The Academy of Medical Sciences and The Lancet International Health Lecture 2018

Dr Irene Akua Agyepong delivered the 2018 Academy of Medical Sciences and The Lancet International Health Lecture under the title 'Universal Health Coverage: Global policy agenda breakthrough or great white elephant'? 

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On Monday 8 October 2018, the Academy of Medical Sciences, in partnership with The Lancet, hosted the 2018 International Health Lecture at the Wellcome Collection, London. 

The International Health Lecture provides a platform for leaders in global health to discuss topics of international significance, promoting debate, discussion and the exchange of ideas on current research. For more information about the lecture series, including past events, please visit this page.

This year's lecture was presented by  Dr Irene Akua Agyepong, a public health physician currently based in the Research and Development Division of the Ghana Health Service (GHS), under the title: Universal Health Coverage: Global policy agenda breakthrough or great white elephant?

To coincide with the lecture Dr Agyepong also wrote a manuscript under the same title, which has been published by The Lancet. You can access the manuscript on The Lancet website, free of charge following registration, by clicking here

Below, the Academy's Vice President (International), Professor Dame Anne Johnson DBE FMedSci, offers her reflections on the lecture. 

On 8 October, I had the pleasure of co-Chairing the 2018 Academy of Medical Sciences and The Lancet International Health Lecture alongside Dr Richard Horton FMedSci, editor of the Lancet. I was happy to see that the audience found the lecture as inspirational and captivating as we did.

This year’s lecture was presented by Dr Irene Agyepong, a public health physician based in Ghana. Dr Agyepong shared her expertise on whether the global ambition to provide universal health coverage to all, as outlined in the Sustainable Development Goals (SDGs), will be a success or an expensive elusive goal - a “great white elephant”.

Dr Agyepong opened the lecture with a personal story of being prevented by a seemingly “unfeeling” grandmother from treating her sick granddaughter. However, the grandmother’s decision to withhold her granddaughter’s medicine turned out to be stoic pragmatism.

The story demonstrated how, in the absence of universal health coverage, many families must decide between paying for expensive medical treatment or being able to feed the rest of the family, a heartbreaking choice which no family should have to make.

She went on to explain how this memory has stayed with her and was influential to her decision to act as an advocate for universal health coverage (UHC) – which means that all individuals and communities receive the health services they need without suffering financial hardship, including health promotion, prevention, treatment and palliative care.

Irene’s motivation to encourage and support UHC in the poorest settings was evident. Yet, despite her enthusiasm, she was equally realistic in outlining the difficulties in implementing it, and eloquently explained the different aspects which influence and shape health processes and policy.

She talked about the four I’s - Ideology, Ideas, Institutions and Interest - which affect how health policy is developed:

  • Ideology refers to the core assumptions of stakeholders
  • Ideas refers to the programs and interventions proposed to address a given problem
  • Institutions refer to the structures and rules of social order
  • Interest refers to what stakeholders perceive, as well as actually stand to lose or gain, by the adoption of particular ideas

Illustrating how these four ‘I’s interact in complex ways, Dr Agyepong used the analogy of bringing up children to describe the unpredictable nature of developing health processes and introducing UHC in different countries - even if you have raised 11 children you cannot predict if the twelfth will grow up the same, as so many different things influence the way a child develops. Some connections are more important and more influential on health policies than others.

Coming back to the white elephant, she explained these variables mean it is difficult to predict whether the SDG Goal 3 to achieve UHC will be a success or an expensive failure, and is unlikely to be answered for many years. However Dr Agyepong shared many lessons drawn from her experience in Ghana which could help guide the introduction of UHC elsewhere and ensure its success.

The clear message from Dr Agyepong was that in order to achieve the sustainable improvement of global health, health systems need to be strengthened on a national level. Importantly however, she stressed that for this aspiration to be successful, it is not sufficient to simply impose a UHC model from one country to another and expect it to work – instead, there needs to be support from within the country leading to national leadership and ownership of the initiative. The traditional global selective health campaigns to improve health do not do so in a long-lasting and sustainable way and do not address the complete range of health issues. As soon as the funding for a selective campaign ceases, if an anchor has not been set up within the country then the programme will also cease to exist.

Dr Agyepong argued that these selective health programmes instead need to be integrated into the existing health system if they are to provide lasting change. She described the interaction between the global directive and national leadership of health improvement as a balancing act, using the analogy of an egg: if the egg is not held on to tightly enough it will be dropped, but held too tightly, it will be crushed.

There is no miracle model for introducing UHC into a country - the models need to be flexible, principles need to be adapted, and the energy within a country needs to be capitalised upon.

During the post-lecture discussion, attendees observed the introduction of UHC and the sustainable improvement of health is often seen, and addressed, as a technical challenge.  However, Dr Agyepong urged that it is also important to consider and address the social and political determinants of health, including sectors like infrastructure and education. She suggested that to improve the way global health money is spent, donors and health policy makers should spend time in a district hospital or health practice in some of the most difficult settings to better appreciate these numerous, interconnecting players.

Throughout the evening, Dr Agyepong continued to emphasise the importance of the medical professional in supporting their patients by being advocates for healthcare improvements, but also highlighted her disappointment that it is not easier for health professionals to engage with advocacy and public policy during medical training. Nonetheless, I hope that Dr Agyepong’s enthusiasm for advocacy work motivated many of the audience to become advocates for UHC and improving health processes in their country and worldwide. 

Dr Agyepong believes you need to be ambitious as an advocate, and that if you don’t shoot for the stars, you don’t shoot at all.  

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