Benjamin Mason Meier and Jocelyn Getgen Kestenbaum
The United Nations recently launched a US $40 billion Global Strategy for Women’s and Children’s Health to accelerate progress on the Millennium Development Goals related to improving the health of women and children. To create state accountability for this bold five-year effort, the World Health Organization has convened a Commission on Information and Accountability for Women’s and Children’s Health to recommend international institutional arrangements conducive to realizing this commitment. With the commission set to deliver its final report in May 2011, this Perspective raises key issues to assist in its rapidly evolving efforts, analyzing the importance of independent monitoring bodies as a means to ensure state reporting, oversight, and accountability.
During the September 2010 United Nations (UN) summit on the Millennium Development Goals (MDGs), UN Secretary-General Ban Ki-moon launched a Global Strategy for Women’s and Children’s Health to accelerate progress on MDGs related to improving the health of women and children.1 These interconnected MDGs for women’s and children’s health—including goals for eradicating extreme poverty and hunger (MDG 1), promoting gender equality (MDG 3), reducing child mortality (MDG 4), improving maternal health (MDG 5), and combating HIV/AIDS, malaria and other diseases (MDG 6)—led states to commit an additional US $40 billion under the global strategy to revitalize international efforts leading up to their 2015 deadline to achieve the MDGs.2 With states seeking to create international institutions of accountability for this ambitious new commitment, the global strategy calls on the World Health Organization (WHO) “to establish a process to determine the most effective international institutional arrangements for global reporting, oversight and accountability for women’s and children’s health”.1
In realizing this mandate for accountability, WHO has convened a Commission on Information and Accountability for Women’s and Children’s Health, chaired by Jakaya Kikwete, President of the United Republic of Tanzania, and Stephen Harper, Prime Minister of Canada.2 This commission—with appointed representatives from developed and developing countries, academia, civil society, and the private sector, organized into working groups on accountability for resources and results—is seeking to recommend international institutions to track progress and assess challenges in saving the lives and improving the health of women and children. Proposing an accountability framework and action plan to help donor and recipient countries monitor resource allocations and health impacts, the commission expects to report back to the Secretary-General in May 2011.3 With this high-level commission meeting throughout the coming months, this Perspective raises key issues to assist the commission in its rapidly evolving efforts, highlighting the advantages of independent monitoring bodies as an international institutional arrangement conducive to state reporting, oversight, and accountability.
I. Accountability through independent monitoring
Grounded in annual monitoring and assessment, this proposed accountability framework would track the commitments of all stakeholders and assess how these commitments contribute to improvements in women’s and children’s health at local, national, and global levels. As WHO Director General Margaret Chan recognized, “accountability is vital. It means keeping promises and measuring results. To measure results, we need much stronger systems for health information.”4 With this accountability framework based on streamlined indicators and submitted information, the commission is expected to urge stakeholders to report annually on assessing policy, program, and financial commitments; monitoring health impacts; and outlining future expectations.
Beyond an emphasis on health information, however, accountability will require independent assessments of national commitments from both donor and recipient countries. Assuring the “mutual accountability” long advocated in foreign assistance commitments, international institutions can be developed to provide predictable, transparent reporting requirements, with government reports reviewed through an independent monitoring body.
Where self-assessment is not sufficient to establish accountability, independent monitoring bodies can assure objectivity in assessments and legitimacy in observations. Monitoring body members, selected on the basis of expertise in women’s and children’s health, could be nominated by governments and assisted in their work by an institutional secretariat. They could compile and summarize independent experts’ findings to provide a global picture of women’s and children’s health in accordance with the global strategy. Through such independence in expert review and support through secretariat staff, monitoring bodies could review state reports and respond to those reports in recommending country-specific policies and programs for women’s and children’s health.
II. State reporting to monitoring bodies
While accelerating development programs to improve women’s and children’s health will require coordinated, sustained efforts among public entities, private-sector partners, and civil society organizations at the international, regional, national, and local levels, accountability mechanisms should ultimately hold states responsible for reporting processes and policy reforms. Under the global strategy, states have voluntarily committed to forming and supporting international accountability institutions, and it is expected that the states would submit themselves to the monitoring institutions established by the commission. With states pledging and receiving critical resources conditioned upon effective monitoring and evaluation, they must honor reporting responsibilities to an independent body — to demonstrate appropriate resource utilization and improved results and to demonstrate accountability for women’s and children’s health.
A. From state report development to independent monitoring body review
To engage in periodic reporting with an independent monitoring body, states must coordinate all national stakeholders and develop strong institutional structures and processes for compiling reports. Through capacity building for reporting to monitoring bodies, states can create a methodical data collection system at the national level for funding allocations, epidemiologic surveillance, evidence-based interventions, and trend analysis. Such reporting structures must facilitate (1) transparent dissemination of resources to local programs, (2) communication networks to overcome implementation challenges, and (3) data collection to assess processes and outcomes. In order to adequately monitor resources, evaluate programs, and measure results, states must work closely with all stakeholders to build the capacity necessary to compile state reports.
To facilitate independent monitoring body review, states should structure periodic reporting processes through a stakeholder working group, appointing representatives from each implementing partner institution to serve as task force members, report on program implementation, and advise the responsible government representative in drafting the state’s periodic report. In such a stakeholder task force, representatives would be responsible for their respective periodic reports, detailing resource allocations, implementing partners, program goals, implementation processes, and result evaluations. These reports should be uniform across national stakeholders and should reflect the guidelines for governmental periodic review to the extent possible, in order to ensure that the task force uniformly collects and coherently compiles appropriate information. Submitted in advance, government representatives could then summarize these organizational reports into a single state report for periodic review.
State reports should follow an official formatting standard, predetermined policy indicators, and standard programmatic results – all developed in accordance with monitoring board guidelines. Measures of resource allocations should adhere to these guidelines for measuring progress, outcomes, and benchmarks for interim state progress on women’s and children’s health. Given that states have different levels of control over the process and outcome achieved, state reports should consider the context of program implementation, limitations on state control, and actions to mitigate impediments. For example, government agencies have more control over the content of guidelines for program planning than the decline in maternal mortality through program implementation. Thus, state reports may enumerate factors limiting programmatic success (such as natural disaster or internal conflict) and describe the steps taken to mitigate the negative consequences of such factors. To the extent that gaps exist in the state’s final report, the monitoring board would have authority to submit issues for clarification or request additional documentation. The state representative could then return to the task force for stakeholder consultations throughout the monitoring board’s constructive dialogue.
B. From monitoring body dialogue to state policy reform
Monitoring body dialogue should be less prescriptive and more constructive. With the independent monitoring body able to review reports and ancillary documentation, assuming that the monitoring body secretariat is given a mandate to keep members apprised of state reports, this body has the opportunity to lay out in advance a list of issues to address during the periodic meeting of the monitoring body. Rather than focusing solely on state reporting, ideally compiled in accordance with the aforementioned stakeholder collaborations, it is necessary that nongovernmental actors also have the ability to communicate independently with the monitoring body. Complemented by findings from the UN’s other international institutions—whether specialized agencies, independent experts, or other monitoring bodies—such nongovernmental communications would allow consideration of all available data on national progress in women’s and children’s health in framing the meetings of the monitoring body.
Through the monitoring body’s deliberative process of “constructive dialogue,” states would have the opportunity to answer questions and respond to comments, with the monitoring body becoming a partner in accountability for women’s and children’s health. Rather than shaming or embarrassing the state, these meetings (held, in accordance with the practice of other bodies, two or three times per year and often lasting one or two days per country) provide a forum for legitimacy and confidence in national efforts. As with treaty monitoring bodies—such as the UN’s Committee on Economic, Social and Cultural Rights—state reports should be examined in public sessions, with expert members engaging in open dialogue with state representatives. Beginning with an opening presentation by state representatives (to summarize the state report and address issues submitted in advance), this government delegation would then submit to questions from (and dialogue with) the monitoring body on national efforts to meet the global strategy.
Based upon the state report, shadow reports, meeting dialogue, supplementary materials, and independent research, the monitoring body could then meet in private to draft concluding observations. These observations would highlight positive developments, identify key national challenges, enumerate unanswered questions, and make recommendations for improving women’s and children’s health. Given follow-up action through the national-level task force, political engagement by civil society, and technical support from nongovernmental and intergovernmental organizations, these concluding observations, and an official response by the state government, could inform national policy reforms – including legal, policy, budgetary, and programmatic reforms in women’s and children’s health.
III. Monitoring bodies as crucial to accountability
Through annual communications between state governments and monitoring bodies, a virtuous cycle emerges by which states set benchmarks, monitor and evaluate resources and results, and continuously build upon past efforts in realizing women’s and children’s health. In its recurring review of past observations and subsequent progress, the expert monitoring body can establish a robust documentation of best practices—sharing information for comparative study, improving understanding of common obstacles, and highlighting precedents for women’s and children’s health initiatives—working with the secretariat to summarize, disseminate, and archive this information for state advancement. Framed by an agreed-upon set of structural, process, and outcome indicators and building on the institutional frameworks of treaty monitoring bodies, the commission can expand opportunities for accountability through an independent monitoring body for women’s and children’s health.
A. Opportunities through independent monitoring bodies
An international monitoring body of independent experts can provide consistency in assessment while allowing flexibility for accountability. Realizing the aspirations of the global strategy, an independent monitoring body would be best-positioned to take advantage of this short window of opportunity to make final observations and constructive recommendations – highlighting unmet commitments, budgetary shortfalls, and policy failures in national efforts to advance women’s and children’s health. In honing its scope of practice and administrative procedures, such a body would prove uniquely suited to meeting the accountability needs of the global strategy through health policy information sharing, cross-national comparative analyses, and participatory policy reform frameworks.
Crucial to good governance, transparency encourages open government decision making through health policy information sharing. Independent monitoring bodies have a vested interest in encouraging open processes to evaluate resources and results—assessing state reports, shadow reports, and independent evaluations to provide access to an unprecedented range of data on women’s and children’s health—using this information to recommend avenues for policy and program reform policies and programs at the local level. Through the transparency enabled by a monitoring body, accountability is encouraged by information flow and constructive dialogue to improve monitoring and evaluation for advancing women’s and children’s health.
By developing systematic mechanisms for reporting and review—in the form of set standards (including structural, process, and outcome indicators), guidelines for program implementation, data collection, monitoring, and reporting—independent monitoring bodies can establish consistent administrative guidelines to facilitate national evaluations. For example, structural indicators might measure whether states have enacted laws and policies to ensure free maternal health care in public health facilities; process indicators might evaluate resource allocation, agency standards, and policy implementation to determine whether the state has fulfilled its commitments. Although states have less control over outcomes given mediating determinants of health, indicators measuring maternal and infant mortality over time could nevertheless denote a state’s effective use of resources toward improving results. Examining these varied data through flexible institutions of expert review and dialogue will best assist an independent monitoring body in evaluating state action and holding states to account for global strategy commitments.
In addition, these mechanisms would facilitate cross-national comparison through standardized state reports and monitoring body recommendations, ensuring consistency and predictability in state reporting. By allowing comparative examinations of health policies and programs across national contexts, a monitoring body would derive “best practices” for achieving results while accounting for meaningful differences in resource allocations.
To ensure public accountability, an independent monitoring body would review state resource allocations and programmatic results through an agreed-upon set of structure, process and outcome indicators, with independent experts assisting the state in institutional problem-solving and policy reform efforts. In preparing a state report, participatory frameworks would allow national actors to share grievances and expose potential public or private corruption, inefficiency, or bottlenecks in systems for allocating resources and implementing results. The resulting state report, grounded in indicators and developed by stakeholders, would thus provide a more in-depth quantitative and qualitative analysis of possible intervening variables that impede the government from reaching agreed-upon benchmarks or outcomes. It would also help identify implementation problems and solutions to improve women’s and children’s health.
B. Challenges in implementation
Outside of highlighting challenges in national efforts to realizing women’s and children’s health and recommending reforms to alleviate these challenges, a monitoring body would have limited authority to prescribe remedies, sanction failures, or punish wrongdoing. Where donor states have not met promised resource commitments, such shortfalls can be easily identified (if not easily rectified), but where a recipient state is not meeting health targets, it is unclear whether an independent monitoring body, even one analyzing robust indicators, would second-guess the national budgetary allocations or policy decisions that led to these results. Yet despite these challenges to enforcement, challenges that transcend international health institutions, an independent monitoring body would add far greater enforcement of commitments to women’s and children’s health, supporting accountability for states in realizing the goals of the global strategy.
The Global Strategy for Women’s and Children’s Health estimates that as many as 16 million additional lives may be saved by 2015, but these prospective gains to the interconnected human rights of women and children will depend upon accountability frameworks to assure that states meet commitments and implement national programs. With states long having resisted accountability frameworks in implementing international health initiatives, this new commission represents a unique opportunity for UN agencies to reassert their role as leading authorities in the realization of global health. By establishing an independent monitoring body for reporting, oversight, and accountability on women’s and children’s health, the commission has the opportunity to develop a new model for international health institutions and secure state progress under the global strategy.
Benjamin Mason Meier, JD, LLM, PhD, is Assistant Professor of Global Health Policy at the University of North Carolina, Chapel Hill, NC, USA.
Jocelyn Getgen Kestenbaum, JD, MPH, is Program Director at the Virtue Foundation, New York, NY, USA.
1. Ban-ki Moon, United Nations Secretary General, Global Strategy for Women’s and Children’s Health (2010). Available at http://www.who.int/pmnch/topics/maternal/20100914_gswch_en.pdf.
2. United Nations, “U.N. Establishes High-Level Commission to Track Results and Resources for Women’s and Children’s Health,” news release, December 16, 2010, http://www.un.org/millenniumgoals/pdf/Press_Release_Accountability_16Dec_final.pdf.
3. United Nations. Every Woman Every Child: Commission on Accountability for Women’s and Children’s Health. Available at http://www.everywomaneverychild.org/pages?pageid=14.
4. World Health Organization’s Partnership for Maternal, Newborn & Child Health, The Global Campaign for the Health Millennium Goals 2010: Putting the Global Strategy for Women’s and Children’s Health into Action (Oslo: November 2010). Available at http://www.who.int/pmnch/topics/mdgs/2010globalcampaign.pdf.