Engaging Politics For Universal Health Coverage: Analyze, Advocate, Align, Account
A mom and her newborn baby at the Maternal & Child Health Training Institute for medically needy in Dhaka, Bangladesh. Photo by UN Photo/Kibae.
By Suneeta Sharma, Anita Bhuyan, and Cathy Barker
The global health community has rallied around universal health coverage (UHC) to ensure equitable access to high-quality services while mitigating financial hardship. UHC is enshrined in the SDGs and government policy commitments around the world. Achieving UHC requires structural changes in how services are financed and how they are delivered in communities. Because UHC reform typically involves re-distributing resources and power across groups, it is often a political (and contested) process.
The Global Symposium on Health Systems Research identifies “engaging politics” as a key to responsive, resilient health systems. Politics are at play across the policy-to-action continuum. “Soft” issues — such as power dynamics and stakeholder incentives — are as essential to expanding UHC as “hard” technical matters. Politics influence the policies adopted, resources mobilized, and programs implemented.
Considerations for Engaging Politics from Policy to Action
Beyond being technically sound, UHC reforms must be politically smart. Health systems researchers can aid this endeavor by integrating multidisciplinary approaches to analyze political histories, economic contexts, and power dynamics in the health sector and generate evidence on politically-informed UHC strategies. Programs in Nigeria and other countries have applied political economy analysis, adaptive management, and other methods to address health, education, governance, and social issues — which can suggest lessons for UHC. One example is a recent stakeholder analysis and assessment of legal, political, and technical aspects of introducing health insurance in Afghanistan.
Evidence-informed advocacy is needed to raise UHC as a priority on national agendas and catalyze political will for legal and fiscal reforms. Advocates — civil society, government champions, the media, private sector players, or others — must be equipped not only with facts about health needs and best practices, but also skills to navigate the dynamic political landscape. In many countries, policymaking is dominated by policy elites and vested interests; thus, strong advocacy must demand that the policy process itself be more responsive to citizens’ voices.
In Guatemala, civil society groups comprising indigenous women and their allies have been instrumental in advocating passage of the 2010 Healthy Motherhood Law and subsequent efforts to secure funding, design regulations to operationalize the law, and monitor outcomes. Advocates took advantage of political opportunities — such as election cycles, evolving legal provisions, and the multisectoral reproductive health watchdog (Observatorio en Salud Reproductiva, OSAR) — to spur action. As a result, casas maternas have been constructed that provide pre- and post-partum accommodation for women who live far from facilities. Birthing centers with culturally-appropriate spaces and trained medical personnel who speak local languages have also increased. The OSAR and civil society groups exerted pressure to keep healthy motherhood, sex education, and family planning on the public agenda during the recent election cycle. Advocates also gained legal changes to eliminate tariff barriers to competitive commodity procurement. Civil society continues to play an active role in shaping ongoing health sector and financing reforms during a time of great political upheaval.
Policy implementation depends on effective alignment of financing mechanisms, regulatory frameworks, governance structures, institutional capacities, partnerships, and information and monitoring systems with the country’s UHC vision. Strong government stewardship, bolstered by ongoing advocacy, is paramount. Implementation also involves engaging a wider range of stakeholders, including some, such as district officials and private providers, who may not have been involved in policy formulation. UHC reform efforts must understand and manage the interests and incentives of diverse stakeholders throughout the process.
For example, Afghanistan, emerging from a legacy of a centralized economy, was characterized by mistrust between the public and for-profit private health sectors. However, the Public-Private Dialogue Forum launched in 2012 has become a venue for joint problem-solving. The Ministry of Public Health and private health associations have streamlined private health sector licensing and made monitoring more transparent. Minimum Required Standards for private hospitals have been jointly revised by both sectors, addressing concerns on both sides. These actions are helping to expand access to quality services through the private sector in the resource-constrained country.
Continued vigilance is needed throughout UHC roll-out to foster accountability, learning, and adaptation. Some previous efforts to make health services more equitable have had unintended consequences. The literature abounds with instances in which government subsidies benefitted the well-off while the poor paid informal fees and high out-of-pocket expenses. Challenges, such as poor budget execution capacity or weak transparency, also keep resources from reaching those most in need.
Guatemala has taken impressive steps to ensure transparency across social sector programs, making data from health and other ministries, from the central to local levels, publicly available through an online portal. Meanwhile, Kenya recently re-launched its free maternity care program, under the National Hospital Insurance Fund, in an effort to make it more efficient and accountable.
Locally-led, Policy-smart Approaches to UHC
There is no one path to achieving UHC. The process is highly local, contextualized, and iterative. Political dynamics can be either an enabler or barrier to reform efforts. Civil society advocates, policymakers, program managers, and health systems researchers must be politically savvy in identifying opportunities and roadblocks to advance universal health coverage.