How to make United Nations high-level meetings work for global health

Last week, on Sept. 25, a fourth high-level meeting, or HLM4, of the United Nations General Assembly was held on the topic of noncommunicable diseases, or NCDs, and mental health. While initial ambitions showed potential, a flawed process led to a disrailing of the negotiation process, a watered-down declaration, and ultimately, negative consequences for global health. These types of meetings present a unique opportunity to raise the political priority of a global health issue. They are attended by heads of state and government, as well as other senior stakeholders, and typically result in a nonbinding political declaration of commitment. Following a series of preparatory meetings and regional consultations, a “zero draft” political declaration was released in May 2025. The zero draft is intended to serve as the starting point for negotiations, with revisions made in response to member state demands. While it was considered that the zero draft “shows potential,” many civil society organizations called for the declaration to be more ambitious in its targets and bolder in its actions. In contrast, what unfolded throughout the negotiations was a weakening of targets and actions, particularly in the areas of tobacco use, unhealthy diets, and alcohol consumption. For example, the zero draft set a target for at least 80% of countries to have implemented or increased excise taxes on tobacco, alcohol, and sugar-sweetened beverages, or SSBs, to levels recommended by the World Health Organization by 2030. This was later dropped. In terms of actions, the zero draft committed to “enact” legislation and regulation on tobacco use, unhealthy diets, and alcohol consumption, but this was watered down to “encourage.” The zero draft committed to increase taxation on tobacco, alcohol, and SSBs — however, the final political declaration merely committed to “consider” introducing or increasing such taxes, referring to tobacco and alcohol only, with reference to SSBs removed. This imitated the pattern of negotiations on the 2018 political declaration on NCDs, when taxes on SSBs were also removed and other evidence-informed interventions negotiated out. As the negotiation process reaches its conclusion, the advanced draft of the political declaration is circulated by the president of the U.N. General Assembly under silence procedure, allowing member states 72 hours to raise objections. If silence is not broken (i.e. no objections are raised), the declaration is deemed to have been adopted. Silence was broken in the lead-up to HLM4, indicating that objections to the political declaration remained, leading to bilateral discussions and further amendments. These amendments failed to meet the demands of all member states, particularly the United States, which rejected the political declaration at HLM4. The grounds on which objections were raised related, among others, to the political declaration going “too far” in recommending measures such as taxes on unhealthy products — actions that had already been significantly scaled back throughout the negotiation process. One of the challenges in the negotiation process is undue interference from health-harming industries. Several authors have recommended the development of inclusion/exclusion criteria for corporate engagement in global health policy development, as well as tools and processes to prevent and manage conflicts. However, such reforms are likely not imminent, and any proposed changes to the engagement of industry will be fiercely contested. We therefore recommend five actions to counter the negative impact of industry lobbying. 1. Tighten control over undue influence First, the process requires tighter controls, at both the global and country level, on the engagement and influence of different types of players, including the private sector. We have witnessed many times the tactics used by health-harming industries to sabotage public health efforts, particularly through use of the “tobacco playbook.” In response, the WHO Framework Convention on Tobacco Control states: “In setting and implementing their public health policies with respect to tobacco control, Parties shall act to protect these policies from commercial and other vested interests of the tobacco industry in accordance with national law.” We call for broader application of this prohibition, such that U.N. processes are shielded from commercial interests. Related to this, while it is claimed that civil society plays a crucial role in high-level meetings, they are very much on the sidelines, participating in parallel meetings and undertaking advocacy, as opposed to having direct formal input. Indeed, the space for engagement of civil society in official processes appears to be shrinking – this must be addressed. 2. Create more openness and transparency Second, greater openness is needed in how decisions are reached. In an era of declining trust in institutions, including the multilateral system, the lack of transparency in relation to the successive declaration drafts and “compilation texts” (i.e., identifiable member state proposed edits) seems archaic. It also obfuscates which governments and blocs are actively seeking to use U.N. forums to undermine health. In addition, the lack of systematic, timely, and transparent information on the negotiations and the draft documents undermines meaningful civil society engagement. 3. Strengthen the collective voice for public health lobbying Third, the public health lobby has the potential to leverage a collective voice on key issues, through groups such as the WHO Civil Society Working Group on NCDs, which is co-chaired by WHO and the NCD Alliance. However, many organizations lobby individually for their specific cause, which can lead to a cacophony of demands, a dilution of clear messages, and confusion over priorities — which widens the scope for more organized corporate lobbies to hold sway. Therefore, we encourage civil society to collectively engage in consultative processes, either with and/or through the WHO Civil Society Working Group on NCDs, or better yet, by setting up a truly independent civil society mechanism. 4. Support government leaders Fourth, we need to ensure our government leaders are firmly in support of public health. We must work closely with our government representatives — the ministry of health and the ministry of foreign affairs — politically, strategically, and technically. This will involve equipping representatives, including member state missions in New York, with evidence and examples of success, committing to support their positions and assisting them to demand more aspirational targets and more strongly formulated commitments. 5. Go big in the zero draft Finally, in these processes, a “technical elements paper” is typically prepared by the U.N. Secretariat — in this case, WHO — for the consideration of the member state co-facilitators as they prepare their zero draft. It is important that both the technical paper and the zero draft are “maximalist,” preempting that the proposed targets and actions will be watered down through the negotiation process. Therefore, civil society has a key role to play in influencing WHO to prepare a technical paper that is ambitious and commanding, demonstrating strong resolve (e.g., agree and commit to) over weak aspirations (e.g., encourage others). While U.N. high-level meetings have considerable potential to shape the response to global public health challenges, current processes are flawed. It could be argued that the prevailing approach undermines global technical consensus — set by normative agencies such as WHO — by legitimizing less meaningful and less ambitious action by governments. In the context of the upcoming overhaul of the U.N., a reform of General Assembly meetings is of urgent priority. In the interim, advocates must organize and mobilize to ensure evidence-informed measures are adopted and implemented in countries, irrespective of global politics. Authors’ note: The authors did not use any generative artificial intelligence or AI-assisted technologies in the writing process. Abdul Malik’s opinions in this piece are purely his personal reflections. Competing interests: Karen Milton represents the International Society for Physical Activity and Health, or ISPAH, on the WHO Civil Society Working Group on NCDs. Abdul Malik represents the Maldives NCD Alliance, which was a strong civil society lobby to the process but has not received any funding from the industry. Kent Buse is the chair of the policy and prevention committee of the World Obesity Federation, which is a member of the WHO Civil Society Working Group on NCDs, and which receives industry funding but not from the food and beverage industry.