Subtheme 1: Implementation challenges and innovative solutions for UHC 2030

Underlying the achievement of most SDG3 targets is universal access to and uptake of quality, affordable health services (SDG target 3.8), the large majority delivered close to where people live and work (i.e. primary care). Most parts of the world have seen expansion in the access to health services and coverage of key interventions over the last two decades. There have also been notable improvements in financial protection. Yet, in many countries, large coverage gaps remain, in particular for the poor and marginalized segments of the population, as well as in fragile and conflict-affected states. It is estimated that still 3.5 billion people lack access to essential health services worldwide. Even when essential services are accessible, they are often fragmented, of poor quality and safety, and do not always address the upstream determinants of health and equity in health. At the same time, the burden of noncommunicable diseases, accidents and mental health problems is growing. Ageing populations are causing people to live longer, but often with multiple diseases and conditions that require complex care over time.

With the growth of social media and digital communication, healthcare users and their families are much more informed (or mis-informed) and are demanding more say in how health services take care of them. As Antonio Guterres, Secretary-General of the United Nations, said the world is suffering from a bad case of “trust deficit disorder”. This is also particularly notable in the health sector with for instance the rise in medical consumerism, malpractice litigation, and lack of trust in vaccination campaigns in more mature health systems. While in more fragile health systems, lack of confidence in health services explains reluctance of population to seek care and has proven to threaten early identification and threatens response and recovery in pandemics. Such as during the Ebola outbreak in Western African countries. This shows that communities are the anchor of nations’ resilience-building efforts. In this context, increased accountability (including social accountability to local communities) and broader stakeholder participation is needed.

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

Political commitment to achieving UHC is strongly affirmed at the global level as the world convened in Astana in 2018 to reiterate their commitment to PHC; and the 2019 United Nations General Assembly United Nations prepares to hold a High-Level Meeting on “Universal Health Coverage: Moving Together to Build a Healthier World”.

In this context, this session aims at building on the global commitments and experiences learned from pioneering countries to go one step further and identify innovative solutions to make significant progress in implementation for local communities, ensuring no one is left behind. This session adopts whole-of-system approach to achieving UHC and considers both the supply and demand side interventions. It is complemented by sub-theme 2 that covers health financing policies to achieve UHC and by sub-theme 3 that set the broader picture and identifies major trends that will influence the service delivery model and capacity to deliver (availability of resources). Hence, interventions to increase population coverage or expand health benefits package or digitalization of health and innovation will be addressed in these sub-themes.

Because of the centrality of promotion and prevention to achieve UHC, those topics will be incorporated within each parallel session: this is an integral part of the Astana Declaration, workforce will need to build their capacity to respond to NCDs and in particular through promotion and prevention, the role of community in creating health environment will be tackled in PS3, and finally, the investment case on UHC should strongly include prevention and promotion as more cost- effective approach to UHC.

Subtheme 2: Sustainable Financing for Expanding Deepening Universal Health Coverage

Universal Health Coverage (UHC) – a policy and political commitment that is part of the United Nation’s Sustainable Development Goals (SDGs) for 2030 – is about ensuring that all people can use the promotive, preventive, curative, rehabilitative, and palliative health services they need, of sufficient quality to be effective, while also ensuring the use of these services does not expose the user to financial hardship. Increasing the level and efficient use of public and other compulsory prepaid/pooled sources of financing – targeted in ways that improve effective service coverage and financial protection, especially for the poor and vulnerable – is necessary for countries to make sustained progress towards UHC.

Since 2000, the world has advanced towards UHC, but not fast enough. At present rates, the 2030 global UHC targets under the SDGs will not be met. Despite progress in recent years, World Health Organization (WHO)-World Bank (WB) estimates indicate that more than half the world’s population still does not have access to a basic package of health services, and more than 100 million individuals annually are impoverished due to high out-of-pocket (OOP) spending at the time and place of seeking care. Where gains in service coverage have been more evident, examples of corresponding improvements in financial protection have been far fewer and less notable across developing countries. Urgent action is needed to speed up gains in the two dimensions of UHC, health service coverage and financial protection, and to ensure that no one is left behind.

To accelerate progress, more funding will invariably be necessary: there are insufficient funds to ensure that all people obtain the health services they need with financial protection to reach the ambitious SDG targets in many low and lower-middle income countries. An important first step for mobilizing sufficient resources is political commitment by Governments. Increasing number of countries have made UHC as an explicit policy objective in national strategies and plans, and health has been used as a winning argument to raise more pro-health and pro-poor revenues. It is important that these examples also catalyze political action by other governments and grassroot actions.

However, more financing on its own will not be enough as countries cannot spend their way to UHC if resources are not utilized effectively: the challenges of sustainable financing are not only to raise more resources in and for countries that need them in equitable and efficient way, but also to ensure that the funds are pooled and used equitably and efficiently as well. This requires consolidating and expanding existing strategies that we know work, implement these strategies more effectively and aggressively, while at the same time continuing and encouraging some degree of focus and attention towards new approaches to raise and use funds for UHC.

The health financing policy landscape – beyond the critical recognition that both financial protection and effective service coverage are co-equal dimensions of UHC – is diverse. Over the past 15 years, a growing number of countries in all parts of the world have moved away from approaches relying on individual, de facto voluntary contributions towards more effective use of general budget revenues derived from broad-based taxes. They often target funds to the poor and channel them to an agency such as a national health insurance fund that purchases services from both government and private providers in a dynamic, data driven approach, while bolstering traditional supply-side public financing to government providers. There remain though significant gaps in the application and adaptation of good practices, and the challenging fiscal context has made progress difficult in most LMICs.

At a decisive time for the global UHC movement in 2020, the proposed series of sessions address policy makers in countries that are striving to sustainably finance accelerated progress toward UHC, along with their national and global partners. The subtheme underscores the argument that the way forward for financing UHC will require strong political commitment as sine qua non underlying principle that is implemented via action on two fronts. On the one hand, countries can get additional mileage from adapting and accelerating core principles for progress derived from proven strategies, drawing on lessons from countries that have seen rapid UHC progress in the past. At the same time, we are living in times of a “second machine age,” the “fourth industrial revolution” driven by very rapid advances in digital technologies and communications. Digitalization of health financing systems, analysis of Big Data accumulating in real time from multiple sources has opened new avenues to stop leakages, detect fraud, facilitate payments, and better understand behaviors of people and institutions. At the same time, health financing systems need to be ready to embrace and support service delivery innovations that can improve access, efficiency and quality. Opportunities may exist for countries to surpass previous achievements by embracing a culture of adaptive learning based on a virtuous cycle of implementation, data generation, analysis, and policy/implementation adjustment. Shared domestic and cross-country learning, as well as courageous leadership willing to make change happen, are key success factors.

The PMAC 2020 and 2 nd UHC Forum will take place after the High Level Forum on UHC at UNGA 2019, where Global Health Organizations will present and commit to coordinated action to support accelerators for achieving SDG3+. These key steps toward a global agenda for UHC financing will build upon and take further the discussions at the 1 st UHC Forum in December 2017, UHC Financing Forums in 2016, 2017 and 2018, Health Finance, Public Finance and UHC Symposia in 2014, 2016, and 2017, and the UHC financing discussions at the G20.

This sub-theme will address the issue of sustainable financing for expanding and deepening UHC – consolidating the lessons and guiding principles for action emerging from global experience with health financing reforms -- while taking stock of why, in many countries, there remains inadequate progress. Within the bounds of these principles, adaptations of “traditional” modalities related to the financing functions of revenue raising, pooling, and purchasing will be explored. Attention will be given to the transition from policy to action (implementation), ensuring that a sense of urgency (given that there are only 10 years remaining for attainment of the SDG UHC target) does not deteriorate into desperation leading to a search for solutions that have been proven to fail (i.e. “keep calm and carry on”). The session will also scan the horizon of “non-traditional, innovative” modalities in health financing, including those spurred by digital technology advancement, to stimulate discussion and highlight potential opportunities.

• Review the global health financing landscape, identify key remaining health financing challenges in the context of UHC, and reflect on what technical and political actions can help overcome obstacles to moving forward much more rapidly. For global landscaping, data will be pulled from the UHC Global Monitoring Report, while other synthesis studies including commissioned work will be used to identify the obstacles and potential solutions.
• Discuss political context of health financing, including ramifications of UHC as social contract and civil society role, demand generation for UHC financing from human rights and economic case arguments, introduction of pro-health and pro-poor fiscal policies.
• Consolidate and broaden consensus regarding core health financing principles that should guide health financing policy-making for UHC in any context.
• Explore and synthesize key lessons from country experience with the implementation of health financing reforms, including deeper dives into specific aspects of health financing reforms (revenue raising, pooling, benefit design, and purchasing, including related actions such as the alignment with public financial management and policy towards private finance and provision.) and draw out the implications of these lessons for accelerated action.
• Understand how technical support in health financing, including cross-country learning, might be adapted to better support countries to build their own capacity and institutions.
• Discuss and identify how technological advances can be (or have been) harnessed to enhance the effectiveness of health financing policies (particularly strategic purchasing) to drive progress towards UHC.

It is important to note that part of the discussion will be very much on “how”: lessons on how countries have achieved political commitment to UHC and transformed core principles into practice, critical implementation steps and sequencing, and also experience of those countries that have not been able to address adequately the obstacles to progress; and, the “what”, in particular to distill from country experience the core guiding principles that should drive actions in revenue raising, pooling, purchasing and benefit design.

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

The environment for health systems has been changing and certainly continues to change globally and nationally. Societies are facing the changing nature of the challenges that impact on health systems. These include systemic shocks such as disease outbreaks, natural disasters, conflicts and mass migration, as well as longer-term processes, such as population growth or shrink, epidemiological and demographic transitions, urbanization, food insecurity, climate change and widening economic disparities. These changes and shocks can affect three core dimensions of UHC: population coverage, health services coverage and financial coverage. Health systems need to continuously adapt to provide appropriate and needed health services. To achieve and sustain UHC through health system strengthening, each country needs to forecast the likely impact of these megatrends on their health systems and adapt them accordingly.

Health and other Sustainable Development Goals are mutually reinforcing. Addressing other SDGs can promote UHC, whereas achieving UHC can benefit other sector goals. Poverty, for example, can prevent people from seeking health services if health expenses are not affordable, as 100 million people are being pushed into poverty each year because they have to pay for health care out of their pockets. Poverty reduction can lead to improved access to health services, and financial protection, as a part of UHC, would prevent poverty. Climate change threatens our health in various ways including increase of extreme whether events or changing patterns of vector-, food- and water- borne diseases. Countries with weak health systems will be least able to prepare and respond to these changes. Thus, health systems need to be resilient enough to anticipate, respond to, cope with, recover from and adapt to climate-related shocks and stress.

Sustainable industry, another focus of SDGs, is critical to continue to boost research and development, and to produce new technologies. The new technologies including medical products could facilitate the progress towards UHC and SDGs in many ways. For example, in the health sector, potent vaccine for HIV, Malaria or Tuberculosis would drastically change the landscape of the disease burden, which could accelerate the progress towards UHC. To this end, as a whole society, sufficient and appropriate investment is needed to promote R&D.

On the other hand, given the growing health expenditure strongly associated with new technologies all over the world, nations and the world need to ensure financial sustainability of health systems. One of the biggest challenges is to expand access to and use of medical products while the provision and its expansion are continuously financed. Mechanisms of properly financing health services as well as technologies (investing in R&D) need to be well designed. How to form a great partnership with the medical product industry with a proper mechanism to tackle this challenge, and eventually to achieve sustainable industry and sustainable health systems is key to promoting the solidarity with common goals of UHC and SDGs.

Innovation has great potential to accelerate human progress and many of SDG agenda including UHC. At the same time, innovation has to lead to societal positive impacts by steering the innovation process. Further, the benefits of innovations need to be accessible to those who most need it irrespective of the wealth. Innovation can address some of our most pressing health-care problems by transforming lives, preventing disease, restoring people to full health and making the health-care delivery system more effective and efficient: point-of-care diagnostics, digital health, artificial intelligence, and internet-of-things based solutions, to name a few. However, “side effects” of innovation also have been seen within and beyond the health sector, including negative impacts on health and environments, ethical issues and economic burden. For example, DDT, a pesticide, used for malaria control has potential negative effects on health and environment; a longtime project on the electronic patient record system was abandoned due to unresolved privacy issues after substantial investment 1 . Moreover, technological innovation could widen disparities across social groups, socio-economic groups, and geographic locations 2 . Given both positive and negative effects of innovation, questions are what mechanisms and processes encourage socially desirable innovation and promote equity driven innovation.

Good governance, and transparent, effective and accountable institutions at all levels themselves are common enablers for SDGs as well as important conduits for peaceful and inclusive societies of SDG 16. These enablers also apply to UHC. Intersectoral collaboration, concerted efforts of stakeholders, good decision-making process, proper financial allocation, enabling legal environments – all these factors that are necessary for UHC result from good governance and effective institutions. Without these as well as peaceful and inclusive societies, UHC is harder to achieve. In turn, good governance and institutions can promote peaceful and inclusive societies with UHC as a means. An adequate health system accessible to all members of society can contribute to societies that value security, solidarity, and inclusiveness. Particularly in fragile and conflict settings, health can be a bridge for peace. Delivery of health services or health workers can be a neutral meeting point to bring conflicting parties.

To seize the above-mentioned opportunities and challenges and transform it into the actual progress towards UHC and SDGs, we need strong leadership that can foster solidarity across different sectors at all levels. In some political context, UHC reform may be resisted by particular interest groups as it would entail redistributing resources across the society. In divided societies such as ethnically, religiously or economically, the drivers of redistribution may be weaker, and the reform would be opposed, for instance, by right-wing populists or ruling elites who wants to distribute patronage favours to supporters. The leaders who have a vision and a broad supporter base could close the divide, and build up the momentum to move things forward. Such a movement can be underpinned and strengthened by evidence on the ground. In fact, often times, there were champions who propelled the movement. The questions are how to produce such champions in societies or countries where such a movement has not been seen yet, and how the global society can help to foster such an environment where they may appear.

This sub-theme will look at megatrends and global issues affecting UHC to find a way to adapt or respond to them, and identify synergistical opportunities and to overcome challenges that the society can synergistically address. With this recognition, it aims at fostering social solidarity toward SDGs by committing to UHC.

• Considering megatrends affecting the achievement of Universal Health Coverage
• Seizing opportunities and addressing threats towards UHC and SDGs
• Building partnerships within and beyond the health sector, and fostering social solidarity by committing to UHC to drive toward SDGs