Considering Leadership and Management for Universal Health Coverage
By: Jay Gribble and Alyson Lipsky
Across the board — from global meetings such as ICPD25 to national meetings that include reproductive health technical working groups — the issue of universal health coverage (UHC) has emerged as a priority on agendas. Much attention is given to how to pay for UHC, but we must also focus our collective attention on the imperative for effective leadership and management. Discussion around UHC generally focuses on low- and middle-income countries, whose health system governance, leadership, and management are typically already strained. When we hear about these issues, we generally think about the health systems building block on leadership and governance and how stewardship functions are critical to advancing health sector priorities. But given that UHC has emerged as a global priority to be implemented at national and subnational levels, we suggest that leadership and management for UHC requires a different take. From our observations, there are three leadership and management needs that are particularly critical for UHC:
· Politically aware and savvy champions committed to inclusive processes
· Leadership and management that fosters a culture of accountability
· More data on the costs of effective management and administration of UHC programs
The Need for Politically Aware and Visionary Champions
First, UHC is a political choice. Political actors, leaders, and champions — ministers of health, parliamentarians, and higher-level stakeholders — must be persuaded to commit to achieving UHC, which requires strategic data use, diving into the complex policy process that UHC requires, and building coalitions among different groups of players, including providers, labor groups, patients, the private sector, and others. For example, in the Philippines, the struggle to achieve UHC has been a 50-year iterative process, which culminated with the passage of the UHC Act in 2019, requiring multiple pieces of legislation followed by a number of policies and other regulations to fulfill the promise of UHC. Implementation of UHC is also political in nature as champions must turn to a set of even trickier topics such as what services are covered, defining roles and responsibilities across cadres and sectors, and financing. Stakeholders with entrenched interests can be barriers to achieving UHC — they may be concerned about losing power, authority, or influence. To successfully navigate these difficult conversations, leaders must be inclusive — ensuring that the many different groups have a voice while also maintaining a strong vision of the end goal. These leaders must walk a fine line between political feasibility and technical and programmatic demands.
Leaders Should Create a Culture of Accountability
Second, when a country has committed to UHC, we expect that the health sector should benefit from a greater influx of funds through the public and/or private sectors. As funding increases, leaders and managers need to create a culture of accountability at all levels of the health system that goes beyond the basics of ensuring people do their jobs. A culture of accountability for UHC should foster a commitment to understanding and fulfilling roles and responsibilities, meeting individual and organizational obligations to achieving UHC, and providing data and information to all stakeholders. One of the key areas to be addressed by a culture of accountability is accountability for results. UHC efforts are often highly visible, with a significant portion of people looking for results. Leaders and managers need to be well-equipped to answer questions not only about where funds are going, but also how health objectives are being met. With successes around financial accountability and accountability for results, political leaders should be able to more effectively make the case for stronger UHC legislation, policies, and related regulations. In Nigeria, the Health Policy Plus project is working to support a culture of accountability for the country’s new Primary Healthcare Under One Roof and the Basic Healthcare Provision Fund by developing capacity of local actors across government and civil society to better understand these new programs; clarify roles and responsibilities of the numerous ministries, agencies, offices, and other stakeholders involved; and strengthen relationships across those stakeholders. Fostering accountability for results ensures resources are used efficiently, while holding institutions responsible for delivering on policies and laws around UHC.
Improve Data on UHC Management Costs
Third, while staff and expertise is needed at both the clinical and management level, very little information exists on the latter level. Most UHC programs call for the management of new health insurance schemes and/or purchasing agencies, but decisionmakers don’t have a solid understanding of the management costs of UHC programs at the national level, and certainly this information is missing at a global level. Key questions for which information is needed include: What are the financial resources and technical skills needed to set up an independent agency for purchasing services? What are the exact roles and responsibilities of administrators and providers of national health insurance schemes? Are countries embedding measures for administrative effectiveness into information systems? Operational questions related to the ease of enrolling or obtaining approval for treatment, the amount of time it takes to address complaints and whether clients are satisfied with the result, and how many administrative staff are needed per the number of insured are all critical to managing national UHC initiatives.
Around the world, UHC has gained significant momentum. To make the most of this opportunity, we must think creatively about the leadership and management challenges that are specific to UHC. The three leadership and management issues raised here — supporting leaders at all levels of the health system, leading and managing for accountability, and knowing the costs and measurable indicators of effective leadership and management — are issues frequently overlooked in discussions about UHC. These issues need to be addressed if large UHC investments are going to yield the results that decisionmakers are looking for.
Jay Gribble is the Deputy Director, Family Planning and Reproductive Health at HP+
Alyson Lipsky is the Technical Lead, Stewardship on HP+ and is a health governance specialist at RTI