Reflections on Japan’s G20 Presidency in 2019 and The Lessons for Future Political Commitment to Universal Health Coverage

doi:10.21203/rs.3.rs-104608/v1

Download PDF

Research

Reflections on Japan’s G20 Presidency in 2019 and The Lessons for Future Political Commitment to Universal Health Coverage

https://doi.org/10.21203/rs.3.rs-104608/v1

This work is licensed under a CC BY 4.0 License

Version 1

posted

You are reading this latest preprint version

Background: The Group of 20 (G20) Osaka Summit 2019 was a large step forward for global health diplomacy to build consensus on universal health coverage (UHC). To strengthen multi-stakeholder UHC partnership, Japan involved the research and policy advice network for G20 (Think 20: T20), civil society (Civil 20: C20), private initiatives of medical professional groups (H20), and the pharmaceutical sector. We attempted to identify UHC-related issues addressed and left unaddressed at the G20 Osaka, to bring lessons for the G20 Riyadh Leaders’ Summit 2020.

Methods: We reviewed the G20 Osaka Leaders’ Declaration, policy-related statements, and voices of the relevant G20 engagement groups and sectors. In 2019 July, after the G20 Osaka Leaders’ Summit, we organized an expert meeting convening Japan-based UHC-related key global health stakeholders. The main findings were presented in form of classifying the voices expressed in the meeting by UHC-related topics, and then definitional ranges of UHC were summarized.

Results: The T20, H20, and the pharmaceutical sector noted during our expert meeting that the ministerial-level health -finance collaboration was one of the key agendas suggested at the G20. T20 and C20 called for a recognition of health needs of refugees, migrants and other vulnerable groups in achieving UHC. Sexual and reproductive health and rights (SRHR) with a human rights-based approach through UHC was raised by the C20 as an issue unaddressed in G20 Osaka. Variation in operative purposes between global health stakeholders led to a definitional difference in the scope of UHC.

Discussion: The definitional difference could delay progress of UHC attainment. Addressing migrant and refugee health and SRHR within the context of UHC is further needed. Understanding perspectives of various stakeholders will become increasingly important to well-coordinate multi-actor cooperation with adequate social responsibility and transparency in UHC achievement and public-private partnership.

Conclusions: At the G20 Riyadh, for UHC there is need of 1) ensuring an integrated yet comprehensive multi-stakeholder approach towards UHC; 2) incorporating important dimensions such as the marginalized population and gender; and 3) ensuring adequate investments toward health information systems and governance to track health data for the vulnerable population and gender-responsive financing.

Health Economics & Outcomes Research

Health Policy

G20

Universal Health Coverage

Global Health

Health Policy

United Nations High-level Meeting

Global Health Diplomacy

Migrant Health

Sexual and Reproductive Health and Rights

Monitoring and Evaluation

Partnership

The Group of 20 (G20) Osaka Summit in May 2019 was a milestone for global health diplomacy to reach a consensus on promoting universal health coverage (UHC). Before then, in the occasion of the G20, UHC was only brought up slightly along with content on safeguarding against health crisis and strengthening health systems in 2017 (1), and no single paragraph existed for UHC in 2018 in the Leaders’ Declarations agreed by G20 countries (2). During the G20 2019, UHC was brought up clearly to recall its commitment for achievement according to national contexts and priorities, in the first paragraph of the global health section of the G20 Osaka Leaders’ Declaration in form of a full paragraph (3). Moreover, in recognizing the importance of sustainable financing for health, the G20 Shared Understanding on the Importance of UHC Financing in Developing Countries (4) was adopted to reaffirm commitment for UHC among the Finance and Health Ministers at their Joint Session, which was simultaneously held during the G20 Osaka Summit (5).

Uniquely, in the occasion of the G20 2019 under Japan’s presidency, Japan took a whole-of-society approach in order to strengthen partnerships and engage in policy dialogues with G20 Engagement Groups. The official G20 Engagement groups include research and policy advice network for the G20 (Think 20: T20) (6, 7) and the civil society (Civil 20: C20) (4). The G20, T20, and C20 have each published their declaration in relations to G20 (6–8). In addition, private initiatives of medical professional groups from the Health Professional Meeting (H20) organized by the World Medical Association (WMA) and Japan Medical Association (JMA) presented their respective memorandum (9), and the pharmaceutical sector driven by the International Federation of Pharmaceutical Manufactures and Associations (IFPMA) including companies in Japan, the United States (US), and Europe published a statement (10) to Japan’s Prime Minister Shinzo Abe in order to accelerate progress towards UHC among all United Nations (UN) member states. Following the G20, the first-ever UN High Level Meeting (UN-HLM) on UHC was held on September 23th 2019, where a political declaration on UHC was adopted by all UN member states. This marked a turning point in the history of global health diplomacy, placing UHC as a major issue not only in global health but for the entire global community.

UHC is gaining political momentum as a key agenda of global health diplomacy. Bloom and colleagues of the T20 called on next steps to be taken for UHC in advance to the G20 Osaka Summit, highlighting that the G20 have made an effort to facilitate crucial actions for UHC (7). However, after the G20 Osaka Summit, issues remain awaited to be addressed in future G20 meetings, which require strengthened visibility for political momentum towards UHC and further understanding of perspectives or various global health stakeholders. However, there is lack of evidence regarding these remained issues in relations to the voices and statements of the G20 Osaka Summit Engagement Groups. Therefore, we attempt to identify UHC-related issues that were either addressed or left unaddressed at the G20 Osaka Summit. Also, we reflected upon outcomes of the first ever UN-HLM, on UHC in September 2019, which followed after G20 Osaka Summit. Lessons learnt in this study are to be applied for at the G20 Riyadh Leaders’ Summit in November 2020, in order to substantially leverage effective UHC in its next miles of political history of global health diplomacy.

We reviewed the G20 Osaka Leaders’ Declaration (3), and policy-related statements and voices of the relevant G20 engagement groups and sectors (the T20, C20, H20, and the pharmaceutical sector). In addition, an expert meeting was held by authors from the Institute for Global Health Policy Research (iGHP), National Center for Global Health and Medicine (NCGM) under the purpose of discussing the addressed and unaddressed issues at the G20 Osaka. This meeting was held on July 30th 2019, which was after the G20 Osaka and before the UN-HLM 2019. The main speakers were Japan-based UHC-related key global health stakeholders from the G20, T20, C20, H20, and the pharmaceutical sector. Information obtained through this expert meeting were also fed into this paper by summarizing the voices from the discussion and answers to common questions (on what were “suggested and agreed by the G20 2019,” “issues not enough discussed at the G20 2019”, “issues to be discussed at the UN-HLM 2019,” and “issues to be discussed at the G20 Health Ministers Meeting 2019”).

We then classified the voices of the T20, C20, H20, and the pharmaceutical sector by UHC-related topics: health systems financing, service quality and delivery; inclusiveness; innovation; operational cooperation and partnership; and prioritization and sustainability, monitoring and evaluation. In addition, based on the stances taken by each of the stakeholders, we plotted the definitional ranges of UHC and perspectives in relations to the G20 Health Ministers’ Meeting and the UN-HLM.

Alongside the strengthened ministerial-level collaboration between health and finance sectors in the occasion of the G20 Osaka Leaders’ Summit, diversified voices were heard among stakeholders, around issues related to monitoring and evaluation of progress towards UHC, actor cooperation between global health and medical entities, and partnership building. To take a further step into the discussion, stakeholders voiced the health needs of refugees, migrants and other vulnerable groups in achieving UHC, and the importance for realizing sexual and reproductive health and rights through UHC. Variation in operative purposes among global health stakeholders has resulted in varying scopes of key understanding behind UHC.

3.1. Diversified voices on UHC with health-finance collaboration agreed to be G20’s key agenda

While the G20 Osaka Leaders’ Declaration called for greater collaboration between health and finance authorities, where its commitment was affirmed by the G20 Finance and Health Ministers during their first-ever joint session at the G20 (11), diversified voices on UHC were heard among stakeholders. The T20, H20, and the pharmaceutical sector noted during our expert meeting that this health-finance collaboration was one of the key agendas suggested to the G20 (Table 1). However, according to the T20, the G20 failed to discuss enough on monitoring tools for prioritizing primary health care (PHC)-based health systems and a common mechanism to monitor UHC. The H20 brought up remaining challenges in cooperation among key global health actors, medical doctors, and medical associations (Table 2). The pharmaceutical sector emphasized the need of establishment of a new public-private partnership (PPP) dialogue platform. In relations to partnership, T20 suggested effective coordination for sustainable UHC. C20 called for a comprehensive and effective review mechanism including independent evaluation of UHC by the civil society. Furthermore, H20 raised further need in health-finance ministerial-level collaboration to promote UHC in developing nations, and the pharmaceutical sector requested to ensure commitment for progress towards UHC not only among G20 countries but among all UN member states.

Table 1

Voices of the T20, C20, H20, and the pharmaceutical sector on achievement of the G20 and undiscussed issues
	Suggested and agreed by the G20 2019					Issues not enough discussed at the G20 2019
Thematic area	Voices	T20	C20	H20	P^*1	Voices	T20	C20	H20	P^*1
Health systems financing, service quality and delivery	Emphasizing health system strengthening while focusing on the quality of services				X	Health financing to achieve UHC		X
	Strong PHC systems that can harness increased ageing and NCD related issues (integrated nursing and medicine with a community-based, life-course approach)	X				Domestic financing for health that reach the 5% GDP target or 15% of national budget, and elimination or minimalization of out of pocket payment		X
	Strengthening human resource capacity for health and policy makers			X		Due to emergence of large multinational IT platform companies etc., financial redistributions among nations are decreasing, by factors such as the globalization of profit structure, or base erosion and profit shifting (BEPS). The fact that the G20 Shared Understanding mentions “financial capacity” and “progressivity” can be evaluated positively to some extent, but doubts remain on its effectiveness.		X
	Strengthening of health systems with a focus on quality both by public and private sectors			X
Inclusiveness	Countries with heavy disease burdens as well as political economic crises should not be left out of achievement of UHC		X			PHC for all people, especially for the marginalized population	X
	UHC should be grounded on human rights-based approach, prioritizing PHC, ensuring SRHR, responding to gender-based violence, and adopting a holistic approach to health including nutrition and WASH		X			Documentation of migrants including health workforce mobility. Health protection for migrants.	X
	Ensure UHC that leaves no one behind, including the most vulnerable and marginalized populations such as migrants and refugees, sexual minorities, MSM, sex workers, etc.		X			UHC that leaves no one behind, including socially and politically marginalized and vulnerable populations		X
						Human rights and human security as a basis for UHC		X
Innovation	Promotion of innovation through public private partnership/ cost effective and appropriate digital health	X
Operational cooperation and partnership	Cooperation between health and finance ministers	X		X	X	Role of physicians and their associations to advocate and ensure UHC			X
	Call for an effective partnership, Effective coordination for sustainable UHC	X		X		Establishment of new platform for public and private (and academia) partnership				X
	Recommending multilaterals and stakeholders to coordinate effectively				X
Prioritization and sustainability, monitoring and evaluation	Recognizing the need for sustainable health financing		X	X		Monitoring tools for PHC-based health system	X
	Each country should achieve 5% GDP for spending on heath, donor countries should achieve 7% ODA target and prioritize health. Ensure sustainability of GF, GAVI and other multilaterals through sufficient replenishment		X			Support for UHC indicator calculation. Common UHC monitoring mechanisms	X
	Commitment to ensure UHC in accordance with each country situation				X
^{* 1} P: Pharmaceutical sector. Abbreviations: UHC: universal health coverage; PHC: primary health care; SRHR: sexual reproductive health rights; WASH: water, sanitation and hygiene; MSM: men who have sex with men; GDP: gross domestic product; ODA: official development assistance; GF: Global Fund; GAVI: Gavi, The Vaccine Alliance

Table 2

Voices of the T20, C20, H20, and the pharmaceutical sector on remaining challenges for the UN High-level Meeting and G20 Health Ministers’ Meeting, 2019
	Issues to be discussed at the UN High-level Meeting 2019					Issues to be discussed at the G20 Health Ministers Meeting 2019
Thematic area	Voices	T20	C20	H20	P^*1	Voices	T20	C20	H20	P^*1
Health systems financing, service quality and delivery	Financing for UHC, particularly on securing domestic financing and achieving 5% GDP target		X			Health financing, (Each country should achieve 5% GDP for spending on heath, donor countries should achieve 7% ODA for health, and prioritize health in their ODA policy)		X
	Recognizing the importance of equitable system for revenue collecting		X			Access to essential medicines in developing countries, lower price setting and securing of new incentives		X
	Ensuring access to medicine, by ensuring low or no out of pocket payment.		X			Development of a process which minimizes the negative impact for middle income countries transitioning from donor funding to domestic funding for health finance resources to ensure UHC		X
	Capacity development of health human resources as well as of policymakers			X		Securing sustainable health financing to ensure UHC			X
	Strengthening of health systems with a focus on quality			X		Talent development for human resources for health to ensure UHC			X
	Recognition for the importance and implementation of sustainable health finance			X
Inclusiveness	Basis for UHC (human rights and human security), as well as achieving UHC that leaves no one behind		X			PHC for all people, especially for the marginalized population	X
Inclusiveness						Documentation of migrants including health workforce mobility, health protection for migrants	X
Operational cooperation and partnership	Effective coordination for sustainable UHC	X				Partnership between physicians and their associations and governments as well as with WHO to ensure UHC			X
	Recognition of civil society involvement in achieving UHC		X			Establishment of new platform for public and private (and academia) partnership				X
	Further coordination between health and finance ministries to ensure UHC in developing countries			X
	Commitment to achieve UHC by all UN member states, not just G20 countries				X
	Further coordination between health and finance ministries				X
	Establishment of the Global Action by G20				X
Prioritization and sustainability, monitoring and evaluation	Holistic review mechanism of UHC that includes an independent evaluation by CSOs		X			Monitoring tools for PHC based health system	X
^{* 1} P: Pharmaceutical sector. Abbreviations: UHC: universal health coverage; PHC: primary health care; GDP: gross domestic product; ODA: official development assistance; WHO: World Health Organization; CSO: chief sustainability officer

3.2. Inclusive UHC to address migrant health and sexual and reproductive health and rights

In response to the last G20, both C20 and T20 called for a recognition of refugees, migrants and other health needs of the vulnerable to achieve UHC (4, 8). Migration and migrants’ wellbeing are critical issues of the twenty first century (12). The T20 further called for data and statistical management of migrant health to understand their needs better and to be able to provide evidence-based policy to address the health needs of migrants (7), but the G20 Osaka left this issue unaddressed. While the Finance and Health Ministers’ meeting in G20 Osaka recognized the need for “high quality primary healthcare services, including immunization, as well as essential medicines, [made] accessible to everyone,” the document did not specify whether this includes migrants, regardless of legal and documentation status. The last G20 meeting seemed to only address UHC as a narrower scope that concerned only its citizens. The G20 countries, instead, are in position to approach UHC from a human security perspective. Having this perspective would be the first step to ensure primary healthcare at an affordable cost to all, including migrants independent of their migratory or legal status.

Realization of Sexual and Reproductive Health and Rights (SRHR) through UHC was another issue proposed by the C20, but left unaddressed at the G20 Osaka Summit. Post G20 Osaka, SRHR was brought up in the political declaration of the UN-HLM in 2019 (13, 14), and its necessity was re-emphasized by the joint press statement developed by 59 government agencies in response to SRHR and COVID-19 (15, 16). The statement raises the need for sexual health services with a priority on funding for SRHR and clearly indicates that it is crucial that leaders recognize the central role of UHC in health emergencies and the need for robust health systems to save lives (15, 16).. The governmental level statement highlights the need for essential health workers and resources to respond to maternal and child mortality, unmet needs for reproductive health commodities including contraception, sexually transmitted diseases, and unsafe abortion (15–17).

3.3. Variation in definition and scope of UHC among stakeholders

The purpose of the UN High-level Meeting and the G20 Health Ministers’ Meeting have dimensional differentials in terms of definitional range of UHC, as well as its perspective regarding aid allocation, here simplified by a binomial dimension on the y-axis: whether it is donor-driven, or based on the recipient countries’ needs and perspectives (Fig. 1). In addition to the country-specific definition of UHC with an absence of global standardization (18), variation in operative purposes between global health stakeholders led to a definitional difference in the scope of UHC. As plotted on the x-axis, the narrowest definition of UHC would be in line with the Sustainable Development Goal (SDGs) 3.8, referring to indicators of service coverage and financial risk protection, namely the gold standards in monitoring and evaluating UHC (19, 20). On the other hand, some global health actors recognize UHC as a broader concept, i.e., inclusive approaches of health-related issues in the SDGs or sometimes beyond (21).

The UN-HLM aims to prioritize accountability over resource efficiency, compared to the G20 health ministers’ meeting which is an opportunity to discuss more technical issues regarding health resource allocation. Although we understand the importance of advocating and investing more in health, the importance of health as an agenda still remains a small part in comparison to other G20 agendas. Therefore, for health, we understand that G20 holds an inclusive stance in pinning the UHC definition not restricting to its meaning of SDG 3.8. As G20 is composed of advanced economies, we see its perspective closer to donor driven on the y-axis. On the contrary, the C20 presented a less donor driven perspective, and emphasized a further need for UHC to meet the needs of the socially and politically marginalized population. H20 was relatively similar to C20 in terms of perspective but was more technically oriented to promote cooperation between Ministry of Finance and Ministry of Health in recipient countries. They had a particular focus on health system strengthening and capacity development of human resources. T20 had a narrower definitional range of UHC compared to other stakeholders, as they emphasized the need for multisector cooperation among government, and their voices were centered around operational cooperation, partnership and innovation. Objectively, T20 had a more donor driven perspective than C20 and H20, as the T20 suggested a strong PHC system to harness issues such as ageing and non-communicable disease, and public-private partnership.

Based on policy-related documents and voices from multi-stakeholders (Table 1, 2), we identified a narrower definition of UHC among T20 and H20, compared to G20 and C20, having a focus on monitoring UHC rather than evaluation for accountability. The T20 and H20 had a higher motivation to seek for further efficient resource allocation, through improvement of UHC indicators and partnerships. Issues on health information systems, especially for migrant health and their social security, were brought up by T20 as an issue undiscussed at G20. The C20 took an inclusive approach both in terms of UHC definition and donor-recipient perspective with attention on expanding the quality and quantity of financing development assistance for health to reach the vulnerable and marginalized population such as migrants.

Definitional difference in the scope of UHC among stakeholders have been identified. This difference could further delay UHC to move forward towards fulfillment of the sustainable development goals (SDGs), in attaining harmonization between aid agencies as well as alignment between donors and recipients. Addressing marginalized issues, such as migrant and refugee health and SRHR, within the context of UHC is needed. Nevertheless, they were unfortunately not brought up clearly as part of the official declarations in the event of the G20 Osaka Summit. In the future, understanding perspectives of the G20, T20, C20, H20, and the pharmaceutical sector will become increasingly important to well-coordinate multi-actor cooperation with adequate social responsibility and transparency in UHC achievement, to build a stronger public-private partnership (PPP).

4.1. Migrant health and sexual and reproductive health and rights as a key issue for comprehensive commitment towards UHC

Through an integrated definition that will eventually harmonize the vision and philosophy of UHC between stakeholders, addressing vulnerable topics such as migrant health and sexual and reproductive health rights (SRHR) may be a key issue for comprehensive commitment towards UHC, amid increase in multi-stakeholder platforms and partnerships. Given our results, all actors need to ensure the ownership of both donor and recipient countries among multi-stakeholders as well as a clearer UHC definition.

G20 countries recognized the growing migration trend as noted in the leader’s declaration (3). With about one seventh of the world’s population currently living in a country outside of where they were born (22), international effort is needed to explicitly acknowledge the health needs of migrants and refugees, to include them in the individual national health policies and plans in advancing “health for all” for UHC. The World Health Organization (WHO) also recognized that the SDG 3.8 on UHC cannot be achieved unless the health needs of migrants and refugees are met and health inequity is reduced (23). Migrants still remain as a challenging issue in relation to health as migration and health have different or incompatible goals (24), despite two World Health Assembly resolutions dedicated to the health of migrants in 2008 (25) and 2017 (26), the United Nations General Assembly High Level Meeting on Large Movements of Migrants and Refugees in 2016, and the Global Compacts on Refugees and Safe, Orderly and Regular Migration adopted in 2018. Many countries, including the G20 countries, do not recognize global frameworks for safe migration that protects migrants’ welfare, including migrants’ health. Although the Global Compact for Safe, Orderly and Regular Migration, explicitly stated that health needs of migrants and refugees should be incorporated in national and local healthcare policies and plans, it was not signed by several countries (27), primarily due to economic and security issues. Migrants often experience cultural and language barriers to healthcare (28, 29), regardless of the legal or migratory status, as well as undocumented migrants suffer from severe out-of-pocket payment due to ineligibility of national insurance schemes, which validate the need of migrant health addressed for UHC.

The lack of international consensus on the definition of SRHR as well as family planning driven from its sensitiveness, makes its realization via a concept like UHC difficult. Reproductive health and rights were defined and agreed during the International Conference on Population and Development (ICPD) in 1994 among 179 states. However, ICPD neither defined sexual health nor explicitly referred to sexual rights while the conference assumed that reproductive health embraces sexual health. There have been several attempts to define sexual rights by some organizations, e.g. WHO (30) and the World Association for Sexual Health but no definition has yet to reach international consensus. The lack of international consensus regarding SRHR also lied in the family planning approach, principally in the right to safe abortion. Different beliefs have existed among G20 member states and some members are negative for abortion. For example, the United States recently decided to withdraw its support for federal funding for overseas family planning and reproductive health organizations that provide abortion services or counselling (31). The key for reaching an agreement on SRHR is to highlight several components of SRHR in association to a more widely recognized human rights with definitional alignment of SRHR and family planning. Although, it is a challenge to standardize its definition in relation to diverse interpretation of safe abortion. However, given that there are also many components that the member states have already admitted, e.g. women and girls’ rights and health care for women before and after pregnancy and childbirth, shedding more light on these areas would serve as the first step for member states to realize at least some of the components of SRHR through UHC.

4.2. Strengthening the national evidence-based monitoring and evaluation system

The UHC monitoring framework indicators, composed of service coverage (19) and financial risk protection (20) suggested by the WHO and the World Bank Group in 2013 (32), emphasizes the need to implement national evidence-based monitoring and evaluation systems that aim to attain country-comparability and national data representativeness (33). At the G20 Osaka Summit, this was reemphasized by countries of strong economy agreeing that investing in health at an early stage of development was important for sustainable and inclusive growth, thus encouraging developing countries to mobilize their domestic resources for UHC (4). At the same time, the digitalization of health data to track UHC indicators is needed, especially for developing nations that do not have sufficient amount of quality data (18, 33). Multi-stakeholder platforms and partnerships took a step to the next level where international coordination became more important, especially for aid recipient countries. International coordination is a crucial challenge in investment for global health due to the increasing role of the private financial sector actors (34). Financial outcomes of long-term funding among government institutions and multilateral agencies could lead to risk sharing among health infrastructure projects, for example, with better credit ratings and lower cost of capital (35).

4.3. Building further multi-stakeholder platforms and partnerships for UHC

In order to follow a global action plan for healthy lives and well-being for all, all relevant stakeholders need to collaboratively make effort for UHC through multi-stakeholder platforms and partnerships to support the efforts of member states, not only to achieve UHC but other health-related SDG targets. Multiple perspectives of the G20, T20, C20, H20, and the pharmaceutical sector need to be understood in order to well-coordinate its cooperation for higher participation and transparency in UHC achievement. Furthermore, despite the countries’ growing motivation towards UHC at the national level, there is an essential need for multi-stakeholder platforms and partnerships that ensure all donor and recipient countries to have ownership to further enhance UHC. The UHC2030 serves as a knowledge hub to deliver experience-based or evidence-based resources bridging upon the WHO and the World Bank (WB). Through the UHC 2030, the WHO and WB have the fundamental demand to further work together to share their strong networks with health ministers and finance ministers, as well as to exchange knowledge on health expertise and financial operations that are unique to their institutions. In addition, finances need to be well coordinated, with synergy of traditional and innovative financing mechanisms, including the Global Fund, GAVI, GFF, and the UN Trust for Human Security. Also, based on current international platforms to develop innovative financing mechanisms via public-private partnership, such as GHIT and CEPI, research and development should be facilitated for knowledge sharing from resource mobilization to implementation through the lens of UHC in order to expand the service delivery of vaccines, pharmaceuticals, and other essential medical commodities.

With limited resources of public funding in health development assistance, the need for strengthening the partnership between government institutions, the private sector, academia, and civil society require further emphasis to achieve UHC through traditional and innovative financing mechanisms, taking advantage of the multilateral systems. The coordination between the Secretary-General of the UN and the Member States to achieve synergistically UHC and all health-related targets of the SDGs would be a way forward in ensuring political momentum to achieve UHC by 2030, and to capture UHC-related targets outside SDG 3.8. including migrant health and SRHR.

In conclusion, we raise three major points to be addressed through the G20 Riyadh Leaders’ Summit. First there is need of ensuring an integrated yet comprehensive multi-stakeholder approach towards UHC, which could in some cases require efficient specialization between actors to overcome its definitional difference. Second, incorporating important dimensions such as the marginalized population and gender, in order for the progress of UHC to respond to structural inequity and leave no one behind, is important. Third, investments toward health information systems and governance to track health data for the vulnerable population and gender-responsive financing are effective, as demonstrated during the global spread of COVID-19.

5.1. Suggestions for G20 Riyadh Leaders’ Summit from experiences of G20 Osaka

In order to take better action for UHC through the G20 Riyadh Leaders’ Summit, there is a need for ensuring an integrated yet comprehensive multi-stakeholder approach towards UHC. This could in some cases require efficient specialization between actors to overcome its definitional differences. Definitional alignment among various stakeholders is needed to reach international consensus on further promotion of UHC, as well as to address marginalized issues that have not been addressed at the G20 Osaka Summit. While between-country dialogue is crucial to effectively achieve UHC, dialogue on UHC between multi-stakeholders may also be a key in understanding how countries could together bring UHC to its next step.

Second, incorporating important dimensions such as the marginalized population and gender, in order for the progress to respond to structural inequity, leaving no one behind, is important. In doing so, we need further commitment towards migrant and refugee health based on what has been agreed at the UN-HLM 2019, and towards SRHR stemming further upon the joint press statement on SRHR and COVID-19 agreed by government agencies of 59 countries calling for gender-responsiveness and multilateral efforts to respond well to COVID-19 (15, 16).

5.2. Further ways of coordination for leadership towards digitalization of health data and optimal resource allocation

Third, investments toward health information systems and governance to track health data for the vulnerable population and gender-responsive financing are effective, especially with the global spread of COVID-19. Investments toward better health information systems and governance to track health data are solutions for better migrant and refugee health (36). Leadership towards digitalization of health records or infectious disease tracking mechanisms could be driven further by technologically advanced countries and actors with a well-established PPP. With the COVID-19 pandemic, continuation of current lockdowns have facilitated gender-based violence and unintended pregnancies, which require implementation of preventive policies to meet the needs of SRHR (37–39). Japan, as being a host country of the G20 2019, is now in place to take these lessons on unaddressed issues, to apply them to the international community to ensure effective UHC among the marginalized and vulnerable population. Given the circumstance of low priority on women and children in UHC strategies (40), counties like Japan with a comparative advantage in information technology face a great amount of opportunity to collaboratively create new platforms and business models for digital health globally, regionally, and locally. This would lead to Japan taking further leadership role for UHC, in order to make sure that the UHC concept adapt to every population and secures human rights for health. This could be enforced by different key actors mentioned in this paper as well as the private sector working together.

Leadership towards digitalization of disease comprehensive health records and its tracking mechanisms via data linkage of individual health records should be driven further not only by health authorities, but also among coordination with humanitarian and non-health authorities, including agencies such as United Nations High Commissioner for Refugees (UNHCR), United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA), or the International Organization for Migration (IOM). Health systems governance and financing require collaboration among multi-stakeholders that quickly respond to health emergencies and allow optimal allocation of existing budgets simultaneously, which could be facilitated by PPP, yet a good balance of input among other supporting actors. From the G20 Osaka, the UN-HLM on UHC (September 2019), and G20 Health Ministers’ Meeting in Okayama (October 2019), and the 2nd UHC Forum in Bangkok (January – February 2020), among others, UHC have continued to gain momentum. In the forthcoming milestones in addition to G20 Riyadh Leaders’ Summit, including the Nutrition for Growth Summit, Japan’s experiences in leading the G20 show challenges and future opportunities to align the definitional disparities between various stakeholders to accelerate inclusive political momentum for UHC, to ensure sustainable commitment towards UHC from both developed and developing nations.

UHC

universal health coverage; G20:Group of 20; UN:United Nations; UN-HLM:United Nations General Assembly High Level Meeting; SDGs:sustainable development goals; WB:World Bank; T20:Think 20; C20:Civil 20; H20:Health Professional Meeting; WMA:World Medical Association; JMA:Japan Medical Association; IFPMA:International Federation of Pharmaceutical Manufactures and Associations; NCGM:National Center for Global Health and Medicine; iGHP:Institute for Global Health Policy Research; PPP:public-private partnership; SRHR:sexual and reproductive health rights; WHO:World Health Organization; ICPD:International Conference on Population and Development

Ethics approval and consent to participate

Not applicable as our research took on a style of an expert meeting where

We did not collect any personal information
We only asked participants of the expert meeting about universal health coverage in general and did not ask any personal health information
No intervention was performed to the patients
We discussed participants of the expert meeting about universal health coverage in general and the participants did not feel any mental or emotional stress during the meeting.

Based on the criteria set by the national guideline, we have determined that our study will not need any ethical approval.

Consent for publication

Not applicable.

Availability of data and materials

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Funding

MKS is supported by the Masason Foundation (MF) and has received a grant from MF. MF has not contributed to the study design, collection, management, analysis, and interpretation; manuscript preparation; or decision to submit the manuscript for publication.

Authors’ contributions

The manuscript was conceptualized by YK and MKS. This paper is based on an expert meeting organized by YK and held at the Institute for Global Health Policy Research (iGHP), National Center for Global Health and Medicine (NCGM), in Tokyo. MKS developed the first draft of the manuscript. All authors edited and approved the final manuscript.

Acknowledgements

We thank members of the expert meeting from key global health stakeholders for UHC in Japan, including those from the Government of Japan, think tank, civil society, Japan Medical Association, and the pharmaceutical sector, as well as expert contributors, for having participated in the meeting as well as offered helpful comments and suggestions during the meeting. The members of the expert meeting were as follows:

Main speakers of the meeting:

Satoshi Ezoe	Permanent Mission of Japan to the United Nations
Saeda Makimoto	Japan International Cooperation Agency Research Institute
Masaki Inaba	Africa Japan Forum
Mari Michinaga	Japan Medical Association
Yasunori Tawaragi	Japan Pharmaceutical Manufacturers Association
Yasushi Katsuma	National Center for Global Health and Medicine
Shinichirou Noda	National Center for Global Health and Medicine

Attendees of the expert meeting:

Yuji Noto	Japan Medical Association
Ikuo Takizawa	Japan International Cooperation Agency
Emiko Nishimura	Japan International Cooperation Agency
Yumiko Yoshii	Japan International Cooperation Agency
Masako Kikuchi	Japan International Cooperation Agency Research Institute
Hideaki Shiroyama	The University of Tokyo
Ayako Takemi	Harvard T.H. CHAN School of Public Health
Hiroshi Matsumura	Ministry of Health, Labour and Welfare
Yusuke Ariyoshi	Shionogi &Co.,Ltd.
Kaoru Chiba	Ministry of Health, Labour and Welfare
Nozaki Ikuma	National Center for Global Health and Medicine
Yuta Yokobori	National Center for Global Health and Medicine

G20 Germany 2017. G20 Leaders´Declaration, Shaping an interconnected world [Internet]. 2017 [cited 2020 Sep 21]. Available from: https://www.g20germany.de/Content/EN/_Anlagen/G20/G20-leaders-declaration___blob=publicationFile&v=11.pdf
G20 Argentina 2018. G20 Leaders’ declaration Building consensus for fair and sustainable development [Internet]. [cited 2020 Sep 21]. Available from: https://www.mofa.go.jp/mofaj/files/000424877.pdf
G20. G20 Osaka Leaders’ Declaration | Documents and Materials | G20 Osaka Summit 2019 [Internet]. G20 Osaka Leaders’ Declaration. 2019 [cited 2020 Sep 1]. Available from: https://www.mofa.go.jp/policy/economy/g20_summit/osaka19/en/documents/final_g20_osaka_leaders_declaration.html
G20. G20 Shared Understanding on the Importance of UHC Financing in Developing Countries - Towards sustainable and inclusive growth- [Internet]. G20 Shared Understanding on the Importance of UHC Financing in Developing Countries - Towards sustainable and inclusive growth-. 2019 [cited 2020 Sep 1]. Available from: https://www.mof.go.jp/english/international_policy/convention/g20/annex8_1.pdf
Matsumura H, Nishimura Y, Horiuchi H, Higashira T, Kita Y, Nishizawa H. G20 Okayama Health Ministers’ Meeting: lessons learned and way forward. Glob Heal Med [Internet]. 2019 Dec 31 [cited 2020 Sep 21];1(2):65–70. Available from: https://www.jstage.jst.go.jp/article/ghm/1/2/1_2019.01033/_article
Bloom G, Katsuma Y, Rao KD, Makimoto S, Leung GM. Deliberate Next Steps toward a New Globalism for Universal Health Coverage (UHC). Vol. 1. 2019.
Bloom G, Katsuma Y, Rao KD, Makimoto S, Yin JDC, Leung GM. Next steps towards universal health coverage call for global leadership. BMJ [Internet]. 2019 May 24 [cited 2020 Sep 1];365. Available from: https://www.uhc2030.org/
C20 Japan 2019. C20 Policy Pack 2019 [Internet]. 2019 [cited 2020 Sep 1]. Available from: https://civil-20.org/2019/wp-content/uploads/2019/08/C20-POLICY-PACK-2019-web2.pdf
World Medical Association JMA. Memorandum of Tokyo on Universal Health Coverage and the Medical Profession, Health Professional Meeting (H20) 2019 [Internet]. 2019 [cited 2020 Sep 1]. Available from: http://dl.med.or.jp/dl-med/wma/h20e.pdf
International Federation of Pharmaceutical Manufactures & Associations (IFPMA). Biopharmaceutical CEOs Roundtable (BCR) joint statement [Internet]. 2019 [cited 2020 Sep 1]. Available from: http://www.phrma-jp.org/wordpress/wp-content/uploads/2019/07/BCRJointStatement_EN.pdf
The Lancet. G20 Osaka: when will global health commitments be realised? [Internet]. Vol. 394, The Lancet. Lancet Publishing Group; 2019 [cited 2020 Sep 1]. p. 1. Available from: https://www.
Abubakar I, Aldridge RW, Devakumar D, Orcutt M, Burns R, Barreto ML, et al. The UCL–Lancet Commission on Migration and Health: the health of a world on the move [Internet]. Vol. 392, The Lancet. Lancet Publishing Group; 2018 [cited 2020 Sep 1]. p. 2606–54. Available from: https://pubmed.ncbi.nlm.nih.gov/30528486/
United Nations. Political Declaration of the High-level Meeting on Universal Health Coverage “Universal health coverage: moving together to build a healthier world [Internet]. 2019 [cited 2020 Sep 1]. Available from: https://www.un.org/pga/73/wp-content/uploads/sites/53/2019/07/FINAL-draft-UHC-Political-Declaration.pdf
International Institute for Sustainable Development. UN High-Level Meeting Adopts Historic Declaration on Universal Health Coverage | News | SDG Knowledge Hub | IISD [Internet]. [cited 2020 Sep 1]. Available from: https://sdg.iisd.org/news/un-high-level-meeting-adopts-historic-declaration-on-universal-health-coverage/
Joint Press Statement for Protecting Sexual and Reproductive Health and Rights and Promoting Gender-responsiveness in the COVID-19 crisis | PPD [Internet]. [cited 2020 Sep 21]. Available from: https://www.partners-popdev.org/speech/joint-press-statement-for-protecting-sexual-and-reproductive-health-and-rights-and-promoting-gender-responsiveness-in-the-covid-19-crisis/
Joint press statement Protecting Sexual and Reproductive Health and Rights and Promoting Gender-responsiveness in the COVID-19 crisis [Internet]. [cited 2020 Sep 21]. Available from: https://um.dk/en/news/newsdisplaypage/?newsid=aa0d171d-a660-46df-b760-effdf4cc555c
JOICFP. COVID-19-related: Japanese government agrees with SRHR joint statement | COVID-19-related | International cooperation NGO JOICFP (in Japanese) [Internet]. [cited 2020 Sep 21]. Available from: https://www.joicfp.or.jp/jpn/2020/05/12/46187/
Vande Maele N, Xu K, Soucat A, Fleisher L, Aranguren M, Wang H. Measuring primary healthcare expenditure in low-income and lower middle-income countries. BMJ Glob Heal [Internet]. 2019 Mar [cited 2020 Sep 1];4(1):e001497. Available from: https://pubmed.ncbi.nlm.nih.gov/30997157/
Hogan DR, Stevens DSc GA, Hosseinpoor AR, Hogan DR, Stevens GA, Reza Hosseinpoor A, et al. Monitoring universal health coverage within the Sustainable Development Goals: development and baseline data for an index of essential health services. Artic Lancet Glob Heal [Internet]. 2018 [cited 2020 Sep 1];6:152–68. Available from: www.thelancet.com/lancetgh
Saksena P, Hsu J, Evans DB. Financial Risk Protection and Universal Health Coverage: Evidence and Measurement Challenges. PLoS Med [Internet]. 2014 Sep 22 [cited 2020 Sep 1];11(9):e1001701. Available from: https://dx.plos.org/10.1371/journal.pmed.1001701
Abiiro GA, De Allegri M. Universal health coverage from multiple perspectives: A synthesis of conceptual literature and global debates [Internet]. Vol. 15, BMC International Health and Human Rights. BioMed Central Ltd.; 2015 [cited 2020 Sep 1]. p. 17. Available from: https://bmcinthealthhumrights.biomedcentral.com/articles/10.1186/s12914-015-0056-9
International Organization for Migration (IOM). World Migration Report 2018. [Internet]. 2018 [cited 2020 Sep 1]. Available from: https://publications.iom.int/system/files/pdf/wmr_2018_en.pdf
World Health Organization. WHO | Migration and universal health coverage and quality [Internet]. Migration and universal health coverage and quality, Refugee and migrant health. 2019 [cited 2020 Sep 1]. Available from: https://www.who.int/migrants/about/mh-qhc/en/
Zimmerman C, Kiss L, Hossain M. Migration and Health: A Framework for 21st Century Policy-Making. PLoS Med [Internet]. 2011 May 24 [cited 2020 Sep 1];8(5):e1001034. Available from: https://dx.plos.org/10.1371/journal.pmed.1001034
World Health Organization. (No Title) [Internet]. Health of Migrants - The Way Forward. 2010 [cited 2020 Sep 1]. Available from: https://www.who.int/migrants/publications/mh-way-forward_consultation-report.pdf
World Health Organization. (No Title) [Internet]. Promoting the health of refugees and migrants. 2017 [cited 2020 Sep 1]. Available from: https://www.who.int/migrants/about/framework_refugees-migrants.pdf
United States Department of State. U.S. Ends Participation in the Global Compact on Migration - United States Department of State [Internet]. 2017 [cited 2020 Sep 1]. Available from: https://www.state.gov/u-s-ends-participation-in-the-global-compact-on-migration/
Suphanchaimat R, Kantamaturapoj K, Putthasri W, Prakongsai P. Challenges in the provision of healthcare services for migrants: A systematic review through providers’ lens [Internet]. Vol. 15, BMC Health Services Research. BioMed Central Ltd.; 2015 [cited 2020 Sep 1]. p. 390. Available from: http://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-015-1065-z
O’Donnell CA, Burns N, Mair FS, Dowrick C, Clissmann C, van den Muijsenbergh M, et al. Reducing the health care burden for marginalised migrants: The potential role for primary care in Europe [Internet]. Vol. 120, Health Policy. Elsevier Ireland Ltd; 2016 [cited 2020 Sep 1]. p. 495–508. Available from: https://pubmed.ncbi.nlm.nih.gov/27080344/
World Health Organization. Defining sexual health: Report of a technical consultation on sexual health [Internet]. Defining sexual health: Report of a technical consultation on sexual health. 2006 [cited 2020 Sep 1]. Available from: https://www.who.int/reproductivehealth/publications/sexual_health/defining_sexual_health.pdf?ua=1
Brooks N, Bendavid E, Miller G. USA aid policy and induced abortion in sub-Saharan Africa: an analysis of the Mexico City Policy. Lancet Glob Heal [Internet]. 2019 Aug 1 [cited 2020 Sep 1];7(8):e1046–53. Available from: www.thelancet.com/lancetgh
Ng M, Fullman N, Dieleman JL, Flaxman AD, Murray CJL, Lim SS. Effective Coverage: A Metric for Monitoring Universal Health Coverage. PLoS Med [Internet]. 2014 Sep 22 [cited 2020 Sep 1];11(9):e1001730. Available from: https://dx.plos.org/10.1371/journal.pmed.1001730
Abdi Z, Majdzadeh R, Ahmadnezhad E. Developing a framework for the monitoring and evaluation of the health transformation plan in the Islamic Republic of Iran: Lessons learned. East Mediterr Heal J. 2019 Jun 1;25(6):394–405.
Krech R, Kickbusch I, Franz C, Wells N. Banking for health: The role of financial sector actors in investing in global health. BMJ Glob Heal [Internet]. 2018 Jan 1 [cited 2020 Sep 1];3(Suppl 1). Available from: https://pubmed.ncbi.nlm.nih.gov/29736278/
Kickbusch I, Krech R, Franz C, Wells N. Banking for health: Opportunities in cooperation between banking and health applying innovation from other sectors. BMJ Glob Heal [Internet]. 2018 Jan 1 [cited 2020 Sep 1];3(Suppl 1). Available from: https://pubmed.ncbi.nlm.nih.gov/29915672/
Bozorgmehr K, Biddle L, Rohleder S, Puthoopparambil SJ, Jahn R. What is the evidence on availability and integration of refugee and migrant health data in health information systems in the WHO European Region? [Internet]. What is the evidence on availability and integration of refugee and migrant health data in health information systems in the WHO European Region? Themed issues on migration and health, X. WHO Regional Office for Europe; 2019 [cited 2020 Sep 15]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/32091682
Countdown 2030 Europe. COVID-19: System strengthening and support to SRHR - the case of Sweden | Euro RH/FP Tracker Countdown 2030 Europe [Internet]. [cited 2020 Sep 15]. Available from: https://www.countdown2030europe.org/news/covid-19-system-strengthening-and-support-srhr-case-sweden
Tang K, Gaoshan J, Ahonsi B. Sexual and reproductive health (SRH): A key issue in the emergency response to the coronavirus disease (COVID-19) outbreak. Reprod Health [Internet]. 2020 Apr 23 [cited 2020 Sep 15];17(1). Available from: https://pubmed.ncbi.nlm.nih.gov/32326943/
John N, Casey SE, Carino G, McGovern T. Lessons Never Learned: Crisis and gender-based violence. In: Developing World Bioethics [Internet]. Blackwell Publishing Ltd; 2020 [cited 2020 Sep 15]. p. 65–8. Available from: https://pubmed.ncbi.nlm.nih.gov/32267607/
Meier BM, Gostin LO. Human rights for health across the united nations [Internet]. Vol. 21, Health and Human Rights. Harvard School of Public Health; 2019 [cited 2020 Sep 15]. p. 199–204. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6927375/

Download PDF

Version 1

posted

You are reading this latest preprint version

Reflections on Japan’s G20 Presidency in 2019 and The Lessons for Future Political Commitment to Universal Health Coverage

Status:

Version 1

Abstract

Figures

1. Background

2. Methods

3. Results

3.1. Diversified voices on UHC with health-finance collaboration agreed to be G20’s key agenda

3.2. Inclusive UHC to address migrant health and sexual and reproductive health and rights

3.3. Variation in definition and scope of UHC among stakeholders

4. Discussion

4.2. Strengthening the national evidence-based monitoring and evaluation system

4.3. Building further multi-stakeholder platforms and partnerships for UHC

5. Conclusion

5.1. Suggestions for G20 Riyadh Leaders’ Summit from experiences of G20 Osaka

List Of Abbreviations

Declarations

References

Status:

Version 1