Robert Yates
Hello. Good morning, good afternoon, good evening to you from all around the world, and welcome to Chatham House and to this special webinar looking at universal health coverage and different perspectives from around the world on universal health coverage, and, in particular, the opportunities to move towards that goal during the COVID-19 crisis and coming out of it. We’ve seen many examples throughout history of countries making big strides towards universal health coverage coming out of crises. You look at the UK, Japan, and France after the Second World War, Thailand after an Asian financial crisis, Sri Lanka after a malaria epidemic. So, might this COVID-19 crisis stimulate universal health coverage reforms in different countries?
And we have three eminent panellists with us today to discuss this topic, each of them in a country where we can see these processes are potentially taking place. So, we’re very excited to hear the perspectives of three different continents, and with me I have Vivianne Ihekweazu, who is the Executive Dir – Managing Director of Nigeria Health Watch, a civil society organisation spearheading UHC reforms in Nigeria, Cheryl Cashin, who is Managing Director of Global Health Practice at Results for Development in the United States, and a big advocate of universal health coverage in New York State, I’m sure she’ll be telling us about that, and also, Dr Mushtaque Chowdhury, who is Professor of Clinical Population and Family Health at Colombia University. He’s also Adviser and Founding Dean of the James P Grant School of Public Health at BRAC University in Bangladesh, a country which is potentially looking at UHC reforms, as well.
I should say that our discussions today are on the record. So, in fact, it’s being recorded, so we’re not following the Chatham House Rule, it’s on the record and, in fact, we’re very much encouraging you to spread the world – spread the word, through social media, and, if you’re using Twitter, please use the #CHEvents. Now, for our discussions today, we’re also very much encouraging you to ask questions of our panellists, and if you would do that, please, by using the Q&A function, not the chat function, the Q&A function. And, if you see a question that’s already been asked and you think that’s a particularly good question that you would like to ask yourself, then if you can just upvote that, sort of, give it a thumbs up, that will push it up the list and it’ll be easier for us to see the more popular questions. And I should say, as well, that, if you want to come on air and ask your question, you know, we might ask you to do that, if you’re willing to do that, and that will give you an opportunity to star in the webinar yourselves.
So, the way we’re going to organise the event today is that I’m going to ask our panellists to give their perspective of the global pandemic, but also, the UHC opportunities in their countries, and each of them will speak for about seven or eight minutes and then we’ll throw it open to Q&A and for you to be able to participate. So, without any further ado from me, Vivianne, if I can turn to you first in Nigeria, Africa’s biggest country, and, you know, have been – made some good strides in tackling the COVID-19 crisis, but how would you say this is, sort of, panning out when it’s coming to the bigger picture of UHC reforms in Nigeria?
Vivianne Ihekweazu
Okay, thank you very much, Rob. Good afternoon to everybody and good afternoon to all the delegates. Nigeria is the most populous country, I wouldn’t say it’s the biggest, in terms of land area, but just the largest economy and the most populous.
So, you know, when we talk about UHC in Nigeria, I think the starting point is looking at the current context in Nigeria, in terms of a lot of the health inequalities we face, and these health inequalities are not unique to health, and really reflect the general access to resources in the country. These inequalities cannot be sourced in health alone, and include other inequalities like access to water, education, electricity, job opportunities, etc., and really needs to be addressed as a bigger issue. And inequalities in health specifically, we can see include access to basic healthcare services, the current divide you have between the rural and urban areas, in terms of the number of health workers, the actual number of health facilities, differences in health literacy, which has a huge impact on healthy behaviour of all Nigerians. Then we have the gender inequalities, so the way and access women have to health is very different from males, and that, you know, we see in the data, reflects a lot of the health outcomes.
So, the inequalities we face are vast, and not forgetting, most importantly, inequality and also ability to pay, and this has an influence in the way people actually access healthcare. So, when we’re talking about how Nigeria so far has been transitioning to UHC and, you know, the stage we’re at, if, when we look at it, the reality is our pathway to UHC has not been fully defined or socialised in Nigeria. So, when we’re talking about universal health coverage, it’s – you – the understanding, even amongst Politicians, is not there. And even as we say we’re transitioning to UHC in the first place, most countries have some defined pathway that has led to UHC or healthcare for all. This pathway has been through taxation, as those have in the UK and other European countries, health insurance, you know, through HMOs, etc., you know, as we have in the US, also, like, a social health insurance model.
So, we have a hybrid mixture of current mechanisms through which healthcare is funded, so it’s not as straightforward as having a clear pathway that has been clearly defined for us. So, for instance, we have examples of social health insurance, like in Germany, the Bismarck model. States have been empowered to implement state health insurance schemes, and the aim of this is to expand coverage to more citizens, especially vulnerable, and making prepayment mandatory, so, as we know, the pool funds will spread the risk, and it’s based on people’s ability to pay and, with a larger pool of funds, then that is an avenue to increase funding and it’s more sustainable.
We have the National Health Insurance scheme, which, where are we now, 2020, was established 15 years ago, yet covers less than 5% of Nigerians, and only really covers employees of the Federal Government. And the national health, after 2014, was as a mechanism that’s supposed to look to expand healthcare through the Consolidated Revenue Fund, so the aim of the national health at the heart of it was to increase funding to health, and 1% of the Consolidated Revenue Fund is supposed to go to a Basic Health Provision Fund, with the aim of bringing more funds to health – with the health – to the health sector, and those funds are supposed to be used to improve services and improve financing.
The implementation was finally flagged off by the President in 2019, although, in 2018, the Senator Tejuoso, the Chairman Committee on Health at the Senate, managed to include the Basic Health Provision Fund in the funding for the state at that point in time, but, since then, funding to Basic Health Provision Fund has stalled, and this is an area of advocacy that, you know, we have been pushing in – at Nigeria Health Watch.
Another means of funding in healthcare has been through private insurance, through HMOs, and, as we know, these are not the – this is not the most efficient way to finance healthcare because this tends to be a very small percent of the population that actually takes out private health insurance, and it’s not an efficient way of delivering healthcare. And Nigeria people are spending currently, about 75% of healthcare expenditure out-of-pocket, and this, again, is not a sustainable model and goes completely against the principles of UHC.
So, Nigeria Health Watch, as – you know, as Rob briefly mentioned, we’re a health communication advocacy organisation, and a lot of the work we have been doing is in advocating for universal health coverage, and it’s been a two-pronged advocacy. First of all, advocating for the government to do the right thing. Do the right thing, in terms of investing more in health. To date, despite Nigeria being one of the signatories of the Abuja Declaration of 2001, where we – all Heads of State agreed to spend at least 15% of total government expenditure on health, to date, Nigeria has not spent more than 5%. I mean, there was one year it went above, and that was just a single year, but, since 2001, less than 5% of the total government expenditure has been on health, and if you imagine, we have a population of 200 million, and this is not a realistic amount to spend. So, advocacy has been – in addition with other CSOs, Nigeria are not in – and Nigeria Health Watch didn’t view this in isolation, to implement the key element of the National Healthcare Act, which is the Basic Health Provision Fund, and the aim of the national healthcare fund is to provide a framework for the regulation and management of the national health system, because there’s serious need to reform it.
And the other way that Nigeria Health Watch has been doing advocacy is supporting and driving demand for health. People in Nigeria do not know what to ask for because there is also a need for them to define what they understand about health, and also, there’s a need to define for people what they should ask for. People have not been exposed to good healthcare, and so accept whatever they get as normal. So, when they go to health facility, it’s overcrowded, the Doctor’s not available, they have poor service. If that is all that they’ve experienced, you can’t expect them to ask for any better if that’s all they know.
And this – you know, this brings to mind, actually, something that Melinda Gates said in a talk, a talk she did about non-profits, what they can learn from Coca-Cola, and she said “the fact that people need something does not mean we do not have to make them want it.” So we have to make people want health. Health is not an issue that is top of the agenda in Nigeria. It is not an issue that wins or loses elections. We saw in, you know, 2012, the London Olympics glorified the National Health Service. It’s a national institution that people are very proud of, so we really need people to understand what health is, what good health is.
And another – and there’s a project we’re doing with Christian Aid currently, and some of our team are in two states in Nigeria, which is helping drive demand for health, and to improve access to health, especially for vulnerable people. So, we’re currently doing some training of community-based organisations, and what they’re doing is encouraging community members, especially lower income, who are always disproportionately impacted by poor health, to advocate for state health insurance ‘cause this is a means to reduce out-of-pocket expenditure. And it’s an important school of thought that also looks at the direct provision of health through taxation.
In principle, you know, this is true, you know, if it works in a country with disciplined government systems, with little corruption, and focused on delivery, we had a single payer system that is tax-funded. But, you know, where governments are not as efficient, this has been experienced in Nigeria, and I look to other sectors like telecoms, which was state-run, and a lot of inefficiency’s meant that, you know, a taxation system may not have – may not be exclusively the best way to – the easiest way, let me put it that way, in a country, where there’s a lot of inefficiencies, to deliver health.
So, you know, we’re looking ultimately to leadership, to supporting improving access to health, and what we’ve found is COVID-19 has woke – reawakened or awoken, let me put it that way, the reality that, without health, nothing is of any use. Economy – our economy has been badly impacted, like many others across the world. We are very dependent on oil revenues, we’ve – we’re – our GDP is going to fall, or has fallen already, and so, there – the connection between health and the economy has not been made any clearer, and, you know, for states, it’s also clear that they need to invest in the health of their population. In Nigeria, our needs are plenty, and so all agencies currently are competing for very scarce resources. We have demands for infrastructure, security, education, and health does not rise high in agenda, never has, and so the government has never really focused on it. So, really, for political leaders to focus on health would really be something that would build the political capital, and for the first – and the first Governor that does this, it will be a gamechanger. And we’ve seen what this has done for Obamacare, enabling more than 20 million Americans to have access to healthcare, and we need to have a similar demand in Nigeria. So, when the political leader does provide healthcare and improve the tenacity, we need to build a positive narrative of why it’s important.
So, yes, just to round off, and I think we’ll go into more detail, in terms of what COVID has done, COVID has shown that our health sector’s very underfunded. Recently, it was April or so, the Secretary to the Government of Federation made a comment that surprised many people, and, you know, quoting what he said, he said, “I didn’t know Nigeria’s health sector was this bad.” And the realisation only came about because, suddenly, we’re having to look inwards. We’re having to look, if you’re sick, you can’t seek healthcare outside of Nigeria.
So, COVID has really thrown up an opportunity, if we grab it with both hands, and, as advocates, this is something we aim to do, because we’ve seen that other health issues have been put to the side and, in the next six to 12 months, we’re going to see repercussions of that. And the last thing we need right now is insufficient funding to support our health sector, and we cannot afford to lose out or go back on any of the positive steps we have achieved in improving health outcomes, and COVID threatens that. So, more – now, more than ever, we need more funding in healthcare, and UHC has to be a way that we enable all people in Nigeria to have access to healthcare. So, I’ll end on that note.
Robert Yates
Vivianne, that’s really brilliant, thank you for those opening remarks and very important, I think, you know, you were emphasising a) the funding, but also b) the political commitment, and I noted you were saying that, you know, the Politicians were just not understanding at the moment, and, you know, this is the big issue, how do we make the Politicians understand more? I also saw, sort of, Cheryl nodding away there, you know, when you were saying that private health insurance isn’t the route to universal health coverage. Cheryl, if I can maybe, sort of, turn to you now. How – what’s the situation in the US now? You know, might this be the great opportunity for the US to take a big leap towards UHC, or are we being too optimistic?
Cheryl Cashin
Thanks so much, Rob, and good morning, good afternoon, and good evening, everyone. Yes, this private insurance issue and the inefficiency, that really rang true for me. The United States is infamous, I would say, for spending more than any country in the world on health and getting worse outcomes and worsening, you know, and there’s a lot of inequity around that, of course, with deep roots, and we’re facing that at the moment, as well. The roots to systemic racism and we’re just facing a lot of things right now, and the COVID-19 pandemic has brought all of this to the forefront. And I think it has really exposed and exacerbated some of the perversities in our system that could be a galvanising moment, I think. And these three perversities that you really won’t find in this way in any other country’s health system in the world, and the first one is tying coverage to employment. So, more than half of Americans who have insurance coverage still get their coverage through their employer, even after the Affordable Care Act and the changes that were enacted, and that link to employment has really proven to be a problem in this pandemic, when the most concentrated job loss ever in the history of our country has happened since March. 40 million Americans lost their jobs, and that has translated into 5.5 million losing their employer-based insurance, and that is expected to go possibly up to 20 million by the end of the year. So, that’s really a potentially catastrophic outcome of the design of our system in this pandemic moment.
The second perversity is this reliance on private for-profit insurance, and this is not just in the employer-based part of our system. There’s private insurance that is permeating all of our public programmes, too, and so this, you know, kind of, reliance on private insurance means that 18 cents of every dollar we spend goes to their administrative costs, marketing and profits. So, that’s a problem when we’re – already we’re seeing the resources available for health contracting in this moment, 18 cents on every dollar going to their profits. And this pandemic has been a boon for private insurers, that, in the time when the pandemic was hitting and all the hospitals had to stop elective services and people stopped going to seek nonessential and sometimes emergency care, the private insurers weren’t paying out, but they were still collecting the same amount in premiums, and they are already talking about raising premiums next year. So they have recorded record profits. This transfer of funds from people to profits in a public health and economic crisis.
And then there’s the third, the other side of that coin, that the providers rely on this model for their business models, they rely on the fee-for-service payments coming from insurers, they rely on the inflated prices that insurers pay, because the insurers don’t have any incentive to negotiate good prices. They can just pass it on to us in the form of premiums and co-payments, so, at the time when the insurers are recording record profits, our healthcare providers have seen their revenues collapse. And we have seen hospitals furloughing employees and taking other cost-cutting measures at a time of a public health crisis. We don’t know what our service delivery system’s going to look like at the other end of this. Are they going to bring these workers back? What’s this going to look like? So, all of this, I think, is very galvanising, and we think that it’s a moment that really people will wake up to the really inherent flaws in our system and the damage that it does to everyone on a daily basis.
I don’t see the reaction as quickly as I would have expected in terms of public support for UHC and to have drastic changes in our system, watching the polls, watching the discourse, it hasn’t changed as quickly as I thought. And there are a few reasons for this, you know, the obvious ones that we have the political and financial clout of the for-profit entities that benefit from the status quo. We have our cultural aversion to taxation and, you know, government programmes, I think, you know, those things are there. The conversations that I’ve had with elected officials and others through my advocacy in New York State has led me to believe that these are not insurmountable problems, that we have seen progress in these areas, and we see this through the Medicare for All bill that Bernie Sanders has made, kind of, mainstream, in conversations, at least, in his last two presidential runs.
In my state of New York, we have the New York Health Act that has been passed by one house of the legislature since 2015. So, these things are really, I think, forward movements, but they, kind of, stalled. The closer we got to these really big steps becoming a reality, they have stalled politically, and so this is where I’ve been focusing my attention, how can we get over that, and what is the real problem? And I think the problem that I see, in my community education activities and discussions with Politicians, it’s what I call the devil-you-know problem. That people – the system is so bad, and maybe because it’s so bad, they think it could actually be worse, and so they’re afraid that it could actually be worse, and, Vivianne, this really – I was thinking when you were saying, and people don’t know to ask for good health. They don’t know to ask for a good health system in the United States, and so I think this is where we need to focus our efforts, to get over this last hump, and use this crisis to really make progress towards UHC.
And I think there are three things that could help do that. I think one is public education. Educating our public officials, but my time talking to them, they don’t really want to know the details, they want to know what their constituencies think. So, we have to make more of an effort to educate people that there are good options out there that could make their lives better tomorrow if they were passed. We don’t have to accept this system. And I think, you know, that’s what we do in my advocacy group, trying to reach the communities. It’s not quite enough, we need the media on board. We need the media to play the role, to educate people, to really not just expose these one-off, really outrages in our system, and that’s what the media focuses on, the medical bankruptcies and the things that are really outrageous, but they don’t connect the dots to the systemic failures. And they don’t do a good enough job sharing the proposals and the options that are out there, they treat it as a political horserace and not really showing that there are practical alternatives that are being discussed.
I think the second thing we need to do and is happening as probably more realistic is having more people get experience with the public systems, with our publicly funded programmes that people are actually very satisfied with. People are much more satisfied with their Medicare and Medicaid and the VA than with their private plans, if you look at the data and people’s satisfaction. So, by extending those programmes to more people, more people will get experience with them, that could also help move the needle, and we’re seeing states expand, access to Medicaid just last week, a very conservative state in Missouri, voters themselves bypassed their Politicians and voted directly to expand access to that programme.
So, the more people who have that, you know, access, they’ll be more comfortable with the public system, and, realistically, this is probably the way that we’re going to go nationally, that, if we get a new President, that there will probably be expansion of the public programmes or public option, give more people access and experience with the publicly funded part of the system, and hopefully get to a tipping point where we – one single plan makes sense. And, you know, this – as a health financing professional, this isn’t what I would recommend and go in this direction because it still keeps the wedge there for the private insurers to keep their place in the system and they always exploit that, but it might feasibly be the way that we get there.
But, in the meantime, the third option, I think, is to show that it can be done, and this is why I will continue to advocate, in my state of New York, to pass the single payer legislation that we have on the table, to show the rest of the country that it’s not that scary, and, you know, that we can actually make it work. And so, all of this, I think – this advocacy, as Vivianne mentioned, to take the moment of this crisis and to accelerate and to try to work on all these funds – all of these funds to get to universal health coverage more quickly. Thank you.
Robert Yates
Fantastic, Cheryl, you know, and very interesting the parallels, I think, you know, between the US and Nigeria there, you know, sort of, about what does it take to get you over the hump, as you say, you know, what catalyses this? Because what’s often really striking about these UHC type reforms is that they happen, big bang, very quickly, you know, that you’ve been frustrated and frustrated, and then, suddenly, it takes off, and, you know, this is what we’re fascinated in, in our programme at Chatham House, and at universal health coverage. What does it take – and I think what we’re recognising more and more, it is, as you’re describing, how do you engage the population, the media, and then the Politicians get it, and then, once you’ve got it, you don’t look back? So, man – it’s so often the case that countries then achieve publicly-financed UHC that, you know, they just can’t believe they didn’t do it before, so it’s what does that take?
Now, switching continents again, if I can bring in Mushtaque from Bangladesh, and, you know, sort of, Bangladesh, a country that’s made great strides in health over the years, but where I think you’re recognising your need to take a bigger leap towards UHC. Mushtaque, I understand you’re sharing your screen with us, so if you’d like to bring your slides up, and as you’re doing that, if I can ask people to put questions in the Q&A that – we’ve got, sort of, four cracking questions already, but that gives plenty of scope for other audience members to ask questions, as well, or upvote questions that are being asked. So, please do put your questions to the panel and maybe share your experiences from your countries, as well. So, Mushtaque, over you. How’s the situation in Bangladesh?
Dr Mushtaque Chowdhury
Thank you, and greetings from Bangladesh. I’m so happy to be on this panel and thanks to Rob and Chatham House for this opportunity. What I’m going to do is to present to you the perspective from Bangladesh, using a few slides, and just to start with some of the best bits about Bangladesh. Bangladesh is a large country of over 165 million population. It’s one of the most densely populated country in the world and, in terms of COVID, it’s not really in a – quite a difficult situation, and as you can see that we are very close to India, in terms of the number of cases and also, in terms of the number of deaths, but when you think about the number of tests, Bangladesh is lagging much behind India.
Now, the – there is a paradox going on in Bangladesh and The Lancet, a few years ago, called this one of the great mysteries of global health, and what is this paradox? So, this one shows that, over time, the mortality rates, as you can see here, through different – the blue curves, the yellow curves, the maternal mortality, the eternal mortality, everything has been going down quite substantially, and, at the same time, the life expectancy has been increasing. And now, the life expectancy has actually crossed about 72, which is – which means that Bangladesh is much ahead of our neighbours, such as India and Pakistan.
Also, here it shows that the total fertility rate has gone down tremendously over the years, and the conducive to prevalence rate has gone over 60%, so – which is quite a significant thing, given that Bangladesh is a Muslim country, kind of a Conservative Muslim country. And this is an interesting graph which shows that the Gini index, in terms of income inequality is quite high. Here, it shows that in 2010, it was about 145. Now it has gone even higher than that, it’s about 148, which means that the income inequality is quite high in Bangladesh, but compare that to the [inaudible – 31:29] index for public health interventions, which show that the [inaudible – 31:27] or the index is about .15, meaning that the public health services, some of the interventions, the preventing with dimensions such as API and family planning, and vitamin A, have actually reached the poor people.
So, there is the paradox, that we have a lot of inequality, but Bangladesh is still poor, but at the same time, we have been able to redu – really do well, with respect to some of the health indicators. But this one is also interesting, in the sense that Bangladesh has done well in its economy. In 2015, we have bought into low and middle-income countries, but if we look at the top graph, which shows that, although the country’s income has gone up, but the expenditure on health has – is one of the lowest in the world. But Bangladesh spends only .4% of the public expenditure of the GDP on health, which is the lowest in the world, I think. And the out-of-pocket expenditure is about 74%, so – which shows that, although the country was doing well, with respect to the GDP per capita, but, at the same time, we – the country – the government hasn’t been spending enough on healthcare.
Now, what is the – or what is happening with respect to universal health coverage? I mean, the Prime Minister went to the UN summit last year in September and she committed that Bangladesh should be achieving universal health coverage. We have a health financing strategy which, sort of, permits Bangladesh to achieving UHC by 2032, and also, Bangladesh is committed to the Agenda 2030, the SDG target 3.8. But what is the current status? If you, sort of, divide this according to the different services, then you’ll see that, I mean, in some services, Bangladesh is doing quite well, with respect to UHC. So, for example, in preventive services, for example, the EPI – the DPI, the [inaudible – 34:09] is over 90%, and it is free, and the people are very happy who deal with these services. Similar with respect to family planning, and also with some of the donor supporter programmes, such as the [inaudible – 34:26]. But, for the vast majority with their health services, for more than 90% of the government spending goals, we haven’t been able to do anything about that, about UHC, unfortunately.
Now, the – what – I mean, the COVID crisis has allocated kind of, an opportunity for Bangladesh to move forward and do some sort of reform, and, as Vivianne was saying about Nigeria, our health is also not on the agenda, on the top of the agenda of the government or the public sector, but the COVID crisis seems to have changed that. Everybody’s talking about health now, and there are a lot of concerns about corruption, the issue of government, the equality of services about that. So, there is some sort of – lot of attention to health and also to universal health coverage, and people are, sort of, demanding reforms in the health system, and there is some sort of unity in the way the people are suggesting or just to know how the reforms should be done.
So, here are the five areas that the civil society is, sort of, pushing the government to really move forward on these. One is to form a department, National Health Commission, whose job will be to really, sort of, decide about the vision for health, including how to implement the universal health coverage for the country. Also, to, sort of, create a separate independent national health security office, which will make this – the public sector more accountable and which will act as the purchaser of health services. Then, also, there is a huge need for improving the governance. Also, there are people talking about that we need to give more emphasis on private healthcare and also, on community participation.
And, lastly, of course, there is a huge need for, sort of, a revamping the planning the certain data systems in the country. So, these are some of the things that people are, sort of, demanding now on – to the government, and the government are – sort of, are – I mean, we are, kind of, a so-called democracy, we have, sort of, a parliamentary formal government, and that there hasn’t been much, sort of, of a – sort of, a reception – a good reception of these. Although, as the people are talking about these reforms and also, how to take the universal health coverage agenda forward. So, that’s – I wanted to, sort of, share with you, and, again, thanks very much for the opportunity.
Robert Yates
Thank you very much indeed, Mushtaque, and I think you make the im – very important point there about, sort of, Politicians sometimes, sort of, giving lip service to achieving universal health coverage, going to a big event at the United Nations, and, you know, that the people back home re – you know, recognise the reality on the ground. And I think we’re seeing this in countries all over the world, the – you know, the COVID threat is also an opportunity because this is exposing the flaws in the health system that have always been there. And I suppose a lot of this is to do with the fact that we’re looking at the COVID crisis affecting literally everyone in society, and that you need the full spectrum of services from promotion, prevention, curative, even palliative care services.
So, we, too, in the UK are seeing the flaws in our health system, and in particular when it comes to the lack of coordination with social care and, you know, this longstanding problem that we’ve had in the UK is all of a sudden top of the political agenda with everyone wondering how we’re going to sort this out. So, I think literally every country in the world, that, you know, their health systems are under the microscope at the moment, and those working in health and global health, you know, it’s a great opportunity to champion better reforms and see how we can work together. So, might I ask participants to keep asking questions, we’ve got a good, healthy number of questions coming in now, which I’m delighted about, and I might, sort of, tip off one or two people if they’re prepared to answer their – ask their question online, then they can come and join us.
The most upvoted question at the moment is actually around cooperation and how we can support countries, from Dr Mohammed Harris Nazeer from Pakistan, and he is, sort of, asking about, sort of, cooperation, particularly in South Asian countries, so a question there that might be directed particularly to Mushtaque, and I saw a question, as well, from Amafeni, who I think might be joining us from Ghana, and looking about the situation in the US, so I don’t know if Ama might be prepared to come online. So, could we maybe bring Dr Mohammed Harris Nazeer to ask from Pakistan? Are you able to come online, Dr Nazeer [pause]? Just wondering if my colleagues can bring Dr Nazeer in, otherwise I can ask the question directly myself.
Ah, apparently, he’s not going to be able to join us online, but if I could ask his question, it says, “Kindly elaborate the scenarios where underdeveloped countries in South Asia can co-operate regionally in the COVID-19 crisis where political differences exist,” and, you know, he’s speaking to us from Pakistan. So, I don’t know, Mushtaque, you know, sort of, the – one sees that, from the statistics, that the situation isn’t that dissimilar in India, Pakistan, Bangladesh, but then there are other countries in the region, as well. What degree of regional cooperation do you see going on at the moment?
Dr Mushtaque Chowdhury
I would say very little, actually, although we have a very common history, and the culture and everything quite similar, but we haven’t been really make use of that to our benefit, and I think the COVID actually, sort of, gives us an opportunity to work together in – and particularly, for example, I mean, actually answering some of the unanswered questions. So, for example, all the three countries, the death rate is quite low compared to other countries, so why – I mean, what is happening here, actually, which, sort of, keeps the – that rate low? And so that – I mean, at least, at the research, sort of, area, there are opportunities for the countries to work together, which will help us to benefit all the countries in the region. And also, to learn from some of the other countries in the region, so, for example, Nepal or Sri Lanka, which has done much better than the three big countries here, so what actually is going on there? And it seems that we are not learning much from the success cases, say in the Sri Lankan case or even the Kerala case in India. So, there are a lot of opportunities to learn from each other in the region.
Robert Yates
Yes, thank you very much, and just to plug a bit of research we’re doing ourselves in South Asia at Chatham House, you’re absolutely right. The – it does seem that the, sort of, smaller countries that are more publicly financed with closer to UHC, Sri Lanka, but also Bhutan, Nepal, they do seem to be doing better, and I – and, again, I think it’s going back to what Cheryl was saying, was a greater emphasis on public financing, less on private financing, and, you know, they’re able to adapt a lot better. Now, maybe if we can go to Amafeni, and, Ama, would you like to, sort of, come on air and ask your question, which I think is largely directed towards Cheryl?
Amafeni
Yes. Good morning or good afternoon, everyone. So, you know, we also have elections coming up in Ghana, and it’s becoming a big, huge ele – political issue. So, I was just wondering if it was the same in the US, and if UHC will become a political issue? Thanks. Over.
Robert Yates
Thanks, Ama.
Cheryl Cashin
Thank you, Ama, thank you for the question. Yes, I recall that we had elections at the same time in 2016, as well, so Ghana and the US, we’re, sort of, in parallel that way. My feeling is that, unfortunately, or I – maybe not unfortunately yet, but having the elections happen now has muted the opportunity of the pandemic as a crisis to be, you know, really galvanising political support for UHC. Everyone’s very risk averse right now, especially in this election because things are so polarised and so – you know, everyone’s just, kind of, holding on, not wanting to rock the boat, just, kind of, get through this. So, it hasn’t been as big of an issue as I would have hoped. It was earlier in the Democratic primary, but now this has just not – I think, once we get through the election and hopefully have a good outcome, then it will be a really important moment to take this opportunity to take the political capital that comes with a win, hopefully, and really then look at the pandemic ve – with very clear eyes and come up with some solutions, so I think we have to ride it out.
Robert Yates
Great, and I’m as intrigued to ask Ama, as well, I mean, I’m not sure if Ama’s still online, that, you know, what is the situation in Ghana? We have been watching, with great interest, and there’s been a long history of the NHIS. I think I saw one of the candidates now talking about providing universal free primary healthcare were he to get elected. Has this galvanised the debate in Ghana, Ama? Are you able to…
Amafeni
Yeah.
Robert Yates
…sort of, give us an update?
Amafeni
Okay, so, what I can say is that there’s a lot of talk about how the government has reacted towards this pandemic, and the opposition party thinks the government is using its mitigation efforts as a political tool, and so, there’s a lot of – you know, everything the government does is done to – is seen through political eyes, and we are saying that, no, we shouldn’t make it a political issue. But I think for us, as healthcare advisers and researchers, this is our moment, you know, and I’m so encouraged by that, and especially that the government is making a lot of efforts with UHC. So, we have a UHC roadmap and we’re all working towards getting a lot of ideas in, and I think the pandemic is a very good opportunity for us to, you know, piggyback on and work harder, so I’m really optimistic about this. Yes.
Robert Yates
Thank you, Ama.
Amafeni
Yeah.
Robert Yates
That’s really positive, and I think, you know, we were just discussing before coming on air that we could have filled this panel about ten times over with countries all over the world with people thinking that now’s the time, and we’re aware of similar, you know, approaches in South Africa and Kenya and Ireland at the moment, and Cyprus. So, there’s a lot going on at the moment. Now, if I could maybe turn to Sumbal in Hong Kong, I think you might have a question around gender inequalities and the importance of tackling those within UHC reforms.
Sumbal
Hello, yes. So, earlier, I agreed with Vivianne, there is definitely a need to have a broader approach to universal healthcare by examining gender, in relation to other social stratifiers. I mean, we all know that COVID-19 has exaggerated gender inequalities in universal healthcare or otherwise. How can you improve the lack of awareness or gender blindness on the part of policymakers and planners? Sometimes we know that even the insurance schemes, their range may be too narrow or even they may or may not include reproductive health services, so I was wondering if you could shed a light on that, please?
Vivianne Ihekweazu
Yes, thank you very much for that question, Sumbal. What’s become very evident with COVID-19 is that women have been object – have been disproportionately impacted by COVID-19, and that is seen in terms of the fact that women are the least – are likely to be in low scale jobs, so many have lost their jobs, and many women are also likely to be in the formal economy, and they have disproportionately suffered because of COVID-19 and it’s been made worse. So, really, what needs to happen, and to remove this, you know, gender blindness you mention is that everything we do now in terms of health policies, reform, etc., has got to be done with a gender lens on it. Gender has got to be integrated not as an afterthought, but when you’re – when putting together any policy, be it, for instance, in water, sanitation and hygiene, we need to make sure that these are near areas where [inaudible – 48:58] or in rural areas where women can easily access them.
As we know, women spend disproportionately large amounts of time doing household chores to take away their time from their children. Right now, throughout the pandemic, the government was giving out palliatives, and palliatives, in our context, refers to food aid, etc., so we don’t have a social security system in Nigeria, so cash cards first have got to be targeted and directed at women. In terms of empowering women and enabling them to sustain their businesses, funds need to be made available to support women because, by and large, this has a huge impact on the ho – on the outcomes of the household. So, really, just summarising, whatever policies we go – we take going forwards, we have to push and ensure that it’s done with women at the heart of it because they – we are seeing that they’ve been disproportionately impacted in many areas.
Robert Yates
Thank you, Vivianne. I was just wondering, as well, Cheryl, are you seeing women very much, sort of, driving the UHC campaign in the US and weren’t aware that, say, in California, I think the Californian Nurses were really, sort of, steaming ahead. Are you seeing a – sort of, a gender divide in the campaigning in the US over health, or is it fairly gender neutral?
Cheryl Cashin
That’s a great question. In my experience, at least in New York, it seems quite balanced. There are, you know, different groups, and it’s really – it’s driven by – I think the grassroots movement is people who have had just a terrible experience with the healthcare system, a lot of cancer patients who have gone bankrupt or thing – and so, a lot of the movement comes from individuals with experience, which cuts across gender lines, although the Nurses’ union is a very strong advocate, and as opposed to some of the other unions in the country that have been opposed to UHC, in a way to protect their own benefits that they have bargained for.
Robert Yates
Hmmm, great, thank you. Now, if I can turn to Nina van der Mark, please, and if we could bring Nina on. I think you have a couple of questions, one about, sort of, financial barriers, and whether we’ve, sort of, seen the crisis triggering changes in policy there. So, Nina, over to you.
Nina van der Mark
Hi, everyone. Yeah, so, as you’ve said, my name is Nina, I work at Chatham House. I just have a question for the panel regarding, let’s say UHC style measures during COVID-19, so social protection measures, cash transfers, as well as removing financial barriers for COVID-19 testing and treatment as recommended by the WHO. And I’m just wondering if this is perhaps an opportunity to build on these types of measures to argue for larger scale implementation and scaleup of those types of initiatives that’s been taken during the pandemic in countries. Thank you.
Robert Yates
Great, who’s going to kick off with that?
Vivianne Ihekweazu
I can do it. I can kick off, if – I would say – our experience in Nigeria, I would say – I’ll use the word fortunate in that the government has basically supported in testing, states have been asked to provide isolation centres, so if someone tests positive, unlike in some countries where they stay at home, then they’re put in isolation centres, and these are funded by the government. So, there has been a, kind of, UHC-style response to COVID, and I think, if there wasn’t one, there would have been – for the first time, actually, there would have been outrage from the Nigerian population. And cash transfers were made available to people, but, having said that, we’ve got a population of 200 million, so the percentage of people who actually had access to that is very limited. But I think what COVID has shown is we need to have these social safety nets in place because that was one of the main reasons why our lockdowns were not successful. People who are largely self-employed had no way of supporting themselves. So, yes, the government has, by and large, supported in testing, providing funds for people in isolation centres, and has supported the treatment, unlike I think in some countries where people are actually asked to pay.
Robert Yates
Great, thank you, and so, I don’t know if other panellists want to come in or not. We’ve got plenty of other questions, in fact, coming in. And maybe can I go to John Sproat, please, who I think has got a question about other services being displaced by COVID activities, and whether you’re seeing that in your countries. So, John, would you like – oh, there, yeah, John, if you’d like to ask your question, thank you. Oh, if you just unmute yourself there, please, John. Uh-huh, there you go.
John Sproat
Yeah.
Robert Yates
Yeah, fire away.
John Sproat
Hello, can you hear me?
Robert Yates
Yes, very well, thanks, John.
John Sproat
What’s going on? No, I can’t hear anything.
Robert Yates
Oh. Oh, dear, and I’m sorry. We can hear you, John. Can you hear us? No, and I don’t think so. Oh, dear, and I’m sorry about that, so I think we’ve lost John. But John was asking about other services being displaced and, in particular, in other infectious diseases like malaria services. Now, maybe, I don’t know, Vivianne, you know, that must be a huge issue in Nigeria, and I’m – you know, and I’m sure as well you’re seeing other services displaced in Bangladesh, as well. So, are you seeing this, that, whilst there’s the bigger effort on COVID, that it’s actually making things more difficult for other services?
Dr Mushtaque Chowdhury
Yes, this is Mushtaque, and it’s – the answer is yes and no, both, I suppose, so no in the sense that, when the – when COVID started, the first cases were – was found in March there, so March and April we have seen a huge reduction in immunisation aid, for example, there – nobody was coming and the health workers also not turning up. But from May, we have seen that the – it’s again rising, which – so, that’s the – that it is saving less of the impact on the preventive services, but it hasn’t really gone back to the pre-March situation. But it’s having havoc on others, for example, maternal health services, the hospital’s ability, the MCD services, etc., and nobody’s going to the hospital now because, I mean, the fear that – the infection fear is there, of course, but also the Doctor is not there or the Doctor is not attentive and the safety issue is there. So, it’s yes and no, both, I suppose, but it’s being seen as more of a yes now because many of the services are being affected because of the crisis.
Vivianne Ihekweazu
Okay and also, yes, just echoing what Dr Chowdhury just said, we are seeing data that has shown that maternal services have been disproportionately impacted by COVID, so mothers are not going to healthcare facilities, visits are being reduced, so we have an increased number of women who are giving birth at home, we’re going to probably see redu – we’ve seen reductions in mothers taking their children to health facilities for immunisation, and we know what that means. Nigeria is not just plagued with COVID right now, we’ve just gotten over our Lassa fever season, we have outbreaks of measles, yellow fever. So, NCDC, Nigeria Centre for Disease Control, is battling all of these things, and what COVID is going – is doing is threatens to reverse a lot of the progress that’s been made in reducing age-related deaths, these were reduced by more than a half since 2004, TB mortality fell by about 42% between 2000 and 2017, malaria deaths decreased by about 60%, you know, in the last five years, and the risk is a lot of these health services are going to be interrupted. For instance, inside the distribution – inside – sorry, insecticide fitted mosquito nets has been disrupted, and we are right now in August in Nigeria, and this is, like, the height of malaria season. So, in short, COVID-19 has and will absolutely reverse quite a lot of progress, very, very fragile progress, I must say, that has been made given that, across a lot of our health indices in Nigerian maternal mortality, infant mortality, Nigeria really does very poorly, and, yeah, more reason for us to push for sustained funding, more funding, to support our health services in Nigeria.
Robert Yates
Thanks, Vivianne, and we’re seeing exactly the same in the UK, you know, major worries, particularly around, sort of, cancer screening, cancer services, and people already predicting what that’s going to do to cancer cases and cancer deaths next year, we – which is extremely alarming. Now, I think we’ve just got time for one more question from the floor, and I’d like to bring in maybe Hans, if he’s still with us, who is asking what about the affordability of all this? You know, it’s all very well and good us talking about UHC, but how, with the economies struggling, are we going to afford it? So, Hans, over to you, are you going to ask your question?
Hans
Thank you very much, this is Hans [inaudible – 59:08]. Yeah, the question, indeed, is that, when you look at UHC programmes that have been highly successful and rapidly developed, and I mentioned Thailand and China, that was done in a time of good, solid and long economic growth. So, this COVID period is, in that sense, not a good period to expect big government investments in UHC, and I see that as a problem, and, of course, that doesn’t mean we shouldn’t ask for it, and that UHC is not the best solution. I don’t want to be negative. The key point is this would be the right moment now to ask what are the real two or three strong arguments to convince government to invest, despite being in an economic, not so very a good period, so we really need the strong arguments now, and which are these? Over.
Robert Yates
Thank you very much indeed, Hans, that’s the perfect question that I would like to put to the panel myself, actually, so you’ve done my job for me there. What are going to be the most persuasive arguments that we can use to our heads of state, to ministries of finance, and – at this time? This has got to be the – you know, the big question. So, if I can maybe put that to all of you, thinking about your countries, and I think we’ll be wrapping up with that question. So, who’s going to kick off? Tricky one. Mushtaque.
Dr Mushtaque Chowdhury
Thank you. I – well, I’m – as I said in my presentation there, Bangladesh bears the least in healthcare, and we know that just an initial of 1% of the GDP to the current expenditure will really, sort of, help the country to achieve UHC, and for a country like Bangladesh, which has been – the economy has been growing very well, so that should not be any problem for the government to spend this additional money, and that can actually get this money out for UHC. And as we have seen that the incentives that the government has given for the COVID comes to about 3. – 2% of the GDP, so it’s definitely possible for the government to spend this extra 1% in supporting the UHC. And Ireland, for example, did the UHC just after the economic recession, and so in China, as well, after SARS and so, it’s a real good time for the countries in our regions, for example, to really work towards a UHC, and in that, money shouldn’t be a problem, in my opinion.
Robert Yates
Great, thank you. Vivianne, what about in Nigeria, what’s going to persuade President Buhari, or perhaps the next political generation in Nigeria?
Vivianne Ihekweazu
I think this is an interesting time for Nigeria because COVID has reawakened everybody that health is important. During the last election, 2019, we did a survey on how important health is for Nigerians and health scored very poorly, in terms priorities when people are voting. So, we have 2023 coming up, and Buhari has just finished his second term, so I think, as advocates, this is really our time. We need to make the business case for health because the funds have to be taken from somewhere. How do you convince the minister of power or minister of infrastructure or transport that money has to be taken from transport or whatever and put into health? It’s a difficult argument. So it’s almost like we have to make the business case for health as advocates because this really is our time. We have seen that, without health, nothing can work. It is really that simple. And everybody, whoever you are, from the [inaudible – 63:05] to the street seller selling bananas, is impacted by health. So, I think that is our role going forwards, we probably – we may get into trouble, and – but I think that is what we’re supposed to do. Educate people, and I like the way Cheryl mentioned the media. The media has got to play a strong voice in supporting this advocacy, and they have to understand what UHC means, as well. I don’t think they do. So, in short, we need to push and advocate for health as top – as a top priority going forwards.
Robert Yates
Great, thank you very much, and, finally, Cheryl, what about in the US, you know, so what’s it going to take to persuade the US Politicians that, you know, now’s the moment?
Cheryl Cashin
I’m not going to speak to the US because I’m so discouraged by the debate, and I – it’s been bungled so badly and the right arguments have not been made at – it’s very frustrating, but, globally, I was so heartened by the IMF. They came out with a very strong statement that now is the time to use every macroeconomic and fiscal tool you have available to stop the loss of life and loss of livelihood. I do – that is just, I think, a very strong statement that is not just left to each country alone, we globally have to make sure that it’s possible for lower income countries to borrow at concessionary rates to not add long-term damage to their economies, and we have to figure this out. And then I would say we have to take the opportunity to build back better. I love that #BuildBackBetter. That we can now address some of the systemic failures and, as we come out of this, not to go back to the old way of doing things.
Robert Yates
Great, thank you very much. You know, it’s – and you’re absolutely right, it is all about building back better, and – you know, but there are, of course, going to be lots of sectors going to be using the slogan as well, so that we in health and global health need to get our act together, you know, to be more perhaps persuasive, or I think, as well, more collaborative with other sectors and recognise that building back better, you know, involving UHC reforms and maybe raising taxes and cutting fuel subsidies and things like this, that you can do lots of things at the same time. And I think, you know, this is our great challenge. I think that we in global health often haven’t been very good at our political messaging, you know, that we’ve often gone in with, you know, rather dry arguments about health system strengthening, and, you know, these – they were the right things to do, but we haven’t been very good at selling it, and I think that, you know, we need to get better at that, and a blatant sales pitch for our Centre for Universal Health at Chatham House. This is what we’re trying to do, is to bring the technical experts together with the communications experts and articulate the case better to ministries of finance and also heads of state, as well. Because I think, at the end of the day, we recognise that UHC reforms are so massive, they’re a head of state issue, you know, that we often make the mistake of just thinking we can do this within the health sector, but thinking about the sums of money involved and the level of political commitment that’s needed, you’ve got to take it right to the top.
So, we’re very keen to work with you in your countries and with the audience watching as well, they – you know, they – we already have seen, sort of, people joining from Hong Kong and Ghana and goodness knows where else. If we can help you in your countries articulate the case, you know, then we’d be delighted to help, and as you can see that we’re building up a network, really, of experts round the world working on this at the moment. So, thank you very much indeed everyone for joining us, it’s been an absolute fantastic panel. I’d like to run this again with more countries in the future. I hope you’ve enjoyed it, and we look forward to supporting you on your UHC journeys and hopefully moving the whole health world towards that great SDG target. So, thank you very much indeed to all of you. Goodbye now.
Dr Mushtaque Chowdhury
Thank you. Bye.
Vivianne Ihekweazu
Thank you, Rob, have a good day. Enjoy the weather.
Robert Yates
Thanks, yeah, we could do with some.
Cheryl Cashin
Thank you, Rob, thank you, everybody.
Robert Yates
Bye, all.
