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Speech by World Bank Group President Jim Yong Kim on Universal Health Coverage in Emerging Economies

World Bank Group President Jim Yong Kim

Center for Strategic and International Studies Conference on Universal Health Coverage in Emerging Economies

Washington, D.C., United States

January 14, 2014

As Prepared for Delivery

Thank you, Steve, and good morning everyone. I want to thank CSIS for taking on the ambitious topic of universal health care for emerging economies. There is strong evidence that investments in people -- like health care, education and social protection -- are not just good for the individuals who directly benefit, they’re also good for their countries’ growth and political stability. 

Likewise, I believe not providing health, education, and social protection is fundamentally unjust -- in addition to being a bad economic and political strategy.

Yet some say our agenda for universal health coverage is too ambitious, too complex, and too costly for high-income countries, let alone for emerging economies.

We’ve heard that argument many times before. 

My first year of medical school was when we first understood the devastation of the AIDS virus.  And in a remarkably short period of time, we developed effective treatments.

But when we thought about bringing those treatments to the poorest people around the globe, the conventional wisdom was that treating people with AIDS in places like Africa was too expensive, too difficult, and offered slim prospects for success.

In fact, some of the most important leaders in public health angrily opposed and ridiculed our efforts, and talked about focusing on the next generation through an emphasis on prevention.

Yet others were compelled to act -- or to ACT UP. They had aspirations as high as the people living with HIV/AIDS everywhere in the world -- indeed, some of these activists were themselves living with HIV/AIDS. As a result, millions were treated, millions of lives were spared, and incalculable human and economic costs were avoided. 

What is the lesson for us here today, as we hear the same negative arguments about universal health care? We saw with AIDS that concrete action often only happens when there is a powerful political and social movement behind it. And just as the AIDS activists drove the movement for treatment – and brought along the scientists, policymakers, the donors and businesses – today around the world we are seeing a large, and growing, movement to achieve universal health coverage. 

Universal health coverage will deliver better health outcomes. But like other investments in people, investing in health is also imperative for economic growth and poverty reduction. Nobel Prize-winning economist Michael Spence, chair of the Growth Commission, noted that health “dramatically improves income and welfare.” The Growth Commission report concluded that investing in good health and nutrition in young children improves the productivity and earning of individuals and households, “with strong implications for economic growth in the aggregate over the longer term” to help break the cycle of poverty.

And the new report of the Lancet Commission on Investing in Health estimates that about 24% of growth in “full income” in developing countries from 2000-2011 resulted from health improvements.  Full income is defined as the sum of the income growth measured in the national income accounts, plus the value of the change in mortality (or life expectancy), in that period.  Projecting forward to 2035, the Commission Report says that better investments in health could yield a 9- to 20-fold return in full income.

Health care is a right for everyone, in every country, rich or poor. As with AIDS, to make universal health coverage a reality, we have to be committed to take on the conventional wisdom and the vested interests. And we should expect to be called some names. But as an experienced health activist -- and as a parent -- I’ve found that gets easier over time.

For us 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. Our aims are clear:

First, everyone should have access to affordable, quality health services. Our commitment is universal, but during the next 721 days until the Millennium Development Goal deadline in December 2015, we are putting a special focus on expanding access to vital services for poor women and children.

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 – are forced into 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 investments in people, like education and social protection, but also things like roads, water and sanitation, and information technology. For example, policy interventions to curb tobacco use or improve air quality, diet, and road safety can all play a critical role in addressing the alarming increase in chronic conditions and injuries in so many emerging economies.

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.  The strong commitments made by the United States and other donors for the recently completed IDA-17 replenishment round will enable us 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 – while promoting greater collaboration between private and public sector health institutions. 

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?

All of us who are committed to improving global health need to document, evaluate, and share lessons across countries. This will help save lives, reduce spiraling health care costs, and demonstrate value for money. That’s why at the World Bank Group we are placing a priority on what we are calling the science of delivery, which for us means a more rigorous and systematic focus on outcomes – and how to achieve them. We need to understand why development approaches succeed in one country or context and fail in another.

This search for global knowledge to solve local problems will be an integral part of our everyday work. Our knowledge must be accessible, useable, and relevant to government policymakers and development practitioners, telling them how to drive decision-making by policymakers, solve political problems, and change behaviors. The ultimate test is whether our science of delivery actually delivers results for the poor.

We are learning a great deal about how countries achieve universal coverage. Last year we produced 27 case studies on universal health coverage experiences from low- and middle-income countries. The countries are geographically, culturally, and economically diverse, but all demonstrate how these programs can improve the health and welfare of their citizens and promote inclusive and sustainable economic growth.

Here are five lessons from country experiences with universal coverage:

  • First, strong national and local political leadership and long-term commitment are required to achieve and sustain universal health coverage;
  • Second, short-term wins are critical to secure public support for reforms. For example, in Turkey, hospitals were outlawed from retaining patients unable to pay for care;
  • Third, economic growth, by itself, is insufficient to ensure equitable coverage. Countries must enact policies that redistribute resources and reduce disparities in access to affordable, quality care;
  • Fourth, 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, countries need to invest in a resilient primary health care system to improve access and manage health care costs.

Not surprisingly, all of these case studies 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. Countries of all income levels which have been most successful in expanding coverage have been in a mode of continuous learning – observing what is happening both inside and outside their borders, and adapting their approaches based on the best available knowledge and evidence.

Let’s take a closer look at a few country examples:

In 2003, Turkey’s infant and maternal mortality rates were among the highest in the region, while life expectancy was 10 years below the OECD average. Despite fiscal difficulties and double-digit inflation, Turkey decided that to become more economically competitive it had to reform its health care. Today, formal health insurance covers more than 95 percent of the Turkish population. Infant mortality has dropped over 40% since 2003. And three-quarters of the Turkish people say they are satisfied with their health services.

Thailand focused on strengthening its health workforce, a network of rural doctors leading the push for reforms. The government increased the number of doctors and nurses, raised basic salaries, and introduced incentives to attract and retain health workers. As a result of this and other factors, catastrophic health expenditures are declining. In the poorest rural northeast region of Thailand, the number of impoverished households dropped by nearly two-thirds.

When Ethiopia launched its free universal primary care program in 2003, at its center was a network of health extension workers. These 35,000 women -- 10th grade high school graduates recruited from their communities -- were trained for one year and redeployed back into their communities. The latest survey data show that child mortality fell by over one quarter, as did child stunting. For women, anemia rates fell and contraceptive use nearly doubled, helping to reduce the total fertility rate. 

Our case studies showed that all countries face challenges implementing complex reforms to achieve universal health coverage. That’s why we need global mechanisms, such as a joint learning network, through which countries can gain access to the latest experiential knowledge. The World Bank Group is now moving toward a Global Practice for Health, Nutrition, and Population as a platform for supporting countries in achieving these goals. 

Our ambition for universal health coverage is very high, as are the ambitions of many nations. Yet no goal is real unless measured against an actual time-bound target. 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.

And 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 the World Bank and WHO have released 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.

We are now consulting with a wide array of partners to work out the details for tracking these targets.

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 we would have 10 million people and counting on anti-retroviral treatment.

I know all of us in this room will help nations who seek the path to universal health coverage. And while the road won’t be easy, the lessons and experiences we are sharing today show that it is possible for all countries to realize this goal.

Because it is possible for all nations to achieve it, let’s make that an explicit goal as well. The goal of universal health coverage should be firmly embedded in the emerging post-2015 global development agenda.

It has been 20 years since the landmark 1993 World Development Report on Investing in Health, which led to a generation of investments that produced dramatic achievements in global health.

It’s time to finish the job in this generation.

Yet as we seek a brighter future, let’s not forget the lessons of the past.

Today, some say achieving universal health coverage is impossible. What I learned from the HIV/AIDS fight is that individuals must stand up and advocate for doing the right thing, despite the difficulty.

Ultimately, it is the duty of each of us -- all of us here today --to persevere through the doubts and indifference, to educate our friends and colleagues, and to work tirelessly to find evidence-based solutions.

With our moral compass as a guide -- and aided by dogged determination -- we can provide quality health care to millions of people. We can help them lift themselves from poverty, so that they may lead healthy, productive lives -- lives with dignity, equity and opportunity.

Thank you very much.