Sustainable Development Goals in Action: Our World, Our Dignity, Our Future – the theme for this year’s EDD, put the focus of the conference squarely on the 17 (!) SDGs. People, Planet, Prosperity, Peace and Partnership – the 5 Ps of the preamble of the United Nation’s 2030 agenda, formed the overall ‘framework’ for EDD16’s rather heavy agenda. And indeed – for those used to attending conferences which focus quasi-exclusively on health – attending an event which brought together the multiple facets of development and people’s well-being was a refreshing experience. It also gave us a chance to attend and contribute to discussions on sectors outside of health, but which impact health directly and indirectly.

Still, we made sure to attend a few of the sessions on health; naturally, most focused on health within the context of the SDGs – with policies, governance and of course, ‘partnerships’ as the dominant themes. Gender, sexuality, sexual and reproductive health featured in an interesting session on Challenging the Influence of Religion and Universal Access to Sexual Reproductive Health and Rights – which focused on the challenges in bringing about deeper social change set against the sociocultural context. This was a session with experiences shared by the panelists and the audience alike! The “all-female, all Asian” panel might have pleased the likes of Owen Barder and Ilona Kickbusch, but it also somewhat represented the huge challenges facing access to sexual and reproductive health around the world.  Change will be impossible without engaging men in the dialogue –with the panel thus unintentionally symbolic of reality. One of our favorites was the session Time to Think Urban: The Challenge of Building Smart, Sustainable Cities – which had a debate-style discussion format. The session’s introductory remarks focused on urbanization – current trends, the future of urbanization as well as ongoing work (towards the preferred future); then the debate moved on to the – in our opinion critical – discussions on integration and making urban spaces more livable. It’s all nice and lovely to build ‘smart’ and/or ‘resilient’ cities, but one would also like to live in a ‘livable’ city, first and foremost. Not everybody wants to spend (like Elon Musk) his final days on Mars.

What can we learn from such a high-profile event? Well, as is often the case with major frameworks, after years of debates on the definition of the goals and the rationale to pick one rather than the other, hours spent on appropriate wording, the development world is now gradually shifting its attention to more practical considerations – more precisely how to implement these SDGs – 17 goals, 167 targets (and don’t even get us started on the indicators!). To be fair, even if you don’t suffer from vertigo, like one of us does, it’s hard not to feel a bit dizzy in the face of such a challenge! If one was to compare with one of the other mega-events that happened over the last month, more specifically the 69^th World Health Assembly in Geneva, the task of addressing 17 goals in 14 years felt like less over there – perhaps because the focus was largely on one SDG? And yet, with the WHA69 discussions still fresh, one can’t help but draw some parallels between the two events, especially the focus on partnerships, and the focus on the ‘key’ role of the private sector.

In the end, the conclusions of many of these sessions did not look unfamiliar: we need quality education, good governance, empowerment, quality health care, etc. One word was missing though: accountability. How come that such a powerful concept was left out? Well, that’s up to you to judge. Another key issue, that comes as a prerequisite for any progress towards the SDGs: the resources – or to be more precise, the issue of “ever-shrinking” financial commitment to health and development, in line with the dark trend towards an ‘ever more diverging’ European Union. True, NGOs like Oxfam tried to open this Pandora’s Box and brought up the issue of constrained financing (fair taxation for sustainable development for example), but financing for SDGs largely remained at the margins of the discussions. One could perhaps be a little more precise here: a new ‘dogma’ is gradually emerging on the (according to “the development powers that be”) necessary shift towards deeper engagement with the private sector and a strong focus on SDG 17: partnership, often equated to Public-Private-Partnerships. With ‘Leveraging’ and ‘blending’ as some of the preferred buzzwords in this brave new SDG world.

This answer seems quite unsatisfactory to us. There is a key issue to be addressed here, that will decide whether the SDGs will be transformative or not: is everyone going to bring their fair share to the table? And let’s not believe in charitable actions conducted under the mantra “Corporate Social Responsibility”. This is about raising sufficient funds via progressive taxes, for which a democratically elected government is held accountable. Can we imagine – as Eva Joly, European Deputy and 2012-green party’s candidate for the French presidential election rightly pointed out – that we can make any progress towards SDGs while in today’s world, Low-Income Countries receive only 1% of the revenues generated by oil extraction on their territory – a figure to be compared to 69% of the oil revenues collected by the Norwegian government.

At a time when diseases such as Ebola and Zika go beyond boundaries; when war and political unrest have created one of the biggest humanitarian crisis in recent times, we would perhaps do well to remember that all-encompassing goals and partnerships to achieve them are all very nice; but perhaps what the world really needs, is a definitive, concerted effort to actually commit to improving the well-being of people.

In many Arab countries, memories of the so called “Arab spring” are still very vivid. However, four years after large swathes of the Tunisian population took to the streets to claim more freedom and improved social justice, a new societal model is still to emerge. Substantial changes in decision making processes still need to happen in order to accommodate the new aspirations towards a more participatory, equitable and evidence-informed decision making process which is in turn expected to lead to a more inclusive and accountable government.

In most of the Arab countries, such a transformation of the policymaking process will be anything but easy. To use a medical metaphor, the delivery will be long and complicated, and “success” is certainly not inevitable. However, a few ongoing initiatives are worth an in-depth look. One of them is certainly the large-scale consultative process – the “societal dialogue” – currently taking place in Tunisia. This dialogue aims to tackle some of the above mentioned governance issues through a high level of citizen involvement in the decision making process. The first phase of this dialogue ended beginning of September 2014, in Tunis, during the national health conference. Its objective was to identify, in a participatory manner, the potential contribution of the health system to the realization of the right to health, recently enshrined in the new Tunisian constitution.

What was the starting point of the whole consultation?

A steering committee composed of 75 representatives of the entire health system and beyond – supported by a technical committee in charge of the coordination of the process – adopted and piloted a national consultation in 2012 comprising the following steps.

First, from June 2013 to March 2014, this steering committee conducted an in-depth assessment of the Tunisian health system, based on a broad literature review, complemented by thematic workshops, expert panels and focus groups with citizens, experts and health professionals. This assessment engaged more than 800 individuals.

Then, in April-May 2014, two health “rendez-vous” were organized in each of the 24 Tunisian administrative regions: one with health professionals, another one with a more or less representative group of citizens. All in all, 3,424 people had the chance to discuss and add to the findings of the above mentioned evaluation, and express their opinion on the values that should shape the Tunisian health system.

A third step, in June 2014, gathered 92 citizens and health professionals (selected through a lucky draw during the “rendez-vous”) together with 15 national and international experts. The people from this group aimed to make a synthesis of the assessment and the large consultation conducted in the administrative regions. They came up with some conclusions which were shared during the last step of the process: the national health conference, which took place from September 2^nd to September 4^th.

We were fortunate to take part in the national conference. This conference brought a real ‘marathon dialogue’ on strategies to align the Tunisian health system with the aspirations of the citizens to a successful conclusion. The event produced the Tunisian white paper for the health sector.

The truly participatory “feel” of the process really struck us. We were impressed by the constant concern of the organizers to give voice to a, till recently, rather “symbolic” figure in the political system: the citizen. They also sent out feedback to the outside world through a website which aims to raise awareness about the health system and the ongoing societal dialogue (see especially the section “Le saviez-vous?”, literally “Did you know that…”). Here we could feel the vigour and enthusiasm of a brand new democracy.

Of course, there were implementation gaps. For example, one of the key questions is to know whether the organizers have managed to assure randomness in the selection process of participants, as intended.

The weak institutionalization of the process is also a great concern today, especially with the rather low level of ownership from both the technocrats from the Ministry of Health – who felt left out of the consultation – and the political parties which didn’t integrate the recommendations of the national conference into their electoral promises – the first democratic elections in Tunisia will take place this weekend (26 October), by the way. But let’s not deny one fact: this was a real attempt to address, within the health system, some of the concerns expressed by the citizens in the streets four years ago. This is evidenced by some key figures e.g. the 120 hours of dialogue recorded/taped in the process. More, it’s probably one of the few key attempts so far, while most of the Arab countries still fail to deliver a new social contract that satisfies the majority of their citizens.

About a year ago, the Moroccan Ministry of Health also organized a national health conference (a new trend in Arab countries?). Goals were similar but the process was different – the Ministry of health took the lead in the Moroccan process.

Two ways, two models to translate social aspirations into political practices? Before we can make such a claim, it’s important to first document these two processes in-depth and identify differences and commonalities. Only then we’ll be able to explore and assess the results of these “models” in their respective contexts. What kind of results? Well, as Rashad’s rightly stated in a Lancet special theme issue on health in the Arab World, last January: “The legitimate aspirations of the Arab population are suffocated by deeply polarized societies and a very narrow interpretation of social justice.” In other words, can these two processes address this gap and make significant steps towards the realization of the right to health?

Let’s wait and see, but what an interesting topic!

This week, the 10^th World congress in Health Economics – organized jointly by the International Health Economists Association and the European Conference on Health Economics, gathered about 800 participants in Dublin around a promising thematic: “Health Economics in the Age of Longevity”. Freshly back from there, I wanted to share some of my impressions “à chaud” on the event. I attended this event with two objectives in mind: first, disseminating some of our findings of the Health Inc research project in Senegal, which evaluated the effectiveness of Plan Sésame – an exemption policy targeting the older population – from a social exclusion perspective; second, learning more about the impact of ageing on health systems around the world (especially in terms of health financing).

Nowadays, almost every country sees the proportion of people aged over 60 years growing faster than any other age group. If the consequences of this trend on health systems and beyond is widely debated in the North, it remains a blind spot in the vast majority of Low- and Middle-Income Countries (LMICs). Although the relative weight of this age group in the national populations is far lower than in High Income Countries , in absolute terms, there are more older people living in LMICs at present. This is the case for more than 40 years already. However, upward trends are impressive: between 1950-2000, 66% of the global increase in people over 60 occurred in LMICs. This brings strong concerns about the implications of such a fast ageing societies for workforces and the sustainability of health and social, in particular long-term, care systems, in particular with the fast-emerging burden of Non-Communicable Diseases (NCDs).

To tell the truth, I was a bit disappointed about the conference. Nothing to deal with the fact that I presented in front of a sparse audience (early morning on the Monday following the world cup final, probably not the best time slot to draw a large number of people). It is rather because it seems that I had misinterpreted the title of the congress: many sessions had actually little to do with the issue of ageing. Furthermore, the logical link between the three or four individual presentations in each session was not always obvious. My opinion is probably biased, as I could not attend all the 14 parallel sessions, of course. However, it seems many people shared the same “gut-feeling”.

So, let me focus on one organized sessions which covered a topic that is often addressed in our newsletter: Universal Health Coverage. The session was organized by the Center for Global Development, in collaboration with the World Bank and WHO. The title was “Developing a standardized framework for measuring universal health coverage”, an endeavor in which the World Bank and WHO are willing to take a driving seat. The two first presenters detailed the process and the content of the proposed framework for UHC monitoring developed jointly developed by the World Bank and WHO, while Gisele Almeida from the Pan American Health Organization attempted to apply it to the case of Latin American Countries.

The development of such a monitoring framework is central for the operationalization of the UHC concept. However, two key components are still missing, I think. The danger is that, if the framework is adopted worldwide in its current state, these two dimensions are likely to remain blind spots of the health sector in the coming years. First, despite the good intent to “adjust” the indicators of financial protection and access to quality services, there is no clear strategy on how to perform such an adjustment, while quality has been proven to be a key driver to access to care (nothing surprising here). Secondly, despite the repeated calls to integrate the social determinants of health in the framework, noticeably by members of the Commission for Social Determinants of Health and from the Civil Society, this dimension is once again left aside.

It is sometimes (if not always) interesting to go back in history to better understand our present. In this case, going back to the 1978 Alma Ata declaration on primary health care and analyse how, after this conference, the concept of “health for all” was gradually transformed into a more reasonable “essential services for all”. . Reasonable? Really? I let you think about it but, in my opinion, I would argue that this was not for the best. If we want UHC to be a driver towards a fairer world, we need to think broad. And if this framework remains as it is, we can expect several articles on “UHC and the missed opportunities” in 10 years from now.