BLOCK 4: HOW TO ENHANCE ACCOUNTABILITY?

HUMAN RIGHTS AND HEALTH EQUITY:IMPLICATIONS FOR ADVOCACY, ACTION AND GOVERNANCE

1. Concept and definition of accountability2. Relationship between accountability and the

Right to Health3. Rights-holders and duty-bearers4. What are the mechanisms for safeguarding

accountability 5. What are the mechanisms for safeguarding

accountability 6. Common challenges to accountability

Outline:

What is accountability?

Question 1:

Defining accountability:

The essence of accountability is answerability: being accountable means having the obligation to answer questions regarding decisions and/or actions (Schedler 1999)

In democratic governance accountability implies transparency

WHO: accountability is linked to the notion of “stewardship” (Travis et al. 2002)

4 dimensions of accountability in health:

to control the misuse and abuse of public resources and/or authority according to appropriate legal procedures, professional standards, and societal values, ensuring affordability of medical goods and services as well as underlying determinants of health (financial accountability)

to support improved health care service delivery and management and overcoming barriers -availability, accessibility, acceptability and quality (AAAQ) (performance accountability)

4 dimensions of accountability in health (2)

to make sure that the institutions, procedures, and mechanisms that seek to ensure that government delivers on electoral promises, fulfills the public trust, aggregates and represents citizens’ interests (political/democratic accountability)

to ensure that the duty-bearers timely and effectively respond to ongoing and emerging societal needs and concern (social accountability)

Financial Accountability

concerns tracking and reporting on allocation, disbursement, and utilization of financial resources, using the tools of auditing, budgeting, and accounting. begins with internal agency financial systems that follow

uniform accounting rules and standards finance ministries, and in some situations planning ministries,

exercise oversight and control functions regarding line ministries and other executing agencies

Since many executing agencies contract with the private sector or with NGOs, these oversight and control functions extend to cover public procurement and contracting

Insurance fund agencies play a key role in financial accountability in health systems that pay providers for predetermined packages of basic services and population coverage

Legislatures pass the budget law that becomes the basis for ministry spending targets, for which they are held accountable

Performance Accountability

demonstrating and accounting for performance in light of agreed-upon performance targets Focuses on the services, outputs, and results of public

agencies and programs, availability, accessibility, affordability and quality of health goods and services

Financial resources should be accounted for are intended to produce goods, services, and benefits for citizens (financial accountability’s emphasis is on procedural compliance whereas performance accountability concentrates on results)

Emphasizes the responsiveness to citizens and achievement of service delivery targets that meet their needs and demands

Political/Democratic Accountability

has to do with the institutions, procedures, and mechanisms that seek to ensure that government delivers on electoral promises, fulfills the public trust, aggregates and represents citizens’ interests.

encompasses citizen expectations for how public officials act to formulate and implement policies, provide public goods and services, fulfill the public trust, and implement the social contract.

acting in accordance with agreed-upon standards of probity, ethics, integrity, and professional responsibility

Social accountability:

responding to ongoing and emerging individual and community needs, demands and concerns.

a central focus here is the issue of equity.

Focuses on the most vulnerable and marginalized population.

deals with the underlying determinants and barriers to health

Different levels of state’s accountability:

International commitments and

agreements (treaties, charters,

declarations, meeting documents,

etc.)National constitutions

Public health laws and policies

Rules and regulations

Implementation and public health outcomes

Public health response monitoring & evaluation

HRBA and

equity Elemen

ts -principles and values

Acco

unta

bility

ch

ain

What is the link between accountability and the right to health?

Question 2:

WHO and the Right to Health and well being:

“The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition." 

WHO Constitution

The Right to Health

[The right to health] “is not confined to the right to health care... It embraces a wide range of socio-economic factors that promote conditions in which people can lead a healthy life, and extends to the underlying determinants of health, such as food and nutrition, housing, access to safe and potable water and adequate sanitation, safe and healthy working conditions, and a healthy environment”.

General Comment No. 14 (“the Right to Health”) to the Article 12 of the International Covenant of Economic, Social, and Cultural Rights

Comprehensive human rights and equity based approach to public health:

Right to health principles and values:

Effective participation and inclusionEquality and non-discrimination

EquityTransparencyAccountabilityRule of lawDignity and respect

6 building blocks of a

health system:• Leadership/

governance• Financing• Health workforce• Information and

evidence• Medical products,

vaccines and technologies

• Care delivery

Underlying determinants of health:

Access to minimum essential food, which is nutritionally adequate and safe, basic shelter/housing, safe and potable drinking water, adequate sanitation, education and access to information concerning the main health problems in the community, including methods of preventing and controlling them, address socio-cultural barriers and gender norms

RTH elements:Availability

Accessibility (incl.

affordability)Acceptability

Quality(AAAQ)

Health

equity

Universal health coverage (UHC) and Right to Health and Equity

The goal of UHC is to ensure that all people obtain the health services they need without suffering financial hardship when paying for them.

Universal health coverage has a direct link to the right to health. Access to health services enables people to be more productive. It also ensures that children can go to school and learn. At the same time, financial risk protection prevents people from being pushed into poverty when they have to pay for health services out of their own pockets.

Universal health coverage is thus a critical component of sustainable development and poverty reduction, and a key element of any effort to reduce social inequities.

WHAT ABOUT RTH AND EQUITY? NEED TO BE CENTRAL TO THE PROGRESSIVE REALIZATION OF UHC

State’s commitments to UHC: WHA58.33(2005) Sustainable health

financing, universal coverage and social health insurance

WHA64.9(2011) Sustainable health financing structures and universal coverage

EMR/RC59/R.3 (2013) Health systems strengthening in countries of the Eastern Mediterranean Region: challenges, priorities and options for future action

EMR/RC60/R.2 (2013) Universal health coverage

UNGA resolution A/RES/67/81 (2012) Global health and foreign policy

Rio+20: The United Nations Conference on Sustainable Development

EMR/RC60/R.2 (2013) Universal health coverage

“Ensure sustained political commitment to universal health coverage in order to ensure that all people have access to essential health services that are of sufficient quality, without the risk of financial hardship, and to achieve the health system goals”

Universal health coverage model: Is this enough to ensure HR and HE

Who should we focus on?

Those with no adequate access to acceptable, affordable, quality health services and prevention programs are in focus!

Ref: Tanahashi framework for effective coverage (WHO, 2010; Tanahashi, 1978)

Who are the stakeholders?Who is accountable to who?

Question 3:

Rights-holders and Duty-bearers:

Rights-holders

health service users/patients women female-headed households children young people elderly people living with disabilities

and special needs refugees migrants internally displaced

populations people living with HIV health care providers

Duty-bearers

ministry of health agencies of restraint and

enforcement funding agencies parliament/legislators local government officials nongovernmental organizations health councils and hospital

boards professional associations and

syndicates health care providers (facilities

and individuals, public and private)

academic institutions international donors

Governance for Health & Health Governance:

Health governance

refers to the players and stakeholders within the health sector response (e.g. Ministries of social Affaires, of environment, planning, finances, sanitation, Trade), insurance, parliamentarians, legislators, public/private health sector, councils, civil society focusing on health issues, etc.)

Governance for health

includes sectors beyond health, but those with the contribution of non-health sectors to the population’s health (e.g. Head of state, Ministry of Interior, transportation, urban planning, communication, etc.)

What are the mechanisms for safeguarding accountability?

Question 4:

Types of accountability mechanisms:

Judicial (entitlement of right-holders to go to court for redress and sanction when human rights are violated or duty bearers fail to meet their human rights obligations. This is used directly to challenge violations of their rights. Has the potential to prompt larger deliberation on how rights should be safeguarded in society and effect policy change)- This should be the last resort

Quasi-judicial/oversight bodies (official bodies, such as auditors, comptrollers, and civil service committees and commissions, and independent bodies mandated by the government, such as ombudsman offices and national human rights commissions. These usually do not have a power of enforcement, therefore their decisions and recommendations depend on State’s consent and public support)

Types of accountability mechanisms: Political (free and fair elections, parliament’s

drafting and passing laws, exercising government oversight, scrutinizing budgets and representing their constituencies’ interests and needs. These may guide health strategies, ensure that legislation respects and promotes human rights, evaluate allocation of resources)

Administrative (institutions meeting standards with regard to transparency, participation, reasoned decision and legality. These are internal mechanisms within individual institutions)

Social (“social accountability”, a broad range of activities in which individuals and civil society organizations act directly or indirectly to mobilize demand for accountability. Data collection, lobbying for transparent access to information, monitoring public expenditure and delivery of public services, etc.)

International (human rights treaty bodies, regional human rights courts and other mechanisms that play judicial or quasi-judicial role at the international level. Human Rights Council, Universal Periodic Review, shadow reports by the civil society, etc.)

Types of accountability mechanisms:

What are they accountable for?

Question 5:

What are they accountable for?Regulatory Body and Supreme Health Council??

Mechanisms are independent or semi-independent internal or external arrangements that serve to ensure and enforce the duty-bearers’ responsibility to be answerable for their decisions and actions

The mechanisms coordinate and/or monitors progressive realization of the right to health (AAAQ), i.e. transforming universal human rights obligations, principles and values into country-level policy and action

The mechanisms oversee that international right to health standards and norms are thoroughly adhered to - from the national constitution to public health response monitoring and evaluation

They promote equity, non-discrimination and ethics They ensure the focus on the most vulnerable segments of the

population with no or limited access to available, acceptable, affordable, quality goods, services and as related to underlying determinants of health

They ensure effective participations of duty-bearers and rights-holders (beneficiaries) and transparency

Accountability benchmarks:

What are the commitments? What were the identified needs? Who are in need and where? Who’s at greater need or risk, and why? What are the gaps, disparities, barriers,

bottlenecks in measures to meet the needs/reduce the risk (in relation to coverage, AAAQ) ?

Are the principles and values fulfilled and respected?

Who are the stakeholders? Structural elements??

What are the challenges to accountability?

Question 6:

Challenges to accountability: Health services are characterized by diversity and

strong asymmetries among providers, users, and oversight bodies in terms of information, expertise, and access

Public and private interests and incentives often diverge, which can limit efforts to increase accountability (conflict of interest)

Institutional and human capacity gaps often undermine efforts to enhance accountability –LINK DUTIES/RESPONSABILITIES and designated AUTHORITY

Increasing proportion of trade and investment takes place within the framework of preferential trade agreements and bilateral investment treaties- no rights based approach and run by commercial trade

Challenges to accountability (2):

Insufficient political commitments and “know how” Unclear roles and mandates of different stakeholders

and lack of cooperation and partnerships Lack of public health legislations and legal

frameworks supporting structural and governance bodies, sectors and mechanisms e.g. councils and ministries

Lack of health legislations (even conflicting) supporting identified policies, commitments and plans

Unstable environment/conflict combined with limited financial resources

THANK YOU FOR YOUR ATTENTION!