No universal health coverage without learning Mar 14, 2016

No universal health coverage without learning

This blog was originally posted on the Harmonization for Health in Africa website. You can access the original version here.

We are entering into the last year of our project ‘Universal Health Coverage in Francophone Africa’. In this blogpost, we present the latest developments, share some early insights from the year 2 and present our plan for year 3. We have made significant progress in our understanding of how to document the learning capacities of ‘UHC systems’. So exciting!

You may remember that in 2012, we launched a brainstorming on the online fora of our communities of practice (Performance Based Financing and Financial Access to Health Services). The purpose was to identify the priority research question that we would like to investigate as a group. A strong consensus emerged from this large consultation: our research project should focus on the fragmentation of health care financing at country level.

In the months that followed, we were able to submit a research proposal to a competitive operational research call launched by the Fonds Français Muskoka(hosted at UNICEF WCARO). The funding had its constraints (it had to focus on Francophone countries, the total annual budget was €90,000 maximum), but an interesting feature was that it was organized along a 3 X 1 year model: if the first year was successful, applicants were eligible for a second year and later a third year. Our proposal was one of the winning propositions.

This project was actually the first research to be carried out by our Communities of Practice (CoPs). We were therefore keen on demonstrating the added-value of entrusting the research to our experts. One of our strengths obviously, is our capacity to carry out investigation in the many countries of our experts. As our experts have various profiles (not just researchers), we can also guarantee a close connection with policies at country level. Our research proposal integrated these core features from the beginning. This allowed us to identify 11 country teams willing to join the project (do the math: this also meant not much money for each country, knowing that there were also some costs for project coordination by ITM).

Year 1: Gosh, so fragmented!

As you probably remember, the focus for the first year was to map health care financing schemes at country level to document the fragmentation of health care financing. Our mapping exercise confirmed that fragmentation was a real problem at country level (you can access a summary of our findings here). Our study also revealed that the information necessary to get an overview of all the schemes making up the health care financing system was actually difficult to collect. One of our conclusions was that all these countries wanting to move towards Universal Health Coverage were actually facing a major challenge: how could one aim to progress towards UHC when all the information of the many schemes constituting your system was either missing or not centralized? You may remember the blogpost Bruno wrote about the need for thinking UHC as an urbanism challenge (and not one for architects)!

After analyses of the findings of Year 1, we reconsidered the objectives for Year 2. We decided that the best action we could develop for countries facing such a ‘jungle of health financing arrangements’ was to assist them in self-assessing and later improving their systemic learning capacities. It is clear that each country will have to find its own path to UHC – it will be a lot of muddling through, and the best resource in such a situation is to have a strong control of one’s learning agendas, processes and capacities.

Year 2: is your ‘UHC system’ a learning system?

We kicked off the year 2 at a meeting in Rabat. Again, we extended a very open invitation: any Francophone low-income country was welcome, the only condition was that the delegation (comprising a researcher, a technician of the Ministry of Health and a technician of another Ministry involved in UHC) had to have an official mission order from the Minister of Health or the General Secretary (a lesson from year 1 was that a strong backing from decision-makers would probably help for a smooth implementation of the data collection). Eleven countries came with that letter. Together we developed the method to evaluate the learning capacities of national UHC systems. We took inspiration from the literature  on learning organizations, but adapted the approach specifically to UHC. Our approach and method to carry out this national self-assessment has been presented here.

As in Year 1, the budget was very tight. We recommended that country teams engage with technical and financial partners to find extra funding back home.  It worked for a few (our gratitude to Cordaid, which sponsored the study in Cameroon and to GIZ, which sponsored the study in Benin), but not for all. The number of participating countries shrank, but a new one, Morocco, joined us.

As of today, six countries have gone through the whole process (we called them the first ‘wagon’ because we are hopeful that other countries will join the process later). Early in January, we held another meeting at the ENSP in Rabat to collectively analyze our findings. We realized that our study – and the comparison across the six countries in particular – was generating very innovative insights in the systematic learning problems prevailing at country level. Together, we also decided the direction for year 3.

Year 3: let’s get serious on learning for UHC

Our ‘Year 3’ will start in the weeks to come. The six country teams (Benin, Burkina Faso, Cameroon, DRC, Morocco and Togo) are currently developing their action plans. A key activity will obviously be the presentation and validation of the findings to national stakeholders (including the many experts who completed the self-assessment survey). The teams are ambitious: they believe that our findings could create more awareness at country level about the importance of strengthening the national learning capacities. Their objective is to use our findings to organize national actors around a common UHC learning agenda, with a road map and so on. Several country teams have also decided to set up a structural collaborative platform at country level. You may have heard about the new CoP hub model; well, after two successful pilots in DRC and Benin, at least three more hubs are launching in 2016.

We will of course also communicate all the lessons of this project to the international community. A first opportunity will be the Global Health Systems Research Symposium in Vancouver in November. If you are there, do not miss our organized session. We also hope to be present at the AfHEA conference in September 2016 (a rendez-vous obligé for our CoPs, as we know we can meet many of you at this event).

With our CoPs, we have now been active with ‘knowledge management’ for more than five years. With this research, we have learned a lot of things, including that if we should focus on one thing it is… ‘learning’. Learning seems an obvious thing, but it is not. It is both an art and a science. We see a destiny for our CoPs: it is to become the incubator for the most innovative and well-thought learning processes for health systems of Africa.  We hope that all of you will be with us for this revolution.