Accountability in the 2015 Global Strategy for Women’s, Children’s and Adolescents’ HealthBMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h4248 (Published 14 September 2015) Cite this as: BMJ 2015;351:h4248
- Julian Schweitzer, senior fellow
- on behalf of the Expert Consultative Group for Every Women Every Child on Accountability
- Correspondence to:
As the era of the millennium development goals (MDGs) draws to a close, each year some 6.3 million children under the age of 5, 289 000 women, 2.8 million newborns, and 1.3 million adolescents still die from preventable causes. Others experience illness and disability, generating enormous loss and costs. An additional 2.6 million babies are stillborn. Building on the 2010 Global Strategy for Women and Children, the forthcoming 2015 Global Strategy for Women’s, Children’s and Adolescent’s Health1 aims by 2030 to end these preventable deaths and to achieve a “grand convergence” in health, giving every women, child, and adolescent an equal chance to survive and thrive. As every preventable death is an affront to human rights,2 the 2015 strategy has human rights at its core. It will be country led, universal, sustainable, equity enhancing, evidence based, partnership driven, and people centred. Robust, country led, multi-stakeholder, and participatory accountability processes, with independent review, unified reporting, and follow-up actions at all levels will be key to monitor and review progress and make the necessary policy adjustments to ensure success.3
A working group convened by the governments of Tanzania and Canada (see appendix) prepared proposals for the accountability framework in the 2015 strategy.1 In the absence of a comprehensive review of the accountability processes proposed by CoIA, the group reviewed relevant country and global reports, including on the implementation of the 2010 strategy.4 Other accountability processes, such as nutrition and education, were also reviewed and are cited below. Consultations were held with stakeholders during 2015, including two review meetings with government, academic, civil society, private sector, youth, and international agency representation.
The right to health
The right to the enjoyment of the highest attainable standard of physical and mental health was first articulated in the 1946 Constitution of WHO. Since then, nine international human rights treaties have recognised or referred to the right to health or to elements of it.5 Every state has ratified at least one such treaty and has committed to protecting this right through international declarations and domestic legislation and policies. In recent years, there has been increasing attention paid to the right to the highest attainable standard of health—for example, by bodies that monitor human rights treaties, by WHO, and by the Commission on Human Rights (now the Human Rights Council), which in 2002 created the mandate of “Special Rapporteur” on the right of everyone to the highest attainable standard of physical and mental health. These initiatives have clarified the nature of the right to health and its achievement. States have the primary obligation to respect, protect, and promote the human rights of the people living in their territory and in turn must guarantee the right to health to the maximum of their available resources, even if these are tight. While steps might depend on the specific context, all states must move towards meeting their obligations to respect, protect, and fulfil.6
Mechanisms of accountability, crucial to ensure that state obligations concerning the right to health are respected, take place at national, regional, and international levels. They involve various contributors, such as the state itself, NGOs and civil society, national human rights institutions, and international treaty bodies. Accountability compels a state to explain what it is doing, why, and how. Without prescription of exact domestic formulas for accountability and redress, the right to health can be realised and monitored through various mechanisms. At a minimum, however, all accountability mechanisms must be accessible, transparent, and effective.
Administrative and political mechanisms are complementary or parallel to judicial accountability mechanisms. For instance, the development of a national health policy or strategy, linked to work plans and participatory budgets, plays an important role in ensuring government accountability. Indicators based on human rights support the effective monitoring of key health outcomes and some of the processes to achieve them. Many groups, including health professionals, play key roles.6 Policy, budget, or public expenditure reviews and governmental monitoring mechanisms hold the government to account in relation to its obligations towards health rights. Some health services have independent or internal systems to receive complaints or suggestions and offer redress. Furthermore, impact assessments and other studies allow policy makers to anticipate the likely and actual impact of policies on the enjoyment of the right to health.
Political mechanisms, together with monitoring and advocacy by NGOs and civil society, also contribute to accountability. Civil society organisations use indicators, benchmarks, impact assessments, and budgetary analysis to hold governments and other service providers accountable. Judicial mechanisms can also provide remedies. Incorporation into domestic laws of international instruments recognising the right to health can considerably strengthen the scope and effectiveness of remedial measures, by enabling courts to adjudicate violations by direct reference to the International Covenant on Economic, Social, and Cultural Rights.6
Accountability in the 2015 strategy
Accountability builds on experience gained over the past decades, particularly since the advent of the MDGs in 2000. In addition to the measures described above, the 2005 Paris Declaration on Aid Effectiveness called for mutual accountability, with donors and partners both accountable for development results.7 Since 2010, a group of countries and donors known as IHP+ (International Health Partnership) have joined together to provide “an independent assessment of results at country level and of the performance of each signatory individually as well as collectively.”8
The 2011 UN Commission on Information and Accountability for Women’s and Children’s Health (CoIA), recognising the crucial links between human rights and health in human rights treaties, included a framework for global reporting, oversight, and accountability for women’s and children’s health and the strengthening of links with mechanisms for human rights.9 The commission recommended improvements in vital registration, health indicators, information and communications technology, resource tracking, reaching women and children, national oversight, transparency, and aid reporting. An independent Expert Review Group (iERG) has reported regularly to the UN secretary general on implementing the 2010 strategy and the CoIA recommendations.10 The CoIA definition of accountability9—a cyclical process of monitoring, review, and action that emphasises human rights principles of equality, non-discrimination, transparency, and partnership—is now widely accepted in global health and will be used in this paper.
The 2010 strategy had four accountability themes:
country monitoring and evaluation
reducing the reporting burdens on poor countries. These countries often find themselves at the receiving end of multiple demands for data from donors and partners
There was no explicit reference to human rights. High level political leadership, public-private partnerships, increased resources, and civil society participation have contributed to progress, particularly on vital registration, information, tracking of resources, and oversight.11 12 Over 50 countries have prepared country accountability frameworks, with WHO participation.13
Serious challenges remain
The previously cited CoIA and iERG reports note weak national accountability mechanisms, lack of transparent data, and health systems under pressure to deliver ambitious political goals, with limited worker and management capacity. “Multiple information-collection systems have emerged, each with its own process for tracking financial and non-financial commitments” (CoIA). “The success of the post-2015 agenda will be judged by the way the current rhetoric on accountability is translated into mechanisms for robust and independent monitoring, transparent and participatory review and effective and responsive action” (iERG).
A preliminary assessment in 2014 by the Every Woman, Every Child (EWEC) movement identified progress but also different dimensions of accountability that needed strengthening.14 Weak data, such as those on births and deaths, use of resources, or quality of services, make it more difficult to devise appropriate policies and solutions and to ensure that resources are prioritised in favour of poor women, children, and adolescents. Poor data can also result in misallocation of resources and inappropriate policies. Bangladesh is an example of a country showing advances and challenges (box 1).
Box 1: Bangladesh civil and vital registration—progress and challenges15
Public facilities in Bangladesh report deaths, and these data are available at the national level
Deaths at most non-government facilities, however, go unreported. Hospital deaths are not reported to the relevant statistical agency
Causes of death are not yet recorded/mentioned in the death register in a manner consistent with ICD-10 (international statistical classification of diseases, 10th revision)
Accuracy, completeness, and quality of recording and reporting are not always at an acceptable standard
Community births and deaths are now reported electronically and cover the whole country
Maternal-perinatal death review based on verbal autopsy without medical certification is in the pilot phase in four districts and will be scaled up in another three districts, but resources are insufficient
There is weak coordination between the agency responsible for statistics and the ministry of health and family welfare (MOHFW), with both collecting data independently
Data on fertility and mortality under statistically valid random sampling are in place and published every year
Other survey data on vital statistics are also generated by the MOHFW from time to time, but data quality is a concern
A health and demographic surveillance system providing regular and timely health data does not yet exist
What have we learnt?
The experience of implementing accountability frameworks arising from the human rights treaties, the efforts to achieve the MDGs, and the EWEC movement since 2010 provide some key messages and principles for a rights based accountability framework. This is not a comprehensive list—others will emerge as the 2015 strategy is implemented and more evidence emerges on the impact of such frameworks on outcomes.
Box 2: Designing accountability frameworks—the key messages
Focus on equity and human rights—The accountability framework, both at country and global levels, needs a firm human rights focus in the nine legally binding international treaties that address health related rights and have corresponding mechanisms to monitor implementation.5 Information needs to be disaggregated by sex, income, and geography to ensure that at risk and vulnerable populations are prioritised
Country ownership and oversight is paramount—Despite decades of efforts at harmonisation, there are still parallel initiatives and data demands by the development partners and sometimes by different country agencies.8 As ever increasing proportions of financing come from domestic resources, the demand for data, review, and action must be home generated, researched, and owned. Countries such as Tanzania, Nigeria, Rwanda, and Bangladesh are developing accountability systems that focus on the local level and, in some cases, the engagement of civil society. Other countries have issued targets, such as birth attendance by a skilled provider, which can be tracked by civil society13
Don’t forget the “health enhancing” sectors—A recent study highlighted the large contribution of “non-health” sectors (such as water and sanitation, girls’ education, etc) to health outcomes for women and children.3 These sectors need to be engaged—for example, through process indicators measuring the extent of partnership between the relevant ministries and agencies. Indicators that directly measure issues such as access to clean water and sanitation can be used as important proxy indicators for maternal and newborn health
Include and engage the private non-profit and for profit sectors that provide the bulk of health services and even financing in many countries, but have been largely ignored in the accountability debate
Engage communities and civil society18—Civil society and local communities must be engaged in issues that affect them and their decision making—for example, on spending priorities and access to and quality of healthcare. Participation is a critical element of a rights based approach. A randomised control trial in Uganda found that community based monitoring had a profound effect on quality and uptake of services and outcomes.19 Other community based mechanisms include assessments of the impact on human rights, reviews of maternal death, health tribunals, and local and traditional courts20
At sub-national levels there needs to be a focus on diverse settings—so that, for example, “hot spots” in areas of high need and/or areas with lack of services are highlighted and large geographical and social inequities in health outcomes can be addressed
The accountability process needs to be transparent, freely accessible, and independently verifiable, with open access to data and scorecards
International agencies need to ensure mutual consistency of their data
To avoid confusion and overload at the country level, the 2015 strategy indicators will be aligned with the SDG health goals and indicators and broader SDG goals and indicators that have an impact on health
Finally, there need to be much stronger linkages between the three parts of a rights based accountability framework: monitoring, review, and remedial action
The accountability framework for the 2015 strategy
The accountability framework builds on these lessons together with the experience in other sectors.21 22 23 The 2015 strategy will likely be launched at the same time as the SDGs, and relevant SDG and strategy indicators are being aligned to minimise overload and confusion between competing data needs. Through its support for the 2015 strategy, the newly created Global Financing Facility (GFF) will also play an important role in providing additional resources for accountability.24 Efforts are under way to align the strategy accountability framework with existing global initiatives, such as Family Planning 2020, to minimise additional demands for data and monitoring.
As countries and contexts differ considerably, a single “accountability blueprint” would not work. Rather, based on experience over the past decades, the accountability working group enunciated a core set of accountability principles for the 2015 strategy:
adherence to human rights including the rights of women, children, and adolescents to receive quality and respectful services
the rights of communities and civil society to participate in monitoring, review, and action, and
the key roles and responsibilities of the different stakeholders in the health sector, from governments and international agencies, to the private sector, civil society, and, above all, the women, children, and adolescents who have the right to survive and thrive.
In some cases, accountability can be assigned to a single stakeholder—for example, the accountability of a government to provide basic health services. In other cases we are talking of mutual accountability—for example, the accountability of partners in an international health partnership to mutually deliver agreed services. These core principles will themselves need regular review to ensure their continuing applicability and relevance.
Box 3: Global Strategy 2015 accountability principles
The purpose, functions, and deliverables of the accountability mechanism in terms of a dynamic process of monitoring, review, and remedial actions must be clear, transparent, and inclusive of all stakeholders
Social accountability—defined as an approach towards building accountability that relies on civic engagement, in which ordinary citizens and/or civil society organisations participate directly or indirectly in exacting accountability25—is critical. Evidence of the impact of social accountability in Uganda has been previously cited
Accountability mechanisms should embody health rights (including sexual and reproductive rights) and equity with appropriate reference to human rights instruments and treaty monitoring bodies. In this regard the rights of adolescent girls to receive access to quality sexual and reproductive health services are paramount. the 2015 strategy accountability processes must therefore be coordinated with other accountability processes, including human rights, enacted by UN and intergovernmental institutions and be aligned with SDG accountability processes
The highest levels of political authority, including government leaders, parliaments, intergovernmental processes, representative bodies such as the Inter-Parliamentary Union, regional and global bodies, and assemblies such as the African Union and the World Health Assembly, must also be engaged, as must national and sub-national institutions, particularly in devolved governments. All are crucial to ensure that the findings of the accountability process are used to shape subsequent investments, budgets, policies, and programmes
Accountability mechanisms should, if possible, be independent. Both real and perceptions of conflict of interest should be avoided. Accountability mechanisms should have established procedures to enable open and transparent engagement with key constituencies
Regular and open reporting: data, scorecards, reports, etc, should be accessible, usable, and verifiable by civil society, communities, and researchers. Monitoring should increasingly focus on outputs/outcomes, rather than inputs. Monitoring is not just about data but includes qualitative issues and adherence to rights. Monitoring of accountability processes and engagement of key parties is also important
National reviews should span the various administrative levels where services are delivered and should be linked to relevant national and sub-national planning and budget cycles. This will be facilitated though strengthening capacity for participatory monitoring and accountability at the local, sub-national, and national levels
The institutions carrying out the accountability process should collect data from various sources. Health systems data as well as independent (for example, citizen collected) data on access, quality, and equity of health services should be reviewed
Resources: the accountability mechanism should be appropriately resourced
Monitoring impact: the accountability mechanism themselves should be regularly reviewed.
Balancing completeness and overload
The goals of the 2015 strategy are to survive (end preventable deaths), thrive (ensure improved health), and transform (expand enabling environments). It will have broad coverage in six strategic areas:
advancing country leadership
maximising agency and potential
strengthening health systems
promoting community engagement
enabling cross sector collaboration, and
improving healthcare in humanitarian settings.
This is a comprehensive agenda, and it will be critical to avoid overloading already stressed country data and information systems with demands for additional data.9 Comprehensiveness, to ensure that policies, budgets, and services for women, children, and adolescents can be adequately monitored (including by the recipients of these services), has to be balanced against feasibility, reliability, affordability, functionality, and access to data systems and their links with the broader SDG system (table).⇓
Country governance and accountability processes depend on factors including the degree of centralisation/decentralisation of health finance and delivery, the public-private interface, legal statutes, parliamentary oversight, the role of audit bodies, etc. The 2015 strategy accountability framework has to build on these processes while incorporating a complex range of data on health outcomes, service delivery, health finance and expenditures, social determinants, human rights, adolescence, and contributions from non-health sectors, disaggregated by income, sex, and location.
Despite progress, there are still countries with weak or non-existent civil registration and vital statistics systems, national health accounts, health management information, and other data systems crucial for determining progress. Processes for review and remedial action can also be weak, with limited engagement with civil society and community. The 2011 CoIA recommendations on strengthening country capacity3 therefore need to be fully implemented, together with assistance to develop capacity for monitoring, evaluation, research, and advocacy, so that the outcomes of the accountability process can be translated into policy and action. Whatever the system of government, a baseline standard of reporting is planned so that progress can be compared across countries and regions. The global accountability system depends on accurate data from countries and is only as good as the sum of its country parts.
Key regional country groupings and organisations play a major role with regional peer mechanisms to review progress and propose remedial action. Regional bodies will be essential to connect and reinforce linkages between global and national mechanisms – facilitating monitoring through regional web platforms (such as AfricanHealthStats.org, CARMMA, ALMA, African Health Budget Network, ARROW) supporting peer learning and review through regional meetings such as African Health Ministers, UN regional commissions, etc, and enabling action with support for countries to act on recommendations and recognition of countries that have exhibited progress and success.
Since 2010, various agencies, including the iERG, CoIA, Countdown to 2015, and the Partnership for Maternal, Newborn, and Child Health (PMNCH), have reported on achievements of the global strategy and highlighted issues for global attention. Each accountability process, however, has had separate mechanisms, with inadequate linkage between them and weak follow-up actions. Global accountability for the implementation of the global strategy will therefore be brought together under a unified mechanism that will prepare an annual report on the “State of Women’s, Children’s, and Adolescent’s Health.” The Partnership for Maternal, Newborn, and Child Health (PMNCH) will play a key coordinating role, with an independent advisory panel appointed by the UN secretary general to ensure greater independence in accountability. An agreed set of data for expenditures, outputs, and outcomes will be used by countries and their development partners, with global and regional bodies providing reviews and facilitating remedial actions (figure⇓).
Review, dissemination, and action
A key lesson from the 2010 strategy was the need to ensure that the accountability process is linked to key intergovernmental mechanisms such as the World Health Assembly and the high level political forum established for the SDGs. Multinational and/or regional representative bodies, such as the Inter-Parliamentary Union (IPU), the African Union, the Partnership for Population and Development, and UN regional economic offices also need to be engaged to ensure that the accountability reports are widely disseminated, discussed, and acted on by key decision makers at the national and international levels.
We need a strong, inclusive, transparent, rights based and independent accountability process, based on experience implementing health aspects of human rights treaties, the MDGs, the 2010 strategy, and other health initiatives
All the stakeholders in women’s, children’s, and adolescent’s health must be engaged to achieve the convergence goals of the 2015 strategy
Key processes and institutions at the country, regional, and global level need to be strengthened and supported
The 2015 strategy will create a unified global accountability mechanism with links to key intergovernmental mechanisms to ensure appropriate actions
Cite this as: BMJ 2105;351:h4248
Contributor and sources: The author is senior fellow at Results for Development Institute. The article is based on the work carried out over the past few months by the accountability working group for the 2015 strategy, co-chaired by the governments of Tanzania and Canada, of which the author was a member, together with subsequent consultations organised by the Every Woman Every Child Movement for this strategy.
Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Not commissioned; not externally peer reviewed.
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