WS 03 - Universal Health Coverage - World Health Summit 2020
Table of Contents
- Good afternoon very well welcome to you the audience...
- Development and innovative ways of accessing communities...
- Well in terms of hospitals overnight you've seen you know hospital...
- Income countries and see just infections and um under nutrition in...
- The next aspect about the people that i think much is about people christina sirensen...
- Their health they're health actors so we we ask or in...
00:06
good afternoon
very well welcome to you the audience
of our panel discussion and to our
distinguished panel speakers
to our panel discussion universal health
coverage
new choices for best practice within the
world health summit 2020
my name is bernadette clapper i'm senior
vice president at the robot bosch stiff
dunk in stuttgart
i'm very honored to share this panel
00:37
discussion
the reason that i that brings me here
as a foundation representative and not
as a scientist
is the cooperation between the robot
bosch foundation
and the world health summit which
started in september
the robert bosch foundation brings in
all the activities
from its initiative restart reforms for
our future health care
we aim to secure health coverage and
01:07
good quality of the care
despite the huge challenges ahead of us
and we all experience with the covet 19
pandemics
a huge challenge already in our days
as of today the interests
in health care reforms brings us
together with the world health summit
our cooperation is about to strive for
health
for all people being here on this panel
01:37
is a milestone in our endeavor
i do want to mention further all further
partners also in this cooperation
it is the berlin brandenburger academy
of science
and the heritage school in berlin
so the title of our panel today is
universal
health coverage new choices for best
practices
what is it about what brings us together
02:08
covet 19 is a magnifying lens
on strength and weaknesses of healthcare
systems
we painfully painfully learn once more
that we cannot be healthy
on our own our health is not only
dependent on effective medicine
but essentially on overall healthcare
orientation in our healthcare structures
with public health
health promotion and prevention building
the basic
fundament sustainable healthcare
structures
02:39
will also reflect and adapt to the
regional needs
in order to balance and address
appropriately
geographical and social differences
they have to rely on evidence about the
given regional and population needs
on monitoring health care status
their progress and successful activities
and they highly depend on social
solidarity
on a robust connection to civil society
a good level of health literacy of both
03:10
decision makers
and population will be the power fuel
of steady improvement
our speakers will now present different
their different perspectives on this
topic
i am very happy to present our first
speaker
dr lakshmi badaji
dr balaji a senior advisor and
and it's it is heading the health
systems rankings unit at unicef
headquarters in new york he is a medical
03:47
doctor
with an advanced degree in public health
and a doctorate in epidemiology
he has been with unicef for over 30
years
and who has worked in both country
regional
and headquarter offices throughout all
these long years dr balagi was
responsible for many important tasks and
programs
for example he was chief of strategic
planning from 2004 to 2014
and was deputy representative managing
04:17
unicef supported programs in afghanistan
for three years
also among his responsibilities dr
badaji manages
equest a system for equity-based
planning and priority
prioritization in primary healthcare
systems
for delivery of public health services
at national
and sub-national levels he also
coordinates unicef support to programs
at country level on various aspects of
primary health care and health system
strengthening for achieving stdh3
04:48
i'm very happy that he will give us an
introduction on the history of universal
health coverage
and we're related to primary care
dr balagi the floor is yours
thank you dr barnard uh let me go
thank you for that introduction and
thank you colleagues good afternoon good
morning good evening
depending on where you're joining this
meeting from
uh as dr bernard mentioned i will
give a little brief uh history of the
universal coverage
05:25
health coverage as you know alma atta
declaration
in 1978 put health as a fundamental
human right and
it primarily was it being aimed at
addressing inequality that is necessary
for equal economic and social
development and peace
and that people have a right and duty to
participate in their health
the alvarado declaration also defined
primary health care
05:58
and several goals were set
40 years later exactly
on 25th of october 2018
two years from uh before on this date
astana declaration was uh
committed by a number of governments
and unicef and who were together with
the government of kazakhstan
the main host to this
06:28
conference the the conference
was organized and the declaration made
bold political choices for health across
all sectors to build sustainable primary
health care
and empower individuals and communities
and aligned the stakeholders support to
help national and sub-national policies
and strategies and plans to achieve
primary health care
last year the un general assembly
07:02
session on universal health coverage
particularly noted the
interconnectedness
of the sustainable development goal 3
with all the other sustainable
development goals
meaning to achieve health you have to
achieve
many other sustainable development goals
the u.n general assembly
declaration of universal health coverage
also
need focused on the need to focus on the
07:34
poor
the most vulnerable and those with
disabilities
people the usc effort has to be people
centered
and quality assured health services
through the full
life course of an individual is
necessary
community based health
with engagement of civil society
organizations and primary
and private sector was felt as a
necessary ingredient
08:04
primary health care and health system
strengthening
was noted as the cornerstone
to achieve universal health coverage
with the emphasis on resilience which
we now realize particularly during kovid
times as being more
more critical the approach to usc and
health well-being
is basically as you see in this uh
graph the center these health and
well-being
08:34
has multi has to have a multi-sectoral
policy and action whether it is food
systems
child protection systems education
systems wash
or the social protection the
interconnectedness with the other
sdgs it has to have the strong empowered
people and communities with community
engagement and systems
with social accountability the primary
health care itself needs to be
integrated to across
many sectors health nutrition hiv
09:07
and ecd services near
and where people live and work
to do to get that you need to have very
strong
health system strengthening at national
and sub-national levels in all of these
seven areas
supply chain management to get drug and
pharmaceuticals closer to people a good
quality of care data and digital
health to inform what happens to the
communities and how our
09:38
systems are functioning a good
governance management and partnership
across multiple sectors
and multiple stakeholders private sector
we
now know is an essential
uh partner in delivering health services
and national and subnational financing
with a strong health force our health
workforce
are necessary ingredients to see that
primary health care
10:10
12 agencies challenged by the
governments of germany
norway and ghana developed the global
action plan for healthy lifes and
well-being
the idea is to provide collaboration and
support
amongst the 12 u.n agencies
and as well as the three global funds to
support countries
that is more purposeful systematic
transparent and accountable
and it leverages the agency's collective
10:42
strengths
it is also to better align their ways of
working to reduce
inefficiencies and provide more
streamlined support
and harmonized support to countries
and it is essentially puts this
country at the center and it is the
country's priorities which inform the
whole collaboration
and support and promote cross-sectoral
issues such as gender equality
11:12
and uh attention to the poor
the marginalized and the most vulnerable
the idea is to engage with the countries
align and harmonize their operational
and financial
strategies accelerate by
supporting the countries around
accelerating teams
and on advancing gender equality
and be accountable by reviewing progress
and learning jointly
11:45
the primary health care
implementation the idea is to provide
intensified primary health care
implementation through enhanced
visibility
and advocacy of the primary health care
increased
technical and financial support good
monitoring and reporting of progress
so using the primary health care
monitoring and evaluation framework
or the primary health care performance
initiative
improvement initiative that many
12:16
countries are doing
improving the access to best practices
and knowledge on plc
and improving the alignment of partner
organizations
around a single primary healthcare
support roadmap
and that way there is decreased
transaction cost
and increased efficiency of investment
on phc by partner organization
the gap itself has several accelerators
these are the seven
accelerators and i will very briefly
12:47
touch on how
covet is challenging all of us
to make the gap accelerator function
even better
primary health care they it is
new ways of delivering essential health
services
and overcome the disruptions in health
services
to the women children adolescents
and all of the people is something that
is being
uh challenged sustainable financing
13:19
countries
are finding that they need sustainable
financing not only to respond to
government but
also to build back better systems
with together with the community and the
civil societies
the new ways of
delivering services are emerging for
example
how to cut down
the number of times people need to
13:48
come to a center by effectively reaching
people through digital
and other innovative ways of delivering
primary health care and get them to a
center
where social dispensing and uh
quality of services through infection
prevention and control
is going on extremely well so that uh
people are safe and they can
access services in a very safe and
14:18
better way the data and digital health
interventions are improving and
real-time info
information is providing support to
communities and to health care workers
in a way which is not happened
before and these hopefully will
remain well beyond the corporate times
so that
this systems are strengthened and i can
function
even better a lot of research and
14:50
development
and innovative ways of accessing
communities
are being tried out and these are indeed
the right gap accelerators which
are now taking a new way of implementing
particularly during the copic times
many countries are looking
at how to overcome the disrupted
services
it is very clearly emerging that
although
15:20
in the government time because of
lockdown or other measures all
activities including
essential public health services at
communities to a certain extent were
disrupted
and hospital services also were oriented
towards
delivering services to those affected by
covet
and very serious and emergency
conditions
it is now these community-based services
are
being revived faster and it is out that
15:53
hospital
services are also catching up and
with improved uh prevention and control
measures in place
they will end up delivering services
in a higher quality and thereby meeting
the objectives
that was uh set out through the primary
health care and the universal health
coverage agenda thank you
dr benedict and i will stop here and
hope
we will have questions later during the
16:24
session
thank you very much dr badaji
for pointing out the
really crucial importance of primary
health care
in the universal health care coverage
scheme
also for saying and reminding us that
uh std sdg iii is not only
scg23 but it has to be achieved
by also working on all the other
sustainable development goals
17:02
and also how to accelerate our systems
in getting there this was very
very appreciative thank you very much so
far
i would go ahead over now to the to our
second speaker
um this is professor mujahid
is professor of health governance at the
heritage school in berlin
and i'm particularly happy to announce
him
as his chair is funded by the robot
bosch foundation
within our initiative we start reforms
17:32
for our
future health care professor
sheikh is professor of health governance
at the haiti school
his research concentrates broadly on the
field of health economics
and management with a focus on health
expenditures
hospitals and efficiency and competition
and health insurance mojang hosts a
doctorate in economics from frankfurt
school of finance and management and a
master and international health
management from imperial college in
18:03
london
he is published in top field journals
and
has won several international awards for
his research papers
however it is his passion for bridging
the divide between policy and research
by informing governance discourse
through rigorous scientific evidence
which defines his spirit as a health
economist and i'm very happy that he
will talk now about the government's
governance side of our endeavor
would you please go ahead thank you very
18:34
much uh benedict for this very nice
introduction uh it is a pleasure to be
on this planet with such
distinguished speakers
and i'm glad that you know the world
health summit decided to host a session
and the robert bush foundation
also jointly with the world health
summit decided to have a session on
universal health coverage
and governance i am wondering if you can
see my slides properly because
uh are yeah so you can read everything
well right
great uh then let's start off um dr
balaji already in the beginning spoke a
19:05
bit about
the sort of the history of universal
health coverage and
how old really is this concept of
universal health coverage
a lot of us will remember it because of
autofond bismarck for instance dating
back to that time
in the 18 in 1883 when the social
insurance
for employees was initiated by him
and then it took off in a lot of other
countries like sweden denmark
with the english nhs in 1948 and so on
recently i came across a financial times
article which basically mentioned that
19:36
it dates back
as far as ancient egypt a civilization
was supposed to be very very advanced
in ancient egypt doctors usually used to
visit the homes of people
to treat especially workers to treat
them for sickness and illness
so it is a really really old concept and
we
do know a lot about universal health
coverage now we've gathered a lot of
evidence over the last decades
on what uhc is what we should be doing
to improve
coverage in across the world in all
countries
20:06
uh however what have we really achieved
and how we are performing
uh when it comes to universal health
coverage so this map over here basically
uh shows the uhc achievement index uh
the darker the green color it means the
better the coverage and the lighter the
color
the lower the coverage so this is as of
uh 2015
uh the data from 2015 and you see a lot
of the countries particularly in the
african continent
in asia and south asia such as india
pakistan and so on
have really low levels of coverage
right and then i started thinking why
20:38
might that be could it be related
in some way to the governance structures
in these countries and
what might it be and then i looked into
how serious countries are
about uhc legislation so as of 2017
this map shows you which countries
actually have a uhc legislation
officially in place in the statutory
laws for instance
um the green countries are the ones
which do have a universal health
coverage legislation
and the red ones are the countries which
do not have the legislation so
it looks very similar to what we saw
21:09
before in terms of the performance
countries which do have a legislation in
place have better
performance in terms of uhc countries
which do not seem to have lower
performance
however two other interesting things to
note over here is that
there are some countries for instance
within the african continent
that do have a uhc legislation in place
such as botswana and bolivia
but still have very poor uhc coverage
and then there is peru for instance in
latin america
which does not have a uh sea legislation
in place
21:40
but if you go back to the previous
figure you see that it's dark green it
does
have high levels of uhc coverage so
what if anything is the relationship
then between having uhc legislation or
governance
embedded within the framework of the
country and uhc coverage itself
if you just take the average performance
of these countries so countries with
no legislation indicated by the blue
bars and countries which
have a uhc legislation with the red bars
you see that country the countries that
do have higher
22:11
uhc legislation in place actually have
better performance overall on
average of course there are exceptions
within these countries as well
but overall you can say on average
countries which have a uhc legislation
do perform better
however do countries with better
governance
have uhc legislations in place to have a
legislation
do you have to have better governance so
if anything what is that relationship
and how do we define governance at all
it has been defined many different ways
for this for the purpose of this talk i
will stick to what the world bank and
22:42
the world governance indicators talk
about it
uh it's basically the traditions and
institutions by which authority is
exercised
it includes the processes by which
governments are selected monitored and
replaced
the capacity of the government to
effectively formulate and implement
policies and the respect of citizens and
the state for the institutions that
govern economic and social interactions
among them
following this definition the world
governance indicators outline
six main indicators of governance which
is voice on accountability
23:13
government effectiveness political
stability and absence of violence
regulatory quality rule of law and the
control of corruption
of course these indicators are not new
uh the wgi has been you know
accumulating evidence
and data on these indicators for a very
long time now
but what does this these indicators mean
for having a uhc legislation itself
as you can see on the y-axis you have
the main
index value of each of these indicators
so
positive values indicate higher
23:44
governance and
negative values indicate lower
governance or lower achievement on
governance indicators
if you look at the countries which have
a uhc legislation
versus the ones which do not have a
legislation the ones that do have the
legislation have
high positive indices and all of these
indicators
right they are better with voice and
accountability with political stability
especially government effectiveness is
one of the highest governance indicators
for the countries which have a
legislation in place
the picture is exactly the opposite for
countries we do not have the legislation
24:14
in place
so it seems that governance after all is
important for simply having the uhc
legislation in place
but does that mean if you have a
legislation in place you're
automatically going to perform better
on these on the uhc index not
necessarily so to understand
that we look at the correlation between
each of these governance indicators
and uhc achievement itself you see there
is a strong positive relationship
between voice and accountability and
political stability
24:44
with uhc achievement itself so higher
the voice on accountability index
better your uhc achievement is the same
thing for political stability as well
you look at the other indicators you
will find the same thing government
effectiveness and regulatory quality
quality
very strongly positively correlated with
uhc achievement
in fact the slope of government
effectiveness is much stronger compared
to any other indicators
so government effectiveness really
matters you look at rule of law or you
look at control of corruption you will
find the same picture again
they're very strongly positively related
25:16
with uhc achievement so it seems
governance is really crucial to having
uhc
not only is it crucial to having a uhc
legislation in place
but it is also crucial to having actual
uhc coverage high coverage
then if you separate uh you know these
uh
the regression analysis basically that
we did to see what the impact of each of
these indicators is
on overall uh achievement
you see government effectiveness clearly
stands out it has a very strong
relationship compared to the other
25:47
indicators
followed by regulatory quality yeah
and then if you split the analysis by
looking into countries that have a uhc
legislation in place
versus that do not have a uhc
legislation in place
you see that the impact or the
relationship of
government in of these governance
indicators is much stronger for
countries that do not have a uhc
legislation
so governance actually matters even more
for those countries
that do not have a uhc legislation in
26:17
place so having a legislation does not
mean you're automatically going to have
high universal health coverage what is
really important
is these indicators of governance
whether you have good governance or not
yeah as dr biology already mentioned
we've had several
uh declarations in the past we've got
we've got the alamata declaration we've
got the asana declaration
uh today when i was watching the news in
the morning uh i saw that
there was a peace treaty signed in libya
to
to sort of stop ceasefire to stop firing
26:47
across the country
and again that's a declaration that
everyone is signed but then when the
citizens were interviewed
we noticed that the citizens were
worried and they said well we've signed
a lot of declarations in the past as
well
but nothing really has changed on the
ground so of course
declarations are important as we saw
having a uhc legislation is
important it does encourage countries to
perform better
but having good governance is equally
important improving government
effectiveness
improving regulatory quality is equally
important just by stating that we have a
27:18
uhc legislation
does not automatically mean governance
structures are in place
of course then you know since we know
all these things what are really the
obstacles then to uhc
i would like to think about it the other
way around what have we achieved over
the last couple of months
we've been thinking about covid as
something that has this disrupted
uh universal health coverage it has
disrupted health care systems and so on
if we flip the coin kovit has actually
made the case for universal health
coverage countries which
thought about not having universal
health coverage now think universal
27:50
health coverage is really important
right so we've seen countries really
making changes
at the speed of light recently whether
it is to do with civil participation
or digital solutions and public sector
innovation
remember we cannot achieve what we've
achieved in kobe without citizen
participation
we have lower levels of covid because
citizens have been following advisory
given by the government
they have been wearing masks and so on
of course there is always a small
minority which says that you know we're
not going to wear masks so we're not
going to
28:21
follow social distancing but this is a
minority and this is the flavor of
democracy
yeah there will be dissent but by and
large citizen
participation has been very important to
controlling kovaid
similarly digital sector innovations and
public sector innovations are very
important
we've come up with a bunch of tracing
apps we've come up with supermarket
tracing in some south asian countries
these are all innovations that happened
at a very short notice
the german government launched the
corona virus hackathon in which citizens
participated
there have been several regulatory
changes for instance pharmaceutical
28:52
trade has been
streamlined uh you know all these
regulatory changes
have been achieved at a fraction in a
fraction of a time that we wouldn't have
imagined
uh before corona uh several global
coalitions have been formed uh
astrazeneca's trial is being carried out
at the serum institute of india
so these coalitions are also increasing
uh rapid capacity management has been
happening for instance in india uh the
government planned to change 20 000
train compartments to isolation wards
for kovaid
um there have been other uh changes as
29:22
well in terms of hospitals
overnight you've seen you know hospital
beds and hospital capacity management
being changed there have been several
budgetary changes that have been
happening government have pledged more
and more governments have pledged
more and more money towards handling
kobed uh so
it's not like we cannot make these
changes happen you know we've seen them
happening over the last couple of months
so if there is political will if we
overcome this inertia that we have
and if we focus on good governance we
will definitely achieve
universal health coverage as well um all
we need
29:54
is to embed universal health coverage
legislation within country frameworks
and to make sure government governance
indicators not just the general
governance indicators that i showed
but also those specifically relating to
health are very important and countries
should focus on changing those
governance indicators
so that was my short and brief talk uh
and i will take on questions later on as
indicated by the moderator
thank you so much mujhay it was really
interesting
that you brought us the evidence about
30:25
how it works with the governments and
the universal health coverage
and that we got a clearer picture on
this how this
is spread across the world
i would like to go now for the next
speaker
who this is dr maripo keaney
um dr keaney is treasurer at santi
mondial
2013 she is currently director of
research at
nsand institute national de la sante de
la roche
medical in paris and also holds
30:56
positions as president of the board of
directors of medicines
pettit poop foundation and dndi drugs
for neglected diseases initiatives
dr kinney served as the assistant
director general for health systems
innovation at the world health
organization she also
directed the world health organization
initiative
for vaccine research from 2001 to 2010.
dr keaney had top research positions in
31:26
the public and private sectors in france
which included assistant scientific
director of transgene sa
from in the in the eighties years
and dr kinney received her phd in
microbiology biology
from the university of montpellier
and she has published over 350 articles
and reviews mainly in the areas of
infectious diseases
immunology vaccinology and health
systems
a very warm welcome to you marie paul
31:57
and we are very much looking forward to
your
thoughts about inclusion and integration
of healthcare system
please go ahead very much
so let me let me share the slides with
you just one second
okay so thank you very much it's a real
pleasure to have the opportunity to be
with you today and
and to actually share my my experience
with
on on health system strengthening when i
was at who
and and beyond and trying to bring
32:44
together actually
uh what i've learned in infectious
disease and
and and uhc and health systems so next
slide
so first sante mondial 20 30 201
the think tank who i'm representing here
was created in 2016 and it's discussing
many areas about global health
so it's an independent think tank
the the chair is jean francois del fresi
whom
many of you may know the the vice chair
33:14
is francoise barissino
the nobel prize and we try to to come
and
provide advice and comments on global
health
global health support also as well
as as how to advance with universal
health coverage and sustainable
development goals
so this is a slide that i was using when
i was at who
indeed we need to take a very integrated
view of universal health coverage and of
33:45
sdg free within the overall universal
healthcare
sustainable development goals framework
and if we have
achieved uhc we have we will have
impact on many of usdg 1
3 4 5 8 16
and going over reverse as was said
previously by the colleague of
unicef if we if we do not take attention
to these other sdg goals
then we won't achieve universal health
coverage that is the
34:17
the definition that we worked on uh in
2017 whether it was there which is about
all people but also communities having
access to needed health services of
sufficient quality
because otherwise would you want to have
it without the risk of being exposed to
financial hardship
so what do we see right now up back
back what it can do back
and show apologies it went
too quickly uh here
34:54
so but what we see and we see you know
even more
with with kovid is
that we have so many competing
priorities
so on the extreme right here you have
you have uhc which is part of a
commitment of of
the u.n member states and double issue
member states and this is a lot about
reinforcing and strengthening health
system at the same time you have all the
world of health security
who wants to uh to move towards
strengthening ihr capacity building
35:28
reinforcing resilience to crisis
now we see with uh with uh covet
response that we need to
to see how we will move in recovery
post-emergency this is a picture of
of a natural disaster but we've covered
it will be the same
how do we get better and resilient
system
at the same time we are also we still
are living in the world which is
inherited from the millennium
development goals which
generated all this vertical
36:00
initiative uh like the global fund uni
unite garvey the partnership for
maternal newborn
and child health so these are all very
good but they are all very vertical
so we have all these multiplicity of of
of priorities and if you see
all those of ihr recovery and the mdg
goals all of these are building their
programs on the premises
that they are existing and strong enough
36:33
health systems which is quite often not
the case
so how can we best integrate health
system strengthening intervention so
these are the
recommendations from a recent study that
our think tank
sante mondial vatrant head on the global
fund
and it's linked with uh with you with uh
health system strengthening
so there was an agreement that uh uh hss
is a good indicator of a global fund
strength and and also room for
improvement
37:03
and uh and the um in the conclusion
of a study which was financed by the ifd
agencies
proposed to strengthen four of the key
historical principles of the global
funds
to reposition the global fund as a
financial instrument
to have more respect for the country
driven
it is country who must decide what they
want to do
on their health programs have also
37:35
moving to a logic of
funding complementarity to that of all
other donors
instead of being standalone and an
imperative for more
uh inclusive participation
so i'm going the other direction so why
is this so important you can see indeed
that it that in order to to achieve
universal
health coverage you know for all these
goals that we discussed for resilience
for
for health security for universal health
38:07
coverage
you need to have put in place uh policy
which are pro-poor and equity policies
indeed matters so this is in slides that
sees the uh
the impact of the financial crisis in
2008 2012
in in in europe and you can see here
that the countries which had proposed
and equity policies actually had the
lowest
impact on uh on access to health
38:38
you can see them on the on the on the
left and you can see that the poorest
quintile actually didn't do didn't do
worse than than the richest quantile
but you can see that in terms of access
to care
there was a sharp drop in the countries
who did not have
in the second round in countries who
didn't have the right policies
and eve although these countries in the
middle
were able to preserve the the poorest
39:09
quantile
more or less whereas you can see that on
the right these countries who didn't
have where the weakest in terms of
pro-poor
and equity policies actually did the
worse
in term of preserving during a crisis
access of a poorest population to health
care
so uh what is my conclusion
i think that and this is also shared
with a
with something modial 2030 of course
we think that time has passed from
39:39
vertical silos
but now we all have to recognize that
health security
resilience universal health coverage all
need strong health systems and therefore
that
investment into strengthening them
should be everybody's responsibility
the people working on have security
cannot
presume that the health posts will have
electricity and water
if they do not contribute for to them
having
40:08
electricity and water it will not happen
cooperation on equal footing should
replace assistant
and truly country different driven
intervention should supersede
good intention thank you very much
thank you very much dr keaney for
bringing us
this really precise picture and about
how
important inclusion is and how
we still live inside us somehow
thank you very much and i would like to
40:45
go to the next speaker to
professor tulula oni
is a public health physician scientist
and urban
epidemiologist a clinical senior
research associate
and joint lead of the global public
health at the university of cambridge
msc epidemic i'm always striving with
all
struggling with this word epidemiology
unit and honorary
associate professor in public health at
the university of
41:18
cape town she holds a master's degree in
public health
at the university of cape town and a
research doctorate in clinical
epidemiology at imperial college in
london
she leads the research initiative for
city's health and
equity rich and she serves on several
advisory boards
including future earth and the african
academy of science open research
platform
she is on the editorial board of lancer
planetary health
41:49
citizen health and the journal of urban
health
she's a fellow of the african academy of
science
past co-chair on the of the global young
academy
and also on the 2015 next einstein
forum fellow and a
2019 world economic forum young
global leader professor only very
welcome
and the floor is huge thank you
thank you for the kind introduction
42:27
um it's a it's a pleasure to be here and
it's been really great
um listening to the other speakers so
far um i i've noted a few words that i
must say that i
it's been a really nice to hear in
discussions uh
around universal health coverage which i
i don't think are
spoken enough we've heard resilience
mentioned a couple of times
issue of governance um the sdgs and not
just the sdg
iii um non-vertical the importance of
42:59
non-vertical
systems the need for integration and
silos
unmet need this is just music to my ears
so
i'm coming at it from um i'm bringing
i'm bringing another sdg that hasn't
been mentioned so far specifically
um around sdg 11 around urbanization
because a lot of my work
um is primarily focused in the african
region which is one of the fastest
urbanizing regions which brings a lot of
advantages but also a lot of um
challenges to health and and forces us
to think um
43:29
long term so i'll be focused on on on
the systems approaches to uhc
and particularly on prevention
key messages so spoiler alert is the
first
is that there is the need for integrated
integrated care and i speak about that
in the context of epidemiol
epidemiological transition um um and
and even so even within health care
systems
we need to think more responsively for
uhc um
and the need for a new uh systems-based
approaches
to build prevention and control so
44:04
firstly we talk about
the reason i thought to highlight um
integrated
care firstly is was just to highlight
the issue
of within within the context of of of
curative and
and management of health care sector um
the silos of diseases that we have
whereas actually when we look at
how the patterns of diseases are
changing globally so this is a global
pattern
um from the 2018 world bank report where
we see
you know um the top of the top two are
44:35
uh what we traditionally call
non-communicable diseases and it's you
know the top ten and largely
um driven by by that approach but
actually when we break it down and when
we look at the different
across a different um uh categories of
of
of countries from low income to low
middle income to upper middle income
into high income
we actually do see this similar trend so
it's
you know contrary to the to the notion
that oh we see largely
non-chemical diseases in in in high
45:05
income countries and see just
infections and um under nutrition in
low-income countries we actually seen
this transition
um of um of the epidemiological
transition
really across the board why does this
matter well not only do they
co-exist but they inter interact so we
see here so this is a study we did
in south africa looking at how
infectious and non-communicable diseases
coexist um and we found a
quite a high prevalence of
45:36
multi-morbidity so from
one of the studies we looked at in in in
cape town where we looked at hiv tb
diabetes and hypertension
found that um really the most the most
common
um co-morbidity with hiv was not tb as
you think and
which is how health care systems are
structured but actually hypertension
and those are very siloed and that um
and the 20
of one in five had more than one
condition um
this was a study across the country um
south africa where we saw this
association between deprivation and
46:07
multi-morbidity
um actually in this study was both uh
association with socioeconomic
disadvantage
and living in an urban versus a rural
area
and um having obesity which um in south
africa
is is quite a a a highly common
um risk factor in disease with 40 of
women um being categorized as having
obesity
so the other reason why it matters and
this is uh this is really important is
that we're seeing this increasingly
46:38
younger ages
um on the african continent the median
age is 19
and this is often spoken about as a a
real dividend and an untapped potential
well if we're not protecting the health
of the younger population then we're
really missing a trick
in terms of the sustainable and
long-term development of the continent
and what we saw in the study was that
we're seeing multi-mobility
of these hypertension diabetes
coexisting with hiv at increasingly
younger ages so that's really concerning
47:10
and just an added sprinkle of complexity
as i mentioned with urbanization because
that's a broader context
within which um uh health is made
or or undermined um so what we're seeing
in many
rapidly urbanizing countries is this
pushing of boundaries of human
settlements which is disrupting ecology
and increasing the risk of emerging
infections we're seeing um overcrowding
and dense informal settlements
that facilitate transmission of both
infectious and non-communicable because
of
um the the environment and we're seeing
47:41
this increased vulnerability to disease
uh from the environment from inadequate
infrastructure
and and this exposure in younger people
and an inequitable access to care
so i just wanted to lay on that
particular um
context because when we're thinking
about addressing
um health um or
universal health coverage we we have to
think about that context
um the other reason um why is important
in terms of when we look at
apart from them coexisting is that these
diseases um
48:12
interact and i put this here just again
just to highlight the
importance of this life course approach
and to start thinking about prevention
and
and particularly in the younger ages
because we know that obviously they
your health and the younger at a younger
age um
influences um the health of the next
generation particularly
but not exclusively women which
determines future adult health
we also know that the risk factors
overlap so then we started thinking
about prevention
so we have this kind of siloed thinking
48:44
often when we think about
oh um infectious diseases we think about
certain risk factors or non-chemical
diseases not certain risk factors but
actually
if we look at um the um
socio-environmental risk factors
across these range of diseases we see
you see arrows going across from e from
both
both sides of the middle um of the
middle uh boxes
to indicate really that issues around
the food environment
blood pressure nutrition issues around
air pollution
49:13
um and and uh as access to um
uh safe uh supportive built environment
really critical across the board so i
hope i've just
laid the scene for why um we need the
spectrum
of of interventions um yes integrated
uh treatment and yes integrated
screening but also really critical to
to do more with upstream
and so the for the second bit of my of
my talk of last bit
i'm just talking about the systems for
49:44
health so this kind of more systems
based approach that um
and i will focus specifically on on um
on prevention
so why this rethink um well
it's a really important issue to
highlight the issue of of
timelines so when we when we're talking
about addressing
um disease and creation of health
um often the timelines are
short of medium and insufficiently long
so we think about how much it would cost
50:14
now and we don't think enough about the
inadvertent
cost to of ill health of the population
level
um and i just want to highlight here the
fallacy and i don't think
i think i'm in the choir here um the the
fact that we can't afford
to solely treat ourselves out of the of
any epidemic
so if i show if i um illustrate this
with an example again
um of south africa where you know where
space for a long time
um there was a study done um there by uh
50:45
by colleagues that showed that
if we look at primary health care
services
for cardiovascular disease alone so just
thinking about the
complex diseases of cardiovascular
diseases at the primary care level alone
if if those guidelines were followed by
up to about 80 of what they should be
that would bankrupt the health the
health budget
of an upper middle-income country so we
really can't
purely think about how you know really
important to
increase um expenditure in health care
51:17
because
a lot of countries are insufficiently
spending but the fallacy
that we can increase enough to catch up
um and solely focus on on treatment
is something that we really need to
think ourselves out of
um that so we really can't afford um to
think in the siloed way the focus is on
acute episodic
care i'm really laboring this point
because
when i actually um was publishing this
this
paper around this a couple of years ago
um the first
51:45
uh the first uh journal that i sent
two that was it bounced back from a
reviewer a comment from a peer reviewer
which
said well you know africa is dealing
with a lot of issues right now and can't
afford to think long term
yes so i mean just really it sounds like
we're saying something obvious but
there's also
in the ways that we're reacting and
thinking about health there are these
biases of
now um and discounting the future that
we really need to um
set us under because ultimately we know
that 80
52:19
at least of factors that influence
disease the risk of disease
lie outside of the health care sector
and if we know that then let's do
something about that
um and uh so so lastly talk about
addressing the systemic
drivers because i think is a critical
that universal health coverage
a key part of that is really looking at
those structural
issues that uh that drive preventable
ill health and so
this is a provocation we think about
systems for health which i
52:50
um dabble with because obviously when we
talk about it really is a health system
but
health system that term you know
conjures up a health care system
with the wh of building blocks etc which
are all very critical
and this is what we think about in terms
of
the healthcare system from prevention
to treatment right through to palliation
and the different exposures to whether
it's available or
affordable etc and ultimately um wanting
to reduce mortality and morbidity
53:21
but in the context of what i just
mentioned what if we thought differently
about what our health services and what
a health system is
what if we thought about habitation in
human settlements um
as a critical health system because we
know these exposures that are
this is just a selection and not
exhaustive really have a
a greater impact on on those in
intermediate
outcomes than than anything within the
health care system and fundamentally
driving
um this this epidemiological transition
what if you thought about transport as a
health system
53:51
what would governance for health and
universal health coverage look like what
would financing for health look like
what if we thought about water and waste
um what if we talk about what we thought
about food as an important critical
health system
and i i'm profoundly using the term that
we normally
reserve for um for the healthcare sector
because
i think we actually need to go beyond
just thinking about the healthcare
sector
interacting with those spaces and we
actually have to think about those
spaces
as systems for health because the
accountability for health
54:22
really does and has to lie in those
spaces and our financing for when we
think about health creation
has to align with what we know
so this was this is my attempt to
i don't even bother trying to follow it
but i just wanted to show if we for
example
will say well what would a covert system
for health look like in the context of
where we are now
in the context of understanding um
factors that inform
um that influence transmission in um
such as overcrowding and and and those
54:53
kind of exposure factors
in the context of what we know about
modifiable vulnerability factors which
speak to population health resilience
you can start to see you know healthcare
service
one of them but the arrows are the the
lines are pointing all sorts of
directions so if we were
if we were going to do it differently
and we knew covert was coming and we
wanted to build a system for health and
universal health coverage
that was um with a population that was
suitably
not um where we reduce the vulnerability
to disease and reduce transmission
55:23
we would have to be thinking very
differently and we've seen that very
different approach
playing out in the context of response
to
to covet so i'm really pleased to be
able to say a lot of the things that
we've time and time again been told is
not possible or
as challenging because we have to change
things slowly
a lot of that has happened very pretty
much overnight and thinking about uh
responding to covet so this is really
um provocation start thinking well if we
wanted to think differently about
integrated governance
55:53
we have to recognize that those risks
are interdependent
and maybe insufficiently also recognize
that often those systems are conflicting
so in in terms of pulling in opposite
directions on the impact on health
and how can we think about um integrated
governance
um in that context so we can come back
to that
if um in the discussion i just wanted to
highlight because in this image i i
talked i mentioned resilience here in
proactive and reactive
resilience i just want to mention the
56:24
point of resilience because i have a
a little bit of a love low thing with
that word sometimes because
obviously really critical but it's often
used and implemented in a reactive way
and i just wanted to highlight that um
certainly i think if we're thinking in
this upstream and integrated way we have
to confront the fact that
many of the factors that we're having to
be resilient against
are preventable and driven by
intentional choices
right they might be unintended
consequences but those intentional
choices
are driving the states the the systems
56:57
into increased exposure of vulnerability
to disease
so when we talk about increasing
resilience it's really critical that we
yes talking about resilience to the
current state but that we're actually
talking about shifting the system and
making the system
more resilient and less vulnerable in
this way by
addressing those those structural
factors that um that influences
structural choices
my last slide um just to highlight that
um some key ingredients and maybe some a
talking point and i
some of this has been spoken about
already in in taking the systems
57:28
approach
um one the critical importance of vision
and uh and and leadership uh so we've
talked about the sdgs already we have to
be thinking so this was written in the
context of of
the urban um they have to be if you
talk about the notion of a city what is
the vision for the city what is the city
trying to
to achieve so uhc is not just one little
thing that's separate
if the other interdependent risks are
actually conflicting against it so we
have to have this coordinated approach
obviously requires a lot of
57:59
intersectional collaboration that's been
spoken about
um performance indicators in in a lot of
the work that i've done looking at
integrating health and human settlements
one of the key barriers to
to aligning the goals are are differing
performance indicators
and so how do we actually think about
that and relatedly
the accountability um forum
for uh for health as part of our
measurement so
can we think about surveillance for
health for example in the concept of uhd
beyond disease surveillance because
that's that's what we don't
58:30
surveil health we surveil disease so how
can we think differently about that
and lastly really as a cut across point
of
focus on both preventive and uh curative
of reactive dimensions
of health and resilience so i'll end
there thank you
thank you professor oni for bringing and
for detailing
this big picture around all the issues
that we have
i particularly liked also that you
brought together what normally
is thought about differently
59:02
non-consumer diseases and infectious
diseases that there are no
so many difference in dealing with it or
in
and even to provoke them um
i had the understanding that you really
argue for a more healthy world overall
and this brings us certainly to the
planetary health approach right
so thank you for this so we will head
for the last speaker of our panel
discussion
um dr christina zurinson who will bring
in
59:32
the next aspect about the people that i
think
much is about people christina sirensen
is a health literacy trailblazer
knowledge broker and trusted advisor on
health literacy and global
health perspectives she is the founder
of the global health literacy academy
her educational background is in
medicine public health and global health
diplomacy
she has served universities
international organizations
companies and public authorities among
others the european commission the
01:00:04
european parliament
the european center of disease control
council of europe the world health
organization mckinsey
sirensen received the european health
award 2012
and the international health literacy
award in 2017.
um the other the ahla
global health literacy award in 2018
she is honorary professor of issue
university in kawasi young in taiwan
01:00:35
and she is currently president of the
international health literacy
association
executive chair of health literacy
europe
and chair of the danish health literacy
network she
is advisory board member positions in
various project
organizations worldwide such as bridge
for health
european health future forum helicopter
and editorial member for the journal
center literacy
research and practice christina please
go ahead
thank you thank you so much for this
01:01:08
nice introduction
and to all my colleagues here for really
setting the scene
for i think a reorientation of health in
the future
this is so exciting i'm learning so much
but i also
see that we are definitely thinking
along the same lines
um and and my talk today really is about
reorientation of of systems
based on health literacy um the world
health organization's three billion
gold calls for reorientation on how we
view health and how we organize our
01:01:39
societal efforts to maintain and promote
health
the three billion goal includes one
billion more
people to benefit from universal health
coverage and one billion more people
protected from health emergencies
and one billion more people enjoying
better health and well-being
and then i'm you know i'm wondering how
do we do this
when we know from our health literacy
research that one in three
two or two in three don't really get
the health information that we try to
01:02:10
provide to them
they don't they cannot find it they
cannot understand
the information we provide they don't
know if it's relevant for them
and they don't know how to apply it in
everyday life so
for me we have a really neglected public
health challenge that we need to
um to tackle and to manage and this is
resources from europe so where we do
think we have
really good educational systems good
welfare societies good health care
systems and still
01:02:40
we fail we don't match the needs of the
people
living their everyday lives and then we
still try to build
universal health coverage but how will
we eventually get there
so i think we need to if we want to get
there to invest in health
literacy of the individuals but also in
the way we design
our systems we need to include health as
a subject for example
in education in primary schools even
maybe in kindergarten
01:03:12
and when we have our systems approach we
really
need to incorporate people-centered
approaches and co-design strategies and
to a much wider degree than what we see
now
i'm also calling for reframing of health
as an
asset not just like a burden of disease
but really as an
asset as a resource as a capacity
where we move away from health care and
fixing
everything and fixing repair
instead of we should really focus on
01:03:44
nurturing
people's health um grounded in health
promotion
and and keep keep people healthy not
only just prioritizing how to cure their
their illnesses and in this way i really
echo
what my colleagues here said earlier
that we should change from a silo model
to what i call a stream model where
people benefit simultaneously from
health promotion disease prevention and
health care and health protection
health security not jumping by one
01:04:15
to the other so when you are a patient
in the
in hospital they will only you know
focus on curing the disease but they
forget to
to give you proper food or get the
exercise that you need so how can we
create a system where we actually
embrace health promotion prevention care
and protection at the same time and then
universal health coverage
entails that we are aware of our rights
and obligations
as citizens but this really requires
that we know our rights
01:04:47
and obligations and this is where health
education and health literacy come into
place
how can we do this if for example by
securing better education but also
better education of health staff
and staff in all this other sectors that
my colleagues have mentioned so
transport
urban health cities and
other areas where health is
really executed so where we live where
we love where we work where we shop
01:05:20
and we have seen now in the recent years
a rise in social mobilization
and bottom-up driven search for making
the wrong policies of governments right
because really access to health is a
human right and with
increased digitization of health we see
that health has actually been
democratized now
and knowledge is being democratized
which makes good health more access
accessible for citizens so we do see
groups who are actually now craving
and calling for for their rights and
this
01:05:51
again takes a better uh governance to
really
shape those rights and entitlements
and so we need a place where it's not
only about
living and surviving but also thriving
and the prevailing pandemic has really
shown us some
gaps and cracks and while we're waiting
for a biological vaccine we could
think about investing in health literacy
as a social vaccine
because this is crucial in the fight
against the virus
01:06:23
and we have seen going to asia that
countries with a common memory on
the sars they know how detrimental an
epidemic can be and many countries
actually invested in their security
systems
and were much more prepared now for this
emergency
and they also not only invested in
mosques
but also in health literacy in order to
act timely and
appropriately so we can learn very much
from them
to raise our levels in the future in the
future
01:06:54
lastly health nature re
health literacy saves money time and
cost
and it generates health empowerment
and capacity for individuals and
societies to take
responsibility for improving health for
all
it's a political choice but it is also
for me
a human calling a human imperative and
we need to respond adequately
to this call and this problem thank you
01:07:28
thank you very much dr sirensen
for reminding us the power of people in
the whole picture
um and well i mean
i was very amazed by your presentations
all over
um but i am a little bit sorry i mean
overwhelmed you said of course we have
to bring up
all the silos we have to break them up
we saw all the complexity
around health on every level
we saw a lot of initiatives that we have
01:07:59
to include
and we have to bring it up onto the very
basic sector to primary care
so i'm wondering we just also saw the
long-term
engagement the need of long-term
engagement and prevention and so on so
it seems really a huge huge endeavor
that we have in mind
and how can we make this happen in this
world
so this is my the first question
and i will try to open the discussion by
that do you
think that the digital transformation
01:08:31
which we all
will be experiencing will this
help us in all this endeavor or will
this more or less be a threat of it
so i'm just looking at my speakers if
someone of you would be ready to answer
this question
and then please one call to the audience
please place your questions
into the questions area beneath
um the screen please so that we can hear
what you want to
01:09:02
uh contribute to the discussion
so is there anybody who want to start
and argue around the digital
transformation how it comes
in to the picture about health in all
policies
about connecting all these different
aspects which are so important around
health
and i think if i if i may i think that
technology is very useful
but technology does not replace
governance it doesn't replace political
will it doesn't engage
01:09:35
it doesn't replace engaging with people
and community so
yes i think digital going digital has
has a value but it is not
a magic wand that suddenly uh systems
will be
uh will be strong and uh and universal
health coverage will be a real
reality
yeah if i may add i think
uh covet has shown that
the digital health can be leveraged for
01:10:09
a number of
innovative ways of acts communities
accessing care kenya for example
has been able to establish a digital
platform through which
they are able to be in touch with
pregnant women and those who are not
able to access services because of
various uh lockdown measures
are continuously in touch with the
service provider the health committee
01:10:41
health
providers and they are able to
determine if for whatever they are
having a particular problem
they need to go to a health provider or
not
thereby reducing the number of people
physically in an overstretched
health center and yet be able to target
their presence in a health facility at a
time when they need
01:11:10
so there is it goes back to what
christian
talked about there is a need for
education in the community and
also in the providers on how to
leverage newer technology
and digital technology to access
services when people need to and thereby
do it in a manner where it is safe
and beneficial to them maybe they can
01:11:41
increase the number of contacts through
these provisions
without really physically being
connected so
there is an opportunity to use it
but it needs to be done very carefully
as
dr mary pierre uh mentioned
thank you very much dr balaji there is
um
an endorsement for the statement of dr
king
in the in the questions area there is
sonia monsalva saying i agree with dr
kinney digitalization will improve
01:12:13
moving faster but will not replace the
analysis
and the use of data by stakeholders
particularly health providers
so professor oni is lifting her hand
please go ahead yes i think i agree with
the
comments that have been made so far i
think the other thing i would add that
has been
made very evident um again by the
pandemic
um is is inequitable access to
um to digital um technologies
01:12:46
uh and to the internet um and so in as
much as
i mean it's absolutely true
digitalization won't solve everything
um but also our approaches to equity
um we're thinking about um implementing
this
kind of intersectoral approach we have
to be thinking about um
access access to to data and access to
internet
actually as as critical for health um i
have an
uh an image that i didn't show today
when i talk about
that connection between the interaction
01:13:18
between human
um human health and the environment and
how that plays out in terms of
transmission
and i talk about transmission in the
context of transmission of disease
but also transmission of ideas and
transmission of communication
and actually if we think about it in
that context
you know we can't have equitable access
to care
without equitable access to information
and we see that in the context of covid
and how
you know you see really um really laid
01:13:50
bare
where there isn't as much um access both
in terms of
understanding what's happening but also
your ability to
to mitigate and to take um
to follow the instructions in terms of
sheltering in place etc
all of those things are influenced by
your ability to connect digitally
so i think just to highlight that
inequity inequity globally and so in the
context of intersectional governance for
health
i would say you know telecommunications
01:14:20
their health
they're health actors so we we ask or in
what role
what roles can that um sector play
in reducing health inequity thank you so
much
yes so i was uh just to add to what dr
owen said i was thinking along the same
lines actually because
there will be a lot of inequities which
may not be realized today
but they may be realized 20 years down
the line and i'm thinking about health
literacy in education
look at low income and middle-income
countries where more than half the
population doesn't even have good access
01:14:51
to the internet how will children study
when you do not study online when you
when you don't have basic internet
services
and there's going to be a huge divide
that we will observe probably 10 years
or 15 years down the line
in terms of just health knowledge or you
know whether it's economic outcomes
health outcomes education outcomes
and one of the reasons goes back to what
was mentioned earlier that
um we we work with political myopia here
politicians that make decisions today
are not going to make decisions 20 years
down the line or will not even be held
accountable for these decisions
so i think that's a strong problem that
01:15:22
we face today so of course uh
digitalization is important but it's not
a magic
one and i would agree with that
statement thank you christina
you raised your hand as well i think we
have to be careful not to be too naive
we saw that there are commercial
determinants commercial stakeholders
that have access to data which is far
beyond what we have
as governmental stakeholders and health
system stakeholders
so i learned you know from this
television series or documentary about
01:15:53
cambridge analytics that they had 8 000
data entries on each user on
social media on facebook you know and i
have my questionnaire on health literacy
which is
quite comprehensive with about 47 items
on health literacy and people complain
that it's too comprehensive
but what can i get out of my 47 items
when they have 8 000 or even more so
no wonder that they can tailor their
information
to you know and create fake news that
are just tailored to people's
01:16:24
interests and and not necessarily needs
so
so my question here would be you know
how can we
as governmental stakeholders healthcare
system stakeholders
overcome this gap of information that
there are other people in society that
have much more information
and with that you know intentions might
manipulate or trick human colleagues to
to to do choices they we would not
necessarily see as the most
timely and appropriate choices so we
01:16:57
should not be naive
thank you christina i'm looking at we
have a couple of questions now in the in
the questions room from our audience
and just uh we'll start with the first
one from san diego
we have seen in dr shike's slides that
some countries that have
high universal health coverage levels
are also known to have a lot of
inequality in terms of health care
access
how can governance support to decrease
inequality in access to health care
01:17:26
and mainly primary health care
yes thank you very much uh for the
question i think what we often
uh think about universal health coverage
when we think about it we think about
access
and then we see inequities or
inequalities and health outcomes
we have to remember and understand that
access does not mean utilization you
can't provide access but that doesn't
mean that the population will be able to
utilize the services
there are several other reasons why
despite having access the population
might still not
utilize uh healthcare services and that
01:18:00
itself leads to a lot of
inequalities so for instance one of the
uh one of the things that wh recommends
as a goal of the health system
is health system responsiveness so
treating uh
for instance patients with respect and
dignity uh client orientation
confidentiality uh prompt uh services
and access to quality services
these are all sort of in a way
non-medical dimensions
of of health and these are often
overlooked
in many countries uh well in one of my
papers we look at
01:18:30
how uh the caste system in india is
responsible for leading to this inequity
and utilization simply because
uh doctors and nurses do not speak
properly with patients
patients hesitate in even using those
services despite having access to those
services
so we need to put in mechanisms
governance mechanisms and mechanisms in
place
that target responsiveness of health
systems we need to hold
providers accountable for the
non-medical determinants uh which
actually lead to utilization so i think
that's very important
yes thank you mujhy it is an interesting
01:19:00
point to look at this like in that way
we have another question from sorry did
i
yeah yeah i just wanted to add that
part of governance also includes
being able to look at indicators and
information
in a more disaggregated way by provinces
by districts
uh by different sub-populations
the wealthy the wealth quintiles by
gender
and so on and try and identify
01:19:30
the uh
the communities and the population
groups as well as geographic entities
where there is enough in inequities and
then
proactively look at the barriers and
bottlenecks that can be
overcome to be able to access to
to be able to provide universal health
coverage so
governance is about looking not at
national averages but also looking at
disaggregated data
and that is where again having people
01:20:04
being a part of the government system
public accountability systems also
brings in a a fair amount of solutions
over thank you very much
um we have a question from david
hipgrave
saying in many countries upwards to 60
percent
of the is out of pocket many have
watered with their feet away from public
facilities they view as
unsafe how does the panel see the future
of effective
01:20:35
for effective and affordable public
private partnership
as a foundation for universal health
coverage
so who wants to answer this question i
may start
if you wish yes i think this this is
again uh
and mujahid said so this is this is a
question of governance
uh and and when
health systems are unsafe it's because
they are left to be under-resourced
because we
leave a situation of corruption uh
01:21:07
and and this generates uh anxiety and
and and fear actually of wrongdoing
in in in health systems and
so so therefore again i think uh
restoring a proper governance giving a
voice of
to citizens so that they can say what
they want from health systems
it will be critical to uh to to move
forward on
on on this over
thank you marie paul would you hate yeah
01:21:41
i'd just like to quickly
uh add to that thank you so i agree with
christina in fact i
i think i recently heard somewhere or it
just came off to me with that
responsibility without resources is like
poetry
or it's it's basically fiction you know
you can assign responsibility to
uh to all the structures and the people
involved but without giving them
adequate resources
you can't really achieve much uh or
going back to you know
the case of public private partnerships
for instance i think when we look at the
sdgs
i i personally believe that we we will
not be able to achieve
01:22:12
uh those without getting the private
sector on board with us without reaching
an agreement with the private sector or
somehow collaborating with the private
sector i think that is so
essential to achieving sdgs because
that's where a lot of jobs are
generated if we're talking about uh you
know having decent jobs for people if
we're talking about
um having safe water having safe
sanitation uh
if we're talking about you know better
food and so on so i think
engaging with the private sector is
absolutely essential
the question the governance question
then is of regulation how do we regulate
01:22:44
what we are doing with the private
sector i think that's
uh that's where the governance aspect of
it comes into play
professor uni
i want to make a tangential point to
that which is important
because the the question was around
talked about
public voting with a feat and what i
heard from that
is is is the the importance of the
demand
side of of things right and
you know we we spoke earlier about you
01:23:16
know
politics being very short term and not
thinking long term
and i i do think that speaking up on
um professor sorenson's point earlier
about
health literacy we have an opportunity
oh
excuse me that timing um
okay sorry about that um we do have an
opportunity when we think about health
literacy and perhaps to some
extent we also are guilty of focusing on
01:23:52
the immediate when we talk about health
literacy so
i mean i should we be asking in addition
to
thinking about um talking about the role
that the public play and kind of voting
with their feet
can we actually increase the demand for
healthy environments can we actually
increase the demand
for intersexual accountability for
health um and can we tailor
when we think when we talk about health
literacy can we tailor our health
literacy
01:24:21
not just to the needs of today um but
actually uh for to create a more health
literate population that's saying
you know i can see how the air i'm
breathing now
is impacting my child's health of
tomorrow and i actually demand health
from the sector that is that is driving
that health
that health pollution so that if we
don't have a political
long-term thinking we're actually
driving increased demand
for for long-term thinking about place
and i think that's something that has to
be deliberate
01:24:53
um and perhaps we don't sufficiently
focus on on thinking about strategies to
increase
the demand side of things for healthy
places
and healthy environments as a critical
part of of
of one's health and the health of one's
community
thank you there might be another
question for you from the audience
a sign up for rookie is asking is
resilience a multi-sectoral concept is
it achievable with cross-sectoral
planning
do you want to answer on this one
yes and yes um
01:25:32
i mean the issue about resilience is
that
um you're right it's absolutely
something it shows that
especially if we're doing if we're doing
thinking about it from a proactive
perspective and we're thinking about
what are the factors what are the
factors um that make us more resilient
to to today's system and what are the
factors that
that are forcing us to need to be more
resilient if you see what i mean
because in a sense you we want to be
driving both increased resilience today
01:26:03
but also reducing the need to be so
resilient
if you see what i mean in as much as
when we talk about health care
we we're both talking about increasing
um or
reducing unmet need for health care but
we're also talking about
reducing the need for healthcare
altogether
because health cannot just be about
healthcare need
we have to be driving we we're actually
saying there's some inevitability sure
but there's
quite a lot of need that is preventable
and so how do we actually
01:26:36
reduce that need and not just focusing
on reducing
the the um unmet health care need
so i think absolutely it has to be
multisectoral and if you
we're thinking of the sexually i hope
then we're thinking um
in that upstream way and planning is an
important um
side of of things because when we're
talking about governance it really is
not just about
what everyone doing what they're doing
normally anyway and bringing it together
in the end
but actually starting from an outcomes
01:27:06
basis to say
um i think professor sorenson mentioned
to thriving a thriving society everybody
talks about
you know any city town country talks
about
a thriving population if that is the
goal
then let's talk about what the
indicators of that would be and let's
talk about
how every single sector is
is contributing to that indicator
because if we're not doing that if we're
not you know
as i mentioned health doesn't trickle
down from good intentions we will have a
situation where the health care sector
01:27:38
is doing their best maybe one or two
others but you have other sectors that
are actively undermining health
so we have to think in this kind of
cross-sectional approach um
to really tackle our resilience
particularly proactively
thank you very much professor oli i
think we have to come to an end the
the point is that we have still a couple
of questions open and i'm just looking
to the support team right now
if we have the possibility that we can
tell people
to connect right away to the speakers
01:28:10
and send them an email with a question
they still have
openly i think this could be possible
right maybe you can give an answer on
this one
no support is silent but this is what i
would like to recommend
um for the for the people who have the
still on their own questions please go
ahead and send an email to the speakers
and they can answer you right away i
would like to thank the whole group very
very much for
01:28:41
really these amazing inputs it was
really really
very interesting overwhelming sometimes
but because i mean the challenge is
really really huge it is indeed but i
think
if we can put element by element um
we go there step by step and this is the
hope that we have
i wish you every good sunday around the
world wherever you are
and yes stay healthy and take care
bye and thank you very much thank you dr
01:29:13
barnett
thanks everyone thank you