Attracting “high-level political will”: the politics of promoting Universal Health Coverage
At the beginning of March 2019, I attended the Africa Health Agenda International Conference (AHAIC) in Rwanda, alongside other members of the project group, Victoria Muinde and Edwin Ameso. In this blog post, I describe some of my observations from the AHAIC and relate them to research I’m currently conducting on Universal Health Coverage (UHC) in Zambia.
Jamie Wintrup, June 2019
The Africa Health Agenda International Conference (AHAIC) took place in March this year in Kigali, the capital city of Rwanda. Although I was aware of its reputation as “Africa’s cleanest city”, I was still struck by how neat and orderly it seemed to be as I travelled by taxi up and down the many hills of Kigali on the way to my accommodation. But the image of the city is politically important and the government invests a great deal of effort in maintaining it.[i] The pristine appearance of Kigali is a way of demonstrating the country’s post-genocide recovery and progress, particularly for the many foreign visitors who arrive in Rwanda. For those of us attending the AHAIC, the conference venue itself offered a further symbol of the country’s emerging status and success. The new Convention Centre is an impressive building that cost $300 million to build and can host over 5,000 people. Designed by a German architect and built by a Chinese construction firm, the Convention Centre has a striking dome – “inspired by traditional hut construction” – that illuminates the skyline after dark (see Photo 1).[ii] Within the grounds of the Convention Centre there is a 4-star hotel and this is where many business representatives, government ministers, and the directors of global health organisations stayed during the conference.
The AHAIC was hosted by the Rwandan Ministry of Health and the African Medical and Research Foundation (AMREF). AMREF is a Kenyan-based NGO who have been vocal proponents of UHC in recent years and who work in partnership with various governments in Africa. But the AHAIC was also sponsored by a range of prominent NGOs and global health organisations, including Last Mile Health and Planned Parenthood, as well as a number of private corporations who have business interests in healthcare in Africa, such as GlaxoSmithKline, Johnson and Johnson, and Philips. These different organisations were invariably described as “stakeholders” – a term that naturalises the idea that these actors and organisations should be positioned alongside the governments and citizens of African countries as equal participants.[iii]
For advocates of UHC, the conference was an important occasion. Although it took place shortly after the World Health Organisation’s (WHO) Global Conference on Primary Health Care in Astana in October 2018 (which was attended by another member of our project group, David Bannister, who wrote this blog about it), the AHAIC was an opportunity to focus on the UHC agenda within Africa. In the words of the organisers, the conference was intended “to build momentum among diverse stakeholders, including policymakers, civil society, technical experts, innovators, the private sector, thought leaders, scientists and youth leaders . . . with a focus on achieving universal health coverage (UHC) in Africa by 2030”.[iv]
If the stated aim of the conference was to “build momentum among diverse stakeholders”, in practice this often meant enabling representatives of NGOs, global health organisations, and private companies to meet with ministers and government officials from a wide range of African countries. Indeed, some of these encounters took place in private sessions that were not open to other conference delegates (such as Victoria, Edwin and myself). But the NGOs and global health organisations who were present did not disguise their aim of trying to attract “high-level political will”. Indeed, throughout the conference various advocates for UHC appealed directly to government ministers, addressing them personally: “You can make a difference when you return to your country”.
In my current research in Zambia, I’m following the introduction of a large-scale Community Health Worker (CHW) programme that is being implemented in the name of achieving UHC in rural areas of the country. I therefore followed many of the debates about Community Health Workers (CHWs) that took place at the AHAIC – for example, there were discussions about whether CHWs should be paid a salary for their work (like other health workers) or whether this might undermine the spirit of “volunteering” that motivates CHWs. But, aside from these discussions, I was also interested in how various organisations were promoting the idea of large-scale CHW programmes as a policy to achieve UHC. For example, the WHO and AMREF were both advocating for the introduction of large-scale CHW programmes as a way of enabling African countries to achieve comprehensive primary health care, particularly in rural and remote areas. The WHO launched a set of policy guidelines at the AHAIC (intended for policy makers and government officials) on how best to introduce large-scale CHW programmes and how they can improve health outcomes and coverage. They were able to identify countries – such as Ethiopia – as success stories in order to encourage government officials from other countries to emulate such examples.
One of the first events about CHWs at the conference was held in the foyer of the convention centre and was organised by AMREF. The description of the event read as follows:
Margaret Kilonzo and Moses Ngwira will share stories about their work and how they are putting communities at the heart of UHC in Kenya and Malawi, tying on the ground reality to our [AMREF’s] global campaign. The campaign aims to generate high level political will and commitment for including and prioritizing quality community health programs that are financially sustainable and integrated in national health systems as part of national and global UHC strategies.[v]
One of the central tactics of organisations such as AMREF and the WHO, who want to see large-scale CHW programmes adopted in African countries, is to attract the attention of government ministers and persuade them of the virtues of large-scale CHW programmes. This is clearly how a lot of global health advocacy works and it is not only at conferences like the AHAIC where this takes place. But, nevertheless, it is worth making this visible as a political strategy because this kind of advocacy has certain effects when it is successful. What happens when these organisations are successful in generating this kind of “high-level political will”? And what happens when government officials return to their countries having been persuaded to promote particular UHC policies?
In my own research in Zambia, I’ve been interested in how a new CHW programme has been developed and implemented with the support of various partner organisations, including the UK government’s Department for International Development (DfID), the Clinton Foundation, and the Global Health Workforce Alliance (GHWA). Many of these organisations have worked hard to generate high-level political will within Zambia. During interviews with policy makers and partner organisations I’ve often been told that the CHW programme I am studying had “high-level” political backing from senior Zambian politicians – and this was one of the central reasons why the programme was implemented. But what are the implications of this politics of high-level advocacy? And what does it mean for the UHC agenda?
In Zambia, the government has introduced a large-scale CHW programme with the “technical assistance” of with various “partner” organisations – most prominently the Clinton Health Access Initiative (CHAI) and I’ve found that the “high-level political will” behind this programme has produced certain effects. Firstly, some partner organisations have felt that they have the authority to begin to deliver the programme in parallel to government structures. So the “ownership” of the CHW programme (to use one of the terms favoured by partners) is not present at all levels of the health system, even if there is “high-level political will” in the Ministry of Health in the capital city. This raises interesting questions about what Hannah Brown (2015) calls “sovereign responsibility”. Many partner organisations in Zambia seem to feel that they have sovereign responsibility (in particular districts) because of the authority given to them through the “high level political will” they have generated at the central level. This has created tension, in certain places, between partner organisations and district-level government officials.
This is one of the effects of high-level political advocacy. And it is important to consider such consequences of high-level political advocacy in order to understand how particular policies are perceived by the partners and government officials who are tasked with implementing them. As the anthropologist Kenneth Maes – who has conducted research on the work of CHWs in Ethiopia – has pointed out:
The last ten years have seen the emergence of the Global Health Workforce Alliance, the Frontline Health Workers Coalition, and the One Million Community Heath Workers Campaign, each of which have had important impacts on global health policy and practice. Despite the connotations of terms such as worker ‘coalition’, ‘alliance’, and ‘campaign’, these institutions emerged not from CHWs seeking to improve their job conditions; rather, they were formed by health professionals and policy experts based mainly in North American and European institutions seeking to promote an enhanced role for CHWs in extending primary health care. (2017: 18)
Maes points out that these organisations “have much to offer to the development of CHW policy and practice”, but he suggests that it would be more desirable for CHWs themselves to be actively shaping the political future.
Given how much the UHC agenda is driven by organisations who engage in precisely this kind of high-level advocacy – at forums such as the AHAIC – it is worth considering the political effects of this kind of high-level advocacy and how UHC is being shaped by these political dynamics in practice. These are issues that I’m interested in exploring further in my work in Zambia. And this is why conferences like AHAIC are significant events – they make visible political dynamics that are important in the world of global health advocacy and the UHC agenda today.
[i] See https://qz.com/africa/509948/kigali-is-africas-cleanest-city-but-that-comes-at-a-heavy-price/ (Accessed September 20th 2019)
[v] It’s not unusual for CHWs themselves to be put at the centre of political campaigns – the WHO used many photos of hardworking and dedicated CHWs in their efforts to promote their vision of primary health care in the 1970s. And in his research in Ethiopia the anthropologist Kenneth Maes describes how CHWs were physically placed at the centre of the annual “Ethiopian Volunteers Day” ceremony in Addis Ababa – although none of them was invited to “provide a candid testimony” (Maes 2017: 6) about their work or grievances.
Hannah Brown. 2015. Global health partnerships, governance and sovereign responsibility in western Kenya. American Ethnologist. 42 (2): 340—355.
Kenneth Maes. 2017. The Lives of Community Health Workers: Local Labor and Global Health in Urban Ethiopia. London: Routledge.