Universal Coverage in Tanzania and South Africa (UNITAS) is a 5-year research partnership funded by the European Union. Launched in 2011, UNITAS consists of partners from Tanzania, South Africa, UK and Belgium.
The goal of universal health coverage is receiving increasing international attention. South Africa is introducing a system of universal health care entitlements to be funded from general tax and additional dedicated tax revenue. Tanzania is integrating existing health insurance schemes for formal and informal sector workers under the management of a single insurer. In both countries, financing reforms are being supported by wide-ranging efforts to improve the delivery and management of health services. Combined, these reforms intend to reduce existing health system inequalities and improve population, health service and health care cost coverage. Translating such health financing, service delivery and management reforms into intended changes ‘on the ground’ requires a well functioning monitoring and evaluation system which provides data that allow policies to be improved over time, and consequently strengthen their potential to achieve universal health coverage. While many questions about the most appropriate design of universal coverage reforms in different contexts remain, even less is known about how to implement reform policies effectively. There is an urgent need to gain detailed insights into reform implementation processes to improve the likelihood of successful health system reform.
The UNITAS project aims to support the implementation of reforms intended to achieve universal coverage in South Africa and Tanzania by monitoring and evaluating the policy processes. Specifically, it seeks to:
- Track policy formulation and planning for implementation;
- Monitor the progress of policy implementation at both the national and district levels, with an emphasis on identifying implementation problems and serving as an ‘early warning system’ for policy makers and implementers;
- Evaluate the impact of interventions aimed at progressing towards the goal of universal coverage;
- Engage with policy makers and implementers at all levels about the research findings throughout the study period; and
- Synthesise the results from the studies in the two countries, and compare these with experiences in other countries, to draw out policy implications on health financing mechanisms and implementation strategies supporting the achievement of universal coverage for quality health care in low- and middle-income countries.
To achieve this, UNITAS will:
- Develop detailed methodological tools for all elements of project; establish the district monitoring and evaluation sites in collaboration with health district managers; and establish the mechanisms for interaction and engagement on research findings with policy makers and implementers.
- Examine the process of policy formulation and preparation for the implementation of the health financing reforms for universal health coverage.
- Monitor policy implementation at the national level and district level, through documenting changes in inputs and outputs and the process of implementation.
- Evaluate policy impact.
- Engage with policy makers and implementers to communicate findings as rapidly as possible and interpret the findings in collaboration with policy makers and implementers at national and district levels.
- Synthesise findings and monitor international experience.
- Coordinate and manage the project
The changes proposed to progress to universal coverage in South Africa and Tanzania involve a complex array of reforms relating to revenue generation, fund pooling, purchasing, service delivery and management and governance. We will evaluate overall progress towards universal coverage at both the national and district level, but we have also chosen to focus on certain reform elements for detailed monitoring and evaluation. In South Africa, we will focus on four initiatives intended to improve service delivery and management at district level: the introduction of ‘PHC ward agents’ (i.e. community health workers); locating a team of specialists (including paediatricians and obstetricians) in each district with the aim of reducing child and maternal mortality; contracting with private primary care professionals to increase the human resource capacity to meet health care needs; and strengthening district management leading up to creating District Health Authorities with delegated management responsibility. We are focussing on initiatives that will improve access to needed care as it is not anticipated that any of the substantive revenue collection, pooling and purchasing reforms will be implemented in South Africa in the life of the UNITAS project. In Tanzania, we will focus on the introduction of TIKA (community based health insurance schemes in urban areas) and efforts to increase enrolment in CHF (community based health insurance schemes in rural areas) as key interventions to extend insurance coverage to a greater proportion of the population to promote greater financial protection and access. We will also evaluate the Primary Health Services Development Program (locally known as the ‘MMAM’ program and which involves the construction of new PHC facilities and staffing and equipping them), which will promote improved access to needed care.
The UNITAS project is expected to produce a range of methodological and empirical results. In particular, it will provide insights into methods for monitoring and evaluating the implementation of key health system reforms and provide a framework and set of indicators for monitoring progress towards universal coverage. It will demonstrate the usefulness of theory of change evaluation approaches in tracking and assessing complex health system reforms, and in understanding how and why reform implementation processes unfold and with what consequences. It will also produce findings on what types of health system reforms best promote progress towards universal coverage in different contexts and how to strengthen implementation processes to achieve reform goals. Ultimately, it is hoped that the UNITAS project will contribute to moving towards universal coverage in both South Africa and Tanzania.