Translated from Japanese: Thank you, Mr. Shibusawa, for that kind introduction, and for the excellent work of JCIE.)
Translated from Japanese: I would like to extend my heartfelt thanks to Minister Aso, Professor Takemi, and the Government of Japan for hosting us, and for the continuing strong partnership between Japan and the World Bank Group.
Translated from Japanese: I also would like to thank all of the honorable ministers from Ethiopia, Ghana, Myanmar, Senegal, and Vietnam who are here with us today. Thank you for your time and for your commitment to universal health coverage.
It is very appropriate that we are meeting in Japan on the topic of universal health coverage. When it comes to universal health coverage, Japan has led the world by example.
Japan achieved universal health coverage 52 years ago in 1961—17 years before the global community gathered in Alma-Ata to call for “health for all” and “development in the spirit of social justice.” The Kishi and Ikeda reforms that led to universal coverage promoted social solidarity and helped unleash Japan’s rapid economic growth and shared prosperity.
Japan is not only a leader in achieving universal health coverage for its own citizens, but Japan is also a leader in extending this commitment to universal health to poor people around the globe. Through its leadership of G8 summits and its various roles on the global stage, Japan has helped mobilize substantial global health and development assistance that has saved countless lives and advanced the health and well-being of millions.
Today, there is a large and growing movement in developing countries to undertake the necessary comprehensive health reforms to achieve universal coverage. To reflect this reality, the goal of universal health coverage should be firmly embedded in the emerging post-2015 global development agenda.
The quest for universal coverage is not only a demand for better health – it’s a demand for equity.
At the World Bank Group, achieving universal health coverage and equity in health are central to reaching the global goals to end extreme poverty by 2030 and boost shared prosperity.
My colleagues and I at the Bank Group are deeply committed to helping countries realize their aspirations for universal coverage. Our aims are clear:
First, everyone should have access to affordable, quality health services. Our commitment is universal, but during the next 755 days until the MDG deadline in December 2015, we are putting a special focus on expanding access to vital services for poor women and children. We are helping the poorest countries scale up results-based financing programs that are already producing dramatic improvements in maternal and child health in countries from Afghanistan to Zimbabwe.
Second, no one should be forced into poverty, or be kept in poverty, to pay for the health care they need. Every year an estimated 100 million people – that’s more than a quarter of a million people every day – face poverty as a result of out-of-pocket health care costs. So we must pay special attention to affordability for the poorest 40 percent of the population in every developing country.
Third, all countries must harness investments in other sectors beyond health that provide the essential foundations for a healthy society. Achieving universal health coverage requires solutions beyond the health sector – including targeted efforts in areas such as education, social protection, roads, transport, water and sanitation, public finance, and information technology.
For example, we know that one of the most successful interventions to improve child health has involved putting money in the hands of poor mothers via conditional cash transfers. Air quality improvements, as well as tobacco taxation and road safety policies can play a critical role in turning the tide on the alarming increase in chronic conditions and injuries we see today in so many developing countries.
Helping countries advance universal health coverage is a strategic priority across the World Bank Group. Through our Bank loans and technical assistance, we are partnering with middle-income countries to design and implement tough health sector reforms and contain costs, while at the same time expanding and sustaining coverage.
Through IDA, our fund for the poorest countries, we are supporting the next generation of countries to lay the foundations for universal health coverage. Japan’s continuing strong support for IDA in our current replenishment round will be critical if we are to scale up our efforts over the next three years.
And through the International Finance Corporation, our private sector arm, we are helping both middle- and low-income countries harness the resources and innovation of the private sector, working in concert with the public sector. The private sector represents a large, and in many cases, growing share of the health care market in developing countries--so the private sector must be integrated into universal health coverage reform efforts.
While there is no single pathway for countries to achieve universal health coverage, all countries can learn from one another’s experiences as they chart and calibrate their own paths. Why, for example, are some countries able to achieve better maternal and child health outcomes than others with the same level of resources? How have some countries managed a rapid expansion in coverage? What are the best ways for governments to engage private sector partners while ensuring equity and quality?
As a global health community, we need to document, evaluate, and share lessons across countries, to save lives, reduce spiraling health care costs, and demonstrate value for the money. That’s why at the World Bank Group we are placing a priority on what we are calling the science of delivery. We are gathering data and evidence on what works and what doesn’t. We are beginning to systematically capture this knowledge and then we will make sure that these lessons from experiences around the world can be applied to local situations.
This is where our Japan-World Bank Group Partnership Program on universal health coverage and this conference play such an important role, yielding a wealth of practical lessons from country experiences.
Today, I am pleased to announce that with our Japanese partners we are releasing a synthesis of case study findings from 11 countries that have achieved, or are committed to achieving, universal health coverage.
These 11 countries are diverse – geographically, culturally, and economically. But all of these countries are demonstrating how these programs can improve the health and welfare of their citizens and promote inclusive and sustainable economic growth.
The good news is that many low- and middle-income countries are introducing fundamental reforms and achieving remarkable progress.
So what are the main lessons from these 11 countries? Here are five:
- One, strong national and local political leadership and long-term commitment are required to achieve and sustain universal health coverage;
- Two, short-term wins are critical to secure public support for reforms as in the case of Turkey where hospitals were outlawed from retaining patients unable to pay for care;
- Three, economic growth, by itself, is insufficient to ensure equitable coverage—so countries must enact policies that redistribute resources and reduce disparities in access to affordable, quality care;
- Four, strengthening the quality and availability of health services depends not only on highly skilled professionals but also on community and mid-level workers who constitute the backbone of primary health care.
- And finally, five, countries need to invest in a robust and resilient primary care system to improve access and manage health care costs.
Not surprisingly, all of these cases also demonstrate that as countries move toward universal coverage, they will confront competing demands and continuing trade-offs. Countries face choices that can either enhance or erode coverage. The countries which have been most successful in expanding coverage have been in a mode of continuous learning – from what is happening both inside and outside their borders – and adapting their approaches based on the best available knowledge and evidence.
A promising message from these case studies is that even low-income countries with low levels of health coverage can still aim for universal health coverage. Countries can start by building their institutional capacity, learn from the experiences of other countries, and adapt innovative approaches that can catalyze the expansion of coverage.
These are the cross-cutting lessons. Now let’s take a closer look at a few of these countries:
In Turkey, an economic crisis in the early 2000s prompted major government reforms and laid the groundwork for the 2003 Turkey Health Transformation Program. Turkey cleaned up government deficits and created leaner and more efficient state bureaucracies—and also opened doors for reform in the health sector by breaking old interest group politics. Outcomes are impressive: Today, more than 95 percent of the Turkish population is covered by formal health insurance. The Program now provides a high level of financial protection and equity while ensuring high and rising levels of patient satisfaction. Furthermore, infant mortality rates have declined from 28.5 per 1,000 live births in 2003 to 10.1 per 1,000 live births in 2010, and the maternal mortality ratio fell from 61 deaths per 100,000 live births in 2000 to 16.4 deaths per 100,000 live births in 2010. Turkey’s example proves that financial constraints—even a major financial crisis—can catalyze the expansion of coverage. The Bank Group has been pleased to partner with the Turkish government to support this effort.
Thailand has focused on strengthening its health workforce, with the Thai Network of Rural Doctors leading the push for reforms. In addition to increasing the number of doctors and nurses, the government raised basic salaries and introduced incentives to attract and retain health workers. As a result of the health workforce scale-up and other factors, popular utilization of essential health services has improved. Since the Universal Coverage Scheme was introduced there has been a declining trend in the incidence of catastrophic health expenditures, defined as out-of-pocket payments for health care exceeding 10 percent of total household consumption expenditure. The incidence dropped from 6.8 percent in 1996 to 2.8 percent in 2008 among the poorest people in the program. The impact on province-specific incidence of impoverishment has been even more impressive: in the poorest rural northeast region of Thailand, the number of impoverished households dropped from 3.4 percent in 1996 to less than 1.3 percent in 2006-2009.
Ethiopia launched its Health Extension Program in 2003 to promote universal coverage of primary care. The program delivers 16 clearly defined packages of health services for free. At the center of the program is the network of health extension workers – all women, 10th grade high school graduates recruited from their communities, trained for one year and redeployed back into their communities. More than 35,000 health extension workers have been trained and deployed thus far, and their services are now in high demand from other sectors as well – such as adult literacy or sharing of sustainable agriculture techniques. The challenge is to continue to enhance the skills and performance of these frontline workers and to protect their time to ensure they can provide communities with the quality health services they need. The latest Ethiopia Demographic and Health Survey data show that between 2005 and 2010, child mortality fell from 123 per thousand to 88 per thousand, a 28 percent decline. Over the same time period, Ethiopia also reports impressive reductions in both stunting among children and anemia among women; and contraceptive use nearly doubled, contributing to a reduction in total fertility rate.
And in Peru, the government is leveraging its sovereign wealth funds to jumpstart ambitious reforms aimed at realizing universal health coverage. The Bank Group is partnering with the Ministry of Health to develop a national set of indicators that will allow them to measure, monitor, and evaluate the expansion of coverage, and take into account the epidemiological transition that the country is facing.
These examples show that all countries face challenges implementing complex health systems reforms to achieve universal health coverage. That’s why we need global mechanisms through which countries can gain access to the latest experimental knowledge of what works and what doesn't, and why. We need to understand how successful examples can be taken from abroad and implemented locally. This points to the importance of having a joint learning platform and network in which policymakers, practitioners, and development partners can engage on the practical, how-to issues of universal coverage reforms, and put knowledge into practice with hands-on problem solving. The World Bank Group is moving toward a Global Practice as a platform for supporting countries in achieving these goals.
This also underscores the vital importance of measurement. Although priorities, strategies, and implementation plans will differ from one country to another, all countries need to make their universal health coverage policies and programs accountable and measurable, so they can track progress and adjust as they go.
But in order for countries to continue learning from one another, and to benchmark progress, the world needs a measurement framework that can provide a common, and comparable, set of metrics.
That’s why at this conference, the World Bank and WHO are releasing a joint framework for monitoring progress toward universal health coverage with two targets, one for financial protection and one for service delivery.
For financial protection, the proposed target is by 2020 to reduce by half the number of people who are impoverished due to out-of-pocket health care expenses. By 2030, no one should fall into poverty because of out-of-pocket health care expenses. This is no small feat: this would mean moving from 100 million people impoverished every year now to 50 million by 2020 and then to zero by 2030.
For service delivery, the proposed target is equally ambitious. Today, just 40 percent of the poor in developing countries have access to basic health services such as delivering babies in a safe environment and vaccinating children. We propose that by 2030 we will double that proportion to 80 percent coverage. In addition, by 2030, 80 percent of the poor will also have access to many other essential health services such as treatment for high blood pressure, diabetes, mental health and injuries.
In the next three months, WHO and the World Bank will consult with partners to work out the details of tracking these targets.
Yes, these targets are bold - but we need bold targets to close the gap on universal coverage. Simply put, targets drive action. Without the ambitious 3 by 5 target for HIV, I do not believe that today that we would have 10 million people and counting on antiretroviral treatment.
So as we consult, let’s also commit to moving this forward. Let’s not make the perfect the enemy of the good. Countries’ futures -- and many people’s lives -- are at stake.
Translated from Japanese: In closing, I want to again recognize our hosts, the Government and people of Japan, for their continuing commitment to UHC.
Translated from Japanese: We must do whatever we can so that every country in the world can benefit from the experience of Japan. Some 30 developing countries are implementing programs to achieve UHC, and many more are considering doing so.
Like our Japanese partners, my colleagues and I at the World Bank Group stand ready to help developing countries advance on the path to universal health coverage. And while this will not be easy, the lessons and experiences we are sharing today show that it is possible for all countries to realize this goal.
It has been 20 years since the landmark 1993 World Development Report, which led to a generation of investments that produced dramatic achievements in global health.
It’s time to finish the job in this generation. Let us all leave Tokyo with a renewed commitment to ensure that everyone in the world will have access to affordable quality care so they may lead healthy, productive lives -- lives of dignity, equity and opportunities
Thank you very much.