 Welcome, welcome back to the second panel. My name is Robert Hecht. I work at the Results for Development Institute here in Washington, and I have the privilege of moderating this, what I think is going to be a fascinating session on country experience. Picking up on the theme of today's event, all of you were very smart to have joined us and come to this event. That show is already smart choices. And I think that CSIS made a smart choice of the panelists. And I'm going to introduce the three of them right now so we can move expeditiously through their initial remarks. First of all, on my far left, Dr. Yot Terawatanan is the founding leader of the Health Intervention and Technology Assessment Program, HITAP, which is a research institute under the Thai Ministry of Health. And I've known Yot for a number of years. He and his institute are really, I think, the global leaders among the developing countries, the middle income countries. Definitely are a leader in the Asia region in this area. So it's fantastic to have you here today, Yot. He's a medical doctor by training. He's worked in Northern Thailand. And he also has advanced training in health policy and in economics. So he's the perfect guy to get us started today. Secondly, and immediately to my left, Dr. Sebastian García Saíso is here with us from Mexico. Sebastian has had a number of different jobs in Mexico. You wouldn't believe it seeing how young he is. But he has done a number of different things in Mexico. He's currently in charge of the director for quality of health care and education in the federal Ministry of Health. So it's fantastic to have him here because as I think we've already started to hear this morning, it's one thing to say we've got it all covered. We have universal coverage. It's another thing to really deliver the services, deliver them at a high quality level and achieve the health improvements that we all want to see. So keeping in mind the possible difference between saying we've got it all covered and we're really getting the job done, Sebastian is our person for that. And finally, in the middle, Yang Zheng Huang is with us today. He's a senior fellow at the Council on Foreign Relations in New York and in Washington. And he directs the Council's program and roundtable on global health and global health governance. He, among his many talents, he's also quite an expert on China's health reform. And so I think this morning we're going to gain some very important perspectives from him on what China's doing perhaps on the plus side and some of the challenges they face. And of course, Sebastian will talk about the experience in Mexico. So we have three fantastic country experiences. Before I hand over to the speakers, I just want to say to try to sort of set the scene, it's really fantastic that in Jeanette's comments this morning, she talked about Chile and we heard about Japan. We heard about the UK. So already I think there's a message here. Even in the more cross-cutting sessions, the country is really where the action is. This is where the choices that we're concerned about on UHC are being made. And I think it's also, at least for me, worth reflecting on the question. First of all, who are the choosers? What are we talking about when we talk about making choices? Who's making these choices? And what is it about UHC and some of the countries here that make the choices especially pertinent today? I'm not going to launch into a long talk on this, but I just think it's interesting that among the different stakeholders, there are lots of people and groups making choices here. We have the providers, the clinicians. They have a lot of views about choices. We have patients and patient groups. We have civil society organizations. And then of course we have the public sector and we have the academics and so on, and they all contribute in different ways in different countries to making these choices. For me, what's distinct about universal health coverage in the countries where it's really happening, and if you can separate the rhetoric from the fact, I think it's important because UHC is much hyped for good reason, but the reality at the country level is not always what it might appear to be at first glance. But what makes UHC possible in my opinion is first of all that countries have reached a point of economic development where there is enough wealth to actually achieve high levels of coverage with a broad range of services for everyone in the population, the equity approach, the truly universal approach. And also, and I think these three country examples are going to bring it out. I hope you'll stress this in your remarks. In countries like Thailand and China and Mexico, that money is flowing through a small number of large payers. And in the end, in some ways, when we talk about benefits packages and what's included and what's excluded, we're talking about whatever the process is within the country, the choices that are being made by those big payers about what gets covered and what doesn't. And I think that's what gives the urgency and the power to this whole discussion about benefit packages and smart choices within UHC. So I just wanted to highlight that. I think these three speakers will bring it out well. That's enough for me. Without further ado, let me start with Yacht. And I think we'll hear from all the panelists about their experience in the country that they know best, Thailand, China, Mexico, about what their country is actually doing to advance UHC through these smart choices. So over to you, Yacht. Thank you, Robert. So I'm going to share you and explain in Thailand where we introduced the University of Calculate for already 12 years. So I would say in the past, we were facing a lot of problems and difficulties from using implicit and silo-based vision makings. So priority setting in the past was set in the closed door by only technicians and politicians. But after five years of introducing the University of Calculate, we found a new way of doing our choice. So that is my main message of my talk today. It's about, first, it's a smart choice about what to be covered for whom and by how in University of Calculate, based on Thai experience, thought it should be made by well-informed stakeholders. And stakeholders, this one is not only vision makers and payers and politicians, but also professional, patient representative, civil society and also industry as well. And the second one is about local capacity to generating and using informed choices that can make the University of Calculate sustainable. Without this, it would be really difficult. We already heard from the first panel on this. So I give you a really quick idea how we do that in Thailand. Actually, this is the process we set for and using for the past five years that we now starting our benefit package development by allowing seven group of stakeholders consisted of vision makers, academic, health professionals, civil societies, patient representatives, the public representative and industry to nominate or to inform the government what should be the new intervention for the University of Calculate. And after that, we have a small group of stakeholders representative to set priorities because we use explicit criteria, magnitude and civility of problems, effectiveness of that intervention, variation in practice, financial impact to household if we not include it and equity and ethical considerations. And after that is the, after priority set, we have a technocad or academic groups including high tap and an IHPP to do the assessment. And the assessment was done with participation of stakeholders. And we informed back to the stakeholders about the value for money, potential budget implication and social and ethical implication of including that intervention in the past case. And then we informed the government. The government is in this case is about the National Health Security Office Board. I would say that the National Health Security Board in Thailand consisted also a wide range of stakeholders. So not only politicians and technocad sitting in the board but also patient representatives, civil society representative, but not private sectors. And this is the selected example of the choice being made or being denied by the government. You can see that value for money and budget impact can make a huge impact on the decision made by the government. You can see most of cost-effective intervention with low budget impact will be included in the package. But for those with low cost effectiveness, which means good value for money. But really high budget implication, for example, we're talking about a few years ago about whether we include a Dow diaper for patient with eulinary or fecal incontinence. And when we found that the budget is quite high. So at the end, the government decided, the board decided to exclude it. But when we're talking about lean-all dialysis, even the value for money is not good and it's really high budget impact. But the government and the board decided to include because this is a life-saving intervention and a lot of people are bankrupt, household are bankrupt, or put in poverty because of this intervention. And we thought Universal Health Calculate for financial protection. So this is the one that should be included and then include. So the last slide, I'm just showing that we're using evidence, health technology assessment evidence, not only to say yes or to say no to intervention, but also to open dialogue for the government to discuss with private sectors. You can see many cases that we found originally that the value for money of intervention not good because at the time the price so high for the type context. And we nicoge at price with industry and we are getting support from industry to reduce the price significantly. And you see that we can save a lot of money. So I heard from the first panel, we discussed whether the HTA is too luxurious or too expensive for a low emitter income country. But I would say looking at the efficiency gains. So it seems to me that HTA is also itself a very good value for money. So I think I end up with this one and welcome for following questions. Great, thank you very much, Yacht. That was fantastic. And people had asked in the first session about the processes that countries follow for making decisions. I think Yacht's second slide which we can return to later brought that out very clearly. And then he applied at least the part of the process that involves his own institute and the IHPP to using cost effectiveness and affordability budget impact in order to make recommendations to this larger process. So that's fantastic. And also the way in which armed with this information it sounds like Thailand is able to come to the negotiating table with the manufacturers of some of these technologies with a better sense of how to negotiate prices that make sense for Thailand. So that's terrific. Sebastian, over to you. Thank you. Well, first of all I want to thank this opportunity to be with you this morning. Thank you to CSIS for this invitation. It's a pleasure to be this forum this morning. I'm gonna present you a little bit of what's happening in Mexico right now and what are the main questions and what are the main issues that we want to address in the near future and how we're actually doing this. And this morning I was told because of a conversation we had last night, if this meant what I was saying meant that it wasn't a success universal coverage in Mexico and what I want to say and the emphasis of this is it's a great success. It works. It has proven it works. But now we need to move to a more sophisticated level of discussion which as Rob was saying before, how we transform this financial coverage into effective access. How we actually make this move into having available resources and priority setting into actually making a difference in people's health. And that's basically where we are and these are the points I'm gonna be covering really quickly because I've been told I only have five minutes for half an hour talk. So this is basically how we've changed and how much we've grown in terms of what we're spending in healthcare in Mexico. This is international data comparing different countries and where we stand now with a more than 4% change in this growth over the last few years which put us among the countries with the largest growth without decreasing. Some countries grew a bit more in the first period but then after 2008, 2009 decrease a lot in what they're spending in healthcare. So we've maintained this growth and we're very proud of this and this is basically how much we've grown and this is the public expenditure the budget available for healthcare from 2001 to 2013 in which you can see that it has more than triple. We have grown and especially this component the blue one at the bottom which is the amount of money based on general taxation available for general services provided by the Ministry of Health and how this from 2003 to 2004 with the launch of Seguro Popular this initiative to cover people without access to social security how it has increased more than five times and now we have this billion pesos so if you want to transform it's an average of 13 pesos per dollar now, 15.8. So this is how we've grown in terms of money available and if you remember the box that Jeanette was talking about so this is how much money there is for what? So this is the amount of people that got coverage by Seguro Popular for the last years. So we talked in 2000 that about 50% of our country's population didn't have access to social security well now they do through Seguro Popular and the main difference in between social security and Seguro Popular is having an explicit benefit package in which we know what we are offering to whom and how much this costs so we can prioritize and we can actually have more funds available for these priorities that we set as a society. So this is 50, 57.3 am I right? It's a bit too far from me, I should have bought my glasses. And then the next question is and what are we doing with this money available for all these people and this is the benefits package and this is I think one of the questions for this morning is how are we actually changing from these very basic coverage that we had in 2004 and four as you can see is more of a community service some forms of public health interventions into this very comprehensive package very close to what we have in the implicit packages offered by social security but with one main difference it's explicit so people know what they're getting and this is very important and so we have now more than 280 interventions for COSIS which is the basic package paid by capitation decided by a commission what it should be included and that has these very specific protocols and clinical guidelines to offer so one of the main reasons we have this is that we can monitor quality as well we can see how things are being done. We have almost 60 interventions in this catastrophic expenditure of fund which pays for the most expensive interventions available in the provision of services and we have 131 interventions for all children under 18 years of age which covers pretty much everything a child could use in terms of healthcare. So as you can see I put the little box at the bottom on the right, we've made huge progress in terms of who's covered, what they're covered for and the amount that we cover from all interventions but we have still huge challenges how we change this into an impact that we can measure an impact that we can use as feedback for this priority setting so we can ask for more funds into healthcare. So it's not just a matter of arguing we need more money because as someone was saying before this could become a bottomless pit. It's having smart choices into where am I gonna put this money because it's creating the best results available and possible and this needs to come from a very strong knowledge of what's happening in the provision side. So this is also an international comparison on how we're doing in terms of equity as well. So how much money, if you go to the, sorry. So how much money we're actually spending in between this complementary or coexistence system. So this is social security versus pseudo-popular and as you can see we've almost reached this one-to-one relationship so we're spending as much money into what we're offering social security cover population to pseudo-popular population. So it's not now a matter of money and where the money is put and who is benefiting from what. It's what we do with this available resources. And this is what we think the next step of this discussion is setting aside the big success that we've had with universal coverage and that we've now reached almost 100% of the Mexican population through our coexistence financial and provision systems. And this is a graph. On the left you see this growth of who is covered and how it's been a really rapid increase in the amount of people and available resources. And this shows how we've reached almost 100% of population. But on the right you have a very crude reality which is survival rates, 30 months survival rate for kids diagnosed with acute leukemia, lymphoblastic leukemia. So you see where even though you have the available resources and you have with this money what we do basically is we pay for technology. So we have the latest technology available for acute lymphoblastic leukemia and we have the facilities and the human resources to do so because we're paying for it. What's happening with this? Well you have hospitals and each one of these points in this nail shaped graph is a unit, a hospital. So you have hospitals that are reaching international standards. Basically what you do with that money and available resources in more developed countries but you also have a coexistent reality which is survival rates below 20% which costs exactly the same. We're not paying more or less to treat one another. So it becomes a point of we still have an equity issue because depending on where you have access to treatment your result and that's I believe is the next frontier and what we want to focus on. If we're paying for universal coverage as a society then we need to guarantee similar results regardless of where we are accessing this treatment. We need you to get through in the next minute or two we'll come back to some of these issues. So basically this is what we did we analyzed each of these units, a credited unit. We have a quality system going on and this is a result. This is for general interventions in pediatric and adolescent cancer and we found that some of this has to do with the provision side. So we're competing for resources and we're competing for demand in some of these units. So what we want to do is basically transform this into a more homogeneous plan on how we provide services with this universality or availability of resources. And this is basically the general map in which we say that we need to move and we need to analyze this system what sort of health risk are we covering and we make huge progress with community risks which we've made amazing progress with financial risk but we still have to make progress with what we call yatrogenic risk which is how the patient interacts with the system and what risk results from this interaction and health services consumption basically. And this is where we're moving for where you see the question marks and what we want to do to actually feedback this priority setting process. Thank you. Great, thank you very much Sebastian. We'll come back to this. So keep that in mind. Mexico, a lot more money going into the system but uneven results across different provider units. A lot of variation and inconsistency. So how to bring all of those units up to the best performing levels is a big challenge. Yang Zhong, you have an easy task. China is a simple country. Yes, it's very simple. Well, thank you Robert. If we examine the health system in China healthcare reform, we know that it was launched in 2009 and now it's more than five years, right? And many of us know that it's made significant progress. We look at state commitment, state investment, right? The percentage of government funding in terms of total health spending increased to 30% and out-of-pocket payment as percentage of total health spending decreased to 36%. And the health insurance coverage increased from 30% in 2003 to 95% today. And if you look at the utilization of the healthcare services but obviously the healthcare reform also released this demand. If you look at the hospitalization rate increased from 69% in 2008 to almost 89% in 2011. So this is all good. And with all the money, the government spent hundreds of billions of dollars on healthcare reform, you would expect to see sort of like what economists call the Pareto improvement. But that is not, seems to be the case. The survey data also just that the people, including the healthcare providers, the patients, they're not happy. Everybody seems to be complaining one year ago when I was here, right? That same, this USC conference, I made that comment that the Chinese healthcare reform failed to fundamentally address issues of affordability and access. By that time, probably not many of the government officials would agree with me. And nowadays, this National People's Congress meeting, it's obviously the consensus that this reform indeed failed to address these objectives in terms of the access and affordability. And so that sustained problems of fairness, accessibility and affordability hindered the achievement of universal health coverage in China. And nothing is that more clear if you look at this defining and prioritizing of the benefit package, we know that in China, well, we say this China is simple, but actually if you look at the healthcare, the insurance schemes, that is very fragmented. Well, they have at least three, maybe four by health insurance schemes, by government insurance schemes, the open employee insurance schemes, open residence employee systems, and the rural based insurance schemes. And it is not universal as well, but it's very localized. In fact, that there are variations in terms of contribution to the different schemes by those provincial contributions to the open residence insurance schemes and the country contributions to the rural insurance schemes also vary. And that, in fact, if you talk about insurance schemes, we're not talking about just the three or four schemes, because if you look at the contributions, the pools, we're talking about several thousand pools in the country. So that difference is in contributions also associated with this large differences in benefit packages, including reimbursement levels, access to healthcare. And the Chinese government like to call their health insurance schemes, the basic insurance schemes, but again, well, the insurance schemes are not that basic. In fact, we saw prioritizing, they should cover inpatient services and catastrophic illness in all the insurance schemes, especially after 2013, insurance coverage moving toward catastrophic illness. They have selected 20 diseases to be covered. Well, there's 20 diseases including some cancers, some rare diseases like congenital heart diseases, some the infectious diseases like HIV AIDS, the multi-drug resistant TB, and also diabetes. The level of inpatient services related to these diseases will be covered by I think less than 70% reimbursement level and can be as high as 90%. But there's two problems here because of this emphasis on catastrophic inpatient services. Many people choose to see the doctors when they're sick because this minor illness is not covered. So when developing to major ones, they will be admitted, but that is going to be more costly to treat. There is also the issue of moral hazard problems because patients, even though they have minor illness, they might seek this, in order to seek this high reimbursement ratio, might choose to be hospitalized instead. That is also encouraged by the local hospitals because then they could obtain the insurance fund from the government. And also there's this problem of wide and shallow coverage. We know that the benefit level remains very low in China. Only on average, 30% of patient services are covered. There's no coverage of dental care, physical checkups are not included in insurance package. Certain drugs, including the life-saving anti-cancer drugs, diagnostic means excluded from the coverage. So despite this wide increased coverage, the out-of-pocket expenses continue to be relatively high, especially in rural areas. We have this reports from the Time Magazine and more recently the Bloomberg News talking about how patients, because they are unable to afford those hospital bills, but they choose by either to not to see the doctors or when the extreme case, this guy, the Hubei province, that cut his left leg because he couldn't afford the hospital bills. So I think the overall, there's some progress we may, but in terms of the benefit level remains low, remains very fragmented. So I think for the government, a more robust benefit package would mean to raise the ceiling for reimbursement of both inpatient and outpatient services, remove the deductibles of insurance schemes and reduce the co-payment rate. And also that involves integrating those different insurance schemes in terms of management, benefit packages, and funding. The government is making efforts to integrate all those three schemes in terms of management because it used to be the case the Minister of Health would manage the fund for rural insurance schemes and the Ministry of the Social Security and Human Resources manage the open-based insurance schemes. But now the Ministry of the Human Resources and Social Security are not taking over the management functions from the Ministry of Health, but that progress is very slow because of the resistance from the Ministry of Health. And in the meantime, we haven't seen any integration efforts in terms of funding and the benefit packages. So there's a lot to be done. Thank you, it's fantastic, Yang Zhong, and we'll come back to you to elaborate on your recommendations for fixing all of these small problems in China. Now everybody has to wake up because we're gonna go out to you for some biting questions. I'm gonna start off with a rapid fire round. I'm gonna give, I'm gonna lob these very easy questions to the three panelists. They're gonna hit it across the street and then you're gonna come in with a really hard question. So my questions will be only 20 seconds long and their answers will be two minutes or less. So somebody's already ready, but you're too ready. Okay, thank you very much. I'm gonna go first. I'm gonna take my prerogative here. Yod, let me start with you. HITAP and IHPP are premier institutions. You do great work around cost effectiveness and affordability. Do most ties understand and respect and accept the kinds of assessments that you make in these institutions? Because you're very specialized, you're very technocratic in a way and sometimes you say no. The recommendation is no. So how is this seen by the Thai population? Yes, I think first I would say the technical process alone is cannot help making smooth priority setting process. But I would say we need to have trust. We need to endorse engagement by stakeholders and that can be done with the process. So that's why I show you in the slide that the process is a big matter as well. So to answer your question, I would say an example of the word from our health minister and general secretary of national health security office. I think five years ago when we decided we're using evidence, the same evidence, the same kind of evidence and we decided to include new trust and reject some interventions. And when they talk to the public because every time we have a board meeting and we include new interventions, the media will come to ask them. So really rarely our health minister or the top labor decision maker at the payers will say, we include this because it's a good value for money. Because it's a cost-saving intervention. We never heard about that. But last year I quote because I think that is significant achievement. Is that all newspapers saying that we include seven drugs and they say this is because we have evidence and clear evidence showing this is good for society. It's a cost-saving intervention. We're doing this and we can save a lot of money in the future. And that is, I think it makes a lot of sense. So that is my question. Thank you. Yad is very famous in Thailand because he has so much power over his minister and what happens in this area. So an important guy to get to know. Sebastian, can you say a little bit, I know it's complex, but can you say a little bit about what the process is in Mexico that leads to the definition of what's in these packages? I note that they've grown dramatically as you've expanded the resource envelope, the financial envelope, and as you've tried to equalize benefits across these. I know Thailand has also done an amazing job of equalizing. It also has three schemes. I think a little bit like Mexico, different schemes. But how do you decide what goes into those packages? Well, there is from the origin and you saw the graph which it was a very small benefits package. That was decided by previous exercises to provide population with a general and basic coverage package. And that was based on available resources, available human resources and facilities, and what we could afford basically. From that and the structure of Ceuta Popular, we created also the agencies and the different bodies within the Ministry of Health to actually make decisions on this. And that's what's led to this increment into the available interventions within the benefit packages. And we have CENETEC, which is a HTA agency that provides all this technical information to the General Health Council. And the General Health Council groups all the institutions within the country, all the providers and the insurers, and they decide based on not just these technical considerations made by CENETEC and some other technical agencies within the Ministry of Health, but also decisions like the political side of it and whether this was already provided by a certain group or if there's pressure by patient groups, for example, which we're trying to increase as well as well so that we have more civil participation in all these processes. And the main technical considerations that we look at is for example cost-effectiveness, one of the main issues and we have to pass all these strict and technical test for each intervention. What's the burden of the disease within the country? That's one of the main issues. Do we really have a problem and do we already have a demand of services in facilities? The total cost and what's the budget impact of including this intervention and so on. So there is a process, we're working to make it this more transparent, meaning so far this is not written down. It's a process that goes through a council, so it's a group decision, it involves many institutions, but there is no written process that should be followed to include an intervention and this goes as well for setting the catalog of technology available for that intervention. So that's what we're going towards. Great, great, thank you very much. And Yang Zheng, you started talking about some recommendations at the end there that you would make to the government. So I guess, and it looks like the big issue that you feel needs to be addressed in China and as you say, it's very fragmented, it's almost as messy as complicated as the United States. I mean, not quite as that extreme, but it's a pretty complex system. You started talking about things that could be done to make sure that this coverage wasn't just superficial, that the coverage was deep and that people were covered to a high level of the cost. The out-of-pocket burden wasn't as unbearable in some ways as it is in certain instances in China. So can you talk a little bit more about what you would advise to the national government and also talk a little bit about the extent to which the national departments at this point are able to influence what happens at the provincial and local levels within China to try to drive improvements in this coverage? Well, I think what this issue is, for certain it's about more money to be spent in the healthcare sector, right? I think for a country where that is now, or the second-largest, cost for it to be maybe the largest, and the government indeed has money to finance a meaningful universal health coverage package. And the sum of the health economists did some analysis. They found that we only need an extra of 460 billion Yuan, about 73 billion dollars. That's about extra 4.6% of the government's fiscal spending could achieve a more meaningful, equal, healthcare benefit package in China. Well, the government has pledged also to increase the investment health sector to 1.3 trillion dollars by 2020. And of course there's challenges in terms of population aging, increasing the non-communicable diseases, but I think the issue here is essentially political will, state capacity to carry out all those in-depth reform measures. Certainly the government should have a clear understanding of the long-term, the complicated nature of the reform process if you look at the experience. But I assume you wouldn't say that money alone will solve this problem. They're trying to conspend its way out of these difficulties. No, it is not the case. I think this is why I think it's important in order for that commitment to be sustained, it is important for the reform to be accompanied by other measures may be beyond the healthcare sector when the governance field states aside relations. Incentive, the bureaucratic incentive structures, the genetic talk about essentially this is a very political process. It's about who gets a what and what costs, right? At whose expense the, for example, the efforts to push for public hospital reform now is encountering very strong resistance from public hospitals as well as the health bureaucrats. You would think in an authoritarian state it has that capacity to be insulated from this fractures, right, vested interest but obviously that is not the case. The Chinese Premier would like to say it's more difficult to touch the interest and to touch the soul. Good, good, well thank you very much. I think we're doing well on the time and we have half an hour. I see a lot of hands going up on this side. These people are asleep over here because they're no hands up. So let's start over here with those that are alert. Actually the gentleman here was first, I believe, down. This is a question. My name is Fernando Zacarias, oh, sorry. My name is Fernando Zacarias, Global Health International Advisors. Yod, I congratulate you for the study on the assessment of technology. With aging populations and the problems of motility, problems of hearing, problems of eyesight, I saw that you had the intraocular lens. But I would like to know if you have done an evaluation of the hip replacement, dentures, hearing aid and things that will increase the quality of life of the aging population. And if that is cost effective, what is what you have found if you have evaluated that? Great, that's a great question. Let's take one or two more. Yod, can you hold that one on some of these other, these technologies for aging populations? Yes, please. Yes, my name is Roman Makaya. I'm Ambassador of Costa Rica. And I've been very interested in hearing about the country experiences and congratulate all the panelists. We've been hearing about how complex it is to make changes in systems to address new realities. You know, you have legacy systems that are decades old. They were designed for a different era with different diseases, different demographics. In Costa Rica, we have a different layer which is probably present in other countries as well, which is the constitution. You know, what does the constitution say? And Dr. Vega mentioned this at the beginning in her opening address. In Costa Rica, we have a universe, a constitutional right to health. And so patients or patient groups can sue or basically go to the Supreme Court to try to get coverage if they think or their doctors think that they are not having real access to health. Sometimes it involves something as minute as whether they get a branded drug or a generic drug. And so you have other decision makers which are Supreme Court judges making technical decisions in this process. My question is, you know, given all these complexities that can vary from country to country, how are countries implementing innovation within the system so that you don't pretend to renew or reform the entire system which has many conflicts of interest, many vested interests, but you sort of unleash social entrepreneurs that can use technology and different ways of doing things to prove a concept at a pilot stage level that can then generate enough political capital to expand that to the rest of the system. Great, thank you. Costa Rica is a very interesting country. Costa Rica is a very important leader in this area. Let's take one more over here, this lady. I know she's been waiting patiently. My name is Elsa Gomez. I'm also with Global Health International Advisors. And my question is to the members of the panel and Jeanette, how does reproductive healthcare is dealt with within benefit packages and that is, who is covered, what benefits and who pays for that, reproductive healthcare, including contraception. Okay, great, thanks. Let's take this first round of questions. Yachty, do you wanna go and provide some quick answers? Sure. Good, but before I answer the first question, I think you can feel in the room that people talking about aging population and will you also, the last lady is talking about reproductive health. So that is actually the fact of life and that is all politicians and people who are introducing universal health categories are facing. I mean, different group of people have different intellect and all of them need to be part of the process to decide together what should be covered and not to be covered because of what and that cannot be made by emotions, but I would say evidence and a deliberative process. So talking about aging populations, based on our experience, I would say there are two things. The first is the lesson learned from us is that many of our work when we discuss about intervention for aging populations, we found that many of them are not good value for money or not good for society to have big investment. This is not because of the intervention itself, but what we found is that we later, we found and we tried to use a portable genet present that we do a population based party setting as well. So we're looking at the population who are elderly and what we found is many of the problems should be tackled or should be managed at early life. For example, many of cancer, many of NCD or even mental health is better to do in early life in order to make elderly a much healthy population. But having said that, it's not mean that the tiger may not invest heavily on a single population, but we do and you can see that lean-out dialysis, mostly of our eligible patients are older than 60 years old and many of the curative intervention also invest for that group of intervention, a group of population, but I would say the message is that once you do priority setting in a board, the same and you get a lot of options and solutions larger than only invest on curative treatment for elderly. Thank you. Does anybody in the panel want to take the tough question from the ambassador there about what's being done to foster innovations and experiments that could eventually be scaled up? Well, how I use the Chinese experience, but I think the Costa Rica experience is a very good one. If you look at their experience of building UHC, it took only 20 years to build UHC compared, well, I read that article, right, which listed the countries, the years in tech to establish UHC, I found in Costa Rica the country with the shortest time period to build a UHC, well, compared to countries like Germany, right, 128 years, that is certainly a time we can't wait. I do believe that even in, democracy is certainly more what they have these advantages, but even authoritarian states which have this central corruption or this in place, the innovation indeed could happen also in the health care sector that provided that you have provided proper incentives, but let me give you that example whether it's that I didn't mention in the opening remarks that recently the Chinese government introduced this so-called second-time reimbursement policy. Basically, after the first reimbursement from the basic insurance for those out-of-pocket payments less than 10,000 yuan, you would have this at least 50% of this second-time reimbursement based on this extra pay out-of-pocket payment. For some of the special cases, they could even allow the third-time reimbursement. So where is the money from? They actually took the money from the health insurance fund then buy extra insurance from the private insurance. So, recently they also started encouraging the health philanthropy, the commercial insurance. So in this way, you don't need to pay, the government doesn't need to contribute extra money, but this innovation itself significantly reduced the problem of affordability. Thank you very much. Sebastian, did you wanna remark on any of the three questions? I think they all go together and it's part of having universal coverage. I mean, you have to have all these different spheres into your site and actually being able to deal with them and the burden of disease and these latest studies by the IHME let us know how we are all getting older. The disease pattern that we had is no longer there so we need to see what's actually gonna be the burden layer and how much this is gonna cost and this is why including this other intervention is essential to actually keep people healthier longer and I think that we're doing all of us in a certain way. Costa Rica is a great example on how they've changed and they've moved very fast and I would say the analogy is actually repairing a fast moving train without having a derail and that's what we do every day and that's what the challenge is about. How do you actually keep on providing services to a population that will not stop demanding just because you are under repairs and actually getting to a place in a stronger and better way than where you were before. So that includes a lot of technical elements of policy making and policy implementation which is I would say the main challenge. I mean anyone can come with brilliant ideas. The problem is actually how you move all these different spheres of political, the economical, the social to actually make this work and make something happen and for better and I think Costa Rica I insist is one of the better examples we have in Latin America together with Chile and we in Mexico follow you guys very closely. I was just in a meeting with one of the key people of the Caja Custadresense basically talking about burden of disease and how we're actually moving towards addressing that not only talking about interventions but how we address this burden of disease and in terms of the interventions on reproductive health I'm not sure about other experiences but in Mexico we have that cover in the very basic package from even the beginning before Seguro Popular that's been one of our highest bets all along in which we believe that if we have a healthier country in terms of reproductive health we will have better outcomes across the entire pattern of disease and demographics. So who pays for that? The government pays for that. It's included both in the social security packages and of course the actually the social security package as insurance is called health and maternity. So basically making very explicit this priority and in Seguro Popular it's covered by causes both the prevention and promotion and the delivery part of that as well. And just really, really quickly what this goes to is once you have everything covered then you start dealing with social determinants that are hard to actually reach from the health perspective and that's where I think our efforts will go as well so that we manage to finance also interventions to deal with social determinants so we have also better outcomes in terms of reproductive health. Thank you. Fantastic, thanks Sebastian. Let's take some more. Good, this side of the room has woken up. Let's take one, two, and I think Jeanette had a question too. Keep the questions agreed please. The comment on insurance, I just wanted to know I mean all three of these countries are countries with fairly large middle classes and very large good economic growth. I mean to what extent is the private insurance company now starting to private sector now looking at covering things that are not covered by the essential plan and also covering the co-payments and are the governments monitoring that? I mean obviously that would leave more fiscal space to worry about the poor if the private sector was handling some of these things. Thank you. So you're asking about health insurance, private insurance as a top-up on top of the basic package, thank you. Not as a substitute. Please go ahead, thank you. Hi, I had a more broad question about the private sector and I just was wondering if any of the panelists would elaborate on the roles of the private health sector and the private insurance sectors and their thoughts on how the relationships with these sectors could be changed to help them achieve their goals in universal health coverage? Ideally, I have another quick, quick question about Mexico and that is that sort of hole in the table about quality. And I was just wondering if you could elaborate now on how quality is monitored there, what institutions are involved and what your current system is, thank you. Thanks, so there are two questions there. Oh, I'm Lisa Tarantino. You have to pay extra because you asked two questions. From App Associate, sorry, I didn't introduce you. Thank you, please, Jeanette. Yeah, it's a kind of a comment and a question. I think that the issue of judicialization, I think it is, of the benefit is a very big issue. And I think that one of the problems is that if you don't advance, I mean, first the coherence in the legal system. If the Constitution is the right to health, that from a point of view of the ethics and the public policy, it's a very good thing. At the same time, you can be sued. And basically in Colombia, it's sort of, the thing is increasing kind of, and we are having the same problem. I wonder if you have any experience how do you deal with it? Because you don't want not to have the right to health in the Constitution. At the same time, you don't want to be basically having the judges making decisions, which is a big risk, and in fact, it's happening in several countries, at least in Latin America. And yeah, that's it. Thank you, Jeanette. So we want health to be a right, but we don't necessarily want it to be a statutory constitutional right subject to Supreme Court litigation. Interesting. Okay, and one other, maybe over here, sure. So this is a question that really gets at the issue of smart choices because, and you have a number of technical folks on the stage that can get at methods. So when you build a mathematical model, what goes into it are assumptions and data. So the assumptions can vary widely, and the data that you put into the model to power it can be also variable. So, and you can vary all these inputs into the model and other factors as well, and you all know this because you work in this field. So the outcomes that you get are really dependent on your data and your assumptions and other factors as well. So when you're trying to make a policy recommendation, how do you deal with that very obvious problem in terms of making a case to the government about what might be, let's say, use your outcome cost-effective or what might be a bad policy decision under those circumstances? Okay, thanks, sir. Just to clarify, you're asking how do we deal with limitations to these models and uncertainty in the data? Is that your question? Yes, it is, okay. Okay, let's keep moving. I just wanna make sure we understand what you're asking. Let's go back to the panel. Yacht, do you wanna go first with one or two of these? Okay. All great questions. Maybe I'll deal with the last one first. The last question is about how we deal with assumptions and uncertainties when we do priority settings. I think we are, I can have a quick, let's point, I think in two ways. The first is that we need to be frank to stakeholders. So we never say that we can decide it on that benefit package with 100% of confidentiality. So we need to say what is an assumption made and what is the limitations of our data that we can extrapolate. The second one is, I think it's more important, because the first one is something inevitable, I mean in the real world, that we never before implement that intervention, so we need to make assumptions and to see what would be likely the cause and outcome. But the second one is that after the decision being made, what we need to have is have good infrastructure that's trying to monitor and evaluate. Whether it's B as we predict. For example, I'll give you an example. Two years ago, the Thai government made, I think it's a very significant decision to include off-label use of cancer drug for eye treatment, the B-varsity map. At that time, the big assumption is that we already know the evidence is that they are equal efficacy between off-label drugs and the registered drug for macular disease, but the price is about 48 or 50 times different. So the Thai government go for the cheaper one as for the off-label use. But the big assumption is that we don't know about safety of that drug, but given the information at that time, it's presumed that it should be equivalent. So the government decided to support the cheaper drug with the condition that we need to following up the safety profile of patients, and now we have 60,000 people who are having off-label drug use and we look at the safety profile of the drug. So that is a thing, is this kind of thing need to be in place when you have universal calculate and you talk about benefit package? You not only talk about the upward policies development, but you need to look at the downward policy implementation as well. Thank you very much. Let's go over to the other, I know you have more to say, but we only have about 10 minutes left and I wanna give you each a chance to make final remarks. So take your choice. Private sector, constitution, whatever you like. Well, I'll be quick, actually. Answer the question about the role of the private insurance, commercial insurance. I know that in the case of China, it's actually less than half of the people in the country actually using the private health insurance. That percent, the share is actually larger in the rural areas, but in the urban areas, actually I think less than 30%, actually the urban residents using the private insurance. So there's certainly a lot of room for the private sector to play on this process, given that the government cannot provide all those benefits, the packages to the people. And speaking of the smart choices, I think it's very important to do evidence-based decision-making, but I think it's equally important, again, to have all the stakeholders to be brought in this decision-making process. And it's unfortunate if you look at the country, like China, where you have all the health bureaucrats, politicians making the decisions, but essentially there's no input of the people, the beneficiaries of that process. So I give you this obvious example, right? We know that it's very expensive for the most effective drugs, for, you know, to be sold in China, some of the anti-cancer drugs, you know, cost $100 per day, where if we talk about, you know, like the one course, two months, that will be about $6,000 US dollars, you know, that is crazy, because, you know, that in the country where the GDP per capita is still just a several thousand dollars, you know. But, you know, the country has this capacity where it could import, for example, the India-made generic drugs, right? Would cost much less, probably, about $10 a day. But the government won't allow that. The public policy won't allow that. And in fact, there are reasons for this guy who bought the drugs from India and the sale that in China was arrested, you know, for smuggling counterfeiting drugs, because anything that is not allowed by the government is considered counterfeit. So, you know, this is a typical example, you know, that in the decision-making they fail to even take into account those, you know, people's desires and wants. Great, well, thank you. You introduced two really hot things here at the end, which is dangerous. One is around drug prices and intellectual property and the other one around... I know, we're in the dangerous... Participations, I'll let you talk to our friends from Pharma here during the lunch. Over to you, Sebastian. Well, really quickly, I think on the Mexico quality surveillance mechanisms that we have, I think we can talk a little bit after we finish, so I don't take more time explaining. And on judicialization, I don't know if that's a correct word, but I didn't mention it before because I think it's something we have been observing very carefully over the past years. We also have that issue in Mexico, especially, well, the probably the largest issue we've had was with the social security side with which implicit coverage means it doesn't say what it covers, so it was forced to offer orphan drugs. So that's one of the biggest issues. It would have probably included it right away after that without having the Supreme Court deciding. And those are the things that come into questioning when you have this very technical side making decision and then you can create also pressure on the other side and then it becomes another group, the judges deciding what the package should be, which is a very important question on this. And just going back to smart choices, I mean, you need the information to make any choice, whether it's smart or not. And if you want it to be smart, then you need to have as much information as possible from not just the technical and very hard side of it, which sometimes it turns out is not as hard as we thought because we have to make many assumptions and the quality of data is not completely there. So you need to make choices anyway, otherwise the train moves and leaves you behind. So I think you have to have all these perspectives that we were mentioning and data, it's a very important one, of course. Great, thank you. I know there are more comments and questions, but we need to wrap up and then go over to our lunchtime speaker. I'm gonna finish by asking each of the panelists, I'm gonna give them a choice, of course, in the spirit of this. And you have one minute and I'm gonna give you three choices. One is any advice for US policy makers on how to make smarter choices under not quite universal coverage in the United States. Secondly, is there anything the United States could do to help countries like your own to make smarter choices? Maybe yes, maybe no. And your third choice is whatever you'd like to say, as long as you keep it to one minute. You're right, thank you very kind. So I take the last one. Actually, I want to respond to Janet about two predictions, I think. If, I think Thailand is really lucky that we don't have that kind of problems, even we have in our in constitution, we say it's right to help, but we never have many court challenges for decision makers who make choice about the universal coverage. And I don't think having charged to make a decision on what should be covered and not to be covered in the benefit packet is not the right approach. I don't think the lawyer is better informed policy decision makers than we do. So I think that is the way that we should do is that the health system and I think in those countries need to think clearly how to, I mean, take away that decision from the lawyer to be the people in the health system. Thank you, thank you. Well, I think probably I'll address the second question. I think for the United States, when we're trying to export our experience, I think one thing that we want to tell the other countries that don't learn from us. The, but well, that is in terms of the healthcare spending. But indeed, this is only half right. I think the US indeed could have a lot to offer in terms of the healthcare, the knowledge, know-how and the management experience and also the investment in fact in the country. Like China is now encouraging social capital to enter the healthcare sector itself. Not just the experience and know-how but also the investment. So this indeed allowed to offer, the United States could offer. Great, great, that's fantastic. Sebastian, last word. I think this already exists and it's both ways. I think we've learned a lot from the US and the US is probably also looking at all these laboratories we have on universal health coverage across the world. Mexico has a relationship which is natural. We share more than 3,000 kilometers of border and our citizens move every day from one country to the other and we offer them different things and we offer different benefits from being part of these two very large moving societies that interact every day. So I think we can still learn a lot and have this very close interaction and continue to build these bridges across our huge border. Great, great, well thank you. I think we've heard three fascinating and very pertinent examples from three very important countries that are leaders in universal coverage. They've all moved dramatically in that direction over the last decade or two. Remarkable progress and all wrestling with trying to make smart choices within the resource limitations that they face. So I think we've learned a tremendous amount. I hope, Jimmy, that this is a good setup for your talk and Steve, trying to shift it over to US policy and what it means for the US and the kind of two way exchanges that perhaps could benefit the US and could also benefit some of the other countries. So I hope you'll join me in thanking the three panelists and giving them a round of applause.