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University of Bonn
Masters on Global Health Risk Management and Hygiene Policies

Building Universal Health Coverage Temple in Africa

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Prepared and designed by Abenezer Giberhiowt

Bonn, Germany
9/21/2018

Table of Content

Chapter one 1
1. Introduce 1
1.1 Global Initiative Towards Universal Health Coverage 2
2. Universal health coverage in Africa 3
2.1 Building UHC Temple in Africa 5
2.1.1 Peace, Good Governance and Leadership 5
2.1.2 Health Financial 6
2.1.3 Health Information 7
2.1.4 Human Resource for Health 8
2.1.5 Medical products, Vaccines, and Technologies 9
2.1.6 Service Delivery 10
2.1.7 Evaluation, Accountability and Transparency 11
Chapter three 12
3.1 Universal Health Coverage in Botswana 12
Chapter four 16
4.1 Conclusion 16
Reference 17

Summery

Universal Health Coverage(UHC) is defined as access to the quality health service with out the risk of financial hardships or without being pushed to extreme poverty due to catastrophic health expenditure. Even if, the system design to provide universal access to the quality health service, it also has significant effect in poverty reduction and increasing social stability.
Besides the pressure from a High prevalence of disease in Africa, the additional reason for focusing into UHC is a moral one: most people are suffering from something that is preventable by integrated health service approach, such as universal health coverage.
Accepting and integration of UHC in the national policy level is not enough, the national polices should be translated in to the ground. still Africa is facing challenge in despite of the national UHC police, with regard to health insurance and financial protection, mobilizing internal resource and quality health service delivery.
There is no single fit model to achieving universal health coverage in Africa. All policies and strategies should consider each country local conditions. Even though , Africa is highly diversified continent most of problems are common for all countries. Africa should work on the basements of universal health coverage temple. such as peace, good governance and health financing. In addition, Africa should also give attention on strengthening the pillars of UHC temple such as Health information, health human resource, medical products(health technologies) and service delivery.

Methods
Internet review
?Literatures
?International and national policies
?Guidelines
Search Engine
?Google
?Google scholar

Chapter one
1. Introduce
Universal health Coverage is a service package in the health sector that design to give a quality health service and financial protection to the entire population in a given country. The central themes of universal health coverage is financial risk protection, improved access to quality health services, and improved health outcomes(1).
Universal Health Coverage(UHC) is the foundation for population stability in terms of health, sustained economic and social development. UHC was brought in to the table by Alma-Ata declaration before 30 years. With a central idea of ”Health for all”. which believed to produce better quality of life as well as prosperity and stability in the world (2).
In most country people rank health as their highest need, in another countries, they rank health following economic issue and poverty. Due this high health need in the society, universal health coverage become a social and political concern(2).
UHC is defined as access to the quality health service with out the risk of financial hardships or without they being pushed to extreme poverty due to catastrophic health expenditure. It is all about quality health service ,accessibility as well as financial risk protection.
Even if, the system design to provide universal access to the quality health service, it also has significant effect in poverty reduction and increasing social stability(3). Because of the political and social nature of the system, the universal health coverage able to attract the attention of all UN state members.
UHC is now become an important policy for all countries to maintain equity, accessibility,resilient and quality health structure. Health system strengthening is a a way out from poor quality health service, high out pocket expenditure and limited access to the health system. To maintain and sustain UHC the focus area should be institution resource and people.
1.1 Global Initiative Towards Universal Health Coverage
The 58.33/ 2005 resolution of World Health Assembly says ”everyone should be able to access health services and not be subject to financial hardship in doing so”. Our world failed to achieve both promises of the resolution.
Sustainable Development Goal(SDG) is the 2030 agenda by UN state members for for addressing poverty, hanger, inequality, Education, energy and environment issues. SDG has 17 goals with a defined priority areas of action. Of them Goal 3 is to ”ensure healthy lives and promote well-being for all at all ages”. UHC has special attention in goal 3 target 3.8 with a promising initiative to grant Universal health coverage (4).
”At least half of the world’s population still do not have full coverage of essential health services. About 100 million people are still being pushed into “extreme poverty” (living on 1.90 USD (1) or less a day) because of health service payment. Over 800 million people (almost 12% of the world’s population) spent at least 10% of their household budgets to pay for health care”(who.int/news-room/fact-sheets)(5). In 2015 as a part of Global sustainable development goal the UN state members agreed to renew their commitment to achieve UHC.
In some setting of the world economy is not the only limitation to the society that hider from accessing health service but also illiteracy, location, disability, war, lack of peace and stability are additional reasons that makes difficulty in accessing health service in-spite of heir high health need. Even some people are able to access to the health services they potentially exposed to high out pocket expenditure. Most often leads them to extreme poverty (1).

Chapter two
2. Universal health coverage in Africa
”Africa is the world’s second largest and second most-populous continent . With 1.2 billion people as of 2016, it accounts for about 16% of the world’s human population. Africa’s average population is the youngest among all the continents; the median age in 2012 was 19.7, when the worldwide median age was 30” (United Nations Department of Economic and Social Affairs, Population Division. Retrieved 10 September 2017)(6).
The continent is still straggling to create sustainable and inclusive social and economic development. In Africa many countries are facing high child mortality, maternal mortality, malnutrition. the strength of health system in controlling and preventing local communicable disease and non communicable disease is limited. These challenges pushed African leaders to renewed their commitments and to accelerate progress toward Universal Health Coverage (UHC) with initiative of delivering quality health service with out high out pocket expenditure(8).
Besides the pressure from a High prevalence of disease in Africa, the additional reason for focusing into UHC is a moral one: most people are suffering from something that is preventable by integrated health service approach, such as universal health coverage. UHC is not only one target orientated approach but it has also impact in promoting workers productivity, educational productivity, and wise use of resource UHC is also a good investment. The challenge in Africa is multi-dimensional require multi-directional solution (7).
Achieving UHC in Africa is still promising concept in Africa but still need much more in terms of good governance, leadership and commitment.
Most African countries have accepted UHC they also included as the part of their national sustainable development plane. If Africa able to achieve UHC by 2030 they could remove the pain of Africa from maternal and child death, outbreak, epidemics and poverty. Not only that, Africa could establish strong foundation for sustainable economic and social development.
But, acceptance and integration UHC in the national police level is not enough, the national polices should translated in to the ground. still Africa is facing challenge in despite of the national UHC police, with regard to health insurance and financial protection, mobilizing internal resource and quality health service delivery.
There is no single rod that leads to the achievement of UHC in Africa, all policies and strategies should consider each country local condition. This UHC temple includes a set of strategic action to achieve UHC in Africa.

2.1 Building UHC Temple in Africa
2.1.1 Peace, Good Governance and Leadership
Peace and good
governance is
basement for the
temple of UHC
African leaders,
freedom fighters,
media, Civil
societies should
put first their
citizen than
there political
agenda and interest.

Fig-1- Shows the the primary basement of the temple of Universal Health coverage

Lack of peace results to the collapse of whole health system, and also create favourable condition for epidemics and outbreaks. this clearly shown in the case of south Sudan, Syria,Somalia and Libya. Not only lack of peace, lack of good governance is responsible in many African countries for not functioning of the health system.
The health of population is dependent on different sectors out of the health system so improving inter-sectoral collaboration is a crucial leadership strategy to protecting and maintaining population health.
Not only Create institution which takes the first step and leadership in the implementation UHC. Ensure easy information flow between all citizens and police makers, leaders in the about UHC.
Making community to be the owner of health system in local, regional or national level.

2.1 Building UHC Temple in Africa
2.1.2 Health Financial
Get rid of beggar
mentality and
aid dependency
culture.
Looking
for Internal
source of income.
Establish
sustainable
income source
internally.
Increase public
and private
domestic
resources.

Fig-2- Shows the secondary basement of the temple of Universal Health coverage

Not only generation of resource, reduce waste is very important, inappropriate wastage usually seen in Africa health care settings. Increase the efficiency of the both public and private health system, wise use of resource for better health out come. Increase domestic mobilization of resource through increasing government spending in the health system.
Use mobilized budgets and resources to reduce out of pocket payment and to make the services affordable to all citizens.
External source of resources should be used as supplement budget for the health system. The sustainability of external source of budget is questionable, no country can have sustainable health system by depending on external source of budget.
Support public private investment in the health sector and create competitive public and private health sector to benefits the large number of population(8,10)

2.1 Building UHC Temple in Africa
2.1.3 Health Information
Health information
is the first
Pillar for Temple
of UHC.
Health
informations
Such as;
Hospital records
Health survey,
Civil registration
demographic
data’s, should
be analysed,
and collected in
Quality and
timely manure
Fig-3- Shows the first pillar of the temple of Universal Health coverage

Health policies, health plan, health budget, hospitals and health facilities should rely on demographic health survey, national health/society health survey, civil registration, vital statistics systems, district health information systems and clinical records.(8,9)

2.1 Building UHC Temple in Africa
2.1.4 Human Resource for Health
The second pillar
in temple of UHC
is health
Professionally.

The should be
Strategy that
Meet the of
health
Professional
in Afriac

Fig-4- Shows the secondary pillar of the temple of Universal Health coverage

The health professional training and education curricula should design in the way that promote competency and compassion. Primary objectives in human resources for health should not be only to train or educate health professionals, but also Africa should design a system to hold professionals in the Country, to prevent brain drain(9,10).

2.1 Building UHC Temple in Africa
2.1.5 Medical products
Medical products
are the third pillar
Of UHC temple.
Medical products
most be assured
in quality and
must be also
in quantity
that meet the
need of the whole
Population.

Fig-5- Shows the third pillar of the temple of Universal Health coverage

Medical product procurement should be performed from known manufacture avoid drugs that is from not known source.
Promote transparency and accountability in the pharmaceutical Agency. strength supply chin components work for safety and security of medical products.
Each pharmaceutical products starting from procurement to prescribing to the patient should be relayed on evidence, standards, regulation and rules (10).

2.1 Building UHC Temple in Africa
2.1.6 Service Delivery

In this temple,
of UHC
Service
deliveries,
are the fourth-
pillars.

Based on local
evidences the
Health service
Should have
All list of
Services to
The society

Fig-6- Shows the fourth pillar of the temple of Universal Health coverage
The government should make accessible to all essential quality health service to the people without any limitation regardless to economic, political, disability, gender, location and time.
Not only governmental but also private health facilities should accessible to those who are in need without any limitation(9,10).

2.1 Building UHC Temple in Africa
2.1.7 Evaluation, Accountability and Transparency
Use evaluation,
accountability
transparency
tools as the
door and
the windows
to regulate
and monitor the
whole Structure
of the temple
of UHC.

Fig-7- Shows the third door and the windows of the temple of Universal Health coverage

Regular monitoring and evaluation to the basement and the pillars of UHC temple. Ensure access to data and information on UHC temple, to those who are concerned. Develop sustainable country capacity in transparency and accountability in law, policy, planning, leadership, and management(10).

Chapter three
3.1 Universal Health Coverage in Botswana
The total population of Botswana was 2,250,000 by the year 2016, in the same year gross national income per population was $15 ranks the five in Africa. Life expectancy at birth by the year 2016 was 66, the African average was 61.2. Total expenditure on health was 5.4 % but WHO recommend Africans should spend 15% of their budget on health(11,12,13).
Botswana categorize three cause of population health problem. One infectious disease, responsible for the cause of death to all age group of population most importantly HIV/AIDS. Two, maternal mortality rate both under five and infant mortality. Diarrhoea and pneumonia are among the top listed cause. Three, non communicable disease(14).

Fig-8 …. Cause of mortality in Botswana
Source; Botswana Health and HIV/AIDS Public Expenditure Review June 15, 2016 Health,

Beside moral initiative, Botswana government is under pressure from high prevalence of HIV, infectious diseases, maternal mortality, Chilled mortality and high health spending. The government of Botswana establish different financial strategies and policy initiatives to improve the efficiency and health outcome.
The central idea behind Botswana policy initiatives is to strength universal health coverage through adequacy, universality, cost effectiveness, affordability, and focus on vulnerable groups.

Health policy initiative in Botswana are:- resource mobilization, increase efficiency, catalyse public/private partnership and improve health insurance(15,16).

Resource Mobilization
Botswana begin to mobilize funding by calculating budget gap and resource need for health. through searching fiscal space for health and increasing government expenditure to health. For example, until 2008, % of GDP allocated to health was only 5.4 compared to south Africa 8.9% and Namibia 7.7%.
Budget gap and resource calculation includes all sector needs such as : primary health care, hospital care, HIV/AIDS response, and policy, planning, monitoring and evaluation, and regulation(15,16).

Catalyse public and private partnership
Transform the Ministry of Health (MoH) from being a pass-through of annual budgets to a contractor by strengthening contracting services and paying for results. Develop a system that gives people the freedom to obtain services from public and private providers.
MoH and Mass aid Scheme (MAS) begin to work in partnership to pay for services. The MoH pays private primary healthcare providers and hospitals to expand coverage and services to the population(15,16).

Improve Health insurance
Redefine the role of commercial MAS to supplement essential health service package (EHSP). Create a national insurance fund that pools contributions from multiple sources of financing. Subsidize MAS enrolment to expand coverage to the entire population. MAS to develop affordable insurance plans to cover EHSP(15,16).
Increase Efficiency
The Botswana MoH begin to asses health system performance in terms of health outcome, service coverage and financial protection to find the gap in efficiency. Regarding health outcome high prevalence of HIV/AIDS, malaria, TB are still the three big infectious diseases in Botswana. Maternal mortality, chilled mortality and infant mortality are the top listed cause of death in Botswana.
Regarding service coverage 94.1% live around 8km reduce of the health facilities the average upper middle income country was 95.4. there is no data on catastrophic health expenditure.
To enhance the efficiency the MoH renew the drug policy, begin to use pool procurement and begin to replace brand by generic drugs.
Increase efficiency and quality by encouraging competition between and among public and private providers.
Create a National Health Technology Assessment Unit to update the EHSP on a regular basis, make recommendations on essential medicines, promote the use of the most cost-effective interventions and issue clinical guidelines. Improve managerial practices and standard operational procedures at all levels to reduce waste and improve operations(15,16).
All Botswana citizens are entitled to free Antiretroviral therapy (ART) and around 66 percent of the HIV-infected population (248,000 people) was receiving ART in 2015. which was a great achievement indeed in reduction in HIV/AIDS related death(15,16).

Fig-8- Percent Cause of death in Botswana Fig-9- Trend Crude mortality rate

Due to those significance policy Initiative, total death in Botswana begin to reduced from 23,600 in 2002 to 13,200 in 2013. In terms of crude mortality rate, reduced from 1.24 to 0.65 percent in the same respective year.
Regarding Cause of death in 2002, 46.6 percent of death in Botswana is HIV/AIDS related death but due to remarkable achievement in improving access to HIV treatment, HIV/AIDS related death in Botswana reduced to 33.3 percent in 2013.

Chapter four
4.1 Conclusion
The 21st century, challenges of universal health coverage is to provide quality health service for all in limited resource setting. There is no single fit model to achieving universal health coverage in Africa. All policies and strategies should consider each country local conditions. Even though , Africa is highly diversified continent most of problems are common for all countries. Africa should work on the basements of universal health coverage such as peace, good governance and health financing. In addition, Africa should also give attention on strengthening the pillars of UHC temple such as Health information, health human resource, medical products(health technologies) and service delivery.

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