 to this special session of the Wonka World Conference 2021. This special session is about universal health coverage. And my name is Professor Amanda Barnard. I'm from Australia and along with Professor Chris Van Weel, who many of you will know as the past president of Wonka, we're chairing this session of four very distinguished speakers speaking on this topic. All the speakers are going to present and we'll have a panel discussion at the end. We are very, very keen to get the questions that all of you will have about this very important topic to us as family physicians. And we encourage you to put your questions in the Q and A section on your screen and we will get those and present them to the panelists at the end. So without further ado, I would like to hand you over to Professor Chris Van Weel to introduce our first speaker. Thank you very much, Amanda. And it gives me great pleasure to introduce as our first speaker the very distinguished person from WHO Dr. Salam, who is educated at Harvard, but more importantly, he is a very experienced staff member of WHO with a very strong feelings about primary care, very supportive for us, but also with a very critical mind to understand what is and what is not important in our discipline. So without much ado, I would like to hand over to Hassan to you for your presentation on universal health coverage. Hello, everybody. My presentation is about universal health coverage in our region, the Eastern Mediterranean region. And which I'm going to focus on three main topics. The first one is dealing with an overview for the universal health coverage in the EMR. Second is about the key challenges facing universal health coverage. And the third is about the priorities and the recommended action towards universal health coverage by the year of the 2030. We are talking about nine years from now. As a background, most probably already familiar with this, and this is dealing with the sustainable development goal, which actually adopted in the United Nations back to the year of the 2015 under the title of 2030 agenda for the Sustainable Development Board. Goal number three is about the good health and the well-being. And the target number 3.8, it is about universal health coverage. What is the situation of the universal health coverage? Still in our region, the UHT 16 basic health service around 40% of our population, they don't have an access to this 16 basic health service, which actually very high comparing to the global numbers. By the way, this is the most updated data. And the data for the 2019 is going to be released in December, this coming December, within a couple of weeks during the World Universal Health Day on December 12th. The universal health coverage actually is facing a serious challenge in our region. And in June, a couple of months ago, we published our report about the progress on the 50 health related sustainable development goal. And actually, this report identified the many challenges facing sustainable development goal. Mainly about the weak governance. This is very serious challenge. In addition to the fragmentation of the health care system and availability of the data, there is a serious challenge about the limitation for the data availability, countries under the emergency, and the gender equality and health disparities. Let us go in more detail about these challenges facing our region to reach to universal health coverage. The most important challenge is the impact of the emergencies for agile and humanitarian sitting. Our region for the Eastern Mediterranean region is the home to more than 100 million people that they need the humanitarian assistance. This is very serious. It's a challenge. In addition to this, around in the range of 40, sorry, 49% of the whole world refugees, in addition to the 44% of the whole internal displayed globally are from our region. This is the most serious challenge facing our region to reach to universal health coverage within the coming nine years. The second one is about the weak governance. Our region is fully committed to the universal health coverage. All the countries are actually committed. But on the other side, still there is a weak technical capacities for the ministries of health to formulate the policies toward effective universal health coverage. This is the second serious challenges facing our region. To start with our region for the Eastern Mediterranean, actually, they are very low investor in health. We keep talking about the primary healthcare that how it is very important for the universal health coverage. But on the other side, the government is spending on the primary healthcare. It may drop to just only 5%. And the most of the budget around between 50 until it reached to around say 80% of the government health budget, it may go to the hospital. Even with this huge budget to the hospital, still it is it may reach between 12 until around 80% of the healthcare associated with infection. And this is by the way, this is the highest in the world, 8% of the in patient cases experience adverse event, which we call it the medical error. And the main reason for this, because almost around say 50% of the countries, almost 10 countries in our region, they don't have infection prevention control problem. Because of the limited budget directed to the primary healthcare sector, and the weak referral system, in addition to the limited quality, this it ends to around say 80% of the reach to 90% of the hospital case actually are treatable at the primary healthcare level. Around 90% of the primary healthcare facilities, they don't have full comprehensive essential medicine list. Just only 10% of them, they have this essential medicine list. And the antibiotics, usually they are provided for almost 70% of the primary healthcare prescriptions. This is very, very serious. Family practice in our regions facing serious problem. The main reason for this, because the shortage of the family physician, and the 93% of the physician working at the primary healthcare level, they are generalists, they are not a general practitioner, and they are not a family physician. The essential service package in most of the countries, it is kind of an implicit one versus to be an explicit one. 80% of the countries, 80% of the countries, they don't provide treatment comprehensive treatment for the non-conventional diseases at the level of the primary healthcare. Such situation, at least that diabetes prevalence in our region, it is the highest globally. All these facts actually leads to that the private health sector taking the lead in the service delivery, and on average it reached around, say, 66% of the services are provided by the health sector provider with very high out of pocket in our region. Above all of this situation, and since March of the last year for the 2020 COVID pandemic impact came. And in a recent study to the World Bank, it mentioned that for each COVID deaths in more than two women and the children had lost their lives because of the disruption to the health systems. Talking about disruption of the health system and in particular for the service delivery, it reached to more than 70% of the service has been disrupted. This is back to early 2020, which was the highest globally. Recently, during this 2021, we conducted the same assessment, and we found that it reached to just only 30%, which is much way better situation now. But the problem, it is not about the disruption of the services only. Now we are in the era for the COVID-19 vaccination. Still around 25% of the countries in our region, it reached less than 10% of the population they received the vaccine. Again, this is very serious challenges in our region. Let us move to the last part of my presentation, and it's talking about the priorities. Recommended action towards universal health coverage by the year of the 2030. Political stability and the ending of the conflict. This is top priority for us without having good political stability. And the ending of the conflict, it will continue universal health coverage for many countries and their population to be as a dream for this population and this campus. On the left side of the screen, you can find that all the countries already committed to the global compact and to universal health coverage 2030. This is on the left side. And on the right side, this is what I got from the internet, which actually presents the tensions between the countries in our region and the cutting of the diplomatic relation. And definitely this situation affected the development in general and universal health coverage in particular. Again, without having political stability and the ending of the conflict between in the countries, this will continue. The issue for the universal health coverage will continue as a dream for most of the population in our region. The second important topic that as I mentioned that the countries are committed to the universal health coverage, but many countries in our region, they are not clear what model of care they are going to use. And I mean by the model of care, not only the service delivery, but in addition to this, we are talking about the governance, about the finance, about the technology, about the information system. All of these things take us an idea about the model of care. In the World Health Assembly, back to the last year for the 2020, they already adopted and approved the operational framework for the primary health care and deliver this including the level number five, which is talking about the model of care. What do we mean exactly by the model of care? The model of care give us a kind of conceptualization of how the service should be delivered. And this is including the management of the population, management of the service in addition to the selection and organization of the service. The third important topic that primary health care partners need to work together through the global action plan. And I mean by the primary health care partners, this is including the WHO, UNICEF, UNHCR, UNFBA and our colleagues from the Arab Board of Health Specialization and of course our colleague from UNCA. In which actually we're already listed that there's four topics of our collaboration for the coming period and actually it started during this year for the 2021 and it's coming and to continue in the next biennium inshallah. Thank you colleagues and I have around 90 second a video that it's talking about the universal health coverage and I would love to share this video with you. 2030, it sounds like years away but the clock is ticking. Time is short and we have a promise to keep. A promise to ensure all people and communities in all countries receive the health services they need when and where they need them without facing financial hardship. But there's still a lot of work to do. At least half of the world's people lack full coverage for essential health services. More than 800 million people spend over 10% of their family budget on health services and close to 100 million people are pushed into extreme poverty because of healthcare expenses. We cannot accept a world like that. We cannot afford a world like that. That's why countries all over the world are investing in universal health coverage by enabling communities to make decisions about their own health like breastfeeding, healthy diets and bed nets. By reaching the most remote villages with life-saving services like vaccines. By building networks of affordable primary care clinics to provide treatment locally for everyday health needs. And by providing more sophisticated services at hospitals for lives ups and downs. The thing is universal health coverage not only improves health and increases life expectancy it also reduces poverty, creates jobs, drives inclusive economic growth improves gender equality and protects countries against epidemics. With investments every nation can increase its range of health services, expand its health workforce, improve its infrastructure, ensure essential medicines are available and protect people from the cost of paying for care out of their own pockets. We call on the global community to make universal health coverage a political priority so everyone can access quality healthcare without facing financial hardship. If we work together we can make universal health coverage a reality and ensure a safer, fairer and healthier world for all. Thank you very much Hassan for this energetic and moving and very realistic presentation. I think we will have a lot of discussion on it but therefore I now immediately go to our next speaker. I'm very happy to introduce to you Professor Shabir Mouza who is professor at Wittwatterrand University in Johannesburg but more importantly has been president of Wonka Africa and has done wonderful things together with the Pima Femmet and the networking in that part of the world therefore who has a better view on universal health coverage in Africa. Shabir over to you. Hi my name is Shabir Mouza I'm going to talk about UAC in Africa, my experiences are experiences and perspectives. I'm going to share a little bit about the history of PAC in Africa, the AHAG report which is really useful and building Afro-PAC as our experience has gone. So let's start with the building history of PAC in Africa. PAC in Africa is not you know just since 1978 in fact in the 1940s the CACs have developed community-oriented primary care in South Africa and there were other elements of such community orientation across Africa but 1978 isn't important hallmark or important milestone in Africa. Certainly in the 80s and 90s despite the alma mater talking of comprehensive health care based on the cheap versions of selective PhD but driven by UNICEF and UNAIDS over the last 20 years or 20 years from 1980s to 2000s has been marked by a very selective primary care verticalised programs. In 2001 heads of state agreed to the Abuja declaration of 15% of health spend by 2015. In 2006 there were resolutions by the AU and the WHO Afro about universal health care being an important question and basing that on a well-functioning district health service and they promoted a medium-up approach. In 2008 the Ugo-Dugu declaration raised the question of that there's a lot of commitment to primary health care but in action it's not really coming through. Primary health care approach was emphasised once more the importance of decentralised care, de-sectoral collaboration and the whole international nature of primary health care being comprehensive, continuous, integrated and community-based was emphasised but still in that declaration the statement was made let's use priority programs as the entry point to strengthen national systems. In fact in 2012 the roadmap for scaling up human resources in African health care did not mention primary health care at all even though it set out six strategic areas for improvement. In 2017 fairly recently WHO resolutions basically called for a holistic approach to strengthening health care systems moving away from the program specific approach of the MDG era and I think that's a major shift and called again for efficient integrated person-centered delivery with the intersection of collaboration for SDGs. Certainly the person-centeredness is beginning to grow in the African context slowly. In 2018 at WHO AFRO there were resolutions around financing and importantly it talked about increasing domestic financing where many have not achieved their budget declaration and talked about the need to move out of pocket into prepayment financing systems and I think that's a very important issue as well as talking about strategic purchasing and the fact that one needs to move away from dependencies on external financing. So these were important debates in the last few years that have shifted the equation. In 2018 the WHO contribution to the Astana report basically complained of the challenge of poor decentralization where not only is the managers on the on the district level not capable the managers higher up are actually reluctant to provide the power for human resource management and financial management procurement and I think this is the problem of chicken and egg in Africa. In 2019 in a report by the WHO on the state of Africa African health it talked about worrying situation with underperformance on several levels and speaking of the WHO building blocks is actually perpetuating a verticalized service and that one needs to somehow move beyond into talking of a intervention that's collaborative and in fact very person-centered. So a PhD performance initiative is certainly a useful framework and in fact many of the issues within the black box of service delivery are not being dealt with adequately and particularly the population management approach which includes impanelment is not in the lexicon of WHO Afro. Team-based care is there but still not very clear and more about tall shifting than actually integrate teamwork. The availability of prime health care providers is still a far distance away with prime health care itself not being clear as to where it sits and where it stops and where secondary care begins in prime health care or in health systems in Africa and I think the nature of prime health care being continuous collaborative and comprehensive is still a dispute within Africa and I think one really needs that to impact as we proceed to support African prime health care for USAIN. So the AHAC report is an important contribution to this debate. Essentially I was a commissioner in that report which is the Africa Health Agenda International Conference and there was a commission called for 12 commissioners and in that we basically came up with four elements showed the you know represented the performance or assessed the performance looked at the challenges the opportunities which we thought important as well as recommendations and I'm going to share those elements very briefly with you. In terms of performance at the health outcomes in Africa are improving but they're still very dismal compared to the global numbers. Effective coverage is very poor only half of the people less than half the people in the in the continent receive what they need in terms of health care and then those who do are more rich than poor and the the quality is not adequate. There's also poor risk protection the financial risk protection with one in ten persons in Africa actually having a problem health problem that that sends them into poverty one you know in one in ten people. The context is in fact very challenging so these are some of the challenges that we have inadequate economic growth and in fact a high dependency number of people in Africa certainly the number of people depending on those who work is very high and we are characterized by political instability and wars and and the fact that we have really rapid and unplanned urbanization. Climate change is an issue in Africa and we also had the legacy of colonization and neocolonial influence and I think these are really important background issues with large corporations as well as governments foreign governments and institutions global institutions that push agendas that aren't for the best of African nations. Yes we do acknowledge that there are serious problems in the health system in that they poorly manage the resources poorly manage their weak governance and accountability issues. We have a high burden of disease and there is a really low trust and ownership by the population in the health systems. We do have challenges in the communities of health beliefs and societal practices that can be very challenging but there are in fact opportunities and these are important to note the African economic trajectory has been really rapidly growing the next century maybe the African and the AU is certainly looking and seeing this as a as a pro-people union of the nations in Africa. The key milestone for that has been the African treated area which is basically coming together to bring the single big biggest economic block in the world together and there's a network of traditional healers healthcare that we need to capitalize on and there's a strong political commitment that we need to strengthen and also use and of course the demographic dividend or the growing population of young people who in fact will contribute to economically in the next century will be quite important to its growth an important opportunity. There are also other opportunities in the continent with a fairly developed private sector. You know we have an ecosystem that is supportive of innovation especially the lack of legacies problems that exist in other parts of the world and the speed with which we can leapfrog others across the world. There's a strong civil society across Africa and growing in time. We do have well-trained and competent health professionals even if they do leave the the continent and of course COVID-19 has also helped us in strengthening health efforts, health strengthening efforts especially with the EU collaborations. The HIG report came up with recommendations and I think I was really pushing for this to be at the top that really we need to reorient the health system towards population of needs especially prevention and promotion and that there needs to be a strengthening of the primary care system and prioritization. Health in all policies that investments come to strengthen it that we actually strengthen health facilities as well as the health care delivery and particularly with flexible non-hierarchical multidisciplinary teams made up of clinical and non-clinical staff to provide integrated clinical care or integrated health care to defined and panel populations and I think this is an important intervention and that these should be you know part of not only delivery but contracting and reimbursement in prepayment models. So this was an important achievement for Wonka Africa in that. Of course there are other health recommendations including input, south technologies, quality, financing and governance in the HIG report and these particularly include that there be cross-cutting development strategy making help that and looking at stakeholder management especially public-private partnerships and to strengthen community participation. These were all health recommendations for health systems across Africa but there were also recommendations for government and states to in fact decolonize health policy as an important consideration. Of course other actions are also important particularly the demographic dividend and investing in that for the future economically. Well let me conclude by saying that we are looking at building Afro-PHC as a important step in UTC in Africa and the Afro-PHC is basically a forum bringing together multidisciplinary primal care team members that's and workforce stakeholders from across Africa and advocating supporting each other and advocating for primal care and universal coverage. The Afro-PHC has was it conceived actually in in the Wonka Africa conference in 2019 and essentially grew through 2020 with a number of workshops and webinars that tried to engage with a whole bundle of stakeholders importantly trying to bring on board the WHO Afro as well as all key stakeholders and growing that network and this certainly has improved in 2021. This year we in fact have a number of workshops that have tried to pull together a number of policy threads and in building on the Afro-PHC statement that came in 2020 where the wide range of members of the Afro-PHC team agreed that all members of the team are important and that one needs to peel that away layer by layer in trying to build primal care and in UTC in Africa. Well with these collaborative interactive workshops we have formally launched Afro-PHC in 2021 with 600 members from 40 countries and a busy developing a position paper on building the PHC team for UTC in Africa. Some of the key ideas is that we need to move away from governments thinking of health systems as driven only by the public service and to think of how to build in a much more wider stewardship of the public service through pooling of funds in national health insurance funds or national funds that are taxed and built through tax and removing and reducing the out-of-pocket in across the content across the countries and to be able to get private administrators and private providers in the mix of public health and private sector and non-state act non-government service providers so that one can really include in small decentralized units of care even up to 10,000 where a doctor can join current clinics and where GPs can actually bring together a team to be able to create empaneled populations of anywhere from 10 to 20,000 to 30,000 depending on the African context and I think there are some key principles behind that that must be built on teamwork, community orientation, referral support and district coordination and supply side innovation that this kind of bottom-up allows us to be able to bring them together adding layers of service that in fact can improve in addition that there's easy possibilities to accredit such units of care, decentralized units of care where enrollment can occur and cover the entire population based on reasonable mixes of of population to human resources, delta submission easily through payment through simple payment management systems peer review and training that would eventually lead to practices that in fact can be across the country and the continent where there's a strong population management by community health workers linked to clinics where there's a reoriented of the re-orientation of the team from managers above to population below using mixed capitation systems and where they stakeholder collaboration and targeted health promotion. I think that these are the various options and I think that there's more on advancing primary health care in Africa at the website of the AFRO PHC I hope this has been useful thank you very much. Thank you Shabir for sharing these important experiences from Africa and it's very impressive to hear both the EMR and the African experiences and from EMR and Africa we now move to South Asia and I'm delighted to introduce to you Raman Kumar, Dr. Raman Kumar who is the past president of Wonka South Asia, he's also the president of the Indian Academy of Family Physicians and who better knows the situation in South Asia than he so over to you Raman. Hello delegates, greetings from India, South Asia. I'm Dr. Raman Kumar, I'm the president of Wonka South Asia region and I'll be giving you a brief update on experiences perspective from South Asia and universal health coverage so this is part of our bigger panel discussions that we are holding in the global health perspective and this is what South Asia looks like we have countries like Pakistan, India, Nepal, Bhutan, Bangladesh, Sri Lanka and Maldives and we are a quarter of human population we are a small Wonka region though and we see a lot of global disparities inequities in qualities unmet needs under double family medicine in primary care because of the special situation of high population and high population density and this is what the map looks like and this is where we are located and there is pressing needs for programs like universal health coverage from South Asian perspective when this region has been trying to catch up globally on universal health coverage and it has been of course impacted during past three years because of the global pandemic because especially the second wave of pandemics really impacted our region and because of the pandemic most of the funding healthcare planning priorities have taken focus on COVID management and in a way the universal health agenda has been slightly delayed I would say because of the pandemic especially but now the the pandemic is settling down it looks like although we are still passing through the pandemic we never know what will happen in coming to say six months but at the moment it is settling and then again we are trying to engage with the universal health coverage agenda of the region. In South Asia I would like to share that the first wave was not that strong but second one wave was really really very bad it impacted whole of the not only health system people but also it has impacted the whole of the economy and it has really adversely impacted the evolving universal health coverage agenda so this is the current situation as of today this is 14 days back it looks much better in South Asia as compared to America or Europe Russia but it was very very bad couple of months back in the months of April and May when we had second wave so we are coming out of it and I have opportunity to attend the Tuberculosis Regional Committee meetings of South East Asia region and from there I can say that universal health coverage is still a priority area and you can see priority issues as they were discussed during the past three regional committee meetings so if you look at number three point annual report on monitoring progress of the USC and health related STGs so this was discussed during one of the committee meetings and other priority areas of our WSU region have also been regulated in spite of the covid challenge so you can see it is still in the focus though slightly delayed I would say and this is what is all universal health coverage about South Asia region it is from WHO page and as we all know universal health coverage has two dimensions access to needed health care and financial protection and region has an essential health services index of 61 in 2019 as compared to 46 percent in 2010 which is improving and strategies are in place and it is evolving it is work in progress and every country is committed what I can see irrespective of the financial situations and I will share this screen this is from World Bank Group and it is the index of universal health coverage and the values you can see the best one from Sri Lanka Maldives and Bhutan because these are relatively small countries India is scoring 55 slightly better than other countries and we do have other challenges political instability other problems in our region financial of course and this report is from 2017 so we are ahead of this by around four or five years though we have lost around two three years in pandemic again but I think we have been making steady progress I briefly discussed about two countries Sri Lanka the best performing in India because we have a huge population to cover and unique in its requirements so that may be of interest to wider global audience so this is again you see all global organizations are focusing towards universal health coverage you see in NSF X-ray team progress was universal health coverage in South Asia in the era of COVID-19 so Sri Lanka is one of the most advanced health systems and largely praised for their intent to implement universal health coverage and they have tried to do it since you know for several decades and everybody gets equal healthcare free at the part of delivery and they have publicly funded through the general tax payment system and it is only controlled by public sector but it is pluralistic encompassing both public and private sectors and the public sector provides good quality healthcare at no cost to patients from primary literacy care but Sri Lankans still rely heavily on the private sector for all patient care which involves out-of-pocket payments so this is a brief situation in Sri Lanka then I'll also talk about India India launched a national flagship program of universal health coverage under the leadership of the Prime Minister it is called Aishwan Bharat Pradhan Mantri Jan Swasthay Yojana which means literally long-lived healthy life prime ministers public health program and this is what it means health coverage up to five lakhs per family to around roughly around seven to eight thousand dollars per year for secondary and tertiary hospitalization under Aishwan Bharat program and this is how it has evolved till now Aishwan Bharat program has crossed one crore milestone one crore people have been given free treatment under this scheme till now and it is a commitment to cover around 53 crore citizens and health insurance cover up to five lakhs per family per year and it will have primary and secondary care treatment at 2100 and 500 in balance healthcare institutions and under this scheme over 3000 citizens were tested this is old data but now we have a wide coverage of COVID treatment as well as screening and you can see our Prime Minister's image on this slide because there's highest level of political commitment for this program and it is a completely cashless, paperless access to services for beneficiaries at both public and private hospitals and this is briefly shows the process of availing care under the universal health coverage that is evolving in the patient hospitalization beneficiary identification registration, free operation request and approval treatment discharge, claim requests and settlements this is the cycle of care and this is how it is digitally managed at the citizen level, hospitals level and the third party or insurance providers and this is overall digital framework in the universal health program and this is the health ID looks like Aishman Bharat Arabga card again a digital identity card for availing this Aishman Bharat universal health service program in India and a national health agency has been established to overview and run this whole process so this is briefly about the universal health coverage development in spite of the COVID challenges we are trying to progress and even during COVID the national health program the universal health care program in India has given coverage for treatment of many COVID patients also and hopefully as we come out of the pandemic it will have significant impact on the lives of the common people because a large session of the population and we promised this and the most populated, one of the most populated countries of the world so thank you very much delegates ladies and gentlemen for patient listening, thanks a lot. Thank you very much indeed panelists we're having a little bit of problems connecting our last speaker Dr Thomas Mianna so we might in the interim start with questions that have come in and the first and I do encourage you to continue to write questions in the Q&A box as we if we can't connect Dr Thomas we will obviously have a little bit more time to ask questions of this distinguished panel and in learn from the discussion there so the first question Hassan is for you in your talk you mentioned as one of the recommendations a regional professional diploma in family medicine and the question is what role do you see family medicine and the development of family medicine playing as part of the solution in delivering universal health coverage in in the emerald region thanks a lot Amanda thank you very good question actually okay we keep saying that the primary healthcare is a cornerstone to reach to universal health coverage talking about universal health sorry talking about the primary healthcare it is not only about the governance or the finance or the information system the core of the primary healthcare is the human resource development the current situation in our region that more almost than a quarter of a million of the physicians they are generalists they are not general practitioners they are not a physician actually the situation that 93 percent of the public primary healthcare facilities are managed by this generalist this current era of generalists to be responsible about the delivering of the primary healthcare definitely it will not reach us to the universal health coverage for sure we need to to go for the family physician this is a key for us to reach to improve the the physicians capacity and to move to the universal health coverage that's why we developed already this regional professional diploma in family medicine in full cooperation with Wonka and we already launched something like more than almost 16 months ago then we decided to go on and to upgrade it for from one year to two years diploma and we are going to launch it in the 20th it's Monday 28th of February and the coming year for the 20th hope that you thank you again thank you very much indeed and I wonder um uh Raman if you would mind um if you are there if you could turn your video on uh and do we have Dr. Thomas now all right ah thank you no Chris I'll hand back to you and we will continue thank you okay okay thank you very much and welcome Dr. Thomas uh meone we have gone through the eastern Mediterranean to Africa to South Asia now we are going to the Ibaramarikana region where initially we had Dr. Jacqueline Ponzo the Wonka president for the region as a speaker she was unable to join but we're very happy Dr. Thomas Meone that you stepped in last minute I understand that you were recommended by her so she I'm sure you will be an excellent expert on the universal health coverage struggled in your region you have not pre-recorded your presentation so you will give it straight on now so I turn over to you the floor is yours good luck thank you very much thank you thank you very much um so honored to be part of the of this panel ingredients from Costa Rica so I will share my presentation uh we will be talking about experiences and perspectives within Ibaramarikana sim in the matter that we are discussing on universal health coverage so we do some work before as in the confederation we have every two years we reunite some people to think about the processes in the different countries of our region then first of all we like to take back the the arms of the whole definition that says that people are increasingly dissatisfied with the inability of health services and health systems have to respond better and faster to the challenges of a changing world so we in Brazil in 2016 we have the Wonka World Conference and before that we achieve a reunion and we discuss the universal health coverage based on qualified primary health care and we define that it means timely access for individuals families and communities without restriction to the goods and services that their health conditions require means access for people to comprehensive and coordinated care for promotion protection assistance and recovery of health in accordance with the needs they presented the course of their lives in the end this is the very reason for being of a service and a health system this is one of the matters that is important to us in the American region our confederation or our organization over the course of more than three decades has worked for the development of family and community medicine and primary health care and to do so we invite the others health actors in Latin America in Latin America Spain and Portugal and every two years we have these our summits these reunions of these summits are political and technical scientific events we exchange of experiences and participatory activities with strategic representative from the field of health education and research and the results are expressed in the form of a letter or we can say like a like a mole which usually bears the name of the city which is carried out I came with this because we talk about universal health coverage very deeply in the fifth summit in Quito in 2014 and family community medicine and social participation in this at that at that moment we came with another definition of universal health coverage that we thought or we think that suits better better for the for the region in spite of the universal coverage definition as it is we added that have or have to have the first levels of care at the axis of care with family and community doctors in the health teams that's for ensuring the first contact of continuous monitoring centered on the person and their family in community context in accordance with the health needs they present in the course of their lives in this summit we identify difficulties in achieving universal access persisting in the American countries especially affecting the most vulnerable people particularly indigenous poor Arula people as we see in other regions regarding the access route to universal coverage the continued dependence on direct payments in our some of our countries including user fees is identified as the greatest obstacle to progress we can name an example like Costa Rica which have a little more than 95 percent of universal public health coverage to Chile that has around 96 97 percent of universal health coverage but it's like 65 public and the rest is private in 2014 only half of the countries in the American region have universal access to health system although in most there are population groups without coverage we have a highly fragmented health systems the rights are granted coverage institutional arrangements vary among different groups like i said before we have usually organized by a combination of traditional public sector services for low-income groups social security service for for formal employees in some cases extends to their families for example Costa Rica is one of the examples and private services for those with ability to pay the lack of coordination between the three sub sectors has been a source of inefficence and inequities once the fragmentation hinders the efficiencies of the recourse resources required to achieve universal health coverage so in the next summit in 2016 in this in in our sixth summit we introduce universality and universal health coverage to a as a continuum for the work that we've been doing and we did a lot of research in the region and we define universality as the coverage that the population has for accessing health services and fulfill their right to it which must be protected financially by public policies and actions of the state and we define them also that might have scale and intensity proportional to the needs we watch define barman mode as proportionate universalism actions must be universal with a scale intensity that is proportional to disadvantage rather than focusing only on the most favor thereby articulating the definition of universality with equity therefore it is necessary to recognize equitable access to health services as a human right and not a privilege for those working in the formal sector or with greater financial resources our countries have a lot of immigration problems we are in continuous movement of people between our countries in the research we found some determinants in latin america the limit achieve universality on the primal health care and in the family community medicine most of the people we do this or we did this with a online survey and most of the people think that the structure and management will be the first thing to achieve to get universality in the primary health care and in the factors limiting considered by country to achieve the universality the most of the countries also think that is structure and management 29 percent around 29 percent report for going need care due to multiple access barriers 17 attribute to organizational issues for example long waiting times inappropriate hours of operation cumbersome administrative requirements and financial barriers were reported in around 15 percent of cases united weight availability of resources like health personal medicines and inputs in around eight percent of episodes and geographic barriers and five percent of the cases 80 percent attributed to acceptability issues for example language barriers lack of trust in health personal or being mistreated by personal preferable traditional and indigenous medicine people and the poorest wealth quintile were more likely to experience barriers related to acceptability issues financial and geographic access and availability of resources so we came with some conclusions to our issues to achieve universal coverage must act strategically in the five key actions areas of primary health care collect and disseminate information for action strengthening social participation fostering skills and knowledge of the population on health training and capacity building of human resources acting intersected really reoriented healthcare there are a consensus in our region that the concept of universality involves the right of the population to have access to primary health care and family and community medicine with comprehensive approach integrated and continues regardless of socioeconomic or geographical condition of the individual family or community and continuous balance and structure work is necessary to ensure that those populations will let access to service reach a staggered and well-defined manner the root process to define this scope according to the realities and the active participation of the member of our regions in the context of development country policies to achieve improved access to services is necessary and binding regional strategies must be generated in which those with more experience provide a platform for the country's universalization find a space of consensus on which to prepare the strategies for presentations to local governments and thank you very much indeed thomas and uh we can have all the panelists now with their videos on we can address some of the questions and again if anybody has any other questions that they would like to ask of the panelists please please enter them and we can address them in the time we have now um this this question is really to all of the panel and it has come up in in from the audience as well uh thomas you mentioned the phrase universality with equity and talked about some of the issues of equity in the in the provision of primary health care and and uh i in in our panel the in the questions that came from the audience it was says how can we address inequities within and between health care systems and the universal health care is a prerequisite but it's not the only but a potentially inadequate goal to address health equity and so i'd be interested in what the panel thought about that relationship between universal health coverage and health equity so i don't know thomas if you would like to start but i'd like all the panelists perhaps to to join in on that okay thank you well i think that to achieve your reverse health coverage with equity we have to hear what the people needs first and take that from the governments and discuss what they really need for example in most of the countries in our region there have to be a hospital side center distribution of the money so primary care and and and that was something that was so obvious with the covid pandemic in the primary care setting we we don't have a lot of resources to to attend the necessities of the of the population but if you go to the hospital you can find the most new technology to attend the the covid patients or or non-communicable diseases or whatever they need in that level so i think that one of the of the best things to do is to try to get the all the levels of attention in one in one route we have we have to build a real net that provide the right road for the people to go to the primary care level with a accuracy diagnosis access to me to medications and access to a consulting or you can send them to the another levels but always came back to the primary primary care setting to the follow-ups so i i think that one of the the most important things to do is to have this strong net between the the levels the different levels of attention in the public setting so the the other thing is to invite the private sector to enjoying the net so we can assure that if if you have an insurance and no matter if there's public or private insurance you get what you really need thank you are the comments from from panel members i think Hassan has got his hand up thank you thank you Chris yes Hassan please thank you thank you very much Amanda yes definitely the three dimensions for the universal health coverage it is mainly talking about the equity but as Thomas mentioned that we have to look for more comprehensive things we are talking about nine years from now let us be realistic some of the countries by the way from our region from the eastern Mediterranean region they already announced that no way that they are going to reach 200 percent or three for the universal health coverage index by the year of the 2030 so the issue so far which is the main challenges that facing the the topic for the equity is the ministries of health capacities they cannot deal with the topic of the universal health coverage why simply because the technical capacities for them if we will go for any ministry of health number of countries in our region still they are lacking this technical capacity to formulate the policies for effective universal health coverage in i'm talking about my region at least this is the most important thing over to you thank you for giving me that chance thank you thank you very much yeah perhaps i can respond as well thanks if you don't mind you know i think equity is an unreachable goal it's something we have to do it's an ideal but i think there's never such a thing as all of us being equal at Sunday it's it's just never going to happen but i think it's an important thing to always ask who's less privileged and how do we constantly address that problem and and aim in that direction i think the in in countries there's a huge problem in and particularly i think in low middle income countries for there to move away from this very bureaucratic approach of managing government which creates public services are unresponsive don't account for the private sector and doesn't bring all of the different you know stakeholders together in that way or providers together to actually look at the best possible outcome for the populations and i think that who is pushing by by suggesting these kinds of approaches bringing the public service uh private sector public into together into nationally funded insurance systems that will create a you know panels and that will manage populations and that's the kind of drive and i think that is certainly something that doesn't need to be overly technically i think technically technically in its management it can be done simply and i think they're good enough instances across the world of that being done fairly simply i think the other problem with equity i have is that in in the globe we have seven trillion of health spend across the world and many of us sit here in different health systems and don't realize that only two and a half percent if only two and a half percent of that would be redistributed to people of need that we would actually solve the global problem of universal coverage to primary of care add another two and a half percent and the full range would be addressed of course the question well what is that what what is that range of universal coverage and i think it tends to be something which one can say in the current you know terminology is relatively basic but it shows the inequity in our globe i think covid itself is shown just how the rich just do not bother when it's survival to think about anybody but themselves and i think we as an organization of family doctors need to ask ourselves which side on this equation are we on thank you very rousing work Shavir um i think that almost draws us to the click to the end but one of the things that we noted during the presentations was that covid has been a huge challenge and a number of you you mentioned the amount of money and and the demands that emergency care had but some of you also said that the covid had actually shown in your regions the importance of primary care and i just wonder if anybody wants to comment on on that potential tension and what covid has has shown us in the role of primary care and obviously in the context of universal coverage yes Hassan thank you thank you very much thanks again Amanda during the first waves by the way about the covid-19 the health system attention was almost more than 90 but almost 100 percent toward hospital care and completely ignoring the primary healthcare i'm talking again about our our region and all the budget all the attention all the human resources everything goes toward the hospital care keep saying that there is no any role for the for the primary healthcare in this i discussed the issue this is back almost to march or every i discussed this issue with the whole partners for the primary healthcare in our region and this is including of course the UNCA UNICEF UNFPA UN8 UNHCR and the Arab Board of Health Specializations and we found that the main reason for this because there is no clear functions for the primary healthcare that's why we developed an online training about the role of the primary healthcare and we disseminated in a joint collaboration with our partners and for the first time ever for the WHO and for the primary healthcare partners we reached to the registration of almost more than 90 000 primary healthcare from our region they registered for this we moved to the next step and we decided to make an kind of any evaluation and to get kind of what kind of impact for this online training we received and a feedback from the primary healthcare physician said that this kind of online training they give us the strength for how to deal with the primary care with the core function during the the COVID so my point is that at the beginning of this pandemic there was no clear functions for the primary care so having kind of clear deliverable things like this online training definitely it was very useful thank you again for giving me that thank you thank you we're almost out of time but I'll just give our last two panelists very very brief couple of words on this so Thomas first and then Ramam thank you Amanda well in primary care in our region COVID it has a lot of tension because of the follow-ups in most of our countries there were telephone follow-ups or video calls to follow-ups in housekeeping or house care of the patients with COVID but not only with COVID we are also so concerned about the next pandemic you know the non-communicable diseases and the other stuff that we are have to face right now so the all the diabetic people and hypertension and everything that is out of control right now because of the COVID thank you and a brief comment Ramam I think during pandemic the first wave there was more focused primarily because of the bureaucratic preference to focus on hospitals because it was easier to you know quarantine and hospitalize that sense but during the second wave which was very huge in a region everybody realized that the you know hospital approach of dealing with pandemics cannot you know solve the problems and overwhelming towards the you know as the second wave rose more and more realization was for primary care and access to you know a basic medical advice was very very valuable because you know nobody was there to do anything no hospital beds no oxygen nothing available and that was exhausted people realized that it was time for home care and then it moved towards home care community-based management even the vaccination started with selective selective hospitals and then it moved into the community to schools and to community health centers and to community setting but it has given a message thank you I think that's that's a very nice phrase to end on it has given a message so I would just like to thank you all very much for the messages that you have given us about universal health coverage in the region the challenges and and the successes and recommendations for way forward that very much involve family medicine and family physicians so thank you all very much and that closes the session thank you thank you thank you very much and see you all soon thank you thank you bye bye