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Accountability in Global Health and the Sustainable Development Goals (SDGs)

Accountability in Global Health and the Sustainable Development Goals (SDGs)


My name is Alicia Yamin. And I’m a senior scholar at
the Global Health Education and Learning Incubator
at Harvard University. Today, we’re going to talk
about accountability and how it applies in global health and
development and, in particular, how a unique mechanism called
the UN Secretary-General’s Independent Accountability
Panel on women’s, children’s, and adolescents’
health has approached the concept of accountability
in the Sustainable Development Goals. When we think about
accountability, it seems like a
straightforward concept. We think about it
as, you do what you tell people you’re going to do. And that’s the way we
normally frame accountability in our personal lives. That’s the way we think
about it with politicians who run for office. But in global health, the
concept of accountability can be more complex. So let’s take a very simple
example of making sure that a medication gets
to patients who need it and look at who is
accountable for what to whom. So first, who is accountable? Even with something as
simple as just making sure that patients get the
medication that they need, there are a lot
of actors who are answerable in global health. So first of all, there
are a lot of providers. There are nurses. There are stockists. There are physicians and
maybe physician’s assistants. There are pharmacists. There are program
implementers who need to focus on supply chains. There are provincial and
national health authorities that need to issue
guidelines and make sure that medication is available
in the right places. And there are responsibilities
that the parliament and the executive
branch have more broadly in terms of issuing
legal frameworks and regulations and oversight
and budgets for medications. And then, at the
international level, there are other
responsibilities. International organizations
have responsibilities, whether it is for securing
specific medications for specific conditions,
issuing essential medicines and diagnostic lists,
such as the WHO does. There are responsibilities
from donors– donor states as
well as foundations who make commitments to the
Sustainable Development Goals, including medications. And there are
responsibilities on behalf of the private sector, both
because the private sector often acts as a provider, and
also because the private sector does research and
manufacturers and distributes specific medications. So just in terms of
who is accountable, there are a lot of actors
involved in global health. Second, accountable for what? We need to have medications
available throughout any given context in rural areas, urban
areas, sometimes remote, mountainous, or jungle
or island areas. We need to have it
be available even when there are
conflict situations or humanitarian
disasters, for example. And that requires communications
and transportation networks. We need to have
medications be accessible– physically accessible,
accessible on the basis of non-discrimination so
that ethnic minorities or racial minorities or women
or discriminated or marginalized groups based on their
sexual orientation or gender identity or persons
with disability can access appropriate
medications. We need to make sure
that they’re economically affordable and
accessible and that there is information accessibility–
that both providers know when the medication
should be used and under what conditions
and also that patients understand the conditions
for which they require this medication
and how to use it. We need to have medications that
are of adequate quality, that are safe as well
as effective, that aren’t diluted and could lead
to resistance, for example. So accountability
for what is also complicated in global health. And finally,
accountability to whom? One way to think about
the health system is about the relationships
in the health system. The goal throughout
a health system is to change relationships
that might be based on largesse or charity to relationships of
what Lynn Freedman has called constructive accountability
so that service providers feel a sense of obligation to
patients, who in turn feel a kind of entitlement to
those services or care. Program implementers feel
accountable to service providers. And policymakers are,
in turn, accountable to program implementers. Elected government officials,
including legislators, have responsibilities
to make sure that those policymakers
get budgets and have guidelines to follow
to meet their obligations. And all of these actors are
responsible to the users of the health system who
are not just patients, but they are also social
and legal citizens who are exercising assets
of their social or legal citizenship in claiming a
medication or another health entitlement. In international
health and development, it’s sometimes hard to trace
the relationships– the source of a funding commitment,
for example, the channel through which it goes, and the
program area and impact it has on the people who use it. The example of
getting medication to patients that need it
is a very small example. But health is much broader than
getting one medication or even a formulary of medications. Health includes
social determinants that go far beyond
the health sector. Health includes
political determinants that operate in transnational
space and legal determinants that shape policy frameworks
and norms and structure institutions. Health includes
commercial determinants that operate within
those frameworks. Moreover, in the
SDGs, goal three, on healthy lives and well-being,
is interdependent on other SDGs– gender equality, education,
reduction of inequalities, access to effective and fair
and transparent institutions and the rule of law,
and others as well. So we can see that
accountability in global health is a very complex tapestry of
relationships and obligations and actors. In tackling the issue
of accountability, the independent
accountability panel focused not on all of
these relationships but on the actions necessary to
take to promote accountability throughout this tapestry. So what is the IAP, the UN
Secretary-General’s Independent Accountability Panel? In 2010, the UN
Secretary-General– Ban Ki-moon, at the time– issued a global strategy on
women’s and children’s health because of lagging progress
in the Millennium Development Goals related to women’s
and children’s health. As a result of that
global strategy, the Commission on
Information Accountability was established under the
auspices of the World Health Organization. And out of that
came a sui generis mechanism called the
Independent Expert Review Group. In 2015, the Secretary-General
issued a new, revised, and broader global strategy
on women’s, children’s, and adolescents’ health in the
Sustainable Development Goals. And this global strategy
focuses not just on survival but on surviving,
thriving, and transforming the conditions that drive
patterns of women’s, children’s, and adolescents’
health and ill health across societies and
within societies. The SDGs deal with
inequalities in rich countries as well as poor countries. As part of that revised
global strategy, the Independent
Accountability Panel was established, with a
broader, more robust mandate to match the SDGs and
the new global strategy. So what are the actions
that are necessary to make accountability real for women’s,
children’s, and adolescents’ health in the Sustainable
Development Goals? The IAP has used this
unified framework for what accountability means
at both global and national levels. And let’s take those
components separately. In health and global health,
accurate, reliable data is absolutely essential
for accountability. But we require more
than just data. Data should be
disaggregated so that we can tell if there are
disparities within population groups. We also want fit for
purpose indicators. And we want to make sure
that indicators chosen don’t lead to any adverse,
unintended consequences, such as coercive practices to
increase the amount of coverage among certain populations. Monitoring also needs to
apply to the private sector and to different
kinds of providers, depending on the context
that we’re looking at. In addition to
monitoring, which is given the lion’s share of
attention in global health, there is a need for
independent review. Independent review tells
us which strategies are working well and
can be built upon and those that are not working
well and need to be modified. Independent review needs to
cover the private sector as well as the public sector. And in global health
governance, there is also a critical need
for independent review. In a way, the role of the
Independent Accountability Panel can be thought of as
a monitor of the monitors that follow data in
women’s, children’s, and adolescents’ health in
the Every Women, Every Child, Every Adolescent ecosystem. Finally, the IAP
expanded the Commission on Information Accountability’s
use of remedial action to action and remedy. Remedies can be
administrative remedies. They can be other
sorts of remedies. But they can also be legal
and judicial remedies. Consider, for example, the
need for independent review and remedies in the
event of non-compliance with the international code
of breast milk substitutes. We might think the same
thing in terms of the example that I gave at the
beginning about pharmaceutical regulation. As Richard Horton and
the Lancet commission on legal determinants of
health have pointed out, the law is a crucial
determinant of health outcomes and access to health. And in democracies, the rule
of law and legal institutions are critical for promoting
the global strategy and achieving universal health
coverage and the Sustainable Development Goals. This needn’t be
thought of as punitive. And it also shouldn’t be thought
of as just within the health system, because we also
need laws and regulations and remedies in the
event of health actions from commercial determinants. Think, for example,
of the tobacco industry and the Framework
Convention on Tobacco Control. Those industries need to
be appropriately regulated. That’s not to say that
the private sector doesn’t have an important role to play
in achieving the Sustainable Development Goals and the
global strategy on women’s, children’s, and
adolescents’ health. But the private sector is
always more accountable when there is a
robust public sector. All of this, of course, requires
strengthening institutions. The IAP has flagged the need
to invest in and strengthen institutions for monitoring
independent review and providing remedies
and normative oversight. The purpose of
remedies and action, and of strengthening
institutions generally, throughout the global
strategy and in the SDGs is always to provide
accountability to those to whom
promises have been made– to leave no one behind. The IAP is a small panel made
up of 10 independent experts appointed by the UN
Secretary-General who serve in a
voluntary capacity and are from different countries
and regions around the world. But the IAP’s experience in
explicating accountability under the global strategy
has useful lessons to expand more broadly to
universal health coverage and to the SDGs in general. The purpose of a mechanism
such as the Independent Accountability
Panel is to clarify dimensions of accountability
and the actions necessary to promote it and to
catalyze greater accountability at national level and at global
level by these institutions that we have been discussing. Ultimately, it is
social accountability that we’re seeking in the global
strategy and universal health coverage and in the
Sustainable Development Goals more broadly, through
citizen-led and community-based empowerment, but also
through strengthening these institutions. And that often requires
unpacking those relationships again. Who is accountable
for what to whom? Because real accountability
is relational in specific contexts where specific kinds
of power relationships operate. The world’s leaders
made a promise to people across the globe to
transform the conditions that produce ill health and poverty
and climate destruction and inequality into
a world that we want through this sustainable
development agenda. To keep that promise requires
meaningful accountability.

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