SDG Goal 3: Good Health

SDG Goal 3: Good Health

Paul Hunt

It is widely recognised that the Sustainable Development Goals (SDGs) need to be supported by more effective follow-up and review—or accountability—processes than were available to the Millennium Development Goals (MDGs). But what should these processes be? In the last three or four years, this question has generated a wealth of literature within the UN and beyond.1 Here I highlight five key points from this rich analysis:

* Monitoring is not accountability, but one step towards accountability.

* Although experts have a significant role to play, accountability should not be reduced to a technocratic exercise; it should be as transparent, accessible and participatory as possible.

* Accountability at the global level is important, but the primary locus for accountability must be at the national and sub-national levels.

* It is difficult for States at the national-level to hold accountable stakeholders, including non-state actors, for their transnational contributions and commitments to development, such as SDG17. One of the most important roles for global-level accountability is to strengthen accountability for these transnational contributions and commitments.

* Because the SDGs are a colossal challenge of extraordinary complexity, they need to be supported by diverse accountability arrangements, what Kate Donald calls “a web of accountability”.2 It is essential the “web of accountability” includes independent review of stakeholders’ progress, promises and commitments.

While this essay considers some of these issues, it is not possible here to provide a comprehensive treatment of accountability and the SDGs. My focus is one vital feature of accountability: review, especially independent review. There are many other important features of accountability, such as monitoring and the use of indicators to track progress, which fall beyond the scope of this discussion.

First, the essay introduces the follow-up and review processes in the draft Transforming our World: The 2030 Agenda for Sustainable Development.3 Second, it outlines the remarkable developments on accountability for MDG4 (child survival) and MDG5 (reproductive and maternal health) that were triggered by the UN Secretary-General’s Global Strategy for Women’s and Children’s Health launched in 2010. Third, it explores the importance of independent review, reporting to high-level political forums, as one part of “a web of accountability” for the SDGs. Fourth, the conclusion signals some of the key elements of global accountability for the health-related SDGs. It also suggests that health could serve as an example and lead the way for effective follow-up and review for other sectors in the SDGs.

The draft Agenda

The draft Transforming our World: The 2030 Agenda for Sustainable Development includes a preamble, declaration, 17 SDGs and their targets, a section titled “Means of implementation and the Global Partnership”, and a closing section on follow-up and review.

SDG3 is to “[e]nsure healthy lives and promote well-being for all ages”. One of its numerous targets is to “[a]chieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all”. While SDG3 is crucial, several other SDGs and their targets are also critically important from the health perspective. SDG5 on gender equality and the empowerment of women and girls, for example, includes a target to “[e]nsure universal access to sexual and reproductive health and reproductive rights”.

The Agenda devotes three of its 29 pages to follow-up and review. This essay gives particular attention to these paragraphs and issues arising from them. The draft says: “To support accountability to our citizens, we will provide for systematic follow-up and review at the various levels, as set out in this Agenda”.4 The “High Level Political Forum under the auspices of the General Assembly and Economic and Social Council will have the central role in overseeing follow-up and review at the global level.”5 The Agenda commits to processes which will be “robust, voluntary, effective, participatory, transparent and integrated”.6

Operating at the national, regional and global levels, follow-up and review will be guided by principles that are set out in nine paragraphs.7 For example, the processes:

* “will take into account different national realities, capacities and levels of development and will respect policy space and priorities”;

* “will be people-centered, gender-sensitive, respect human rights and have a particular focus on the poorest, most vulnerable and those furthest behind”;

* will be based on data “disaggregated by income, sex, age, race, ethnicity, migration status, disability and geographic location and other characteristics relevant in national contexts.”

One of the striking features of these—and some of the other principles—is that the UN human rights system has been applying them in practice for about half a century.

The SDGs and their targets will be followed-up and reviewed using a set of global indicators. The High Level Political Form (HLPF) will meet annually for a few days and be informed by “an annual SDG Progress Report to be prepared by the Secretary-General”, as well as the Global Sustainable Development Report required by Rio+20.8 The “HLPF, under the auspices of ECOSOC, shall carry out regular reviews”.9 Also, “(t)hematic reviews of progress on the Sustainable Development Goals, including cross-cutting issues, will also take place at the HLPF.”10

Although instructive, the Agenda’s section on follow-up and review is sketchy. When the time arrives for stakeholders to put flesh on these bones, the global health community has a major advantage: it has been here before.

Back to the future: the Commission on Information and Accountability for Women’s and Children’s Health

Concerned by slow progress towards MDG4 (child survival) and MDG5 (reproductive and maternal health), the UN Secretary-General launched his Global Strategy for Women’s and Children’s Health in September 2010.11 The Strategy has explicit and implicit human rights content. The Secretary-General established a small unit in his Office, known as Every Woman, Every Child, to mobilise an ambitious multi-stakeholder movement for the Strategy’s implementation.12 Because the Strategy did not establish accountability arrangements, the Secretary-General asked the Director-General of WHO to “chair a process to determine the most effective international institutional arrangements for global reporting, oversight and accountability on women’s and children’s health, including through the UN system.”13 In December 2010, WHO established a Commission on Information and Accountability for Women’s and Children’s Health. Supported by two expert Working Groups, the 30-member Commission was high-level, for example, it included 11 current Presidents, Prime Ministers or Ministers, as well as other prominent leaders in global health, including from civil society. In mid-2011, the Commission produced its final report, Keeping Promises, Measuring Results, which included 10 recommendations.14 In accordance with one of these recommendations, the Secretary-General established a time-bound, nine-member, independent Expert Review Group (iERG) with responsibility to hold accountable all stakeholders, including donors and business enterprises, for their commitments arising from the Global Strategy. To date, the iERG has published three substantive annual reports.15 The Group’s mandate finishes at the end of 2015 and its last annual report is expected shortly.

The four initiatives—Global Strategy; Every Woman, Every Child; CoIA; iERG—have helped to generate a period of extraordinary dynamism in women’s and children’s health. There is evidence of significant improvements in women’s and children’s health over the last five years. The initiatives have reinforced the relationship between health and human rights. A number of iERG’s recommendations have been adopted, such as the new global investment framework for women’s and children’s health, which is a major achievement.16 Here I do not aim to survey and critique the four initiatives. Instead, I briefly discuss a couple of achievements, and a difficulty, which bear closely upon follow-up and review for the SDGs.

Some health professionals equate monitoring, or tracking progress, with accountability. By doing this, they eviscerate the concept of accountability. In Keeping Promises, Measuring Results, CoIA made a number of important contributions. One was, in the context of the Global Strategy, to unpack accountability to mean monitoring, review and remedial action.17

Monitoring is familiar to health professionals. According to CoIA, it means “providing critical and valid information on what is happening, where and to whom (results) and how much is spent, where, on what and on whom (resources).”

CoIA holds that review has two limbs. The first is also familiar to health professionals: “analysing data to determine whether … health has improved”. Health professionals tend to be less familiar (and less comfortable) with the second limb: “analysing … whether pledges, promises and commitments have been kept by countries, donors and non-state actors.”

This second limb of review is absolutely vital. It can either be undertaken through a political process, for example, peer-review by States, that is, a form of mutual accountability. Or it can be undertaken by independent bodies. In the context of the Global Strategy, both are essential, a point I return to shortly.

It is important to note that, according to CoIA, review not only looks at “countries” but also “donors and non-state actors”. This has major implications for the draft Agenda and the SDGs, especially SDG17.

Also, CoIA emphasises that, in the context of the Global Strategy, review is not a finger-wagging exercise. Rather, it is “a learning process that involves recognizing success, drawing attention to good practice, identifying shortcomings and, as required, recommending remedial actions.” This is not far from what Lynn Freedman calls “constructive accountability” and “the commitment to an ongoing public, transparent process of assessment, change and reassessment”.18

Remedial action can be understood as measures to put things right, as far as possible, if they have not gone as promised or planned. There has been criticism that this understanding of remedial action does not include judicial remedies. However, CoIA is discussing remedial action in the context of the Strategy. Because the Strategy and CoIA do not establish a legal or judicial process, they do not give rise to judicial remedies. Equally, the Agenda’s follow-up and review will not be a legal or judicial process and will not give rise to judicial remedies. While CoIA’s important distinction between monitoring and review applies generally to accountability, whether remedial action includes judicial remedies depends upon the nature of the process, that is, whether or not the process is judicial.

In summary, one of CoIA’s key contributions was to clarify (a) monitoring is not accountability, but a step towards accountability and (b) accountability requires some form of review to evaluate “whether pledges, promises and commitments have been kept”.

By way of illustration, here is a brief example of how iERG reviewed whether the business community was keeping its “pledges, promises and commitments”.

The Secretary-General’s Strategy affirms that many stakeholders, including the business community, have responsibilities to advance women’s and children’s health. The iERG is mandated to consider the roles of all stakeholders, including the business community. In 2014, iERG was invited by the Government of Peru to visit the country and report what stakeholders in Peru were doing to advance the Strategy and CoIA. Although not comprehensive, the country report looked at a range of stakeholders, including governmental authorities and the country’s business community.19 Following meetings with business representatives, the review concluded: “We learned that the [for-profit] private sector has very limited familiarity with the Global Strategy and CoIA; corporate social responsibility (CRS) is underdeveloped; and the sector does not have a CRS strategy. Accordingly, we conclude that the corporate sector is not in conformity with its responsibilities arising from the UN Secretary-General’s Global Strategy and CoIA, and it has a responsibility to address this shortcoming.”20 The report also made corresponding recommendations, such as: “we recommend that the Chamber of Commerce takes the lead and develops a CRS strategy encompassing women’s and children’s health. The strategy should not only be developed in consultation with the Chamber’s members, but also with the participation of the Government, UN Country Team, and the pobladores communes.”21

Of course, if these and the iERG’s other findings and recommendations are to be implemented numerous measures are needed, such as endorsement by a high-level political body to generate the political will necessary to ensure Peru’s for-profit private sector plays its part to advance women’s and children’s health. But, for present purposes, the key point is that the country report went beyond monitoring and reviewed whether the for-profit private sector in Peru was keeping its “pledges, promises and commitments” in relation to the Strategy and CoIA. The iERG’s review, findings and recommendations are relevant to the SDGs because the draft Agenda also explicitly encompasses the for-profit private sector, as confirmed in its section on the Global Partnership.

This is an example of review in relation to just one group of stakeholders: business enterprises in Peru. The iERG also reviews whether other stakeholders are keeping their commitments arising from the Strategy and CoIA.

I now turn briefly to a difficulty encountered by iERG. The Group reports to the Secretary-General. It does not report to a high-level political body and this tends to limit its impact and influence. It would have been helpful if iERG reported to one or more political bodies, such as the General Assembly, WHO Executive Board, World Health Assembly or UN Human Rights Council. In keeping with the idea of “a web of accountability”, the selected political body (or bodies) would receive reports and information from a range of sources, including iERG, before deciding what position to take on a particular issue. In other words, an independent body analyses “whether pledges, promises and commitments have been kept” and then sends its independent evaluation to a political body for consideration. The two bodies have different, but complementary, functions. Both are needed. One provides an independent expert evaluation about progress, promises and commitments, while the other makes a political decision about what to say or do about it. The political body’s view has greater credibility, authority and legitimacy if it benefits from an evaluation prepared by way of independent review.

To conclude, the four initiatives—Strategy; Every Woman, Every Child; CoIA; iERG—represent a bold and unique response to the need for greater accountability of all stakeholders in women’s and children’s health. In the health context, CoIA’s clarification that monitoring is not accountability, and accountability requires some form of review to evaluate “whether pledges, promises and commitments have been kept”, is extremely important. It is also important that independent reviews are submitted to high-level political bodies for their consideration.

A political heavyweight, CoIA advised on accountability arrangements for MDGs 4 and 5. As we approach the health-related SDGs, it would be a travesty if CoIA’s insights, and other lessons learned, were overlooked.

Independence

CoIA firmly recognised the importance of independent review. It explicitly recommended an independent global oversight body. In relation to national oversight, it recommended ways “to increase the independence of the review”, such as the appointment of a health ombudsperson.22 Moreover, the Secretary-General’s Global Strategy for Women’s and Children’s Health (2010) is likely to be replaced later this year by Survive, Thrive, Transform: the Global Strategy for Women’s, Children’s and Adolescents’ Health.23 Based on extensive consultations and the latest evidence, the draft Survive, Thrive, Transform adopts a global accountability framework which is based on CoIA’s monitoring, review and remedial action, and it includes an Independent Accountability Panel.24

What is independent review and what does independence mean? Societies have asked these questions for many generations and have devised answers although they are always open to challenge. Independent institutions are a feature of democratic governance. Many constitutions establish the separation of powers, including an independent judiciary. But the requirement of independence is not confined to the judiciary. In many countries, the value of independence has led to statutory independent oversight bodies of the police, prisons, media and schools, as well as ombudspersons, national human rights institutions, and privacy and similar commissioners. In some countries, there are also statutory independent oversight bodies of health services, overseas development assistance, measures against modern forms of slavery, and so on. The importance of formal (or institutionalised) independence of this sort is also recognised in international organisations, such as the International Health Regulations Review Committee, World Bank Inspection Panel, ILO Committee of Experts, the Committee on the Rights of the Child, as well as other international human rights treaty-bodies.25 The Universal Declaration of Human Rights requires “independent and impartial” bodies.26

In short, the value and importance of formal independent review is widely recognised at the national and global levels. However, when discussing independent review with colleagues, two issues often arise.

First, they may acknowledge the importance of independent oversight but suggest it is adequately provided by assemblies, the media and civil society. My response to this is that, of course, these bodies and institutions make an indispensable contribution towards accountability. But members of assemblies are often aligned to political groups, or instructed by their capitals, and are therefore required to adopt a particular position on most issues. The media’s attention often wanes after a global summit or launch of a new national initiative. The programmes of civil society organisations may fluctuate with the availability of funding and priorities of senior management. I cannot over emphasise that these bodies and institutions are vital parts of the “web of accountability”, but I am unaware of any country that relies exclusively on them to provide independent oversight of the long-term implementation of large-scale, highly complex policy initiatives by multiple stakeholders.

Second, some colleagues question what independence means and doubt that any person, or body, can be truly independent. However, as already observed, there are many national and global independent review bodies composed of individuals, often experts in their field, who do not take instructions from those nominating or appointing them, or from any other person or organisation. They exercise their professional, autonomous judgement in good faith. This means, for example, they do not have a line-manager who can tell them what to say or do. They must not only be independent, but also be seen to be independent. Before discharging their duties, members of UN human rights treaty-bodies are required to make a public declaration: “I solemnly undertake to discharge my duties as a member of the [Committee] impartially and conscientiously.”27 It is easy to disparage this and say everyone has bias and baggage. Nonetheless, there is a long history of women and men of integrity discharging formal independent mandates without fear or favour and thereby making distinctive and invaluable contributions to their societies.

Would it not be bizarre if an enterprise as vital and complex as the SDGs did not benefit from some form of formal independent oversight reporting into a high-level political process?

Some commentators favour ‘open-source’ accountability whereby all stakeholders hold each other to account.28 This may be close to “the web of accountability” that I have strongly advocated. If ‘open-source’ accountability includes a place for formal independent review, along the lines of what I have outlined here, then I warmly welcome it. If, however, ‘open-source’ accountability is a substitute for any type of formal independent review, it is seriously misguided. ‘Open-source’ accountability, without any form of formal independent review, will favour the well-connected, well-funded and the loudest among a clamour of voices. It will run the risk of neglecting the invisible, not identifying systemic failings and blurring accountability. If the invisible are neglected and systemic failings are missed, it will be nobody’s responsibility. If this haphazard, hit-or-miss, ‘casino’ accountability is suitable for the SDGs then, logically, countries should abolish the numerous formal independent oversight bodies at the national and global levels, which have taken generations to establish, and instead invite everyone to kindly hold each other accountable.

Conclusion: thematic global follow-up and review

Like this article, these concluding remarks have a narrow focus. They make suggestions on thematic global follow-up and review, that is, global accountability for the health-related SDGs. They look at follow-up and review neither at the national-level nor the overarching global-level based in New York. Their focus is neither monitoring, nor remedial action, but the review feature of accountability.

According to the draft Agenda, the HLPF will receive “(t)hematic reviews of progress on the Sustainable Development Goals, including cross-cutting issues” (emphasis added).29 Because of the Global Strategy, Every Woman, Every Child, CoIA and iERG, as well as the accountability experience of UNAIDS and other key global health stakeholders, the health sector is well placed to establish effective thematic follow-up and review for the health-related SDGs.

Here I briefly outline three crucial components of this thematic follow-up and review. Each is an indispensable part of a “web of accountability” for the health-related SDGs.

1. High Level Political Forum for Health. Led by WHO and other key stakeholders, the global health community should establish a HLPF for Health with oversight of the health-related SDGs. Governing bodies of major health organisations might nominate one or two members to sit on the HLPF for Health, for example, the Executive Board of WHO might nominate two States and ask them to report back to the Board. On a rotating basis, different organisations might host meetings of the HLPF for Health, for example, WHO might host the first, UNAIDS the second, UNFPA the third, and so on. Supported by a small secretariat, the HLPF for Health would report annually to the overarching HLPF in New York, which has oversight of all SDGs.

The SDGs will demand many challenging initiatives and sustained coordination between agencies, funds, programmes and other stakeholders. Countries, donors and non-state actors will have vital responsibilities for achievement of the health-related SDGs. The HLPF for Health would invite and receive data and information, in particular from those responsible for monitoring or tracking progress towards the SDGs. In a constructive spirit, the HLPF for Health would review stakeholders’ progress, promises, commitments and responsibilities in relation to the health-related SDGs.

In short, the HLPF for Health would not be independent but a political body providing stakeholders with mutual accountability. However, to add credibility, authority and legitimacy to its deliberations, the HLPF for Health would greatly benefit from the views of its formal independent review body.

2. Formal independent review. The iERG was established, and its members were appointed, by the Secretary-General and not by a political body. In some quarters, this diminished iERG’s legitimacy. Accordingly, in its submission on post-2015 accountability, iERG advised: “Whatever global accountability mechanism is devised should have political legitimacy – that is, it should arise from a formal inter-governmental-generated political process that endorses and supports its creation”.30

Learning from this experience and advice, the HLPF for Health should endorse the creation of a lean (but not stunted) independent body whose mandate would be to review stakeholders’ progress, promises, commitments and responsibilities in relation to the health-related SDGs. The HLPF for Health would also endorse the membership of the review body. Once appointed, the members would be independent, like many other national and global independent oversight bodies.

The independent review body would report to the HLPF for Health, other key high-level political bodies in global health, and the UN Human Rights Council. The mandate of the independent body would need strategic definition, for example, should it confine itself to review of stakeholders’ transnational contributions and commitments? Also, its working methods would need careful attention. On the whole, however, the independent body would not require more reports from stakeholders, instead it would review the data and information already gathered by others, as part of monitoring or tracking towards the SDGs, and then it would evaluate whether commitments are being kept. So as to avoid overlap, the review body would come to an arrangement with the Independent Accountability Panel anticipated by the draft Survive, Thrive, Transform: the Global Strategy for Women’s, Children’s and Adolescents’ Health.

In this way, the mutual accountability provided by the HLPF for Health would be informed and strengthened by its formal independent review body. The political and independent would complement and reinforce each other.

3. Civil society and all stakeholders. The “web of accountability” must extend beyond the HLPF for Health and its formal independent review body. Civil society and all stakeholders should be encouraged to hold each other accountable. Some may wish to focus on monitoring, for example, tracking progress. Others may prefer to focus on review, for example, evaluating stakeholders’ progress, promises and commitments. Some will have special interests. Civil society might wish to establish a SDGs Health Watch. The many diverse voices of civil society and other stakeholders would help the HLPF for Health, assisted by its formal independent review body, to provide constructive follow up and review in relation to the countries, donors and non-state actors with responsibilities for the health-related SDGs.

There is no flawless follow-up and review for the health-related SDGs. I suggest the approach sketched here signals the most promising way forward. Given its unique experience since 2010, the global health community can serve as an example and lead the way for effective follow-up and review for other sectors in the SDGs.

Paul Hunt, UN Special Rapporteur on the right to the highest attainable standard of health (2002-2008), and Senior Human Rights Advisor to WHO Assistant Director-General, Dr. Flavia Bustreo (2011-2013), is Professor of Law at University of Essex, UK and Adjunct Professor at University of Waikato, New Zealand/Aotearoa.

References

1 See Marianne Beisheim, Reviewing the Post-2015 Sustainable Development Goals and Partnerships: A Proposal for a Multi-level Review at the High-level Political Forum, German Institute for International and Security Affairs, 2015; Shannon Kindornay and Sarah Twigg, Establishing a Workable Follow-up and Review Process for the Sustainable Development Goals, ODI, 2015; Emma Clippinger and others, Accountability through Civic Participation in the Post-2015 Development Agenda, UNDP and NYU, 2014; Who will be Accountable? Human Rights and the Post-2015 Development Agenda, OHCHR and CESR, 2013; Delivering a Just Future for All: Why Human Rights Matter to Sustainable Development, Amnesty International, 2014; A Post-2015 Vision: The Third Report of the independent Review Group on Information and Accountability for Women’s and Children’s Health, WHO, 2014.

2 Kate Donald, Breaking the Accountability Taboo in Sustainable Development Negotiations, CESR, 2nd June, 2015.

3 Transforming our World: The 2030 Agenda for Sustainable Development, Finalised text for adoption, August, 2015. Available at: https://sustainabledevelopment.un.org/content/documents/7891Transforming%20Our%20World.pdf

4 Ibid, para 47.

5 Ibid.

6 Ibid, para 72.

7 Ibid, para 74a-i.

8 Ibid, para 83.

9 Ibid, para 84.

10 Ibid, para 85.

11 UN Secretary-General Ban Ki-moon, Global Strategy for Women’s and Children’s Health, United Nations, 2010.

12 http://www.everywomaneverychild.org/

13 UN Secretary-General Ban Ki-moon, Global Strategy for Women’s and Children’s Health, United Nations, 2010, page 15.

14 Keeping Promises, Measuring Results, Commission on Information and Accountability for Women’s and Children’s Health, United Nations, 2011.

15 http://www.everywomaneverychild.org/accountability/independent-expert-review

16 http://www.who.int/maternal_child_adolescent/news_events/news/2013/global-investment-framework/en/

17 see note 14, pp. 6-7.

18 L.P. Freedman, “Human Rights, Constructive Accountability and Maternal Mortality in the Dominican Republic: a Commentary” International Journal of Gynaecology and Obstetrics, 82, (2003), p. 111.

19 A Post-2015 Vision: The Third Report of the independent Review Group on Information and Accountability for Women’s and Children’s Health, WHO, 2014, Annex 5, Peru Country Report.

20 Ibid, p.120.

21 Ibid, p.119.

22 see note 14, p.16.

23 Survive, Thrive, Transform: the Global Strategy for Women’s, Children’s and Adolescents’ Health, Final Draft, 31st July, 2015.

24 Ibid, pp. 31-32.

25 For a discussion, see A Review of Global Accountability Mechanisms for Women’s and Children’s Health, PMNCH, 2011.

26 Universal Declaration of Human Rights, 1948, article 10.

27 UN Committee on Economic, Social and Cultural Rights, Rules of Procedure, E/C.12/1990/4/Rev.1, 1st September 1993, Rule 13.

28 Peter Godwin and Sujaya Misra, Report of the External Review of the Accountability Work for Women’s and Children’s Health, 17th October 2014, pp. 50 and 52.

29 see note 3, para.85.

30 see note 19, Annex 6, p.125.

 
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