A participant of the Leadership for UHC Program: Robinah Kairitimba, Uganda NHCO
The difference the "Leadership for UHC" Program makes: Olalekan Olubajo, Nigeria NPHCDA
“By 2030, no one should fall into poverty because of out-of-pocket health care expenses.” As World Bank President Jim Yong Kim acknowledged when he made that statement in January, that is a very ambitious goal.
Every day, according to the World Bank, more than a quarter of a million people are forced into poverty as a result of paying for their health care. Hence the global push for Universal Health Coverage – the effort to ensure that everyone gets the health care they need without suffering financial hardship.
The question then is how to achieve it. Financing is most often the focus as some of the poorest countries in the world struggle to pay for even basic health services. Training such as the World Bank’s Flagship Course on Health System Strengthening and Sustainable Financing are helping to build technical skills.
But less attention has been paid to the capacity of individuals who have to move systems off the drawing board and into the real world
That is where the new programme in Leadership for Universal Health Coverage comes in. It is jointly run by the World Bank Institute and GIZ as part of their support to the P4H network.* The first course, beginning in June, will bring together 25 people already working in health and related sectors, mostly in eastern and southern Africa.
Portrait of Kai Straehler-PohlImages© Kai Straehler-Pohl
Kai Straehler-Pohl has responsibility for the project at GIZ and says the aim is to instil confidence in participants so that they learn to stretch their authority. Listen to an audio clip (0:45 min.)
Stretching authority to influence upwards
Senior civil servants in relevant ministries have been invited to apply for the course, along with the directors of civil society organisations, health service providers and even Members of Parliament, to develop their own and their collective competencies as leaders. Kai Straehler-Pohl has responsibility for the project at GIZ and says the aim is to instil confidence in participants so that they learn to stretch their authority.
“These are people with some level of authority backed up by institutions,” says Mr Straehler-Pohl. The course will take them off the daily treadmill so that they gain a much wider perspective – as well as a greater understanding of their own abilities. “A lot more could be done if people were not so imprisoned by their positions,” he adds, acknowledging that one of the biggest challenges for senior technocrats and administrators is gaining the confidence “to make use of their authority and mandate and to stretch it to influence upwards”.
Spread over six months, with a mixture of workshops, practical assignments and mentoring, the Leadership for Universal Health Coverage curriculum has a strong emphasis on collaborative work and on learning to build alliances to support reform.
Facilitator Martin Kalungu-Banda, a Zambian expert in innovation and organisational change, says the participants will begin with some introspection. Before looking at the system he suggests, we have to “turn the camera onto ourselves so that we can see more of who we are.” He adds that leaders need to think about their purpose in life, asking themselves, “what am I seeking to bring forth rather than what does my job description say.”
Portrait Martin Kalungu-BandaImages© Martin Kalungu-Banda
Facilitator Martin Kalungu-Banda describes how course participants will learn to innovate and introduce change.
Listen to an audio clip (1:45 min.)
Learning to listen
Amongst other things, that involves an appreciation of the various different levels on which individuals listen and converse. This training in strategic communication will be invaluable as participants then start building alliances.
Here, Mr Kalungu-Banda, a former Chief of Staff to the Zambian President and advisor to several governments and international organisations, says the participants will be taught some of the techniques learned from studying innovators in the public and private sectors over many years.
The research shows that effective change-makers identify people who have “convening power,” those who can bring others along with them. But the more diverse those individuals are in terms of gender, ethnicity, skills and beliefs the better says Mr Kalungu-Banda. “The only common element is the desire to resolve a particular issue,” he adds.
Portrait Chris AtimImages© Chris Atim
Chris Atim of the World Bank talks about the skills potential leaders will learn on the course. Listen to an interview with him (2:32 min.)
Identifying the forces blocking change
Dr Chris Atim, senior World Bank health economist for Africa, says that learning to build viable coalitions is crucial to implementing change. As a leadership programme facilitator, Dr Atim will contribute his expertise in UHC to supporting participants as they learn some of the practical skills needed for leading reform.
One of those is stakeholder analysis, identifying the forces that will support or oppose change. “It’s about having the tools to analyse those different institutions and their relationships,” says Dr Atim, “and then knowing how to build a viable coalition to enable you to do what you want to do.”
Tackling specific projects
The 25 aspiring leaders in UHC will all be people already responsible for creating or administering projects in their own countries, whether as a Permanent Secretary in a Ministry of Health, a director of a major hospital, or head of the national insurance fund. Working in teams of four or five, they will tackle a specific project that will help implement the UHC agenda in their country.
Facilitator Martin Kalungu-Banda again cites research into leading innovators who, he says, “know that the answers don’t lie in brainstorming within the four walls of their offices.” Instead, they go out to observe as much as possible, to talk to people in the field and assess what works and what could be done differently.
Using evidence effectively is something that Dr Chris Atim believes needs to be cultivated, especially when it comes to challenging entrenched interests. “It’s not a question of succumbing to the status quo or listening to those protecting vested interests,” he says. Instead, leaders need to be able “to analyse what they’re hearing and assess whether or not it’s going to change the situation.”
The point at which things "start to tip"
Nobody is expecting sudden, dramatic results – not least because as Martin Kalungu-Banda puts it, “So often the system you are working in has the capacity to beat you back.” Hence the importance of learning in groups, and of taking small steps towards reform. Some of those steps will be rejected; some will have to be tweaked. But others will succeed and eventually, when the new leaders have implemented lots of small initiatives, says Mr Kalungu-Banda, “there is a point at which things start to tip and the system starts to change.”
Change in the Making: Intermediate Results
As of December 2014, six countries in Anglophone Sub-Sahara Africa have completed the first two modules of the program’s first edition. They have defined their respective collective action initiatives and have started implementing them. The Ethiopian Team, a mix of central and provincial officials from the Ethiopian Health Insurance Authority wants to develop a supervision system for the community-based health insurance schemes that are to provide social health insurance the majority of Ethiopians. The Kenyan team, which includes a County Government’s Health Minister, the National Hospital Insurance Fund and the Ministry of Finance, wants to bring the County Council on Health into the official policy dialogue structure on UHC.
The process of moving an ambition like UHC from drawing board into reality is a huge challenge. The Advisor for Social Health Insurance in the Zambian Ministry of Health, Mpuma Kamanga, says about his work on social health insurance: “We thought that once we got the technical work done, it would be smooth sailing. [But] managing the various stakeholders’ interests has been a politically profound process.”
In March 2015 teams will come together to present their work to each other at the final module. The signs are promising. For Olalekan Olubajo of the Nigerian National Primary Health Care Development Agency the program has already changed the way he wants to work: To be more inclusive, listen more and build more on his team – for better results.
For more information on the programme, contact the program leaders directly:
Kai Straehler-Pohl email@example.com and
Ceren Ozer firstname.lastname@example.org
by Claire Bolderson
* The GIZ project supporting the P4H network and, as part of this, the leadership programme, are co-financed by the Swiss Agency for Development and Cooperation SDC