One year on from the UN High-Level Meeting on UHC, the State of UHC Commitment Review published by UHC2030 “examines a simple question: Are governments taking action towards meeting their UHC commitments?”. Here an initial assessment of the synthesis report of this review, looking at it as a remarkable piece of targeted political communication.

“We urge all partners of UHC2030 to use our review’s political messages and ask national political leaders in all 193 UN member states to take action on universal health coverage. Specifically, we call on all national political leaders to:

  • Prioritize UHC to tackle and recover from the COVID-19 pandemic, stop anxiety and rebuild trust.
  • Address the systemic inequities that are widening with COVID-19 by creating stronger social and financial safety nets and prioritizing equity.
  • Expand and strengthen UHC legislation and regulations, set clear targets, and communicate better.
  • Support, protect and care for health workers, and innovate to improve and maintain quality during emergencies.
  • Invest in public health and primary health care as a joint effort of health and finance ministers, and local governments.
  • Build partnerships through genuine civil society engagement.
  • Empower women, who are proving to be highly effective leaders in health emergencies.
  • Give UHC principles more weight in every crisis response and build emergency preparedness into all health system reforms.” (quoted from the report website)

Obviously, the team in the lead of the “State of UHC Commitment review“ had to cope with the distortion of national health systems and global health caused by the Covid-19 pandemic (the pandemic being framed in the report as a “stress test” for Universal Health Coverage). In this extraordinary situation, the review’s ambition to provide a baseline for a continued assessment of the state of UHC commitment and related action is just impossible. However, instead of simply admitting this, the synthesis report tries to integrate these two fields of public health: Setting up universal and equitable health systems (UHC) and adequate pandemic preparedness and response (Covid-19).

By doing so, the report fails twice. The UHC related analysis (or rather: messaging) gets blurred, and in the sections related to the Covid-19 response and public health at national and global level, the report does not provide new insights beyond what readers already known from many other (and stronger) papers. And the linking piece, the report’s argument for “giving UHC principles more weight in every crisis response” or to “prioritize UHC to tackle and recover from the COVID-19 pandemic” remains superficial and vague.

Anyhow, the synthesis report is a “must-read” for those engaged in the promotion of universal access to health care and the related political debate. So our main recommendation is clear: read it (or read at least the executive summary). If you have limited time (or a limited span of attention, because you are an important political leader), you might rather read only the report and not our initial analysis below that looks at the report as a remarkable and ambivalent piece of targeted political communication.

“UHC Commitment”: Better than life

The report is a smart piece of communication in two ways. First, with its overall narrative and messaging, it remains on the safe ground of diplomatic language so that it reaches the intended audience of “political leaders”. Instead of applying a sharp political lens and language (universal access to health care as a matter of social justice and human rights), the report rather refers to concepts of “investing in health”, “rebuilding trust” and similar that do not hurt anybody.

And, who wonders, the report links UHC to the currently dominating global health issue of Covid-19. And it is published and disseminated right ahead of the UN General Assembly Special Session on the pandemic on 3-4 December (according to a covering letter, this is “an invaluable advocacy opportunity”). We have seen this pragmatic “we too” approach many times before, e.g. when advocates linked their particular cause and messaging to UHC, in the run-up to the UN High-Level Meeting last year…

The report is also smart by proposing to use the “key targets, commitments and actions in the political declaration of the 2019 High-level Meeting on UHC” as an “agreed reference” for the review. Doing so, the review presents these commitments in a way that makes the political declaration of the High-Level Meeting much stronger and more tangible than it is in reality. Despite some apologetic WHO rhetoric (“the most ambitious, comprehensive political declaration on health in history”), the outcome document of last year’s High-Level Meeting on UHC is in fact disappointingly vague, technical and uninspired, lagging considerably behind a remarkable set of six “Key asks of the UHC movement” drafted and presented by UHC2030 ahead of the UN meeting.

In 2019, we proposed to “support, challenge, strengthen, defend the key asks: They are surprisingly strong, political, precise, far beyond multistakeholder mainstream blabla.“  And it is these “UHC2030 key asks” to which the review of UHC Commitment refers in its outline, adding the two fields of gender (as requested by the gender lobby ahead of the HLM) and emergency response.

As a result, some of the public health language in the synthesis report is sound and convincing. It might have been written by the same people who drafted the 2019 “key asks”…

Cracks, tensions, blind spots

However, within and beyond its overall rhetoric of “UHC, public health and pandemic preparedness: it is all the same investment in health”, the reports shows (by trying to hide them…) some remarkable cracks and tensions, and there are some obvious blind spots.

Invest in UHC and/or in health security? This is an old dilemma and old battle, and it might be one of the biggest challenges in times when huge amounts of money are spent in vertical disease control programmes and emergency response and recovery. With its common-sense recommendation to “give UHC principles more weight in every crisis response, and build emergency preparedness into all health system reforms” the report does not provide a solid answer to the question when it is time to move attention from the current Covid-19 emergency back to the constant, systemic crisis, how to conciliate the priority of setting up strong, public health systems based on Primary Health Care and universal, equitable access to health with the priority of being ready for the next pandemic. Again, we have seen stronger and sharper analysis and proposals. And we just read a new Lancet research report stating: “Although WHO approaches these agendas in principle as imminently convergent inputs towards a strong health system, scarce resources and political realities force policy makers to make tough choices, usually prioritising one agenda over the other.”

Follow science or follow people and their realities and experiences? The report includes some remarkable language on active citizenship and social participation in health governance, but also states that “stakeholders” have a rather narrow view (rather requesting services that benefit individuals) and that “it is hoped that population will begin to demand better performance from their public health systems”. And also the report’s statement that Covid-19 shows that “it needs empathetic leaders who make decisions based on science not populist urges” is rather understandable, but ambivalent. So don’t you trust the people and communities you refer to?

What civic space in public health? For having benefitted of strong input by civil society organizations, the report is also particularly weak on human rights. The tension between public health (disease control, enforcement of public health measures, surveillance state) and civic rights (freedom, entitlements) exposed by the Covid-19 response is merely dealt with. And this dichotomy goes far beyond ”authoritarian policies”. It has been made visible in every country, every society.

Private sector as partner? For 90 percent of the synthesis report, the term “stakeholders” refers to civil society or to people, and the notion of “public health” also includes public health care systems. But, then the report takes up again a blurred “multistakeholder” and “partnership” narrative and provides recommendations on including the private sector for which there is no evidence (at least not presented in the synthesis). The role and contributions of the private sector needs to be looked at more carefully and deserves its own attention and space in a state of UHC (commitment) review. And Covid-19 indeed provides some insights and lessons.

 “Universal Health Coverage” is still a difficult concept. It is at the same time funny and sad to read that “one of the key findings from the 2020 UHC Survey is that stakeholders are unclear about what constitutes a UHC commitment and what, if any, commitments their governments have made recently or in the past. In referring to commitments, survey respondents often mentioned references to health in their country’s constitution or laws or vague policies or statements made in meetings or in the media.” Well, this conclusion comes by no surprise. It was already visible in the failure of the UN High-Level Meeting on UHC in 2019.

The proponents of Universal Health Coverage as overarching health goal too often neglect themselves their “simple” definition of UHC as “all individuals and communities receiving the health services they need without suffering financial hardship”. The attention given to the political processes around UHC has been misused to attach all kinds of particular issues to UHC, resulting in confusion, as expressed in the Political Declaration of the High-Level Meeting. Just read it again, and you will see.

It is high time to get more rigid, or to get rid of UHC and call the challenge by its real name: Universal and equitable access to health care, as one of the health system’s main contributions to the goal of ensuring health and well-being for all. People, governments and “stakeholders” would understand this better.

A synthesis of a thorough review

In its executive summary, the synthesis report provides a blunt assessment of the attention span of its main expected audience: “Political leaders who are responsible for fulfilling their country’s commitment to UHC are unlikely to engage with detailed findings and recommendations”. As a consequence, and with the report’s triple structure (foreword, executive summary, main report) and resulting redundancy, it takes quite an effort to reach the level of “findings” in the synthesis report itself. And then it is still impossible to see how the raw material collected by the reviewers has been assessed and transformed into drafting the “synthesis” with its specific narrative and set of recommendations. So we admit that a proper “review of the review” itself (and not the synthesis report) is still to be done, also in view of providing sound recommendations for its follow-up.

All in all, and appreciating the remarkable endeavour of undertaking the review, collecting the data (including those from the already existing SDG “Voluntary National Review” system) and digesting them into the “synthesis report”, we dare to ask how many parallel accountability lines and related reviews of the “state of UHC” are feasible and meaningful.

Doing so, we refer to the announcement of the WHO Director General to launch a “Universal Health and Preparedness Review”, again with national level reporting. Is it time to integrate all these efforts into one?

Thomas Schwarz, Executive Secretary
Medicus Mundi International Network (MMI)
3 December 2020

This is a personal blog. Views or opinions represented are personal and do not represent those of the MMI Network or its members. MMI is a member of both UHC2030 and its Civil Society Engagement Mechanism.