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‘Our country has passed a law on Universal Health Coverage – but how do we make UHC a reality?’ In a spacious, well-lit room, high-ranking ministry officials, political leaders, civil society representatives and health professionals from Benin, Chad, Côte d’Ivoire and Madagascar are debating this challenge. This article is also available in French. Universal Health Coverage (UHC) means in essence that everyone receives the health services they need without suffering financial hardship. It is a key target among the world’s newly adopted Sustainable Development Goals and many governments have moved the UHC agenda forward by passing relevant legislation. Yet as countries embark on transforming this ideal into reality, they often encounter unexpected challenges – and, time and again, the process gets stuck. This is where the P4H Network’s joint Leadership for Universal Health Coverage (L4UHC) programme comes in. Realising UHC at country level requires effective leadership which is able to rise above bureaucratic, social and other obstacles by aligning divergent, often conflicting interests among key stakeholders. The programme alternates group learning and exchange with country action on the UHC agenda. The first francophone cycle of this programme targets Benin, Côte d’Ivoire, Chad and Madagascar. High-level stakeholders from different ministries such as Health, Finance, Planning, Labour and Social Affairs, as well as civil society representatives and members of parliament, have come together for intensive training – first in Tunis in November 2016, and then with a second four-day module in Rabat in January 2017. The final meeting, in Paris in May 2017, will focus on reviewing experiences and on exchanging on the way forward towards UHC in the respective countries. What has been the experience of the leaders on this journey so far? How is this transforming them and their way of working together to advance towards UHC?
A personal and collective transformational journey
At the introductory module in Tunis, many of these leaders met the other participants from their own country for the first time. Prodded by the illustrations and questions of a stellar team of international facilitators, each group reflected on the complexity of the challenges to overcome on the road to UHC in their own country. This was the point of departure for each country group to brainstorm on their role and responsibility as leaders: How could they develop a common vision for UHC in their national context? What would it take to mobilise other stakeholders to create effective coalitions for change?
An important dimension of the programme is focussing leaders’ awareness on their own perceptions, assumptions and judgments and how these affect their interactions with other stakeholders. For one of the civil society representatives, this new perspective marked a turning point: ‘I felt like this module was organised for me. I was a strong activist for UHC, but I must admit that in the last months I had lost hope: I thought this was a lost cause for my country. These three days together give me the strength to continue. I had the chance to see the commitment of decision-makers in my country. With such a commitment from their side, civil society has no reason to give up now. More than ever, we need to continue the dialogue!’
Thought-provoking exercises
Two months later, in Rabat, the second module took participants further in developing their collective understanding and self-reflection on leadership.
One exercise had each participant reflect on a personal leadership challenge with the inputs of two other participants in the role of ‘angels’. One ‘angel’ encourages the participant to react to the challenge in the ‘usual way’, while the other encourages the participant to respond in a new way, taking the risk of doing things differently.
In another exercise each country team was presented with a set of building blocks and was asked to propose a specific construction without actually manipulating the blocks. This practical exercise helped participants reflect on how they negotiate and reach agreements among themselves. Here participants realised that while building a common vision they can adopt different approaches: for example, creating from what is on the table – the reality – or starting with a vision, irrespective of what blocks are on the table.
Such exercises gave participants the opportunity to further reflect on what leadership truly means to them, how they can be more effective leaders and what makes a coalition work or fail. This gave participants the chance to engage in the UHC discussion with a completely different mind-set and on a different level.
Learning from the host countries through ‘sensing journeys’
In the host countries Tunisia and Morocco participants honed particularly their listening skills by interacting with local stakeholders involved in moving the national UHC agenda forward. Groups of participants visited hospitals, insurance companies, Ministries of Health, of Economy and Finance and the Office of the Prime Minister. It proved a sensitive but rewarding task for participants to engage in open conversations on personal and collective leadership issues – which practical challenges stakeholders had encountered in these two countries and how they had addressed them to move forward.
Advancing the UHC agenda requires stakeholders to think beyond their own boundaries and focus on the overall goal. For a national UHC strategy this can mean negotiating and compromising, and sometimes also taking ‘the long way’ to accommodate divergent interests, as in Morocco’s gradual reform of its health insurance system. Tunisia’s post-revolution ‘societal dialogue’ also inspired participants as a bold example engaging all stakeholders (care-givers, citizens, unions…) in redefining their country’s priorities for UHC.
In-country activities: taking concrete steps towards UHC
Between the first and second modules, the country teams laid the groundwork for pursuing concrete action towards UHC. In each country the emphasis was on sharing the learning experience, getting the highest authorities on board and creating broad coalitions to start building a common vision for UHC. The Benin team, inspired by the Tunisian societal dialogue, even mobilised funds from a Belgian NGO to conduct public consultations on UHC and social health insurance in 12 locations with workers from the informal and agricultural sectors.
From the start of the programme in Tunis, each country team had been reflecting on the most effective short-term action they could pursue in order to help their country progress toward UHC. In the second module, this reflection coalesced into concrete planning of Collective Action Initiatives, to be implemented between February and May 2017 with support from an in-country coach and local P4H partners. What is important in the Collective Action Initiative is not just the objective, but the motivation and the joint spirit created by successfully working together, in a reflective manner, to make a difference. Each of these initiatives fits into its country’s overall UHC plan, of which it ‘tweaks’ a particular, sensitive aspect:
- The Benin group intends to broaden the UHC consultations with the informal sector to include health-care providers. Among other topics they want to tackle issues related to quality of care and negative experiences from previous management of social health contributions.
- The Madagascar group will push for the joint inter-ministerial development and adoption of a ‘decree’ to establish the two institutions for UHC implementation as outlined in the country’s UHC Strategy.
- The Chad group plans a societal dialogue with workers and health service providers in three pilot regions in view of operationalising the local health insurance scheme.
- The Côte d’Ivoire group plans to reengage with their country’s new government to develop a national UHC coalition, and increase enrolment of students and private-sector employees in a pilot health insurance scheme.
All the country initiatives will be shared and analysed during L4UHC’s final module in May 2017 in France.
It is already evident that the L4UHC programme has contributed to catalyse coordinated action towards UHC in the four countries. The collective actions and reflection throughout this programme are only the beginning of the journey. They are also an important incentive for all involved to continue to jointly move towards UHC. Throughout the programme, leaders will not just learn and talk about, but personally live and experience, the difference they can make through uniting their forces and efforts behind the common vision of UHC. As a participant from Madagascar has put it, ‘What was important in these modules was creating a team committed to work together, not only for the Collective Action Initiative, but for success of UHC altogether.’
Mary White-Kaba & Juliette Papy
March 2017
