By Tonny Odokonyero
Monitoring and Evaluation (M&E) is the only mechanism that guarantees evidence-based programming and understanding whether healthcare interventions work or not. It fosters evidence-driven implementation, something critical for the design and implementation of Universal Health Coverage (UHC) related interventions. There are a number of health sector M&E initiatives that the government has established (e.g. Annual Sector Performance Review and Health Management Information System (HMIS)). However, given the current national goal of UHC, there are new performance dimensions (e.g. equity in healthcare coverage and full spectrum of health services), that the country needs to start monitoring in addition to routine performance metrics. Indeed the UHC agenda presents yet another fresh M&E challenge, given that it is a relatively new concept that gained prominent ground in the recent era of Sustainable Development Goals, requiring expeditious actions to review existing M&E system, in order to mirror issues related to UHC. Instituting an effective monitoring mechanism for this relatively new concept of healthcare service delivery is essential in shaping desired progress.
This article is a reflection of key observations that need to be considered for conducting M&E for UHC in Uganda, as deliberated during the 2017 Symposium on Health Financing for UHC in Low and Middle Income Countries organized courtesy of the SPEED initiative.
Indeed the desire to realize UHC in Uganda has gained considerable momentum. Almost everybody who hears about UHC is extremely excited. Participants of the symposium were equally exceedingly excited about UHC, and most importantly, the inquisitiveness and anxiety is on how the country can get ‘there’.
One critical area that need keen attention in order to accelerate progress towards UHC which is fundamental in ensuring that the country keeps on the UHC track, is establishing a strong M&E system for tracking progress of UHC efforts in the country. During the symposium, one of the sessions tackled this very important topic and consensus was built around four crucial M&E considerations that need to be taken into account for monitoring and securing accelerated UHC progress.
The first consideration is that UHC must be viewed as both a national and sub-national agenda which must be monitored to ensure the country is on track with the UHC goal. Accordingly, it is important to seize all available opportunities to ensure an M&E framework supported by all actors.
Second consideration is that, any effort for monitoring UHC must take stock of the following three measurable and core UHC performance dimensions or indicators: (a) financial risk protection. This relates to a condition in the economy where individuals do not meet undue financial hardship and are not impoverished due to healthcare expenditure; (b) full spectrum of health services for the population – i.e. coverage for all healthcare interventions and quality of care; (c) equity, i.e. health for all – which addresses issues of; physical accessibility, financial affordability, and social and cultural acceptability. For effective monitoring of equity, there is need to harmonize or identify stratifiers of policy relevance (e.g. based on socio-economic and demographic conditions). It must be noted that equity and quality of healthcare are paramount in any UHC effort, and must be emphasized at all times and followed up during any UHC monitoring. Also, equity dimension calls for a multi-sectoral approach to improving health with implications to health reporting. Consequently, there is need to include the equity dimension in any measurement effort.
Third is pertaining to data consideration for UHC monitoring. Reliable data sources must be established. Among others, potential data useful for monitoring UHC include; routine health information system data as well as administrative data and medical records; population based surveys (e.g. Demographic & Health Survey, National Household Survey data, and malaria indicator survey data, etc.); facility assessments, and research. Given that UHC is relatively a new initiative which requires a lot of effort to unpack the concept, the role of research must be strongly emphasized for generating relevant evidence to inform UHC related policy or programming processes.
Fourth, the responsible government institution(s) need(s) to identify all areas relevant for UHC that are not addressed in the current M&E (or performance assessment) framework, assess existing gaps, and fix the gaps to ensure effective UHC monitoring. There is no need to reinvent the wheel for successful UHC monitoring – government should fit UHC monitoring within the already existing M&E framework. But to take care of UHC in existing framework, it is important that gaps within the framework are identified, highlighting UHC dimensions. After identifying the gaps, efforts should be made to address them, focusing on incorporating UHC measures.
To foster the above considerations and ensure effective UHC monitoring in the country, the following interventions will play important roles: first is balancing investments in strengthening monitoring and implementation for UHC progress – UHC related investments should not only focus on implementation, but M&E as well. Second, it is important that for monitoring, emphasis is put on strengthening and utilizing existing information system, and all stakeholders (especially policy makers) should promote use of data or evidence for UHC related planning and decision making. There is need to address existing data gaps, and UHC monitoring must be mainstreamed within country mechanisms of performance assessment. Third, research must be strengthened as part of UHC monitoring. Last, there is need to operationalize a fully-fledged M&E division within the Ministry of Health to support UHC monitoring, since the existing structure at the ministry’s resource center is not mandated to take on all M&E roles, as the center’s core mandate is limited to managing health database (HMIS/DHIS2).
Tonny Odokonyero is a Researcher at Economic Policy Research Centre – SPEED for Universal Health Coverage.