25–27 March 2019Manila, Philippines

Meeting Report

WORKSHOP ON STRENGTHENING GOVERNANCE FOR HEALTH EQUITY

TO ADVANCE THE SUSTAINABLE DEVELOPMENT GOALS

Wor

ksho

p on

Str

engt

heni

ng G

over

nanc

e fo

r Hea

lth E

quity

to A

dvan

ce th

e Su

stai

nabl

e De

velo

pmen

t Goa

ls25

–27

Mar

ch 2

019

Man

ila, P

hilip

pine

s

WORLD HEALTH ORGANIZATION

REGIONAL OFFICE FOR THE WESTERN PACIFIC

RS/2019/GE/14(PHL) English only

MEETING REPORT

WORKSHOP ON STRENGTHENING GOVERNANCE FOR HEALTH

EQUITY TO ADVANCE THE SUSTAINABLE DEVELOPMENT GOALS

(COLLABORATIVE WORKSHOP 1)

Convened by:

WORLD HEALTH ORGANIZATION

REGIONAL OFFICE FOR THE WESTERN PACIFIC

Manila, Philippines

25–27 March 2019

Not for sale

Printed and distributed by:

World Health Organization

Regional Office for the Western Pacific

Manila, Philippines

June 2019

NOTE

The views expressed in this report are those of the participants of the Workshop on Strengthening

Governance for Health Equity to Advance the Sustainable Development Goals (Collaborative

Workshop 1) and do not necessarily reflect the policies of the World Health Organization.

This report has been prepared by the World Health Organization Regional Office for the Western

Pacific for Member States in the Region and for those who participated in the Workshop on

Strengthening Governance for Health to Advance the Sustainable Development Goals (Collaborative

Workshop 1) in Manila, Philippines from 25 to 27 March 2019.

CONTENTS

SUMMARY ............................................................................................................................................ 1

1. INTRODUCTION .............................................................................................................................. 2

1.1 Meeting organization ..................................................................................................................... 2

1.2 Meeting objectives ........................................................................................................................ 2

2. PROCEEDINGS ................................................................................................................................. 2

2.1 Opening session ............................................................................................................................. 2

2.2 Setting the scene ............................................................................................................................ 3

2.3 Country experiences on governance for equity ............................................................................. 4

2.4 Contextualizing governance for health equity: learning from global experiences ........................ 6

2.5 Understanding public policy process and the different forms of intersectoral governance .......... 9

2.6 The role of stakeholders in whole-of-government approaches ................................................... 11

2.7 The leadership role in advancing governance for health equity .................................................. 11

2.8 Negotiating for health .................................................................................................................. 13

2.9 Measuring progress: evaluation and monitoring governance for equity ..................................... 15

2.10 Reflections and next steps ......................................................................................................... 16

2.11 Closing session .......................................................................................................................... 16

3. CONCLUSIONS AND RECOMMENDATIONS ........................................................................... 16

3.1 Conclusions ................................................................................................................................. 16

3.2 Recommendations ....................................................................................................................... 17

3.2.1 Recommendations for Member States 17

3.2.2 Recommendations for WHO 17

ANNEXES ............................................................................................................................................ 19

Annex 1. List of participants

Annex 2. Programme of activities

Annex 3. Presentations

KEYWORDS: Universal coverage/ Regional health planning/ Health equity/ Social determinants of

health

1

SUMMARY

Attention to equity in health is central to the principle of leaving no one behind in advancing the

Sustainable Development Goals (SDGs). Health inequities – the unfair and avoidable differences in

health between population groups – are primarily due to the social determinants of health, requiring

intersectoral collaboration for health equity. This challenge is heightened by rapid demographic and

societal changes occurring in the Western Pacific Region (for example, migration and urbanization).

The SDGs emphasize that in this increasingly complex world, new approaches are required so that

difficult issues are addressed while ensuring no one is left behind. This will mean strengthening

governance for health equity, including building the capacity of intersectoral and intergovernmental

mechanisms to ensure equity goals are reached.

Attention to intersectoral governance for health equity is not new. In collaboration with partners, the

WHO Regional Office for the Western Pacific has been supporting various capacity-building

activities in countries to strengthen governance for health equity, such as organizing training

workshops, conducting policy advocacy and dialogue, and convening Member States to share

experiences and learn from each other. To provide more strategic focus and support to these efforts,

the Regional Office is now implementing the regional initiative titled regional governance for health

equity project, with the objective to strengthen intersectoral collaboration and governance for health

equity. This initiative involves six countries (Cambodia, China, the Lao People’s Democratic

Republic, Mongolia and Viet Nam) and is based on a multidisciplinary science-of-improvement

approach (comprising capacity-building, innovation, rapid cycle field testing and dissemination). The

Workshop on Strengthening Governance for Health Equity to Advance the Sustainable Development

Goals (SDGs) is the second of three regional meetings and is an important milestone in implementing

the project’s activities.

2

1. INTRODUCTION

1.1 Meeting organization

The Workshop on Strengthening Governance for Health Equity to Advance the Sustainable

Development Goals (SDGs) was held in Manila, Philippines, from 25 to 27 March 2019. This second

of three regional meetings is an important milestone in implementing project activities. The workshop

built on discussions from the WHO-led Workshop on Governance for Health Equity held as part of

the International Conference on Equity and Social Determinants of Health in November 2018 in Seoul,

Republic of Korea that was co-organized with the Korea Institute for Health and Social Affairs

(KIHASA). The workshop presented findings from the first phase of the WHO project on regional

governance for health equity, including the country situational analysis, and supported participants in

finalizing a priority topic and action plan to be field-tested.

1.2 Meeting objectives

The objectives of the meeting were:

1) to follow up on discussions at the WHO-led workshop in November 2018, discuss and share

country experiences on equity and social determinants, and identify a priority topic for each

country under the project;

2) to develop country action plans and agree on next steps for field-testing in countries,

including needed technical support; and

3) to build capacity of participants to strengthen intersectoral governance for health equity in the

context of the SDGs, including competencies for working across sectors with different

stakeholders.

2. PROCEEDINGS

2.1 Opening session

Dr Peter Cowley, Acting Director of the Division of Health Systems, WHO Regional Office for the

Western Pacific, opened the meeting on behalf of Dr Takeshi Kasai, WHO Regional Director for the

Western Pacific. He highlighted that poor health and well-being are often the result of unequal

distribution of power and resources. Poverty, poor education, a lack of local services, gender and

housing, among other factors, can contribute to poor health. He noted that despite improvements in

health and health systems, achievements have not benefited all groups in an equitable manner, with

900 million people in the Asia Pacific region living on less than US$ 2 a day, 105 million people

experiencing financial catastrophes and 70 million being impoverished as a result of paying for health

care. Universal health coverage (UHC) draws attention to people and communities calling for health

systems that are equitable and responsive to the needs of diverse population groups, particularly those

left furthest behind. UHC constitutes a platform that brings health and development together. It is a

whole-of-systems approach to improving health systems performance and sustaining health gains for

all. With health influencing and being influenced by multiple SDGs, the Agenda for Sustainable

Development presents an opportunity to strengthen governance for health equity, and the Western

Pacific Region must continue to build upon its successes to achieve health equity, UHC and the SDGs.

The participants introduced themselves, and Dr Cowley nominated the following office bearers:

Dr Oyunkhand Ragchaa (Mongolia) as chairperson

Dr Ir Por (Cambodia) as vice chairperson

Ms Thuy Thanh Phan (Viet Nam) as rapporteur.

Dr Kira Fortune, Unit Coordinator of Equity and Social Determinants of Health, provided a short

overview of the background of the meeting including the objectives and agenda. Ms Britta Baer,

3

Technical Officer (Gender, Equity, Human Rights and Ageing), provided logistics information to

participants.

2.2 Setting the scene

The session started with Mr Emmanuel Eraly (WHO Regional Office for the Western Pacific)

presenting an overview of regional data on health and health equity. While the Western Pacific

Region has experienced significant economic growth, a closer look at the Gini coefficient shows

disparities within and between countries. Trends in the Region such as urbanization, increased access

to mobile phones and the Internet, ageing, climate change, internal displacement and increasing

prevalence of noncommunicable diseases (NCDs) are important to consider in understanding the

challenges that countries face. For example, an estimated 80% of the population in the Region will

live in an urban area by 2050. Ageing has spiked in the Region since 2010, with 10% of the Region

comprised of an older population. Countries such as Japan and China have a more significant elderly

population than, for example, the Philippines and thus need different approaches to health. As a result

of climate change, the occurrence of floods in Asian countries and of storms in Pacific countries has

increased. NCDs are now responsible for more deaths than communicable diseases, with this trend

expected to continue increasing over time and indicating a need to respond appropriately. Lastly,

while government spending on health care has increased and out-of-pocket expenditure has decreased

in countries such as China and Japan, others are still seeing quite a high percentage of out-of-pocket

expenditure. This correlates with challenges for health equity. Mr Eraly concluded by emphasizing the

importance of good data that can be presented to high-level politicians to drive action for equity in

health.

Following this presentation, Dr Fortune provided an overview of the frameworks within which

countries in the Region are working towards the reduction of health inequity. She shared that, despite

successfully reaching all of the health-related goals of the Millennium Development Goals, the

Region still faces challenges of health equity, so the new regional strategies emphasize the need for

multisectoral work. The 2030 Agenda for Sustainable Development (adopted in 2015) and the WHO

Western Pacific Region action framework for UHC (adopted in 2016) provide opportunities to work

towards health for all. Specifically, the UHC action framework moves beyond the traditional building

blocks (workforce, financing and equity) towards five health systems attributes (quality, efficiency,

equity, accountability, and sustainability and resilience) with domains on which the countries can

advance the UHC and SDG agendas. Member States also adopted the Regional Action Agenda on

Achieving the SDGs in the Western Pacific in 2016, which outlines the role of the health sector.

Globally, countries are also working to meet the primary health care aims under 40 years of the

Declaration of Alma-Ata and towards the “triple billion” targets in WHO’s 13th General Programme

of Work. Participants in this meeting will identify concrete actions within these frameworks using the

evidence and good practices now available. The WHO Regional Office for the Western Pacific has

put together the regional governance for health equity collaborative to strategize around this agenda to

improve health equity in the Region.

Then, Ms Baer put the meeting into context within the frameworks. She explained that the Action

Agenda on the SDGs is the basis of the collaborative, which was created to help operationalize the

Action Agenda principles. They include cross-regional collaboration and learning to address health

equity and the social determinants of health through strengthening cross-sectoral collaboration. By

using the theory of improvement methodology, the collaborative is meant to create a space for

practical exchange and mutual learning, with an emphasis on how to work in an intersectoral manner

to address health equity. It brings people together to: share ideas on what needs to be done, create

plans for action and reunite to share lessons learnt. Countries can test their action plans in the time

between meetings and share lessons regarding what worked and what created bottlenecks. Since

March, at least three countries have conducted a situational analysis. With guidance provided by the

experts attending the meeting, this will allow appraising the information on health equity and

consequently identifying priority topics and actions to be tested in the following months.

4

The session concluded with questions and comments from participants. Ms Baer clarified that in

selecting the scope of the health issue to be tackled, participants should be able to commit to and

control the actions to be implemented and that these should be aligned with what is already in place in

their country. She stressed that it will be important to learn from what worked and what did not work

within the country context. She also highlighted that reducing access barriers for services and having

so-called best buys or win–win collaborations across sectors are two important pillars of action to

move forward the work on the SDGs.

2.3 Country experiences on governance for equity

2.3.1 Cambodia

Dr Por Ir (Cambodia) shared that the country has made considerable progress over the past 15 years in

improving health-care coverage, health status and financial protection for its relatively young and

predominantly rural population. Cambodia has: significantly reduced the burden of infectious disease;

reduced maternal, infant and child mortality rates; and eradicated diseases such as poliomyelitis.

Despite these improvements, disaggregated data by population groups and geographic areas show

disparities in health care, health status and financial protection. For example, women in the lowest

economic quintile and in rural areas had low educational attainment. Also, the majority of the poorest

quintile in Cambodia lives in rural areas, while the richest quintile predominantly lives in urban areas.

Teenage pregnancy is higher for women lacking education, rural families have more children, and

antenatal care and skilled delivery rates are lower among poor, rural and low-educated groups.

To address health inequities, the Cambodian constitution affords free medical care for the poor.

Cambodia also has a Health Strategic Plan (2016–2020) to promote health and well-being for all and a

National Social Protection Policy Framework (2016–2025), which addresses UHC. Initiatives such as

the Health Equity Funds exist to support the poor and informal workers in accessing health care,

including initiatives that provide incentives to work in remote areas and with ethnic minorities. While

there are multisectoral mechanisms for the SDGs, social protection and UHC, no mechanisms specific

to health equity exist to monitor health inequalities. Equity analysis is essential not just to monitor

inequality but to inform targeted health policies to close gaps, and local capacity for surveillance of

health equity needs to be strengthened. There could potentially be a multisectoral committee for

health equity governance, monitoring and planning to support the work for health equity.

Following the presentation, participants shared reflections and questions regarding: Cambodia’s

experience funding the Health Equity Funds, the possibility of collecting qualitative data and

mainstreaming health equity instead of creating a new committee, the value of monitoring primary

health care as it expands and the quality of care, and the challenges in funding health equity impact

assessments. Another delegate from Cambodia shared that provincial committees for health financing

also monitor and measure free access to health facilities by the poor. Dr Ir explained that with respect

to monitoring, funds must be used strategically to ensure their efficient use.

2.3.2 Mongolia

Dr Oyuntsetseg Purev (Mongolia) presented an overview of Mongolia’s experience in governance for

health equity. Life expectancy is very different for men (69 years) and women (75 years), and there

are gender and geographic differences in NCD prevalence. While the country has decreased its infant

mortality rate, some regions continue to have high rates. To tackle health inequality, the Government

is trying to reduce barriers to access to health care. For example, a law has been passed to ensure free

primary health care for everyone. The Government also covers services for children, older people and

pregnant women. Additionally, to address the significant geographic barriers, the Government is

implementing mobile health and technology projects with WHO support, in addition to restructuring

service delivery by making more basic hospitals available.

The Government has been implementing health equity governance projects with WHO support in two

cities. These include a healthy behaviour programme through intersectoral work, which focuses on

improving health knowledge and health promotion activities. In addition, within the framework of the

Public Health Intersectoral Cooperation Implementation Plan (2018–2020), the Government has

5

organized a wide intersectoral forum to improve population health as well as local-level workshops

and training of health workers to improve health equity. Among lessons learnt, the Government must

ensure human resource sustainability at all levels and continuous capacity-building for health equity.

Also, the Government should show good achievements and practices across sectors to encourage

cross-sector collaboration for win–win initiatives, involving no more than two or three sectors. Some

examples of good practices include the Reach Every District or RED Strategy and m-health at the

primary health care level. The challenge is to ensure sustainability mechanisms of the various projects

and to include equity indicators in the performance contracts of ministers and governors as well as

indicators in policy, programme and strategy monitoring process.

In answer to participants’ questions, Dr Purev explained that the Prime Minister signs contracts for

the ministries. Within this, the Ministry of Health actively champions health outside the health sector

by including equity indicators in contracts and by signing contracts with governors. She clarified that

haemodialysis services are covered through the Government and health insurance and that the

evaluation and monitoring for the healthy behaviour programme is underway using mobile

technologies such as apps. Mobile health is operationalized in Mongolia by bringing mobile

technology to primary health care and by health care workers travelling to remote households with

portable devices to screen family members and provide services, in addition to helping them

understand how to access care if they are uninsured. Dr Purev explained that the difference in life

expectancy between men and women is partly because men consume more tobacco and alcohol and

are involved in accidents. Among initiatives to address men’s health, WHO is supporting the country

in leading a multisectoral healthy city initiative.

2.3.3 Viet Nam

Ms Thanh Thuy Phan (Viet Nam) presented on the mechanisms for intersectoral work in Viet Nam.

It is a lower-middle-income country where rural areas and population groups with low education

levels have significantly poorer health outcomes. A large share of the population is experiencing

uncontrolled spontaneous migration, rapid urbanization and rapid ageing. While NCDs are among the

top health issues, the country also faces challenges related to climate change, high risk of national

disasters and access barriers to health services (given limited primary care services and fee-for-service

models). To improve health equity, the Government subsidizes the enrolment of poor and vulnerable

populations with social health insurance for the poor, children aged under 6 years and people over

85 years of age. The country is also in the process of strengthening its primary health care network,

with 100% of communes having a commune health station and 90% of doctors working in a

commune health station. Both central and local governments are committed to expanding the social

health insurance scheme.

To address the SDGs and the social determinants of health, there are governmental institutional

arrangements. These include the Vietnam Business Council for Sustainable Development, the

National Council for Sustainable Development and Competitiveness Enhancement and an Inter-Sector

Working Group on the SDGs. National strategies such as the Resolution of the Party (2017), the

SDGs National Action Plan (2017) and the Vietnam Healthy Agenda (2018) also serve as

mechanisms for intersectoral work. These establish intersectoral committees/cabinets, integrate health

targets in socioeconomic development plans at national and local levels, ensure participation of

affected communities, orient and build the capacity of public servants from other sectors on

intersectoral action for health equity, and generate and disseminate evidence regarding health and

health equity for advocacy. Nevertheless, while it can be easy to agree on goals, it is difficult to agree

on policy results, sources, and allocation of necessary financial and human resources, especially since

other sectors do no prioritize health, and their structure and ways of measuring success are different.

While health equity assessments have been implemented, they are limited, and the voice of the

affected people needs to be strengthened. Ms Phan concluded that, despite challenges, health equity

work is facilitated by the collaboration mechanisms with other sectors, the high commitment from

central and local governments, and the health-related targets of the SDGs that are integrated into

national strategies and plans.

6

Participants inquired about successful intersectoral action, facilitators for getting people involved (not

just professionals or affected communities), risks associated with hospital autonomy and tackling

access barriers (not just availability) to health-care services. Ms Phan explained that a successful

example is the National Assembly agreeing for 30% of the health budget to be allocated to preventive

health. She also shared that collaborations with civil society and online platforms for the public allow

people and communities to be involved in intersectoral work. She said that the risk with hospital

autonomy is that the Government may not be able to control the quality. Lastly, she responded on the

question about barriers to services that some minorities receive subsidies that can help with

transportation and food.

2.4 Contextualizing governance for health equity: learning from global experiences

2.4.1 Governing multisectoral action for health in low- and middle-income countries

In his presentation on governing multisectoral action for health in low- and middle-income countries,

Dr Kumanan Rasanathan (Secretariat) invited participants to reflect on the different perspectives that

sectors may have on a health issue such as family planning. Some viewed it as a human rights issue,

an economic development issue or a religious issue. Considering other sectors’ perspectives as well as

power dynamics and political processes is paramount in intersectoral work. Though the health sector

is not typically interested in power dynamics, it must make an effort to engage with these realities. In

working across sectors, it is important to think about who is seeking to put the issue on the agenda and

why, to what extent the interests are aligned, diverse or opposing, and to what extent there is strong

local ownership versus externally imposed initiatives.

In multisectoral work, consideration must be given to the flows of power and where the power is

operating, by observing the interests, institutions and ideas. For example, the Ministry of Health is

most judged on the delivery of health care, and other sectors have their respective incentives and goals

such as educating children (education) or reducing congestion (transport). The health sector needs to

consider the hierarchies, authorities and loyalties for partnership and acknowledge that there may be a

lack of experience, funds and human resources to execute the multisectoral work. The health sector

needs to go beyond informing other sectors on their role in health, and move towards incentivizing

them to collaborate, given their role in determining health.

Moving forward with multisectoral action requires mapping the key actors, the political context, the

type of multisectoral action required, and the interests and institutions. It is also often important not to

have too many sectors in any one initiative. It is necessary to frame the issue in the most strategic

manner, define clear roles with specific interventions according to sectors, use existing structures

unless there is a compelling reason not to and pay explicit attention to the roles of non-state sectors. In

addition, there is need to address conflicts of interest and manage trade-offs, distribute leadership for

sustainability, develop financing and monitoring systems to encourage collaboration, strengthen

implementation processes and capacity, and support mutual learning and implementation research.

2.4.2 Health poverty reduction in contemporary China

Dr Jiehua Lu (temporary adviser) gave a presentation on poverty reduction in China. The country’s

economic reform lifted 233 million rural people out of poverty, and it was the first developing country

to achieve the Millennium Development Goal on poverty reduction. Over time, the Government

reduced poverty through a relief-oriented approach, then a work-for-relief-oriented approach and

finally a comprehensive approach. Despite progress, 16.6 million people in rural China remain below

the poverty line, making it a challenge to successfully eliminate absolute poverty. Thus, over the past

three years, the Government has coordinated with ministries and nongovernmental organizations

(NGOs) to reduce poverty to improve health. The Government also identified the reasons for poverty

and diseases that cause people to fall into the poverty, made health care more accessible in poverty-

stricken areas and controlled the medical expenses for poor populations, among other poverty

reduction actions. It also invested in accelerating the improvement of access to quality health care for

poor populations as well as improved the awareness of disease prevention and promotion of public

health in poor areas.

7

The Top-Level Framework for Health Poverty Reduction in China is an example of intersectoral

action between the office responsible for poverty alleviation and the National Health Commission.

Their work seeks to: make health care affordable, ensure there are doctors available, improve the

treatment that people receive, and maintain people’s health through prevention and health promotion.

As a result of the Government and health insurance covering the payments for health care, individual

expenditure has been declining since 2016. Despite progress, challenges persist. These include: the

need for the Government to find a balance between the quantity and quality of health care; the need

for a stable financial system that is sustainable so that the medical security policy for the poor can be

maintained; the need for more medical care available in poor areas (not just mobile health); the need

to improve health literacy; and the need to pay attention to social forces such as enterprises and NGOs

for poverty reduction. Given these challenges, Dr Lu recommended for coming up with a

conceptualization of big health and healthy countryside, for perfecting a top-level design with long-

term guarantee mechanisms, for strengthening grass-roots forces and improving service availability,

for implementing an accurate policy focused on the most poverty-stricken areas, and for increasing

engagement of social forces for poverty reduction.

2.4.3 Chile Crece Contigo

Dr Orielle Solar (temporary adviser) presented on an experience of intersectoral work in Chile: Chile

Crece Contigo (or Chile Grows with You). Chile is a small high-income country in South America

where inequality is high. Since 1990, the Government has been addressing social gaps by

universalizing the right to education, improving housing policies, investing in the labour market and

establishing policies for justice and income redistribution. The sectors involved in work on health

equity are the Ministry of Health and the Ministry of Social Development and Family. Chile Grows

with You is part of Chile’s Intersectoral Social Protection System. It responds to inequalities in

educational attainment that are correlated with mortality rates. As part of the Social Protection System,

it is a comprehensive support system for children and their families to have opportunities for

development. It offers differentiated support to the most vulnerable children and their families. After

the Government announced their interest in advancing equity in 2005, a large interministerial

committee was created to devise a proposal, and Chile Grows with You was launched in 2007. The

system is coordinated by the Ministry of Social Development in collaboration with the Ministry of

Health and the Ministry of Education at the national level, but it is operationalized with the support at

the regional/provincial level with implementation by the municipal-level governments. Through Chile

Grows with You, all children have access to education, health care and social services until the age of

9 years, with preferential access to the most vulnerable. Leveraging existing infrastructure, it

addresses the inequality that begins before birth and uses a life-course approach by intervening

simultaneously from multiple fields during early childhood development. The benefits of a

nonsectoral ministry leading the coordination is that it mitigates tensions with respect to interests and

budgets, cultural resistance, differences between sectors (health and education) and any form of

political forms of resistance or power differentials between ministries. Among its strengths, Chile

Grows with You emphasizes the importance of working across government levels, especially with

local-level governments, given their proximity to people, focus on participation and cross-sectorality.

2.4.4 Lessons learnt from Europe and the Western Pacific Region on governance for health

equity

Dr Riitta-Maija Hämäläinen (WHO Regional Office for the Western Pacific) began her presentation

with lessons learnt from Europe. There, welfare policies have three large objectives: diminishing

social risks (such as losing housing, health or jobs), investing in citizens (through education) and

promoting social unity (to prevent discrimination). She presented models of welfare states and shared

legislation and regulation for accountability across sectors, mechanisms to involve local people and

stakeholders in identifying problems and solutions, and feedback mechanisms such as workshops or

lectures. She also stressed building different forms of evidence to ensure that policies address the

causal pathways of health are among the facilitators for governance of health equity in Europe.

Dr Hämäläinen specified that it is best to build services for all, addressing the social gradient, with

specific services for the most disadvantaged.

8

She said that actions should use the life-course approach and be integrated in the settings where

people spend their time. Dr Hämäläinen added that actions should also tackle the processes that create

exclusion and be based on resilience, capabilities and strengths of individuals and communities. She

stressed that there must also be spaces for engaging people and support participation as well as

consideration of the impact of policy for future generations, specifically in the education and social

services sectors. She presented an example of determinants of health inequalities in Scandinavia by

mapping the sectors that should address them. In the context of the Nordic Welfare State, she

explained that to implement governance for health equity there should first be a conceptualization of

the problem, then knowledge about the potential solution and lastly an administrative infrastructure

for cross-sectoral governance.

Dr Hämäläinen then presented the example of Finland, which transitioned through investing in

education from one of the poorest countries in Europe and an agrarian society into an industrialized

country. She explained that social policies after the Second World War – including policies for equal

opportunity and equity, good education for all, the right to work, and equal access to free or

affordable public health care services – contributed to gender equality, social cohesion, inequality

reduction, well-being of children and older people, lower maternal mortality rates and more. She

shared examples of multisectoral collaboration to promote physical activity and improve workplace

health, showing the importance of involving diverse and relevant actors for each. She concluded by

emphasizing that for countries to do intersectoral work, there needs to be increased advocacy and

interaction between various stakeholders – who must be engaged in different ways – to create a better

fit between policy, practice and research. She added that win–win solutions must be proposed and

good governance nurtured to build trust. She closed her presentation by affirming that WHO is

committed to supporting health equity in various settings.

2.4.5 Closing of day 1

Ms Phan shared reflections from the first day, noting that across the Region, countries face similar

issues such as increased NCDs, effects of climate change, ageing population and urbanization,

regardless of their economic development level.

She summarized the main messages from the presentations of the experts. Across the board, different

sectors have different perspectives on health issues, and it is important for the health sector to

consider these when attempting to engage with them. Health outcomes need to remain a priority,

while still considering their point of view and objectives. The Chinese experience showed that poverty

reduction can be an entry point to work across sectors to both improve health and reduce poverty. The

Chilean experience for early childhood development showed the importance of working horizontally

across sectors and vertically across levels of government, which is a good way of mapping which

sectors and which level of government must take action. The Scandinavian experiences showed a

matrix, where the mapping of determinants of health and sectors responsible for these determinants,

enabled areas for action.

Participants shared their reflections on lessons learnt from the first day of the meeting, including

learning from practices of other countries, such as benefit packages for health and using mobile health

in remote villages to increase access to care. They also shared that they learnt about the importance of

thinking of the other sectors’ interests and ideas to create win–win proposals. They furthermore said

that a stakeholder analysis will be important to identify with which sector the health sector needs to

work and with what purpose. Working across sectors can be challenging, such as the case in Viet Nam,

in order to apply WHO tools for health equity (for example HEAT) and focus on preventive care.

Participants also highlighted that there must be a move from concepts to operation and noted that

health and health equity should be considered in social policies and that there should be a life-course

approach to consider everyone. Lastly, while indicators speak to the outcome, the starting point and

processes need to be looked at using a comprehensive evaluation process to understand the outcomes.

9

2.5 Understanding public policy process and the different forms of intersectoral governance

2.5.1 Healthy China 2030

Dr Daping Song (China) presented on the Healthy China 2030 strategy, which was launched in 2015,

when China outperformed international averages in life expectancy at birth, infant mortality rate,

under-5 mortality rate and maternal mortality ratio. Despite progress, the health needs in China

increased more rapidly than the amount of doctors available to meet their needs, as China faces health

issues of developing and developed countries. In this perspective, China saw a need to change its

system from disease oriented to health centred, since health is a must for human development and

socioeconomic development. Healthy China 2030 was launched by the National Committee of the

Communist Party of China and was drafted with an expert panel from over 20 ministries. It included

comments from social groups, public institutions, local governments, industry and the general public.

The Central Committee and the State Council issued the outline of Healthy China in 2017. The main

goal is to maintain a healthy population by providing equitable, accessible, comprehensive and

continuous care and addressing the key social determinants of health. It seeks to cover all populations

across the life-course through the following three steps: becoming a well-off socialist country by 2020,

fulfilling the SDGs by 2030 and becoming a modernized social country by 2050. To reach these goals,

the tasks are to: have healthy living for all, optimize health-care services, improve health security,

build a healthy environment and develop the health industry.

Among the most important partnerships is that with the political bureau of the Communist Party,

which passed the strategy and requires local government, ministries and agencies to put Healthy

China at the top of their agenda. Healthy China is integrated into local economic and socioeconomic

development plans as well as key health indicators. The Government’s responsibility, shared between

central and local levels, is to increase financial input into health, with an emphasis on underdeveloped

areas. The government functions should be strengthened health legislation, standards, protocols and

guidelines. They also have intersectoral cooperation for health comprised of government sectors such

as health, agriculture and rural affairs, and the United Front, composed of social groups, and

population group federations. Social agencies are multiple sources to improve health financing, can

support with public services to improve professionalism and flexibility, provide services to improve

efficiency and reduce cost, and conduct patient rights advocacy to improve health utilization and

health protection. The monitoring and evaluation includes 13 core indicators under five dimensions

that are tracked, ranging from air quality to life expectancy and size of health industry. Of these,

seven indicators provide public data and show that infant mortality rate and under-5 mortality rate are

already outperforming targets.

Participants asked clarification questions regarding the indicators used and the measurement of health

equity within the indicators. The Chinese delegation clarified that provinces have their own indicators

to determine equity within regions, and that there are three insurance schemes, two of which are

currently merging.

2.5.2 Intersectoral governance to advance health equity in the Lao People’s Democratic

Republic

Dr Bouaphat Phonvisay (Lao People’s Democratic Republic) started the presentation by highlighting

that occupation and education are important determinants of maternal health and that the Lao People’s

Democratic Republic is attempting to lower maternal and infant mortality rates. The burden of NCDs

is also increasing, accounting for 48% of deaths. Health-care service utilization is low, especially

among poor and ethnic groups in residing remote areas. The quality of those services may be poor,

and there are often high out-of-pocket payments. Among governance instruments utilized for health

equity, the Immunization Law aims to cover the most remote communities, the Law on National

Health Insurance provides essential services, and the Law on Tobacco increases the budget for

national health insurance. In terms of intersectoral governance for health equity, the health sector is

working with other related ministries and is conducting a National Health Insurance assessment. They

have five technical working groups for health sector reform and a five-year health sector development

10

plan within which they try to collaborate with other sectors for planning and reporting. Lastly, they

use a unified online platform across the ministry of health for monitoring and reporting on progress

towards achieving UHC and the SDGs.

To build capacity for health equity, they have in-service public health training and utilize priority

setting, costing, planning and budgeting for health services. The Lao People’s Democratic Republic

has legislation and regulation on monitoring and evaluating the national health insurance scheme.

2.5.3 Advancing governance for health equity: Philippines

Mr Ray Justin Ventura (Philippines) presented the experience in the Philippines, sharing that

approximately 60% of Filipinos die without seeing a doctor. Challenges in achieving UHC in the

Philippines include inefficient health financing mechanisms (fragmentation and high out-of-pocket

spending), incomplete population covered and inequitable services covered. Richer segments of the

population tend to use health-care services and health benefits more than the poorest segments, likely

because of their greater spending power and awareness of benefit entitlement. Out-of-pocket spending

comprises approximately 56% of health spending. This puts financially vulnerable families at risk of

impoverishment when seeking health care. In 2015, 240 000 households were impoverished due to

out-of-pocket spending. NCDs are the predominant burden of mortality and morbidity. Urbanization,

unmanaged markets, varying levels of literacy and differences in economic opportunities are often

linked with NCDs.

To promote health equity, the Department of Health elevates concerns in interagency groups to

practise Health in All Policies. The role of the Department of Health varies by interagency groups

depending on the issue. The Department has adopted a formula that is the blueprint of the health

sector plans and commitments for the medium term and recognizes that UHC can only be achieved

through multisectoral collaboration. The goal of this formula is for Filipinos to be the healthiest

population in South-East Asia by 2022 and of Asia by 2040. The Department of Health also worked

with Congress to pass laws that benefit health such as a sin tax law, a sweet beverages law and a UHC

law. The sin tax law has increased the health budget while reducing the prevalence of smokers. The

UHC law (2018) emphasizes healthy environments and addresses health financing issues to improve

coverage and reduce out-of-pocket spending. The law explicitly notes health promotion and health

impact assessments, which require collaboration with non-health sectors. It also includes sections on

equity. The Department of Health prioritizes marginalized groups such as geographically isolated

disadvantaged areas, underserved areas, indigenous peoples and urban poor communities.

2.5.4 Group work

Prior to starting the group work, participants reflected on the presentations, noting that government

leaders – and not necessarily the health sector – in countries such as the Philippines and China have

championed initiatives for governance for health equity. Participants reflected on the challenges in

operationalizing the intersectoral work, including low health literacy levels in some countries.

Dr Fortune then presented a summary of the factors for successful governance for health equity:

building on existing structures;

identifying high-level champions;

aligning with a formal framework and policy vision;

designating a unit or person with specific responsibility for leading the work;

distributing leadership;

having clear roles and responsibilities for all partners;

using tools (monitoring and evaluation, advocacy tools, etc.) where useful; and

having ongoing training and capacity-building.

Ms Baer presented on the purpose of the exercise, explaining that the main objective was to get the

participants thinking about what they will work on after the meeting. In working towards the action

plan, participants identified a priority health equity challenge, actions to take, who would take the lead

and which stakeholders should be engaged. They also defined how to monitor progress. Ms Baer

11

prompted participants to pick a priority issue, informed by the health equity analysis in their

respective country, and to identify existing policy frameworks of action to align with and potential

stakeholders to engage.

2.6 The role of stakeholders in whole-of-government approaches

Dr Sally Fawkes (temporary adviser) provided an overview of the group work activity focused on a

rapid stakeholder analysis. She emphasized that in addition to the what and how, it is just as important

to think about the who, as implementation failure can be related to insufficient, weak or inauthentic

stakeholder engagement. She proposed a four-step process for the stakeholder analysis:

1. Brainstorm stakeholders, listing the major stakeholders in relation with the project at hand.

2. Classify stakeholders based on their level of interest and on their level of influence. In some

countries, the health ministry has more influence than others.

3. Plot the stakeholders on a matrix that superposes interest onto influences.

4. Propose a stakeholder strategy to engage them in an appropriate way to get them to take

action. For example, for stakeholders with high influence but low interest, you need a strategy

to increase their interest. In some cases, a stakeholder may have high influence and be against

your interests, so you might need to strategize to decrease their influence on this topic.

After the participants completed this activity, Dr Fawkes facilitated a dialogue session where each

team reported back. The delegates from Cambodia, China, Viet Nam, Mongolia and the Lao People’s

Democratic Republic presented their strategies to increase the interest of high-influence but low-

interest stakeholders. These included: recruiting support of other stakeholders, providing incentives

(such as promotions) for the powerful stakeholders, conducting advocacy based on evidence on the

health issue, improving health education and health promotion of affected communities, and forming

alliances with other important stakeholders who have influence on the powerful stakeholder. The

delegates from the Philippines proposed that for stakeholders with high interest but low influence, it

could be strategic to align their missions and build up their collective influence, harnessing their

energy and directing it towards a common goal.

During the discussion, Dr Fawkes highlighted that engaging multiple stakeholders could be useful to

increase the level of interest of powerful but low-interest stakeholders. She noted in conclusion that

many matrices did not have a lot of stakeholders in the quadrant of low influence and low interest, but

that thinking about these is also important as their level of influence might change.

2.7 The leadership role in advancing governance for health equity

2.7.1 Climate change and health

Dr Rok Ho Kim (WHO Regional Office for the Western Pacific) started the session by engaging

participants in an exercise where participants reflected on whether they identify as a leader (someone

with a vision and impact on the world), a manager (someone who manages the funds and tasks) or a

survivor (someone who is not sure if they will have a job the following year). He highlighted that it is

very important to recognize the leadership role everyone plays, as how they think, act and lead

influences people’s health.

Practising participatory leadership in the coming years is important so that leaders can merge their

respective expertise when proposing solutions to public health issues. For example, while medical

doctors are experts in matters of human health and disease, they do not necessarily have the training

regarding all issues that affect health, such as air pollution, water contamination, disasters and climate

change. As such, unless they engage with other sectors, their leadership is not complete. Participatory

leadership is particularly important given that the root causes of health issues are often beyond the

health sector. It is also a useful practice to work towards the achievement of the SDGs, as they

provide a framework for co-benefits between sectors, and to respond to climate change, the

environment, health security, communicable diseases, NCDs and ageing issues, all of which are

interlinked. For example, countries in Asia and the Pacific have met every three years since 2005 at

12

the Asia-Pacific Regional Forum on Health and the Environment, which brings together health and

environment ministries. The Forums put health at the centre of their discussion, seeking to provide

mechanisms to share experiences across countries to improve policies and regulatory frameworks as

well as to promote the implementation of integrated environmental health strategies and regulations.

WHO and the United Nations Environment Programme serve as the secretariat for this high-level

Forum and, by showcasing their collaboration at the international level, provide an example at the

country level. The Paris Agreement provides support for countries to mitigate effects of climate

change as well as adapt to it, providing funding for low- and middle-income countries. Examples such

as these show the importance of participatory leadership in producing impacts in the Region.

Dr Kim concluded by emphasizing that the most important part of this process is for resources to be

mobilized. He said that leaders should be guided by knowledge from different sources for actionable

evidence and be capable of operating in uncertainty and limited evidence. He added that participatory

leadership should be institutionalized to make the system less vulnerable to changes.

2.7.2 Exploring the leadership role in strengthening governance for health equity to advance the

SDGs

Dr Catherine Hannaway (temporary adviser) led the last presentation of the day. She concurred with

Dr Kim’s presentation by emphasizing that managers are not necessarily leaders and vice versa, and

that very often one needs to be both. She noted that leadership at the macro (national) level is

important so that people at the meso and micro level can understand how and why they are working

and what they are contributing to. She invited participants to write out attributes of a good and

facilitated dialogue around their suggestions, such as emotionally intelligent, positive thinker, role

model, visionary, accountable and reliable, among others. Then, Dr Hannaway noted the difference

between leader and leadership: focusing on leader means the knowledge, skills and values that a

leader demonstrates and applies to help individuals become more proficient in their ability to direct

others, while focusing on leadership promotes sustainability and emphasizes the quality of leaders

throughout an organization, not just an individual leader, and the systems and processes that create

these leaders.

In showing Dahlgren–Whitehead’s (1991) framework for the social determinants of health, she noted

that we operate as a complex adaptive system, a collection of individual agents with freedom to act in

ways that are not always totally predictable, and that one agent’s actions changes the context of other

agents. Then, she explained that leadership and cross-governmental action is required to solve so-

called wicked problems, which have multiple causes, are interdependent and require cross-

governmental action that is context dependant. She noted that one of the first challenges for leadership

is to acknowledge the existence of wicked problems, value a whole-of-systems approach and

understand the political nature of complex systems. She invited participants to reflect on other

leadership skills necessary to address wicked problems, which skills they each have or could develop,

and to identify whether the health issue they will be focusing on is a wicked problem. Among others,

she stressed that for leadership and intersectoral work, it is important that different actors take

leadership depending on the relevance and context at different times, and for leaders to be politically

astute.

Dr Hannaway then presented lessons from research on public health partnerships, including that

policies and procedures should be more streamlined, focusing on outcomes; that those higher strategic

levels could learn from frontline practices which operate in a more organic and integrated way; that

partnerships in practice can be rather messy; that one should not over-engineer partnerships and lose

clarity of its purpose; that trust and goodwill are often more important than structures; and that

different leadership styles should be practiced. In addition, innovation and windows of opportunities

are important to solve wicked problems. She asked participants to share examples of windows of

opportunity for their respective health issue. Examples from the countries included leveraging on

existing processes (such as sin taxes), engaging with existing agendas such as the SDGs or UHC, and

participating in campaigns.

13

Dr Hannaway reflected on the participants’ comments, emphasizing that it will be important to reach

out to various stakeholders to learn about windows of opportunities. She highlighted that sharing

values and stories can be a compelling way to motivate stakeholders to join. She shared that for teams

to be functional, they should have trust, commitment, attention to results, communication and no

conflicts. Finally, she closed the session by providing participants with some guided self-reflection

questions to grow their leadership.

2.7.3 Closing of day 2

Ms April Joy David (WHO Regional Office for the Western Pacific) mentioned that the key theme of

the day was the need to take a multisectoral approach to address health challenges, with examples

from three countries. In China, this approach was used early on in the planning process of the national

health strategy. In the Lao People’s Democratic Republic, it was at the national level with different

government agencies. In the Philippines, it was used at the subnational level to develop and

implement different health services. In order to systematically identify and know how to engage

different stakeholders, participants conducted a stakeholder analysis. They learnt ways to shift power

dynamics between different stakeholders. For organizations that are competing and influential, there

are strategies to decrease their interest in the matter. For this, leadership is required. While

participants came from different countries, they identified similar attributes for leadership.

Specifically, it is important to engage different experts and let people do what they do best.

2.8 Negotiating for health

Dr Fortune began the session by reiterating the context of the Region, which faces challenges around

urbanization, NCDs, ageing and climate change, which are so-called wicked problems that require

complex solutions. These require looking at the root causes and working beyond the health sector.

The Agenda for Sustainable Development is an outcome of three years of negotiation. The political

landscape is changing, with health becoming more political. In 2017, global health was placed on the

agenda of the G20 meeting, specifically the topic of antimicrobial resistance. This calls for arriving at

the table with leadership skills and negotiation skills. Achieving joined-up governance is an important

contemporary challenge involving reflecting on how to bring people together under the leadership of

heads of government to make health a social goal of governments. This requires reflecting on the

limits and influence on other people and sectors as well as what kind of leadership is needed. Stages

of negotiation include: understanding the problem and its causes; identifying stakeholders and their

interests; consulting with stakeholders; establishing a negotiation agenda; developing positions and

strategies; negotiating with stakeholders; and assessing the proposed agreement.

2.8.1 Negotiating antimicrobial resistance

Then, Mr Eraly presented on the experience of addressing antimicrobial resistance (AMR) in

Viet Nam. AMR is an issue that does not only concern the health sector. Among others, the private

sector is involved in the process from the production of antimicrobials to their procurement.

Antimicrobials are used in humans and animals. When these expire, they need to be safely disposed of.

AMR has issues related to the UHC health systems attributes. Access to antimicrobials in the Region

is inequitable. AMR is an issue that goes beyond one country and requires an approach that tackles

issues at the global, regional and national levels. To address AMR, the health sector needs to negotiate

with various sectors (private sector, NGOs, scientists, activists and media) that have different interests

than keeping people healthy, so it is necessary to be well prepared for these interactions. Hospitals

have reported high levels of AMR in Viet Nam, as have animal farms and producers of meat products

and seafood about foodborne bacteria. Prescriptions that go against local and international evidence

guidelines and sales without prescriptions contribute to the high AMR rates, as do the antimicrobials

used in food animal production.

To understand how to respond to this issue, the health sector in Viet Nam has examined the

government context, especially with its many ministries operating vertically. It is important to identify

allies and to secure high-level commitment from people who can work across ministries. WHO

worked with the Ministry of Health to address AMR, first to raise awareness within the ministry, then

14

to build a national action plan on AMR and finally to go beyond the health sector. The Minister of

Health became vocal about AMR in various forums, which led to the multisectoral collaboration. Four

ministries (health, agriculture, trade and environment) committed to take responsibility for their

respective areas in 2014. This created a clear direction for each partner and other stakeholders were

invited as observers such as embassies (Japan, United States of America, the Netherlands and others)

given the important role of trade. They created a high-profile, low-effort awareness-raising campaign,

and the heads of the four ministries spoke publicly about everyone’s role (the public, policy-makers,

and human and animal health professionals) in responding to AMR. As this example demonstrates,

negotiating with other ministries means finding champions and easy entry points (awareness

campaigns, mission trips, etc.).

2.8.2 Working with partners: Public health strategy against overweight and obesity in Mexico

Dr Ljubica Latinovic (WHO Regional Office for the Western Pacific) presented a practical example

of addressing obesity and overweight in Mexico, one of the most obese countries in the world. In

Mexico, 70% of deaths are attributed to NCDs, the prevalence of obesity and overweight has tripled

in Mexico since 1980s, and inequities related to the accessibility of healthy foods and affordability of

unhealthy foods remained. Mexico addressed these issues by adopting two national policies (in 2010

and in 2013) and by working with diverse stakeholders, including the private sector. Both policies

were supported by the respective presidents and engaged various ministries (education, agriculture

and rural development, social development, economy and finance, labour, and others), the governors

of all the states, academia, and the private sector (associations of food and beverage, bread industry,

private medical institutions). While the first policy was more health-promotion driven, the second one

stressed the importance of the primary health care sector.

The National Agreement for Nutritional Health: Strategy Against Obesity and Overweight (2010) was

adopted after two years of negotiations between the stakeholders in an intersectoral committee, within

which the same person participated from each sector at each meeting. The committee advocated

shared responsibility and solidarity between different actors (transport, economy, taxation and others),

defined roles and responsibilities, and established indicators for following up the process.

Accountability and transparency were instrumental, and it was agreed that there would be a gradual

implementation of the policy, especially in view of working with the private sector. The ministries of

health and education successfully banned sweet beverages from primary schools, and the food and

beverages association agreed to work on health promotion activities, such as sharing information,

health education and social marketing strategies to promote physical activity among children. With

the support of a self-regulation code on advertising, the Government successfully restricted

advertising of sweet foods and beverages to children, but was unable to get rid of rewards such as toys

in fast food kids’ meal, as there were gaps in the interpretation of the code.

The second policy (2013) tackled diabetes in addition to overweight and obesity. This policy was

comprised of a public health component (epidemiologic surveillance, health promotion and

prevention), a medical care component, and a regulation and fiscal policy component (labelling,

advertising and fiscal measures). Taxation money was used for medical care related to diabetes. There

were more limitations for the industry in this policy as a result of increased control of advertisements

and taxation, coupled with an engagement with the pharmaceutical industry to address diabetes.

Evaluations were conducted by academia, and data showed that the policies had inequitable effects:

the acceleration rate of the prevalence of obesity and overweight among urban men decreased, while

rates continued to increase among rural men and women both urban and rural (with the prevalence in

the rural population higher than that of the urban population).

Dr Latinovic concluded her presentation by highlighting that it was important for these policy

processes: to consider the different interests and the hidden agendas of stakeholders, to be prepared to

manage potential conflicts of interest, to reorient health services for stronger health promotion, to

leverage new technologies, to form and maintain alliances for health with the public and private

sectors, and to follow up during a change of government. She also shared that strengthening health

literacy, working with civil society (NGOs) and working within the framework of the SDGs are

important to move this work forward.

15

2.8.3 Climate change funds and health

Dr Kim continued his presentation from the previous day. He emphasized that with the Green Climate

Funs in the Paris Agreement countries would make US$ 100 billion dollars available to address

climate change, with US$ 12 billion already collected and US$ 4 billion already allocated, though

none to health. He invited participants to take the opportunity to work in climate change and health.

He stressed that it is important when negotiating to understand the language, value and objectives of

the partner. In working with ministries of environment, he said that knowing their purpose and their

expectations of the ministry of health are important also. In most developing countries, the main

climate change actions involve adaptation, while developed countries are often focused on mitigation,

he noted. He stressed that resilience is a key concept for climate change adaptation. Dr Kim explained

that work joining climate change and health has begun and WHO offices have focal points to work on

this matter. He concluded his presentation by inviting participants to engage in opportunities of the

Green Climate Fund such as the Readiness Program, which provides sectors with technical support to

prepare proposals on climate change and to meet with the Fund’s Nationally Designated Authority of

their respective countries to present proposals for health sector actions within climate change, with the

potential of receiving up to US$ 10 million for micro-projects.

2.8.4 Group discussion

In answering questions about their presentations, Dr Latinovic clarified that the changes in obesity

and overweight among urban men may be due to visible changes in lifestyle, and that in creating the

aforementioned policies, the health insurance stakeholders were not heavily involved. Dr Kim

reemphasized that there is momentum and funds to work in climate change and health, and that, to do

so, the health sector must be well equipped to work across sectors. Dr Latinovic and Dr Kim

concurred that being attentive to our own language and that of the other sectors can help in working

with various stakeholders towards a common goal.

2.9 Measuring progress: evaluation and monitoring governance for equity

Dr Rasanathan presented on the importance of evaluating and monitoring inequalities to advance

health equity. Monitoring for health inequality is similar to monitoring health, but instead of just

selecting health indicators, both health indicators and the dimensions of health inequality need to be

selected. Monitoring inequality requires disaggregated data (income, education, sex and others), but

the lack thereof means checking if obtaining data for health indicators is possible or if they can link to

other data sources. Data analysis provides calculations of health estimates disaggregated by: (1)

inequality dimensions (prevalence of NCD risk factors by education, access to health facilities by

place of residence), which can become quite long; or (2) the summary measures of inequality. The

simplest measures are differences or ratios, and these are often easier for policy-makers to understand.

When reporting, the audience, design and effective data visualization have to be taken into

consideration, while including key aspects of the analyses (latest situation, change over time and

benchmarking), making sure that the descriptions make sense to the audience and preferably choosing

results that can serve as an incentive to move work forward. Furthermore, the reporting of data should

identify patterns of inequality and look at multiple dimensions simultaneously to explain what type of

inequality exists (mass deprivation, queuing, marginal inclusion, no inequality) as this has

implications for policy-making. Limitations of absolute and relative measures can be addressed by

using complex measures to calculate a regression, a slope index of inequality (only used with ordered

measures) and a relative index of inequality. These take into consideration the situation in all

subgroups but can sometimes be hard for policy-makers to understand.

It is important to use the reporting of results as part of the process for policy-making because it helps

to define priority areas for action. This requires working with strategic stakeholders who can put the

data into context with respect to political agendas, political will, funding and feasibility, timing and

cost-effectiveness of actions – that is, tell a story that people understand. Dr Rasanathan concluded by

stressing that the purpose of monitoring is to move into action, for example so that the worst-off

16

group can improve faster than the best-off group. Tools such as HEAT (WHO) and Equist (United

Nations Children’s Fund) are useful for monitoring and can drive action to address the social

determinants of health.

2.9.1 Group discussion

Participants then discussed some of the challenges and opportunities in monitoring. Among the

challenges, participants noted: that though complex measures of inequality can be useful, they are

often not commonly understood by policy-makers; that quantitative measurements do not necessarily

explain why the inequalities occur; and that there is limited capacity to analyse data in many countries.

Working with academia and government to calculate and explain composite measurements, collecting

qualitative data and working with other sectors (such as education) can help address some of these

challenges. Importantly, the health sector must be compelling in communicating health issues with

important stakeholders and partners.

2.10 Reflections and next steps

Throughout the meeting, participants worked on action plans based on their country’s situation

analysis as well as on the presentations and discussions. Each country presented their action plan,

which included identifying a topic, the relevant stakeholder that should take leadership, which

stakeholders should be engaged, what milestones will be reached after three, six months and a year,

and how they should monitor progress.

The priority topic chosen by the participants were the following:

Cambodia: a system for equity monitoring on health and social protection

China: health-related poverty reduction by improving the provision of health care in rural

areas

Lao People’s Democratic Republic: improving access to health services for the poor

Mongolia: improving intersectoral collaboration to implement health policy

Philippines: improving health outcomes in urban poor communities

Viet Nam: governance for health equity among older people as they are among the top 10

countries with a rapidly ageing population

2.11 Closing session

Ms Phan presented the participants’ conclusions and recommendations, and Dr Fortune closed the

meeting by delivering the closing remarks on behalf of Dr Kasai. Attention to the issues discussed is

timely as leaving no one behind is a core principle of the SDG agenda. Health in the SDGs goes

beyond SDG3 and influences and is influenced by all other goals. The challenge of achieving health

equity is heightened by the rapid pace of change in the Region, including urbanization and migration.

In this increasingly complex world, new approaches that build partnerships across sectors and

stakeholders are needed. Strengthening governance for health equity, including building the capacity

of all partners, will require whole-of-government and whole-of-society approaches for health. WHO

Member States highlighted this when they adopted the Regional Action Agenda on Achieving the

SDGs. WHO is committed to working with Member States in taking this work forward to reduce the

health inequities across the Western Pacific Region.

3. CONCLUSIONS AND RECOMMENDATIONS

3.1 Conclusions

As Member States advance UHC and the SDGs in the Western Pacific Region, attention to

strengthening intersectoral governance for equity in health is paramount. While the Region is very

diverse, health equity is a common challenge. It requires responses within the health system, as well

17

as in partnership with other sectors to address the social determinants of health equity. Attention to

health equity and the social determinants is not new. The Region has many good practices to learn

from. Country participants provided many examples of actions in their countries and had the

opportunity to learn from global experiences. While much is known about what needs to be done,

there is a need for ongoing capacity-building on the how. Exchanges between countries are valuable

to facilitate this learning and to build practical skills among participants.

3.2 Recommendations

3.2.1 Recommendations for Member States

Member States are encouraged to consider the following:

1) Take actions to strengthen intersectoral governance for health equity in line with the action

plan and skills developed during the workshop and report back on lessons learnt from trialling

these actions at the next meeting.

2) Continue to build partnerships on the social determinants of health and navigate the policy

system, including stakeholder mapping and analysis, leadership and so on.

3) Continue to advocate for health equity informed by strong equity-focused monitoring and

evaluation, including ongoing efforts to build capacity for equity analysis and knowledge

translation in countries.

3.2.2 Recommendations for WHO

WHO is requested to consider the following:

1) Continue to provide technical support to Member States on strengthening intersectoral

governance for health equity on the path towards the SDGs, including to those Member States

specifically targeted under the regional governance for equity project and others interested in

sharing experiences and advancing action.

2) Document experiences form the second phase of the intersectoral governance for health

equity project and continue to deepen country network so that lessons learnt from the piloting

initiative can be shared on an ongoing basis.

3) Bring participants back together and organize a meeting in September 2019 to share country

experiences from the pilot initiative and facilitate ongoing dialogue on intersectoral

governance for health equity in advancing the SDGs.

19

ANNEXES

Annex 1. List of participants

CAMBODIA Dr NGY Mean Heng, Director, Phnom Penh Municipal Health

Department, Phum Chres, Street 2011 Sangkat Kok Khleang,

Khan Sen Sok, Phnom Penh, Tel. No.: (855) 11 848687,

Email: ngymeanheng2016@gmail.com

Dr KROS Sarath, Director, Siem Reap Provincial Health Department

Administrative Centre of Siem Reap, Health Department

Sangkat Slorkram, Siem Reap City, Siem Reap Province

Tel. No.: (855) 88 5565666, Email: sarathkros@gmail.com

Dr IR Por, Deputy Director, National Institute of Public Health

Lot # 80, 289 Tuol Kork, Phnom Penh, Tel. No.: +855 12 65772,

Email: ipor@niph.org.kh; irpor@yahoo.com

Dr LOUN Mondol, Chief, Policy, Planning & Health Sector Reform

Bureau Department of Planning and Health Information,

Ministry of Health, No. 80, Samdech Penn Nouth Blvd (289) Sangkat

Boeungkak 2, Khan Tuol Kork, Phnom Penh, Tel. No.: (855) 23 885916,

Fax.: (855) 12 891290, Email: lounmondol@gmail.com

CHINA Ms CAI Xiaoqin, Officer, Department of Planning Development and

Information Technology, National Health Commission,

Room 808, Building 1, No.1 Xizhimenwai, South Road, Xicheng District

Beijing, Tel. No.: (86) 10 68791229, Fax No.: (86) 10 68792845,

email: caixq@nhc.gov.cn

Dr SONG Daping, Professor, China National Health Development

Research Center, National Health Commission, 3/F, Block B3,

Wudong Building, #9 Chengongzhuang Street, Xicheng District, Beijing,

Tel. No.: (86) 10 82805250, Email: songdaping@126.com

LAO PEOPLE'S Dr Bouaphat PHONVISAY, Deputy Director, National Health

DEMOCRATIC Insurance Bureau, Ministry of Health, Ban thatkhao, Sisattanack District,

REPUBLIC Rue Simeuang, Vientiane, Tel. No.: (856) 21 840784,

Fax: (856) 21 840812, Email: bouaphat@gmail.com

Dr Daoduangchanh BOULOMMAVONG, Head, Advancement of

Women and Mother & Child Division, Ministry of Health,

Ban thatkhao, Sisattanack District, Rue Simeuang, Vientiane,

Tel. No.: (856) 20 22234647, Fax: (856) 21 840760,

Email: ddchanh@gmail.com

20

MONGOLIA Dr Oyunkhand RAGCHAA, Director, Department of Policy Planning,

Ministry of Health, Government Building VIII, Olympic Street II

Sukhbaatar District 14210, Ulaanbaatar, Tel. No.: (976) 991 3923,

Email: ragchaah@yahoo.com

Dr Uuriibayar MUNKHCHULUUN, Director-General,

Department of Health, Khuvsgul province, 8th bagh, 22th Building, 111,

Murun soum, Khuvsgul aimag, Tel. No.: (976) 9906 8726,

Email: uurii999@yahoo.com

Dr Zendmaa LAMJAV, Deputy Director, Ulaanbaatar City Health

Department, Khangarid Palace, 901, D. Sukhbaatar Square 11

Ulaanbaatar, Tel. No.: (976) 99287055, Email: zendmaal@gmail.com

Dr Oyuntsetseg PUREV, Senior Officer, Department of Policy

Planning, Ministry of Health, Government Building VIII, Olympic

Street II, Sukhbaatar District 14210, Ulaanbaatar,

Tel. No.: (976) 999 964 34, Email: oyuntsetseg@moh.gov.mn

PHILIPPINES Mr Ray Justin C. VENTURA, Chief Health Program Officer

Bureau of Local Health Systems Development, Department of Health

San Lazaro Compound, Rizal Avenue, Sta. Cruz, Manila,

Tel. No.: (632) 6517800, Email: rayjustinventura@gmail.com

Ms Josephine A. SALANGSANG, Planning Officer IV,

Health Policy Development and Planning Bureau,

Department of Health, San Lazaro Compound, Rizal Avenue, Sta. Cruz

Manila, Tel. No.: (632) 6517800 local 1327, 1331,

Email: jasalangsang.hpdpb@gmail.com

VIET NAM Ms PHAN Thanh Thuy, Official, Department of Planning and Finance

Ministry of Health, 138A Giang Vo Street, Ba Dinh District, Hanoi,

Tel. No: (84) 913 313 497, Email: thuypt.khtc@moh.gov.vn

Dr PHAN Hong Van, Head, Department of Science, Training and

Inter-collaboration Health Strategy and Policy Institute, Hanoi,

Tel. No: (84) 904 804 286, Email: phanhongvan.hspi@gmail.com

Dr PHAM Xuan Anh, Vice Head, Medical Professional Department

Hanoi Department of Health, No. 4, Son Tay Street, Ba Dinh District,

Hanoi, Tel. No: (84) 912 171 997, Email: xuananhpham70@gmail.com

2. TEMPORARY ADVISERS

Dr Orielle SOLAR, Professor, Programme for Work, Employment, Equity and Health

Latin American Social Sciences Institute (FLACSO), Av. Dag Hammmarskjöld, 3269 Vitacura

Santiago, Chile, Tel. No.: (56) 942176101, Email: orielle.solar@flacsocghile.org

21

Dr Sally FAWKES, Senior Lecturer, Department of Public Health, La Trobe University,

Bundoora VIC 3086, Melbourne, Australia, Email: S.Fawkes@latrobe.edu.au

Dr Catherine HANNAWAY, Global Health Consultant Director, Catherine Hannaway

Associates Ltd., Ripon, North Yorkshire, United Kingdom, Tel/WhatsApp 0044 7810836306,

Email: Catherine@CatherineHannaway.com

Dr LU Jiehua, Professor, Gerontology and Social Policy, Institute of Sociology and

Anthropology, Peking University, Beijing, China, Tel. No.: (8613) 601331045,

Email: lujiehua@pku.edu.cn

3. SECRETARIAT

Dr Kira FORTUNE, Coordinator, Equity and Social Determinants, Division of Health Systems,

WHO Regional Office for the Western Pacific, P.O. Box 2932, 1000 Manila, Philippines,

Tel. No.: (632) 528 9806, Email: fortunek@who.int

Ms Britta Monika BAER, Technical Officer (Gender, Equity, Human Rights and Ageing),

Equity and Social Determinants, Division of Health Systems, WHO Regional Office for the

Western Pacific, P.O. Box 2932, 1000 Manila, Philippines, Tel. No.: +632 528 9084,

Email: baerb@who.int

Ms Corey Jean HENDERSON, Consultant, Equity and Social Determinants, Division of

Health Systems, WHO Regional Office for the Western Pacific, P.O. Box 2932, 1000 Manila,

Philippines, Tel. No.: (632) 528 9844, Email: chenderson@who.int

Dr Kumanan Ilango RASANATHAN, Coordinator, Health Systems, WHO Representative

Office in Cambodia, 1st Floor No. 61-64, Preah Norodom Blvd. (corner St. 306) Sangkat Boeung

Keng Kang I, Khan Chamkamorn, Phnom Penh, Cambodia, Tel. No.: (855) 23 216610,

Email: rasanathank@who.int

Dr Erdenechimeg ENKHEE, Technical Officer, Health Systems Strengthening and Financing,

WHO Representative Office in Mongolia, Ministry of Health, Government Building VIII,

Olympic Street II, Sukhbaatar District 14210, Ulaanbaatar, Mongolia,

Tel.: (976) 11 327870/30, Email: enkheee@who.int

Ms April Joy DAVID, Technical Coordinator, WHO Representative Office in the Philippines

Ground Floor, Building 3, Department of Health, San Lazaro Compound, Rizal Avenue,

Sta. Cruz, Manila, Philippines, Tel. No.: (632) 3106370, 7438301 local 1931,

Email: adavid@who.int

Ms Tracy YUEN, Consultant, WHO Representative Office in the Philippines, Ground Floor,

Building 3, Department of Health, San Lazaro Compound, Rizal Avenue, Sta. Cruz, Manila,

Philippines, Tel. No.: (632) 3106370, 7438301 local 1931, Email: yuent@who.int

Ms PHAM Dieu Linh, Consultant, UHC, WHO Representative Office in Viet Nam,

304 Kim Ma Street, Hanoi, Viet Nam, Tel. No.: (844) 38500306, Email: phamd@who.int

22

Annex 2. Programme of activities

Time Day 1, Monday, 25 March WPRO (Room 210)

Time Day 2, Tuesday, 26 March WPRO (Multi-function room)

Time Day 3, Wednesday, 27 March WPRO (Multi-function room)

8:30-9:00

Registration and Secretariat meeting

(Room 414-A)

8:30 Secretariat meeting

(Room 414-A)

8:30 Secretariat meeting (Room 414-A)

9:00 -10:00 Opening plenary

Welcome remarks

Introduction of participants

WHO Secretariat: Welcome, objectives & agenda

Administrative announcements

Group photo

9:00-9:30 Welcome, reflections and introduction to Day 2

9:00-9:30 Welcome, reflections and introduction to Day 3

09:30-11.00 Session 5: Understanding public policy process and the different forms of intersectoral governance

Presentation on framing and windows of opportunity

Experiences from the Lao People's Democratic Republic and the Philippines

Group work to identify the priority issues that participants wish to work on

9:30-11:00 Session 8: Negotiating for health

Negotiating antimicrobial resistance (AMR)

Working with Partners: Public health strategy against overweight and obesity in Mexico

Interactive exercise on approaches to policy negotiation: characteristics of "cooperative negotiating"

10:00-10:30 Coffee/tea break 10:30-11:00 Coffee/tea break 11:00-11:30 Coffee/tea break

10:30-12:00 Session 2: Setting the scene

Background to the collaborative, health equity and social determinants in the context of the SDGs

Overview of regional data on health equity and social determinants

Key concepts and approaches

Q&A

11:00-12:00 Session 6: The role of stakeholders in whole of government approaches

The role of government

Stakeholder analysis and evidence

11:30-12:30

Session 9: Measuring progress– Evaluation and monitoring governance for equity

Introduction to equity monitoring and evaluations of governance for equity (e.g. HEAT)

Group discussion

12:00-13:00 Lunch break 12:00-13:00 Lunch break 12:30-14:30 Lunch (& finalization of action plan)

13:00-14:30 Session 3: Country experiences on governance for equity

Presentation of country situational analysis

Cambodia

Mongolia

Viet Nam

13:00-15:00 Session 7: The leadership role in advancing governance for health equity

What kind of leadership is required?

Lessons learnt from the field of Environmental Health and Climate Change

14:30-15:30 Session 10: Reflections and next steps

Presentation of action plans

Q&A

14:30-15:00 Coffee/tea 15:00-15:30 Coffee/tea 15:30-16:00 Coffee/tea

15.00-16:30 Session 4: Contextualising governance for health equity: learning from global experiences

China 2030

The Case of Chile

Lessons learnt from Europe and the Western Pacific on governance for health equity

Q&A Closing of day 1

15:30-16:30 Session 7: The leadership role in advancing governance for health equity (continued)

The leadership challenges in promoting governance for health equity

Closing of day 2

16:00 Closing session

Concluding remarks

Closing

16:30 Secretariat Meeting (Room 414-A) 16:30 Secretariat Meeting (Room 414-A) 16:30 Departure

17:00 Reception – Al Fresco area

23

Annex 3. Presentations

24

25

26

27

28

29

30

31

32

33

34

35

36

37

38

39

40

41

42

43

44

45

46

47

48

49

50

51

52

53

54

55

56

57

58

59

60

61

62

63

64

65

66

67

68

69

70

71

72

73

74

75

76

77

78

79

80

81

82

83

84

85

86

87

88

89

90

www.wpro.who.int