The author

Thomas Schwarz is Executive Secretary of the Medicus Mundi International Network and the Geneva Global Health Hub (G2H2) and a member of the G2H2 working group on WHO and global health governance and financing. Contact: schwarz@medicusmundi.org.

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Universal Health Coverage: It’s up to you, New York, New York…

With a short accreditation process (deadline for applications: 3 March!) and a series of consultations, the preparations for a UN High-Level Meeting (UN HLM) on Universal Health Coverage (UHC) that will take place on 23 September 2019 are already in full swing. The theme of the UN HLM will be “Universal Health Coverage: Moving Together to Build a Healthier World.”

For organizations such as Medicus Mundi International and many of our Network members and partners who have been engaged in promoting access to health and strengthening of people and community centred national health policies and systems in their technical and political work over decades, it is difficult to resist the temptation. You know: if I can make it there, I’ll make it anywhere…, or, in the words of the Civil Society Engagement Mechanism of the UHC2030 Alliance: “Don’t miss it! Get your voice heard at this critical moment for UHC.”

Nevertheless, allow me to look at the meeting and its preparatory process with a little bit – let’s say threes steps – of distance:

Another UN High-Level Meeting

After Tuberculosis and Non-Communicable Diseases last year, it’s now up to Universal Health Coverage (UHC) to enter the limelight of a UN High-Level Meeting in Ney York. The concrete output of such meetings is difficult to assess; after last year’s events, feelings of WHO staff were quite mixed. And if you fail with the key metrics (in particular: number of heads of state attending), you have a problem. However, “going to New York” has become a core strategy – and ritual – for WHO.

The dilemma is obvious: If, to fulfil this core function of “providing leadership on matters critical to the health of all people”, WHO needs to “advocate” for health “at the highest political level” (quoted from WHO 13th General Programme of Work), and if to reach that highest level, this means that health or a particular a health topic need to get the blessings of a UN High-Level Meeting, this has the potential to undermine both the status of the World Health Assembly (which should itself represent the highest political level for global health matters) and the status of WHO and its Geneva Headquarters as authoritative convenor.

And there are costs related, and not only for the WHO. “Being in New York” adds to “being in all these places” where global health is featured. No problem for those who have the money and capacities, but not easy for civil society organizations with small budgets and tough decisions on priorities. Two years ago, MMI Network opened an office in Geneva, to be closer to the WHO and to better play its role of contributing, also by hosting the “Geneva Global Health Hub”, to civil society coordination related to the processes in “Global Health Capital Geneva”. We have never been in New York so far…

Another Political Declaration

The call by UHC2030 to “contribute to the UN HLM preparation” and to participate in a consultation on “key asks” to be considered for the UN HLM political declaration is worth to be looked at in detail. As a starting point, here is a key quote from the introduction to the call:

“Before 2023 – the mid-point of the SDGs – this will be the last chance to mobilise the highest political support to package the health agenda together, under the umbrella of UHC, and sustain health investments in a harmonised manner. To fully accomplish these objectives, it is critical to identify how the UHC political declaration can add value and set milestones to accelerate progress towards achievement of UHC by 2030.”

Can a Political Declaration “add value” to what is already being done to achieve Universal Health Coverage? In this regard, the outline of the current consultation on “UHC2030 key asks” is disappointing: It includes, in its background information, a long and detailed list of previous commitments or declarations they considered in the drafting of these “key asks”. These references should also be respected in the contributions to the consultation: “Are there agreed targets or text that have been through the UNGA member states consensus process? Adoption or improvement of existing approaches/language (previously supported in UN declarations or resolutions) is most likely to be acceptable in the HLM negotiations.”

If adoption or improvement of existing approaches and language is the ambition regarding the outcome of the High-Level meeting and the content of the Political Declaration, the case for “adding value” is already lost: The meeting and its declaration will be just another tick box. It will confirm the status quo and current minimal consensus. The High-Level meeting will not contribute to debating or even resolving some of the challenging realities and questions regarding UHC.

…and another “Multi-Stakeholder Process”

Already the ambition to use the High-Level meeting to “package the health agenda together, under the umbrella of UHC” (see above) would be worth a public debate, and I am quite confident that this debate would be pretty controversial. The same counts for some of the “key asks” proposed. So yes, there are crucial questions such as what shall/can be the health system’s contribution to the achievement of the right to health and what could be the political space for shared responsibility are crucial ones, and yes, we would have something to say.

However, the invitation to engage, in the preparation of the UN HLM, in a “multi-stakeholder process” with a series of meetings and online consultations does not mainly intend to foster such a debate, but rather aims at fabricating consensus. It is another mandatory tick-box: Yes, we consulted “the stakeholders”, and yes, everybody had an opportunity to contribute.

Our experiences with similar consultations (such as the recent one on the Astana declaration) indicate that there is little space for hope that this tokenism can be overcome this time. With the strict guidance on how the topic and questions are framed, with the short deadlines (the consultation on the “UHC2030 key asks” will close on 10 March), and with the consultation process set up as a black box (participants have no idea how their input is dealt with and, for example, why a key demand is neither considered nor referred to in the further process), we only can guarantee that, yes, there will be a reference to a “broad and inclusive consultation process” in the Political Declaration.

Referring to the civil society participation in the World Health Organization’s governing body meetings, I recently concluded that there is a gap between the rhetoric and reality of “inclusive” processes, and this gap is a governance issue that needs to be urgently addressed.

So what…

So yes, the MMI Network nevertheless submitted an application for accreditation for the UN HLM. For our preparation – if we are accepted as a participant – we would love to know from colleagues within and beyond the MMI Network what are your concrete expectations and ambitions, and how, together and as civil society we can make the most out of the meeting and its preparatory process, within and beyond the standard “format”. You might remember the civil society café session on “Calling for a New Global Economic Order – the forgotten element of the Alma-Ata Declaration” at the Astana PHC conference last year…

And yes, we will nevertheless contribute to the various consultations related to the High-Level Meeting, as a civil society member of UHC2030 and its “Civil Society Engagement Mechanism” (CSEM) that has itself already set up its own consultation “to inform Global Health Initiatives in 2019”, again with a short deadline. You might read, in the “High-Level meeting” section of the new CSEM website, what a “genuinely transformative” UN High Level Meeting would mean for them – and make up your mind.

A key challenge will be to agree on advocacy and communication strategies to promote the issues that, once more, risk to be neglected in the mainstream conversation on UHC and health system, such as: redistribution at national and international level to undo health inequities; governance and democratic legitimacy of health policy making, regulation not only in the health care sector but also on international financialisation, trade rules, capital flight and economic conditionalities that currently hinder or undo policy advances towards UHC.

So yes, let us engage, but at the same time continue to keep a bit of distance anyhow, not by bad intentions, but as an intellectual and political starting point, and to see things more clearly.

……………….
Published on 26 February 2019, also as editorial in the MMI Network News

Two documents added on 9 March:

  • Input by MMI to the UHC “key asks” consultation: PDF file
  • MMI discussion paper 2013 (!) on UHC: PDF file