Spotlight on Universal Health Coverage: Financing UHC

How can health systems make progress towards financing UHC? What are the different approaches? And why don't voluntary contribution and out-of-pocket systems perform as well? Editor-in-chief of The Lancet Global Health, Zoe Mullan, is joined by Irene Agyepong and Joseph Kutzin to discuss how funding affects UHC, in the first of a series of podcasts spotlighting UHC's importance to health.

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Transcript

This transcript was automatically generated using speech recognition technology and may differ from the original audio. In citing or otherwise referring to the contents of this podcast, please ensure that you are quoting the recorded audio rather than this transcript.

Hello and welcome to the first in a series of podcasts on universal health coverage. I'm Zoe Mullen and I'm the editor in chief of the Lahtsit Global Health. This series is itself part of a wider initiative to shine a spotlight On key areas of health research policy and practice championed by the Lancet over the course of its 200 year history.

Today, my guests and I will be talking about the financing of universal health coverage. And joining me today, a Dr. Irene Aguipong, who's a public health physician within the Ghana Health Service. And Dr. Joe Kutzin, who's a health economist leading WHO's work on health financing policy for universal health coverage.

So welcome Joe and welcome Irene. Thank you very much for joining me. Thank you. Thanks. So I'll start with you, Joe, maybe if I can. So financing UHC is a, is a pretty technical thing. I think that people often don't really feel they have a, have a grasp on. So. Maybe if we start with some basics around the different models that we've heard about for, for financing universal health coverage.

So we hear about things like general taxation, mandatory social insurance. So where people contribute a portion of their income, which is matched by contribution from their employer. We hear about voluntary private insurance. We hear about out of pocket payment, and then we hear about sort of donor funding.

And these are the sort of Models that we hear about. Is that a good way to think about financing universal health coverage? 

Joe: Thanks, Zoe. It's probably one of my favorite questions. I would say very directly. No, it's not a good way to think about financing in a sense, because each of what you described are not models.

They're sources of funds. And I'll come back to that in a moment, but just to say that for health finance, when we think of the combination of the sources of funds, how they're pooled or organized. And how the providers are paid. As well as how policy on benefits and the rationing of those benefits, such as copayments or waiting times, how those policies are made.

And 1 of the important lessons, I think, from experience from all over the world. Is that the source of funds doesn't have to determine the rest. Backstead, as revenue sources, there are definite pros and cons with each of those sources that you mentioned. In general, what we know from experience is that countries that rely predominantly on what we call compulsory sources of funds, which in some form of taxation, And whether that is, you know, through income tax, mandatory social insurance contributions are another form of taxation as well where that where there's predominant reliance on that.

There tends to be less dependence on out of pocket spending, which is quite problematic because that. Exposes people to potentially difficult choices in terms of the severe economic consequences. For the household of making those payments or actually the need to pay being an actual obstacle to using care.

So, compulsory sources of funding work better. The other that you mentioned that is highly problematic is voluntary health insurance and. There's no country in the world in a sense that relies predominantly on that and makes any progress really toward or much progress towards universal coverage. The reason is simply that this is kind of one of the, I mean, there's a strong theoretical reason why in terms of how the economics of health insurance works.

It's in practice where voluntary health insurance is large. In the sense as a share of spending in the economy, and it tends to have very negative effects. It's largest in a financial sense. It's largest in Southern Africa. South Africa has the largest share of health expenditure through voluntary health insurers in the world, nearly half of health spending flowing through that, but only about 16 percent of the population covered.

So, in that context, it's actually skewing a lot of the system's resources on behalf of a relatively small share. Of the population. So there's a lot of reasons why it doesn't work. But in general, we, we counsel countries to try to minimize private involuntary sources of funding donor funding again is not a model or anything like that.

It's not a recommendation. It's just a reality that in low income countries, in particular, on average, about 30 percent of health spending is finance externally. I think the main recommendation there is not more or less. It's to ensure that whatever, whatever that level of external funding, you have a strong domestic health financing policy health systems policy so that you're in a better position to align that external funding with your domestic policies.

Would you agree with that then, Irene, how, how Joe has framed that there, and the fact that there are certain sources of funding that are more preferable than others? Which, Joe touched on it a little bit, but which approach would you say is currently the most prevalent in lower middle income countries?

And has there actually been a shift towards or away from a particular source since universal health coverage became an SDG target? 

Irene: Thank you Zoe. I would agree with the comments that Joel has made. You know, that's really, you can't get, if you're If what you are interested in is equity, universality, and so on, you really can't get there with private and out of pocket point of service use, voluntary insurance, premium contributions.

Unfortunately, it looks to me like in many of the poorest low income countries, and even in slightly economically better, lower middle income countries, financing of health remains largely today, as in the past, private, out of pocket. At points of service use or voluntary insurance premiums. It's almost like the needed radical reforms towards UHCR to add.

I'm kind of frightened or maybe not understood. Yeah, because of macro financial, you know, it's the wealth of the country, but also technical and administrative. capacity and then political priority constraints. And like Joe said, I think it becomes harder if people are looking at models of financing rather than looking at the function you want to attain and how to use what resources you have to attain that function and not get hung up on models.

There is an issue, I think you, you mentioned obviously, Joe, that that the public financing or, or the sort of mandatory components. Is, is what you would generally ad advise countries to, to move towards, but you know, it, the, the reality there for many governments is that they're going to struggle to raise those sorts of funds from from taxation in reality.

Can you briefly out deny some of the ways other than economic growth, which of course is, is one way to increase your, your fiscal space that, that, that countries could increase their budgets for UHC. Is there any advice you would recommend there? 

Joe: Yeah, but just, just to say, and picking up on what Irene had said, the, you know, the ongoing large role, especially for private pocket spending is not, I don't think a choice that is made as, as Irene was saying, it's also, it's just a consequence of a lot of time of the, of the macro fiscal environment is one.

The other strangely enough is also at least prior to COVID has been economic growth in the sense that as. As people have more income, they're more able to buy things, and some of that is buying health care as well, buying medicines and so on. So part of the, in a sense, improvement that we saw, much of the improvement, perhaps, that we saw in service coverage, in terms of the UHC indicators since 2000, is simply due to income growth, in a way, and then public spending not keeping up, or public policy as well not really keeping up.

So I think that's. That part of the challenge and then I want to talk about now what's changed in that context you know, as a consequence of what COVID has meant for companies, but in terms of actually measures to increase public spending in this very difficult context, we can think of things that are both beyond the health sector and within the health sector, you know, much of this is beyond in the sense that it's a matter of tax policy and, and growth, as you said, There's a big agenda, I think, for countries to improve their taxation measures.

They're still both domestically as well as internationally. When, when internationally really has to do with the issues around tax avoidance, there's some moves like with this minimum corporate tax and so on, but clearly a lot more can be done. I think within the health sector it's generally not our role.

We're not ministries of finance where we do have several to play. An important one has to do with taxes that affect health, right? So, when we talk about the, you know, so called health taxes for, you know, alcohol, tobacco, sugar, sweetened beverage, I think increasingly we need to look at environmental taxes and subsidies as well as part of this agenda rather than something in parallel.

It's not that this is money for health, that's money for government, but more importantly, it's about improving by reducing, you know, harmful behaviors. So just to be clear, you know, whether or not the funds are earmarked for health and, and probably Irene can say a lot about the failures of earmarking based on Ghana's experience, but, you know, it, it varies, right, by country.

So it's not about the earmarking of the revenues, but it is about these taxes being important instruments on their own. Within the health sector, I think some of them, the major challenges we have to make more funds available or to get more from existing funds. A lot of this falls in the domain of public financial management.

Or how budgets are formed, how they're allocated and spent in many countries. I can think of, for example, in. India is one in some other places where budgets flow according to very rigid line items and sometimes are allocated late. A lot of the, you know, when we look after the year is over, a lot of the money that was allocated is still not spent.

And so calling already there, they, the Ministry of Finance might say, why are you asking for more if you're not spending what you have? Well, we need to unpack and we are starting to unpack why that money isn't always spent. And a lot of it has to do with the rigidity in in the budgets that don't actually allow managers to respond.

So there's a big agenda in public financial management to effectively get more out of the budgets that are allocated. And that will lead to somewhat higher spending to the extent that money is not returned at the end of the year back to the, to the treasury. I think last thing is just as, as we often say, and even, even though it won't be sufficient to relook again at some of the major efficiency challenges.

In the sector, and for me, and this speaks a little bit also to the role of international agencies, including even though we're not a funding agency. Is the, the, you know, the ongoing situation of having many siloed approaches. In the health sectors of, especially in low and middle income countries. And.

We use the word sustainability a lot. We need to take the perspective of a overall Ministry of Health or ministry of Finance, rather than each program manager in looking at, at this, because this leads to a lot of duplication and overlap. None of these measures alone will solve this problem, but it it's really critical to, to take them seriously and and to try to act on all for us.

To address the revenue challenge, which is critical. Yeah. Yeah. It sounds like some, some joined up thinking is, is necessary and all this sort of the siloing is a. is a real problem. Irene, I've, I've been reading a little bit about something called a community based financing. And also, I've heard it described as, as cooperative healthcare, which is a, is a sort of seems to be a kind of alternative approach to get around the fact that, that, that currently there is you know, limited public sector financing.

Can you elaborate on this, let's not call it a model, a bit more and, and, and give us your, give us your thoughts on it. Is this something that can work for particularly low and middle income countries? 

Irene: I think community based health insurance is a starting point, and it's definitely better than leaving things as they are with, you know, out of pocket payments at points of services, inadequate financing, and so on.

It raises awareness of the feasibility. Of other financing mechanisms. If I can use an example for my own country back in the 90s, a lot of community based health insurance schemes started as grassroots experiments. There was the Nkranza scheme, there was the district wide scheme in Dangbe West that we were running as an experimental pilot, and several others.

It generated contextual knowledge. It generated the interest. The downside is that it cannot get a country to UHC to my observation, and then if you remember the point Joe made earlier on many of these schemes rely on voluntary contributions and the reality is that if your interest is equity. And universality, there has to be a way of making contributions compulsory because of your interest is equity and universality.

You really want contributions and in relation to ability and expenditure in relation to needs. So you have to find a way of pulling things. And So there is a limit in my observation to how far community based health insurance can take a country, but it's definitely a good starting point. And Within the context of that, I would say that the advocacy for more central tax funding and pooling of resources needs to be done, even in the community based health insurance scheme I was involved in in the late 90s, early 2000s in Dangwe West.

Apart from the engagements with the community, the agreements on, you know, this is what we can contribute because we were in the peculiar situation of also being the district health managers at that time, we actually took the financing government was giving the district to create exemptions for children under five and added to the pool.

And said all Children under five, you are part of this insurance pool now, so that's otherwise you couldn't expand if you just left it to parents to walk up to the health center and write down the names of their Children and rule them. And once the political priority window open for national health insurance, all the repeated brainstorming explorations of options to make this work work, despite fiscal constraints pointed to finding ways to increase tax financing.

And finding ways to go closer towards compulsory rather than voluntary. We still haven't succeeded, currently the window of reform is a bit closed. But I just used these examples to show that really it's a good entry point if there's nothing else. But you need to be aware that you still need to think beyond that.

Joe: Maybe just to Follow up on that because I think it's a good example of where we started in terms of the model discussion. Because, as Irene was saying, that basically, you know, you have sources of funds in this case, you have the community contributions, but then you needed government budget to step in and think about how to pull them together ultimately, and then thinking about purchasing.

So this is a good example of that. It's not like we're talking about, you know, some sort of monolithic tax funded system or community based insurance system or social health insurance system. It's really about, you know, saying, okay, how do we, how do we think stepwise? Right. And that's also what I was just hearing from Irene.

You know, we, we have this starting point, it could go so far. And then we have to, but we realize we have to now combine it with general revenues, if it's really going to, to make another step, I think what we're seeing. What I've seen in very in other parts of the world, I think of it like in Central Asia, where I worked in Kyrgyzstan, they were starting from a very highly rigid budgetary system and to get out of that and to move away from that, they created a national fund.

It remained predominantly and still is predominantly funded from general revenue. There's some small contributions, but it's mostly general revenue funding, but they use that first to pull the funds at at a regional level, which lasted for about 3 or 4 years and ultimately made a decision to go national.

This is for a much smaller country with all of maybe 7 million populations, so smaller than Ghana, but the idea was that, you know, you kind of look at what your problem is, see that, you know, when you have. A population that is predominantly not informal employment that is, you know, so difficult to tax, you need to use other forms of, you know, more probably more based on consumption taxes or things, which may not be the most desirable, but that's what's feasible in a way, and then work out how to use this better and and have a system that then can evolve and improve over time.

Last thing I'd say on that, which I think is part of this and what we've been. Recommending increasingly from from these experiences, even as one moves step wise. There are certain things that could be. Universalized at an early stage. 1 thing that we try to emphasize a lot and this is again, based on my experience, but we've seen this in some other places.

Is that even before you can cool all the money, can you, it should be possible to unify certain underlying systems, especially on data so that you can have 1 database on patient activity so that when someone is discharged from a hospital. You know, their insurance status or exemption status is just another field on the board, but all of the clinical data, everything is, is the same, regardless of that status.

And then you kind of got a very solid. Technical foundation with which to kind of simulate different coverage, expansion. Options in a way, so that idea of kind of cooling the data 1st. The important lesson for a lot of countries, my own country. The U. S. Is really a mess when it comes to data. It's got a lot of other issues in the health sector, but part of it is that, you know, it's very hard to know what's going on except for those programs like for the Medicare for over 65 that you can look at the database, but there's no database to look at on the whole population.

You can just do samples. And, you know, country should not do that, right? You, it's possible to think about how to have, you know, unified, these unified systems, even in, in some European countries that use multiple insurance funds, like here in Switzerland, there's one underlying database, right? And there's one payment system.

This is something that even as one is moving stepwise, thinking about some of those foundations first. Is really important even if before you can flow all the money and it may actually be much safer political because it's quite risky to put everything together before you have the systems in place to manage.

So I think that that's another important issue. 

Irene: I want to really agree with Joe on this issue of systems. You know, you can't emphasize unified systems and I totally agree you work progressively towards it. 

No, that's, that's great to emphasize that. Yeah. And I think the, the importance of health information systems is, is one that, that doesn't often come up in, in the conversation about financing, but it's.

It's super important. You've made that, you've made that point really clearly. Both of you, Joe, you've talked about this pooling of funds quite a lot now. And so that's, and you, and as you explained at the beginning, that's, you know, that's one of the elements of, of financing, you know, you've got the sources, you've got the pooling.

What, what does that mean exactly? This is, this sounds a bit like an economist speak to me. What, what does risk pooling mean? You 

Joe: say that like it's a bad thing. 

And, and, and are there any, and the other thing I was just going to ask you is, are there any reforms that you can recommend in, in, in that regard?

Joe: A lot. It's one of my favorite topics. Just to say that, I mean, it comes a little bit, we can think of it in two ways. One is more from the perspective of, of an objective, right? So when we think of UHC you know, we always say this, that UHC is not something you implement. It embodies objectives you're trying to achieve, right?

So you're trying to, you know, basically reduce the gap. Between the need for services and the use of services, you're trying to improve quality and you're trying to improve people's protection against financial risk. A lot of that of matching resources to needs requires some amount of redistribution of the funds that are in the system.

And that is enabled. It doesn't happen through pooling, but pooling enables that to happen. Right? So that the, the, in a sense, the larger your cool, the more scope there is for this redistributive effect. Just to say that cooling also itself as a function really means in a simple way that we're whatever the amount of prepaid funds is, this is what is being accumulated For the needs of some or all of the population, ideally all, but in many places, most places, there's some degree of fragmentation that limits the extent to which the redistribution can take place.

We also see. Cooling issues related to the silos we talked about, whether that is between health insurance teams or say, between the HIV program and the TV program and whatever other program that can be more of an efficiency problem again, if they each have separate information systems and separate procurement systems and so on.

So it is mostly about. Setting the potential to redistribute resources to where the needs are. The critical things we look for in terms of the directions of changes, size. So bigger is better when it comes to pooling diversity, and in particular, diversity of health risks, right? So, you know, and oftentimes we talk about wanting systems that are able to redistribute from the healthy to the sick as in a broad sense, well, for that to happen, you need the healthy and the sick in the same pool.

If you just have, you know, people with HIV or diabetes or conditions that, you know, you know, that are high risk that, you know, they're going to need a lot of services. If they're in one pool, you don't have any scope for for redistributed, right, you just kind of, you either pay for that or you don't pay for it.

So you want to kind of put together with with a wider population. And the other is where we started a while ago that basically. You need compulsory or automatic participation to the extent that participation is voluntary than what we see from the poorest to the richest countries in the world is that younger and healthier people are less likely to join, you know, older and sicker people are more likely to join.

And ultimately the market crashes essentially that that basically it uninsures the people who need it most. This is why, for example, like in the Affordable Care Act of the United States, the issue of compulsory participation was so critical because you need to have the younger, healthier people putting in to look after people, older people like me, you know, who are gonna, who are more likely to, to need the services.

So this is, this is really critical, the size, the diversity, and the compulsory participation, and the biggest threat we face, that countries face. Really has to do with fragmentation. And we can talk about it if you want, but there's there's there's a lot of ways to either try to deal with that directly or often indirectly because fragmentation and separation of Rules is a highly politically charged issue in terms of dealing with it.

So we have to find ways around rather than through oftentimes. 

I mean, you know, it is, it is a very political thing, isn't it? This, this, this kind of reform. And so we, yeah, the idea that you have to work with the realities of different countries, political situations is, is really important. And on, on that note, Irene, I mean, some of these reforms are.

You know, going to be quite challenging for, not just for governments, actually, but maybe for providers and And for patients as well can you talk to that aspect a little bit and maybe describe any evidence based mechanisms for improving buy in to some of these reforms? 

Irene: And I'm not sure there are any prescription approaches for improving buy in, you know, from my personal experience of working in Ghana's health system as a systems manager.

And advocate and for a long time, I was really a big advocate for you. It's buying is a very political process and already services technical as well as political, and it's almost sometimes a bit like navigating rapids. So we are navigating rapids, your ability to react in real time with a tacit knowledge and experiential knowledge is really important.

And to get that ability, you really need to have a deep knowledge of the issues, the context, the actors, and that requires a prolonged engagement, you know, you have, and then it also requires. Observing, analyzing, thinking through, and managing in real time diverse stakeholder perspectives, interests, and values.

And also recognizing that knowledge is impaired, such mistakes are possible and okay. And being ready to immediately acknowledge and learn from mistakes. You know, if you can correct them, do it. And then the other thing I would say is that We also need to be aware that reform and often to get to real UHC, it needs radical reform, which is tailored to context.

It has costs as well as benefits. Now, and sometimes the problem is those who pay the costs of reform are not necessarily those who benefit. If I can illustrate in Ghana, we took the decision after much brainstorming that, okay, 2. 5 percent of VAT must be earmarked for. UHC. It has its pros, it has its cons.

The goods that are consumed predominantly by the poor must be exempted. Now, the poorest often don't consume the goods on which this VAT is because the VAT was put on goods that are consumed by the wealthier. So you had a lot of Push back from those who are more likely to be paying VAT. I'm just using it as an example.

So it's not too theoretical. So and then the other thing is those who most need the benefits may be relatively silent and not empowered as individuals. Their power could increase if they mobilize as a group, but they're also not mobilizing that you're not aware of their needs. So sometimes in the debates out here, both sides of the argument say that they are arguing for the poorest of the poor, and I never had a word from the poorest of the poor.

They were all busy in the market trying to get their days meal. So you need to be aware of all these things and be able to. If you really want equity, make sure you find a way of getting these other voices. onto the table, get some of the more powerful to advocate for them. And then also think trust between key stakeholders is an important but neglected essential part of getting buy in for reform that needs to be cultivated and managed if you want to improve radical reform.

I said we all learn from failure as well as success. One of the Randical reforms I was involved in, which didn't make it, was trying to move to a per capita payment system for primary care. And one of my major observations was that the long standing mistrust between the payer, the health insurance authority, and the purchasers, the providers, both public and private, was such that The trust level was so low, you could explain issues over and over again.

And it's like these purchasers are trying to push all the risk onto us. And the purchasers are thinking these providers are trying to fleece us. And basically you have a deadlock. You don't get anywhere. So I would say that really work on trust, and trust is basically the conviction that the other party is not out to harm you deliberately or knowingly, that we have a shared interest, and it requires long term engagement, credibility, and consistently ethical behavior.

So that's something I would put in there. 

I love that. Yeah, there's some really really, really sage advice there. I think, Irene, thank you so much. So well, we're, we're coming to the end of our, our discussion now, but I, I know that there are. Some countries that, that may have sort of done better than others in, in recent years.

I can think of countries like Thailand and, and Rwanda in, in in moving forward with, with universal health coverage. But as we, as we've said, every country is different in terms of its economic development, its political economy, its labor force structure. So, you know, like we said, some countries have a very high informal labor force.

But are there any sort of cross cutting lessons you can draw out from these successes? That might be useful for other countries. Irene, you've, you've mentioned trust as a big one there. Are there, are there any others? Joe, maybe you can give us some of my 

Joe: thoughts. Yeah. I mean, the, the Thai experience is cited a lot and, and rightly so.

I think on a number of dimensions, including what Irene was just talking about, that they invested a lot engagement with the population into their reform effort and with the providers as well, and basically. You know, they have been able to keep their reforms on track through both democratic and military governments.

I think one thing that Irene mentioned that I wanted to highlight because it doesn't get enough attention, at least internationally, is the role of knowledge in all of this. I mean, one thing that ties have done well, I know that Irene's been part of the Ghana as well, is the analysis of. What that, you know, what are, what are we implementing and what are the consequences of that?

So in the Thai case, at least they produced evidence that this program that they had developed was having, you know, pro or the facts at the level when you measured at the level of, of the whole population, that basically the value of the benefits to the war was greater than the, you know, that, that they were capturing a disproportionate share of benefits, which was, you know, good, that was part of the intent of this.

And that the, the investment in the institutions and the people to continually produce. Knowledge and analysis doesn't get a lot of attention internationally. I would say the global organizations, not only, but and the whole process. Sometimes comes down to please give us the data. Right rather than and in a way we say monitoring and evaluation when we've only really met monitoring.

So, we need to kind of think about investing more and focusing on. Domestic institutions to learn and adapt whatever problem. You know, a country is facing today, even if you solve it, you'll have new problems. Tomorrow, right? So, it's, you know, do you have the basically the systems in place that where you're able to generate.

Data and knowledge basically generate data people to turn that into knowledge to analyze it and then to link it to decision making or at least put it into the public debate for analysis and there's no SDG on that, right? But this is really critical for the long, longer term success of countries is doing it a lot of technical.

Issues in terms of lessons from experience without going into huge detail, just to say that the work on what we call the purchasing of services. And I rementioned that per capita payment experience in Ghana. This is very closely linked to the data issue that we were talking about as well. Because in order to not just reimburse whatever the provider says, or not just to give a line item budget, you need data on what the providers are doing, what the population is getting and so on.

And and basically you want to put that data on a system wide basis so that basically the way that you pay for services is linked to that data. Right? So this is something that I think has been important. Highland again, being a very good example of that, and I think you mentioned Rwanda too. It's been it's a little less clear, but certainly.

1 of the things again, moving away from models is that while they use the label of community based insurance, there's a very strong role for central government funding. Which goes into the system and to some extent, I mean, in each case, there's this general move of either eliminating or softening the link between entitlement and contribution, which has been.

Critical and in a way for me, you know, really moving away from the idea that you're, you, you only benefit if you contribute, you know, moving away from that means fully embracing you in a sense, because it means that actually you're kind of saying, in fact, this is a right of being a person rather than just an employee benefit, you know, and, and that's kind of the, the change that we're hoping to see, of course, the history and institutions of countries Matter in terms of how one moves in that direction, but at least trying to reduce that linkage, if not eliminate it, is an important direction that we'll see.

Thanks, Joe. Thank you. Irene. 

Irene: Yeah, yeah. If I can follow on, I think it's important to learn from other countries. The problem is we often tend to couch it as learning from success, but the learning should be both from failure, so that you learn about how and why not to, as well as success, how and why to.

And even in the same country, you need to learn from failure and from success. I think there's an unfortunate tendency sometimes to hype success and push weakness and failure into the shadows and this really limits the ability to learn from each other as well as within the same country over time. And just to make it practically, I can illustrate from Ghana.

In fact, when the, the policy window opened and there was now a Ministry of Passport in the Ministry of Health in 2001, discussing which way to go. One of the paths that came up is, let's do classical social health insurance. Let's start with those in the formal sector and the pushback that, no, we need to find an innovative way to reach the non-formal sector as well.

And. Keep the two together, actually came from digging back into the failures of the past. Hardly anybody talks about it, but actually in the 90s, the Ministry of Health spent a lot of money trying to find a way to social health insurance in Ghana with a big pilot in the eastern region. I think because not a soul was insured and so much money was spent, you know, people kind of don't talk about it, but just digging back into that failure.

Helped to make the convincing argument that please, let's not go that way again. Not only do we know a bit globally, we even know from our own failure here. So I would suggest that really, let's not push weakness and failure into the shadows. And let's not overhype success. And then the other thing is to be really careful about instant standardized toolkit solutions, you know, because what happens is that decision makers of necessity have to be a bit of generalists.

I mean, if you are sitting in the Ministry of Health overseeing the whole policy direction of the ministry, you are not going to be an expert on UHC or health secrecy or health promotion. You have enough understanding. To steer things, you need to be working with people who have strong technical and administrative skills.

To actually make things work, who can advise and who are embedded in the local context and can do local analysis. My observation is sometimes we are struggling in low and middle income countries, and it touches to a point Joel made earlier. Build those capacities in the Ministry of Health. The capacity hasn't been built, we want to get around it, so we bring in an external expert.

Now you may be an expert on risk pooling, on what to do. DRGs on computation, whatever. It's global generic knowledge. To make it work in Ghana, it has to be applied with deep contextual knowledge. And your best route to that is to build people in the country within the Ministry of Health and so on, so that it works.

Otherwise, you bring in the world's greatest experts and it's still not working. I, I mentioned that countries learn from each other. In 2006, we visited Thailand and met with, you know, the, the, the reformers in Thailand. Then, you know, we really want to learn from you. And then I remember on the closing day, you know, we asked, what one piece of advice would you give us?

And they said, you know what, don't make the mistake of thinking that Anybody, no matter how experts can come in from outside and make things reform work in Ghana, they can't catalyze. The World Bank, IMF, whatever, can bring all their resources to bear on your country. If the deep knowledge within country and the adaptation doesn't occur, you'd be surprised it's going to fail.

So, I would kind of want to put that in, in ending, and really encourage new and middle income countries, build the capacity, respect. Your local contextual knowledge and don't assume you know that if you forgive me for saying this is an expert from the US, they are written a powerful country, and the greatest innovators it's true they are technologically innovative, I always say I don't think you can beat.

the US for innovation and breakthroughs in technology. It doesn't mean nobody can beat them in innovations and breakthroughs for social programs. So you do need to be a bit 

critical. Thank you. Thanks, Irene. I think that's a fantastic note to finish on. I love the idea of using, you know, the skills you have in the country to actually build the systems.

We need to be looking for tacit knowledge as well as, as well as hard data. We, we need to be having conversations with. With the whole, the whole populace, not just the, not just the politicians talking to each other, it's politicians talking to providers, providers talking to patients, purchasers, payers, and and so, and, and, and keeping the the concept of universal health coverage as a, as a concept, not a, not a, not a sort of a a hard kind of thing that, that we're working towards, like a model or something.

It's the, it's, we're talking about equity, the right to health for everyone. We could talk about this for hours, but we'll have to finish there. Thank you so much to Irene Aguipong and Jo Cutson for joining me today. I hope you'll join us for more podcasts in this series on universal health coverage and for more podcasts in our series celebrating 200 years of the Lancet.

Thanks very much.

Gavin: Thanks

so much for joining us for this episode of The Lancet Voice. This podcast will be marking The Lancet's 200th anniversary throughout 2023. by focusing on the spotlights with lots of different guest hosts from across the Lancet group. Remember to subscribe if you haven't already, and we'll see you back here soon.

Thanks so much for listening.