Achievements during the past decade in Ghana and Rwanda suggest that progress towards universal coverage could move quite rapidly in Africa if supported by strong political leadership. Ensuring access to quality health care and financial risk protection for all citizens is primarily the responsibility of the state. Translating the vision of universal coverage into reality requires political leadership and a greater role for the state in health care financing. African states should take greater fiscal responsibility for the health care of their citizens and strengthen policy measures to meet the Abuja target of 15% of government spending occurring in the health sector. Increased tax funding is critical for achieving universal coverage in Africa, whether this is used to directly purchase health care (in the case of tax-funded systems) or used to subsidise insurance contributions for those outside the formal sector to achieve an integrated insurance risk pool for the whole population. African states also need to strengthen their regulatory role and capacities to ensure not only the provision of quality health services by public and private health care providers, but also the solvency of health insurance organisations and the protection of citizens. The state should also play a role in promoting social responsibility within the private health sector and ensuring that private providers and insurance groups act in the public interest.

In addition to state actors, including those elected and appointed, politicians and civil servants in Ministries of Health and Finance, there are a range of other actors who will be interested and involved in universal coverage reforms. For example, depending on the extent of donor dependency and influence, international organisations, both multi-lateral and bi-lateral can become major actors. Technical analysts and researchers in academic institutions, private providers (particularly large commercial groups such as private hospitals and pharmaceutical manufacturers), existing voluntary health insurance schemes, front-line health care workers, formal sector employers and trade unions can also potentially be important stakeholders.

Individuals, households and communities are the principal beneficiaries of universal coverage reform. The poorest households often stand to gain the most from successful universal coverage reform. Unfortunately these groups do not always have a voice in universal coverage reform. Civil Society Organizations (CSO), as well as other forums for ensuring adequate participation by the poor, can play a role in making these actors more visible, and their voice better heard.

All reforms have social and economic costs and benefits. These costs and benefits are not evenly spread in society and do not necessarily affect the same groups to the same extent. A stakeholder analysis of actors potentially affected by the reform, the costs and benefits they will experience, their potential position in relation to the proposed reform (i.e. support or oppose) as well as their power in the reform process is therefore a critical part of managing universal coverage reforms. For example, a major source of controversy in the Ghana NHI reform was the proposal that formal sector employees who were members of the Social Security and National Insurance Trust (SSNIT) would have to contribute 2.5% of their SSNIT contribution the NHI fund. Almost all members of organised labour unions in the country contribute to this fund. The initial proposals did not make it clear what benefits would accrue to SSNIT contributors and they felt the deductions would threaten the viability of their pension payments. Therefore, trade unions mobilised to resist these proposals. They were able to secure a concession from policy-makers whereby their SSNIT contributions did not increase and were guaranteed that the 2.5% contribution to NHI would not affect their pension funds. In effect, policy-makers agreed that the SSNIT contributions to NHI would be a ‘loan’ that will have to be repaid from tax funds when current SSNIT members retire and expect full pension payouts. A more careful stakeholder analysis and the development of effective actor management strategies to inform the design of the reform proposals and the management of policy processes may have avoided some of these complications.

All major reform, such as universal coverage, is political as well as technical. It is essential to have politicians and technical actors engaged and well-informed for successful reform.