When historians look back, will this year mark a turning point in global health? Certainly some of the big issues on the agenda in 2019 might suggest that we are at a crossroads. We can expect to see an intensification of the push for universal health coverage (UHC), culminating with a first-ever high-level United Nations meeting, and a shift away from disease-specific interventions towards more integrated approaches. Health Policy Watch spoke with a range of leading global health policy experts from the World Health Organization, NGOs, industry and foundations to get their take on the top issues, and here is what they said to watch for in 2019 in five priority areas.

• Universal Health Coverage
• Primary Health Care
• Health Systems Strengthening
• Health Financing
• Access to Medicines

First UN Meeting on Universal Health Coverage

While still some months away, the United Nations General Assembly meeting on universal health coverage (UHC), planned for 23 September, is expected to be a peak moment for this initiative, which has been championed by the World Health Organization’s new Director-General Dr Tedros Adhanom Gheyebresus.

The meeting, entitled “Universal Health Coverage: Moving together to build a healthier world,” will be the first-ever high-level meeting on the issue at the United Nations, which passed a resolution in 2017 supporting UHC and resolving to hold the special session this year.

“It will be the most significant political meeting held on UHC to date, and will result in a Political Declaration on UHC, negotiated by Member States and endorsed by Heads of State. The Political Declaration will form the basis for global efforts to provide universal access to affordable and quality health-care services, in line with SDG target 3.8,” according to UHC2030, a multi-stakeholder movement for UHC.

Universal health coverage “means that all individuals and communities receive the health services they need without suffering financial hardship.” It should include “the full spectrum of essential, quality health services,” according to the WHO, which has made UHC a cornerstone of its five-year Global Programme of Work (2019-2023) [pdf].

The WHO 2017 UHC Global Monitoring Report states that “at least half the world’s population still lacks access to essential health services. Furthermore, some 800 million people spend more than 10 per cent of their household budget on health care, and almost 100 million people are pushed into extreme poverty each year because of out-of-pocket health expenses.”

The proportion of people with access to essential health services ranges from less than 30 percent in some countries of Sub-Saharan Africa to more than 80 percent in many developed countries, according to WHO data. Explore UHC coverage at a country-level in an interactive map here.

Experts describe the push for UHC as part of a broader shift from the disease and issue-specific approach of the Millennium Development Goals (MDGs), towards the more integrated, systems-thinking approach of the Sustainable Development Goals (SDGs).

Among the range of different health stakeholders, the pharmaceutical industry is also backing universal health coverage, and has proposed public policy principles to guide UHC in a joint publication [pdf] of its largest associations: IFPMA, PhRMA, EFPIA and JPMA.

“If you have half the world’s population … which have to pay out of pocket – not just for medicines but for diagnostics, and visiting doctors – they will never get the care they need,” Thomas Cueni, secretary-general of the International Federation of Pharmaceutical Manufacturers and Associations (IFPMA), told Health Policy Watch.

That is why this is at the top of the agenda for the upcoming G20 meeting, and for the UN high-level meeting, he said. See also (IPW, Health & IP, 16 January 2018).

“The opportunity of such a big resolution in September is also an opportunity for us as a [global health] community to do a bit of taking stock and self-reflection, and then to galvanize ourselves and create momentum across these health challenges,” Ed Whiting, director of policy and chief of staff at Wellcome Trust, told Health Policy Watch.

“And 2019 is the year when we can defragment the global health system together, and really push things on,” he said. Details on the agenda of the September meeting can be found here [pdf].

Increasing Investments in Primary Health Care

This year should also see a shift towards increased investment in primary health care as a nexus where a range of preventive services and disease control programmes can be integrated to support UHC.

This follows from the 2018 Astana Declaration [pdf] made at the Global Conference on Primary Health Care, which affirmed that primary health care “is a cornerstone of a sustainable health system for universal health coverage (UHC) and health-related Sustainable Development Goals.” Investments in quality primary health care are also considered by the WHO as the “most efficient and cost effective way to achieve universal health coverage around the world.”

Primary health care constitutes the service delivery aspect of UHC, and it involves bringing good quality health services as close as possible to the population, experts explained.

An example is the fight against malaria, where there has been backsliding on progress over the past decade in some high-burden countries, according to the World Malaria Report 2018. This is partly attributable to weak delivery of services, the report notes.

“2019 is a critical year where rethinking the march for the long haul and what’s going to be required, is making us ask good questions,” George Jagoe, executive vice president for Access & Product Management at Medicines for Malaria Venture, told Health Policy Watch. “Are we thinking holistically enough about what it means to fight this disease?”

He explained that vertical approaches to disease control need to be aligned and integrated with primary health care. Jagoe highlighted seasonal malaria chemoprevention (SMC), as one initiative that shows particular promise as a preventative measure in the fight against malaria, which among other initiatives, he said, will be strengthened through integration.

Health Systems Strengthening – Core Work for the WHO

Strengthening national Ministries of Health is the key means by which the WHO intends to advance the “triple billion” targets embodied in its new Global Programme of Work (2019-2023) [pdf]. This ambitious new plan aims to see 1 billion more people benefitting from universal health coverage, 1 billion more people better protected from health emergencies, and 1 billion more people enjoying better health and well-being within the next five years.

Countries need to become more adept at involving multiple stakeholders, including those outside the traditional health sector, to define the most important health issues, risks and solutions, and take action as efficiently as possible, experts explained.

Strengthened national health systems, with more efficient and effective approaches, would be better equipped to address a range of emerging issues including growing climate and environmental health risks, the threat of antimicrobial resistance, emergency preparedness needs and the burden of non-communicable diseases.

Air pollution, which kills some 7 million people a year and is closely linked with climate drivers, is among the WHO list of Ten threats to global health in 2019. For Whiting of Wellcome Trust air pollution and climate change are among the greatest “political failures” of our age, but also “one of the most fertile areas for international collaboration and agreement.”

Antimicrobial resistance, also on the WHO list, represents a long-term global threat that, according to the WHO, “threatens to send us back to a time when we were unable to easily treat infections such as pneumonia, tuberculosis, gonorrhoea, and salmonellosis.”

To address antimicrobial resistance, Bernard Pécoul, executive director of DNDi, told Health Policy Watch that “we systematically need to combine preventive measures with developing treatments that are effective,” and that “keeping the good balance between the two is the best way.”

“The Global Action Plan on Antimicrobial Resistance developed by the WHO is a combination of these actions, and this is what you need if you want to have a chance of confronting this problem,” he said.

The Interagency Coordination Group on Antimicrobial Resistance (IACG) will also be releasing its new report in 2019, and according to Whiting, this presents “an opportunity to redouble our efforts, ensure that we have the right global architecture to tackle antibiotic resistance,” and advance towards “consensus on a way forward, that will put us in a fundamentally better position than we are now.”

As for emergency preparedness, for threats including pandemic influenza and Ebola, Whiting also noted that “we need to continue making the case for effective preparedness at that national level, and make sure that we as a global health community can recommend the capabilities, the tools, and the investments that would make the biggest difference for governments and health systems.”

The challenge, Whiting noted, will be the “low probability, high impact” risk for governments to invest in and prioritise emergency preparedness.

Effectively addressing non-communicable diseases, a growing burden for low and middle-income countries in particular, will also require a reorientation of health systems from focusing primarily on acute care towards accommodating treatment for chronic care as well, Katie Dain, executive director of NCD Alliance, told Health Policy Watch.

In order to track progress on national and global commitments and targets, she said that better mechanisms for accountability will be needed, and that this is where civil society can play a key role.

“Across these areas,” Whiting said, “what we need is really deep and effective international cooperation and collaboration, sustained investment and willingness of nation states around the world to work both for themselves and for each other.”

Health Financing

In light of ambitious targets for realising universal health coverage, investing more in primary health care, and strengthening national and international health systems, ambitious investments in financing health will also be needed, and 2019 will be a key year for this.

New funding targets for UHC, along with member state commitments, are expected to be a core part of the political declaration resulting from the high-level meeting on UHC in September. The Global Fund to Fight AIDS, Tuberculosis and Malaria will also be replenished at an October conference in France, to raise new funds for the next three years and to mobilize partners toward ending AIDS, TB and malaria by 2030.

According to experts, an interesting dynamic to look out for in 2019 is how disease control funders will contribute to UHC, as this would signify an important paradigm shift – one that is in line with WHO objectives as well as country priorities.

Investing in UHC will also necessarily include greater investment in addressing NCDs, which according to Dain of NCD Alliance, has been lacking. “Financing has always been the big Achilles heel of the NCD response,” she said. “The fact that less than 2% of $22 billion of development assistance for health is currently going to NCDs, despite the burden in low and middle-income countries, is a huge paradox really.”

With this shift towards a more integrated UHC agenda, some experts stress that large global health funders should not reduce their efforts. “In the beginning of the year 2000, the development of the Global Fund, GAVI, and others, have made a major difference. Twenty years later, I’m not sure there is the same enthusiasm, or the same political environment to take some risk on this field of global health,” Pécoul of DNDi said. “It’s a big concern.”

Another important aspect of health financing high on the agenda across issues and sectors is how to increase domestic financing for health. While experts agree that there is a need for increased external aid, they also agree on the even more critical need to mobilize and use government resources more effectively.

According to a recent WHO report Public Spending on Health: A Closer Look at Global Trends [pdf], high amounts of external aid provided for health corresponds with reduced domestic funding for health. Experts warned that this dynamic must be considered when balancing the provision of external funding with the aim of strengthening national health systems.

“Are we ready to have a commitment from a large number of countries to make a major investment in global health?,” Pécoul asked.

Access to Affordable Medicines

Realising universal health coverage will require sustainable national health budgets, which in part depends upon access to affordable medicines.

“Medicines pricing will be a big theme of this year,” Ellen ‘t Hoen, director of Medicines Law & Policy, told Health Policy Watch. “It’s very difficult to say we need universal health coverage, and to not have a mechanism to make sure that the health expenditure fits within the budget that countries can make available.”

“As part of the deal, pharmaceutical companies should offer their products at reasonable prices,” she said.

‘t Hoen explained that drug companies “keep raising prices… and the revolt [against this] is taking all kinds of shapes” including “conflicts at the national level.” She explained that these conflicts are not just for low and middle-income countries, but for high-income countries as well.

To address high medicines prices, ‘t Hoen noted that compulsory licensing continues to be one strategy that governments can use to protect public health. Medicines Law & Policy recently published a database that tracks trends in the use of compulsory licensing, and offers tools to help countries to issue a compulsory license.

According to Cueni of IFPMA, he has “no illusion” that the debate about pricing of pharmaceutical products will go away.

Drug pricing will be discussed at the next Fair Pricing Forum, led by the WHO and other stakeholders, which according to a source will take place in Johannesburg, South Africa on 11-13 April.

The issue of drug pricing, ‘t Hoen explained, used to be primarily for treatment of communicable diseases, but now it has shifted to non-communicable diseases, and for cancer drugs in particular.

While the Medicines Patent Pool has expanded its mandate to also work with cancer medicines, ‘t Hoen explained, she “hasn’t seen any cancer drug manufacturers coming forward to make cancer drugs affordable.” Though “that may change, 2019 might be the year,” she said.

Apart from cancer drugs, the Medicines Patent Pool has made progress in licensing drugs for HIV and Hepatitis C, among others, for generic production and distribution in low and some middle-income countries.

Earlier in 2018, Charles Gore, executive director of Medicines Patent Pool, told Health Policy Watch that the norms are changing, and that it is becoming increasingly unacceptable for drug companies to not offer affordable access programs for life-saving medicines (IPW, Health & IP, 12 November 2018).

‘t Hoen agrees, but warns that this “may mean that drug affordability depends on company policy and only some drugs become affordable. What we need is for all essential medicines to be available affordably.” She explained that this list “should be drawn up based on what is needed, not on what is available based on cost.”

 

Image Credits: WHO, WHO/Christopher Black.