Public and private sector viewpoints from Thailand, Iran, Nigeria and Malawi and Germany
At the heart of Sustainable Development Goal (SDG) 3 is the vision that all people should be able to use the health services they need, of sufficient quality to be effective, without facing financial hardship. This vision now enjoys strong international support and many countries have embarked upon far-reaching reforms to achieve Universal Health Coverage (UHC) by 2030. Implementing UHC at country level is far from straightforward, however. Not only are there complex technical questions to be resolved, but generating political will to invest in UHC requires joint action from the whole of government and from society at large.
On October 16, Ilona Kickbusch, Director of the Global Health Center at the Graduate Institute of International and Development Studies in Geneva and Co-Chair of UHC 2030, moderated a panel discussion at the 10th World Health Summit in Berlin on challenges and breakthroughs on the road to UHC. Organised by Germany’s Federal Ministry for Economic Cooperation and Development (BMZ), the session sought to bridge the gap between the global UHC agenda and the process of national implementation. What social and economic benefits can be seen in places where the UHC agenda is far advanced? What obstacles stand in the way of achieving this goal? What needs to change to ensure that no one is left behind?
UHC as a driver of inclusive and sustainable development
In her introductory comments, Ilona Kickbusch welcomed UHC coming into the global spotlight as ‘the driver that is taking us forward in this new time of coordination and working together.’ Referencing the upcoming celebration of 40 years of the Alma Ata Declaration, and the fact that many of the goals elaborated at that time have not been fully realised, Kickbusch said: ‘UHC is a new historic chance we’ve been given. We must use it and we must not fail.’
Esther Werling, an adviser with the Deutsche Gesellschaft für Internationale Zusammenarbeit GmbH (GIZ) agreed that UHC is fundamental to implementing the Agenda 2030 for the SDGs. ‘To push forward this agenda health needs to be positioned as a critical driver for employment, sustainable economic growth and inclusion,’ said Werling. Health should be understood as a global public good, which must be protected and promoted not only by ministries of health and health professionals, but across governments and societies as a whole.
Thailand is a leading example of how investments in UHC can generate benefits which go far beyond health. Piya Hanvoranvongchai, a co-director of the Equity Initiative: Transformative Leaders for Health Equity, described how fundamental health financing reforms implemented in his country since 2002 have not only led to expanded access to affordable health services, but have helped to improve health outcomes, mitigate the social consequences of diseases such as HIV, and reduce economic inequality across provinces. ‘There is now a sense among the public that health is a key human right, and a lot of people are now ready to defend their rights, instead of seeing healthcare as a government welfare programme that one must beg or ask for.’
Investing in human resources to meet people’s needs
Such transformations cannot happen without careful attention to the role of the health workforce. Amirhossain Takian, the Acting Deputy Minister for International Affairs at Iran’s Ministry of Health and Medical Education, shared his country’s experiences in tackling health workforce challenges. Over the past 30 years, Iran has invested heavily in hospitals, health facilities and universities as the training grounds for the country’s health workforce. Graduates are absorbed directly into Iran’s extensive public health system, including in rural areas. The uneven distribution of health workers across a large territory remains a challenge, but the Ministry of Health has begun to address this as Iran moves towards UHC. ‘If you are a physician, you can stay in the remote areas and your payment will be higher than for those working in the center,’ explained Takian. ‘We are also providing health workers such as nutritionists and mental health workers who were not previously part of the health system. Although we are still facing huge challenges for distribution, what helps is identifying local needs and distributing resources accordingly.’
Digitalisation helps to ensure that no one is left behind
While Iran is now in a position to ‘export’ its health workforce, Malawi continues to grapple with severe shortages. ‘I don’t think we’ll ever have enough,’ said Andrew Likaka the Director of Quality and eHealth at Malawi’s Ministry of Health. ‘This forces us to think about efficiencies.’ For Likaka, this is where digitalisation comes in: it’s very difficult to track efficiencies using paper-based systems. Are health workers seeing patients? What services are they providing? Are the treatments they offer safe and appropriate?
Digitalisation can solve other critical bottlenecks to achieving UHC, including the expansion of services to vulnerable individuals. ‘UHC is about accountability,’ says Likaka. ‘Who am I liable to provide care to?’ At the primary care level health workers must know their catchment populations and must be able to track who is being reached with services and who is being left behind. Digital systems now make this possible.
Aligning public and private interests
The push for universal coverage is unfolding against the backdrop of steady increases in the burden of non-communicable diseases (NCDs) around the world. While this poses stark challenges in terms of both rising costs and increased pressure on drug supply systems, it is also creating opportunities to align public and private interests to expand and accelerate patients’ access to medicines. Oladipupo Hameed, the head of Roche Nigeria, explained how his company has been working with the government of Nigeria to improve patients’ access to cancer care. ‘When we started three years ago we “walked the patient journey” from start to finish to see where there were inefficiencies,’ said Hameed. ‘The main question we’ve been tackling is how to get drugs faster to patients.’ Working closely with the Ministry of Health, Roche received approval to provide medications directly to public hospitals, rather than working through multiple levels of wholesalers. As a result, drugs of assured quality now reach patients quickly and at a much lower cost. Roche has also supported the government to develop a national cancer control plan and is generating evidence on the need for a catastrophic health fund for cancer care. ‘If such a fund was passed it would be a way to ensure that cancer patients are not left behind on the road to UHC,’ said Hameed.
More action needed on the determinants of health
The lively and far-reaching discussion ended where it began, with a reference to the Alma Ata Declaration and the need to do more to strengthen entry points to the health system in the interest of patients.
‘Health systems strengthening is the way to go, and we need more investment in that, but in doing so we shouldn’t forget the other aspect, which is about building stronger systems for health,’ said Esther Werling of GIZ. ‘Here we must work more deliberately on the social, economic and environmental determinants of health – and, as we’ve heard at other sessions this week, on the political and commercial determinants, too.’ This final statement was greeted with applause from the packed auditorium. ‘She took the words right out of my mouth,’ laughed Ilona Kickbusch, as she concluded the session.