Professor Khama Rogo, global authority on health systems and health coverage, was in the Netherlands at the invitation of Cordaid. We took the opportunity to interview the Lead Health Specialist of the World Bank. Is Universal Health Coverage by 2030 feasible or bound to fail? How does one even start setting up a health system in countries ravaged by decades of war? An in-depth talk with a man who has been in public health for 40 years, in the most challenging settings.
(Professor Khama Rogo during the ASBC Conference in Nairobi, Kenya. February 2019. © ASBC)
Before we address the topic of Universal Health Coverage, we’d like to ask some more basic questions. What is health and what is a healthy health system?
We tend to take good health for granted. But it is only when you cannot sit on your backside, because it is too painful, that you realise sitting is actually a very good thing. Health is much more than the mere absence of disease. It covers the whole range of well-being – physical, psychological, social. Not just the individual must feel healthy, but the community and the environment in which the individual lives must feel and remain healthy.
“Most health systems in the developing as well as developed world are neither healthy nor relevant.”
When good health is lacking, it reduces the capacity to perform, of people, of families, of communities. And by performing, I mean the capacity to maintain your very being. The capacity to take care of yourself and of others. When you are ill, others will suffer too, as they have to take over from you. Ill health of one person puts an extra burden on a lot of others. That is why optimal health is not just a personal but a communal and eventually a global responsibility.
UHC explained in 2 minutes:
A healthy health system responds to the health challenges of the community. This means health systems cannot only be global, they need to be locally relevant. They must give affordable and sustainable health care solutions to community members. Only then can the system remain healthy and relevant. Currently, most health systems in the developing as well as developed world are neither healthy nor relevant.
If you were to take an X-ray of the current global health system, what would be your diagnosis?
The status of health globally is dynamic. Sometimes the progress we think we have made appears not be progress after all. For example, in highly mechanised societies – where cars replace walking – obesity has becomes a major health problem. Solutions to problems are always relative. They can create new problems.
The international community has set this ambitious goal of reaching universal health coverage – UHC – by 2030. Is that realistic and feasible or is it a dream we chase?
If one is a student of language, one could say that we have been rather repetitive. We are stammering. For the year 2000 we had set the goal of ‘health for all’. I believe this means the same thing, to a large extent, as ‘universal health’. UHC is part of the wider agenda of the Sustainable Development Goals, the SDGs. Before the SDGs we had the Millennium Development Goals, the MDGs. They are similar in many ways. So, to a large extent over the years, we have been repetitive and saying the same things. Now, it is time to stop the stammering and start doing. And above all, start doing things differently. It is not so much the feasibility that we need to question, but the sustainability of the actions we undertake to get us there.
Let’s talk about the actions then. Are we on track for 2030?
If you look back historically and consider the time it took to realise certain changes, I think there is less likelihood that we will achieve the global UHC goals we have set, with business as usual. The pace and the way we do things must radically change.
“Business models of the health care market and politics are the major factors that hamper breakthroughs to universal health coverage.”
What must change?
The solutions need to be local. They lie within the communities. The big mistake is to come up with prescriptions, with top-down solutions that are not geographically specific or relevant. Take the tropical areas of the world. Does anybody believe we are going to eradicate the tropical infections within the next 10 years? No. But can we significantly reduce mortality and morbidity from these infections in the coming 10 years. Yes. Rather than being discouraged that we cannot reach global goals, such as universal coverage, we should endeavour to make irreversible progress in alleviating major health challenges.
We should stop doing business as usual in order to move forward in reaching UHC, you say. Making smarter use of the cell phone in in health care is an example you gave in your Ted Ex talk. Can you give other examples of innovations that can strengthen health systems?
There are many examples, and they don’t always have to be new to deliver on the promises They can be old things done differently. Take the way we finance the health sector. Look at what social health insurance has done to The Netherlands. Once someone has the card that guarantees a certain quality of care, that person starts owning his or her health. Every person, everywhere should have such a card. It is a universal mandate. And it can be done. Technologies, new, mobile payment systems have made it possible. And the costs per person, not more than a few dollars a month, is not what is blocking it either. Look at the US, a society that seems unable or unwilling to build a social health insurance system. It is not due to lack of technology, but because of the limitations in thinking and wrong politics. This is what retards progress towards UHC.
Can you be more concrete?
I will even be bold. In the change of any system, there are winners and losers. When you change the way we pay for health care, who are the winners and losers? If the winners are the millions who are covered and insured, and they were the sole decision makers, then we would reach a conclusion fast. But there are other people who benefit from a fragmented system and inefficiencies in the decision making process. In the US, different insurance groups fear that if you have universal social insurance coverage, there will be more rationality in what premium people pay. Their profit levels go down. They would rather cover a few people at a high premium, than many people at a low premium. Not introducing universal coverage through social health insurance is therefore a business decision, not a health outcome decision.
Then there are the pharmaceuticals. Medicines can be cheaper when they are generic and the supply chains are efficient. You can still make a profit if you sell more medicines at a lower cost to more people. But big pharmaceuticals would prefer to sell fewer medicines to fewer people at a higher cost, because the profit margins seem to be higher.
“The cell phone industry has done it. Coca Cola has done it. Why haven’t the people who are selling health care products succeeded?”
So in the end, business models of the health care market and politics are the major factors that hamper breakthroughs to universal health coverage.
Are the solidarity principle of universal health coverage (‘leaving no one behind’) and business principles of the health care market compatible?
It is not a question of either or. We need the market, we need producers, as consumers need goods. The key question is to make the health market efficient enough to serve the ones who are most in need. Unfortunately, there is no single bullet answers to this question. If I had it, I would be nominated for the Nobel Peace Prize. But let me give some possible answers, as I still have the hope to be nominated one day.
Even the poor are a market. We know that ever since Yunus showed us ways to bank the unbankable. Some of the fastest growing banks in the world, especially in Africa, are the ones that are focusing on the poorer sections of society, formerly known as the ‘unbankable’. That has been the success of the cell phone industry as well. Only once it became affordable to the poor, did the cell phone become a real, global market. Today there is a 80% cell phone coverage in most African countries. So there are markets now that used to be unthinkable. Yunus has described it. The cell phone industry has done it. Coca Cola has done it. The big question is, why haven’t the people who are selling health care products succeeded?
Part of the answer is a belief that health care products are self-marketing. That they shouldn’t be marketed. I think they should be marketed, but more efficiently and on a much bigger scale. Then there is a part of health care, which is much less saleable and marketable, namely the prevention of disease, the efforts to stay healthy, instead of getting waiting to be treated when already sick. This side has been largely ignored by the health industry and by politics alike. If I am a president today, I will be remembered or re-elected for the number of new hospitals I built and opened. Not for the number of children I helped to vaccinate, or the number of women who got access to family planning. We can gain a lot by making prevention a more saleable, profitable and politically correct business.
Are there lessons European health care systems can learn from the way health care is marketed and organised in African countries?
Many. Look at how Kenya and other countries have leapfrogged over Europe in introducing mobile payment systems like Mpesa. And how efficiently these systems can be applied in emerging markets, by health insurance systems. Or look at the task shifting in human resources in many African health care systems. We allow non-physicians to provide some aspects of health care, that in Europe only doctors are allowed to do. We allow community nurses to do that what only highly trained nurses can do elsewhere. Shortage of human resources and finances forces us to adopt innovative approaches. And it works. This is how we expanded our ARV programs in the fight against Aids. Allowing non-doctors to prescribe ARVs.
“Social insurance is so important in our health care systems. It makes people own their own health care. The masses stop begging and start owning.”
To give just one example: the countries in Africa that have the highest contraceptive prevalence rate, are not the ones with more doctors and high level clinics, but the ones that have adopted community based distribution of contraceptives. Community based distribution works, because people trust the providers they know. This is the basis for social marketing, where for example the local shopkeeper can be the distributor of health care products. Europe can learn from this and make healthcare delivery more efficient and sustainable.
What is your message advice to international NGOs, many of whom are competing in the health care sector, whether in Africa or elsewhere?
That it takes more than money to make things happens. And that strengthening local health systems is more than a game of logos and branding. Rather than programmatic attributing success to donor countries and organisations, more recognition should go to the people and local health workers in the villages. They ‘did it’. They do the bulk of the work, take the risks and face the frontline challenges. And if they do not own the projects and programs, they stop working once the donor/NGO leaves and stops financing. Ownership is key and it is built on trust. This is why social insurance is so important in our health care systems. It makes people own their own health care. The masses stop begging and start owning.
You often say that health care as such should not be expensive. 5 dollars a month should assure anybody in the world access to the health that is needed. Why is this not the case then?
Because of the number of intermediaries. A tablet of paracetamol made in India may cost 1 euro over there. By the time it arrives in DR Congo, it costs 15 euro. This is not due to transport cost, but to the number of intermediaries between manufacturer and consumer. There might easily be 14 intermediaries and each one makes a profit. Each one is a cost centre. This, basically, is making health systems too expensive. By cutting the number of intermediaries, there is a lot to be gained. We pay very expensively for these obvious inefficiencies.
“You end up balkanizing the county, with each NGO trying to appear to do something different.”
There are also inefficiencies of health care as provided by INGOs. They represent an industry that has massively grown over the last 40 years. I have witnessed it, because I have been in health care for that long myself. Each INGO has overhead costs of 10 to 40%. And a lot of money is lost because of overlap of their activities and geographical coverage Too many people doing the same thing, but giving it a different name or brand. Take any county in Kenya. Thousands of NGOs are working on HIV/AIDS advocacy. Each one of them has an office, staff and a couple of 4 wheel drives. And they are all serving the same population.
You end up balkanizing the county, with each NGO trying to appear to do something different. But how many different HIV/AIDS prevention messages can you give? So there is plenty of room for consolidation. Room to cut down on overhead costs, reduce wastage, be thinner and more effective as organisations. On top of that, the large numbers of INGOs working in the same areas and the same fields, make it hard to build efficient working relationships with local governments. Audiences and meetings tend to become ceremonial, rather than technical and impactful.
You mentioned Kenya. What is your advice to those who wish to improve health systems in conflict-affected and deeply volatile countries such as Afghanistan and South Sudan?
I can only describe the enormity of such an undertaking. I led the Health reconstruction team in South Sudan, back in 2006, just after the Peace Accord was signed. The new, and first, ministers were appointed, many having lived in refuge for 30 years, far outside South Sudan. How well did they know their own country? During the war, the country was partitioned between Khartoum government and the liberation forces. The ministers were committed to improve their sectors, but asked themselves these questions: ‘I have no office, no staff, no files, no records… nothing. Where do I start? Who do I recruit and how? There are no newspapers, no radio, no telephone network. In health for example all the South Sudanese doctors and nurses eligible for recruitment are still in exile, abroad.’
They started with what they had. Used tented offices as accommodation, moving gradually into containers, then into prefabs, and finally into the office and accommodation they occupy today. Those buildings had been bombed during the war and had to be rebuilt or renovated.
“UHC does not mean you give everything to everybody. It means that everybody should get something.”
Imagine the ministers and their senior staff working under these difficult conditions as they set up new directorates. During this time, international humanitarian organisations were the only ones providing health care to the people. But who controlled them? As humanitarian organisations, were they answerable to their funders or to the new government? Did this government have the capacity to oversee their work and the transition from NGO led to government led health care? Would the NGOs accept to work under a government that lacks infrastructure and regular funding?
You have a government that is struggling to govern versus big NGOs who are not used to reporting locally and do not want to be controlled, in a country that is extremely volatile. It was painful. Resources are scarce and you wish to see both groups working together to establish efficient health systems. The minister has no budget yet some NGOs can fly in planes and communicate directly with their powerful embassies and donor governments. This is the typical situation one finds in fragile and post conflict environments. The power asymmetry makes the transition painfully long, acrimonious and most inefficient. It takes time to establish trust and systems of accountability.
Does that mean that Universal Health Coverage is automatically impossible in a country like South Sudan?
It doesn’t. UHC does not mean you give everything to everybody. It means that everybody should get something. And the amount people get depends on what is available and the capacity to deliver. UHC is not just about giving. it is about building local capacity of people to do more for themselves. Advocating for people to boil their water before drinking it, to wash hands, to sleep under mosquito nets, to breast feed their children long enough… Those are health interventions that people can do for themselves anywhere.
This is an essential part of UHC. It starts from personal hygiene, prevention, to being able to identify early symptoms and seeking care. This is something any community, however poor, can have. It is not always a money issue. Extra layers of care, on top of the primary health care, take time to build and should not be the singular entry point to UHC. And they can be achieved! It is possible, in my opinion, to create a continuum of care, anywhere in the world.
What exactly do you mean by that?
The divisions between primary, secondary and tertiary care are administrative and continue to play mind games in this sector. Disease does not respect those divisions. Within an hour a disease that should be manageable at primary care level, can rapidly evolve into a complication too complex for that level. What people need is an assurance of continuum of care, and the confidence that they can seamlessly be moved easily from one level to the next, depending on the dictates of the disease condition. This requires a higher level of trust of the health system, eliminating the fear to start at the primary care level. Maybe this continuum cannot be organised everywhere. But genuine efforts must be directed at building that cascade.
“The health industry is currently too inefficient and myopic to win the war against disease.”
Suppose I am in Kenya and doctors discover I have cancer of the prostate at the lower levels. They may not be able to treat me at this level but they can refer me to higher level hospital in the country or abroad. This doesn’t mean that UHC has failed in Kenya, but that UHC establishes a viable referral mechanism that leaves no one behind. Tasks are shared by referring patients to the right levels in the right places at the right time. These levels are local, regional and international. They go from the tiniest village in Africa, to provincial capitals, regional hubs, all the way to New York or Singapore.
That is how to run a trusted continuum of care program and step wise attainment of achieving universal coverage. One interconnected health system in the district, county, region and eventually global. A lot of the things that can make this a reality already exist. Like the technology, health insurance systems and medical know how. The only thing we need to do now is to practice global public health in a radically different way.
Let’s learn from the airline industry in terms of both safety standards, connectivity and universality. Look at how the airline industry works: I came to Holland from Kisumu, Kenya. First I take a local flight to Nairobi. Then Kenya Airways to Amsterdam. KLM, Air France and Kenya Airways are partners. So I can pick my flight, my date even my preferred hour of arrival. What made KLM, Air France and Kenya Airways work as partners? They wanted to become more efficient, convenient and profitable. Instead of KLM running a fleet of small planes flying all over East Africa, they decide to partner with Kenya Airways that already has that fleet on the ground. They agree on safety standards, IT systems. They share for reasons of efficiency.”
“This is a model that could radically change the efficiency and impact of the global health systems. This is what the UN system and WHO should be working on. For that to happen, public health managers and decision makers need to become more sane, more rational. And to understand the health market better than they do today. The health industry is currently too inefficient and myopic to win the war against disease. The overlap and competition between NGOs is too big. Private and public sectors are far too provincial and selfish to address emerging health threats that humanity must address. So let’s study the airline industry and learn from their successes and failures. It could give wings to glide towards the noble goals of Universal Health Coverage.”