Gavin Yamey: Can Japan rouse the G7 nations to action on universal health coverage?

Gavin_Yamey3In Tokyo last week, at a workshop to prepare for the May 2016 G7 summit in Ise Shima, I arrived early at the hotel’s conference room; I was giving a presentation later that day and wanted to pre-load my slides. The hotel staff were setting up the room, placing print copies of the day’s meeting agenda at each place setting at each table. To ensure precision in their task, two women were using a length of string that they pulled taut along each table and that they used to confirm an exactly equal spacing between the print-outs. It was an impressive display of dedication, focus, and seriousness of purpose. A perfect metaphor for how Japan is approaching its role of G7 chair.

The day before the workshop, Japan hosted an extraordinarily high level one-day international conference on “Universal Health Coverage (UHC) in the New Development Era.” In a sign of Japan’s determination to use its political capital to put global health high on the 2016 G7 agenda, Prime Minister Shinzō Abe himself kicked off the day, echoing the messages of his editorial in last week’s Lancet, called “Japan’s vision for a peaceful and healthier world.”

“One of the overarching goals of my tenure as Prime Minister,” said Abe, “has been to make a proactive contribution to peace based on the principles of international cooperation.” These principles, he said, are to contribute to “world peace and prosperity,” including through global health, “based on the concept of human security.” Japan will use its G7 chair status, said Abe, to push for UHC—particularly for building “resilient, sustainable, inclusive health systems that can deliver basic services to all” and to strengthen global outbreak responses. Japan’s own history of UHC has delivered the world’s longest life expectancy, some of the world’s best health outcomes, and a reduction in health inequalities, so it is clearly leading by example.

As I argued recently in The BMJ, with my colleagues Sabine Campe and Sara Fewer, Japan’s track record in hosting G7 meetings has been impressive. The 2000 summit in Okinawa, for example, which focused on achieving measurable progress on HIV/AIDS, tuberculosis, and malaria, led to the formation of the Global Fund, which has signed grants worth over $US 33 billion. Is a repeat performance likely, given that the focus this time is on the “fuzzier” concept of UHC rather than targeting specific diseases?

It’s a question that I think was at the heart of the debates at both the conference and the workshop. What the G7 summits do well is to give a global health issue legitimacy, attention, and—sometimes—funding. The goal needs to be clear, understandable, and focused, and the issue needs to play well to the citizens of the G7 nations, given that the heads of state always have one eye on the electoral prize. The “big three” killers (AIDS, TB, malaria) fit the bill. But it isn’t clear that UHC will be as rousing a concept.

One way to make UHC compelling—an avenue suggested by Abe and echoed by other speakers, especially David Heymann, Head of the Chatham House Centre on Global Health Security—could be to link UHC to the worldwide concern about pandemics in the wake of the Ebola crisis. Heymann, who led the global response to SARS when he was Executive Director of the WHO Communicable Diseases Cluster, argued that the G7’s focus should be on “personal human security,” which includes UHC and access to medicines and vaccines. “Smallpox eradication, a global public good, was only possible,” he said, “because individual protection was possible, and polio eradication is only possible with a personal vaccination.” Collective security, exemplified by the International Health Regulations, has been easy to understand, said Heymann, but is impossible to achieve without human security.

Security quickly became the buzz word of the conference, a way of talking about UHC that builds on post-Ebola concerns. But this framing is a double edged sword—it certainly captures attention (and plays well to the media and the electorate) but it also carries risks.

The “securitization” of health makes many of us uncomfortable, as it conflates public health—with its core principles of justice, equity, and a focus on the poor—with military and intelligence concerns. We saw this kind of fusion of two worlds when the CIA used a vaccine programme as a way to gain information about Osama bin Laden’s whereabouts, which had appalling consequences, such as an increase in public mistrust of vaccines and physical attacks on vaccination workers.

Perhaps the addition of the words “human” or “health” ahead of “security” will make all the difference in preventing such conflation, especially if the agenda that ensues is about people rather than (geo)politics. That’s certainly the argument behind a recent policy paper in The Lancet on the lessons from Ebola, which argued that health security “comes from personal access to safe and effective health services, products, and technologies” and “what matters is the centrality of people—not borders, not economies, and not even international relations.”

So you should expect to be hearing rather a lot about health security over the coming year—particularly in The Lancet, which just deemed it to be “the big idea of our time” and “the defining challenge of 2016.”

Gavin Yamey is a professor of the Practice of Global Health and Public Policy, Duke Global Health Institute, Duke University, Durham, North Carolina, USA.

Competing interests: My travel costs to Tokyo were covered by the meeting organizers (Japan Center for International Exchange; Ministry of Foreign Affairs of Japan; Ministry of Finance of Japan; Ministry of Health, Labour and Welfare of Japan, and Japan International Cooperation Agency). I have received grant funding from the Global Fund (to conduct analytic work related to the Affordable Medicines Facility-malaria and to integrating HIV/AIDS, TB, and malaria with maternal and child health services) and travel expenses from Chatham House (to participate in a workshop on “rethinking the global health system”).