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Towards Universal Health Coverage in Cambodia, Lao PDR and Nepal

Group picture at Kuala Lumpur module

The P4H Leadership for UHC (L4UHC) programme’s first Asia cycle is in full swing

As the Asian cycle of the P4H Leadership programme is moving into its final phase, 32 high-level stakeholders from different sectors of government and civil society have begun to change things on the ground, thanks to hands-on leadership training and support to in-country activities moving the national UHC agenda forward.

In Asia, the ‘Leadership for Universal Health Coverage’ (L4UHC) programme of the Providing for Health (P4H) network kicked off in May 2016 for leaders from Cambodia, Lao PDR and Nepal with an initial four-day module in the Philippines. A second module followed in August in Malaysia and the third and last one will take place in Japan in April 2017. While each of these workshops enables participants to learn and reflect intensively on the collective and personal leadership qualities required to advance their own countries towards UHC, the periods in between them are equally important for their individual and team learning.

Collective Action Initiatives to get the ‘UHC ball rolling’

During the first two modules, the country team conceived results-oriented, short-term initiatives designed to help advance their respective countries’ UHC agenda. These ‘Collective Action Initiatives’ are meant both to build team members’ confidence and skills, and to spread the spirit of strategic inter-sectoral cooperation in the contexts and networks in which they work. ‘I appreciate being part of a team to which I can contribute in my own way,’ shared one participant. ‘Together we have a strong vision of how to change things on the ground’.

Based on a systemic analysis of their respective country situations, the Collective Action Initiatives in Lao PDR, Cambodia and Nepal each work on a particular challenge whose resolution is perceived as a priority to advance the UHC process:

  • In Nepal, the unavailability of essential drugs in the health services, focusing on hospitals and primary health centres
  • In Lao PDR, inadequate integration and limited geographical coverage of Social Health Protection schemes
  • In Cambodia, suboptimal inter-sectoral collaboration on Social Health Protection and inadequate quality assurance of health care services.

The Collective Action Initiatives all fit into the UHC strategy of their respective countries, and in each one a L4UHC participant has been put in charge of an essential feature of the reform.

Nepal: making essential drugs available

New pharmacy in Primary Health Centre, Ilam District
New pharmacy in Primary Health Centre, Ilam District

In Nepal, still recovering from its devastating 2015 earthquake and in the process of state restructuring under a new constitution, the country team successfully lobbied the new Minister of Health to create a National Steering Committee and Technical Working Group on UHC. The L4UHC country team, which is headed by Dr Lohani, Executive Director of Nepal’s Social Health Insurance Scheme, was itself given an official status as ‘UHC Leadership Group’. The group focused its Collective Action Initiative on a fundamental obstacle to UHC: the lack of essential drugs. These are provided free of charge in public health facilities, but a recent survey found less than 5% in stock.

In January 2017 four Collective Action teams were launched – on central level and in three districts – with the mission of increasing availability of essential drugs, particularly in Primary Health Centres, which did not have their own pharmacies. Through complementary action on central and district levels, important strides have been made: the Ministry of Health has amended its Hospital Pharmacy Guidelines to establish pharmacies at Primary Health Centre level, and guidelines for these pharmacies developed by the central Collective Action team are in the process of being approved by the Ministry. As a result of the Collective Action Initiatives on district level, Ilam District has established pharmacies in all four of its Primary Health Centres; sustained application of inventory management tools has ensured uninterrupted drug supply for the last 100 days in Ilam District and increased availability in Palpa District; and Achham District is improving the rational use of medicine, starting with a baseline survey of prescriptions, of which 47% were revealed to be incorrect. These results guided the Chief of the District Health Office in targeting health-care providers with appropriate training in diagnosis, prescription and standard treatment protocols, including adequate counselling of patients.

Lao PDR: integrating and extending Social Health Protection

The Lao People’s Democratic Republic aims to achieve Universal Health Coverage by 2025. While significant progress has been made in improving health outcomes in the past decade, challenges remain in access to health services in remote areas and in protection against health-related catastrophes. The UHC process accelerated in 2016 with a new government committed to health sector reform. The L4UHC programme, which coincided with this change of government, has helped convene the high-level leaders involved in this reform to build a common understanding on UHC. The country team chose as their Collective Action Initiative to support the government’s planned integration of the four existing financial risk-protection schemes under the newly created National Health Insurance (NHI) Bureau. One of the participants, Dr Bounfeng Phoummalaysith, Deputy Cabinet Director of the Ministry of Health, has been put in charge of this bureau.

Over the past months, the Initiative has been supporting the government’s far-reaching reforms, which include 1) the creation of the NHI Bureau as a semi-autonomous unit within the Ministry of Health; 2) the launch of a unified and budgeted social health protection scheme for the whole informal sector; 3) the integration of a policy of Free Maternal and Child Health services (and possibly family planning) within the NHI; 4) the agreement with the Ministry of Labour and Social Welfare to transfer the health benefits of workers in the formal sector to the new NHI scheme. The geographic coverage of the NHI is expanding rapidly: from 6 provinces in December 2016, it is expected to cover 15 out of Lao PDR’s 18 provinces by the end of 2017. Related developments, both in enhancing health care quality and in institutional strengthening of the NHI, augur well for the progress of the country towards UHC.

Cambodia: Intersectoral collaboration on Social Health Protection and quality assurance

In the Kingdom of Cambodia social health protection involves the Ministry of Health, the Ministry of Economy and Finance, and the Ministry of Labour. Since leaders from these different ministries, as well as from civil society, participated in the first two L4UHC modules, Cambodia’s team is well positioned to promote intersectoral cooperation in their support to the country’s fresh emphasis on UHC.

The L4UHC team from Cambodia
The L4UHC team from Cambodia

In fact, the team’s reflections on an improved framework for social health protection have fed directly into the government’s new national social protection policy, whose development has been entrusted to the L4UHC country team leader, Mme Sokha, Secretary of State of Cambodia’s Ministry of Economy and Finance. She explains, ‘We try to encourage different parties to understand what the common goal is, and from there create a common platform and coordinating structure. Governance is an important issue for us.’

Working with an interministerial steering group, Cambodia’s team is implementing an ambitious plan consisting of three Collective Action Initiatives: 1) paving the way for the establishment of an independent Payment Certification Agency for social health protection schemes; 2) advancing the National Quality Enhancement Initiative to enforce standards of care in public health services; 3) facilitating the legal requirements for setting up the National Social Security Fund as a contributory scheme for civil servants.

The new institutional arrangements are part of the Social Protection Policy that the government is expected to endorse soon. Their evolution shows the importance of intersectoral collaboration for any breakthrough towards UHC: While the Ministry of Economy and Finance defined the arrangements, with the Ministry of Health in an advisory role, the National Social Security Fund under the Ministry of Labour was made the sole implementer for the social protection of civil servants, as well as of workers from the private and informal sectors.

The way forward: Module 3 and beyond

At the third workshop of the Asia cycle in Japan participants will take stock of the reform processes that their country team initiatives have supported and reflect on their personal leadership journeys. ’This programme helped me to search for the leader inside me’ noted one participant at the end of the first module, ‘and it taught me that change can be possible from within myself.’

The collaborative learning within and across country teams will continue beyond the final module. ‘In our country teams we discussed that the contexts in which we work are very different. But we have all become better leaders,’ found one of the participants. ‘This leadership programme gave us the enthusiasm to become champions for the right course for UHC.’

To maintain the positive spirit of these UHC champions the P4H network will provide a platform for exchange between the L4UHC alumni as well as support to activities which may result from the L4UHC programme.

Juliette Papy and Mary White-Kaba
April 2017

© GIZ/Franz von Roenne
© GIZ Nepal
© Cambodia L4UHC Team
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