Universal Health Care Coverage & Immunisation

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A 2011 Pacifc Health Summitworkshop report

IMPACT & INNOVATION SERIES

Universal Health Coveraand ImmunizationMutual Rein orcement or a Healthier Wor


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Published by Te National Bureau of Asian Research1414 NE 42nd Street, Suite 300Seattle, WA 98105, USAPhone +1 206 632 7370Fax +1 206 632 7487E-mail [email protected]://www.nbr.org

2011 by Te National Bureau o Asian Research (NBR)

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Printed in Seattle, USA

Written and compiled by Karuna LuthraDesigned by Margaret relevenParticipant photos by Mark Weeks

Cover photo of Bachi Karkaria, Jonathan Quick(L-R)Table of Contents, top photo by PATH/Carib Nelson


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Table of Contents

Introduction 1

Linking UHC and immunization:Are they mutually rein orcing? 2

Who pays or an integrated approach? 5

How will the vaccines o the uturet into the UHC package? 9

Di erent sectors, di erent roles,but one aligned mission 11

Areas or practical engagement 13

Challenges o today, visions or tomorrow 15

Contributors 17


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Introduction

n June 24, 2011, the Paci c Health Summit1 convened the workshop, Integrating Immunization: Ensuring aHolistic Approach to Strengthening Health Systems.2 Tis discussion built on growing momentum around themovement or universal health coverage3 (UHC), including the 2010 World Health Report, several relevant health

system resolutions rom the World Health Assembly in May 2011, and numerous notable examples o developing countriesaround the world pursuing policies and programs to expand healthservices coverage. Additionally, the workshop is the third in a series o

annual Paci c Health Summit ora that explore UHC through di erentglobal health lenses. Te workshop also re ected the excitement aroundincreased attention and resources being ocused on immunization, asexempli ed by the success ul GAVI replenishment meeting in June 2011and the work o the Decade o Vaccines Collaboration.

Te discussion linked e orts to expand immunization coverageworldwide with strong desires to strengthen health systems throughthe lens o UHC. wo core questions ormed the oci o the discussion:

1) Can an integrated health systems approach really contribute to achieving immunization targets, particularly in a worlo increasingly constrained resources; and 2) What are the undamental synergies between the UHC movement anduniversal immunization?

Tis report provides a summary o the conversation that took place between leaders rom across sectors, including science,industry, policy, public health, civil society, and academia.

1 The Paci c Health Summit (www.paci chealthsummit.org) began in 2005 to connect science, industry, and policy or a healthier world. Theinvitation-only gathering provides a unique opportunity to engage diverse stakeholders around a theme o critical importance and has a track record o ostering innovative partnerships and meaning ul action. The 2010 Summit theme was Vaccines: Harnessing Opportunity in the 21stCentury. The Paci c Health Summit is co-presented by the Fred Hutchinson Cancer Research Center, Bill & Melinda Gates Foundation, Wellcome Trust, and The National Bureau o Asian Research, which serves as the Summit Secretariat.

2 For more in ormation, see the background reading or the workshop, Integrating Immunization: Ensuring a Holistic Approach through StrongerHealth Systems, (S. Wilhelmsen, J. Quick, R. Hecht), www.paci chealthsummit.org/downloads/2011%20Summit/UHCBackground.pd .

3 Universal health coverage is de ned in this context as access or all to appropriate health services at an a ordable cost.

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Linking UHC andimmunization:Are they mutually

reinforcing?

How do we create e ective synergiesbetween the UHC movement and the immunization feld, and what compelling linkages already exist?

articipants debated whether global e orts toexpand immunization coverage while also movingtoward a higher level o coveragee orts o en

simultaneously taking place in many o the same countriesare supportive and mutually rein orcing, or i there aretensions or competing threads between them. JonathanQuick, President & CEO, Management Sciences or Healthand Faculty Member, Department o Global Health, HarvardMedical School, argued that a mutually rein orcing powerexists between the two movements: Within the vision o UHC is the vision o universal immunization.

Yot Teerawattananon, Leader & Founder, HealthIntervention and echnology Assessment Program, Tailand,agreed, adding that vaccines were a great starting point orexpanding health service delivery via UHC e orts. Vaccinescan provide the link or both healthy and unhealthy mothersand children to come and see their health pro essionals andreceive other e ective health interventions.

Fundamentally, UHC is good or immunizationtheresno contradiction, statedRobert Hecht, ManagingDirector, Results or Development Institute, in urthersupport o this hypothesis. He noted urther that many o the countries that are truly pursuing and achieving

universal coverage are also strong per ormers inimmunization, yet cautioned participants to not takethis link or granted. Te countries that are on the roadto universal coverage still need to make special e orts toensure that they boost their immunization programs.

Amie Batson, Deputy Assistant Administrator, GlobalHealth, U. S. Agency or International Development

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(USAID), o ered a similar viewpoint rom theimmunization side. Te world o immunization needsto shi rom ocusing on the barriers and constraintsacing immunization delivery into thinking more aboutstrengthening the overarching systems, so that you arereaching a child with a package o interventions. Tis smartintegration is proving to be much, much more efcient interms o how you deliver services.

Te potential o the package approach resonated, andparticipants emphasized how strong immunizationprograms can help improve the delivery o other healthservices such as maternal and child healthcare and vise versa.Benjamin Schwartz, Senior Director, HealthPrograms, CARE USA, urther explored possible synergies,urging participants to conceptualize health service delivery more holistically and to consider the whole health system.We need to put our resources where they can do themost good, and not think o vaccines in isolation, he said.

Participants overwhelmingly agreed that including vaccinedelivery under the umbrella o UHC does just this, as itreafrms the cost-e ectiveness o immunization.

Participants also noted that the lens o , and tools or,health systems strengthening (HSS) can complementUHC e orts, as strong health systems play a key role inincreasing immunization coverage. Workshop participants

o en drew upon the six building blocks o strong,unctioning health systems: service delivery, humanresources or health, leadership and governance, healthnancing, in ormation, and medicines, vaccines, andtechnologies (or health commodities).

From rhetoric to reality: examples o integration in action

While synergies exist on paper, the on-the-groundimplementation side o integrating immunization withUHC e orts in-country is ar rom simple. Participantsraised numerous practical questions and challenges aroundmoving rom theory to policy and practice.

A top concern was how to t immunization, o en a ree, vertical program in most countries, into the package o guaranteed UHC services. It was also unclear i countrieswould be able to move in both o these directionssimultaneously and with more ease than obstacles.

K.O. Antwi-Agyei, National Program Manager, ExpandedProgram on Immunization (EPI), Ghana Ministry o Health, addressed these questions, noting than in Ghanathe shi toward UHC over the past ew years has, in act,positively impacted immunization. Immunization has notsu ered; rather, weve seen constant improvement since thelate 1980s when Ghana rst began these system re orms. Wemoved rom around 80% immunization coverage in 2000,and in the past our years, our DP 3 and measles coveragehave been well above 90%. Tere have been no deaths

rom measles in Ghana since 2003.

Vaccines can provide the link or both health and unhealthy mothers and children tocome and see their health pro essionals and receive other e ective health interventions.

Yot Teerawattananon, Leader & Founder, Health Technology Assessment Program, Thailand

We need to put our resources wherethey can do the most good, and not think o vaccines in isolation.

Benjamin Schwartz, Senior Director, Health Programs, CARE USA

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There have been no deaths rom measlein Ghana since 2003.

K.O. Antwi-Agyei, National Program Manager, ExpaProgram on Immunization (EPI), Ghana Ministry o H

Another noteworthy success story o integratingimmunization with UHC re orms is that o Rwanda. Since2003, when Rwanda implemented its universal healthinsurance coverage scheme, Mutuelles de Sant, on anational level, over 90% o the population has been coveredas o 2010 and independent evaluations have con rmedan increase in the use o and access to health services.4 Immunization has clearly bene ted under this nationalschemeearlier this year, Rwanda became one o the rstcountries to introduce universal HPV vaccination oradolescent girls.Maurice Gatera, EPI Surveillance Ofcer,Ministry o Health, Rwanda, participated in this discussionand represented the critical strides orward that Rwanda hasmade in recent years.

Brazils UHC system, Sistema nico de Sade (UnitedHealth System), also has a success ul national immunizationprogram covered under this UHC umbrella, which includesboth national immunization campaigns and routineimmunization provided at primary healthcare acilities.o augment the reach o the national immunizationprogram, under UHC, speci c poor populations were

reached via the PSF (Programa Sade da Famlia) amily health program implemented in 1994, which aims to targetpoorer communities with comprehensive health servicedelivery, including immunization.5 Immunization coverageamong poor populations in Brazil has increased underthese re orms, and the success o Brazil in implementingUHC and high immunization coverage, as well as a thriving vaccine manu acturing industry, was represented at theSummit by a high-level Brazilian delegation.

Te success story o Tailand in providing UHC in thecountry under its Universal Coverage Scheme (commonly known as the 30 Baht Scheme) continues to serve as anexample o success ul integration o immunization into thepackage o guaranteed services. Tailands high immunizationcoverage is directly related to the UHC system and the reeimmunization provided under it, said Yot eerawattananon,noting that recent studies in Tailand indicated that the publicwas more willing to pay or treatment than prevention romout-o -pocket unds. We asked i there was no universalcoverage on a particular preventive intervention, whether [thepublic] was willing to pay. We ound that people are willingto pay less than hal o the cost or prevention than they arewilling to pay or treatment.

Tailands scheme even goes beyond o ering immunizationto only those enrolled in the countrys UHC program: allTai citizens are eligible to receive immunizations rom thenational immunization program, as well as have access toother prevention-based services.6

While applauding these and other noteworthy successes,participants voiced concerns about countries that have not,and may not likely soon move toward, universal coverage,

and everyone agreed that e orts to increase immunizationrates should not wait.

4 For more in ormation, see Rwandas country pro le on the JointLearning Network or Universal Health Coverage, http://www. jointlearningnetwork.org/content/rwanda.

5 For more in ormation, see the World Bank document, Reaching thePoor with Health Services - Brazil, http://siteresources.worldbank.org/INTPAH/Resources/Reaching-the-Poor/RPPBrie sBrazil.pd .

6 For more in ormation, see the case study document, Movingtoward Universal Health Coverage - Thailand, http://jlw.drupalgardens.com/sites/jlw.drupalgardens.com/ les/Thailand_Case_Study_2-24-10%20FINAL.pd .

Within the vision o UHC is the vision o universal immunization.

Robert Hecht, Managing Director, Results or Development Institute

Young gir

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Who pays oran integratedapproach?

Immunization as a basic, guaranteed service: sustaining country prioritization

everal innovative nancing mechanisms oruniversal coverage and immunization exist. Notableexamples include the Advance Market Commitment

and the International Financing Facility or Immunization.Per ormance-based nancing programs in Haiti andRwanda have increased the efciency o available undsthrough incentives or achieving immunization and otherpriority health system targets. Te Sabine Vaccine InstitutesSustainable Immunization Financing program, launched in2010, has as one o its aims to build an embedded level o advocacy or immunizations within ministries o nanceand among parliamentarians in countries in A rica and Asia.Countries as diverse as Costa Rica, Haiti, Mexico, ajikistan,and Vietnam are experimenting with raising immunizationresources through lotteries, oil revenues, luxury taxes, andlevies on harm ul products such as tobacco.

Nonetheless, in todays resource-constrained environment,securing sufcient nancing or health services remains acritical concern. How have countries committed to UHCnanced immunization packages?

Including immunization in the basic package or services(o en a health insurance package) is one key approach.By making immunization a guaranteed health service,countries theoretically guarantee domestic support andprioritization o vaccines. Tis approach addresses theobstacle o competition that vertical programs ace whenthey must vie against each other or limited resources andattention rom ministries o health.

Noting the example o his own country, K.O Antwi-Agyeishared that Ghana implements a comprehensive approach

A child is vaccinateduring a poliommunizationampaign inthiopia.

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to healthcare. Financing is provided to districts, which inturn disburse unds in an integrated manner. He explainedthat this scheme guarantees that vaccine programs willalways receive unding, despite the uctuations in budgetsrom year to year. Importantly, Ghana has managed to keepimmunization coverage quite high as it has shi ed towarduniversal coverage. Its the system that has really led to thatsort o achievement, he explained.

Several participants commented on how unctioning healthsystems that are accessible to populationswhether via reeservices or health insurance schemeswere o en indicatorso the potential or increased immunization coverage.Prashant Yadav, Director, Health Care Delivery Research,William Davidson Institute & Faculty Member, RossSchool o Business & School o Public Health, University o Michigan, o ered comparisons between two systems. Eventhough di erent on several other dimensions, one similarity between China and Ghana is the start o a social healthinsurance set-up. In Ghana, the coverage is moderate; inChina, its higher and growing rapidly, and so it will soon bethe worlds largest social health insurance system. Chinassystem provides ree, basic immunizations reaching over90% o the population at the township level.

As in the cases o many o the countries represented atthe workshop, basic immunization is o en ofcially a reeservice, spanning the spectrum o countries with widespread

health insurance and strong health systems to those withlittle health insurance coverage or poorly unctioninghealth systems. In cases where unding or immunization isbudgeted separately rom broader health system unding,participants expressed concern about competition betweenhealth priorities and agreed that unding to expandUHC should not detract rom unds available to provideimmunization services. Avoiding this competition trap isparticularly important as countries seek to introduce andexpand UHC, considering the act that a key goal o UHC isto reduce out-o -pocket expenditures or the poor.

Underscoring the importance o ensuring unds orimmunization during the transition to, and implementationo , UHC re orms, Robert Hecht added, Making sure thattheres money there or immunizationthat what is in theguaranteed package really aligns with the availability o theundsis extremely important.

You have to make choices, and we think immunization is a smart choice to make.

Amie Batson, Deputy Assistant Administrator, Global Health, USAID

Making sure that theres money thereor immunizationthat what is in theguaranteed package really aligns withthe availability o the undsis extremely important.

Robert Hecht, Managing Director, Results or Development Institute

Jonathan Quick, Bachi Karkaria, James Allen(L-R)

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Donor fnancing

Participants noted that external partners, in additionto leaders within countries, have a critical role to play in turning the dial or immunization and UHC, as wellas approaches that integrate the two. Acknowledgingthat donors inevitably have to choose their investmentpriorities, Amie Batson described USAIDs perspective:Weve looked very hard at our programs and budgets toconcentrate our e orts where we think we can have the bestimpact and really advance national and global e orts. You have to make choices, and we think immunization is asmart choice to make.

While intentions are good, donors can also be perceivedas pushing a zero-sum game scenario, in which di erentprograms nd themselves pitted against each other orlimited unds or in the awkward position o having toadjust their priorities to t the donors unding guidelinesrather than the situation on the ground. Te GAVIAlliance, UNICEF, and other international organizationsthat support vaccine procurement and create access orlow-income countries are essential partners in ensuringglobal success in increasing immunization coverage, yetsome raise concerns that their unding structures promote vertical programs and approaches, pushing those onto

countries. Participants especially questioned i moniesor immunization rom donors decreased unding orHSS and other integrated approaches, while exacerbatingan o en competitive environment when resources arelimited. Countering this perception, Amie Batson pointed

out that donors are conscious o these concerns andnoted, Tere are tremendous efciencies to be gainedin terms o how were doing business. By integratingprograms, were saving money.

No one could deny that partnering with donors bringschallenges along with opportunities. K.O. Antwi-Agyeiacknowledged that progress has been made in addressingthese issues, but also observed, Donors o en come withtheir di erent ormats, reporting systems, and timelines.And the act that they can be aggressive on programs andhave very complex reporting procedures; these are someo the things that a ect the integration and sustainability o health services.

One mechanism aiming to address these siloed issues,

participants noted, is the Health Systems FundingPlat orm (the Plat orm). Supported by the World HealthOrganization (WHO), Te GAVI Alliance, the GlobalFund, and the World Bank, all present at the Summit, thegoal o the Plat orm is to streamline donor unding withcountry priorities and allow countries to strengthen theiroverall health systems and be less encumbered by di erentdonor requirements or priorities. Tis mechanism hasallowed Te GAVI Alliance, or example, which has helpedacilitate a tremendous increase in global immunization

over the past decade by supporting the immunizationo over 288 million children, to extend their support orimmunization beyond a vertical programmatic approachand within the systemic context o the di erent GAVI-eligible countries.

K.O. Antwi-Agyei

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Looking to the uture o donor support around integration,Jonathan Quick noted, In the last ew years, there has beenmore and more talk about HSS and UHC, which are bothmovements that are integrative and holistic and we arelooking orward in 2012 to the GAVI evaluation o theintersection o HSS and investments in immunization.

Economic development: a prerequisiteor success?

Another discussion thread explored whether economicdevelopment is an absolute precursor or countries tosuccess ully and sustainably expand UHC and ully coverbasic immunizations.

Tsung-mei Cheng, Co-Founder, Te PrincetonCon erence and Health Policy Research Analyst, WoodrowWilson School o Public and International A airs,Princeton University, voted yes. Economic developmentis a necessary condition or building a health system that

serves universal needs.

Many participants agreed with this viewpoint, observingthat many countries around the world, such as Tailandand South Korea, rst experienced economic growth be oreimplementing universal coverage.

I want to posit that Tailand didnt actually recognizethe importance o universal health coverage when we rsthad an economic boom. But once we had an economic

recession, we implemented the universal coverage because itwas an opportunity or the government to protect the poor,said Yot eerawattananon.

Citing the example o India, however,Bachi Karkaria, Journalist, Media rainer, & Consultant,Times o India, pointed out that economic growth has not yet produced ahealth system that meets the needs o all o the countrys

citizens. India has an economic growth rate o 8%, yet44% o the countrys children remain unimmunized, sheremarked. Indias economic development and growth areundeniable, making the countrys health access disparities,particularly in rural parts o the country and or poorpopulations, appear dismal in comparison.

Yet there are signs o improvement within the health sector.Commenting on the status o UHC in India, Bachi Karkariaadded, Tere are really good showpiece states and projects,and weve had some very good vertical programs in health.

But its a question o these vertical silos coming together andreally talking to each other.

aking a di erent view o India, Robert Hecht predicted, en years rom now, I would expect that India will havetaken on the challenge o building a health system that ina sense catches up and truly starts to match its economicper ormance [with health per ormance].

Economic development is a necessary condition or building a health system that serves universal needs.

Tsung-mei Cheng, Co-Founder, The Princeton Con erence, and Health Policy Research Analyst, Woodrow Wilson School o Public and International A airs,Princeton University

Weve had some very good vertical programs in health [in

India]. But its a question o thesevertical silos really coming together

and talking to each other.

Bachi Karkaria, Journalist, Media Trainer, & Consultant, Times o India

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hile many o the countries that have adoptedUHC are able to include the vaccinesrecommended via the WHO Expanded

Program on Immunization (EPI) in their guaranteed set o health services, it is unclear whether those countries will beable to continue the same level o coverage i they were toadd the new vaccines in development today to their basicpackage. Looking to the uture, participants explored theprospect o additional and more expensive vaccines beingintroduced into health systems and the potential challengesaround integrating these new, o en costlier vaccines.

Historically, noted Robert Hecht, Te countries that areurthest along in trying to achieve universal coverage are alsoleaders in primary healthcare and immunization, and they tend to be among the early adopters o the new vaccines.

Some participants questioned how countries just nowadopting UHC would realistically also lead the way in new vaccine introduction.Najwa Khuri-Bulos, Pro essor, Pediatrics and In ectious Disease & Deano Research, Jordan University and Adjunct Pro essor,Vanderbilt University School o Medicine, explained thatdespite Jordans success ul immunization program andhigh provision o ree health services, the country aces

Yot Teerawattananon, Tsung-mei Cheng(L-R)

How will the vaccines of the futuret into the

UHC package?

The WHO provides vaccinationsfor displaced Haitians who haveset up camp in Port-au-Princes

National Stadium.

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challenges around adding new vaccines to the programtoday. I think that UHC has gotten to the point where wehave problems with introducing new vaccines. Te healthsystem is able to und the latest health technologies and givebasic EPI vaccines or ree at a time when we cannot a ordto include and provide the pneumococcal vaccine. Te two[UHC and immunization] cannot always run together.

Will including immunization within the guaranteed packageo services provide more consistent unding streams or the vaccines o the uture? Prashant Yadav posited, Given thatimmunization is in the long term the most cost-e ectiveway o preventing disease and illness, it may be easier tobuild a case or a ar-sighted health insurance manager thanit is to ring- ence money or vaccination with a minister o health, i youre pulling rom the budget.

Yot eerawattananon agreed that having undingallocated or vaccination, as well as making the case that

immunization is a good investment, do not necessarily sufce when striving to secure a line item or new vaccinesin the health ministrys budget. Recounting his experienceat a recent meeting with a group o health pro essionalswho were lobbying to include HPV vaccine in TailandsUHC bene t package, he shared that once ofcials learnedabout the cost and budget indicators, Tey said thatthe vaccine is like a bicycle. Its good or health and theenvironment, but why buy the bicycle at the same cost o acar? In other words, the vaccine might be good but at the

same time, its una ordable or the country; you cannot justi y the price.

Participants generally concurred that the price o individual vaccines matters and will be a key actor in determiningwhether countries decide to include them in health andUHC budgets in the uture. Making the case to continue

pushing or increased coverage o new vaccines, Bachi

Karkaria pointed out that prioritizing vaccines may ultimately reduce costs o other health services as more andmore diseases are prevented. Immunization is prevention,she said. And i you have prevention, then you are really taking this whole burden away rom the primary, secondary,and tertiary health services. So that in itsel would solve agreat deal o the problem.

Given that immunization is in the long term the most cost-e ective way o preventingdisease and illness, it may be easier to build a case or a ar-sighted health insurancemanager than it is to ring- ence money or vaccination with a minister o health, i youre pulling rom the budget.

Prashant Yadav, Director, Health Care Delivery Research, William Davidson Institute & Faculty Member, Ross School o Business and School o Public Health,University o Michigan

Young family in Brazil. BrazSistema nico de Sade (

System), covers both national campaigns and routine im

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Di erent sectors,di erent roles,

but one alignedmission

uilding on the Summits goal o connectingunlike minds and identi ying creative, cross-sector opportunities, this workshop provided the

opportunity or a variety o voices beyond the traditionalcircle o experts and practitioners to become involved in thisimportant conversation. One notable voice participating wasthat o the private sector.

Industry is de nitely interested in the health o its

employees and their communities, said James Allen,

Asia-Paci c Medical Director, Chevron Corporation.Our horizon is long-term. We want to invest in ourcommunities wel are and well-being.

Building on di erent opportunities or industry engagement, James Allen explained, Tere are six buildingblocks essential or strengthening health systems and orUHC to work, and I would say that energy companiesand companies working in extractive industries have thepotential and experience to work on and contribute toseveral o those blocks, particularly with human resourcesand delivery o medicines, vaccines, and logistics, becausewere therewere boots on the ground.

Participants expressed interest in learning about what wouldincentivize companies to become more invested in thissphere. Te answer: more in ormation. Many companieswant to contribute directly to social well-being and the healtharena, but they lack sufcient in ormation, data, and guidanceon where and how to invest, James Allen responded.

In addition to more in ormation about the problems orkinds o needs, the private sector must also be able todemonstrate the return on the investment o becominginvolved UHC e orts. James Allen added, Companies havean obligation to their shareholders and their stakeholdersto demonstrate that theyre getting a return on what theyre

There are six building blocks essential or strengthening health systems, and or UHC towork, I would say that energy companies and companies working in extractive industrieshave the potential and experience to work on and contribute to several o those blocks because were therewere boots on the ground.

James Allen, Asia-Paci c Medical Director, Chevron Corporation

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ames Allen


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doing. In the business mindset, i we cant demonstrate thatreturn, then our managers are going to look elsewhere.

Underscoring the importance o working across sectorsrom a di erent angle, Amie Batson declared that many o the critical actors that undamentally change andstrengthen health systems go well beyond the medicalworld. She said, Its about engaging ministries o nance, aswell as ministries o planning, regulatory agencies, unions,and a number o other critical partners and issues.

Participants agreed that there were roles or many sectorsto play. Te roles o donors and other technical partners,or example, go beyond unding and technical assistance,to also contributing to raising political will. Noted Amie

Batson, Groups like USAID and Te World Bank havethe capacity to elevate the visibility [o the issues] and holdother leadersthose in government, the private sector, andNGOSto account: Is every child being immunized?

Participants also explored the role o the media in the UHCmovement, and coverage o health issues more broadly. Bachi

Karkaria acknowledged, Te media really needs to allotmuch more space to health than it does currently. Terewas discussion on how di erent varieties o media should beutilized, targeting the source and types o news outlets thatconsumers utilize the most, including electronic media andentertainment television. Other participants commentedthat the media has sometimes played an unproductive role inits coverage o health issues and health systems, o entimesportraying such e orts or systems in a poor light.

But responsibility and accountability extend beyond themedia sector, and the medical eld has a key role in theseareas rather than to always shoot the messenger, counteredBachi Karkaria. I think that, really, i you immunize youruniversal health coverage system against inefciency, againstinadequacy, against inequity, and most importantly, againstcorruption, I think thats really the real protection.

Calling upon others to continue the cross-sector dialogueand collaborations beyond the Summit, James Allen issueda call to action: Now that weve come together romsuch disparate outposts, can we continue to be a voiceor integrating immunizations into UHC in our varioussettings, perhaps by calling on each others expertise,advocacy, anecdotes, and ideas? Tese discussions arecontinuing beyond this session, and this very report is anexample o a next step ollowing the workshop.

I you immunize your universal health coverage system against inefciency, against inadequacy, against inequity, and most importantly, against corruption, I think thats really the real protection.


Now that weve come together rom such disparate outposts, can we

continue to be a voice or integratingimmunizations into UHC in our varioussettings, perhaps by calling on eachothers expertise, advocacy, anecdotes,and ideas?

James Allen, Asia-Paci c Medical Director, Chevron Corporation

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Prashant Yadav


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Areas orpracticalengagementEmpower health system consumerswith in ormation

onsumers o health systems have a key role to play in driving orward re orms and expanding thecoverage and reach o services. Bachi Karkaria

suggested that re orms be demand-drivenbottom uprather than top down. Once people know that [access toservices] is their right, then they will make the demands ontheir government to provide it. Demand rom the publicaround health access can change the paradigms o a society and accelerate the rate o UHC re orms. UHC is a socialethic that drives, uni es, and develops public support,concluded Jonathan Quick.

But how do we reach that tipping point at which populationsknow what services to demand? Tis is particularly challenging in geographies with diverse terrains and lowlevels o education. Drawing connections to Nigeriasexperience,Dorothy Esangbedo, President, Pediatric

Association o Nigeria, observed, A lot o times, weequate illiteracy to ignorance in many communities. Itsnot the same. I the ignorant woman is empowered within ormation, this will help her make demands or her healthrights, and this will help sustain the health system throughher demands.

Access to in ormation or health system consumers is acritical component o all health systems, and particularly crucial or immunization, around which the public o en has

di ering views. Despite the challenge o illiteracy, Dorothy Esangbedo noted, It does not prevent uptake o appropriately

delivered in ormation on immunization by the parents inthe communities. She urther observed that greaterinnovation is needed in strategic ways to increasehealth literacy and delivery critical in ormationaround immunization and other health needs andservices to amilies and communities.

Amie Batson

I the ignorant woman is empowered with in ormation, this will help her make demandsor her health rights, and this will help sustain the health system through her demands.

Dorothy Esangbedo, President, Pediatric Association o Nigeria

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Participants also discussed how education and in ormationcan help ensure increased accountability by governmentsto promote UHC. Bachi Karkaria pointed out, Teres agreat deal o value in taking the showpiece programs orshowpiece states and putting them into the public domain,because that will goad other departments or other states to

ollow that example.

Linking back UHC e orts to increasing immunizationrates, Dorothy Esangbedo added, National campaigns onimmunization will only work or certain vaccines or instance,the oral vaccines like the ones or polio and rotavirus. But inthe case o injectable vaccines, routine immunization, whichrequires a strong, unctioning health system that citizens caneasily access, is best. o sustain routine immunization, it isimportant that the consumers know that they should go or

it and demand it, she said. Doing this helps us in sustainingthe demand or strengthening the health system.

Support country leadership and program ownership

Strong leadership and commitment rom within countrieswere also identi ed as key actors in the success o any UHC e ort. Citing the example o China, sung-mei Cheng

pointed to very strong country leadership: Te role thatleadership plays in Chinas success ul health re orm to dateis really leadership at the top. Tere is also governmentcommitment and recognition that health is a right. Once youhave that social ethic laid down, all else ows rom there.

Amie Batson concurred, noting the importance o governments having skin in the game, including by payinga part or all o the costs o immunization. She supported ulltransparency around these issues. We really have to elevate

the role o governments holding each other to account andquestioning commitment and unding.

Pointing to Indias emerging national public health insurancescheme, which currently cover more than 200 million

Indians below the poverty level, Robert Hecht pointed outthat the success o this program resulted rom the leadershipand program ownership o the Indian Ministry o Labor.It has moved beyond being just a slogan in the ministry o health or a high-level expert group, he said.

Share experiences, leveragebest practices

Participants unanimously agreed that one o the moste ective ways to help strengthen health systems andpromote UHC is or countries to continue to learn romeach other. Fora such as the Paci c Health Summit thatallow those at the policy level to share strategies and advicewith one another, with critical input rom on-the-groundpractitioners, create a dynamic eedback loop or sharingbest practices.

Other important e orts target on-the-ground practitionersand those working in-country to implement technical andnancial re orms in real time to expand coverage. Teseleaders can o en provide the most e ective support systemsor one another, and their shared experiences are criticalin helping countries navigate challenges and take on realownership o the re orm process at a national level.

One notable example o the dynamic network o supportthat exists among country leaders is Te Joint Learning

Network,8

which brings together a group o leadingcountries in the process o implementing health systemre orms and moving towards UHC, many o which wererepresented at this Summit workshop, including Ghana,India, Nigeria, Rwanda, Tailand, and Vietnam.

[UHC] is a social ethic that drives,uni es, and develops public support.

Jonathan Quick, President & CEO, Management Sciences or Health and Faculty Member, Depar tment

o Global Health, Harvard Medical School

8 The Joint Learning Network or Universal Health Coverage (http://www.jointlearningnetwork.org) is a resource or countries in the process o implementing UHC. Current members include: Bangladesh, Ghana, India, Indonesia, Kenya, Malaysia, Mali, Nigeria, the Philippines, South A rica, Thailand, and Vietnam.

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Challenges o today, visions fortomorrow

ooking to the uture, participants agreed thatseveral key challenges lie ahead as more countrieslook to expand and adopt UHC while also ensuring

that speci c programs such as immunization continue togrow and do not languish as a result. As the session drew toa close, Jonathan Quick pushed the group to think not only about aspirations, but also how the group gathered mightwork together, along with other Summit participants andother key constituencies to address the key challenges andopportunities that lie ahead.

Key challenges identi ed by participants included:

Ensuring reliable and sustained funding forimmunization within UHC

Including new, costlier vaccines within a guaranteedpackage o services, and managing the tension between vaccine introduction and provision o other healthinterventions

Collaborating and communicating across sectors

Building country leadership, accountability, and capacity

Addressing disparities between economic growth, qualityo health systems and services, and the demographicand epidemiological transitions to older populationsand more chronic non-communicable disease

Inspiration to address these challenges o en comesrom learning rom each other and di erent countriesexperiences, and many countries take di erent paths toachieve UHC, Jonathan Quick reminded the group, noting,It was a er World War II in Europe, which destroyed thecontinents economy, that many countries achieved large-scale coverage at quite a reasonable cost. It was the visiono universal coverage in the ace o extreme economic

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Vaccinators transport polio vaccines incold boxes during an Ethiopian polioimmunization campaign.

devastation that orced the creation o pretty efcient healthsystemsand it didnt have di erent parts o these healthsystems quibbling with each other.

Participants also agreed that the collective country experiences and cross-sector viewpoints o those gatheredin the room and at the Summit provided each other withgreat resources and expertise. Pointing to the opportunitiesthat come with challenges, the workshop concluded on ahope ul note. Despite the impediments that lie ahead, by

collaborating with and being open to new partners andresourcesmany ormed among the group gatheredcreative solutions will continue to emerge.

Immunization remains one o the most cost-e ective healthinterventions in our global health arsenal. Strengthening thehealth systems that deliver them, and expanding access toimmunization and other critical health services or whichthe UHC movement advocates, participants agreed, shouldbe a priority or all.

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For in ormation about Paci c Health Summit discussions andparticipants, as well as in ormation on resulting

initiatives and collaborations, visitwww.pacifchealthsummit.org

Contributors James Allen, Asia-Paci c Medical Director, ChevronCorporation

K.O. Antwi-Agyei, National Program Manager, ExpandedProgram on Immunization (EPI), Ghana Ministry o Health

Amie Batson, Deputy Assistant Administrator, GlobalHealth, USAID

Tsung-mei Cheng, Co-Founder, The Princeton Con erenceand Health Policy Research Analyst, Woodrow Wilson Schoolo Public and International A airs, Princeton University

Dorothy Esangbedo, President, Pediatric Association o Nigeria

Maurice Gatera, EPI Surveillance Ofcer, Rwanda Ministryo Health

Robert Hecht, Managing Director, Results or DevelopmentInstitute


Najwa Khuri-Bulos, Pro essor, Pediatrics and In ectiousDisease & Dean o Research, Jordan University and Adjunct

Pro essor, Vanderbilt University School o Medicine Jonathan Quick, President & CEO, Management Sciencesor Health and Faculty Member, Department o GlobalHealth, Harvard Medical School

Benjamin Schwartz, Senior Director, Health Programs,CARE USA

Yot Teerawattananon, Leader & Founder, HealthIntervention and Technology Assessment Program, Thailand

Prashant Yadav, Director, Health Care Delivery Research,William Davidson Institute & Faculty Member, Ross School o Business & School o Public Health, University o Michigan

Universal Health Care Coverage & Immunisation

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Transcript of Universal Health Care Coverage & Immunisation