 Good morning and welcome. It's great to hear from Dr. Kim about emerging efforts to measure progress towards universal health coverage, which of course will be a major factor in this effort. My name is Nellie Bristol. I am a research fellow at the Center for Global Health Policy at CSIS, and I've been here for about a year and a half, and before that I was a freelance journalist covering global health policy for publications like The Lancet and Health Affairs. And before that I was a reporter on Capitol Hill covering domestic health policy for two decades. So this has been fascinating for me to get to delve into how these issues are being dealt with on a global scale. And we have this great panel here. We have a great day. We have an all-star lineup, so I'm really excited and looking forward to learning a lot more today. This first panel will be kind of an overview. We'll look at some of the history of universal health coverage with some specific examples in countries, some of the trends in the ways that countries are approaching this issue. We will look at some points of contention, both globally and nationally, and we'll look at international organizations and donors and their role. Later in the day we'll be looking at the role of the private sector and breaking down more individually the pieces of a universal health coverage system and looking at ways to optimize resources under universal health coverage. So today we will start with Ariel Pablos-Amendez, who is the Assistant Administrator for Global Health at USAID, and has been involved in this issue for many, many years previously at the Rockefeller Foundation. Thank you very much, Nellie, and thank you all for joining us. I also want to thank Steve Morris and CSIS. It's great to be back in one week in this new nice building. It's clearly a pivotal time for the global health agenda, and so this conversation is indeed crucial. I know it's my current role, I think, that Nellie, which we have interacted with, but also the work that I did when I was at the Rockefeller Foundation, and given you invited me to talk about history, I had to go back. In fact, there are about three different historians who, in the last month or two, have been coming for interviews, so I'm beginning to feel like an old fellow. One of them, of course, Jesse Baum, who is on the left here, actually commissioned a first history of universal health coverage back in 2008, and to just look at how all this happened around the world. And even at the time, they were skeptical that the complexity of the political economy to drive agendas is not something we could just easily just notch from New York or Geneva or Washington. And yet we are seeing now dramatic attention gain. Universal health coverage, which I like to define as access for all to appropriate health services without suffering financial hardship, is something that doesn't occur automatically, even though we are seeing growth in economics of many countries around the world that used to be developing stage of economics. Policies matter, as we heard from Jim just now. There are many models that may allow us to decrease catastrophic expenditure out of pocket expenditure as a proportion of the total, which in Africa is 40, 60 percent, in Asia 60, 80 percent. We can do that. It's been done in many places. I want to clarify these historical remarks that people ask us, how about Alma Ata and how does that compare? Clearly Alma Ata was an inspiration for many, but also it was not an inspiration for many others. Although the call to help for all resonates with the call for universal health coverage, Alma Ata was not very explicit about how you will pay for things. What was the health financing arrangement? And in fact, with universal health coverage is extreme opposite. We have been accused of focusing too much on how the economics and the health financing arrangements will be, because we believe are essential if we're going to be credible with such a bold agenda. And of course it was a cold war. It was a difficult political time for agendas. This time it's different. We have both the W Show, and David is here, and Margaret has been a champion, Jim, team, champions from the World Bank. So it's great to have W Show and the World Bank aligned on an agenda. It's unusual that that has happened. And it's also, we have, positively, we were discussing these agendas in, I see also Kate Ball, who was also referred at the time, working with us. It was a bold agenda, but we saw the pendulum of agendas moving. There is such a thing in any economy that the pendulum exhausts the budget crisis we saw as an opportunity to rethink what is it that we should do going forward. And more importantly, the economic transition. Countries were now growing in an unprecedented way, and that called for new possibilities. Universal health coverage in the international agenda has never been about global donors paying for health insurance. It has been about reorganizing that growth in a more rational, equitable, and sustainable manner. Clearly, universal health coverage is not new. Bismarck, back in the 1880s, introduced the idea of employer-based social insurance. And he was facing an election, and he had to trust a bond to the labor unions. And so that was the way, and it worked for him. But it took more than 50 years for all of the Germans to have social protection. So it took a long time to achieve universal health coverage in the very first case study of history. After World War II, there was a lot of possibilities because of solidarity growth through the war, particularly in the UK, but also in Japan. And it's following World War II that you saw those tax-based single-payer system, the National Health Service of the UK. And they went right off the bat with the aspiration of calling everybody not everything, but eventually, indeed, most everything. Many others followed in Europe, and where we usually take as reference. But also in New Zealand, Latin America started having many systems in Mexico where I was born in the 40s. We had the first social protection systems, which covered between civil service and the formal economy, nearly half of the population. South Korea, Taiwan, fantastic systems evolved in the 70s and the 80s. The United States, who started with a Bismarck employer-based insurance system in the 30s to 40s and 50s, really got to Medicare, Medicaid, and 365, of course, more recently, Obamacare. As we entered these millennium, Turkey, Thailand, Ghana, post-genocide, Rwanda, Mexico went all the way to 100% with the Seguro Popular. These were dramatic developments, and they were now occurring in the places where you didn't expect that to be possible. And Thailand, as we heard against World Bank, and maybe WTO Advice at the time, but they done a fantastic job. And Mexico also, like Thailand, has documented the experience very well, and that's been very important to the understanding of what is possible. And in every successful story, institutional capacity development has been essential. It's not just a conversation. You need institutions, you need new capacities, you need a lot of evidence to guide policy and to navigate the complex political economy waves that you would have to confront over years. But Thailand accomplished universal coverage, and Turkey also in 10 years. So compared to the Germans that took them 50, somehow we were learning and doing things better and faster. Many more countries have followed. I mean, China, big commitment has been so important in terms of global targets for team and team. China's move is going to be very important to move that needle. Vietnam, Indonesia, many other countries who have gone the first way and are moving to try to see through the conversation in India, fascinating that even, and Srinath has been a leader in that mobilization, even without a full universal coverage system, just with the current arrangements that have emerged in India, RSBY and others, India probably has more citizens covered than the United States already. So it's quite incredible that these things are taking place. And in each case, the political dynamics have been key, but also the timing of the economic growth. It cannot happen if there's no economic, the economics are changing. In fact, almost all of the country's stories happen when health expenditure reaches 4 to 5% of the GDP of a country, including our own Medicare, Medicare reforms here in 1965 are about 5%. So many countries are reaching that station. That's why it's ripe for the political spark. So while all this happening in the over the decades, nothing was happening in the global conversation. The global conversation was not acknowledging all of these developments around the world. So indeed, I think the work that we were very involved in at Rockefeller pretty much drove on this. And I think that at the time, I was at W Show in 2005, when David Evans and Tim Evans who penned the concept, the actual wording of universal coverage in that 2005 World Health Assembly resolution. Tim was my boss at the time. And the idea, the concept, even the term, has gone through a lot of challenges at the time. 2007, 2008, should it be universal health care, universal health access, social protection, universal health security. And there are many reasons why we're sticking to universal health coverage. And in fact, the consistency itself has been part of the success. I came back to Rockefeller and I want to acknowledge the importance that the foundation played in 2006, 2007. A new president who said, well, there's PEPF already. There's the global fund. There's Bill Gates. Maybe the Rockefeller doesn't need to do anything else in global health. And so I had to come out with something that was different and yet important as I led the global health program. And Pivotal meeting in Pocantico in New York in 2007 that got also the Secretary General in the UN to step out the plate on health. This was followed. I mean, we began to make the case for health systems and the transformation of health systems as a new agenda and to develop the arguments for that from the private sector through the economics. And we also believe that universal health coverage was a better way to communicate health systems. The health systems was fuzzy in its communication that it was not getting the traction perhaps it deserved. And the universal health coverage was a bolder way to get politicians, lay people to engage. The World Health Report 2000 was brilliant, but it didn't quite take for many reasons. And so we also showed that it was possible. I think that President Carter hosted a meeting in Atlanta in 2008 where health systems, maternal health entities were positioned in the agenda Secretary General take on. In 2008, the G-8 in Japan explicitly put health systems on the agenda with Keiso Takemi and that was a shift in the conversation with the G-8 from the recent round. The election of President Obama here also added a loudspeaker to the conversation of possible reform and that carried of course in the global space as well. The Rockefeller Board agreed to this vision in 2008 and supported a move to universal health coverage understanding that in low and middle income countries we needed to see not only as a laudable but unrealistic aspiration and indeed as something that was economically feasible and unavoidable. I think much has happened in 2009. We published in the Lancet with Larry Garrett, a paper on all for universal health coverage. We was making an explicit call for that and Russia Horton, the editor of the Lancet became an instant champion and has been since. When I moved to Rockefeller, David Ferranti was just leaving the bank and we got going, something called Resource for Development which is a great action tank now. But it was very important also in the genesis of this mobilization, Bernard Kushner, who founder of MSF and then Minister of Foreign Affairs in France, we engaged in this conversation and he helped us position this in France who has been a champion. We helped establish something called the Jolli Learning Network a dozen countries who were implementing universal coverage to begin to share their experiences and so on. And indeed, then support for David's leadership in the WTO to see the World Health Report in 2010, the Montreal Conference that year also and all the way to the aspirations that have been crystallizing of seeing both the World Health Assembly Resolution in 2011 and the UN General Assembly Resolution in 2012 which has helped us bring the conversation to this stage much more is to happen. USAID has established a new office of health systems precisely to help drive this in partnership with all of you. We look forward to this conversation. Thank you. Thanks very much, Arielle. Gina, can you talk about some of the trends? Gina Lagmasino with Results for Development Institute. Can you talk about some of the trends in how countries are approaching this issue? Each country is looking at it from its own perspective but what are you seeing in terms of what countries are doing? Sure. Well, thanks so much, Nellie, for inviting me to join this very, very distinguished panel and thanks also for this very daunting task of trying to summarize in five or so minutes what many different countries around the world are doing in terms of pursuing universal health coverage. And I think your video earlier today summarized well the point that every country is taking its own path and there's a lot of different unique paths to universal health coverage. What I'm going to try to do is to draw a few generalizations based on some analysis of nine low and lower middle income countries who have pursued universal health coverage reforms through major health insurance, national health insurance reforms in the last decade. And this was some findings that were published in the Lancet by me and some other colleagues about a year ago. And first I'd just like to caveat that national health insurance is not the only path to universal health coverage. Even some of the countries that we looked at have other universal health coverage reforms going on at the same time as health insurance. These countries include India, Indonesia, Vietnam, Philippines, Ghana, Kenya, Rwanda, et cetera. So they're all pursuing things differently but I think a number of them got started on this path and made this a domestic priority for similar reason. And that was that people in these countries basically got fed up with paying high out-of-pocket costs at the point of care. They're tired of sometimes not being able to have access to care because things were too costly or feeling like they're getting pushed into poverty because of these costs. And I think a related concern in some of the countries is that people in the poor and emerging middle classes were finding that the wealthier populations maybe had access to different types of care, maybe the private sector or perceived higher quality care. So there in many of these countries was really a major domestic political push to try to move towards universal health coverage. Now how have these countries pursued this? Ariel gave a nice summary of some of the history, the various models, beverage, biz, market, et cetera. When we looked at these nine countries, we tried to see were they pursuing the same strategies of previous higher income countries. And what we found is no, they're actually creating their own new models and they all vary. But there are a few areas of convergence that we were able to find. So let me first mention three areas of convergence. The first is that each of these countries is really prioritizing government financing of services. And they are raising new revenues. They're increasing government health expenditure. And they're usually combining multiple different revenue sources. There's often a debate about what's better, general taxes or payroll taxes or premiums. Most countries are combining multiple sources of revenue based on what's domestically, politically feasible in their context. And those include all of those revenue streams. A few are even creating new sources of revenue. Ghana is an interesting example where they've created a new value added tax that was passed in 2006 that is earmarked for their national health insurance scheme. And that's enabled them to create a new revenue stream. So they're all increasing government spending. A second area of convergence is that they're all actually moving in the direction of creating broad national coverage programs that cover everyone. And they haven't all achieved that yet, but they're moving in that direction. And this is different if you think about what they were doing a few decades ago. A number of them had created programs that were targeting just one population. So they might have had a national health insurance program that was mainly targeting people that worked in large companies. They might have had a separate program for civil servants and maybe something else for the poor. But what you're seeing is an attempt to try to bring those programs together in some cases by adding additional populations to existing programs. One of the commenters earlier mentioned Kenya. Kenya has had a national hospital insurance fund for decades, and they have attempted in the last few years to try to expand that program to include civil servants and the informal sector. Another interesting example is Indonesia, where they have passed a law to merge five separate schemes, health insurance schemes that are already up and running for different segments of the population. And if they are able to achieve this kind of daunting challenge of merger of five schemes, there's a single payer system in the world. So this is an interesting trend toward trying to create broad national schemes that cover everyone. And really, I think the goal is equity, trying to create better equity so everyone has access to the same types of benefits and services, and also efficiency. Many countries feel like the single risk pool is more efficient. A third area of convergence that we found is all of these countries that we looked at have either created and new or strengthened their independent health purchasing agencies, or sometimes called national health insurance agencies. And this is a bit of a departure from the past where in the past many countries funneled a large percentage of their government dollars directly to public providers through their budgets. And now there's more money getting funneled through these purchasing agencies, which is actually enabling in some countries purchasing from both public and private sector providers. An interesting new phenomenon. India is a great example of this where a number of different health insurance programs, both at the state and national level, have emerged in the last decade. And many of them are purchasing care from private providers using government revenues. And this is creating new revenues that are attached to poor people. That's really shaking up the market in India and I think has a potential to do so in other countries too. So all of these countries are making some progress. I think we found that almost all of them have been able to, at least to some extent, reduce out-of-pocket expenditures as a percentage of their total health expenditures, which suggests that probably there are fewer people getting pushed into poverty. But they all are experiencing really daunting challenges with getting these programs implemented. And several people, Dr. Kim and Arielle have mentioned the Joint Learning Network for Universal Health Coverage, which is a platform that a number of these countries have created for practitioners and policymakers to come together and learn together about the practical how-tos of implementing these reforms. And I've had the pleasure of working with this group of countries over the last few years. And so let me just list a couple of the challenges that are common across countries. There's many, there's a long list, but just to name a few, they're trying to raise revenues, enough revenues to cover the entire population. They're encountering the problem of, even though their economies may be growing, their tax base doesn't necessarily grow as fast as the economy. So many of these countries still have large informal worker populations. It's difficult to collect revenues from these workers because they don't get paychecks, so you can't withhold taxes and premiums. So they're struggling with, how do you get enough revenues from the private sector populations? That's a big challenge. A second challenge is related to quality. So as these countries begin to push more government revenues through their health financing schemes, there's a lot of pressure on them to make sure that they're actually purchasing high quality of services. And at the same time, there's increasing evidence that quality is pretty bad in a lot of these countries across the spectrum in the public and the private sector. So they're grappling with what are the right kind of institutional mechanisms for monitoring and improving quality. Everything from how do you create and push out standardized treatment protocols to what's the role of facility accreditation and indicators, things like that. And how do you actually construct the right institutional framework in the country to get all this done? What's the role of the Ministry of Health? What's the role of the National Health Financing Agency? So there's a lot of debates going on in these countries. The piece of that, I think there's a growing focus on primary care and how do you actually make sure that people are getting access to the right primary care services, many of which that Dr. Kim mentioned, that are actually going to improve health, not just pay for high cost hospital services. So that's a big challenge. A third challenge, of course, is costs. Every time you give a population access to new benefits, their demand is going to go up. The providers are going to see this as new potential forms of income. And so a lot of countries are grappling with the fact that the minute they institute a major coverage program, costs begin to rise. So they're struggling with what are the right incentives that they can put in place to manage these costs, while also promoting quality. And so as a result, a number of countries like Vietnam, Ghana, Kenya, et cetera, are trying to move away from fee-for-service payment models toward more capitation-type payment models. And this has been a big challenge. These are complex reforms, and they haven't all gone smoothly, which brings me to my final point on a common challenge being experienced across all these countries. And that is the problem of domestic stakeholder politics, which I think Dr. Kim also alluded to. So you have providers, groups of providers that are resistant to maybe these new payment reforms. You have employers and unions that might be resistant to increases in premiums that are designed to expand benefits. But they're hitting the pocketbooks of their members or their employees first. So there are a lot of challenging domestic political challenges that these countries are facing. And even after they have gotten legislative commitments to programs, actually implementing them can be a big challenge. And we, of course, here in the U.S. are no stranger to those kinds of challenges. But despite all these challenges, I think I'm still pretty optimistic that it's exciting that so many countries, even those on the lower-income spectrum, have embraced this commitment to universal health coverage. I think the fact that they are committing to this and committing to their populations means that even if they don't get it right the first time, they're getting held accountable for improvements and iterating. I was in Ghana just a couple of months ago that they were celebrating the 10th anniversary of their national health insurance scheme. And it was really heartening to see a group of government implementers, even parliamentarians, able to sit and have really important conversations about what they have achieved, what they haven't yet achieved and where their big challenge is, and then actually have really intelligent conversations about the trade-offs that they face in the coming decades to achieve universal health coverage. So I think there's a lot of reason to be optimistic about the potential, even as we need to continue to work to support countries that are making this major commitment. Thank you, Gina. So now we'll move to Jonathan Quick, president and CEO of Management Sciences for Health. We're going to talk about some of the points further elaborating on Gina's points of contention and political issues. Thank you, Nellie. Thank you to Stephen Morrison and CSIS. And also congratulations on getting a global action about despite being some result of an awful horse just before it was due. As many of you know, Management Sciences for Health is a nonprofit organization that focuses on building local leadership and strong local health systems. And we've been vigorously supporting universal health coverage for two reasons. First, as a matter of human rights and being a vehicle to realize that right and the fact that health shouldn't be a matter of the accident where you were born. The second is it's the only approach that, as Gina's pointed out, mobilizes and focuses both domestic and international resources that improves health care delivery that provides financial protection and that adapts to changing health situations. We do that with working to mobilize and get engaged in universal health coverage, working to mobilize civil society, working with advocacy in Africa and on some key intervention and implementation issues like access to medicines. I want to pause for a minute and Jim Kim talked about AIDS and the amazing achievement there and imagining the impossible and then making it happen. If you had asked the global health community in the year 2000, if you had described to them what actually existed in the year 2010 and Paul Davis and others can verify this, the majority would have said impossible, impossible, not in the world I know. There were four barriers that had to be crashed. The feasibility barrier, it wasn't feasible. The cost barrier at $12,000 per person per year who was going to invest. Then the money barrier when prices came down and then the scale of barrier. The common element across all of those barriers was the activists. Each, they could hammer barrier by barrier and that was civil society and it's been really interesting in universal health coverage. One of the challenges and we've been working through the Revitalized Global Health Council, the new executive directors here from the US, the Action for Global Health in Europe and Global Health South which bans several hundred NGOs from the South to try to get a uniform view toward universal health coverage and I have to say we're not quite there yet. We're not quite aligned. So one of the challenges is that there are some skeptics out there who aren't quite sure. Last week, so let me talk about three of the kind of barriers. One on the essential benefits package. Last week the head of our AIDS program for MSH, our global lead who's done some pioneering work in preventing maternal to child transmission for AIDS comes in and sits down and he says, Jono, when we started talking about universal health coverage several years ago, I thought you were crazy. I thought it was pie in the sky. He walked into my office after having had a conversation to get him to write an article on AIDS and universal health coverage. So he says, he concludes, but I'm convinced. And I think that reaction that it's not going to, it's the what about me reaction. When there's change, people think about the change and then it's the what about me. Another group that is anxious and ambivalent is the women's health and reproductive rights group. That's an area where there's tough fighting. They're worried about losing family planning services. So last week MSH with the Harvard School of Public Health in Plos Medicine, the online publication did an article on improving women's health through universal health coverage. And we looked at very concisely at the huge inequities that exist for women. And then looked at the experience with universal health coverage in Mexico, the data from there, from Thailand, from elsewhere and then identified five critical factors that need to be considered in the design and implementation of women's health. So essential benefits package is going to be a lot of fighting there and skepticism and worry can our health priority get in there. The other question, and Jim Kim really got at this, the whole question of whether the poor will really benefit. History is that the rich tend to, or the better off, tend to capture the health services in their communities. And so there's concern whether and resistance in some pockets for those that are worried about the impoverished. Despite the goal there, it's will we get the services. And actually the data, it's fascinating to look at 10 and 20 year time series from Brazil, from Mexico, where you can see by income quintile the increase in services. So universal health programs who make a commitment and really try to target the poor get there. The third area of tension, contention, is this prevention treatment. And in September, the week before, the week during the UN General Assembly, the Rockefeller Foundation time mission convened a round table of the vertical disease program. As I said, we're the vertical disease gang. So we had TB, chronic diseases, malaria, and the essential drugs folks. And it was particularly the malaria people and the malaria people and the chronic disease people who worried about this balance. The terminology confuses this. Universal health care is not just about treatment. It's the whole continuum prevention on. And you can see the programs that have that vision. Again, Rwanda. The first country, as far as I know in the world, is part of the universal health coverage vision. We committed to 100% coverage with a cervical cancer vaccine, the HPV vaccine. So that prevention is an essential part of universal health coverage. But treatment's always fighting with it and for resources. And it shouldn't be that way, but it is. So we also at this meeting in September heard the example from Ghana. The first year of their program, medicines were 25% of the budget, 2006. By 2008, they were 45% of a budget that had gone sixfold because they were growing. The latest figure, it's over 50% because it was a budget that wasn't, it was a benefit that wasn't managed. Some of that was on that need, but some of that was in, much of that was just an unmanaged benefit. So three sort of risks and things to look at in getting through and envisioning the impossible and then making it happen. Thank you very much, Jeff. That was a helpful scene, what other countries are grappling with. It's not just us, apparently. So Tim Evans is the director of health, nutrition and population at the World Bank. He's going to talk about the role of international organizations and donors. I will thank you, Nellie. And I realize that people are getting a little anxious here and I think Jim, Kim, in his opening remarks sort of summed up the real value of international organizations when it comes to universal health coverage and that is that they should be ignored. As the ties did, they ignored the advice from WHO and the World Bank and look at how well they've done. So I think we can stop there. But if I were to defend my job, at least, for a little longer, there are four things that I think would be our value-added areas for international institutions. First is their roles in policy advocacy and convening. On the policy front, we are in the post-2015 vortex of action. It's a little bit more comfortable than the polar vortex we had last week, but not much more. For those who are actively engaged, it's high-stakes politics. But there we have an opportunity of getting UHC on the agenda. And as Jono said, it's not a given. There's a lot of reasonable people who are quite angered by the thought that poor countries dare to think about universal health coverage, just as poor countries were daring to think about access to ARV treatment. So I think we have to embrace that. The Bank and WHO come together in, I think, a very productive way and put out a set of targets that can enter that debate. And I think this takes us from the rhetoric or the sense that this is idealistic and non-measurable to the concrete. And we've defined that imperfectly. But at least there is something on the table which says that there's a fair financing dimension of that which is nobody should be impoverished due to expenditures on health care. And there, very importantly, is an equitable access to services across the spectrum according to need and of good quality. And we can now, albeit modestly, we can measure UHC. The great thing is that it is universal. And there isn't a country in the world that has achieved universal health coverage. Because even if you have a country that has zero impoverishment from health care expenditure, perhaps like Canada or perhaps some other pillar of wonderful health performance and other performance. I'm a Canadian, by the way. There is the issue of access to services. And when you look at effective coverage, quality-adjusted coverage for things like chronic diseases, the performance across the world is very poor, especially if you look with respect to the poorest 40% of the population. So this really is a target in the sense of the post-2015 development agenda which is universal and isn't one where we had a problem with respect to the MDGs in which it was only for the poorer countries and the richer countries that all achieved these targets. So I think that's very important. Advocacy is very important. The rationale associated with investments in health and entitlements, rights are extremely important and international agencies can make those arguments very well and convening. We have to go beyond the sense that it's just governments and we have to think about the reality of most health sectors which is the public, civil society and private sectors all play increasingly important roles and we ignore them at our peril. So that's policy advocacy and convening. Strategic investments. I say strategic because I don't think there's any international agency or institution that should be thinking that its finances and activities are sufficient or anything but stop gap to countries actually managing their own investments increasingly in the future except perhaps in emergency humanitarian disasters. But there are three areas of strategic investments that are particularly important. First on financing, we have to, as Gina said, get beyond what I would call 20th century or 19th century solutions with respect to the health sector which were never perfect but what I like to say is going beyond beverage and Bismarck. Tax financing is very important but many countries have very, very weak fiscal collection capability. Social health insurance or employment based is great if you have large formally employed populations but many countries have very high informal sectors. So I think we really need to begin to push the envelope in bringing in a new set as many countries are doing but a new set of efforts to think about financing. More importantly, international organizations need to think about what their explicit strategy is to support national financing. And at the moment too many including our own institutions simply think that by making a loan or making an investment to scale up a service that that is financing. Yet it is completely delinked from a strategy towards financing the health sector in a more equitable way such that everybody has access to coverage. So I think that one practice that could be adopted is that every international organization develops a checklist with respect to how their investments their financial investments are contributing to a national financing strategy with respect to UHC. The second area is to think and this is very important about how to scale up services equitably. And we're really at the cusp I think of understanding not only the wonderful legacy of scaling up antiretroviral therapy but also increasingly with respect to maternal and neonatal child health. We're seeing huge increase in scale and access of services with the use of incentives, with the use of community health workers. And so there's really an opportunity there to think about how we can get to high quality, low cost, comprehensive primary care systems with appropriate referral. And how we do that is an area where I think the international agencies can continue to play an important spearheading role. The last area that is very important in the context of strategic investments and this is an area of tension which is that and very important for us at the bank is that it isn't just the health sector. We really have to make sure that other sectors that lay the foundations for healthy societies are doing what they need to do. You have to have safe roads, otherwise you've got terrible problems with road traffic fatalities and chronic disability, which the health system, if it's really good might be able to manage but it manages at its most or highest cost point. So those preventive efforts that are inherently intersectoral and most efficiently done need to be captured and emphasized. So that's the secondary strategic investments. The third is with respect to what I call global public goods and scale efficiencies. And so there is a lot of opportunity in setting norms and standards and other sorts of things like that, which allow countries to avoid recreating wheels. Okay, so if you do have some good standards, best practices, things that have been proven to work, measures that can be used across contexts, then you take away the need for countries to try to come up with their own. And I think there's great value in that. But there's also great value and increasing value in the context of the scale efficiencies that come from cross-border collaboration. And we've seen this in the context of pool procurement, which takes the opportunities for bargaining for much lower costs for drugs or vaccines in the context of GAVI. Those are very important mechanisms in increasing affordability in countries. They're tougher issues related to managing labor markets for skilled health workers. And we know that those forces of international labor migration in the health sector are only growing. And so we will need some capacity to manage those moving forward. The last area is capacity, capacity, capacity. And I think international institutions can do much better than they have been doing on this front. It relates not only to the technical assistance agenda, but really parlaying that more into strengthening the next cohort of leaders who are the financiers, the technical accountants, the frontline health workers who are actually going to do this on the ground. And how do we make sure that we're investing in the national institutions that generate those workers rather than relying, sorry, Jono, on those that are in places like Washington and fly out and give advice and tell people how to do it. We really have to invest in those national institutions. Investments in those institutions, it appears, is actually quite cost-effective. And there's a great study that Rockefeller did looking at how much money needed to be invested in certain types of institutions that are critical to accelerate reforms towards UHC. And it's somewhere around 2% of the total cost of what's spent in health to get that fundamental institutional capacity which is necessary for running financing institutions, national health security offices, those sorts of things which are important. The final area of capacity which I like to refer to is infrastructure, and it's infrastructure and information. And if we don't invest in, for example, vital statistics or clearly giving people national identifiers and registering in them and giving them identity, then we really have no business talking about UHC because we don't know the denominators. And to me, in this day and age, it is really an offense in terms of people's essential rights and entitlements that they aren't in some way registered and counted in some country. And too many people still remain invisible. So if we're serious about UHC, we have to get serious about investing in those information systems that give people identity and allow us to get real denominators to understand how many of the total population we're getting coverage to. Thanks very much. All right, thank you very much. So we have a half an hour-ish, okay? So I'm going to ask a couple questions. I would love it if any and all of you would like to weigh in. So we've talked about the differences between middle-income countries and low-income countries. What are some of the unique challenges and opportunities for middle-income countries in universal health coverage? What's different about how their approach might look versus a lower-income country? Well, for middle-income countries, they're at a critical point because what happens, we've heard about the growth in income. And there's a chart from the economists that's vividly burned in my mind that showed the growth in Africa during the time we were melting the economy of the North and there was at least a half a dozen countries in Africa that were growing at 5% to 10% per year. We know that that growth of economic resources fuels health. Health spending goes up. But if it goes up in an uncoordinated, unfocused way, what you do is you grow an uncoordinated, unfocused health system. And so the opportunity is to get in now and as the economy starts to take off and help get that vision because the thing that the countries have learned without mentioning any in particular is that if you get a huge share of the national economy in the hands of one industry, it's hard to reform it. I'm speaking to the health industry. So that's the opportunity in middle-income countries. Gina? Yeah, just to underscore Johnna's point, I think the big challenge a lot of middle-income countries are seeing right now is a two-tier system that has emerged because they didn't early enough in their history create a strong framework for national universal health coverage. So they might have had some public delivery. That was primarily focused on the poor and as more and more people moved into the middle and upper classes, a private insurance industry emerged and a lot of private providers emerged and more and more people started to join that system and now they're faced with the challenge of how do you actually get those people to pay into a national system so that you can cross-subsidize? How do you get the people on the lower end of the spectrum that are looking at others and saying, they have access to providers I don't have access to. How do you bring all that together? I think South Africa is a very stark example of this. They're obviously a unique country, but they have made a major commitment to try to get to universal health coverage and one of the things they're going to have to get past is the fact that they have a two-tier system, one system for the rich, a different system for the poor, with a lot of the total revenues and health being spent on a small segment of the population in private insurance and private delivery and how do you reconcile that? And I think that similar challenge is maybe not quite as stark, but being faced in places like Indonesia and Malaysia and a number of the other emerging economies and that's a big, I think a big challenge for many of these middle-income countries. Something, Arya? Well, in addition to, comparing emerging economies with OECD economies, in addition to learning from many, many, many experiences, many processes already, the issue of timing is crucial. Indeed, when countries are beginning to spend $50 to $100 per capita in health, five, six percent of one to $3,000 per capita income, reform is tough, but it only gets tougher later. That is, if you do not reorganize your health financing, the political and fiscal challenges only grow. So, in a way, for the United States, with 18 percent of the largest economies in the world, trying to reorganize that is what we have seen, you have lived through how difficult that can be. It's a lot easier. So it's a lot easier, actually, in an emerging economy than a rich established economy to reorganize the health financing towards universal health coverage. And I think that Gina was alluding to the sense that as you begin to be explicit about the funding, particularly public financing of health, that you may see inflation because the demand might grow. And actually, the reality is not so much so. The demand searches with the economy. The demand is there. And the governments who do not meet it will see their people paying out of pocket. So, when the governments begin to meet that demand, it doesn't mean that the growth just carries on beyond what the GDP or the economies will call for. And in fact, those societies that have organized their universal health coverage are not spending more than those who have not. So organizing your financing doesn't, per se, increasing the cost of demand. That seems to happen just because of social demand with health, with economic improvement. Tim? Yeah, I think most has been said, but I think it's very hard to generalize other than middle-income country health economies are larger and more complex. And therefore, managing them is probably more complex than low-income settings. And so one of the things is to understand the diversity experience, there's a lot of positive deviance or great experience in that Jim mentioned Turkey. There are at least a dozen fascinating things that they did in implementing their comprehensive reforms in 2003, which are indicative not only of the science, but the art of managing complex reforms. And it's as simple as the sort of thing of securing short-term wins so that you have more time to manage the more complex agendas. But it's also as attention to detail the Minister of Health saying he made over a thousand visits to the field during his time in office because he just could never believe that whatever was written on paper was an accurate reflection of what was actually happening on the front line. So reality check, reality check, reality check. And those are the sorts of things that I think are, I call them pearls. Those are the sort of, get wisdom from people who have great experience in high performance. And if one can pass those on and share them, and I think there's opportunities for getting greater sort of know-how in managing complex reforms, and I think the opportunity for low-income countries is in a sense a bit of a leap-frogging opportunity. Less complex systems, less established vested interests, so there's an opportunity relatively earlier on to begin to think about how to get everybody under the same tent and begin to manage that difficult, ongoing steer and negotiate to try and move towards a common vision for the health system. Okay, well I'm going to take the privilege of asking one more question and then we can open up to the audience. So there's been some talk about the post-2015 agenda and UHC potentially as a goal in that what would that mean to the UHC movement if it were included as a goal and what would it mean if it weren't included as a specific goal? I'll go first here. For us, I'm just going to talk about our own institution. We're setting plans. Our president has basically identified goals for the institution as a whole by 2030, which is to eliminate extreme poverty and boost shared prosperity. And for each of the practices now within the bank, HNP, health nutrition population, being one of them, we have to identify how it is we're contributing to that goal and what our specific sub-goals are. And our sub-goals are universal health coverage. And we've defined that in two ways together with WHO, which is one, to eliminate impoverishment due to health care expenditure. And we're bound and determined to do that not only because we care about that in the context of health, but we know that that's going to contribute to the larger development objective of eliminating extreme poverty. But secondly, we want to make sure that we can contribute through our investments to increasing access to care. And our target is that we'll reach 80% coverage for essential interventions, which cover both the MDG or post-MDG type interventions, which is more the MNCH and HIV TB malaria, where there will be continued targets, as well as what we call chronic conditions and injuries, which is NCDs, non-communicable diseases, mental health and injuries. And on those, what we want to do is try and make sure that the bottom 40% of the population have at least 80% coverage to essential high-value interventions. So that's what we're going to do. Now, if we fail in the high stakes of the post-2015, it doesn't matter for us because our presidents already set the goals. We are committing to this. So we move forward no matter what. We hope, however, and we're working very hard unabashedly at the moment to try and make sure that the post-2015 agenda reflects what we as an institution and other institutions like WHO believe is the right direction with respect to UHC. Jenna? So one way to look at the post-2015 health aims is as a three-legged stool. You've got the unfinished agenda of the MDGs, which everybody agrees we've got to finish. You've got, as we know, this new acronym, which I only saw last night, CCI, the chronic conditions and injuries. That dwarfs the unfinished agenda in terms of human impact. You can't achieve those without universal health coverage. I would put that forward that you're not going to get there. I don't know any countries that have. And so that's the three-legged stool. You've got an option. You can bring universal health coverage up as the umbrella, but from a communications point of view, you don't want the driving vision being something that people have to define. So the driving vision of healthy lives or something like that makes sense. But if you take away any leg of those stools, it's not a matter of what happens to the universal health coverage agenda. It's what happens to the health of the people in the countries who are meant to benefit from this. And you won't get there without all three legs. Gina? So I'm optimistic and hopeful that UHC will be chosen as one of the major post-2015 goals. And I think part of the reason is because this morning we've talked a lot about how the global health agenda has been quite fragmented with so many different communities pushing for focus on different diseases and different aspects of the health system, which has led to a lot of really positive impact, but has also led to this fragmentation that a few people illustrated very well. Dr. Kim talked about the village with different buildings for different aspects of TB prevention and treatment. So I guess my hope is if this metric gets selected for the next round of the MDGs, it will actually help those different communities to come together, not losing sight of their own specific goals, but it'll force them to actually think about how everything they're doing fits together and what is the right framework for them to be working together. And hopefully it will give countries the impetus for providing that framework for all of the various stakeholders and groups. So that would be my hope about if we do it that the UHC is a goal. As a development agency, USAID really aspires to create systems that will be resilient, that will be equitable, that will be sustainable, because indeed we are not going to be there forever. So our work on health systems is very much geared to the process that universal coverage involves to think in terms of equitable, sustainable development for health sector. And so as such we've been doing that. And in fact most of the countries where USAID has graduated from, whether it's Mexico or Thailand or South Korea, have systems of universal health coverage. And I think it's very important for our work to carry to do so. This is the global agenda. My sense is although there's been a tension in the conversation, because people are fighting for agendas, it's less on the countries. The countries are already moving. So in a way the horse has left the stable already. I mean we are talking about heads of states, Senegal wind selection, the President wants to see universal health coverage. And I say well, maybe it will take 10 years, maybe it will take 50. But if they begin to commit to health, to invest or mobilize public financing for health and equitable and sustainable systems, that's already a good thing this year. And I think that that is happening because it resonates with people. As I said, when there was no money in a very poor country and you were not spending, it was a different agenda now. It's just the times call for it. And I think countries have been leading, probably building this, and not only Mrs. of Health, who are already pretty much on board, but Mrs. of Finance and Mrs. of Labor, Mrs. of Foreign Affairs. So we can take some questions from the audience. We'll take two or three. We have, do we have a microphone somewhere? Is that okay? So this woman right here in the back. Thank you very much. My name's Jeeling, with Voice of Vietnamese Americans. Thank all the panelists for a very comprehensive approach and points. And I'd like to ask Mr. Tim Evans from the World Bank Groups and also Gina, regarding the particular case of Vietnam, we'd like to bring it into implementations and focus. You brought up the case of infrastructure and building capacity. And you also make the point that we need to know our denominators. We need to know who we work with. And in the case of Vietnam, as Gina points out, we do have a two tier system where the rich got everything better than here and the poor got nothing. So how is it to bring in more inclusive growth with the civil society efforts? Is there a plan, or is there a plan in the future to work with all the civil societies besides the government? Because as of now I know the World Bank Groups work directly financing through the government and many NGOs in Vietnam actually are government controlled. And regular NGOs are not able to access your resource. So how do we get the normal 80% to access to your resource? And also that the Vietnamese diaspora in the US and also internationally we are willing to help. We've been helping on our own. But how do we collaborate with you to work in that end? Because legally we do not have the status to work with you. Thank you. Thank you. We had a question way over here. Thank you very much. My name is Marielle Hart. I'm policy manager with the International HVH Alliance. I'm the organization's global policy lead on post-2015. And I'm also co-chair of the Global Health Council working group on post-2015. And I would really like to thank the panel for the excellent contributions and also to say that we've been working very closely with MSH and others to really get the health agenda right for the post-2015 agenda. This morning we've heard a lot about the lessons learned of the AIDS response. And one of the crucial issues that has so far been missing in the discussion is what we have really learned from the AIDS response is if you don't target marginalized and vulnerable populations that really goes beyond poverty. But those populations that don't have access to services because of stigma, discrimination, marginalization and criminalizing laws. First of all, we're not going to achieve the end of AIDS, but also we will not achieve universal health coverage. So I, we and many others that we are working with have been a little bit concerned to see that the WHO and World Bank have been very focused on a target that addresses the poorest of the population and addressing the obstacles for poverty and access to services but that there hasn't been a discussion on very specific targets to also address the other factors of vulnerability such as stigma discrimination and marginalization. And we would really like to engage in a discussion on how we can also address those factors beyond poverty in a very specific target. Thank you. Just joining me here. Hang on a second. Good. I want to apologize to the audience but I promise you this is my last question of the day. Dr. Quick, I was intrigued by your comment related to injuries and the role of the health sector. Most of the injuries are due to homicide or traffic related injuries. And those are almost completely outside the health sector. If you think about young men in any country or in most countries one of the first, third or second cause of death is homicide or traffic injuries. So I would like for you to explain how can this problem be approached? Of course you need an intersectoral approach but it's mostly policy regulation especially because of the increasing number of motorcycles for example in some cities in Latin America there are more motorcycles than cars and that poses a new challenge. So that's my question. Thank you. Anybody? We can do some answers now. Do you want to start with NGOs or motorcycles? Well, I can comment briefly on Vietnam. Gina was engaged on that as well and I think there's a difference. Yeah, I've got a... How's that? Yeah, that's better. And then the question on AIDS vulnerability I think is directed towards David and I. So I'll take those. So just in turn I think the point you're making is yes the World Bank does work primarily with its clients as government and however we do have as part of our institutional corporate structure the International Finance Corporation which works much more explicitly with the private sector and there's really a priority to try and bridge that in operations in a much more explicit way but it really links to the bigger picture of understanding the necessity for all health systems to deal with all of the participants and civil society and NGOs whether either governmental or non-governmental NGOs as in the case you identified in Vietnam are very important. To be honest I don't think the World Bank has figured out how to do that really well across all countries. There are places where we have our investing in social accountability mechanisms. We have a full strategy at least in North Africa now where the focus on governance and social accountability in health systems is giving a lot of attention to civil society taking a role and demanding accountability but more specifically in the context of Vietnam we've been putting quite a bit of energy into strengthening frontline primary care services and I think that in the context of that there is some work on how the interface between non-governmental organizations and government services can be better aligned. So I think there is some work but we can perhaps follow up on that. With respect to the issue of other stratifiers of access to care beyond income poverty you're absolutely right and I think if you go to the paper that we've posted online for consultation that what we do is we're putting forward a poverty criteria for stratification but we say that this is one of many stratifiers of access to care and that countries depending on their context should look at that spectrum gender, place of residence different type of religious or sexual persuasion those sorts of things occupational things those are we know very important stratifiers that we're not saying very importantly is that countries should not pay attention to those we're saying that for the purposes of global monitoring we're advocating an income poverty measure of stratification but that countries according to context should be looking at and making sure that they identify those vulnerable groups as part of their commitment to health care so on injuries I think that's a great question because it brings out the benefit of a universal health coverage program you've got to ask the question why was it only in 2012 that the world began to discover that there were 28 million chronic disease deaths in low and middle income countries compared to 5 million AIDS, TB and malaria combined that more women in their productive ages were dying from cervical cancer and breast cancer alone a lot of which is preventable more than in pregnancy and childbirth if you looked at health systems and listened to the press you could be forgiven for concluding that women in low and middle income countries didn't get cancer why did that happen no one was looking they were looking at what they were getting funded to do when it comes to injuries you're right and they can ring the bell I would really encourage you to look at the Lancet series on Mexico and how they develop their system we hear a lot about prosalud to health insurance there's a great graphic there which is Julio Frank's original as minister of health from Mexico vision for where he was going the universal health coverage component was part of it there was a lot on prevention there was a lot across and that's where we needed new set of skills and ministries of health when Julio Frank was minister of health in Mexico he knew he couldn't talk to the finance people he hired the best economist in the country gave him a big office and a big title and took him everywhere to finance and health can ring the bell and cares but it is then having a different skill set to link politically across benefit of universal health coverage because if you're paying to take care of people who are in it's not just the desk it's the money it's firstly the desk so a great question we only have a couple minutes left and I think we can't take another round we got more time from Dr. Kim than we were expecting which was great so I'd just like to thank you all it was a great overview not only was it an overview but it was very detailed and we got into some really substantive issues and thank you very much