Category Archives: Advocacy

Reflections on the struggle for the right to health

My journey to the fight for the right to health stems from a personal health experience: as a three-year-old, I almost lost my left kidney due to infection caused by a congenitally blocked ureter. But, because of the heroic advocacy of my parents, and the resources we had available to us, I was able to receive the reconstructive surgery necessary to repair the damage and save my kidney.

Because my story is the exception, not the norm, I’ve become veritably obsessed with political, social, and economic forces that systematically exclude the vast majority of humanity from access to the care they need to live. Why is it that effective surgical intervention is reserved to the top 1% of humanity? Why is it that I, a privileged white, wealthy, cis-gendered, straight man, am nearly guaranteed a life of comfort and freedom, despite a nearly life-ending congenital illness as a child? Why is it that if I had been born into another body, or in another place, I’d likely not be alive to write these words?

We know the answer: most humans on the planet are deeply constrained by intersectional forces of grinding poverty, racism, sexism, homophobia, and democratic exclusion. Paul Farmer and others have termed this ‘structural violence:’ the violence that seems to have no individual perpetrator–it appears to be all around us, yet not advanced by any of us in particular–that causes the systematic and unnecessary death of the poor, excluded, marginalized, different.

Today, though, we have a name to put to structural violence. It’s called the GOP-led efforts to repeal the ACA and dismantle the only safety-net healthcare program in the U.S. aimed at enabling the poor and disabled to gain access to healthcare: Medicaid.

And, we have a perpetrator. 51 one of them, in fact. Sen. Mitch McConnell’s efforts to destroy healthcare for the poor, and his craven band of greedy sycophants disguised as public servants, are guilty of structural violence. We know what will happen if they get their way: 31, 16, or 15 million people will lose health insurance depending on which of their undemocratic bills pass. Most of these people will be poor, elderly, disabled, or children with severe health problems. Tens of thousands of unnecessary deaths annually can be predicted as a result.

This is structural violence with a face. It’s happening in real time, in front of all of us. We watch in horror at our Twitter streams or our Facebook news feeds at the latest news from Washington. We applaud and click the “like” button for our friends who share progressive articles cheering distant protests with arrests, sobbing, and screaming. And we go about our day, even if a little shaken.

All of this brings up another question: what obligation do we have to ACT? As people claiming the mantle of health and human rights workers, what responsibility do we bear to stand up and actively fight back against the obvious perpetrators of structural violence?

I would argue that for those of us making strong claims about the right to health comes great obligation to fight to protect and realize those rights. Certainly, this fight must come in many forms. But, it also certainly involves more than the ongoing clicktivism that we so often see as our primary mode of action.

I’ve made the 10-hour bus ride to DC and back on three separate occasions in the last three weeks, doing all that I can with my body, my money, and my effort to stop this heinous and undemocratic attempt to destroy healthcare for the poor. I don’t say this to be self-congratulatory.

I say this because my efforts have paled in comparison to members of the disabled community. Members of ADAPT, mostly wheelchair users with significant disabilities camped outside in front of the Russell Senate Office Building for three-straight nights and days, in the pouring, thunderous rain, to be seen and heard. They chained their chairs together in defiance of the Capitol Police in the center of the Hart Senate Office Building, sending their own thunderous roar through the halls of Congress. They did this because they knew it was life or death for them.

I say this because my efforts have paled in comparison to members of the LGBTQ community. Gay, lesbian, and transgendered people are leading this fight, putting their bodies on the line, getting arrested in civil disobedience, and putting themselves through the real risk, cost, and humiliation of jail time. They did this because they know what is at stake, having lived, or at least heard tales, of the fights of the 80’s and 90’s in the AIDS treatment struggle. And, they are facing the realtime threats of this administration in the ongoing fight for LGBTQ civil rights. Their heroism, borne of self preservation, protects us all.

I say this because my efforts have paled in comparison to the efforts of people of color: A mother, her teenage daughter, and their aunt from Georgia made the trek to D.C. because of their need to access to mental health and diabetes medicines to survive. An elderly man from Kentucky who needs support for his blood pressure medicine. Each on Medicaid and limited income, they are desperate to see these repeal efforts fail. And so, they are the ones turning out, showing up, and laying it all on the line.

Our community needs to be doing more. When I say, “our community,” I know that it’s a fraught term. But, let’s say the “health and human rights community.” We have resources, some time, and a hell of a lot of privilege and power at our disposal. I know that there are a million challenges and problems that we are dealing with on a nearly daily basis–our solidarity efforts in clinics and offices here, or in Rwanda, Sierra Leone, and Haiti will be ever present–but when clear and readily apparent structural violence is being advanced in front of our eyes, are we not obligated to act?

The only cure for structural violence, as Paul Farmer would say, is pragmatic solidarity. It’s about making common cause with the suffering and doing what needs to be done, as it’s needed, to practically advance their needs and demands.

This is a moment for pragmatic solidarity in America. And pragmatically, this means standing together in direct, non-violent, political action against the named perpetrators of structural violence: the leaders of the GOP.

Why we are unionizing at Boston University

bu-grad-students-union Here’s some exciting, positive news: colleagues at BU and I are launching a campaign to unionize graduate student workers at Boston University with the Service Employees International Union (SEIU)!

This August, the National Labor Relations Board authorized “student workers” (basically everyone from graduate students to teaching and research assistants) the right to collective bargaining and unionization. Although the implications of unionization efforts by graduate students is yet unknown, many graduate students are taking up the cause at universities across the country. So far, I believe, only NYU has actually “won” their union and have negotiated a contract with their university administration. But, there are at least 23 other universities that are also launching campaigns to unionize their graduate student workers as well including Brandeis University, Brown University, Columbia University, Pennsylvania State University, Tufts University, University of Chicago, University of Virginia, and Yale University.

Here is our open letter about forming the union at BU:

grad-student-letter

I see this as an incredibly important opportunity for a few reasons. First, as I’m beginning to learn firsthand, academic labor is precarious. There is next to zero job security (unless you are able to land a coveted tenure-track job) and the compensation for graduate student employees (who provide the vast majority of teaching labor at a university like BU where tuition can top $50,000 per year) comes to be less than minimum wage (about $22,000 per year). Because we as graduate student teachers and research assistants do provide the academic labor backbone for most universities, we should be able to engage in collective negotiations with our administration. We must be able to work together to demand fairer compensation, health insurance, and other forms of support to make this vocation and commitment to academic life more manageable, especially for those who do not have pre-existing financial means. Collective action is necessary to advance fairness and justice for academic laborers across the U.S.

Second, collective action and unions will be desperately needed to combat the oncoming tidal wave of Trumpism. Action such as the fight for $15 amongst fast food workers and other efforts to advance worker rights are going to be under attack from what is certain to be a kleptocratic regime that will attempt to crush workers rights. Graduate student unions have the potential to be a useful source of ally power. We will have unique sets of resources, relationships, access, etc to bring to bear in working with people struggling for basic social and economic rights.

Finally, as academics, many of us will work in public policy, government, think tanks, non profits, etc. Having a generation of academics, thinkers, policy makers, and NGO leaders with deep experience in collective action, organizing, and unions potentially could bode well for the labor movement in the future. If more people have a personal experience with unions, see the value of this type of collective action, we could imagine a comeback for unions. But, this is also the big danger: it’s reasonable to think that Trump will be hell bent to crushing collective labor. He’s had a long history of harming his own employees workers’ rights. In fact, unions are already bracing for policy shifts.

So, now is the time to act. We’ve got to move quickly at BU and I hope that other schools can make big gains in organizing and unionizing in the coming months. The future of collective bargaining, and social justice for workers across industries and fields, may be at stake.

General skepticism, overestimation, and growing political divide

The Kaiser Family Foundation has continued their work to track and interpret American’s evolving views and opinions of development assistance for global health and recently released a report summarizing their findings. They have some of the best and clearest analysis of U.S. appropriations for global health. ¹ ²

Some key points that seem particularly relevant to the global health political field:

Americans really don’t know much about development assistance and foreign aid as it relates to global health. Americans believe that we should be the world leader in global affairs, but also that we are doing more than our fair share already.
Foreign aid is initially viewed with skepticism, but with a little more information and context, people’s views change favorably.
Americans systematically overestimate of the amount spent by the U.S. on foreign aid for global health purposes.
There is a growing political rift between Democrats and Republicans about the value of U.S. investments in global health.

Skepticism:

There seems to be misunderstanding of what USG investments are being made for global health purposes and a general skepticism about their effects. People think that we should be serving as a (or the) world leader on global affairs, but then at the same time think that we are already doing our “fair share”.

doubt in value of global health investments

Additionally, people feel like corruption is one of the most important problems with development assistance for health.

corruption biggest problem

Overestimation:

Americans also consistently and wildly overestimate the amount of money committed to global health programs, answering on average that they think at least 31% of the federal budget is spent on foreign aid.

It would be interesting to dig more into why this is the case. Do people have no idea what the federal budget really is? Do they have any sense what constitutes U.S. global health funding? Do people similarly overestimate the amount of funding for other types of programs / elements of the federal budget?

overestimation of US contribution to global health

Political Divide:

Finally, there is a growing partisan divide in the level of importance that democrats and republicans place on USG global health investments. This partisan divide on global health, though while not enormous, has grown by 11 percentage points since 2012.

partisanship in global health spending

To me, everything about this research points to why a community organizing model of movement building for the global right to health is so important. People generally have very little clue what we mean when we talk about U.S. investments in global health and they assume that we spend far more money than we actually do on programs that they assume don’t work very well. This absence of data / narrative / perspective fuels a partisan divide that stems from a fundamental difference of opinion of the role of government.

As I discussed in my recent previous post about opportunities for research in the social movement for the right to health, McAdam’s political process model ³ describes the emergence of social movements through the mobilization of organized grassroots groups, generation of new stories / narratives / evidence / data of possibilities to enable new frames of ‘cognitive liberation’ that can be disseminated by organized groups, and the harnessing of newly emergent political opportunities.

Luckily this report does point to one important political opportunity: Americans believe that investing in programs that advance global health is the right thing to do.

“Although many acknowledge there are domestic interests that could benefit from global health aid, nearly half of Americans (46 percent) say that the most important reason that the U.S. spends money on improving health for people in developing countries is because it’s the right thing to do.”

moral reason for global health spending

This is a significant political opportunity. In the wake of the Ebola epidemic, the emergence of the Sustainable Development Goals (though they note that very few Americans know what the SDGs are) and despite the skepticism and growing partisan gaps, Americans still think that we should invest in global health because it’s the right things to do. This moral imagination is something that must be harnessed.

We need to continue to share the stories of patients, of systems, of transformation, and demonstrate what is truly possible with a commitment to building systems oriented to the most poor and marginalized.

http://kff.org/global-health-policy/issue-brief/the-u-s-global-health-budget-analysis-of-appropriations-for-fiscal-year-2015/ ↩
http://kff.org/global-health-policy/issue-brief/the-u-s-global-health-budget-analysis-of-the-fiscal-year-2015-budget-request/ ↩
McAdam, Doug. Political Process and the Development of Black Insurgency, 1930-1970. Chicago: University of Chicago Press, 1982. 40-51. ↩

Grassroots advocacy: Congressional meetings and calling for more resources

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Through PIH | Engage, we’ve been excited to dive head-first into working with our community organizing teams across the country to begin to have meetings with Representatives and Senators, calling on them to increase the resources available for nutrition and maternal and child program funding through USAID. Collectively, along with our partners at RESULTS, we are calling Congress to appropriate $200 million for Nutrition and $800 million for Maternal and Child Health in the FY15 federal budget. These are only modest increases from last year and are backed by a coalition of NGO’s working on health and development.

Some more background on the asks and why it matters: 2014 03 14 Advocacy Leave Behind vF

In order to contribute to this campaign and build power around these asks, we devised a three phase process:

We worked through email campaigns and social media to promote an online letter-writing action. View the online tool and take the action here: http://act.pih.org/page/speakout/secure-funds
We’ve worked to train our network of PIH | Engage teams across the country to schedule and participate in direct in-person meetings with their Representatives and Senators, asking them to urge their colleagues on the Foreign Operations Committee to allocate the requested funds to nutrition and MCH.
We will be working this May to get Letters to the Editor published in newspapers across the country that discuss the importance of this funding to save the lives of moms and babies around the world.

Our training consisted of a large number of personal coaching calls with Sheena and the Community Coordinators as well as a series of three webinars hosted on a great platform called BigMarker.

Take a look at our webinars below:

Webinar #1: Campaign Overview

Webinar #2: Understanding the Talking Points

Webinar #3: Practicing Face to Face Meetings

In all, this campaign has been successful already – both in terms of the outputs we’ve been able to produce and in terms of learning how to do this grassroots advocacy ever more effectively. So far, we have:

Written a total of 6,300+ unique letters to U.S. House Representatives and Senators
Hosted three training webinars with more than 75 people attending / watching in total
Had 2 meetings with Representatives so far; have 10 meetings scheduled for the coming weeks

By the end of the campaign, I hope that we can:

Write 10,000+ letters
Participate in 15 direct in-person meetings with legislators
Have 15 letters to the editor published in newspapers

Again, this is all modest and pretty basic stuff when it comes to advocacy. Our hope though is that we can start to build a base of individuals and teams, aligned with PIH’s mission to advance the right to health, who are also competent and motivated to engage in direct advocacy and the political process. This base can hopefully continue to grow in the coming years, providing a powerful platform that can argue for far greater resources invested in public health systems globally.

PIH | Engage: Forward Progress

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It’s only been about 2 months since my last post about PIH | Engage, but our progress on the spring campaign seems exponential. Early in 2014, teams across the country sat down at community “retreats” to lay out a gameplan for the spring, setting ambitious yet realistic goals and devising the timeline, roles, and sets of work necessary to make their ideas a reality. We’re approaching a crucial moment for PIH | Engage: in just a few months, the yearlong campaign will wrap up and we’ll head into a summer of reflection, re-grouping, and rebuilding for next year. The question for these retreats was: how will communities meaningfully demonstrate the significant power they’ve built through months of organizing and hard work?

The power that we’ve built:

PIH | Engage teams have built up to this moment through many small campaign successes. Just in terms of people power, the movement has grown to more than 430 members! A personal fundraising push around the holidays resulted in more than $26,000 in December alone, and events across the country have brought our total beyond $52,000 to date.

Our winter advocacy push focused on generating media around the Global Fund to Fight AIDS, Tuberculosis, and Malaria replenishment conference. The Global Fund is an international financing institution that has brought unprecedented resources to fight these epidemics, and through submitting letters to the editor to our local newspapers, PIH | Engage called on the U.S. to pledge $5 billion to the Global Fund over the next three years. At least 8 letters were published! In addition to these campaign victories, communities hosted many awareness-raising events, panels, film screenings, and social gatherings.

The community on Bainbridge Island, Washington hosted a “Soup Night” at a local bookstore with PIH guest speaker Jon Lascher.

The Washington D. C. group held a World Cancer Day happy hour.

The team in Madison, Wisconsin bonded at their community retreat.

Where we’re headed:

Now, the question is how PIH | Engage can display this power in a final campaign push. First, teams aim to host culminating fundraising events that rally entire communities around the vision of Partners In Health. Not only can these events raise substantial funds, they can engage a broad audience about the work of PIH and PIH | Engage. One idea that many communities have taken on: “Strides for Solidarity” walkathons where people walk in solidarity with community health workers, who often travel many miles over rough terrain to reach vulnerable patients. Community health workers are the cornerstone of the health care systems PIH works to build – we employ more than 8,000 CHWs across our sites. By the end of this year’s campaign, I’m confident that PIH | Engage will host more than 10 Strides for Solidarity walkathons.

Communities are also working to push forward an exciting advocacy campaign. As I write this, Congress is debating funding levels for next year’s federal budget, including key foreign aid programs that could bring millions to global health interventions. Congress gives less than 1% of the budget to humanitarian aid – we need to tell them to do better. PIH | Engage will engage with our legislators through in-person meetings, letters, phone calls, and emails and urge them to make global health a priority in next year’s budget. Specifically, we’re asking them to increase funding levels to $800 million for global maternal and child health, and $200 million for nutrition programs.

By the end of June, PIH | Engage organizers will have held dozens of meetings with Congressmen to discuss these issues. And, as you’re reading this, I hope you’ll join us! We’ve created an easy tool that helps you write a letter to your Senators and Representative in Congress in just 2 minutes:

www.pih.org/speak-out

Sign this call to action now and share with your friends and family!

It’s taken a lot of work to get here, and I can already think of dozens of ways I’d like to change the campaign, our training, and our recruitment for next year. But thinking back to our launch in September, it’s incredible to have seen individual Community Coordinators grow into passionate, dedicated teams ready to host walkathons and meet with Congress! I can’t wait to see what we accomplish by the end of this campaign.

—

By Sheena Wood

Sheena works as the Community Organizing Assistant at Partners In Health. A recent graduate from Brown University, she enjoys reading about community organizing and global health, traveling, and eating dark chocolate.

Medical-legal partnerships and the right to health

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Just finished reading the fantastic article by Elizabeth Tobin Tyler on how we might start to conceptualize and advance a strategy for health as a human right in the United States. It made me realize just how weak our (in the U.S.) legal precedent and political appetite is for positive social and economic rights, including the right to health. The paper reinforced for me the history that the commitment to social and economic rights is, actually, deeply American, but was derailed by the politics of east-west / capitalist-communist posturing of the Cold War. It also gave me some hope that we may be able to begin to move away from a futile top-down, overly litigious, court-driven means of advancing the health as a human right agenda.

The idea advanced in this paper is centered around the potential power of linking health practitioners, lawyers, and community organizers: politicizing health care delivery and baking rights-based advocacy right in to the process of providing services:

“A systemic health and human rights strategy should be built upon interdisciplinary partnerships among health care providers, public health practitioners, lawyers, and community organizers. It should be founded on three principles: bearing witness to human rights violations within the community context; tracking systemic failures through data collection and monitoring; and broad-based legal strategies which include both individual and policy advocacy in a given community.”

Medical-legal partnerships are one way that this type of community-level partnership has been built between these different professional disciplines.

“The medical-legal partnership (MLP) movement in the US exemplifies a community-based health and human rights strategy that implements a legal advocacy and social accountability approach by connecting lawyers, health care providers, and public health practitioners. The MLP model, first established in a safety-net hospital pediatrics department in 1993, now exists in over 500 legal and medical institutions in the US. The model is also being adopted in both Australia and Canada.”

Clearly, MLPs should play a role in a rights-based advocacy strategy in the U.S. But, I wonder how this type of patient-provider-level accountability and advocacy could be used to politicize the act of global health delivery in low income countries? If the goal is to enable MOHs and governments to take on the responsibility for protecting the right to health of their citizens, don’t those citizens need mechanisms to hold those governments accountable for delivering on that duty?

It seems like a movement for the right to health requires both the “supply side” — creating the policy and financing space through foreign aid and “accompaniment” — and the “demand side” — legal recourse for those receiving substandard care or none at all.

Definitely some interesting stuff when considering a country like the U.S., which should have dealt with these issues long ago. But, for nations interested in building the systems of social protection and healthcare delivery to protect citizens’ right to health, ideas such as MLPs should be built in.

Purpose, Technology, Communtiy Organizing

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Check out this great and brief presentation by Jeremy Heimans who is the founder of Purpose, a group working to help organizations and movements harness the myriad of tools available today to combine and build power around issues that matter.

The thing that strikes me most about Purpose, and most conversations about ‘social movement building’ in the 21st century, is the focus on technology and new tools that allow people to associate and communicate. As Heimans discusses in his talk, it was only a couple of decades ago when the finest piece of organizing technology available was the fax machine. How does the accelerating pace of the development of tools, platforms, and modes of communication create new structural potential for people to work together on issues that matter?

There’s no doubt that technology, novel platforms, and modes of communication have the potential to revolutionize the way we aggregate power. But I also hope that the focus on technological innovation doesn’t distract us from the task of building human, person to person, real organizations that allow people to form new relationships that are rooted in common purpose and that allow those people to act collaboratively to take action with one another.

I don’t think that these things are by any means mutually exclusive. But, I do sense a tension between the silicon-valley-esque slickness of online mobile platforms and the very 20th century seeming models of old school community organizing. In the end, the space of innovation is probably someplace at their intersection. We need to simultaneously innovate on tech tools while also better cultivating organizations and institutions that foster the relational capacity between people to get real work done.

Improving Health while Preserving Wealth

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The Center for Strategic and International Studies is hosting what could be a very interesting conference / webinar on advancing universal health coverage in emerging economies. The meeting will be chaired by Jim Kim and will have representatives from a wide range of institutions/governments including USAID, several universities, PAHO, and the WHO.

You can register for the webinar here, for free.

I’m particularly interested in seeing how the conversations and the outcomes from this meeting fit with the ideas laid out in the Global Health 2035 report.

Global Health 2035: a new roadmap for global health advocacy?

Background

The World Development Report in 1993 focused on the economic value in focusing on a narrow set of health interventions.

On the 20th anniversary of the highly influential 1993 World Development Report, titled ‘Investing in Health’, an independent commission convened by The Lancet has developed a potentially groundbreaking report (Global Health 2035: a world converging within a generation) summarizing the current research demonstrating the potential economic value of universal health coverage, and lays out an aggressive but fairly straightforward set of policy recommendations that could help ministers of health, civil society, and advocacy organizations push forward legislation and regulation necessary to secure the right to health.

I think that this report is very significant for a few reasons:

The commission is a mix of the right players (Harvard academics and administrators, ministers of health, USAID, World Bank, IMF, etc).
It is fairly critical of the failings of the 1993 WDR. And, it offers sound analysis and recommendations about how to build off of the successes, failures, and lessons gained during the tumultuous decades in global health and development since then.
It seems to have Partners In Health’s strategy and logic all over it. From the almost explicit ‘preferential option for the poor’ language to the model of structure and function for emerging health systems, PIH has certainly influenced this important vision for the future.
The report is coming at just the right moment. Twenty years after the ‘Investing In Health’ WDR and approaching the end of the era of the Millennium Development Goals, we sorely need a progressive, ambitious, and inspiring vision to guide us. As I’ve written previously and continue to witness/study, more students than ever are passionate about advancing the right to health. Our work with PIH | Engage shows that people of many ages and demographics are eager to participate as well.

Major concepts in GH2035:

There is a major economic payoff in investing in global health.

How does investing in health effect personal and national income?

The report builds off of the work of the 1993 WDR in making the case that investing in health is not only a moral imperative – it is actually just that, an investment in the productive capacity and “full income” of a country. By solely using GDP growth (only accounts the market value of goods and services produced in one year) as the metric of development success, a lot of important value is missed and policy is built and evaluated in an incomplete way.

“On re-reading WDR 1993, admittedly with the benefit of hindsight after two decades, we believe that it had two major limitations. First, although WDR 1993 discussed the “instrumental value” of better health (eg, better health improves worker productivity), it did not attempt to quantify the “intrinsic value” of health (the value of good health in and of itself). Our report summarises research that quantifies the intrinsic value of mortality reduction— the findings should, we hope, lead to a notable reassesment of the priority of health in national and international investment portfolios. In particular, benefit-to-cost assessments and a strong implementation record point to the value of increased commitment to health.

Second, financial protection failed to receive sufficient attention in WDR 1993, although very few data were available in 1993 about out-of-pocket spending and catastrophic financial expenditures. Moreover, only a few analyses pointed to financial protection as an important goal of health systems. By contrast, the role of UHC in providing financial protection is a major feature of our report.”

The analysis that they have gathered shows that fully 24% of “full income” growth in low income and middle income countries can be attributable to the “value of additional life-years” which is linked to expanded investments in health.

What’s happened in global health over the past 20 years that has led to such success? Well, they’ve kindly summarized their finding in a handy table:

A grand convergence of death rates from infectious disease, child, and maternal mortality between the high and low income countries.

With the right investments made by local governments, appropriate investment in health systems strengthening, renewed commitment to expanding development assistance for health from wealthy countries, we could see an incredible convergence of rates of infectious disease death, childhood death, and maternal mortality. The report builds the case that by 2035 we could see rich and poor countries alike experiencing very little unnecessary deaths from these completely preventable sources.

What kinds of investment are necessary? Well, the price tag over the next twenty years is not small – an aggressive investment scenario calls for at least $500 billion to be invested between 2016 and 2035 in low income countries’ health systems. Here’s the breakdown:

But what types of health outcomes could you conceivably see as a result of that type of aggressive investment in health? Perhaps as many as 7.5 million lives saved across low income countries during that time period:

Fiscal policies (taxation, regulation, etc) are a major lever in controlling non-communicable diseases.

The report advocates for aggressive use of fiscal policies as levers to combat what will be rapidly growing rates of chronic and non-communicable diseases, especially in low income countries. These polices include but aren’t limited to heavily taxing tobacco and other harmful substances as well as reducing subsidies on fossil fuels.

“Progressive universalism” is the most efficient way of achieving financial protection for health programs.

For me, the most striking focus of this report is the extraordinarily pro-poor focus on achieving universal health coverage through two potential pathways that they describe as “progressive universalism.” They conceptualize the process to move toward universal health coverage using the “universal health coverage cube – a way of understanding the trade-offs and choices policy makers must make along the way.

The cube consists of three dimensions: the percentage of the population covered, the percentage of costs pre-paid at the point of service (the rest paid for out of pocket), and the percentage of interventions that are covered by prepaid schemes.

Essentially, if a system has no one covered, none of the real costs associated with clinical interventions are pre-paid, and no interventions are covered through pre-paid schemes, that’s bad and does not approach UHC. You’re in a system that is in the bottom, right, front corner of the cube. Conversely, if people within a health system have all of their costs pre-paid at the point of service, all possible services are covered within the pre-paid scheme, and everyone within a population is covered, then you’ve got universal health coverage.

The report outlines two ways of “moving through the cube.” The first, and ideal strategy, would be to create a publicly financed health insurance system that would cover essential health interventions for entire populations. Basically, using “x, y, and z” coordinates imposed on the cube above, it would mean a large x (population covered) and a large z value (percentage of costs prepaid vs out of pocket), but a relatively small y (percent of all interventions that are covered through the system).

The second feasible strategy would be to provide a larger benefit package, financed through a mix of public and personal resources, from which the poor would be exempt. Basically, a smaller x value, similar z value, and a larger y value.

Potential implications for advocacy strategy?

I’m personally most interested in this report because I think that it provides a viable “stake in the ground” around which nonprofit organizations, civil society, advocacy networks, and ministries of health can mobilize and direct collective effort. It presents an ambitious vision for what could be. It provides the beginnings of a roadmap for how we could plausibly build upon the successes and challenges of the last 20 years in global health and actually make headway in recasting health expenditure from being considered sunk costs to be minimized, and moving towards a commitment of robust investment. And, just maybe, we can even move past the idea of investment and consider health a fundamental human right to be protected as a central component of modern citizenship.

This is, of course, where politics and advocacy come in. Some questions emerge:

What types of organizations and grassroots campaigns are necessary in high-income countries to create the political space necessary to create the necessary development assistance for health funding streams necessary to see a plan like this enacted?
What types of organizations and campaigns are necessary in low-income countries to hold their governments and elected officials accountable for adequate public sector investment in health?
What type of advocacy is necessary to bring the lessons and innovations from low income countries working to pioneer UHC to high income countries, in order to disrupt dysfunctional health systems with massive politically and economically entrenched interests?

A Critical Engagement

A dialogue on advancing justice in health