Dr. Ricardo Baptista Leite is a Medical Doctor and Member of the Portuguese Parliament, where he sits on the Health Committee and on the Foreign Affairs Committee.
Q: How can we achieve the Sustainable Development Goals [SDGs] and what contribution can cities deliver in regard to climate change?
LBL: In my city, Cacaes, we started to adapt the global indicators to the local level, and in that sense, we are advanced. The SDGs are a great baseline that show where we should be, but we have to be ambitious and go way beyond, but especially in the developed world. They should rather be perceived as the minimums we have to achieve. Climate change is no different to this: if we go down to the specifics, there are always angles that could and should be improved, lowering our carbon footprint. This influences multiple determinants. The SDGs give us a holistic approach, and we can use this great tool for society, as well as for the individuals, while leaving no one behind.
When this assessment is made wholeheartedly, we can push the public, the private and the social in the same direction.
Q: Was it difficult to translate the broad SDGs onto the local levels?
LBL: That was a big challenge. Fortunately, the SDGs are broad, so there is no way to say: „we have finished our job.” We saw this happen with the MDGs [Millennium Development Goals] – some countries have reached their target and that was it. With the SDGs, we are never done. As long as someone is lagging behind, we still have to continue in achieving those goals.
Translating global goals to municipality level is challenging. Throughout the whole year, we worked with a team – our chief sustainability officer, our technical team – to look at each and every of the 169 indicators of the 17 Goals. We had to identify which of those made sense at the local level, and only then find a way to successfully translate them. Let me give you one example: within the SDG 3 Health & Wellbeing (access to UHC), we use the indicator showing that every family has access to a family doctor. It may be different in other settings, but we have to embrace SDG 17 Partnership, and therefore, make sure everyone is engaged. This checklist is not just for city officials, who go through it every time they present a proposal. Rather, the society is focused on the same goals and moving the city in the same direction. Open access ensures that other cities can copy that, and we can support each other with comparative data.
Q: In your experience, how do you involve all stakeholders in the policies you develop?
LBL: Well, first of all, there are digital tools that are available at low cost, like social media. Secondly, already 10-15 years ago, the city equipped the local spokesperson with a communication kit, including a cellphone, to stay in touch. Also, we developed an app using georeferencing. With this app, people can voice their concerns, which include the time and the exact location of the submission. The submission is added onto a to-do list, and once it’s solved, the citizen gets a direct feedback. This app allows us to increase citizen engagement.
Another aspect is a participatory budget. A part of the budget is used for citizens to develop projects and put them up for an SMS vote. The city acts according to the people’s voting. What is curious is that more people vote on participatory budgets than in local elections in Cacaes.
Q: You pushed a performance based payment scheme for Hepatitis C (HEPC) medication in Portugal. Can such a model work in other countries and for other diseases?
LBL: In terms of access to HEPC medicine and treatment, Portugal was truly an inspirational example for many European countries in 2015. In terms of risk sharing, we stopped paying per pill or per cycle of treatment, and we started paying only when the patient was clinically proven to be cured. Still, we went even further. We did a volume-based agreement with pharma, which means: the more we treat, the cheaper it gets. We set up a digital registry to follow the evolution of the patients and the epidemic. But, what is most important is what is underlying: does the government need to embrace this and set up the negotiations seriously? We understood we finally had a cure for a chronic deadly disease. Therefore, for the first time in history, we have the opportunity to eliminate HEPC in our generation. We are still lacking a proper action plan that focuses on prevention, on testing and diagnosis, on linkage to care. We cannot continue to spend millions of euros on curing people, while not closing the tap on the new infections, with the virus still prevalent in the community.
I have been advocating for Portugal and many other countries to have a very strong, sustainable financial solution for the access to medicine with the condition of embracing a full-scale elimination strategy. This was implemented under the troika program. So, if we were able to do it, everyone should be able to do it, especially with the possibility of joint procurement under the Lisbon treaty.
Q: Can one apply this to other diseases? What indicators can be used? Should we be cautious?
LBL: We have to be humble. Looking at the rise of NCDs, there are no incentives to prevent them, to diagnose them early, there are no incentives to find thoe patients and get them in the health system and treat them as quickly as possible. So, the only panacea that could solve the health system problem is to restructure the whole financing scheme into what I would call a community value based approach. Until then, there is the HEPC example which can still be somewhat translated to other fields. I agree the HEPC is the easiest example, it is black and white, cure or not cure. It is a no-brainer, but still, many governments are not embracing it.
If we look at HIV, there could be simple indicators, such as viral load and CD4 counts. Those are sufficient enough to understand if patients are being diagnoses, if they are being treated, and if they are compliant to that treatment. We used those indicators in Portugal to define health budgets.
There needs to be an individual strategy for almost every disease or condition. That is time-consuming and involves a lot of expertise. Governments tend towards one-shot solutions, a framework that works for everything. But we have seen that we need a community based approach that would build on the precision based approach. It’s complex. But it is possible if you have the right focus.
We need to create the right financial incentive to go into a community and find the patients that have not been diagnosed, thus reducing avoidable diseases. This requires a local authority that is responsible for that.
This means putting public health in a leadership position within communities and making them accountable for the results.
Dr Leite is Head of Public Health at the Institute of Health Sciences of the Católica University of Portugal, Coordinator of the Sustainable Healthcare Unit at the NOVA Information Management School and Guest Lecturer at NOVA Medical School. He is also City Councilor of Cascais where he’s responsible for local health strategy, economic diplomacy, international relations and youth and employment policies.
Prior to being elected MP, he was a practicing physician for 7 years, including a 5-year Infectious Diseases residency and an internship at the World Health Organization Regional Office for Europe (Copenhagen). Founder of CREATING HEALTH – Research and Innovation funding (http://creatinghealth.ics.lisboa.ucp.pt) and Co-founder of the Estoril Conferences (www.estorilconferences.com).
Author of the books “Citizenship for Health” and “Strategic Consensus on Integrated Management of Hepatitis C in Portugal”, among other publications.
Ricardo is one of six people to have been acknowledged globally by ‘The Economist’ as a ‘HCV Change Maker’ in recognition of his leadership in the field of hepatitis c.
The interview has been condensed for better comprehension.
Interview conducted by Petronille Bogaert and Robert Ofner.