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A Sketch of a Ministerial Meeting on Universal Health Coverage

Adam Wagstaff's picture

I had been warned—I found it hard to believe—that WHO ministerial meetings can be rather dull affairs of little consequence. Ministers typically take it in turn to read their prepared speeches; their fellow ministers appear to be listening attentively through their headsets but some, it seems, have been known to zap through the simultaneous translation channels in search of lighter entertainment. Speeches aren’t played over the loudspeakers for fear of waking jetlagged ministers from their afternoon naps. WHO is a very considerate organization: it likes to make sure that while on its premises visitors reach “a state of complete physical, mental and social well-being.”

Well I’m happy to report that last week’s ministerial meeting on Universal Health Coverage (UHC)—held in Geneva on February 18-19, jointly organized by WHO and the World Bank, and attended by delegates from all over the world (see map)—didn’t fit the stereotype.

The sister act 
I suspect this had something to do with the fact that two formidable women, WHO’s Margaret Chan and the World Bank’s Tamar Manuelyan Atinc (they call one another “sisters”) chaired most of the sessions. Between them they set a cracking pace, politely but firmly keeping everyone in line. They set the facilitators free to pace athletically around their central enclosure quizzing ministers and UN ambassadors, interrupting anything that looked like a set speech.

For the most part, the ministers and ambassadors seemed to like these new punchier rules of engagement. There were fun moments, and some slightly offbeat ones too. The Samoan Minister of Finance recounted how Samoa had recently changed its time zone. “We were the last country in the world to see the sun set. Now we are the first to see it rise.” There was a lot of chumminess. Finance and health ministers smiled at one another. Several finance ministers actually said they had every confidence in the health ministry. (In my country when the prime minister says that of a minister she’s actually about to fire him.) 

#UHC we can!
There are a couple of features of WHO ministerial meetings that are apparently hard to change. Technical people are to be seen but not heard at these meetings, rather like children who are allowed to stay up after bedtime to see their parents welcome their guests to a dinner party. Many of us resorted to Twitter, broadcasting in real time to the outside world in 140 characters or less everything that seemed newsworthy; the number of tweets mentioning #UHC spiked on the days of the conference thanks to our efforts (see chart). The other immutable feature of WHO ministerial meetings is the absence of real debate: however hard they tried, the moderators rarely got the delegates to disagree with one another. Some of us used Twitter to debate issues among ourselves and with anyone who was online and following our tweets; flash points included the roles of voluntary insurance and the private sector. 

So what did we learn?
Delegates expressed support for the ideas underlying UHC—that everyone, irrespective of their ability to pay, should have access to the care they need, without putting their family at financial risk. As Ms Manuelyan Atinc put it, “No one should have to choose between the health care they need and feeding their families.” Dr Chan, citing the Lancet, said UHC is “sweeping the globe, changing how health care is financed and how health systems are organized.” South Africa injected a sense of realism into the proceedings: “UHC is an orientation not a destination.” it warned.

Many delegates spoke of the importance of getting political commitment to UHC at the highest level. South Africa said that a strong partnership between the MOF and MOH is essential: “In South Africa”, the delegate said, “the two ministries now dance together.”

Several countries, including Morocco and Nepal, spoke of their decision to focus their limited resources initially on the poor and vulnerable. In her closing remarks, Ms Manuelyan Atinc expressed her approval of this approach, but urged health ministries to work closer with social affairs ministries to ensure consistency of targeting efforts across social programs. Delegates also spoke of the need to be realistic about what could be covered initially.

How to finance UHC was a common theme. Marie-Paule Kieny from WHO reminded everyone that UHC isn’t just about formal health insurance; taxes and other forms of government revenue also contribute to financial risk protection. With the exception of Senegal, there was little talk of voluntary insurance being a serious choice along the road to UHC. Ghana reminded us that despite its name the National Health Insurance Scheme is largely tax-financed. A recurring theme was how to raise additional revenues to expand and deepen coverage. Ghana’s scheme has a chronic deficit, forcing the government to think of raising the VAT rate. The Philippines is introducing a sin tax on tobacco and alcohol, and is earmarking revenues for an expansion of PhilHealth coverage, beginning with the poor and vulnerable.

There was agreement that human resource shortages posed a challenge. The international brain drain was discussed, with fingers pointed at certain rich countries that are proving popular destinations for medical migrants. The US outlined its efforts to reduce its demand for medical migrants and its efforts to help build more capacity in the developing world. Dr Chan commended the UK for its efforts to stem the tide of medical migration to the UK. Brazil urged delegates to think not just about the overall number of health workers, but also their distribution, especially between poor and more affluent areas.

Several delegates argued—especially those representing finance ministries—that the health sector could do much more with existing resources. The Nepal delegate argued for “spending wisely, not widely”. Improving information systems was a common theme. “Without such improvements”, Colombia said, “it’s hard to ensure that government funds are actually used on delivering necessary patient care.” Chile told delegates that its experience had shown that strong accountability and a good information system are both essential to ensuring results. Mexico outlined new rules that will force states to be more accountable to the center for its federally-funded health spending. Morocco pointed to the need for strong accountability to reduce waste and ensure quality care for everyone. Several delegates highlighted the need to provide providers with the right incentives. Georgia said it is moving to DRGs and introducing quality assurance programs.

There seemed to be some disagreements beneath the surface about the role of the private sector in delivering publicly-financed care. Dr Chan spoke of the trust the public sector enjoys but its poor record on efficiency. The finance ministry delegate from the Philippines noted that there privatization of water and power had resulted in improvements in service delivery. “Shouldn't the government explore contracting with the private sector?” he asked. Someone pointed out that Japan had achieved UHC with 70% of care provided by private sector.

The importance of data and monitoring progress towards UHC was a recurrent theme. " Ghana spoke eloquently of the country's culture of use of data and evidence to promote accountability in the drive toward UHC. The Philippines said it would judge the success of the sin tax reform in terms of lives saved and the health improvements, adding that metrics are essential to ensure that UHC initiatives don’t become “a black hole”. South Africa said it was putting quality at the center of its UHC agenda, and said the government wants to know whether mortality and morbidity will improve as a result of UHC. Zambia said it wanted evidence specifically on the impacts of UHC initiatives, not just of the health system in general. Josep Figueras, one of the facilitators, asked how in monitoring progress toward UHC we could balance richness of UHC and the need for simplicity. He urged us to “avoid paralysis by analysis.

Inevitably the role of UHC in the post-2015 agenda came up. In the shortest intervention of the meeting, Turkey encouraged all to place UHC at center of post-2015 development goals, and said it would like to work with other countries on this agenda. The US concurred that UHC could be the unifying post-2015 health development goal. Closing the meeting, Ms Manuelyan Atinc said she too agreed but suggested that there should be an overall health outcome goal too, like healthy life expectancy. “Better health is, after all, what we’re all about.” she reminded us.



Submitted by Martin Schwartz on
The tweets dropped off fast, so you need another meeting? You do give a entertaining description of the proceedings, so let's hope for many more meetings. Meanwhile there is a big lack of results for clients health outcomes in Haiti and not because they have too little of UHC:

Submitted by Martha Penn on
I can see the burst in tweets. That's a wonderful accomplishment, and yet ..... not really what you really want to see when "taxpayer money is at work. ". A hundred thousand dollars or more, for expenses of the meeting (geneva is pricey, many flew from -and to far away) all for a brief tweet blip? The participants said what sounds like they have said and heard hundreds of times before. At least judging from what's written in the report. How much was poverty reduced because of this meeting? Will some things be different in lives of poor people in the next 12 months because of this particular meeting. Can the rapporteur please elaborat?

Submitted by Prashanth on
Thank you for a very nice (yet light) account of the proceedings. One thing that immediately springs out is the missing perspectives of India and China. That's over 2 billion people there and a lot of work to do, but are they reasonably engaging at this debate at the global level? At least in India, there is "some" debate happenign at the Centre, but none at the states, where it is more crucial. And of course, just out of curiosity, I wondered what (if any were expressed) were the US perspectives on this UHC thing.

Submitted by Tamar on
Adam, thanks for your usual substantive and at the same time witty blog and for chronicling so well my last meeting representing the Bank. Whether it is a sister or a brother that follows me,I do hope that the mature sibling relationship that we have managed to foster with WHO will continue to be nurtured. There is much to gain from working closely with WHO and the universal health coverage agenda needs both institutions to actively engage countries at the policy level and yes through the wonderful technical staff who should join the dinner table!

Submitted by Mariette Ered on
First problem: What about the 1 bottom billion who do not have enought to eat? Does this not make UHC less relevant? Really the first priority needs to be ensuring enough food consumed so that millions of people do not become ill from lack of food. Will UHC pay for food for starving and malnourished people? Why not? Because it will only pay doctors and pharma companies? Why is food not covered? No matter how much you scheme to extend, deepen or enhance UHC , even with all imaginable preventive services , as long as this is the main problem: UHC is not really relevant to poverty and health outcomes. Second problem: Why a global target? There is no logical raison d'etre except if you want to have Mutual support among health misnisters in their pursuit of more resources, at the expense of other pressing needs? The main beneficiary of UHC is the doctors and sealth care bureaucrats and pharma companies profits.

Submitted by Toomas Palu on
Well put, as we have come to expect from Adam's blogs. Where the sisterhood (or brotherhood) between the two agencies would have to be most effective is at the country level. Sincerely hope that the message gets down to the trenches where UHC and other health development issues and debates become very concrete. We have a great experience in Vietnam, good cooperation with WPRO, but also several countries where we could do much better. Toomas is health sector manager for the World Bank East Asia and Pacific region.

Submitted by Dean Shuey on
These comments were initially triggered by the recently released 22 country case study on UHC which I think was meant to coincide with the meeting on UHC being discussed. I find it fairly amazing that the World Bank can put out a summary of over 100 pages on Universal Health Coverage (UHC) and not even mention or reference Primary Health Care (PHC) once. Perhaps since the Bank and the IMF spent a good deal of the 1980's and 1990's actively encouraging countries to starve and dismantle the existing, albeit poorly functioning, frameworks for universal health systems I should not be surprised. Yes, it is a paper reviewing evidence, but it is treating what is a social and value laden decision about 'health for all' as if it can be a painless technocratic fix if we just pick the right tools or knobs to twist. And, even though it is about UHC, the fourth one of their lessons about the value of highly focused interventions puts the authors firmly in the camp of 'selective PHC', targeted projects, and ignoring the underlying social determinants. I am a bit surprised that WHO, which was too quiet about the effects of structural adjustment in the 80's and 90's, is now seeming to let go of one of the core parts of Dr. Chan's manifesto for her election, the revitalization of PHC. You can say that rebranding things is sometimes necessary, but I think the 'right to health' is a more fundamental concept, not a commercial product being sold. You don't really think of the 'Declaration of the Rights of Man' or 'life, liberty and the pursuit of happiness' asa concepts that are rebranded. The whole round of meetings, resolutions and banners can be a distraction. A new tag line can divert people from the hard decisions needed. If implementing PHC, or UHC, was easy, it would be done already. UHC needs to build on existing work. I hope I am wrong in my pessimism. I end with what I see as the core paragraph of Alma Ata. "Primary health care is essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self- reliance and self-determination. It forms an integral part both of the country's health system, of which it is the central function and main focus, and of the overall social and economic development of the community. It is the first level of contact of individuals, the family and community with the national health system bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process." Has UHC really added much to that? Dean Shuey

Submitted by F. Upham on

I attended that inter-governmental meeting a civil society (DGH). My 'inside' view of the meeting is very very different from the report I read. There were no consensus by Member States on 'targetting' as proposed by the organizers. Many countries identified that they did not want 'poor health care for the poor'. Senegal said the poor would reject care if it was not comprehensive. Many countries object to 'packages of minimal care', with vouchers (replacing user fees but in a similar mindset)
Many countries also stressed that good health output in their countries were reached by strong public health care systems. Public health care allowed for citizens to have access to primary health care and also hospital care. The private sector contributes but hangs on the strength of the public system. France-Germany health specialists favor universal social security insurance system while the UK favors a charity based model. The debates were strong even if the tone is always very diplomatic. And the sound system is meant to allow delegates to discuss the issues among themselves while listening to the speakers without disturbing others. I have attended the World Health Assembly for over 20 years, and what is a pity is that the reports from these are always bland, spiceless, while many governement are in fact often enough showing courage.
In a lunch time meeting with the Bank and WHO DG Dr Chan this past Friday (during the WHA in Geneva), we heard Nils Daulaire (US rep.) speak of the Right to Health, and stress it was the first time ever that the USA spoke that language. This is progress.
In a nutshell I would say the underlying debate is really whether countries can undertake to achieve "Quality Health Services for All" (after all even very poor Cuba achieved that, besides Sri Lanka, France, Brazil, Thailand, Costa Rica etc etc. El Salvador and Ecuador are making great progress... And many differ from Dr Margaret Chan when she said this Friday : While many British "hold dearly to their NHS...UHC is all services for all people? NO!". Some of us, basing ourselves on evidence of countries such as Brazil strongly believe we should all strive for that. We say "YES we could." Of course it cannot be overnight, but the question is not money, the question is political will. And true enough it demands a proper approach in economics, a notion of developmental State. In 2011 China adopted a continental European social protection system, including health, retirement etc., if the BRICS countries pull the chariot of UHC, then we might get somewhere.

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