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Political rationale, aims, and outcomes of health-related high-level meetings and special sessions at the UN General Assembly: A policy research observational study

['Paolo Rodi', 'Centre For Multidisciplinary Research In Health Science', 'University Of Milan', 'Milan', 'Department Of Surgery', 'Campus Virchow-Klinikum', 'Campus Charité Mitte', 'Charité Universitätsmedizin Berlin', 'Berlin', 'Werner Obermeyer']

Date: 2022-01 

Abstract Background Recognising the substantial political weight of the United Nations General Assembly (UNGA), a UN General Assembly special session (UNGASS) and high-level meetings (HLMs) have been pursued and held for 5 health-related topics thus far. They have focused on human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS, 2001), non-communicable diseases (NCDs, 2011), antimicrobial resistance (AMR, 2016), tuberculosis (TB, 2018), and universal health coverage (UHC, 2019). This observational study presents a comprehensive analysis of the political and policy background that prompted the events, as well as an assessment of aims, approaches, and ultimate outcomes. Methods and findings We investigated relevant agencies’ official documents, performed a literature search, and accessed international institutions’ websites for the period 1990–2020. Knowledgeable diplomatic staff and experts provided additional information. Outcomes were evaluated from a United Nations perspective based on national and international commitments, and funding trends. Eliciting an effective governmental response through UNGASSs/HLMs is a challenge. However, increased international commitment was evident after the HIV/AIDS (2001), NCDs (2011), and AMR (2016) meetings. The more recent TB (2018) and UHC (2019) HLMs have received general endorsements internationally, although concrete commitments are not yet documented. Although attribution can only be hypothesized, financial investments for HIV/AIDS following the UNGASS were remarkable, whereas following HLMs for NCDs, AMR, and TB, the financial investments remained insufficient to face the burden of these threats. Thus far, the HIV/AIDS UNGASS was the only one followed by a level of commitment that has likely contributed to the reversal of the previous burden trend. Limitations of this study include its global perspective and aerial view that cannot discern the effects at the country level. Additionally, possible peculiarities that modified the response to the meetings were not looked at in detail. Finally, we assessed a small sample of events; thus, the list of strategic characteristics for success is not exhaustive. Conclusions Overall, UNGASSs and HLMs have the potential to lay better foundations and boldly address key health challenges. However, to succeed, they need to (i) be backed by large consensus; (ii) engage UN authorities and high-level bodies; (iii) emphasise implications for international security and the world economy; (iv) be supported by the civil society, activists, and champions; and (v) produce a political declaration containing specific, measurable, achievable, relevant, and time-bound (SMART) targets. Therefore, to ensure impact on health challenges, in addition to working with the World Health Assembly and health ministries, engaging the higher political level represented by the UNGA and heads of state and government is critical.

Author summary Why was this study done? Between 2001 and 2019, 5 health-related topics reached the United Nations (UN) General Assembly in the form of special sessions or high-level meetings: human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) (2001), non-communicable diseases (NCDs) (2011), antimicrobial resistance (AMR) (2016), tuberculosis (TB) (2018), and universal health coverage (UHC) (2019).

Tackling these issues requires not only a response to biomedical threats, but also interventions in society, health systems, and markets, and engagement of heads of state and government in what is one of the most important political fora today: the UN General Assembly.

To our knowledge, a comprehensive observational analysis of processes, political aims and motivations, policies, and financial outcomes of these meetings is missing. What did the researchers do and find? We assessed the political process conducive to organisation of the above-mentioned meetings by looking at relevant documents of the UN and other global health agencies, and published literature. We identified how strong support from countries and civil society contributed to raising the visibility of and commitment to health challenges at the UN General Assembly level.

We established 2 political criteria (national and international commitment) and 2 financial criteria (domestic and international investments) for evaluation of the UN event outcomes.

Increased international commitment was evident after the HIV/AIDS, NCDs, and AMR meetings. The TB and UHC high-level meetings (HLMs) received general endorsements internationally, although concrete commitments are yet to be documented. Financial investments for HIV/AIDS were remarkable following the UN event, whereas for NCDs, AMR, and TB, they remained insufficient.

Finally, we looked at pre- and post-event changes in the global burden of the conditions at stake. Thus far, the HIV/AIDS UN General Assembly special session (UNGASS) was the only one followed by a reversal of the previous burden trend, although this outcome is multifactorial in origin. What do these findings mean? We conclude that UNGASSs and HLMs have the potential to promote the political visibility of key health challenges, and mobilise funding to face them, although this ultimately also depends upon the leaders’ political will, the consensus generated, and the engagement of civil society.

To achieve impact on major health challenges, besides working within the context of the World Health Assembly and ministries of health, there is a need to advocate internationally at the higher political level of heads of state and government.

Citation: Rodi P, Obermeyer W, Pablos-Mendez A, Gori A, Raviglione MC (2022) Political rationale, aims, and outcomes of health-related high-level meetings and special sessions at the UN General Assembly: A policy research observational study. PLoS Med 19(1): e1003873. https://doi.org/10.1371/journal.pmed.1003873 Academic Editor: Megan B. Murray, Harvard Medical School, UNITED STATES Received: March 21, 2021; Accepted: November 23, 2021; Published: January 13, 2022 Copyright: © 2022 Rodi et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability: A collection of the data can be found at the following link: https://doi.org/10.13130/RD_UNIMI/EO5VNS. Funding: The author(s) received no specific funding for this work. Competing interests: The authors have declared that no competing interests exist. Abbreviations: AMR, antimicrobial resistance; DAH, development assistance for health; HIV/AIDS, human immunodeficiency virus/acquired immunodeficiency syndrome; HLM, high-level meeting; NCD, non-communicable disease; OECD, Organisation for Economic Co-operation and Development; SDG, Sustainable Development Goal; SMART, specific, measurable, achievable, relevant, and time-bound; TB, tuberculosis; UHC, universal health coverage; UN, United Nations; UNAIDS, Joint United Nations Programme on HIV/AIDS; UNGA, United Nations General Assembly; UNGASS, United Nations General Assembly special session; WHA, World Health Assembly; WHO, World Health Organization

Introduction The United Nations General Assembly (UNGA) carries a weight that is politically greater than that of any international health-related body worldwide, including the World Health Assembly (WHA) of the World Health Organization (WHO) [1]. Since 2001, 5 pivotal meetings on global health challenges have taken place at the United Nations (UN) in the form of either UNGA special session (UNGASS) or high-level meeting (HLM). They focused on human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) in 2001 [2], with follow-up HLMs in 2006 [3], 2011 [4], and 2016 [5]; non-communicable diseases (NCDs) in 2011 [6], with follow-up HLMs in 2014 [7] and 2018 [8]; antimicrobial resistance (AMR) in 2016 [9]; tuberculosis (TB) in 2018 [10]; and universal health coverage (UHC) in 2019 [11]. These major events were an attempt to engage more strongly heads of state and government to galvanise political efforts and pursue increased support, particularly financial, towards well-defined health challenges. Not by chance, the 5 selected challenges have an extraordinary impact on humankind. According to the WHO Global Health Observatory, NCDs, TB, HIV, and AMR, combined, cause nearly 50 million deaths every year. In the years of the respective UNGA events, 1.4 million people died from HIV in 2001, nearly 30 million from NCDs in 2011 [12], and 1.4 million from TB in 2018 [13]. AMR was estimated to have led to 700,000 deaths in 2016, and this figure was predicted to grow to 9.5 million annually by 2050 [14]. Implementation of UHC, on the other hand, has been associated to an increase in life expectancy, although other social determinants of health, e.g., education, contribute to this composite outcome [15]. Furthermore, economically, the HIV/AIDS pandemic has negatively affected economic growth in African countries [16], while NCDs and AMR are projected to result in losses of tens of trillions of US dollars worldwide by 2050 if not properly tackled [17,18]. Countries where UHC is not implemented result in 100 million people falling into poverty each year because of catastrophic health expenditures [19], and the TB scourge may cost the global economy nearly US$1 trillion by 2030 [20]. Tackling these issues is not a mere matter of responding to biomedical threats, but requires comprehensive, multisectoral, cross-disciplinary interventions in society, health systems, and markets. New effective rules in the global governance for health are needed for countries to take appropriate collaborative actions, and to transform global health to sustain the health gains achieved thus far. These actions cannot be pursued by WHO alone but require political action at the highest level, hence the need to engage heads of state and government in what is one of the most important political fora today: the UNGA. It is thus far unclear to what extent health-related HLMs have mobilised resources to address priority global health conditions. While specific topics have been raised to higher political levels, the impact on decision makers may be undermined by the growing number of health issues discussed at those events in recent years [21]. It is indeed the case that countries often respond alone to health threats rather than through a unified strategy under the UN umbrella or an international coordination mechanism, as would be desirable when facing global challenges [22]. Moreover, some observers have speculated that some HLMs are unlikely to be effective, such as that on NCDs because of a conflict of interest by food and beverage corporations in tackling collaboratively the determinants of NCDs [23]. Others have proposed strategies to solve current weaknesses in global health governance and to effectively motivate policy makers and the public at large. These strategies would require modifying the narrative and looking at health in terms of investments, global public good, human security, development and human rights, and global justice [24]. The need for further research has been emphasised [25]. A comprehensive and comparative assessment of the health-related UNGASSs and HLMs is still missing. To our knowledge, this is the first study that attempts to review and compare the processes and outcomes of UN health-related events. More specifically, it aims to assess the approach, rationale, aims, motivations, and political decisions that succeeded in elevating key global health issues to the highest political level at the UNGA and to report on potential improvements in global health following such extraordinary events. Ultimately, these observations may help shape international cooperation and support political leaders in addressing global health threats effectively.

Methods To document the processes and outcomes of UNGASSs and HLMs, a thorough analysis of UN documents was undertaken. The search focused in particular on official documents, records, and audio-visual content of UN assemblies and related meetings collected via the UN Digital Library [26], with the support, as needed, of librarians available ‘live’ online. For our search, we used the following keywords: ‘high-level meeting’, ‘United Nations special sessions’, ‘United Nations General Assembly’, ‘official records’, and ‘draft resolutions’. We also searched through WHO, WHA, and WHO Executive Board resolutions from 1990 to 2020 on the WHO governance web page [27], using the following key words: ‘HIV’ or ‘AIDS’, ‘non-communicable diseases’, ‘antimicrobial resistance’, ‘tuberculosis’, and ‘universal health coverage’. In addition, we looked at WHO dedicated online archives for the 5 topics at stake: HIV/AIDS, NCDs, AMR, TB, and UHC. Furthermore, we accessed G7, G8, and G20 communiqués starting from the 1979 G7 Tokyo summit, when ‘health’ was mentioned for the first time; the 2000 G8 Okinawa summit included the first formal invitation of WHO. We examined Oslo Group communiqués, which were retrieved via the web-based archives of the ministries of foreign affairs of the respective member states. The Oslo Group is a formally recognised network of ministers of foreign affairs of 7 countries (namely, Brazil, France, Indonesia, Norway, Senegal, South Africa, and Thailand) that agreed to establish a group within the UN system to provide a framework for consultation on key health issues [28]. A literature search was performed on PubMed and Google Scholars with the following key-words: ‘high-level meeting’, ‘UN General Assembly’, ‘HIV’ or ‘AIDS’, ‘non-communicable diseases’, ‘antimicrobial resistance’, ‘tuberculosis’, ‘universal health coverage’, and ‘global health’. A specific search was undertaken in The Lancet online archive [29] using the same keywords. Political and financial outcomes were analysed on the basis of published data in the online repositories of (in alphabetical order) the Bill & Melinda Gates Foundation; Bloomberg Foundation; Global Health Data Exchange; Global AMR R&D Hub; Institute for Health Metrics and Evaluation; Joint Programming Initiative on Antimicrobial Resistance (JPIAMR); Kaiser Family Foundation; Organisation for Economic Co-operation and Development (OECD); Rockefeller Foundation; SDG Tracker; The Global Fund to Fight AIDS, Tuberculosis and Malaria; UN Digital Library; Joint United Nations Programme on HIV/AIDS (UNAIDS); US Congress; World Economic Forum; WHO Global Health Expenditure Database; and WHO Global Health Observatory. Newspaper articles and interviews were collected via Google searches filtered by the ‘News’ category and the specific dates of the UNGASS/HLMs using the same keywords that pertained to the literature search. To obtain additional information not readily available in published documents, we interviewed knowledgeable staff from the WHO office at the UN in New York, New York, US, and the WHO headquarters in Geneva, Switzerland. These informants were identified based to the authors’ knowledge of their direct involvement in the organisation of the HLMs. Information was obtained through email correspondence and personal interviews. As often used within the UN system to measure performance [30–32], the establishment of specific, measurable, achievable, relevant, and time-bound (SMART) targets in the political declaration was assessed. The evaluation of outcomes was based on the assessment of commitments and trends of financial resources that followed the UNGASS and HLMs. National commitments were evaluated on the basis of countries’ implementation of budgeted national plans and on the endorsement of targets and the progress towards them. This evaluation was drawn from follow-up HLM reports or from notes by the UN Secretary-General, as well as from progress reports submitted by member states and/or developed by WHO. The reports provided a global state-of-the-art overview of what was expected from the political declarations of the first UNGASS/HLMs. This allowed progress assessment from the UN system perspective. International commitments were assessed on the basis of inclusion of the health topic in the international agenda of relevant UN agencies, important international fora (e.g., G7, G8, or G20), and other relevant bodies, and the adoption of a specific target or indicator as part of the 2030 Sustainable Development Goals (SDGs). Assessment of financial resources for health included those from governmental sources and their bi- and multilateral mechanisms; multilateral agencies; international funds like The Global Fund to Fight AIDS, Tuberculosis and Malaria; philanthropic foundations; and non-governmental organisations (NGOs). Development assistance for health (DAH) as measured by the Institute for Health Metrics and Evaluation was considered in the analysis. DAH included financial and in-kind resources transferred from agencies engaged in international development cooperation (governments, multilateral agencies, corporations, philanthropies, and other agencies) to low- and middle-income countries. Fluctuations over time of these contributions against a proxy of the global burden of each health challenge were plotted for the 5 topics at stake. Before the beginning of the study, despite awareness of the scarcity of literature information, an initial analysis plan was conceived that aimed at comparing political rationales behind the meetings with global burden changes, a proxy of UNGASS/HLM impact. However, following assessment of the initial data collected, the 4 aforementioned evaluation criteria were introduced to facilitate analysis: national and international commitments, and domestic and international financing.

Discussion Although some research exists on this topic [21], a comprehensive and comparative analysis of processes, political motivations, aims, policies, and financial outcomes of health-related UNGASSs and HLMs is—to our knowledge—missing. This study aimed at filling this gap. Overall, the UNGASS/HLMs were followed by a boost to the political discussion on relevant health topics and augmented the visibility and importance of global health challenges in the international agenda. However, only the UNGASS on HIV/AIDS was followed by a strong, unquestionable political mobilisation resulting in a tremendous increase in financial investments, both domestically and internationally, and significant declines in mortality over the subsequent years. Attribution of the obvious progress solely to the UN event would not be prudent given the general ‘AIDS exceptionalism’ that characterised the unprecedented response in the first 3 decades of the epidemic [60]. However, the UN event further raised the quest for a human rights approach and universal access to treatment. The HLMs on NCDs and AMR were also followed by increased visibility of these 2 health challenges. Indeed, in 2015 NCDs were prominently included among the SDG 3 targets after they had been long neglected by leaders prior to 2011. Likewise, after the HLM on AMR, AMR began to emerge as a major issue in the high-level political agendas of the G20, G7, and UN agencies, although important, game-changing developments are yet to be seen. The HLM on TB was an historical event, but political declaration goals are not on track towards agreed targets, although the ultimate outcomes will need to be fully assessed in the years to come. The HLM on UHC cannot yet be evaluated, as it was held just 1 year before the conclusion of this study—insufficient time to allow leaders to respond concretely and to measure outcomes. Furthermore, the COVID-19 pandemic has shifted the focus away from UHC and all other priority global health challenges faced within previous HLMs. Whether this will imperil UHC implementation especially through domestic health spending is an open question given the economic impact of COVID-19, although history shows that several countries made progress towards UHC as a result of national crises (e.g., the UK following World War II or Thailand after the Asian financial crisis). There are several limitations to our study. First, this study looks at the global context, and does not discern changes that took place in each country. As described in the Methods, results are inferred from reports and notes obtained mainly from the UN system. Measuring individual countries’ outcomes (through indicators such as political commitments and funding) would certainly increase accuracy, but this would require a different approach to data collection. Second, improvements in global health are multifactorial. The assessment in this study is based on general key criteria principally allowing an aerial view of the health topics. Searching for singularities that hindered response in each country—e.g., lack of capacity despite commitment to act in low-income settings—was not part of our approach and would require a more intensive effort. Finally, the study identifies the political process leading to the UNGASS and HLMs and examines national and international commitments, as well as domestic and international financing after the events. As described in detail below, a list of strategic characteristics conducive to concrete results after each meeting can be drawn. Given the small sample of UN events and the study design, this list, although making useful suggestions, is not exhaustive and does not seek to fully explain the success or failure of each UNGASS or HLM. Similarly, a causation effect of an UNGASS or HLM on the global response cannot be properly drawn. One cannot exclude that other elements conducive to success (or failure) existed independently of the UN events, or that the outcomes represent a mere manifestation of already existing favourable background conditions. In the end, given the approach used to identify relevant informants, we cannot exclude some information gaps. Study limitations notwithstanding, given improvements observed in addressing the challenges and the general increase in international commitments, in our opinion UNGASSs and HLMs have the potential to lay a stronger foundation for governments and all stakeholders to address global health challenges. However, several factors should be accounted for when pursuing advocacy on a health issue at the highest UN level and among its member states. By comparing the elements underpinning the political process leading to the health-related UNGASS and HLMs with the way political commitments and financing unfolded—as shown in Table 2—one can design a strategic approach to foster the success of an HLM similar to those observed, particularly in the case of HIV/AIDS. Chances of success may increase if the HLM (i) is backed by large consensus when constructing the rationale to address the challenge with the need to go beyond established frameworks; (ii) engages UN authorities and high-level bodies such as the UN Secretary-General, the UN Security Council, and the UN Economic and Social Council; (iii) emphasises implications for international security and economic impact, and is fully endorsed by key political and economic bodies such as the G7, G8, G20, and World Economic Forum; (iv) receives full support and engagement by civil society, health activists and champions, and the general public; and (v) produces a political declaration containing SMART targets. An HLM that is organised without considering these criteria may fail in its scope and jeopardise actions and political mobilisation undertaken with intensive efforts by the health community to engage leaders and decision makers. Some have claimed that the UNGA has now eclipsed the WHA thanks to its greater political weight [1]. The work of WHO and the resolutions and decisions made at the WHA remain critical to define global health priorities, set strategic objectives, recommend solutions, and catalyse an effective response on key global health topics. However, the initially ineffective COVID-19 pandemic response is teaching us that an international collaboration coordinated at the highest level is fundamental when facing a global threat, rapidly pursuing research, or attempting to ensure equitable distribution of vital goods, e.g., a vaccine. A wider effort through the highest international political bodies such as the UNGA is therefore a desirable aim, as are new effective policies for countries fostering better collaborative actions. The demand to re-imagine and transform global health to sustain the gains achieved thus far and effectively face future threats has never been so strong [61]. This study suggests how a new model pursuing global collaboration to reach targets and mobilise resources for global health priorities is necessary, and could be more effective if political opportunities are exploited to the full and if unprecedented resources are eventually mobilised, such as in the case of the COVID-19 pandemic. It also suggests that advocacy and political efforts should be directed not solely towards (often underfunded) health ministries and the WHA, but also towards the highest decision-making levels nationally and internationally by engaging heads of state and government. The UNGA has a key role to play towards this coordinating goal. However, while UNGASSs and HLMs can play a crucial role in addressing key health challenges, the differences observed in national commitments and mobilisation of domestic resources after UN high-level events suggest that it is the political commitment and will of individual leaders, underpinned by the momentum generated within a society, that ultimately makes a difference in achieving health goals in the pursuit of greater well-being and equity for all.

Supporting information S1 Appendix. SMART targets. The appendix reports the specific, measurable, achievable, relevant, and time-bound (SMART) targets contained in the political declarations of the high-level meetings on human immunodeficiency virus, non-communicable diseases, tuberculosis, and universal health coverage. https://doi.org/10.1371/journal.pmed.1003873.s001 (DOCX)

Acknowledgments We thank Dr. Hailyesus Getahun and Dr. Carmem L. Pessoa-Silva, WHO Headquarters, Geneva, Switzerland, for providing information on the HLM on AMR. We are grateful to Professor Peter K. Piot, London School of Tropical Medicine & Hygiene (former Executive Director of UNAIDS) for providing key information by email correspondence on the HIV/AIDS event.

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