When simple is successful: Gates Foundation on UHC

A recent drive led by the World Health Organization to prioritize universal health coverage within the post-2015 development agenda is gathering support — but one of the world’s largest and most influential donors is yet to be convinced. Implementing UHC that everyone can afford implies building or strengthening systems, training health workers and ensuring access to medicines — not to mention financing all of those things. Indeed, it is a much broader and more complex task than achieving specific targets, such as reversing the spread of HIV under the current Millennium Development Goals. This is one of the reasons the Bill & Melinda Gates Foundation — which has spent some $8 billion on global health programs to date — has still not clarified its position on UHC. But why? According to Mark Suzman, the organization’s president for global policy and advocacy, the Gates Foundation favors something simpler and easier to measure. “Our view is very strongly that what works in goals is keeping them very simple, very easy to understand — including [to] the general public, wherever possible,” Suzman told Devex. Under negotiation The current United Nations “zero draft” document on the sustainable development goals puts health under the headline goal to “ensure healthy lives and promote well-being for all at all ages.” But several countries, among them Japan and France, want that goal to talk specifically about UHC. Since 2010, more than 80 countries have asked WHO to help them make steps toward UHC, according to the U.N. agency. A great value of prioritizing universal coverage, said Liam Sollis, policy and advocacy adviser at Action for Global Health, a network of European nongovernmental organizations, is the clear “commitment to the rights-based approach to health — so that ‘no one is left behind.’” If implemented, it could do much for the 1 billion people who lack access to basic health care and the one-third of households in Africa and Southeast Asia that have to borrow money or sell assets to pay for health care. Yet UHC is “inherently political,” Sollis said, requiring far-reaching reforms of health systems. Even if there is broad agreement that UHC should be a part of addressing the future disease burden, the question remains: Where does it fit into the post-2015 framework? Means versus goals The view that everyone should have access to the health care they need without being financially out of pocket as a result is “a powerful and persuasive vision — and we agree with that,” Suzman said. The Gates Foundation, he explained, considers UHC valuable as a means and even “essential for long-term success,” but “less helpful as an overarching goal [compared with] updated MDGs around child and maternal mortality, and other more clearly measurable and politically resonant targets.” This is partly due to the fact that UHC still means different things to different people, which makes it “quite difficult to measure, because people have different views on what’s the basic intervention they need, what’s the definition of ‘out-of-pocket’ if you’re lower income, versus middle income,” Suzman said. It’s also unclear if work on UHC should be limited to interventions within the health sector, or if it must also include other services that can significantly affect health, like sanitation or nutrition. A Gates Foundation paper published last year pointed to a “lack of robust evidence of links between UHC ... and the desired impact of improved health outcomes.” That’s no doubt a crucial factor for an organization known to be obsessed with figures. Bill Gates’ 2013 annual letter, for instance, centered on “knowing the numbers” and called for better measurement tools to determine which approaches work and which do not. So while Suzman welcomed what countries like Thailand are doing on UHC, he also added, “We really would like it to happen with a very deliberate, systemic, pro-poor lens. And for us the best way to do that is to focus on primary health care systems, [with] a real focus on outcomes. “Those outcomes are the measurable outcomes, like child and maternal mortality.” ‘People get it’ While not officially involved in the U.N. negotiation process, the Gates Foundation does have substantial access to policymakers and is one of a number of influential NGOs helping to shape discussions, Sollis said. Some aid groups are concerned by the extent of that influence. Earlier this year, civil society organizations protested at Melinda Gates’ invitation as keynote speaker at the World Health Assembly, given that her husband Bill Gates had appeared on the same stage twice in the past 10 years. But as major supporters of the MDGs, the Gates Foundation has undoubtedly helped drive progress. MDG 4, on reducing child mortality, is often cited as an example of success: The number of deaths worldwide in children under 5 declined from 12.6 million in 1990 to 6.6 million in 2012, which translates into about 17,000 fewer children dying each day. For Suzman, the lesson is clear. “The easiest, most measurable, most visceral” goals work, he explained, because “people get it. The importance of saving kids’ lives is something everyone will agree on, no matter what side of the political spectrum you are on.” That doesn’t take away from a broad approach to well-being. Indeed, the Gates Foundation supports work on UHC, funding a knowledge-sharing platform for countries working to get those systems in place. And his organization’s overarching vision is one in which people can live a healthy and productive life, Suzman highlighted. “It’s not just about preventing diseases — that’s why we work in areas like financial services and agriculture, to ensure those children are able to grow up and live productive lives,” he said. To mobilize action, though, the foundation’s advocacy chief believes easily communicated goals are most effective. For instance, when Suzman recently met with the prime minister of Senegal, he recalled the first thing he talked about was how pleased he was with his country’s progress on child mortality, but that they had more work to do on the maternal mortality MDG. “The very fact that that discussion is on the national level — that drives attention and energy, and that’s what we want to preserve,” he explained. Sticking to strengths Even if UHC is included as a goal title, whether that would galvanize the political will needed to drive real change would depend on how the framework is communicated globally and interpreted nationally, Sollis said. And whatever is agreed on by the end of 2015, the Gates Foundation is likely to remain committed to the “unfinished” MDGs. Despite the rise of noncommunicable diseases — which kill more than 36 million people each year — there is still “more than enough work to do” on major infectious diseases that disproportionately affect the world’s poorest, Suzman said. Not because NCDs are less serious, he underlined, but because these attract significant private and public investment already. And as a philanthropic organization the Gates Foundation focuses on “filling gaps,” allocating scarce resources to more neglected areas and to where they will most help the poor. Suzman’s comments echo a speech he gave last year that argued for post-2015 goals to “continue to focus on the biggest gaps in global equity” — child and maternal mortality, infectious diseases, clean water and sanitation, childhood stunting, and agricultural productivity — and called for goals to be “ambitious but achievable.” He also noted how the foundation’s intention to stick to its areas of expertise — mainly health and agriculture in its international program — is also a question of impact. “It is very difficult to try to spend [huge amounts of money] effectively and responsibly against the kind of benchmarks and outcomes we’re talking about,” he said, which is “why we’re quite hesitant about going into new areas because we spend a lot of time trying to develop particular expertise in sectors and then developing their comfort level and then saying, we’re pretty confident, with all the caveats, that the investments we choose to make, by the time we make them, are broadly likely to be impactful.” Check out more insights and analysis provided to hundreds of Executive Members worldwide, and subscribe to the Development Insider to receive the latest news, trends and policies that influence your organization.