A mix of many minds – of thought-leaders, decision-makers, researchers, implementers and global young changers from various sectors and countries - congregated in Berlin, Germany, for the Global Solutions Summit 2019, to discuss achievements and challenges and generate policy recommendations on major G20 and G7 issues, including on sustainable development, infrastructure finance, financial architecture, trade and investment, universal health coverage, climate change, future of work and education, social cohesion and the future of politics, policies for aging populations, and more.  All discussions linked to the overarching narrative of recoupling economic, political and social progress. The Summit served as a stepping stone to the Japanese T20 Summit in May 2019 and the Japanese G20 Summit in June 2019. 

Two sessions were dedicated to the UN Sustainable Development Goal 3.8 for achieving universal health coverage (UHC) by 2030. Underpinning the UHC agenda is the belief that access to health care is a fundamental human right that advances equality and safeguards human dignity. UHC is central to global health security. Landmark commitments to achieving UHC through “financial risk protection, access to quality essential healthcare services and access to safe, effective, quality and affordable essential medicines and vaccines for all,” are being made by heads of state in many Low and Middle Income Countries (LMIC), with broad political consensus that Primary Health Care (PHC) is the essential foundation toward achieving UHC.

Countries are at various stages of implementation, reacting to their own interpretations of both UHC and PHC, developing or modifying their health systems to achieve UHC, with many challenges and some successes along the way. To mention a few that featured prominently among Summit participants, across presentations and during informal discussions along the corridors.

The principle of “leaving no one behind” is central to UHC, but substantial inequities in access to care continue to persist within as well as between countries. Many LMIC continue to face financial constraints with declining investment in public systems, resulting in weak and overstretched systems - understaffed and overcrowded healthcare facilities, which are crippled by long waiting times and shortages of essential medical supplies and services. This is further aggravated by the increasing burden of non-communicable diseases (NCDs), which are largely preventable, in addition to the prevailing major health risk of communicable diseases. Robust health systems are the prerequisites for achieving UHC.

Four decades after the Alma-Ata Declaration articulated primary care for all as being a most important worldwide social goal, limited access of the most vulnerable to affordable and quality essential services, as well as underinvestment in primary health care systems, remains a major impediment to achieving UHC. Speaking during a panel on the transformational ambition of UHC, Uganda’s minister of state for Health, Joyce Kaducu Moriku underscored the importance of investing in primary healthcare, as the “cornerstone to achieving universal healthcare”.  Prioritizing reliable domestic financing is a prerequisite to sustain the gains made towards UHC and requires enlightened leadership and deliberate dialogue, not only between finance and health ministries, but also with high-level political actors, other ministries and sectors and communities to build public and political support. The increase of NCDs has centered attention on the importance of addressing the “determinants of health drivers outside the health system”, to leverage intersectoral funding for realisation of UHC.

Human resources challenges cut across presentations and were often related to discussions about achieving high quality health care. Workforce shortages from ‘brain drain’ to the private sector and migration out of LMICs were a common concern. Speaking at the same panel on the transformational ambition of UHC, the Managing Director of Nyaho Medical Centre in Ghana, Dr Elikem Tamaklo, drew attention to the importance of Public-Private Partnerships in the health care sector as a deliberate means to improve quality health care delivery. Private health sector in Ghana accounts for about 40-60% of all health care provision, but is fragmented and therefore remains under represented in key decision making fora – a missed opportunity to consciously promote diversity and inclusion of relevant policies towards improved quality of health care.

Given constrained national budgets and competing priorities amidst declining external aid, discussions centred around how to effectively engage the private sector for UHC needs, without further aggravating the existing inequities in access and rising health expenditure? Along the corridors concerns were voiced on can the private for-profit providers be interested in PHC? Private sector (for profit) provision is prolific across many south Asian countries and growing in a number of Sub-Saharan African countries.  What lessons can be drawn from their experiences? Methods for developing PPPs remain in its infancy in the health sector and there is much to investigate and learn about this. Urgent policy level exploration is required for recognizing and strengthening public-private links to achieve comprehensive PHC and UHC.

There was considerable interest in investing and harvesting in digital technology –artificial intelligence, which brings new opportunities (such as being emergency prepared and reducing costs of treatment through early detection technologies). Deployment of various forms of technology in Uganda has reportedly resulted in reduced costs of operating facilities, improved efficiency in data collection and overall improved provision of services to Ugandans, according to Uganda’s minister of state for Health.

Achieving full UHC is a daunting task. The financial cost of massively expanding access to health care globally is a formidable barrier to achieving UHC. Clearly, a phased approach to rolling out UHC programs in stages will be necessary, whereby selected health services  - a smaller package of core interventions - are offered broadly and affordably to all citizens by the government.

Several other concerns were raised with no clear answers. For example:

• What are the essential health benefits  - promotive, preventive and curative, being provided in different contexts, and their potential role in building universal, equitable and integrated health systems that leave no one behind?  And what triggers and transitioning processes should be used to move from "minimum" to more comprehensive benefits for all? What are the operational and financial demands of implementing such a comprehensive universal health benefit, and how can this inform global health negotiations, including on advancing the SDG goals and UHC?
• How can citizens and civil society constructively engaging and contributing to global and national debates about how to reform the health system to ensure that all its people have the right and access to quality, affordable health care?

Overall, there is a consensus among all that we need to figure out how to capture and share country experiences around mobilizing resources, prioritizing interventions and building delivery systems, and find solutions on how to get there.

This year (2019) is shaping up to be the biggest year yet for the global UHC movement. Alongside the technical questions of what sort of package to deliver to all, and how to deliver and finance this noble goal, making progress towards achieving the UHC agenda is very much a political process. LMIC budgets are constrained and attention is focused on how to spend on health versus education and the many other competing priorities. How can we overcome current challenges encountered in adverse political environments with emerging nationalism? Health for all is not possible without multi-sectoral collaboration and strong partnerships between governments, the private sector and citizens.  Domestic resource mobilization is going to be the most important source of financing for the SDG goals.

Written by Masuma Mamdani, Research Scientist, Ifakara Health Institute