The current model of voluntarism for most community-level programmes is not effective or sustainable
By Prof. Freddie Ssengooba
It is good to dream but better to implement the dream. In 2015, the global community, committed to the Sustainable Development Goals (SDGs) — an ambitious dream for accelerating development across countries.
In pursuing the SDGs to ensure no one is left behind, the UN crystallised the need for partnerships as one of the guiding mantra for peace, development and prosperity.
As the ambitions of SDGs expanded, there was a call for countries to customise the goals to country contexts, capacities and resource profiles. Resource profile is only helpful if there is effective pooling of capabilities to implement UHC and related policies.
Winston Churchill once said: "Healthy citizens are the greatest asset any country can have." To the economist, these assets are referred as human capital. Countries develop, if their people are in good health, well skilled and linked to job opportunities. This path has three main challenges we need to overcome. The first one is the rapidly increasing population. In the African region, Uganda is in second position for the fastest growing population at a rate of 3.2% annually.
Programmes to enable women to plan when to get pregnant are less appreciated let alone implemented or financed. The youth outside marriage that contribute to the highest number of pregnancies are in the most part excluded from receiving effective means to delay pregnancies. Moral, cultural and religious concerns prohibit effective access to family planning and education about reproductive health and rights and obligations.
The second challenge is failure to invest at community level, where health promotion and prevention programmes are most effective. Besides immunisation programmes, few resources are directed at keeping communities in good health.
The current model of voluntarism for most community-level programmes is not effective or sustainable. With more resourcing directed at community-based programmes, health promotion and wellbeing can be improved resulting in less people becoming sick or requiring hospital services.
The third problem is the failure to broker partnerships needed to keep people healthy, skilled and linked to decent work and jobs. Fighting poverty, achieving universal education, just like universal health coverage require partnerships and collaboration ranging from upstream ministries and government departments to local government and communities at the downstream. Complex development outcomes like poverty reduction and UHC are only feasible by pooling together ideas, resources and capacities.
The challenge, however, relates to a failure to develop a shared vision, weakness in co-ordination and weak incentives for co-operative action during the design and implementation of public policies and programmes. Although departmentalisation and specialisation are known to create order in government and most organisations, the ‘silo norms' they create are inferior to the collaboration necessary to solve complex development problems.
Collaboration thrives on participatory approaches that harvest knowledge, ideas and resources from a large pool of stakeholders. It also enables mutual support and accountability within the same network. Increasingly, the Government is required to implement multi-sectoral arrangements - implying working together by different ministries, departments and agencies.
Most ministries have a statement in their plans that commits to focusing on multi-sectoral collaboration, as a priority action. What is consistently missing, however, are effective mechanisms to implement the commitment. In Uganda, the Office of the Prime Minister (OPM) is expected to co-ordinate actions and programmes across government. However, co-ordination at local government and community levels is muted in nearly all sector plans. At district and sub-county level, the leaders work in the shadow of public policies, with little purposive programmes to act on.
How can partnership be improved and scaled up? Henry Ford once said: "coming together is the beginning, keeping together is progress, but working together is success." He was referring to the complex nature of managing business relationships needed to manufacture cars and tractors by General Motors — one of the largest automobile companies in the US. The big challenge is not about knowing what to do to build partnerships, but sustaining those relationships during the implementation of policy programmes. The nature of partnerships depends on the type of programmes and actions being implemented. For example, malaria control by spraying houses requires local partnerships.
Local council leaders can mobilise and co-ordinate community-owned resources like volunteers, extension workers, and village philanthropists to bring labour and money to the task. Hospital-based workers can take responsibility for training, chemicals, equipment and oversight. Agriculture extension workers can bring expertise for using locally available spray equipment. Religious leaders can expand awareness and reassure the communities about the safety and effectiveness of the programme. Similar partnerships are feasible for creating awareness for reproductive health, rights and obligations, for improving community food security, for reducing domestic violence and teenage pregnancy.
Finding effective and sustainable solutions is about bring different resources and groups to work together. There is need to mobilise across government, private sector and communities to work together to solve public problems and advance big goals like universal health coverage. Working together requires special competencies which can be across the board. Resources from the government budget or one organisation, ministry, department or agency, may not be enough to achieve Universal Health Coverage in Uganda. Rather, significant progress can only be made by pooling resources from strategic partners at central, local government, and community levels.
The writer is a Professor of Health Policy and Systems Development & Director SPEED program, Makerere University School of Public Health