22 June 2005 Tokyo Chair’s Summary High-level Forum on Health MDGs in Asia and the Pacific Introduction The Government of Japan, in cooperation with the Asian Development Bank, World Health Organization, and World Bank, convened the High-level Forum on Health Millennium Development Goals (MDGs) in Asia and the Pacific from 21 to 22 June 2005 in Tokyo. The Forum was opened by Mr. Ichiro AISAWA, Senior Vice-Minister for Foreign Affairs, Mr. Hiroyoshi NISHI, Senior Vice-Minister of Health, Labour and Welfare, and Dr. Shigeru OMI, Regional Director of the Western Pacific Regional Office of the World Health Organization, with the participation of Ministers in charge of development, finance and health (1 Vice Prime Minister, 7 Ministers of Health, 2 Ministers of Finance and 1 Minister of Natural Resources and Environment) and equivalent persons from 24 countries in Asia and the Pacific, 6 donor countries and the European Commission, international organizations, regional organizations, foundation and partnerships. The Forum took stock of progress and identified challenges and opportunities for accelerating efforts towards achievement of the health MDGs. Experiences and best practices from Asia and the Pacific will be an important input to the G8 Gleneagles Summit and the High-level Plenary Meeting of the United Nations General Assembly on the Millennium Declaration. The Forum participants expressed appreciation to Japan’s assistance and welcomed the new Health and Development Initiative of Japan. High-level Forum on Health MDGs in Asia and the Pacific will be followed-up through annual meetings of the WHO Regional Committees. Better health is central to the achievement of MDGs, both as an end in itself and as a major contributor to the overarching goal of reducing poverty and to economic growth. Asia and the Pacific, as a group, have fared relatively well in reducing poverty (Goal 1 of MDGs). However, most countries will miss the target under current conditions regarding reducing child mortality (Goal 4), poor progress is observed on improving maternal health (Goal 5), and majority of the countries are not doing well in combating HIV/AIDS and only modest progress is being made in controlling malaria and other diseases (Goal 6). If countries of the region do not take adequate measures on prevention and care for combating HIV/AIDS and reduce the new infections to at least 50% of the present level, not only would Goal 6 become unattainable, but Goal 1 on poverty may also be delayed in some countries. The participants acknowledged the progress made by countries in the region, but there remain many challenges. The participants resolved to strengthen efforts to achieve the health MDGs based on ownership and partnership. 1 The Forum focused on four key cross-cutting issues that are crucial for achieving the health MDGs in Asia and the Pacific, namely, (1) strengthening health system through capacity building, (2) promoting cross-sectoral actions to achieve the health MDGs, (3) securing resources and increasing effectiveness to achieve the health MDGs, and (4) ensuring equity in access to quality health services. Session A Strengthening health systems through capacity building Analysis of the current situation and key challenges in the achievement of the health MDGs shows that the technical interventions are, in fact, available. What is often critically missing are effective health systems that can ensure that these interventions are delivered to those most in need. In particular, effective interventions are failing to reach the most vulnerable groups. Countries need to ensure sustainable public investment in the essential public health functions. Key dimensions of health systems - Health systems are a means of achieving health outcomes. - Health system performance should be measured by the extent to which it is able to achieve the various health MDGs and other health outcomes. These could be taken as evidence of the overall success of the health system. - In many countries, weak health systems pose a considerable obstacle to the achievement of the MDGs. National and international support to strength these systems are urgently required. - Linking various health programmes can promote synergies to accelerate progress towards the health MDGs. For example, sexual and reproductive health and HIV/AIDS programmes could be more successfully integrated, offering women a confidential location for VCT and family planning services, giving the opportunity to intervene in the early stages of the HIV epidemic. z Appropriate health systems model to deliver the health MDGs - Clearly there is no single model.countries vary enormously. Even within countries, there may be an overall guiding framework, but there certainly need not be a single system dominated by the public sector. z Planning, organization and delivery - Governments have to take the responsibility to ensure the availability of a minimum package of essential health services, especially for the poor. Services can be augmented by public-private partnerships or other strategies. - Health systems operate in different kinds of settings.for example, fragile states. Getting health systems right in those circumstances may require different approaches. z Health services regulation - Governance and stewardship are important. The question of regulation of the health sector is more relevant where government is not the sole provider. - Ensuring the quality of health services is a key challenge. Using the example of PPM-DOTS India demonstrated how regulation and stewardship role of governments can ensure this. 2 z Financing the health system - We have good estimates of the minimum investment needed to establish an adequate health system. Countries need to ensure adequate financing, including pro-poor health care financing. However, in poorer countries, external assistance will continue to play a vital role. - Donors need to deliver on their internationally agreed commitments. The quality of donor assistance is as important as quantity and can improve health system performance. Ways to strengthen health systems Country-level actions z Health policies - Health should be encapsulated in an overall clear set of widely understood and known development policies and strategies. - There is a need to ensure national ownership of health systems policies, around which donors should align. Political commitment is important in this regard. - Setting clear priorities is critical. Policies should lead to clear and effective strategies for implementation. - Strengthening the referral system at multiple levels is critical for overall health system development. Health infrastructure development should be complemented by appropriate human resource development policies. z Human resources - Addressing human resource shortages and work conditions is a priority within the health systems agenda and requires long-term commitment and planning. - Samoa demonstrated that an appropriate skill mix can promote delivery of services in far-flung areas and can be particularly important for improving service quality and ensuring retention. - Even with a clear commitment to achieving the MDGs, managerial and implementation capacity are often weak and need strengthening. .. Pharmaceuticals and vaccines - As Sri Lanka case study shows governments have a role to play in effectively regulating the supply of affordable essential drugs and vaccines and their prices and quality. Governments must also ensure effective drugs storage and distribution system. - Countries also face challenges in keeping prices of drugs and vaccines down, particularly in the context of countries’ entry into agreement with WTO and the opportunities created under TRIPS. z Health information, knowledge management and research - There is a need to strengthen capacity in the production and use of quality evidence to support policymaking. - Health information needs to be timely and reliable. Disaggregation of health information by various indicators of social exclusion enables the analysis of equity. - In translating evidence into decision-making, information needs to be packaged in a user-friendly way and factors that push managers to use evidence need to be analyzed. - Health system research can help address important health challenges. 3 - There may be imbalances in the use of research resources, with a large share of the resources being devoted to the health research priorities of developed countries. - It is sometimes more cost-effective to use research capacity in developing countries to undertake health systems research related to their needs and priorities. - Donors have a role to play in supporting health systems research. Role of international partners, harmonization and global partnerships - Clear domestic polices are important, but they need to be supported by concerted international action in accelerating the achievement of the MDGs. - It is critical for donors to align their support to the national government’s mandate and priorities. - There is need for a more coherent architecture of international support that addresses coordination. Donors should use existing national structures rather than set up new ones. - Global initiatives, such as GAVI or the Global Fund to fight AIDS, Tuberculosis and Malaria, have a role to play in strengthening health systems as part of their core business. Harmonization between these initiatives and among the various stakeholders is important. Session B Cross-Sectoral Actions to Achieve the Health MDGs It is well recognized that health is significantly influenced by social and other non-health factors. Achieving the non-health MDGs will have a direct impact on the health MDGs. Progress on Goal 1 poverty reductions and Goal 2 on primary education affect progress on Goals 4, 5, and 6. In addition, progress on Goals 4, 5 and 6 are dependent on Goal 7 on environmental sustainability and Goal 8 on global partnership for development. However, the corollary notion that non-health sector actions are also needed to successfully achieve health sector objectives is not always equally well appreciated. This session discussed governance issues, especially how systematically integrating non-health sector actions in support of desired health outcomes can be achieved through institutionalizing appropriate procedures and organizational arrangements. In particular, it considered examples where institutional mechanisms have been established, in Indonesia and in the Kyrgyz Republic, to achieve cross-sectoral integration with regards to policy, planning and implementation in support of health sector objectives. z A cross-sectoral approach combining health, nutrition, education, agriculture and infrastructure, as well as addressing cross-cutting issues such as gender, environment and governance, is needed and highly effective in achieving health MDGs through shared responsibility. - The Kyrgyz Republic established an effective partnership among government, commercial private producers and other interested parties to address the specific health objective of reducing iodine deficiency. - Indonesia has developed a broader approach in planning and implementation that integrates health and non-health concerns across all relevant sectors in the context of decentralization. - Incorporating components addressing health issues in projects that are not directly related to the health sector is an effective way to improve health indicators and avoid any adverse effects on health. For example, transport infrastructure is essential for ensuring access to health services in terms of both supply (provision of quality health services/ supplies) and demand (user’s 4 accessibility to such services), but could also have negative impacts that need to be mitigated , such as the spread of HIV/AIDS and communicable diseases. - In another example, there is a possibility that a micro-credit project involving women might inadvertently affect children’s health because it demands too much time from the mothers without offering alternative support for the children in the short-term. Leadership and ownership . Leadership and ownership at all levels are essential to raise the priority attached to the health MDGs. Strengthened analysis of the economic benefits of health will contribute to raising the priority of health. Capacity for research and analysis needs to be developed. . Health is more than the absence of disease; it includes physical, social, mental, and spiritual well-being. Therefore, health should be the concern of everyone. . Cross sectoral actions in support of health MDGs need to be integrated in strategic planning and budgeting at the macro level, where competing national priorities are identified and selected. . Governments may consider establishing a high level, multi-sectoral national steering committee that monitor and evaluate programmes to facilitate cross-sectoral actions and coordination. Economic growth . Significant investments needed to meet the MDGs require appropriate domestic resources -- including from the private sector. . Economic growth is ultimately the only road to financial self-sufficiency on a sustainable basis. . In the meantime, increased ODA aligned with national priorities will still need to be mobilized, particularly by the low income countries in our Region. Participation . The peoples’ will to be healthy is often underestimated. An approach that takes the perspective of human security and emphasizes protection from threats and empowering people is essential. . People’s lives are multi-sectoral. People are making multi-sectoral decisions for themselves every day. Therefore, a decentralized cross-sectoral approach most closely conforms with peoples’ actual lives. . Decentralization facilitates participation of all stakeholders in decision making at the local level, thereby strengthening local ownership and sustainability. Joint health committees established at local levels in Indonesia are an example of the institutionalization by the government of a participatory process. Involvement of NGOs and civil society plays an important role. . The bottom-up approach implies that lower levels influence decisions at higher levels. Health and education can be entry-points for promoting rural development based on participatory approaches, particularly in fragile states. Sharing knowledge/ Building capacity . There is a need for more knowledge generation, management and sharing about effective cross-sectoral actions for health. . Focusing on health outcomes inherently leads to a cross-sectoral focus while focusing on inputs tends to emphasize individual sectors. 5 . Identifying good practices requires evaluation to assess the outcomes and determine the factors of success and failure. This requires appropriate tools; for example, health impact assessments. . Evaluations will enable us to scale-up successful interventions through sharing our experiences in the region and in other regions. . Least developed countries, island states, fragile states and states emerging from conflicts need particular attention. . Regional and South-South cooperation should be encouraged as an effective way of sharing knowledge and experiences. Session C Securing Resources and Increasing Effectiveness to Achieve the Health MDGs Current resources for health fall far short of needs in most countries. Countries are challenged to afford basic health services for their populations, assure financial protection, and achieve the MDGS. High levels of out-of-pocket spending dominate and are indicative of limited risk pooling and financial protection. As a result of the economic structures in many countries, domestic resource mobilization efforts are frequently severely constrained, and are not efficient, equitable, or sustainable. Moreover, available resources are frequently not used effectively. This comes at a time when the need for scaling up programs is putting already weak health systems under increasing strain. Health sector specific bottlenecks and other institutional and macroeconomic absorptive capacity constraints often preclude effective use of available external funding. Moreover, the health and nutrition transitions are putting new cost pressures on countries in terms of growing populations, aging, and higher dependency ratios. Thus, it is important to improve domestic resource mobilization efforts, obtain external grant funds, and to assure that funds are spent in an equitable and efficient manner. Health investments need to be guided by clear and effective strategies linked to outcomes, closely aligned to broader national development processes, such as in PRSPs and SWAps/PBAs, and be consistent with medium term expenditure frameworks (MTEFs). Effective macroeconomic management is a critical concomitant for providing the ‘fiscal space’ needed to absorb large new external investments in health and laying the bases for sound future financing of Asia’s health systems. The cases of Thailand and Bangladesh provide important examples of countries which are effectively grappling with these financing issues. In the case of Thailand, the Government has now achieved universal coverage by extending coverage to 18 million uninsured for a basic package of essential services under the ‘30 Baht Scheme’ and increasing the Ministry of Health’s budget in a strongly pro-poor manor by focusing on rural primary health facilities including community hospitals and health centers. Political will and leadership were critical concomitants of implementing the reform as were peace and economic growth which provided the fiscal space for increased allocations to the health section. As a result of these policies, Thailand has achieved universal coverage and better financial protection for the poor, improved allocative efficiency through a more effective focus on primary care and the poor, and has increased public health spending to over 10 percent of the national budget. The country is also earmarking tobacco and alcohol taxes for health in order to assure long-term sustainability. In the case of Bangladesh, the government has not yet achieved universal coverage of health services but has over the past five years focused spending on the Essential Services Package (ESP) - thus 6 shifting resources from tertiary and secondary to primary the level. It has increased its budgeting allocation in real terms by about 17 percent and donor support has increased by some 60 percent. The proportion of public health expenditure going to ESP rose by over 50 percent. The country has committed to increased allocations to the MOHFW budget by at least 10% annually, while efforts will be ongoing to increase the absorptive capacity through improved and more transparent procurement and financial management systems. The MOHFW will reallocate resources to the poorest districts, and design and implement a beneficiary identification system in order to target public subsidies in favor of the poor thus ensuring reduction in health inequalities. Furthermore, the MOHFW has already initiated demand-side financing pilots (e.g. vouchers for maternal health) as an alternative way of reaching the poor. The MOHFW also is moving towards more diversified service provision through greater public-private partnerships. Important remarks and lessons were shared by the Delegates from France, IPPF, Mongolia, Tonga, UNAIDS, UNICEF, U.S., Pakistan, Malaysia, ESCAP, GAVI, UNFPA, Nepal, and Japan. The importance of donor coordination, the need to include NGOs in national health strategies, accountability, and the importance of sharing Asian experience was highlighted. The U.S. Delegate informed the group about new Maternal, Newborn and Child Health Partnership, which will be launched at the United Nations General Assembly in September. UNICEF shared its 10 principles for developing MDG-oriented health systems and policies. The Japanese delegate stressed the importance of ownership, country-specific approaches, and the importance of the complementarity of aid approaches. Ways to Secure Resources and Increase Effectiveness .. Taking into account country-specific demographic and epidemiologic trends is critical for developing both short and long-term financing strategies: .. Securing adequate public and private resources in an equitable, efficient, and sustainable manner linked to results is critical for achieving the MDGs and preventing individuals from falling into poverty from health shocks; .. Improving domestic resource mobilization is a critical concomitant of effective and equitable financing policies; .. Using resources more effectively can result in both important health gains and improved equity; .. Obtaining increased external grant funding through better alignment of country and donor strategies and removing barriers to the effective use of external funds are necessary conditions for meeting the MDGs, particularly in low income countries; .. Improving the predictability, longevity, and coordination of donor aid is essential for reducing transactions costs on countries, creating fiscal space, and assuring medium to long-term financial sustainability. .. Placing economic growth at the heart of the overall development policy is essential to ensure sufficient and sustainable finance needed to realize health MDGs. .. Peace and security are necessary conditions for sustainable efforts in health, development, and fiscal space. The imperative to preserve health infrastructure against willful destruction in conflict situation was emphasized. .. Promoting and strengthening support for South-South Cooperation is an effective way of sharing good practices and know-how among developing countries faced with similar challenges and should 7 be supported by donor countries. z Building public and private partnerships among various stakeholders at the community, national, and international levels is important for mobilizing resources, effective service delivery, and increasing development impacts. Session D Promoting equity in access to quality health services Many countries in the region are making good progress in achieving the health MDGs. However, regional averages mask a widening of health inequalities and increasing inequalities to access to quality health services. This session discussed key dimensions of equity in relation to the health MDGs and considered ways to close the disparities. Among the main points raised at the session were the following: Key dimensions of equity z Important health inequities exist in the Asian region, as in other regions. z There are many important sources of inequity in health: social disparity including gender; geographic, urban-rural, economic, ethnic, and others. The situation varies greatly among countries and regions. z Even basic health services intended to reach the poor normally achieve higher coverage rates among the better off, thereby exacerbating disparities. z Reaching the poor and excluded is not only a human rights imperative but also essential for reaching MDGs. Ways to close disparities z Protect the poor by integrating health dimensions in Poverty Reduction Strategies (PRS). z Identifying and remaining vigilant to the existence of disparities in health service coverage constitutes an important starting point. For this purpose, there is for a need for collecting and analyzing data on health that are disaggregated by economic status, gender, and other types of inequity. z An approach based on the perspective of human security, which places the focus on individuals and emphasizes protection from threats and fear as well as empowerment of the people, is important in addressing disparity. z To address health disparities related to gender, promotion of women’s empowerment, gender equality and universal access to reproductive health services in accordance with the Beijing Platform of Action and the ICPD Program of Action are important. In this context, it was suggested to add the target of universal access to reproductive health by 2015, in relation to MDG 5 to address women’s health beyond mortality prevention . also recognizing its importance in combating HIV/AIDS and reducing child mortality, as well as in promoting gender equality and eradicating poverty. z Many different techniques for orienting health services toward the poor have been found to work well in certain situations. Examples covered in the discussion include: - Focus on poor areas during the initial stages of a universal coverage program. While blanket 8 approaches can be effective, for the most marginalized, special intervention may sometimes be needed. One way of doing this is through giving high priority to delivering services to districts with low levels of human development. - While improving services including more service-oriented attitudes by health staff to everybody is important to reach the poor and marginalized, one cannot reach them just by waiting in health facilities for people to come to use the services. Outreach to bring services to people, empowerment of people to raise awareness of need to use services and of right to demand good services is as important. - Support NGOs shown to work effectively with marginalized and low-income communities. - Participatory project development has shown to work more effectively than a top-down approach addressing in equity. - Provide subsidized health insurance to poor individuals identified through a means test, as in the Philippines. Philippines national health insurance program, “Philhealth”, succeeded in extending coverage to 84% of the population, including self-employed, rotaries, migrant workers, through cross-subsidy between central government, local government and the relatively well off. - Cambodia’s Equity Fund that is currently under development aims, inter alia, to facilitate access of the poorest to priority public health services and to protect the poor from falling into deeper poverty due to catastrophic health events. - Vietnam has established a health care fund for the poor that, since 2002, has provided free care for more than 14 million people, and covered 77% of Vietnam’s poor people in a joint effort of the government and the society. Vietnam also has a health care network at grass-roots level through which national programs to control such diseases as TB, leprosy, malaria, goiter have been successfully implemented. - Monitoring access to essential health services including reproductive health services and health outcome based on appropriate indicators and under a multi-sectoral system such as a high, level steering committee is necessary for addressing health inequity. - Changing attitudes needs person-to-person communication but also promotion of social dialogue by diverse groups. This social dialogue is needed for widespread attitude and behavioral changes that help individuals make decisions that were not part of their deep-rooted traditions. 9