All programmes assessed within the portfolio of UK health ODA can be seen to contribute to the umbrella goal of universal health coverage (UHC), with most in-country programmes incorporating some element of health system strengthening. In addition, our portfolio analysis found seven active flagship programmes – totalling £814 million – which sufficiently encompass health systems-wide approaches to be considered specific to UHC.
Despite a robust portfolio of health systems-focused grants – complementing many more which invest in health systems under a headline focus on a specific issue – ICAI’s 2018 report found that ‘the new international goal of achieving universal health coverage is weakly reflected in DFID’s ongoing programmes’. Its assessment of DFID’s maternal health programmes found a limited focus on improving national health infrastructure, and that the quality of maternal health services still presented a chronic problem despite expanded access. The report gives an example from Malawi, where as a result of UK programmes ‘more women are giving birth in health facilities, but severe shortages of beds, trained personnel, equipment and supplies mean that women remain at risk of dying from basic obstetric complications’.
Essentially, across UK ODA to health, investment in health systems seems to be insufficient to address needs and is often disproportionately directed towards ‘quick wins’ such as increasing access to family planning commodities. Beyond maternal health, the focus on non-state actors across many UK health ODA programmes (e.g. LAFIYA-UK Support for Health Programme in Nigeria(£84.5 million)) which plans to work with the private sector to deliver affordable health services, and the Harnessing Non-State Actors for Better Health for the Poor (HANSHEP) initiative (£33 million)) may also undermine public provision of healthcare where multiple systems exist in competition.