A quick guide to HLM4

The fourth UN High-level Meeting on NCDs and Mental Health has at last taken place: 25 September 2025 was the culmination of months and years of discussion, consultation, numerous reports and the painstakingly negotiated Political Declaration.

HLM4 followed the structure of previous such meetings: a main plenary running for eight hours without a break and, in parallel, two two-hour roundtables. An impressive number of governments – over 120 – made statements in the plenary session, and the roundtables also gave airtime to civil society organisations including the NCD Alliance. (A quick word of thanks to the facilitators of the plenaries for genuinely holding speakers to time: once the allotted three minutes were up, the microphones were unceremoniously cut – or we would all still be there!)

And what were some of the strands that emerged in the plenary?

Sustainable financing: We all know that governments the world over are cash-strapped, so finding funding today (and using it to find ways to spend less tomorrow) were constant themes.

Prevention of NCDs: Addressing the major risk factors makes great health and economic sense, as many statements reiterated. But few explicitly mentioned the WHO’s Best Buys, which can give a return on investment of 4:1 as early as 2030.

Equity: The title of the Political Declaration is ‘Equity and integration’ … but apart from this mention, every single occurrence of equity, equality and equitable were excised from the Political Declaration. It baffles me that fair, equitable access to prevention and treatment could possibly be a bone of contention – and, thankfully, many of the speakers focused strongly on it.*

Mental health: This was the first HLM on NCDs explicitly to include mental health – and many raised particular concern about for the mental health of children and adolescents.

Climate change: As at other HLMs, it was the small island developing states that are most focused on the links between NCDs and the climate emergency. Of the nine heads of state and government who spoke,** seven were from SIDS –indicative of the deep, dual crisis faced by these small nations.

Humanitarian emergencies: About 15 countries focused on the need for NCDs to be fully embedded in emergency response, which may not sound like many, but I was still heartened. At the last HLM, in 2018, humanitarian settings only squeezed into the Political Declaration at the last minute, whereas this time around there seems to be growing awareness of the need to take NCDs seriously during crises.+

Working together: The US and Argentina gave blustering statements that did nothing to dampen the growing fears that so many of us have for the world, rejecting the Political Declaration on extraordinarily spurious grounds. But many, many other ministers were vocal in their explicit support for multilateralism and for the WHO in particular. It was a relief to be reminded that, while those who shout loudest and most rudely are the ones who make the news, there are many quiet, strong leaders who fully appreciate that combining science and collaboration is the way to make progress. It was also good to hear the UK’s international development minister talking about the need for working together – though I’m not sure what her ‘new modern partnership’ will look like.

As for missing strands, I was surprised by the relative lack of focus on obesity, which currently affects 1 in 8 of the global population but was mentioned by only about 20 speakers. I was disappointed that many more countries didn’t talk about health taxes on unhealthy products, despite their being such a proven win-win for health and economies. Very, very few countries mentioned gender, despite gender-responsiveness being absolutely essential to good health care. Rehabilitation and palliative care, which are so crucial to the continuum of care, were almost entirely ignored. And the meaningful engagement of people living with NCDs barely got a look-in (despite a powerful statement at the end of the day by Kwanele Asante, a person living with NCDs from South Africa).

The next step is that the Political Declaration needs to be formally approved in the UN General Assembly in the next couple of weeks. This would usually happen automatically but on this occasion, thanks to its rejection by the US, the Declaration may be pushed to a vote. However, given the overwhelming and vocal support from ministers at the HLM, one hopes that this will be a formality (albeit a frustrating and distracting one)….

* The irony is that the United States – a principal force behind the removal of ‘equity’ – refused to endorse the Political Declaration anyway. Would it, in fact, have been more sensible to keep it in, given that the US would probably reject the Declaration? I’d be interested to hear answers!

**Regrettably, significantly fewer than the 34 who spoke at the first HLM on NCDs, in 2011.

+ A target on emergency preparedness and response was removed from this year’s Political Declaration. Again, if anyone knows why, I would love to hear about it.