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Social Inclusion: What Does It Mean for Health Policy and Practice?

Delivering the keynote speech at the Prince Mahidol Award Conference 2017, Gro Harlem Brundtland highlights the importance of inclusive health policy, praising hosts Thailand for progress towards achieving Universal Health Coverage and calling on all leaders to ensure no-one is left behind.

Gro Harlem Brundtland delivers the keynote speech at the PMAC 2017 Conference.
Gro Harlem Brundtland at the PMAC 2017 Conference in Bangkok.

Your Royal Highness, Excellencies, Ladies and Gentlemen,

Thank you for that warm welcome and introduction. It is an honour to be addressing this conference here in Thailand, home to one of the most impressive and progressive health systems in the world.

PMAC has a justified reputation in being the foremost gathering in global health focusing on issues of rights and equity, and in recognizing that health, and access to healthcare, are critical political issues. I have worked at the intersection of public health and politics my entire life, both as Prime Minister of Norway and as Director-General of the World Health Organization, so I am delighted to be amongst kindred spirits.

Many of you will know that I am now Deputy Chair of The Elders, the group of independent former leaders founded ten years ago by Nelson Mandela to work for peace, justice and human rights.

So I am extremely pleased that the theme of this year’s PMAC “Addressing the Health of Vulnerable Populations for an Inclusive Society” tackles issues of health and human rights and guides us to look at our societies far beyond the health sector.

To improve health for all we need to fight for and protect the human rights of all people. This will require taking affirmative action to assist disadvantaged groups such as women and children, LGBT communities, the elderly, disabled people, ethnic minorities, refugees and migrant populations. So I am very pleased to see that this year’s PMAC conference will address means to improve the health of all these groups that face social exclusion.

If we are serious about wanting to address the health of vulnerable populations, we need to recognise that many of the most important interventions will need to take place outside of what we regard as the health sector.

This will involve tackling the social determinants of health - reducing inequalities and eliminating discrimination in other sectors, such as education, housing, employment and agriculture - and tackling environmental protection.

I was thrilled to see that the recipient of last year’s Prince Mahidol Award was Professor Michael Marmot of University College London, who is the leading exponent of the social determinants of health.

In the global health community, we must recognise that if we are to achieve the health Sustainable Development Goal to Ensure Healthy Lives And Promote Well Being For All At All Ages, we need to promote change also beyond our own sector and seek to improve people’s health through more effective policies across the board.

As well as treating diseases we need to address the reasons people get sick in the first place. As I started my work in WHO, one of my first initiatives was to make tobacco control one of our top priorities. The Framework Convention on Tobacco Control is one of our greatest collective achievements in public health.

It was also necessary to make global leaders aware that as Presidents and Prime Ministers they were in fact Health Ministers and Environment Ministers themselves, fully responsible for the health of their peoples and societies.

Back in the 1980s, as I chaired the World Commission on Environment and Development we found that many of the crises affecting the planet are closely intertwined, be they social, economic, environmental – and require comprehensive solutions involving all sectors of society. We called for a new era of collaboration for sustainable development, the only alternative if we were to protect humanity and Planet Earth.

I am delighted this emphasis on tackling development priorities simultaneously has now finally been enshrined in the Sustainable Development Goals.

I remain convinced that poverty remains the biggest source of ill health – the poor are more susceptible to diseases because of malnutrition, inadequate sanitation, and lack of clean water. Conversely, ill health in turn breeds poverty.

This is why, while in WHO, I established the Commission on Macroeconomics and Health, chaired by Professor Jeffrey Sachs. It showed conclusively that investing in health, especially for women and children, also accelerates economic growth and is a very effective way to reduce poverty levels.

Just as social determinants influence health, we know that improving the health of a population generates other benefits to societies. Disease is a drain on societies. Improving people's health stimulates economic growth, facilitates educational gains, reduces poverty and helps build social solidarity.

Ladies and Gentlemen, it is to the health sector and the healthcare system and their importance to vulnerable populations and inclusive societies I now want to turn.

These will remain the key focus of the practitioners here today and across the global health community. We therefore need to ask precisely how we can ensure that our health systems are truly inclusive and actually do improve health for all.

Here the concept of Universal Health Coverage is a critical guide. In 2016, The Elders launched a new campaign to support UHC. It is a key target within the health Sustainable Development Goal and we believe it is the best way to meet the overall health Goal.

UHC means that everybody receives the health services they need without suffering financial hardship.

It is based on a foundation of equity and rights, consistent with the overall message of the UN’s 2030 Sustainable Development Agenda to “leave no one behind.” It is about all people receiving the health care they need. So UHC is of central importance for this conference.

As vulnerable and excluded groups generally need more health services than they are currently receiving, UHC requires a redistribution of health resources to these groups.

UHC explicitly recognises that vulnerable groups often do not access health services, quite simply because they do not have the financial resources to pay for the care they need. Currently hundreds of millions of people are denied life-saving health services, or are plunged into poverty because they are forced to pay unaffordable fees for their care.

In saying that people must not suffer financial hardship when accessing health care, UHC specifically addresses the economic inequalities that stop vulnerable people receiving the services they need.

The only way to achieve this outcome is to develop a health system whereby healthy, wealthy people help cover the costs of health services for the sick and the poor.

In other words, we need to establish a health system whereby more privileged members of society pay for, and therefore include, groups that have been previously excluded. UHC is therefore all about social inclusion.

Of course you don’t need me to tell you about this here in Thailand, home to one of the most socially inclusive UHC systems in the world.

At the turn of this century you created a health system, which extended effective health coverage to all your people – nobody was to be left behind.

As you faced constraints in public financing, you could not offer an unlimited package of services to everyone, but as your economy has grown you have extended your benefit package using efficiency and equity as your guiding principles.

Moreover, your health system has secured a degree of political support and consensus that has enabled it to expand and develop under successive governments, and become a model for health reforms across the world.

As developing countries move towards UHC there is often a debate as to whether it is better to include everybody from the outset with a modest package of services, or to only cover selected segments of the population first. I believe that your success, and that of countries like Sri Lanka and Malaysia, shows us that your strategy is the best. It is more efficient and also fair to provide a universal entitlement to healthcare when poor people are not discriminated against.

However, in guaranteeing access to everyone, it is essential for governments to focus their public financing on meeting the needs of the poor and vulnerable first. This strategy is what a Lancet Commission in 2013 called “progressive universalism”.

As part of this strategy, The Elders believe it is important to start by offering a package of primary healthcare services, free at the point of delivery, for everyone, prioritising the services that women and children need the most.

We think these lessons are highly relevant for other countries in Africa and Asia that are planning their UHC strategies, and I know many governments at national and regional levels are now adopting progressive universalism similar to Thailand.

For example, I am aware that the State Government of Delhi, represented here at PMAC, is pioneering universal free health services in the Indian capital. Like Thailand, they are focusing first on primary healthcare through building up a network of free “Mohalla” or ‘neighbourhood’ clinics in poor parts of the city. I understand that in just over seven months since their launch last year, these clinics saw an astonishing 1.5 million people – indicating the huge unmet demand for universal free healthcare in India.

They are also providing universal access to free essential medicines and diagnostic tests throughout the entire public health system. This is reducing the need for people to buy medicines over the counter from private drug shops, which we know is one of the factors driving antimicrobial resistance in India and across the world. The health reforms being undertaken in Delhi therefore strike me as an excellent strategy to build an inclusive health system in India and bring UHC to its people.

I really want to emphasise that the experience of Thailand, Sri Lanka, the new health reforms in Delhi and progress being made in countries such as Ethiopia and Rwanda, demonstrate that ALL countries at ALL income levels can move towards UHC.

No one should say that UHC is unaffordable or they don’t know how to do it. This point was made very forcibly in 2015 by Professor Amartya Sen, with us here today, when he described UHC as “the affordable dream”.

Learning from these UHC successes, there are a few key reforms that ALL countries can take to create a functioning primary healthcare system, one accessible to all.

I am now going to spell out some of these crucial health system reforms because I want to stress that many issues and how to tackle them are relatively straightforward, at least from a technical perspective.

First, it is key to increase levels of public financing allocated to the health sector. Every Government should commit to spending at least 5% of GDP on health and to moving progressively towards this target.

All governments can afford this. It is a question of priorities and political commitment. If Thailand can find 5.6% of its GDP and Malawi 6.1% of its GDP to fund its public health system why can’t countries in South Asia, currently spending only 1%?

Also don’t let it be said that economic pressures won’t allow countries to increase their public health financing. Don’t forget that Thailand launched its UHC reforms in the immediate aftermath of the Asian Financial Crisis, finding an additional 1% of GDP in one year, to provide healthcare for all.

Of course there remains a vital role for international aid to augment domestic public financing and fill funding gaps in countries with weak economies. In low income countries with binding resource constraints, development partners will provide support if they see clear leadership and a sensible strategy.

Second, countries that have introduced free primary healthcare successfully have prepared for this by recruiting more health workers, increasing salaries and cleaning up their health sector payrolls to ensure all frontline workers are paid on time every month.

Third, as demonstrated by Ethiopia and Rwanda, creating a network of community health workers is an important step that can bring rapid results with limited resources. With advances in technology available through mobile phones, community health workers will soon be able to provide a broader range of diagnostic, preventive and curative services. This will be more efficient and enable more people to receive vital healthcare.

Fourth, countries have focused on sorting out their medicine supply systems, so essential free medicines and preventive commodities are always available at all health units

Finally, implementing mass information campaigns is crucial to ensure that all population groups are aware of their rights to free primary care.

Experience shows that these simple reforms can be accomplished within six months to a year if they are planned, implemented and financed properly. Moreover countries such as Malawi, Bhutan and Nepal have shown that it is perfectly feasible to sustain universal free healthcare for the entire population even at relatively low income levels.

What these countries and many here today have demonstrated is genuine political commitment and leadership.

We call on all countries to show this leadership. Take advantage of this wonderful opportunity to learn from our Thai hosts, who started with these key reforms, made a limited package of key services available to everyone and now have a system that even offers free kidney dialysis.

I would also like to congratulate the Thai people for recognising that UHC doesn’t only involve covering ones own citizens - it means ensuring all people within your borders receive the health services they need without financial hardship. This includes refugees, migrant populations and visitors to your country.

Thailand is one of the few countries in the world whose publicly financed UHC system covers literally everybody, including migrants. I would argue that in population terms you are closer to the ideals of UHC than many high income countries.

Moving towards and sustaining UHC is an inherently political process that is likely to be opposed by privileged groups who want better access to care and who may not want to help cover the costs for the vulnerable.

We cannot be naïve and ignore these forces that seek to exclude weaker groups and therefore increase inequalities.

In fact as we look at a number of recent political developments in the last few years we can see that these political pressures have been building. In Europe austerity policies have resulted in public financing to health being cut which has reduced access to services especially amongst the poor and vulnerable.

In addition political leaders that have tried to introduce more equitable health systems in countries like the United States and South Africa have faced intense political opposition from powerful vested interests.

I believe there has even been calls to introduce user fees into Thailand’s UHC system, which we know from experiences from around the world would reduce access to vital services. Typically such fees do not raise much revenue and are expensive to administer.

Most importantly – and the evidence is absolutely clear on this – even small fees exclude the poor and vulnerable. If Thailand is to maintain its reputation as a world leader in UHC and social inclusion in health, I would strongly recommend that you do not introduce user fees to finance your health system.

As we enter 2017 there are worrying signs that political forces working against social inclusion are gaining momentum and that nationalist politicians are looking inward and are focusing solely on the needs of their own citizens.

In health we know that this is extremely dangerous. So many of the issues that impact on the health of all of us are global in nature and require international cooperation.

Controlling epidemics, reducing anti-microbial resistance and tackling climate change are obvious examples. The recent Ebola epidemic and the ongoing battle against TB show vividly how we need to sustain and strengthen international cooperation.

In West Africa, there had been commendable efforts to extend health coverage to vulnerable populations in Sierra Leone and Liberia. But when Ebola broke out their underfunded health systems were unable to cope with the intense pressures caused by this deadly disease.

The international community helped deal with the immediate emergency but going forward, if we are to improve the health security of people in these countries, and also the rest of the world, we need to help rebuild their health systems to achieve UHC.

Antimicrobial resistance (AMR) also poses a massive threat to global health security and was a priority issue at last year’s United Nations General Assembly. We know that one of the driving forces behind this increase in AMR is people buying inadequate doses of often inappropriate medicines over the counter. Private financing of medicines is fuelling drug resistance and this is particularly the case in India, which is seeing an explosion in drug-resistant TB. This is very dangerous, not just for India’s people but for the world.

This underlines the need for everyone – all the vulnerable populations – to be able to access good quality, publically financed and regulated health care. Achieving UHC will also be the best way to secure global health security.

As we discuss social inclusion and implications for health policy at this conference, it is vital that we recognise that literally nobody on the planet should be left behind in the campaign to reach UHC.

In this globalised world with emerging diseases it is foolish as well as fundamentally unjust to build health systems that cover the wealthy and privileged whilst the poor and vulnerable remain excluded.

As we champion UHC in the SDGs it is my hope that more countries follow the lead of Thailand and recognise that UHC really does mean UNIVERSAL coverage, and that the key to social inclusion in health is to ensure that everybody receives the services they need.

Our work | Universal Health Coverage

Universal Health Coverage

Universal Health Coverage means everyone receives the health care they need without suffering financial hardship. We believe this is a goal all countries can reach.

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