CAPABILITY STATEMENT - UNIVERSAL HEALTH COVERAGE

1.0 BACKGROUND
Good health is essential for the economic and social development of all nations. Access to quality
health services is crucial for maintaining and improving health. At the same time, people need to
be protected from being pushed into poverty because of the cost of health care. In recognition
of these imperatives, the global momentum for
universal health coverage (UHC) has greatly
increased, with the 2030 Agenda for Sustainable
Development setting it as a central tenet for
improving the health and well-being for all people
and includes delivery of disease prevention, health
promotion, treatment and rehabilitation, and
palliative care, while ensuring that individuals are
not driven into poverty due to the cost of health care.

The objectives of UHC include: (i) Equity in access

to health services - everyone who needs services
should get them; (ii) The quality of health services
should be good enough to improve the health of
those receiving services; (iii) People should be
protected against financial-risk, ensuring that the
cost of using services does not put people at risk of
financial harm. Accountability is a critical Figure 1: UHC Objectives

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component in the UHC journey to ensure that commitments relating to access, quality, and
financial protection translate to action. To be effective, accountability mechanisms for UHC need
to ensure transparency and citizen participation (social accountability). Social accountability
relies on civic engagement - citizens and/or civil society organisations participating directly or
indirectly in exacting accountability from public officials.

Despite the global momentum on UHC, half the world’s population still lacks access to essential
health services. Close to 12% (800 million people) of the world’s population spend more than 10
per cent of their household budget on health care leading to almost 100 million people being
pushed into extreme poverty each year because of out-of-pocket health expenses (WHO 2017).
Africa faces a grimmer scenario. The region, which is home to 11 percent of the world’s
population, accounts for 24 percent of the global disease burden and accounts for less than one
percent of global health expenditure. The region’s poor health status is mirrored by perennial
crises in health financing and human resources for health. With only 3 percent of the global
health workforce and only 1 percent of the world’s health expenditures and weak health systems,
most African countries remain ill-equipped to adequately address their health problems. Low per
capita income, limited capacity for domestic revenue mobilisation, and pervasive health system
bottlenecks complicate the ability of governments to respond the health challenges (Africa Union,
2016).

To confront these challenges, we can look to and apply lessons from the many African countries
taking the lead in implementing UHC reforms such as Rwanda, Ghana and Ethiopia. These
include building strong, efficient, resilient and well-run health systems that focus on primary
health care; creating sustainable financing for health services; improving access to essential
medicines and technologies; improving governance and management of health services;
maintaining a sufficient capacity of well-trained, motivated health workers; and having robust
information systems to inform decision-making.

In Ethiopia, a Health Extension Program trained and deployed over 38,000 health workers to
deliver primary health care services in rural communities. Running from 2003, this program was
essential to expanding access to primary health care. Its success - made possible by
commitments of the Ethiopian government, partners, and of course dedicated health workers -
demonstrated the importance of investing in human resources for health and delivering essential
health services at the community level. In Ghana, a tax-funded national health insurance system
known as the National Health Insurance Scheme covers 95% of diseases that affect Ghanaians,
enabling financial protection and expanding coverage. This system is an example of the type of
reform that can help countries minimise catastrophic out-of-pocket health care costs that all too
often lead to or exacerbate poverty. Rwanda has also made significant strides toward universal
health coverage. By implementing ambitious reforms starting in 2000, the country has
transformed its health system through the Community Based Health Insurance Programme
(CBHI) for the informally employed, and a state social health insurance system for employees
in formal employment. The CBHI has an enrolment rate of 80% and is financed by member
contributions (66%), state subsidies for indigents (14%) and the balance (20%) by development
partners.

In 2017, Kenya commenced an ambitious journey towards UHC following declaration by

President Uhuru Kenyatta of affordable health care as one of the Big Four pillars of his plan for
socioeconomic growth, alongside food security, affordable housing and manufacturing). The
implementation of the UHC pilot programme commenced in December 2018 and the pledge is

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to make affordable quality health care services available to all households within four years - an
ambitious target in a country where 80 percent of the population does not have any form of health
insurance. In 2018, Zambia enacted the National Health Insurance Bill into a law. The country
is putting in place systems and structures to support implementation.

2.0 OUR APPROACH

With over six decades of experience in health Box 1: Amref’s Role in Universal Health
systems strengthening and a vision of creating Coverage
lasting health change for communities in Africa,
 Advocacy and brokerage for rights based
Amref Health Africa catalyses progress towards
PHC & UHC policy and legal reforms
UHC through solutions in human resources for  Budget advocacy & tracking to improve
health, innovative health service delivery, and resource allocation & utilisation
health financing. Across Africa, Amref reaches  Technical advisory & coordination with
approximately 12 million direct beneficiaries each governments on core UHC imperatives
 Enabler to UHC through community
year with services and information. We focus on
mobilisation
strengthening systems for primary health care as  Implementer of programs to improve
a cost effective approach to enable Africa progress access, quality, financing
towards UHC. This approach further prioritises  Capacity building on technical & social
working with community health workers (CHWs) to accountability skills for citizens/CSOs
 Convenor for policy makers, researchers,
bridge the gap between communities and formal
practitioners to deliberate on UHC
health systems, bringing health care and
information as close as possible to where people
live and work. The community-based approach ensures that communities cease to be passive
beneficiaries of the desired change and instead become drivers of the change, building on the
inherent human and social capital that exists within all communities.

In order to propel Africa towards UHC, Amref deploys a number of often catalytic initiatives (see
box 1 and selected examples below).

Advocacy and brokerage: Amref is contributing to the Global Health Agenda through advocacy
with the organisation’s Group CEO Dr Githinji Gitahi being co-chair of UHC 2030. In addition,
Amref and her partners worldwide are at the forefront in advocating for formal recognition and
remuneration of CHWs throughout Africa to optimise their contribution to primary health care and
UHC as a redress to the critical shortages of frontline health workers.

Technical and coordination support: In Kenya, Amref in conjunction with development partner
Children Investment Fund Foundation (CIFF) is collaborating to drive the UHC agenda through
the development of a UHC policy paper, provision of coordination support to critical arms of
government in the design and implementation of UHC and to support the operationalisation of
the National Health Observatory that will ensure a system for data and knowledge management
for accountability. As a co-convener with others, Amref has catalysed the development of the
Africa Health Agenda International Conference (AHAIC) as a thought leadership platform for
policy policymakers, civil society, technical experts, innovators, private sector, scientists and
youth leaders to chart new paths and home-grown solutions to the continent’s most pressing
health challenges, with a focus on achieving UHC in Africa by 2030.

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3.0 OUR SOLUTIONS
In this section we highlight specific examples of how we are catalysing progress in the core
imperatives of UHC summarised in the table below.

UHC Theme What We Do Cross Cutting

Action
Equitable • Reaching those left behind by working with CHWs,
Access innovative outreach models, and Amref Medical
Specialists Consortium in conjunction with Amref Flying
Doctors
• Policy and legal reforms to strengthen primary health care

Strengthening leadership, management and governance

e.g. CHW agenda.
Quality • Training of facility and community-based front line health
Improvement workers using blended learning approaches
• Application of appropriate quality improvement models in
health care settings
Financing • Budget advocacy
• Building capacity of counties on planning, prioritising and
budgeting
• Financial protection through enrolment into tax or
insurance funded schemes
• Health financing reforms at national and devolved levels
• Blended financing including Public Private Partnerships
• Strategic purchasing
Accountability • Training & mentoring grassroots CSOs, CHWs, community
groups on accountability.
• Generating evidence on effective social accountability
models through research
• Increasing coordination, collaboration, and learning by
organisations in the social accountability space
• Strengthening capacity of civil society, government, health
care providers and the media to engage in social
accountability
• Integrating social accountability in all Amref’s
programmatic interventions.

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3.1 Equitable Access

Equity is the most important

principle in UHC - ensuring that
socially disadvantaged and
marginalised populations have
access to health care - and fully
realise their right to health.
Amref works with governments
and development partners to
operationalise mechanisms for
reaching those left behind.
Universal Health Coverage
means providing effective
coverage for the entire
population (“breadth”), for all
necessary care (“depth”), at
affordable costs and under Figure 2: Dimensions of universal health coverage with equity
conditions that are not burdensome, as well as offering particular benefits to address the
differential needs of the least well-off (“height”) – see Figure 2.

In order to support equitable access,

Amref is a champion of PHC and believes
that appropriate targeting and design of
interventions will address the health
needs of marginalised and vulnerable
populations. As a core part of the PHC
approach, CHWs contribute to bridging
the gap between communities and the
formal health system, playing a key role
in community engagement, referral,
health promotion and disease prevention
at community level. Full utilisation of
CHWs would save the lives of many An Amref trained community health worker during a
people in Africa. However, for the household visit

community-based approach to be effective, CHWs need to be motivated and remunerated just

like other cadres, underpinning the CHW advocacy agenda that Amref is leading - pushing for
CHWs to be formally recognised and have a scheme of service. Amref continues to advocate for
other innovative solutions to remedy gaps in CHW programmes - for example in Kenya, we are
working with the government to develop CHWs Bureaus that will provide an innovative way of
managing CHWs through a sustainable and non-duplicative coordination and compensation
structure using cross-sector partnerships. In Malawi, Amref Health Africa is building the capacity
of 5,000 community health workers through mhealth focusing on the three major killer diseases
of new born babies namely, pneumonia, malaria and diarrhoea.

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In order to ensure that no one is left
behind in the UHC journey, Amref
continues to deploy last mile social
innovations especially new outreach
models to reach the most vulnerable
communities with primary health care
services. For example, through a
USAID-funded programme in the
remote and vast northern region of
Kenya, we have deployed a cross-sector
service delivery approach where human
and animal health, as well as social
development services, are provided to
nomadic pastoralist communities - an
approach christened Kimormor A community health worker in Turkana providing services
(meaning all under one roof in Turkana during a Kimormor outreach
language). The same project has
successfully deployed ‘camel mobile’ clinics to reach pastoralists far from passable roads with
essential services including family planning and immunisation. Similarly we have deployed
container clinics strategically located along the migratory routes of nomadic pastoralists in
Northern Kenya to provide access to PHC services. In the city of Nairobi, we have successfully
deployed ‘walkway clinics’ to reach busy men with screening for non-communicable diseases
when they are walking home in the evening from their places of work, after we failed to get them
to come to health facilities since they are busy earning a living during the day.

3.2 Quality Health Services

The success and value of UHC depends on the ability to provide quality services to all people
irrespective of social economic differences with no risk for catastrophic health expenditure. It is
therefore important to place quality and continuity of care at the centre of country, regional and
global action, in order to progress towards effective UHC. For this to happen, health systems
need to be complete with fully functional health system blocks including HRH and LMG. Our
experience across Africa has demonstrated that LMG is a core driver of health system
effectiveness.

In order to support the delivery of quality health services, Box 2: Role of Amref in Human
Amref supports the training of mid-level and community Resources for Health
health workers through in-service, pre-service and
 Strengthening capacity of health
continuing professional development. Between 2011 and
institutions and organisations
2015, we trained over 700,000 health workers in Africa  Increasing the number and priority
through blended learning approaches - traditional and ICT- skill sets among health workers
propelled education and training methods e.g. eLearning  Strengthening Leadership,
and mLearning. Using these approaches, we train over Management and Governance
 Leveraging technology in scaling
100,000 health and health-related workers every year on
health training programs
different diseases as well as Leadership Management and  Advocacy for improvements in HRH
Governance programmes for Health Systems e.g. e CHW agenda
Strengthening including the delivery of quality health  Facilitating negotiations to improve
services. In addition, Amref is in process of developing a industrial relations
UHC curricula targeting senior level managers.
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Amref has over the years garnered immense experience Box 3: Our experience in LMG skills
in strengthening LMG (see box 3); we have capacities development
within Amref’s Institute of Capacity Development and the  Management Development Institute
recently launched Amref International University to deploy (MDI) Programme
 LMG for Health Systems
interventions namely: (i) design and adaptation of LMG Strengthening (HSS)
training programmes focusing on the needs of the  USAID-funded LMG Project (sub-
intended audience. Key areas covered in the training recipient to MSH)
programme include organisational development and  USAID HRH 2030 Programme
 Partnership in HSS in Africa
system strengthening, planning, financial management
programme
and sustainability and advocacy. The trainings are made  Tailor-made LMG programs to meet
available through face-to-face and eLearning approaches client needs (e.g. work done with
to increase access and sustainability; (ii) enhance the Afya Timiza, GSK NCD Project and
capacity of relevant Ministry of Health officials in strategic LMG trainings targeting District
Health Management Teams in
leadership, management and accountability at both Zambia and Malawi)
national and county levels; (iii) advocate for the integration
of LMG in the curricula of tertiary and mid-level training Institutions as well in CPD courses to
ensure that health workers have the necessary skills to provide leadership in the management
of health programmes.

In addition, we have successfully implemented data informed quality improvement

approaches in health care settings. These include Continuous Quality Improvement (CQI) using
the Amref Health Africa CQI toolkit, Partnership Defined Quality at the community level, and
Kenya’s Quality Model for Health applied in health facility settings. In Zambia, Amref is providing
Respective Maternity care trainings to health care workers to influence positive attitude towards
mothers in service provision.

3.3 Financing and Financial Protection

The practical application of UHC principles has found that moving away from Out of Pocket
expenditure to protect people from financial hardship hinges on financing arrangements
consistent with equalitarian viewpoints. Protection from financial hardship requires decoupling
financial contributions from service utilisation - given the potentially large direct costs of health
products and services for most income groups. Towards this, Amref has been at the forefront in
advocating for increased investments in health through budget advocacy and tracking,
blended financing, financial protection of citizens and strengthening strategic purchasing.

For Africa to achieve UHC, countries need to increase funding and domestic resources for health
care to a recommended target of at least 5% of GDP as a percentage of government budgets.
We address this through budget advocacy to increase the allocation of resources to health
dockets at national and devolved government levels. In Kenya, we are tracking budgets from
national level to implementation in UHC pilot counties.

We have successfully built the capacity of devolved governments in Africa on planning,

prioritising and budgeting to increase the allocation of funds for health service delivery. For
example, in Northern Kenya, support from Amref enabled Turkana County to increase the health
budget by more than 50%, and we are now working with the county towards a county law on
ring-fencing these resources. With the increased resources, the county is now able to finance
medical commodities in time, support community health workers with stipends, pay health worker
allowances thus averting strikes, strengthen emergency response, and is now drafting the county

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UHC framework. Similarly, in Malawi and Zambia, Amref is advocating for specific and ring-
fenced budget-lines for family planning services and community health workers.

In order to achieve financial protection, Amref advocates for and supports either tax-based or
insurance-based models of financial protection. In addition to supporting the rollout of the
ongoing Kenya UHC pilot in four counties, we have partnered with the national Ministry of Health
through the National Hospital Insurance Fund to accelerate uptake of the national social
insurance health benefit package by under-served communities. To achieve this, we have
deployed mHealth technology - a digital health platform that links CHWs and the community with
health insurance - making the process of household registration efficient and user-friendly. Amref
has managed to digitally map close to 200,000 households and register more than 50,000
households into the NHIF in Kiambu, Laikipia, Taita Taveta and Makueni counties with a robust
plan of covering the entire country.

In collaboration with Results for Development, Amref is implementing the Strategic Purchasing
Africa Resource Centre (SPARC) to build capacity enabling countries undertake Strategic
Purchasing. As countries move toward universal health coverage, resources are constrained
and funds must be used wisely. ‘Strategic Purchasing’ is one way to get more value for the
money spent whilst ensuring equity. Strategic purchasing means that those who purchase health
services and medicines on behalf of populations actively consider and make transparent
decisions about: (i) what the purchaser will buy e.g. types of benefit packages, medicines or
diagnostic services, etc., to be offered?; (ii) who will provide the services to patients - will it be
primary care or more specialized providers? Public or private?; (iii) how the services and
medicines will be purchased. How will providers be contracted? What are the provider payment
methods and rates? How will provider performance be monitored and anti-fraud practices
implemented? When successful, strategic purchasing creates the right incentives for quality and
efficiency. These efficiency gains free up resources which allow ministries and other purchasers
to provide access to higher-quality services to more people. Strategic purchasing is central to
good public financial management for health and sustainable progress toward UHC. SPARC has
adopted a three-pillar model for achieving its objectives - country engagement, coaching and
mentorship, and knowledge management.

Towards blended financing, Amref continues to advocate for the review of Private-Public
Partnership (PPP) regulatory frameworks in Africa as a means to unlock new finances for the
health sector. We are also at the forefront of testing scalable models of PPP for PHC. For
example, the Makueni Partnership for Primary Health Care that has applied a blended financing
model through a PPP engagement – see figure 3 below.

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 Figure 3: Makueni Partnership for Primary Health Care pilot business model

3.4 Social Accountability

The current momentum toward achieving UHC in sub-Saharan Africa will only lead to results if
commitments made by leaders are turned into action through adequate accountability
mechanisms. We believe that strong and widespread practice of social accountability is the key
to achieving results. Social accountability is an approach towards building accountability that
relies on civic engagement. In social accountability, ordinary citizens and/or civil society
organisations participate directly or indirectly in exacting accountability from public officials
(World Bank, 2004). Using social accountability, citizens and providers are educated about their
rights to health, mechanisms are employed for their voices to be heard, and tools are utilised to
hold duty-bearers accountable for policy and programme implementation and results. In the case
of UHC, their perspectives and priorities for defining what is needed for UHC – including but
beyond financing – will be a key component of success. By engaging citizens in the development,
implementation, and evaluation of health policies and programming, the accountability and
allocation of resources and services will lead to improved health and well-being across the
country. In Malawi, Amref Health Africa is training citizens in selected districts on use of
scorecards as a tool for tracking quality of health services in their communities. The collected
evidence is used by the citizens to lobby duty bearers for improvement in health delivery.

However, social accountability for health is still a relatively new Box 4: Guiding Principles -
practice in sub-Saharan Africa, with a range of challenges to Social Accountability
its full implementation and impact. The tools that exist are often • Community-driven
not documented, measured, and shared. There is no mapping • Inclusive
or network of those who are engaged in social accountability, • Transparency
which leads to duplication of efforts and lost opportunities to • Collaborative
find synergies in learning and practice. Funding for social • Constructive
accountability is still nascent, with many donors still seeking to
• Innovative
understand how and where they can support its efforts most
• Evidence-based
effectively.

In response to these challenges, Amref has through a consultative process developed a robust
Social Accountability Framework to catalyse progress towards UHC in Africa by working with
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partners to enhance citizens’ voices to improve government and health care policies, resources,
and practices. The framework has clear guiding principles and outcomes identified by
stakeholders (see figure 4 for our theory of change and text box 4 for guiding principles).

Figure 4: Theory of Change – Amref’s Social Accountability Framework

We will deploy our capabilities at convening, wide reach across

Box 5: Amref’s Experiences in
sub-Saharan Africa, trust by communities and government Social Accountability
alike, and significant experience in deploying social • Youth in action & youth
parliaments
accountability interventions in sub-Saharan Africa. Working
with other partners we have strengthened social accountability • Partnership defined quality
and engagement mechanisms with civil society, the media and • Citizens jury
parliaments to hold governments accountable for sufficient • Council of elders
investment, robust policies and plans, and timely and effective • Community scorecard
implementation to leave no one behind in pathways towards • Community dialogue days
UHC. For example, through an initiative funded by the Bill and
• Africa Media Network
Melinda Gates Foundation called the Y-Act, Amref Health
Africa has engaged over 3,000 youth and over 700 youth
advocacy organisations in advocacy for health indicating strong interest in advocating for their
priorities in the UHC process (See box 5 for Amref’s experience in social accountability).

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