The UN High-Level Meeting on Universal Health Coverage: What Happened? / HealthChoice

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okay good afternoon welcome to CSIS good afternoon to those assembled here and those that are online watching us I know you're all eager to get to the Nationals Dodgers game at 8:45 so we're going to get you out of here on time for that I'm Steve Morris and I'm a senior vice president here on director our global health policy work this session is the high-level meeting on universal health coverage what happened special thanks to my colleague Samantha

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Stroman for engineering today's events special thanks to two Jeffster Chia from president CEO of Raymond Martin he's a long-standing close friend and supporter of CSIS he's a senior non-resident senior associate with us has been extremely generous over the years in his contributions to our work he's a member of our of our CSIS Commission on strengthening America's health security is a very visible and activist convener of private sector interest across the

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spectrum of health issues in a many different fora and has been deeply involved in the early consultations that led up to the high-level meeting in New York we're also using this occasion to spotlight a book that he co-edited with Elena with Ilona kick bush and Lois galambos the road to universal health coverage and we also have with us today Cecily Thomas one of the authors of one of the chapters we have jeff has kindly

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arranged for those of you who are here to take copies after the event so they'll be on a table outside and there's also they don't care to carry and copy around there's a little little card you can put in your pocket that has all the information on this so thank you so much Jeff and congratulations on the publication of that this is the second volume that I'm aware of edited collections looking at this topic right we did a roll out two years ago well that was that was non communicable

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diseases that was the NCD well blending all blends together we have where special thanks to Ranieri Guerra who's with us today he's the assistant secretary-general for strategic initiatives at WH o was tasked several months back by dr. tad rose to take the lead to take the lead of pulling the pieces together and we'll hear more about how that process unfolded and he

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kindly agreed to be with us this afternoon to share his insights into what happened what's the meaning of this what lies ahead and so special Craig congratulations to him to dr. Todd rose to our other friends at WH o Peter Salam and others who put in enormous amount of work we're joined today also by an Amanda Glassman executive VP and senior fellow at the at CJD the Center for Global Development she too has been carefully tracking and and commenting in

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her blog on the preparations and she like jeff attended the the high-level meeting all three were there this high-level meeting follows several previous ones there's been a surge of them in recent years the most the the first was of course HIV in 2001 which was very dramatic highly impactful and has become part of a sort of historical a milestone in the legacy and history of the International response around HIV some of the more recent ones that have

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been clustered have raised all sorts of additional issues around the import of the event itself and and what the downstream impacts are and and and they've occurred in much more complicated and and more difficult to interpret situations so we'll be talking about these but I want to offer just a few quick remarks before I turn to two Ranieri to kick things off with his sort of overview of what happened and then we'll hear from Amanda and and Jeff for their

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opening thoughts but just a few quick quick comments please this high-level meeting like the others marked a big moment it's signaled the graduation of these issues into the political domain they're being brought to consideration among the assembled heads of state they are blessed by the secretary-general and embraced these events so it is a big moment by definition and I would argue

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in some respects it's even bigger this one stands out in a couple of respects and we'll hear more from Ranieri on that it's very integral to the vision that dr. Tadros has laid out which is a highly ambitious and a five-year strategic plan calling for the three billions achieving the three billions it's tied very deeply to the sustainable development goals as we'll talk about the asks that are contained in the

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declaration and in the affiliated remarks are eye-popping there's a declaration a consensus statement that's an amalgam and set some milestones but you know this because this is calling for 1 billion people to be provided with quality services and affordable medicines by 2023 and 2 billion by 2030 those are those are big asks it does place primary health care

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at the very center of the discussion in the stage a very dramatic and very important moment calling for a doubling of coverage the price tag is eye-popping three point nine trillion dollars by 2030 and additional resources it put a special focus on tackling the shortfall in health workers 18 million s made it calls for 40 million positions to be created those are just a few of the examples of the things that marked

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this is particularly dramatic and ambitious now the debate can be where does it cross the line from being bold and and catalytic versus being a lunar and you know that's part of the debate around what do these things mean we had embedded within this and on the sidelines big controversies appear the most notable and the one that got the greatest press was around reproductive rights and it became very public and very confrontational that confrontation

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ultimately did not derail the creation of the unanimous consensus declaration fortunately thanks to Renier ease expert diplomacy but we nonetheless that confrontation was very visible out there in the statement that the u.s. aligned itself with and the other 18 states that included DRC Iraq Russia Saudi Arabia United Arab Emirates Yemen hungry in Egypt 19 states 1.3 billion people a

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coalition that encompasses all of those states and in secretary as our statement the fundamental argument was urging world leaders to expand access to health care but without using expressions such as reproductive rights and health such an biggest big ewis terms can quote undermine the critical role of the family and promote practices like abortion and circumstances that do not enjoy international consensus and can which can be misinterpreted by human agencies on the other side of the fence

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was the statement that was led by the Dutch Minister Sigrid COG 58 countries lining up around an imposing statement that was verily a reaffirmation of them of the much more familiar and liberal concept of women's rights gender equality of emerging sexual and reproductive health rights over the last few decades there was a concrete call

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for in this for to to reduce the out-of-pocket costs towards those by bringing the investments up to nine dollars per capita in order to do that we also saw some sharp statements made by Jeffrey Sachs by winning be anima ahead of of Oxfam international soon to be UN aids Jeff Sachs from from Columbia

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University these were these were fairly radical statements in terms of saying well the solution to the gap the finance gap is to tax or convince the fifteen richest billionaires to come to the rescue or to nationalize Pharma or to engage in in massive tax schemes there's always tensions the last closing remark and we'll hear more from Jeff there's always tensions between the private sector and the public health advocates now this was no exception I

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think some of what's contained in this declaration is pretty standard reflection of a kind of continued unresolved debate around that there were many positives to come out of this we'll hear from our speakers I mentioned primary health care being put at center stage we had the appearance by the New World Bank chief Malpass great attention on the margin there to the a.m. are several key state leaders stepping forward and saying very important things there were a couple of new initiatives a

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Rockefeller Foundation announcement of a hundred million towards a data initiative the coalition of foundations and states putting twenty nine million towards dr. Moretti at afro which was a very positive powerful signal of confidence and support to her and afro in moving this agenda for those are just a few elements so Thank You Ranieri Amanda Jeff for being with us Ranieri let's just say in advance we knew they'll have to exit but somewhere in - 15 - 30 something around there so

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in advance if he gets up and walks out it's not because any of us said anything we'll carry on a little maybe so and we'll go a little bit beyond that so Ranieri thank you so much the floors - you tell us what happened okay thank you very much and good afternoon to you all it's a good opportunity to remember what happened because I've been trying for the past few days to forget it's been a

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nightmare lasting for the porter negotiation as you may know as being extremely tough we had some 15 16 iterations with all my mistakes or omissions in New York silence procedure was adopted by the PGA the president of the General Assembly three times it was broken all three times by two countries focusing very much on the sexual reproductive health and rights as well

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as some migrants health which were the two big controversial areas in the Declaration luckily we managed to persuade them not to not to destroy the entire process and to block the declaration but in the end the correction was adopted but as as you heard they disassociated themselves during the during the general discussion do you enjoy a debate when this big hug was sorry was given the there is a big

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difference between this declaration is high-level meeting and what followed and all the others including you may know that the same day we had a climate summit that was going on 25 meters far from the blocks that we use for the high-level meeting see the difference is that this was a member state managed conference and declaration which means that commitments

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are binding and that's why the Declaration of the process of generating the declaration and those commitments has been so difficult and so tough because heads of state prime ministers as a government those would declare - stated their support for the declaration we're taking a commitment in front of the world the SDG the summit the climate summit meeting has been called by the secretary-general so it's basically

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binding in the UN system not the Member States member states can sign in or specific areas or work on specific issues that are may like or may not like depending on their attitude and their political environment but the high-level meeting on UHC is binding so in other words we can expect to see something now being implemented by all the Member States because they took that commitment and if you look at the decoration yes I

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mean it's long you will recognize several several agreed language pieces because the process was not really to create anything new it was to rather to identify in the different steps eras over previous declaration a grid language somewhere by someone something that would fit everyone's expectations and potential agreements and support so

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the difficulty has been to find references to everything that is included there which is not exactly you had seen the classical sense of the work is mainly global health everything that relates to health and that system performance access to services but also quality services the rephrasing of the primary health care concept you know very well that primary health care after Mohamed Atta's being mass a real fella is probably the worst

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failure of the health workforce and the political supporters of health in that sense because no qualities we insure the false concept mean that primary health care is for the pores where I was all to reach a should have access to different kinds of service provision with different quality with different control and with different remuneration for providers so the the Istana declaration last year that opened the doors for this

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declaration in New York is indeed something that aims at revitalizing the primary health care concept saying that the system methods and the system is organized on the first level of care which is primary care where where we have a concentration of different aspects that belong to public health in the general sense of the word to prevention to health promotion and others which are at the core of the entire system perspective not at the

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core of investments though because I want to open the door for debate and this because we predicates substantially and continuously that prevention prevention prevention methods but we are not investing seriously in production if you look at the way countries garments invest health is still in the best the best case you get fifty percent that goes to the hospital level you get forty

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forty five percent that goes to GPS primary care and you get systematically less than five percent that goes to public health and prevention and this is not serious because prevention is is highly effective but it's not cheap it calls for money for investments it goes for systematic investment by your garments into something that matters more especially now that we are getting into the difficult ocean of ensign where prevention is probably the first

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and the Apple's the main the main tool we have to mitigate massive expenditure and investment just in treatment in clinical care for four ten three days just to give you an example coming from my my own country the new treatment for cancer the immunotherapy for cancer which cost anything between five to eight thousand dollars per person per year is going to destroy the overall budget in less than ten years simply

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because it is highly effective people who are diagnosed the cancer used to die within 24 months since diagnosis with traditional treatments with a new treatment the life expectancy is 15 years or more which means that unless we close the tab there will be accumulation of cases for the last few years hundred fifty thousand cases of cancer in my country every year which means three hundred thousand next year after median that I'm in two years and so and so

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forth for 50 years and you can understand that providing care to these people who do not die we cost an enormous amount of my unless we change the way we work and this has been clearly stated by the declaration Sarah in several areas overall we had 83 countries Member States 193 that signed in every 183 member states who to the floor and made the statement under a

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forty requested the floor 30 heads of state and as a government which is a record for these kind of declarations very well said health is now graduating as a huge relevant political issue and gain was in fact to move health from the technicalities of the discussion in Geneva at the world assembly into something which is of the highest political level in new

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the question was why do you want to move health from Geneva to New York and the answer is that because New York is where the political commitments come Geneva is ministers of health we work about friends but we don't work among friends with ministers of finance and prime ministers and their government that's a fight as you as you well know the the two countries that disassociated of the US and endocrine basically but you know

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that it didn't block the decoration which means that out of the 80 far grass that the declaration is composed having having controversial issues on just two points doesn't mean much because garments as we know can change their attitudes and political atmosphere a political scenario can be can be can can move from one side to the other at any at any goal change at any political election the the logic that we try to

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present the word was with the us see the universe' care coverage report that we generated and the word that was lost the day before the high level meeting that identified the gaps saying for instance that 3.7 billion people we still lack services they need which means 44 percent of the population if we do not change pace over now will not be served accordingly in 2030 which

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is the deadline for the SDG it means that basically a for the world population will be we stay out is not leaving someone behind is leaving after the world population behind which is unacceptable it means that 930 million people are currently facing catastrophic ad spending which is net increased from the 800 million in 2010 and this is mainly due to other pockets payment for accessing ad services

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des no story prefer story is his friend giving up treatments which were expensive for his cancer because they didn't want to destroy the future of his own children using the money that was set aside for their studies in the future and he died of course the the commitments around four major areas financing high-impact services within the primary healthcare new revolution if

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you wish a strong work force it has been said that today we are short of 18 million medical doctors nurses and other and other health workers these 80 millions unless we change will become 40 millions by 2030 there is no way we can provide services of the right quality unless we have the workforce that we need which means trained competent capable deployed where they are needed

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with a reasonable salary to survive and to perform with the kind of accountability that governments may provide with the kind of participation and partnership that the private sector can can agree upon one point raised was the the issue of additional financing these are being reorienting the trans financing health costs around the world

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some up to 10 percent of the global GDP 10 percent of the global GDP invested in health is an awful lot of money we can do much better we can generate quality we can generate value for this invest which is not the case now think for instance that I mean this country is a unique is an example of how investments and money can be wasted if you wish

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close to 20 percent of GDP is is an outlier compared to all the other countries in the world in my country we invest 9.5 percent of GDP in health which means 6.7 percent of the government expenditure public expenditure that that goes in providing services of a good quality over ISM of course you know the bloomberg assesses the capacity and the performance of health systems around the world every

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year and we run more or less first second third whatever which means that with with less than 10% you can achieve a lot you can provide services to the entire population if you are serious about distributing the money in a reasonable way if you are serious about investing the money where it's needed the current movement of value for for services is is indeed aiming at that so we will see something new I guess in the

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last few years however there is a shortage of money especially in in low and middle income countries we estimate that we need another 371 million billion dollars in annual spending to achieve USC by 2030 as the SDG Global Initiative prescribes the current expenditure to give you the absolute number is seven point five trillion dollars per year so it's not a huge amount of money which is

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missing the the justification for the political declaration was given with these numbers then we had political declaration that leaders to cast as a commitment to change the pace to change the way we operate globally then the next day we provided with two options to opportunities the USC partnership which is a program that whu-oh facilitates rather than manages

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with a number of donors and with more than hundred countries enrolled to receive catalytic funding not extensive funding not replacing domestic resources which is the key for progress and the key for achieving the SDGs domestic resource is mobilization meeting for instance the Abuja declaration for African countries that said that 15 percent of government Spenser invested in health was the target met by two countries in the African continent

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not exactly the research Tanzania donado and Ghana so it's it shows it can be done it can be done that way but there are countries that are in turmoil there are countries where the situation is so weak the system is so weak that they will need support DRC is one definitely Yemen Syria in all the countries that you know very well arena in a kind of extremely difficult situation or which

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which have no government or extremely weak government Somalia and others the one critical point raised was the collaboration with the private sector which is critical I mean we all want to have a proper partnership and balanced collaboration but we also need a regulatory framework otherwise we cannot achieve that and trusting each other building a mutual trust means having a regulatory framework which is usually

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agreed that sets the rules for the game the rules for the game for the government for the public sector the rules of the game for the private sector as well because we need that otherwise we can create challenges which are an accessory the takeaways of the declaration that obviously development and prosperity depends on a healthy population which is crystal clear it is the first time which is written and carved in stone in a way you would

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see is the key driver for social justice the point we raised is that no health system is perfect no country even the researched is perfect we still have 20 25 15 percent of population which is not accessing services which has to be reached out in a different way which has which has to be provided different opportunities to access health services and these odd services must be proactively proposed not passively managed or administered the way we are

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used to going quickly governance is another issue that we raised and we where we concentrate a few issues governance is a key challenge because several health system are fully decentralized to the lower level which means sub-national or local municipalities and this is an opportunity by the problem at the same time because we don't we lose control of the quality of services or the

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standardized possibility of of accessing the service quality that we need and that changes depending very much on the local administrators the challenge is that we tend to risk a huge fragmentation of the way we provide services and we stimulate internal migration of people trying to access those services which are provided with her with the perceived quality that they need and of course we have technology

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technology is there and as as guns they may be dangerous they may be of course the kind of innovation that we need a lot of researchers need an implementational research is the key to understand what works what doesn't work but we also need to invest massively in understanding how digital technologies change the entire sector how big data generation and management has to be secured in a regulated way how the omec

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Sciences are currently changing into a panorama services and that and how will how the parameter will be changes in the next five to six years because if we are serious about that we need to train our daughters today for what we laughing in five six is time which is sometimes unpredictable buts and sometimes quite easily pretty predictable but if you look at the academia the way they train our future doctors is is not exactly

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with based or informed by the vision of what will be the system in five to six years when they come out and they become professionals and obviously the big issue the big current issue is gender equality is the the capacity of system to provide the legal framework that facilitates the the delivery of our services final points you'd see is a

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political choice it's definitely political choice and this is the reason why we move to New York as well as well as why the inter-parliamentary Union in two weeks from now we'll take a similar resolution on USC which may sound strange the inter-parliamentary Union is the union of parliamentarians worldwide they will meet in by great on a 16th of this month and they will take resolution speaking about UHC and how the legal determinants

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of health can be put into the big picture how the first legislative power in the countries can keep government's accountable based on the declaration that they with which they committed do something and this something has to be measured cause we we we also provide some issues some suggestions to countries on

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taxation for instance which is targeted taxation on some products like luxury tobacco and a few others to me it's a nonsense because I said in my country the estimate is that fiscal revenues from tobacco selling for the government for the Ministry of economics in the range of eleven twelve billion euros per year what we spend from the ad sector in treating conditions of coarsely due to

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the tobacco consumption of asperities in the range of twenty three twenty five billion euros per year so if we want to make a financial case we have a strong habit as that it doesn't work that way of course we talked in the declaration about specific population groups like women girls but also for the first time in a structured way about a dollar sense the children of yesterday ND and also tomorrow you are in the in a sort of

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transition age by which no one really looks at them in the in the proper way a dollar signs are those that are at risk of starting consuming drugs opioids you have a major outbreak of opiates in this country we do at the same Europe as as you know it's probably the the worst possible scenario for the future these people will will be brainwashed in a month they will become violent I mean

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the old the old story I don't need to spend time [ __ ] we also presented the so called as the g3 global action plan which is what the UN system can provide in support of the country is in technical financial systems assistance with the so called accelerators 12 agencies are trying to merge their capacities at a country level providing services in an integrated way without competition

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competing with each other without overlapping rather working together which is an incredibly difficult challenge and task because these are agencies that are used to work in a totally different way and to compete for resources and to compete for political visibility in the country these accelerators are primary health care set sustainable financing for health community and civil society engagements determinants of health

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innovative programming fragile vulnerable settings for disease outbreak responses research and development innovation and access and finally data and digital health on the data this is not trivial data is crucial because it's by disagree gating properly data collection that we can understand what happens especially to those groups that may be minority groups and may not come into the big discussion of priority setting things would think for instance

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of migrants the only two countries that collect disaggregated disaggregated data which are migrant sensitive in the world are Serbia for some reasons and Switzerland for obvious reasons and that's it so the central statistic office in the UN in New York has finally agreed to provide instructions and a template for member states to collect the data at the level of this aggregation that we need without data

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you are not existing you do not exist for the system without data we do not know where we need to pump resources that make sense without data we do not know what what kind of priorities or what kind of situation we are trying to change for the best and we are not we will not know whether we are successful or not and this is fundamental we will try to minimize the number of reports and the final paragraph in the declaration says

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very clearly that we are not going to organize other specific health related conferences meetings at the Younger next year until 2023 so health will stay we go back to Geneva it's now protected by the political leaders and I put by the political declaration we are not going to report back until 2023 when we will have another high-level meeting dealing on dealing with results this time where

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leaders will come to New York to the Unga and will show what they have achieved obviously we are we are framing we are drafting a accountability framework that we like that thank you very much now we're gonna ask Amanda and Jeff to offer some quick remarks on their perceptions on what happened and then we're gonna have a conversation around some of the issues that grow out of all of this and then we'll eventually turn to you all to hear from you all so

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Amanda give us your quick five minutes on what happened okay well I was glad that you ended with the idea of an accountability framework and accountability for outcomes because that's obviously the big piece that was left unclear from the declaration that came out of the high-level meeting I think what is clear are the outcomes from universal health coverage that articulated in the declaration but with it even though we can all agree that essential services are important and decreasing impoverishing out-of-pocket spending is also important the question

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of what those contain is not fully defined between the various agencies that are involved in this discussion I think in the end I'm not sure if the one of the billions that was on essential health services related to UHC was adopted by the World Bank in the WHL fully or not and how maybe you can tell us about that later but you know what is inside that package of essential services that would be measured as defined as part of UHC is is one big

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issue that needs to be clear I think in the public domain and then on out-of-pocket spending everyone can agree on the idea the only problem is that historically when we look at how low-income countries become middle-income countries they actually spend more out-of-pocket if we just do projections of what we know about what would happen with domestic revenue mobilization and growth in some of these countries going ahead we expect that middle-income will be you know 70 to 80 percent out-of-pocket for the next decade and I think that is the big issue is it true that government can capture

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and revert what has happened historically in many middle-income countries and capture that big out-of-pocket set of money I mean I certainly think they there's lots that we could do differently but I think the timeline to getting to financing that is pooled by the public ex ante is probably optimistic so that is something you know we I think everyone agrees on the aspiration but the question is really what is realistic between now and 2030 and in three years what would we hope to

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see we might see people spend more out-of-pocket and that would actually be good news because they're seeking care for the first time you know when you look at household survey data you see poor people don't spend at all many times so that's just something to think about as we go forward well the other big issue of course is the competing demands within the health sector and you talked about this as well that you know most countries have exactly the opposite perhaps of the shares that go to primary health care versus tertiary care and reverting that

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trend you know away from 70 percent urban tertiary to end and more towards rural primary healthcare and things like that really takes a force of will so watching that process and how governments manage that process I think would be an important part of the follow-up to this I think there are some countries that are definitely going to move and that will matter for global health if we were looking at global figures those countries are China and India and Indonesia that have these massive schemes that are spending much

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more year on year many times inefficiently but are beginning to take measures to make their spend more efficient we would likely see outcomes on that so maybe it will look very good in three years on the back of those big middle-income but that sort of begs the question what does it matter for global health if it's you know if what we'll see in three years is really going to be about those three big upper middle-income you know what does it mean the SDG three action plan how will the

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vertical funding streams really play out visa visa primary healthcare their pros and cons of integrating verticals into primary health care and primary healthcare payment mechanisms and I feel as a community we've really just begun to that conversation and what does that mean practically at the country level I think what we see you know a country like Kenya for example which started a National Health Insurance Fund is that they want to cover dialysis and they want to cover childhood cancer and that is completely legitimate but that is

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very different from primary health care and that dialysis budget on its own can eat half of your budget that's available that you have at hand and so I think these are real pressures and their pressures that are facing countries like Rwanda you know the countries that are high performers on primary health care but they are under pressure now to provide those basic services so I think it's a it will be an interesting decade ahead I would also suggest there should be accountability for the accountability people so if there's if there's an

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assess dg3 action plan who is it that will call out the verticals the disease-specific donors or the the w-h-o or whoever it might be if they're not all playing in the way that they have agreed to play because we have had several years of trying to get on the same page the H for the g8 I don't remember all of the different acronyms we've given it over time but what can we do differently this time around that would really create incentives for those different flows to work together to improve

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outcomes Thanks thanks Amanda Jeff your thoughts what did you see well I agree with a lot of what Ronnie Aryan and Amanda said and I want to thank granny area for that comprehensive overview of both the political context and some of the details of the political declaration let me just start with two points and then make a couple of other comments in to other areas on financing and on the last point that Amanda made I'll just build

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on that the the need for cooperation but the overall theme is that what struck me about the high-level meeting once that it was an example of business as usual and I think what we're going to need for all the reasons that you've already heard is an approach from around the world of business unusual that we really need to approach these issues in a different way so the first point is and I'm just reeling a point that Ranieri already made as Ted Rose said in the run-up to the to the the high-level

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meeting as well that health is a political choice so I think part of the problem that we face is that you know as advocates for health as global health experts you know we're focused on if only we can be passionate enough about the issues that lonley we can get enough evidence from studies of what will make a difference of what actually works that the world will move in that direction but I think it's clear that there are many other issues on the global agenda and health won't always get the priority that we think it should have unless we

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take into account the political issues that surround these choices on what to do about health the second point I just want to emphasize at the outset is that every country is going to face or have a different path to universal health coverage you know there will be some similarities there will and and the political declaration points out dozens of areas in which countries will probably need to make progress but every country has a different financing a compliment of financing options every country has a different population with

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demographic and epidemiological characteristics that that are unique every country has a different way of governing its health system and making these kinds of political choices so we won't expect to see one path to universal health coverage and Amanda's already given us some examples of countries that have taken varying paths in the last few years so those are two of the key points I will say I think that you know although the declaration spelled out a detailed series of

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commitments literally from antimicrobial resistance the ZOA notic diseases it's the question now is having committed themselves to act will countries act so that's a question I'm sure we'll come back to in the discussion and so the the political declaration provides a roadmap for the actions that are needed and I think the most important thing about it from my perspective is that it's a powerful signal about policy ambitions and it becomes a rallying point for many

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of us for advocacy in action on the key milestones on the road to universal health coverage over the next couple of years actually the next 11 years - to 2030 later on I might mention that Ranieri's already mentioned a couple of the key provisions in the political declaration I was encouraged by he mentioned the the two paragraphs on on digital health tools and digital technologies I think that's quite interesting he mentioned the emphasis on regulatory systems and the way that we

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need to have strong robust regulatory systems in order to ensure that new health technologies reach the people who need them in an appropriate way there were also a number of paragraphs in the declaration around incentives for R&D so that we can bring new technologies to the work and then also issues around access to medicines and affordability and transparency and those are all issues that are clearly on the agenda I was also

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please to see the emphasis on partnerships at the regional global and national level and you already mentioned the the in the disposition to work more closely with the private sector through those kinds of partnerships I think those are all good things let me just spend two more minutes on two broader issues and and this in a way I'm just building on what Ronnie Aryan and Amanda have already said business unusual to come back to that point I want to just

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emphasize two points one is is financing and the other is the way in which the private sector can can help so we've heard the WTO report that came out just before the high-level meeting estimated a global financing gap of 370 billion dollars per year to achieve universal health coverage of that about 170 billion is for the essential package and 200 billion is to ensure that we have primary health care that will meet the demand by 2030 I just want to point out and here I'm drawing on work that the

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Institute for Health metrics and evaluation published earlier this year that's two and a half times that is the 370 billion is two and a half times the total amount of Oda last year of a hundred and forty nine billion and it's nine and a half times the total development assistance for health which was about 39 billion so before we get depressed about that gap another point that Ranieri mentioned is that if we look at the total spending on health around the world not just the government

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budget on health it comes close to ten trillion dollars if you look at it in purchasing power parity terms and that's going to grow according to IH NV by 2050 to 21 trillion dollars so so that's actually encouraging that's the good news the bad news is that spending is highly skewed so we've already alluded to this and I mean I don't want us to be awash in statistics but just a couple of other points are useful in 2016 the most

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recent year for which we have comparable data the US alone accounted for 42 percent of that total and less than one half of one percent of the total went to low-income countries one of the the statistic that really struck me in reading this paper in The Lancet was that their high-income countries spend a hundred and thirty times as much on health as low-income countries so Ranieri already mentioned

49:03

that the wo chose analysis shows that at the current trajectory or on the current trajectory we'll probably only get to the point where half of the people in the world will have will be covered by universal health coverage systems so one of the reasons that that's the case is that right now we have the skewed distribution of health spending and as again as the Institute for Health metrics and evaluation shows in a very intriguing analysis what's happening is that countries are growing economically

49:36

and that's leading to a lot of an increased investment in health so actually the amount of health spending is going to increase as I mentioned before but because the rate of growth of government budgets is less than the rate of growth of health spending what that means is that in most cases you'll see what Amanda said that it's going to lead to more out-of-pocket expenditure now that's not necessarily a bad thing and and the last point I'm gonna make about the private sector we'll come back to that but what it means is unless other

50:07

actions are taken left to its own you know those trends without any kind of intervention will mean that it's likely that there will have a disproportionate impact on the poor who won't be able to afford the out-of-pocket expenditures and won't be able to get the services they need from governments that are facing increasing demand so if we really mean to leave no one behind we have to come at this with new ways of thinking and business unusual then the last comment I'll just make at this point is

50:36

that we have to also remember that that health system there's one health system all right we're not going to have a private health system and a public health system but countries are going to have to find ways to develop mixed systems that take the best of what's available through the private sector and through the public sector and then use those resources in a way to provide the most health for the money for as many people as possible so the key point when we think about the private sector is not should it be part

51:10

of universal health coverage solutions but what's the best way to take advantage of the resources and capabilities of the private sector in a context in which as you said there has to be the right regulation the right rules of the road the right stewardship so that's where I think we'd like to see new ways of thinking about this on the part of governments but also I think what I'd like to suggest and we can come back to this in more detail is we need to have a mindset shift that because we're trying to work on creating the

51:41

best possible health system to cover as many people as possible by 2030 what we should think about is how to use all of the resources that is total health spending in the country not just government health spending and also the corollary of that is and again this is why the partnerships clauses in a political declaration is so important is that it's not just the government that is providing health care and so if we work with communities if we work with civil society if we work with the private sector both you know those who

52:12

are running private clinics and hospitals and pharmacies and those who are doing the innovations that's leading to new drugs and vaccines and those who are actually you know doing work in logistics and supply management and you know I can just go down the list what we need is a new way of thinking about how to bring all of those resources together in a way that will actually lead to universal health coverage in a way that's sustainable and that doesn't leave anybody too kind so I'm really

52:42

just reiterating points that both Ranieri and Amanda made but I think those are some of the the key conclusions that occurred to me as I reflected on the high-level meeting great thank you very much thank you all it's two o'clock I'm going to offer a couple quick remarks and then we're gonna go to you all because I know some of you will have questions for Ranieri and we want to open that dialogue before he has to exit for the airport a couple of impressions from what we heard this is an era of

53:13

particular turbulence that this was attempted in other words just listening and reading the accounts and the like you can't do a big event of this kind around universal health coverage without running into all of the turbulence surrounding migration all of the turbulence surrounding populist nationalism and authoritarianism and all of the turbulence surrounding gender and

53:43

the in some respects you know you were very successful at holding things together even while having to obviously make some compromises or to allow space for some of these schisms to manifest themselves by still keeping a focus on what was the core consensus and so congratulations to you but I mean it's just listening and reading and thinking about this it strikes me that this is this is not a very auspicious time to be

54:15

trying to do what you were attempting to do and and you were gonna take a lot of hits along the way in trying to do that I think that you've outlined all of you have outlined some of the the big promising achievements contained in this and that this can this does offer us an opportunity to to build out and to move forward and there's some momentum there may be some additional money that comes forward but in terms of the debate and

54:46

the signaling and them and and their like this is quite important but beneath that are risks and I think we need to be we need to be conscious of those risks the astronomical numbers are ones that beg the question of in another three or four years is the credibility of this effort going to be eroded and spent by the fact that the projections were so out of line with reality or not and that's I think a

55:16

serious risk having the open confrontation between a coalition of authoritarians populist nationalists and and others versus another 59 states around the gender agenda is that is that a regression as that or is that damaging is that regressive and damaging to what had been decades of effort at trying to build towards a consensus and not have that what what are have we entered

55:47

another moment in which there the the battle lines are drawn in more vivid and turbulent ways or not but I think there's a risk there that we are that we've invited inadvertently we've had some some damage done so there's credibility there's the credibility of the overall effort if it's if progress is going to be centered in India China Indonesia that implies that we're going to have a further widening of results where those that are the those that are

56:19

the poorest and least capable in the lower income states are going to be still in the position of left behind now there were some very interesting statements that Kenyans statement the Rwandan statement there were some very encouraging cases where there is a will and there's important progress to be made but I think in the big picture it's looking like a widening a widening rift in that regard and the final point I want to make before we open for this is

56:49

the private sector every one of these last series of high-level meetings has had pretty much the same standard language in it about public-private partnerships and and I think you can make the case that not a whole lot has happened as a result that it's it's a somewhat stuck problem in some you may not agree with me but I think it that from a distance it looks to me like

57:20

we're still we're still going around the track at the fourth high-level meeting with this rhetorical commitment but still as sort of standoff in between between important parties where they're having a very hard time figuring out how to move ahead so I'm just gonna stop there and I'm gonna turn to you all and and we will take a bundle of comments and questions please identify yourself please make a single intervention I had asked Cecily to speak very briefly

57:52

around some of the points around private sector I see a hand up at Carolyn and we have a hand here let's take Erin let's take four or five start with Carolyn Cecily Erin hi thanks that was great carolyn reynolds CSS so I'm gonna ask maybe a comment and a provocative question that brings together what you just talked about Steve on the financing the numbers but also the political will and the

58:23

accountability which I know Amanda will have something compelling to say on that so we there's a lot of not only these huge astronomical numbers overall on the ask but there's also different numbers on the financing gaps globally the the GMR comes out with the 370 plus billion different the Bank report that went to the g20 had half that because they used different assumptions and different focus of countries that GMR goes larger

58:54

and includes countries like India that are going to be upper middle income countries estimated to be by 2030 so numbers all over the place and as you say Jeff also don't you know don't look at the holistic don't tend to look at the holistic numbers of what is the contributions from the private sector when we look so I guess there's a question about actually advocacy to build the political will and the accountability going forward is so what's the question so the question is one are we done can we put 15% budgets to rest for Abuja like as

59:26

advocacy point because that has not entered it into this and I don't think I think we are long past the point where a number a target number is the compelling or percentage of budget is compelling as an advocacy point but what is what is the right compelling message when it comes to and and consistent message when it comes to what are the financing needs thank you over here Aaron and then assess Lee I

59:57

think you this is Aaron oh you stand up please identify yourself Ben very succinctly everybody thank you this is Aaron Emma from the global health advocacy incubator thank you very much my question is about the role of indigenous national civil society what is the expectation of their role not only in service delivery but also in holding their governments accountable for the commitments made in New York and also helping them to advocate for domestic budgets for health Thank You Aaron could you hand it just - you're just here hiya Sicily Thomas with results for

01:00:30

development I guess I just want to draw on a few things that were said there at the end about private sector and I think one is this idea of the whole health system one health system that Jeff brought up and I might actually tie it to your provocative comment about is this you know the business as you we've always had private sector on the agenda we hear it all the time what's the change and I think that might be the change I think we hear a lot about public private engagements

01:01:01

public-private partnerships that are sometimes vertical in that system and how are they tied in completely to that system so I guess what my question to the group for debate is in terms of the approach that we take to realizing this goal of better leveraging the private sector is it really thinking about how countries can take the lead how they can steward this more effectively and and that approach of of leadership of a whole health system versus a one-off

01:01:31

intervention is that a potential for moving forward thank you let's take a couple more crisps and then right next to Chris there I'll come back to your Keith in the second round go ahead Chris thank you for these comments very helpful I mean to you who are you did you identify yourself he did I'm sorry sorry Chris Collins friends the global fight against AIDS tuberculosis and malaria Amanda you were issues of you know we need to think about how the

01:02:03

vertical programs and those financing flows relate to UHC I just wanted to give you a little bit more space to fit to talk about you know your vision about you know thinking of us elected officials on the mission ahead for them and grappling with us what does that look like how do they think about the bilateral programs both on just and just any thoughts about how we can harness those vertical programs not lose the emphasis on results and outcomes in

01:02:33

those disease areas but also advance racing thank you I'm Daniel cochlear until a few months ago it was I directed the World Bank's universal health coverage series of study I I wanted to invite some comments about how useful it is to be a little bit more control more confrontational

01:03:02

it's the question you asked but specifically I am perhaps you could refer to primary health care there is that last year there was an attempt to bring that up to the fore this year there was a call which sounded like something very specific and sounded like something but for which an accountability framework could be developed to add 1% of GDP spending to

01:03:34

it except that we don't have a definition for primary health care that is agreed and we have no idea of how much any specific country is spending or primary health care so how would we know if they've increased it or not thanks okay I think we've got five very very significant and quite different questions here Ranieri I'm gonna start with you there's a couple that are directed specifically to Amanda well one one and I think to

01:04:06

Jeff as well but Ranieri let's start with you I know time is getting short can I can I take a little bit of the the issue of the vertical music-video result or whatever you remember the initial days of primary health care selective comprehensive we are going back to that and that's that's very sad because it seems that lessons learned have been vanished somewhere in the global space but let me say one thing about Global Fund whoever funds you initially wanted to

01:04:36

target three diseases conditions he took them eight rounds to come to the conclusion that without an infrastructure without a system without logistics without workforce it's just impossible to target a specific disease which means that we need to have a system in place and therefore the Global Fund is now targeting not only system strengthening as Garvey is doing but is targeting also mobile populations

01:05:06

because the current world is not made of residential groups is is on on the move and we need to understand that because this is this is where we go the second point that was raised is that the the the issue let me make an example just to clarify this we being with being working on polio eradication for 35 years now

01:05:39

three years ago we were just adi just at the end the where two three cases in afghanistan five cases in pakistan and it seems to be solved just by pumping additional financial resources pumping additional awareness pumping additional vaccinators around those corridors that we understand are still at risk then suddenly last year we started to see

01:06:12

outbreaks of vaccine d right for your viruses simply because the system the new team reservation system is not in place today we have ebola outbreak and every outbreak in the DRC we have three outbreaks of measles in the DRC we have two outbreaks of Cholera into the c plus plus plus we I'm sure we have yellow fever somewhere the dear C and so forth which means clearly that unless we

01:06:44

move in into building the system pillars we are going to fail because the answer is not pumping additional financial resources into something which is not in place which has to be fixed so I in a way we we know and we don't know we have an estimate of what primary health care allocation is at least in 50 countries that are reporting and we are inferring that more or less this is what

01:07:14

we need to see there is no UN global force that can persuade leaders at the country level to do what a declaration foresees or commits people they will have to do it we are there to assist but their civil society the Parliament the legislative power we led to converge into making governments accountable and I'm saying governments are comfortable because without governments we go nowhere

01:07:47

provisional care can be left to the private sector is no way no no reason to to keep it in the public domain but the control the government I don't think we have options because we've seen around the world that unless the regulatory system is there unless governance is public unless governance is transparent is visibly visibly in the hand of people if you wish governments should be the

01:08:17

people's manifestation the the the visible way that we we the democracies around the business unless we do this we are going to face renewal do you have an answer to Carolyn's question around or is there a reset on the target for investment by country is sort of as a aspirational goal and percentage of budget I think we've seen we seem different systems and different countries moving Kenya has been quarters who are this being quoted

01:08:48

but you know China's being ported in just be important and many others you have a fantastic example from Bangladesh which is not exactly the richest country in the world Bangladesh not only has committed massively towards rebuilding primary health care towards mobilise in human resources where they are needed at periphery of the system not in Dhaka not necessarily in Dalian Dhaka Bangladesh has approved a universal coverage legislation that

01:09:21

includes migrants as well providing the same level of care because they are listed in the International Insurance Scheme and the opposite you have South Africa which is embarking now in their ambitious national succession insurance scheme whereas at the same time within the public consultation what they're saying is that insurance will be linked to residency which means that if people from problems a moved to province

01:09:52

B they will lose the benefit which is you know comment is we live in a crazy world and sometimes this is true so how can we make sure that the South African government is is kept accountable for what they do by means of an alliance between civil society between professionals and between those who detained a legislative power and I think we don't have any other option so on the issue of verticals and primary health care I you know what's

01:10:27

interesting is that you know you mentioned something about we've we've not looked at routine immunization and it's sort of campaigns versus routine immunization I think what's clear is that it's campaigns and routine immunization always with the focus on the coverage outcomes that those government's want to see if you look in Latin America and what they've been successful it's the combination I think that is necessary so you know we shouldn't throw the baby out with the bathwater when we talk about that when we think about the US government you know clearly you USAID has done plenty

01:10:59

of support to payer organizations for example and I hate to use the example of Liberia in a robe for just one area thank you so much sorry I can't disappear he heard the reference to the US and decided a thank you thank you thank you so and there are a couple of cases to Lake and Burundi where the

01:11:29

where the Global Fund and sometimes PEPFAR will join with if to finance a package of care in a single place but to purchase that care to the per from providers in an integral way right so I think that is probably the way forward to look at these purchasing entities or commissioning entities within governments and see maybe we don't need to pool because that would be difficult for the US but you can imagine them being in charge of ARV quality care and

01:12:00

adherence whereas Gabby is gonna fund the vaccines and in command in ways that this could happen I would say it's it's odd that more of that hasn't happened and I think part of its that the gut you know it happens mainly in countries where government knows what it wants to do clearly and in other places where that's less the case it's sort of a free-for-all even within some of the USG programs where they compete in terms of how the service model they're using what kinds of providers exist what are

01:12:31

the results that they want to see so I think part of its getting our own act together as well I also think that the banks have an important role to play here because they're the ones that sit with governments and make plans to carry out our reform and I mean I think maybe it's not popular anymore to talk about reform and looking at Danielle who asked that question but when I also think back to my Latin American experience the reason there was equity or primary health care was because the government said yes they wanted to do politically and then they had this whole set of people who came and work with them to develop the plans and it came with money

01:13:02

and they tracked results even then it was a mixed bag but it was a step in the right direction I totally agree that we should drop Abuja I think that these ideas of earmarks on the budget or you know looking for the hundred and thirty dollars per capita we're not gonna see that it's hard to track that's not how country's budget and spend we should really look at you know effective coverage of immunization full adherence to hiv/aids treatment finding all the

01:13:34

people that need to be on treatment in a timely way lidly let's keep the focus on the thing that matters for health outcomes and then let's say something about how much it costs to do it because we don't know the way that we construct those those kinds of estimates are are very imperfect right just gives you an order of magnitude and I think it can be kind of demoralizing to think about such a large number and not being able to do anything and if you would you anticipate that the World Bank and the regional banks are going to step forward or already are stepping for Memaw Pass

01:14:06

showed up and made a strong statement that was I think significant but in this phase as people look at this and say okay we really do need to move things for and we had the Argentine Health Minister here yesterday and he was describing how the real way of getting provincial health ministries to move ahead with primary care is through the 650 million dollar bank facility that empowers him to get family

01:14:37

teens out and around and it implies a long-term budgetary commitment to follow through and we can see more of that in his face which I guess you know the Hale health portfolio at the bank's hasn't actually changed that significantly over time you do one operation for a five-year period sometimes it's hard to spend it so I think you know it really depends on the demand from governments yeah it depends on other things that they want to get done it depends on the success of the IDA replenishment which is also coming up next gosh not next week but first week in November so you

01:15:09

know if all those things are in place if there's space and governments to prioritize it you know I don't when you talk to ministers of finance you don't necessarily see them putting the health sector at the top and that has something to do with the efficiency of the health sector but also because government's want to do a lot of different things with their money secondary education etc so it's just I think your ongoing if to create demand for the bank that's also a civil society that's also the international agencies it's not like the bank person decides oh thank you

01:15:39

Geoff Cecily raised the question around whether there's been a change of thinking and out look around private sector and stewardship and whole-of-government approaches we also had the question Erin raised around the role of in civil society what can you say to them sure well let me let me respond to those two points and also the one you raised about you know there's been plenty of talk about public-private partnerships as anything actually changed but first you know I completely agree with Amanda that the answer to you

01:16:10

know whether the bank and other international financial institutions can put more money into health is exactly what you said there has to be more demand from the country you know from the the countries that are working with you know and we know that those of us and you know I'm glad Daniels here and I highly recommend everybody interested in UHC but you take a look at his book which is a really rich set of case studies about how countries have been approaching these questions but you know but the bank really is may have a point of view about these things but at the

01:16:41

end of the day what do countries need what do they want what what where do they want to put our financing so but a way to to make progress along those lines to get countries that a man more in health actually comes back to the questions that that's Sicily and and Aaron raise because I think of you know of all the things in the political declaration there are two that seemed to me to be real potential levers for better action in the future and one of them is there's a call for multi sectoral engagement

01:17:11

mechanisms so that as governments begin to put plans in place to achieve universal health coverage part of that should be a mechanism you know examples like the global funds country coordinating mechanism come to mind where you can get everybody around a table and talk about priorities in a resource allocation and you know and the government may not do everything that people want but at least if you have a seat at the table there's more probability that you'll be able to push things in the direction that you'd like to see and related to that and with the private sector is you know there should

01:17:41

it should also those multi sectoral engagement mechanisms should also include the private sector because remember I mean a point I eluded to is that you know virtually the whu-oh in this report we were talking about that comes up with an estimate of 370 billion dollars of the gap in financing they all they also say that the average engagement of the private sector in health care delivery in countries around the world is 60 percent so you know there are some countries like India where the private sector is much more active there are other countries both low and middle income countries in which

01:18:12

it varies you know think of our country you know the u.s. is largely delivering health care through the private sector in one way or another you know there's Medicare and Medicaid but even so delivery of those services are largely through the private sector so that's just one example so if you have an environment in which the private sector is already providing you know delivering health care services of the primary care level the private sector is involved in providing the the drugs and the vaccines that people need and they're part of this multi sectoral engagement mechanism

01:18:44

so the government is taking seriously the perspectives of everybody the civil society as well as the private sector chances are you're going to find new ways of working and new methods of building on successes and and after all one of the things that you know we talked earlier about political will will the countries have the political will to make the changes that need to be made you know political will is itself socially constructed and one of the things that goes into whether politicians will actually make the decisions you'd like them to make is that they are able to learn from

01:19:16

examples that actually produce results and then they can adapt those results and those methods to other problems that are still think they're still facing and that that will move the ball forward and so I think that you know it's one of the ways to ensure we have enough political will and the right kind of political will is to think more about experimentation learning adaptation and that's where the examples you know and you know it was kind of you to mention the book earlier Steve and I hope everybody will take a copy as they leave

01:19:46

there are lots of examples in this book of what how the private sector is working at different levels in many different countries already to show those examples that work that can then be incorporated into into what countries have to do to get there I have just two further points back to Aaron's the Aaron's comment because the other thing in the pool in the political declaration or what was missing from it but I was pleased to hear Ranieri say that they have plans to now think about building an accountability framework you know if you think about every woman every child

01:20:17

which was launched in 2011 under Ban ki-moon and secretary-general one of the things that has made that movement so successful is that there was an independent accountability panel that every year since has brought back a report saying here's the progress we've made on the commitments that were were launched in 2011 here are some interesting examples where things are really working well here are some examples that aren't working well and here are examples of where governments haven't done what they said they would do so that independent accountability panel has helped to hold people's feet

01:20:48

to the fire so so I think that the other thing that we should do is advocate for and a sort of citizens accountability mechanism in each of the countries around the world now you know in Syria that's probably not going to go very far just to take one but there are plenty of other countries where there are precedents and there are opportunities to build that kind of accountability mechanism so if you have that plus a multi stakeholder engagement mechanism over time I think we'll be able to move in the right direction the last point I want to make is about you

01:21:21

know Steve keeps saying these are astronomical asks that Amanda said the same thing Ranieri alluded to this in passing but I think it's important remember I used this 10 trillion dollar figure versus the 370 billion dollars that's required to achieve universal health coverage or the gap in financing you know that's all that's less than or excuse me it's about 4% of 10 trillion dollars so if we think again about ways to tap into where the money is and put

01:21:50

it to better use for achieving better health it's not inconceivable that the world could find 4% to invest and remember most countries are growing so economic growth itself is going to lead to more money that could be invested in health and also if you think amanda mentioned financial flow is another one that sticks in my mind is that Oda is a hundred and fifty billion dollars or was last year that's not quite the highest that's ever been but it's it's close to

01:22:21

it although it's flattening out but international foreign direct investment flows are about six times that every year so it's not that there isn't enough money in the world to do what we need to do to achieve universal health coverage it's just do we have the will and the creativity and and the commitment to actually allocate those resources in a different way and if we do that we'll find that not only can we achieve what we need to do in health but because that will then lead to greater productivity

01:22:51

and you know all the other benefits that come from investment in health that will actually spark greater economic growth that it will make it easier to find more money to continue to do those things as we have an aging population that is living longer so anyhow I maybe I said before I'm a half glass full kind of person so that's another comment along those lines thank you let's open the floor let's do one more round and then we'll wrap things up I know Keith had his hand up can we bring

01:23:23

a microphone and we'll take several other Nellie Keith be very brief introduce yourself be very brief one intervention Keith Martin's consortium of universities for global thank you for your presentations comment the this political will and as public institution capacity I think we certainly need to strengthen public institution capacity not only in ministries of Health but in public works justice environment and others my question is I'm a third pillar of an effective Pub public health

01:23:54

institution I didn't hear anything about surgical care which is absolutely essential to address in CDs whether it's injury cardiovascular diabetes obstetric complications where is access to quality surgical care in this picture and also the social determinants about both in combination there's a great rate of return investment that you can get from both of them thank you thank you Nellie I know Lee Bristol with the Global Health Policy Center at CSIS I'm just curious what was what was the reaction to the u.s. in some of these

01:24:25

conversations because it had been out of the UHC Club and then was in the UHC Club and now at least on some levels desperately trying to get back out of the uhd Club so I'm just wondering what was the reaction and what was the commitment at the political level from the US thank you we have a hand over here hi Vince blazer frontline health workers coalition and intra health I was a wondering if you guys could comment on the complexity of financing the health workforce Ranieri mentioned workforce a

01:25:00

couple of times it are inherently the issues of Health Labour migration make it complex already but it's made increasingly complex by the political issues that Steve raised as well as the deliberate attacks on health workers that safeguarding health and conflict Coalition documented in 23 countries last year so just just wondering if you can comment on that Pete Salama at w-h-o raised the idea of raising a billion dollars for an

01:25:32

investment fund with the European Investment Bank and World Bank and others last week so wonder if you could comment on that thanks thank you do you have any other any other questions or comments anyone else care to jump in okay let's come back to our speakers at surgical care reaction in the US and health workforce Amanda so I mean well in the whu-oh triple

01:26:03

billions metrics firt which was not necessarily sort of taken on board by everyone nor is it specifically referenced in the document however in the list of essential health services under surgical care there's some tracer interventions that are being tracked so I think understanding what's next for that is part part of this piece I had the other question is it sort of has to do with what is primary health care and how do countries decide what is universal health coverage and what is not you know I think each country really needs to determine the criteria for

01:26:34

determining what would merit public subsidy this is one of those underinvested areas there's many of them and so the question is what is it that we the governments are doing and what are we as external groups doing to improve the process of getting the most cost-effective and important services into these UHC packages so I think that's kind of an ongoing issue actually I thought that you said social care which I thought was also really important and I think one of the challenges with the UHC is that both

01:27:05

public health and preparedness and things like social care are sort out of the definition of these Dan's today and yet a lot of out of pocket spending is on things that really have to do with data take care of people especially in you know where people are living longer etc so you know all of that really just part of the part of the issue and the question should we emphasize the UHC narrow or should we try and take this larger view and then what happens with the accountability it's complicated okay on the US I I have no inside track on

01:27:36

that probably Steve is better qualified to mention but I think what's interesting when you see secretary azar well first that we signed up to this and second that secretaries are was in DRC talking about health system support because they had to they were sort of saying well you know yes we support the Ebola fight but we also recognize that you know people actually don't find it acceptable only to provide one intervention and so we're supporting the whole set of interventions in these places in DRC so maybe that's a positive sign that we're taking that more

01:28:08

holistic view on on health workforce I really hope that we don't go down the route of worrying about brain drain and that we should think of win-win solutions that would enable investments to train many people in country but also to acknowledge that migration is a really good thing and also that health systems in high-income countries have huge needs and so at the Center for Global Development we've worked on this idea of a called a global skills partnership which is this idea over training nurses or home health care

01:28:42

workers in sending developing countries giving some of them some kind of work visa to go to wherever it might be but having enough local supplies still in place to enhance the capacity respond and I think those are the kinds of kind of practical thinks that we might try to look for in the next decade on the on a question around us then question Nellie raised you know we did we weren't party to the negotiations that went on we were only you know privy okay to occasional

01:29:12

comments around that process but I think it's fair to say that the us engagement in the negotiations was erratic and uncertain it didn't begin with a clear set of targets it shifted around and landed and in a sort of ultimate position that's one point second point is I think we should celebrate the fact that secretary a czar has taken a leadership position on TRC yeah together with all the others that came with him with Ted Ross to DRC and those

01:29:45

commitments and that's terribly important that happened just prior to this I think there were completely contrary or opposing impulses running through us behavior and postures and the clash around the statement of nineteen represented one very powerful part of this administration driving that agenda forward we did sign on to this declaration and to go to paragraph 56 it's completely contradictory to the

01:30:16

statement that was issued by the nineteen countries so you know we we were walking both sides of the street in some ways on the questions around gender and gender the value of mainstreaming gender equity and human rights which is the title of that paragraph we're signatories statements so we're signatories to two completely contradictory statements in the same day issued in the same day with I'm sure that's the first time I'm sure there's some caveats or proviso said in one

01:30:47

statement says ignore paragraph 56 but but but we were we had different opposing impulses through different parts of this administration on different for different purposes and the fact that we signed on to the Declaration was important we haven't talked at all the Declaration has implications for the United States I mean if if you want to you know we're not on the sidelines we're signatory to this so those

01:31:18

provisions that are in this have application to our own domestic health and we haven't talked about that and I think that's that's a whole other conversation as to whether that that means much of anything Jeff you I'm sure have some things to say I'm interested around the the question Vince raised around a major initiative is Missouri is there is a prospect we had the Rockefeller Foundation come in with a hundred million on a data initiative was

01:31:48

very timely I thought really smart sort of movement the 29 million put towards afro around this another sort of way of signaling you're doing good work we have confidence in hope here's a strategically important area let's move forward could we see something like that in health workforce led by Europeans no I think it's I think it's it's entirely possible and one of the reasons that I'm optimistic about that it's well an

01:32:17

optimistic today I think it's fix that I just find in this work you have to be optimistic otherwise it's hard to keep going but but I think that you know one just coming back to the book again there's a chapter on the health workforce by Jim Campbell and Pascale Zirin and their colleagues who lead the health workforce work at whu-oh and in one line the the conclusion is that we have to start looking at the health workforce as an investment not a cost

01:32:50

and you know that sounds cliched but you know if you look at their analysis it's really quite important because first of all the health workforce in many countries is growing in other areas of the workforce or not these tend to be good jobs if they lead they mean that people then have income the can spend on other things so there's a multiplier effect of investing in the health workforce that's good for the economy and then there's the economic benefit of having more trained and and you know well deployed and and well

01:33:22

compensated health workers in actually improving the health outcomes that you get with the money that's invested so there's an efficiency argument in how it adds to getting more health for the money so on all of those levels investing in the health workforce is a good thing so if you're now in the Ministry of Finance you're trying to think what are you going to do with the limited resources that we have and you know here's the request from you know for the president's office or from the Health Minister on how we're going to set the health budget for next year it

01:33:53

actually makes sense to put more money into the health workforce because that's going to help you achieve other targets that you have somebody and for more details and a much more sophisticated analysis I refer you to that chapter I wanted to comment also on Keith's question about the social determinants of health because you know we haven't talked a lot about prevention it's it's been alluded to but and this also relates to the Rockefeller new data for health equity initiative because one of the things they're going to be doing is

01:34:23

using big data and artificial intelligence to analyze the impact of poverty housing education transportation resources and others on the risks that people have of becoming sicker or remaining healthy and so you know I think we'll see some interesting work that comes out of that but it's based on on a conviction that the only way we're going to really make improvements as we move toward universal health coverage is to look at all of the determinants of health

01:34:53

Ranieri mentioned legal determinants so we need better regulatory systems and we need to make changes in the way migrants are handled in different systems and other things you know there's been work that alone and cake Bush has also been leading with a group of other scholars on the commercial determinants of health and you know we also he also alluded to that in his remarks about targeted taxation so you know sin taxes on sugary beverages or alcohol you know alcoholic beverages tobacco products and we know from the global

01:35:25

health 2035 report that you know Larry Summers and and Dean Jamison and their colleagues said the single best thing that governments can do for improving health and achieving universal health coverage is to just tax the hell out of tobacco products because it's not very costly to do it and it just you know can be immediately reinvested that money can be reinvested in in health care and and and then have great great benefits so so I think that you know there's a sense that one has to look at all of these

01:35:57

determinants of health not just the usual things that the Ministry of Health is concerned with and that's why these multi sectoral engagement mechanisms are so important because you need to think about what is leading to a higher risk of developing non communicable disease for instance you know if people are engaging in risky sexual behaviors if they're not exercising if they're eating you know fast food diets and becoming obese if they're drinking too much if they're smoking those are all things

01:36:29

that can be prevented and that lead to tremendous gains in health and also to gains in the economic efficiency of what one does with the health budget is you don't have to spend money on that you can spend it on things that will actually lead to health and in other ways like surgery for instance to come back to the other point and I think you know I look at at surgery which as Amanda alluded to is also on an area of underinvestment you know there is some interesting work that octel Gawande and others have done

01:36:59

on you know sort of an essential package of surgical interventions I think that as government's begin to create their plans for how to achieve universal health coverage they'll have to look at making sure that the essential package of surgical services is available to people just as an essential package of primary health care services have to be available and just as you know the work that's already been done and some of the vertical programs has to continue because that's making tremendous gains and it's also leading to strengthening the system in ways that make it more resilient to deal

01:37:31

with the next infectious disease outbreak for instance or you know with a growing tendency of people that contract diabetes or or different cancers so it's it's this emphasis on a holistic approach that will lead to a more resilient system that's going to help us get where we need to go thank you well we've gotten to the end of our time I think we've covered an enormous amount of ground I'm very grateful to you Amanda and Jeff for doing this special

01:38:02

thanks to samantha straumann for putting this all together please grab a copy of the book Jeff will follow up with a quiz in about a week we've got all we got all your emails so thank you and join me in thanking our speakers [Applause]

The UN High-Level Meeting on Universal Health Coverage: What Happened?

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