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At the World Bank Spring Meetings in April earlier this year, World Bank President, Ajay Banga along with the World Health Organization (WHO) Director-General, Tedros Adhanom Ghebreyesus and Japan’s Minister of Finance, Shunichi Suzuki announced the launch of the Universal Health Coverage (UHC) Knowledge Hub in Japan, set for 2025. This initiative, which was initially proposed based on the April 2023 G7 JCIE report recommendation, formalizes and strengthens the collaboration between WHO and the World Bank to support countries toward achieving UHC. But the success of this new and important Hub hinges on strong leadership to clearly define its functions and ensure the strategic prioritization of activities as the Hub is launched. In this blog, we delve into the four key areas—packages, politics, analytics, and assistance—that the Hub can address to bridge the gap between finance and health communities and help to achieve the shared goal of expanding UHC.
The Hub’s significance
The Hub is central to the World Bank’s ambitious goal of expanding UHC to 1.5 billion people by 2030, encompassing the life course, remote areas for last-mile delivery, and addressing financial barriers to access. In our view, this Hub represents an important, formalized partnership between WHO and the World Bank on UHC for several reasons:
Marrying finance with health communities: The Hub can offer an integrated approach that bridges the communication and philosophical divides between ministries of finance and health—by leveraging both WHO’s core mission of delivering knowledge and evidence and the World Bank’s expertise in development finance, as well as a knowledge bank. This marriage can help to address the financial sustainability of health programs in challenging times. In some sense, this organizational marriage of finance and health would be comparable to the G20 Joint Finance and Health Taskforce, but on a larger scale. As the World Bank assists over 100 countries in providing comprehensive health services, this partnership provides an opportunity to enhance and expand these efforts globally in partnership with WHO which has 192 member states.
Sharing expertise in economics and public finance: Rising public debt and interest payments severely impact government spending capacities, especially in low- and middle-income countries, constraining their ability to invest in health. As countries allocate more revenue for interest payments, health spending often suffers. Both organizations share expertise in economics and public finance to help countries to navigate fiscal pressures, albeit with different ministerial counterparts as well as with different professional staffing and occupational outlooks (economists vs physicians). Together this collaboration emphasizes the need for strategies that enhance efficiency, restructure debt, and leverage external financing sustainably. The Hub offers an explicit opportunity to share this expertise, enhance coordination, and reduce duplication of effort.
The horizontal framing: The Hub offers an explicit focus on UHC programs that go beyond the litany of vertical single-disease, biomedical siloed programs, or other health emergency programs that characterize global health. The leadership from Japan does not go unnoticed, particularly in a global health donor environment that predominantly leans hard on vertical approaches and specific diseases. Japan has long championed UHC (see here, here, and here), not only as a means to improve livelihoods, but also as the basis for “human capital development and sustainable growth” and human security. This vision of UHC is one compelling alternative to the “vertical stove-piping” of global health over the last 20 years. Indeed, some might argue that WHO’s own organization chart has been dominated by individual disease focuses—“territories” associated with political appointments, headcount, and budget. Other donors that value horizontal over vertical approaches should take note—perhaps the UK, Norway, and South Korea.
Strategizing the Hub’s focus areas
As the Hub launches, we highlight at least four areas where it could focus: designing cost-effective health benefits packages; applying political analysis for health reform; analyzing data on health budgets and expenditures; and sharing capacity building and technical assistance efforts.
Design cost-effective health benefits packages
Building on the World Bank’s seminal World Development Report 1993 (WDR1993), the Hub should prioritize the development of comprehensive and cost-effective health benefits packages. The Hub could also support health technology assessment agencies, a vital component often neglected but now receiving renewed attention to get more health for the money. Additionally, revitalized efforts to generate more comprehensive and country-specific evidence for cost-effective interventions are essential to advance this agenda. This approach to benefit packages also aligns with the forthcoming Lancet Commission on Investing in Health, nearly thirty years after the WDR1993 report.
The design of health benefit packages is a key part of strategic purchasing, including pooled procurement of medicines, particularly newer medicines that are very expensive. Certain global health initiatives have a significant emphasis on procurement of health products, but from the country perspective, there is generally a single authority for procurement. Thus, the Hub could prioritize strategic national purchasing for UHC.
Use applied political analysis for health reform
Effective health care reforms demand political buy-in, not only technical solutions. Politics, though infrequently studied by medical doctors or public health practitioners, is a closely related subject to economics. Indeed, politics may well be the most important determinant of health equity and outcomes. One essential lesson arising from the aftermath of the COVID-19 pandemic is the urgent need to design and communicate health reform agendas that fit the historical moment in politically feasible ways that build trust rather than the opposite. However, these lessons have not been effectively translated into institutional and organizational efforts to improve health system performance.
The Hub could promote the use of applied political analysis to design reform proposals are politically feasible, navigating the complexities of competing fiscal priorities. It could also make the independent WHO Council on the Economics of Health for All more actionable, framing the world in terms of economics, markets, and government, but with a more effective recognition of the importance of politics. The World Bank’s engagement with ministries of finance, combined with WHO’s health ministerial connections, could ensure that the Hub’s efforts resonate at the highest governmental levels and align with political priorities. The Hub could also have a convening function through the use of high-level fora on UHC and other high-profile events to gain commitments—be they national, regional, or global.
The Hub could promote the use of applied political analysis to design reform proposals are politically feasible, navigating the complexities of competing fiscal priorities.
Data on health expenditures and budgets
How much government resources are countries spending on health? What is the plan for how governments will increase health financing? How will a country plan its health financing transitions to reduce out-of-pocket spending and respond to changes in external financing? Perhaps most importantly, who is keeping track of domestic government health financing metric as the true indicator of sustainability?
In this regard, WHO has some strengths. Its annual Global Health Expenditure Report and Global Health Expenditure Database (GHED) provide insights into health spending trends and inequalities. In contrast, the World Bank’s Government Health Budgets and Spending Database drew on data from nearly 2000 budget documents to estimate central government spending on health. Both data sources on expenditure and budgets are valuable for getting a whole picture of health finance in a country, even as both data sets face challenges in data gaps and limited country participation.
The Hub can ensure that the valuable data resources on health financing from both WHO and World Bank are integrated and used to inform strategic decisions and optimize resource allocation. The Hub can also integrate information and increase transparency on the uncoordinated donor policies on domestic government financing, so-called “cofinancing”.
Capacity building and technical assistance
Beyond strategic alignment and policy integration, the Hub can serve as a cornerstone for capacity building and technical assistance for UHC. Technocrats could receive targeted training in designing health benefits packages and integrated modeling approaches, applied political analysis, and health financing strategies. Both WHO and the World Bank each have training courses on health financing and health care reform, such as the WHO’s Barcelona Course on Health Financing and its online course on Health Financing for UHC as well as the Bank’s Flagship Course on Health Systems and its online platform.
The Hub could strengthen and reduce duplication in curriculum across two major international institutions as well as join forces in bridging the divide between health and finance communities. The Hub could also consider strategically partnering with other institutions of higher education such as Harvard, which has the Harvard Ministerial Leadership Program developed by Julio Frenk, and others. The training and curriculum could also be closely tied to the areas described above, particularly in terms of applied political analysis as well as.
Finally, as countries grow economically, both the WHO and the World Bank will increasingly focus on knowledge and bridging the gap between knowledge and action. To quote Julio Frenk and Lincoln Chen: “Knowledge is one of the most potent instruments we have for improving health worldwide. Yet, large gaps persist between knowledge and action… There is a cycle of knowledge: it is produced through research; it is re-produced through education and training; it is translated into actions that improve health; and it is evaluated scientifically, which feeds back into the production of more knowledge.”
Defragmentation of global health financing
In recent blogs, we’ve discussed the challenges of fragmentation in global health financing (see here and here)—which can manifest in fragmented procurement as well as fragmented domestic financing policies and uncoordinated donors. The job of defragmentation, coordination, and consolidation of global health financing is unglamorous, but could help to set the tone for a new and collaborative approach to global health. This Hub could also help to address some of these challenges, while working closely with the UHC2030 and the G20 Joint Finance and Health Taskforce:
“Past efforts by UHC2030 and various initiatives such as the International Health Partnerships (IHP), Health System Funding Platform, Sector-Wide Approaches (SWAp), all called for greater country-led national plans for health systems supported by donors… The idea that there should be country compacts where all donors integrate into a country plan, rather than each donor operating independently in each country as they wish. However, one of many recurrent problems in realizing the IHP vision was procurement…”
Will the marriage work?
The Hub may represent the first and true marriage between WHO and the World Bank on UHC, so congratulations! The World Bank and WHO have collaborated extensively in the past, but we couldn’t think of a WHO-World Bank institutional partnership off the top of our head where both organizations shared in building an organization together dedicated to UHC (with the Pandemic Fund coming to mind as an important but targeted collaboration).
Regardless of whether this is the first marriage or not, like a corny greeting card, we would like to wish you a wonderful journey as you build this shared life together. In all seriousness, with any marriage and partnership, communication and setting realistic expectations are key, alongside respecting and appreciating what each partner brings to the relationship.
But honeymoons don’t last for too long. As this Hub grows, the two partners will need to address several key process elements—from finding a leader who has a big vision to establishing the budget and headcount, from defining core activities and a common language to plotting the roadmap and identifying clear metrics of performance. These practical considerations, though less romantic, are essential to the Hub’s success.
We think this marriage of finance and health for UHC could be the start of a very fruitful collaboration, lifting the lives of a billion and a half people. But it’s not guaranteed. We’re eagerly watching in support and hope others will too.
We thank David Watkins, Ole Norheim, Michael Reich, Kalipso Chalkidou, and colleagues at the World Bank for their helpful comments.
Disclaimer
CGD blog posts reflect the views of the authors, drawing on prior research and experience in their areas of expertise. CGD is a nonpartisan, independent organization and does not take institutional positions.
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