I argue in this short piece that this quote does not capture the very nature of UHC, is somewhat misleading and can lead to (possibly, massive) implementation failure. The quote is a key component in the packaging of UHC, though, globally and nationally. It occupies a prominent place in all key communication tools of WHO related to UHC. You find it for instance on the WHO UHC website. Above, I highlighted some of the terms in the quote I find especially troublesome.

Let’s focus first on UHC as a ‘single concept’.

Dr Margaret, engages herself deeply in this quote (see ‘I regard…’). She gives the quote in this way all the symbolic value attached to her function as the Director-General of WHO, but also commits herself as an individual human being to UHC. This personal engagement is powerful and important. So far so good.

Admittedly, the phrase ‘the single … concept that …’ may be stressing more the overall powerfulness of the UHC idea, in the quote, rather than UHC being a ‘single concept’.

Still, the very term ‘the single concept that …’ is a bit misleading. It gives the overall impression that UHC is a unique, clearly circumscribed concept that can be reached fully by Public Health (and once achieved, can be taken pretty much for granted). True, that is not WHO’s view. Elsewhere for instance WHO acknowledges: “Universal Health Coverage is a dynamic process. It is not about a fixed minimum package, it is about making progress on several fronts”.  WHO also considers UHC as an “umbrella target” in the SDG health agenda, with the target 3.8.

If you have Joe Kutzin’s razor sharp intellectual abilities, then UHC is in fact a clearly defined concept – in a recent WHO Bulletin piece, he sets UHC (successfully) apart from Health Systems Strengthening (HSS), resilience of a health system & health security. In a previous one, he already convincingly argued that not anything goes under the umbrella of UHC.

Yet, for most people on the globe, not the least citizens, UHC will always be a bit fuzzier, and not that easily isolated from other objectives (or even means). And that is just fine! Indeed, the ongoing quest to set UHC “apart” (while at the same time seeing UHC as an umbrella target), while understandable, entails some risks as well. No doubt, the isolation attempt also has to do with other (good) reasons such as the need to have well-defined and measurable indicators, but there’s always a risk of branding UHC as yet another vertical program (which could then further jeopardize national health systems). This is one of the reasons why I find the quote a bit problematic.

The definition (as in target 3.8) – “Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all”  – already tells a different story on the nature of UHC.  As Joe, Adam Wagstaff & many others (including Chan) rightly argue, UHC in its very nature is composite. There are several key sub-dimensions such as equity and quality, it’s about more than (just) access and coverage (or the UHC ‘cube’). Those concepts of equity and quality are themselves hard to define, grasp, measure and achieve, and require very complex interventions that still need more clarification from the global community of researchers.

Lately, UHC is also increasingly being linked to global health security & resilient health systems, for obvious reasons – in the words of Marie-Paule Kieny for example, the “Post-Ebola realisation of the crucial importance of HSS, and the intimate connection between HSS, UHC and health security”. Those ways of looking at UHC are great, and deserve a more prominent place in the global branding effort.

I have a hunch that the original quote from Chan was inspired by the initial focus on the (still very relevant) “UHC cube”. Yet, by now, UHC has become a “benign” beast with many more heads and subdimensions –  quality, equity, global and national health security concerns, … are all becoming more important in the new SDG UHC era. So rather than UHC as a ‘single’ concept, I’d argue it’s ‘married, and even polygamous & unfaithful’ ! (Which might, at least in the UHC case, not necessarily be a bad thing  ).

Let’s go then to the second criticism: the quote states that UHC is a concept “that …Public Health has to offer”.

In my opinion, public health in several low and middle-income countries has a rather limited clout and leverage in terms of boosting and providing of UHC. In several African countries, for example, public health is integrated in the ministry of health or the ministry of public health. Medical doctors usually lead this governmental body. While they do very important work, I strongly believe that UHC requires a double social transformation: the first one involves going from an individualistic perception of life to a society with more social cohesion and a new social contract; a second transformation is also required to reach a global and national “mutualization” of efforts and resources in order to achieve better social inclusion and protection. This double social transformation requires in many LMIC settings, among others, a key governance transformation, which would hopefully spark – very importantly – also more trust in (national, regional, …) governance entities. The Ebola outbreak in West Africa just showed – again – the importance of the latter. Something similar is true for UHC – by way of example, why on earth would people in communities trust an (in their view unreliable and/or corrupt) government with collecting national health insurance premiums? Catalyzing and leading these sorts of broad societal & political transformation, taking also into account the unpredictable and complex nature of UHC reform, are far beyond the scope of capacities of a public health body dominated by medical doctors. So in the post-2015 era, among others, “governance” has become a key UHC concern, as parts of WHO themselves emphasize.

The focus on ‘public health’ in Chan’s quote can probably to a large extent be explained by the (initial) capture of the concept by the ministries of health, and the tacit or explicit exclusion of other key social bodies that have a key (and often more crucial) role to play in the process.

So with the current knowledge of the global health community, I feel the quote has to be adjusted. It has to recognize that ‘public health’, dominated as it tends to be by medical doctors, is limited in its capacity to help societies adopt and move faster to UHC. At the very least, the quote would have to use a term like ‘Public Health 2.0’. Also, Chan would do well to recognize that UHC is not particularly ‘single’ either.

For the ones who want to quote me on this: “I strongly believe that UHC is a polygamous, married and slightly unfaithful concept. The achievement of UHC requires the engagement of all the ‘driving forces’ in the country (as well as relevant global ones) under the leadership of – transparent and trusted- public governance.” This is the kind of UHC quote, I’d like Chan (or her successor) to come up with someday. (I admit, it feels a bit odd, having ‘unfaithful’ and ‘trusted’ in the very same quote. But health systems are complex!)

By the way, WHO and many other key global health actors in favour of UHC seem to understand this too, increasingly – see the idea to set up a UHC 2030 Alliance, as discussed at the latest IHP+ Steering Committee meeting in Geneva.

So who knows, maybe one day Chan will utter the magical words?

The ongoing refugee crisis in Europe is described as the most important one since the second world war. That might be a bit of an overstatement, but with mass media and social media spreading 24 hours a day heartbreaking images, the global impact of this crisis is certainly very real. Later this week, the issue will also be a hot button-issue at the UN “SDG” summit in New York. Switching the poles, in this post, 3 Emerging Voices from Africa and Latin America zoom in on the refugee crisis in Europe, somewhat surprised at the low resilience of supposedly “developed countries”. They wonder how the crisis may affect the global community’s stance on issues such as the status of refugees and migrants, global inequity and an overall social contract, in the new SDG era.

What makes the refugee crisis in Europe so special?

According to the International Organization of Migration (via the Missing Migrant Project), in 2015, as of 22 September, there were already 481,612 arrivals of refugees and migrants (the distinction between the two categories isn’t always that clear) by sea to Europe. Many were from Syria, but they also come from other countries and regions, such as Eritrea, Afghanistan, Pakistan, Nigeria, Somalia, Sudan,  Iraq, …. In 2014, according to a 2014 UNHCR  report , there had been 219.000 arrivals by sea to Europe, already an almost fourfold increase of the 60.000 reported in 2013. In 2015, due to the sudden spike, European populations, politicians and media finally began to pay attention, even if boat catastrophes had already happened in 2013 (for example off the coast of Lampedusa). It’s hard to predict how the situation will further evolve, but even acknowledging the record influx of refugees, if you compare these figures with the unprecedented nearly 60 million of people worldwide that were forcibly displaced at the end of 2014, from the outside this refugee crisis still looks manageable, especially for a rich continent like Europe. Especially if you keep in mind that 82% of these displaced people are hosted by developing countries.

So if it’s not the stats, what makes the crisis in Europe so special then?

The deaths, first and foremost. The contrast between Europe’s worldwide image as a fairly safe continent and its newly acquired ‘status” as one of the most dangerous destinations in the world is striking. Thousands of people have died already. Many deaths occur during the often deadly travel in unsafe conditions over sea. 2,872 dead/missing are reported in the Mediterranean alone among migrants and refugees since January 2015. This figure represents 73.6% of the 3,901 deaths/missing reported worldwide among migrants and refugees, far before the Bay of Bengal where about 12% of the worldwide deaths/missing migrants and refugees are reported. The 3-year-old Syrian Alan Kurdi  from Kobani, found dead on a beach in Turkey is no doubt the most heartbreaking symbol of this carnage. But not just the Mediterranean sea is proving deadly. The images of the 71 refugees who died in Austria from asphyxia in a trunk reveal another deadly face of this refugee crisis.

Another striking aspect of this crisis are the often severe “clashes” with the border policies of Europe as implemented by Frontex and European national governments. Coverage in media presents a rather different picture of Europe and many Europeans than what the world is used to – as you know, the EU prides itself on its values and human rights and aims to be a global role model. Instead, European authorities struggle to keep up with the fast evolving crisis, and often resort to heavy handed methods and measures to deal with the “crisis”. There are currently 8 main migration routes to Europe: the Western Balkan and Eastern Mediterranean routes are probably the most important ones. The others are international airports (for the lucky ones), the Western African route, the other Mediterranean routes (Western and central), the Apulia and Calabria route (i.e. via Italy), the Circular route from Albania to Greece and the Eastern Borders route. According to the Dublin agreement, refugees seeking asylum are supposed to apply in the first member state they reach until the decision about the asylum is taken. The countries in this case – the so called “frontline” states – are Greece, Italy and Hungary (although the latter refuses this status). As their economic situation isn’t exactly brilliant, they are mainly perceived by refugees as transit destination to richer countries such as Germany, Sweden and England, countries that offer more jobs, or so they hope. So aspirations of refugees clash  with the current border policies of Europe, which has led to violent reactions from border officers, mistreatment, the erection of a new Hungarian “wall”, putting refugees in cages, tear gas used by police and army on refugees, all in violation of international conventions. One of the scenes which went viral involved a Hungarian “journalist” kicking refugees. The Dublin agreement is dead and buried now, and Schengen is under huge pressure as well, after Germany’s decision to close the borders and a domino-effect thereafter.

The third element relates to the media. Audiovisual and other mass media all provide 24-hour coverage of the plight of refugees and other migrants in various European countries. Cyberspace and social media amplify this, the many tweets from Peter Bouckaert (Human Rights Watch), who tries to put a human face on the “crisis” and the “stats” are just one example. By now the whole world cares, everybody has an opinion on what’s happening at Europe’s borders and inside Europe now, much in line with what Appadurai already predicted   and described in his classic ‘Modernity at large: Cultural dimensions of globalization’ (1996): he reckoned the media and population migration are the most important factors defining today’s global world, exploring among others their joint effect on global ‘imagination’. What is happening now is a clear case in point. (PS: anecdotal evidence also shows that the first commodity that many refugees value is their smartphone, far ahead of food and shelter, as it allows them to communicate with their relatives and friends. In some cases they also use it as a tool to send out distress signals in case of major danger).

As a result, frustration of refugees towards European authorities is piling up as Juncker, Hollande & co don’t seem up to the challenge, to put it mildly. In addition, European leaders are seen as constantly hesitating and disagreeing among each other. The predictable result: uncoordinated reactions, near-constant violation of international refugee laws, (more) deaths and unworthy conditions for thousands of women, children and men on a very difficult journey (that needn’t be so difficult in the first place). Let’s hope that with the recent “momentum” in Brussels that will change now.

In the following, we will first discuss the position and “leadership” shown by Europe, the UN and the African Union in this crisis.  We will then reflect on the deep reforms needed to overcome this crisis (sustainably, preferably) and prepare the world for the 21^st century, according to many ‘the century of migration’.

Europe, the UN and the African Union:  lack of leadership

The refugee crisis is a test of the European Union, probably one of the biggest in its history (if not the biggest). And it comes right after the latest (Greek) episode in the Eurocrisis saga, which also put(s) severe stress on the European construction. The European reaction to the refugee crises so far has been utterly disappointing. You can say European leaders failed this ‘stress test’, at least for now. Nevertheless, two phases can be distinguished: the one before the death of Aylan and the period after that.

Before the iconic picture of Aylan went viral, Europe as a whole pretty much looked away from the refugee crisis, counting on Frontex and unsafe journeys to limit the number of refugees trying their luck. In short: much more “Fortress Europe” than “Europe as a role model” for the rest of the world. As an example, the horrific situation of refugees in Calais, trying to reach the UK, only bothered a minority of European citizens. True, humanitarian – some would say near-criminal – catastrophes like the one in Lampedusa had shaken up European technocrats and populations briefly, but that usually didn’t last long. By and large, Europe shied away from a moral leadership role, basing its positions and policies (or lack of it) on an effort to contain nationalist or even xenophobic reactions from extreme-right and/or Eurosceptic parties. Beefing up of Frontex was one of these measures taken. The multi-level governance in the hybrid European polity made the decision making process also not any easier.

Among the population, there were (and are) huge divisions as well, both among and between European member states. In all European societies, a large proportion of the population feels somewhat torn between the desire to show some solidarity to people clearly in need, also in line with human rights and international conventions, and on the other hand a fear that cultural identities will be affected, and national security systems will come under more pressure. Unlike civil society organizations, most people feel a bit ambiguous; many are also downright xenophobic. In line with their populace, national leaders also take ambiguous positions, matching lofty human rights and solidarity rhetoric with a rather stingy quota/repartition approach (about only 120000 refugees!). This approach even failed to materialize for a long time, in spite of huge pressure from Juncker and others. Some Eastern European states refuse quotas, and want every commitment to be ‘voluntary’, to avoid precedents. At the Europe level, several summits failed to deliver a clear consensus. A coherent European policy remains a distant dream for the time being, even if Ministers of Internal Affairs reached a deal yesterday on the repartition, after a vote.  (apparently, the word “quota” is dropped now – as even European technocrats feel there’s something wrong with using the term “quota” for human beings (as in “milk quota”)).

Admittedly, to some extent, the European mood, both among people and leaders, changed with Aylan, even if it remains to be seen whether the toddler’s sad fate will really change the course of the response to this crisis. But after the sad picture was shared all over the world, the refugee crisis got at last a human face, beyond the mass pictures of refugees on boats or in makeshift camps such as in Calais. Germany stood out as a moral leader in the days and weeks after the global commotion over the picture and what it represented – a horrendous failure of the international community, Europe first and foremost. In the words of Angela Merkel: “What we are experiencing now is something that will occupy and change our country in coming years, we want the change to be positive and we believe we can achieve that.”  “Wir schaffen das” is already one of the catchphrases of 2015…  Pope Francis couldn’t stay behind – he asked every catholic parish and monastery in Europe to welcome a refugee family on its premises, welcoming himself 2 families at the Vatican. The (catholic) Prime Minister of Hungary, Orban, didn’t exactly cheer, from what we heard.

The German “can do” attitude & scenes of applauding citizens (on the sight of arriving refugees in German train stations) also created a wave of optimism and positive reactions in other countries, including in Hungary (with plenty of volunteers working hard to help refugees). But in spite of many uplifting stories (such as the little kid kicked by the Hungarian journalist, re-appearing with Real Madrid player Christiano Ronaldo on the pitch, beaming) fragmentation in Europe on this issue still runs deep, as the reintroduction of border controls by Germany proved, frustrated at Hungary’s (and other Central and East-European countries’) lack of commitment. A coherent European policy is still lacking. The vote needed yesterday among Ministers of Internal Affairs evidences the fragmentation. And let’s hope that some of the more wacko ideas don’t materialize. An example of the latter: important European decision makers (such as Hollande but also some politicians in Belgium) are floating the “new” (and rather lousy) idea of European military action in Syria itself. Many others understand that would probably worsen the situation (rather than help).

In short, the EU hasn’t yet gotten its act together, and one wonders whether it ever will. Worse, the crisis has already shaken the European construction itself to the core. Like in the Eurocrisis, it turns out the EU is far less resilient to some of the globalized challenges of the 21^st century than its citizens (and leaders) perhaps thought.  Not to mention the sorry fate of the refugees themselves, obviously.

The United Nations and its specialized organizations showed poor leadership as well. The UN High Commission of Refugees (UNHCR) is a prime example, together with the World Food Programme (WFP) one of the key UN agencies in charge. UNHCR is facing more and more criticism, even if not every analyst agrees. Many critics contend, for example, that the refugee agency “should have been more assertive in opening doors in Europe, as it has done in past crises”.  UNCHR has not been very present in many cases and places where migrants were struggling and suffering (in terms of health assistance, protection, or defending their rights when they were beaten, rejected at the borders or mistreated in inappropriate camps). UNHCR typically reacts by unenforceable statements and invitations to European countries to revise their positions. Underfunding is a key issue as well, in a story familiar to other UN organizations. Underfinanced and largely depending on European countries, UNHCR is currently facing the largest ever number of displaced populations and may not consider refugees migrating towards and in developed European countries as being as much at risk as those travelling from south Sudan to neighboring countries or fleeing from Boko Haram, for instance. Overall the limited reaction capacity of UNHCR and its lack of moral leadership in these times of enormous humanitarian crises is a key issue that may affect the overall future of UN global leadership, even if there are mitigating circumstances.

As for the African Union (AU), the organization again demonstrated its brilliant absence in times of crisis. We’re still waiting for a meaningful AU response to the deaths of several hundreds (or thousands?) of Africans dying in the Mediterranean sea while trying to reach Europe. And let’s not forget about the ongoing brain drain. In the absence of any coherent migration policy, the continent is still losing a huge proportion of qualified resources purposively selected, attracted and kept in (some) European countries or in American countries with targeted immigration policies such as Canada and the US. Despite the financial and other contributions of this diaspora to the development of their home countries and the continent, the huge brain drain prevents the emergence and flourishing of locally adapted initiatives to solve context-specific problems. A vicious poverty cycle on the continent is the result, at least in a number of SSA countries:  1) Countries are poor 2) there’s massive emigration of qualified and talented human resources. 3) Countries lose key actors that can help develop them 4) Countries thus remain poor or become even poorer. Now more than ever, it is time for the African Union to speak out, and design and implement a clear and sustainable policy on migration.

So there were clear leadership & governance gaps at many levels and in many corners (and we haven’t even discussed other stakeholders, like the Gulf countries, the US and Russia & China). But the ones we mentioned here should clearly get their act together via thorough reforms, coherent policies and the like. Having said that, it’s also time for global actors and stakeholders to address the root causes of this – to some extent predictable – crisis.

Instability in the Middle East & North Africa and Inequity are the root causes of the problem

Many observers already made the link between this refugee crisis and the SDG agenda, and rightly so. The current mass migration to Europe’s heartland has complex origins, though, one of them the war led by the West (“from behind”?) in Libya and the horrific civil war in Syria, where there are plenty of other “stakeholders” present, besides Assad and IS. A lot of the current unrest and wars in the region started with the Arab Spring, as you might recall. The Arab Spring was, initially, to a large extent about inequity, and the inability of governments in these states to respond adequately to the growing demands of political inclusion, good governance, job creation and policies of inclusive growth. The ecological pressure, a key determining factor of  the Syrian crisis , also illustrates the close links between ecology, stability, economy and migration in a globalized world. The 21^st century world is a complex world in which everything is connected with everything, and with crises rapidly spiraling out of control, if not nipped in the bud. Some observers use the term ‘disintegrative crises’.

Let’s hope that out of this European refugee crisis, a crisis with global causes as well as ramifications, the world will learn that no sustainable development is possible if it is not shared. Whether economic, imperialist, hegemonic, climate, religious or political reasons play a determining role or not, for sure this refugee crisis reveals the current state of our world: we live in a world with huge inequities in terms of economic capital, environmental and/or political safety. This crisis reveals that building a wall and borders as perfect filters to allow in and keep only “the best” human resources is unsustainable. This crisis clearly shows how strong and determined even desperate people can be in their search for a better future in a world, which is now virtually borderless, at least on the level of imagination. Information on opportunities, dreams, achievements and successes is shared very fast and reinforces the aspirations of many people around the world, dreaming of a better life. Chances are this trend will not stop any time soon – Pierre Lévy is one of the many predicting  that human beings are once again becoming ‘nomads’.

The migration also crisis shows – mercilessly – that “ideal type”-neoliberal globalization remains far off: nation states are advocating free movement of goods and capital but clearly not of people. European authorities are even fussy about refugees, let alone migrants. Yet, due to this quantum leap of global imagination and interdependence, real and even biopolitical borders are increasingly turning out more porous than thought.   If we were to put the same amount of resources into the battle to prevent deaths from migration (such as Aylan’s) (as we are doing trying to stop migration), we would no doubt end up with a safer world. However, the world is still acting as though creating insecure routes for migration is a “prevention tool”.

Equity, Resilience and a Global social contract

We believe that this crisis will not end soon and will transform the world, for better or for worse.  Already, it changed the face of Germany, even if not all German citizens agree with the moral stance and leadership of “Mutti” Merkel. Like Germany’s leaders, we think that the ones who will eventually get the best positive effects out of this crisis, will be those emphasizing Equity, Resilience and a New Global Social Contract.

During the 30s, Roosevelt came up with a “New Deal” for America. Now the world is in dire need of a “New Global Social Contract”. The SDG agenda launched later this week is a start, but only a start. If we want a resilient and equitable world, much work remains to be done and many battles still need to be fought. But let’s learn from the courage of many refugees, including old and very young ones: they show the grit we will all need in the coming years.

Equity requires shared well-being and is “now more than ever” a key criterion of sustainable development, all over the globe. We are far removed, however, from a world in which everybody is (or will be) happy wherever he/she is. We might in fact never reach that point since migration has been a force of nature throughout human history. Hence, the capacity of countries to react quickly and adapt their systems and societies to absorb different kinds of shocks – their “resilience” in other words – also has to be debated in the framework of such a New Global Social Contract, both for developed and developing countries.

Last but not least, in spite of the trend whereby in an increasingly globalized world national identities are somehow getting stronger, often around the key issue of social contracts, a truly Global social contract cannot stop at national social contracts and security systems. That is a tricky position, politically speaken, in most European countries for the time being – many populist politicians (Bart de Wever in Belgium, for example) even want to restrict the social rights of refugees ( going against international conventions), as compared to ordinary citizens. So refugees would get a different (“second rate”) citizenship compared to normal citizens. The claim is often, that refugees shouldn’t “take advantage of social security systems without having contributed to it”. But that’s a dead end, whether European citizens like it or not.  Perhaps the time has come to start a real debate on a borderless social insurance scheme? Could it be that the social contract based on territory and national identity is reaching its limits, now that the world is moving at an incredible speed, both in cyberspace and the real world?

Conclusion

This European refugee crisis is perhaps not the biggest one in history but it is safe to say that it has already mobilized the biggest “collective intelligence” (if you allow us a buzzword) ever, with an unprecedented number and sorts of channels for interactions, and mobilization of interests and skills of a huge number of actors across the world. The world will be changed one or another way after this  crisis. Let’s hope the global response will be grounded in equity and dealing effectively with the current – suboptimal – resilience (capacity) of developed and developing countries versus demographic & migration changes and all kinds of other shocks (not the least the coming waves of climate refugees). Let’s also hope that the post-2015 world will heed the call for a new generation of social insurances schemes in the new anthropological global cyberspace.

Are we culturally and mentally prepared for a world in which many human beings are becoming nomads again?

Only time will tell.