Healthcare for all: history in the making, but will it be delivered?

It was never going to be just another United Nations General Assembly (UNGA). As well as the high-security fanfare in New York as world leaders were escorted along cordoned streets and onto the global UN platform, this was an UNGA that was always going to hit the headlines: dramatic global politics coinciding with Prime Minister Boris Johnson downplaying the ruling of the illegal prorogation of the UK parliament, impeachment proceedings being launched against President Trump, and other controversies surrounding other delegates.

What makes the 2019 UNGA historic was not just that it marked the UN’s 75th anniversary or Greta Thunberg’s fantastic speech to urge political leaders to pay more than lip service to taking climate action – firmly directing the world’s attention on bringing the issue forefront of the global agenda. It was also historic because it heralded the first ever UN Political Declaration on Universal Health Coverage (UHC), agreed at the High-Level Meeting on UHC on 23rd September 2019. This includes strong commitments for how governments will make ‘universal’ a reality, illustrated by many world leaders’ claims for shortened distances for remote populations to access health facilities – nice soundbites for “making the last mile the first mile” – a massive re-endorsement of the importance of primary health care, and powerful assertions about how UHC is not just about freedom from disease, but the right to a healthy life.

There was some drama too with the politics surrounding the inclusion of sexual reproductive health and rights (SRHR) in the declaration – a phrase that the USA and 18 other countries objected to as it would ‘promote practices like abortion.’ Worryingly, U.S. Health and Human Services Secretary Alex Azar added that U.S. would ‘only support sex education that appreciates the protective role of the family in this education’. Thankfully, objections from the detractors were overruled, largely due to a powerful statement on behalf of 58 countries (including the UK) by the Prime Minister of Sint Maarten of the Netherlands, Leona Marlin-Romeo, that SRHR is ‘integral to UHC and the SDGs’, which received the most resounding applause of the day.

Many statements made the welcome recognition that investing in health is one of the best investments a country can make, and that money spent should be seen as investment, not just as expenditure. This is an important nuance, one that resonates with the driving emphasis that Options places on promoting national ownership for financing health systems in the drive towards UHC.

So once the noise of UNGA soundbites subsides, what change will these high-level statements really make to populations, and can those living at the last mile really be reached first? My search for answers to these questions were mostly in the broad arena of health financing. Not surprising, given Options’ current leadership of domestic financing strategies in the UK government’s flagship programme for Women’s Integrated Sexual Health (WISH). These then, are my top four UNGA takeaways:

1. The most pertinent discussions were those looking at domestic financing: how will governments pay for health services? The target of 1% extra from GDP is well short of the 5% recommended in the draft statement – there is considerable civil society advocacy on this point.
2. Where health is treated as a top priority, as recounted by the Rwanda ex-Minister of Health at a thought-provoking side event[3], the priorities are made with ministries of finance as well as ministries of health. In Rwanda’s case, this resulted in the allocation of 17% of the country’s budget to health.
3. Promoting good health involves adaptive management across sectors. An excellent WHO-led session explored the cost of Common Goods for Health (CGH) citing the huge cost of health emergencies and disaster risk management – around $170 bn per year – as compared to investing in CGH which was estimated to cost a twentieth of that (data presented by David Peters, Johns Hopkins & Bloomburg School of Public Health at side event on Financing Public Goods) – i.e. cross government actions in preventative approaches which would ideally require an adaptive management approach. Tools such as the Pathways of Change methodology that Options has developed for the WISH programme could be applied to support these approaches.
4. Reliable data is key for promoting accountability – and thereby putting words into action. Options’ experience in the field of maternal and newborn health is that working with multi-stakeholder accountability mechanisms can really shift the political will needed to drive change. The UHC commitments will need good data that can be used to promote accountability and maintain the priority for strong national-level investment in health.

Without meaningful engagement, multi-stakeholder platforms run the risk of tokenism and accountability for UHC commitments may elude those that need it the most, those at the last mile. There have been UN high-level meetings in the past, and many a global commitment made on specific health issues. But for this Political Declaration on UHC to become a reality, it will require financial commitments, prioritisation, good data and accountability. With the right attention in the aftermath of this UNGA, the UHC declaration has the potential to be transformational for the lives of the many that are otherwise left behind.