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OptionsforanAccountabilityFrameworkforUniversalHealthCoverage:ConsultationReport

Acknowledgements...................................................................................................................1Foreword...................................................................................................................................2Executivesummary...................................................................................................................31. Consultationprocess..........................................................................................................5

Inputstotheconsultation.....................................................................................................5Numbersofsubmissionsandparticipants........................................................................6Characteristicsofsubmissionsandparticipants...............................................................6UHC2030...........................................................................................................................6

2. Feedbackreceived.............................................................................................................6Appropriatenessoftheproposedframework.......................................................................6

TheimportanceofaccountabilityforUHC........................................................................6Principlesandobjectives...................................................................................................7Importantquestionsraised...............................................................................................8

Rightsandparticipation........................................................................................................8Functionsofaccountability.................................................................................................10

Monitoring......................................................................................................................10Review.............................................................................................................................13Action..............................................................................................................................14

Thewayforward.................................................................................................................15TheglobalarchitectureforUHCaccountability..............................................................15

3. Recommendations&nextsteps......................................................................................16Keyrecommendations........................................................................................................16Proposednextsteps............................................................................................................17

Annex:OptionsPaper.............................................................................................................18

AcknowledgementsThisreportwaswrittenbyLaraBrearleyatManagementSciencesforHealth(MSH).MSHwouldliketothankTheRockefellerFoundationfortheirfinancialsupportforthiswork,andthefollowingpartnersfortheirongoingstrategicengagementinthisproject:theGovernmentsofJapan,Germany,USAID,WHO,theWorldBank,SavetheChildren,ActionforGlobalHealth,CHESTRAD,GlobalHealthAdvocatesandGlobalHealthStrategies.ManagementSciencesforHealth(MSH)partnerswithlow-andmiddle-incomecountriestosavelivesandimprovehealthbyensuringequitableaccesstohealthservices.Formorethan40yearsinover130countries,MSHhasworkedwithcommunitiestobuildstrong,locally-ledhealthsystemsthatimprovereproductive,maternalandchildhealthaswellasfightinfectiousandchronicdiseases.MSHbelieveseveryoneshouldhavetheopportunityforahealthylife.Formoreinformation,www.msh.org

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ForewordItisencouraginghowmuchtheworldisfocusedonachievinguniversalhealthcoverage,andtheSustainableDevelopmentGoalsonlyaddtothatmomentum.WhilemuchcourageousleadershipandthoughtfulworkhaveledtoamazingprogresstowardUHCinmanycountries,thereisstillmuchtobedonebeforeallpeoplehaveaccesstothequality,affordablehealthservicestheyneed.ThisthoughtfuldocumentisaprogressreportontheworkofmanyorganizationstodevelopconcretemeasurementsofUHCprogress–forbothaccesstobasiccareanditsaffordabilitytoall.IfwearetomeettheSDGUHCtargetby2030,weneedcommonlyagreedmeasurestoaidusinchartingprogresscountrybycountry,tocelebratesuccess,tomakeadjustmentswhenwefallshort,andtoholdourselves–allofus–accountableforachievingSDG3.8.AndUHCprogress,asweknow,facilitatestheachievementoftheotherSDGhealthtargets.Thisreporthelpspointthewayforwardtocompletingthisimportantwork.TheRockefellerFoundationisproudtosupportthisreportandthemeetings,discussionsandanalysesthatledtoitundertheableleadershipofMSH.SpecialthanksgotoLaraBrearleywhoablyshepherdedthisprocess.Withappreciationforeveryoneinvolvedinthiswork,MichaelMyersManagingDirectorTheRockefellerFoundation

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ExecutiveSummaryThisreportsummarizestheresponsesreceivedthroughapublicconsultationontheUHCAccountabilityOptionsPaperthattookplacebetweenDecember2015andFebruary2016.ThiswaspartofaManagementSciencesforHealthprojecttostrengthenaccountabilityforUHC,supportedbyTheRockefellerFoundationandimplementedwithpartners.Approximately100peopleparticipatedintheconsultation(onlineandateventsheldinMontreuxandBangkok)fromallregionsandawiderangeofconstituencies.Therewasconsensusontheimportanceofstrengtheningmulti-stakeholderaccountabilityforUHCandthetimelinessofthisinitiativeasweareatthestartoftheSDGimplementationperiod.ThefeedbackreceivedconfirmedsupportfortheproposalsintheOptionsPaperandtheUHC2030Alliance/Partnership(hereinreferredtoas‘UHC2030’)astheglobalmechanismtodrivethisagenda.RespondentsacknowledgedthepoliticalnatureofaccountabilityforUHCandemphasisedmulti-stakeholderparticipationaskeytoanyapproachpursued.Thefollowingrecommendationswereidentified:• UHCaccountabilityframework:

o AmoresystematicmappinganddeeperreviewofaccountabilityinitiativesundertheMDGstoanalysewhathasbeeneffective,whathasn’tandwhy,aswellashowtobuildonandleveragetheseexperiencesandeffortsforhealthsystemsandUHCacrossSDG3.

o Country-specificconsultationstoidentifygapsandopportunitiestostrengthenmulti-stakeholderaccountabilityforUHCacrossthefunctionsofmonitoring,reviewandaction.

o SecuringreferencetoaccountabilityinintergovernmentalresolutionsincludingtheWHAresolutionontheSDGs,specifyingobligationsofMemberStates.

o Betterdefinitionof‘non-compliance’whenitcomestoUHCimplementation,andspecificationofopportunitiesforpolicyguidance.

o ExplorationofthehumanrightsandlegislativemechanismsthatcanbeleveragedforUHCaccountability.

• UHC2030:o Acommitmenttothemandatetostrengthenaccountabilitywithsufficient

humanandfinancialresourcestosupportimplementationoftheaccountabilityframework.

o Areviewofexistingmodelsformulti-stakeholdergovernance(suchastheILO,GlobalFundandPMNCHBoards),toinformthedesignoftheUHC2030SteeringCommittee.

o AconsultativeprocesstoinformacollectiveproposalfortheCSOconsortiumundertheumbrellaoftheUHC2030.

o SufficientdonorinvestmentintheUHC2030tooperationalisetheaccountabilityframework,includingcapacitystrengtheningofcivilsociety,parliamentarians,mediaandotherstakeholders,toeffectivelyengageatcountrylevel.

• IndependentAccountability:o ExpansionofthemandateoftheIAPforEveryWomanEveryChildtothewhole

ofSDG3,andacorrespondingrestructure.

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Theproposednextstepsarelistedbelow:• UpdateandfinalisetheUHCaccountabilityframework,incorporatingthefeedback

receivedandaddressingthequestionsraisedincollaborationwiththeUHC2030stakeholders.

• TranslatetheframeworkintoacostedactionplanaspartoftheoverallUHC2030workplan.

• ContinuetoadvocatetosecurepoliticalcommitmenttoaccountabilityandUHCandtoinformthedesignandsupportfortheUHC2030.

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1. ConsultationprocessTheOptionsPaperandconsultationarepartofaManagementSciencesforHealth(MSH)projecttostrengthenaccountabilityforUHC,supportedbyTheRockefellerFoundation.ThedevelopmentofanOptionsPaperwasagreedatabrainstormingmeetingarrangedbyMSHandhostedbyTheRockefellerFoundationinpartnershipwiththeGovernmentofJapan,theWorldHealthOrganisation(WHO),theWorldBank,andUSAID,duringtheUnitedNationsGeneralAssembly(UNGA)inSeptember2015.ThisOptionsPaperwasproducedcollaborativelywithastrategiccoregroup1whoprovidedinputsthroughoutthedraftingprocess.TheOptionsPaperwaslaunchedinDecemberintimeforUHCDayandotherrelevantevents.Atwo-monthpublicconsultationtookplaceinDecember2015andJanuary2016,whichincludedanonlinesurveyanddedicatedemailaccount.TheconsultationprocesswassponsoredbyTheRockefellerFoundation,JICA,IHP+,ActionforGlobalHealth,andtheUHCDayCampaign.TheOptionsPaper,withinformationabouttheconsultationprocess,wasdisseminatedbyemailfromMSHintheirDecembercommunicationtoallpartners,bytheProjectDirectortoallstakeholderswhohadengagedinthegranttodate,andbyGlobalHealthStrategiesinvariousemailstoapproximately730organisationsacross116countriesintheUHCDayCoalitiontoencourageinputs.ItwasregularlydisseminatedthroughTwitterduringtheconsultationperiod.TherewasadedicatedpageontheMSHwebsitewithablogfromtheProjectDirector,andthePaperandconsultationwereadvertisedontheWHOwebsite.Flierswerecirculatedatrelevantevents,suchastheUHCmeetinginTokyoinDecember,andthePrinceMahidolAwardConference(PMAC)inJanuary.In-personconsultationmeetingswereheldduringaWHOworkshopinMontreuxonharmonisation,withkeycivilsocietyorganisationsanddevelopmentpartners,andatthePMAC.ThePMACside-eventwasco-hostedbyUSAID,TheRockefellerFoundation,WHO,SavetheChildrenandActionforGlobalHealth.TheProjectDirectorpresentedonthePaperatUHCDayevents,asapanellistattheWHO/SavetheChildreneventinGeneva,co-hostedbyvariousmemberstates,andduringawebinarorganisedbyActionforGlobalHealthandGlobalHealthCouncil.

InputstotheconsultationAwiderangeofsubmissionswasreceived,inrelationtothenumberofstakeholders,thetypesofconstituencies,andtheregionalspread.

1ThecoregroupincludedTheRockefellerFoundation;theGovernmentofJapan(JICA,theMinistryofHealth,LabourandWelfare,andtheMinistryofForeignAffairs);theGovernmentofGermany(GIZandtheGermanMissiontotheUN);USAID;WHO(includingtheDepartmentofHealthSystemGovernanceandFinancing,theDepartmentofServiceDeliveryandSafety,theDepartmentofInformation,EvidenceandResearch,ProvidingforHealthandtheInternationalHealthPartnershipandrelatedinitiatives(IHP+));theWorldBank;SavetheChildren;ActionforGlobalHealth;CHESTRAD;GlobalHealthAdvocates;GlobalHealthStrategies;andtheInternationalHealthPolicyProgramme,Thailand.Membershipwasdeterminedbyself-nomination.

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NumbersofsubmissionsandparticipantsThisincluded40entriestotheonlinesurvey,approximately10submissionsbyemail,approximately20organisationsparticipatedintheMontreuxsidesession,andover30attendedthePMACevent.

CharacteristicsofsubmissionsandparticipantsTherewassignificantregionalrepresentationintheinputstotheconsultationreceived.Submissionstothesurveywerefrom25countriesandparticipantsatthePMACeventwerefrom14countries,andthroughthecourseoftheconsultationstakeholdersfromallWHOregionsparticipated.TheconstituenciesthatengagedintheconsultationincludedMinistriesofHealth;civilsocietyorganisations(sub-national,national,INGO,andCSOsthatarehealthspecificaswellasbroaderinmandate);bilateraldevelopmentpartners;multilateralorganisations;donortrustfunds;researchinstitutes/academia/thinktanksfromglobal,regionalandnationallevels;theprivatesector;mediaorganisations;healtheconomicsassociations;patientrepresentationcouncils;andregionaltechnicalcommunitiesofpractice.

UHC2030TheideaofUHC2030wasfirstdiscussedduringthebrainstormingmeetingorganisedbyMSHinSeptember2015.AlsoduringtheUNGA,theGovernmentofJapanhostedasideeventon‘ThePathtowardsUHC’wheretheneedforastrengthenedpartnershiponhealthsystemsandUHCwasraised.TheProjectDirectorwassubsequentlyaskedtosupportWHOasaconsultantinthedevelopmentoftheconceptnotefortheUHC2030toensureconsistencywiththediscussionstodateandcomplementaritywiththeideasonaccountability.

2. FeedbackreceivedTheconsultationproducedfeedbackontheoverallframework,theimportanceofrightsandmulti-stakeholderparticipationthroughoutthecycleofaccountability,aswellasonthefunctions(monitoring,review,action)andproposedactivitiesforstrengtheningaccountabilityforUHC,asoutlinedintheOptionsPaper.

AppropriatenessoftheproposedframeworkAllsurveyrespondentsexceptone(98%)consideredtheOptionsPapertopresentanappropriateframeworktostrengthenaccountabilityforUHC.Theonewhodisagreedfeltthatthepaperneededmoreclarityandspecificity.Therewasasimilarlevelofinterestinremainingengagedinthisagenda,with95%ofsurveyrespondentsindicatinginterestinreviewingarevisedpaperforsignon.

TheimportanceofaccountabilityforUHCTherewasclearagreementthataccountabilityiskeytoinformthespeedanddistributionofprogresstowardsUHCatcountrylevel.CitingakeypartnerduringthePMACconsultationevent,“Nowthisiswheretherubbermeetstheroad”toguideimplementationofUHCasatargetoftheSustainableDevelopmentGoals(SDGs).TheThaiphilosophyof“thetrianglethatmovesthemountain”wascited,wherebyknowledge,socialmovementandpoliticalinvolvementcometogethertoaffectpositivechange.Theneedtofocusoncountrylevelaccountabilityreceivedwidespreadsupport.Theemphasisondomesticresources,aspertheFinancingForDevelopmentagenda,makesin-

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countryaccountabilityprocessesevermorecritical.Thisisprimarilybetweencitizens–asrightsholders–andstates–asdutybearers.Theimportanceofpublicscrutinyofgovernmentbudgetsandexpenditures,theuseofdemocraticinstitutions,andthefocusonparliamentaryoversightareparamount.Inaddition,mutualaccountabilitybetweenawiderangeofstakeholders,atcountryandgloballevels,isalsorelevantinthecontextoftheSDGs.Atthesametime,thereisanimportantroleforglobalaccountability.Severalrespondentsemphasisedtheimportanceofsharedresponsibilitytofillthefinancinggapforlow-incomecountriesandtheneedforinternationalredistribution.TherewasacallforincreasedmomentumbehindtheprinciplesofeffectivedevelopmentcooperationthroughtheInternationalHealthPartnership(IHP+),whichcouldsupportgovernmentstewardshipandoversighttomanagetheapparentincreaseinverticalisedapproaches.MutualaccountabilityintheSDGsisbroaderthanthedonor-MinistryofHealthaxesandshouldincludeothergovernmentdepartmentsrelevanttoUHCsuchasfinanceandlabour,aswellasawiderrangeofinternationalactorsincludingUNeconomicandsocialcommissionsandotherregionalbodiesetc.Therewasdiscussionabouthowtoincentivisestakeholderstostrengthenaccountabilityandtheneedtomotivatethegovernment,astheprimarydutybearerfortherighttohealth,andotherkeystakeholders,abouttheimportanceofaccountability.TherequirementforcommunityparticipationintheWorldIDABankdisbursementbasedindicatorsinMyanmarwascitedasaneffectivetooltofosterparticipation:“Thishasshiftedthelandscapeandincreasedthegovernment’swillingnesstoengagenon-stateactors”inpolicyprocesses,statedoneparticipant.SomegenericcommentsweremadeaboutthenatureofaccountabilityforUHC.Variousinputsemphasizedthepoweroftheconstitutionalprovisionoftherighttohealthtopopularizetheentitlementandprovidethebasisforlegislativeaction:Inthewordsofoneparticipant,“Otherwiseaccountabilityisjustanicenarrative”.Anothersubmissioncalledforanon-rivalryapproachthatcanstrengthenpublicsystems,promotetransparency,andboostcountryownership.

PrinciplesandobjectivesVariouspartnersstressedtheimportanceofthefollowingguidingprinciplesintheOptionsPaper:

• Buildingontheexistinglandscapeandavoidingduplication• Focusingactionatthecountrylevel,andlocalownership• Theneedforauniversalframeworkthatisbeadaptableandapplicabletolow-

middle-andhigh-incomecountries• Theimportanceoflearningfromexistinginitiativesandthroughoutimplementation.

Inrelationtothislastprinciple,therewasarecommendationforadeeperreviewofaccountabilitymechanismsundertheMillenniumDevelopmentGoalstoanalysewhathasbeeneffective,whathasn’tandwhy,aswellashowcanwebuildontheseexperiencesandinitiatives,suchasparliamentarycommittees,healthcentrefacilityassessments,maternalmortalityenquiries,citizenshearingsetc.Ahypothesissuggestedthatthismightshowthatgreaterfocushasbeenontheaccountabilityofdevelopingcountrygovernmentstodonorsandinternationalinstitutionsratherthanstrengtheningtheaccountabilityofdifferentduty

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bearerstocitizensandthemutualaccountabilityamongpartners,andthisshouldinformtheprioritiesidentifiedforstrengtheningaccountabilityundertheSDGs.BuildingontheOptionsPaper,therewereproposalsforspecificreferenceto:

• Culturalappropriateness• ThedimensionsoftheUHCcube(population,serviceswithquality(bothtechnical

and“perceived”quality,financialprotection)• Essentialpublichealthfunctions,suchasInternationalHealthRegulationscore

capacities• Theneedforaccountabilityprocessestobecontinuousandadaptive.

AnimportantreferenceistheguidingprinciplesoutlinedbyGlobalHealthVisionsforin-countrycivilsocietyactionforaccountability.2Ontheobjectives,therewasasuggestiontospelloutthatprogressiveuniversalismmeansthatprogresstowardsUHCshouldbenefitmarginalisedanddisadvantagedpopulationsfirst,inlinewithhumanrightsobligationsandtheprincipletoleavenoonebehind.Anadditionalobjectivetoenablecitizenstomonitor,reviewandfollow-uponhowgovernmentsareperformingaccordingtotheirUHCobligationswasrecommended.

ImportantquestionsraisedThefeedbackraisedimportantquestionsinrelationtotheaccountabilityframework:

• Whataretheboundariesoftheaccountabilityframework?Whatisnotincluded?• Unpackingwhoisaccountabletowhom:governmenttocitizensandmutual

accountability?HowdoesourunderstandingofmutualaccountabilityneedtoevolveintheSDGera?WhichotherstakeholdersshouldmutualaccountabilityforUHCinclude?WhatkindofaccountabilityforUHCisnecessaryatregionallevel?Howdoweholdtheprivatesector(inallofitsformsfrommultinationalpharmaceuticals,privatehospitalsandinsurancecompaniestofaith-basedprovidersandlocaldrugsellers)accountablefortheirperformancetowardsthecommongoalofUHC?

• Howtoadaptaccountabilitymechanismswherethereisdecentralisation?• Whataccountabilityisnecessaryandappropriateatregionalandgloballevels,for

instanceinthecaseoftheEbolapandemicwherearegionalresponseisrequired?• Howdowestrengthenlinkagesbetweenlocal,national,regionalandglobal

accountability?• Howdowestrengthenaccountabilityinemergencycontexts,forinstancefollowing

anaturaldisaster?• Whatistheroleoftheprivatesectoracrossthemonitoring,reviewandaction

functions?

RightsandparticipationTherewassubstantialemphasisontheimportanceofhumanrightsattheheartoftheUHCaccountabilityagenda.Legalprovisionsofthisrighttouniversalcoverageareimportantandshouldbesecuredinallcountriesandforallpopulations,particularlyvulnerableandmarginalisedgroups.Suchlegislationunderpinsthesocialcontractbetweencitizensand

21.Buildfromthegrassrootsandknowyourcontext.2.Creatediversecoalitions.3.Developanddisseminatetheevidence.4.Engagewithpartnersandcreatespaceformeaningfuldialogue.5.Strengthenoversight.6.Communicateandfollow-up.GlobalHealthVisions.2015.EngenderingAccountability:Upholdingcommitmentstomaternalandnewbornhealth.

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state,andisaprerequisiteforequityinpathwaystowardsUHC.Itisthissocialcontractthatisfundamentaltoaccountability.Mechanismsforchecksandbalancesinthehealthsystemhelptofostertrustinthepublicsystemandtheappropriateuseofpublicresourcesforthepublicinterest.ConstitutionalprovisionfortherighttohealthandUHCcanbeausefultoolforcitizensineffortstoholdtheirgovernmentsaccountable.PopularawarenessoftherighttoUHCandrelatedcommitmentsthathavebeenmadebytheirgovernmentsisaprerequisiteforeffectiveparticipationandstrengthenedaccountability.Withoutknowingyourentitlements,youcannotholddutybearersaccountableforthemtobemet.Similarly,communitiesneedtobeawareofhowtheycanparticipatemeaningfullyinthehealthsystem,policyprocessesandaccountabilitymechanismsinordertorealisetheirrights.AprogressivepathwaytowardsUHCshouldbenegotiatedthroughdomesticdialogueaboutthepopulation’sneedsandhowthepoliciesandsystemwilladdressthese.TheprincipleofredistributioniscentraltoUHC,whichmakesinclusivedomesticdebateabouttheuseofpublicresourceskeytodesigningandimplementingpoliciestoexpandcoverage.Effortstoincreasecoverageinvolvedifficultdecisions,withmanytrade-offs,thatwilldeterminewhobenefitsfirst:additionalpopulations,servicesorsubsidiesforfinancialprotection.Assuch,UHCisinherentlypolitical3andaccountabilitymechanismscanhelptoexposethepoliticalinterestsandstrengtheninclusivepoliticaldialoguesaboutpublicresources.Budgetadvocacywithpopularcampaignscanimprovetransparency,accesstoinformationandstimulateamorepublicdialogueabouttheuseofpublicresources.SubmissionscitedtheAccountabilityLoopBudgetAdvocacy(ALBA)workshopsasexamplesofeffectivemulti-stakeholdercapacitystrengtheningledbyarangeofpartnersincludingWHO,UNICEF,ThePartnershipforMaternal,NewbornandChildHealth,SavetheChildren,FamilyCareInternational,andInter-ParliamentaryUnion.4Thisrequirescitizenengagementandparticipationasactiverightsholders,notjustpassivebeneficiaries.Accountabilityatthecommunityandfacilitylevelstrengthenstherelationshipbetweenpatientsandserviceproviders,suchasthroughvillagehealthcommittees,whichmonitorserviceprovision,orpatientfeedbackmechanismsatclinics.Participationshouldhappenatalllevelsofthesystem–frompolicydialoguestoservicedelivery–andthroughouttheprocessofsituationalanalysis,planning,costing,budgeting,implementationandreview.Respondentsalsoflaggedthattheparticipationofmarginalisedgroupswillneedtoberesourced.Citizenshearingswereraisedasaneffectivemechanismtobringthevoicesofpeopletolocal,national,regionalandglobaldebates.Organisingandempoweringcitizenstovoicetheirconcernsinadialoguewithpolicymakersisaneffectivemechanismtostrengthenaccountability.Suchhearingsshouldbeinstitutionalisedinhealthsystemgovernance.TheexampleofeffortsbySavetheChildren,InternationalPlannedParenthoodFederation,

3OnerespondersaidthatthepoliticalopportunityofUHCshouldbeacknowledged,citingexamplesofSierraLeoneandThailandwhereUHCreformshavebeenatthecentreofelectoralvictories.4Furtherinformationavailableat:http://www.who.int/pmnch/media/events/2013/meeting_nairobi/en/

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WhiteRibbonAllianceandWorldVisiontosupportcitizenhearingsincountryandattheWorldHealthAssemblywassubmittedtotheconsultation.5Civilsocietyincountryhasvariousrolesforaccountability:asserviceprovider,theyshouldbeaccountabletothepopulationstheyserveandthehealthsystemtheyaresupporting;asadvocatetheyshouldbeaccountabletothemostmarginalisedandvulnerablepopulationswhoseintereststheyrepresent.CSOsarealsoaccountabletothedonorsfundingtheiractivities.Assuch,civilsocietyisbothapartner/allyofgovernment,andawatchdog.SubmissionscalledforstrongerCSOmobilisationonUHCasanintegratedhealthagenda.Forthistohappen,citizensshouldbemorefamiliarwithIHP+andUHC,asthesearenotwellunderstoodinmanycountries(citingNepalandGeorgia).ParticipantsatPMACagreedthatstrengtheningnationalCSOplatformsiskey,andhowtobestdothiswilldependonthecontextandstrengthofexistingCSOplatforms.AnotherchallengeistherealitythatexistingCSOplatformstendtofocusondonorpriorityagendas.Forexample,inGeorgia,theCountryCoordinatingMechanismisstrong,withafocusonHIV,AIDSandHepatitisC.Donormoneyenablestheplatformtodeliver,buthowtoovercomethesiloedfocusofdonorssettingtheagenda?Strongerparticipationatgloballevelwasalsoraised.Onerespondentcalledforstrengtheningthecitizenvoiceaspectofaccountabilitymechanismsbuilt-intoglobalhealthinitiatives.Therewasarecommendationfordevelopmentassistancetofocusonstrengtheningnationalaccountabilitymechanismsandparticularlythecitizenvoiceandparticipationcomponentofgovernance.

Functionsofaccountability

MonitoringAlotoffeedbackwasreceivedinrelationtomonitoringprogresstowardsUHC.Thisincludedsuggestionsonwhatshouldbemeasuredandhow,theimportanceofdisaggregation,reflectionsontheproposedadvisorygroup,potentialtoolsformonitoringincludingcommentsonUHCcountryprofiles,andsystemcapacityrequirements.Therewasstrongsupportforuniversallyagreed,specific,measurableandtime-boundindicatorsformonitoringUHC.Theprinciplesoftransparency,universality,equity,rightsanddignitywereunderlinedinthefeedbackreceived.Regardingwhatshouldbemonitored,participantscalledforgreaterfocusonrightsandlegislation.Therewasconcernthatthe80%servicecoveragetargetintheWHOandWorldBankmonitoringframeworkwasinadequate,andthattargetsshouldbeconsistentwiththeuniversalambitionofUHCat100%.Therewasalsoconcernthatthecurrentframeworkfocusedtoonarrowlyonafewdiseaseswithacallforamoreholisticapproachtoservicecoverage.Feedbackemphasisedtheimportanceofeffectivecoverage,withmeasuresofthequalityofcare.Inaddition,therewererequestsforhealthsystemstrengthtobemeasured

5Seethe2015GlobalCitizen’sHearingsreport:‘NothingAboutUs,WithoutUs:CitizensVoicesforWomen’s,Children’sandAdolescents’Health,availableathttp://www.citizens-post.org/global-citizens-hearing-report/.

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aspartofUHC,withessentialpublichealthfunctions(suchasInternationalHealthRegulationscorecapacity),andhealthworkforcedistribution,employmentandconditionsprovidedasexamples.ResourcetrackingwasraisedasakeycomponentforUHCmonitoring.Onerespondentcalledfortheconceptoffinancialprotectionandaffordabilitytoincludeincomesupportduringtimesofsickness.Stakeholdersalsorequestedanindicatoroncitizenparticipationtomonitorstakeholderengagement.TheInternationalLabourOrganisationsubmittedalistofproposedindicatorsforUHC.6AreferencetothePrimaryHealthCarePerformanceInitiativewasrequestedasarelatedmonitoringinitiative.Atthesametime,partnersraisedtheimportanceofbeingpragmatic,andawarenessofthepotentialtensionbetweendemandsformoredata,andbetterqualitydata.Varioussubmissionsemphasisedtheimportanceofknowingthedistributionofprogress,throughsystematicdisaggregationacrossthefullrangeofsocialandeconomicgroupsasoutlinedintarget17.18andparagraph74GoftheAgenda2030.Thiswillhelptobringattentiontoinequitiesincoverage,outcomes,financialprotectionandtheinvestmentsmade.TheproposalforanadvisorygroupontheWHO/WorldBankUHCmonitoringreportwassupported,asamechanismtoformalisewiderstakeholderengagement,onbothmethodologicalissuesandalsothepresentationanduseofthedata(involvingcivilsociety,mediaandparliamentarians).Thetermsofreferenceshouldbeclearonthemandateandscopeofthegroup.Respondentsstressedtheimportanceoftransparencyofmonitoringandpopularaccesstodata,sothatindividualsandcommunitiescanbetterunderstandwhethertheirgovernmentsandotherstakeholdersaremeetingtheircommitmentstoUHC.Thisshouldbetimelyandinanaccessibleformattonon-technicalstakeholders.Feedbackproposedstrengtheningacentralglobaldatahubtoprovideup-to-datedatathatisavailabletoallstakeholdersonUHC.Respondentsalsomentionedglobalwebsitesonaccountability–forinstance,WASHwatch.org,wherecommitmentsaretracked.Thisrequiresacountry-ledmonitoringandreviewsystem.Theplatformimprovestransparency,efficiencyandinclusivitywithdatapresentedandaccessibleononeglobalsite.TheOverseasDevelopmentInstitute’swebsite,deliver2030.org,wasalsoprovidedasanexampleofawebplatformwhereallstakeholderscanshareevidenceonprogressorunderperformance.Therearevarioustoolsforpresentingdatathatcanbeemployedtoempowerarangeofstakeholderstoengageindialoguesaboutprogress.Howdataisreportedcanaffectthemotivationsofdutybearerstoact.Respondentsproposedscorecardsandleaguetablesasusefultoolsforaccountability,atdifferentlevels,forexampleresourcetrackingthatcouldincludepublicandprivate(includingdonor)atfacility,districtandnationallevels.Trackingcommitmentsvis-à-vis6Theseincludethelegalhealthcoveragedeficit(percentageofthepopulationthatisexcludedandwithoutanyrightsduetolackofaffiliationtoascheme);staffaccessdeficit(percentageofthepopulationthatisexcludedduetoinsufficienthealthworkforceratios);financialdeficit(percentageofthepopulationthathasinadequateaccessduetoinsufficientfinancialresources);out-of-pocketpaymentsasashareoftotalhealthspending;maternalmortalityratioper10,000livebirths.

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disbursementsandprogresstowardsrecommendedthresholdssuchastheAbujatarget,increasingpublicspendingandreducingprivateout-of-pocketexpenditure,wasrecommendedasamechanismtoestimatepoliticalcommitmenttoUHCandausefultoolforUHCaccountability.TheActionscorecardsonimmunisation/GaviAlliancefundingandonnutritionwerecitedaseffectiveglobalexamples.Atthesametime,respondentsnotedtherisksofnaming,shamingandblaming,andtherewerecallsformoreofapartnershipapproachtoaccountability.ItwaswidelyagreedthatcountryprofilesonUHCwereagoodideaandwouldaddvalueatthecountrylevel,expandingaccesstodatatoawiderrangeofstakeholders.Feedbackreflectedonwhatshouldbemeasured,whoshoulddevelopthem,howtheyshouldbeused,andhowtolinkwithbroaderprocessesforSDGmonitoring.TherewasbroadagreementthatUHCcountryprofilesshouldprimarilybeforuseatthecountrylevel.Tomaximisetheirutility,countryprofilesshouldbetailoredtothecountrycontextandfacilitateamoreconsolidatedoverviewofSDG3,aligningwithnationalprioritiestoavoidfurtherfragmentationbyanarrowfocusonUHCglobalmeasures.Atthesametime,tradeoffsforinternationalcomparisonorglobalusewereacknowledged.Anotheroptioncouldbeforacorelistofcomparableinternationalindicatorstobeusedwithspaceforadditionalindicatorsasrelevanttothecontext.Stakeholderscalledformeasuresofpreventive,promotive,curative,rehabilitativeandpalliativecare;qualityandeffectivecoverage;disaggregationforequity;healthsysteminputs;thebroaderdeterminantsofhealth;analysisofchangeovertime;anddescriptionsofpoliciesandprocessesincludingcitizenparticipation.Therewerereflectionsaboutwhocouldproducetheprofiles,withpreferenceforcountry-basedstakeholdersincludinggovernment,academiaandcivilsociety,overexternalconsultantsorglobalpartners.Thiswouldstrengthencapacitiesandpromotesustainability.Theuseoftheseprocessestoengagewiderstakeholders,suchasparliamentariansandmedia,indiscussionsonprogress,wasraised.ItwouldalsobeimportanttoconsiderhowtheprofilescouldlinkwithSDGreportingtotheHighLevelPoliticalForum.Variousexamplesofglobalcountryprofilesweregiven.Forexample,theGlobalNutritionReport,whichincludescountryprofilesfornutrition.Countdownto2015profilesonmaternalandchildhealthweredeemed‘acceptable’butwithhightransactioncostsasittookyearsofnegotiationtoagreeontheindicators.However,thishelpedtobreakdownthesiloswithinthecontinuumofcare.Broaderhealthsystemandpolicyreportingwasincludedbutremainedachallenge.TheGlobalNetworkforHealthEquityhasappliedastandardisedframeworktodevelopcountryprofilesthatanalysisrevenuecollection,pooling,purchasing,withfeaturesofthehealthsystemthatseekstoexplainthepatternofprogressasasteptoidentifyingrecommendationsforimprovement.Theneedtostrengthenhealthsystemsfortimely,accurateandeffectivemonitoringwasraised.Alignmentofpartnerswithdatasystemswasencouraged,withacalltoavoidadhocdatacollection.Thisinvolvesimprovinghealthmanagementinformationsystems,expendituretrackingusingstandardisedmethods(SHA2011),measurementoffinancialriskprotection,disaggregation,anddataquality.

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Feedbackincludedtheneedtostrengtheningcapacitiesfordataanalysisanduse.Intheabsenceofrecentanddisaggregatedhealthresourcedata,budgettrackingbycivilsocietyinpartnershipwiththegovernmentcanbeausefulexercise,aspertheALBAapproach.Resourcetrackingisalsocrucialtoexposetheleakageoffundsandpotentialcorruption.Widerfiscalspaceanalyses,toexplorethepolicyoptionstoincreaseresourcesforhealth,wasalsoencouraged,shouldbemoreroutinelyemployed,alongwithcost-benefitanalysis.Researchthatcomparespolicyprioritieswithresourceflowscanstrengthenaccountability,andthereisinadequateuseofpoliticaleconomyanalysisinUHCreformprocesses.Respondentsalsoraisedthevalueofcasestudiesthatunpackwhyresultsareastheyare,whichcanbepromotedtogetpoliticalandpublictraction.Countdownto2015’smulti-stakeholderapproachtodoingthiswasgivenasanexample.Identifyingpolicyrecommendationsbasedonthedatacanhelptoimprovetheutilityofmonitoring.Itisimperativethatmonitoringhasapurpose,toinformtherestofthecycleformulti-stakeholderreviewandremedialaction.Forthistoworkeffectively,inclusiveprocessesforeffectivedisseminationandparticipationarekey.

ReviewTherewasconsensusontheimportanceofmulti-stakeholderandindependentreview.Theconsultationprovidedfeedbackontheprinciples,stakeholderstoengageandmandateofmulti-stakeholderreviewmechanisms,andreflectionsontheproposalforanindependentpanelonUHC.ItwasalsonotedthatUHCreviewmechanismsshouldalignwithSDGmechanismsforreviewandfollow-up,withreferencetotheproposalslaidoutin‘The2030AgendaforSustainableDevelopment’and‘Resolution67/290’(paragraphs74,78-79and80-81.TheHighLevelPoliticalForum–asthemainreviewmechanismfortheSDGs–presentsanimportantopportunityforareviewofprogresstowardsUHCandthehealthSDG.Variousprinciplesforreviewprocesseswereidentified:Reviewprocessesshouldberegularandtransparent.Theyshouldbeinclusive,consultativeandparticipatory.Theyshouldbeinformedbyevidenceandunpackwhyprogresshasorhasn’tbeenmade.Andtheyshouldbeaction-orientedtoinformthepolicyresponsetoaddressgapsandobstacles.Securingsafespaceforgenuineandmeaningfulparticipationiskey.Guaranteeingtherightsandfreedomsofexpression,association,peacefulassemblyandaccesstoinformation,inlawandpractice,cancreateanenablingenvironmentforthis.Respondentsspecifiedtheconstituencieswhoshouldbepartofreviewmechanisms,asbothmulti-stakeholderandmulti-sectoral.Theseincludedministriesofhealth,finance,socialsecurityandlabour,citizens(andspecificallywomenandyoungpeople),marginalisedgroups,informalsectorworkers,patientgroups(representingarangeofdiseases),civilsocietyorganisations,non-governmentalorganisations,academia,healthcareprofessionalassociations,healthworkersandministryofhealthofficialsfromnationalanddistrictlevels,parliamentarians,developmentpartners(multilateralsanddonors)andtheprivatesector.Therewaswidespreadagreementthatgovernmentrepresentativesshouldconvenetheprocess,astheultimatedutybearersandstewardsofthesystem.WhetherthisshouldbetheMinistryofHealthorco-convenedbytheMinistryofFinancewasdiscussedatthePMACevent.Participantsacknowledgedthechallengeofhowtogetappropriaterepresentationfromdifferentconstituencies,andcalledforlearningfromexistingefforts,includingtheCountryCoordinatingMechanismoftheGlobalFund.

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Onthemandateofreviewmechanisms,therewasthesuggestionthattheseshouldbebothstrategicandoperationalinfunction.Twospecificopportunitieswerecited:toreviewcountryimplementationplansforSDG3.8andthetargetsandmeasuresidentified;andtoreviewcountryreportsonSDGprogressbeforeitissharedwiththeUnitedNations.Therewasalsoacallformulti-stakeholderreviewtohappenatvariouslevelsdeterminedbywheredecision-makingpowerexists,especiallyinthecaseofdecentralisedsystems.Inaddition,inter-governmentalplatformsatregionalandgloballevelsareimportantforaforreviewwiththeopportunityofpeerpressuretoincentiviseaction.Theconsultationemphasisedtheneedformandatedinstitutionsforaccountability,suchasindependenthumanrightsinstitutions,parliamentsandsupremeauditinstitutions,tomonitorgovernmentprogresstowardssustainabledevelopmentgoalsandtargets,withtheparticipationofcitizens.Institutionalisingaccountabilityinresolutionswasalsorecommended,suchasthroughtheWorldHealthAssemblyresolutionontheSDGs.Therewasclearagreementonthevalueofindependentreviewatglobalandlocallevels,andsupportforsuchamechanismtocritiqueprogresswiththepoliticalclouttodriveaction.However,therewasastrongcalltoavoidestablishingaseparatesiloedpanelforUHC.Instead,therecommendationisforanintegratedhealthpanelforSDG3,whichcouldevolvefromtheexistingIndependentAccountabilityPanelforWomen’s,Children’sandAdolescents’Health,toincludearangeofcommunities,diseasesanddisciplines.Influentialfiguresoperatingintheirindividualcapacitywiththecouragetobeconfrontationalcouldbringteethtotheaccountabilityagenda.Quotingonerespondent:“Theglobalhealthcommunityistoopoliteandsensitive;weneedtocalloutgovernmentsandagenciesthatareblatantlyfailingonUHCagendas”.Examplesgivenwereofbilateralspromotingcommunitybasedhealthinsuranceschemes,andpublicprivatepartnershipsthatareunderminingequityandefficiency.Atthesametime,therewasscepticismaboutthefeasibilityofpreserving‘independence’.Howwouldthisgrouphavethelegitimacyandauthoritytoholdotherstakeholdersaccountable?AppointmentbytheUNSecretaryGeneral,aspertheIAPforEveryWomanEveryChild,andadirectreporttotheHighLevelPoliticalForum,wasproposedasawaytosecurethis.Atthecountrylevel,therewasacallfornon-stateoversightoftheprotectionofmarginalisedinterestsinUHCeffortstobesupportedwithfundingfromdevelopmentassistanceforhealthandtechnicalassistance.

ActionCoursecorrectionstoadheretotheprinciplesandobjectivesofUHCwillbenecessaryalongthepathwayofprogress.Sanctionsfornon-complianceorpoorprogressshouldbeclearandpredictable.Theactionfunction,within-builtfollow-upmechanisms,isimperativeforaccountability.Yettherewerethefewestresponsestothisfunctionintheconsultation.Thismayhavebeenbecauseofthebreadthofinterpretationofwhat‘action’meansinregardstoUHCaccountability(fromlegislativesanction,topolicyreform,resourceallocation,andadvocacytodrivethis),andthedifficultyofdefining‘non-compliance’,punishmentandrewardinrelationtoUHC.HowenforceableistherighttohealthandUHC?Thevoluntarynatureofthe2030Agendaposesachallengeforaccountability.Respondentsnotedtheimportanceofclarifyingjudicialandnon-judicialmechanismsforaction.Humanrightsframeworksofferthepotentialforenforceability.Non-judicialapproachesinvolveadministrative,politicalandsocialreforms.Evidence-basedadvocacycanbeeffectivetomobilisethepoliticalwillforreform,hencetheroleofcivilsocietyisimportant.Atthegloballevel,theUHCDaycampaign,coordinatedbyGlobalHealth

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Strategies,couldbeausefulbasisforcoordinatedadvocacy.Respondentscalledforsmallgrantstofundlocally-ledadvocacyforaccountabilitywithincountries.ElectioncampaignscanbeimportantopportunitiesforsubstantialreformandacceleratedprogresstowardsUHC.TheprocessesbywhichcountriestranslatetheSDG3priorityforUHCintonationalplans,policiesandbudgetsshouldhavepotentialforaction.Criteriaforcompliancecouldincludeadherencetotheprincipleofleavingnoonebehind,withstrengthenedplansthatprioritisetheneedsofmarginalisedgroupsanduniversalentitlements.PolicyguidanceforUHCwillbeimperativetoensurenotanythinggoesonthepathwaytowardsUHC.TherewasacallforstrengthenedcapacityonUHC,includingresourcetracking,tofacilitateactionandaccountability.Thiswasdeemednecessaryforallstakeholders,includingministryofhealth,finance,parliamentarians,civilsocietyandmedia.Withoutsufficienttechnicalgraspoftheagenda,stakeholderswillbelimitedintheircapacitytounpackandcritiquepoliciesandplans.Arespondentproposedregionalhubsandmentorstofacilitatethis.Atthesametimeasinstitutionalisingaccountability,systemsforresourcemanagementandgovernanceshouldbestrengthened,andtherewasspecificmentionoftheimportanceofpublicfinancialmanagementforacceleratedprogresstowardsUHCandimprovedaccountability.

ThewayforwardInlinewiththeOptionsPaper,therewasanagreementthateffortstostrengthenaccountabilityforUHCshouldleverageandbuildonexistinginitiatives.Forexample,tostrengthenmonitoringsystems,theHealthDataCollaborativeisunderwayandshouldbethevehicleforinvestmentstostrengthenmonitoringforUHC.Fordevelopingandsharingbestpractices,existinglearningplatformsshouldbeused–suchasconferencesandcommunitiesofpractice,includingHarmonisingforHealthinAfricaandtheJointLearningNetwork.WhilemanyCSOandmulti-stakeholderplatformsforhealthexistatcountrylevel,thesetendtobeissue-specificandnotsectorwide.Strengtheningandharmonisingorintegratingtheseplatforms,withafocusonhealthsystemstrengtheningforequitableandsustainableUHC,shouldbethefocusinsteadofsettingupnewUHC-specificinitiatives.OnerespondentaskedwhetherCountdownto2030couldbroadenitsmandatetoundertakedataanalysisforUHC.Amoresystematicmappingofexistingrelevantinitiativeswasrecommended,withrecommendationsforhowthesecanbeleveragedforUHCaccountability.Asmentionedabove,theexistingIAPshouldevolvetohaveabroadermandateacrossSDG3,includingUHC,withacorrespondingrestructuretoachieveanappropriatebalanceofexpertise,skillsandpoliticalclout.

TheglobalarchitectureforUHCaccountabilityNorespondentschallengedtheproposalthateffortstostrengthenaccountabilityshouldbedrivenandcoordinatedbytheUHC2030orPartnershipastheevolutionofIHP+.Ahighlevelmechanismthatbringstogetherglobal,nationalandcivilsocietyactorstogeneratepoliticalmomentum,improvecoordinationandstrengthenaccountabilitywassupported.OnerespondentproposedthatthiscouldabsorbtheGlobalHealthWorkforceAllianceandincludeafocusonhumanresourcesforhealth.SomerespondentsproposedthatthiscouldbethemechanismtooverseeandoperationalizeimplementationoftheHealthySystems-HealthyLivesRoadmap.TherewasacallforglobalhealthinitiativestobewillingtoharmonisetheirhealthsystemssupportandaccountabilitymechanismsthroughtheUHC2030.TheneedforsustainedcommitmenttotheIHP+principlesandworkwasemphasised.HowtheUHC2030wouldlinkwithotherexistinginitiativesneedsfurtherelaborationandclarity.Arespondentaskedthepertinentquestion:towhatextentwillUHCserveasan

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integratingagendaforallofSDG3andhealthsystems?OntheaccountabilityfunctionoftheUHC2030,onerespondentfeltthatalltheOptionsPaperproposalswerevalid,buthowwouldpriorityactionsbeidentified,giventhatitmaybetoomuchtotakeonallofthesesuggestionsatonce.ThegovernanceoftheUHC2030shouldbemulti-stakeholderortripartite,withrepresentationfromkeyconstituenciesincludingcivilsociety.Existingmodels,suchastheGlobalFundBoard,theInternationalLabourOrganisationandothers,shouldbereviewedtoinformthisdesign.TheUHCCSOconsortiumproposalwassupportedasapartoftheUHC2030,withamandateforadvocacytomaintainpoliticalcommitment,toensureequityisprioritised,totrackresourceallocationsandexpenditures,tostrengthenCSOsaswatchdogsatlocalandnationallevels,andtofacilitatepeerexchange.AspertherecommendationintheOptionsPaper,theexistingIHP+CSOrepresentativesaredevelopingaconceptnoteonthis.ArespondenturgedthatthisIHP+proposalshouldtakeaccountoftheshortcomingsofthecurrentIHP+CSOprocesses,statingtheirconcernthatthesehavebeenweakandfailedtoengagesouthernCSOseffectively.AnannualCSOalternativereportonUHCprogresswasalsoproposed.Thisconsortiumcouldbeco-hostedbyarotatingSouthernpartner,withaco-hostintheSecretariatoftheUHC2030tomaximisesynergieswithrelatedinitiativesandopportunitiesforinfluencewithintheUHC2030structure.LinkswiththeHealthDataCollaborativeCSOinitiativearecrucial,andthepotentialforajointsecretariatorcommonfunctions(suchasgrantgivingtolocalCSOs)shouldbeexplored.FortheCSOcapacitybuildingprogrammeofwork,theALBAapproachwithhealthfinancingdiagnosticswasproposed.Itwasnotedthatresourceswillbeneededtotakethisforwards,anddonorsshouldstepuptofillthisgap.BetterclarityonthefinancingimplicationsoftheUHC2030wasrequested,includingoperationalizingtheaccountabilityframework.TheSecretariatstaffdedicatedtoaccountabilityshouldbeintegratedintotheUHC2030Secretariat.

3. Recommendations&nextstepsTheconsultationdemonstratedconsensusontheneedandopportunitytostrengthenaccountabilityforUHC.TherewasbroadsupportfortheproposalslaidoutintheOptionsPaperandagreementthattheseshouldbetakenforwardsundertheumbrellaoftheUHC2030.

KeyrecommendationsBelowisasynthesisofthekeyrecommendationsidentifiedthroughtheconsultation:• UHCaccountabilityframework:

o AmoresystematicmappinganddeeperreviewofaccountabilityinitiativesundertheMDGstoanalysewhathasbeeneffective,whathasn’tandwhy,aswellashowtobuildonandleveragetheseexperiencesandeffortsforhealthsystemsandUHCacrossSDG3.

o Country-specificconsultationstoidentifygapsandopportunitiestostrengthenmulti-stakeholderaccountabilityforUHCacrossthefunctionsofmonitoring,reviewandaction.

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o SecuringreferencetoaccountabilityinintergovernmentalresolutionsincludingtheWHAresolutionontheSDGs,specifyingobligationsofMemberStates.

o Betterdefinitionof‘non-compliance’whenitcomestoUHCimplementation,andspecificationofopportunitiesforpolicyguidance.

o ExplorationofthehumanrightsandlegislativemechanismsthatcanbeleveragedforUHCaccountability.

• UHC2030:o Acommitmenttothemandatetostrengthenaccountabilitywithsufficient

humanandfinancialresourcestosupportimplementationoftheaccountabilityframework.

o Areviewofexistingmodelsformulti-stakeholdergovernance(suchastheILO,GlobalFundandPMNCHBoards),toinformthedesignoftheUHC2030SteeringCommittee.

o AconsultativeprocesstoinformacollectiveproposalfortheCSOconsortiumundertheumbrellaoftheUHC2030.

o SufficientdonorinvestmentintheUHC2030tooperationalisetheaccountabilityframework,includingcapacitystrengtheningofcivilsociety,parliamentarians,mediaandotherstakeholders,toeffectivelyengageatcountrylevel.

• IndependentAccountability:o ExpansionofthemandateoftheIAPforEveryWomanEveryChildtothewhole

ofSDG3,andacorrespondingrestructure.

ProposednextstepsTheproposednextstepsarelistedbelow:

• UpdateandfinalisetheUHCaccountabilityframework,incorporatingthefeedbackreceivedandaddressingthequestionsraisedincollaborationwiththeUHC2030stakeholders.

• TranslatetheframeworkintoacostedactionplanaspartoftheoverallUHC2030workplan.

• ContinuetoadvocatetosecurepoliticalcommitmenttoaccountabilityandUHCandtoinformthedesignandsupportfortheUHC2030.

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Annex:OptionsPaper

OptionsforanAccountabilityFrameworkforUniversalHealthCoverage

1. IntroductionTheadoptionoftheSustainableDevelopmentGoals(SDGs)includesarenewedcommitmentbyMemberStatestoglobalhealth.ThehealthgoalintheSDGsisanopportunitytopromoteacomprehensiveandcoherentapproachtohealth,anduniversalhealthcoveragei(UHC)maybeavehicleforthis.UHCisthefocusoftarget3.8intheSDGsanditunderpinsthehealthgoaliiwithaviewtohowthehealthsystemdeliversintegrated,people-centredhealthservices.UHCisfundamentaltothehumanrighttohealthiiiwhichgovernmentsareobligedtofulfil.ivItisinherentlyapoliticalagendavasitpertainstotheredistributionofresourcesinsociety.Asahealthsystemgoal,itisthepolicychoicesthataremadeonthepathwaytowardsUHCthataremostimportant.WhilethereisnoblueprintforprogresstowardsUHC,pathwaysmustfulfilcertainprinciplestobeconsistentwiththerighttohealthandthepromiseoftheSDGstoleavenoonebehind.Theseprinciplesincludeprogressiveuniversalismvi,sharedresponsibilityandparticipatorydecisionmaking,amongothers.viiviiiAccountabilitymechanisms–encompassingtheinterconnectedfunctionsofmonitoring,reviewandremedialactionix–willbeimperativeforguidingimplementationandacceleratingprogressontheSDGs.ArobustframeworkforaccountabilityforUHC,atcountry,regionalandgloballevels,caninformthepathwayandpaceofprogress.Itcandrivemorecomprehensive,system-wideresultsacrossSDG3,identifiedbytheindependentExpertReviewGroup(iERG)asa“compelling”needintheir2015report.xThecostsoffailingtoseizethisopportunityaresubstantial.Withanincreasednumberofissue-specifictargets,theSDGsriskexacerbatingfragmentationandverticalisationinthehealthsector.Accountabilitycanhappenatalllevelsofthehealthsystemandbeyond,inpoliticalforaandthecourtsoflaw,andbetweendifferentstakeholders.Thispaperfocusesonmechanismstoadvanceaccountabilitybetweenrightsholders(individualsandcommunities,andparticularlymarginalisedgroups)anddutybearers(countrygovernmentsanddevelopmentpartners).AccountabilityforUHCshouldaddressthethreedimensionsofthedefinitionofUHC:whichpopulationsarecovered,forwhatservicesofgoodenoughqualitytobeeffective,andtowhatextentoffinancialprotection.Thiswillrequireaccountabilityforfinancialresources(suchastrackingallocationsanddisbursements),forperformance(services,outputsandresults),andforpolitical/democraticprocesses(theinstitutionsandprocessestoensurethegovernmentdeliversonthepopulation’sneedsandelectoralpromises,includingpolicy-making).xiThispaperproposeskeyfeaturesofanaccountabilityframeworkasthebasisforaconsultationtostrengthenmulti-stakeholderaccountabilitymechanismsforUHCwithinthecontextofthehealthrelatedSDGs.Inparallel,aprocessisunderwaytoexplorethepotentialforamulti-stakeholderUHC2030,withoneofitsobjectivetoadvance

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accountabilityforUHC.TheoutcomesofthisconsultationwillinformaproposalofprioritiesfortheUHC2030AccountabilityFramework,tobeimplementedwithinthewiderarchitectureoftheUHC2030.

GuidingprinciplesAnyefforttostrengthenaccountabilityforUHCinthecontextoftheSDGsshould:● Advanceanintegratedapproach,focusingonpeople’shealthneeds,theirdeterminants

andthehealthsystem’sresponse● PromoteequityinimplementationofUHCandtheSDGs● Applytoallcountries,regardlessofincomelevel,andwithaspecialfocusonvulnerable

groups● Ensurecountryownershipandsustainabilitythroughinstitutionalisingmulti-stakeholder

mechanismsforaccountability● Beevidence-basedandfostercollectivelearninginassessingpathwaysforprogress

towardsUHC● Haveadistinctmandateandaddedvaluetopreventduplication● Strengthenlinkagesacrosstheprocessesofmonitor,reviewandaction,with

transparencyandmeaningfulmulti-stakeholderparticipation● Supportstrengthenedcountryhealthstrategiesandplansandalignmentofpartners

behindthese● Beresultsdriven,trackingprogresstowardstime-boundandmeasurablegoals

• ObjectivesTheUHC2030AccountabilityFrameworkshoulddeliveronthefollowingobjectivesatcountry,regionalandgloballevels:1. IncreasedpoliticalprioritizationofUHC;sufficient,sustainableandequitable

investment;andimplementationofrobustpoliciesforprogressiveuniversalism2. StrengthenedevidenceforadvocacyandaccountabilityforUHC3. Institutionalised&harmonisedmulti-stakeholdermechanismsforUHCaccountability,

alignedwithcountryprocessessuchasplatformsforinformationandaccountabilityandJointAnnualReview(JAR)

Theseobjectivesarenotcomprehensiveofallthatisneededforaccountability,buttheyseektoaddvaluetotheexistinglandscapeforUHC.TheyalsocomplementtheobjectivesoftheHealthDataCollaborative,whichfocusesonstrengtheningcountrysystemsformonitoringprogressandperformanceforaccountability,providingastrongbasisfortheUHC2030AccountabilityFramework.

• AddedvalueTheUHC2030AccountabilityFrameworkshouldlearnfromtheexperienceofothereffortstostrengthenaccountabilitywithinandbeyondthehealthsector,andcomplementtheexistinglandscapeofrelatedinitiatives.

LearningfromexperienceAccountabilityhappensatalllevelsandinvolvesamultitudeofstakeholders–fromthepointofservicedelivery,tonationalpolicyprocesses,courtsoflawandinternationalfora.Keycomponentsthatemergefromexperienceinclude:xiixiii● Monitoring:Regular,timelydataofgoodqualitythatistransparent,publiclyavailable

andeasilyaccessible.Thereshouldbewelldefinedindicatorframeworksthatalignwith

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thenationalmonitoringandevaluationplanandglobalreportingrequirements,xivandthisrequiresstronginformationsystemsthatareabletoreportdisaggregateddata.

● Review:Researchanddataanalysistoevaluatewhethercommitmentsarebeingmet,withmulti-stakeholdermechanismsforreview.Itisnecessarynotonlytofocusonwhathappened,butalsohowandwhyithappened.Theseprocessesshouldbeinclusiveandtransparent,withmultipleinputs(includingcountry,donorandnon-stateactors),andaction-orientedtoinformbetterpoliciesandimplementation.Theseshouldprovideevidenceandrecommendationstoinformtheworkofdecision-makingbodies,suchasparliamentsatcountrylevel,andintergovernmentalmechanismsatregionalandgloballevels–forinstancetheAfricanUnion(AU),WorldHealthAssembly(WHA),UNGeneralAssembly(UNGA),IMFandWorldBankSpringMeetings,HighLevelPoliticalForum(HLPF)andtheHumanRightsCouncil(HRC).Independentmonitoringandreviewareimportantatcountryandgloballevels.xv

● Action:Thisincludesstrengthenedpolicies,plansandresourceallocationofcountries,developmentpartners,non-stateactorsandglobalinitiativesthatrespondtorecommendationsfrommulti-stakeholderreview.ItalsoincludesmutualaccountabilitymonitoringofeffectivedevelopmentcooperationinhealthandadherencetoIHP+principles,whichwouldgoalongwaytowardseffectivelyimplementingthecountryhealthstrategy,includingitselementsonUHC.Advocacybycivilsocietyandengagementofthemediaandparliamentarianscanhelpbringaboutsuchchange.Processestofacilitatefollow-upandreviewofimplementationofrecommendedactionsareimperative.

Accountabilityshouldapplytoallstakeholders,includingcitizens,donorsandnon-stateactorsaswellasgovernments.ThisconceptofmutualaccountabilitywasespousedintheParisDeclarationof2005,itremainscoretotheGlobalPartnershipforEffectiveDevelopmentCooperation,anditisapriorityoftheInternationalHealthPartnership(IHP+).Theimportanceofindependentreviewisincreasinglyacknowledged,forexamplethroughtheIndependentAccountabilityPanel(IAP)fortheGlobalStrategyforWomen’s,Children’sandAdolescents’Health(GlobalStrategy)anditspredecessortheiERG.TheiERGalsorecommendedthatgovernments,withthesupportofH4+,establishcountry-basedIAPs.Civilsocietyhasacrucialroletoplayinaccountability,throughadvocacyandparticipation,empoweringthevoiceofmarginalisedcitizens.Accountabilityeffortsneedtoberesourced,bothatthenationalandgloballevel.Globalaccountabilitymechanismsshouldbebasedonnationalmechanisms.

BuildingontheexistinglandscapeMuchisalreadybeingdonetoadvanceaccountabilityforUHC.Whilethisisnotacomprehensivemapping,theUHC2030AccountabilityFrameworkbuildsonandcomplementstheinitiativeslistedinTable1.Table1:MappingexistingaccountabilityinitiativesrelatedtoUHC

Monitoring Review Action● Amonitoring

frameworkoftargetsandindicatorstomeasureprogresstowardsUHCatglobal

● TheannualWorldHealthOrganisation(WHO)andWorldBank(WB)reporttrackingprogresstowardstheSDG3.8indicators.

● Otherrelatedreportsincludingthe

● TheUHCDaycoalition,coordinatedbyGlobalHealthStrategiestobuildmomentum,

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andcountrylevels,adheringtothe100CoreHealthIndicators.

● Technicalsupporttostrengthennationaldatasystems,includingservicecoverage,quality,nationalhealthaccounts,nationalhealthworkforceaccounts,financialriskprotectiondata,andpublicexpendituretrackingsurveys.

● TheHealthDataCollaborativewithanobjectiveofstrengtheningcountrysystemsformonitoringprogressandperformanceforaccountabilityinhealth.xvi

IHP+stateoftheworld’seffectivedevelopmentcooperationinhealthreport,andreportsproducedforsub-sectoralareas,suchastheIAPreportonwomen’s,children’sandadolescents’health,thenon-communicablediseasescountdownreportandreportsoninfectiousdiseases.

● Advocacytoolssuchasscorecardsandcivilsocietybudgettracking.

● OfficialSDGreportingmechanisms,yettobedefined.

● Technicalsupporttostrengthencountrycapacityandprocessesformulti-stakeholderreview,includingtheWHOprogrammeonnationalhealthpolicies,strategiesandplans,andIHP+guidance.

● Relatedmulti-stakeholderreviewmechanismsatsub-sectorallevel,suchascountryplatformsfortheGlobalFinancingFacilityfortheGlobalStrategy,andCountryCoordinatingMechanismsassociatedwiththeGlobalFund.

strengthenmessaging,andsupportpartneractivitiesatglobal,regionalandcountrylevels.

● Intergovernmentalreviewofexistingresolutions,suchasUNGA67/123,WHA64.9.

● Nationalpolicies,strategiesandplansrelatedtoUHC.

● TechnicalsupportandpeerexchangeonpoliciesandprogrammesrelatedtoUHC,suchasProvidingforHealth(P4H)andtheJointLearningInitiative(JLN).

• RecommendationsfortheUHC2030AccountabilityFramework

Drawingonthelessonsandexistinglandscape,thefollowinggapshavebeenidentifiedandpresentpotentialopportunitiestostrengthenaccountabilityforUHC:

IndependentAccountabilityPanelforUHCAglobalIndependentAccountabilityPanelforUHC(IAP-UHC),comprisedofeminenttechnicalandpoliticalfigures,withthecredibilitytochallengeandconfrontdutybearerstobetterdeliverontheircommitmentstoUHC.TheIAP-UHCwouldproduceanannualcommentary,assessingprogresstowardsUHCdrawingonexistingevidence,suchastheWHO/WorldBankUHCmonitoringreport,officialSDGmonitoring,StateoftheWorld’sEffectiveDevelopmentCooperationinHealth,sub-sectoralreportsandcountryspecificreports.Thecommentary,withclearpoliticalandtechnicalrecommendations,wouldbetimedtoinformdeliberationsatintergovernmentalaccountabilityforasuchastheHLPFandWHA.TheIAP-UHCwouldmeetin-persononceperyeartofinalisetheircommentaryanddevelopadisseminationstrategy.TheywouldbesupportedbytheUHC2030Secretariat.

AdvisorygroupfortheWHO/WBUHCmonitoringreportAnadvisorygroupwouldprovideasystematic,coordinatedandtransparentmechanismformulti-stakeholdercontributionstotheUHCmonitoringreport.Memberswouldincludetechnicalexpertsfromresearch,academia,implementingcountrygovernmentsanddevelopmentpartners,aswellascivilsociety,parliamentariansandmedia.Thegroupwouldadviseonthemethodologicalissuesaswellasthepresentationofdatatomaximise

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utilisationbyarangeofstakeholdersforaccountabilitypurposes.Thiswouldformalisetheexistingmechanismsformulti-stakeholderinputstothereportcurrentlyconvenedthroughBellagiomeetings.Asauthorsofthereport,theWHOandtheWorldBankcouldconvenetheadvisorygroup.

CountryprofilesonUHCprogressCountryprofilesonprogresstowardsUHCthatgobeyondtheindicatorsforSDGtarget3.8,couldhelptounpackprogresstowardsUHCwithahealthsystemslens.ThesecouldweaveintheotherSDGhealthagendasandpresentevidenceonthepolicyframeworkforUHCacrossthethreecoveragedimensionsofpopulation,effectiveserviceandfinancialprotection.Theycouldbedevelopedatcountrylevelbylocalstakeholders,tailoredtonationalprioritiesandusingcountrydata.Thiseffortcouldlearnfromtheexperiencesofexistingefforts,suchastheCountdownto2015profiles,AfricanLeadersMalariaAlliancescorecardsandIHP+Resultsmutualaccountabilityscorecards.

Strengthenedmulti-stakeholderplatformsforUHCreviewMulti-stakeholderplatformsforhealthsectormonitoringandreviewarecriticalatcountryandsub-nationallevels.Thiswouldstrengthenexistingstructures,adheringtotheIHP+principleofonecountry-ledinformationandaccountabilityplatform.xviiWherecountrieshaveestablishedjointannualreviewmechanismsxviii,theseshouldbeused.ThiswouldbuildontheWHOprogrammeonnationalhealthpolicies,strategiesandplans,documentingandsharingexperiences.

CSOconsortiumThiscouldbuildontheIHP+structureforCSOengagement,withanorthernandasouthernrepresentativetoengagebroaderconstituenciesonaccountabilityforUHC,includingeffectivedevelopmentcooperation.AfocalpersonattheSecretariatcouldfacilitatepeerexchangeacrosscivilsocietyonaccountabilityefforts,providefinancialandtechnicalsupportforcapacitybuildingonadvocacyforaccountabilityonUHC,developguidelinesandtools,andincreasecoordinationwithotherCSOhealthcoordinationmechanismstopromoteharmonisation.

CommunityofpracticeonmonitoringandaccountabilityofUHCThiscouldbuildontheJointLearningNetworkwithaforumforpeerexchangebetweencountrystakeholders(MinistryofHealth,MinistryofFinance,MinistryofSocialAffairsorequivalent,civilsocietycoalitions,parliamentarians)ontheexperienceofstrengtheningmonitoring,reviewandactionforaccountabilityforUHC.

• OperationalisingtheUHC2030AccountabilityFramework

Asmentionedabove,theseinitiativescomprisepotentialprioritiesfortheUHC2030AccountabilityFramework.ThisFrameworkshouldbeflexibletoexpandandchangecourseasnecessarythroughtheimplementationperiodoftheSDGs.Asmallsecretariat,hostedwithintheUHC2030,wouldcoordinatetheFramework.Itcouldalsoimproveinformationexchangeacrossdifferenthealthmonitoringandaccountabilityinitiativestomaximisesynergies,suchaswiththeGlobalHealthDataCollaborative,theunifiedaccountabilityframeworkforwomen’s,children’sandadolescents’health,theNCDCountdown,andIHRmonitoring.Thesefunctionswouldbeintegratedintotheworkplanof

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theUHC2030SecretariatandoverseenbytheUHC2030SteeringCommittee.TheactualimplementationoftheFrameworkwouldbefundedandundertakenbyarangeofpartners.

ResourcerequirementsTheanticipatedstaffingneedstocoordinatetheUHCAccountabilityFrameworkwouldbe2fulltimeposts:aseniortechnicalofficerandatechnicalofficer,withadministrativeandcommunicationssupportsharedacrosstheUHC2030Secretariat.Theactivitybudgetwouldvarydependingontheworkplan(suchasconveningtheIAP-UHC,CSOcapacitybuildingandcatalyticgrants).iDefinedas:ensuringthatallpeoplecanusethepromotive,preventive,curative,rehabilitativeandpalliativehealthservicestheyneed,ofsufficientqualitytobeeffective,whilealsoensuringthattheuseoftheseservicesdoesnotexposetheusertofinancialhardship,http://www.who.int/health_financing/universal_coverage_definition/en/.iiUNGA.2015.TransformingourWorld:The2030AgendaforSustainableDevelopment.ResolutionA/RES/70/1point26.iiiAvailability,accessibility,acceptabilityandquality,whichareessentialtotheenjoymentoftherighttohealthbyall,arecentraltoprogresstowardsUHC.ivhttp://www.who.int/mediacentre/factsheets/fs323/en/.vGreer,S.L.,Mendez,C.A.2015.UniversalHealthCoverage:APoliticalStruggleandGovernanceChallenge.AmericanJournalofPublicHealth,105:S5.viAsdefinedbyGwatkin&Ergo:“adeterminationtoensurethatpeoplewhoarepoorgainatleastasmuchasthosewhoarebetteroffateverystepofthewaytowarduniversalcoverage,ratherthanhavingtowaitandcatchupasthatgoaliseventuallyapproached”,inGwatkin,DR,Ergo,A.2011.Universalhealthcoverage:friendorfoeofhealthequity?TheLancet.Vol.377,No.9784,pp2160-1.viiSridhar,D.etal.2015.UniversalHealthCoverageandtheRighttoHealth:FromLegalPrincipletoPost-2015Indicators.InternationalJournalofHealthServices,45(3):495-506.viiihttp://www.who.int/bulletin/volumes/91/1/12-115808/en/.ixAspertheCommissiononInformationandAccountability’sframework:http://www.who.int/woman_child_accountability/about/coia/en/index5.html.xPage88,IndependentExpertReviewGroup.2015.Everywoman,everychild,everyadolescent:achievementsandprospects:thefinalreportoftheindependentExpertReviewGrouponInformationandAccountabilityforWomen’sandChildren’shealth.WHO.xiBrinkerhoff,D.2003.AccountabilityandHealthSystems:Overview,Framework,andStrategies.Bethesda,MD:ThePartnersforHealthReformplusProject,AbtAssociatesInc.xiiTheselessonsdrawonthefollowingdocuments:Bruen,C.etal.2014.Aconceptinflux:questioningaccountabilityinthecontextofglobalhealthcooperation.GlobalisationandHealth,10:73;CHESTRAD.2015.AmplifyingVoicesandEnablingAction:StrongerAccountabilityforGlobalHealthintheSustainableDevelopmentGoals;CommissiononInformationandAccountability.2011.Translatingtherecommendationsintoactionworkplan;CommitteeforDevelopmentPolicy.2015.TransitioningfromtheMDGstotheSDGs:accountabilityforthepost-2015era:AbackgroundreportbytheCDPsubgrouponAccountability.CDPBackgroundPaperNo.25.UNDepartmentofEconomic&SocialAffairs;GlobalHealthVisions.2015.EngenderingAccountability:UpholdingCommitmentstoMaternalandNewbornHealth;Greer,S.L.,Mendez,C.A.2015.UniversalHealthCoverage:APoliticalStruggleandGovernanceChallenge.AmericanJournalofPublicHealth,Vol.105,No.S5;Hunt,P.2015.SDGsandtheImportanceofFormalIndependentReview:AnOpportunityforHealthtoLead

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theWay.HealthandHumanRightsJournal;OfficeoftheHighCommissioneronHumanRights.2015.IntegratingHumanRightsintothePost-2105DevelopmentAgenda:Follow-upandReview:EnsuringAccountabilityfortheSDGs;Schweitzer,J.2015.Accountabilityinthe2015GlobalStrategyforWomen’s,Children’sandAdolescents’Health.BritishMedicalJournal,351:Supplement1;Victora,C.G.etal.2015.Countdownto2015:adecadeoftrackingprogressformaternal,newborn,andchildsurvival.TheLancet,publishedonlineOctober16,2015;WHO,USG,WorldBank,UNICEF.2015.TheHealthDataCollaborative:Measurement,PerformanceandLearningforAccountability.OperationalWork-plan2016-2020.Version1.0(13November2015).xiiihttp://www.internationalhealthpartnership.net/fileadmin/uploads/ihp/Documents/Key_Issues/Mutual_Accountability/Consultation_on_follow_up_and_future_of_IHP_monitoring_summary__4_.pdf.xivSuchastheGlobalReferenceListof100CoreHealthIndicators,http://www.internationalhealthpartnership.net/fileadmin/uploads/ihp/Documents/Key_Issues/One_M_E_Platform/WHO_HIS_HSI_2015.3_eng.pdf.xvSuchastheiERGandtheIndependentMonitoringBoardoftheGlobalPolioEradicationInitiative.SeeIndependentExpertReviewGroup.2015.Everywoman,everychild,everyadolescent:achievementsandprospects:thefinalreportoftheindependentExpertReviewGrouponInformationandAccountabilityforWomen’sandChildren’shealth.WHO;Bristol,N.,Millard,C.2015.ThePowerofStraightTalk:TheIndependentMonitoringBoardoftheGlobalPolioEradicationInitiative.CenterforStrategicandInternationalStudies.xviAsperthedraftOperationalWork-plan,2016-20,version1.0(13November2015).xviihttp://www.internationalhealthpartnership.net/fileadmin/uploads/ihp/Documents/Tools/M_E_Framework/M%26E.framework.2011.pdf.xviiihttp://www.internationalhealthpartnership.net/fileadmin/uploads/ihp/Documents/Results___Evidence/HAE__results___lessons/ihp_jar_oct2014_en_web.pdf.