf. WHO
6. WHO Regional Office for Africa (2017) The First WHO Africa Health Forum. Putting people first. The road to Universal Health Coverage in Africa. http://www.afro.who.int/publications/first-who-africa-health-forum-report. Accessed on 26 April 2018.
7. World Bank. (2016.) UHC in Africa: A Framework for Action. World Bank, Washington, DC. © World Bank. https://openknowledge.worldbank.org/handle/10986/26072 License: CC BY 3.0 IGO.”
8. Government of the Republic of Zambia. (2017) Seventh National Development Plan 2017-2021:”Accelerating development efforts towards vision 2030 without leaving anyone behind” GRZ, Ministry of National Development planning, Lusaka, Zambia
9. United Nations (2012) Health: Essential for sustainable development. UN Resolution on Universal Health Coverage. http://www.who.int/universal_health_coverage/un_resolution/en/. Accessed on 26 April 2018.
10. SDG 2015
11. Ministry of Health (2017) National Health Strategic Plan 2017-2021. Ministry of Health, Lusaka, Zambia.
12. Demographic and Health Survey, 2013-14, Volume 1. Zambia: Demographic and Health Survey, 2013-14, Zambia. Central Statistical Office. Contributors, Zambia. Central Statistical Office, Zambia. Ministry of Health, MEASURE DHS (Program). Publisher, Central Statistical Office, 2015.
13. World Health Organization. Regional O¬ffice for Africa (2017), Leave no one behind: strengthening health systems for UHC and the SDGs in Africa 20http://www.afro.who.int/sites/default/files/2017-12/UHC%20framework_eng_2017-11-27_small.pdf. Accessed on 26 April 2018.
14. World Bank. 2016. UHC in Africa: A Framework for Action. World Bank, Washington, DC. © World Bank. https://openknowledge.worldbank.org/handle/10986/26072 License: CC BY 3.0 IGO.”
15. World Health Organization (2017) Universal Health Coverage (UHC). WHO Fact Sheet. WHO, Geneva Switzerland.
16. World Health Organization (2017) WHO Country Cooperation Strategy 2017-2021. WHO, Lusaka, Zambia.
17. Tracking universal health coverage: 2017 global monitoring report. World Health Organization and International Bank for Reconstruction and Development / The World Bank; 2017. Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data.CIP data are available at http://apps.who. int/iris.
18. World Health Organization. Regional O¬ffice for Africa (2017), Leave no one behind: strengthening health systems for UHC and the SDGs in Africa 20http://www.afro.who.int/sites/default/files/2017-12/UHC%20framework_eng_2017-11-27_small.pdf. Accessed on 26 April 2018.