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Pooja: Hello, thank you to all the listeners for tuning in for this podcast. I'm Pooja Jha, Editor in Chief of the Lancet Regional Health Europe, based in the Lancet Munich office. This is the second podcast for our Universal Health Coverage Spotlight. In the first podcast, financing of universal health coverage was discussed, and today we will discuss innovation in universal health coverage, also abbreviated as UHC.

Now when we talk about UHC, the first thing that normally comes in everybody's mind is more investment in health system and need for more financing in the health system. But UHC is not only about more money or having more resources. An important pillar of UHC is innovation. That is, bringing innovation in health systems so that the limited resources can be used most effectively.

And this is what we are going to discuss today. So we will address four core aspects of innovation in UHC in this podcast. What is innovation in UHC? What it means for different countries? Because it can mean different things to different countries and in different settings. Then we will discuss why innovation is central to the success of UHC, followed by the challenges in innovation in UHC, and then what should be done to by the policymakers to make a difference in UHC.

And to discuss this, we have three fantastic guests who have worked in the area of innovation in UHC from two contrasting candidates continents of the world, from Europe and from West Africa. I'm very pleased to welcome Sara Thompson and Trinh Habit from the WHO Barcelona Office for Health System Financing, which is part of the WHO Regional Office for Europe.

And we have Haja Wouri from University of Sierra Leone in West Africa, and she is also the Kofi Annan Global Health Leader Fellow at Africa CDC. Thanks, Sara, Trinh, and Haja for joining us today and for this very interesting discussion that we are going to have on innovation in UHC. How are you all doing today?

Good, thank you, Pooja. Very well. Sara, let's start with you. Can you tell us what innovation in UHC means to you? Yes, to 

Sarah: me, innovation means doing something differently so that you're really better able to meet your goals. It doesn't have to be about blue sky thinking. It could be finding a way out of pulp dependency of being stuck in a rut.

In Europe, we can see that progress towards universal health, health coverage towards UHC is often bogged down by pulp dependency and coverage policy by countries doing things the way they've always been done. Even though times have changed or new evidence has come to light. And this matters because coverage policy.

is a major determinant of UHC. It determines who benefits from access to health care, what services they're entitled to, and how much they might have to pay those services at the point of use. 

Pooja: Thanks, Sarah, for sharing this very interesting concept about PATH Dependency Challenge. Can you share us an example of this type of PATH Dependency Challenge?

Sarah: Yes, I've got two examples from a project that we're working on called Can People Afford to Pay for Health Care? The first challenge is when countries punish people who can't pay their taxes by denying them access to healthcare. This sounds like a crazy policy, but it happens in, in many countries with social health insurance schemes when entitlement to healthcare is linked to payment of contributions.

And if people don't pay these compulsory contributions, which are basically taxes the punishment they face is denial of access. to healthcare. And this is a real problem for UMHC in Europe, leaving millions of people without coverage. The people who suffer most from this are people who work in the informal sector or who have some other kind of precarious work.

So generally it's people with low incomes. 

Pooja: So why do countries do this, so called punish people who don't pay taxes by denying, denying them access to healthcare and how can they innovatively move away from it? 

Sarah: I think countries do this in large part because of history. So when national social health insurance schemes were first being set up in Europe, beginning in the 19th century.

They really aim to protect workers from loss of earnings when they got ill and couldn't work. And in that context, it made sense to, to focus health insurance, to build health insurance around employment and to have this link between entitlement and payment of contributions. But in today's context, in the context of UHC, where the goal is really to make sure that everybody can access healthcare.

This policy looks out of date. It's no longer fit for purpose and the health system really shouldn't be working for the tax agency. So here's the innovation and it's, it's really simple. It's to break the link between entitlement to healthcare and payment of contributions and to base entitlement on residents instead.

France was one of the first countries with a social health insurance scheme to make this change in, in 2000. And today, France still has a social health insurance scheme. And that scheme is still financed through contributions, but now it automatically covers all residents. And this means that the French health system can really get on with the job of providing health care and leave the tax agency to worry about whether people are paying their taxes or not.

And if every country with a social health insurance scheme adopted this innovation, it would improve access to health care for millions of people. So another coverage policy challenge is The use of copayments and these are charges or fees that people have to pay at the point of using health care.

Policymakers often argue that copayments are needed in health systems to stop people from using too much health care. That medicines, for example, if they're free, people use them more than they need them and this is wasteful to the system. But lots of evidence shows that copayments are not a good instrument for reducing waste.

What they are good at is blocking progress towards UHC because they create barriers to access and cause financial hardship, especially for people with, with no incomes or chronic conditions. Luckily, countries are beginning to recognize how harmful copayments are and are trying to protect people, but sometimes administrative barriers get in the way.

This time the, the innovation comes from Estonia and again, it's, it's a relatively simple change. So for several years now, the Estonian health system has tried to protect people by reducing copayments once people have spent a certain amount of money out of pocket on medicines. And in the past to benefit from this policy, people had to keep all their pharmacy receipts and then at the end of the year, they would count them up and submit them to the health insurance fund.

And eventually they'd get some money back, but the policy clearly wasn't working because hardly anyone applied for the extra benefit. And even though they were spending a lot on medicines. And it turned out that many people didn't know about the benefits in the first place. So Estonia found a digital solution to this problem.

Instead of people having to submit receipts at the end of the year, the pharmacy IT system tracks how much people are spending on copayments in real time. And as soon as a person reaches the limit, the system automatically reduces their copayments. And this change has made a huge difference because now everyone is eligible for benefits and then the benefit is felt immediately.

Pooja: Thanks, Sarah, for sharing these encouraging and interesting examples from France and Estonia where simple innovation of decoupling payments of taxes from entitlement to healthcare and the use of IT system in pharmacies has made a huge difference in UHC. And this is encouraging, not only for Europe, but can be adopted in many other countries.

So this is quite encouraging. Trinh, coming to you and speaking about your experiences with the innovation in UHC, can you tell us what innovation in UHC meant in the context of the COVID 19 pandemic and with the ongoing Russian invasion of Ukraine? 

Triin: Thank you so much, Pooja. COVID 19 pandemic and the war in Ukraine are both enormous crisis that overnight have created significant disruptions in the health systems.

In the case of pandemic, we have had to cope with a new disease that we do not fully understand, making it difficult to diagnose and treat, and leaving us unsure how to protect everyone. In the case of war, millions of people have been forced to flee their homes, healthcare facilities have been destroyed, and supply chains are disrupted.

These are extremely challenging and complex problems that require immediate solution as people's lives depend on it. The positive aspect is that program solving is at the heart of innovation. And crisis creates a strong human desire to help others. A perfect environment for innovation to thrive. 

Pooja: So can you give us example of how innovatively problem solving made an actual impact during the pandemic and in Ukraine?

Triin: Sure, sure. One example of innovation during the pandemic was the rapid scale up of telemedicine services. People were unable to visit healthcare facilities in person and their health needs still required medical attention. For example, during the first months of the pandemic in my own home country, Estonia, about one third of all outpatient consultations were done remotely.

And for example, in psychiatric care, it was close to 80%. The same, we also observed, for example, in Catalonia, in Spain, where about 70 percent of encounters switched to virtual mall. This occurred to some extent in every country. To make all this happen, adjustment had to take place in healthcare facilities regarding how care is provided.

But also changes were also needed in how purchasers are paid for these services. These innovations happened very quickly and not only in high income countries as we in early days of the pandemic the WHO conducted a global survey among lower and middle income countries. And we see, we saw that the majority of countries such as India, Armenia they all introduced or further incentivized telemedicine services in different modalities, such as video.

Phone and email. Another example I I want to bring comes from Ukraine. During the war in Ukraine, there have been many examples of innovations in health systems, such as scaling up delivery of mental health services. In Ukraine's conflict affected areas, it is estimated that more than 20 percent of We likely have some form of, a form of mental health challenge over the next decade which means that it's, it's almost 10 million people at risk of mental disorders, including acute stress, anxiety, and post traumatic stress syndrome.

To address this urgent need the Mental Health Gap Action Program activities have been expanded throughout the country. Training primary health care workers to be the first point of contact. And in addition, by using an online adapted version of the training, the aim is to train 50, 000 primary health care workers across the country.

These are just a few examples. Of how a crisis can act as a catalyst for innovation in the whole system. 

Pooja: Thanks, Trinh, for sharing these examples, which go on to highlight how important innovation is for dealing with any kind of crisis. And without innovatively adapting to any crisis, UHC will really collapse.

So, now let's look at what innovation in UHC means in the context of Africa, where financing in health sector has been a big bottleneck. So the resources there are really limited. Haja, can you share with us what innovation in UHC means to you and share some of the initiatives you are involved in, where despite limited financing, innovation in UHC has made a difference?

Thanks. 

Haja: Thank you Pooja and good day everyone. So for me, innovation in UHC means introducing new and effective ways of doing something to achieve a goal. So if I just talk briefly about the context in Sierra Leone, particularly the health system. So mistrust in the health system has been a challenge, particularly in the face of shocks, as we saw during the Ebola outbreak and the COVID pandemic, and this mistrust can hinder efforts to achieving UHC.

As people may be hesitant to seek care or may not trust the healthcare services that are available. So how can innovation help achieve UHC in such a context? One innovative tool that can be utilized is social accountability, and this refers to the process by which citizens and communities hold their leaders accountable for delivering quality services such as healthcare.

In Sierra Leone, social accountability can be used to ensure that healthcare services are accessible, affordable, and of a high quality. So what does social accountability look like in practice? It means moving away from the notion of policies or approaches being developed at the national level and replicated at the, at the district level without taking into consideration the context specific needs or challenges at the district level.

Instead, community engagement should be central UHC, and who better to bring these diverse views to decision making spaces than community leaders that have been appointed. By the communities themselves. So social accountability should be done through the gender equity and social justice and inclusivity lens, ensuring that the voices of all are heard in decision making spaces.

In other words, what I'm trying to say is that bottom up approach should be strengthened, ensuring that community voices are included in decision making spaces. And also in the implementation of next steps. This goes a long way in ensuring that healthcare providers and policy makers are held accountable, which can translate into improvements in the delivery of healthcare services and ensure that everyone has access to the care.

They need addressing this mistrust. 

Pooja: So, can you give us examples of how social accountability can impact better UHC and make UHC more efficient? 

Haja: Certainly. So there's a study that I'm currently involved in. It's funded by FCDO, Rebuild for Resilience. It's all about community resilience and the overarching aim is to test approaches to improving community leaders engagement.

and support resilient capacities of the local health system through the inclusivity and accountability lens. And the approach we have used in terms of the methodology is participatory action research, where we've divided the data collection into phases. So three phases specifically. So phase one is where we map the current situation to try to find out who are the community leaders, what are their levels of trust.

And also, how do they relate with one another using health, public health situation as a reference point. So once we've mapped the current situation, then we identify the leverage point. And when I say we, it's the, the, the community leaders that we've engaged with in this study, identifying the leverage point.

And then they come up with solutions as to how they can address the challenges that they've, they have identified in phase two. And phase three is where we document these innovative approaches that they've come up with. We implement these activities and ensure that we have a cycle of reflection and documentation.

So, for example, some of the activities that have come out of this study in terms of what are the innovative ways in which we can address these challenges is establishing a harmonized platform for all ongoing community engagement activities related to emergencies, health promotion, reproductive, maternal and child health issues.

And also environmental health. So it's quite multi-sectorial. And this involves developing a protocol for early warning systems in coordination with the district health management team and the m and e office at the district level, linking this to the One health platform, ensuring there's routine analysis of the data being gathered.

And this will then in turn inform. The development of bylaws instituted by the traditional leaders and health talks on, on radio shows and all the sensitization platforms. So what is the innovation in this? So the, the, the, the, the example that I've given you then all the other activities that came out of this study were activities that were already planned within the district health management team.

So we are not reinventing the wheel. We're just there to ensure that we put the community leaders, the And the other relevant stakeholders in the driving seat. Utilizing resources and coordination streams that they, that they already have within their system. So it's no new investment and we're just providing tools for them to be able to measure impact and promote coordination.

And that goes a long way in promoting ownership and leadership and sustainability at the district level. Thanks 

Pooja: Hajah for sharing how innovation, it's really simple social measures and using bottoms up approach. Can make a difference. A huge difference actually. So we've heard what innovation in UHC means in different countries and in different settings and how important innovation is for UHC.

Now, can we hand one takeaway from each of you on what your recommendations to decision to decision makers would be for innovation in UHC? Sarah, let's start with you. Thanks 

Sarah: Pooja. So in, in the two coverage policy cases that I mentioned in France and in Estonia, I think there's been a recognition that doing things the way they've always been done isn't necessarily the right thing to do if the circumstances have changed.

Or we have new evidence and the innovation has really been to move away from something that's no longer fit for purpose and to forge a more effective path towards UHC. And I think in both cases it's also been underpinned by a desire to make things as easy for people as possible. 

Pooja: Thanks, Sarah. Trin, what would your message be?

Triin: Actually I have two recommendations. Firstly, health systems are incredibly complex as human beings. We have what neuroscientists are calling complexity bias meeting meaning we tend to prefer complicated solutions over simple ones. Therefore, we must make a conscious effort to simplify things.

This is precisely the kind of innovation that is very much needed in our health system. Innovation that simplifies care pathways for patients and eliminates administrative barriers. And of course, the digitalization has great potential here. My second recommendation relates to the complexity of health systems.

Although we'd very much like to have big bang innovations to solve complex problems there is a risk of trying to swallow the elephant full. Instead we can break up the problem we need to solve into smaller pieces and approach them incrementally. Putting it in, in other words, when eating an elephant, take one bite at a time.

Thanks, 

Pooja: Trinh. I like your analogy of the elephant. Haja, coming to you, what will your message be for the policy makers? 

Haja: So I think 

Pooja: it's, 

Haja: For those involved in health system strengthening research, generating the much needed evidence to inform policy and practice. It's being intentional about engaging in research with communities as opposed to research for.

And that really makes a significant difference where if you engage the communities effectively into the design and also throughout the research process, so effective community engagement, it goes a long way in promoting ownership. And leadership and sustainability at the community level. So it's moving away from doing research for and being intentional about doing research with the communities and also innovation in, in UHC should be aimed at ensuring equitable access to healthcare services for all.

including marginalized and underserved populations. Decision makers should ensure that the benefits of innovation is distributed fairly across different population groups. 

Pooja: Thanks, Hajo. So, that's great. We have three strong takeaways and message for policymakers from our speakers. First, for bringing innovation in UHC, moving away from things that No longer fit the purpose.

Second, simplifying things and approaching them incrementally. And lastly, ensuring that research and work is with engagement with the community and not for the community. And ensuring that benefits of innovation are distributed fairly across different population groups. Thanks so much, Sara, Trinh, and Haja for sharing your insights today.

I thoroughly enjoyed our discussion and I'm sure listeners also would have enjoyed this podcast. Thank you to all the listeners for tuning in today, and do stay tuned for our next podcast on another compelling UHC topic. Thank you, and bye bye to everyone. Have a nice rest of the day.

Gavin: Thanks so much for joining us for this episode of The Lancet Voice. This podcast will be marking the Lancet's 200th anniversary throughout 2023 by focusing on the spotlights with lots of different guest hosts from across the Lancet group. Remember to subscribe if you haven't already and we'll see you back here soon.

Thanks so much for listening.