 Good morning and welcome to the Center for Strategic and International Studies. I'm Steve Morrison. I'm a Senior Vice President here in Direct the Global Health Program, and we're delighted to be able to host this very timely and really fascinating gathering here today. I want to also welcome those who are coming online to join us today. This is being webcast live. The video from this will be posted subsequently on csis.org, as well as smartglobalhealth.org, our microsite for our program. Today's goal is to examine a vitally important and complex dimension of universal health coverage, and as we'll hear from all of our speakers over the course of the morning and into the afternoon, the core question really amounts to, as countries move to provide an expanded mix of health services to meet demands, to meet expectations that are evolving, how to make quality choices on the best mix of benefits. And this may sound simple, but it's not. It's not so simple on how to reach informed decisions amidst financial scarcity, competing demands, complex political realities, fluid market conditions, and multiple uncertainties that one has to make some estimation of what those represent and how to navigate those. So in an ideal world, folks aspire to, it seems to me, a common set of quality in this to reach informed decisions that are evidence-based, that are transparent, that are linked to clear public health outcomes, and that are sustainable, and that are defensible to multiple audiences, that are defensible to heightened scrutiny by civil groups, by voting publics, by ministers of finance, by interested private sector players who contribute very importantly to these outcomes in mixed systems that we have, very complex and variable mixed systems for public and private interests, bringing forward services. As we'll see today, we're in the midst of a very lively and important debate. On the approach, on the philosophy, on the methodology of proceeding here. And there's a growing body of very important evidence that we'll hear about. There's a growing body of analytic content and of country experiences, of global approaches that are evolving on this, and as we'll hear, there are no simple or magical answers and solutions to this question. But there's lots of people coming from different perspectives who are investing considerable expertise and talent in trying to arrive at better and better approaches. The approach that we're taking here today is to use our convening power to bring together a diversity of experts, folks from the World Health Organization, from the World Bank, from the U.K.'s NICE, from the private sector, national leaders, leaders of national programs, independent experts, representatives of other think tanks. And this builds very effectively, I believe, on the successful conference that we had on universal health coverage in January of 2014, a little over a year ago. And both today and what we did a little over a year ago were really the fruit of the effort of CSIS senior fellow Nellie Bristol. So I want to single her out for special thanks and appreciation for the intellectual leadership she brought to this, as well as the determination to find the best experts and get their guidance and input and bring them forward here today. I also want to offer special thanks to my colleague Sahil Angelo, who has made a very significant contribution to this. There are a number of other folks here at CSIS who have assisted us, colleague Catherine Peck, Katie Addis, and Travis Hopkins here, who is helping us with the program and the AEV, Jesse Swanson, on photography. I also want to offer a very special thanks to Pharma, its office here in Washington, for its expertise in financial support, particularly Kevin Henninger and Fumi Grejo, who have been longstanding partners in thinking about these issues in a very open way. What we're going to have happen here this morning, time is tight. We have a very ambitious program. In just a moment, I will introduce our opening keynote speaker, Jeanette Vega. She will open with a keynote, then we'll have a brief conversation afterwards, and then we will move to two successive panels, one on global approaches, one on country experiences, and then we will regroup for a luncheon discussion with Assistant Secretary Jimmy Coker from the Health and Human Services Department. And as we did in January of 2014, we've tried to bring this back since we are in Washington, since our orientation here, and our comparative advantage is trying to shape U.S. approaches. We wanted to bring the debate back at the close around what does this mean to U.S. global health approaches? What's the fit? What contributions does the U.S. make in this domain? How does it fit in the larger, in the larger, uh, uh, ambit of U.S., multiple U.S. investments and programmatic engagements in global health? Of course, we're all familiar with the continued debate that goes on domestically within the United States around the Affordable Care Act, which adds a further dimension, very profound dimension to the politics and the perceptions around something that we call universal health coverage in talking about this in global terms. So, uh, Jimmy kindly has agreed to come. I want to thank, there are many speakers who came considerable distance to be with us, uh, from Sydney, Australia, from Bangkok, Thailand, from London, Geneva, Mexico City, New York City, and elsewhere. And thank you all, those of you who came a considerable distance to be with us today. I know this is a big bite out of your schedules and, um, and it shows really the seriousness with which you're approaching all this, and we're very grateful to you. Our first speaker, our keynote is Jeanette Vega. She's the director of FONASA, the National Chilean Public Health Insurance Agency. She's been in that role since March of 2014. So she's at the one-year mark on that. She's an MD, PhD in public health, has had a remarkable career. She returned in 2000 to Chile, uh, to join the executive committee for health reform, which was a pivotal moment in, in executing and thinking through, uh, the reform of the Chilean system. She served in very senior position at a very critical moment at WHO as director of the Department of Equity, Poverty, and Social Determinants for four years until, until taking up her most recent post, was a managing director at the Rockefeller Foundation, which is, you all know, has really been, uh, the font of much of the intellectual leadership here in the United States around these issues of universal health coverage. So Jeanette, thank you so much for agreeing to do this. And I'd like to invite you to come forward and deliver your, uh, keynote address. So please join me in welcoming Jeanette Vega. Thank you. Good morning and thank you to all for being here. I first like to, uh, thanks the Center for Strategic and International Studies for inviting me to this very, very exciting, uh, morning. Uh, let me try to put my presentation. So my presentation today will have four parts. First, I will discuss the definition of universal health coverage and some key concepts. Then I will expand on some critical issues around implementing universal health coverage. Next, I will show you a country example in, in fact, I will show you my own country example. And then I will conclude with some, uh, final reflections. So let me begin with the exact definition of universal health coverage that comes from the 2010, uh, World Health, uh, World Report. Um, probably most of you know this definition by now and it is stated that all people should access the health services they need without incurring on financial hardship. There are two interrelated concepts coverage with needed quality services and financial risk protection. Both are intrinsic goals. All, and although are also instrumental in obtaining better health outcomes. And of course, and this is quite important when we talked about health services, we are talking about prevention, promotion, treatment and rehabilitation. The other important point I'd like to make is that we can measure access by using proxy indicators such as utilization rates for different conditions and events. We can also measure financial protection by using the most common indicators such as percentage of catastrophic payment and out of pocket expenditures. I, again, would like to emphasize that advancing towards universal health coverage is much more than focusing on health financing. In fact, it's about focusing on the whole architecture of the health system. So let me discuss now how do we in practice move to implementing UHC in countries? Well, one of the most helpful way to conceptualize the strategic choices facing governments as they undertake the journey is the policy box used by the WHO. This diagram proposes that governments plan their universal health coverage strategies, taking into account three key policy questions. The first one is who in the population should be covered? The second one is what services should be covered? And at what level of quality? And the third one, what should be the level of financial protection that citizens should have when accessing services? Who should be covered? In allocating financial resources, policy makers need to make choice on population and service coverage at the same time and make trade-offs between these two dimensions. Deciding how to start on the journey towards universal health coverage is critical. Countries usually push one of two broad strategies. The first one is to extend financial coverage for the whole population for a priority package of services. The second one is to prioritize financial coverage to specific population groups. People in formal employment or the poorest of society, for example, offering them a broader range of services. Now, there has been a lot of discussion about which strategy to follow. And I would say that in the last year there is a consensus emerging that at least in developing countries it's better to begin from the beginning universal. So it's better to begin covering the whole population from the beginning, even if it is with a small set of services, and then expand the set of services as countries developed. The experience of countries that have chosen to restrict financial coverage to selected population groups is that usually a polarization occurs. And we in Latin America have a lot of experience on that. Healthcare coverage is maximized for the world's groups in society who are covered by either private or publicly subsidized health insurance schemes. Meanwhile, some attempt is made to cover the poorest member of society with a publicly financed, usually public service. But most often this public service is less generous and with less quality than the rest that is offered to the other groups of population. This approach, and this is the important part, tends to create a missing middle, which in many countries represents the majority of the population, in particular in those countries where there are large percentage of informal workers that are not covered by health insurance. And for them that remain at this stage are therefore ineffective because there is a large proportion of the population uncovered inefficient because the fragmentation of health systems have a higher administration cost and inequitable because the richest households benefit disproportionately. The 2013 Lancet Commission on Investing in Health make a strong case in favor of compulsory, publicly governed health financing in its review of five different pathways to achieve universal health coverage. Unfortunately, it's not showing very well in the slides. Those are the five possibilities and then you see the effect on health and financial risk protection. We'll send this slide so you have a more detailed view, but basically it goes from progressive universalisms, which is basically paying for all towards public finance of only catastrophic coverage. To truly achieve universal health coverage of the whole population with the services you require to make a policy choice that is to use mandatory financing mechanisms. The WHO, the World Bank and the Lancet Commission have endorsed this statement. Furthermore, evidence points to the importance of publicly governed system and the importance of minimizing the fragmentation in funding pools. However, when you advance towards UIC, there is one key issue which is defined how to prioritize. Priority setting means basically deciding who is to get what at whose expense. In the context of health care, the what in that statement refers to different sorts of health care and the who to different sorts of people. The whose expense is not so straightforward. It appears to refer to who will pay the bill, but in the context of an economic rather than a financial analysis, the phrase at whose expense can be interpreted in a different way based in the notion of opportunity cost rather than in the notion of expenditure. Which is interesting because I understand that you were having this conversation last night. And the key concept here is opportunity cost is not expenditure. It means who is to go without a specific health interventions in order that others have it. Giving priority to one group of people means taking it away from another group. Giving priority to some interventions means deprioritizing others. Why priority setting? Well, because claims whether needs or demands on health care are always, always greater than the resources available. Because in the absence of a specific and a well-designed process of priority setting, what happens is ad hoc priority setting that can usually disproportionately affect those that are in most need. Because as we all know, health care cost growth is always greater than income growth. And because we need to increase efficiency and equity of health funding. So there are many applications for priority settings, achieving national objectives, allocating resources, defining the benefit package, and introducing and assessing new technologies including RACS, which is the very, very popular field of health technology assessment. Priority setting exists at all levels. At the broader level, the government makes decisions. And that is usually the case for decisions that involve the whole country. At the other end, we have the decisions that individual clinicians and people make all the time regarding their patients. And I just want to emphasize that sometimes these decisions, the ones that are made at the micro-level are the ones that create the bigger impact in terms of cost. The other thing that I'd like to emphasize is that the organizational level sets the context for the micro-clinical-level priority setting. Health practitioners, jointly with the patients, determine who will receive access to what intervention. And then, at this level, choices are made about specific treatment priorities, approaches, and the type of patients that will receive these treatments. The problem is that most of the time the decisions made at this level are not evidence-based. And in most of the countries are completely unregulated. So most of the cost of the system is out of the possibility of really controlling it. That's why it's so important to introduce clinical guidelines and to enforce the use of clinical guidelines in the countries. Another distinction that I like to make, and this is an important distinction, is that there are different approaches to priority setting. There is one approach that is called the vertical approach that basically deals with setting priority among patient groups in the same disease category, but with diverse needs. An example, for example, all the guidelines for different treatments, one example that I have here is the National Guidelines for Stroke Care that are usually published in Sweden almost every year. The other type of priority setting is what we call horizontal priority setting that refers to setting priorities among different areas or practice or among different disease groups. These choices in horizontal priority setting usually do not focus on individual users. And most of the time the definition of which population and the whole horizontal priority setting is our decision that are made by governments or regional authorities. One example is the state of Oregon's experience in prioritizing procedures across all disease groups to arrive at a set of procedures for which the state would pay using Medicare. In addition to this traditional division between vertical and horizontal, a third form has emerged. Priority setting mostly prioritizing specific groups that are defined not by common health problems, but by economic, social, or ethno-cultural characteristics that are determinants of health. Let's move on to the most common practical translation of priority setting. The design of benefit packages. The progress toward universal health coverage is faster by prioritizing universal entitlement to a defined benefit package. In Latin America we have a lot of experience on this and we have used different approaches to design and deliver these benefit plans. For example, in Uruguay. Uruguay provides integrated universal health care for health conditions through the life cycle independent of providers. This could be an example of comprehensive benefit package for all. Chiles au je-plan includes legally enforceable entitlements to a comprehensive set of services for a prioritized group of disease. While the rest is business as usual. This is an example of comprehensive for some. Peru, the plan esencial de aseguramiento en salud, prioritize health conditions but provides more limited essential health care services for specific groups. That could be an example of some scope for some. There are also differences of course in how broad or narrow is the scope in terms of technologies to be used in eligible populations. The Mexican benefit plan for example, prioritize catastrophic coverage for very complex benefits. Now, the most common use criteria to prioritize for defining a benefit packages are the ones that are there. The first one is the magnitude that is usually measured using burden of disease studies. And basically it is how severe is the problem and how many people are involved at each level of severity. The second one is the criteria of effectiveness and efficacy. Do we have effective interventions to address the problem? The third one is cost of course. How much will the interventions to address the specific problem cost? The fourth one and then that relates the connection between effectiveness and cost of course connect through cost effectiveness studies. The fourth one is feasibility and this is quite important because usually when you are really doing policy making this is probably the most important one. Is it feasible to put in place the interventions that exist or is there a potential to do that in a time that is reasonable? And then of course the last one, quite important is the risk harm criteria. Good intervention entail risk or harm at acceptable level. Many examples, the Oregon basic bundle of services, the New Zealand benefit package, the Israel basket of services covered by sick funds and the UK of course health technologies are praised through explicit cost effectiveness evaluation and clinical guidelines. Let's me move on then to show you one case study of definition of a specific benefit package and the case study is in Chile, my country. Let me give you some background. Chile basically relies on mandatory social health insurance to provide universal coverage for its population since 1952 but the population that is not covered by mandatory insurance which is basically 7% of the salary in the people working on the formal sector is covered through taxes. So we have a mix of the rich basically and benchmark. But during the Pinochet dictatorship that system was segregated and basically they created a different system, a different insurance system that is called they suppress where it's basically what you do is that you put your mandatory 7% to these private insurers and then the rest you pay out of pocket. What this created is an extremely segregated system because basically the most affluent part of the population went to suppress and the rest remain in the public insurer which is for NASA. And the second problem of this is that because of the logic that is very different the logic in the private insurers is a pure insurance logic while the logic of the public system is the social insurance logic. That means that you contract individually to the private insurer and when you cannot pay the premium you are basically thrown out of the system because you can't pay. And what happened then that happens usually when you are older and you are retired. And then because we have mandatory universal health coverage those people goes to the public system. So we are subsidizing the private system with the money that is basically public. So and just to show you this is the coverage by socioeconomic quintiles and you see that they suppress basically are in the upper quintile that those are their clients and the rest is mostly insured by the public system. Now we have when we when we began with restored democracy we had a big problem and the big problem is that Pinochet led some specific laws related to social benefits very very very difficult to be changed because he changed the constitution and in order to change some of these laws we required five out of seven by your majority vote in Congress. So it was basically impossible. So what we needed to do is that we needed to define a way to equalize the situation for people and the way that we did that is to use what we call a system wide benefit package that is the Alche package where what we specifically said is that we define a specific package of benefit that would be mandatory for both the private and the public insurance system and by doing that we basically pass a law to make sure that those guarantees were enforceable and by doing that then we make sure that those priorities in health would be equalized for both the private and the public system. So what we did is we say okay yes in theory we have a universal health coverage because everything is covered you cannot go in Chile without having medical care. However of course the system regulates using waiting lists. So what we say that is that on top of the traditional system with traditional guarantees we add four additional guarantees for 80 priority health events. 80 basically diseases that were the ones that created the biggest burden of disease. Those four were access for NASA and the SAPRES are legally bound to cover the explicit benefit package. Quality health interventions that are included in the complete treatment of the specific disease cover are basically have to be delivered by properly registered and certified providers but according to a standardized that can also be challenged legally clinical guidelines. Third opportunity health interventions must be delivered within explicit maximum time periods and for financial protection. They both for NASA and SAPRES must cover at least 80 percent of the guarantee package of health benefits. That is the least is 80 problems including the most frequent like hypertension diabetes and so on some catastrophic cancers and etc etc. So the question then becomes how do we prioritize what is included in our here and the way that we did is by using basically five criteria. The first one importance according to burden of disease which means having all the studies of burden of disease in the country. The second one high cost effectiveness of available treatments which basically meant that we needed to implement health technology assessment to make sure that we were able to do the cost effectiveness analysis. Third feasibility of supply to provide treatments which meant that we needed to have a very good understanding of the providers map them and understand exactly what type of services they could provide. For the importance of financial burden to households and we put a catastrophic level in the coverage and five social consensus on priority and in order to get that we basically did and we usually do a qualitative study to make sure that we are capturing the social preferences. And that is the way that we decided what is included in the benefit plan. For each one of the problems we basically calculated the cost and what you see there is for one specific problem. Problem out here number one end stage renal disease. For this end stage or problem number four eight breast cancer etc. For each one of them we need to make sure that we have the set of a specific interventions that are in fact defined and then costed. And what basically shows there is that from 56 problems that we originally include we came out with 446 major treatments and those major treatments included 1,320 different health interventions and we had to estimate that. To calculate what? To calculate the premium. The premium right now is estimated at one hundred forty dollars per beneficiary for the public sector. So the final benefit package is a mix of diseases with high burden for example schizophrenia, hypertension diseases with high financial burden for example end stage chronic renal failure, variety of cancers and heart disease, HIV and AIDS, diseases with existing high cost effective interventions for example cataracts and hip fracture and diseases with high social priority for example lower acute respiratory diseases and oral health. So I just want to finish by putting some conclusions for discussion. The first one is that I truly believe that in order to advance towards UHC we need to reflect in every country who should be covered how to pay for it and what services should be covered first. Second I just want to emphasize that priority setting is a complex political and muddy process because whatever the criteria to prioritize that you use at the end of the day the decision of what is in and what is out is political. There are no technical methods to define what is in and what is out. Third I'd like to emphasize that there are various tools for priority setting and when we evaluate success we need to consider not only the outcome of the process but also the process itself and the process need to be informed and participatory because if we do that then the decision is a societal decision and it's not a decision of a group of technical people. Four priority setting usually or should usually translate into the very practical thing of defining the benefit package. Five each benefit package of course must be should be constructed based in the local context with explicit prioritization criteria and enforceable guarantees. There is no point in building a benefit package if you cannot enforce that it is in fact delivered. Six that goal is that intentions really meet the reality and seven of course the need to monitor and measure to ensure that what you have planned and put in place is really happening and that there is impact in the final goal which is basically improving the health of the population. Many thanks. Jeanette we we have just a little bit of time here before we're going to need to move to the first panel but I'd like to first of all congratulate you and thank you that was a wonderful and rich and very very lucid presentation. Thank you we're off to a great start here. I was I was struck by your closing remark where you said it's just fundamentally political and this is fundamentally muddy which was a very good choice of term. Maybe you could offer a bit of I know you're in a you're in a senior position within the Chilean government maybe that constrains you a bit but maybe you could offer a little bit more illumination on this question of politics with reference to the Chilean case. How has over time the reform process you've now gotten a decade and a half of reforms underway. How has that political process unfolded with respect to the subject that you're treating here. How would you summarize what's the story in terms of political calculation at the national level and among the various constituencies that come into play. Yeah well let me just describe what has happened in the Chilean system. What has happened in the Chilean system over the next over the 10th year that we have been having out here in place is that this probably is the most successful policy in health that we have had. It has 80 percent approval right and people that are using are protected by out here basically think very highly of this policy. That let me give you first the pros and then I'll give you the cons. The second pro is that because of this process we had been able to open the door to truly change the system and right now we are in the process of discussing basically creating one pool as opposed to the 15 private pools and one pool for the public system. We are in the process and we are just going to get sending the law to the Congress to create one pool and at the beginning it will probably be with multiple insurers but with the idea and the goal to go towards one insurer for the full population and that discussion could be unthinkable 10 years ago. So that is the second one. Let me give you the cons now. The main con the main problem in our case is that when you prioritize you de-prioritize other things. So those things that are not included in out here what you see is that the waiting list for those particular things is increasing and the main issue now is how do you go and basically increase what is included in these guarantees because once before people would basically would wait whatever they needed to but now because they know that if you are in out here you have a specific times then everybody is basically pushing and all the interest groups and physicians and all of them are pushing to be included in out here that is updated every three years. So that is our experience that show what happens when you define benefit packages that the thing is not only to begin the problem is then once you have it how do you update it and what are the issues that come after. So when you look back I mean what I hear you saying is the arc of the politics over the over the 15 year period has been has been a positive one because you were building momentum politically around rewarding a broad segment of the population that raised its confidence that the system was working to their benefit but also delivering on the promises in a cost effective way. That was fundamental. Was somehow fundamental was getting the politics right and then proving the concept repeatedly and then in time that gave you the political space to continue to innovate. That political confidence that was broadly shared then permitted you to think in bigger strategic terms around further reform. Yes. Now let me just provide you with an example or give you share with you a bit of history when we embark on this it was extremely hard when you try to define benefit packages or advance increasing health insurance for example and putting it mandatory. It's extremely difficult because when you talk about this and you talk to one person the person basically the first reaction is to say I don't want to have restricted access. I don't care. I want to have the best care when I need it. So I'm not willing to go into putting my money is to basically to favor others. And that is an extremely charged discussion because basically you have the view your view as a policymaker that are thinking maximizing the everything for the population. But the person but if it is your mother you don't care about maximizing cost and benefit for everyone. You just care that your mother gets the best care whatever did cost that could save her. Now the way that I usually deal with this conversation is that when I in this discussion that we are having now which is basically going to one poor and then people say why should I contribute. I want to contribute only for myself. The way that people understand at least in my experience is that if you refer to them and you basically say fine you are OK now but think what is going to happen when you are older and when you are when you retire when you are older and you retire. If you continue to be in this system you basically want to be able to get the care that you need. So what you are basically doing is that you are saving for later. Even if you don't take into account the rest of the people it is sort of a saving for retirement type of approach. Two questions and then I think we will need to close. One is where is the private sector in this. I mean you are talking about a consolidation. You are talking about expanding the market. You are talking about expanding the public financing. In that sense it is a greater set of opportunities but you are also moving towards a more consolidated system. Where does the private sector fit in with it. Well of course we have had a lot of issues and discussion with the private sector in Chile in particular because the private sector was really taking advantage of these laws which is not necessarily the case in most of the countries or at least in some. Let me say that. But the thing is that for the private sector it is also it can also be an opportunity because basically there is a lot of waste of money and inefficiency in the way that the public the private sector is dealing with insurance. For the private and the public sector pulling is a good thing. For the private and the public sector using mechanisms to purchase services that are more efficient is a good thing. What it means though is that you need to improve your efficiency. And right now in Chile this year we are basically changing the way of purchasing services in the public sector. And what is happening is that the private insurers are also changing the way they purchase services. So there is an opportunity for the private sector assuming that the private sector in the country is willing to be efficient and to do business with a reasonable amount of gains of financial gains. If that is the case there is no contradiction on what I'm talking about. Just a closing question is what keeps you awake at night? No. Well I have several things that keep me awake. But regarding to this what keep me awake is that we are savvy enough to have this discussion in a way that most of the people of the country understand and agree in the changes that we need to do. We I had the experience I participated in the group that did the reform in 2005. And at that time we use a strategy that basically was to make sure that we were always in the middle. So the people that were opposed had another group that were not us that was basically confronting them. And keeping us in the middle, in the middle, in the middle was kind of the goal. I'm trying to do that now. I'm not always successful. Some of you that know me probably remember a huge, a huge controversy in the newspapers last year where I was like for three weeks in the front page of the newspaper saying that basically I was going to get away all the basically confiscate people's money. And that I would say is the most difficult part to maintain your credibility that you are really caring for everyone. Thank you so much. We have a problem here in the United States with a pragmatic center and preserving it as well. So I think that's a familiar problem we face. Please join me in thanking Dr. Vega. Thank you.