2030 AGENDA FOR SUSTAINABLE DEVELOPMENT

Deliberate Next Steps toward a
New Globalism for Universal
Health Coverage (UHC)
Gerald Bloom (Institute of Development Studies)
Yasushi Katsuma (Waseda University)
Krishna D Rao (Johns Hopkins University)
Saeda Makimoto (JICA Research Institute)
Gabriel M Leung * (The University of Hong Kong)on behalf of the Working Group on UHC of T20 Task Force 1 1
Submitted on March 15, 2019
Revised on March 31, 2019

Abstract
Much effort has been expended on promoting universal health coverage (UHC). We focus
on four areas that, on current trajectories, are unlikely to achieve sufficient progress tomeet Sustainable Development Goal (SDG) 3.8. These are also issues for which G20 can
provide significant traction. The principle of “leaving no one behind” is central to UHC.
Migrants and migrant health workers are too often overlooked, as is genuine support for
primary health care at the community level. Prioritizing reliable domestic financing
requires enlightened leadership and deliberate dialogue between finance and healthministries. Harnessing, and regulating, innovation for a future where multi-omics,
immuno-biology, artificial intelligence, social communications and health care converge
against threats from climate change, humanitarian crises and emerging and antimicrobial
resistant infections requires judicious planning. Finally, mutual learning and harmonized
aid amongst countries remain unfulfilled priorities of good governance.
* Correspondence to gmleung@hku.hk
1 The member list of the working group is in the Acknowledgments.

2030 Agenda for
Sustainable Development
Challenge
1. Leaving no one behind
Substantial inequities in access to care continue to persist within as well
as between countries. Vulnerable populations face a higher burden of
morbidity and premature mortality due to easily preventable andtreatable causes. Their limited access to affordable and quality essential
services, as well as underinvestment in primary health care systems, is amajor impediment to achieving UHC. Such inequities also threaten humansecurity [1].
Access to health care is an important concern for all vulnerable groups, such as
the poor, older people, women, children, minorities and migrants. Some ofthese have been the focus of ongoing national and global efforts for redress.
However, global migration, especially related to migrant workers poses uniqueand so far neglected challenges to UHC progress. There is a significant increasein the global movement of people due to economic, political, conflict, andenvironmental reasons. Protecting the health of migrants is challenging forboth high and low income countries. Information systems on migrants are
weak. Migrant workers often work in difficult and dangerous environments andhave limited entitlement to health care in the host country or when they returnhome. Further, the migration of health care workers often depletes the abilityof resource poor countries to provide health services to all citizens.
2. Prioritizing reliable domestic financing and cost-effective best buys
Social, economic and institutional transformations require innovative financing
to sustain the provision of adequate health care domestically in all countries.
Additionally, health development assistance should be re-designed to support
countries to transition toward reliable self-sufficiency. Implementing either orboth remains a vexed challenge.
3. Harnessing innovation and access to technology and medicine judiciously
Technological innovations in health care (pharmaceuticals, diagnostics,
devices etc.) and in information and communication technologies have thepotential to substantially accelerate progress towards UHC. Markets, on
their own, are unlikely to produce innovations that increase access at scale22030 Agenda for
Sustainable Development
and on a sustainable basis. There is also a risk of undesirable outcomes,
such as the emergence of antimicrobial resistance, rapid increases inhealth care costs and the exclusion of some people from access to medicalcare.
4. Supporting common monitoring mechanisms, mutual learning platforms, andcoordinated international cooperation for UHC
Common methods that would make cross-country data on UHC monitoring
directly comparable are unevenly deployed, mostly due to variable
technical competence and non-standardized approaches in data collection.
While countries take different paths towards UHC, there are common
lessons. However, they have not been effectively shared.
Individual G20 members already provide technical and financial support
to global partners and other countries, albeit in an uncoordinated,inefficient and non-transparent manner.

Proposal
1. Leaving no one behind
1-1: Strong primary health care for health equity
Strong primary health care (PHC) systems are effective in reducing
inequities of access, through the core principles of first-contact, continuous,comprehensive, and coordinated care [2–4]. Following the Alma Ata
Declaration that was recently reaffirmed in Astana, PHC, with its relianceon community health workers, basic curative health interventions, andfocus on preventive and promotive care and empowerment of individuals
and communities, is a proven means of advancing UHC.
Strengthening PHC systems to reduce inequities requires action on many fronts
but two issues are particularly important for governments. First, domestic
financing and development aid should emphasize investments in essential
services that can be provided locally at the community level and by basic healthworkers. Making essential medicines universally affordable and available is32030 Agenda for
Sustainable Development
critical. The emergence of HIV/AIDS and resurgence of tuberculosis andmalaria have focused global funding towards the control of these emergencies.
While major progress has been achieved, this was often accomplished bybuilding parallel financing and delivery systems [5]. G20 and development
partners should bring about a renewed focus on PHC systems by making
comprehensive care central to activities, with particular attention to
marginalized groups. This includes bringing a PHC systems strengthening focus
to global disease control programs. In particular, G20 should promote bettermeasurement of PHC systems performance and support and expand ongoing
efforts such as the Primary Health Care Performance Initiative (PHCPI –https://improvingphc.org).
Second, population aging and the growing burden of non-communicablediseases (NCD) pose new challenges to country health systems. The global
population aged 60 years or over was estimated at 962 million in 2017 and, is
expected to double by 2050 [6]. Two-thirds of the world’s older persons
currently live in low- and middle-income regions [6]. The preoccupation with
infectious diseases and reproductive conditions has shaped the organization of
PHC systems in many countries. Older people, however, are more likely tosuffer from NCDs that require sustained care. The development assistancepolicy of G20 members should encourage investments in re-orienting PHC
systems to integrate packages of cost-effective promotive, preventive andcurative NCD interventions, such as those identified in the Disease Control
Priorities, which can be delivered through population-based, community,
health center and hospital platforms [7].
1-2: Health of migrants and health care worker migration
There were 258 million migrants in 2017, representing 3.4% of the world’s
population [8] (Figure 1 (a)). People leave their homes to relocate within or
across national borders due to economic, political, and conflict-related reasons.
While the health of all migrant groups is equally important, the right of migrant
workers to health care in destination countries is much debated.
Crossing national borders to work is one of the key motivations behind global
migration. According to International Labour Organization (ILO), there
were 164 million (64% of all migrants) migrant workers globally in 2017 [9](Figure 1 (b)). While the United Nations General Assembly recently endorsed
the Global Compact for Safe, Orderly and Regular Migration supporting the42030 Agenda for
Sustainable Development
right of migrants to health care and encouraging countries to incorporate theirhealth needs into policies, there remains too little attention given to the health
implications associated with migration [10].
G20 members, many of which are important players in global migration [11],should spearhead inter-governmental action to establish reliable information
systems on migrants. This includes having an agreed set of standardized,
publicly available migration indicators that source and destination countries
collect [12]. Further, it is important that routine national statistical systems
also include and identify migrant populations. This can help governments
understand the scale of migration, develop evidence-based policies, and toknow the extent to which refugees and labor migrants are able to access healthand other social services [8,12].
The productivity of migrant workers is tied to their health. Therefore it benefits
the host country to invest in their health [13]. In addition, the documented
migrant labor workforce contributes to the host economies through taxation.
Many migrant workers often perform jobs that have poor work environments
thus placing them at higher health risk while they may not have access to caredue to government policy, lack of citizenship, or clarity on legal status [14].
Some destination countries extend health care coverage to migrant workers,
their families in the home country, and offer portability of health benefits when
migrant workers return home [15].
First, migrant workers should be offered similar access to health and social
security benefits in the country where they work as local workers [10,16].
Second, health benefits of migrant workers should, to the extent possible, becoordinated by both source and destination countries through mechanisms
such as bilateral social security agreements [14]. Third, G20 members should
explore the potential of extending health benefits to the families of migrant
workers and making health benefits portable such that such benefits will
become available to migrant workers after they return to their home country.
The migration of health care workers from resource-poor to high-income
countries can constrain the ability of source countries to benefit from theirinvestments in health professional education (Figure 1 (c), 1(d)). At the sametime, these workers are an important resource for both source and destination
country health systems. In return, migration offers health care workers
opportunities for better compensation and professional development. In 2010,
World Health Organization (WHO) adopted the Global Code of Practice on the5

2030 Agenda for
Sustainable Development
International Recruitment of Health Personnel to encourage ethical and fairhiring [17].
G20 action is necessary for systematically measuring health workforce mobility[17]. Additionally, G20 is uniquely placed to facilitate a shared understandingof the complex web of inter-relationships, at the country and global levels,
between workforce migration, health workforce needs, workforce planningand production. Such an understanding requires engagement with multiple
sectors – education, health and labor ministries within national governments,
international recruitment stakeholders, health professional groups, and UN
agencies including WHO and ILO.

Figure 1 (a) Total migration by source and destination region as estimated by UNDESA (2017); (b) Total labor
migration by destination region as estimated by ILO (2017); (c) Total foreign-trained doctors in destination
region of the OECD (2012-2016); (d) Total foreign-trained nurses in destination region in the OECD (20122016)62030 Agenda for
Sustainable Development
2. Prioritizing reliable domestic financing and cost-effective best buys
Health systems will increasingly need to adapt to rapid and interconnectedchanges, with a major impact on the demand for health services and thecapacity to pay for them. Population aging, the growing burden of complex,
chronic non-communicable diseases, developments in medical technologies
and the multiplicity of communication channels are driving increasing
expectations for medical care. This is happening, in many countries, at a time of
fiscal stagnation linked to population aging and changes in the labor market infavor of the informal economy. Countries are at risk of a variety of shocks
related to climate change, economic transitions, pandemics, amongst otherthreats. These can affect both the demand for health services and the resources
available to pay for them. The patterns of inequality and of population groups
at risk of being left behind are also changing. Access to health services can makean important contribution to the ability of individuals and societies to adjust tochange. Also, recent experiences with humanitarian crises such as the Ebola
outbreaks have demonstrated how the lack of effective and trusted healthservices increases the risk of major shocks.
Many G20 countries are implementing innovative approaches for coping with
rapidly increasing demand and/or challenges associated with fiscal stagnation[18–21]. Whereas mobilizing domestic resources to reliably finance needed
health care is crucial, fiscal discipline in resource allocation and spending isequally critical to ensure long-term sustainability. One example is Japan, whereclose collaboration between the Ministries of Health and Finance, throughperiodic social insurance fee schedule review, have enabled it to control overall
expenditure while meeting the health needs of a rapidly ageing population [22].
We recommend that the G20 support systematic studies of their own country
experiences with health finance and establish mechanisms for mutual learning
about what works, how and why, involving ministries of finance in addition to
health.
G20 members have mechanisms to ensure that their less-developed
subnational regions receive appropriate financial support for health services.
Some also provide health development assistance to low-income countries. We
call on G20 to continue providing financial support for countries and regionswith very limited capacity to sustainably finance effective health services. The
form this support takes needs to take into account big changes in economic
development. A number of countries and regions are experiencing increases in
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Sustainable Development
average income, especially in rapidly growing urban areas and in resource-rich
localities. Their governments face special challenges in establishing effective
and reliable mechanisms for financing health services that meet the needs ofall. We call on G20 to reallocate its health development assistance gradually to
areas with the greatest need, while providing support to other areas to become
self-sufficient. This will involve providing opportunities for mutual learning
about effective strategies for health finance, support for strengthening healthfinancing institutions and tapering of support to avoid sudden shocks. We also
call on them to establish coordination mechanisms to ensure that assistancecontributes to the establishment of long-term, sustainable health financing
solutions.
Increased health finance needs to be complemented by measures to ensure that
resources are used well. One important area for intervention is on access toeffective and appropriate drugs. This requires measures to reduce their cost to
patients and ensure that their quality is good and they are used well. This isespecially important for antimicrobial drugs because of the healthconsequences of treatment failure and the risk of antimicrobial resistance.
Commitments by G20 to invest in antimicrobial drug discovery must becomplemented by measures to increase access to treatment and improve
management and stewardship of such drugs [23–26]. Low-income
communities require financial support to purchase and distribute these drugs,
as is already the case with the treatment of tuberculosis, malaria and HIV/AIDS.
Measures to reduce the cost of drugs should be complemented by actions toensure appropriate use, such as the introduction of treatment guidelines,
agreements by pharmaceutical companies to end incentives that encourage ahigh volume of sales and public information campaigns (Figure 2). Also, thedevelopment of affordable and good quality point-of-care diagnostics canencourage rational use. G20 should support the incorporation of thesemeasures into national action plans as well as development cooperation plans
for addressing the challenge of infectious diseases and making progress
towards UHC.

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Figure 2 Examples of how the UHC agenda and AMR global action plan converge
92030 Agenda for
Sustainable Development
3. Harnessing innovation and access to technology judiciously
Technological innovations hold enormous promise as contributors to rapid
progress towards UHC, especially in low and middle-income countries. This will
involve new forms of collaboration between public and private sectors.
Governments can make important contributions by creating an environmentthat encourages research and development, supporting measures to ensure
equitable access to technologies and medicines and creating regulations toprotect the public against unintended harms. UHC2030 (www.uhc2030.org)
has established a private sector constituency to support public-private
partnerships for meeting health care needs at scale. G20 should encourage andsupport this.
One important area of innovation is in information and communications
technologies, which have the potential to enable countries to leapfrog previous
ways of increasing access to health information and care and accelerating
progress towards UHC [27,28]. Bilateral development agencies andinternational philanthropies have invested in a number of successful pilots andsome large companies are investing heavily in the development of digital healthservices, but the impact on access to health services has been limited [29–31].
The factors listed below suggest that this is likely to change [32]:•rapid falls in the cost of smart phones and access to the internet andin the development of low-cost diagnostic technologies,•
the development of smartphone applications that link information on
symptoms and diagnostic indicators to advice on treatment,•
the emergence of business models that enable information platforms
to link to suppliers of goods, such as drugs, at scale and•the creation of platforms that maintain secure personal health records
and enable people to link to different types of health care provider.
Government action is needed to ensure that digital health and otherinformation-based technologies contribute to UHC, rather than to meeting theneeds of a privileged minority, to expanding markets for suppliers of drugs ordiagnostic devices, or to generate data for commercial use. Governments canwork with development agencies to accelerate progress by shifting investment102030 Agenda for
Sustainable Developmentfrom pilots to routinized efforts supporting the provision of bundled services
to meet needs, the development of new types of partnership between thehealth, technology and communications sectors and the creation of businessmodels that combine markets and public finance. This will require investment
in building the capacity of government agencies to provide effective
stewardship for digital health (Figure 3) [33].

Figure 3 Harnessing technology in pursuit of UHC

The increasing importance of digital health is creating new regulatory
challenges [28, 32]. How can new health platforms be influenced to prioritize
the needs of the public, rather than commercial interests? To what extent
should online medical advice be regulated and should algorithms be produced
and made available as public goods? Who should own the data from users ofdigital health services and who should modify treatment algorithms on thebasis of these data? How can issues of personal privacy be taken into account?
What are the implications of the development of these platforms for the
regulation of health care professionals?
Digital health technologies are potentially disruptive: leading to the creation of
new kinds of partnership between organizations in the health, knowledge andtelecommunications sectors; altering the relationships between individuals,
their families and usual providers of health care and creating new kinds of11

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distance services within countries and across borders. Recent experience has
shown that incremental changes can lead to a tipping point and subsequenttransformation of an entire sector. In some cases it has led to the rapid growthof large and very powerful corporations. This is a possibility in the healthsector, which could greatly influence future development. It is important thatgovernments put a regulatory framework in place before that point is reached.
We recommend that G20 establish a working group involving all relevant
ministries to work with their supranational interlocutors, as well as private
industry, to review opportunities and challenges associated with the rapid
development of digital health services and the deployment of disruptive
technologies. This group could identify areas for collaboration in accelerating
progress towards UHC and for establishing regulatory standards for digital
health services and systems. It could also identify the appropriate global agency
to support ongoing work on this issue.
4. Supporting common monitoring mechanisms, mutual learning platforms, andcoordinated international cooperation for UHC
G20 should support, amongst others, the Group of Friends of UHC and Global
Health in strengthening global and regional governance mechanisms for UHC,
working with UN member states at the upcoming UN High-level Meeting on
UHC in September 2019.
4-1. Common UHC monitoring mechanisms
The 17 SDGs comprise 169 targets, and in turn for each target, one or moreindicators are defined to monitor progress in the run up to 2030. The global
indicator framework for the SDGs and their targets were adopted in July 2017[34] and further refined in March 2018 [35].
Target 3.8 of SDG 3 directly concerns UHC for which two specific indicators
monitor progress in coverage of essential health services and financial
protection. The methodology and country data requirements of these
indicators are already defined [36]. The annual UN High-level Political Forumon Sustainable Development has a central role in the follow-up and review ofprogress towards the SDGs, receiving voluntary national reviews from member
states.
Current priority is for a common operational protocol that should be shared
between countries, especially those in resource-limited settings so that all
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member states could produce directly comparable statistics. A globally-sharedmechanism of technical support, sufficiently contextualized to allow for
between-country differences in data availability, including data disaggregation
to capture equity perspectives, amongst other variabilities, should beestablished to provide assistance in monitoring and evaluation of progress
towards UHC. In addition to formally tracking progress through the SDG
indicators, on-the-ground practical experience sharing and monitoring would
be important for operational improvement. G20, bilaterally or multilaterally
through international organizations such as the WHO, should help othercountries strengthen national capacities, introduce new facilitativetechnologies, improve health information systems, better analyze and use datafor improving resource allocation and operational management, and enhance
multistakeholder policy dialogue. Accordingly, G20 should provide direct andin-kind support to academic institutions in their own countries to further
develop a global technical support network.
4-2. Mutual learning platforms for UHC both at global and regional levels
Actioning the UHC agenda at the country level is vexed with difficult decisions.
Policymakers must decide which services to expand, whom to include as
beneficiaries or service providers, and how to shift from out-of-pocket payment
towards prepayment, and in what order, with a commitment to fairness andconsideration of social needs and political realities. These policies and theirimplementation should be developed based on evidence and social values withpublic participation, being accountable to the people [36].
Mutual learning between policymakers as well as health and finance program
managers and sharing of country experiences will promote progress. As there
are multiple paths towards UHC, empirical lessons and good practices of G20
members in particular should be documented with robust research evidence
and widely and effectively shared with those who are responsible for
implementing UHC in their respective countries.
We already have a number of such platforms, such as UHC2030’s UHC
Knowledge Hub and the Joint Learning Network, which can be further
strengthened to foster mutual learning at the global level in a coordinatedmanner. In addition, regional platforms, such as the Regional Observatories on
Health Systems and Policies, Technical Advisory Groups on UHC or equivalentat WHO Regional Offices, or ASEAN+3 UHC Network etc., should be enhanced
132030 Agenda for
Sustainable Development
to provide more timely and contextualized advice. G20 members should
proactively contribute to these mutual learning platforms for UHC both at
global and regional levels, also encouraging their academic institutions, thinktanks and civil society organizations to participate.
4-3. Coordination of international cooperation for sustainable UHC
While G20 members provide most of the available development assistance tolow- and middle-income countries, increasingly greater emphasis is placed on
mobilizing domestic resources within developing countries in achieving the
SDGs. The UHC2030 statement on sustainability and transition from externalfunding sets out key principles of sustainability and transition and encourages
all countries and health partners to invest in health in ways that will explicitly
sustain equitable coverage of essential health services, beyond the duration of
external financing [37]. G20 members should work together to help facilitate
this financing transition in developing countries, while harmonizing theircontributions in providing technical assistance at the country level, avoiding
duplications and filling gaps.
Recent G20 meetings have agreed on a coordinated global preparedness andresponse to health risks and on making connections and encouraging
partnerships between international stakeholders and national governments,
including those from non-G20 countries, for the mutual benefit of all and inorder to align activities and avoid duplication of efforts [38]. Similarly,
development partners, including G20 members, should consider harmonizing
aid for progress towards UHC within the existing health sector aid coordination
mechanism at the country level (Figure 4). While acknowledging that there may
well be a role for direct bilateral aid, G20 members should consider information
sharing on and harmonizing development assistance for UHC. The annual G20
Health Working Group meeting could serve as an initial platform for such
coordination [39].

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Sustainable Development

Figure 4 Congestion and gaps in a complex web of global health development aid in a
typical recipient country

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Health-Related SDGs. Geneva; 2108.

AppendixAcknowledgments
We thank members of the Working Group for the generation and discussion of
the content and review and comments by other expert contributors, as listed
below.
The authors however bear sole responsibility for this Policy Brief.
Working Group members:
Name
Pascale Allotey
Agnes Binagwaho
Gerald Bloom
Mina Chiba
Tomoko Fukuda
Piya Hanvoravongchai
Reiko Hayashi
Ayako Honda
Mihoko Kashiwakura
Yasushi Katsuma
Masako Kikuchi

Affiliation
United Nations University International Institute for Global
Health (UNU-IIGH)
University of Global Health Equity
Institute of Development Studies
Waseda University
Japanese
Organization
forInternational Cooperation in Family
Planning (JOICFP) as representativeof C20Chulalongkorn University
National Institute of Population andSocial Security Research, Japan
Sophia University
Bill & Melinda Gates Foundation
Waseda University
JICA Research Institute192030 Agenda for
Sustainable Development
Sengchanh Kounnavong
Soonman Kwon
Gabriel M Leung
Saeda Makimoto
Walaiporn Patcharanarumol
Krishna D. Rao
Gaurav Sharma
Tomohiko Sugishita
Jason Dean-Chen Yin
Yuta Yokohori

Lao Tropical and Public HealthInstitute
Seoul National University
The University of Hong Kong
JICA Research InstituteInternational Health Policy Program(IHPP), Ministry of Public Health,ThailandJohns Hopkins University
Global Development Centre (GDC),
Research and Information System
for Developing Countries (RIS)Tokyo Women’s Medical University
The University of Hong Kong
National Center for Global Health &Medicine(NCGM)

Expert contributors:
Name
J.N. Ahamarshan
Hirotsugu Aiga
Sandro Galea
S. Raghavendra Guru
Masaki Inaba
Mitsuo Isono
T C James
Ilona Kickbusch
Kiyoshi Kodera
Hoang Van Minh
Rintaro Mori

Affiliation
Independent researcher
Japan International Cooperation
Agency (JICA)
Boston University
Independent researcher (Instituteof Chartered accountants of India)
Africa
Japan
Forum
as
representative of C20
Japan International Cooperation
Agency (JICA)
Research and Information System
for Developing Countries (RIS)
Graduate Institute of Internationaland Development Studies
Overseas Development InstituteHanoi University of Public Health
United Nations Population Fund,
Asia and the Pacific Regional Office202030 Agenda for
Sustainable Development

Shintaro Nakamura
Joji Sugawara
Tomoko Suzuki
Takao Toda

(commented as an individual
researcher)Japan International Cooperation
Agency (JICA)
Health and Global Policy InstituteJapan Center for International
Exchange
Japan International Cooperation
Agency (JICA)

National Center for Global Health & Medicine(NCGM) and UHC2030 provided
comments as organizations.

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