Reinforcing locally led solutions for universal health coverage: a logic model with applications in Benin, Namibia and Uganda

Abstract

Development assistance for health programmes is often characterised as donor-led models with minimal country ownership and limited sustainability. This article presents new ways for low-income and middle-income countries to gain more control of their development assistance programming as they move towards universal health coverage (UHC). We base our findings on the experience of the African Collaborative for Health Financing Solutions (ACS), an innovative US Agency for International Development-funded project. The ACS project stems from the premise that the global health community can more effectively support UHC processes in countries if development partners change three long-standing paradigms: (1) time-limited projects to enhancing long-lasting processes, (2) fly-in/fly-out development support to leveraging and strengthening local and regional expertise and (3) static knowledge creation to supporting practical and co-developed resources that enhance learning and capture implementation experience. We assume that development partners can facilitate progress towards UHC if interventions follow five action steps, including (1) align to country demand, (2) provide evidence-based and tailored health financing technical support, (3) respond to knowledge and learnings throughout activity design and implementation, (4) foster multi-stakeholder collaboration and ownership and (5) strengthen accountability mechanisms. Since 2017, the ACS project has applied these five action steps in its implementing countries, including Benin, Namibia and Uganda. This article shares with the global health community preliminary achievements of implementing a unique, challenging but promising experience.

Critical barriers to sustainable capacity strengthening in global health: a systems perspective on development assistance

“…There are many instances in the literature that point to shortages in health human resources and challenges to deploying and retaining a capacitated health workforce in LMICs [37][38][39][40] . The effects of misalignment between external funding and country priorities, time-limited programs and rigid funding/implementation structures, and enduring system fragmentation, as illustrated by the vast number of vertical health programs and reporting systems, are also well documented 4,18,27,[41][42][43] . Spicer et al 18 indicate that these enduring challenges to development assistance reform undermine the effectiveness of health programs and threaten the achievement of better and sustained health outcomes.…”

“…This donor-recipient dichotomy has created power imbalances that favor donors and has led to many well-documented challenges, including a misalignment between donor and recipient country priorities, short-term and often complex funding structures and processes, the introduction of parallel systems, and a “fly-in fly-out” approach to technical assistance (TA) that can undermine capacity strengthening efforts and sustainability 1 , 3 . These factors have contributed to inefficiencies and are believed to have stifled health program co-design and capacity strengthening in ways that hamper local ownership, sustainability, and progress toward desired health outcomes 4 , 5 . The coronavirus disease (COVID-19) pandemic has amplified many of these inefficiencies and exposed gaps in the development assistance system that hinder response efforts and 6 – 8 , in some instances, further fragment health services 9 .…”

How to Achieve Universal Health Coverage: A Case Study of Uganda Using the Political Process Model Comment on "Health Coverage and Financial Protection in Uganda: A Political Economy Perspective"

“…To enable multi-sectoral participation, the UHC roadmap is publicly available, and it is shared with country partners. 14 Academic experts also have a role to play. This is the case, notwithstanding the important observation of the accompanying paper, that academia and civil society have overall relatively little influence on Uganda’s policy decision-making.…”

Exploring system drivers of gender inequity in development assistance for health and opportunities for action

“…Other donors have opted to create pooled funding mechanisms via multi-donor collaborations that incorporate incentives for harmonized efforts in addressing gender 73 . Donors are also being called on to finance and convene platforms for demand-driven multi-stakeholder co-learning including groups most affected by gender and health inequities 85 . Some donors have added resources for groups typically excluded from DAH, such as grassroots civil society organizations and activists 56,73,74,80 .…”