Article Written by Dr Moses Guya

Universal Health Coverage (UHC) according to WHO means that all individuals and communities receive the health services they need without suffering financial hardship. It further states that the essence of UHC is comprehensive access to a strong and resilient people-centered health system with primary healthcare (PHC) as its foundation. Key components which constitute a strong platform for PHC upon which UHC needs to be built, include: community-based services, health promotion, disease prevention, and immunization.

       Data from WHO suggests that half of the people in the world do not get the health services they require. In addition, about 100 million people are pushed into extreme poverty each year as a result of out of pocket spending on health. Furthermore, 930 million people spend at least 10% of their income on healthcare. These statistics are especially damning for low- and middle-income countries (including Kenya and most of Africa), since most of this population already lives below the poverty line, earning less than 2 dollars a day. When people struggle to access basic needs, health care becomes a secondary need for most, and for some, a luxury. Given the current global COVID-19 pandemic, these countries with already over-stretched health systems will struggle even more to access health services, and potentially suffer grave consequences.

            The above scenario moved the world into action, and in 2015 UHC was included under SDG 3(3.8) as a priority to be achieved by the year 2030 at a rate of 1 billion people every 5 years.  UHC is also firmly based on the 1948 WHO constitution, which declares health a fundamental human right and commits to ensuring the highest attainable level of health for all. To make this a reality, we need: high quality health services available to individuals and communities, skilled health workers to provide quality people-centered care, and policy-makers committed to investing in UHC.

             UHC should be based on strong, people-centered primary healthcare, which in Kenya is at the community level. A community is described as a group of people brought together by sharing culture, geographic location, and/or other common interests. Good health systems are rooted in the communities they serve, therefore, community engagement is integral to attaining UHC in Kenya and most other countries. Community engagement is defined as the process of working collaboratively with and through communities to address issues affecting the well-being of those people (source: Centers for Disease Control and Prevention). This is essentially how to earn “buy-in” for any policy, idea or project that one may want to introduce to a certain group/population. There are principles that guide this process, including: doing research about the community, doing research about your organization, allowing community members to self-identify, prioritizing unheard perspectives, valuing other’s time, avoiding tokenism, recognizing already existing strengths and assets, being proactive (especially with like-minded partners), ensuring that communication is ongoing, being transparent, and meeting people where they are.

     One out of 47 counties in Kenya, championed by the governor, had UHC as its flagship project after voters complained about lack of access, quality, and affordability of healthcare. After keenly listening to the public, teams were formed and dispatched to grassroots level to introduce the idea of UHC, its elements (including PHC, the role of community health volunteers (CHV) and & Social Health Insurance (SHI) – NHIF), and its potential benefits to the communities. This was done on market days, during chief’s meetings, in church, and other areas of community congregation.

The feedback formed the basis for the strategies employed to entrench a PHC network led by CHVs.  Each CHV had to: be from the village they represented, be selected in the presence of administrative leaders, be a permanent resident of the area or reside there for 3-5 years, and be of good standing and acceptable to the community. These criteria were decided upon after engaging with the different communities for weeks and involving them in the process of creating the strategies to attain a strong PHC network. Over 1,000 CHVs were selected to represent the various communities, with more than 60 active community units providing monthly reports of their efforts, with all of them having undergone basic training before carrying out their duties. This is an illustration of how community engagement can help to identify and prioritize the needs of the people, use already existing systems and strengthen them, involve and maintain communities in their goals and targets in a sustainable way, and more importantly, earn their trust through transparency and communication.

     SHI is a kind of public health program which provides protection against various economic risks associated with poor health. It pools the health risks of the people on one hand, and the contributions of individuals, households, enterprises and government on the other. It protects people against financial and health burden and is a relatively fair method of financing healthcare. While this approach favors countries with a larger proportion in the formal rather than informal sector, there is evidence that supports its positive impact on low- and middle-income countries where majority of the population is in the informal sector. There are also solutions being developed like community based health insurance (CBHI) which attempt to address the current challenges. While it may not be perfect, it serves to ensure that less and less of the population is vulnerable to poor health and its (especially financial) effects.

     In the same county in Kenya discussed above, they set out to discover why SHI uptake was so low amongst its citizens. This was done via a simple survey and results revealed that close to 30% were not aware of what health insurance was, and another 30% were not sure how it worked or its potential benefits to them. Again, this was used to steer the strategic approach to guiding the population to first understand SHI, and then to eventually sign up for the same. After concerted efforts by the political class and technocrats, with the help of the elaborate PHC network led by the CHVs, they managed to move from less than 30% of the population to over 60% signed up within 18 months. This was the highest rate in the country at the time. It translated into more people having access to healthcare without being susceptible to financial ruin. This being a big feat, there were challenges that arose, such as the retention rate of clients on the SHI scheme and cases of corruption among its managers. Notwithstanding these setbacks, SHI did more good than harm in the long run and that can still be considered a step in the right direction.

     Many low- and middle-income countries are yet to achieve UHC and some are arguably far from it owing to the myriad of problems that must be overcome to get there. This, however, does not take away from the encouraging results seen in countries that have been committed to the cause and have managed to properly engage with their citizens on all matters UHC. While community engagement and SHI are undeniably important towards achieving UHC, especially in our setting, there still needs to be support from the executive, policy makers, partners, and other relevant stakeholders. The dream of UHC is largely still a team effort.