The Rockefeller Foundation's Heather Grady on politics, policy-making, and the implementation of health financing and delivery mechanisms

I recently joined a panel at the Prince Mahidol Award Conference in Bangkok on The Complex Nexus: Political will, civil society and evidence in achieving Universal Health Coverage with Michael Cichon from the ILO, Jon Ungphakorn of Thailand’s AIDS Access Foundation, Tim Evans of BRAC University, Bheki Ntshalintshali from the Congress of South African Trade Unions, and David Legge from La Trobe University in Australia.

The Rockefeller Foundation is pleased to have contributed early and steadfastly to conceptual work and practice in support of the movement toward universal health coverage, which links to the Foundation’s two goals of building resilience and promoting growth with equity.

Our objectives in this work are to decrease the financial burden from out of pocket health expenditures and improve access to quality health services through more equitable health systems, and in the medium-term, sustainably improve health outcomes for poor and vulnerable people. Our systems approach at the Rockefeller Foundation is emphasized through our health work and has taught us the importance of working with a range of actors within a system – politicians, public sector, civil society and the private sector.

The link between political commitment to UHC and changes in the lives of poor and vulnerable people spans the levels of politics, policy-making, and implementation of both health financing and delivery mechanisms. Political commitment at the very highest levels to raising adequate funds for health, reducing financing barriers through prepayment and subsequent pooling to spread risks, and using resources more equitably and efficiently is essential. As with progressive social policy in other areas, there are a set of factors that make a difference: the personal conviction of leaders; political interest in getting the support of domestic constituencies; pressure from NGOs, media, academia and health care professionals themselves; and pressure and support externally from donors, UN agencies such as WHO, and CSOs and foundations, as well as from other countries that are pursuing or have achieved UHC.

A Georgetown University study completed last year, supported by the Rockefeller Foundation, identified factors for an enabling environment for the transition to UHC – the existence of a ‘social contract renegotiation moment’, a period of greater economic resources availability - which today exists in a majority of developing countries, existence of infrastructure and delivery capacity, and not least, popular demand and solidarity and a willingness to cross-subsidize between richer and poorer parts of the population. 21st century trends like aging populations, and increasing migration to cities where health systems are more complex, make the task ever more urgent.

In our work in countries such as Rwanda, [Ghana](], [Vietnam]((] and Bangladesh, this combination of factors exist in different combinations. In Thailand, where I lived from 2000-2004, an active civil society that launched movements around AIDS, access to medicines and compulsory licensing was a natural home for pressure to expand and deepen UHC. A long-standing commitment on the part of the government and the royal family to public health infrastructure, combined with a stable, committed, and very highly skilled group of technocrats, made it possible to respond to these demands effectively.

Senior officers, mid-level managers and frontline workers are often unrecognized decision-makers and those who turn commitments into action, but not all countries have the support and knowledge to push for change like Thailand. With this in mind we launched the Joint Learning Network on Universal Health Coverage, which brings together about a dozen key countries as a hub for on-demand learning and exchange, multilateral learning workshops, documentation of countries’ experiences, and operational research and analysis. The topics covered include provider payment mechanisms, information systems (including open source interoperable ehealth systems), improving quality within systems, and how to most effectively and efficiently expand coverage to include citizens who are poor and/or in the informal sector—those most likely to fall through the cracks of any UHC system. This approach is a harbinger for a fundamental shift regarding how UHC may spread in the future. A number of countries, including Thailand, Ghana, Rwanda, India, and Colombia have become models for differing approaches to pursuing UHC, and are actively sharing their learning and skills with others who are pursuing these objectives.

The energy of a growing movement of practitioners and academics notwithstanding, there are daunting financing challenges that most developing countries face given social and economic systems that differ significantly from OECD countries. First and foremost, a high proportion of the workforce is in the informal sector, so government revenues for prepayment and risk-pooling must come from something other than – or in addition to - payroll taxes or social insurance.

Equally important is keeping an unflinching eye on equity outcomes – because not all universal systems will bring greater equity. Individuals may demand expanded access – but we must remember the ‘true north’ is less impoverishment and better health outcomes measured over time, especially for those who are living in poverty and most vulnerable. To build the evidence base on this, we recently supported a 72-country survey by UNICEF examining national hybrid health insurance schemes in Asia and Africa.

The moderator of our panel session was eager to contrast the drive toward universal health coverage with longer-standing efforts to promote the right to health and the broader array of human rights. First and foremost, we need to emphasize that expanding quality coverage is a contributor, not a cost, to development efforts and economic growth. Second, we know that when people become accustomed to receiving entitlements though an expansion of what are considered ‘basic needs’ (like primary education), they eventually begin to expect them and claim them as rights. Third, we know that we cannot achieve universality without political will, civil society pressure, strong technical leadership within countries, and international agencies coming on board to this shared agenda.

On this path of change we must remember the importance of strong leadership and champions for predictable, sustainable international support; increased technical assistance to facilitate in‐country progress in implementing innovative experiments and broader system reforms; and greater experience‐sharing across countries, particularly from countries with recent and relatively successful reform experiences. It’s a path that will help us achieve more equitable and resilient societies in the 21st century.

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