by Werner Soors (ITM)

The beautiful Centre de Cultura Contemporània de Barcelona hosted a two-day seminar, Building a global health social contract for the 21st century, on 7th and 8th November. With such a title, no wonder friend and colleague Gorik Ooms was asked to give a key presentation. After all, he has been pioneering the concept of a global social contract for years. Less evident is that I – not a regular visitor of global health circles – was given the opportunity to witness the seminar, which was on invitation only. Let me stress here two things: (1) I am very grateful for this opportunity; and (2) no conflict of interest resulted.

Do not expect a full report of the seminar here: mine is just a personal impression. Both Martin McKee’s and Kevin Watkins’ keynote speeches are online and freely accessible. What I retain of McKee’s opening keynote – and consider the most valuable novelty of the seminar – is the framing of a global health social contract while pursuing UHC. Very timely indeed. What I retain of Watkins’ closing keynote – and consider a most promising way forward – is his proposal of ‘stepping stone equity targets’ for the post-2015 development goals. Those should be context-relevant and short-term. Examples would  be targets like ‘halving the gap between richest and poorest in 5 years’ or ‘between rural and urban in 5 years’ within an ideal goal of ‘all children surviving by 2030’. As Watkins put it straightforward: “If you don’t have equity goals in the post-2015 agenda, it isn’t worth the paper it is written on”.

In between these two keynotes were a series of presentations, not all of them clearly related to the central theme of a global health social contract. The latter came to the fore in Gorik’s well-received intervention, announced as ‘Why we need a global social protection scheme for health’. His central rationale is clearly reflected in the title of a paper soon to be published, “Helping oneself by helping others: How a global equalization scheme for universal health coverage would benefit the people of all countries”, co-authored by Rachel Hammonds, Attiya Waris, Bart Criel, Wim Van Damme and Alan Whiteside. You’ll hear from it soon, I hope.

So far, so good. What struck me most in the seminar however was what I would call the self-assured insulation of civil society. Martin McKee very convincingly listed the elements (and mechanisms) needed to reach UHC, including functioning institutions, tax-gathering capacity, political commitment and a favourable context. Kevin Watkin’s plea for equity goals was entirely framed within global goals to be realized at national levels. Yet, few of the invited actually seemed to miss state actors (who had been invited by the organizers, but few actually managed to attend). When poor David Evans put forward that “among all the actors in global health, we at WHO are the only democratic one, 1 country – 1 vote”, he was attacked from all corners. Throughout the seminar I was baffled by the aplomb of many a speaker. Governments were blamed for lack of accountability and transparency. But how civil is a civil society that seems to position itself above the states, and how representative is it for society? (my exaggeration, I admit). Many interventions gave the impression that a global society with a central role for global civil society is in the making, and paid relatively little attention to the role of states in a global social contract. For the time being, it appears, though, that a global social contract for the 21st century can only be a social contract between states. That wasn’t the overall tone of the interventions though, and most thus didn’t mention the problem of ‘unwilling states’ and/or the possibility of a ‘coalition of the willing’, for example.   Several participants called, instead, for “a new narrative” to move forward. But do we really expect narratives to make up for (failing) legal democratic institutions? I don’t have the answers, but I do think it is high time to ask the questions.

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