The World Bank pioneered global HIV and AIDS financing early in the emergency and remains committed to achieving Millennium Development Goal 6, to halt by 2015 and begin to reverse the spread of HIV and AIDS, through prevention, care, treatment, and mitigation services for those affected by HIV and AIDS.
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Thank you, Dr. Komatra for the kind introduction. I would also like to thank Professor Vicharn and the PMAC Secretariat for all your hard work in organizing the conference; the Royal Thai Government f... Show More +or their hospitality; Professor Rachata; Lincoln Chen and our fellow conference co-hosts and partners in JICA, USAID, WHO and the Rockefeller Foundation; and to my good friends, Dr. Suwit and Paul Farmer.Yesterday I was honored to share the Prince Mahidol award with a distinguished group of individuals who have spent many years fighting to end the HIV-AIDS epidemic. I accepted the award on behalf of a broad and diverse group of advocates who worked as part of a global movement to make treatment accessible to people everywhere, no matter their income or geography.Sadly, our work is unfinished. Millions are still becoming infected each year, and many are shut out of treatment because of inadequate services and frankly, discrimination. Yet a new generation of activists has joined the fight, and I am confident that in our lifetimes we will end the scourge of AIDS and unlock the potential of millions caught in its grip.When that happens, we will owe tremendous thanks to many people living with AIDS, health workers and activists in Thailand. They were early and visionary leaders in this fight.Thanks to their work, Thailand was the first developing country to mount a successful HIV prevention response. It reduced new HIV infections by over 90 percent, from 150,000 in 1990 to about 10,000 in 2013. This prevented a stunning 7.7 million HIV infections, and saved over $18 billion dollars -- a monetary return over 40 times the investment.Over 250,000 people are on AIDS treatment in Thailand, reducing HIV deaths by at least half. Yet AIDS still ranks high on the list of causes of premature death in Thailand, so there is more to be done in Thailand and globally – and we will continue working together until the last person living with HIV receives life-saving treatment.Thai health care policy makers, health workers and activists have shown a strong commitment to the poor and vulnerable. Thailand’s successful universal health care scheme, which includes AIDS treatment, commands global respect and influence.It’s easy now to look back at these amazing successes and think they were inevitable.Many of you in this room who lived through the early days of the AIDS fight know it was far from certain that we would ever succeed.In my first year of medical school we began to understand the devastation of the AIDS virus -- it seemed an impenetrable enigma. The epidemic threatened us like an approaching cyclone. AIDS was projected to kill tens or even hundreds of millions of people. It was an incomprehensibly large and complex public health challenge.Yet, more quickly than we could have ever imagined, we developed effective treatments. HIV activists attacked every link of the value chain for drugs and treatment, starting from nowhere until we had developed drugs that treated the disease. Tony Fauci was instrumental in the race to get drugs to market, from the first antiretroviral drug approved for the treatment of HIV in 1987, then single and double combinations of drugs, followed by David Ho’s pioneering work in the use of highly active antiretroviral therapy. Those infected went from just 28 weeks median survival to perhaps 50 years for a young person. A broad team effort in science and advocacy turned the world’s greatest public health crisis into one of the most extraordinary accomplishments in the history of public health and medicine.But when we thought about bringing those treatments to the poorest people around the globe, the mood changed. The conventional wisdom was that treating people with AIDS, in places like Thailand and elsewhere in the global south, 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 even ridiculed our efforts, and talked about focusing on the next generation through an emphasis on prevention.Thankfully, many others saw the suffering and were compelled to act -- 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.The visionary leadership of Thai health professionals and activists saved lives here, and around the world. They showed us what was possible. People like Mechai Viravaidya – or Mr. Condom as he is known here – and my friend Dr. Wiwat Rojanapithayakorn, broke the taboos on talking about condoms and sex. Thailand’s commitment to treatment and prevention, and its integration within the universal health scheme, were prescient and spared many, many lives.Just as Thailand’s successes in AIDS prevention and treatment were not inevitable, neither was its quest for universal health coverage. In fact, it seemed quite unlikely at the time of its inception in 2001.A few years earlier, in 1997, Thailand’s economic bubble burst. Growth plummeted. The baht was devalued by 45 percent. Unemployment soared, and the stock market lost three-quarters of its value. The government committed to a $21 billion IMF bailout, and the imperative to stabilize the economy made it very challenging to propose new programs.Few people saw this as an auspicious time to advocate for universal health coverage for all Thais. Yet a handful of Thai visionaries had been dreaming -- and scheming -- for decades, and would not be denied.They had many opponents. Not the least of which was the World Bank Group. That’s right. The institution where I now serve as President was an outspoken opponent of Thailand’s aspiration to provide all of its people health coverage. The Bank and others said it was the wrong time for universal health, that it wouldn’t work, and that it was fiscal suicide.Another major opponent was the World Health Organization -- whose constitution says it exists for “the attainment by all peoples of the highest possible level of health.”Yes, I used to work at the World Health Organization, too.I’ve tried to imagine what those conversations must have been like.“I’m sorry Thailand, but when we talked about ‘Health for All’ by the year 2000, that was actually a typo. We actually meant Health for All by the year 3000.So, with powerful opponents like those, some might lose faith and walk away.Not the Thai people.The Thai people have a deep commitment to economic justice. They had worked for decades to provide universal coverage to their people. In fact, Thailand’s constitution guarantees the right of every Thai citizen to health care, even the poorest. By 2001, when Thailand introduced its universal coverage scheme, nearly a third of its people were still uncovered. Many of these were poor people whose families could be made destitute by a serious illness.It took civil society activists, as well as civil servants and health professionals, to build broad grass-roots support for reform. The Universal Coverage Scheme -- or UCS -- has remained a top priority through several changes in government. Thailand’s health professionals have made smart choices and used evidence-based decision-making to build a system that works for its people.Today, UCS provides comprehensive health services, and it has made the nation healthier and more productive. Within one year it added 18 million previously uninsured people to the rolls of the insured. As in many other nations, the integration of AIDS treatment and prevention has only strengthened the system’s breadth and effectiveness.One key reason for Thailand’s success was the acceleration of a two-decade-long shift of resources and health staff from urban to rural areas, where more of the poor and uninsured lived. Successive governments have provided strong and positive incentives for health workers to work in these previously undeserved areas, and to increase their motivation, skills and effectiveness. They even paid them more than their urban counterparts.We should acknowledge the contributions of Prawase Wasi, the great hematologist who established the rural doctors’ movement in Thailand and who wrote a seminal monograph entitled "The Triangle that moves Mountains". The triangle referred to three points of engagement that are critical in enacting reforms: wisdom, state, and society. This combination of forces certainly provided strong stewardship for universal coverage in Thailand.In the first 10 years of UCS, Thailand had strong GDP growth. This provided the fiscal resources for the reforms to survive and take hold. And this growth has been shared with the poorest. A recent study showed that over the past decade, among all Southeast Asian nations, Thailand is the only country that offers universal health coverage, and the only nation where lower income consumers have increased their share of total consumption.UCS is a gem beloved by the Thai people -- 90% of them are satisfied with it -- and their strong voices ensure it is funded and nurtured. And this despite the fact that when UCS was launched, Thailand had the lowest per capita income of any nation ever to achieve universal coverage.It’s not a perfect system. It faces growing pains as more people use its services; as people age; and as injuries from road accidents and non-communicable diseases like diabetes rise. This is normal. Managing health care systems is like tending a tropical garden. There will always be more weeds to pull, flowers to plant, and branches to prune. I have faith that Thailand will succeed in its pursuit of greater quality and equity in its health care. As it stands now, UCS is a remarkable, living legacy of many dedicated civil servants, activists and health workers, all who were committed to justice in health care.As I travel across the world, I tell the Thai UCS story as an example to other nations who aspire for the same results for their own people.I thank you, and congratulate you for your achievement.So, what are the lessons from the fight for AIDS treatment and universal health coverage?First, we’ve learned that investing in people is not just the right moral choice. It also results in real economic and political benefits. I have dedicated my life to demonstrating that not providing health, education, food, and social protection is fundamentally unjust -- and that it is also a bad economic and political strategy. The Lancet Commission on Investing in Health estimated that up to 24 percent of economic growth in low- and middle-income countries was due to better health outcomes. The payoffs are immense: health spending yields a 9 to 20-fold return on investment.And the Growth Commission, led by Nobel Prize-winning economist Michael Spence, reported that “No country has sustained rapid growth without also keeping up impressive rates of public investment” in things like education, and health -- in addition to physical infrastructure. These investments in people don’t crowd out private investment; they crowd it in. New enterprises are born, and returns rise because workers are healthy and educated.The second lesson is that ambitious reforms require skillful balancing of competing demands; they also require continuous learning and adaptation, based on the best global knowledge and evidence. Thailand’s health workers’ and activists’ achievements in universal coverage and AIDS demonstrate important elements of what we at the World Bank Group are calling the science of delivery.They paid careful attention to all the factors that affected success -- everything from the cold chain for vaccines to financial management of their health system; from roads and electricity for clinics to girls’ education.Two days ago I visited Myanmar, which has just launched its own effort to achieve universal health coverage. Myanmar can learn from Thailand’s approach to effective health care reform.To achieve such complex reforms, an unforgiving focus on results is imperative.Good intentions alone are little use to a pregnant mother in a rural village. She needs an effective and stable health care system to give birth to a healthy daughter, to protect her from childhood diseases, and to help her child become an educated and productive member of her community. In addition, their leaders and health officials have to maintain a strong public commitment to delivering quality services, weaving through the political maelstrom, and fostering a change in behaviors which affects the health and livelihoods of everyone.The third lesson is that even a handful of committed people with vision have the power to change the world. Believing in the possibility -- but not the inevitability -- of a better world is the first step in achieving it.The global fight against AIDS was a triumph of a bold vision for fundamental human rights, combined with scientific progress, and global solidarity.Here in Thailand, through the tenacity and grit of thousands of health workers and activists, you showed all of us how to pursue a vision for health equity. You built movements that saved lives, changed your nation, and provided a contagious hope to millions.These lessons are universal -- and timeless.We can achieve great things, if we learn from history, and contribute to a lasting evidence-based wisdom.Our work is unfinished. Yet, as I look out at all of you here, I have an abiding faith that, together, we can build a world with greater opportunity…equity…and justice.Thank you very much. Show Less -
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... Show More + -- 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. Show Less -