On 12 December – Universal Health Coverage Day – let’s be clear about one thing. As the World Health Organization Director-General Tedros Ghebreyesus has said, “Universal health coverage is a political choice.”
And health, he reminds us, is a fundamental right.
A right not a privilege
Despite substantial progress in reducing child and maternal mortality, half the world still lacks access to basic health care. Children still die from hunger and preventable diseases. Women continue to die in childbirth. And governments and policy-makers still allow these violations of human and children’s rights to happen.
The people who experience this loss and deprivation are frequently forgotten and rarely asked by decision makers as to what they want, how they feel or how they can be supported to improve their lives. Decisions continue to be made by people far removed from the realities of poverty, inequality, and injustice.
The space to hold these decision-makers to account is shrinking. Amid the coronavirus pandemic, lockdown restrictions across much of the world in 2020 have made it difficult for civil society – including communities and children – to take part in decision-making on health.
But despite those challenges, and at great personal risk, civil society around the world has mobilised to bring attention to the needs of the most vulnerable people, and demonstrated the invaluable role it plays in addressing inequities and championing health for all.
Save the Children pledges to support any opportunity or initiative that encourages inclusion as a right for all, not a privilege for the few.
Accountability – the beating heart of universal health coverage (UHC)
The overriding finding of the first State of Commitment to UHC report – launched earlier this month by UHC2030 – is that people are “anxious about their health, their finances and their futures, and trust in government and political leaders is eroding” as health needs are not met and poor people are left behind.
The review also finds that accountability has suffered during the pandemic: lines of communication have broken down and people have been less consulted and less included in decision-making. A key recommendation of the report is that no matter the circumstances, mechanisms should be set up by governments for civil society to hold them to account in a more systematic way.
Our new briefing Accountability – the beating heart of UHC takes this discussion one step further. We look at:
- Why should accountability be put at the centre of efforts to achieve UHC?
- How can we do it?
Why inclusive governance makes a lot of sense
Families living in poverty must work hard to survive and to bring up and educate their children. And they must make tough financial decisions around poverty and ill health. So, they know which health services are important, at what level and how much should be allocated to them. They’re highly capable of developing cost-effective and practical plans and making pragmatic choices. And have a personal interest in questioning those who misuse, or waste precious resources meant for improving their health.
Unless governments ensure policy-making, planning, budgeting and monitoring processes and systems are open to social participation, health governance will suffer. And UHC will remain a distant dream for most poor people in the world.
Only when civil society – including children and communities – has more control over decisions affecting people’s lives, including their health, can truly inclusive governance result in public resources being used for the betterment of the many and not the few.
Why is civic space fundamental to achieving UHC?
The allocation of resources to health does not happen in a vacuum. It’s often influenced by the participation of civil society – including children and communities – to express people’s needs. And in return, by how responsive a government has been in meeting these needs.
Source: CIVICUS and Save the Children
Data shows a strong association between civic space and health spending. Countries with open civic space tend to be those that allocate more resources to health. Countries where civic space is narrow or non-existent tend to invest less in health (Figure 2).
Figure 1. Countries with open and transparent civic space spend more on health
For social participation to flourish, civic space needs to be available and safe. Time and time again, our policy engagement work in many countries has shown there are huge disconnects and blocks to civic space that deny civil society the opportunity to engage meaningfully in health governance and in holding their government accountable.
When civil society’s role in governance is not accepted, it cannot access the information it needs to organise and campaign effectively for change. And in these circumstances, when civil society does try to engage in accountability activities, it’s not afforded the protection of the State.
The curbing of civic space and freedoms is the norm rather than the exception: today, almost 97% of people live in countries where civic space is restricted in some way.
How can we put accountability at the heart of healthcare?
Our commitment is that we will promote inclusive governance and will strive to open spaces for civil society, children, and communities to engage meaningfully in decisions that affect their health. And we’ll support them to hold governments and policymakers accountable.
We’re calling on governments, donors and global health institutions to move from the promise of health for all, to making it happen. In short, from commitments to action.
And we’re calling on them to recognise that health for all must be built by all – through taking these nine steps:
- Protect and expand civic space to encourage civic engagement.
- Ensure inclusive and responsive institutions for improved health governance.
- Encourage transparent information sharing and processes.
- Actively engage in global accountability processes.
- Use global processes to hold Member States accountable to UHC commitments.
- Build civil society’s capacity to engage in planning, budgeting, and monitoring.
- Institutionalise civil society participation in global health institutions.
- Establish the WHO Civil Society Commission.
- Measure and report on governance and accountability indicators at all levels.
Health for all