1Backgroundpaper–G.Schmets,O.Hanssen,A.Soucat,D.Porignon–HIS/HGF–7Nov2017

WHOBackgroundpaperpreparedforUHC2030

InterconnectednessofUHCandhealthsecurity

FirstFace-to-FaceMeetingoftheUHC2030WorkingGrouponSupporttoCountrieswithFragileorChallengingOperatingEnvironments

1.InterconnectednessofthehealthsecurityandUniversalHealthCoverageagendas

Healthsystemsarecriticaltoprevent,detectandrespondtohealthcrises.TheEbolaoutbreakandotherepidemicssuchastherecentYellowFever,ZikavirusortheMiddle-EastRespiratorySyndromecoronavirusoutbreakshavehighlighted thedeficiencies in the capacityof health systems todeliver public health atcritical moments. Governments, experts and development agencies now strongly advocate for healthsystemstobepreparedandcompetenttoguaranteethehealthsecurityofthepopulationandresilienceofsocieties,clearlylinkinghealthsystemstrengtheningandthenationalandglobalhealthsecurityagendas.

WHOandUHC2030partnersneedtojointlyworkonhealthsystemsstrengthening,IHRcomplianceanddisasterpreparedness toefficiently support theachievementofUHCandHealth Security.Workingonseparateagendasin isolationleadstoaduplicationofefforts,misplacedprioritiesandinefficiency.WHOandUHC2030partnersneedtosettheexample,promotingbroaderintegrationofIHRandpreparednessintoNationalHealthSystemStrategiesandPlans,healthsystemstrengtheningintoNationalActionPlansforHealthSecurity,andbettercoordinationbetweenEmergencyandHealthSystemsagendas.

EmergencypreparednesscanbeachievedinallcountriesonthewaytowardsachievingUniversalHealthCoverage,anditsrelatedSDG-targets.

The Emergency Preparedness and Health Systems frameworks are fully compatible, and a mutualreinforcement of emergency preparedness and health systems strengthening strategies is needed toensureanoptimaluseofscarcedomesticandinternationalresources:

Figure1:WHOEmergencypreparednessandHSSforSDGsframeworks

Butnocherrywithoutthecake:investmentsintheinstitutionsthatguaranteehealthsecurityneedtobetwinedwithinvestmentsinhealthsystems’foundations

“Universalhealthcoverageandhealthemergenciesarecousins—twosidesofthesamecoin. Strengthening health systems is the bestway to safeguard against health crises.Outbreaks are inevitable, but epidemics are not. Strong health systems are our bestdefencetopreventdiseaseoutbreaksfrombecomingepidemics.”TedrosAdhanomGhebreyesus,“Allroadsleadtouniversalhealthcoverage”,TheLancet,17July2017

2Backgroundpaper–G.Schmets,O.Hanssen,A.Soucat,D.Porignon–HIS/HGF–7Nov2017

2.WhatisthecosttoachieveemergencypreparednessforhealthsecurityontheroadtoUHC?Using a framework developed for health systems strengthening for attaining the health-related SDGs,WHO cost projections for 43 low- and middle-income countries1 from 2016 to 2030 show that anadditional US$21 billion average annual spending is needed to reach sufficient levels of EmergencyPreparedness or Health Security2. This is the equivalent of an average additional annual US$ 14.3 percapitaforthe43countriesconsidered3.

Figure2.InvestmentneedsontheroadtoEmergencyPreparednessandUHCThis amount is reasonable. However, a financing gap can be expected for many (mainly low-income)countries to reach sufficient levels of health security, being in total an averageof $8.6 billion a year.Figure3belowshowsthatwhilemostmiddleandstablelow-incomecountriesshouldbeabletofinancetheseneeds(leftgraphic),countriesaffectedbyconflictandthoseinvulnerablecontextsareparticularlylikely to have a financing gap,while also being those countrieswith the greatest needs (right graphic).External supportwill beneeded to fill in this gap in thesemost fragile countries. This funding shouldcoverpriorityHSSinvestmentsontheroadtowardshealthSecurityandUHC.

Figure3:InvestmentneedsvsprojectedTotalHealthExpenditurein14conflict&vulnerablestatesandin29stablecountries

1LICs:Afghanistan,Benin,BurkinaFaso,Burundi,Cambodia,CentralAfricanRepublic,Chad,Comoros,DemocraticRepublicoftheCongo,Eritrea,Ethiopia,Gambia,Guinea,Guinea-Bissau,Haiti,Liberia,Madagascar,Malawi,Mali,Mozambique,Nepal,Niger,Rwanda,SierraLeone,SouthSudan,Tanzania,Togo,Uganda,Zimbabwe:MICs:Algeria,Angola,DominicanRepublic,Ghana,Kazakhstan,Kenya,Nigeria,Pakistan,Romania,SriLanka,Sudan,Tunisia,Turkey,Yemen2Method:(1)BenchmarksforeachHSScomponentwerebasedonmedianlevelsinthe24countriesintheSDGsamplewithdemonstratedemergencypreparedness,detection and response capacity (Azerbaijan, Bangladesh, Brazil, Cameroon, China, Colombia, Cote d`Ivoire, Ecuador, Egypt, India, Indonesia, Iran, Iraq, Malaysia,Mexico,Morocco,Myanmar,Peru,Philippines,Thailand,SouthAfrica,Ukraine,Uzbekistan,Vietnam);(2)Costsforeachhealthsystemcomponentwerecounteduntiltheweakest part of each component reached its respective benchmark (ie. human resource costsweremodelled until all three healthworker category densitiesreachedtheirbenchmarks);(3)Foremergencypreparedness,itincludedinterventionssuchasstrengtheningriskcommunication,regulationandlegislation,pointsofentry, laboratorycapacities,all-hazardhealthworker training,emergencysimulationsandexercises,masscasualtymanagement,emergencykitsandequipment forrapidresponseteams,andnationalplanningexercises.3Simpleaverageofannualcountrypercapitaneeds.Apopulationweightedaveragepercapitaneedforthe43countriesconsideredis$21.4

3Backgroundpaper–G.Schmets,O.Hanssen,A.Soucat,D.Porignon–HIS/HGF–7Nov2017

3.CombinedhealthsecurityandUHCeffortsshouldwork!As illustrated in figure 4 below, the resources needed for emergency preparedness in 14 conflict andvulnerable countries (left) and in 29 low andmiddle income stable countries (right), are mostly aboutaddressing health systems foundational gaps, mainly infrastructure and health workforce. ThisdemonstratesthatemergencypreparednessisanintermediatesteptowardshavingahealthsystemthatcandeliverservicesonthepathtowardsUniversalHealthCoverage(additionalSDGneedsblueline).

Figure4:resourcesneeded–breakdownin14conflict&vulnerablecountriesandin29stablecountries

4.FourWHOmodalities4tosupportcountriesontheirjourneytowardshealthsecurityandUHCAllcountriesaredifferentandWHOcountryspecificapproachestailoredtocountrycontextareneeded.As formulated in its recent draft 13th General Programme ofWork4, WHO intends to take operationalactioninalimitedsetofhighlyfragile,vulnerableandconflict-affectedStates.Inalargersetofcountries,WHO will strengthen its technical assistance capacity and strategic advisory function, supportinggovernanceininstitutionbuildingandthestrategicdevelopmentofhighperforminghealthsystems.Inallcountries,itwillengageinpolicydialogueontheevolutionandincreasedinvestmentsinhealthsystems,continuousinnovationandthesharingofbestpractices.Tothisend,fourWHOsupportmodalitiesneedtobeused:

• WHOModality1–PolicyDialoguepartner:drivePolicyDialogueinallMemberStates.Thefocusandtopicsofthispolicydialoguewillvarydependingonthematurityofthehealthsystem.Inveryhighperforminghealthsystems,thisdialogueislikelytofocusoninnovationsandbuildinghealthsystemsofthefuturethatcanthenbeusedtoinspireothercountriesstrivingforexcellence.

• WHOModality2–StrategicSupporter:providespecificStrategicSupporttoassistcountrieswhichhavematuringandalreadyfairlyresilienthealthsystemsinplace,butwhichseektomaximizetheirrobustnessandsystemsperformanceintermsofhealthresults,equityandfinancialsustainability.

4WHOdraft13thGeneralProgrammeofWork–November2017:http://apps.who.int/gb/ebwha/pdf_files/EBSS4/EBSS4_2-en.pdf?ua=1&ua=1

4Backgroundpaper–G.Schmets,O.Hanssen,A.Soucat,D.Porignon–HIS/HGF–7Nov2017

Strategicsupportwillbedeliveredthroughin-countrynational-levelpresence,subregionalofficesordirectsupportfromregionalofficesorheadquarters,dependingonthecontext.

• WHOModality3–TechnicalAssistancepartner:providehands-onTechnicalAssistance,workingside-by-side with the government and in tight collaboration with other partners to identify,respond to and overcome key health systems and health security bottlenecks, attract sufficientfinancing and buildmore robust institutions over time, in settings of weak health systems andmoderatetohighvulnerability,includingcountriesfacingrecurringacutecrisestomanageand/orongoing protracted crises at a subnational level. Assistance in such settingswould be deliveredthroughacombinationofnationaland,whereappropriate,subnationalpresence.

• WHOModality4–ServiceDeliveryPartner:Provide intensifiedServiceDeliverysupporttohelp(re)build health systems and security foundations, and ensure continued service delivery incontexts of extreme fragility, vulnerability and large-scale conflict. It is an existing modality inrelation to the WHO Health Emergencies Programme that will also include actions related tohealthsystemstrengtheningandpreparedness.Sometimesitmayonlycoverpartofthecountry..WHOand itsUHC2030partnerswill operate through a combinationof national and substantivesubnational presence. In such settings, coordination among United Nations agencies anddevelopmentpartnerswillbeparticularlyimportant.

Dependingontheprevailingsituationincountries,WHOanditsUHC2030partnerswillneedtooptimizethesequencingandcombinationoftheabovefourmodalitiesthatcanco-existsimultaneously(figure5):

Figure5:FourWHOstrategiestobecombinedandsequencedadequatelytoreachhealthsecurityandUHC

5Backgroundpaper–G.Schmets,O.Hanssen,A.Soucat,D.Porignon–HIS/HGF–7Nov2017

Asillustratedinfigure6below,theTechnicalAssistanceandServiceDeliverymodalities3and4willmainlyfocusonaddressingsixcriticalhealthsystemsgaps:

Figure6:Criticalgaps–PhotosD.Porignon-SierraLeone2016

5.RolesandresponsibilitiesInmostcountries,domesticresourcesshouldcoverhealthrelatedinvestmentplans.However,incountriesbenefitingfrommodalities3and4,UHC2030partners’externalinvestmentwillbeneeded,inadditiontotechnicalexpertise:

Figure7:HealthsecurityandUHCinmotion:rolesandresponsibilities

6Backgroundpaper–G.Schmets,O.Hanssen,A.Soucat,D.Porignon–HIS/HGF–7Nov2017

6.Preparedness&IHRIntegral to the Technical Assistance modality 3 and Service Delivery modality 4 is the building of corecapacities for epidemic and disaster preparedness, in particular human resources, surveillance andinformationmanagement,anddiagnosticservices.

TheStrategicSupportmodality2willaimatstrengtheninginstitutionstoguaranteeefficienthealthsystememergencypreparednessstrategiesinfullcompliancewiththeInternationalHealthRegulations.

And the Policy Dialogue modality 1 will make sure that the health system emergency preparednessstrategyensuresenoughflexibilitytocopewithchangingenvironmentsandunexpectedemergencies.

Depending upon the situation prevailing in the country, WHO will decide which combination andsequencingofmodalities1,2,3and4asneeded.

7.Pointsfordiscussion

• UHC2030partnershavealargeroletoplayinhelpingcountriestowardsbeingpreparedforthenextbighealthemergency,aspartofbeingkeypartnersalongeachcountry`spathtowardshealthsecurityandUHC.

• Each country can benefit from a right combination and sequencing of investments and technicalexpertise, all of which would fit into larger national priority setting processes and sectoral planningstrategies.

• In concerned countries, UHC2030 partners need to support countries in leveraging domestic andexternalresourcestoaddresscriticalfoundationalgaps,andonconveningandfacilitatingdialoguewithnational and international stakeholders (in line with the IHP+ principles) on resource allocation forhealthsecurityandUHC.

• UHC2030partnersneedtoagreeonrolesandresponsibilities,andmakesurefoundationalinvestments(thesixcriticalgaps)aredulyaddressed.

• InlinewiththeUHC2030andtheIHP+principlesofaideffectiveness,inconcernedcountries,partnersneed to agree on ways of working, roles and responsibilities and financial contribution in terms ofinvestmentsandtechnicalexpertise.ThiscouldbeformalisedinaUHC2030“NewCompact”forHealthSecurityandUHC.