The US capital was the setting for three days of meetings and events to mark UHC Day and the release of ‘What’s In, What’s Out: Designing Benefits for Universal Health Coverage’.

IDSI’s time in DC kicked off with a Global Health Initiatives meeting attended by representatives from the Gates Foundation, World Bank, Givewell, the Center for Global Development (CGD), PRICELESS South Africa, the UK Department for International Development (DFID), Clinton Health Access Initiative (CHAI), Japan International Cooperation Agency (JICA), the Joint Learning Network (JLN), Tufts Medical, Disease Control Priorities (DCP), the Health Intervention and Technology Assessment Program (HITAP), the Norwegian Institute of Public Health (NIPH) and Gavi the Vaccine Alliance.

During the meeting iDSI, CHAI, JLN, NIPH and Tufts Medical Centre showcased their initiatives and the concentration of their work including their successes, focus countries and potential future opportunities.

Amanda Glassman

Attendees then heard from Global Development Funders’ representatives: David Wilson from the Gates Foundation, Julia Watson from DFID, James Snowden from GiveWell, Adrien de Chaisemartin from Gavi, Naina Ahluwalia and Somil Nagpal from World Bank and Yosuke Kobayashi from JICA; with all agreeing each partner group is carrying out valuable efforts in the bid to expand and improve healthcare globally.

Tuesday 12 December was the celebration of UHC Day around the world. A sold-out event at the CGD offices saw presentations from iDSI Director Professor Kalipso Chalkidou, CGD Chief Operating Officer Amanda Glassman, Professor Karen Hofman from PRICELESS, Waranya Rattanavipapong from HITAP, iDSI Board chair Professor Tony Culyer and a keynote speech by Dr Mark McClellan.

Copies of ‘What’s In, What’s Out’ were available for attendees to take away and Amanda Glassman explained how the creation of an explicit health benefits plan is an essential element in creating a sustainable system of UHC. With limited healthcare budgets comes tough decisions for policymakers, along with the many facets of governance, institutions, methods, political economy and ethics that are needed to decide what’s in and what’s out in a way that is fair, evidence-based, and sustainable over time.

Dr Mark McClellan

At the heart of Dr Mark McClellan’s keynote address was opportunities for greater value for healthcare spending – specifically, the ‘accountable care’ model, which sees providers held jointly accountable for the cost and quality of care for a defined population of patients.

Dr McClellan, a doctor and economist, said: “There is more healthcare can do than ever before, however this means rising costs in healthcare. The value of healthcare can be improved by developing and implementing evidence-based policy solutions.”

The importance of sharing data and creating interoperability to understand health outcomes within an accountable care system was also put forward by Dr McClellan, who provided Nepal as an example of success in utilising remote personal health tools, telemedicine and lower-cost sites of care: “In Nepal a simple process of patients’ texting in information can result in a visit to their homes by community care workers and a potential prescription of antibiotics. Investment in these modest but effective interventions can also gather useful metrics in the form of electronic health records. We need to move from ‘siloed’ data to data that provides intelligence about our populations.”

Waranya Rattanavipapong

HITAP’s Waranya Rattanavipapong presented on building research capacity for UHC in Southeast Asia and told of how analysis by HITAP revealed Indonesia could save 90% of its insulin budget. Waranya said: “Indonesia has a current budget of $18 million per year for insulin. Tens of millions more than necessary is being spent on modern insulins to treat diabetes despite evidence cheaper products work just as well. Our analysis revealed switching from insulin analogue to human insulin and negotiating to Thai prices ($2 for human insulin and $9 for insulin analogue, compared to $20 for human insulin and $22 for insulin analogue in Indonesia) could save 90% of the budget.”

Professor Karen Hofman detailed the strides South Africa has taken towards promoting the health of the population by passing a bill to implement a tax on sugar-sweetened beverages. Professor Hofman, who proudly sported an ‘I am #sweetenough’ t-shirt supporting the sugar tax, focused on fiscal levers in South Africa and the positive impact they have had in the past: “After the increase in the excise tax on cigarettes, sales reduced between 1993-2009 by one third and per capita consumption decreased by 50%. With 25% of teenage girls in rural areas overweight in South Africa, the time is now for translating evidence on sugar to policy. There will inevitably be push-back from various sources but the passing of the bill, which will be implemented in April 2018, is a powerful step forward.”

Professor Karen Hofman

Professor Tony Culyer rounded up the event and took to the stage to emphasise iDSI’s objectives to help low- and middle-income countries to transition from aid, develop skills to spend smarter and to increase access to quality healthcare so they can achieve UHC: “Our aim is to give LMICs capacity to produce policies that will have an impact of health. We wish to leave behind an endowment of expertise for LMICs to build better worlds for themselves.”

A recording of the ‘Better Decisions, Better Health: Practical Experiences Supporting UHC from around the World’ event is available on the CGD website (1 hour 32 minutes).

UHC Day, commemorated each 12 December, is the anniversary of the first unanimous United Nations resolution calling for countries to provide affordable, quality healthcare to every person, everywhere. The United Nations Sustainable Development Goals, that all UN Member States have agreed to, try to achieve UHC by 2030. This includes financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all.

Professor Tony Culyer

In a recent policy brief, Oxford Policy Management and the International Decision Support Initiative (iDSI) have asked “would the VfM analysis that the UK’s Department for International Development conduct on their programme expenditure be more useful if lessons were learnt from the iDSI Reference Case for Economic Evaluation?”. It is argued that significant methodological improvements are available to DFID – which could make the information they generate more useful for their decision makers. These recommendations are also applicable to other donors who follow similar guidelines for monitoring their VfM.

Alex Jones’ blog post exploring some of the issues raised in the brief is available on the Oxford Policy Management website.

NICE signs MOU with CNHDRC during UK-China health talks

September 2015

NICE International holds final discussions with CNHDRC ahead of Clinical Pathways dissemination event in October

NICE International visit China with Indian colleagues

Qingdao Health Bureau and NICE sign a Memorandum of Understanding

Pilot project in China

The China National Health Development and Research Centre (CNHDRC) in collaboration with NICE International have embarked on a pilot project involving the design and implementation of evidence informed pathways of care, linked with payment reform with an emphasis on integrated care, for two high priority disease areas (chronic obstructive pulmonary disease [COPD] and stroke). This builds on the initial (Phase I) ‘Clinical Pathways’ (CP) project associated with the Health XI initiative and initiated in 2009, with WB, DFID China an DFID UK support.

The Chairman of NICE and the Director of NICE International spent a few days in Beijing meeting with NICE’s major partners in China and publicising NICE’s work in the rural health reforms.

September 2013

The meetings included a day-long meeting at Renmin University, the fifth annual bilateral conference between NICE and Renmin, which, this year, was focused on care quality, hospital reform and the role of integrated care, including primary care. The conference, hosted by Renmin, one of the most prestigious and oldest universities in China, with a track record in social sciences and health policy in particular, was attended by over 100 colleagues from across China, including the Beijing and Shanghai Health Bureaus, the newly formed National Health and Family Planning Commission (NHFPC), the Ministry of Human Resources and Social Security, as well as officials from the provinces, academics and hospital administrators. We look forward to continuing and intensifying our partnership with Renmin in the coming year.

On the second day of our visit we met with senior officials from the World Bank and with our long-term partners in China, the think tank of the ministry of health, the China National Health and Development Research Centre (CNHDRC). We discussed progress with implementation of our NCD clinical pathways across four rural pilot counties and plans for scaling the pilots up.

On day three we had the honour of meeting, together with CNHDRC, the Director General of Planning and Information, a new division at the NHFPC, with her colleagues, including the officer leading on the design of the 13^th 5-year strategic Plan and the Head of international affairs for Europe and North America. All three sides reiterated their commitment to working together, emphasising the need to improve efficient resource allocation at the micro/technology and macro/service delivery levels, and the importance of good quality community/primary care as the only means of achieving sustainable universal coverage.

This meeting was followed by a high level session with Vice Minister Ma where the Vice Minister called for NICE to continue and intensify its involvement in the Chinese health reforms, incl. urban health reforms, public hospital reforms incl. referral pathways and integration between prevention and treatment, and low and high tier hospitals. The Minister called for a strategic partnership between NICE, the Ministry and CNHDRC for institutionalising a Chinese model of Health Technology Assessment to meet China’s needs.

The second half of the day was spent at the Development Research Commission, the prestigious think-tank of the State Council, the Chinese equivalent of the Cabinet Office. The session was attended by colleagues from the National Development and Reform Commission, the NHFPC and different DRC divisions, and was supported by the British Embassy in Beijing. NICE offered to work with DRC in their research on HTA and quality standards and how these notions relate to the ongoing Chinese health reforms.

Clinical pathways and payment reform project launched in China

The discussions focused on our practical support to decision makers in Kerala (India) and China, funded by the Health Partnership Scheme. We have worked on request with government institutions to implement quality improvement in maternal health and the management of non-communicable diseases. The field reviews and key stakeholder interviews conducted by Itad emphasised the value of the ‘NICE brand’, and of our power in convening policymakers, healthcare providers and clinicians in joint-working to develop locally-owned, sustainable, and transparent processes for priority-setting.

For supporting countries that are aspiring towards universal health coverage, the NICE International approach may be a useful model for laying down some of the important institutional foundations of health systems strengthening. Dr Francoise Cluzeau, Associate Director of NICE International, will be returning to the DFID lunch seminar series in April to discuss in-depth the impact of our ongoing engagements at state and central levels in India.

Itad’s report on NICE International’s engagement in India, which explores the findings in more detail, has now been published online and is available here. NICE International and Itad are collaborating to build a robust M&E framework for the International Decision Support Initiative, to understand and share lessons on our role in institutional strengthening in low and middle-income countries.

Find the presentation here 

April 2017

Members of a collaborative Cuba-UK-South Africa project exploring the value of Cuban-training for South African medical students met this year to discuss how the programme can promote Universal Health Coverage (UHC).

The ‘South Africa-Cuba doctors programme’, which offers bursaries to South Africans from disadvantaged backgrounds to study medicine in Cuba as part of a deal struck by Fidel Castro and Nelson Mandela two decades ago, was the subject of a Department for International Development funded policy research project, which included researchers from London School of Hygiene and Tropical Medicine (LSHTM), Imperial College London, Public Health England and the Human Sciences Research Council (HSRC), South Africa.

The large number of Cuban-trained South African would-be doctors returning to work in South Africa (600-900 medical students return each year) are a major resource with the potential to re-engineer South Africa’s primary healthcare system to focus on preventive care and promote UHC. The researchers noted this was especially advantageous as they found few South African-trained doctors wish to make a career in family medicine (general practice). Therefore, improving the quality and quantity of family physicians (GPs) is critical for South Africa to achieve UHC. Returning trained doctors from the programme plug some of this gap as they go on to work as doctors in the public sector; they are also more likely to work in underserved areas that they come from long-term.

A major recommendation of the project was for improved support and re-integration of the doctors trained in Cuba upon their return to South Africa. Returning students must undergo up to three years of additional training to ensure they have experience of diseases such as HIV/AIDS, TB and malaria, which no longer exist in Cuba. As a result, some of them effectively return to train as 3rd year medical students, despite their six years of training in Cuba.

The research also found that students experience personal, academic and structural challenges when they return to study in South African medical schools. Duration and content of orientation programmes differed between the schools; language difficulties made studying difficult (Cuban-trained students spend their first year on premedical bridging training and become proficient in Spanish) and cultural adjustment after six years away was needed. Findings also indicated returning students had to adapt to more hospital and ‘rescue’ medicine emphases; and experienced difficulties with an unfamiliar exam system.

Further recommendations included: more systematic collection of data on both Cuban- and South African- trained cohorts to enable monitoring of careers pathways and relevance to South Africa’s needs; investment of new resources based in rural and urban underserved areas for medical training in South Africa; and for future research to focus on the political economy of medical education to understand the challenges, agents for change and examples of success that can be expanded.

The end-of-project meeting, which took place in April 2017, was attended by representatives from Imperial College, LSHTM, Public Health England, the Royal College of General Practitioners, Tropical Health & Education Trust (UK), HSRC, Medical Executive Committee for Health (South Africa), Cuban-trained doctors returned to South Africa from the University of Cape Town and Cuban representatives from the Ministry of Health, the Pan American Health Organization. Read the meeting agenda, full meeting report, a longer blog (at project end) by Shah Ebrahim, view key presentation slides; and watch video interviews with Dr SM Dhlomo, the Member of the Executive Council for Health in KwaZulu-Natal, South Africa and a medical student from the South Africa-Cuba doctors programme. 

NICE International co-hosts Cuba medical education workshop in Pretoria 

June 2015

At the end of June 2015, NICE International participated as a co-organiser with London School of Hygiene and Tropical Medicine (LSHTM), Public Health England (PHE) and the Human Sciences Research Council (HSRC) of South Africa in a two-day conference in Pretoria, about the value of Cuban medical training to the South African setting, as part of the DFID funded project.

With support from HSRC and LSHTM, NICE International will be carrying out a health technology assessment of alternative training models with a view to drawing lessons for primary care transformation models in Sub Saharan Africa, but also in countries like the UK, which are facing a crisis with regard to human resources for primary care.

Read more about the event in Shah Ebrahim’s blog, and read more about the project in the concept note submitted to Ministry officials in Cuba and Republic of South Africa, and the case study prepared for UN High Level Commission on Health Employment and Economic Growth.

Panel discussion event at the house of Lords

March 2015

On the 4 March 2015, NICE International, Public Health England and the London School of Hygiene and Tropical Medicine held a panel discussion event at the House of Lords.

The discussion looked at the ‘Potential Lessons for Primary Care Emerging from the Cuban Model of Medical Education’. The event was hosted by the All Party Parliamentary Group on Global Health and Chaired by Lord Crisp. Speakers included representatives from the Pan American Health Organisation, the Faculty of Public Health, the World Health Organisation and the Embassy of the Republic of Cuba.

The event highlighted the Cuban approach to medical education and looked at research being undertaken to test how effective this approach is. The event also looked at how transferable the Cuban model could be into other contexts. Contrasting views of the successes of the Cuban model were shown in two video presentations shown at the event. The presentations stimulated audience discussion around the future development of primary care and medical education in the UK.

The discussions will be used to inform the ongoing project exploring the applicability of the Cuban model to other settings.

Read more in Professor Shah Ebrahim’s blog post about the event.

Scoping visit to Havana

October 2014

A team from NICE International (Kalipso Chalkidou), LSHTM (Shah Ebrahim) and Public Health England (Neil Squires) (formerly DFID), visited Havana to scope out the joint project on the Cuban model of medical education for Africa. The project is being run by NICE, PAHO, LSHTM and the Cuban MoH.

The team also participated in the 2nd International Conference on Medical Education for the 21st Century organised by the Cuban Ministry of Public Health. The Conference was attended by over 400 people from several countries including Angola and Latin America. Over three days, the conference explored the direction of travel in modern medical education in light of countries’ commitments to Universal Healthcare Coverage and of emerging challenges of chronic diseases and increasing financial pressures on limited budgets.

Dr Neil Squires gave a plenary address during which he highlighted the importance of publicising the lessons of the Cuban medical education model, supported by evidence of its effectiveness and cost-effectiveness, and using these lessons to influence the ongoing consultation by WHO on a longer term global healthcare workforce strategy.

During a whole day side event organised by the Ministry, the UK team had the opportunity to connect with major stakeholders in Cuba including the Rector of the Latin American University, senior professors including the vice president of the University of Havana’s Medical University, the secretary of the Cuban university accreditation board, the CEO of THEnet, the Director of the Cuban School of Public Health, members of the Board of and the CEO of MEDICC, senior MINSAP officials including Dr Ileana Morales, the President of the Conference, and PAHO, including the Director of the country office. The discussion explored the research proposal which recently gained approval from DFID, its policy implications and practical ways for taking the work forward incl. major partners in Cuba and in Arica.

In addition, the UK team had working meetings with PAHO and visited the British Ambassador in Cuba who has been supporting the DFID funded work since its launch.

NICE/LSHTM/PHE will work with their Cuban counterparts and African researchers to modify the research protocol, assign research tasks and organise additional field visits to Cuba and Africa over the next 12 months, with a view to using it research findings to influence the ongoing consultation on the WHO’s Human Resources for Health Strategy, due to report in 2016, but also with the aim of further publicising the attributes of the primary care-focused Cuban model and its potential relevance for the UK setting.

NICE International visited Cuba to scope out partnerships on policy and research

November 2013

This is the second visit, following summer 2013, when we visited supported by the Rockefeller Foundation, to take part in a Lancet organised event on learning lessons from the history and evolution of Latin American and Caribbean healthcare systems.

With support from the PAHO country office, the NICE chairman, Professor David Haslam, the director of NICE International Kalipso Chalkidou, and Professor Shah Ebrahim of LSHTM and an honorary NHS consultant with NICE, spent 3 days meeting senior academic colleagues, including professors and deans of the National School of Public Health, the Cuban Medical University of Havana, the Cuban International Cooperation Centre, managing the Cuban Medical Missions overseas, as well as officials from the MoH, including the Vice Minister and Centro Nacional Coordinador de Ensayos Clínicos (CENCEC), the clinical trials regulatory authority of Cuba. INFOMED, the medical electronic portal of Cuba, and Escuela Latinoamericana de Medicina(ELAM), the Latin American Medical University training overseas students from LAC, Asia and Africa, where also part of the visit. Finally, they had the chance to meet the British Ambassador in Havana.

NICE International, with its academic partners in the UK, will be looking to engage in a collaborative research project with the Cuban academics to assess the primary care and prevention focused model of medical education of Cuba in the context of Sub Saharan Africa.

Cuba maintains medical missions in over 60 countries around the world, working in emergency situations or in remote rural areas and is in parallel, training – mostly for free – thousands of doctors in Cuba or Cuban Universities overseas.

Another aspect of our partnership could focus on methods for developing and implementing clinical guidelines and HTA with an emphasis on quality and efficiency, taking a whole system (as opposed to a technology focused) approach. Options for partnering up with LSHTM and with the Public Health Foundation of India, were also discussed.

NICE International visits Cuba to take part in the Lancet meeting on universal health coverage

July 2013

Kalipso Chalkidou, Director of NICE International visited Cuba to take part in the Lancet meeting on universal health coverage (UHC) in the Latin American countries (LAC), with support from the Rockefeller Foundation. Cuba has a primary care focused healthcare system, which ranks highly globally in terms of access, quality and health outcomes and efficiency.

During the short visit, Kalipso met colleagues from:

• government
• the regulators
• universities
• non-government organisations
• Pan American Health Organization (PAHO), including the Director of PAHO, Dr Carissa Etienne.

There is a joint commitment for PAHO, NICE and Rockefeller, working together on priority setting for UHC and on sharing the knowledge and experiences (good and bad) of the LAC region with other countries transitioning towards UHC. We will work together with other partners such as the Department for international development (DFID) and the World Bank, to set out specific actions we can carry out together, in accordance to the strategic priorities of PAHO and the countries in the region and with an emphasis on catalysing South-South partnerships with countries in LAC but also sub-Saharan Africa.

The visit offered the opportunity to meet the Minister of Health of Cuba and his vice ministers, including the vice minister responsible for international cooperation with whom, along with the PAHO lead and the Director for International cooperation, Kalipso discussed opportunities for partnerships and sharing our system’s experience, and for working on a tripartite basis in countries where Cuba supports human resources and medical education and NICE offers technical assistance for strengthening priority setting processes and technology evaluation.

Finally, Kalipso visited the Cuba neuroscience centre, which concentrates on developing high value low cost diagnostic, screening and management technologies for high priority diseases and conditions, to serve the needs of the Cuban population. The Centre also exports technologies and healthcare solutions (e.g. screening policies for hearing impairment and learning difficulties in young children) around the world.

There was broad agreement as to the potential for partnership up with the Cuban Ministry of Health and sharing experiences with countries in the region and beyond. NICE International will work with PAHO, Rockefeller and also with the Ministry of Health of Cuba and the UK’s DFID to scope out potential joint projects especially on capacity building for UHC in sub-Saharan African countries.