Aspirational goals and targets often guide global health and development initiatives. The millennium development goals (MDGs), signed off by 189 countries in September 2000, aimed to reduce maternal and child mortality by 75% and 66% respectively (using figures from 1990 as a baseline). Although there was little precedent that such gains were achievable within 15 years, this aim caught the attention of governments and civil society, and by the end of 2015 the world saw remarkable progress in reducing maternal and child (under 5s) deaths. 
The transition of the MDGs to the vastly more ambitious sustainable development goals (SDGs) in September 2015 followed a process of global and national consultations. Despite much scepticism, the collective political will and optimism of 193 countries prevailed. The health and health related SDGs helped propel forward an integrated health and development agenda that forced politicians and planners to look beyond their narrow country level silos to an integrated strategy that tackled the key social, political, and commercial determinants of health.
As a high level forum of global leaders ratifies the universal health coverage (UHC) declaration in New York today, it is important to reflect on the process that led us here. UHC is an effort to live up to the promise made in the World Health Organization’s constitution of 1948, which declared health as a fundamental human right and also builds on the “health for all” agenda set in the Alma Ata Declaration of 1978.  The global strategy for UHC is based on the principles of primary healthcare and moves away from the narrow focus of the MDGs to a more comprehensive global goal for optimising health.
The genesis of UHC lay in the collective experience of the MDGs where many issues of health and gender inequities, catastrophic health expenditures, and poor quality health services were poorly appreciated with limited efforts to tackle them systematically. [3,4] Therefore, the three pillars of UHC include equitable access to safe, effective, good quality, and affordable essential medicines and vaccines, provision of high quality essential healthcare services, and protection against financial risks. These are firmly embedded in the SDGs. This is the human face of UHC that must be supported. This will also inevitably require that ministries of health work with other sectors providing social protection, improving environmental health and living conditions, and providing protection from shocks related to climate change. The UHC model is predicated on effective and accountable governments that are capable of providing oversight and overseeing public-private partnerships and have the ability to mobilise resources for domestic financing of health.
As countries align behind this important global agenda, it is also imperative that we recognise the limitations of these approaches in many geographies and contexts. Over a billion people worldwide live in conflict and humanitarian emergencies. Many of the areas with continuing high rates of maternal and child mortality are conflict zones or areas with population displacement due to humanitarian disaster.  Some—illustrated by the Ebola outbreak in the Democratic Republic of Congo and persistent polio virus circulation in the Afghanistan-Pakistan region—represent complex emergencies that place global health security at risk. Transition to functional health systems after conflict is possible, but in many countries with active or residual conflict there is little or no rule of law, and the will of the “state” is imposed by brutal dictators, terrorist organisations, or warlords. There is no single model of successful healthcare delivery in such settings, and what exists relies heavily on non-government organisations, community volunteers, and a small but resilient stock of healthcare workers. It is therefore imperative that there is clarity and consensus on how we could promote and implement effective UHC in such humanitarian settings. At the very least, this will require agreement on core essential interventions in various populations and age groups, prioritisation of neglected areas such as mental health support, assurance of sexual and reproductive health services, and innovative financing strategies that do not further burden impoverished and displaced people. Even if such interventions exist, there is sparse guidance on how best to finance and deliver essential packages for prevention, promotion, clinical care, and rehabilitation in such contexts at scale, while ensuring safety and security of the health workforce. Apart from a consultation on the subject at the World Health Assembly in 2018, with several calls for greater experience and learning on the ground, progress since has been limited.  One can only hope that the ratification of the UHC declaration this week will jumpstart this process.
Zulfiqar A Bhutta is the coordinator of the BRANCH Consortium (Bridging Research & Action in Conflict Settings for the Health of Women & Children) working on issues of reproductive, maternal, and child health in conflict settings. He is the Robert Harding Chair in Global Child Health & Policy & Co-Director, SickKids Centre for Global Child Health, The Hospital for Sick Children and Founding Director, Centre of Excellence in Women & Child Health, The Aga Khan University, South Central Asia, East Africa & United Kingdom, Pakistan.
Competing interests: None declared
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