The first ever United Nations High-Level Meeting on universal health coverage is an opportunity to consolidate unaddressed issues from G20 Osaka Summit in 2019, say Yasushi Katsuma and Maaya Sugai

This week’s United Nations High-Level Meeting (UN-HLM) on universal health coverage (UHC) in New York provides us with an opportunity to reflect on progress in global health and on the outcomes of the G20 Osaka Summit in June 2019. At the UN-HLM, heads of state and government will pledge their support for adopting Universal Health Coverage (UHC) as a strategic framework to achieve “Health for all,” including infectious disease control, health systems strengthening, an inclusive UHC policy for refugees and migrants, and ensuring sexual and reproductive health rights. 

The G20 Osaka Leaders’ Declaration called for greater collaboration between health and finance authorities. [1] The declaration was the first agreement among G20 countries that “primary health care including access to medicines, vaccination, nutrition, water and sanitation, health promotion and disease prevention is a cornerstone for advancing health and inclusion,” and recognised “the importance of sustainable financing for health.” Nonetheless, there are many issues that were not addressed at the G20 Osaka, and still need to be discussed at the UN-HLM on UHC. 

Firstly, the definition of UHC is wide ranging. A common understanding of UHC as a strategic framework to integrate infectious disease control and health systems strengthening in achieving SDG3 is missing. On one hand, a minimalist approach to UHC is to refer to service coverage and financial risk protection only, in line with Sustainable Development Goal 3. These are the gold standards in monitoring and evaluating UHC. [2,3] On the other hand, an increasing number of people working in global health see UHC in a more holistic way and as part of all health-related multi-sectoral issues in the SDGs. Some see it as extending beyond this, for example, in terms of prioritising domestic resources and building resilience to prepare for ageing populations. [4,5] 

At the G20 in Osaka, global health leaders and think tanks emphasised the absence of clear goals for domestic financing for health relative to GDP, the need for primary health care for all, especially for marginalised populations, and human rights and human security as a basis for UHC attainment. [6,7,8] Also there were calls for physicians and their associations to advocate and ensure UHC, and for a new platform for public-private (and academia) partnership to be established to emphasise a common understanding of UHC as a strategic framework in achieving SDG3. [9,10]

Secondly, the health of migrants and their social security, were not discussed at the G20. [7,8] This is despite past and recent World Health Assembly resolutions dedicated to the health of migrants, as well as the Global Compact for Migration. [11,12,13] Migrants often experience cultural and language barriers in accessing healthcare regardless of their legal or migratory status. [14,15,16] In addition, undocumented migrants frequently have to pay for their healthcare themselves as they are ineligible for national insurance schemes, or free healthcare. These are all setbacks for achieving UHC. In response to the G20 Osaka, there have been calls to expand the quality and quantity of financing for development assistance for health to reach the vulnerable and marginalised population, including migrants. [6] 

Finally, and regrettably, the G20 Osaka fell short of addressing sexual and reproductive health rights (SRHR). A lack of international consensus on SRHR and family planning negatively affects the success of  UHC, making it difficult for G20 countries to integrate SRHR into the UHC agenda. This is due to challenges in standardising actions toward safe abortion. The global health community has consistently voiced the need for human rights and human security approaches as a basis of UHC. [6]

How will we effectively implement UHC globally and achieve health for all without addressing these points? The UN-HLM on UHC provides an opportunity for global leaders to commit to UHC as a strategic framework to integrate infectious disease control and strengthen health systems, as well as to commit to clear actions on issues such as migrant health and SRHR. These issues have more potential to be achieved effectively if all UN member states are in agreement. 

Yasushi Katsuma, director of global health affairs & governance Institute for Global Health Policy Research, National Center for Global Health and Medicine, Tokyo, Japan; professor Graduate School of Asia-Pacific Studies, Waseda University, Tokyo, Japan; co-director Master’s Program in Global Leadership, Vietnam-Japan University, Hanoi, Vietnam
Competing interests: None declared

Maaya Kita Sugai, research fellow at Institute for Global Health Policy Research, National Center for Global Health and Medicine, Tokyo, Japan and Department of Global Health Policy, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
Competing interests: None declared
Twitter: @MaayaKitaSugai

References

1. G20. G20 Osaka Leaders’ Declaration 2019 [Available from: https://g20.org/en/documents/final_g20_osaka_leaders_declaration.html]
2. Hogan DR, Stevens GA, Hosseinpoor AR, Boerma T. Monitoring universal health coverage within the Sustainable Development Goals: development and baseline data for an index of essential health services. Lancet Glob Health. 2018;6(2):e152-e68.
3. Saksena P, Hsu J, Evans DB. Financial risk protection and universal health coverage: evidence and measurement challenges. PLoS Med. 2014;11(9):e1001701.
4. Abiiro GA, De Allegri M. Universal health coverage from multiple perspectives: a synthesis of conceptual literature and global debates. BMC Int Health Hum Rights. 2015;15:17.
5. G20. G20 Shared Understanding on the Importance of UHC Financing in Developing Countries – Towards sustainable and inclusive growth- 2019 [Available from: https://g20.org/pdf/documents/en/annex_05.pdf. ]
6. C20 Japan 2019. C20 Policy Pack 2019 2019 [Available from: https://civil-20.org/2019/wp-content/uploads/2019/08/C20-POLICY-PACK-2019-web2.pdf. ]
7. Bloom G, Katsuma Y, Rao KD, Makimoto S, Leung GM. Deliberate next steps toward a new globalism for universal health coverage (UHC) 2019 [Available from: https://t20japan.org/wp-content/uploads/2019/03/t20-japan-tf1-1-deliberate-next-steps-toward-new-globalism-for-uhc.pdf. ]
8. Bloom G, Katsuma Y, Rao KD, Makimoto S, Yin JDC, Leung GM. Next steps towards universal health coverage call for global leadership. BMJ. 2019;365:l2107.
9. World Medical Association JMA. Memorandum of Tokyo on Universal Health Coverage and the Medical Profession, Health Professional Meeting (H20) 2019 2019 [Available from: http://dl.med.or.jp/dl-med/wma/h20e.pdf. ]
10. (IFPMA) IFoPMaA. Biopharmaceutical CEOs Roundtable (BCR) joint statement 2019 [Available from: http://www.phrma-jp.org/wordpress/wp-content/uploads/2019/07/BCRJointStatement_EN.pdf. ]
11. World Health Organization. Health of migrants: The way forward. 2010.
12. World Health Organization. Promoting the health of refugees and migrants. 2017 [Available from: https://www.who.int/migrants/about/framework_refugees-migrants.pdf.]
13. Global Compact for Migration. Global Compact for Safe, Orderly and Regular Migration. 2018.
14. Rao KD, Makimoto S, Peters M, Leung GM, Bloom G and Katsuma Y. “Vulnerable populations and universal health coverage” in Kharas H. McArthur JW, and Ohno I (Eds) Leave no one behind: Time for specifics on the Sustainable Development Goals, New York: Brookings Institution. 2019 [Available from: https://www.brookings.edu/wp-content/uploads/2019/09/LNOB_Chapter7.pdf]
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16. O’Donnell CA, Burns N, Mair FS, Dowrick C, Clissmann C, van den Muijsenbergh M, et al. Reducing the health care burden for marginalised migrants: The potential role for primary care in Europe. Health Policy. 2016;120(5):495-508.

Contributors and sources:

This paper is based on an expert meeting organized by YK and held at the Institute for Global Health Policy Research (iGHP), National Center for Global Health and Medicine (NCGM), in Tokyo. MKS drafted the manuscript. YK provided critical revision of the manuscript for important intellectual content. All authors approved the final version of the manuscript.

Acknowledgements

We thank members of the expert meeting from key global health stakeholders for UHC in Japan, including those from the Government of Japan, think tank, civil society, Japan Medical Association, and the pharmaceutical sector, as well as expert contributors, for having participated in the meeting at iGHP as well as offered helpful comments and suggestions during the meeting.