WS 03 - Universal Health Coverage - World Health Summit 2020 / HealthChoice

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

WS 03 - Universal Health Coverage - World Health Summit 2020

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