Health Systems & Reform ISSN: 2328-8604 (Print) 2328-8620 (Online) Journal homepage: http://www.tandfonline.com/loi/khsr20 Who Needs Big Health Sector Reforms Anyway? Seychelles’ Road to UHC Provides Lessons for Sub- Saharan Africa and Island Nations Netsanet Walelign Workie, Emelyn Shroff, Abdo S. Yazbeck, Son Nam Nguyen & Humphrey Karamagi To cite this article: Netsanet Walelign Workie, Emelyn Shroff, Abdo S. Yazbeck, Son Nam Nguyen & Humphrey Karamagi (2018) Who Needs Big Health Sector Reforms Anyway? Seychelles’ Road to UHC Provides Lessons for Sub-Saharan Africa and Island Nations, Health Systems & Reform, 4:4, 362-371, DOI: 10.1080/23288604.2018.1513265 To link to this article: https://doi.org/10.1080/23288604.2018.1513265 Published with license by Taylor & Francis Group, LLC© 2018 International Bank for Reconstruction and Development / The World Bank Accepted author version posted online: 24 Sep 2018. Published online: 06 Nov 2018. Submit your article to this journal Article views: 280 View Crossmark data Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=khsr20 Health Systems & Reform, 4(4):362–371, 2018 Published with license by Taylor & Francis Group, LLC ISSN: 2328-8604 print / 2328-8620 online DOI: 10.1080/23288604.2018.1513265 Research Article Who Needs Big Health Sector Reforms Anyway? Seychelles’ Road to UHC Provides Lessons for Sub-Saharan Africa and Island Nations Netsanet Walelign Workie1,*, Emelyn Shroff2, Abdo S. Yazbeck3, Son Nam Nguyen1, and Humphrey Karamagi 4 1 Health Nutrition and Population Global Practice, World Bank Group, Washington, DC, USA 2 Research Unit, Public Health Authority, Victoria, Seychelles 3 International Health, Johns Hopkins University, Baltimore, MD, USA 4 World Health Organization Regional Office for Africa, Brazzaville, Republic of Congo CONTENTS Abstract—The road to universal health coverage (UHC) needs not be Introduction driven by big reforms that include the initiation of health insurance, Methodology provider–funder separation, results-based financing, or other large health Seychelles’ Health Sector Structure and Outcomes sector reforms advocated in many countries in sub-Saharan Africa and Key Factors That Facilitated Success elsewhere. The Seychelles experience, documented through a series of The Next Challenges analytical products like public expenditure reviews and supporting sur- veys with assistance from the World Bank and World Health References Organization (WHO), shows an alternative, more incremental reform road to UHC, with important lessons to the region and other small- population or island nations. Done well, in some countries, a basic supply-side funded, publicly owned and operated, and integrated health system can produce excellent health outcomes in a cost-effective and sustainable way. The article traces some of the factors that facilitated this success in the Seychelles, including high political commitment, strong voice and a downward accountability culture, strong public health func- tions, and an impressive investment in primary health care. These factors help explain past successes and also provide a good basis for adaptation of health systems to dramatic shifts in the epidemiological and demo- graphic transitions, disease outbreaks, and rising public expectation and demand for high quality of care. Once again, how the Seychelles responds can show the way for other countries in the region and else- Keywords: access to services, political commitment, primary health care, where regardless of the types of reforms countries engage in. public health, Seychelles, universal health coverage, voice and accountability Received 13 April 2018; revised 6 June 2018; accepted 10 August 2018. *Correspondence to: Netsanet Walelign Workie; Email: nwalelign@world- bank.org Color versions of one or more of the figures in the article can be found online INTRODUCTION at www.tandfonline.com/khsr. In recent years, the universal health coverage (UHC)1 agenda © 2018 International Bank for Reconstruction and Development / The World Bank developed and promoted by the World Health Organization This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits (WHO) has galvanized the global health community2-4 and unrestricted use, distribution, and reproduction in any medium, provided the original features prominently in the Sustainable Development Goals,5 work is properly cited. specifically in Sustainable Development Goal 3—achieve 362 Workie et al.: Who Needs Big Health Sector Reforms Anyway? 363 Fiji Cabo Verde Barbados Seychelles Mauritius Maldives Malta Population (’000) 898.8 539.6 285.0 94.7 1,263.5 427.8 437.4 GNI per capita, Atlas method (current USD) 4,780 2,970 15,210 15,410 9,770 10,380 24,190 Current health expenditure (% of GDP) 3.6 4.8 7.5 3.4 5.5 11.5 9.6 Life expectancy at birth, total (years) 70.3 72.8 75.9 74..3 74.4 77.3 81.8 Mortality rate, infant (per 1,000 live births) 18.7 18.2 1147 12.3 12.2 7.3 5.9 MMR (per 100,000 live births) 30 42 27 0a 53 68 9 a Three maternal deaths were reported in the national statistics for Seychelles in 2015. For most years prior to and after 2015, maternal mortality was reported as zero in the national statistics. Source: WDC11. Health expenditure data are for the year 2015. GNI: Gross National Income; MMR: Maternal Mortality Ratio TABLE 1. Selected Health Indicators, 2016 universal health coverage, including: financial risk protection; What is interesting about the Seychelles health system is that access to quality essential health care services; and access to the country has one of the most effective health systems in safe, effective, quality, and affordable essential medicines and Africa and among comparable small population countries vaccines for all. The goal of UHC provides countries with a (Table 1) and has achieved this without major reforms along clear objective for health system strengthening and reforms. the lines described above. This is achieved through continued But the health sector reform agenda has been around for a investment in the public health system with little to no distrac- longer time, going back to the Declaration of Alma-Ata in tion by complex health reform interventions such as a health 19786 and more explicitly with the publication of the World insurance program and results-based financing. That is not to Bank’s World Development Report 1993: Investing in say that Seychelles did not constantly improve the health sector Health.7 What UHC does differently is identify and articulate or that it cannot improve the sector further. The point is that a universal objective, which is the universal coverage of Seychelles offers an alternative approach for achieving UHC— critical health services. UHC then serves as an overarching showing that with common sense and sensible incremental theme for all country-specific objectives that have motivated improvements, much progress can be achieved at a relatively reforms in the past, including access, quality, and efficiency low cost. This article does not argue that only common sense of health services in decreasing mortality and morbidity; the and incremental improvements should be how every country decrease of inequalities in both health outcomes and use of strengthens the health sector but rather that these changes are health services; lowering of the financial risks faced by critical regardless of the health sector and the reform journey a vulnerable populations due to the cost of health care services; country undertakes. This article also does not argue that a as well as the responsiveness of health system to population publicly funded, organized, and owned health system is appro- needs and preferences. UHC therefore provides an excellent priate for every country. Lessons from Seychelles will add to the entry point for a health system reform agenda. few global examples of well-functioning dominantly publicly Over the years, reforms have taken many forms and owned and run public health systems, including the examples of covered a range of topics and approaches. In terms of Cuba,8 Costa Rica,9 and the Indian state of Kerala.10 It will also financing health care, efforts included changing funding provide insights for other countries in the African continent. sources such as user fees and related exemptions or differ- ent forms of insurance structures and models. How health care providers are paid for delivering care has also figured METHODOLOGY prominently in reforms, including output-, performance-, The article presents Seychelles’ experience with health reform and results-based financing. In terms of service delivery documented through a series of analytical products like public and organization, health system reform efforts have expenditure reviews and supporting surveys12-14 carried out by included public–private partnerships, decentralization, new the Ministry of Health with the support from the World Bank and public-sector management, and facility autonomy, among WHO. Over the last decade, the World Bank has conducted three others. Most of these efforts have focused on large struc- analytical products—public expenditure reviews (2009 and 2014) tural changes to how health is either financed or delivered and health services reviews in Seychelles: availability, quality of and, in some cases, both. care, and efficiency in health spending (forthcoming).14 In 364 Health Systems & Reform, Vol. 4 (2018), No. 4 drawing conclusions and lessons, findings from these analytical how providers are paid, and how services are delivered have products are complemented by the authors’ longstanding engage- remained stable. It could be argued that the general stability ment in Seychelles and extensive discussions with a wide range of of the sector may reflect success in achievements but, regard- national experts and policy makers in multiple ministries. less the reason, Seychelles has consistently invested to The public expenditure reviews, using audited financial improve access to and availability of services. The constitu- statements from the Ministry of Finance, applied a standard tion of the country grants all citizens free access to primary approach to analyze how public funds are spent in the health health care.22,23 In reality, free access is implemented at sector and what was achieved as a result. The public expen- higher levels of care as well. Citizens therefore do not pay diture analysis is further complemented by the detailed for care at point of use in public facilities. A largely equitable analysis of private spending and donor funds channeled to mechanism exists for supporting overseas medical treatment non-state sectors as documented in the national health for services not available in country for the population. accounts. Seychelles has conducted four rounds of national Globally, this is a unique case in which the free benefit health accounts (2009, 2013, 2014, and 2015)15–17 with sup- package is more generous de facto than de jure. Seychelles’ port from WHO and the World Bank. The last three were health system is, for all practical purposes, supply-side conducted using the System of Health Accounts 201118 meth- focused, financed through general government revenues, odology, whereas the 2009 round used the national health and dominantly publicly owned and managed. accounts 2003.19 As part of the 2017 efficiency and value for The health sector serves a small population of 94,677 money in health spending study, a benchmarking of quality people (mid-population in 2016)24 spread across 115 tropical and efficiency of care in Seychelles against Organization for islands. Over 85% of the population lives on the main island, Economic Cooperation and Development (OECD) countries Mahe, and this is where health facilities are concentrated. As was conducted. a result, access to services is high: travel time to a health In addition, several facility and patient exit surveys gen- facility is less than 30 minutes for more than 75% of patients, erated primary data sets that facilitated further triangulations and waiting time is less than 30 minutes for 70% of the of the Seychelles’ experience: (1) Service Availability and patients. Consultation remains the main purpose of visit to Readiness Assessment (SARA 2017)—a health facility sur- a health facility, and 70% of patients are seen by a doctor/ vey using WHO standard questionnaires and methodology20 medical officer during a visit.14 Health care facilities are that covered almost all health facilities and generated reliable overwhelmingly publicly owned. As a result, most providers information on general service availability, general service (for instance, 83% of doctors and dentists in 2016) are readiness, and specific service availability and readiness for practicing in the public sector. Private providers are part of 18 selected services; (2) patient safety situational analysis the health sector landscape, particularly pharmacists, dentists, (2017)—a health facility survey using WHO standard and some general practice providers.24 questionnaires21 that assessed all health facilities in 12 key Seychelles has developed an extensive network of health action areas of patient safety; (3) patient exit surveys (2013, infrastructure that in some respects exceeds WHO-recom- 2017)—two rounds of patient exit surveys on their choices mended norms. Due to this extensive network of facilities of, access to, and satisfaction with the care they received relative to the population and the tradition of free access to using the same questionnaires to maintain comparability; WHO proposed and (4) a health worker survey (2013)—a survey adminis- Seychelles benchmark tered to all health professionals that covered critical themes including health worker density, transfer and attrition, work- Health infrastructure ing conditions, and ability and willingness to perform. Number of facilities per 10,000 2.6 2.0 Number of inpatient beds per 29.7 25 10,000 population SEYCHELLES’ HEALTH SECTOR STRUCTURE AND Number of maternity beds per 23.8 10 OUTCOMES 1,000 population Health utilization The detailed analytical work described in the previous section Annual hospital discharge per 100 12 10 allows for the presentation of the main characteristics of the population health sector in Seychelles and the successes achieved over Annual outpatient visits per capita 6 5 the years. Over the last 15 years, the health sector has under- TABLE 2. Health Infrastructure and Utilization in Seychelles, 2017. gone several structural changes in accountability and organi- Republished with permission from World Bank13 zation, but the main elements of how the sector is financed, Workie et al.: Who Needs Big Health Sector Reforms Anyway? 365 care, Seychelles boasts impressive utilization statistics that also Detailed assessment of readiness of each facility was also exceed average benchmarks and norms set by WHO conducted for 18 specific services covering both communic- (Table 2).14 Seychellois thus have very good access to both able and noncommunicable conditions. Facility readiness for inpatient and outpatient services. All age cohorts—from preg- each specific service is measured through assessing tracer nant mothers to the elderly—have specific services tailored for items across the six domains: trained staff, guidelines, equip- their health and well-being. In addition, Seychelles has a net- ment, diagnostic capacity, medicines, and commodities. The work of community-based adolescent centers and homes for the results present a mixed picture. For about two thirds of the elderly where these populations can interact with each other specific services, availability of tracer items is higher than and access preventive and promotive services to improve their 50%. However, very few services scored more than an 80% health-seeking behaviors. This is unique in the African region, mean score of availability. Noncommunicable disease (NCD) where services are primarily focused on mothers and children, services have higher scores, which is commendable given the with less attention to adolescents, adults, and elderly persons. burden of NCDs in Seychelles.14 One way to gauge access to services is to survey tracer Total current health expenditure, in per capita USD, has elements in selected domains. WHO’s SARA survey approach increased from 298 in 2009 to 450 in 2015 (a 65% increase). assesses general service readiness based on the capacities However, total current health expenditure as a share of gross (inputs) of health facilities to provide general services in five domestic product (GDP) has remained relatively flat, with domains: basic amenities, basic equipment, infection preven- only a slight increase from 3.1% in 2009 to 3.4% in 2015. tion, diagnostic capacity, and essential medicine and commod- Government funding from general tax revenue accounts for ities. Seychelles performed very well in the areas of basic the bulk of total current health expenditure: 87% in 2009 and amenities, basic equipment, and infection prevention, with 97% in 2015 (Figure 2). The share of health in general mean scores of 88% and above, whereas the scores for diag- government expenditure increased from 8% in 2009 to 10% nostic capacity and essential medicines are lower, at 41% and in 2015 (a 24% increase). Private health expenditure, 75% of 61%, respectively (Figure 1). The low scores for diagnostics and which is household out-of-pocket payment, accounts for a essential medicines are partly because of the Seychelles context small fraction of total current health expenditure (7% in 2009 and service delivery setup and do not necessarily signify short- and 2.5% in 2015). External funding has been very small and age. For instance, all diagnostic tests are centralized at declining over the years, from 6% in 2009 to 0.5% in 2015 of Seychelles hospital; stocks of all essential medicines are kept total current health expenditure.15–17 at Seychelles hospital and the smaller health facilities do not Seychelles’ spending on health, 3.4% of total GDP in stock certain essential medicines that should be used only in 2015, is low in comparison to OECD countries (Figure 3) hospital setting. Seychelles remains a top performer in general and other income peers, including Mauritius (4.8%), service readiness and domain scores for health facilities in Maldives (13.7%), and Cabo Verde (4.8%). However, the comparison to other sub-Saharan Africa countries (Uganda, return for its investment measured in health outputs and out- Kenya, and Sierra Leone, to name a few) that have conducted comes is reasonably high and comparable to that of its peers, a SARA survey.25 suggesting an efficient health system that is better able to 100% 96% 92% 88% 76% 75% 63% 50% 41% 25% 0% General service Standard Basic amenities Basic equipment Diagnostics Essential readiness index precautions mean score mean score mean score medicines mean mean score score FIGURE 1. General Service Readiness in Seychelles, 2017. Republished with permission from World Bank13 366 Health Systems & Reform, Vol. 4 (2018), No. 4 600 12% % general government expenditure and GDP 450 8% Per Capita US$ 300 4% 150 0 0% 2009 2013 2014 2015 Government Private Rest of the world % general governament expenditure % GDP 14, 15, 16, 29 FIGURE 2. Trends in Health Expenditures in Seychelles Authors computation. 29 FIGURE 3. Current Health Expenditure as a Share of GDP, 2015 Authors computation. translate investments into good health outcomes. An impor- prevention, compare favorably to OECD countries.9 tant measure of a health system’s effectiveness is the extent to Considering the level of spending relative to national income, which the sector produces good health outcomes. Mortality the country provides good quality services to the population, and life expectancy at birth are common health outcome which has high levels of utilization. As noted in the financing measures. Seychelles’ infant mortality, under-five mortality, data, out-of-pocket spending on health care services is very and life expectancy at birth compare favorably to its income low despite high levels of service utilization. In other words, peers (Figures 4, 5, and 6), which is indicative of an effective the health system succeeds at providing financial protection and efficient health system. Of course, in addition to the and ensures no financial barriers to use. important roles of a health system, it is important to acknowl- Seychellois are also highly satisfied with health services. edge the contribution of socioeconomic development to The 2013 and 2017 patient exit surveys (Figure 7) present improved health outcomes. For example, Seychelles has improvements in satisfaction for most areas, except for ade- achieved 92% literacy level, leading in Information quate opening hours, cleanliness of the facility, and travel Communication Technology (ICT) in Africa, and in 2015 convenience from home or work to a health facility.14 It is became a high-income country. important to note that the 2017 exit survey also recorded that Available data also point to an efficient health system. 70% of patients reached a health facility in less than Various measures of efficiency, such as bed occupancy rate, 30 minutes. average length of stay, number of magnetic resonance ima- We therefore see evidence of a predominantly supply-side, ging and computed tomography scans, and allocation to publicly owned, publicly financed, and publicly managed Workie et al.: Who Needs Big Health Sector Reforms Anyway? 367 Infant mortality, 2015 80 60 Infant mortality rate (per 1,000 live births) 40 Algeria 20 Jordan Mexico Brazil Tunisia Peru Mauritius Barbados Seychelles Armenia Saudi Arabia Thailand 10 Turkey Argentina Romania Malaysia Chile United States Canada Poland Greece Australia Portugal Czech Republic Spain Sweden Estonia 500 1000 5000 10000 50000 GDP per capita, current US$ 29 FIGURE 4. Infant Mortality versus GDP per Capita. Authors computation. Under-five mortality, 2015 150 100 Under-five mortality rate (per 1,000 live births) 50 Algeria Jordan Mexico 15 Peru Brazil Mauritius Tunisia Armenia Seychelles Saudi Arabia Thailand Barbados Turkey Argentina Romania Malaysia Chile United States Poland Canada Greece Australia Portugal Czech Republic Estonia Spain Sweden 500 1000 5000 10000 50000 GDP per capita (Current US$) 29 FIGURE 5. Under-Five Mortality versus GDP per Capita. Authors computation. 368 Health Systems & Reform, Vol. 4 (2018), No. 4 90 Life expectancy, 2015 Spain Australia Greece Sweden Portugal Canada 80 Life Expectancy at birth, in years Chile Czech Republic United States Poland Mexico Algeria Estonia Malaysia Argentina Tunisia Thailand Barbados Brazil Romania Jordan Mauritius Turkey Saudi Arabia Peru Armenia Seychelles 70 60 50 500 1000 5000 10000 50000 GDP per capita, current US$ 29 FIGURE 6. Life Expectancy versus GDP per Capita. Authors computation. Trust decision No language barrier Trust skills Friendly and approachable Thorough and careful Quality of service Adequate opening hours Sufficient time with staff Enough privacy Waiting time Easy access to meds Explained condition well Staff courteous and respectful Facility is clean Travel convenience from work to facility Travel convenience from home to facility 0 10 20 30 40 50 60 70 80 90 100 % in 2013 % in 2017 FIGURE 7. Patient Satisfaction. Republished with permission from World Bank13 health system that has produced excellent utilization and KEY FACTORS THAT FACILITATED SUCCESS quality results at a relatively low expenditure level. The Some of the factors that facilitated this success of the health different measures of universal health coverage show that sector in Seychelles include high political commitment, a the country has largely assured for its population a wide strong voice and downward accountability culture, a clear range of available services and a high level of utilization of separation of functions between service delivery and public relatively good quality services, with high levels of user health and policy, and an impressive investment in primary satisfaction and financial risk protection. In the next two health care. sections, we trace the success factors, extract lessons for At independence, in 1976, Seychelles had a very rudimen- other countries, and describe the remaining challenges of tary health system for its population, which was served by a the health sector in Seychelles. Workie et al.: Who Needs Big Health Sector Reforms Anyway? 369 total of eight public health facilitiesa(five on Mahe, one on It is not uncommon to come across similar language in Praslin, one on La Digue, and one on Silhouette islands), two many constitutions of nations across the globe; however, private practices, 15 doctors, and five dentists. Of the eight in the Seychelles case, the pledge to provide free care has public facilities, two catered to patients with specific condi- been achieved and maintained. Health is a priority sector tions only, namely, mental health and leprosy. With the and that shows in the annual budget appropriation, exception of Seychelles hospital, which had four wards, all where allocation to health has continued to rise to other facilities had small capacities. The predominant causes respond to the changing needs and demands of the of ill health were communicable diseases, although the pre- population.15–17 viously high incidence of tuberculosis had by then been Despite several reorganizations of the health sector, brought under control.26 particularly in the last decade, the public health function In the ensuing years, Seychelles embraced the primary has remained adequately staffed and funded. This is impor- health care approach promoted by WHO and defined its tant considering the high burden of NCDs in the vision and principles for equitable and accessible primary Seychelles and the potential return to investment in health care for all. It invested incrementally to expand the primary and secondary prevention of NCDs. primary care network and health infrastructure in general, Budget allocation and expenditure on prevention activities to equip and stock facilities, to train and deploy health have steadily increased as shown by national health professionals, and to promote and educate individuals accounts, from 6.4% of general government expenditures with regard to responsibility for their own health. The in 2009 to 12.5% in 2015, which is higher than the OECD investment paid off handsomely. Two decades later, in average. With the 2014 reorganization,23,27 which intro- 2000, the number of health centers more than doubled duced a separation of functions (policy, service delivery, to 17; the number of doctors and dentists increased more and public health), a public health authority was estab- than fivefold to 119; coverage of essential child, maternal, lished as an independent entity to regulate public health and reproductive health pushed to the upper 90%; the matters and protect the population’s health. infant mortality rate dropped by over three quarters from In addition, the country stands out with a culture of down- 43.2 per 1,000 live births in 1977 to 9.9 per 1,000 live ward accountability, strong citizen voice, high transparency, births in the year 2000; and average life expectancy for and low corruption. In the Ibrahim Index of African both sexes increased from 69.5 in 1980 to 72.7 years in Governance that considers a composite set of measures (i.e., 2000.26 In addition, by early 2000, most communicable safety and rule of law, participation and human rights, sus- conditions were under control and the burden of disease tainable economic opportunity, and human development), started to shift to NCDs. During this same time period, Seychelles is a top performer with an overall governance the economy has prospered and living condition have also score of 73.4/100 in 2017, second only to Mauritius.28 improved. Similarly, with a score of 60/100 in the 2017 Transparency In 1993, the government enshrined the right to health and International’s Corruption Perceptions Index, Seychelles is respect to human dignity in its Constitution.22,23 It spells out the second least corrupt country in sub-Saharan Africa after a clear commitment and states that: Botswana and ranks 36/180 globally.29 In the health sector, some of these governance characteristics might have more to … the State recognizes the right of every citizen to protection do with the country’s small population, the cohesion of the of health and to the enjoyment of the highest attainable society, and the Seychellois culture than anything else. standards of physical and mental health and with a view to Nevertheless, they suggest that the essential ingredients of ensuring the effective exercise of this right, the State good governance are no less important than specific recipes undertakes: of health reforms. The story of Seychelles’ health system is one of evolu- ● to take steps to provide for free primary health care in state tionary development achieved through decades of consis- institutions for all its citizens, tent commitment to (1) investing in primary health care; ● to take appropriate measures to prevent, treat and control epidemic, endemic and other diseases, (2) making health care free and accessible to all; (3) ● to take steps to reduce infant mortality and promote the maintaining and strengthening public health functions healthy development of the child, regardless of structural changes in the sector; and (4) a ● to promote individual responsibility in health matters, and ● high level of accountability to the population. In addition, to allow, subject to such supervision and conditions as are necessary in a democratic society, for the establishment of there is keen interest in using evidence, generated through private medical service. surveys and studies, to guide decision making. This 370 Health Systems & Reform, Vol. 4 (2018), No. 4 intelligence-driven stewardship has allowed the evolution DISCLOSURE OF POTENTIAL CONFLICTS OF of services that are attuned to the legitimate needs of the INTEREST population, improve efficiency, and sustain high levels of The authors declare no conflict of interest. satisfaction and utilization. ORCID THE NEXT CHALLENGES Humphrey Karamagi http://orcid.org/0000-0002-6277- We have discussed above how Seychelles has improved its 2095 population’s health and well-being through an approach that largely focused on supply-side investment in primary care, funded and managed by the public sector, with real commit- REFERENCES ment to making health care free, explicit emphasis on public 1. World Health Organization. Health systems financing: The path health functions, and a high degree of transparency and to universal coverage. Geneva (Switzerland): World Health accountability as well as use of evidence to inform decision Organization; 2010. making. It is natural that success brings a new set of chal- 2. Mexico city political declaration on universal health coverage: lenges. For instance, the population is aging and the health sustaining universal health coverage: sharing experiences and burden has shifted to predominantly noncommunicable con- promoting progress. 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