Accelerating Progress Towards UHC

The Prince Mahidol Award was established in 1992 to commemorate the 100th birthday anniversary of Prince Mahidol of Songkla, who is recognized by the Thais as ‘The Father of Modern Medicine and Public Health of Thailand’.

In 2015, the world united around the 2030 Agenda for Sustainable Development, pledging that no one will be left behind and that every human being will have the opportunity to fulfill their potential in dignity and equality. UHC is the aspiration that all people of all ages can obtain the health services they need, of good quality, without suffering financial hardship. Health services cover promotion, prevention, treatment, rehabilitation and palliative care, and all types of services across the life course. However, recent monitoring indicates though that progress is off‐track for achieving stated UHC goals by 2030. Large coverage gaps remain in many parts of the world, in particular for the poor and marginalized segments of the population, as well as in fragile and conflict‐affected states. Even for the countries that have seen an expansion in the access to health services and coverage of key interventions over the last decades, sustaining these achievements is challenged by the rise in the burden of NCDs and the aging of the population occurring on a compressed timeline. In middle‐ and lower-income countries this increase in the burden of disease is observed without corresponding rapid increases in economic and societal prosperity, as well as in fiscal capacity.

Hence, UHC needs to be seen within the context of megatrends, including other issues beyond the health sector, that shape global health. Societies are facing the changing nature of the challenges that impact health systems. These include systemic shocks such as disease outbreaks, natural disasters, conflicts, and mass migration, economic crises, as well as longer‐term processes, such as population growth or decline, epidemiological and demographic transitions, urbanization, food insecurity, climate change, and widening economic disparities. These changes and shocks can affect the three core objectives of UHC: the gap between service needs, availability and use; quality of services, and financial protection. Health systems need to continuously adapt to provide appropriate and needed health services, and more generally, to ensure equitable progress along the related dimensions of population, service, and cost coverage.

These megatrends, in the context of the alarming growth of NCDs, require the development of systems that are integrated and sustainable, not just the sum of their parts. Hence, forty years after Alma Ata, the world is making a new commitment to primary health care, but in ways that reflect vast changes that have occurred in medicine, economics, and society since the late 1970s. The key to dealing with today’s public health challenges and changing landscape is not to change strategic direction but to enable a shift from health systems designed around diseases and health institutions towards systems designed for people, with people is required. This entails developing a competent health workforce, building the capacity of local and sub‐national health authorities to lead change at their communities, and engaging patients and relatives in the co‐creation of health.

The way forward for financing UHC will require strong political commitment as the sine qua non-underlying principle that is implemented via action on two fronts. On the one hand, countries can get additional mileage from adapting and accelerating core principles for progress derived from proven strategies for sustainable and equitable resource mobilization, pooling and purchasing for UHC, drawing on lessons from countries that have seen rapid UHC progress in the past. At the same time, we are living in times of a “second machine age,” the “fourth industrial revolution” driven by very rapid advances in digital technologies and communications. Digitalization of health financing systems, analysis of Big Data accumulating in real-time from multiple sources has opened new avenues to stop leakages, detect fraud, facilitate payments, and better understand the behaviors of people and institutions. At the same time, health financing systems need to be ready to embrace and support service delivery innovations that can improve access, efficiency, and quality.

Countries would need strong and informed governance to harness innovations that can potentially address some of our most pressing healthcare problems by transforming lives, preventing disease, restoring people to full health, and making the healthcare delivery system more effective and efficient. Such innovations should be guided by clear public policies oriented to equitable pathways towards UHC. Realizing these opportunities will also depend on sufficient and appropriate investment in R&D, figuring out common interests, accountability, and partnerships with industry, ensuring that benefits of innovations are accessible to those who most need it irrespective of the wealth, mechanisms, and processes that encourage socially desirable innovation and promote equity-driven innovation.

To seize the above‐mentioned opportunities and challenges and transform them into actual progress towards UHC and SDGs, we need strong leadership that can foster solidarity across different sectors at all levels. The role of local authorities and the engagement of communities in concretely moving from commitment to action should not be understated. Good governance and transparent, effective, and accountable institutions are enablers for UHC. Giving the civil society a voice and an active role in advocating for and supporting progress to UHC is critical. In this context, health systems should become adaptive, learning systems that are able to adjust over time by analyzing past implementation and anticipating future challenges.

An adequate health system accessible to all members of society can contribute to societies that value security, solidarity, and inclusiveness. Particularly in fragile and conflict settings, health can be a bridge for peace. PMAC 2020 will be good timing to review the progress made over the first five years on this pathway towards 2030 goals and to strategize for the final decade. This conference will present evidence and advance the discussion on:

• Progress on UHC goals and challenges for the next decade in the context of global megatrends and other SDGs.
• Developing PHC‐based health systems to efficiently and effectively meet the needs of people over the life course, including consolidated actions to develop a diverse and sustainable health workforce.
• Transforming service delivery models and implementing quality improvement strategies to achieve people-centered and integrate care
• What does it take to implement and scale up the core principles and strategies of health financing for UHC?
• Harnessing socially responsible and equity enhancing innovations in medical technologies, digital health, service delivery, and health financing that help to accelerate progress towards UHC goals.
• Strengthening leadership and accountability to accelerate progress towards UHC and SDGs and the role of local authorities and civil society in moving from commitment to action.

A couple of topics are critical to be addressed for a robust UHC design and implementation;

Subtheme 1: Implementation challenges and innovative solutions for UHC 2030

Underlying the achievement of most SDG3 targets is universal access to and uptake of quality, affordable health services (SDG target 3.8), the large majority delivered close to where people live and work (i.e. primary care).

WHO estimates that around half of the world’s population lack access to essential health services worldwide. Even when essential services are accessible, they are often fragmented, of poor quality and safety, and do not always address the upstream determinants of health and equity in health.

At the same time, the burden of non-communicable diseases, accidents, and mental health problems is growing. Aging populations are causing people to live longer, but often with multiple diseases and conditions that require complex care over time. With the growth of social media and digital communication, healthcare users and their families are much more informed (or misinformed) and are demanding more say in how health services take care of them. Significant rise in medical consumerism, malpractice litigation, and lack of trust in vaccination campaigns are observed. In more fragile contexts, the lack of confidence in health services and has hampered efforts to control communicable disease threats. This shows that communities are the anchor of nations’ resilience-building efforts. In this context, increased accountability (including social accountability to local communities) and broader stakeholder participation is needed.

The key to dealing with today’s public health challenges and changing landscape is not to change strategic direction – primary health care remains the cornerstone of a sustainable health system and is the foundation for an essential part of achieving universal health coverage– but to transform the way health and social services are organized, funded and delivered. For health care and coverage to be truly universal, it calls a shift from health systems designed around diseases and health institutions towards systems designed for people, with people. This is required to meet the evolving needs of the population, ensure population trust in services and subsequently their effective use, and curb inefficiencies related to duplication and waste. In the wider context of Sustainable Development Goals, health workers are also expected to demonstrate their social responsibility: protecting the general public’s well‐being and meeting social expectations, while also aiming to reduce the impact on the environment of their activities.

Subtheme 2: Sustainable Financing for Expanding & Deepening Universal Health Coverage

The world has advanced towards UHC, but not fast enough. More than half the world’s population still does not have access to a basic package of health services, and more than 100 million individuals annually are impoverished due to high out‐of‐pocket (OOP) spending. Political commitment is the first step to mobilize more funding. Health can be a winning argument to raise more revenues in a pro‐health and pro‐poor manner. But countries also need to achieve more health for the money, i.e. to use the funds efficiently and equitably. It is essential to encourage and learn from new approaches, such as those involving digital, technological, financial, and social innovations to raise and use funds for UHC. Progress requires consolidating and expanding existing strategies that reflect principles of good practice while managing the political as well as technical challenges to implementation. The SAFE (Sustainable, Adequate, Fair, Efficient) approach to health financing offers useful guidance for the way forward.

Subtheme 3: Adapting to the Changing Global Landscape: Fostering UHC‐ based Solidarity to Drive Towards SDGs

The world needs to put the progress towards UHC on track to be able to achieve it by 2030. To this end, the global community must rise to the coming challenges that can affect UHC (including service needs, availability and use issues, quality of services, and financial protection). It is essential that we forecast important changes in the global landscape over the next decade, and that we identify opportunities with the potential to accelerate progress towards UHC. Challenges and opportunities are context‐dependent. For example, the economy(industry), society(technology), politics, and environment are all key aspects that can affect this progress.

Subtheme 4: Making and Using (Fiscal) Space for UHC

Public financing is key for universal health coverage (UHC). Despite progress, the recent World Health Organization (WHO)‐World Bank (WB) estimates indicate that almost half the world’s population still does not have access to a basic package of health services. Further, more than 100 million individuals are impoverished annually due to high out‐of‐pocket (OOP) spending at the time and place of seeking care. Increasing the level and progressivity of public financing, expended in ways that increase access to services while improving financial protection by reducing high levels of OOP payments, will be essential for accelerating and sustaining progress towards UHC.

Given this backdrop, assessing fiscal space for UHC – i.e., finding options for increasing public financing for health in an efficient, equitable, and sustainable manner ‐‐ is a key challenge facing many countries. Fiscal space for health can typically be realized by:

(a)Conducivemacroeconomicconditions, such as sustained economic growth and increases in aggregate public revenues, both of which are outside the immediate domain of the health sector but are nevertheless important determinants of public financing for health.

(b) Increasing the health sector share of aggregate public expenditures by reprioritization. In many countries, this requires a deeper understanding of how the allocation of resources is determined and whether there are key obstacles hindering this increase.

(c) Introduction or expansion of earmarked consumption or income taxes, including via social health insurance (SHI) where levels of formality of the labor might make this a feasible option.

Effective expansions of public financing for health across countries have typically resulted from a combination across all three dimensions, in addition to improvements in the efficiency of spending that can help realize effective fiscal space for health while at the same time being an important determinant of reprioritization. Further, in some low‐ and middle‐income countries, development assistance has often played a key role in increasing fiscal space, especially for expanding service coverage and financial protection for the poor and vulnerable and for priority programs.

Recently, the definition of ‘fiscal space’ has evolved in the literature: e.g., the International Monetary Fund (IMF) has broadened previous definitions by recognizing the multiplicity of macro-fiscal factors in facilitating fiscal space expansions, giving it a more dynamic character to the concept. These developments have implications for the health sector and it is important for the health community to be aware of them.

Subtheme 5: Smart Health Financing – Seizing Digital Opportunities

Financial flows of health systems are increasingly digitized ‐ flows between payers and providers, but also direct system contributions and payments from people. This digital transformation creates opportunities for step‐changes in financing policy and performance. They generate vast data about provider and patient behaviors that hold the potential to substantially improve transparency and accountability as well as purchasing decisions. In parallel, the rapid growth in the use of mobile phone systems can facilitate direct contributions to health insurance schemes, improve the targeting of subsidies, and empower people to make better-informed decisions. The benefits of the digital transformation are, however, not guaranteed, for example, poor change management, system fragmentation and lack of interoperability/data compatibility, weak regulation all-too-often impede the use and benefits of information. The transformation also carries significant risks, most importantly, threats to data privacy and security.

Subtheme 6: Health Financing Transitions: The Role of Development Assistance on the Road to Sustainability

In the SDG era, many countries – particularly lower‐ and upper-middle-income countries ‐‐ are experiencing transitions that impact health financing. Epidemiologic and demographic transitions demand more resources for NCDs and attention to UHC. As countries grow, external financing supporting key health programs often declines, prompting a greater need to transition these programs to domestic financing, service delivery, and program management, and/or integrate them further into the health system. In parallel to these transitions, countries are also working to translate economic growth into increased public financing for the health sector to improve financial protection and reduce the impoverishing impact of out‐of‐pocket (OOP) expenditures. Transitions are not necessarily correlated with high and equitable coverage of essential health interventions, so countries not only have to manage the transition, but also continue to improve program performance and sustain/scale service coverage at the same time.

The rapid expansion of development assistance for health (DAH) during the MDG era was critical to expanding coverage of life‐saving interventions, however during the SDG era, DAH has plateaued. Given global political and economic trends, prospects for DAH growth are uncertain. While DAH continues to play a prominent role in health financing in low‐income countries, on average it comprises a relatively small percentage of total health spending when lower and middle‐income countries are combined. At the same time, however, we are seeing foreign direct investment (FDI) increase into LMICs. Given these dynamics, there is a need to place both resource mobilization (public and private) and overall health system strengthening at the center of the efforts to move towards Universal Health Coverage (UHC). Within this context, important questions arise about how DAH can be most effectively used to mobilize and complement additional public and private resources for health and improve the efficiency of health spending. It also raises questions about how donors can responsibly decrease external financing or transition in a manner that ensures the health outcomes they were supporting can be supported, sustained, and scaled by domestic financing and health systems.

Subtheme 7: Investing in the Health Workforce for the 21st Century

The Astana Declaration recognized the importance of health workforce education, employment, motivation, and retention and pledged to strengthen the primary health care workforce to effectively respond to community and population needs. Estimates show a projected shortfall of 18 million health workers by 2030 to achieve and sustain universal health coverage (UHC), primarily in low‐ and lower-middle-income countries. The Global Strategy on Human Resources for Health and the report of the United Nations’ High‐Level Commission on Health Employment and Economic Growth have each elaborated on a health workforce transformation and investment agenda for UHC and the SDGs. In 2017, the ILO‐OECD‐WHO Working for Health Programme was established to advance the operationalization of the Commission’s recommendations, particularly at the country level. This session will present and discuss country experiences, highlighting priority actions taken to close the anticipated 18 million health worker gap and expand and transform the health and social workforce for universal health coverage and the SDGs.

Subtheme 8: Leveraging Strategic Purchasing for UHC through Strengthened Governance

Moving towards more strategic purchasing of health services – linking the allocation of resources to providers to data on provider performance and the health needs of the populations they serve, while managing expenditure growth – is increasingly recognized as one of the critical means by which health financing reforms can drive and sustain progress towards UHC. But weak institutional capacity and governance can be a binding constraint for going to scale with strategic purchasing reforms

Many countries have taken important steps to address these challenges, and their experience can shed light on key implementation issues. They have strengthened accountability mechanisms, created a virtuous cycle of data analysis as an input to reform and continuous review, emphasized the outcomes of efficiency and equity, and aligned public financial management with strategic purchasing objectives.

Other Reads:

Designing the Health Benefit Package

Health management information systems for universal health coverage

Primary Health Care the Building block for UHC

Thai UHC Implementation Approach

Source: PMAC2020 Provisional Conference Program