The attainment of UHC is by no means a simple path. Challenged by the disruptive trends of climate change, changing epidemiological patterns, poverty and inequity in many countries, the need to strengthen health system performance for UHC has become more critical than ever.

Albeit slow, there has been incremental progress to place health on the political stage, most notable of which is the adoption of the first United Nations Political Declaration on Universal Health Coverage, the Global Action Plan on SDG 3 and the Astana Declaration on PHC for UHC.

In the WHO-Africa Region, efforts have been made to provide countries with guidance as they chart this path to attaining UHC. The development of the Framework of Actions for HSS towards UHC and the SDGs at the inaugural  regional forum on Health Systems Strengthening in December 2016 Windhoek, Namibia, set the ball rolling for the region.

At the recently ended 4^th Regional Forum (11-14 November 2019), held in Douala Cameroon, a strong focus was placed on providing member states with a platform to review, discuss and share challenges and lessons in optimizing the performance of their health systems for the attainment of UHC. Over 150 participants, representing 43 of the 47 member states in the WHO Africa Region participated in this forum, together with 38 WHO staff from the WHO Regional Office for Africa and WHO Headquarters, as well as representatives from the African Development Bank (AfDB) and the West African Health Organization (WAHO).

The meeting was centred around peer-to-peer exchange on the system performance dimensions of the UHC Framework: user access to essential services, quality of essential services, demand for essential services and the resilience of the health system. 24 member states were invited to share their unique experiences across these areas.

Most echoed amongst the challenges shared by countries were issues of domestic resource mobilization, given the rapidly occurring economic transition (LIC to LMIC) facing many countries in the region, persisting data gaps, low analytical and knowledge generation capacities in health information; suboptimal oversight capacities, including for sector coordination, integrating multisectoral contributions and engaging the private sector in health governance and service provision (they currently deliver 50% of services in Africa) as well as distribution challenges in the health workforce (rural vs urban).

Member states like South Sudan and the Central African Republic, which are dealing with the issue of rebuilding fragile systems, shared challenges around extended product stock-outs, and geographical and security threats that further hinder access to services. For such settings, it emerged quite clearly from the forum deliberations that a transition from humanitarian assistance to development assistance will be key to unlock improvements in the health sector and the social sector as a whole.  

Countries with better performance across the system performance areas also shared lessons and novelties that have led to their success. Lessons shared included improving quality of care through championing patient rights in health facilities, increasing taxes to widen fiscal space and increase health budgetary allocation, setting up mobile health teams to serve hard to reach populations, engaging the community in health facility boards to increase demand for services and the centralization of some functions of procurement, warehousing and distribution of essential medicines to achieve economies of scale, the institutionalization of pairing between lower level facilities and reference hospitals in different regions to expand the provision of patient care as well as the use of social marketing to promote demand for services.

As was the case at the 3^rd Regional Forum in Cote D’Ivoire, the issue of developing Essential Health Packages arose, and countries expressed a high need for technical assistance from WHO-AFRO, to develop these packages, to guide their service delivery interventions across all levels of care.

Delegates emphasized the need for a toolkit to integrate health security and health systems strengthening. This will aid in building system resilience and ensure that the health systems of member states are better prepared and equipped to absorb shocks as they arise. This proposal was adopted as one of the recommendations of the forum, and action will be taken over the course of the coming year.

The session ended with an increased appetite from countries to learn from each other through the documentation of best practices to accelerate attainment of UHC and other health related SDG targets in the region. The experiences shared by countries will be integrated into a paper on the state of health systems in the African Region, to be presented at the 70th Regional Committee of the WHO Africa Region.

Indeed, the conceptualization, operationalization and implementation of UHC is complex, but it is possible. We will not stop till no one is left behind.