There is unprecedented political commitment to universal health coverage (UHC) in sub-Saharan Africa today as well as a set of well-developed technical solutions and tools for helping to make progress toward this goal. But while many governments have translated their commitments into country-specific UHC plans, they face obstacles in their implementation and breakdowns in the process of translating known solutions into action to spur progress toward UHC. As a result, implementation falters, commitment risks erosion, and equity, quality and financial protection issues persist.
The African Collaborative for Health Financing Solutions (ACS), funded as a broad agency agreement out of the United States Agency for International Development’s (USAID) Africa Bureau, ran from March 2017 to March 2022. The overarching objective of ACS was to support sub-Saharan African countries advance their universal health coverage (UHC) agenda. ACS’ approach to supporting countries to drive their own UHC agendas focused on working with an inclusive set of country stakeholders to identify (technical, social and/or political) entry points, meeting them where they are in the process, and bringing support through process facilitation, stakeholder engagement, deep systemic root causes analysis, solution co-creation, capacity building and explicit adaptive learning. A key element to ACS was strong core funding from the Africa Bureau for support through a regional work plan that allowed ACS to provide wrap-around support in terms of ACS’ five functions, while tailoring country-specific support to each country’s needs and priorities and to build a strong, complementary network of African institutional partners to lead the way.
Strategic African institutional partner network leading collectively
Through ACS, Results for Development (R4D) cultivated six African Institutional Partners (AIPs) who became the connective tissue across the continent between francophone and anglophone countries and who are today carrying forward and expanding on ACS’ legacies and approaches that worked well. ACS AIPs worked collectively on regional support activities, each bringing its value-add and seeking to complement one another to strengthen their collective impact and to strengthen an African institutional ecosystem to support countries on their UHC journeys.
ACS Legacies and lessons
All of ACS’ knowledge production is available here as well as on the websites of our AIPs for use across the African continent. As a high-level overview, ACS identified four legacy achievement areas that demonstrate solid evidence on the kind of changes to which ACS has contributed across the countries it has supported (Benin, Uganda, Burkina Faso, Togo, Namibia and Botswana).
|Legacy||Harmonized resource tracking (HRT) improves efficiency and holistic health financing decision-making|
|Tools and Products||
|Legacy||Countries catalyze UHC progress through collective internal learning strategies|
|Highlighted Results||AM-ARCH health insurance pilot in Benin is more effectively scaling, driven by ongoing learning agenda and willingness to adapt|
|Tools and Products||
|Legacy||Facilitation and Institutionalization of Inclusive, Multisectoral Dialogue advances UHC|
|Tools and Products||
|Legacy||Collaboration among African institutions strengthens the ecosystem of support for national UHC processes|
|Highlighted Results||3 African UHC resource hubs housing ACS tools and approaches and capacitated and networked to provide ongoing sustainable support|
|Tools and Products||
ACS also delved deeply into conceptualizing, mapping, and activating the accountability dynamic in the UHC space, which we include alongside the four legacies not because it has yet yielded the same level of evidence of impact, but because of its promise to catalyze UHC progress going forward.
Across these legacy areas we found:
- Consistency in the mechanisms that were effective in contributing to UHC progress, namely: demand and situation assessments to identify country-specific challenges and those most prioritized by stakeholders; facilitating multisectoral groups to consult, advise, or make decisions; and generating and sharing evidence from outside the focus country to catalyze insights and solutions in different contexts and programs.
- Importance of supporting inclusive and diverse dialogue to build common purpose and advance UHC progress.
- Improvement in UHC processes and approaches (like using evidence, learning from mistakes, and including diverse voices) lays an important and necessary foundation for country- and region-driven progress that policy changes alone cannot achieve.
ACS’ approach of strategic partnerships with local institutions, and of facilitation, knowledge brokering, technical coaching and mentoring of country actors allowed ACS to be responsive to countries’ priorities and build on country institutions, expertise and processes and to create ownership, capacity, and coherence at the country level. African institutional partnerships and leadership were key tenants of ACS and were pivotal to its legitimacy and successful support in all countries. While there is much focus today on locally led development, the ACS experience provides rich learning on how this goes beyond empowering/funding individual local partners, but rather strengthening the ecosystem(s) of local institutions that can collectively support ambitious goals like UHC (or sustainable financing for health, etc.). In project-funded development efforts, little investment reaches the ecosystem level, but instead supports time-limited project-defined consortia, usually with an international institution in the prime role. For locally led development to be authentic, diverse local institutions will instead need to develop collaborations and synergies to collectively support governments to advance country priorities. This paradigm shift toward locally led development means redefining the role of international NGOs like R4D in supporting complex, long-term priorities like achieving UHC. The ACS experience embodies one model of what this might look like: providing strategic technical coaching and mentoring to enhance local institutional and individual capacity; continuously harnessing, coordinating, and brokering experience and evidence across countries and local institutions to strengthen ecosystems of support for health systems.