Resilient health systems for attaining universal health coverage

The Millennium Development Goals (MDGs) galvanised global-level, regional-level and country-level efforts to scale up health interventions and improve health outcomes for health-related MDGs. However, despite improvements in coverage and in the health status of the African people, there persist challenges, to which countries need to pay attention. The 2013–2016 Ebola virus disease (EVD) outbreak in West Africa revealed many weaknesses in the health system detection, preparedness and response systems of the three most affected countries (Liberia, Guinea and Sierra Leone). These pointed to major gaps in the implementation of Integrated Disease Surveillance and Response and the International Health Regulation (IHR) 2005, as well as the weakness of health systems overall.^{1 2}

More importantly, it brought to the fore the importance of building resilient health systems that can withstand shocks and sustain provision of regular health services. Kieny and Dovlo underscored this point and asserted that ‘…we need to build systems that are grounded in primary healthcare principles and capable of responding to routine as well as unexpected challenges that might arise in the future….’³ In pursuant of this agenda, the WHO Regional Office for Africa developed a framework for ‘Strengthening health systems for Universal Health Coverage (UHC) and the Sustainable Development Goals (SDGs) in Africa’ which consolidates systems and services around a logical results chain with the desired impact as attainment of the SDG three goal. The framework further provides a menu of options that countries can choose from to strengthen their health system.⁴

The global-level and country-level commitments provide a favourable window for building resilient health systems; a quest that is arguably not new—but should we have waited to be reminded by an unfortunate event of the EVD outbreak? Travis et al in 2004 did raise similar concerns regarding health systems weaknesses impeding progress towards health goals in the MDG era.⁵ In building a case for health system strengthening as a prerequisite to global progress, Frenk in 2010⁶ highlighted the need for a better understanding of health systems and the prevalent misconceptions, which view the health system as ‘a black box (too complicated), as a black hole (too costly to fix), or as a laundry list (inventory—mere list of organisations)’. Perhaps this explains years of seeming neglect and fragmented approaches.

Articles in this supplement address these issues and provide clarity on concepts as well as practical options. For example, inasmuch as district health systems should anchor UHC, current weakness are rooted in the colonial past and Tumusiime et al⁷ identified the required strategic shifts to strengthening the district health system. The shortage of health workers is among the major bottlenecks African countries need to address. In response to this, the WHO African Region developed a Road map for scaling up the health workforce, but progress has been mainly in developing strategies and plans. Afiriye et al⁸ noted that a lot still needs to be done to primarily improve the quality of the human resource for health (HRH) strategies and ensure coordinated and effective implementation.

Furthermore, in curbing the HRH crisis, Asamani et al⁹ proposed a regional approach to replace the current inefficient and compartmentalised approach in meeting the region’s human resource requirements. Community health workers as service providers were a response to the HRH gaps and have played a role, but experiences are varied. This has prompted the need to review community health workers’ programmes and Lehmann et al¹⁰ provide lessons as well as key foundational elements of successful community health worker programmes.

Supportive supervision engenders an opportunity to strengthen health workers’ skills, improve human resource management and improve quality of care. This is indeed an old practice, but it is yet to yield desired results.¹¹ Avortri et al¹² drew attention to the misunderstanding of the concept and its implementation. They provide a deeper understanding of supportive supervision and how re-organisation of the approach can contribute to improved performance. Access to essential medicines and commodities is vital for good health outcomes and is indeed one of the indicators under SDG 3 ‘3.b.3 Proportion of health facilities that have a core set of relevant essential medicines available and affordable on a sustainable basis’. Droti et al highlighted the dire situation in the 8 WHO African Region Member States assessed. They make a case for strengthening medicine supply systems and allocating adequate funding for medicines as critical to remedy the situation.¹³

UHC is a broad agenda and the public sector cannot go it alone. In this regard, we turn to the role of the private for-profit sector who are already significant players in health service provision. In embracing this potential resource, Nabyonga-Orem et al highlighted the caveats and caution us that there are prerequisites that must be in place.¹⁴ A large segment of the population in sub-Saharan Africa turns to the traditional sector when ill. Relatedly, advances in research on traditional medicines implore us to forge meaningful partnerships with the traditional medicine sector for better health outcomes. Kasilo et al¹⁵ trace advances in research, product development, integration of traditional medicines into health system, as well as regulatory practices for traditional health practitioners. They highlight important considerations necessary to maximise the potential of this sector for UHC.

The role of context-specific evidence in navigating the road to UHC cannot be overemphasised and in this regard national health research systems must be strengthened. As Nabyonga-Orem and Okeibunor¹⁶ argue, global and regional opportunities must be harnessed but in doing so, countries need to create an enabling environment.

The WHO in the Africa Region is committed to supporting Member States to build resilient health systems for UHC and health security. Provision of tools, guidelines, capacity building and strengthening collaboration with global and continental players to harness all available resources and political leverage are among the approaches to achieve these goals.