Is civic space the cornerstone of universal health coverage?

The march progress towards universal health coverage (UHC) is gaining momentum. More and more countries are passing legislation and developing policy frameworks, guidelines and implementation plans in support of advancing the UHC agenda. National developments are increasingly aligning with global moments – such as this month’s World Health Assembly and the UN High-Level meeting on UHC in September 2019.  Alongside that, the civil society engagement mechanism for UHC2030 is pushing for greater accountability and civil society participation in order to achieve UHC and Sustainable Development Goal 3.

Civil society organisations, both globally and nationally, have been the drivers of much of this change over the years. They play a critical role in holding governments and global health organisations accountable to commitments they have made. There is broad acknowledgement that strong and active civil society and community involvement is an integral component of a country’s progress towards UHC. To achieve the goal of UHC, it’s therefore clear we need to build resilient national health systems. And an important component of them is resilient social accountability systems.

Taking resilient systems for health first, we know that they require:

• legislative frameworks
• policy guidelines
• adequate financing and domestic resources
• good-quality health workers who are employed, remunerated and deployed to areas of need
• strong leadership, political will and transparent governance
• comprehensively financed primary healthcare services
• freely available medicines, vaccines and commodities
• systematic digital health information systems.

Many countries try to address certain components within these pillars, but very rarely do we see all pillars working together in a systematic manner.

Social accountability systems, on the other hand, are less clearly defined. Perhaps as a result, they don’t get the same attention from governments, donors and even civil society. Effective social accountability systems require that:

• civil society and communities are informed and empowered with skills, capacity and voice to engage in an informed way
• they have access to information on planning and budgeting, supported by legislation
• they can engage in a meaningful way in a safe environment
• perceptions about corruption do not deter participation, reporting and whistleblowing
• government understands, accepts and encourages the role that civil society and communities play in planning, budgeting and holding them accountable.

At the 72^nd World Health Assembly 2019, Save the Children is launching a Universal Health Coverage and Accountability Index. It highlights the importance of looking at systems for health in a more integrated and comprehensive way – by bridging from traditional health indicators to accountability ones. The hope is that governments, donors and civil society will give equal importance to accountability indicators when they are working towards building stronger health systems. The Index also calls for increased public health financing, improved and more equitable health coverage, prioritisation of primary health care and increased investment in skilled health workers.

On those points, we know that investing in more skilled health workers can often reduce child mortality. We also know that many countries with higher expenditure on health often have lower child mortality. The Index goes a step further: it shows that countries with less civic space are often those with higher child mortality. And the data in the index reveals that many of those countries have higher perceived levels of public sector corruption and less budget transparency. These factors make it a challenge for civil society and communities to engage in processes and decisions that impact their lives.

These are critical correlations for governments, donors and civil society to take note of for future investment and planning. We cannot go about business as usual if we want to achieve UHC.  Financing mechanisms for achieving UHC need to go beyond government stakeholders to include civil society and community. Only when government, civil society and donors are in equal partnership can we build an equal playing field to jointly achieve UHC.