SC2 UHC2030 accountability strategy initial scoping...Document SC2. UHC2030 accountability strategy – initial scoping UHC2030 Steering Committee meeting, Geneva, 15-16 June 2017

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2030International Health Partnership

DocumentSC2.UHC2030accountabilitystrategy–initialscoping

UHC2030SteeringCommitteemeeting,Geneva,15-16June2017

TableofContents1.Background–Purposeofthepaper...........................................................................................................22.UHCAccountabilityintheSDGcontext.....................................................................................................33.UHC2030roleintheUHCaccountabilityarchitecture:possibleelements......................44.Potentialactivities...................................................................................................................................85.Nextsteps....................................................................................................................................................96.Annex1.UHC2030indicatorframework....................................................................................117.Annex2.Backgroundinformationonspecificinitiatives.....................................................148.Annex3.OverviewofexamplesofaccountabilityrelationshipsrelatedtoUHC........17

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1.Background-PurposeofthepaperOneofthefouragreedobjectivesforUHC2030istofacilitateaccountabilityforprogressonhealthsystemstrengthening(HSS)towardsuniversalhealthcoverage(UHC)andthroughthistocontributetoamoreintegratedapproachtoaccountabilityforSDG3,andSDG3.8inparticular,buildingonexistingeffortscontributingtoaccountability.AspartoftheUHC2030revisedworkplanfor2017,itwasagreedtodevelopastrategyforUHC2030fordeliveryofthisaccountabilityobjective,specifyinghowthepartnershipcanaddvalue;identifyingspecificactivitiestostrengthenmonitoring,reviewandremedialactionsatvariouslevelsofUHC;andwaysofworkingtosupportimplementation(e.g.roleforamulti-stakeholderworkinggroup).ItshouldbenotedthatsuchastrategyisnotaboutaccountabilityinrelationtointernalgovernanceofUHC2030(e.g.effectivenessofthepartnershipanditsmembersindeliveringonthemandate,lessonslearningandknowledgesharing)whichshouldratherbeaddressedaspartofthepreparationofworkplanandassociatedreportingprocess.ThepurposeofthispaperistostimulateinitialdiscussionwithintheUHC2030SteeringCommitteearoundsomeofthekeyquestionsrelatedtocarvingouttheroleforUHC2030inrelationtooverallarchitectureofaccountabilityforUHC.AnimportantguidingthreadishowUHC2030,asaglobalpartnership,canbehelpfulatthegloballeveltoinfluencechangeincountries.ThepaperhasbeenpreparedbytheCoreTeam,drawingoninputsfrominitialpreparatoryworkwhichincludeddeskreviewandinterviewswithasmallnumberofinformants(selectedexpertssupportingaccountabilityprocessesrelevantforUHC).ThepaperaimstosupporttheSteeringCommitteediscussionwhichwillguidetheCoreTeamtodraftafullstrategytobefinalisedforreviewbytheSCbyend2017,identifyingareasthatmayrequiremoreindepthconsiderationandfurtherconsultationofawiderrangeofpartners.

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2.UHCAccountabilityintheSDGcontextAccountabilityforUHCrestswithnationalgovernments.193countrieshavecommittedtoUHCthroughtheSDGsandadedicated2013UNUHCresolution.Withinthesecountries,adevelopmentcontinuumexiststhatvariesbyincome,politicalsystem,expenditureonhealthandthepatternofhealthcareprovisionandfinancing.Eachcountryhasitsownspecificaccountabilityprocesses,whichworktodifferentdegreesofeffectiveness,includingvariationwithinthecountry.EverycountryhasscopetoimprovepoliciesandactionstowardsUHCbutprioritiesdependoncountrycontext.LessonsonhowtoprogresstowardsUHCcanbelearnedbothwithinandacrosscountries.Governmentsreceivetheirmandatefromcitizens.Socialaccountabilityincludingtheroleoflocalauthorities,civilsociety,privateproviders,citizenvoiceandthemediathereforeplayacentralroleinholdingMinistriesofHealthandgovernmentaccountable.Regionalandglobalprocessescanplayaroleinsupportingandadvancingnationalaccountability.Multipleconnectionsexistbetweengovernmentsandregional/globalorganisations,aswellasbetweennationalandinternationalcivilsocietyorganisations.Developmentpartneraccountabilityprocessesexistalsotosupportaid-recipientcountriesandshouldthereforebeaccountabletonationalauthorities.Dependingonthenatureofthedevelopmentpartner(bilateral,multilateral,etc.),theyarealsoaccountabletotheirownpoliticalsystemsormanagementboards.AccountabilityondevelopmenteffectivenessisdistinctfromaccountabilityforUHC,butcontributestothelatterinanindirectmanner.UHCisanimportantaspirationbothinitsownrightandasastructuralplankofthewiderSDGs,underpinningothergoalssuchaseconomicprosperityandlifelonglearning.1UHCcontributestoSDG3healthtargets,alongsideprogressinothersectorslikewaterandsanitationandfactorsthatmaybeinfluencedbybutarenotunderthedirectcontrolofhealthsystems.UHCisalsoboundedbyfiscal,demographicandtechnologicalpressuresandopportunitiesthatconstantlyevolve,requiringdynamicadjustmentbyhealthsystems.Thesecross-cuttingpriority-settingresponsibilitiesunderlinethecountrylevelastheprimaryfocusofSDGaccountability,withnational,regionalandinternationalmonitoringandreviewmechanismsultimatelyfeedingintotheUNHighLevelPoliticalForum(HLPF)astheapexbodypromotingandreviewingSDGprogress.

1UHC2030,2017,Healthysystemsforuniversalhealthcoverage–ajointvisionforhealthylives

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3.UHC2030roleintheUHCaccountabilityarchitecture:possibleelementsThe75signatoriestoUHC2030haveagreedfourmainobjectivesforthepartnership.Thispaperrelatestohowthe3rdobjectiveshouldbeenacted:

1. ContributetoimprovedcoordinationofHSSeffortsforUHCatgloballevel,includingsynergieswithrelatedtechnicalnetworks

2. Strengthenmulti-stakeholderpolicydialogueand coordinationofHSSeffortsincountries,includingadherencetoIHP+principlesandbehaviorsincountriesreceivingexternalassistance

3. Facilitate accountability for progress towards HSS and UHC thatcontributestoamoreintegrateapproachtoaccountabilityforSDG3

4. Buildpoliticalmomentumarounda shared global visionofHSS forUHCandadvocate for sufficient, appropriate andwell-coordinated resource allocationtoHSS.

Alotofworkonaccountabilityinthebroadersphereofhealth,withsomedirectorindirectlinkstoUHC,isalreadyongoing,atnational,regionalandgloballevels.WHOandWBhavedevelopedaframeworkfortrackingglobalandcountryprogressonUHC(Box1)2.TheframeworkwasappliedforthefirsttimeinthefirstglobalmonitoringreportforUHCusingasetofaggregatetracerindicators(Annex1).ThefirstglobalmonitoringreportonUHCoutlinesthreemajorchallengesintrackingUHC;firstsourcingreliabledataonabroadsetofhealthservicecoverageandfinancialprotectionindicators;second,disaggregatingdatatoexposecoverageinequities,thirdmeasuringeffectivecoverage,whichnotonlyincludeswhetherpeoplereceivetheservicestheyneedsbutalsotakesintoaccountthequalityofservicesprovidedandtheultimateimpactonhealth.3

2WHO(2014)MonitoringprogresstowardsUHCatcountryandgloballevels:framework,measuresandtargets.Geneva:WHO/HIS/HIA/14. 3WHOandWorldBank(2015)Trackinguniversalhealthcoverage:firstglobalmonitoringreport.Geneva:WHO.

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VariouseffortsarealsoongoingtoaddressdatachallengesincludingthroughtheHealthDataCollaborative(HDC)(Box2).Box2.HealthDataCollaborativeIftheSDGsaretobemet,includingallthehealth-relatedSDGs,itwillrequireanewapproachtotheproductionanduseofsocial,economic,andhealthdata,includingdataonlifestyleandvitalstatistics.TheHealthDataCollaborative(HDC)wasformedin2016tosupportcountriestoimplementthe2015MeasurementandAccountabilityforResultsinHealthSummit’sCalltoActionand

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HealthMeasurementandAccountabilityRoadmap.TheHDCisajointeffortbyseveralglobalpartnerstoworkalongsidecountriestoimprovetheavailability,qualityanduseofdataforlocaldecision-makingandtrackingprogresstowardthehealthrelatedSDGs.HDCapproachiscrucialinhelpingcountriesimprovetheirhealthinformationsystemsby:

• Supporting countries to improve their technical and institutional capacities togenerate,analyzeandusequalityhealthdataandvitalstatistics;

• Coordinatingexistingeffortsandinvestments;• Rationalizingglobaldemandfordata(byfocusingonjust100coreindicators);and• Harmonizing tools and guidance, which should improve the efficiency and

effectivenessofpartnersupporttocountriesDespitethecomplexaccountabilityarchitecture,thereisemergingconsensusoverareasinwhichUHC2030couldaddvalue.Thereexistsapossible‘accountabilityniche’forUHC2030thatcomplementsarangeofefforts.PreliminarypreparatoryworkpointstothreemainareaswhereUHC2030wouldlikelyaddmostvalue,andforwhichthereseemstobestrongdemand:

1. Bridging between technical and political fora to help highlight emergingUHCproblemsandprogress

2. A‘networkofnetworks’, linkingexisting initiativesasaneffectiveandagilelearning

3. Actingasapeerreviewplatform.Accountabilityisgroundedinthegovernancefunctionofacountryhealthsystem,andisassuchreflectedinthecycleofprioritysettingactionmonitoringandreview.Thisismirroredinaccountabilityapproachesofotherpartnerships:e.g.theEWECmodelwithitsthree-stagecyclearoundmonitor-review-remedialaction(Annex2).IncountriesthemandateforhealthsystemstrengtheningtowardsUHCisinmostcasesdelegatedtoGovernmentandMOH.Theyinturnexercisethisbysettingnationalplans,nationalhealthtargets/nationalhealthpriorities,systemreformobjectives,etc.(theremedial/priorityactionpart)Inrecognitionofthecomplexityofactorsinvolvedthisneedstoinvolveabroadrangeofstakeholders,othersectors,subsectorandcommunitylevels,privateactorsandcaninsomecasesbeinfluencedbyregionalorevengloballevelcommitments.Forthemonitoringpart,atthesystemlevelmanycountrieshavesomesortofprocessesofselectingasubsetofindicatorsthatareregularlyassessed,sometimeswithintheframeworkofnationalplansandsometimesnot.UHCobjectivesarecloselyassociatedwithhealthsystemgoals/outcomesandhealthsystemperformance,whiletheydonotrepresentasubstituteforhealthsystemgoalssuchasimprovedsurvivalorhealthylifeexpectancy.Forgoodstewardshipofthehealthsystemakeyactionisreviewofasubsetofindicatorsinformingonprogressonkeysystemgoals/outcomes.Thiscanhappenbyassessmentsofnationalplans,regularreviewoftheindicators,ordedicatedhealthsystemperformanceanalysisexercisesdonebycountries.InsomecasesWHOand

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otherpartnersarehelpingwiththis.WPROhavefocusedonparticipatorydevelopmentofaUHCassessmentframeworktohelpcountriesassessthesystemprogresstowardsUHCandthendetermineprioritiesforimprovement,whereasinSEAROtheRegionalofficehashelpedcompileprofileswithdataonprogressonsomeofthekeyindicatorsfortheuseofpolicymakers.Mechanismsforpeople’svoicearecentraltoaccountability.AvarietyofmechanismsofvoiceandcommunityempowermentinhealthservicedeliveryconveythecollectivepreferencesofcitizensincludingNationalHealthAssemblies,communityownership,communitymanagement,andcommunityandcitizensmonitoringandreportcards.Atthegloballevel,UHC2030couldplayaroleatthelevelofreviewandremedialaction,inthefollowingways,aimingatsoftaccountability,basedonpeerreviewandexchange,ratherthanhardenforcement:1. To share country experience and lessons focused on the tough, practical

choicesaroundexpandingUHCthroughHSS.2. Tohelpshareandstrengthenconsensusonbestpracticeprinciplesformoving

towardsUHC.3. To act as an informal clearing-house and sounding-board, to help coordinate

(with a light touch) among other initiatives targeting specific diseases,conditions or groups in need, and especially to helpmake thesemore coherentwithbroadersystemicstrengtheningapproachesandinitiatives.

4. To act as anexus between existing data collection and analysis platforms(suchastheWHOUHCDataPortalandtheGlobalHealthObservatory)andpolicymakerstoassistwiththeprocessofusingdatainpolicydecisionmaking.

IntermsoffacilitatingcountrylevelaccountabilityUHC2030canaddvalueindirectlybyhelpingstrengthenconsensusonprinciplesofgoodpracticeforUHCapplicableatcountrylevelaswellassharinglessonsonaccountabilityprocesses.UHC2030canalsohavearoleinreinforcingprinciplesofEDCthatareupdatedfortheSDGeraincountrieswhereexternalpartnersplayarole.Asamulti-stakeholderpartnership,UHC2030canhelppromotesocialaccountability,workingcloselywiththeCivilSocietyEngagementMechanism.Citizens’platformsareessentialfortheformulationandreviewofstrongnationalhealthpolicies,strategies,andplansthatenableprogresstowardsUHC.FORSTEERINGCOMMITTEECONSIDERATIONDoestheSteeringCommitteeagree:1. That the main locus for responsibility for UHC accountability rests with

nationalgovernments,fortheirdomesticactions?2. That promoting EDC is not the major focus of UHC2030 work on UHC

accountability but remains a significant complementary objective in lowincome countries and some lower-middle income countries, where externalfinancestillplaysarole?

3. That supporting ‘social accountability’ by strengthening civil societyinstitutions and other non-state actors who play a central role in holdinggovernmentsaccountableisofcentralimportance.

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4. ThatUHC2030,atgloballevel,shouldoperateasabridgingforsharinglessonlearningonUHCacrosscountries,drawingontheworkofotherorganisations,bridging coherent communication between technical and political discussionfora and strengthening political buy-in to best practice on UHC servicedelivery,financingandgovernance?

4.PotentialactivitiesHavingagreeditspossiblerole,andestablisheditsaccountability‘niche’,UHC2030needstoconsiderthekindsofactivitiesitwantstoengagein,andprioritisewithinalimitedresourceenvelope.Thefocusshouldbepractical,addressingissuesthroughthelensofquestionslike:whatwillthisactivitychangeinreality;whatwoulditlooklikeifweweredoingitright;howwillweknowifwehavedoneit?Whileconsideringpossibleactivities,itisimportanttokeepinmindimportantconsideration.ThefocusofUHC2030workonaccountabilityshouldbemostlyfocusedtowardsdataanalysis,disseminationanduseratherthannewdatacollection,seekingtobridgepoliticalandtechnicalagendas.FurtherUHC2030willmostlyseektoachieveitsobjectivesbyindirectworkincountriesratherthanintensivedirectcountryfocus(Box3).Box3.ConsiderationstokeepinmindThedegreetowhichUHC20320wantstocollectdedicated/newdataortocollate/analyse/useexistingdata.UHC2030shouldcarveoutanicheintheareaofdatauseinpolicy,ratherthangatheringanynewdataofitsown.MajorhealthactorsincludingWHOandWBhaveestablishedmandatesindatacollection,includingforUHC.Theonlypartial,andpotentiallycontestedexception,couldfordataonEDC,whichisnotcurrentlycollectedelsewhereatthesamelevelofdetail.Eventhere,however,thefirst-bestapproachwasthoughttobetobuildonnationalsurveyinstrumentsandprocesses.Theintensityofcountryfocus.Encouragingdecisionmakersthroughgreaterefficiencyofinformationmanagementandfeedbackloopsisanintensivepolicyprocess.TheIHP+hadastrongtrackrecordofdevelopingandpromotingpracticaltoolsforimprovingnationalplanningandfinancialmanagementsystems.UHC2030couldbuildonthisexperiencethroughtransparentdiscussionsoftheutilityofthesetoolsandtheirimpactonchangingprocessesatnationallevel.AsforIHP,ratherthantestingand/orrollingoutsuchtoolswithdirectinvolvementincountries,UHC2030shouldbecomemoreofanintelligent‘curator’anddiscussion/disseminationhubforcountryexperiencesbuildingonsuchtools,primarilysupportedbyotheractor’salreadypresentin-country.UHC2030wouldalsoneedtobuildonitsdirectlinkstootherinitiativessuchastheJointLearningNetwork(JLN)andtheHealthDataCollaborative(HDC),thatprovidesupportinspecifictechnicalareas.Balancebetweentechnicalversuspoliticalengagement.UHCaccountabilityrestsonbothapoliticalandtechnicalprocess.UHC2030partnersalreadyoperateleversthroughexistingpoliticalmechanisms,suchastheWorldHealthAssemblyortheWorldBankSpringMeetings,aswellastheHighLevelPoliticalForum.OtherleversexistregionallythroughWHOregionalofficesorbodiessuchastheAfricanUnionorASEAN.Atregional

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andgloballevels,UHC2030mayhaveopportunitiestoaddvaluebyconnectingupthedifferentlevels,andhelpingbridgebetweentechnicalandpoliticallevel,promotingpeerreviewortrafficlightmechanisms,aswellasSouth-Southlearningopportunities.These‘soft’accountabilitymechanismsofferthepotentialforforwardmomentum.Inordertosupportnationalpoliticalprocesses,UHC2030shouldhelp‘makethebulletsbutnotshootthem’.ThesecouldforexampleincludehelpingforgeorbroadenconsensusondifferentbestpracticesforUHC.Table1containsalistofpossibleactivities,bynomeansexhaustive,whichemergedthroughpreliminarypreparatorywork.SomewouldbeacontinuationofthekindsofthingsthattheIHP+did,whileotherswouldbenewdepartures.Prioritisingtheseactivitiesshouldbeledbyanassessmentofpotentialvalueaddedandtransactioncosts.

Table1PossibleUHC2030accountabilityactivities

HelpdevelopandhelpbroadenconsensusongoodpracticeformovingtowardsUHCPlayingaroletobridgethegapbetweentechnicalandpoliticalprocesses,forexamplebydebates,reviewandcommunicationsaroundtheWHO/WorldBankUHCMonitoringReportEstablishingacentralUHCknowledgeplatform,aimingtobuildonandensurecohesionamongstthemultipleotherinitiatives;Providingregularopportunitiesformembersforopen,transparentinformationsharingonprogress,achievementsandchallenges–‘soft’accountabilitythroughpeerreviewSupportingsharingofexperiencethroughdialoguebetweengovernments,localauthority,CSOsandprivatesectorstakeholdersonprogresstowardsUHCMaintainingafocusonEDCinaid-dependentsettingsPromotingsynergiesbetweenkeyactorsatdifferentlevelsandplatformssuchastheWHA,theSpringMeetingsortheAU,whileavoidingraisedtransactioncostsWorkingtoharmoniseaccountabilityworkacrossrelatedHSSandhealthfinanceinitiativese.g.withtheEveryWomanEveryChild(EWEC)processandothers.Facilitateadvocacy/otheractivitiesbycivilsocietyorganisations(CSOs),includingcitizen’svoice,professionalorganisations,andbuildingonothersworkinthisarea,Developingandoperationalizingspecialisedtools,suchasscorecardsorbenchmarks,forusebynationaland/orregionalstakeholders

FORSTEERINGCOMMITTEECONSIDERATION:WhichactivitiesinTable1doestheSteeringCommitteethinkarelikelytodelivergreatestreturnoninvestmentformakingprogressonaccountabilityforUHC?

5. Nextsteps

Indevelopingthestrategy,thecoreteamwouldbenefitfrombeingguidedbyatimeboundadvisorygroup,drawingonthedifferentexpertisethatexistsamongpartners,includingUHC2030relatedinitiatives(e.g.HealthDataCollaborative,HealthSystemsGovernanceCollaborative,JointLearningNetwork)andtheCivilSocietyEngagementMechanism,giventheircontributiontoaccountabilityrelatedwork.Consultationswithcountriesareessentialandshouldbeenvisaged,takingadvantageofrelevantregionalorinternationalgatheringstakingplaceinthecomingmonths,workinginparticularcloselywithWHOregionaloffices.

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WhilefurtherworkisneededtodeveloptheaccountabilitystrategyforUHC2030,itisproposedtomaintainmomentumandnotmissimportantopportunitiestoinfluence.Thisincludesthepreparationofanaccountabilityreporttoreviewprogressincoverageandfinancialprotection.Thisreportwillcomplementthe2ndannualUHCmonitoringreportandinformdiscussionsattheUHCForum2017thatwilltakeplaceinTokyo,inDecember.WHOexpertswillprovidetheanalysiswhileUHC2030canfacilitatesomeadditionaltechnicalconsultationsthatwillhelptoframekeysummarymessages.FORSTEERINGCOMMITTEECONSIDERATIONDoestheSteeringCommitteeagreethattheCoreTeamistaskedtodevelopastrategyforUHC2030roleinfacilitatingaccountabilityforUHCwithintheSDGframeworkbyend2017,workingwithagroupofexperts?

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Annex1:UHCindicatorframework4

4 WHO and World Bank (2015) Tracking universal health coverage: first global monitoring report. Geneva: WHO.

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Annex2:Backgroundinformationonspecificinitiatives

TheIHP+accountabilityframework,performancereportsandJointAssessmentsofNationalHealthStrategies

TheIHP+hasincreasinglyevolvedinthedirectionofacross-countrylearningplatform,withafocusonbroadhealthsystemstrengthening(HSS,includinghealthfinancingwritlarge).Itsaccountabilityframeworkisbasedon(1)asinglecountry-levelmonitoringandevaluationplatformand(2)mutualaccountabilitybetweencountriesanddevelopmentpartners,basedonperiodicperformancemonitoringofthesevenbehavioursenshrinedintheIHP+Principles.Oneadditionaltool,theJANS(IHP+2009,revised2013),straddlesthe‘what’andthe‘how’ofHSS,byprovidingbothastandardizedplanningguideandasystematicproblem-solvingagendatowhichseveralpartnerscancontribute,identifyingfurtheractionandresourceneeds.JANScoversfiveareas,examiningthesoundnessof:situationanalysisandprogramming;thenationalstrategyprocess;costsandbudgetframeworkforthestrategy;implementationandmanagementarrangements;andmonitoringandevaluationmechanisms.JANShavebeenfound(IHPReviews,2014and2016)tohelpstrengthennationalhealthstrategiesandbuildconfidenceinthem,andtoreducetransactioncostsassociatedwithmultipleseparateassessments.Theirlinkstofundingbehaviourchangebypartners(inamountorpredictability)arelessclear.Thisreflectsthebroadareasofstrengthandweaknessalreadynotedinthe2014IHP+PerformanceReport,mappingtofourofthesevenIHP+principles:• Partner country delivery on sector strategies, results and strengthened accountability

systems: progress on the first two, stagnation on the third and on civil societyengagementinpolicyandplanning.

• Development partner alignment and participation in national accountability processes:progressinresultsframeworksandsupporttoCSOs,stagnationinmutualassessmentofprogress.

• Partnercountries improvement inhealthfinancingandfinancialmanagement: progressinbudgetshareandpredictability,stagnationinpublicfinancialmanagement.

• Performanceofdevelopmentpartnersonfinancingandfinancialmanagement:stagnation(1/4indicators)ordecline(3/4)acrosstheboard.

Theasymmetriesherearequitemarked,andpointtotheneedformorerealismperhapsinmutualexpectationsofthePartnership’simpactonfuturefundingdecisionsmadebydevelopmentpartners,whilebuildingontherelativesuccesswithnationalprocessesandfundingmechanisms.ThesefindingswerealsobroadlyvalidatedbytherecentRapidIndependentReviewofIHP+5whichemphasisedthethreemainareasinwhichIHP+wasfoundmostuseful:asaninclusiveplatformfor

5https://www.internationalhealthpartnership.net/fileadmin/uploads/ihp/Documents/About_IHP_/mgt_arrangemts___docs/Core_Team/Rapid_Review_of_IHP_._Final_Report_16_DEC_2016_1.pdf

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exchangesofviewsonHSS;asawayofkeepingeffectivedevelopmentcooperationonthenationalandinternationalagenda;andforitspracticaltools,includingJANS.

An example of a partnership framework n accountability: EWEC’s Unified Accountability Framework (UAF)

Examiningexperiencesandstructureofotherhealthrelatedpartnershipaccountabilityframeworkscanprovideusefulinsights.TheEWEClaunchedin2010isamovementofinternationalandnationalactorson toaddressthemajorhealthchallengesfacingwomen,childrenandadolescentsaroundtheworld.ThemovementputsintoactiontheGlobalStrategyforWomen’s,Children’sandAdolescents’Health. TheUAFhasathree-stageaccountabilitycycleof‘Monitor-Review-Act’operatingbothatnationalandatgloballevels(figure1).Thishasrecentlybeenaddedtowitha‘remedy’stage,morefocusedonunderlyingstructuralcausesofhealthoutcomes.Theframeworkpresentstwinaccountabilitycycles–nationalandglobal–thatarelinked,crucially,bycountryreportsandscorecards,bypeerreviews(regionalinthisschematic,butpotentiallyalsocross-regional)andbyregionalreportstogloballevel.ThepeerreviewelementlooksimportantforUHCalso,especiallyinthelightofIHP+experience.

Figure1TwinaccountabilitycyclesschematicoftheUnifiedAccountabilityFrameworkfortheUNGlobalStrategyforWomen’s,Children’sandAdolescents’Health6

Recognisingthatcountrycontextsdiffertoomuchforasingle‘accountabilityblueprint’towork,EWECdistilledinsteadacoresetofaccountabilityprinciplesfortheGlobalStrategyagreedin2015:6Schweitzer,J.(2015)Accountabilityinthe2015GlobalStrategyforWomen’s,Children’sandAdolescents’Health.BMJ351:H4248.

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• Adherence tohuman rights, including the rightsofwomen, childrenandadolescents to receivequality andrespectfulservices;

• Therightsofcommunitiesandcivilsocietytoparticipateinmonitoring,reviewandaction;and• Thekey roles and responsibilitiesof thedifferent stakeholders in thehealth sector, fromgovernments and

internationalagencies,totheprivatesector,civilsocietyand,aboveall,thewomen,childrenandadolescentswhohavetherighttosurviveandthrive.

ThesecoreprinciplescouldbeusedasanexampleforinspirationtobuilduponforthebroadertargetgroupsofUHC,applicabletoUHC2030.ImplementationofEWECaccountabilityprocesses(suchasanannualmulti-agencyperformancereport,peerreviews,andsupportingtheworkoftheIndependentAccountabilityPanel,whichhasbeensetuptoprovideanindependentreviewoftheGlobalStrategy)istheresponsibilityofthePartnershipforMaternal,NeonatalandChildHealth(PMNCH).

Rockefeller Foundation 2016 consultation recommendations on UHC accountability

WithregardtoUHCaccountabilityoverall,consultationsundertakenonbehalfoftheRockefellerFoundation7identifiedtheneedtotakestockfromexperiencewithrelevantaccountabilityinitiativesintheMDGera,includinghowtoleveragetheseexperiencesandeffortsforhealthsystemsandUHC.Thisispartlybeingimplementedthroughthepresentreview,asconcernshealthinitiativesinparticular.Othertop-levelRockefellerconsultationrecommendationsonUHCincluded:theneedforcountry-specificconsultationstoidentifygapsandopportunitiestostrengthenmulti-stakeholderaccountabilitiesformonitoring,reviewandaction(asintheEWECschematicpresentedabove);securingreferencetoUHCaccountabilityinintergovernmentalresolutionssuchastheWHAresolutionsontheSDGs;abetterdefinitionof‘non-compliance’inrelationtoUHCimplementation;andexplorationofthehumanrightsandandlegislativemechanismsthatcanbeleveragedforUHCaccountability.WithspecificregardtoUHC2030accountabilitymechanisms,recommendationsincluded:aclearcommitmenttothemandatetostrengthenaccountability,withsufficienthumanandfinancialresourcestocarryitout;inspirationfromexistingmodelsofmulti-stakeholdergovernance(suchastheInternationalLabourOrganisation(ILO),GlobalFundandPMNCHBoards)toinformthedesignoftheSteeringCommittee;aconsultativeprocessleadingtoaCSOconsortiumundertheumbrellaofUHC2030;andsufficientdonorinvestmentinoperationalisingtheaccountabilityframeworkatnationallevel,includingcapacitystrengtheningofcivilsociety,parliamentarians,mediaandotherstakeholders.TheconsultationsalsorecommendedthatthemandateoftheIndependentAccountabilityPanel(asofnow,establishedtoservetheEWECinitiativeonly)beexpandedtothewholeofSDG3–includingofcourseUHC,withappropriateredesignandresources.

7Brearley,L.(2016)OptionsforanAccountabilityFrameworkforuniversalhealthcoverage.NewYork:ConsultationReportbyManagementSciencesforHealth/RockefellerFoundation.

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Annex3:OverviewofexamplesofaccountabilityrelationshipsrelatedtoUHCAccountabilityforUHCliesprincipallyatthenationallevel,andderivesfromgovernmentcommitmentstotheircitizensandcommitmentstotheSDGs,underwhichUHCsitswithinSDG3astarget3.8.However,manyotheractorsareinvolved,operatingacrossmultiplelevelsandcountries.ThisannexpresentsthefindingsofamappingexerciseundertakentoshedlightontheinstitutionalgeographyofaccountabilityforUHC.Thepurposeistoidentifygaps,overlapsandcomplementaritiesandsetthesceneforthediscussionofthepossibleaccountabilityroleofUHC2030.Ratherthantabulatingacomprehensivesetofinformationonalltheinitiativesateverylevel,whichwouldbelargeandunwieldy,a‘mindmap’approachhasbeentakentohelpvisualisethispicture(Figure1overleaf).Themapisneitherencyclopaedicnordirectlyderivedfromanytheoryofglobalgovernance.Itissimplyanattempttorepresentthecomplexwebofaccountabilityrelationshipsatnational,regionalandgloballevelsinavisuallyaccessibleway.Itshouldbenoted,however,thatnotalltheaccountabilitylinescontributetoUHCinthesamedegree:whiletheyarelinked,theymaynotbeallfullyrelevantforanoverallUHCaccountabilityframework.Totherightofthemindmap,variousinstitutionscontributingtotheSDGsarepresented,withtheUNSDGprocessesatthetopand,underthem,relatednationalandregionalinstitutionsthatcouldplayaroleinsupportingimplementationandaccountabilityforSDG3.Atthebottomrightareasetofdevelopmentpartneraccountabilityprocesses:High-levelincomecountrieswouldthereforehaveaccountabilityforUHCderivingbothfromtheirowncommitmentstoUHCfortheirdomesticpopulationsandanysupporttheyprovidetoaidrecipientcountries.Ontheleftsideofthemindmaparethreebroadgroupsofinitiatives:thosethat,inonewayoranother,formpartoftheUHC2030family;thosethatformpartofthefamilyoforganisationsthattogetherseektodelivertheUNSecretaryGeneral’sEWECmovementanditsassociatedGlobalStrategyforWomen’s,Children’sandAdolescents’Health;andthosethataddressassociatedspecifichealthissuessuchasNCDsorhealthsecurity.Someoftheseorganisationscouldfitinmorethanoneoftheseareasbutforconveniencehasbeenplacedwheretheyappearedtoconcentratemoston.Manyadditionalrelationshipscutacrossthismap:forexample,manyoftheinitiativesonthelefthavedirectrelationshipswithnationalorregionalinstitutionsontheright;likewisethereareobviouslymultipleformalandinformalconnectionsbetweennational,regionalandglobalinstitutions.Furthermore,virtuallyallgovernmentsarerepresentedonthegoverningbodiesofalltheinternationalhealth-relatedagencies,andcanholdtheirmanagementstoaccountthroughthosechannels.Themaprecognisestheimportanceofsomeoftheseconnectionsbuthasleftthemouthereforthesakeofvisualsimplicity.

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Figure2MapofaccountabilityrelationshipsrelatedtoUHC(tobeprovidedduringthemeetinginadifferentformat)