An incredible amount of human and financial resources are directed towards international health programs. For example, total U.S. global health funding was $11 billion in 2019 alone. A large part of these resources goes to bilateral and multilateral organizations, such as the World Health Organiztaion, UNAIDS or the UN Development Program, international NGOs, and other partners active in the health sector. As this huge amount of resources is directed towards these organizations working in similar fields, the work can often overlap, be duplicated, or simply fail to address local priorities. To address this problem the governments of Ghana, Germany and Norway, in April 2018, requested that the World Health Organization (WHO) take the lead in an initiative to improve the coordination of international cooperation in the health sector.
In response to this request, the WHO and eleven multilateral organizations (Gavi, GFF, Global Fund, UNAIDS, UNDP, UNFPA, UNICEF, Unitaid, UN Women, WFP, and the World Bank) developed the Global Action Plan for Healthy Lives and Well-Being (GAP) which puts forth a vision to align work across sectors, accelerate progress in global health across seven cross-cutting measures, and account for their efforts through a common framework for assessing results. This plan is to be implemented to move the world more expeditiously toward realizing Sustainable Development Goal 3: Ensure healthy lives and promote well-being at all ages (SDG3).
The GAP will be launched at the UN General Assembly in September 2019. It will inform several summits and high-level meetings, including the September 23rd High-Level Meeting on Universal Health Coverage where countries will sign what the WHO calls “the most comprehensive declaration on health in history”.
In developing the plan, however, there has been very limited consultation with civil society. Indeed, as can often happen in developing these high-level plans and initiatives, those around the table have been limited to multilateral organizations and their partners–far from the voice of the people whose lives this plan would impact the most. In April 2019, WHO held a day-long public consultation with communities, civil society, and non-state actors, but this was limited to around 85 participants and those who could afford the trip to New York City where the meeting would take place. And later, in June 2019, WHO briefly opened a broad, public consultation through which all stakeholders, including civil society, might give input.
These inputs were focused on the GAP generally as well as on discussion papers on the seven “accelerators”, which have been identified as cross-cutting areas where collective action has the most potential to speed up progress towards achieving the health-related SDGs. They include:
Accelerator 1. Sustainable financing
Accelerator 2. Frontline health systems/Primary health care
Accelerator 3. Community and civil society engagement
Accelerator 4. Determinants of health
Accelerator 5. R&D, innovation and access
Accelerator 6. Data and digital health
Accelerator 7. Innovative programming in fragile and vulnerable states for disease outbreak response
Civil society organizations, including several partners from PHM’s network, submitted comments to the consultation. While these groups welcomed the vision and spirit of the GAP, several called attention to the process around developing the plan, noting that it did not adequately include input from communities who are working on the ground to tackle issues the plan intends to address. They find this to be a missed opportunity for the GAP to address the needs of the people in a meaningful way that will move all countries toward achieving SDG3.
These groups also highlight the following as shortcomings and areas for improvement across the GAP and the accelerators that may make the plan more inclusive and get us closer to the goal of health for all:
Equity, especially gender equity, should be more explicit throughout the GAP, especially how equity may be operationalized. It should be woven throughout each accelerator in a way that reflects its cross-cutting nature. (Wemos, Women Deliver, UHC2030)
Achieving health equity for all people should be a clear goal of the GAP. However, the determinants of health discussed in connection with Accelerator 4. Determinants of Health, excludes the vulnerabilities and struggles of LGBTQ+ people. Health Alliance International emphasized that the GAP must not perpetuate the exclusion of LGBTQ+ individuals from this dialogue.
Primary health care & universal health coverage
One of the GAP’s strengths is that it has a strong focus on strengthening primary health care with the focus of Accelerator 2. Frontline health systems/Primary health care. However, to achieve Universal Health Coverage, we must also have multisectoral action at all levels of the health system. (Partners in Health)
Further, national governments must be included as a partners to inform priorities, not only rich countries, donor agencies, and multilateral organizations as has been the case for far too long. (Health Alliance International).
Finally, to accelerate progress toward UHC, the GAP should adopt several milestones, similar to those that UHC2030 has laid out, which include the aim for governments to introduce legal and regulatory measures that accelerate progress toward UHC. (UHC2030).
Human resources for health
Human resources for health is gravely undervalued in the GAP. Public Services International decried the omission of human resources for health itself as an accelerator as “improving employment and working conditions in health services should be one of the GAP’s key elements.” The health workforce in many LMICs suffers growing shortages due to inadequate funding, and Wemos stressed that the GAP and Accelerator 1. Sustainable financing should address this directly.
The GAP should also, particularly with Accelerator 2. Frontline health systems/Primary health care in mind, overtly address the role NGOs play in preventing countries from attaining PHC through, for example, contributing to brain drain and undermining the health system. The GAP should include language that requires a commitment from NGOs to health system strengthening. (Health Alliance International)
Community and civil society engagement
The involvement of local communities and civil society is key in identifying problems, laying out priorities, and developing paths forward to achieve goals. However, local communities too often find their voices and concerns drowned out by donor priorities. And while they do sometimes have a seat at the table, these communities are often not included as part of decision-making.
To address this, Accelerator 3. Community and civil society engagement should provide a clear roadmap for the meaningful participation of communities and civil society and for overcoming barriers to participation and for inclusion in decision-making. (Partners in Health) Moreover, the GAP should facilitate and finance civil society participation. (UHC2030)
Sustainable financing for health
Powerful political and economic forces have for too long dictated the current under-financed and dwindling resources for health. Macroeconomic policies that have shaped the current financial situations in many countries must be taken into account and rectified, and IMF reform must be more than a dialogue but a demand for the end of conditionalities and for debt forgiveness. (Health Alliance International, UHC2030)
Further, the GAP should be more ambitious in calling on high-income countries to increase development assistance for health. (Wemos) While the GAP’s proposal of taxation on products that are harmful to health is welcome, it should call for progressive tax systems and a scale-up of global efforts to end tax avoidance and evasion as well as decreasing corporate taxes. (Public Services International, Wemos, UHC2030)
Importantly, resource mobilization must ensure that it effectively reaches the poorest and most vulnerable people in a country, and to that end coordination efforts will require commitment to more funding for the poorest countries. (Partners in Health)
You can see the full package of over 300 pages of comments here. You can also read selected comments from PHM friends Partners in Health, Wemos, Health Alliance International, UHC2030, Public Services International, and Women Deliver here.
The GAP will be officially launched at the UN General Assembly that opens on 17 September. We will be following closely to ascertain whether and how civil society inputs were integrated into the GAP. We’ll also be following other summits and high-level meetings, including the Climate Summit, the high-level meeting on Universal Health Coverage, and the SDG Summit, to see how the GAP informs these meetings and their outcomes.