This comment is written by Mariska Meurs and Remco van de Pas, both working for Wemos [1], the Netherlands, on behalf of the Medicus Mundi International Network (MMI). MMI has been strongly involved in the consultation and debate on health in the post-2015 development agenda. Firstly, by harnessing the viewpoints of a wider group of civil society actors under the umbrella of Beyond 2015 [2]; secondly, by participating in a first expert review of this synthesis report, that took place on the 17th of January 2013 at WHO in Geneva. MMI continues its further engagement and activism in the beyond 2015 framework, with the aim to have a fair and just representation of health as one of the core elements of human development. We like to highlight four main areas of the draft Global Consultation Report [3]:

I. Equitable and comprehensive future health goals

We welcome the report’s recommendation for an overarching goal to increase healthy life expectancy, in connection with next-tier goals – including Universal Health Coverage and equity – as it corresponds to the need for a comprehensive approach to health, moving away from fragmented goals and targets, and incorporates the need to duly address underlying determinants of health. By strongly emphasizing health equity, the report does justice to the many contributions to the consultation that have stressed the importance of increasing equity in health. In this regard, we are glad to see that the report explicitly mentions equality of access in its proposed universal health coverage goal, as well as in the corresponding set of indicators referred to as “increased equity and financial protection”.

We consider this to be an important improvement over the way in which Universal Health Coverage is framed in the recent World Health Organization’s Report by the Secretariat on Universal Health Coverage (EB132/22, 18 January 2013 [4]), which states that UHC “…is, by definition, a practical expression of the concern for health equity and the right to health”. Past experiences have shown that “some reforms, often implemented in the name of expanding coverage, may actually compromise equity” [5]. For Universal Health Coverage to contribute to health equity, it is crucial to take lessons from past experience into account, and to monitor progress using indicators that address both equitable and effective access to health services and financial risk protection.

The combination of two interrelated comprehensive health goals (a) to increase healthy life expectancy and (b) Universal Health Coverage seems to be the most relevant approach as it provides attention to the wider determinants of health as well as the coverage of health services itself. The combined goals mimic in a proper way the Human Right to Health framework which is built on the AAAQ principle (Availability, Accessibility, Acceptability and Quality of health facilities) and on the right to healthy environmental, living and working conditions, amongst others determinants of health. Indeed, a healthy life expectancy goal would provide more qualitative data on how the health status of a population improves, especially when due attention is given to reducing the health equity gap within and between countries. Proper disaggregation of data is a must, and indicators need to be developed for this.

Because of its cross-sectoral nature, the health life expectancy goal should be reflected as a sub-indicator in other thematic goals and their ensuing accountability & monitoring framework. This doesn’t have to be at the impact level, but rather at the outcome level, e.g. the number of national plans on climate change that have included a policy on health impact and health sector responsiveness. Health equity indicators could also be one of the outcome measurements in a Global Inequalities goal. Likewise in this Global Inequalities framework, the role of the health sector and Universal Health Coverage in reducing inequalities could be included.

II. International Financing for Health

There is no question that, ideally, investments in health care and health determinants be financed with domestic resources. There is also no question, though, that many low-income countries do not have the resources to offer a meaningful package of essential services to their entire population, and therefore UHC risks becoming a meaningless concept for those countries. The above-mentioned Report by the WHO Secretariat on Universal Health Coverage clearly indicates the magnitude of the shortage of funds in many low-income countries “to ensure universal coverage with even a minimum set of health services (that is, to support prevention, promotion, treatment, rehabilitation and palliative care)” (para.17).

Without a clear financing goal, we believe that post-2015 health agenda risks becoming a hollow promise. We need to move beyond aid and the underlying charity concept to new innovative financing approaches. Hence, we strongly recommend that the report includes a recommendation on improved international financing that overcomes the many problems associated with ODA. This innovative financing mechanism must at its core have a redistributive mechanism, one that is based on a legally binding global agreement between states. Fair domestic and international progressive taxation policies (e.g. on carbon emissions) are properly suited to provide the necessary funds for such a global redistributive agreement. Indeed, in an interdependent, globalized world, we ultimately have to come to such a global solidarity fund to retain peace and stability.


III. The need for strong global governance for health

Several highly relevant references are made in the consultation report to the need for improved global governance for health, which we would like to see included more strongly in the recommendations in the final chapter. Chapter eight calls for a “new vision and approach to development that goes beyond measuring progress in economic growth and gross national product, and instead measures development in terms of well-being, health, security, and quality of life. This will require, among other things, addressing the social, cultural, economic, environmental, and political determinants of health, tackling risk factors, building health promoting environments, and strengthening health systems.”

But  in terms of recommendations, the report does not go further than stating that “Where possible, other goals related to health determinants should incorporate a health approach; at the very least, they must not undermine the right to health”, and proposes that health indicators be used to measure goals that impact on health (such as migration, education, water and sanitation, gender equality, youth empowerment and employment, environmental sustainability, population dynamics, and good governance). We believe it is an omission that no mention is made in this regard of trade agreements and economic policy conditions or tax treaties that erode public sector budgets.

An international perspective is also missing in chapter four, addressing the linkages between health and the other thematic consultations. When it comes to the link between economic growth and employment, we need to look beyond fair employment relations and decent work policies at the national level, and take into consideration international taxation and trade regimes that contribute to the ‘race to the bottom’ between governments trying to attract overseas investments through lowering taxes and deregulation, thereby eroding public sector budgets globally. When it comes to governance, mention is made of wasting of health expenditures, but not of international agreements on intellectual property rights that up to now work more towards protecting the interests of pharmaceutical companies than those of people in need of medicines.

The importance of global governance issues is recognized in chapter 6, referring to the need for “a broader view of development, a more democratic and participatory regime of global and national governance, and a configuration of economic relations that supports equity, decent living conditions, and ecological sustainability”. This recognition should be translated into the recommendations in chapter 8, acknowledging that ambitious goals are needed in global governance for health, including in the area of economic and financial policies, to achieve health equity in the coming decades.

The overarching principles and recommendations for global governance for health can be summarized in three points (the three R’s): Systemic resource redistribution between countries and within regions and countries to enable poorer countries to meet human needs; effective supranational regulation to ensure that there is a social purpose in the global economy; enforceable social rights that enable citizens and residents to seek legal redress [6].

IV. An inclusive and transparent process

We note with some concern that, while efforts are made to organize a transparent and participatory process on the post-2015 development framework, high-level consultations are on-going between development partners about the framing of Universal Health Coverage, where civil society has no clear voice. At the WHO/World Bank Ministerial-level Meeting on Universal Health Coverage in Geneva (18–19 February 2013 [7]), a selected group of civil society organizations is invited to showcase their contributions towards UHC, but there has been no invitation to sit at the table and participate in the dialogue.

We wish to see an inclusive and transparent process in relation to all aspects of the post-2015 development framework, including the consultations on UHC and how these relate to the process of development of indicators (as referred to in paragraph 27 of the Report by the WHO Secretariat on UHC, EB132/22) for tracking “progress towards universal health coverage in different ways depending on their own health problems and capacities to monitor and evaluate”.



Notes and references

  1. www.wemos.nl
  2. Beyond 2015 position paper, December 2012. The post-2015 development agenda: What good is it for health equity?, see also: http://bit.ly/mmi-beyond2015call
  3. http://www.worldwewant2015.org/node/304902
  4. http://apps.who.int/gb/ebwha/pdf_files/EB132/B132_22-en.pdf
  5. Joseph Kutzin, Anything goes on the path to universal health coverage? No. In: Bulletin of the World Health Organization 2012; 90:867-868,http://www.who.int/bulletin/volumes/90/11/12-113654/en/index.html
  6. Labonte & Schrecker, Globalisation Knowledge Network: Towards Health – Equitable Globalisation. Rights, Regulation and Redistribution. Final report to the commission on social determinants of health, 2007, p116-130,http://www.who.int/entity/social_determinants/resources/gkn_final_report_042008.pdf
  7. http://www.who.int/mediacentre/events/meetings/2013/universal_health_coverage/en/index.html

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This blogpost has been crossposted from the Get involved in global health blog with permission.

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