Political rationale, aims, and outcomes of health-related high-level meetings and special sessions at the UN General Assembly: A policy research observational study.

BACKGROUND: Recognising the substantial political weight of the United Nations General Assembly (UNGA), a UN General Assembly special session (UNGASS) and high-level meetings (HLMs) have been pursued and held for 5 health-related topics thus far. They have focused on human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS, 2001), non-communicable diseases (NCDs, 2011), antimicrobial resistance (AMR, 2016), tuberculosis (TB, 2018), and universal health coverage (UHC, 2019). This observational study presents a comprehensive analysis of the political and policy background that prompted the events, as well as an assessment of aims, approaches, and ultimate outcomes. METHODS AND FINDINGS: We investigated relevant agencies' official documents, performed a literature search, and accessed international institutions' websites for the period 1990-2020. Knowledgeable diplomatic staff and experts provided additional information. Outcomes were evaluated from a United Nations perspective based on national and international commitments, and funding trends. Eliciting an effective governmental response through UNGASSs/HLMs is a challenge. However, increased international commitment was evident after the HIV/AIDS (2001), NCDs (2011), and AMR (2016) meetings. The more recent TB (2018) and UHC (2019) HLMs have received general endorsements internationally, although concrete commitments are not yet documented. Although attribution can only be hypothesized, financial investments for HIV/AIDS following the UNGASS were remarkable, whereas following HLMs for NCDs, AMR, and TB, the financial investments remained insufficient to face the burden of these threats. Thus far, the HIV/AIDS UNGASS was the only one followed by a level of commitment that has likely contributed to the reversal of the previous burden trend. Limitations of this study include its global perspective and aerial view that cannot discern the effects at the country level. Additionally, possible peculiarities that modified the response to the meetings were not looked at in detail. Finally, we assessed a small sample of events; thus, the list of strategic characteristics for success is not exhaustive. CONCLUSIONS: Overall, UNGASSs and HLMs have the potential to lay better foundations and boldly address key health challenges. However, to succeed, they need to (i) be backed by large consensus; (ii) engage UN authorities and high-level bodies; (iii) emphasise implications for international security and the world economy; (iv) be supported by the civil society, activists, and champions; and (v) produce a political declaration containing specific, measurable, achievable, relevant, and time-bound (SMART) targets. Therefore, to ensure impact on health challenges, in addition to working with the World Health Assembly and health ministries, engaging the higher political level represented by the UNGA and heads of state and government is critical.

Paths towards Universal Health Coverage: beyond political commitments.

The rapid economic growth in low and middle-income countries provides the opportunity of translating political commitment into action for achieving Universal Health Coverage. However, this is not straightforward. High donor dependence in low income countries; the lack of fiscal space; the inadequacy of attention to primary health care and under-developed pre-payment systems all pose challenges. Windows of political opportunity open up and ensuring that Universal Health Coverage makes it into the agenda of parties and subsequent holding them accountable by citizens can address political inertia. Not only is more money for health needed, but governments also need to gain more health for money through effective strategic purchasing and addressing the main drivers of inefficiency. Moving Universal Health Coverage from political aspiration to reality requires approaching it as a citizen's rights and entitlement to health, through full subsidies for the poor and vulnerable.

Addressing NCDs: A unifying agenda for sustainable development.

Despite the mounting evidence that they impede social and economic development, increase inequalities, and perpetuate poverty, Noncommunicable diseases (NCDs) remain largely absent from the agendas of major development assistance initiatives. In addition, fundamental changes are developing in patterns of development assistance for health, and more of the burden for fighting NCDs is being placed on domestic budgets, thus increasing pressure on the most vulnerable countries. The paper argues, however, that a new day is coming. With the inclusion of NCDs and related targets in the 2030 Agenda for Sustainable Development, there is an unprecedented opportunity to explore linkages among the sustainable development goals, enhance policy coherence and advance the NCD agenda as part of sustainable development. International development partners (bilateral and multilateral) can help in this important effort to address NCDs and their shared risk factors by providing catalytic support to countries that are particularly vulnerable in terms of the disease burden but lack the resources (human, financial) and institutional arrangements to meet their commitments at national, regional, and global levels.

The Economic Transition of Health in Africa: A Call for Progressive Pragmatism to Shape the Future of Health Financing.

Abstract-The new financing landscape for the Sustainable Development Goals has a larger emphasis on domestic resource mobilization. But, given the significant role of donor assistance for health, the fungibility of government health spending, and the downward revision of global growth, this article looks at what is possible with regard to a country's own ability to finance priority health services. Using cross-sectional and longitudinal economic and health spending data, we employ a global multilevel model with regional and country random effects to develop gross domestic product (GDP) projections that inform a dynamic panel data model to forecast health spending. We then assess sub-Saharan African countries' abilities to afford to finance their own essential health needs and find that there are countries that will still rely on high out-of-pocket or donor spending to finance an essential package of health services. To address this, we discuss policy opportunities for each set of countries over the next 15 years. This longer-term view of the economic transition of health in Africa stresses the imperative of engaging policy now to prioritize customized strategies and institutional arrangements to increase domestic financing, improve value for money, and ensure fairer and sustainable health financing. We address the need for rhetoric on UHC to incorporate "progressive pragmatism," a proactive joint approach by developing country governments and their development partners to ensure that policies designed to achieve universal health coverage align with the economic reality of available domestic and donor financing.

[Global health 2035: a world converging within a generation]. / Salud global 2035: un mundo convergiendo en el lapso de una generación.

Prompted by the 20th anniversary of the 1993 World Development Report, a Lancet Commission revisited the case for investment in health and developed a new investment framework to achieve dramatic health gains by 2035. The Commission's report has four key messages, each accompanied by opportunities for action by national governments of low-income and middle-income countries and by the international community. First, there is an enormous economic payoff from investing in health. The impressive returns make a strong case for both increased domestic financing of health and for allocating a higher proportion of official development assistance to development of health. Second, modeling by the Commission found that a "grand convergence" in health is achievable by 2035-that is, a reduction in infectious, maternal, and child mortality down to universally low levels. Convergence would require aggressive scale up of existing and new health tools, and it could mostly be financed from the expected economic growth of low- and middle-income countries. The international community can best support convergence by funding the development and delivery of new health technologies and by curbing antibiotic resistance. Third, fiscal policies -such as taxation of tobacco and alcohol- are a powerful and underused lever that governments can use to curb non-communicable diseases and injuries while also raising revenue for health. International action on NCDs and injuries should focus on providing technical assistance on fiscal policies, regional cooperation on tobacco, and funding policy and implementation research on scaling-up of interventions to tackle these conditions. Fourth, progressive universalism, a pathway to universal health coverage (UHC) that includes the poor from the outset, is an efficient way to achieve health and financial risk protection. For national governments, progressive universalism would yield high health gains per dollar spent and poor people would gain the most in terms of health and financial protection. The international community can best support countries to implement progressive UHC by financing policy and implementation research, such as on the mechanics of designing and implementing evolution of the benefits package as the resource envelope for public finance grows.

Salud global 2035: un mundo convergiendo en el lapso de una generación / Global health 2035: a world converging within a generation

Con motivo del 20º aniversario del Informe sobre el Desarrollo Mundial 1993, una Comisión de la revista The Lancet reconsideró el argumento a favor de la inversión en salud y desarrolló un nuevo marco de inversión para lograr mejoras dramáticas en materia de salud para el año 2035. El informe de la Comisión contiene cuatro mensajes clave, cada uno acompañado de oportunidades para los gobiernos nacionales de países de ingresos bajos y medios y para la comunidad internacional. En primer lugar, invertir en salud acarrea enormes rendimientos económicos. Las impresionantes ganancias son un fuerte argumento a favor de un aumento en el financiamiento nacional de la salud y de asignar una mayor proporción de la asistencia oficial al desarrollo de la salud. En segundo lugar, en el modelo creado por la Comisión se encontró que es posible lograr para el año 2035 una "gran convergencia" en salud, consistente en la reducción de las tasas de mortalidad materna, infantil y por infecciones a niveles universalmente bajos. Tal convergencia requeriría la ampliación de las herramientas de salud existentes y un incremento agresivo de nuevas herramientas, y podría ser financiada en su mayor parte con recursos derivados del crecimiento económico esperado de los países de ingresos bajos y medios. La mejor manera en que la comunidad internacional puede apoyar la convergencia es financiando el desarrollo y suministro de nuevas tecnologías de salud, y frenando la resistencia a los antibióticos. En tercer lugar, las políticas fiscales -tales como los impuestos al tabaco y al alcohol- son una palanca poderosa y subutilizada que los gobiernos pueden emplear para detener el avance de las enfermedades no transmisibles (ENT) y las lesiones, a la vez que elevan los ingresos públicos para la salud. La acción internacional sobre las ENT y lesiones debería enfocarse en proporcionar asistencia técnica sobre políticas fiscales, en cooperación regional para el combate al tabaquismo y en financiar investigación sobre políticas e implementación para ampliar las intervenciones que enfrenten estos problemas. En cuarto lugar, la universalización progresiva -una vía hacia la cobertura universal de salud (CUS) que incluya desde el comienzo a los pobres- es una manera eficiente de lograr la protección a la salud contra riesgos financieros. Para los gobiernos nacionales, la universalización progresiva produciría elevadas ganancias en salud por cada dólar que se gaste en ésta, y los pobres serían quienes más ganarían en términos tanto de salud como de protección financiera. La mejor manera en que la comunidad internacional puede brindar apoyo a los países para implementar una CUS progresiva es financiando la investigación sobre políticas e implementación, por ejemplo, sobre la mecánica del diseño e instrumentación de la evolución del paquete de beneficios conforme crezca el presupuesto para las finanzas públicas.

Prompted by the 20th anniversary of the 1993 World Development Report, a Lancet Commission revisited the case for investment in health and developed a new investment framework to achieve dramatic health gains by 2035. The Commission's report has four key messages, each accompanied by opportunities for action by national governments of low-income and middle-income countries and by the international community. First, there is an enormous economic payoff from investing in health. The impressive returns make a strong case for both increased domestic financing of health and for allocating a higher proportion of official development assistance to development of health. Second, modeling by the Commission found that a "grand convergence" in health is achievable by 2035-that is, a reduction in infectious, maternal, and child mortality down to universally low levels. Convergence would require aggressive scale up of existing and new health tools, and it could mostly be financed from the expected economic growth of low- and middle-income countries. The international community can best support convergence by funding the development and delivery of new health technologies and by curbing antibiotic resistance. Third, fiscal policies -such as taxation of tobacco and alcohol- are a powerful and underused lever that governments can use to curb non-communicable diseases and injuries while also raising revenue for health. International action on NCDs and injuries should focus on providing technical assistance on fiscal policies, regional cooperation on tobacco, and funding policy and implementation research on scaling-up of interventions to tackle these conditions. Fourth, progressive universalism, a pathway to universal health coverage (UHC) that includes the poor from the outset, is an efficient way to achieve health and financial risk protection. For national governments, progressive universalism would yield high health gains per dollar spent and poor people would gain the most in terms of health and financial protection. The international community can best support countries to implement progressive UHC by financing policy and implementation research, such as on the mechanics of designing and implementing evolution of the benefits package as the resource envelope for public finance grows.

Applying lessons learned from the USAID family planning graduation experience to the GAVI graduation process.

As low income countries experience economic transition, characterized by rapid economic growth and increased government spending potential in health, they have increased fiscal space to support and sustain more of their own health programmes, decreasing need for donor development assistance. Phase out of external funds should be systematic and efforts towards this end should concentrate on government commitments towards country ownership and self-sustainability. The 2006 US Agency for International Development (USAID) family planning (FP) graduation strategy is one such example of a systematic phase-out approach. Triggers for graduation were based on pre-determined criteria and programme indicators. In 2011 the GAVI Alliance (formerly the Global Alliance for Vaccines and Immunizations) which primarily supports financing of new vaccines, established a graduation policy process. Countries whose gross national income per capita exceeds $1570 incrementally increase their co-financing of new vaccines over a 5-year period until they are no longer eligible to apply for new GAVI funding, although previously awarded support will continue. This article compares and contrasts the USAID and GAVI processes to apply lessons learned from the USAID FP graduation experience to the GAVI process. The findings of the review are 3-fold: (1) FP graduation plans served an important purpose by focusing on strategic needs across six graduation plan foci, facilitating graduation with pre-determined financial and technical benchmarks, (2) USAID sought to assure contraceptive security prior to graduation, phasing out of contraceptive donations first before phasing out from technical assistance in other programme areas and (3) USAID sought to sustain political support to assure financing of products and programmes continue after graduation. Improving sustainability more broadly beyond vaccine financing provides a more comprehensive approach to graduation. The USAID FP experience provides a window into understanding one approach to graduation from donor assistance. The process itself-involving transparent country-level partners well in advance of graduation-appears a valuable lesson towards success.

Human resources for health and universal health coverage: fostering equity and effective coverage.

Achieving universal health coverage (UHC) involves distributing resources, especially human resources for health (HRH), to match population needs. This paper explores the policy lessons on HRH from four countries that have achieved sustained improvements in UHC: Brazil, Ghana, Mexico and Thailand. Its purpose is to inform global policy and financial commitments on HRH in support of UHC. The paper reports on country experiences using an analytical framework that examines effective coverage in relation to the availability, accessibility, acceptability and quality (AAAQ) of HRH. The AAAQ dimensions make it possible to perform tracing analysis on HRH policy actions since 1990 in the four countries of interest in relation to national trends in workforce numbers and population mortality rates. The findings inform key principles for evidence-based decision-making on HRH in support of UHC. First, HRH are critical to the expansion of health service coverage and the package of benefits; second, HRH strategies in each of the AAAQ dimensions collectively support achievements in effective coverage; and third, success is achieved through partnerships involving health and non-health actors. Facing the unprecedented health and development challenges that affect all countries and transforming HRH evidence into policy and practice must be at the heart of UHC and the post-2015 development agenda. It is a political imperative requiring national commitment and leadership to maximize the impact of available financial and human resources, and improve healthy life expectancy, with the recognition that improvements in health care are enabled by a health workforce that is fit for purpose.

Parvenir à la couverture sanitaire universelle (CSU) implique la répartition des ressources, et en particulier des ressources humaines pour la santé (RHS), afin de répondre aux besoins de la population. Cet article étudie les leçons politiques sur les RHS de quatre pays ayant accompli des progrès durables en matière de CSU: le Brésil, le Ghana, le Mexique et la Thaïlande. Son but est d'informer sur les politiques globales et les engagements financiers dans les RHS visant à promouvoir la CSU.L'article décrit les expériences des pays à l'aide d'un cadre analytique examinant la couverture efficace par rapport à la disponibilité, l'accessibilité, l'acceptabilité et la qualité (DAAQ) des RHS. Les dimensions DAAQ permettent de réaliser une analyse de traçage des actions politiques en RHS depuis 1990 dans les quatre pays étudiés, par rapport aux tendances nationales des statistiques de main-d'oeuvre et des taux de mortalité de la population. Les résultats indiquent quels sont les principes clés pour la prise de décisions basées sur les faits sur les RHS visant à promouvoir la CSU. Premièrement, les RHS sont essentielles à l'expansion de la couverture des services de santé et de l'ensemble des avantages; deuxièmement, des stratégies RHS pour chacune des dimensions DAAQ favorisent collectivement les progrès vers une couverture efficace; et troisièmement, le succès est atteint à travers des partenariats impliquant des acteurs tant médicaux que non médicaux.Répondre aux défis sans précédent dans les domaines de la santé et du développement, qui concernent tous les pays, et transformer les faits RHS en politiques et en pratiques doivent être à la base du programme de CSU et de l'agenda de développement post-2015. C'est un impératif politique qui exige un engagement et un leadership nationaux pour optimiser l'impact des ressources financières et humaines disponibles et accroître l'espérance de vie en bonne santé, avec la reconnaissance que les progrès dans le domaine des soins de santé ne sont possibles qu'avec une main-d'oeuvre de santé adéquate.

Lograr una cobertura sanitaria universal implica una distribución de los recursos, en particular, de los recursos humanos para la salud (RHS), a fin de satisfacer las necesidades de la población. Este documento examina las lecciones sobre políticas relacionadas con los RHS de cuatro países que han conseguido avances ininterrumpidos en materia de cobertura sanitaria universal: Brasil, Ghana, México y Tailandia. Su objetivo consiste en exponer la política mundial y los compromisos financieros sobre RHS como ayuda para una cobertura sanitaria universal.El documento explica las experiencias de los países mencionados por medio de un marco de trabajo analítico que examina la eficacia de una cobertura en función de la disponibilidad, accesibilidad, aceptabilidad y calidad (DAAC) de los RHS. Los aspectos DAAC permiten llevar a cabo análisis de seguimiento sobre las acciones políticas relativas a los RHS desde 1990 en los cuatro países de interés en relación con las tendencias nacionales en el número de trabajadores y las tasas de mortalidad de la población.Los resultados muestran los principios fundamentales para la toma de decisiones basadas en pruebas científicas sobre los RHS como apoyo a una cobertura sanitaria universal. En primer lugar, los RHS son esenciales para expandir la cobertura de los servicios sanitarios y el conjunto de prestaciones. En segundo lugar, las estrategias RHS en cada uno de los aspectos DAAC respaldan de forma colectiva los logros en la eficacia de la cobertura y, en tercer lugar, los buenos resultados solo pueden conseguirse a través de la asociación de actores sanitarios y no sanitarios.Hacer frente a los desafíos sanitarios y de desarrollo sin precedentes que afectan a todos los países y traducir las pruebas científicas sobre RHS en políticas y prácticas deben convertirse en los puntos centrales de la cobertura sanitaria universal y de la agenda de desarrollo a partir del año 2015. Se trata de un imperativo político que requiere un compromiso y liderazgo nacionales para potenciar el impacto de los recursos financieros y humanos disponibles, y así mejorar la esperanza de vida saludable, sin olvidar que las mejoras en materia de asistencia sanitaria son posibles gracias a un personal sanitario apto para tal propósito.

Ending Preventable Child and Maternal Deaths in Latin American and Caribbean Countries (LAC) / Fin a las muertes evitables maternas e infantiles en los países de Latinoamérica y del Caribe (LAC)

Many countries in Latin America and the Caribbean (LAC) have reached or exceeded their Millennium Development Goal, despite this progress, significant work remains in order to end the millions of preventable child and maternal deaths that occur annually. This will require increasing coverage of high-impact interventions, strengthening the health systems that support these interventions, and addressing major equity gaps within and among countries. On June 14-15, 2012, in Washington, D.C., the Governments of Ethiopia, India and the United States, together with UNICEF, convened a global "Child Survival Call to Action" (CSCTA) to achieve an ambitious yet achievable goal: to end preventable child deaths. A central premise of the Call to Action is that we already know how to prevent most child deaths and can do so by scaling up existing, practical, affordable interventions. The CSCTA and the follow on activities under A Promise Renewed , led by UNICEF, emphasize the importance of developing country-led planning and marshaling of countries' own resources to improve child health. Under this vision, donor support is to be supplementary -not the primary force shaping developing countries' work to reduce child mortality. As a result of the meeting, 175 countries around the world have signed a pledge committing to address child survival, including 31 countries in the Latin American and Caribbean Region.

La mayoría de países de Latinoamérica y del Caribe (LAC) han alcanzado las metas del milenio; no obstante estos progresos, aún es necesario efectuar un esfuerzo intenso para frenar los millares de muertes maternas e infantiles que ocurren anualmente y que son prevenibles. Este esfuerzo requiere de una serie de intervenciones de alto impacto, el fortalecimiento de los sistemas de salud nacionales y la disminución de las brechas de equidad entre los diferentes países de la región de LAC. En junio de 2012, los gobiernos de Etiopía, India y los Estados Unidos, en conjunto con la UNICEF, convinieron en efectuar un "llamado a la acción por la supervivencia de los niños" (CSCTA), proponiendo la meta de frenar las muertes infantiles prevenibles. La premisa central de este llamado es que ya se debe de saber cómo prevenir estas muertes, y poder llevar a cabo las intervenciones de manera asequible y práctica. El CSCTA, conforme las acciones subsecuentes a llevar a cabo, siguiendo a la UNICEF, enfatiza en la importancia de que cada país planifique y calcule los recursos propios que deberá invertir para reducir las muertes infantiles. Bajo esta visión, los soportes económicos de apoyo de organismos internacionales sólo deberán ser suplementarios, no el recurso principal de los países en desarrollo, para reducir la mortalidad infantil. Como resultado de la reunión de junio de 2012, 175 países alrededor del mundo han firmado los compromisos del CSCTA, incluyendo 31 países de la región de LAC.

Human resources for health: overcoming the crisis.

In this analysis of the global workforce, the Joint Learning Initiative-a consortium of more than 100 health leaders-proposes that mobilisation and strengthening of human resources for health, neglected yet critical, is central to combating health crises in some of the world's poorest countries and for building sustainable health systems in all countries. Nearly all countries are challenged by worker shortage, skill mix imbalance, maldistribution, negative work environment, and weak knowledge base. Especially in the poorest countries, the workforce is under assault by HIV/AIDS, out-migration, and inadequate investment. Effective country strategies should be backed by international reinforcement. Ultimately, the crisis in human resources is a shared problem requiring shared responsibility for cooperative action. Alliances for action are recommended to strengthen the performance of all existing actors while expanding space and energy for fresh actors.