In September, the United Nations will convene a High-Level Meeting on Universal Health Coverage (UHC), with heads of state encouraged to attend. As typical for such meetings, a key outcome with be a political declaration, in this case on countries’ commitments around UHC. In May, a “zero draft” was made publicly available; as states negotiate the final document, additional drafts are being developed. Alas, the initial document is all too typical of high-level declarations and outcome statements – plenty of assertions about commitments to important broad principles — like human rights — that many states seem to have little or no real interest in taking seriously, recommitments to past commitments (again like human rights), and a host of generalities.
Take a focus that we have had here at the O’Neill Institute, health equity. Equity is fundamental to achieving UHC, for without deliberate efforts to include even the most marginalized and disadvantaged populations, people with the fewest resources and least economic, social, and political clout will continue to be left out, betraying the promise of universal health coverage and undermining the effectiveness of the UHC declaration.
The importance of equity – and its Sustainable Development Goals (SDGs) emphasis, which has become captured in the call to “leave no one behind” – is incorporated into the draft declaration in a number of ways. But the phenomenon of important but broad principles and repetition of previous commitments dominates. States commit to reduce financial barriers, though this is already core to any even half-hearted UHC effort. The document’s commitment “encourage incentives to secure the equitable distribution of qualified health workers especially in rural and hard-to-reach areas” is quite welcome, though entirely in accordance with the Global Strategy on Human Resources for Health (which the declaration cites), which governments have already committed to, having adopted the strategy in 2016 (WHA 69.19) through the World Health Assembly.
States commit to “maximize the efficiency and equity of health spending” – all to the good, certainly, though this provides little guidance – or anything by way of a priority to equity if efficiency and equity may conflict (for from the perspective of reaching the most people at the lowest cost, the most efficient health spending might leave out hard-to-reach populations, like people living in remote rural areas). And one wonders, in states where public health spending is heavily titled towards tertiary care – generally a less equitable approach to health spending than focusing resources on primary care – will these few words lead to any significant action to dramatically re-orient health spending?
Data disaggregation is critical in order to understand equity gaps, develop policies and programs to respond, and monitor progress towards equity. One of the declaration’s most detailed provisions is a commitment to data disaggregation across a number of markers – a commitment that larger mirrors one of the targets already agreed through the SDGs (17.18).
This is not to say even these are not small steps. However vague, maximizing equity in spending is something that advocates can measure, monitor, and seek to hold governments accountable for. The commitment around the equitable distribution of health workers is new at the head of state level, and the declaration applies the general SDG commitment on data disaggregation to UHC.
The draft commits to ensuring universal access to sexual and reproductive health and rights (one hopes that this survives interstate negotiations, what with the backlash against these rights in the United States and elsewhere) – though this is also a commitment in the SDGs (5.6). And the commitment in gender equity specifically – on gender mainstreaming “with a view to reducing gender-related inequities” is less forceful than the SDG target (5.1) to “[e]nd all forms of discrimination against women and girls.”
Along with these particular areas of equity, the declaration’s overall commitment to equity comes through its overall commitment that states will ensure that no one will be left behind, but given the extreme generality of that statement, the vast gap between this promise and reality, and the fact that this repeats an overriding commitment heads of state have already made through the Sustainable Development Goals, it does not inspire confidence for spurring the transformations needed to actually leave no one behind.
The declaration also includes a commitment to “[b]uild effective, accountable and inclusive institutions at all levels to ensure social justice, rule of law, and health for all.” Such institutions are critical to achieving health equity, for without accountability, promises and policies, even laws, may go unfulfilled, unimplemented, and unenforced. Yet this commitment is little more than a combination of two already in the SDGs (16.6 and 16.7).
How to strengthen the declaration with respect to health equity? How to make it so that it has a meaningful chance of not primarily — or even only — marking where governments are today on UHC and equity (at least in their rhetoric and stated commitments), but instead might actually drive action tomorrow – like the 2001 Declaration of Commitment on HIV/AIDS?
First, the declaration should include clear targets, indicators, and benchmarks, whether globally or – like the commitment in the draft declaration to set national targets and indicators in-line with achieving UHC by 2030 – at the national level. Setting targets, indicators, and benchmarks requires clear action – namely, creating these targets and other markers where none might now exist – and are key source of holding governments accountable. The declaration needs targets on health equity.
Second, the declaration should commit countries to specific approaches, mechanisms, and actions – again, requiring clear action. In this case, countries should commit to developing health equity programs of action. These would be systematic, systemic, inclusive sets of action, incorporated into national health or development plans, that encompass all marginalized and disadvantaged populations, as well as the social determinants of health. Such programs of action could turn the commitment to leave no one behind into meaningful action to in fact help ensure that no one is left behind.
And third, the declaration could help reinforce norms – not unlike the presently included commitment on sexual and reproductive health and rights – or, more powerfully, begin to establish new one. Here, ideally the declaration could, for instance, establish the norm of non-discrimination against immigrants, regardless of their legal status (already required by international law). But as that seems extraordinarily unlikely in the current xenophobic environment, perhaps the best we can hope for is to emphasize the norm of non-discrimination. The declaration could, though, establish the goal of not only reducing health inequities, but rather of eliminating them altogether. It could also clarify commitments to such broad principles as participation and inclusivity, which should entail governments working hand-in-hand with vulnerable, stigmatized, and marginalized populations (to use the declaration’s terminology), who should be partners in the policy process, with a genuine role in making the decisions that affect their health (see para. 11).
If you are interested in what this might look like specifically, building off of the zero draft of the UHC declaration, please see below. And even if not, please share these ideas with anyone who know who is – and may even be able to influence their own government’s positions.
Proposals to strengthen position of equity in the UHC declaration
We propose the following additions to the UHC declaration. The first set of possibilities includes different approaches to incorporating health equity programs of action or their basic approach. The second set of proposals are other ways to strengthen equity within the declaration.
Health equity programs of action and their approach
In section “mainstreaming gender, equity, and human rights,” add a new paragraph: “Develop systematic, systemic, and inclusive approaches to health equity, encompassing each vulnerable, stigmatized, or marginalized population and the social, economic, commercial, environmental, and legal determinants of health, such as by developing health equity programs of action;”
After para. 58 on leaving no one behind, add a new paragraph: “In concert with vulnerable, stigmatized, and marginalized communities, assess obstacles to high-quality, affordable health services for each vulnerable, stigmatized, and marginalized population and develop and implement laws and policies to remove obstacles;”
In para. 58 on leaving no one behind, add “by developing systematic, systemic, and inclusive approaches to health equity, encompassing each such population and the social, economic, commercial, environmental, and legal determinants of health, such as by developing health equity programs of action, addressing” (“Ensure that no one is left behind, especially those who are vulnerable, stigmatized or marginalized, by developing systematic, systemic, and inclusive approaches to health equity, encompassing each such population and the social, economic, commercial, environmental, and legal determinants of health, such as by developing health equity programs of action, addressing, among others….”)
Less forceful but still significant edits to para. 58 would be to add “including through legal, regulatory, and policy measures to ensure non-discrimination, protect the rights of, and take proactive measures to ensure health services for” (“Ensure that no one is left behind, especially those who are vulnerable, stigmatized or marginalized, including through legal, regulatory, and policy measures to ensure non-discrimination, protect the rights of, and take proactive measures to ensure health services for, among others….”)
Strengthening equity throughout the declaration
After para. 58 on leaving no one behind or after para. 62 on national UHC target-setting, add a new paragraph: “By 2020, set national targets through highly inclusive processes towards reducing and ultimately eliminating health inequities;” OR “By 2020, set national targets through highly inclusive processes towards eliminating inequities in access to high-quality, affordable health services;”
In para. 62 on setting national targets, add: “, including towards eliminating health inequities,” (“set national targets, including towards eliminating health inequities, for the achievement of universal health coverage in 2030”)
In para. 45 on accountable and participatory institutions, edit beginning to read: “In concert with civil society and vulnerable, stigmatized, and marginalized communities, identify approaches to” and add at end “and undertake all necessary legal and policy measures to build such institutions;” (“In concert with civil society and vulnerable, stigmatized, and marginalized communities, identify approaches to build effective, accountable and inclusive institutions at all levels to ensure social justice, rule of law, and health for all, and undertake all necessary legal and policy measures to build such institutions;”)
After para. 58 on leaving no one behind, add a new paragraph: “Support civil society organizations comprised of and working with and on behalf of vulnerable, stigmatized, and marginalized populations towards achieving UHC;”
In para. 46 on legislation to support UHC, add “non-discriminatory and equitable,” “affordable,” “enable inclusive participation in health-related policymaking” (“enacting legislations that ensure non-discriminatory and equitable access to affordable health services, products and vaccines, assure the quality and safety of services, products and practice of health workers, and enable inclusive participation in health-related policymaking;”)
In para. 50 on health worker training, add “including on human rights and non-discrimination: (“Develop, improve, and make available evidence-based and culture and gender-sensitive training, skills enhancement and education of health workers, including on human rights and non-discrimination….”)
After para. 62 on national targets for UHC, add a new paragraph: “Every X years beginning in 2020, jointly assess obstacles to UHC with vulnerable, stigmatized, and marginalized populations and develop, implement, and monitor legal and policy responses;”
The views reflected in this expert column are those of the individual authors and do not necessarily represent those of the O’Neill Institute for National and Global Health Law or Georgetown University. This blog is solely informational in nature, and not intended as a substitute for competent legal advice from a licensed and retained attorney in your state or country.