Case Study: Resilient and Sustainable Systems for Health, Universal Health Coverage, and the Private Sector in Ethiopia and Morocco
By Kaitlyn Rice
Universal health coverage (UHC), an integral part of the United Nations Sustainable Development Goals (SDGs), is a unique and ambitious target that embodies progress towards almost every global goal, including health security, economic development and equity. The upcoming United Nations High-Level Meeting on UHC and the UHC2030 movement are examples of increasing momentum towards UHC across stakeholders. The UN has highlighted primary health care (PHC) and health system strengthening (HSS) as modes to achieving UHC, and has worked with the WHO to create a comprehensive definition of what UHC entails. UHC2030, a global movement to promote HSS to achieve UHC, further delineates this definition into three key policy areas for health systems: service delivery, health financing, and governance.
But these are high-level guidelines; what does progress towards UHC actually look like on the ground? This case study seeks to begin to answer this question by contextualizing the funding requests of two Global Fund (GF) HSS grants in Ethiopia and Morocco within the UHC2030 key policy areas. It will also explore how the private sector is currently involved in HSS in both grants and in the global movement. A more specific understanding of the relationship between HSS and UHC represents a step forward in how global actors like the Global Fund and the private sector can utilize their strengths to work together towards the mutual goal of UHC.
Why the Global Fund is Involved in the Fight for UHC
The GF, as a vertical program focused on HIV, malaria, and tuberculosis, has reframed its approach to also include grants for Resilient and Sustainable Systems for Health (RSSH), the Fund’s term for HSS. The GF declared that robust health systems are essential to end the three diseases and ultimately engendering UHC. Investing over USD 1 billion a year, the GF is the largest multilateral funder of healthcare systems globally. In fact, RSSH now constitutes 27% of GF total investments, the majority of which are integrated within disease-specific grants.
The GF has drawn on the World Health Report on Health Systems to create the following investment areas for the development of RSSH: human resources for health, integrated delivery and quality improvement, health management information systems and monitoring & evaluation, procurement and supply chain management, national health strategies, community responses and systems, and financial management. Comparing the RSSH investment areas prioritized in the Ethiopia and Morocco grants in the context of the three UHC2030 key policy areas can illuminate what specific aspects of HSS are currently prioritized on the ground and how development in these areas represents progress towards UHC.
The Private Sector in the Overall Fight for Universal Coverage
As noted by each RSSH grant discussed in the case studies below, the private sector holds many unique and valuable skills that are relevant in the strengthening of health systems. In fact, many health systems have 30% to 80% of health services delivered through the private sector, and on average, countries with a mix of public and private systems have more success in providing universal access to their citizens. The power of the private sector in research and development for new innovative health commodities demands not just the cooperation, but full participation, of many private actors. The private sector also holds technical expertise that the public sector often lacks, in areas such as procurement and supply chain logistics, which can be monumental in building sustainable systems for health.
UHC2030 also encourages strengthening platforms and partnerships to ensure the participation of all stakeholders, including the private sector, in addressing determinants of health, systems and capacity building and innovation. In that vein, UHC2030 has a Private Sector Constituency to promote dialogue, alignment, and collaboration within the constituency and among all UHC partners. The Private Sector Constituency has 30 members and welcomes for-profit private sector actors that directly provide services and goods for health markets, such as service providers, health insurers, and manufacturers and distributors of health commodities.
Case Study: Ethiopia
Looking at Ethiopia’s current grant, titled Strengthening Health Systems capacity to provide equitable, effective and efficient package of comprehensive and quality health services to Ethiopian people, we see that the Ethiopian Federal Ministry of Health (FMOH) has earmarked funding areas that correspond to each of the three UHC2030 key policy areas.
The FMOH denotes five areas for funding in this active RSSH grant, three of which fit in the UHC2030 first policy area of service delivery: human resources for health, integrated delivery and quality improvement, and procurement and supply chain management. Together, these three areas represent almost half of the grant funds requested. Specifically, the requests within this module will:
- Train Health Extension Workers to accurately and efficiently track and diagnose infectious diseases, especially the three Global Fund diseases
- Fully equip recently constructed laboratories and hospitals, especially through the procurement of equipment necessary to diagnose HIV/AIDS, TB, malaria and other infectious diseases
- Utilize technical advisors from both local and international sources to share knowledge of how to increase the efficiency of its procurement process, warehouse procedures, and distribution systems
The FMOH requests funding for one module that corresponds to the second action policy area, health financing: strengthening of financial management systems, which represent about a fourth of the total grant request. Within this action area, the FMOH plans to:
- Provide financial and non-financial incentives to retain quality finance staff members in technical roles and provide them with technical assistance in areas such as performance and risk mitigation
- Initiate an assessment of the grant management system to identify challenges and sources of inefficiency, the results of which the FMOH will use to enhance resource allocation and utilization
One module in Ethiopia’s grant, health management information systems and monitoring & evaluation, focuses exclusively on the data component of the last policy area, good governance. This module represents the smallest amount of the funding request to the Global Fund, and will largely be financed by domestic resources or other partners. In this area, the FMOH plans to:
- Standardize the country’s electronic Health Management Information System (eHMIS) which captures data on national health indicators
- Train HMIS officers at zonal and woreda (district) levels, who will be in charge of administering and managing the information system
- Improve accountability by way of technical assistance for timely and proper liquidation of financial resources
Ethiopia’s FMOH makes multiple references to hiring international or national technical assistants from any sector to help with their procurement and supply chains and to strengthen their internal audit performance. One major area of need in Ethiopia specifically is in regards to their pharmaceutical quality assurance system. They identified a need to create trainings for workers to improve inspection capacity, which could be provided by private sector companies that hold expertise in quality assurance of health commodities. Another area of need is for technical guidance on implementing improvements to its procurement and supply chain, such as efficiency gain and warehousing, distribution and fund management processes, a noted strength of private industry that can be shared. These are all areas where private sector can contribute their skills and expertise.
Case Study: Morocco
Within Morocco’s active RSSH grant, three of the four modules its Ministry of Health (MoH) requests for funding correspond with the UHC2030 definition of service delivery: integrated delivery and quality improvement, procurement and supply chain management, and human resources for health. Integrated delivery and quality improvement alone represents half of the grant funds requested from the Global Fund by Morocco. These funds are earmarked to:
- Invest in equipment and infrastructure to upgrade and expand primary care and mobile health care units, purchase testing equipment for all its health facilities, and integrate HIV and TB at every level of care
- Develop a Logistics Management Information System (LMIS) to manage healthcare products throughout the system and to improve storage and transport capacity for pharmaceutical supplies at the central level
- Strengthen human resource departments via the establishment of a system for employee performance evaluation and corresponding incentives, as well as via the development of interactive workshops and accredited training modules for healthcare workers
While Morocco’s request does not include any type of financial management system strengthening that corresponds to the policy area of health financing, the MoH of Morocco similarly proposes in its final module on program management to increase salaries for staff to enhance their performance in their roles of grant implementation and improve grant monitoring and evaluations via technical assistance.
The last service area, governance, is incorporated as a secondary goal in two modules in Morocco’s grant, integrated delivery and quality improvement and human resources for health. The MoH identified the need to:
- Promote multisector participation in Morocco’s health strategy and governance via partnerships with community organizations
- Foster advocacy and resource mobilization among local health actors, especially promoting the participation of the private sector in the development of local and central health authority strategies
Private Sector Engagement
Given Morocco has a comparatively well-developed private health system alongside its public system, its MoH was more explicit than Ethiopia’s FMOH about private sector assistance in tackling its healthcare challenges. For example, as part of the country’s health reform, it specifically calls out its goal to develop public-private partnerships in the pursuit of universal access. Regarding procurement and supply chain management improvements, the Moroccan MoH has already worked with professionals from the pharmaceutical industry to develop a drug pricing policy which improved patient access to drugs and optimization of resources. The MoH also acknowledges the lack of involvement from its private and community sectors in health policy and emphasizes its goal to involve all stakeholders in the governance of its health system.
Morocco’s identified need to strengthen its procurement and supply chain could be tackled by companies with experience in managing products at all levels of storage and transport. They also desire private sector advocacy and involvement in local and national planning, an area in which private companies with experience in government relations in developing countries could also be involved to promote private sector involvement for the mutual goal of better health policy.
In conclusion, these case studies demonstrate what progress towards UHC looks like on the ground, and shows the impact of Global Fund funds in that context. Analyzing what RSSH grants specifically aim to accomplish within the context of UHC2030 action areas represents a first step to understanding how best RSSH, HSS and UHC policies can be intertwined to make tangible improvements to health systems globally. Moreover, determining what significant areas of need are in various developing health systems, such as enhanced training and improved procurement, demonstrates the ability and the need for private sector actors that hold that technical knowledge to lend support and resources to accelerate towards UHC.
Achieving UHC requires active participation from all global actors, including traditionally vertical disease institutions like the Global Fund and the untapped diverse skills of the private sector. Only by the unification of all key players – playing to each of their strengths – can we hope to achieve UHC for all in the coming decades.