Definitional difference in the scope of UHC among stakeholders have been identified. This difference could further delay UHC to move forward towards fulfillment of the sustainable development goals (SDGs), in attaining harmonization between aid agencies as well as alignment between donors and recipients. Addressing marginalized issues, such as migrant and refugee health and SRHR, within the context of UHC is needed. Nevertheless, they were unfortunately not brought up clearly as part of the official declarations in the event of the G20 Osaka Summit. In the future, understanding perspectives of the G20, T20, C20, H20, and the pharmaceutical sector will become increasingly important to well-coordinate multi-actor cooperation with adequate social responsibility and transparency in UHC achievement, to build a stronger public-private partnership (PPP).
4.1. Migrant health and sexual and reproductive health and rights as a key issue for comprehensive commitment towards UHC
Through an integrated definition that will eventually harmonize the vision and philosophy of UHC between stakeholders, addressing vulnerable topics such as migrant health and sexual and reproductive health rights (SRHR) may be a key issue for comprehensive commitment towards UHC, amid increase in multi-stakeholder platforms and partnerships. Given our results, all actors need to ensure the ownership of both donor and recipient countries among multi-stakeholders as well as a clearer UHC definition.
G20 countries recognized the growing migration trend as noted in the leader’s declaration (3). With about one seventh of the world’s population currently living in a country outside of where they were born (22), international effort is needed to explicitly acknowledge the health needs of migrants and refugees, to include them in the individual national health policies and plans in advancing “health for all” for UHC. The World Health Organization (WHO) also recognized that the SDG 3.8 on UHC cannot be achieved unless the health needs of migrants and refugees are met and health inequity is reduced (23). Migrants still remain as a challenging issue in relation to health as migration and health have different or incompatible goals (24), despite two World Health Assembly resolutions dedicated to the health of migrants in 2008 (25) and 2017 (26), the United Nations General Assembly High Level Meeting on Large Movements of Migrants and Refugees in 2016, and the Global Compacts on Refugees and Safe, Orderly and Regular Migration adopted in 2018. Many countries, including the G20 countries, do not recognize global frameworks for safe migration that protects migrants’ welfare, including migrants’ health. Although the Global Compact for Safe, Orderly and Regular Migration, explicitly stated that health needs of migrants and refugees should be incorporated in national and local healthcare policies and plans, it was not signed by several countries (27), primarily due to economic and security issues. Migrants often experience cultural and language barriers to healthcare (28, 29), regardless of the legal or migratory status, as well as undocumented migrants suffer from severe out-of-pocket payment due to ineligibility of national insurance schemes, which validate the need of migrant health addressed for UHC.
The lack of international consensus on the definition of SRHR as well as family planning driven from its sensitiveness, makes its realization via a concept like UHC difficult. Reproductive health and rights were defined and agreed during the International Conference on Population and Development (ICPD) in 1994 among 179 states. However, ICPD neither defined sexual health nor explicitly referred to sexual rights while the conference assumed that reproductive health embraces sexual health. There have been several attempts to define sexual rights by some organizations, e.g. WHO (30) and the World Association for Sexual Health but no definition has yet to reach international consensus. The lack of international consensus regarding SRHR also lied in the family planning approach, principally in the right to safe abortion. Different beliefs have existed among G20 member states and some members are negative for abortion. For example, the United States recently decided to withdraw its support for federal funding for overseas family planning and reproductive health organizations that provide abortion services or counselling (31). The key for reaching an agreement on SRHR is to highlight several components of SRHR in association to a more widely recognized human rights with definitional alignment of SRHR and family planning. Although, it is a challenge to standardize its definition in relation to diverse interpretation of safe abortion. However, given that there are also many components that the member states have already admitted, e.g. women and girls’ rights and health care for women before and after pregnancy and childbirth, shedding more light on these areas would serve as the first step for member states to realize at least some of the components of SRHR through UHC.
4.2. Strengthening the national evidence-based monitoring and evaluation system
The UHC monitoring framework indicators, composed of service coverage (19) and financial risk protection (20) suggested by the WHO and the World Bank Group in 2013 (32), emphasizes the need to implement national evidence-based monitoring and evaluation systems that aim to attain country-comparability and national data representativeness (33). At the G20 Osaka Summit, this was reemphasized by countries of strong economy agreeing that investing in health at an early stage of development was important for sustainable and inclusive growth, thus encouraging developing countries to mobilize their domestic resources for UHC (4). At the same time, the digitalization of health data to track UHC indicators is needed, especially for developing nations that do not have sufficient amount of quality data (18, 33). Multi-stakeholder platforms and partnerships took a step to the next level where international coordination became more important, especially for aid recipient countries. International coordination is a crucial challenge in investment for global health due to the increasing role of the private financial sector actors (34). Financial outcomes of long-term funding among government institutions and multilateral agencies could lead to risk sharing among health infrastructure projects, for example, with better credit ratings and lower cost of capital (35).
4.3. Building further multi-stakeholder platforms and partnerships for UHC
In order to follow a global action plan for healthy lives and well-being for all, all relevant stakeholders need to collaboratively make effort for UHC through multi-stakeholder platforms and partnerships to support the efforts of member states, not only to achieve UHC but other health-related SDG targets. Multiple perspectives of the G20, T20, C20, H20, and the pharmaceutical sector need to be understood in order to well-coordinate its cooperation for higher participation and transparency in UHC achievement. Furthermore, despite the countries’ growing motivation towards UHC at the national level, there is an essential need for multi-stakeholder platforms and partnerships that ensure all donor and recipient countries to have ownership to further enhance UHC. The UHC2030 serves as a knowledge hub to deliver experience-based or evidence-based resources bridging upon the WHO and the World Bank (WB). Through the UHC 2030, the WHO and WB have the fundamental demand to further work together to share their strong networks with health ministers and finance ministers, as well as to exchange knowledge on health expertise and financial operations that are unique to their institutions. In addition, finances need to be well coordinated, with synergy of traditional and innovative financing mechanisms, including the Global Fund, GAVI, GFF, and the UN Trust for Human Security. Also, based on current international platforms to develop innovative financing mechanisms via public-private partnership, such as GHIT and CEPI, research and development should be facilitated for knowledge sharing from resource mobilization to implementation through the lens of UHC in order to expand the service delivery of vaccines, pharmaceuticals, and other essential medical commodities.
With limited resources of public funding in health development assistance, the need for strengthening the partnership between government institutions, the private sector, academia, and civil society require further emphasis to achieve UHC through traditional and innovative financing mechanisms, taking advantage of the multilateral systems. The coordination between the Secretary-General of the UN and the Member States to achieve synergistically UHC and all health-related targets of the SDGs would be a way forward in ensuring political momentum to achieve UHC by 2030, and to capture UHC-related targets outside SDG 3.8. including migrant health and SRHR.