What does universal health coverage mean for Africa?

I was asked this question while speaking at Harvard Business School a few weeks ago. I don’t like the question for a lot of reasons, but I figured it’s worth exploring because people seem to ask it a lot. I’ve visited hospitals and clinics in a few African contexts (Rwanda, Ghana, Ethiopia, Senegal, Cote d’Ivoire, Togo) and here’s what I’ve learned.

Let’s start with this: universal health coverage (“UHC”) means different things to different people, and it definitely means different things in different places. Before diving into the topic of UHC, we have to first remember that Africa is an enormous place. Questions like this fall into the intellectual trap of giving all of Africa’s nations, cultures, and economies a monolithic and unproductive label. There is an incredible amount of diversity between countries, and even within a single country we can observe widening resource and lifestyle gaps between rich and poor, urban and rural, tribal divisions, and so on. Africa is diversifying and diverging rapidly, with some standout countries experiencing accelerated economic growth like Ghana and Rwanda, while plenty more countries are still stuck where they were decades ago.

In short, UHC will mean one thing for Nigeria, and an entirely different thing for Niger.

But having said that, there are definitely productive ways to think about healthcare for the continent and beyond. First, any country’s benchmark for universal health coverage should be the quality of healthcare its poorest and most vulnerable people. Metrics like number of hospital beds and doctors trained might be useful for some planning and policy purposes, but it doesn’t have an impact on UHC if only a small slice of a country’s population actually has access.

Second, geography really matters. In the US, 30M rural Americans live more than one hour from a hospital. That’s almost 10% of the population that doesn’t live anywhere near medical care. Has America achieved universal health coverage? By higher standards befitting the country’s GDP, absolutely not. This geographic issue is a bigger struggle in African contexts where the majority of populations continue to live outside of major metropolitan areas. Universal access to hospitals and doctors is deeply obstructed simply by geography alone.

Third, quality is the name of the UHC game in Africa (and in Asia as well). Many countries across the continent are aggressively extending and improving their supply chains, building more last mile health clinics, and training more health staff. But as public health systems expand, the central and administrative resources to monitor and control them spread thin. Are doctors effectively treating patients? Are facility budgets managed properly by administrators? Are medicines and supplies arriving on a regular basis and stored in correct conditions? The problem is now ensuring that growing health systems are delivering high quality care even at the margins.

Quality control example: storage of medicines

Quality control example: storage of medicines

So what does UHC mean for Africa? It depends on the country, but from what I’ve seen it should involve a combination of optimizing for the most vulnerable citizens, geographic disparities, and service quality.