UHC in Africa: A Framework for Action _____________________________________________ EXECUTIVE SUMMARY EXECUTIVE SUMMARY ______________________________________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________ Why Invest in UHC? UHC in Africa: Progress and Challenges Investment in Africa’s health systems is key to inclusive and sustainable growth. Health expenditure in Africa have increased significantly, but domestically financed government spending has stalled. Strong economic growth in recent years has helped reduce poverty to 43 percent of the population. Yet, as Africa’s population expands—it is estimated to reach 2.5 billion by 2050—the region faces a critical Total health expenditure has grown rapidly over the last two decades, in particular in middle-income challenge of creating the foundations for long-term inclusive growth. Many countries still contend with countries. But this increase has been driven mainly by out-of-pocket spending by households and high levels of child and maternal mortality, malnutrition is far too common, and most health systems are development assistance, about half of which was earmarked spending for HIV/AIDS. In contrast, not able to deal effectively with epidemics and the growing burden of chronic diseases, such as diabetes. government spending on health as a share of total government spending has decreased in half of the These challenges call for renewed commitments and accelerated progress toward Universal Health countries in the region (figure 1). Only four countries met the Abuja target of 15 percent of general Coverage (UHC)—the principle that everyone receives needed health services without financial hardship. government spending in 2014. Limited commitment of domestic resources is often reflected in shortages of critical inputs such as human resources for health and pharmaceuticals. Investing in UHC pays off. Coverage of key health services has increased but critical gaps remain. The primary reason for investing in UHC is a moral one: it is not acceptable that some members of society should face death, disability, ill health or impoverishment for reasons that could be addressed at Africa has seen rapid improvement in coverage of insecticide treated bed nets for children, which limited cost. However, UHC is also a good investment. Prevention of malnutrition and ill health is likely accounts for an important share of the decline in child mortality. Other indicators related to maternal and to have enormous benefits in terms of longer and more productive lives, higher earnings, and averted child health services, such as antenatal care and skilled birth attendance have also improved. Yet, wide health care costs. Effectively meeting demand for family planning will accelerate the fertility transition, disparities remain within countries, and coverage gaps remain large for many critical services. Access which in turn will result in higher rates of economic growth and more rapid poverty reduction. And strong to HIV, TB, and malaria services also remains uneven and is lower than for other core indicators of UHC health and disease surveillance systems halt epidemics that take lives and disrupt economies. In 2015, progress. Progress has also been slow in the case of improved water and sanitation, and the region is far the forgone economic growth due to Ebola amounts to more than a billion US$ in the three countries hit from reaching the 2030 Sustainable Development Goal (SDG) basic essential health services objective of by the epidemic. 80 percent population coverage. Millions of Africans fall into poverty due to high out-of-pocket health payments. Financial protection is generally low in Africa, requiring most patients to pay for health services from their own household income, so-called out-of-pocket (OOP) payments. Patients in low-income and lower-middle-income countries are less protected against high OOP than those in higher-middle-income countries. Out-of-pocket payments have increased in nearly all countries, and the regional average has increased from US$15 per capita in 1995, to US$38 in 2014. As a result, 11 million Africans are falling into poverty every year due to high out-of-pocket payments. Protecting people against the impoverishing effect of health payments is a cornerstone of UHC and will help prevent poverty in Africa. GOVERNMENT SPENDING ON HEALTH IN TOTAL GOVERNMENT SPENDING fig.1 ______________________________________________________________________________________________________________________________________________________________________ 35 2002 2014 30 28 26 Number of countries 25 20 18 14 15 10 6 5 3 4 5 0 BELOW 5% 5% – 10% 10% – 15% OVER 15% Government spending on health in total government spending Universal Health Coverage in Africa | 2 A Framework for Action | 3 EXECUTIVE SUMMARY EXECUTIVE SUMMARY ______________________________________________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________ Accelerating Progress toward UHC: UHC in Africa: Opportunity, Directions and the A Framework for Action Way Forward Accelerating progress toward UHC in Africa is within reach but will require political leadership and a 1 / FINANCING More and Better Spending and Effective Financial Protection clear strategic vision. >> Improve efficiency of public and private health spending for better outcomes and resource expansion Most African countries have integrated UHC as a goal in their national health strategies. Countries that >> Increase government spending on health through budget re-allocation and increased domestic achieve their UHC targets by 2030 will eliminate preventable maternal and child deaths, strengthen resource mobilization resilience to public health emergencies, reduce financial hardship linked to illness, and strengthen the >> Use budget resources to reduce financial barriers to care and make services affordable to everyone foundations for long-term economic growth. Yet, progress in translating commitments to UHC into >> Ensure that the poor, and people working in the informal sector benefit from pre-payment, and that expanded domestic resources for health, effective development assistance, and ultimately, equitable and providers get a fair deal quality health services, and increased financial protection has been slow. >> Improve the effectiveness of development assistance for health through improved coordination and use of country systems There is no one-size-fits-all approach to achieving UHC—strategies will depend on local circumstance and national dialogue. 2 / SERVICES People-Centered Services, Quality and Multisectoral Action Despite the great diversity of African countries, many are facing common challenges. This framework >> Establish people-centered health services to improve quality of services and patient safety proposes a set of actions for countries and stakeholders involved in the UHC process. It is intended to >> Prioritize investments in community and primary health care services within the framework of viable stimulate action by demonstrating that progress toward UHC is not only possible, it is also essential. local governance systems >> Partner with civil society and non-state providers to expand access to key services and interventions >> Invest in pre-service education, particularly in underserved areas >> Engage in multisectoral action to address determinants of health 3 / EQUITY Targeting the Poor and Marginalized and Leaving No One Behind >> Target vulnerable populations and design programs tailored to their needs >> Expand service delivery to marginalized groups and settings >> Scale-up pro-poor interventions such as demand-side incentives, including vouchers and conditional cash-transfers >> Ensure the rights and entitlements of women, children and minorities, particularly during vulnerable parts of the life course 4 / PREPAREDNESS Strengthening Health Security >> Improve national preparedness plans including organizational structure of the government >> Promote adherence to the International Health Regulations (IHR) >> Utilize international framework for monitoring and evaluation of IHR >> Enhance relevant partners’ and across countries’ collaboration to prepare for and respond to public health emergencies 5 / GOVERNANCE Political and Institutional Foundations for the UHC Agenda >> Establish platforms and processes to foster societal dialogue >> Enhance effective mechanisms for inter-sectoral dialogue and action >> Establish transparent monitoring and reporting on progress toward UHC >> Ensure that all citizens have access to data and information on UHC, as part of societal dialogue and participatory processes >> Strengthen national institutions and organizations to lead implementation of reforms for UHC Universal Health Coverage in Africa | 4 A Framework for Action | 5 Universal Health Coverage in Africa | 6