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Toward Sustainable Universal Health Coverage

Speakers: Michael S. Chen, Associate Professor, National Chung-Cheng University, and Margaret E. Kurk, Assistant Professor of Health Policy and Management, Columbia University
Presider: Yanzhong Huang, Senior Fellow for Global Health, Council on Foreign Relations
February 9, 2012
Council on Foreign Relations

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YANZHONG HUANG: Welcome to the Council on Foreign Relations. I'm Yanzhong Huang. You can call me Andrew or Yanzhong, but Andrew is my undocumented, illegal -- (laughter) -- so I'm a senior fellow for global health at the Council on Foreign Relations. And this is our second meeting of the new universal health coverage roundtable series.

Universal health coverage, that could be dated back to Otto von Bismarck's Health Insurance Act of 1883. Obviously, it is now gaining momentum globally. And today we talk about the fourth wave of democratization in the Middle East. But to me, there is also the third wave of universal health care transpiring worldwide, if we count the rise of the welfare state in the post-war era. The first wave and the launch of universal health coverage programs in the post-Cold War era as a second one.

And in 2010, the World Health Organization published its annual report focusing on universal health coverage. By the end of that year, China announced that it had already achieved 95 percent coverage of its population.

Just last month, health ministers worldwide gathered in Bangkok issuing a statement, committing themselves to, quote-unquote, "raise universal health coverage on the national, regional and global agendas, and to advocate the importance of integrating it into forthcoming United Nations and other high-level meetings related to health or social development, including the United Nations General Assembly, and promoting its inclusion as a priority in the global development agenda."

And last week when I was visiting New Delhi, Dr. Srinath Reddy, president of the Public Health Foundation in India and chair of a high-level, expert group on universal health coverage in India, gave me a copy of the expert group's report, which includes a framework for providing easy, accessible and affordable health care to all Indians by 2022.

So if all goes well, we could anticipate that by then, I mean, 2022, most of the world's population would be covered by some kind of health insurance. If we think about that, the fact that people today, there's 1 billion people worldwide today do not have access to health care, and 150 million people face catastrophic health care costs each year because of direct payments for health care, and 100 million (people) are driven below the poverty line. I think this would be a true milestone in human history of achieving universal health coverage by 2022.

But the issue here is not just about scalability, that is the spread of the schemes of universal health coverage, but sustainability as well. That is, how to sustain the existing program instituted for achieving universal health coverage. This is certainly a major concern of low-income or lower-middle-income economies.

Just last month -- (inaudible) -- announced that it would abandon free health care for all due to skyrocketing costs. And last October, Uganda also -- this free health care system was in crisis. And in Rwanda, one of the most successful examples of universal health coverage, I will say that foreign donors contributed 53 percent of the total health expenditure.

And even upper-middle-income economies' sustainability is a major concern. Brazil's contracting economy is now threatening the already-underfunded universal -- unified health system called SUS. And in China, the burst of the real estate bubble and the over-reliance of local governments on land sale for revenue growth raised questions on the availability of future funding for its universal health care program.

Indeed, universal health care programs in even high-income economies are struggling to cope with the rising health care costs, slacking economic growth, globalization of disease, population aging, and the rise of noncommunicable diseases and, of course, also the increasingly costly medical technology.

So what lessons can we draw from their experiences? Is there a model that is socially desirable, politically acceptable, technologically feasible and financially sustainable?

It is for this reason we choose "Sustaining Universal Health Coverage" as a title for today's roundtable discussion. We are fortunate to have two leading experts to speak on this issue. Each speaker will talk actually on the issue of universal health coverage representing a particular group of economies. Michael Chen will speak on the experience in Taiwan, which represents high-income economies. Margaret Kruk will speak on the experience of low-income economies, particularly sub-Saharan Africa.

Both of our speakers full biographies are included in your handouts, so I'm not going to repeat them. But I want to just give them a brief introduction.

Michael Chen -- Michael is associate professor for the Department of Social Welfare at National Chung-Cheng University where he teaches health policy and health economies. Michael is also president of Taiwanese association for social welfare. He served as vice president and chief financial officer for the Bureau of National Health Insurance, Taiwan, from 2006 to 2010.

We know that National Health Insurance has been acknowledged as one of the most successful health insurance models in the world.

Margaret -- Margaret is an assistant professor for the Department of Health Policy and Management at Columbia University Mailman School of Public Health. Prior to coming to Columbia, she was an assistant professor in health management and policy at the University of Michigan School of Public Health, and policy adviser for health at the Millennium Project, that is an advisory board to the U.N. secretary-general on the Millennium Development goals. She conducts quantitative health systems and policy research in sub-Saharan Africa, with a focus on population preferences for health care, determinants of health service utilization, policy options in human resources for health and evaluations of large-scale health programs.

So we're going to begin with brief remarks from both speakers. And after their remarks, we will open up the floor to questions and discussions. And this meeting, just to let you know, is on the record, so you can feel free to use and quote today's discussion.

But please turn off your cell phones. And if you don't and if it rings, you'll be fined, according to our global health program rules, $50 that will go to a charity fund. (Laughter.) This is my distinguished speaker Laurie's rule. So we're going to follow happily.

So we're going to begin with Michael.

MICHAEL S. CHEN: OK, thank you, thank you, Yanzhong.

Well, I only have 15 minutes, and I'll try to control my tongue.

Good afternoon, ladies and gentlemen. When it comes to policymaking, nothing can be worse than working on a wrong assumption. For if the first step goes awry, then the following steps tend not to be right.

And experiences are notoriously difficult to be transferred between countries. But comparative studies can oftentimes shed light on whether one is operating on the wrong assumption.

And to make my point clear -- and I hope at this point -- (inaudible) -- to all nations -- I would like to point out a few myths or misconceptions that I observe in the U.S. health policy information.

Actually, I must be too provocative, but I just try to make my point clear. And after each of these points, I will substantiate my argument based on my field work with the Taiwanese NHI program.

The first one to point out is that in this country many people believe that a health (cost ?) function is linear and additive in terms of the size of the covered population. And if you subscribe to this notion, then it will be mind-boggling the amount of money to be added to the already 2 trillion U.S. dollars now if the nearly 40 million uninsured Americans are to be covered.

However, I would have to say the cost function is neither linear, nor necessarily additive. Take Taiwan's -- (inaudible). Before the implementation of NHI, the annual increase rate in health care costs was somewhere between 8 (percent) to 10 percent. But after that, especially since 2002 when we implement a global budget, the increase rate has been under control to somewhere between 4 (percent) to 5 percent annually.

So if you are old enough, like me, to remember the line created by Jane Fonda for her iron-pumping business -- (chuckles) -- then you know the -- (inaudible) -- control the costs is try to cut the fat and keep the muscle. (Laughter.) And as a well-managed, nationwide program, the authority had a lot of -- had a pretty good -- (inaudible) -- to control costs. And the global budget is the first line of defense in this regard.

Well, the -- (inaudible) -- is for cost containment has a lot to do with the nature of this program, which is single-payer. While I believe that one of the most (rooted ?) problems in the U.S. health care system is the inability to conduct cross-subsidization. And under single-payer system, because the program has the maximum capacity to carry out -- (inaudible) -- cross-subsidization, and it makes other measures relatively (hard ?) to carry out.

And the second myth that I want to point out is that a lot of people, again, believe that a NHI program will take away the freedom of choice that is very cherished by all Americans. In response to this, I would like to ask, which freedom of choice are you talking about?

In this country, yes, you do have a lot of choice when it comes to the insurers. But under each of your insurers, you can only choose from a very limited number of the providers. While in Taiwan, no, you don't have any choice about your insurer because there is single-payer; however, under the single-payer system, you enjoy virtually unlimited freedom of choice to the providers.

So with a card -- everyone in Taiwan has a card like this, NHI card -- you can walk into any of the more than 18,000 facilities, large and small, like walk into your own kitchen. Oftentimes, you don't even need to make a reservation.

So that is not -- so the bottom line really is, which freedom of choice are you talking about?

And the third myth that I want to point out is that a compulsory program is an evil that -- (inaudible) -- coercion and hurts the core value of freedom. Well, even in Taiwan, some people insist that the state has no right to impose an obligation that is not found in the constitution. But I will say, this is a typical case of sacrificing the essence for an imprecise expression.

Because of what's on the table, if you look at it now, yes, it says that you either join or pay the penalty. However, in reality, it (strikes ?) quite a different meaning for this word "compulsory." And I don't know if you can find this word in the Obama plan.

Well, it means -- in Taiwan, it means that this program is compulsory on the government rather than on the people in a sense that, as it is a compulsory program, and indeed government is obligated to make a -- (inaudible) -- all the way out and try to, like, seek out anyone in the street corner or in the remote areas and make sure, so-called leave no stone unturned and no individual uncovered. So that's the true meaning of the word "compulsory" in Taiwan's NHI.

And well, the -- (inaudible) -- is going to be Supreme Court rule coming out in, like, a few weeks or so. But the supreme court in Taiwan has ruled that the contribution and the health care must be decoupled. Meaning that, even if you fail to pay a premium, your service cannot be suspended.

As a consequence, the Bureau of National Health Insurance has come up with a really elaborate -- (inaudible). And because I do not have time to go into detail, it suffices for now to say that under this -- (inaudible) -- I can claim that in Taiwan no single individual is denied health care for whatever reason.

And well, but I want to play a role as an exorcist to expel the fear that you might have in your mind for what you will call socialized medicine. And I want to say that the program is a gentle program. Well, if you fail to pay, as I just say, if you fail to pay the premium, it doesn't matter. Well, and if you pay a lot of visit to your physician, we will just gradually escalate or pressure on you. And well, no matter how you do it, you can still finally -- maybe you can only -- (inaudible) -- occasions in the -- (inaudible) -- because we want to put a bug on your card, but still allow you to visit -- (inaudible) -- locations. That's one example to be gentle with this program.

And the last myth I want to say is, well, some people believe that under such a program, physicians will be rendered -- (inaudible). Well, in Taiwan, doctors resist at first for fear, doubt and uncertainty. But as time passes, they realize they had nowhere to turn to but to cooperate. But in the end, that was beneficial for them.

And in the program, physicians play a variety of roles. So I would say, instead of becoming -- (inaudible) -- physicians grow as the program grows.

Well, maybe you would say the Obama plan has been passed, but you must think I am beating a dead horse. However, it's implementation is anything but certain. And that (makes ?) me to invoke an old Chinese saying. They told us it would take 10 years to implement the program. Ten years actually is quite a long time. In Taiwan, people always say, I want it all, and I want it now. So if not 10 weeks, then it wouldn't be longer than 10 months to implement a program.

So that makes me to invoke an old Chinese saying, which says that if the night is long, the dreams will be many, and not all of them are going to be sweet.

So for now, we just have to cross our fingers and hold our breath and look at what is going on in Washington, D.C. And of course, the only thing that doesn't change is change. And under the pressure of being the fastest-aging society in the world, we have (come up with other sources ?) to make sure the financial house is in order for the program.

So that's why we had a so-called second-generation reform enacted last year and implemented sometime this year or next year, which will expand the premium base from payroll only to other incomes, like rentals -- (inaudible) -- or some capital gains.

If we implement this -- well, we have been in debt for a few years. And as a chief financial officer, well, I, I would tell people don't look at those figures in the financial report because that is not a bottom line. The bottom line -- because Taiwan spends only, like, somewhere between 6 (percent) to 7 percent to cover all the population. So we actually still have some luxury to spend more, just a matter of who is going to pay.

So that is why -- (inaudible) -- problem, there is a problem of cash flow, not a real economic issue. So don't need to look at the financial figures. Instead, just make sure that everyone, especially the (funded ?) people, are well taken care of. That will be -- that will provide sufficient legitimacy to push the program go on.

All right. And if you ask me if the program can survive for the next century, the quick answer is probably not. But let's now try to cross the bridge when we come to one. And you know what they say. When the going gets tough, the tough gets going. Then by that time, we should be able to exercise our wisdom and come up with ingenious solutions for our problem.

Thank you very much.

HUANG: Thank you, Michael.

And Margaret?

MARGARET E. KRUK: So thank you so much, Yanzhong and Laurie.

And thanks to the Rockefeller Foundation for organizing this forum. I think it's both timely and incredibly important.

And it's really an honor to also be here with this diverse and august audience, expert in this area.

I understand that a month ago, Bill Hsiao and David de Ferranti told the forum how to achieve universal coverage. So I've got the easy part, just sustaining it.

CHEN: We had the tough part.

KRUK: Yeah, right. Well, I think if achieving universal coverage is the sprint, and I think we see a lot of countries getting in the race, not least of which our own country, but also this is gaining momentum around the world, as you know, WHO and others, the meetings that Yanzhong referred to, I think sustaining universal coverage is obviously the marathon.

And my perspective is that getting to the finish line depends strongly on getting the most health out of the universal coverage, but also getting public support behind it.

The WHO defines universal coverage as all people having access to services, without suffering hardship in paying for them. And I completely agree that reducing financial hardship is a priority, both here where we know medical bankruptcy is a major issue, but also overseas.

Yanzhong cited some very important figures about people pushed below the poverty line, due to medical expenses. In a complementary analysis we showed in a recent paper, looking at 40 countries, representing 58 percent of the world's population, low and middle-income countries, that one-quarter, fully one-quarter of all families had to borrow money or sell assets from their home to pay for health care in the past year.

So we know that these types of expenditures reduce families' investments in education, reduce their future earning potential, and obviously, the productivity of countries. So we're fully -- very fully behind that noble aim.

But I want to focus today on the first part of WHO's definition of universal coverage, which is universal access to health services. And I will argue with you that there are at least two considerations beyond the notion of access, that are crucial to sustaining universal coverage, and those two are: the scope of the services, and their quality.

So let's consider a low-income country. We've had a great example from Taiwan in a high-income setting. But low-income countries are struggling with these issues and trying to tackle them. I will tell you a little bit about Tanzania where I've been doing research for the past seven years.

In many ways, Tanzania has met the definition of universal access. For example, geographic or physical access to a health facility is excellent. More than 90 percent of Tanzanians today live within 10 kilometers or a two-hour walk of a health facility. Moreover, financial barriers are low. So for example, user fees have been abolished for all maternal and child health services, for services for the elderly, as well as most disease treatment.

And yet, in Tanzania, maternal mortality is 500, about 50 times higher than here in the U.S. And only half of all women have a baby in a health facility. Instead, most deliver at home or have delivered at home.

So is this universal access? If so, is this access we want to sustain?

I don't think that access is the sole issue of importance, actually. I think we should be asking a different question, which is, access to what?

In many African countries and in South Asia where health goals, such as the Millennium Development goals, are far out of reach, I would argue that, in addition to focusing on expanding coverage, we really have to reconsider the importance of the composition of this health-service package and the quality of the services provided in it.

We've seen, for example, in our research that women vote with their feet, and even very poor women bypass poor quality of care if they can at all afford it. Meaning they will go around, and we have figures to show 40-plus kilometers walk to find a facility with better services.

And what's more tragic is that many more women and men and families simply ignore the health system that is not delivering for them, and instead continue to deliver babies or look after their sick children in the home and/or with the help of traditional providers who are untrained.

And so if we don't insure a larger and better-quality package of care, populations will not use services and will not support the system, which I think strains the social contract that is required to sustain universal coverage.

Moreover, if not used, expanded services will not bring us the longer and healthier lives that is the key impetus in the push for universal coverage. And I think this may be one reason why countries like Ghana, for example, are struggling in expanding its health insurance offering. And I have worked in Ghana and have colleagues in Ghana who tell me that people want to know that they can buy quality services with this insurance before they invest in the insurance. And they're not entirely sure that they can do that today in many parts of the country.

It's also probably the reason that only 15 percent of Tanzanians have purchased community health insurance, which is an additional supplementary insurance, again, because that insurance is focused very narrowly in a small set of primary care services.

I think we need to shed the assumption -- and I'm very much behind Dr. Chen's theme of revisiting assumptions -- that populations in low-income countries will be grateful for and use whatever is provided. So as long as we cover them with something, that's going to be good enough. We're not seeing that. We're learning just the opposite, actually, that they are health care consumers, perhaps not so different from us.

In fact, in policy simulations based on some econometric research we've done in Tanzania, we show that potentially up to 90 percent of women would move from the home and into facilities to deliver if they were assured of a system with reliable medicines and competent and courteous providers. And that's up from 46 percent delivering in those facilities today.

I don't know if we're right. And we're probably not right. But we're in the midst right now of an NIH-funded experiment to test exactly this, whether this can happen.

And so to sustain universal health coverage, governments and their development partners need to make sure that their populations value and use services. When they value them, they will support them. Governments in rich countries know very well what we're talking about. They've experienced the wrath of citizens when trying to reduce, for example, or limit health coverage. In fact, some of the fight over the Accountable (sic) Care Act is because of the -- (inaudible) -- comparative effectiveness research and the notion that it might limit care available to populations and families.

And I think populations in poor countries are just waking up to that very fact as well. So I think we can't be naive about the importance of a robust, quality, health care package in poor countries. We have evidence that this matters not just for people's health and utilization of services, but also for their perception and participation in this social contract.

For example, we found that in Liberia and in other low and middle-income countries, higher-technical-quality of care, of health care, more responsive service delivery, and financial risk protection, but not physical access, were important predictors of trust in government.

I'm aware that my points raise more questions than they solve. For example, improving scope and quality of services is a tall order. All of you know that in Africa the health systems are overburdened, hugely under-resourced. We're in the midst of a health provider crisis.

On average, sub-Saharan African countries spend about $21 per capita on health care, so now 8,000 (dollars), not 6,000 (dollars), but $21. And so it is a very big deal to try to expand services and build their quality at the same time.

However, I think meaningful universal coverage is a different thing from universal coverage, and we should be pursuing this goal. And it needs to be done really simultaneously. We can't wait, because I think we will lose the trust and the faith of the population.

I do think it will pay off. I think that giving people health care that they will want to fight for and get behind will pay off, both in better use of services and in better health outcomes, but also, and maybe more crucially to the question of sustainability, in building public support for health services. And that support is surely one of the pillars of sustaining universal health coverage.

So thank you, again, for giving me the opportunity to participate in this exciting conversation.

HUANG: Thank you, Margaret.

I feel this is very interesting, because when we talk about universal health coverage, we also focus on achieving accessible, affordable health care. And few actually, especially for developing countries, are talking about achieving quality health care.

And Margaret just pointed out actually having this quality health care in fact could encourage access to health care. And I find that this is a very interesting finding.

And also, thank you, Michael, for -- (inaudible) -- even though it's the pessimist -- you have a pessimistic sort of prospect on the Taiwan's, the universal health coverage program, but I'm curious, because when you talk about focus on the demand side, but you haven't talked about the supply side, the health providers. I'm curious, how -- or maybe, what do you have in mind in sort of structuring the governance of the public hospitals and clinics, to really improve their efficiency, to reduce the (induced ?) demand, therefore to increase the sustainability of health care in Taiwan?

And Margaret -- I guess the next question is probably to both of you. Because one of the challenges is to ensure the money is spent on the target beneficiaries, you know, that would entail, of course, bringing down the administrative costs and avoid misdirecting the funds to unnecessary investments, such as, you know, buying fancy cars, you know, lavish, new buildings.

So we know that this technology is like a double-edged sword. It could improve, it could increase the cost of care. But I'm -- I'm interested in hearing about how the new technologies could play a role of reducing the cost, and therefore improving the sustainability?

Michael, you just showed me the smart card. Is that -- how is that technology going to play in reducing the cost?

CHEN: OK, two questions. About how to promote the efficiency of the supply side, I would say it's as much as the obligation of the medical association as it is for the government, especially after the introduction of (global ?) budget. Well, we look at the performance of the associations, medical associations of different specialties. We can realize that if an association can do their job well in reining in the behavior of its members, that if members will give a lot of benefit without over-working.

Because in the past -- for instance, in the past, doctors in Taiwan were washing their dirty (shirts ?) in public now. That physicians in Taiwan did not have any (location ?), they don't have break time, work long hour. So after the introduction of global budget, it doesn't make sense to render so much service.

So but, well, there is so-called dilemma of the prisoners, right? So if everyone in their specialty will just rush, offer more and more services, than each one will get lower and lower in the (point of ?) value, because the reimbursement is defined in terms of the number of point instead of number of dollars under the global budget.

However, that -- (inaudible) -- pretty well and making sure that people are satisfied with their service. For instance, they were asked -- (inaudible) -- on this side of the street can take off this weekend and those on the other side must open. So public will still have dentists to visit over the weekend, and (these ?) can have a vacation every other week.

So that's what I mean by that is as much as a responsibility of the -- (inaudible) -- association as well as it is for the government.

So and actually, as you must know, that after the introduction of some sort of pre-paid system, it will force the entire medical sector to improve in their administration, like the United States experienced when the DRT system was introduced in 1980s, because you have to come up with all kind of SOP to take care of patient and reduce the cost.

And talking about the smart card, I actually -- we take a lot of pride in this card. And I -- this card, I will say, we don't have the best technology, because we borrowed or purchased the technology from other countries, for instance from Germany. However, that is our system. That is the single-payer system that enables the -- (inaudible) -- utilization of this IT.

For instance, Germany has better technology; however, they have hundreds of sickness (fund ?). So it's impossible to consult the data. But in Taiwan, we have only one database with which you can do all kind of data analysis. You can actually -- let me put it this way. Actually, we can look over your shoulder for whatever move that you just made.

(Cross talk.) (Laughter.)

No, no, no. OK, I know you will have this kind of response. Why I -- in my remarks, I already emphasized that this is a very gentle and also very respectful and respecting program. Of course, we are not going to monitor your behavior in your home. But whenever you insert this card into any of the facility, then, well, the entire system is activated, and we know how many times you visit.

And as I say, well, if you pay more than 20 visit for a month or 50 for three months or 200 for a year, then we will send you a postcard saying, how may we help you? And if you don't change your behavior, then we'll send our pharmacists to make a house call to you and face-to-face ask, how may I help you?

So even in the end, as I said, you can still visit (three ?) locations. So that is not big brother at all. And the big brother is so caring. Why not have one? (Laughter.)

HUANG: to keep harassing you until you just become more responsible.

CHEN: Well, it's not so much as harassing, but caring, I would say. (Laughter.

HUANG: Margaret?

KRUK: Well, I think that the question of how new technologies can help reduce costs and improve efficiency is actually very relevant in low-income countries as well, which I would argue are operating below the efficiency threshold. When you have systems that are so, you know, basic and barely functional in some ways, it creates a tremendous amount of inefficiency. So you know, people have to create parallel systems to be able to run an effective program, data systems and so on.

I think what is exciting -- and I've seen this in a few countries, particularly post-conflict countries that are sort of hoping to wipe the slate clean and trying to think anew -- is that they are able to leapfrog some of our inefficiencies and some of the things we've perhaps, you know, taken circular routes on or perhaps haven't been as effective.

So implementing, you know, electronic records in very low-income countries, trying to track the population in more innovative ways, you know, using -- in India, for example, but even in very nomadic societies like Chad, I've seen sort of electronic vital registry systems that are, you know, essentially acknowledging the fact that people aren't accounted, that we don't know what happens in health care -- the complete opposite of Taiwan.

We know nothing about the population. If people are not counted, then governments cannot be accountable. They cannot hold governments to account. And so I think there are some examples of where technology can come in and help both understand the scope of the problems, but also rationalize the solutions so that we're not building multiple systems that population.

HUANG: Thank you.

So I want to open the floor up to questions. Please identify yourself and your affiliation before responding. And please also flip your card, your tent card, to indicate that you have a question. We also allow the one-finger rule, if you have a quick follow-up question or remarks.

So, Laurie?

QUESTIONER: Thank you very much both of you for joining us here today. It's wonderful to have you here.

When you -- Dr. Chen, when you said we can look over your shoulder, I saw Ron Paul leaping into my mind, and that's a very American reference. But I don't think that that advantage, as fantastic as it is for the sake of epidemiology, is one that the average American is going to embrace unfortunately.

But my question actually goes to Margaret's presentation. We have all been struggling with this notion of, how do you combine the drive for universal health coverage with the drive for quality health? And you're absolutely right, there's no reason to believe that the two are necessarily bound together.

So this comes down to trying to figure out who defines what a package for universal health coverage is. Can that only be defined at the local level? Or are there ways that WHO, for example, could set some kind of model standards?

And then the second piece of that is then, who implements it, which was, you know, clearly, what you were driving at.

I wanted to ask you if stovepiped programs and initiatives are detrimental to trying to reach a baseline notion of UHC in resource-scarce countries.

KRUK: Thank you very much, Laurie. Predictably -- (inaudible) -- questions from you on this.

I think to your first point about who defines the package, so I think one error we've made globally is trying to have -- and I will completely confess to participating in this activity myself at the U.N., where we try to say here are the 12 services. And we've been in this exercise, as you well know, since the -- well, since maybe Alma-Ata, but certainly since the '90s with the World Bank, '93 report and WHO and so on.

And I just -- in my work in countries and with governments, I do feel these fall rather flat, both in terms of ministries of health, although I think they look at them, but also in terms of consumers. And what are people looking for from the health system?

So as I mentioned, for example, the lowest level of the health system frequently provides -- if you look at their list of provided services, which often they post even on the walls of a dispensary, you know, they really can check off most of those boxes that we, you know, we promulgated in the Millennium Project and others.

But again, you know, I think defining the package is a rhetorical exercise. And it's perceived as that, I think, by ministries and certainly by people.

So I would say that the greater -- so yes, I think having some global understanding of what our basic services is helpful perhaps for the global conversation. I don't think that it's been dramatically -- that it's been all that impactful or powerful in countries in terms of bringing services to people in need.

So some -- so I think the answer would be some combination. And I think individual countries have also their individual priorities which they would want to -- so, I think, customizable packages make a lot of sense.

But then I think, coming to the who implements it, it's interesting you ask about vertical programs and their role in universal health coverage, because I've actually been involved in some of these debates recently with the CDC and PEPFAR and the Growth of Global Health initiative, of course. And it's struggled to define how our joint struggle, I would say, to figure out how we're going to get more health out of essentially the same (bucks ?), and not just for HIV patients, but for women and girls and others.

So you know, to the -- so let me maybe put it this way. I think to the extent that some of these vertical programs or categorical disease-focused initiatives, such as PEPFAR, but others, malaria initiatives and others, can show us what great quality looks like, I in fact think we can learn from them.

I do not think that health systems folks and vertical program, you know, communities or supporters need to be at loggerheads here. In fact, the study I briefly referred to, in Tanzania, is exactly an example of that. We proposed to the NIH that, look, PEPFAR has invested millions in that country. It has great antiretroviral coverage there. And yet, again, half the women are coming to health facilities to deliver because they're a much more straightforward (service ?).

So in many ways, it's a one-off, right? Instead of a chronic, lifelong disease, why can't we make it better for these women, to make quality of care better?

So we actually proposed lifting, hopefully lifting, three or four quality-improvement strategies from HIV and transplanting them onto the rest of the health system. And then, of course, the challenge here is to make sure the health system doesn't collapse under the weight of all that. And I think that's one of the big issues in sustainability.

So I would argue that some of these vertical programs with their focus on quality have actually raised the level of ambition. We're just right now submitting a paper showing actually pretty positive synergies between measures of quality of HIV programs and maternal health utilization in the same facilities.

I do think that potential exists. But it can't be harnessed unless we think differently, which is that quality has to be uppermost in our considerations and expanding coverage to these other services.

HUANG: And actually, we saw the same experiment actually in Rwanda -- (inaudible) -- actually experimenting of supporting the entire health system instead of just treating the three diseases (she ?) has named. So it's -- so I think there's a report in The New York Times last October on that.

Harry?

QUESTIONER: Thank you. Actually, Margaret, I found your remarks more pessimistic than Michael's. And I thought I would add to that.

As chronic disease becomes a greater and greater, let's say, recognized burden around the world, and the time for intervention is during a period when the patient is asymptomatic, then you have the added burden of getting people involved in your system, whatever it is, without symptoms. That's a hard sell here. It took us 70 years to get 50 percent of hypertensives to go, in the most expensive system known to man. And so doing that abroad and in developed countries is going to be extraordinarily difficult.

And if you put a financial barrier where the patient pays for access, then you cannot make probably any headway. And telling somebody in Mumbai or in Dar es Salaam that they have to pay to get a treatment or an assessment of a disease that won't have an effect in 25 years is not an effective marketing ploy, at least.

So in a lot of the developing world, there is a move to go from -- to get lower and lower the amount of money the patient pays for access. I mean, here we're doing the reverse. We cut our health care bill by cost shifting, nothing else, no reform, just shift the cost to the patient. And this is going to be a huge problem when the global health, you know, health community starts to really adopt the need to approach chronic disease.

But the financial barriers would be just lethal to the chronic disease management.

KRUK: Yes, I couldn't agree more. In fact, I am a huge proponent of no user fees. I mean, I think however the insurance model is structured, and I think the conversation we've had as well, you know, it cannot involve a payment, maybe any payment actually for the very poorest, at the point of care. And so prepayment, which is what, you know, we're all talking about, is required.

So I couldn't agree more. I do think that chronic disease is a great example of expanding the package, right? The reality is, right now, blood pressure cuffs in many of these first-level dispensaries don't work or are missing or are fully occupied in the neonatal care clinic where blood pressure, you know, checks happen. It's not even on the -- you know, it's not in the mind-set of providers.

We had at the Mailman School of Public Health, we had 10 or 15 sub-Saharan African health ministers a few months ago talking about noncommunicable chronic disease, and they all agreed they need a stronger health system to be able to deliver those services. That cannot happen in isolated, siloed, vertical programs.

Again, as the U.S. government is realizing, PEPFAR, you know, this is a legacy program. We're in it for life of these folks. Obviously the same for many of these diseases. And yet, what was really fascinating to me is just watching them just kind of throw up their hands and say, where do we even start with this, because we're so far from reaching our -- fulfilling our agendas on the communicable side, and you're all telling us now we need to invest in the NCDs.

And I just think the only common denominator in this discussion is the health system. Because if we don't make that strong and resilient, we're certainly not going to achieve either of those two.

HUANG: Thank you, Margaret.

Ms. Alina (ph)?

QUESTIONER: Thank you. That was definitely very interesting. I have two questions: a simple one to only Dr. Chen, and a broader one to the whole panel.

The alarming issue of 20 visits per month or whatever, 200 a year, I mean, what percent of beneficiaries are we really talking about so that -- I mean, we generally understand how much of an issue this really is?

And the broader question is, as we talk about the meaningful or quality universal coverage, what other models are there other than a prepayment health insurance model that we are looking at? And this may be -- I don't know if you want to open it up to others so that we can talk about other examples that may be more relevant in low-resource context, that have worked.

HUANG: Margaret, that's your question again?

(Cross talk.) (Laughter.)

CHEN: Well, if you look at the statistics, Taiwan has like a 14 visit per year, per person. That is a little more than this country, probably only second to Japan or maybe another country, (Hungaria ?). I don't know what is going on (Hungaria ?).

Well, there is a -- as a health economist, I don't like to look at those numbers. However, well, by doing -- well, by receiving this many patients, probably there is a benefit in it, because on the one hand, you can find out the minor disease and get rid of the minor disease so that maybe you can avoid the more serious disease by doing this.

And then the other reason is a little political, because for a program like this, you want to have support from all the citizens in this country. And while some people would suggest that we take out, like, a common cold from the benefit package, so by doing that, a lot of people are not coming to pay a visit under the program, so why would they support this program?

OK, so that is --well, if you try to put the thing under the positive light, that is one way to answer your question.

KRUK: And actually, I want to comment on this one, too, wearing my physician hat. I no longer see patients. But in Canada, our way of dissuading, we didn't have such a sophisticated look-over-your-shoulder health information system. But I think what was really done was that the system sort of rations these visits. What happens is, when you have heavy utilizers, providers themselves will institute waiting times for those folks, so that it actually will become, you know, mathematically impossible for them to come 20 times in a month because you'll make them wait five days. You know that that's -- you know, they're not ill or they might need other services.

Of course, what we're always looking for is the how-can-we-help-you opportunity to ask that question, because obviously there are other things going on there that the health system is not assisting with.

So in Canada, I think I would say we would use wait times to ration even primary care access very informally and don't -- I'm sure the Canadian government would -- well, anyway, I have dual citizenship now, so I probably -- (laughter) -- (inaudible) -- American passport -- (inaudible).

OK. But on your harder question about what works, what other alternatives are there, you know, I think that, again, the WHO in its 2010 report, I think, did a very nice job of sort of scanning the horizon and looking at what's effective. Unfortunately in the lowest-income countries, that is a pretty small set of options. And that's, again, because of the just incredibly low funding base, the resource base.

In theory, we could contemplate the same range of options as we have here, with some mix of private and public or all public and tax-based or social health insurance. I think that a lot of the health financing community is coming around to social health insurance as perhaps a, you know, a more readily acceptable and implementable option than purely tax-based financing.

But I will say that there's been plenty of experimentation in the lowest-income countries. And one area that we know a lot about is community-based insurance where communities create risk pools in which they can cross-subsidize members. And on that, I think we have a fairly definitive set of answers, that it's really not a pathway, in general.

And I will accept Rwanda, although it is a special case, because their community-based insurance is not really just community based, it's got a lot of donor support and government subsidies built in. So it's some sort of a hybrid, I would say.

But in purely community-based models where people are paying ahead of time for services, either those schemes tend to be really difficult to scale up or they're not sustainable because, you know, small proportion of high-expenditure cases bankrupts those schemes.

So I think it's easier to answer what doesn't work than what does. In the remainder of the African -- sub-Saharan African countries, there's no insurance to speak of, but rather there's this guaranteed set of services that are available for free. And you know, part of my argument is that those services just are not good enough.

HUANG: OK. The -- (inaudible).

QUESTIONER: Thank you very much. I come from the population field. I used to work for the United Nations in population. And we know that the changes in life expectancy are not always driven just by the health care system. So -- and one of the problems is, as you were pointing out, does the population really understand what a health care system can deliver?

And I think the question asked by Mr. Greenberg is very appropriate. Unless people understand that disease can be affecting you before you notice that you're dying, they won't use the systems effectively.

So one thing I would like you both to comment on is, what element, if at all there is, in terms of either the health system or the government to think of educating people, and by that I don't mean in the educational system, about the importance of taking care of yourself in a more-enlightened way?

I know that in Africa, one of the problems that people have is that they always have relied on their traditional way of taking care of themselves, and they don't really trust the health care system to start with. So it's not only that they can access quality, there's no trust. And if one doesn't start building that trust, the other means that are not necessarily the clinic over there and you have to go there, you probably won't jump that barrier.

And I'm not sure that anyone is really focusing on that type of aspect.

CHEN: Yes. In Taiwan, health promotion is a responsibility for -- of another agency under the Ministry of Health. There is a Bureau of Health Promotion. And of course, they have a lot of programs for health promotion, just like in the United States. But what our National Health Insurance program does is to help them to efficiently take care of the reimbursement.

So if there is any medical causes involved in any activity of health promotion, like a smoking-cessation clinic and obesity clinic, et cetera, then we look at a budget from Bureau of Health Promotion and help them to reimburse. Because we have the routine connection with all the providers, so that makes the entire -- it is not directly contributing to health promotion, but -- (inaudible) -- job.

KRUK: Thank you for that question. I think you're very right. The focus of today's session is about the health care system and health services. I fully agree with you that the majority of determinants of longevity and health are outside of the health system, actually. And certainly start with education.

There was a nice paper that Chris Murray and colleagues published in The Lancet not so long ago that suggested that maybe 50 percent of the child -- the gains in child mortality, the reductions in child mortality, may be due purely to educating girls through high school level, you know, rather than anything done with antibiotics or in a health clinic.

And that's -- but I just would stress that I think based on that kind of, I think, that kind of evidence, at least my belief is that the educating people in general will accomplish much of the goal that you're looking for, which is making people aware and educated about what the health system can also provide.

I do think that Africa is covered under a deluge of promotional material, health promotional materials, like photos from many of the countries I've worked in where it's, you know, every tree, every facility has got what you're supposed to do with this pregnancy, what are signs of danger.

You know, health promotion has definitely been, you know, accepted and taken up by governments in very -- so could we use more of it? Probably.

But I think what we really could use more of is education, particularly to the secondary level or above, and I think that will take care of a lot of these concerns around understanding what the health system does.

And I think your second point, the one on trust, is a really interesting question. And I think this is where maybe some of my research and our team's research clashes a little bit with more of what I considered a kind of anthropological perspective on people and systems.

I don't think that poor people in rural areas are immutable to change or that change -- change happens very quickly actually. You can see that with mobile phones, where five years ago nobody knew what one was, now I can get a connection to any village and any village chief that I want. People are very eager to take on and pick up services and goods that they think will benefit them.

And I think -- so it's a two-way street. It's not just waiting for the trust to develop, but it's providing services that can help build that trust. We see this when people -- I just find this fascinating. People say, oh, no, women will never deliver, they're so used to the traditional birth attendant. We published a paper that said actually they fully realize a birth attendant isn't able to save their lives, but their choices are limited.

And also, you see this in the urbanization trends, which is that the women get to a city, suddenly they're delivering in the health facility and are doing -- and again, they're the same culture, they haven't shifted.

So I do think it's an interaction, a probably complex one, between individuals, their education level and their understanding of the system. But very importantly, what's available to them in that system.

QUESTIONER: What is your 50 percent figure includes? Does that include the U.S., the gain in child mortality?

KRUK: Oh, this was in -- this was a global figure. So the reductions -- well, the U.S. never had a -- was not a large contributor, of course, to child mortality, because our under-5 mortality levels are so low by global standards, not by developed-country standards, but by --

QUESTIONER: Not by developed-country standards.

KRUK: No, by developed-country standards, we are an outlier in the wrong direction.

QUESTIONER: May I ask one?

HUANG: You have a quick follow up?

QUESTIONER: Yes, because, you know, we study everything, and everything does better with education. But my problem is that I know the numbers of people that are coming up, the cost of education, and you're not going to save children's lives by waiting to educate all the women that haven't been educated already at the secondary level. They haven't -- many haven't even finished half primary and a lot of them are illiterate. So the interventions that are needed now need to be done to the mothers that are not going to get the secondary education.

We also have -- (inaudible) -- with how to educate people of having reduced fertility and having reduced child mortality. So there are other interventions.

The problem that I see now in these multinational comparisons is that, of course, the countries that have better child mortality also have better education. So that's what this is picking up.

And we know that on health, even in Sweden, there's a gradient with higher education, you (die ?) less. But it's not clear that education in the form of -- (inaudible) -- is necessary for these changes. That's the question. What else is acting up?

And I think there's more of a need to bring in these other factors that could be changed possibly. Quality might be an important thing, but all services. But not to wait because everything I hear is educate them -- yes, when? And will that really change if you don't -- suppose you never change the health system and you educate everyone, will that still reduce mortality as much? I'm not so sure.

KRUK: Just a quick response. I couldn't agree more. We need to proceed on two tracks. I think we're all in the business to save lives.

HUANG: Laurie -- (inaudible).

QUESTIONER: I'm doing the one-finger rule. I'd like to bring us back to the topic of today's discussion, which is trying to build sustainable universal health coverage. And back to the question I asked Margaret before about, you know, who decides what's in the package and defines the package?

I'd like to ask Michael and also -- well, Margaret, you probably want to chime in on this, too.

One of the debates that's been unfolding is for countries, particularly emerging-market countries or middle-income, that are trying to roll out some form of universal health coverage is, do you do it in gradients? So do you decide on a certain set of basic services with an intention to add to the service list over time and build a long-term sense of financial capacity to grow over time?

Or do you come in shock and awe -- (chuckles) -- and give the nation this huge package and -- boom! -- hope that you get the buy-in that creates the consumer demand and expectation and utilization?

So what do we see when we look at the landscape out there, what works, what doesn't work? Which is the better way to go, or is there a better?

CHEN: Taiwan, prior to the implementation of the NHI, we already had several social insurance programs that offered health component. So when we implemented the program, we just took out the health component from those programs and put them into one now-single-payer system.

So in order to have an easy start, we did not change a lot of things among those programs. Well, whatever people already had, we kept that, OK?

But in order to meet the people's expectation, we will occasionally add more and more items to the program. And right now, well, let me quote a professor from Princeton. She says that Taiwan's system covers virtually everything under the sun. So for instance, for the drugs, the program covers more than 16,000 items on that. And -- (inaudible) -- to enlist more items or more services to the package, we have a committee comprised of the people from the government as well as people from the professional groups. So they will meet and determine who is going to be added to the program.

And I want to emphasize that our people in Taiwan are so impatient, so they won't wait (with sickness ?) to take their case to the media. So the process is quite quick.

For instance, there was an example, there was some kind of drug for -- (inaudible) -- disease because it was -- (inaudible) -- we didn't even know if there are anyone had that kind of problem. But, well, this patient just took his case -- (inaudible) -- the media. And well, we have expedited process to consider that item. And in a matter of, like, a couple of weeks, we had that item included. So --

QUESTIONER: Just give us a timetable. At what point do you introduce universal health coverage with your base plan?

CHEN: 1995.

QUESTIONER: So between 1995 and today, you go all the way up to 16,000 indications that are covered.

CHEN: Six thousand drugs -- 16,000 items that --

QUESTIONER: Items are covered.

CHEN: Yes.

QUESTIONER: Wow.

KRUK: Well, so just quickly, so obviously, that's very far out of the reason of low and middle-income countries. I think that the word "comprehensive" means different things to different people, obviously, but I do think there's a threshold below which people just don't buy it, don't think that it's -- you know, back to a discussion -- many of us in public health recognize that people don't value preventive health services. We've talked about that already. If that's what you provide, you're going to find no buyers for that insurance.

If you add on a few, you know, primary care services, that is not what frightens people. What frightens people is getting really, really sick, needing to be in the hospital. On the other hand, if you only sell catastrophic insurance, you know -- so your package has to hit some -- the happy spot between being, of course, affordable, but having enough things in it that people will find it of value.

And I actually think we have ways to assess what people are looking for. Let me give you an example of Ghana. You know, when I looked -- and I work in Ghana and looked at their package, the scope of their package, it's certainly a longer list of services, even in a low-income country, than either the Millennium Project or the World Bank or the WHO would say should be in a package.

For one thing, although we're all obsessed with the Millennium Development goals, Ghanaians also care about appendicitis, and they really care about broken legs. And they want treatment for injury, they want treatment for mental health issues which are a huge, still under-recognized agenda.

Liberia, post-conflict country with no money in the health system, is adding mental health to its basic package.

So I do think that, a, it has to be some customization; but b, it has to be robust enough to seem credible to the population or to be valued by the population.

HUANG: Margaret, I have just a quick follow up. This may be also about sustainability issue, all of it. Yeah.

In some countries, they have multi-tiered system, right? When we talk about universal health coverage was, like, giving you an impression that it's a one, single, universal package, you know, that covers everybody. But in some countries, including China, they have a multi-tiered system, even though they claim it's a universal health coverage. But they have, like, three -- a list of three systems that covers urban residents, rural residents and government officials. Yeah, actually -- (inaudible) -- employees, respectively.

So can we call that real universal health coverage, as they claim?

KRUK: Well, I think it's not so -- I mean, I think kind of a patchwork approach to the -- you know, is not so different from many social health insurance models where you're covering your formal sector employees under one, you know, cover and then using some of their funds potentially to cross-subsidize a broader service.

In fact, Ghana does this. It has multiple kind of versions.

I think what matters there for the social -- for kind of the social-cohesion aspect of this is that there be a floor that everybody understands. That whether you're in the -- a civil servant or you're informal -- (inaudible) -- on the street, a merchant on the street, that, you know, there's a certain floor below, you know, I think below which people won't get behind it.

HUANG: (Inaudible.)

QUESTIONER: Thank you. I'm with the World Health Organization office here in New York. When we talk to the member states and we mention that more than 1 billion people cannot use health services either because they cannot afford it or it's simply not available, most of them think it is another figure. But we've seen in the last few months in particular, when we say people are impoverished because they cannot access health services, and they're also impoverished because they cannot work, this makes sense and it resonates with the diplomats in particular.

And I was struck by what you said, Margaret, about the African health systems which we all know are overburdened. A country like Rwanda, which has received a lot of attention because it was one of the eight pilot countries, is perhaps not a very good example to use.

Ghana and South Africa are leaning more towards the middle-income than the low-income side.

But if we look at the statistics that indicate more than 50 percent of people in Africa and Asia will be in (service ?) in (2015 ?), 30 percent of them will be living in informal settlements or slums, which will exponentially add to the burden of chronic disease.

This kind of (lot ?) of capacity in low-income countries, and Africa in particular, is a serious challenge, which I wonder if you have any thoughts on how African countries and low-income countries, that is your research are looking at this? And what kind of -- you addressed this already just now -- what kind of minimum standards or minimum basic package of services should be delivered at the point of care?

KRUK: Yeah, you raise another really important assumption for us to question, which is that most of our vision of Africa is rural. For most of us, that's what we imagine. And certainly, that's an area with very large problems, but so is this new and growing group of folks who are living in informal settlements. Where we actually see this -- some studies showing that, depending on country, in Kenya, for example, some of the both access figures and also health outcomes can be worse in these informal settlements, as you know, compared to villages.

And I think that here this is, I think, a wonderful area for a public-private sort of thinking, at least. You know, we talk a lot about private-public partnerships, and I'm quite skeptical of what they can accomplish in countries where people just do not have money for private services, private health care. They have very little disposable income.

I think, however, in informal settlements, we've seen good examples in (Kabara ?) and other parts of -- kind of creative thinking. You know, in areas without sewers and without water systems and toilets, you know, setting up clinics that may be staffed by private providers, there may be in those instances where some co-pay because people are earning some money. I think it depends very much on what the local situation is.

But what I do agree with completely is that the health system, the strengthening of the health system for that population is absolutely essential, but it has to go hand-in-hand with all the determinants of health -- the sanitation and the water supplies. And I think if we see them as that basic package the government owe those populations, in a sense it's not different than the other priorities that they face.

HUANG: Great. James?

QUESTIONER: Thank you. I'm James Tunkey. My question is for Dr. Chen, Professor Chen.

It seems to me that Taiwan enjoys this unique mix of a benevolent society as well as a democracy. And I think you've done a nice job of speaking a little bit to how you've -- the system has chosen to manage access to care.

But I'd like to draw you out a little bit more on management of lifestyle, in particular problems such as obesity or smoking. If "health" is defined as DNA, lifestyle, access to care, and the environment, it seems like you've done a reasonable job in Taiwan of addressing access to care.

How is lifestyle being addressed? And what can we learn from Taiwan as a democracy?

Thank you.

CHEN: Lifestyle -- well, in Taiwan -- thinking -- (chuckles) -- OK --

QUESTIONER: Unprotected sex, a variety of things.

CHEN: Well, when I visit Korea, I always have difficulty handling the problem of drinking, because of you don't drink, well, probably I'm going to hurt diplomatic relationship between the two countries. So I try to avoid going to the country. Well, in this country, well, it is OK, because even you have a glass of wine, it's (wrong ?) of you, nobody will urge you to drink anything.

What I want to say is, in Taiwan, everything goes. And well, maybe some people talk about the big brother problem. Actually, the government in Taiwan -- I should say, politicians in Taiwan are extremely reluctant to impose any restriction on freedom of choice, freedom of anything.

So pretty much that the government, especially the Bureau of Health Promotion, will do a lot of work trying to promote health, healthy lifestyle. We have a program for health promotion hospitals and healthy schools, et cetera.

But in other regards, for instance, there has been a lot of talking about imposing tax or surcharge on alcoholic beverage. But it's not easy to implement it. Up to this point, we only implement surcharge on tobacco as a supplementary revenue for program. But I don't see that kind of things in the pipeline for other items, even (not include ?) -- (inaudible) -- which has a lot of negative effects on people's health. But that is so difficult because a lot of people like that. And it's very difficult. So many people have their income relying on that kind of product, so the government has been reluctant to impose anything on that.

So of course, there is a long way to go that we can gradually convert people's lifestyle and make a good lifestyle healthy.

HUANG: Margaret, do you --

KRUK: No, no.

HUANG: OK. Karen.

QUESTIONER: Hi. Karen Sealey from the World Health Organization. I am from the -- (inaudible) -- regional office of the Americas. Thank you very much for the very stimulating discussion.

I couldn't help thinking that in all of the discussion so far, I haven't been hearing -- we've been touching on the role of the community to participate, coming around to, and I haven't heard anything about primary health care. So in the definition of what should be the services, we seem to have forgotten that we do have a philosophy that's encouraging the countries to do for themselves to choose, I do think, to choose those services.

And I want to give you an example of how important it is for the countries to do that. In one country in the Caribbean, I went in the country, in which perhaps the minister got ahead of himself in terms of wanting to provide free drugs. The cost of the free drugs are now -- it's not sustainable. And so in fact, the government is having to reduce the number of drugs on that because of the number in this country, they spend 8 percent of the GDP on two chronic diseases -- 8 percent of the GDP.

And now that the community has been asked to -- and the question that they are asking is, why didn't you involve us at the beginning when in fact you thought you were doing a good thing in increasing the number of drugs?

So I think it's -- I don't see how we can escape involving the communities, whether it's at a rural level, even if it's in an urban level, for them to make the choice, because it is they who are going to have to bear the costs in one way or another, whether it is through taxes or what.

And then I wanted to make a comment in fact to Taiwan, to Dr. Chen. And link to that -- I had the privilege of visiting Taiwan about 12, 15 years ago. And I was impressed at how Taiwan was, at that time, trying to transform what they were calling their army of nurses, community health nurses, who were focusing on maternal and child health, in fact the health promotion at the household level.

And I'm linking that to a question for you, Margaret. To what extent are the countries, the low-income countries, have the capacity to transform their services? I mean, you know, you get a little bit some things come, projects being done here and there. But which country is in fact transforming their service sustainably, do you think?

KRUK: Well, so the participation of communities is, I think, one of those things that is very frequently mentioned and very rarely implemented in a meaningful way in countries. And I think even ministries of health speak it. It's become part of the language and the framing the posturing frankly is my personal opinion.

Interestingly in one of the studies I referred to, we specifically used a variable that said I consider myself involved in the design of the health system, which the World Health Survey collected. And that was very strongly associated with people's trust in government and trust in the system.

And so I couldn't agree more that that participation is essential. I think that we can have a probably longer debate about whether Alma-Ata pushed too much responsibility onto communities in the sense that communities have to also live their lives and don't only have health care to worry about, but many other things, and may not be able to run the micro health systems all by themselves.

But I couldn't -- I fully agree that without that insight from women, from men, from their families, we can't do it. And in fact, that's actually a lot of the focus of my research. I felt that we hadn't heard from the patients, and now we do population-based studies in which we ask people, what is it you want from the health system, how should it look, what's an optimal clinic look like? And I think that's then going to help us to rationalize and prioritize the services.

And for example, just to be radical -- onto your second question about how do we reorganize and which countries have the capacity -- maybe -- maybe -- having a million clinics in every village, which is what the current president of Tanzania is committed to as part of his platform, building a facility in every village is really maybe not the answer.

We've seen that people will go a little farther if they can know that that's a good service. And so I think, you know, here's where politics and evidence and effectiveness issues clash often, because health services are visible, and everyone wants to claim they train x doctors or built x clinics. And I think we have a huge disconnect actually between what we're finding and what -- not just we, but what the evidence is and what's happening.

CHEN: And may I make a comment?

HUANG: Uh-huh, go ahead.

CHEN: Well, I would like to make a comment on Karen's comment. Well, Rome is not built in one day. So it took us several decades trying to spread out medical resources across even just a small island. So when I heard China is going to pump a huge amount of money and claim that everyone will be covered in, like, one or two years, well, I couldn't believe that, because I think that it's been, like, 20 years or even longer just try to spread out the resources. Otherwise, it doesn't make sense to have insurance (resources ?).

HUANG: OK. I'm going to -- we only have five minutes left, so I'm going to collect all -- I think we have three questions left. Betsy, Julie and Ben -- have I missed anybody? Harry. Oh, you already asked one, so we'll skip you this time. (Chuckles.)

(Off mic commentary.)

Yes, please.

QUESTIONER: Hello. Julie O'Brien from Management Sciences for Health. First I want -- (inaudible). You both have mentioned the private sector or public-private partnerships. And the question is, what do you see their role in sustaining universal health coverage in the larger picture?

HUANG: Betsy.

QUESTIONER: I assume you're trying to rationalize a model that people could adapt. So how are you going to rationalize it? And what would be the criteria?

Because in the United States as well as in Japan and other European countries, the aging are taking up most of the money and the time. So how do you rationalize that? And also, the addiction problems of the young, I mean, how do you decide what are the priorities?

HUANG: Ben?

QUESTIONER: Ben Liebman, Columbia Law School. I have a very specific question about Taiwan, although it has implications for China and the rest of the world. Which is, in your view, how integral is the process of democratization, full democratization happened in '96, to the creation of national health insurance? And could this system have been as successful or sustainable without democratization?

KRUK: So thank you for these questions. On the public-private partnerships, I, again, I think this is another area where rhetoric out paces real action and real evidence of effectiveness. I think one area that is very much under-explored is the notion of management and management competence, which we know private sector, particularly large, multinational companies that have managed, you know, to adapt their services to different countries, to different audiences, to different funding systems, cultures and so on, they have a huge amount of that knowledge and information inside their organizations, and I think finding ways to share that.

So, you know, we have a lot of corporate social-responsibility efforts, very few of them are actually focused on what I think are the core competence of the private sector, which is management, and that is a huge missing link in health systems in Africa.

So here's, I think, a tremendous opportunity for a company to say, you know, I'm not going to give drugs or donate my time, but I'm actually going to bring some of my best managers to sit with you and look at a district health system and see how we could try to run that better, even with existing resources. So to me, that's very much under-explored.

And then I think the question about how do you rationalize and set priorities, as you know, there are major global initiatives to help with priority setting, such as the burden of disease work that's ongoing right now, where in fact colleagues are working in Australia and throughout the world on redefining what's killing us and also what's making us sick. And those are, of course, different things.

So where we look at what's making us sick, mental health ends up being extremely high on that list, in fact first or second. It may not kill us, but it makes us miserable.

And I think that kind of evidence, including diseases aging -- which by the way, interestingly, noncommunicable diseases are very prevalent among the young in low-income countries, where here we see them among the older ages. So that kind of information is absolutely critical to a country, to a government, before -- and to all the development partners before it can really decide what to fund.

HUANG: Michael?

CHEN: The implementation of NHI in Taiwan had a lot to do with the democratization process there. But I want to emphasize, there is a very important difference between the relationship between health care and democracy in Taiwan versus in this country.

I think the major difference in this is, which is very relevant to policy formation, that is, we don't have ideological problem. So every political party -- if one party proposes something, the other party will only add more and more. And sometimes, they add so much that the system breaks down under its own weight.

And I understand that's not a situation in this country. (Laughter.) So -- but there are still some things similar, that is, in Taiwan, it took a lot of political will to -- (inaudible) -- over all the (resistance in the way ?). And in the end, the program benefited virtually everyone in Taiwan. So you can just insist doing the right things at the right time.

HUANG: So I assume that in Taiwan, this universal health coverage is like a politically-neutral party, correct? So every party is actually (on ?) in that -- (inaudible).

CHEN: Yes. And sometimes we just need to -- because the other party will just add more and more. So the problem is, well, not to defend your own proposal, but to protect, well, we are not going to do too much.

HUANG: OK. (Chuckles.) Well, thank you, Michael, and thank you, Margaret, for this fascinating -- (inaudible) -- discussion. (Applause.) Very much appreciate it.

Like to also thank the Rockefeller Foundation, so Robert, for the general support to make this roundtable series possible.

I'd like also to thank our RAs, research associate interns, for their help in organizing this roundtable, and particularly Zoe, you will have probably met Zoe Liberman. She's played actually a critical role in organizing this roundtable, and to also -- (inaudible) -- Lee and Catherine (sp), that they also helped.

I'd like also to thank Taipei Economic and Cultural Office in facilitating Michael's trip to New York.

And last but not least, thank you all for coming and participating and making this a stimulating and fruitful discussion.

And just to let you know, this is the second of our series on universal health coverage. Our third meeting will be in mid April. I think it's about April 18th where we're going to release a report on universal health coverage. So stay tuned. Thank you. (Applause.)

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