In Paris in 1851, physicians and diplomats from 12 states gathered for the first International Sanitary Conference. Their immediate concerns were cholera, quarantine and the movement of ships. The meeting was an important step towards international health cooperation. It also revealed a tension that has never entirely disappeared: global health rules were written mainly by those with the power to protect borders, commerce and national interests. The people most affected by those rules were rarely present as equal authors.^1,2

Nearly 175 years later, global health institutions are broader, more representative and more interconnected. Yet the central question remains unchanged: Who defines the problem? Whose knowledge counts? Who controls the resources? And who decides whether an intervention has succeeded?

The colonial gaze is not simply a way of seeing; it is a way of governing. It determines whose experiences become evidence, whose expertise is recognised, whose priorities shape policy, and who is permitted to decide.

These questions become particularly important for Universal Health Coverage, or UHC. A health system can describe itself as universal yet remain distant from the people it seeks to serve. A migrant may have a legal entitlement to care but no interpreter. A refugee may be included in a national policy yet fear that seeking treatment will expose the family to authorities they do not trust. A service may be free at the point of care but remain inaccessible because of transport barriers, insecure work, digital exclusion, or administrative complexity.

The decisive test of UHC is whether people can reach services, understand them, trust them and ultimately help shape them.

Progress without universality

Progress towards UHC has been substantial, but uneven. According to the 2025 global monitoring report from the World Health Organization and the World Bank, the UHC service coverage index* rose from 54 in 2000 to 71 in 2023. Since 2015, however, the pace of improvement has slowed to around one-third of its previous annual rate. In 2023, an estimated 4.6 billion people still lacked full coverage of essential health services, while 2.1 billion experienced financial hardship from out-of-pocket health spending.³

These figuresillustrate the scale of the challenge but reveal less about who continues to be excluded and why. National averagesmay improve while migrants, refugees, Indigenous peoples, rural communities, and people in insecure employment continue to face barriers that remain hidden within aggregated statistics. Coverage may widen, while decisions about priorities, evidence, resource allocation and measures of success remain concentrated elsewhere. As a result, health systems may become more extensive without becoming more inclusive in how they are governed.

Beyond financing and servicedelivery, UHC is fundamentally a question of political and epistemic power. It concerns who sets health priorities, what counts as evidence, whose expertise shapes policy, and how success is defined. Communities should participate not only in receiving and delivering care, but also in generating knowledge and sharing responsibility for the decisions that shape, organise and evaluate health systems.

A principle older than the language of decolonisation

The call for meaningful participation is not new. In 1978, the Declaration of Alma-Ata described health as a fundamental human right and primary health care as the route to 'Health for All'. Crucially, it affirmed that people should participate in planning and implementing their own health care, and that primary care should develop through self-reliance and self-determination.⁴

Almost half a century later, that promise remains incompletely realised. Although the vocabulary of decolonising global health is relatively recent, the underlying principle is much older. People should not merely be consulted after priorities have been chosen. They should share authority before programmes are designed, budgets allocated and indicators selected.

The failure has therefore not been a lack of declarations. It has been the distance between declaration and institutional practice.

The foreign gaze and foreign partnership are not the same.

The colonial gaze describes historical structures of power. The “foreign gaze,” as articulated by Seye Abimbola, describes the standpoint from which knowledge is produced and the audience for whom it is written. The “local gaze” proposed here is not the opposite of international engagement, but a practical framework for shared authority in research, policy and healthcare.

A foreign perspective is not automatically colonial. It can bring solidarity, comparison, technical expertise and resources. In an interdependent world, international partnership is indispensable.⁵

The problem begins when foreign participation becomes a foreign monopoly over authorship: distant institutions frame the problem, hold the grant, own the data, validate the findings, receive the recognition and leave when the project ends.

The opposite of the foreign gaze is not isolation. It is reciprocity. But reciprocity requires more than partnership; it requires a local gaze: a framework in which communities share authority over defining problems, producing knowledge, and determining success. 

A reciprocal partnership recognises that scientific standards can be shared globally while priorities, evidence, and delivery models must be rooted locally. It values external expertise without displacing lived experience. It measures success not only by publications or pilot outcomes, but by whether local institutions retain capability, decision-making authority, and public trust long after a project has ended.

Migration is the stress test for Universal Health Coverage

Migration exposes the strengths and weaknesses of UHC more clearly than almost any other circumstance. WHO reported in March 2026 that more than one billion people - around one in eight globally - are migrants or forcibly displaced. This includes an estimated 304 million international migrants and more than 117 million forcibly displaced people. Low- and middle-income countries (LMICs) host most of the world's refugees and others in need of international protection, even though many major policy and funding decisions are still made elsewhere.⁶

There is encouraging movement. WHO also reported in 2026 that more than 60 of 93 surveyed countries now include refugees and migrants in national health policies or laws. That is important progress. Yet inclusion in a policy is not the same as usable coverage.^7,8

The same assessment illustrates why legal inclusion alone is insufficient. The distance between entitlement and practical access remains one of the defining challenges of UHC. Only 37% of responding countries routinely collect, analyse and disseminate migration-related health data. Training in culturally responsive care remains uncommon, reported by fewer than 40% of countries, while only 30% have implemented campaigns to address misinformation and discrimination. In most countries, refugees and migrants remain under-represented in health governance.^7,8

Some countries are beginning to translate inclusion into institutional practice. Thailand has expanded migrant health-insurance coverage, Belgium uses intercultural mediators, and Chile has involved migrant community representatives in primary-care decision-making. These approaches differ, but they share an important lesson: the local gaze becomes meaningful when it changes financing, communication and governance.⁸

Nominal coverage asks whether a migrant appears in the policy. Usable coverage asks whether the person can find the service, afford the journey, communicate symptoms, understand consent, receive continuity of care and seek help without fear.

In clinical practice, I have learned that exclusion rarely announces itself as exclusion. It appears as the patient who misses follow-up because the appointment letter was incomprehensible, the family that cannot navigate a referral pathway, or the worker who delays treatment because attending a clinic may cost a day's wages. These are not peripheral inconveniences. They determine whether a formal right to health becomes meaningful in everyday life.

Universal does not mean uniform. It means designing services around the realities of the people they are intended to serve. 

A local gaze reveals the everyday realities that standardised programmes often miss: how shift work affects clinic attendance; how visa status changes help-seeking; how family and community structures influence care; how language alters diagnosis; and how earlier experiences of state authority shape trust. 

Consider a woman displaced from Ukraine who is rebuilding her life in Germany. Shortly after arriving, she experiences a transient ischaemic attack (TIA). She is entitled to healthcare. Yet her medical records have been interrupted by conflict, appointment letters arrive in an unfamiliar language, specialist referrals require navigating an unfamiliar health system, and caring for young children competes with attending clinics. Secondary stroke prevention depends on timely neurological assessment, appropriate medication, vascular (carotid and cardiac) investigations, recognition of recurrent symptoms, and continuity of care. Missed appointments may be interpreted as poor adherence when they are often evidence that services have not been organised around the circumstances of displacement. Coverage exists on paper. Preventing a disabling stroke depends on language, continuity, trust, and a health system designed around people’s lived experience.

Local knowledge should not be romanticised. Communities also contain hierarchies, exclusions and competing interests. 'Local' must therefore be plural and accountable. Women, migrants, refugees, Indigenous peoples, frontline workers and people with lived experience must have genuine decision-making roles, not ceremonial seats at the table.

From consultation to shared governance

Migrant-responsive UHC requires a change in institutional design.

• First, consultation must become shared governance. Community representatives should hold paid, formal roles in governance and priority-setting.
• Second, multilingual service design should be embedded from the outset rather than added after implemention. Language, health literacy and cultural mediation should shape services from the beginning.
• Third, short projects must build durable institutions. External funding should strengthen primary care, public health systems and trusted community organisations rather than create parallel structures that disappear when grants end.
• Fourth, data extraction must give way to data stewardship and reciprocity. Communities and local institutions should help govern data, retain access to findings and receive the training, infrastructure and health benefits created through their participation.
• Finally, national averages must give way to equity-sensitive accountability. Health systems should know who is missing from their clinics, datasets and outcomes, and why.

A historical test for the new South-North Commission

Germany's newly established South-North Commission on Development offers a timely opportunity to put these ideas into practice. It builds on the legacy of the Brandt Commission, which began work in 1977 and published North-South: A Programme for Survival in 1980.^9,10

That title remains strikingly relevant. Today's crises - health insecurity, climate change, displacement, conflict and economic inequality - cannot be managed through charity from one side of the world to another. They require shared institutions, mutual obligations and a redistribution of decision-making power.

The new Commission plans regional consultations and is expected to present interim outcomes in 2027 and a final report in 2028. Its success should not be judged only by the geographical diversity of its membership or the elegance of its final recommendations.¹⁰

Representation matters. Authority matters more. The test is not who is invited to the table, but who shapes what happens after the meeting ends.

The Commission has an opportunity to demonstrate that participation is not measured by attendance, but by influence. It should ask: Who sets the agenda before consultation begins? Whose evidence is accepted, and in which languages? Who controls commissioned research and implementation funds? How will migrants, local communities and frontline practitioners shape recommendations? What capacity and financing will remain in local systems after the Commission completes its work?

Changing 'North-South' to 'South-North' has symbolic value. The deeper reversal must occur in the flow of authority.

That reversal should be visible in practical choices: who chairs the discussion, who is paid for expertise, where research funds are held, which languages are treated as legitimate, and whether communities can alter a proposal rather than merely endorse it.

A local-gaze standard for global health

Global health institutions often speak of 'giving voice' to communities. Communities already have voices. The institutional task is to change who is heard, who decides and whose knowledge carries consequence.

The Global Health Hub Germany, the South-North Commission and their partners could lead by adopting a public local-gaze standard for UHC and migration initiatives. Every programme should disclose five things:

1. Who defined the problem and selected the priorities?
2. How do affected communities share decision-making authority and control over resources?
3. Who governs the data, and how are knowledge and findings returned?
4. What skills, infrastructure and institutional capacity will remain locally?
5. Who remains accountable after the funding or project ends?

These questions strengthen international cooperation by redefining partnership as shared responsibility rather than delegated participation. In doing so, they make cooperation more legitimate, more effective and more durable.

Universal Health Coverage will depend on health systems that are locally rooted, scientifically rigorous and jointly governed. Greater generosity alone cannot deliver this transformation.

That is the move from inclusion to shared authorship.

Only then does 'universal' begin to mean everyone.

References

1. Howard-Jones N. The Scientific Background of the International Sanitary Conferences, 1851-1938. World Health Organization; 1975.

2. Harrison M. Disease, diplomacy and international commerce: the origins of international sanitary regulation in the nineteenth century. J Glob Hist. 2006;1(2):197-217. doi:10.1017/S1740022806000131

3. World Health Organization; International Bank for Reconstruction and Development/The World Bank. Tracking Universal Health Coverage: 2025 Global Monitoring Report. World Health Organization; 2025. Accessed July 29, 2026. www.who.int/publications/i/item/9789240117808

4. World Health Organization; United Nations Children's Fund. Declaration of Alma-Ata. International Conference on Primary Health Care; September 6-12, 1978; Alma-Ata, USSR. Accessed July 29, 2026. www.who.int/publications/i/item/WHO-EURO-1978-3938-43697-61471

5. Abimbola S. The foreign gaze: authorship in academic global health. BMJ Glob Health. 2019;4(5):e002068. doi:10.1136/bmjgh-2019-002068

6. World Health Organization. Refugee and migrant health. Updated March 25, 2026. Accessed July 29, 2026. www.who.int/news-room/fact-sheets/detail/refugee-and-migrant-health

7. World Health Organization. World Report on Promoting the Health of Refugees and Migrants: Monitoring Progress on the WHO Global Action Plan. World Health Organization; 2026. Accessed July 29, 2026. www.who.int/publications/b/81850

8. World Health Organization. Encouraging progress in inclusive health policies for refugees and migrants. Published March 26, 2026. Accessed July 29, 2026. www.who.int/news/item/26-03-2026-encouraging-progress-in-inclusive-health-policies-for-refugees-and-migrants

9. Independent Commission on International Development Issues. North-South: A Programme for Survival. MIT Press; 1980.

10. German Federal Ministry for Economic Cooperation and Development. The South-North Commission on Development-a network to tackle global challenges. Accessed July 29, 2026. www.bmz.de/en/issues/ensk

*WHO (2024): “The UHC Service Coverage Index is a WHO composite indicator (0–100) that provides an overall measure of how well a country’s population can access essential health services. It is derived from 14 tracer indicators covering reproductive, maternal, newborn and child health, infectious diseases, non-communicable diseases, and health service capacity and access.”

We invited Hub member Prof. Dr. Sonu Bhaskar to share his reflections on the connection between the colonial gaze and the concept and goal of universal health coverage. The views expressed are his own and do not necessarily reflect those of the Global Health Hub Germany.