Transcript - Toward Universal Health Coverage for 2030 - April 11, 2014

April 11, 2014



Dr. Jim Yong Kim, President, World Bank Group

Ban Ki-moon, Secretary-General of the United Nations

Lawrence H. Summers, Professor and President Emeritus, Harvard University

Michael Bloomberg, Entrepreneur, Philanthropist and Three-Term Mayor of New York City

Ngozi Okonjo-Iweala, Minister of Finance, Federal Republic of Nigeria

Margaret Chan,Director-General,World Health Organization



DIRECTOR‑GENERAL CHAN:  Let me begin by thanking all of you for a wonderful, wonderful morning, and, of course, I want to thank Jim working with WHO to promote universal health coverage as an important mechanism to end poverty.  The panel four‑‑I tell you, I'm shaking.  Did you see it?  I have an awesome panel. 


Don't laugh like that. 

Let me begin by introducing His Excellency, of course, Mr. Secretary‑General.  He is the eighth Secretary‑General of the United Nations.  He needs no introduction.  We see him on TV all the time, right?  He's a busy person, but he lends his support to this very important issue.  And I have to tell you, in the last how many years we worked together, I'm truly impressed by his commitment and conviction to MDGs, especially MDGs 4 and 5, for women and children's health, for climate change, for energy, for nutrition.  The list is so long.  Sometimes I said, you are also the DG of the big show, aren't you, now this is a Secretary‑General who sees the importance of the interconnection of different sectors in order to put people in the center. 

Mr. Secretary‑General, without further ado, the floor is yours.


SECRETARY‑GENERAL BAN KI‑MOON:  Thank you, Dr. Margaret Chan of WHO. 

Ladies and gentlemen, it is a great pleasure to meet you to discuss these very important universal health coverage issues.  I'm immensely grateful to the President of the World Bank, Dr. Jim Yong Kim.  And we have been working very closely on many development issues, and thank you for initiating this one.  In fact, we traveled a lot together, at least twice the last year.  We are also planning to do the same joint visit to Africa, which country I'm not going to disclose at this time. 

And I'm also very pleased to see Minister Ngozi, who has been a strong supporter.  I think she is familiar with the institute here.  As you know, she was a Vice‑President of this.  She also worked as one of the high level panel of eminent persons to define sustainable development.

I'm also very pleased to be here with Harvard President Emeritus, Dr. Lawrence Summers.  We have both a connection to Harvard University.  Thirty years ago I was just a student when he was one of the youngest faculty members, youngest ever in the history of Harvard.  And I have a deep admiration for him.

And I'm also very happy to be here with Mayor Michael Bloomberg, who is now working as U.N. Special Envoy for Climate and Cities.  And he's a strong champion since he was the mayor of New York City, and I'm very glad.

Ladies and gentlemen, countries around the world have achieved great advances on health through MDG.  Billions of women and children have been spared preventable death.  The spread of HIV/AIDS has been slowed, and malaria is being contained, and there is progress against tuberculosis and other infectious diseases.  For now we have to go farther, and that means reaching the most vulnerable people. I have seen that success is possible.  In rural parts of Africa, Asia and beyond, I have visited small health posts that deliver big results.  In fact, I have traveled together with Dr. Margaret Chan in Asia and somewhere else to raise the awareness on the importance of women's health and children's health.  That was quite effective, and I have witnessed immense relief on the faces of women, pregnant women, when they find skilled attendants to help them during delivery. 

You may know that this health post is the unit, I think minimum unit, then you go health clinic, then from health clinic then you go to hospital.  But going to hospital, that means you see almost the same facilities.  But when you visit health post, I was very much humbled about the level of the facilities.  But when I saw the women and children lying in a room, they were thinking that they were fine with the help of this health post.  That really made me very much humbled that we have to do even this minimum facilities we should establish more.  I have spoken to adolescents and young adults who need sexual and reproductive health services, and I have underscored the importance of helping members of the older generations who may require special care. 

The Lancet Commission on Investing in Health Report points to an opportunity to close the gap by 2035.  In this crucial period, we can bring maternal and child death and preventable infections to similar low levels in all countries, rich and poor.  Today, we can celebrate the fact that, for example, virtually all mothers in Sweden will survive childbirth, but we cannot forget that in South Sudan, one in seven pregnant women will not live to see her baby.  

Addressing these inequalities is a matter of health and human rights.  The Commission also pointed out that non-communicable diseases, mental health problems, and injuries are becoming more deadly, even in low‑income countries.  This is an important trend to consider as we shape the post‑2015 development agenda, a transformative and universal agenda, which builds and expands on the MDGs. 

To secure health, we need to take all preventive actions.  We have to think in terms of reducing exposure to pollution, improving nutrition, and promoting overall well‑being.  The concept of universal health coverage can be an important catalyst.  Right now, an estimated 100 million people fall into poverty because health costs break their family budget.  Universal coverage would protect them and build resilience across society. 

Our vision is an aspirational approach that allows countries to realize their goals on their own terms. Interest is growing.  In 2012, Member States adopted a general assembly resolution on the need to move towards universal health coverage.  Today, more than 70 governments have asked the United Nations for technical and policy support to achieve this goal.

Measuring progress is essential.  I'm pleased that WHO and the World Bank are developing monitoring framework.  This will help countries measure progress in a standardized manner.  Ladies and gentlemen, universal health coverage is a big concept, and you are all big thinkers, but I would have framed this ambitious goal in plain terms.  This is about relatively small investments that pay off huge dividends.  It may cost a lot of money on the government's side, and you may think that only rich countries can do it, but I was very much surprised and encouraged to see that in Thailand, when their per capita GDP was just $400, they started national universal health coverage.  So it's not a matter of GDP, the size of GDP.  When there is political will, it can be done, even with the little and less GDP.

We should remember the power of simple solutions.  A trained midwife can help a pregnant woman survive birth.  An inexpensive vaccine can spare a child from disease.  A bed net that costs just a few dollars can protect a family from malarian mosquitoes for years.  Universal health care can be the model for the 21st century.  It provides access to services, prevents against exclusion, and protects people from financial risk. 

This will bring more than health.  It will bring equity and contribute to a life of dignity for all. 

Thank you very much.


DIRECTOR‑GENERAL CHAN:  Thank you, Mr. Secretary‑General. 

Now, Jim, come on up.

The 12th President of the World Bank Group.


PRESIDENT KIM:  Thank you, Margaret.  Thanks, everybody, for being here. 

I'm so grateful to our panelists, and I'll say a word about‑‑maybe more than a few words about each of them because each of them represents something so important in our effort to scale up universal health care.

We have just 629 days until the deadline for the Millennium Development Goals.  The World Bank Group remains deeply committed to helping countries push as far and as fast as possible toward all the goals.  We cannot take our eye off the current goals as we think about the future goals.  There will, though, be a lot of unfinished business at the end of 2015.  Too many people will be dying from preventable causes because they lack access to a central, quality care or because they can't afford to pay for the care they need. 

So, as you and Member States come together to forge the post‑2015 development framework, we must keep a few things in mind.  The development landscape is changing.  Between now and 2030, about half of today's low‑income countries will graduate to middle‑income status.  Not only that, but the burden of disease is evolving, including the alarming spread of chronic conditions such as heart disease and diabetes.  We must build on the progress made through the health MDGs and work together to set goals that are universal and based on the principle of health equity for all. 

We need a bold health goal for 2030 that encompasses both the health outcomes we want and the path to get us there.  We now have the evidence that we can end preventable maternal and child deaths.  Let's have the courage to set a goal to do it. We have the evidence showing us that we can significantly reduce deaths and disability resulting from chronic disease.  So let's set a goal that will help us scale up those interventions.  And we also have a growing body of evidence that the most equitable and sustainable way to achieve the health outcomes we all want is through universal health coverage.  So, let's set a goal that will make that happen by 2030.

Countries like Japan, Thailand, and Turkey have shown the promise of universal health coverage for their people, and a growing number of countries like Myanmar, Nigeria, Peru, Senegal, Kenya, South Africa, and the Philippines have made universal health coverage a top priority.  They're mobilizing resources and pursuing reforms to turn universal health coverage from a slogan to a reality. 

Thanks for a collaboration with WHO and for Margaret's great leadership.  For the first time we now have two time‑bound targets for universal health coverage.  These targets will allow us to chart progress, both in scaling up equitable access to essential services and in preventing poverty due to catastrophic out‑of‑pocket payments for health.

These targets can be applied to all countries, rich and poor, and as envisioned under the sustainable development goals.  Time‑bound targets for universal coverage in the post‑2015 framework will drive policy and program choices that lead to better health such as investing in strong, front‑line primary care that is accessible to the poorest and most marginalized communities.  

Good primary care delivers the essentials like antenatal care, skilled birth attendants, child vaccines, blood pressure and diabetes monitoring, and other interventions that prevent health crises and keep health care costs from escalating.  We also know from the Lancet Commission on Investing in Health chaired by Professor Summers that investments in health deliver great economic returns.   And let me just take a step back.

I think if you were to ask who are some of the most influential people in global health, not very many people would say Professor Larry Summers.  He authored the report in 1993, "Investing in Health," that started everything going.  We could then‑‑we began to make the argument that health care expenditures are an investment, and it also happened to be the most influential book that Bill Gates ever read.  So Larry Summers brought Bill Gates into global health.

But now, I have to say, this report is even more profound.  I find myself quoting you, Professor Summers, all the time from this report.  This report showed that from 2000 to 2011, some 24 percent of economic growth was due to better health outcomes.  That is a profound number, and I think Professor Summers will talk a little bit more about the return on investments in health that really make it a no‑brainer.

In meetings with Finance Ministers, we're having a different discussion today on health to a great extent because of the work that Professor Summers did 20 years ago and the work he that he did just very recently.  Universal health coverage is our aspiration.  A progressive pathway that will save lives, increase economic growth, and help millions of people lift themselves out of poverty.  But some ask whether universal health coverage by 2030 is possible.

A decade ago, no one thought it would be possible to get 3 million people on antiretroviral treatment.  And today, there are 10 million and counting, and I have to tell you, when we really‑‑when we first trotted that idea out‑‑and Margaret was there‑‑people were saying "you are absolutely crazy.  It's not possible."  The reasons for this being not possible, you would‑‑you know, I just want to remind you one very top official said, "How you can ask Africans to take antiretrovirals when they have no concept of time?  They know morning.  They know midday.  They know the dark of night, but they have no concept of time.  How you can ask them to take a drug five times a day?"

Well, one, the drugs were not five times a day, and two, this particular official had just visited Africa and the Africans' remark was that the only one who was late for every appointment was that official.


But that's the world that we lived in, and what we learned from the 3-by-5 movement was that unwavering political commitment, clear progressive goals, and measurable targets can drive achievements that most people would think are impossible.

This afternoon’s session is built on terrific morning panels, but this panel is very special.  First, Minister Ngozi is leading a charge toward universal health coverage that leaves us all breathless.  To think that a country as large and complex as Nigeria could reach the goal of universal health coverage is just awe inspiring, and we applaud her leadership for taking us in that direction.

And I think that, as we look back in the years and decades to come, we will remember Mayor Michael Bloomberg as one of the greatest leaders we've ever had.  What he was able to do in health was just astounding.  He was courageous enough to take measures to change the fundamental rules about everything from the use of trans fats to calorie counts, and he did it.  He experimented with it, he kept going with the things that really worked, and the world will look like New York City soon enough.  But even more‑‑well, gosh.  Is that funny?


The world will look like New York City in terms of the way it deals with public health very soon.


But, here's the other thing.  It's not just public health.  Mayor Bloomberg said that they were going reduce the carbon footprint in New York by 2030‑‑wasn't it originally‑‑by 30 percent.  They're going to get the job done by 2017.  Once again, I hope, that from the perspective of sustainability, the world will look a lot like New York very soon.  So, we're extremely lucky to have this particular panel. 

These are absolutely brilliant leaders in so many other areas.  We're so lucky we have them here with us talking about health, and they're going illustrate to us why it's time to take on universal health coverage.

Thank you very much.


DIRECTOR-GENERAL CHAN:  Thank you very much, Jim.  You make my life easier.  You did part of my job.

Now, it is my great honor and great pleasure to invite the panels up on stage.  What an awesome panel.  Please join me in welcoming them.


Of course, we have with us today Professor Larry Summers, Charles Eliot University Professor and President Emeritus of Harvard University; Minister Ngozi, my sister from Nigeria; last, but not the least, a great leader, a great mayor, and a great supporter of some difficult issues, his name is Mike Bloomberg.  For those of you who don't know him‑‑


I have the easy job.  You guys have the difficult task.  I'm going to ask questions, and you have to answer.  And I was instructed the instruction to be given to all of you is "crisp, sharp, focused answer."  That's not too difficult with this panel, is it?  Never.

And also to remind you, we are also connected with the outside space by Twitter, by Chirp and whatever.


And for those of you who are online, please remember the hashtag is UHC2030.  And, of course, feel free to submit your questions to this illustrious panel.

Let me start with you, Larry.  We promise to be informal.  You don't mind me calling you Larry, do you?  You just chaired the Lancet Commission on Investing in Health, and the Commission reports make a compelling economic case for investing in health.  Why should you think Minister of Finance should take heed of the Commission's finding?  What are you going to say to them to convince them?

PROFESSOR SUMMERS:  Ministers of Finance should take heed because the case can be rooted strongly in economics.  I would say to Ministers of Finance that health care is an issue that should matter to you profoundly if you care, and it is an issue that should matter to you profoundly if you count, that the case can be made in the most concrete terms, and I would highlight three points.

First, and‑‑and I'll think of this as speaking to the typical finance minister of a typical lower‑, middle‑income country.  First, a once‑in‑human‑history transition is possible in this generation.  Until 200 years ago life expectancy was about the same everywhere.  Life was nasty, brutish and short.

And then, with the industrial revolution, that all changed, and profound divergences opened up between societies where 20 children lost their lives before the age of 5 out of every thousand in societies where that number is 200.

It is, again, possible to achieve convergence; this time, at low levels.  The strategy laid out in our report would reduce child mortality to levels typical of the industrial world at the end of the 20th century.  It would reduce AIDS mortality to below 8 per 100,000, and it would reduce tuberculosis mortality to below 4 per 100,000.  It would mean essentially a convergence in health outcomes around the world.

I would say, second, this strategy is affordable and has a high return.  Our estimate is that implementation of this strategy would cost about $60 billion a year over the next decade, and about $75 billion a year in today's dollars over the decade after that.  To put that in perspective‑‑and if you remember only one number from what I say, remember this one:  That cost is 1 percent‑‑actually a bit less than 1 percent of the extra income that will be made available by economic growth between now and 2035.  1 percent of the income growth that will be made available by growth in low‑ and middle‑income countries.  It is affordable.

Mayor Bloomberg probably has some experience with investments that pay off even better than 10 to 1.


Most of us don't, and the public sector traditionally hasn't, but our estimates show that in low‑income countries, the payoff from this investment, once all the various consequences in terms of increased productivity, in terms of the way people value better health for their children are taken account of, that the payoff on that investment is 20:1 in low‑income countries, and 9:1 in middle‑income countries.

Third message that I would give finance Ministers is that even as you take on that challenge, you will then face the challenges that the industrial countries face, the challenge of chronic disease, cancer, heart disease, diabetes.  That you will need to think carefully about your strategy with respect to providing care, but there is no single issue more important than prevention.  The single most important thing that can be done globally to reduce mortality is the‑‑is an appropriate attack on tobacco.  A 50 percent tobacco tax in China would save 20 million lives over the next 50 years.

That issue around diet and food are today where the tobacco issue was in the 1970s.  The research is increasingly clear.  The consequences are devastating.  The evidence is mounting that public policy interventions can make a profound difference, and that the challenge is to find a way to respond to the fact that for the first time in all of human history, many more people will be suffering because they are eating too much than because they are eating too little.  But that, of all problems, should surely be one that is solvable and from which the economic return just in terms of reduced health care costs, if nothing else, will be immense. 

This is investment.  It is not consumption.  It is enormously productive intervention for raising the income level of your country, not to mention improving the quality of life of your fellow citizens.  That would be the message of the report to finance Ministers.



Mr. Secretary‑General, can I get your permission to appoint him as my special envoy?


Normally the Director‑General of an organization can appoint ambassador.  The Secretary General would appoint special envoy.  I need to appeal to you.  Let's talk later.


Ngozi, my sister, Minister Ngozi, you are the Minister of Finance.  Feel free to challenge Larry.  He gave you three reasons why you should listen, so that's one question to you, whether you agree or disagree with him.  But more importantly, let me ask you another question.  Two weeks ago President Goodluck, Jonathan, hosted a very important summit on universal health coverage, and he made the announcement that Nigeria is going to achieve universal health coverage.  Do you feel the burden on you?  So what are you going to do to deliver the President's agenda, but at the same time improving the growth of the country?  Over to you, Sister.

MINISTER OKONJO-IWEALA:  Thank you, Margaret.  Thank you very much.

I think that Larry has, of course, made a brilliant and compelling case, but whilst I'm talking, maybe he can also figure out what the returns to invest in basic education, primary education, secondary and tertiary will be in a country like mine.  He also needs to figure out the returns to investigate in an infrastructure, which can also be very critical for delivering on health outcomes.

When you talk about investing in power and water, sometimes we find, as you all know, you health people in the room, that maybe one of the best things you can do for health is to invest in ancillary things and related things like water and sanitation.  So, what I'd like to ask Larry is if he can do some quick calculations to help a poor Finance Minister who is faced with many priorities and has to arbitrate where the money goes.  That would be very helpful.

But that being said, you know the work I want to commend Larry and the Lancet Commission on the work done.  It's very exciting.  And actually it's because of the excitement of this work, if, as you say, you can see the ratios.  If in a middle‑income country or a low‑income country‑‑sorry, middle‑income, the returns are 9:1, and low income countries 20:1, then you know in a country with fairly poor health indicators like we have in Nigeria, that if you grasp this message and you can turn your investment into health, you know what that will mean in terms of economic development.

And I think it's this message that came out of the report, and the fact that, if we put our minds to it, it is doable that convinced the Minister of Health, and they deserve all the credit, not me at all, in leading the charge‑‑I'm just coming from behind‑‑in convincing the President to convene this and look at the issue of universal health care.  So I think we are convinced, although I'll still hold out for my answer in that message.  And, therefore, I think I do feel the burden because now we've got the messages.  Now, we see the economics of it.  The issue becomes how do we finance it?  How do we make it work in a sustainable fashion?  And there are one or two points I'd like to make about this.

The first point that I made to my colleague on the health side is that universal health care is an aspiration for us.  It's a goal that we think we can reach progressively and, therefore, we must put in place the instruments that will take us along the path.  The first is that throwing a lot more money at it right now may not be the answer.  We need to look at the efficiency of what we are spending now.  We need to look at results being delivered by that spending.  We know that that spending is quite unequal, and that we need to look at the progressivity of what we spend.  So these are the questions I had for him:  How do we make more efficient what we spend now?  How do we make it more equitable?  Because I think that we can release some resources within our present spending, small as it is that can also help to us finance and address that goal. 

In my country, I think one‑third of health care is public; about two‑thirds is private, and of the private, 95 percent is out of pocket.  And you know, we all know that when poor people spend in that way, they get thrown further into poverty.  So, we need look at that where we're addressing our money.  So that's the first point, and that's the first challenge.

The second challenge I think we have is, that being said, how do we work out a financing system that is equitable?  And, of course, there are many options that we can look at.  I think Ghana increased the VAT, its VAT by a couple of percentage points in order to address this problem.  We can certainly‑‑that's one of the things we can look at in my country.  VAT is one of the lowest in the world at 5 percent, so throwing in a couple of percentage points.  We're already taxing goods like tobacco and alcohol quite highly and, of course, you can do more, but I think looking at real sources of funds that can sustain the system will be important.  So that's one of the tools we're looking at.

An intriguing idea.  Larry mentioned that globally‑‑I think, you said it would cost 60 billion a year for the first decade, maybe 75 billion to tackle this problem.  Let's think of one thing.  I just came from a session now that is looking at an interesting source of funding, and I prefer to treat it as an innovative means of financing, and this is illicit flow of funds. 

African Finance Ministers just set up a panel chaired by former President Thabo Mbeki to look at this issue because numbers show that we're losing $50 billion a year annually in illicit flows that go from transfer pricing and tax evasion out of our countries because of the kind of asymmetry of information we have that we don't have the kind of asymmetry of knowledge.  We don't have the kind of knowledge, capacity to deal with multinational corporations that evade taxes, that do transfer pricing, that take huge sums of money out of the country.  And we've been debating among ourselves that we could finance a lot of these health challenges and education challenges by simply beginning at home to put in place the kinds of systems that will prevent and keep this money back.  Then we don't need to look at other sources, so if you think about the 50 billion a year and you couple that with maybe the money that will come from additional growth. 

In my country we just re‑based the GDP, and we're twice the size we were.  We're at 510 billion now.  Growth will be lower because of the bigger base.  But even if we tax some of that and we add some of these resources, these are some possibilities for being able to finance this kind of access to universal health that we can think about.  We'll come back to it, but I just wanted to throw a couple of different ways of thinking about this.  So, it is doable, but it would take us a process in which we also look at results all along the way.  Thank you.


DIRECTOR-GENERAL CHAN:  Watch out.  Minister Ngozi was talking about more money for health, so watch out corruption.  Watch out tax evasion.  She's coming. 

Now, the important thing is also about more health for the money, efficiency and effectiveness, but wise investment is important.  And talking about wise investment, now is a good segue to ask Mike a very important question:

As mayor of New York City, and you were renowned worldwide, and I know that because I worked in WHO.  My 194 countries just love him, and I'm getting quite jealous at some point.  But anyways, you were really, really ambitious in promoting reforms and to promote healthy lifestyle attracting a lot of attention to prevention. 

Prevention was mentioned by the audience this morning, how important it is, and we have many policymakers in the audience.  Can you advise them what makes you champion for tobacco control, reducing sugar, salt, and all these?  It is not popular.  You know that.

MAYOR BLOOMBERG:  It's not popular until you do it, and then afterwards, I don't think anybody seriously thinks in New York they would roll back the antismoking policies that we have being in public places.  It leaves things controversial, but that's what leadership is all about.  You don't do a poll to see where the public wants to go and then follow them.  Leaders decide where things should be and then get people to come along behind them.

Prevention is so much more efficient.  It's so much more humane than cure, so the first thing you have to do is stop people from self‑destructing or from getting sick, if you can do that.  If you can get rid of the mosquitoes, for example, you would not have malaria.  If you could get people to stop smoking and eating too much, you would get rid of a very big chunk of diabetes and cancer and heart disease. 

This is not rocket science.  There is no new science that we need to do this.  We know most things that are detrimental to your health that people do day in and day out, and we've got to find ways to convince them, incent them, or force them to take care of their own lives.

Now, that's not to say there isn't a policy that we should have to help people once they do get sick, but when you get to that, the other issue is really do you spend too much, not too little.  In some countries, clearly we don't have the resources, and we haven't spent the money.  But there is an awful lot of evidence that in a lot of places, we waste our money, and there's only a certain amount that the public is willing to come up with in taxes or corporations are willing to come up with in extra expenses. 

If you take a look in the United States, we spend roughly $7,500 per capita per year on health care.  In Western Europe they spend $3,300.  Their life expectancy is greater than ours.  There is something wrong there. 

The diets rate basically the same.  The education level is basically the same.  If you take a look at the things that have improved life expectancy and quality of life in New York, they have not been things that required any appreciable amount of money.  Today, New Yorkers live three years longer than they did 12 years ago.  The country has only come up by one year, and in New York City, the life expectancy is 2 1/2 years greater than the average across America.  And I can tell you the things that we've done all of which go to make that change, but not one of them costs a lot of money. 

Getting people to not smoke.  We just banned it in certain places and raised taxes.  Taxes on cigarettes help in getting children to stop smoking.  For adults, they don't have a lot of impact there.  It's where they can't smoke or where it becomes unfashionable.  And so we've tried to have movies deglamorize smoking and not be able to smoke in restaurants and theaters and to have it‑‑when you're standing outside a building holding a cigarette and people walk by, hopefully people look at you with disgust, and you say, "Wait a second.  I don't want this," and you stop smoking. 

And the number of people that have stopped smoking is dramatic in New York City, bringing down crime.  It doesn't cost a lot of money.  It just means enforcing the laws and going after kids with guns because that's where most of the crime is.  10,000 fewer people get killed every year.  Less die from smoking, and we used to have a murder rate of 2,300.  This last year we had 300 in rough numbers.  So you can do a lot of these things. 

Telling people which restaurants have bad health practices.  Salmonella really is dangerous.  Telling people which foods have a lot of calories.  You go into a restaurant, and you say, "Oh, I'm gonna be great.  I'm going to take care of my waistline.  I'm going to have a salad."  You can go to an IHOP and have a 1500‑calorie salad.  I mean, you've got to explain to people what is.

The strategy you have to have is‑‑we always have this saying in New York "In God we trust, but everybody else has to bring data." 


And so you have to figure out what's in the public's interest, and then you have to tell them. 

And the last thing I would say is, Government can only do a certain amount.  Most changes in our lifestyle, for good or for bad, are done by public-private partnerships or the private sector. 

You go back to when Ira Magaziner and Hillary Clinton wanted to change health care as we know it, and everybody blasted them.  And then in the next 10 years, all major corporations adopted most of the things that they had recommended.

If you just go and say it is a‑‑companies are environmentally friendly because it's good for their business.  My company, we generate 50 percent of our electricity from solar, and the payback is in a couple of years.  It's good business, but it's also great business because if you want to attract the young people today, you've got to convince them that you're environmentally friendly, and you go right down the list.

I would argue that what Government should do is explain to people what's in their interest, give them some economic incentives to do some things and disincentives to do others, like cigarette taxes or taxes on full‑sugared drinks because, keep in mind, a billion people are going to die this century from smoking, and obesity looks like it's going kill even more people.  And the worst thing there are the full‑sugared drinks that people drink because they're calories they take in, and they don't even get full from it.  So you would be better off eating‑‑you're better off eating 500 calories of McDonald's french fries than drinking 500 calories of full‑sugared drinks by a lot.

DIRECTOR-GENERAL CHAN:  Take that advice, huh?


MAYOR BLOOMBERG:  Except that, Margaret, if you take a look, there's a good article on Wall Street Journal yesterday.  Sales of Coca‑Cola, both the full‑sugared and Diet Coke, are down dramatically.  People are starting to understand.  Companies are starting to say to their employees, "This is what is in your interest."  They want to have healthier employees.  They want to be able to have lower taxes.  We know what to do, but we needed some leadership from the top.  That's what Government can provide and then stand out of the way and business will do it for us if you give them a few incentives and explain why it is in their interest.



Of course, Mike talked about the importance of leadership.  That doesn't mean you can be popular, but just do the right thing based on evidence.  Thank you for that.

Now, I had some good help getting some questions from the audience as well as from online.  What I'll do is, I'll read out some of these questions.  Feel free to answer any one of them.  If some of them are too difficult, you can leave it to Jim Kim.


The first question is, what is the role for private sector financing for universal health coverage?  And what is the single best value for money investment to improve health?  And, oh, the third one‑‑this really needs to go to Jim or Tim‑‑what should the World Bank do to help countries achieve universal health coverage? 

Last, but not the least, this is a question from the United States online audience, what is the role of civil society in accelerating progress towards universal health coverage?  How can intergovernmental agencies and civil society work together to ensure UHC is prioritized? 

Who would like to take the question?

MAYOR BLOOMBERG:  Oh, efficiency is prevention.

DIRECTOR-GENERAL CHAN:  Efficiency is prevention.



MINISTER OKONJO-IWEALA:  Well, on the role for the private sector, it's actually interesting that in my country, the private sector‑‑some members of the private sector, particularly some wealthy members, have been coming together and looking at this issue and seeing what is their role in partnering with Government and financing health care and in improving health care within the country.  I think the realization of the returns to health, even for their workforce, is dawning on them that this is an area in which these partnerships can deliver a win/win for everybody. 

And I'm proud to say several of the high‑net‑worth individuals in the country got together and said, "Instead of trying to do things by ourselves"‑‑they have two sets of things within their companies, but also in their philanthropic endeavors.  They got together and said, "We'll form a private sector health alliance that will look at how to partner with the public sector in trying to solve some of these health problems that we have in the country." 

And I think that there's a definite role for the private sector to play in this, and the issue is how the Government will work with the private sector in order to leverage the resources that they have towards universal health care.  The thinking about it has just begun.  We're not there yet, but we can see a definite role for that.

DIRECTOR-GENERAL CHAN:  Larry, you know Ngozi gave you a few assignments, and she did say that you needed to do a quick calculation.  What is the return on investment for education?  Infrastructure?  What is it in sanitation?  What is your answer?  

PROFESSOR SUMMERS:  I think the evidence‑‑this is something I worked on during my time at the World Bank 20 years ago and have followed the literature‑‑the evidence that in the developing world, primary and secondary education for girls is an enormously high return investment.  It pays off hugely as a health care investment in reduced maternal mortality, reduced child mortality, reduced fertility. 

Women who are educated are more empowered and are likely to lead healthier and more fulfilling lives and cause their children to do that.  So that is a particularly high return on investment. 

I have no doubt that the right investments in water and sanitation can make a big difference of all the environmental problems.  Unsanitary water is, by a wide margin, the one that accounts for the most suffering and death.  And we sometimes don't think of it when we think of environmental problems, but it is a profoundly‑‑it is a profoundly important one.

You raised the question of what the highest return investment was, and I would just highlight two aspects of that.  One, just to emphasize what Mike said, usually the idea about investment is you pay money and then you get benefits from paying money.  When you put a tax on tobacco or a tax on sugar, the idea is you get money and then you get benefits.  And so that is an extraordinary investment, far better to tax those things than to tax good things like work and saving.

The second thing I'd say‑‑and this in a way brings together the question about what the private sector can do and the question of high return investments that I want to highlight because it hasn't been discussed yet on this panel‑‑is we need to devote more resources to the production of global public goods in the health area.  Whether it is research on cures, whether it is research on preventive techniques, whether it is research on the methods of service delivery.  No one country has the incentive to do that because it captures only a portion of the benefits which go to all countries. 

And there's one example‑‑this is not something I had studied before working on the Lancet Commission Report.  One aspect of this that made a huge impression on me was this:  The risk of pandemic flu.  Optimists think that that risk is 1 percent a year.  Pessimists think that that risk is 2 percent a year.  Pandemic flu, if it came today, would quite likely be worse than 1919 because of the greater communicability around the world.  And I'm told, Margaret, that the WHO's budget for influenza is half that of New York City.  If that is close to right, I wonder if the world is making the appropriate provision for something that could be cataclysmic in its impact.  That's just an example of a global public good.

DIRECTOR-GENERAL CHAN:  Give him a big clap. What a man. I thought you were an economist,you’re a health person as well. What he said at the beginning really touched my heart. He gave us three Cs, and I would repeat that but I would ask the panel, What is your one minute or thirty second take home message for the audience? What Larry said at the beginning was, Care, Count and be Concrete. So those three Cs are extremely important for ministers of finance as well as for ministers of health. But from my perspective, Larry, I have already asked the SG for permission to appoint my, and I will appoint both of you now, Mike, take home message?


MAYOR BLOOMBERG:  Margaret I don’t think anybody realizes that in 1919 one quarter of Europe was wiped out by a pandemic. And the fact that, Larry’s right, because people move around, you would not contain it to Europe, you would go around the world very quickly. Also the water thing, there are a whole bunch of cities in China where fifty percent of the people, fifty percent of the people live in the city have stomach cancer, from the water. It’s just all of a sudden and we have a <inaudible> some things like this, all the pollutants go right in. West Virginia’s the same thing but it’s only a small number of people. In China, there are a million people dying every year from pollutants from coal fired power plants. I mean there are some things you could do to really improve public health that don’t cost all that much. But, let me come back to one other thing, and then I’d leave you with the thought. We say, you phrased it – what can government do versus the private sector. Government is the private sector, nobody just prints money. That’s our money. Every taxpayer’s money. And so if we’re all in this together the question is who has the commonsense to focus the money and demand results. And sadly governments don’t seem to do that very well in many cases. Just take a look at our immigration policy in the United States. Just take a look in the United States where we’re defunding medical research, we’re not exactly, we should not be held up as a standard, a gold standard to the rest of this world.


MARGARET CHAN:  Ngozi what is your thirty second take home message for the audience?

 NGOZI:  I think Mike was more than thirty seconds.


MARGARET CHAN:  There’s a competition going on here.

NGOZI:  My take home message in all seriousness is that, you know the point is clear. Investing in health pays. But we’ve got to pay for that investment in health. And so the message that I have to the health community, most of who is here, is: how? Come back and figure out how in a developing country with multiple challenges, we make the kind of resources available that can take us towards universal health care. We’ve got the message, we’ve got the results, we just need to plan the “how”. And Larry did not quite answer my question, because he said investing in girls’ education is very high pay off, and I totally buy that. In fact it’s such high pay off that if you invest in girl’s education you might be able to take out most of the health problems of the family. So take home thought for you again is help us as ministers of finance to prioritize which ones to do first. Thank you.


MARGARET CHAN:  I have one question from Women Deliver. It’s about women empowerment. And I think Larry’s earlier comment has already answered your question. You know this is so important. Now Larry, you have the final say. More than thirty seconds.

LARRY SUMMERS: I think this is probably the single most important area for productive investment on behalf of mankind. And I think what’s been said here is fundamentally three things. One, that there needs to be an awareness of the stakes involved. Facts like the one that the Mayor just cited, that a quarter of the people died in Europe in the 1919 flu, and odds are that something like that will happen during this century, and we need to be ready. These kinds of facts need to be known by every child, and if these facts come to be known that will drive responses, awareness, resources. These things do, as the Minister keeps emphasizing, cost money. There’s plenty of money in this world, and we need to figure out how to find some of it. I think the ideas around illicit capital flows, are, if done right, actually very promising. And with those resources, there’s the capacity to make an enormous difference. But the third thing is actually most important. And that is results. You can spend a lot of money and get next to nothing for it. The extra eight percent of GDP that the United States spends on healthcare, well over a trillion dollars, stands as an example of that proposition. And so it is not enough to care, it is not enough to insist on more resources, it is not enough for international organizations to vow goals and pledge coordination and demand cooperation. You need concrete steps that work. And the public sector needs to learn what the private sector is actually much better at. What the private sector is very good at is when something works, it grows fast.  And when something fails, it loses the oxygen of money and it shrinks. And we need that with respect to public sector efforts in every sphere, no sphere more importantly than in healthcare.


MARGARET CHAN:  Audience, participants, either online or in this room, I want you to join me, put your hands together and thank this awesome panel.