Sally Fitzgibbons Foundation

Beginning the Academic Essay

University of Bonn
Masters on Global Health Risk Management and Hygiene Policies
Building Universal Health Coverage Temple in Africa

Prepared and designed by Abenezer Giberhiowt
Bonn, Germany
9/21/2018
Table of Content
TOC o "1-3" h u HYPERLINK l _Toc9651 Chapter one PAGEREF _Toc9651 1
HYPERLINK l _Toc3544 1. Introduce PAGEREF _Toc3544 1
HYPERLINK l _Toc4383 1.1 Global Initiative Towards Universal Health Coverage PAGEREF _Toc4383 2
HYPERLINK l _Toc7316 2. Universal health coverage in Africa PAGEREF _Toc7316 3
HYPERLINK l _Toc8456 2.1 Building UHC Temple in Africa PAGEREF _Toc8456 5
HYPERLINK l _Toc11045 2.1.1 Peace, Good Governance and Leadership PAGEREF _Toc11045 5
HYPERLINK l _Toc25234 2.1.2 Health Financial PAGEREF _Toc25234 6
HYPERLINK l _Toc9839 2.1.3 Health Information PAGEREF _Toc9839 7
HYPERLINK l _Toc6686 2.1.4 Human Resource for Health PAGEREF _Toc6686 8
HYPERLINK l _Toc18482 2.1.5 Medical products, Vaccines, and Technologies PAGEREF _Toc18482 9
HYPERLINK l _Toc3521 2.1.6 Service Delivery PAGEREF _Toc3521 10
HYPERLINK l _Toc19484 2.1.7 Evaluation, Accountability and Transparency PAGEREF _Toc19484 11
HYPERLINK l _Toc10399 Chapter three PAGEREF _Toc10399 12
HYPERLINK l _Toc15948 3.1 Universal Health Coverage in Botswana PAGEREF _Toc15948 12
HYPERLINK l _Toc26072 Chapter four PAGEREF _Toc26072 16
HYPERLINK l _Toc14062 4.1 Conclusion PAGEREF _Toc14062 16
HYPERLINK l _Toc10283 Reference PAGEREF _Toc10283 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.
Beside the pressure from High prevalence of disease in Africa the other 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 limited cost.
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
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Chapter one1. Introduce
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).
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 aim and objective of universal health coverage is financial risk protection, improved access to quality health services, and improved health outcomes(1).
In most country people prefer health one of their highest priorities, in another countries,they rate health before only economic concerns, such as unemployment, low wages and a high cost of living. Due to high health priority 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.
Achieving UHC is an important objective for all countries to attain equability, accessibility, accountability, resilience and sustainability health structure. Health system strengthening is a means to progress towards UHC. A functioning UHC is organized around the people, institutions and resources that are mandated to improve, maintain or restore the health of a given population.
1.1 Global Initiative Towards Universal Health Coverage
The World Health Assembly resolution 58.33/ 2005 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 governments and the international community to renew their commitment for improving social and political stability. 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 for all people and communities having access to quality health services without risking financial hardship(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(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 income is not the only factor influencing service coverage but also illiteracy, location, migrants, ethnic minorities and indigenous people use services less than other population groups, even though their needs may be greater. The other side of the coin is that when people do use services, they often incur high, sometimes catastrophic costs in paying for their care. Only one in five people in the world has broad-based social security protection that also includes cover for lost wages in the event of illness, and more than half the world’s population lacks any type of formal social protection, according to the International Labour Organization (ILO), Only 5–10% of people are covered in sub-Saharan Africa and southern Asia, in Ethiopia only ;1% of the population has Health insurance, while in middle-income countries coverage rates range from 20% to 60%(1).

Chapter two
2. Universal health coverage in Africa
Africa is the world’s second largest and second most-populous  HYPERLINK "https://en.wikipedia.org/wiki/Continent" o "Continent" continent . With 1.2 billion people as of 2016, it accounts for about 16% of the world’s  HYPERLINK ;https://en.wikipedia.org/wiki/Human_population; o ;Human population; human population. Africa’s average population is the youngest among all the continents; the  HYPERLINK "https://en.wikipedia.org/wiki/Median" o "Median" median age in 2012 was 19.7, when the worldwide median age was 30 (6).
The continent is still straggling to create sustainable and inclusive social and economic development. In Africa many countries are facing high levels of child mortality, maternal mortality, malnutrition, and most health systems are not able to deal effectively with epidemics and the growing burden of chronic diseases, such as diabetes. These challenges forced African leaders to renewed their commitments and to accelerate progress toward Universal Health Coverage (UHC) with initiative of everyone receives needed health services without financial hardship(8).

Beside the pressure from High prevalence of disease in Africa the second 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 limited cost. However, UHC is also a good investment. Prevention of malnutrition and ill health is likely to have enormous benefits in terms of longer and more productive lives, educational productivity, and reducing health care cost. Effectively meeting demand for family planning will accelerate the fertility transition, which in turn will result in higher rates of economic growth and more rapid poverty reduction. And strong health and disease surveillance systems halt epidemics that take lives and disrupt economies. The challenge in Africa is multi-dimensional require multi-directional solution (7).

Achieving UHC in Africa is still promising concept 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. Even though the great diversity in African, many are facing common challenges. This temple has a proposed set of actions for countries and stakeholders involved in the UHC process.
2.1 Building UHC Temple in Africa2.1.1 Peace, Good Governance and Leadership
1233170137160Peace and good governance is basement
for the temple of UHC
Peace and good governance is basement
for the temple of UHC
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.

127952590170Peace, Good Governance and Leadership
Peace, Good Governance and Leadership

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.
Develop sustainable country capacity in law, policy, planning, leadership, and management. The health of population is dependent on different sectors out of the health system so improving inter-sectoral collaboration is a crucial 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 Financial117475093345Health financing is basement for UHC temple
Health financing is basement for UHC temple
Get rid of beggar
mentality and
aid dependency
culture.

Looking
for Internal
source of income.

Establish
sustainable
income source
internally.

Increase public
1410335220980Health Financing
Health Financing
and private
domestic
122809093980Peace, good governance and leadership
Peace, good governance and leadership
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 Information115697092710Health Information is a pillar for Universal Health
temple in Africa

Health Information is a pillar for Universal Health
temple in Africa

Health information
is the first
Pillar for Temple
6134101090930Health Information
Health Information
of UHC.
ensures that
countries
collect,
analyze,
disseminate,
and use
timely and
High quality
143002039370Health financing
Health financing
health
1294130113665Peace, Good Governance and Leadership
Peace, Good Governance and Leadership
information.

Fig-3- Shows the first pillar of the temple of Universal Health coverage
Priority objectives in health information are to ensures that countries collect, analyze, disseminate, and use timely and high quality health information. The primary objective health information are to Create a culture of evidence based informed decision making.
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 Health1221105252095Human Resource for Heath
is the second pillar for
UHC temple
Human Resource for Heath
is the second pillar for
UHC temple
Develop and
implement models
to address special
718185963295Health Information
Health Information
1266190960755Human Resource for Health
Human Resource for Health
human resources
for health needs.

Conceive and
adapt effective
models for
transformed
education and
1511935127635Health Financing
Health Financing
maintenance
1389380215265Peace, Good Governance and leadership
Peace, Good Governance and leadership
of skills/
competence.

Fig-4- Shows the secondary pillar of the temple of Universal Health coverage
Ensure countries to have a technically competent, well-deployed health workforce that provides essential services in accordance with standards in a timely, patient centred manner. 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, Vaccines, and TechnologiesStrengthen supply
1215390172085Medical Product and technologies are third
pillar to bullied the temple UHC
In Africa
Medical Product and technologies are third
pillar to bullied the temple UHC
In Africa
chain components
to ensure the
6019801384300Health Information
Health Information
uninterrupted
37528501135380Medical Product and Technologies
Medical Product and Technologies
10064751121410Human resource for health
Human resource for health
supply of quality-
assured health
commodities,
including
creating a
supportive
environment
for commodity
security and
145224550800Health Financing
Health Financing
sustainable
1294765169545Peace, Good Governance and leadership
Peace, Good Governance and leadership
supply chains.
Fig-5- Shows the third pillar of the temple of Universal Health coverage

Ensures that people have sustained access to and make appropriate use of essential medical products that are safe, effective, and assured quality.
Strengthen supply chain components (forecasting, supply planning, procurement, storage, distribution, inventory control and logistics information systems, laboratory harmonization, and waste management) to ensure the uninterrupted supply of quality-assured health commodities, including creating a supportive environment for commodity security and sustainable supply chains.
Strengthen medicines regulatory capacity to protect the public health from counterfeit and substandard products and pharmaceutical sector governance to promote transparency and accountability through appropriate laws, regulations, policies, and standard operating procedures.

Increase and enhance human and institutional capacity to manage pharmaceutical systems and services, including promoting evidence-based use of medications, assuring therapeutic efficacy, protecting patient safety, and slowing the emergence and spread of antimicrobial resistance(10).

2.1 Building UHC Temple in Africa
2.1.6 Service Delivery
1162050252095Service Delivery as forth pillar
to bullied the temple UHC
in Africa
Service Delivery as forth pillar
to bullied the temple UHC
in Africa

Scale up quality,
coordinated
36048951195705 Service Delivery
Service Delivery
31121351202055Medical Product and Technologies

Medical Product and Technologies

9493251198880 Human resource for health
Human resource for health
4978401196340Health Information
Health Information
delivery of
essential,
evidence-
based health
services.
Develop and
implement
Cost effective
1411605160020Heath Financing
Heath Financing
essential health
1336040251460Peace, Good Governance and leadership
Peace, Good Governance and leadership
services packages.

Fig-6- Shows the fourth pillar of the temple of Universal Health coverage
ensures access to effective, safe, and high-quality public and private sector services by those who need them, when and where they are needed, with maximum efficiency and patient choice.
Regular Scale up for quality and coordinated delivery of essential, evidence-based services. Develop and implement cost-effective essential health services packages(9,10).

2.1 Building UHC Temple in Africa
2.1.7 Evaluation, Accountability and Transparency
1142365108585Universal Health Coverage
Universal Health Coverage
1132840101600Use evaluation,
10979151102995Human Resource for Health
Human Resource for Health
accountability
369252591440Accountability
And
Transparency
Accountability
And
Transparency
transparency
39471601039495Service delivery
Service delivery
5016501029970Health Information
Health Information
9709151035685Health Information
Health Information
3272155168275Accountability and
Transparency
Accountability and
Transparency
34575751032510Medical Product and Technologies
Medical Product and Technologies
10896601036955Human Resource for Health
Human Resource for Health
tools as the
door and
the windows
267208066675Evaluation
In terms
Of quality
efficiency
equity

Evaluation
In terms
Of quality
efficiency
equity

to regulate
2408555139700Evaluation
In terms of Quality
Efficiency
Equity
Evaluation
In terms of Quality
Efficiency
Equity
and monitor the
whole Structure
of the temple
of UHC.
1377950260350Health Financing
Health Financing

1261745104140Peace, Good Governance and Leadership
Peace, Good Governance and Leadership

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, as part of societal dialogue and participatory processes. Develop sustainable country capacity in transparency and accountability in law, policy, planning, leadership, and management(10).
Chapter three3.1 Universal Health Coverage in BotswanaThe 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).

-98361512065
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).

3252470126365-43815142240
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.
Reference
World Health Organization (November 22, 2010).  HYPERLINK "http://www.who.int/whr/2010/en/" "The world health report: health systems financing: the path to universal coverage". Geneva: World Health Organization.  HYPERLINK "https://en.wikipedia.org/wiki/International_Standard_Book_Number" o "International Standard Book Number" ISBN  HYPERLINK "https://en.wikipedia.org/wiki/Special:BookSources/978-92-4-156402-1" o "Special:BookSources/978-92-4-156402-1" 978-92-4-156402-1. Retrieved April 11, 2012
HYPERLINK "http://www.medicc.org/mediccreview/index.php?issue=17" Achieving Universal Health Care (July 2011). MEDICC Review: International Journal of Cuban Health and Medicine 13 (3). Theme issue: authors from 19 countries on dimensions of the challenges of providing universal access to health care.

HYPERLINK "http://www.rockefellerfoundation.org/news/publications/catalyzing-change-system-reform-costs" Catalyzing Change: The System Reform Costs of Universal Health Coverage (November 15, 2010). New York: The Rockefeller Foundation. Report on the feasibility of establishing the systems and institutions needed to pursue UHC.

HYPERLINK "http://www.who.int/bulletin/volumes/95/7/16-187476/en/" http://www.who.int/bulletin/volumes/95/7/16-187476/en/
HYPERLINK "http://www.who.int/news-room/fact-sheets/detail/universal-health-coverage-(uhc)" http://www.who.int/news-room/fact-sheets/detail/universal-health-coverage-(uhc)
HYPERLINK "https://esa.un.org/unpd/wpp/DataQuery/" World Population Prospects: The 2017 Revision". ESA.UN.org (custom data acquired via website).  HYPERLINK "https://en.wikipedia.org/wiki/United_Nations_Department_of_Economic_and_Social_Affairs" o "United Nations Department of Economic and Social Affairs" United Nations Department of Economic and Social Affairs, Population Division. Retrieved 10 September 2017
Delivering quality health services A global imperative for universal health coverag
Universal Health Coverage framework for action in Africa
Universal Health coverage in Africa from concept to action; AU/WHO/2014/DOC.1
USAID’S vision for health system strengething 2015–2019
HYPERLINK ;http://www.who.int/countries/bwa/en/; http://www.who.int/countries/bwa/en/
HYPERLINK ;http://www.who.int/healthsystems/publications/abuja_declaration/en/; http://www.who.int/healthsystems/publications/abuja_declaration/en/
HYPERLINK ;http://www.who.int/gho/mortality_burden_disease/life_tables/situation_trends_text/en/; http://www.who.int/gho/mortality_burden_disease/life_tables/situation_trends_text/en/
Republic of Botswana, Botswana Health and HIV/AIDS Public Expenditure Review June 15, 2016 Health, Nutrition, and Population Global Practice Africa Region Document of the World Bank
Health financing in Botswana; landscape analysis; USAID, February 2016
Improving Efficiency to Achieve Health System Goals in Botswana: Background Paper for Botswana’s Health Care Financing Strategy; September 2016; USAID

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