BACKGROUND

The Prince Mahidol Award Conference (PMAC) is an annual international conference focusing on policy-related health issues of global significance. The conference is hosted by the Prince Mahidol Award Foundation, the Thai Ministry of Public Health, Mahidol University and other global partners. It is an international policy forum that Global Health Institutes, both public and private, can co-own and use for advocacy and for seeking international perspectives on important global health issues. The Conference in 2015 will be co-hosted by the Prince Mahidol Award Conference, the World Health Organization, the World Bank, Joint United Nations Programme on HIV/AIDS, U.S. Agency for International Development, Japan International Cooperation Agency, the Rockefeller Foundation, China Medical Board, and Chatham House with the support from other key related partners. The Conference will be held in Bangkok, Thailand, from 26 -31 January 2015. 

The year 2015 marks a significant year; it is the year set for the achievement of the Millennium Development Goals. The timing is appropriate to review the situation and determine forthcoming challenges. Several forums have been organized to brainstorm on a set of new targets for the post 2015 development agenda, which will be adopted at the Development Summit in September 2015.

There are serious concerns on which global health issues should be included in the post 2015 development indicators and targets. Some prefer targets on the progress with health systems, including Universal Health Coverage, human resources for health and access to essential medicines. Others prefer specific targets on unfinished agenda around maternal and child health and infectious diseases such as HIV, TB and malaria (MDGs 4, 5 and 6), and also non communicable diseases (NCDs). Finally, a few additional global health indicators and targets may be put to the post 2015 development goals.

There is a need to agree on a set of priority global health issues to be collectively tackled by the global community. This will enable commitments to addressing these priorities irrespective of their inclusion into the post 2015 development goals.

Furthermore, there is a consensus from every major forum that inequity in health outcomes between the rich and the poor is unjust and unfair and should be reduced. Changes are needed in health financing systems that put the economic burden inequitably on poor households with income losses and unreasonable health care payments associated with ill-health. The movement to address health inequities has started more than a decade since 1998 with the World Health Assembly resolution to reduce socioeconomic inequalities in health. The WHO Commission on Social Determinants of Health was established in 2005 and issued a report on “Closing the gap in a generation: health equity through action on the social determinants of health” in 2008 which called attention to the collective action needed globally.

The World Conference on Social Determinants of Health in Rio de Janeiro, Brazil in October 2011 stressed the importance and urgency of taking action on social determinants of health to reduce health inequities between and within countries. Likewise, the Report of the Global Thematic Consultation on Health in April 2013 proposed guiding principles for new development agenda to include human rights, equity, gender equality, accountability and sustainability.

The landscape of health governance has changed substantially in the past two decades. With many other global health initiatives established, the players now involve not only public entities but also non-state actors including private sectors and civil societies. Non-health sectors are also contributing much more. The World Trade Organization is one of the most important international institutions in public health policies especially related to trade policies that impact on health products and pharmaceuticals. There is serious concern that the trade and economic policy based on neoliberal approaches including global economic liberalization, privatization, market competition, and the pursuit of efficiency, may worsen health inequity. Likewise, economic and geopolitical transitions have influenced how local and national leaders promote and invest in health systems, legislation and service delivery.

International finance institutions have also put priority on global health issues. The World Bank’s first report on Investment in Health in 1993 and the more recent one in 2013 on “Global health 2035: a world converging within a generation” highlighted priority health issues and the gains from investing in health.

PMAC 2015 will focus on accelerating health equity by discussing important health issues; governance and health financing systems that will reduce gaps in social stratification, differential exposure, differential vulnerability, and differential consequences of ill health and improving the quality of health care services. The theme of ‘inequity’ cuts across all issues and will be the focus throughout all the consultations. Concerted efforts from multi-stakeholders are crucial for successful implementation of the policies. The conference will also discuss measurement and information systems that need to be strengthened for monitoring health inequities over time.

SUBTHEMES AND ISSUES 

Issues to be discussed will be under three main sub-themes below: (1) Priority global health issues and health related Post-2015 development goals/targets/indicators; (2) Moving towards new global health governance; and (3) Global Health Systems and Financing Priorities for the Post-2015 Agenda.

Sub-theme 1

Priority global health issues and health related Post-2015 development goals/targets/indicators

Global Health deals with issues affecting health that cannot be resolved by one country or agency working alone. It demands the creative engagement and commitment of many different bodies including governments, international agencies, civil society and the private sector. Global public health is impacted upon by a variety of strategies and policies, at the local, the national and the international  levels, and is  concerned with the biological, economic, environmental and social determinants of health that affect us all as global citizens, whether in high-, middle- or low income countries. 

The full enjoyment of the right to health is critical for the enjoyment of other human rights.  Good health is thus an end in itself and it plays an integral role in human capabilities and well-being.  Health is central to sustainable development and to economic development and health is both a beneficiary of and a contributor to development.  Health is also a key indicator of what people-centred, rights-based, inclusive, and equitable development seeks to achieve.

Today, health is on the radar of Heads of State because it has become integral to at least three global agendas:

Security—driven by the fear of global pandemics or the intentional spread of pathogens and an increase in humanitarian conflicts, natural disasters, and emergencies;

Economic—concerned not only with the economic effect of poor health on development or for example of infectious disease outbreaks on the global market place but also the gain from the growing global market in health goods and services; 

Social justice—reinforcing health as a social value, human right and essential component of human security, supporting the United Nations Millennium Development Goals and the Post-2015 development agenda, advocating for access to medicines and primary health care at an affordable cost, and calling for high income countries to invest in a broad range of global health initiatives.

Thus, it is no longer Ministries of Health alone who design policies for health, but increasingly, Ministries of Foreign Affairs, of Finance, Home Affairs and Defence are taking an active role. In order to increase strategy and policy coherence, it is important to understand the range of  interests that governments have in global health: this will help to identify the policy space for public health. 

This sub-theme will consider how health is prioritized or de-prioritized and address the underlying challenges for policy coherence at the various levels of governance (local, national and global) as well as to identify the policy space to address key equity issues. 

Sub-theme 2

Moving towards new global health governance

There are several reasons why the issue of global health governance needs to be reviewed. 

The health sector has no longer the sole control “over health” as health is influenced by a multitude of factors. The social determinants of health are the conditions in which people are born, grow, live, work, age and die. Such conditions have a much bigger impact on population health than the health sector itself. In the last 20 years, economic transformation in the global economy has vastly increased the resources available for investment in health but has also resulted in massively increased social and economic inequalities, including in health status. There is an urgent need to understand how public health can be better protected and promoted in the realm of global governance.   

Actions taken by governments and actors outside the health sector – in relation for instance to trade, economics, migration, conflict and the environment – increasingly have an impact on people’s health in ways that are not properly identified or monitored. There are political determinants of health where global accountability is deficient.   

The private sector plays an increasing role in governing health. The intensified inter-relations, connections and mutual dependencies between States, societies and corporate businesses can be described as the commercial determinants of health. The way in which global food, soda and tobacco do their business, and how they interact with each other and with national, regional and international organizations needs to be much better understood by public health actors.  

Health has become one of the most important of the world’s industries. The last decade alone has seen a doubling of global health spending from 3 to 6.5 trillion USD. 

Health has increased in importance on the national and global policy agendas. More and more national elections are won or lost on population health matters. Increasingly, public health issues and policy are discussed by heads of state.  Finally, there are an increasing number of actors – new global health institutions, increasing interest by non-state actors active in global health. 

In broad terms, global health governance concerns the actions and means adopted by a society to organize itself in the promotion and protection of the health of its population.

The organization and function can be formal or informal to prescribe and proscribe behaviour.  The governance mechanism can be situated at the local/subnational, national, international and global levels.  Health governance can also be public, private or a combination of both.  

Core functions of the global health system include the production of global public goods, management of externalities across countries, mobilization of global solidarity, and stewardship.

This means architecture is also needed to support technical work, monitoring, multilateral negotiations, etc.  

Global health governance is often used to refer to the governance of the global health system and focuses on the actors and institutions with the primary purpose of health.  Global governance for health refers to all other governance areas that can affect health and implicitly, it makes the normative claim that health equity should be an objective for all sectors. 

This sub-theme will consider that there currently exists no global mechanism that follows all parallel and ongoing discussions related to global public health, particularly given the broad spectrum of fora addressing issues that impact public health including the World Trade Organization, ILO, WIPO, NGOs, civil society and others.  The broad spectrum of subject-matter with direct impact on public health (trade, climate change, development, governance, water sanitation, etc.) further heightens inherent complexities and challenges.  

Today there is increasing recognition that the existing rules, institutional mechanisms and forms of organization need to evolve to better respond to the emerging challenges of globalization and ensure that globalization benefits those currently left behind in the development process.

This sub-theme will address both the issues of “global health governance” as well “global governance for health”: 

On global health governance, discussions will be held around the following issues: 

• The role of state actors – UNAIDS, WHO, UNICEF, GAVI, World Bank, G8, G20, regional health collaborations and others;
• The role of the non-state actors – private sector, social enterprise and civil society organizations, especially in terms of health in critical underprivileged groups;
• Appropriate and effective monitoring and evaluation mechanisms as well as global health information systems to ensure transparency, accountability and fit for purpose. 

On global governance for health, discussions will be held around: 

• Social, political and commercial determinants of health and “health in all policies;”
• Appropriate coordination mechanisms to ensure that health is being considered in broader policy development (joined-up government at all levels);
• Appropriate instruments to assess the potential health and social impact of policies during the policy development process.

Sub-theme 3

Global Health Systems and Financing Priorities for the Post-2015 Agenda

This sub-theme focuses on how management and financing of health systems can improve quality, equity and raise health outcomes.   The discussions will foster wider agreement of collective actions for providing financial protection, ensuring programs are responsive to people’s expectations and services address the needs of poor and vulnerable populations.  A number of tenets will guide the discussions:

• The dynamic nature of health priorities require flexible and adaptable financing, management and delivery systems;
• Achieving quality and financial sufficiency are not the end but the means to achieve better health;
• External financing should not crowd out but promote domestic resource mobilization;
• As countries go through economic transition, stewardship of the health sector should prevent disproportionate increases in out-of-pocket expenditures and further disparity in access;
• Health financing strategies should work with the contribution from non-health sectors, such as  education, defense, labor and social security sectors, and the influence of trade and foreign policies;
• Universal Health Coverage requires political commitment and calls for expanding services to the underserved, with financial protection and resilient health systems that meet quality standards.

At PMAC 2015, the international community will take pulse on the status of health financing globally and discuss trends and new ideas in resource mobilization.  The growing trend of disparities among countries and strong upward pressures increasing costs and financing requirements will be reviewed with an analysis of the drivers.  Weighing costs escalation against the returns on investing in health, the meeting will provide a venue to develop a good value proposition on increased financing on health for wider acceptance at global and country levels.  This is critical for the debate on universal health coverage and has implications on both international financing and domestic resource mobilization.   The discussions will highlight advocacy for poor countries to spend more, and for rich countries to get more value for the money spent.  And overall, to re-affirm the notion of good health for low cost and review lessons learned amongst all countries.  

The key pathways to achieving equity and improved health outcomes are adequacy/sufficiency, allocative and technical efficiency (including sub-sectoral priorities and incentives) and the level of financial protection provided.  The sessions will review financial investments and with emphasis on the need to demonstrate measurable results.   The discussions will take stock of accountability by the international development community as well as Ministers of Finance asked to increase outlays and Ministers of Health who have to decide among competing priorities.  

Worldwide, countries are weighing the unfinished agenda in health, emerging priorities such as non-communicable diseases, pandemic threats and global climate change.  Common threats to health security call for shared solutions including cross-border and regional collaboration, and the need for strategies to finance regional public health goods.  In addition, the sub-theme will provide opportunities for an exchange with emerging donor countries, and learn about their shared interests, strategic priorities and explore partnerships with long-standing donors.   Special sessions may be arranged with BRICS countries, and other transitional economies that are moving into upper middle income status, their experiences with moving towards donor status, reaching self-reliance, including the assurance to procure and supply sufficient drugs, vaccines and other health commodities.

Collectively, the sessions under this sub-theme will address the following issues:

• What is the current situation with health financing globally?  What progress has been made with mobilizing domestic resources and establishing sustainable sources of financing? 
• What are the lessons learned from vertical global financing mechanisms, sectoral programs and what is needed to address neglected health threats and broader health goals?
• What are the emerging challenges for the next two decades that will define plans for reaching universal health coverage and what adaptations are needed within service delivery and financing systems to address them?
• What systems changes are needed to enable providers and managers to manage for results, including practical, manageable and measurable improvements in quality?
• What are the lessons learned with innovative strategies such as using incentives to promote quality of care?  How can results-based financing systems extend coverage and improve quality?  How can demand-side subsidies reduce out of pocket expenditures?
• How can clients and civil society effectively participate in decisions on service delivery, quality and financing of health care?