The G7 presidency and universal health coverage, Japan’s contribution

Abstract Problem If universal health coverage (UHC) is to be achieved globally, it needs sustained promotion and political awareness and support. Approach During its presidency of the Group of Seven (G7) industrialized nations in 2016, Japan aimed to raise the issue of UHC to the top of the global health agenda. Local setting Japan has promoted a health agenda at all of the G7 summits since 2000 that it has hosted. Human security has been the core foundation of Japan’s foreign diplomacy for several decades and, consequently, there was no apparent opposition within Japan to the inclusion of UHC on the agenda of the summit in 2016. Other G7 governments appeared keen to promote such coverage. Relevant changes Since the 2016 summit, UHC has remained a central agenda item for the United Nations and World Health Organization, even though the leaders of both these global organizations have changed. In 2017, Japan hosted the UHC Forum in Tokyo. The participants, who were the heads of United Nations agencies, politicians and other decision-makers from all over the world, showed their continued commitment towards UHC. Lessons learnt In the raising of awareness of an item on the global health agenda, high-level champions are critical. Although they may be very diverse, all relevant stakeholders need to be connected and allowed to discuss policies with each other. Having too many allies can, however, lead to policy fragmentation, especially when there is commitment from the highest echelons within each country.


Introduction
According to the World Health Organization (WHO), universal health coverage (UHC) "means that all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship. " 1 One main aim of the Agenda for Sustainable Development, as adopted at the United Nations (UN) General Assembly in 2015, is to achieve such coverage by 2030. 2 For several decades, the Japanese government has prioritized global health in its international diplomacy. For example, in all of the summits of the Group of Seven (G7) industrialized nations (Canada, France, Germany, Italy, Japan, United Kingdom of Great Britain and Northern Ireland and the United States of America) that Japan has hosted, global health has been a main item on the agenda. When Japan last held the G7 presidency, in 2016, much of its focus was on global health and, particularly, on UHC. In the promotion of UHC to the top of the political agenda at a global level, the experience that the Japanese government gained in 2016, in terms of global health diplomacy, could serve as a useful cornerstone.
In April-June 2016, we conducted interviews with employees of the Japanese ministries of finance, foreign affairs and health, labour and welfare who worked in departments connected to global health. Our aims were to investigate the preparatory process behind the 2016 G7 summit, which was held in the Ise-Shima area of Japan on 26-27 May 2016, and its related meetings, investigate how the Japanese government obtained consensus among the diverse stakeholders involved in the summit and determine which people and which other factors appeared most important in the global promotion of UHC.

Local setting
By 2016 there was already some precedent for Japan's prioritization of UHC. For several decades, Japan had promoted health systems strengthening, in conjunction with the idea of human security, as a central tenet of its foreign policy. For example, such strengthening was placed high on the agenda of the G8 summit in 2008, which took place in Toyako. 3 Within Japan, the political will to include UHC as a top priority within the G7 agenda was already present during preparations for the 2016 G7 summit in Ise-Shima and the 2016 G7 health ministers' meeting in Kobe. At the same time, UHC was already central to the global health agenda, as clearly indicated in the sustainable development goals. 2 There was no apparent opposition, from other G7 governments, to the inclusion of UHC on the main agenda of the 2016 G7 summit in Japan. In collaboration with WHO and under the leadership of Chancellor Angela Merkel, the German government, in particular, had already made considerable efforts to promote and support UHC. Responding to the need for health systems strengthening, as indicated in the conclusions of the 2015 G7 summit, which was held in the German village of Krün, 4 Germany began to develop a roadmap towards UHC in 2015. 5 After the 2016 G7 summit, Germany hosted the first meeting of G20 health ministers and this resulted in the so-called Berlin Declaration, which indicated the health ministers' continuous support for UHC. 6 Problem If universal health coverage (UHC) is to be achieved globally, it needs sustained promotion and political awareness and support. Approach During its presidency of the Group of Seven (G7) industrialized nations in 2016, Japan aimed to raise the issue of UHC to the top of the global health agenda. Local setting Japan has promoted a health agenda at all of the G7 summits since 2000 that it has hosted. Human security has been the core foundation of Japan's foreign diplomacy for several decades and, consequently, there was no apparent opposition within Japan to the inclusion of UHC on the agenda of the summit in 2016. Other G7 governments appeared keen to promote such coverage. Relevant changes Since the 2016 summit, UHC has remained a central agenda item for the United Nations and World Health Organization, even though the leaders of both these global organizations have changed. In 2017, Japan hosted the UHC Forum in Tokyo. The participants, who were the heads of United Nations agencies, politicians and other decision-makers from all over the world, showed their continued commitment towards UHC. Lessons learnt In the raising of awareness of an item on the global health agenda, high-level champions are critical. Although they may be very diverse, all relevant stakeholders need to be connected and allowed to discuss policies with each other. Having too many allies can, however, lead to policy fragmentation, especially when there is commitment from the highest echelons within each country.
Lessons from the field Japanese support for universal health coverage Haruka Sakamoto et al.

Approach
In the preparations for the 2016 G7 summit, the strongest drivers for Japan's prioritization of UHC appeared to be three high-level Japanese champions of global health: Prime Minister Shinzo Abe; Yasuhisa Shiozaki, a former Minister of Health, Labour and Welfare; and Professor Keizo Takemi, a member of the House of Councillors.
In 2013, Shinzo Abe had made health one of the main pillars of his new strategy to promote Japan's economic growth 7 and expressed his interest in global health in general and the global achievement of UHC in particular. 8 In 2015, he published an article in The Lancet -entitled "Japan's vision for a peaceful and healthier world", in which he explained how Japan's priorities, as holders of the G7 presidency in 2016, would include UHC. 9 Though it remains unusual for a head of state to summarize their political priorities via a medical journal, this article helped demonstrate the Japanese government's unwavering commitment to the support of UHC globally. Prime Minister Abe also raised the issue of UHC, as an agenda item, in bilateral meetings with several other heads of state and, ultimately, initiated dialogue with G7 governments to cultivate the wider support that enabled Japan to prioritize UHC on the agendas of the 2016 G7 summit and its related meetings.
By 2016, Yasuhisa Shiozaki recognized the main strengths of Japan's health system and the need to communicate more widely with the global community, in an era of globalization. In conveying strong political messages to the global community at several international conferences, he has been a vocal advocate for global health and UHC. 10 Like Prime Minister Abe, he has published articles in internationally recognized journals while maintaining dialogues, on UHC, with health ministers and heads of international organizations.
Keizo Takemi has drawn on his academic and policy-making background and published papers that appear to have influenced the advisory processes associated with the 2016 G7 summit. He led and coordinated domestic negotiations for the health agenda at the summit while hosting several meetings with relevant ministry officials.
At these meetings, Japan chaired dialogues, with other G7 nations, that led to the drafting of the main outcome documents of the 2016 G7 summit and related meetings, i.e. the G7 Ise-Shima Declaration 4 and the G7 Kobe Communiqué, 11 and the identification of points of consensus. Over the same period, Japan hosted a series of UHCrelevant conferences: a side event to the Seventieth UN General Assembly in 2015; an international conference on UHC in Tokyo in 2015; and with Germany as a co-host, a side event at the Sixty-ninth World Health Assembly in 2016. At these conferences, Japan used the outcomes of earlier G7 summits as launch-pads for UHC-focused discussions with the representatives of G7 and other governments.
The Sixth Tokyo International Conference on African Development, held in August 2016, was the first such conference to make health a major agenda item. 12 At the 2016 conference, Yasuhisa Shiozaki and the then President of the World Bank Group, Dr Jim Yong Kim, co-chaired a thematic session entitled "Promoting resilient health systems for quality of life." In the subsequent negotiations on the conference outcomes, Yasuhisa Shiozaki and relevant ministry officials led the debate, among the representatives of many African countries and international organizations, that ultimately contributed to the so-called Nairobi Declaration and Nairobi Implementation Plan and the outlines of a framework for interventions to support UHC in Africa. 13,14 By hosting such high-level events, Japan deepened the UHC debate both within and outside of the G7. 11 The resultant outcome documents, which are widely distributed and read, serve to promote the UHC agenda globally.

Relevant changes
Although the G7 summit in 2016 encouraged the global community's continued commitment to UHC, that commitment may have been weakened when, in the same year, the UN's Secretary-General, WHO's Director-General and several other strong advocates for UHC were replaced. At the end of 2017, however, the participants at the UHC Forum in Tokyo, who included the new Secretary-General, new Director-General and high-level politicians from all over the world, professed their sustained support for UHC.
Changes in financial trends that supported UHC were observed. Historically, UHC and health systems strengthening have been under-funded and most donor funding has gone to vertical programmes, such as those directed at human immunodeficiency virus. In 2016, however, there was a transition in which some organizations, such as the Global Fund to Fight AIDS, Tuberculosis and Malaria, began to invest in health systems strengthening and UHC. The Global Fund, together with the World Bank Group, announced that it would contribute 24 billion United States dollars (US$) to those African countries that attempted to achieve UHC by using the framework developed at a side event to the Sixth Tokyo International Conference on African Development. 15 Throughout 2016, when it held the G7 presidency, Japan committed US$ 1.1 billion to global health institutions. 16 This financial support demonstrated Japan's strong political commitment to addressing the global health challenges highlighted at the 2016 G7 summit.

Lessons learnt
The main lessons learnt from the G7based Japanese promotion of UHC are summarized in Box 1.Strong leadership can push issues to the top of the political agenda very effectively 17 and the hosting of high-level political dialogue, both within and outside of G7, can be a very strong driver in promoting a policy agenda. The outcomes of the 2016 G7 summit and related meetings in Japan 4,11 are expected to be the basis for future policy-making. Although G7 is an influential body with respect to

Box 1. Summary of main lessons learnt
• In the raising of awareness of an item on the global health agenda, high-level champions are critical. • Although they may be very diverse, all relevant stakeholders need to be connected and allowed to discuss policies with each other. • Having too many allies can lead to policy fragmentation, especially when there is commitment from the highest echelons within each country.
Lessons from the field Japanese support for universal health coverage Haruka Sakamoto et al.
global health, it cannot raise awareness and move forward the global health agenda optimally without the support of other stakeholders and expansion of the debate beyond G7. In 2019, the G20 summit and the UN high-level meeting on UHC should provide further opportunities for promoting UHC at scale.
One remaining potential issue is that, in the global promotion of UHC, Japan has had several powerful allies and no obvious vocal opponents. It has been suggested that too many allies can be detrimental and lead to policy fragmentation. 18 Governments may disagree over the control and development of global policy. Although the UHC2030 platform was launched as an international framework to coordinate the efforts, by relevant stakeholders and various initiatives, to develop UHC globally, the coordination is still a work-in-progress. 19
Lessons from the field Japanese support for universal health coverage Haruka Sakamoto et al.